meeting name: nhs south cheshire ccg primary care ... · other gp services- all of the budget lines...

NHS South Cheshire Clinical Commissioning Group NHS Vale Royal Clinical Commissioning Group

Meeting Name: NHS South Cheshire CCG Primary Care Commissioning Committee and NHS Vale Royal CCG Primary Care Commissioning Committee

Venue: Boardroom 2, Bevan House, Barony Court, Nantwich, CW5 5RD

Meeting No: 5

Date/Time: Friday 1st February 2019 13:00 – 16:30

Chair: Terry Savage

Quorum: No business shall be transacted at the meeting unless the following members are present, including: the Committee Chair (or Vice-Chair, if the Chair has declared a conflict of interest); NHS SCCCG and NHS VRCCG Chief Finance Officer (or nominated deputy); at least one other NHS SCCCG and NHS VRCCG Executive Director (or nominated deputy), plus one other voting Committee member.

Item No.

Business Subject

Topic No. Topic Name Lead

Time Slot

Reports/ Verbal

Page No.

5.1 Committee Management

5.1.1 Welcome to all in attendance and apologies. Confirmation of quoracy. Chair

13:00 Verbal

5.1.2 Declarations of Interest Chair Verbal

5.1.3 Minutes of the meeting held on: • 7th December 2018 Chair

13:10 Pg. 3 - 11

5.1.4 Action Log Chair Pg. 12

5.1.5 Risk Register C Leese 13:15 Pg. 13

5.2 Business

5.2.1 Primary Care Strategy Update D Scott 13:20 Verbal

5.2.2 Primary Care Commissioning Update AB 13:40 Pg. 14 - 23

5.2.3 NHS England Update NHS England 13:50 Verbal

5.2.4 Public Health Update

• Cheshire East • Cheshire West & Chester

FR HB

14:00 Verbal

5.2.5 Healthwatch Update LB 14:10 Verbal

5.2.6 Primary Medical Care - Commissioning & Contracting Governance Review LE 14:20 Pg. 24 - 44

5.2.7 Medicines Optimisation in Care Homes JK 14:30 Pg. 45 - 48

5.2.8 Primary Care Estates Group Update JB 14:40 Verbal

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5.3 Finance 5.3.1 Finance Update L Weekes-Bailey 14:50 Pg. 49 - 55

5.5 Any Other Business

5.5.1 Terms of Reference Chair 15:00 Verbal

5.5.2

The next meeting of the Primary Care Commissioning Committee is:

13:00 - 16:30 – 5th April 2019

Boardroom 2, Bevan House

Primary Care Committee Meeting Schedule

2018-2019 August October Dec Feb Apr Primary Care

Commissioning Committee

03/08/2018 05/10/2018 07/12/2018 01/02/2019 05/04/2019

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Meeting Name: NHS South Cheshire CCG and NHS Vale Royal CCG Primary Care Commissioning Committee

Date/Time: 7th December 2018 13:00 – 16:30

Venue: Boardroom 1, Bevan House, Barony Court, Nantwich, CW5 5RD

Chair: Terry Savage Meeting No: 4: Reporting Period: 2018/19

PCC Attendance

Name Organisation Role /

Terry Savage NHS Vale Royal CCG Chair + Governing Body Lay Member

Lucy Andrews NHS SC CCG + NHS VR CCG Project Support Assistant

Louise Barry Healthwatch

Amanda Best NHS SC CCG + NHS VR CCG Service Delivery Manager

Helen Bromley Cheshire West & Chester Council

Consultant in Public Health Apols

James Burchell NHS SC CCG + NHS VR CCG Senior Primary Care Accountant

John Clough NHS South Cheshire CCG Governing Body Lay Member

Tracey Cole NHS SC CCG + NHS VR CCG Executive Director of Commissioning

Mandi Cragg NHS SC CCG + NHS VR CCG Executive Assistant to the Clinical Chairs

Lin Elliot Mersey Internal Audit Agency Audit Manager

Ann Gray NHS SC CCG + NHS VR CCG Governing Body Lay Member

Caroline Harley NHS SC CCG + NHS VR CCG Primary Care Contracts Manager

Kevin Highfield NHS SC CCG + NHS VR CCG IT Manager Apols

Christopher Leese NHS SC CCG + NHS VR CCG Service Delivery Manager

Dr Annabel London NHS South Cheshire CCG Governing Body GP

Diane Noble NHS South Cheshire CCG Governing Body Lay Member

Fiona Reynolds Cheshire East Council Director of Public Health Apols

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Name Organisation Role /

Lynda Risk NHS SC CCG + NHS VR CCG Chief Finance Officer

Cathy Rowlands NHS England Assistant Contract Manager

Tracey Shewan NHS SC CCG + NHS VR CCG Executive Director of Quality & Safeguarding

Apols

Andrea Steel NHS England

Lorraine Weekes-Bailey

NHS SC CCG + NHS VR CCG Primary Care Accountant Apols

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Ref. Discussion and Action Points Name

4.1 Committee Management

4.1.1

Welcome and Apologies Terry Savage, Chair, welcomed everyone to the NHS South Cheshire CCG and NHS Vale Royal CCG Primary Care Commissioning meeting. Apologies were noted from: Kevin Highfield, Tracey Shewan, Helen Bromley, Fiona Reynolds, Louise Barry and Lorraine Weekes-Bailey It was further noted that the meeting was quorate.

Noted

4.1.2 Declarations of Interest The Chair reminded attendees of their obligation to declare any interest which may be perceived as presenting a potential conflict of interest with their CCG role and their role on the Primary Care Commissioning Committee. Declarations are listed in the CCG’s Register of Interests. The Register is available from the CCG office or via the CCG website. All attendees declared their roles and confirmed that there were no other interests that were relevant to the agenda that had not been previously captured on the Registers aside from: • Tracey Cole declared herself to be a patient at Weaverham Surgery. • Lynda Risk declared herself to be at patient at Danebridge Medical Practice. • John Clough declared himself to be a patient at Ashfields Primary Care

Centre. • Cathy Rowlands declared herself to be a patient at Nantwich Health Centre. • Terry Savage declared himself to be a patient at Willow Wood Surgery. • Mandi Cragg declared herself to be a patient at Weaver Vale Surgery. • Lucy Andrews declared herself to be a patient at Audlem Medical Practice.

4.1.3

Minutes from the previous meeting held on: • 5th October 2018. The minutes were agreed as an accurate record of the meeting with the following minor amendments: Page 7 – eighth bullet point to read ‘vulnerable patients’. Page 9 – typo ‘in’ not ‘ion’. Page 10 – missing ‘asked’ from sentence commencing ‘John Clough …’ Page 13 – AOB from Tracey Cole updated to include ‘transformation support funding’.

4.1.4

Action Log Update

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The Primary Care Commissioning Committee noted the submitted action log updates: • Action 15: Action completed. CLOSED • Action 16: Paramedic is in post - working closely with CCICP community

teams and will be attend care community meetings. ONGOING • Action 17: Amanda Best to pick up action. CLOSED • Action 18: Medicines Management will not attend PCCC routinely, but will

attend meetings where something directly involves them. Medicines Management to attend the Primary Care Operations Group. Christopher Leese to amend the ToR to reflect this. ONGOING

• Action 19: Given that there are proposals to merge the CCGs and the move towards holding committees in common it was discussed whether Vale Royal required separate clinical representation. The Committee took the view that it was still necessary and asked Christopher Leese to continue with the action. ONGOING

• Action 20: Action completed. CLOSED • Action 21: Action completed. CLOSED • Action 22: Action completed. CLOSED • Action 23: Action completed. CLOSED

4.1.5 Risk Register • Risk 1: Christopher Leese gave assurance that that the finance risks outlined

in risk one now incorporated the financial risk relating to estates.

4.1.6 Primary Care Commissioning Committee Terms of Reference (ToR) Christopher Leese confirmed that the following amendments will/ have been be made to the terms of reference: • Page 22 and page 23 – Medicines Management to be listed under ‘standing

invitee’ without voting rights. • Page 23 – NHS Vale Royal CCG GP representative added. • Page 23 – point 23 to state ‘7 days’ instead of ‘5 working days’. • Quorum – nominated deputy text has been updated. Action 24: Christopher Leese to amend the terms of reference as agreed at the meeting and to send the revised document to Dylan Murphy. NHS South Cheshire CCG and NHS Vale Royal CCG Primary Care Commissioning Committees: • Approved the revised terms of reference.

4.2 Business

4.2.1

Internal Audit Framework for Delegated Clinical Commissioning Groups – Terms of Reference (ToR) Lin Elliot of Mersey Internal Audit Agency (MIAA) introduced the report and

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stated that the listed terms of reference are the formal ToR for the Governance Review work. Further background was given as follows: • This audit work will be undertaken for each CCG as a separate entity as

NHSE has asked for this assurance. • The methodology was developed to meet NHSE’s audit requirements.

Fieldwork has been conducted and a draft report sent to NHSE for consideration. Full assurance has been offered to NHSE.

• Lin Elliot suggested that the Primary Care Commissioning Committee’s role in respect of risk management responsibilities needs to be added to the Primary Care Commissioning Committee terms of reference.

• Local agreement has to be received by early January; therefore these ToR will be submitted to the Governance and Audit Committee meeting scheduled for 22nd January 2019.

• The final report will come back to the Primary Care Commissioning Committee. Within one month of the final report being agreed it will be submitted to NHSE.

• Lin Elliot will continue to provide updates to this meeting. Action 25: Lin Elliot to send the Governance Review reports to the Working Together Across Cheshire workstream and to link in with Phil Meakin. Action 26: Christopher Leese to circulate the draft report to PCCC members following the meeting. Any comments to be sent to CL by 6th January 2019. Action 27: Christopher Leese to amend the PCCC Terms of Reference in respect of risk management responsibilities. Linked to action number 24. NHS South Cheshire CCG and NHS Vale Royal CCG Primary Care Commissioning Committees: • Noted and agreed the Terms of Reference and related actions.

LE

CL

CL

4.2.2 Winter Assurance Process Christopher Leese introduced the submitted report stating that in terms of primary care various documents had been appended to the report for assurance purposes including: • Extended access template/ letter to all practices. • Out of hours – the GP Alliance is providing additional cover for the Christmas

holidays. Tracey Cole advised that the report had been received at both the A&E Delivery Board and the joint Governing Bodies and added that additional schemes will be implemented over the winter period as additional monies had been made available. NHS South Cheshire CCG and NHS Vale Royal CCG Primary Care Commissioning Committees: • Discussed and noted the process for Winter Plans and Arrangements for

Primary Care 2018/19 submitted to the Committee for assurance purposes.

