primary care commissioning committee · 2020-06-24 · primary care commissioning committee . 30th....

PRIMARY CARE COMMISSIONING COMMITTEE

30th March 2017 9.00am – 11.30am, Conference Room B, 1829 Building

AGENDA

Item No. Time Item

Action

needed/ Paper

Presenter

2017-014 9.00 Welcome, Introduction and Apologies

- Chair

2017-015 9.04 Declarations of Interest - All

2017-016 9.05 a. Minutes of last meeting 14th December 2016

DR

16.a Primary Care Commissioning Commi

Chair

b. Action List D

16.b Action List - March 2017.pdf

2017-017

9.15 Primary Care Commissioning Report DR

17. Primary Care Commissiong Report M

Sarah Murray

2017-018 9.20 Primary Care Quality Report D

18. Primary Care Quality Report March

Tanya Jefcoate-

Malam

2017-019 9.30 Repeat Prescribing wastage Report DR

19. Repeat Prescribing Report Ma

Sarah Murray

2017-020

9.40 Primary Care Contracting Report DR

20. Primary Care Contracting Report M

Tanya Jefcoate-

Malam

2017-021 10.00 Update on Delegation Process D Verbal

Sarah Murray

2017-022 10.05 Primary Care Support / Capita D

Verbal

Carla Sutton

2017-023 10.15 Any Other Business - Chair

CONSENT ITEMS 2017-024 -

Minutes of the Primary Care Operational Group I

Primary Care Commissioning Committee of 2 NHS West Cheshire Clinical Commissioning Group 30th March 2017

Item No. Time Item

Action needed/ Paper

Presenter

19th January 2017 Minutes from GP Access Fund Steering Group: 16 Nov 16 Minutes from GP Access Fund Steering Group: 18 Jan 17 Minutes from Infrastructure Board: 4 Oct 16 Minutes from Infrastructure Board: 19 Jan 17 Minutes from Infrastructure Board: 16 Feb 17

1. Primary Care Operational Group.pd

2. GPAF Steering Group - Meeting Note

3. GPAF Steering Group - Meeting Note

4. Minutes - IT Infrastucture Board 0

5. Minutes - IT Infrastructure Board

6. Minutes - IT Infrastucture Board 1

DATE OF NEXT MEETING

11.30 27th April 2017, 9.00am – 10.30am, Room B

11.30 –12.00: PART 2 AGENDA

I – Information D – Discussion DR – Decision Required

Primary Care Commissioning Committee of 2 NHS West Cheshire Clinical Commissioning Group 30th March 2017

Agenda Item: 2016-016.a


14th December 2016

11.00am – 12.35pm, Conference Room B, 1829 Building

PRESENT: Smith, Pam (PS) (Chair) Lay Member, Patient and Public Involvement, NHS West Cheshire

CCG Barry, Louise (LB) Health Watch Representative Charles-Jones, Huw (HCJ)

Chair of NHS West Cheshire Clinical Commissioning Group

Guinan, Kevin (KG) Vice Chair, City GP Locality Network, NHS West Cheshire Clinical Commissioning Group

Lee, Alison (AL) Chief Executive Officer, NHS West Cheshire Clinical Commissioning Group

Marsh, Laura (LM) Director of Commissioning, NHS West Cheshire Clinical Commissioning Group

McAlavey, Andy (AMcA) Medical Director of West Cheshire Clinical Commissioning Group Murray, Sarah (SM) Head of Primary Care, NHS West Cheshire Clinical Commissioning

Group Powell, Simon (SPow) Local Medical Committee Representative Sutton, Carla (CS) Senior Contract Manager, NHS England North (Cheshire &

Merseyside) James, Gareth (GJ) Sarah Smith Contract Manager, NHSE Wedd, Paula (PW)_ In Attendance: For Agenda Item: Carbery, Kevin (KC) Project Manager 2016-020 Jefcoate-Malam, Tanya (TJM)

Deputy Head of Primary Care and Being Well 2016-018

Jones, Clare (CJ) Governing Body and Committees Coordinator

Agenda No

Agenda Item Action

2016-014

Welcome, Introduction and Apologies The Chair welcomed everyone to the meeting and introductions were made around the table. Apologies were noted on behalf of Annabel Jones, Jeremy Perkins

2016-015 Declarations of Interest None

2016-016

a. Minutes of last meeting 19th October 2016 The minutes of the last meeting were agreed as an accurate record of the

meeting. Matters Arising not on action list:

Primary Care Commissioning Committee Minutes 14.12.2016 1 NHS West Cheshire Clinical Commissioning Group 30th March 2017


Agenda No

Agenda Item Action

Page 7 – Primary Care Update Report – Minor Ailments Service – it was noted that the policy has been updated and agreed virtually

b. Action List

003 – SM fed-back that a workshop was held with Practice Managers in November 2016. The feed-back from this has informed the GP Forward view plan, which is on the agenda. 007 – SM confirmed that the LMC have supported the survey that has been written by the Clinical Commissioning Group in order to determine workforce and succession planning – this has now been circulated and therefore this action is complete. 009 – The Clinical Commissioning Group has now received further clarity on the split of funding to be provided by the NHS / property services dependent upon whether the development is undertaken with a third party, privately or with NHS property services. This information has now been shared with the Practices involved.