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4.2.3 NHS England Update

Cathy Rowlands updated the meeting verbally as follows: • A letter has been sent to all practices from NHSE advising that Primary Care

Support England (PCSE) is undertaking quality checks on GP lists for ‘ghost patients’. Letters have been sent to the following categories of patients and if no response is received, PCSE will deregister following consultation with the practices.

o Patients aged over 100. o Patients aged under 16 and living alone. o Patients living in demolished properties. o Students resident in student properties for over 4 years. o Multi-occupancy addresses. o Transient patient addresses.

Action 28: Cathy Rowlands to forward a copy of the 'ghost patients' letter to Amanda Best and Christopher Leese. GP Forward View Andrea Steel provided the following information. • Workforce retention is a priority and monies have been put into new

initiatives including: o Career Plus pilot o Online training o New primary care roles such as physician associates o Rotating paramedics will be employed by NWAS but will work in the

community and across primary care networks • IAPT provision is a postcode lottery at the moment. NHSE will be asking

CCGs to look at the contracts and at practices. Some IAPT services are based within practices and practices are charging the provider to use their rooms.

• Five year plans will include: o Demographics o Housing o Systems workforce

• Primary Care Network Funding bids have been received and monies will be distributed in December 2018. No details around the scheme or monies involved for the next few years are available yet.

• Various Primary Care Network training programmes will be delivered. The next one is in February and themed around workforce.

• It is intended to increase the numbers of pharmacists in practice. There has been a low uptake so far.

• NHSE is developing a template to gather workforce information to help with forward planning. This will be collated nationally, so details are not available yet across Cheshire and Merseyside.

Responses were received as follows:

o Dr Annabel London expressed interest in seeing the Primary Care Strategy and workforce plan, adding that it would be useful to see local data as it would help to inform future planning.

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o Amanda Best advised that there was some local data but it was not robust.

o Dr London asked how the CCGs and practices could feed into the report with a view to creating something more Cheshire focused. Amanda Best advised that workplace sub-groups are embryonic, but further information would be brought back to the Committee as the subgroups developed.

o Andrea Steel highlighted the need for more collaborative working both now and going forward. NHSE is working hard to ensure that collated data is more robust, but that practices are relied upon to provide a lot of the data and overburdening them must be avoided.

Action 29: Christopher Leese, Amanda Best and Andrea Steel to pull out some of the current data and report back to the PCCC.

4.2.4 Public Health Update Public Health was not represented at the meeting therefore an update was not received.

4.2.5 Healthwatch Update Healthwatch were not represented at the meeting therefore an update was not received.

4.2.6 Primary Care Strategy Tracey Cole introduced the item, which comprised a PowerPoint presentation, and advised the Committee as follows: Dawn Scott of Healthskills is leading on a review of primary care strategy across the two CCGs, and has spoken to and collated information from the CCGs, Membership, practice managers, the GP Alliance, LMC and NHSE. The Strategy will also include a review of best practice, consideration of the wider primary care team, local/ national review of best practice, potential provision within the ICPs, the implementation plan for 2019/20 and recommendations for the primary care charter. Tracey Cole observed that reporting might be too late for the primary care charter. Dawn Scott will link in with the Primary Care Commissioning Committee and circulate a GP survey. An LMC stakeholder event will be held in February 2019, with the strategy due for completion by February/ March 2019. Dr Annabel London asked how the work would be assured, commenting that sufficient challenge had to be included in order that something meaningful could be delivered. It was decided that: Action 30: Mandi Cragg to distribute the PC Strategy presentation and Dawn Scott's contact details. The Committee can feedback to Dawn Scott, deadline 17th December 2018. Action 31: Dawn Scott to be invited to the Primary Care Commissioning

MC MC

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Committee meeting of 1st February 2019. It was noted that there were no additional monies to pay for this; the visit must be included within the OD service specification.

4.2.7 Primary Care Commissioning Update Amanda Best delivered a verbal report to the Committee as follows: • Extended Access achieved 100% cover across South Cheshire and Vale

Royal in October 2018. The CCGs are working with some practices to advertise the service in terms of informing patients how the service is provided.

• NHS Digital is starting to distribute the pre-work to the automated data extraction tool. The CCGs have received a template around the data governance. Returns from NHSE will be simplified into one automated return from March/ April 2019.

• The terms and conditions for anti-viral prophylaxis in care homes have been finalised and GPs have been notified of in-hours arrangements.

• A flu planning workshop was held on 6th December which all partners and stakeholders found very positive.

• Uptake for flu vaccinations is slow but it is starting to pick up. o Terry Savage asked for an update of staff uptake also. Tracey Cole

advised that she would ask Kathryn Cooper to explore this. • All practices are working to the requirements of the primary care charter.

One or two have raised questions around the standard frailty template; however the CCGs are working with them to address this.

• Primary Care Network Development funds are due to be released to the care communities for the specified projects. Amanda Best assured the meeting of the governance around the way monies are spent.

o Terry Savage advised that he had not received much information regarding the infrastructure of the care communities. Amanda Best advised that they are still evolving and that there is a lot of work ongoing.

o Andrea Steel commented that there are lots of ways in which they could be structure and that NHSE is supporting funding for projects. These monies are not to be used for legal fees for practice merging.

o Terry Savage commented that one of the big issues is for indemnity insurance. Amanda Best clarified that primary care indemnity will be underwritten if it is in the GMS contract. This change will take place from April 2019.

Action 32: Tracey Cole to ask Kathryn Cooper for information on staff uptake of the flu vaccination. Action 33: Amanda Best to liaise with NHSE re updates around indemnity charges.

TC AB

4.3 Finance

4.3.1 Finance Update James Burchell introduced the paper and stated that there are continued pressures within primary care, particularly in terms of business rate increases

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and rent reviews. Comment was received as follows: • Terry Savage expressed appreciation in terms of the way in which the report

is written. • John Clough asked where else the underspend identified in Table 6a, page

52 of papers, might be spent. James Burchell clarified that the contents of the table represented a line in the overall budget and that the figures could fluctuate. The table will be removed from the paper.

NHS South Cheshire CCG and NHS Vale Royal CCG Primary Care Commissioning Committees: • Discussed and noted the financial information contained within the report.

4.4 Any Other Business

4.4.1 John Clough asked whet the CCGs might do to mitigate against the costs incurred by people failing to get their prescriptions by Christmas Eve and then turning up in A&E. Terry Savage advised that there was a message on his last prescription reminder him to ensure he was covered for Christmas. Dr Annabel London and Christopher Leese advised that practices routinely remind patients. Action 34: Tracey Cole to speak to the Communications Team and ask if they are working around reminding patients re ordering/ collecting prescriptions prior to Christmas Eve.

TC

4.4.2 Date, Time and Venue of Next Meeting

1st February 2019 – 1.00pm - 4.30pm Boardroom 2, Bevan House, Nantwich, Cheshire, CW5 5RD

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Action Log No.

Original Meeting Date

Ref in Minutes Description Action Requirements from the Meetings By

Whom By When Comments/ Updates Outside of the Meetings Status

18 05-Oct-2018 3.4.1 PCCC ToRTracey Cole to speak to Mark Dickinson regarding Medicines Management attendance at the meetings. TC 07-Dec-2018

07.12.18 - Medicines Management will not attend PCCC routinely, but will attend meetings where something directly involves them. Medicines Management to attend the Primary Care Operations Group. Christopher Leese to amend the ToR to reflect this. Completed

19 05-Oct-2018 3.4.1 PCCC ToRChristopher Leese to word a request for the Chair to send out to NHS Vale Royal CCG clinicians in relation to attending PCCC meetings. CL ASAP

02.01.2019 - Request sent to VR CCG clinicians. 07.12.18 - Given that there are proposals to merge the CCGs and the move towards holding committees in common it was discussed whether Vale Royal required separate clinical representation. The Committee took the view that it was still necessary and asked Christopher Leese to continue with the action. Completed

24 07-Dec-2018 4.2.1 PCCC ToRChristopher Leese to amend the terms of reference as agreed at the meeting and to send the revised document to Dylan Murphy. CL 01-Feb-2019 28.12.18 - TOR amended and forwarded to Dylan Murphy. Completed

25 07-Dec-2018 4.2.2Internal Audit ToR & Update

Lin Elliot to send the Governance Review reports to the Working Together Across Cheshire workstream and to link in with Phil Meakin. LE 01-Feb-2019

17.01.19 - Final report was shared with Phil Meakin on 11.01.19. Report will got to Governance & Audit Committee on 22.01.19. Completed


Christopher Leese to circulate the draft report to PCCC memebrs following the meeting. CL 10-Dec-2018 28.12.18 - CL confirmed action completed. Completed


Christopher Leese to amend the PCCC Terms of Reference in respect of risk management responsibilities. Linked to action 24. CL ASAP 28.12.18 - TOR amended and forwarded to Dylan Murphy. Completed

28 07-Dec-2018 4.2.3 NHSE UpdateCathy Rowlands to forward a copy of the 'ghost patients' letter to Amanda Best and Christopher Leese. CR ASAP

29 07-Dec-2018 4.2.3 NHSE UpdateWorkforce data: Christopher Leese, Amanda Best and Andrea Steel to pull out some of the current data and report back to the PCCC.