2016-017 Primary Care Commissioning Report The committee was informed that this paper was sent out after the deadline for papers due to information that was released post deadline following a GP Forward View Meeting. The options within the paper were summarised, with a recommendation that Option 1 is recommended by the committee for approval at Governing Body. This option stated that funding already received as part of the Primary Care Commissioning for Quality and Innovation Scheme is used for this purpose. The detail of this was discussed. The GP representatives present and particularly the Local Medical Committee representative wished to minute their disappointment in this recommendation. This was due to this funding already being tied up in work that is taking place within the Primary Care Commissioning for Quality and Innovation Specification and the work involved could be seen as increasing as this specification moves into new programme areas. The representative made it clear that Practices were hopeful that the GP Forward View would lead to additional funding in order to improve workforce, engagement and the quality of work delivered. In particular, this would support those Practices that are struggling to recruit and survive in the current climate. Clinical Commissioning Group representatives recognised that the decision to include the £3 per head as part of the Primary Care CQUIN was not a decision that had been taken lightly and should be viewed within the context of a number of difficult decisions the Clinical Commissioning Group is having to take. Ideally, the Clinical Commissioning Group would wish to increase investment within Practices in order to increase the pace of Primary Care transformation work, but due to the financial constraints of the organisation, this is not possible.



Agenda No

Agenda Item Action

The group discussed the potential requirements of the Primary Care Commissioning for Quality and Innovation Scheme for 2017/18. Concerns were raised over stretching this into more areas. However, the Clinical Commissioning Group clarified that the draft requirements aim to be complimentary to the current service specifications and realistic for Practices to achieve. The Clinical Commissioning Group is currently having to make difficult decisions not to invest in a number of additional areas other than for Primary Care due to the financial situation. It would therefore be difficult to commit the Clinical Commissioning Group to increasing levels of funding within Practices without the corresponding increase in budget to enable this. It was recognised that the current key performance indicators within the scheme are not always focusing work onto the right areas. The proposals for this scheme would be re-visited in light of these discussions. The committee discussed other areas of work underway with Practices in order to make cost savings and improve the financial situation of the local health economy. One of these areas is the Primary Care “Escalation and Support” process, working with Practices to reduce referrals to local and out of area providers where appropriate. It was stated that the Clinical Commissioning Group is struggling to get engagement with all Practices and Clusters around this important issue. This impetus is also needed for the repeat prescribing project, working with Practices to try to reduce medicines wastage within the NHS. Again, this level of engagement isn’t being achieved in all Practices. A lack of funding within Primary Care was suggested as one of the main reasons that engagement within these projects may not be seen, and in more general terms, a lack of investment within Practices was considered a thematic problem. The Health Watch representative gave a patient view and context into the discussion, that patients understand that funding within the NHS is decreasing and this is having an impact on services. The Clinical Commissioning Group clarified that the lack of this funding within Practices for this purpose should have no direct impact on patient care. In addition, the Clinical Commissioning Group wished to state that in times of financial constraints, development work that aims to give providers more headspace in which to transform their services tends to get pulled-back. This should not mean that transformation stops, but instead that this is slowed. In addition, there needs to be acknowledgement that some work that currently takes place within the Acute Trust could occur within other parts of Community / Primary Care Services. Therefore this should still be investigated through the Primary Care Commissioning for Quality and Innovation Scheme. After discussing the options in more detail, and agreeing that by encompassing this support within the Commissioning for Quality and Innovation Scheme would not require significant additional workload within Primary Care but engagement within the GP Forward View schemes and plans that are already progressing within West Cheshire, the committee voted as follows:



Agenda No

Agenda Item Action

• All those with a conflict or pecuniary interest were not able to vote • Option 1 was recommended to be approved by the Governing Body

The committee then moved on to discuss the remaining sections of the paper. In terms of the investment of Personal Medical Services into the Village Surgeries, the committee wished to understand why retrospective funding was not being clawed-back from the Practice owing to their late submission and lack of evidence relating to achievement of key performance indicators. It was stated that this “claw-back” process is not usually used for other elements of Primary Care funding, e.g. the Commissioning for Quality and Innovation Scheme, and in order to avoid the de-stabilisation of the practice, was not recommended by the Primary Care Operational Group.

• It was agreed that the option to with-hold funding from quarter three onwards would be recommended for approval by the Governing Body

In terms of future Personal Medical Services re-investment from 2017/18 the options were reviewed and discussed, including the recommended option to reinvest this funding equitably across all Practices within the Commissioning for Quality and Innovation Scheme, as recommended by the Primary Care Operational Group. However, since this meeting, further information had come to light to ask the Clinical Commissioning Group to consider the possibility of stabilising funding within one Practice, Western Avenue, due to the health inequalities experienced by their population, and to utilise the Fountains’ funding within Care and Nursing Homes, as per its original intention and current arrangement. The group discussed these options, and agreed as follows:

• The majority of reinvestment funding should be equitably split across all Practices in West Cheshire as per the Commissioning for Quality and Innovation Scheme

• There was some merit in splitting some of this funding across those Practices which look after care and nursing homes and this should be worked up further and discussed at the Primary Care Operational Group

• There was some merit in continuing a level of funding into Western Avenue Practice due to the needs of their population. This would again need to be worked up and discussed in more detail at the Primary Care Operational Group so that further approval can be sought from the CCG through the appropriate committees.

In addition, the committee noted the Practices to enter the Escalation and Support process as per the report. It was noted that there were a significant number of Practices now within this process, and further work may need to take place to refine the criteria for Practice selection. In addition, the report created in order to update the committee regarding the rationale applied to the Practices selected may need to be expanded to ensure the committee have more context.