CL, AB & AS 01-Feb-2019

30 07-Dec-2018 4.2.6 Primary Care Strategy

Mandi Cragg to distribute the PC Strategy presentation together with Dawn Scott's contact details. The Committee can then give feedback to Dawn Scott, deadline 17th December 2018. MC 10-Dec-2018 10.12.18 - Email sent with presentation and DS's details. Completed

31 07-Dec-2018 4.2.6 Primary Care Strategy

Dawn Scott to be invited to the Primary Care Commissioning Committee meeting of 1st February 2019. No £s to pay for this - should be in OD service spec. MC ASAP 18.12.18 - Action completed. MC. Completed

32 07-Dec-2018 4.2.7Primary Care Commissioning Update

Tracey Cole to ask Kathryn Cooper for information on staff uptake of the flu vaccination. TC ASAP

16.01.19 - TC emailed Tracey Shewan/Kathryn Cooper re this. Awaiting update. Ongoing

33 07-Dec-2018 4.2.7 Commissioning Update Amanda Best to liaise with NHSE re updates around indemnity charges. AB 01-Feb-2019

16.01.19 - Confirmed in the NHS Long Term Plan, page 83, point 4.28 confirming a new state backed GP Indemnity Scheme from April 2019. Completed

34 07-Dec-2018 4.4 AOB: Xmas Prescriptions

Tracey Cole to speak to the Comms Team and ask if they are working around reminding patients re ordering/ collecting prescriptions prior to Christmas Eve. TC ASAP

16.01.19 - TC spoke to Katy Brownbill - there was a national campaign on this which the CCGs followed. In addition there was an incentive scheme in place for all practices to clear repeat prescription requests prior to the Xmas period which was very successful. Completed

Date: Meeting 4 - 07.12.2018

Primary Care Commissioning Committee Action Log

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Risk Response

Initial

Current Controls AssurancesRisk Descriptionea

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Historic Funding issues are well documented , this risk is in relation to CCG Budgets (including Premises Cost Pressures) Financial N/A

Apr-

17

Treat 4 16* Managed at the Primary Care Operational Meeting and Primary Care Committee* Regular reporting mechanisms and escalation process in place * Regular Financial internal meetings and forecasts * Monthly reports from Finance

* Regular Finance Budget forecasting *Actions in place to mitigate return to control totals

New Risk for 2018/19 -this is ongoing GAPS to be identified and discussed at the Committee. 4 16

May 2018 - Further discussion at the Primary Care Committee in respect of new financial year. To be discussed in conjunction with the Primary Care Finance report at the May meeting. JULY 18 Budget issues escalated for discussion with NHSE - refer to narrative in Primary Care Finance Report. October 2018 - Slightly improved position in each CCG following agreement with NHS England, more information will be given within the Finance Report section. Still awaiting revised Premises Directions

Ongoing

Oct

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NHS England tendered the contract for primary care support services formerly undertaken by Cheshire Health Agency. The

new provider commenced 24th March, however there have been some operational issues with regards to ordering supplies,

medical records and payments to practices.

Financial Operational Reputational Ap

r-16

Treat 4 16

* CCG Primary Care Team are supporting practices as far as possible with escalating issues direct to Capita (new supplier)* Standing item for discussion at Delegated commissioning task and finish group / Primary Care Operations Group* Log issue escalated direct to NHSE who attend face to face meetings with Capita* BMA/GPC have written direct to NHS England to raise practices' concerns. * July 2016 NHSE are having regular meetings with Capita * The LMC and GPC continue to support practices in escalating their issues as do the two CCGs.

* Continued dialogue with NHS England and PCSE* Reports back on log issues to the CCG and dialogue between NHSE and CCG in this respect.

* Potential risk for practices and the infrastructure supporting them to enable a business as usual. CCG is not direct contract holder with Capita.* July 2016 update. Practices are still experiencing some issues and concerns with medical records deliveries & collections, and reciept of medical supplies. Jan 2017 Records movement issues reported and GP registrar reimbursements. Key issues from CCG practices are: medical records movement; superannuation payments; Performers List. Practice issues are still be escalated. May 2017 - some issues still reported.

4 16

Ongoing monitoring and escalation process in place for NHS England, CCGs and Practices. June 2017 Risk will continue to be a risk on the 2017/18 risk register and issues will be escalated via agreed process. Dec-17 PEMs have contacted Practices to ascertain position. March 2018 - Further discussion at PCSE and agreed to keep risk as current

Jan-18

Oct

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The CCG has taken on Delegated Arrangements from 1st April 2016 (full Guidance available on implications of this via NHS England Website). The risk is that the increased workload will impact on all areas of CCG operations unless managed in terms of enough staff to undertake the required roles/manage the workload.

Operational Financial

Reputational Compliance

Aug-

16

Treat 3 9

* Joint working with Eastern Cheshire/Other CCGs*Overarching document which clearly lists the functions within delegated and those outside (e.g complaints) *Additional Staffing in place SDM for Primary Care Operations *Monthly Operational Group in Place (PCOG)*Single Operating Model/Policy Document adhered to for contracting issues *NHSE continue to provide contracting support and guidance during transition year *Primary Care Commissioning Committee in place

*Minutes of Task and Finish Group and Primary Care Commissioning Committee reflect actions taken to manage workload and outcomes *Progress against clear contracting issues mapped and overseen using relevant policy book

Further exploration of Joint working with Eastern Cheshire CCG this is ongoing. Internal management of functions

3 9

* Ongoing Monitoring of workloads and issues via the control mechanisms. Further work required in respect of understanding primary care quality and primary care contracting interface. * June 2017 Although work has been undertaken to reduce this risk it will be added as a risk on the new 2017/18 register to be monitored. Efficiences by joint working with ECCCG & WCCCG should assist with managing the workload but these are not fully developed as yet. In addition NHSE staff allocated to the Cheshire CCGs to support CCGs will the Five Year Forward view and support the CCG transformation and accountable care work. Jan-18 Discussion with ECCG and WCCG ongoing.. JULY 18 - Workshop with East and West Cheshire to explore joint ways of working,. October 2018 - Exec Lead appointed to Primary Care Operations workstream, first meeting taken place end of September.

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Assurance in respect of process for visits

Clinical Operational

Financial Compliance

Apr-

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* The Committee has received and commented on the suggested framework for Annual Contractual and Quality Visits - The Committee agreed to (1) a rolling programme of planned contract and performance visits over a 3 year period, (2) Responsive visits outside the cycle as required e.g. contractual, quality and soft intelligence or (3) A triggered visit e.g. CQC Requires Improvement - the latter 2 are already in place* Almost all Practices have received CQC visits providing a benchmark

Paper to the Primary Care Committee in September agreed this - some further detail for the framework

* Framework was approved by the committee before being implemented. *The Operational Group with Quality will work up the detail outside of the Committee * Discussion regarding Staffing within Quality in relation to Primary Care

3 9

* Rolling programme of quality visits will be developed, tying in with contracting visits - these will be potentially on a three year rolling programme commencing in 2018 but the targetted visits etc outside of this already take place as required. March 2018 - A Paper outlining a framework for Quality Visits and escalation has been completed and should be returning to the Committee in May, which details our approaches to this. JULY 18 Quality Paper with framework for visits to return to the Committee in July. August 2018 Paper agreed and working group set up to take forward visits and framework. October 2018 - Further discussions ongoing in respect of this when visits will commence, working group established meeting regularly to take work forward.

Dec-18

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*Communication and engagement with practices around access, capacity and demand. *Proactive conversations and action plan to develop sustainability plans for General practice through the transformation team on 10 high impact changes*Seek support through GP Alliances towards delivering new models of Care*Partnership and engagement with NHS England and Health Education England (HEE) regarding education and training / succession planning for primary care workforce.* New Primary Care Contracting team has been visiting most vulnerable Practices to offer support and guidance, this support is now being picked up through the element of care communities* Practices have been signposted to apply for funding the GP resilience programme. Second wave of application shave been approved. *Quality and Primary Care Team following up with Visits Practices identified as RI under CQC * Comms to practices outlining support available and key messages* Comms plans (both patient and practice focused) agreed and currently being rolled out.* Exploration of more joint working with neighbouring CCGs* Discussion with NHS England in respect of ongoing financial risks to practices and CCGs.* Primary Care Charter rolled out and GP signed upto. * Ongoing general support through development of care communities

* Results of the latest GP Survey * Regular Communication with the Practices * Contracting Issues picked up through Delegated Contracting *Exploration of new models of contracting via Connecting Care/Care Community* Agreed GP FYFV plan is ongoing and updated via CCE and primary care committee. * Regular update of practices facing challenges at part b of the primary care committee. * Care Community meeting assurances ongoing. *Workforce development plan ongoing* additional Resilience work streams agreed at LDS/STP level ongoing.

*Gaps are documented in the GPFV Plan/Operational actions to address reported within this 4 16

* GPFV Plan documents ongoing actions to support sustainable General Practice* These specific actions and strategic direction are ongoing and available to the Committee/Governing Body * The risk was reviewed by the Primary Care Committee in March and agreed to keep at current. *Risk and Actions fully reviewed and discussed at Primary Care Operations Group Aug 18. Agreed to keep risk at 16 but also keep under review.

Jan-18

Aug-

18

Failure of any one or number of practices will have a significant and detrimental impact on the delivery of health care services across Primary and Acute Care.Significant reduction in capacity in an already stretched health economy.Detrimental impact on local / neighbouring practices. Reduction in Access and access survey results.Contractual implications where practices close their lists.Financial consequence for the CCG under delegated authority if support or interventions are required.Potential financial impact to the CCG through increased activity through secondary care.

Clinical Reputational Treat5

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On-going stability of Primary Care. Practices are under increasing pressure through

challenges in workforce recruitment and retention, increased patient demand, aging populations and increasing multi morbidity

which is collectively placing significant pressures on the operability of General Practice across South Cheshire and Vale

Royal.

CCG Financial Challenges in relation Budget Allocations for 2018/19

Primary Care Support Services England (PCSE) - issues in relation to PCSE and

concern regarding any onward effects to Practices across both CCGs.

Increased workload due to Delegated Commissioning in respect of Primary Care, Finance and Quality impacting on existing

staff and priorities.

Programme of Practice Rolling Visits have not yet commenced

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Report Author(s)

Name/s Amanda Best Title/s Service Delivery Manager Primary Care

Date 14th January 2018 Clinical Lead / Clinician Sign-Off Executive Lead Sign-Off

Name Dr Annabel London Name Tracey Cole

Title Clinical Lead Title Executive Director for Commissioning

Date 18th January 2019 Date 16th January 2019 CCG Strategic Priorities (5+1) supported by this paper

Transforming Primary Care

Transforming Mental Health

Transforming Urgent Care

Integration

Person Centred Care

NHS Constitution Targets Outcome Required Approval Assurance Discussion Information

Recommendations:

The Primary Care Commissioning Committee is asked to:

• Receive the report • Note the progress in delivering key objectives under the heading set out below:

Primary Care Commissioning (local), Primary Care at Scale, General Practice Forward View initiatives (GPFV) Quality Visits Primary Care working together across Cheshire

Reviewed by (e.g. committee/team/director)

Dr Annabel London 18th January 2019

Tracey Cole 16th January 2019

Report To (committee): Primary Care Commissioning Committee Report Title: Primary Care Commissioning Update report

Meeting Date: 1st February 2019

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Finance implications

Funding required? (Please tick. If yes, please complete section A) Yes No

Section A

Service Title Recurrent (£000s) Non-Recurrent (£000s)

Included in 18/19 budget? (Please tick. If no, please complete section B) Yes No

Section B

Have the following areas been considered whilst producing this report? Yes N/A

Other resource implications (apart from finances covered above)

Equality Impact Assessment (EIA)

Health Inequalities (JSNA, ISNA)

Risks relating to the paper

Quality & Safeguarding (6 C’s +1, CASE)

Stakeholder engagement/involvement (member practices/GP Federations, patients & public, providers etc.)

Regulatory, legal, governance & assurance implications

Procurement processes Glossary/Acronyms

PCCC CCICP OOH ICP GPFV PCCC GP TSF PPG SRO HCP ILI CCDT

Primary Care Commissioning Committee Central Cheshire Integrated Care Partnership Out of Hours Integrated Care Partnership General Practice Forward View Primary Care Commissioning Committee General Practice Transformation Support Fund Patient Public Group Senior Responsible Officer Health Care Partnership Influenza Like Illness Care Community Development Team

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1. Purpose of the paper 1.1 The purpose of this report is to provide an update to the Primary Care Commissioning

Committee (PCCC) on the progress of Primary Care in the following key areas: • Primary Care Commissioning (local), • Primary Care at Scale, • General Practice Forward View initiatives (GPFV) • Quality Visits • Primary Care working together across Cheshire

2. Primary Care Commissioning

2.1 Extended Access Contract

2.1.1. The Extended access contract remains in place and both CCs are reporting 100% population coverage. Work continues to support those practices that have yet to sign electronic data sharing agreements but the service remains in place for all patients. During the course of the year, increasing focus will be on advertising to patients and how this services is more fully integrated into the wider extended access offer with GP out of hours and primary care streaming.

2.1.2 The CCG continue to provide monthly returns to NHS Digital which includes activity related

to the Access contract.

2.1.2 The CCG continue to provide monthly returns to NHS Digital which includes activity related to the Extended Access contract. A copy of the return can be found in Appendix 1.

2.1.3 In addition, the local extended access service across both South Cheshire & Vale Royal is

averaging around 42 minutes per 1000, this includes the Christmas and New Year reporting period. The NHS England core requirements for the service mandate 30 mins per 1000.

2.2. Primary Care Charter.

2.2.1 Delivery of the Primary Care charter remains on track. This includes elements that relate to the Transformation Support fund (TSF).

2.2.2 The Charter for 2018/19 continues to provide General Practice with a framework for working

collaboratively, improving local care and raising quality with an additional emphasis this year on Standardisation and Harmonisation of processes across all practices that allows for consistency.

The aims of the Primary Care Charter in 2018/19 are: • Maintaining sustainability in General Practice. • Increasing Capacity to improve the quality of Primary Care • Delivery of Care Communities, • Continue to Implement the GPFV and 10 High Impact Actions – Delivering the CCG

Primary Care Strategy • Describe the role of Primary Care in supporting delivery of system controls and CCG

performance targets (IAF) and Planning Guidance.

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2.2.3 The Care Community Development Team (CCDT) has continued to support practices with a variety of discussions/facilitation/templates/courses to assist the delivery of the charter for this year.

Key areas that remain a focus are:

• Practice level achievement of the Dementia Diagnosis rates.

Current CCG achievement rates are 65.5% for NHS South Cheshire CCG and 67.2% for NHS Vale Royal CCG. Those practices that have some way to go in attaining the national aspiration have been contacted with an offer of support.

• Deployment of the combined APEX / Insight workforce planning tool. • Increasing uptake in the use of the Comprehensive Geriatric Assessment (CGA)

template in the frailty domain. • Increase the uptake and use of the EPaCC template for those with complex frailty using

a standardised coding.

Monthly meetings continue between the CCDT and GP Alliance to share progress on work areas within the Charter for 2018/19.

The CCDT have developed a monitoring template to assist practices in measuring progress and delivery.

2.3 Transformation Support Fund (TSF)

2.3.1. The CCG has committed and approved all funding applied for by Care Communities under the Transformation Support Fund (TSF). These projects include:

• Northwich Care Community to support the Lyndsey Leg club and to undertake a piece

of work to improve health outcomes in the community based on public health indicators • Winsford – Development of an urgent paediatric service. • Nantwich and Rural – for the development of a care community breathlessness service • Crewe – Progress Improving Primary Care (workforce and standardisation); Upskilling

Mental Health and reviewing of available resources and the development of the Lyndsey Leg Club

• SMASH - Systems, Processes and Protocols review as well as purchase if IT equipment

All projects are now at mobilization stage or are being delivered.

Care Community Project Status Northwich Lyndsey Leg Club Service in place and operational Winsford Urgent Paediatric service Service in place and operational SMASH Systems, Process &

Protocols Clinical ITC and Equipment

Project Manager appointed and project moving to implementation.

Crewe • Improving Primary Care (workforce and standardisation)

• Improving Mental Health

• Lyndsey Leg Club

Projects agreed and moving through implementation.

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Nantwich & Rural Breathlessness Service Discussions have taken place between the project lead and MCHFT. MCHFT are currently looking into the activity and feasibility of the project before agreeing to go forward.

2.4 Post Exposure Prevention for Flu in Care Homes

2.4.1 As previously reported the post exposure for Influenza Like Illness (ILI) in Care homes service went live in October 2018.

2.4.2. The Provider, the South Cheshire & Vale Royal GP Alliance have put arrangements in

place to respond to any potential flu outbreaks in Care Homes during the weekend and bank holiday period, including Christmas and Easter. This includes for all patients in care homes, where 2 practices have not signed data sharing agreements for sharing electronic clinical information.

2.4.3 The first suspected case of flu like illness was reported in mid-January and the provider was

able to respond in a timely and effective manner. On call managers have received updated information within their on call packs and a local multi organization workshop was held in December to share learning and best practice in managing suspected flu outbreaks in Care Homes.

3. Primary Care at Scale

3.1 Care communities Highlight reports for each of the 5 Care Communities are attached in Appendix 1.

3.2 Primary Care Network Development Fund (PCNDF)

3.2.1 Funding under the Primary Care Network Development bids has now been approved by the CCG.

3.2.2. Back in July, each of the Care Communities submitted applications to NHS England,

Cheshire & Merseyside for funding to accelerate the development of Care Communities via the Primary Care Network Development fund (PCNDF).

3.2.3 Nantwich and Rural Care Community were approved funding to enable then to develop a

project called Connected Communities, that links with the Local Authority, charitable and voluntary organisations and the End of Life partnership to support local residents to feel supported and empowered in their own health and wellbeing within the local community. The project is built on best practice and evidence based, being recognized in the South West. The project is in startup phase.

3.2.4 The CCG further negotiated an additional £230K non recurrent funding from NHS England

for the remaining Care Communities to revisit the original bits with a view of progressing these ambitions.

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3.2.5 The funding for the revised bids was approved in November by NHS England, with delegated responsibility to the CCGS for oversight of delivery.

3.2.6 The CCG has agreed terms with each of the Care Communities including formal sign off by

all practices of the bids. An MOU has been shared with each Care Community clinical lead to ensure that there is a robust Governance process in place for how the projects will be delivered and funds accounted for.

3.2.7 The CCGs have adopted the NHS England monitoring template for consistency. This will be

reported to the CCG on a monthly basis.

3.2.8 The CCT have agreed with each Care Community that projects need to be mobilized and funds accounted for by the end of March 2019. Projects also need to have a clear exit strategy as to how they will be continued or reviewed for continuation into 2019/20.

The table below summarises the projects in each Care Community

Care community

Project Funding

Northwich (1) Addressing workload challenges • Time to scope collective solutions to common challenges • Looking at overview of systems that Practices could ‘do once’

across the patch

(2) Improving Quality – Development of a Quality Toolkit

(3) An Education and Audit Programme

£55,000

Winsford (1) Scoping Shared Back Office/Administrative functions into a single model for future roll out.

(2) Aligning Policies and Procedures Across the Network

£27,000

SMASH (1) New Solutions to address increasing workload • Examining APEX and other data sources • This to inform solutions to demand and capacity issues • Outcomes such as inter practice solutions and agreements to

manage demand collectively (2) An Education and Audit Programme

(3)Addressing Operational Challenges -Development of a Quality

Toolkit

£66,000

Crewe (1) Scoping, Project Development and delivery of an integrated and sustainable workforce model to support Patients with complex needs, with a focus on patients in Care Homes and frailty.

Including an Educational development Programme

£86,000

4. General Practice Forward View (GPFV)

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4.1 Patient on Line

4.1.1 Patient Online is an NHS England programme designed to support GP Practices to offer

and promote online services to patients, including booking and cancelling appointments, ordering of repeat prescriptions and access to coded information in records.

4.1.2 NHS Digital provides an overview of key Patient Online Management Information (POMI)

data from the latest reporting month (currently November 2018). There is a national-level summary, a practice-level page, and some more detailed CCG-level data (which provides comparisons to regional and national level values).

4.1.3 Full information and access to the interactive report published by NHS Digital can be

accessed via the link below. https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-collections/pomi

4.1.4 Measuring across the Cheshire and Merseyside footprint, NHS Vale Royal CCG practices

have the highest percentage of patients registered for one or more online services at 42.2%.

4.1.5 Nationally, they are third highest after NHS Rushcliffe CCG (48.2%) and NHS Wandsworth

CCG (42.8%). NHS South Cheshire CCG currently has 25.9 % registered. The two charts below compare our two CCG against, STP, North, and England overall data.

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https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-collections/pomi


4.1.6 Local Data:

The infographs below show practice list size measured against percentage of patients registered for Patient Online Services.

Vale Royal

All 12 practices have 20% or more patients registered to book / cancel appointments on line 11/12 practices have an uptake rate greater than 30% 2/12 (Weaverham Surgery and Middlewich Road Surgery) practices have achieved an uptake rate of greater than 50%

South Cheshire

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12/17 practices have 20% or more patients registered to book / cancel appointments on line. 6/17 practices have an uptake rate greater than 30% 1/17 (Kiltearn Medical Practice) has achieved an uptake rate of greater than 50% Weaverham Surgery has the highest percentage of patients registered for one or more online services with 62.5% of their patient list online. They are closely followed by Middlewich Road Surgery at 57.9% and Kiltern Medical Centre at 52.8%.

The CCG continue to promote and encourage practices to increase the uptake of patient on line.

4.2 Care Navigation Training

4.2.1 Planning continues for the Care Navigation workshops (provided via West Wakefield, facilitated by the Care Community Development Team) and online training for receptionist. Six further half day workshops are planned for January 2019.

4.2.2 As at the end of December, all practices across both CCGs have engaged with the

programme and a total of 100 in South Cheshire and 82 in Vale Royal reception and clerical staff have been training in active signposting, to ascertain the patient’s need and signpost them to the most appropriate person or service referring to a local directory.

Six further half day workshops are planned for January 2019 which will increase the above figures.

4.3 Releasing Time to Care

4.3.1 The CCGs worked with general practice to submit a bid to NHS England for funding for places on the Releasing Time to Care Programme. The programme is commissioned by NHS England as part of the GPFV and supports groups of groups of practice staff to identify projects that are relevant and beneficial to improving the practice systems and process and using quality improvement methodologies work though the improvements that can be applied.