TJM



Agenda No

Agenda Item Action

• The group noted the Practices to be moved into stages of the

Escalation and Support Process, with further updates to be provided to this group following the Primary Care Operation Group in the future

Finally, the committee noted that there is currently no consistent provider of prophylaxis anti-virals to patients within a care home setting in the case of a flu outbreak. The Clinical Commissioning Group has been delegated the responsibility to commission this service from NHS England and after significant work with multiple providers to find a solution, this has not been forthcoming. The Clinical Commissioning Group has approached Practices to request support in delivering this work, however, there has been a mixed response. The Local Medical Committee representative wished to state that this work is not a part of GP contracts, a fact that was disputed by the Clinical Commissioning Group and NHS England representatives present. In addition, the clinical risk around failing to deliver this service and the lack of equitable service provision to vulnerable patients was cited as a concern and risk by Clinical Commissioning Group Quality and Safety representatives present.

• This risk was noted, with a request to pursue NHS England for a response to this risk identified by the Clinical Commissioning Group.

In addition:

• The amendments to the Memorandum of Understanding with Primary Care Cheshire were approved

• And the minutes of the GP Access Fund were noted.

TJM

TJM



2016-018 Primary Care Operational Group Quality Report The Primary Care Commissioning Committee noted the work of the Primary Care Operational Group in relation to Primary Care Quality as requested. The issue of where Primary Care quality and safety incidents are best reported was discussed. It was agreed that the Chairs of the Primary Care Commissioning Committee and Quality Improvement Committee would discuss this outside of the meeting to determine where this was best reported going forward.

PS & SF

2016-019 GP Forward View Plan It was stated that the draft plan has come to this committee for note. It was stated that some minor changes will need to be made to the Appendices at the back of the document, but that this draft has been shared with NHS England and the Clinical Commissioning Group have received positive feedback. The chair requested that any further comments are emailed to the Head of Primary Care if required.

ALL

2016-020 Primary Care Infrastructure Report The committee discussed the report. It was noted that the Clinical Commissioning Group is disappointed that the Blacon development is no longer considered a viable option and therefore this work is going to have to be closed. In the meantime, the Clinical Commissioning Group is working closely with GP Practices in the area to ensure that other building opportunities are exploited in order to develop services where possible and to ensure all providers are able to continue to deliver services.

• The committee acknowledged that the NHS building within the Blacon Parade will not proceed.

The committee then moved on to discuss the Information Technology sections of the report. A Clinical Commissioning Group representative explained that three bids have been put forward by the organisation to deliver work that should improve the integration and use of technology for GP Practices. A summary of these schemes was given, as per the paper. As these options were discussed, the Clinical Commissioning Group representative set-out the revenue risks and implications for the Clinical Commissioning Group, but also the positives that can be gained in terms of Information Technology security and collaboration that could be achieved if successful. The Practice and Local Medical Committee representatives wished to ensure that the schemes within would be assessed against delivery and would be reported to Practices with significant engagement around roll-out. Engagement was assured due to this taking place at a number of forums



(including Practice Managers Forum and ICT Operational Group) however this would be repeated and further communication to Practices made. It was noted that all bids relate to projects that have already been approved as part of the Prime Ministers Challenge Fund and are a key part of the Clinical Commissioning Group’s Primary Care strategy. Concerns were raised around the spike in revenue implications within 2019/20. This risk was recognised, along with the benefits of completing this work. It was also noted that this financial implication was forecasted at this stage but may change owing to future price shifts and potential additional future schemes that could be accessed by the Clinical Commissioning Group. Concerns were also raised over the real-time impact of this work and whether it would demonstrate the types of outcomes the Clinical Commissioning Group wishes to achieve within GP Practices. It was agreed that these would need to be closely monitored throughout this project. As these schemes are being delivered across a Cheshire and Wirral footprint, this would need to be assessed over a broader area and fed-back to both the Clinical Commissioning Group and Practices as required. Recommendation over future development work that could reduce this financial burden, e.g. moving to an “open office cloud” approach rather than a specific package were discussed, with assurance that these would be explored to ensure value for money within this scheme. In addition, best use of commissioning support unit budgets was discussed and the need to review this as part of the progression of Primary Care Information Technology transformation work. The primary care commissioning committee:

• Received and noted the contents of the report • Agreed that the clinical commissioning group will confirm to NHS

England and Cheshire West and Chester Council that the Blacon development is no longer being considered as a potential facility for healthcare provision

• Approved the request to agree to the potential revenue implications associated with the Estates and Technology Transformation Funding

• Note the contents of the minutes of the IT Infrastructure Project Board.

KC

KC

2016-021

Procurement Update The NHS England representative present gave a procurement update. It was stated that the Frodsham Procurement is now on track to deliver by the 1st January 2017 as required, with approval being sought from the Primary Care Commissioning Committee and NHS England. In terms of the procurement process for the St Werburgh’s Practice for the homeless, NHS England has hosted a successful market engagement event which was well attended by NHS, third sector and private stakeholders. All comments and discussions are to be included within the service specification. A Clinical Commissioning Group representative commented that tailoring the procurement of Primary Care services to local



needs was essential and seemed lacking somewhat within the questions asked of providers within the Frodsham process. These comments were noted and will be taken on board for future processes.

SS

2016-022

Update on Delegation Process The committee were updated by the Head of Primary Care that an application to move to delegated commissioning of Primary Care has been submitted as per the relevant processes. The group discussed this decision and also noted the risk in this decision, including the financial risk of potential future contracting implications and the additional work-load this will require within the Primary Care Team at the CCG. It was noted that a staffing budget would not be transferred by NHS England, although support and transition planning would take place with the team at NHS England. The move towards delegated would mean that NHS England would still be available to attend committees and support, but final decisions would need to be made solely by the Clinical Commissioning Group rather than in partnership with NHS England. The risks associated with this approach were discussed, including the potential change in Clinical Commissioning Group structure over the coming years as the health economy moves to an Accountable Care Organisation. If the Clinical Commissioning Group decided that it did wish to go ahead with this arrangement, approval would now need to be sought from Practices at Membership Council. The Health Watch representative commented that the decision to move to delegated commissioning seemed to create more risk than benefits, although the impetus from NHS England is to move into this arrangement. It was agreed that this would be discussed further within the Clinical Commissioning Group and fed-back to Members.

SMT

2016-023 Primary Care Support / Capita Finally, the Clinical Commissioning Group noted their concerns around a quality and safety perspective that the issue with receiving patient notes and other implications from the failure in Primary Care Services since their transfer to another provider. The Director of Quality and Safety wished to note that the Clinical Commissioning Group has done significant work to note their concerns and share with the provider and NHS England, but significant assurances or improvement has still not been made. The director will contact the provider and NHS England to reiterate the importance of this issue and requesting an urgent response. This has already had patient implications, with the LMC and Clinical Commissioning Group working together to attempt to resolve issues of GPs not being able to Practice and cancel clinics due to the out-dated performance list, and significant safeguarding concerns due to this failing process also. It was noted that more communication has been received from the provider however significant assurance has not been gained by the Clinical Commissioning Group.

PW



This is now being reported within the public domain through Governing Body.

2016-024 Any Other Business There were no other items of business discussed.

CONSENT ITEMS 2016-025 Minutes of the Primary Care Working Group

The committee accepted the Primary Care Working group notes.

Date and Time of the next meeting 27th April 2017, 9.00am, Room B, 1829 Building


Agenda Item: 2016-016.b


Action List – March 2017

Agenda Item

Mtg. Date

Action Action By

Due Date

Status

2016-003 19.10.16 Implications for the CCG and Primary Care of the NHS Operational Planning and Contracting Guidance 2017-19 – Work is to be undertaken in November 2016 at GP locality Networks and PM Forums re. progression of the 10 high impact actions, and an update will be provided to the next meeting.

LM/SM 14.12.16 On Agenda GP Forward View Plan to

be discussed

2016-005 19.10.16 Procurement Update – St Werburgh’s Practice for the Homeless – Update to be provided to the next meeting re. the scheduled stakeholder event.

CS 14.12.16 On Agenda Update to be provided at

March meeting 2016-007 19.10.16 Primary Care Update Report –

Discussions to be held with LMC to determine whether they could work with the CCG to develop a structure outlining earliest retirement timescales for retirement of staff, and the subsequent impact on the remaining workforce.

SPow 14.12.16 Complete

2016-009 19.10.16 Estates Update a. SM to provide clarity on the meaning of ‘Only a 20-30% funding allocation’,

which is listed against some of the ETTF projects. SM 14.12.16 Complete

b. Feedback on the current position of the projects to be provided to the practices involved.

14.12.16 Complete

2016-017 14.12.16 Primary Care Commissioning Report a. Escalation and Support Process - TJM to provide a report to update the

committee regarding the rationale applied to the Practices selected.

TJM 30.03.17

b. Further update to be provided following Primary care operational Group meeting on escalation and support process.

TJM 30.03.17

c. Provision of prophylaxis anti-virals to patients within a care home setting in the case of a flu outbreak. pursue NHS England for a response to this risk identified by the Clinical Commissioning Group.

TJM 30.03.17

2016-018 14.12.16 Primary Care Operational Group Quality Report Discussions to take place outside of the meeting on where best incidents iPrimary Care are reported.

PS & SF

30.03.17

Primary Care Commissioning Committee Action Log NHS West Cheshire Clinical Commissioning Group 30th March 2017 1/ 2

Agenda Item: 2017-16.b

2016-019 14.12.16 GP Forward View Plan The chair requested that any further comments are emailed to the Head of Primary Care if required.

ALL

30.03.17 Complete

2016-020 14.12.16 Primary Care Infrastructure Report a. Information Technology - Engagement was assured due to this taking

place at a number of forums (including Practice Managers Forum and ICT Operational Group) however this would be repeated and further communication to Practices made.

KC 30.03.17 Complete

b. review of budgets as part of the progression of Primary Care Information Technology transformation work.

KC 30.03.17

2016-022 14.12.16 Update on Delegation Process Further discussions relating to the delegated commissioning to take place within the clinical commissioning group

SMT 30.03.17 Complete

2016-023 14.12.16 Primary Care Support/Capita Contact the provider and NHS England to reiterate the importance of this issue and requesting an urgent response.

PW 30.03.17

On Agenda/Complete Overdue On-going For future meeting

Primary Care Commissioning Committee Action Log NHS West Cheshire Clinical Commissioning Group 30th March 2017 2/2

AGENDA ITEM: 2017-017

Primary Care Commissioning Committee

1. Date of Meeting: 30th March, 2017

2. Title of Report: Primary Care Commissioning Report

3. Key Messages:

• The Primary Care Operational Group met on 16 February 2017 and 16 March 2017 and made a number of recommendations for approval at the Primary Care Commissioning Committee. These relate to:

o The recommendation to approve the updated Minor Surgery Local Enhanced Service specification

o The recommendation to approve the updated Member Practice Engagement Scheme

4. Recommendations The Primary Care Commissioning Committee is asked to: a. Approve the recommendations of the Primary Care

Operational Group as follows: i. Approve the updated Minor Surgery Local Enhanced

Service Specification ii. Approve the updated Member Practice Engagement

Scheme

5. Report Prepared By: Sarah Murray, Head of Primary Care

Tanya Jefcoate-Malam, Deputy Head of Primary Care

Charlotte Love, Commissioning Manager, Planned Care

Colin McGuffie, Locality Project Manager

1 Primary Care Commissioning Report NHS West Cheshire Clinical Commissioning Group March 2017


NHS WEST CHESHIRE CLINICAL COMMISSIONING GROUP


PRIMARY CARE COMMISSIONING REPORT

PURPOSE 1. The purpose of this report is to seek approval from the Primary Care

Commissioning Committee for the commissioning and re-commissioning of a number of services.