Participate in the Releasing Time to Care Programme was also included in this year’s Primary Care Charter.

4.3.2 NHS England accepted 12 practices in South on the scheme under Cohort 1. The CCGs reapplied to NHS England under a second Cohort for the GP fundamentals programme for the remaining practices which has been accepted.

4.3.3 For the remaining practices in South Cheshire and all the practices in Vale Royal representatives will be attending a 2 day workshop in February to complete the quality improvement course which is being funded by NHS England. This will mean all practices will have completed the releasing time to care programme to achieve this part of the charter.

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4.3.4 The programme has been well received by practices who have not only actively engaged but who have seen real tangible benefits in streamlining processes and increasing efficiencies in the way practices operate.

4.3.5 Practices in Cohort 1 have shared the learning amongst themselves and we envisage that a

similar success will apply to the remaining practices in this programme.

5. Primary Care Quality Visits

5.1 As reported via the Primary Care Operational Group (PCOG), the Primary Care Quality visits

are on hold pending a review of the process in line with feedback from a number of practices.

5.2 A pilot visit will continue in one practice in Vale Royal and learning from the visit will be brought back to the CCG for discussion. A Quality visit meeting has been arranged for mid-January and it anticipated that the revised visit process will commence in the new year lead out by the Quality team, supported by Primary Care.

6. Primary Care Across Cheshire

6.1 Primary Leads from all CCGs in Cheshire have been meeting regularly over the past 2 years to share learning and best practice and to streamline how primary care is delivered as part of the GPFV programme.

6.2 From January, the format of the meeting will be amended to better reflect the Working together across Cheshire programme and for leads to further develop links that bring workstreams together, this will include how operational functions, local commissioning and primary care support around Care communities can be best managed.

7. Recommendations

The Clinical Commissioning Executive is asked to:

• Receive the report • Note the progress in delivering key objectives under the heading set out below:

Primary Care Commissioning (local), Primary Care at Scale, General Practice Forward View initiatives (GPFV) Quality Visits Primary Care working together across Cheshire

8. Appendices Appendix 1 – Care Community Highlight reports

Crewe CC - Commissioning Progra

Nantwich and Rural CC - Commissioning Pr

SMASH CC - Commissioning Progra

Northwich CC Highlight Report Dec 1

Winsford CC Highlight Report Dec

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Report Author(s) Name/s Christopher Leese/Lin Elliot

Title/s Primary Care Manager/Mersey Internal Audit

Date Monday 18th January 2019

Clinical Lead / Clinician Sign-Off Executive Lead Sign-Off Name Name Lynda Risk

Title Title Chief Finance Officer

Date Date 18th January 2019 CCG Strategic Priorities (5+1) supported by this paper

Transforming Primary Care



Integration

Person Centred Care

NHS Constitution Targets

Outcome Required Approval Assurance Discussion Information

Recommendations: The Committee had previously discussed the Terms of Reference for the Internal Audit of the CCG’s Delegated Primary Care (General Practice) functions. The Final Report has now been released and is for discussion and approval, the report having previously been circulated to members of the Committee for comments. The Committee should also note the assurances given within the report.

Report To (committee): Primary Care (General Practice) Commissioning Committee PART A

Report Title: Primary Medical Care – Commissioning and Contracting Governance Review – Final Report 2018/19

Meeting Date: 1st February 2019

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Executive Summary (key points, purpose, outcomes) Background From 2018/19 NHS England required an Internal Audit of Delegated CCGs Primary Medical Care commissioning arrangements, the purpose of which is to provide information to CCGs that they are discharging NHS England’s statutory primary medical care functions effectively. A Guidance document was released which was discussed at the Committee meeting in October which set out the key components in scope of the audit and provides Guidance under each component. This should be undertaken as part of the CCG’s internal audit arrangements. Review From this Guidance, MIAA (Mersey Internal Audit) produced a Terms Of Reference for the work which was shared with the Committee in December. The draft review was shared with Committee members for comments, following the December meeting– the final draft, taking into account any comments from members is attached with this covering paper. The Committee should note full assurance has been given. Next Steps This report will be reported to the CCG’s Audit Committee in due course. The assurance opinion should be included in the CCG’s annual report and governance statement. The CCG should complete the reporting template contained with the NHSE – Primary Medical care Commissioning and Contracting – Internal Audit Framework for delegated Clinical Commissioning Groups Guidance within one month of the date of the final audit report for each annual audit of Primary Care. NHS England will be collating assurance ratings from delegated CCGs and reporting these annually to its relevant Committees to ensure that there is national oversight on assurance of its delegated functions. Action for the Committee The Committee is expected to take a Lead role in discussing the report – it is included with this paper for final discussion and approval, noting the next steps above. The Committee should also note the assurances given within the report. Lin Elliott will be in attendance at the Committee to discuss and answer any further queries in relation to the report. Reviewed by (e.g. committee/team/director) Name (Individual or Group) Date

Finance implications Funding required? (Please tick. If yes, please complete section A) Yes No

Section A

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Service Title Recurrent (£000s) Non-Recurrent (£000s)

Included in 17/18 budget? (Please tick. If no, please complete section B) Yes No Section B Proposed source of funding N/a Have the following areas been considered whilst producing this report? Yes N/A








Procurement processes Glossary/Acronyms CCGs Clinical Commissioning Groups

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QD-5 Rev 1

Primary Medical Care Commissioning and Contracting:

Governance Review

Final Assignment Report 2018/19 NHS South Cheshire & Vale Royal CCGs

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Primary Medical Care Commissioning and Contracting - Governance Review

523SCVRCCG_1819_002

NHS South Cheshire and Vale Royal CCGs

P a g e | 1 QD-5 Rev 1

Contents

1. Introduction and Background

2. Objective

3. Executive Summary

4. Findings, Recommendations and Action Plan

5. Recommendations

Appendix A: Terms of Reference

Appendix B: Assurance Definitions and Risk Classifications

Appendix C: Report Distribution

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NHS South Cheshire & Vale Royal CCGs


1. Introduction and Background NHS England (NHSE) became responsible for the direct commissioning of primary medical care services on 1 April 2013. Since then, following changes set out in the NHS Five Year Forward View, primary care co-commissioning has seen the Clinical Commissioning Groups (CCGs) invited to take on greater responsibility for general practice commissioning, including full responsibility under delegated commissioning arrangements.

In 2017/18, 84% of CCGs had delegated commissioning arrangements (82% - £6,247.6 million – of the primary medical care budget, with the remainder being spent directly by NHSE local teams). In 2018/19 this has increased to 96% with 178 CCGs now fully delegated.

In agreement with NHSE Audit and Risk Assurance Committee, NHSE will be requiring the following from 2018/19:

Internal audit of delegated CCGs primary medical care commissioning arrangements. The purpose of this is to provide information to CCG’s that they are discharging NHSE’s statutory primary medical care functions effectively, and in turn to provide aggregate assurance to NHSE and facilitate NHSE’s engagement with CCGs to support improvement.

The Primary Medical Care Commissioning and Contracting Internal Audit Framework for Delegated CCGs was issued in August 2018. This document provides a framework for delegated CCG’s to undertake an internal audit of their primary medical care commissioning arrangements.

The audit framework is to be delivered as a 3-4 year programme of work to ensure this scope is subject to annual audit in a managed way within existing internal audit budgets. This will focus on the following areas:

Commissioning and procurement of services Contract Oversight and Management Function

Primary Care Finance Governance (common to each of the areas)

For 2018/2019, the review of Governance has been undertaken. The remaining reviews will be incorporated into the planning cycle for the internal audit plan.

2. Objective The overall objective was to evaluate the effectiveness of the arrangements put in place by the CCG to exercise the primary care medical care commissioning function (Governance) of NHS England as set out in the Delegation Agreement.

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3. Executive Summary The overall assurance rating is provided as per the NHSE guidance. A comparison of NHSE and MIAA assurance ratings is at Appendix B.

Full Assurance

The controls in place adequately address the risks to the successful achievement of objectives; and the controls tested are operating effectively. There are no noted gaps in the assurance review and/or areas for improvement.

The following provides a summary of the key themes.

Elements Key Themes

Delegation Agreement / Memorandum of Understanding (MOU) Delegation Agreements from 1 April 2016 between NHSE and the CCGs are formally signed off and in place. The MOU is based on the NHSE (Merseyside) and Liverpool CCG model. The roles and responsibilities are clearly defined in the MOU including decision making and the authority to act. Delegated commissioning allows the CCGs to assume full responsibility for commissioning and contract management for general practice services, while NHSE retains residual responsibility of clinical performance. The MOU identifies the NHSE stakeholders on the Primary Care GP Commissioning Committee (PC (GP) CC) and the key operational/finance leads for delegated functions. There is a shared understanding of the delivery responsibilities including decision making and the authority to act. The MOU identifies the NHSE team members/job holders who will act as strategic partners on the PC (GP) CC. Also it details the job holders with operational and finance responsibilities for the delegated functions/services.

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Elements Key Themes

There is an explicit expectation in the governance arrangements that underpin the MOU that the operation of the PC (GP) CC will mitigate against the occurrence of conflict situations. In the event of any disagreement on operational delivery, decision making or resource allocation, resolution will be channelled through the next scheduled meeting of the Committee. If resolution of matters arising cannot be agreed a referral to the Area Team Director and/or the CCGs Accountable Officer (NHSE/CCG) are jointly responsible for ensuring a mutual resolution.

Formal approval letters from NHSE were received by both CCGs on 23 March 2016.

CCG Constitution Governing Body approved Constitutions for each CCG are in place. Formal approval letters from NHSE have been received by the CCGs in respect of Primary Care delegated functions. Roles and responsibilities for delegated responsibilities are accurately reflected in the Constitutions of the two CCGs.

Consultation / Patient Engagement A Communication and Engagement Plan is in place for both CCGs. This includes patient engagement and how the CCGs gathers, interprets and applies the views of the local population. This is applied in particular to the CCGs primary care processes in relation to undertaking consultation, public events and surveys to inform decision making. Oversight and review of the CCGs Plan is undertaken by the Executive Team and reported to Governing Body. Our review of Plan demonstrates that this is being monitored and that patient engagement and involvement is integral to the delegated responsibilities of the CCGs for Primary

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Elements Key Themes

Care Commissioning. Performance reporting and updates to the Governing body including impact and outcomes is evident.

Consultation processes are clearly defined in the Plan and examples of their effectiveness are made visible in Committee reporting.

The TOR for the PC (GP) CC defines that the Committee will ensure that patient/public consultation will be considered and undertaken when appropriate to aid decision making.