DECISION 1 – UPDATED LOCAL ENHANCED SERVICE SPECIFICATIONS 2. The Clinical Commissioning Group has been working with Clinical Leads from

Primary Care and Secondary Care to update the following Local Enhanced Service Specifications: a) Anti-Coagulation LES b) Minor Surgery LES c) Vasectomy LES d) Medicines Managers LES

3. The updated specification for the Minor Surgery LES can be viewed within

Appendix 1. This has been recommended for approval by the Primary Care Operational Group and the Local Medical Committee has also agreed the specification.

4. The remaining Local Enhanced Services are currently out for consultation and will either be circulated for virtual sign-off or submitted for inclusion at the next Primary Care Commissioning Committee. The key changes that have been made can be summarised as follows:

a) Minor Surgery LES:

- Service Payment Levels: Updated to include the total procedure cost for registered patients,

rather than the top-up figure only - Skills experience:

Important information wording changed to reflect ongoing education could come in the form of rolling half days and would also form the basis of the Dermatology Peer Review group.

The Peer Review group is specifically for Level 3c. Evidence of resuscitation update is required every 12 months, in line

with existing general practitioner appraisal requirements. - Clinical Governance and Clinical Audit sections have been combined and

the audit information list refined. - Local Enhance Services Funding:

Minor changes to wording so it reads more clearly. - Declaration:



Table removed as duplicated previous section, declaration wording added.

- Appendix 1 – Performers Register Level 3 split out to 3a&b and 3c Additional wording added to be clear whether practitioners have

been on the listed before and if not, referee and training details are needed.

Part B and C brought together to deal specifically with Level 3c

DECISION 2 – UPDATED MEMBERSHIP ENGAGEMENT SCHEME

5. The Member Practice Engagement Scheme , detailed in Appendix 2, has been updated. The main change to this scheme is that the requirement for the Practice to host a Practice Visit has been removed, based on feedback from Practices. It is recommended that this updated specification is also approved by the Committee.

RECOMMENDATIONS

6. The Primary Care Commissioning Committee is asked to: Approve the recommendations of the Primary Care Operational Group as follows:

a) Approve the updated Minor Surgery Local Enhanced Service Specification b) Approve the updated Member Practice Engagement Scheme


Agenda item: 2017-17

APPENDIX 1 – LOCAL ENHANCED SERVICE SPECIFICATIONS

Local Enhanced Service for Minor Surgery

Author(s): Amanda Ridge/Steve Pomfret

Issue Date: March 2017

Version No: 12

Status: FINAL

Review Date: March 2018

Destruction date: 31st March 2019

Primary Care Commissioning Report 4 NHS West Cheshire Clinical Commissioning Group March 2017


Document Change History:

Version Status Summary of key changes Date of issue

12

Final Service Payment Levels: Updated to include the total procedure cost for registered patients, rather than the top-up figure only Skills experience: Important information wording changed to reflect ongoing education could come in the form of rolling half days and would also form the basis of the Dermatology Peer Review group. The Peer Review group is specifically for Level 3c. Evidence of resuscitation update is required every 12 months, in line with existing general practitioner appraisal requirements. Clinical Governance and Clinical Audit sections have been combined and the audit information list refined. Local Enhance Services Funding: Minor changes to wording so it reads more clearly. Declaration: Table removed as duplicated previous section, declaration wording added. Appendix 1 – Performers Register Level 3 split out to 3a&b and 3c Additional wording added to be clear whether practitioners have been on the listed before and if not, referee and training details are needed. Part B and C brought together to deal specifically with Level 3c

11 Draft Medicines Management Wording removed in relation to medication required for use during minor surgery should be provided under the terms of the LES. Sentence added about consumables being prescribed for individual patient use only

March 2017

5

Primary Care Commissioning Report NHS West Cheshire Clinical Commissioning Group March 2017


10 Draft Document viewed and edits suggested by: Dr Philip Milner – GP Clinical Lead Dr Steve Pomfrett – GP Clinical Lead The following changes have been made: Update section 3b. Section 3d - Additional narrative: Existing Practitioners will be required to provide audit information to demonstrate competence as part of their annual appraisal. Sustained level of activity at level 1/2/3 in order for Practitioner to maintain their competency. For Level 3c each Clinician will complete an application for the Performers Register held by the responsible practice (Appendix 1). Section 4 – Additional narrative: Practitioners to provide feedback at the Dermatology Peer Review Group. Attend, at least annually, an educational meeting (organised by the Dermatology Service). Section 7 – additional narrative The Practice is responsible for any follow up dressing requirements that has resulted from the procedure that been undertaken. Any consumables prescribed are for individual patient use only. Any unused consumables remain the property of the patient. Section 8 – Additional narrative: Only a single item is to be used in any minor surgery procedures (Appendix 2). Section 11- Additional narrative: Attend a minimum of one Dermatology Peer Review Group meetings per year. Add in Appendix 1 - to be completed by all GPs wishing to provide Minor Surgery Local Enhanced (LES) Services. Add in Appendix 2 - Single use and reusable cautery tips and devices information.

March 2017

6



9 Draft Additional information to cover Types of Procedures, Training, Medicine Management, Exclusions, etc

TBC

8 Final Level 3 service split into 3a, 3b and 3c to take account of NICE guidance issued (Skin Cancer Measures for West Cheshire CCG 08-6A-103) Price uplifted by 1.7% from April 2009

November 2009

7 Final Price uplifted by 1.5% April 2008 6 Final Removed word ‘registered’ from 6.(iii) 23 August 2007 4 Draft Ellesmere Port & Neston GP Network

Agree removal of BCCs “in accordance with NICE guidelines” rather than “on trunk and limbs” Injection of varicose veins to be taken out as this procedure is largely cosmetic and not carried out in surgery Injection of haemorrhoids to be taken out as this is part of the sigmoidoscopy service.

28 June 2007

3 Draft Chester City GP Network Clarified that consultation fee only applies to patients cross-referred from another practice and only applies if procedure is NOT carried out Agreed to include aesthetic guidelines as an appendix Referral to NICE guidance clarified Levels of sebaceous cysts removal clarified Up to 3 removals are counted as one procedure - to be included in the specification.

21 June 2007

2 Draft Rural GP Network Inclusion of sebaceous cysts in level 2 and level 3b clarified

13 June 2007

1 Draft Group of interested GPs 28 March 2007

7



Local Enhanced Service for Minor Surgery

1. INTRODUCTION All practices are expected to provide essential and those additional services that they are

contracted to provide to all their patients. This enhanced service specification for the provision of minor surgery services outlines the details of the service to be provided. The specification of this service is designed to cover the enhanced aspects of the clinical care provided to the patient, all of which are beyond the scope of essential services. No part of the specification by commission, omission or implication defines or redefines essential or additional services. This service does not include the provision of Implanon implants.

2. BACKGROUND This LES recognises the need for a consistent approach to rewarding GPs equitably for

providing minor surgery services within their own practice. This service will be commissioned in the context of ensuring more patients are

appropriately treated in primary care rather than attending secondary care. Treatments should be carried out in line with West Cheshire CCGs policy statements on

procedures of Limited Clinical Value and threshold policies for potentially cosmetic treatments.

3. SCOPE OF SERVICE TO BE PROVIDED Cryotherapy, curettage and cauterization will continue to be provided by general

practitioners as an additional service and practices wishing to opt out of providing these treatments will be obliged to apply to do so in the prescribed manner. Procedures in the categories below and other procedures, which the practice is deemed competent to carry out, will be covered by a directed enhanced service. These procedures have been classified into the following groupings for payment:

(i) injections – Joint problems treatable by steroid injections (muscles, tendons and joints)

(ii) invasive procedure – Procedures which can be routinely performed (Including incisions and excisions)

3a. SERVICE OUTLINE This Local Enhanced Service will fund the four levels of service outlined below. Practices

will be able to choose the level of service that they wish to provide for their patients. Where a practice chooses not to provide a service, another practice will be able to provide that service on their behalf.

8



3b. SERVICE PAYMENT LEVELS

PAYMENT LEVEL

TYPE 1 Aspiration of:

• Joints • Ganglion • Cysts • Bursae • Hydroceles (where corrective

surgery is inadvisable/ unacceptable)

• Surgical Haematoma

• Seroma • Capsulitis • Bursitis • Compression

Entheosopathies/Tendinitis • Tenosynovitis

Injection of: • Joints (including tennis elbow, trigger finger, plantar fasciitis) • Bursae Excludes: • Insertion of Hormonal implant (Includes Zoladex and Triptorelin) • Insertion of subcutaneous contraceptive • Local anaesthesia prior to minor surgery

Indications: Diagnostic or therapeutic and where such treatment will be likely to improve clinical outcomes. Any procedure that has been requested for cosmetic reasons will not be considered under this Local Enhanced Service.

COST 2017/ 18

Registered Patients:

Procedure = £44.11 Top up = £0.46 per procedure. Procedure total: £44.57

Patients referred from other practices:

£60.12 per procedure. £25.92 consultation fee if procedure is not carried out (one fee for up to two consultants per patient)

PAYMENT LEVEL

TYPE 2 Excision of: (Where these is suspicion of malignancy or subject to repeated trauma)

• Pigmented Skin Lesion • Nodule Subcutaneous • Other Skin Lesions • Lipomata if <3cm • Sebaceous Cysts (not on head/neck) • Simple toe nail removal with no additional procedure • Pigmented and vascular lesion where histopathology is required

(excluding suspected melanomas) • Lesions of atypical behaviour such as bleed or colour change

where histopathology is required (Papilloma, Dermatofibroma or Seborrheic Keratosis)

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• Lesions that are symptomatic and/or have been inflamed on more than one occasion at the time of consultation

• Epidermoid Cysts that are symptomatic and/or have been inflamed on more than one occasions at the time of consultation

• Keratoacanthoma • Surgical Drainage of Abscesses and Haematomas where this is

deemed best treatment • Removal of Foreign Bodies only where local anaesthetic and

incision is required as part of the procedure Incision of:

• Abscesses • Cysts • Thrombosed Piles • Surgical Haematomas

COST 2017/ 18

Registered Patients: Procedure = £88.22 Top up = £0.92 per procedure Procedure total: £89.14



PAYMENT LEVEL

TYPE 3A

• Removal of Toenail with Ablation • Wedge Excision of Toenails / Total Toenail Excision • Lipomata if >3cm