GP Contracts & Practices All practices have been provided with a General Practice Medical Services (GMS) Contract for 2017-18 and this includes how the respective roles and responsibilities should be fulfilled and demonstrated. Minutes of the PC (GP) CC meetings demonstrate the understanding and application of the delegated roles and that these are meeting GP and the CCGs expectations. Formal Contract variation procedures are in place and can be applied as/if a need arises. General Practice performance dashboards and reporting mechanisms are in place and operating effectively.

The dashboards provide real time practice level data for local intelligence and decision making. Performance is managed by the CCGs and its PC (GP) CC with an escalation route to the Governing Body if required. The Committee Minutes demonstrate how scrutiny and challenge is applied to Practice performance including support for challenged Practices and decision making (or voting) on resolution of matters arising. There is an element

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Elements Key Themes

of contract oversight and management defined within the PC (GP) CC TOR.

A strategy for General Practice 2016-2021 has been approved by the Governing Body in June 2016 and shared with all key stakeholders. The strategy sets out the overarching vision for General Practices in NHS South Cheshire and NHS Vale Royal and the key principles for delivering improved primary care through a Programme of nine step changes aligned to the CCGs strategic priorities.

The CCGs Primary Care Strategy sets out how the CCGs are working with Practices and partners to deliver the NHS Five year General Practice Forward View (GPFV). We provided assurance on the progress of implementation of the deliverables in the GPFV in December 2017 noting the progress being demonstrated across the five domains and the actions taken by the CCGs that visibly demonstrate achievements and outcomes.

Primary Care Commissioning Committee: Composition, Establishment & Duties

The CCGs have put in place a PC (GP) CC with Governing Body approved Terms of Reference (TOR). The TOR was approved in May 2016 and subject to review and revision pending Governing Body sign off as at the time of our review. A draft refresh was discussed at the October 2018 meeting of the PC (GP) CC and approved for Governing Body sign-off. The TOR states that the Committee must contain at least 2 lay members, one from each CCG (SC & VR). This is evident in the Committee’s representation and membership noting three lay members attend, one of which Chairs the meetings. The TOR

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Elements Key Themes

includes a standing invitation to Health Watch and the Local Authorities (eg, the Health and Wellbeing Board). Committee minutes show frequent attendance from partners in the health economy including active participation and involvement in the Committee meetings. The auditor has observed beneficial information exchanges, collaborative working, presentations and mutually supportive dialogue in the Committee meetings in year. The TOR defines quoracy and frequency of meetings noting that this is being complied with as per the recorded Minutes of the meetings. Voting rights are also explicit in the TOR and Minutes of the meetings. Where a vote was cast the Minutes demonstrate compliance with these. Further the Auditor as attended PC(GP) CC meetings and observed good practice in respect of voting rights being applied. As per good practice we note there are more Lay and Executive members combined than clinical members and that representation at the meetings is proportionate to the business need and aligned to the approved TOR. The auditor has observed the mix of representation working effectively in meetings. The PC (GP) CC is accountable to the CCGs Governing Body and provides assurance and reporting to them. This is operating effectively and demonstrated in Minutes of the PC (GP) CC and the CCGs Governing Body meetings. There is a clear line of

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Elements Key Themes

accountability and reporting demonstrated in how the Committee interfaces with the Governing Body and reports performance, issues and matters arising. This is evident in Committee and Governing Body Minutes.

Primary Care Commissioning Committee: Operation and Oversight

The PC (GP) CC operates in accordance with the CCGs Standing Orders and its defined roles and responsibilities in the TOR; aligned to the CCGs Constitutions.

We have reviewed the in-year Minutes of the PC (GP) CC and have attended the majority of meetings held in an observer/critical friend capacity. We can confirm that the operational effectiveness and business conduct of the meeting is well performed and aligned to its agreed TOR.

Oversight arrangements are applied as outlined above and as per the agreed TOR. This is visible in the Minutes of the PC (GP) CC and the CCGs Governing Body Minutes of meetings.

We note the establishment of a Primary Care Operational Group in 2015-16 and the decision to discontinue this Group in May 2016. Following the first year of delegation 2016-17 a Primary Care Task & Finish Group continued to operate – this became the Primary Care Operations Group in May 2017, it meets monthly to ‘do the doing’ as directed from the PC (GP) CC as reflected in the Minutes from meetings.

The Minutes of all PC (GP) CC are shared with NHSE. Further Executive Summary Reports are provided to NHSE bi-monthly.

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Elements Key Themes

The PC (GP) CC are held bi-monthly. Minutes are recorded for each meeting.

Decision Making Decision making including voting (when required) follow the GP (PC) CC TOR and are visible in the recorded Minutes of meetings.

Decision making is set out and defined in the GP (PC) CC TOR, the CCGs Constitutions and the Scheme of Reservation and Delegation.

The GP (PC) CC make decisions within the bounds of its remit.

The decisions of the Committee are binding on NHSE and NHS South Cheshire CCG and NHS Vale Royal CCG.

Risk Management

The CCGs have a Governing Body approved Risk Management Policy in place. Minutes from the Primary Care (GP) Commissioning Committee meetings show evidence of the use of a risk register within the PCC including application of scrutiny and challenge of scoring therein. This has been observed in meetings and recorded in the Minutes. The Risk Register is a standing item on the Committee Agenda. The risk register highlights the current risks for the primary care work programme including its description, its risk level and the action of how they are to be mitigated, followed by any updates to the risk and whether they are open of closed. The register also contains a RAG rating system based on its total risk score aligned to the CCGs risk management policy and requirements set out for risk identification and standard scoring matrix. The risk

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Elements Key Themes

register was up to date and the subject of review at the October 2018 meeting/during the course of this audit. Further we noted 2 red RAG/high scored live risks on the CCGs Corporate Risk Register as at November 2018 in relation to GP operating pressures and PC Support Services. Mitigation plans are in place and the Corporate Risk Register is being managed by the CCGs, with oversight being applied at the bi monthly Governance and Audit Committee meetings. There were no Primary Care related risks escalated to the CCGs Board Assurance Framework as at November 2018. The TOR for the PC (GP) CC does not include any responsibility relating to risk management; however we note that this was the subject of review during the Audit; and that this will be refreshed to include a risk management reference.

Primary Care Charter A Charter aligned to NHSE Policy has been developed by the two

CCGs and a final version was presented to the joint Governing

Body during their April 2018 meeting and approved.

The Charter gives a clear summary of the principles, roles and

responsibilities that the CCGs have set out, including aims,

delivery guidance and the KPI’s in order to ensure these are

delivered correctly.

Primary Care Committee Meeting Minutes (June 2018) confirm

this has been rolled out and the majority of GP’s for the two CCGs

have signed up to this in principle.

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Elements Key Themes

Strategic Plans

The CCGs have a strategic plan for 2017-2021, this was approved

by the Governing Body in February 2017. The plan defines the

vision and strategic priorities for Central Cheshire and contains plans for developing and delivering accountable care for the CCG’s population. The strategic plan describes how the CCG aims and plans to develop accountable care, based on a Multi-specialty Community Partnership in order to develop 5 Care Communities. The plan also consists of managing workload, developing infrastructure, primary care redesign and an operational delivery plan. The CCGs have developed Primary Care Implementation Plans for each Care Community

The Strategic plan is published on the CCG’s websites.

Annual Report As at the time of our review a draft annual report was being agreed for wider sharing within the CCGs. The report includes the cycle of business, matters dealt with, committee performance and sets out the achievements in year of the Primary Care Commissioning Committee.

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P a g e | 12 QD-5 Rev 1

4. Findings, Recommendations and Action Plan The review findings are provided on a prioritised, exception basis, identifying the management responses to address issues raised through the review.

To aid management focus in respect of addressing findings and related recommendations, the classifications provided in Appendix B have been applied. The table below summarises the prioritisation of recommendations in respect of this review.

Core Elements Critical High Medium Low Total

Delegation Agreement / Memorandum of Understanding 0 0 0 0 0

CCG Constitution 0 0 0 0 0

Consultation / Patient Engagement 0 0 0 0 0

GP Contracts 0 0 0 0 0

Primary Care Commissioning Committee: Composition, Establishment & Duties

0 0 0 0 0

Primary Care Commissioning Committee: Operation and Oversight 0 0 0 0 0

Decision Making 0 0 0 0 0

Risk Management 0 0 0 0 0

Additional Elements Critical High Medium Low Total

Primary Care Charter 0 0 0 0 0

Strategic Plans 0 0 0 0 0

Annual Report 0 0 0 0 0

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A p p e n d i x A | 1 QD-5 Rev 1

Appendix A: Terms of Reference The overall objective was to evaluate the effectiveness of the arrangements put in place by the CCG to exercise the primary care medical care commissioning function (Governance) of NHS England as set out in the Delegation Agreement.

Limitations inherent to the internal auditor’s work We have undertaken the review subject to the following limitations.

Internal control

Internal control, no matter how well designed and operated, can provide only reasonable and not absolute assurance regarding achievement of an organisation's objectives. The likelihood of achievement is affected by limitations inherent in all internal control systems. These include the possibility of poor judgement in decision-making, human error, control processes being deliberately circumvented by employees and others, management overriding controls and the occurrence of unforeseeable circumstances.

Future periods

The assessment is that at November 2018. Historic evaluation of effectiveness is not always relevant to future periods due to the risk that:

The design of controls may become inadequate because of changes in the operating environment, law, regulation or other; or

The degree of compliance with policies and procedures may deteriorate.

Responsibilities of management and internal auditors It is management’s responsibility to develop and maintain sound systems of risk management, internal control and governance and for the prevention and detection of irregularities and fraud. Internal audit work should not be seen as a substitute for management’s responsibilities for the design and operation of these systems.

We shall endeavour to plan our work so that we have a reasonable expectation of detecting significant control weaknesses and, if detected, we shall carry out additional work directed towards identification of consequent fraud or other irregularities. However, internal audit procedures alone, even when carried out with due professional care, do not guarantee that fraud will be detected. The organisation’s Local Counter Fraud Officer should provide support for these processes.

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A p p e n d i x B | 1 QD-5 Rev 1

Appendix B: Assurance Definitions and Risk Classifications

MIAA Definitions NHSE Definitions

Level of Assurance Description Level of

Assurance Description

High There is a strong system of internal control which has been effectively designed to meet the system objectives, and that controls are consistently applied in all areas reviewed.

Full The controls in place adequately address the risks to the successful achievement of objectives; and,

The controls tested are operating effectively.

Substantial There is a good system of internal control designed to meet the system objectives, and that controls are generally being applied consistently.