COST 2017/ 18

Registered Patients: £124.38 per procedure (Up to 3 removals are counted as one procedure)



PAYMENT LEVEL

TYPE 3B

• Removal of Sebaceous Cysts, etc on Head/Neck

COST 2017/ 18

Registered Patients: £124.38 per procedure (up to 3 removals are counted as one procedure)



PAYMENT LEVEL

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TYPE

3C • Removal of Low Risk Basal Cell Carcinoma (BCC) (In accordance with

Section 3d NICE Guidelines) Cost 2017/ 18

Registered Patients: £124.38 per procedure

(up to 3 removals are counted as one procedure)



3c. EXCLUSIONS

The following procedures will NOT normally be funded under Minor Surgery Enhanced Service:- Excision of Benign Skin Lesions:-

i. Removal of obviously clinically benign moles should NOT be done on cosmetic grounds. In some cases the distinction between suspicious and purely benign moles is clear cut, but suspicious pigmented lesions should always be referred for an opinion

ii. Other benign skin lesions e.g. skin tags and seborrheic warts removed on cosmetic grounds will NOT be funded

iii. Treatment of skin lesions that require treatment using cryotherapy, curettage or cautery

are funded under Additional Minor Surgery services within the GP contract. Practices need to have opted into this Additional Service in order to be able to carry out and get remunerated for provision of this service under their contract

iv. Removal of sutures

Procedures undertaken under this specification must comply with the relevant NICE Guidance. Practices should note that procedures carried out that are NOT included in the Minor Surgery Specification, the Approved Procedures list and/ or contravene NICE Guidance WILL NOT be funded by West Cheshire Clinical Commissioning Group (CCG).

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3d. SKILLS / EXPERIENCE / QUALIFICATIONS REQUIRED

Level 1 • New Practitioners will be required to attend a Minor Surgery course or provide evidence of

equivalent experience. • Existing Practitioners will be required to provide audit information to demonstrate

competence as part of their annual appraisal. • Doctors carrying out minor surgery should demonstrate a continuing sustained level of

activity at level 1 in order to maintain their competency. Level 2 • New Practitioners will be required to attend a minor surgery course or provide evidence of

equivalent experience. • Existing Practitioners will be required to provide audit information to demonstrate

competence as part of their annual appraisal. • Doctors carrying out minor surgery should demonstrate a continuing sustained level of

activity at level 2 in order to maintain their competency. Levels 3a & 3b • Practitioners will need to provide a self-declaration of training and experience with

recognition of their limitations in expertise and knowledge. • Practitioners will be required to provide audit information to demonstrate competence as part

of their annual appraisal. • Doctors carrying out minor surgery at this level should demonstrate a continuing sustained

level of activity at level 3 in order to maintain their competency.

Level 3c • In accordance with NICE guidelines Practitioners will need to be operating at an appropriate

level of skill and competence in order to meet the standard required to carry out the relevant procedure or accredited as a GPwSI in dermatology/ skin surgery.

• Practitioners will be required to provide audit information to demonstrate competence as part of their annual appraisal.

• In order to be accredited, practices will be signed up to the West Cheshire CCG Minor Surgery Enhanced Service and each Clinician will complete an application for the Performers Register (Appendix 1) which will be held by the responsible practice (copies are to be made available to West Cheshire CCG upon request).

IMPORTANT INFORMATION:

To maintain competencies, practitioners should take part in regular education events run locally e.g. Rolling half days. These events would also provide the basis for the Dermatology Peer Review Group. The types of injections and numbers undertaken on an annual basis must be fully recorded for training, monitoring and auditing purposes.

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4. CRITERIA FOR ACCREDITATION & ELIGIBILITY All GPs and Clinicians taking part in any minor surgery activity should be competent in resuscitation and, as for other areas of clinical practice, have a responsibility for ensuring that their skills are regularly updated. They should be able to demonstrate this to their appraiser. Doctors carrying out minor surgery should: • Demonstrate a continuing sustained level of activity in order to maintain their competency • Conduct regular audits (as stipulated in section 6) • Be annually appraised on what they do • Take part in necessary supportive educational activities GPs and Clinicians performing skin surgery on low-risk BCCs within the LES framework should: • Demonstrate competency in performing local anaesthesia, punch biopsy, shave excision,

curettage and elliptical excision using the direct observation of procedural skills (DOPs) assessment tool as set out in the Department of Health Guidance for GPwSIs in dermatology and skin surgery and then follow a revalidation programme

• Have specialist training in the recognition and diagnosis of skin lesions appropriate to their role

• Send all skin specimens removed to histology for analysis • Provide information about the site of excision and provisional diagnosis on the histology

request form • Maintain a ‘fail-safe’ log of all their procedures with histological outcome to ensure that

patients are informed of the final diagnosis, and whether any further treatment or follow-up is required

• For Practitioners intending to operate at Level 3c, feedback should be provided at the

Dermatology Peer Review Group regarding histology reported as required by the national skin cancer minimum dataset including details of all proven BCCs

• Provide evidence of an annual review of clinical procedures compared with histological

accuracy in diagnosis for low-risk BCCs they have managed at their annual appraisal • Attend, at least annually, an educational meeting (organised by the Dermatology Service),

which should:

o Present the 6 monthly BCC network audit results, including a breakdown of individual practitioner performance

o Include one CPD session (a total of 4 hours) on skin lesion recognition and the diagnosis and management of low-risks BCCs

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5. CLINICAL GOVERNANCE & AUDIT

It is a requirement that all GP practices keep full records of all procedures undertaken and should be maintained in such a way that aggregated data and details of individual patients are readily accessible to authorised people if required. Practices should regularly audit and peer-review minor surgery work. Practices providing Minor Surgery services are required to submit monthly/quarterly claim forms together with their monthly/quarterly minor surgery audit report. West Cheshire CCG and NHS England will undertake random audits to verify that minor surgery procedures are being undertaken in accordance with the approved list of procedures and full minor surgery criteria. Additionally, some Practices may be selected for audits based on ratio of procedures to population if activity is unusually high.