Substantial The controls in place do not adequately address one or more risks to the successful achievement of objectives; and / or,

One or more controls tested are not operating effectively, resulting in unnecessary exposure to risk. Moderate There is an adequate system of internal control, however,

in some areas weaknesses in design and/or inconsistent application of controls puts the achievement of some aspects of the system objectives at risk.

Limited There is a compromised system of internal control as weaknesses in the design and/or inconsistent application of controls puts the achievement of the system objectives at risk.

Limited The controls in place do not adequately address multiple significant risks to the successful achievement of objectives; and / or,

A number of controls tested are not operating effectively, resulting in exposure to a high level of risk.

No There is an inadequate system of internal control as weaknesses in control, and/or consistent non-compliance with controls could/has resulted in failure to achieve the system objectives.

No The controls in place do not adequately address several significant risks leaving the system open to significant error or abuse; and / or,

The controls tested are wholly ineffective, resulting in an unacceptably high level of risk to the successful achievement of objectives.

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A p p e n d i x B | 2 QD-5 Rev 1

Risk Rating Assessment Rationale

Critical Control weakness that could have a significant impact upon, not only the system, function or process objectives but also the achievement of the organisation’s objectives in relation to:

the efficient and effective use of resources

the safeguarding of assets

the preparation of reliable financial and operational information

compliance with laws and regulations.

High Control weakness that has or is likely to have a significant impact upon the achievement of key system, function or process objectives. This weakness, whilst high impact for the system, function or process does not have a significant impact on the achievement of the overall organisation objectives.

Medium Control weakness that:

has a low impact on the achievement of the key system, function or process objectives;

has exposed the system, function or process to a key risk, however the likelihood of this risk occurring is low.

Low Control weakness that does not impact upon the achievement of key system, function or process objectives; however implementation of the recommendation would improve overall control.

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A p p e n d i x C | 1 QD-5 Rev 1

Appendix C: Report Distribution

Name Title Report Distribution

Clare Watson

Lynda Risk

Tracey Cole

Chief Officer

Chief Finance Officer

Director of Commissioning

Final

Final

Final

Chris Leese

Primary Care (GP) Commissioning Committee

Primary Care Operations Manager

ALL MEMBERS

DRAFT/FINAL

DRAFT/FINAL

Review prepared on behalf of MIAA by

Name Lin Elliott Name Sam Reavey

Title Senior Audit Manager Title Principal Auditor

07767 233865 0151 285 4603

[email protected]

[email protected]

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mailto:[email protected]


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A p p e n d i x C | 2 QD-5 Rev 1

Acknowledgement and Further Information MIAA would like to thank all staff for their co-operation and assistance in completing this review.

This report has been prepared as commissioned by the organisation, and is for your sole use. If you have any queries regarding this review please contact the Audit Manager. To discuss any other issues then please contact the Director.

MIAA would be grateful if you could complete a short survey using the link below to provide us with valuable feedback to support us in continuing to provide the best service to you. https://www.surveymonkey.com/r/MIAA_Client_Feedback_Survey

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https://www.surveymonkey.com/r/MIAA_Client_Feedback_Survey


Report Author(s) Name/s Janet Kenyon

Title/s Deputy Head of Prescribing and Medicines Optimisation

Date 11 Jan 2019

Clinical Lead / Clinician Sign-Off Executive Lead Sign-Off Name Name

Title Title

Date Date CCG Strategic Priorities

Delivering Financial Balance

Quality, Safety and Experience at the heart of Commissioning

Delivering National Priorities ‘must do’s: FYFV, GP FYFV, MH FYFV, IAF, NHS Constitution Targets

Clinical Commissioning Priorities: • Respiratory • Frailty • Mental Health

Cheshire & Merseyside Health & Care Partnership (delivery of business plan)

Cheshire System Transformation: Developing ‘place’, joint commissioning, working with HCP, developing care communities

Single strategic commissioner Outcome Required Approval Assurance Discussion Information

Recommendations: NHS South Cheshire CCG and NHS Vale Royal CCG Primary Care Commissioning Committee is asked to:

• Note the contents of the report for information • Advise of any related pieces of work that should be considered to inform the development of

the Medicines Optimisation in Care Homes service

Report To (committee): Primary Care Commissioning Committee Report Title: Medicines Optimisation in Care Homes Meeting Date: 1 February 2019

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Executive Summary (key points, purpose, outcomes) NHS South Cheshire CCG and NHS Vale Royal CCG have been supported by the STP and NHS England to develop a Medicines Optimisation in Care Homes Service. The service will consist of 1 pharmacist and 1 technician to cover the care communities in NHS South Cheshire CCG and NHS Vale Royal CCG. These posts will be hosted within the Medicines Management Team, together with another 3 pharmacists and 1 technician working with the Care communities in NHS Eastern Cheshire CCG. This disparity in service provision is a result of greater levels of funding being invested by NHS Eastern Cheshire CCG. Recruitment to the posts in underway. Reviewed by (e.g. committee/team/director) Name (Individual or Group) Date


Section A Service Title Recurrent (£000s) Non-Recurrent (£000s)

Included in 17/18 budget? (Please tick. If no, please complete section B) Yes No Section B Proposed source of funding Funding has been agreed with NHS England, and approved via JET Have the following areas been considered whilst producing this report? Yes N/A







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Procurement processes Glossary/Acronyms

MOCH MMT PIF

Medicines Optimisation in Care Homes Medicines Management Team Pharmacy Integration Fund

1. Medicines Optimisation in Care Homes

1.1. NHS England is supporting investment in pharmacy professionals to support Medicines

Optimisation in Care Homes.

1.2. Vanguard pilot sites have been identified previously, and the work is being rolled out to other areas. The Medicines Management Team has worked with colleagues across Cheshire and Merseyside to attract funding for these posts.

2. Discussion

2.1. It is estimated that South Cheshire has: • 17 practices with a total population of 185,125 covered by 3 Care Communities • 31 care homes homes (18 homes have nursing and the remainder are residential care) with a

total of 1394 residents; • 2109 people aged 80+ years and on at least 10 medicines.

2.2. It is estimated that Vale Royal has: • 12 practices with a total population of 106,500 covered by 2 Care Communities • 20 homes (9 homes have nursing and the remainder are residential care) with a total of 857

residents; • 899 people aged 80+ years and on at least 10 medicines.

2.3. Recruitment is underway to identify a pharmacist and a pharmacy technician to support

Medicines Optimisation in Care Homes in both NHS South Cheshire CCG and NHs NHS Vale Royal CCG. It is expected that candidates will be offered posts by the end of January with a view to commencing the service as close to 1 April 2019 as possible.

2.4. The team members would be expected to align to care communities, and provide the following services:

2.4.1. Visit each nursing home at least monthly to conduct medicines reconciliation reviews to keep the practice clinical record and care home medicines administration records in alignment, and advise on the ordering, storage, administration and disposal of medicines with the care home.

2.4.2. Prioritise patients for a clinical pharmacist medication review, working with GP practices to determine their priorities and align with the approach taken by the practice.

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2.4.3. Attend Care community multidisciplinary team meetings 2.4.4. Implement Medicines Management Team Quality, Innovation, Productivity and

Prevention plans in the care home population 2.4.5. Answer queries relating to medicines for the Care Home population 2.4.6. Develop links with other services in Care Homes and the community with a role in

managing the care of frail older people.

2.5. The following facilities and resources will be required to enable the services to be operated as described:

2.5.1. Support for the 18-month training package being made available by NHS England for the pharmacist and Technician

2.5.2. Support for mobile working, including appropriate access to EMIS while in the care homes and other bases as agreed

2.5.3. Appropriate links with Prescribing support colleagues within the Medicines Management Team

2.5.4. Engagement with colleagues across Cheshire and Merseyside who are working on the Medicines Optimisation in Care Homes programme of work.

2.5.5. Appropriate clinical supervision within the care communities 2.5.6. Appropriate arrangements for non-medical prescribing when the pharmacist training

package is complete.

3. Conclusion

3.1. The PCC is asked to note the development of the Medicines Optimisation in Care Homes service.

3.2. The PCC is asked to consider what other services and developments should inform the development of the project within care communities.

4. Reference

4.1. Medicines Optimisation in Care Homes Programme overview. https://www.england.nhs.uk/wp-content/uploads/2018/03/medicines-optimisation-in-care-homes-programme-overview.pdf

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https://www.england.nhs.uk/wp-content/uploads/2018/03/medicines-optimisation-in-care-homes-programme-overview.pdf

https://www.england.nhs.uk/wp-content/uploads/2018/03/medicines-optimisation-in-care-homes-programme-overview.pdf


Report Author(s) Governing Body Lead Name Lorraine Weekes-Bailey Name Lynda Risk

Title Primary Care Accountant Title Chief Finance Officer

Clinical Lead / Clinician sign-off Name Dr Annabel London Name

Title Clinical Lead for Primary Care Title CCG Strategic Priorities (5+1) supported by this paper Transforming Primary Care



Integration

Person Centred Care

NHS Constitution Targets Outcome Required Approval Assurance Discussion Information

Recommendations: NHS South Cheshire CCG and NHS Vale Royal CCG Primary Care Committee are asked to:

• Discuss the financial information noted in the report

Executive Summary (key points, purpose, outcomes) The purpose of the paper is to update the Committee on the overview financial position of the Primary Care budget for Month 9, period ending 31st December 2018, and the projected outturn for the year. Based on latest projections the Primary Care Delegated budget is forecast to over spend by £0.531m, in NHS South Cheshire CCG and £0.427m in NHS Vale Royal CCG. The main reasons for the overspend are not locally influenced and are due to the national uplift on the GP contracts and guidance which states that Clinical Commissioning Groups holding delegated budgets must plan for the GP Forward View monies which was allocated from the delegated budget. Reviewed by (e.g. committee/team/director)

Report To (committee): Primary Care Committee-Part A Report Title: Primary Care Finance Report Meeting Date: 1st February 2019

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Name (Individual or Group) Date

Katie Riley –Associate Director of Finance 17/01/2019


Section A Service Title Recurrent (£000s) Non-Recurrent (£000s)

Included in 18/19 budget? (Please tick. If no, please complete section B) Yes No Section B Proposed source of funding Have the following areas been considered whilst producing this report? Yes N/A








Procurement processes Glossary/Acronyms CCG FYFV PMAF GMS PMS NHSE QOF DES MPIG

Clinical Commissioning Group Five Year Forward View Prime Ministers Access Fund General Medical Services Personal Medical Services NHS England Quality Outcomes Framework Direct Enhanced Service Minimum Practice Income Guarantee

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1. Purpose of the paper 1.1. The purpose of this paper is to update NHS South Cheshire and NHS Vale Royal Clinical

Commissioning Groups’ Primary Care Committee on the financial position as at Month 9 (April 2018-December 2018) and the projected outturn for the year.

2. NHS South Cheshire CCG Financial Position

2.1. The overall Primary Care financial budget for NHS South Cheshire CCG is currently forecast to overspend by £0.531 million by the end of the financial year, as shown in Table 2a.

2.2. The majority of the overspend is due to the increase in the GP Pay Award. As discussed

previously the uplift is significantly higher than the percentage increase that was awarded within our allocation. The spend is summarised in Table 2a and in the narrative below the table.

Table 2a

Primary Care SummaryBudget Allocation

2018/19Budget YTD Actual Variance (in month) Forecast

Variance (FOT v Budget)

Delegated Primary Care 23,891,000 17,917,700 18,268,375 (350,675) 24,613,524 (722,524) Local CCG Primary Care 4,066,000 3,040,000 2,905,693 134,307 3,874,923 191,077 DELEGATED PRIMARY CARE TOTAL 27,957,000 20,957,700 21,174,068 (216,368) 28,488,447 (531,447)

Delegated Primary CareBudget Allocation



General Practice - GMS 10,613,600 7,960,210 8,071,709 (111,499) 10,773,760 (160,160)General Practice - PMS 5,182,700 3,887,030 3,956,970 (69,940) 5,289,145 (106,445)Other List Based Services 0 0 0 0 0 0Premises Reimbursements 3,938,700 2,954,100 2,994,065 (39,965) 4,003,105 (64,405)NHS Property Services 0 0 0 0 0 0Other Premises 123,000 92,250 72,180 20,070 151,410 (28,410)Enhanced Services 530,900 398,180 388,354 9,826 519,830 11,070QOF 2,708,200 2,031,150 2,031,126 24 2,708,200 0Other - GP Services 793,900 594,780 753,971 (159,191) 1,168,074 (374,174)DELEGATED PRIMARY CARE TOTAL 23,891,000 17,917,700 18,268,375 (350,675) 24,613,524 (722,524)

Local CCG Primary Care Budget Allocation



Charter Phase 1 976,000 729,500 731,542 (2,042) 975,388 612 GP Care Homes Scheme 270,000 203,000 191,250 11,750 255,000 15,000 Practice Staff 600,000 449,000 451,174 (2,174) 601,565 (1,565) Primary Care Other 393,000 288,000 281,287 6,713 375,049 17,951 Primary Care Access Fund 983,000 739,000 737,250 1,750 983,000 - GPFV Practice Nurse Allocation 29,000 21,500 21,750 (250) 29,000 - GPFV Clerical & Reception Training 31,000 23,000 23,000 - 31,000 - GPFV Online Consultations 39,000 29,000 29,000 - 39,000 - GPFV Primary Care Network Development Funding 152,000 114,000 114,000 - 152,000 - Primary Care IT 593,000 444,000 325,439 118,561 433,920 159,080 CCG PRIMARY CARE TOTAL 4,066,000 3,040,000 2,905,693 134,307 3,874,923 191,077

Primary Care Month 9 Position

NHS South Cheshire CCG

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2.3. Key Variances-Delegated Primary Care

2.3.1. Premises Reimbursements- There is a variance of £64,000 which is a result of business rates increases for practices that we have been made aware of after the initial budgets were set at the beginning of the year.

2.3.2. Other GP Services- All of the budget lines were costed using the month 12- 2017/18

forecast outturn and using information we had received from other bodies i.e. NHS England’s contractual change guidance, however due to the significant shortfall in allocation we have identified the cost pressure under the category “Other GP Services”.

3. Key Variances-Local CCG

3.1. Primary Care IT- There is a favorable variance of £159,000 for GP IT is due to the

contract value from NHS Midlands and Lancashire CSU being less than budgeted.

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4. NHS Vale Royal CCG Financial Position

4.1. The overall Primary Care financial budget for NHS Vale Royal CCG is currently forecast to overspend by £0.427 million by the end of the financial year, as shown in Table 4a.

4.2. The majority of this overspend is similar NHS South Cheshire CCG, being due to the

increase in the GP Pay Award. The spend is summarised in Table 4a and in the narrative below the table.

Table 4a

4.3. Key Variances-Delegated Primary Care 4.3.1. Premises Reimbursements – There is a variance of £37,000 which is a result of

business rates increases for practices that we have been made aware of after the initial budgets were set at the beginning of the year.

4.3.2. Other GP Services- To be consistent across both NHS South Cheshire CCG and NHS

Vale Royal CCG all of the budget lines have been costed using the same methodology as stated above, therefore the significant shortfall in allocation is identified under the category “Other GP Services”.

Primary Care SummaryBudget Allocation

2018/19 Budget YTD Actual Variance (in month) ForecastVariance (FOT v

Budget)Delegated Primary Care 13,211,000 9,908,800 10,165,040 (256,240) 13,725,711 (514,711) Local CCG Primary Care 2,323,000 1,737,400 1,698,962 38,438 2,235,286 87,714 DELEGATED PRIMARY CARE TOTAL 15,534,000 11,646,200 11,864,002 (217,802) 15,960,997 (426,997)

Delegated Primary CareBudget Allocation

2018/19 Budget YTD ActualVariance (in month)

ForecastVariance (FOT v

Budget)General Practice - GMS 8,634,700 6,476,070 6,530,914 (54,844) 8,720,623 (85,923)General Practice - PMS 719,000 539,250 543,452 (4,202) 721,220 (2,220)Other List Based Services - - 0 0 - 0Premises Reimbursements 1,610,700 1,208,080 1,235,596 (27,516) 1,647,458 (36,758)NHS Property Services - - 0 0 - 0Other Premises 85,000 63,750 64,067 (317) 100,816 (15,816)Enhanced Services 309,300 232,040 231,628 412 308,836 464QOF 1,539,900 1,154,960 1,154,906 54 1,539,900 0Other - GP Services 312,400 234,650 404,478 (169,828) 686,858 (374,458)DELEGATED PRIMARY CARE TOTAL 13,211,000 9,908,800 10,165,040 (256,240) 13,725,711 (514,711)

Local CCG Primary Care Budget Allocation

2018/19 Budget YTD Actual Variance (in month) ForecastVariance (FOT v

Budget)Charter Phase 1 574,000 432,000 423,737 8,263 564,987 9,013 GP Care Homes Scheme 260,000 195,000 195,000 (0) 220,000 40,000 Practice Staff 300,000 224,000 224,643 (643) 299,524 476 Primary Care Other 272,000 199,000 201,935 (2,935) 279,247 (7,247) Primary Care Access Fund 544,000 408,000 408,000 - 544,000 - GPFV Clerical & Reception Training 18,000 13,500 14,150 (650) 18,000 - GPFV Online Consultations 53,000 39,100 39,100 - 53,000 - GPFV Primary Care Network Development Funding 82,000 61,500 61,500 - 82,000 - Primary Care IT 220,000 165,300 130,897 34,403 174,529 45,471 CCG PRIMARY CARE TOTAL 2,323,000 1,737,400 1,698,962 38,438 2,235,286 87,714

Primary Care Month 9 PositionNHS Vale Royal CCG

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5. The GP Pay Award

5.1. The Pay Award 5.1.1. The Government made the decision to award GPs and practice staff a 2% pay uplift in

2018/19, which was backdated to 1 April 2018.

5.1.2. A 1% pay uplift had already been implemented and a further 1% uplift was agreed in August 2018; this has now been backdated to April to deliver a total of 2%. As a result, the Global Sum per weighted patient figure will increase by 1.2% to £88.96 as shown below in Table 2b. The pay award has created an additional cost pressure for both NHS South Cheshire CCG and NHS Vale Royal CCG of £196,300 and £115,300 retrospectively; this pressure has been included in the CCG financial position as shown in table 2a and 4a.

5.1.3. When the delegated allocation uplift was calculated by NHS England the pay award

was not accounted for as it was not agreed at this point.

5.1.4. The NHS England Primary Care Strategic Finance Team have noted this discrepancy but have confirmed no further allocation will be received by the CCG’s from NHS England to help bridge the funding gap. The finance department will need to closely monitor the expenditure for 2018/19.

5.1.5. The additional 1% was paid to practices in October via Open Exeter and has been

back dated from April 2018. Table 5a

Detail Current Revised £ %Global Sum price per weighted patient £87.92 £88.96 £1.04 1.20%

Additional Increase

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6. Types of reported spend- Delegated Primary Care • General Practice GMS- This contains General Practice- contractual global sum and MPIG

(Minimum Practice Income Guarantee) payments. • General Practice PMS- This contains General Practice PMS contractual payments and

any list size adjustments. • Premises Reimbursements- This includes budgets for rent, rates, water and service

charges. Premises budgets are also allocated on a contractual basis and have very little scope for local influence.

• Other Premises- This contains budgets for clinical waste and pathology collections. • Enhanced Services- This includes budgeted spend on the basis of historic achievement

for the ad-hoc smaller payments or recognising the potential full achievement for those which are list size/patient driven for the practices that have signed up to the particular services, e.g. extended hours. Payment is based upon achievement so variances against budget can occur.

• Quality Outcomes Framework (QOF) - This budget/spend is aspiration payments that

are based upon 70% of the previous year’s achievement adjusted for year on year points and price changes. Budgets are set in line with this and pro rata to reflect final forecast achievement. As payment is based upon actual achievement this means that the CCG may have a financial risk or benefit depending on future practice achievement.

• Other – GP Services- This include budgets and payments for seniority, dispensing &

prescribing professional fees and locum allowances such as for maternity, paternity and adoption cover. Budgets for the locum allowances are not allocated at practice level at the start of the year as claims can be difficult to forecast. Translation costs, CQC payments, PMS deduction and PMS Re-investment

7. Types of reported spend- Local CCG Primary Care • Charter Phase 1- This includes budget and payment by cost per head for £2.70 core

charter funding, £1.50 transformational support, £0.14 suture and clip removal, £1.00 GP Alliance funding.

• GP Care Homes Scheme- Funding for the local GP care homes scheme.

• Practice Staff- Historic funding awarded to practices

• Primary Care Other- This includes budget and costs for anti-coagulation and near-patient testing, counselling services, fostering and adoption medical fees, minor surgery, carpal tunnel, vasectomies, dermatology and Weaver Lodge.

• Primary Care Access Fund (PCAF)- Budget and costs for the improving access programme.

• GP Forward View- Budget and cost for development of Reception & Clerical training and Care Navigation.

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meeting name: nhs south cheshire ccg primary care ... · other gp services- all of the budget lines...

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