• Any Practitioner wishing to provide surgery for low risk Basal Cell Carcinoma must be fully accredited in line with NICE Guidance (GPwSI) and maintain performance in line with the Guidance

Any Practitioner who is carrying out invasive minor surgical procedures must meet the standards set out in the DH Guidance which requires: • New Practitioners must be able to provide evidence and training to prove that they are

competent to perform the designated procedure(s), these are usually through a competency based tool i.e. Direct Observation of Procedural Skills (DOPS)

• Existing Practitioners wishing to be re-accredited should demonstrate competency to a qualified external body using Direct Observation of Procedural Skills (DOPS) within the previous 3 years or continues to perform skin surgery within regular, sustained and audited levels of activity. Auditing outcomes at this level of activity will generate evidence for revalidation and re-accreditation

• All Practitioners wishing to practice at level 2 and 3 must be able to demonstrate their

training and any ongoing medical education in the recognition and management of skin lesions appropriate to their specific level

• Detailed activity records or log books should be maintained by the Practitioner i.e. copy of

the practice audit data should be available upon request by their Appraiser, West Cheshire CCG or NHS England

• Practitioners taking part in minor surgery should be competent in resuscitation and

provide evidence of a resuscitation update within the last 12 months and have a responsibility to ensure their skills are regularly updated

• Practitioners performing minor surgery should conduct regular audits, be appraised of

their skills and take part in any necessary supportive educational activities

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Audits include checks to ensure:

• All skin specimens are removed and sent to histopathology for analysis • All information about the excision site and provisional diagnosis is included on the

histopathology form • Rates of infection • Unexpected or incomplete excision of basal cell tumours or pigmented lesions which

following histological examination are found to be malignant • A fail-safe log of all procedures with histopathological outcomes are in place to ensure

patients are informed of diagnosis, treatments and follow ups, this is to be maintained by the physician, as well as logging who within the practice undertook the procedure.

o Histological diagnosis at significant variance to clinical provisional diagnosis

6. MEDICINES MANAGEMENT The Practice is responsible for any follow up dressing requirements that has resulted from

the procedure that been undertaken. Any consumables prescribed are for individual patient use only. Any unused consumables remain the property of the patient.

7. LOCAL ENHANCED SERVICES FUNDING

The Local Enhanced Service (LES) will fund the following at all levels:

• Appropriate and timely referral where appropriate and/or follow up arrangements • Adequate facilities including premises and equipment, as are necessary to enable the proper provision of minor surgery services including facilities for cardiopulmonary resuscitation

• Nurses or Healthcare Assistants (HCAs) to provide care and support to patients

undergoing minor surgery services. Nurses/HCAs assisting in minor surgery procedures should be appropriately trained and competent, taking into consideration their professional accountability.

• Consent: In each case the patient should be fully informed of the treatment options and the treatment proposed. The patient should give written consent for the procedure to be carried out and the completed consent form should be filed in the patient’s lifelong medical record

• Maintenance of Infection Control Standards: It should be noted that only a single item is to be used in any minor surgery procedures (Appendix 2)

• Maintenance of records of all procedures: Practices must ensure that details of the

patient’s treatment as part of the LES is included in his or her lifelong record. If the patient is not registered with the practice providing the LES, then the practice must send this information to the patient’s registered practice for inclusion in the patient notes

• Pathology: All tissue removed by minor surgery should be sent routinely for histological

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examination unless there are exceptional or acceptable reasons for not doing so

• Data submission to the West Cheshire CCG: Practices are required to provide activity data to West Cheshire CCG on a quarterly basis to include the number of procedures completed in quarter for each of the levels

8. DURATION OF SERVICE This service is offered initially for the period from 01st April 2017 – 31st March 2018, to be

extended with agreement between West Cheshire CCG and the Practice thereafter. West Cheshire CCG may wish to agree an activity cap with each Practice for each level.

9. COSTS In 2017/18 each Practice contracted to provide this service will receive fees attached to the

level of service that they are contracted to provide. 10. DECLARATION

Please ensure that all clinicians undertaking Minor Surgery meet the relevant skills and experience and have read/understood this document. GP Practice: GP Practice Name Snr Partner/ Lead GP for Enhanced Service:

Snr Partner/ Lead GP Name

Snr Partner/ Lead GP Signature

16



This page has been left intentionally blank.

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Appendix 1 – Performers Register

PART A (Levels 1-3) This Section to be completed by ALL GPs wishing to provide Minor Surgery Local Enhanced (LES) Services Details of GP Surname

Forename

Email Address

Date of full registration

GMC Number

Practice name (s) at which Minor Surgery LES services are to be carried out

POST GRADUATE QUALIFICATIONS Please list all post graduate qualifications (relevant to your application).

Qualification Date Achieved



Providing minor surgery services in General Practice. Please indicate which level/ s of minor surgery service/ s you wish to provide:

Please delete as appropriate:

Level 1 – Injections and aspirations

Yes/ No

Level 2 – Invasive procedures, e.g. incisions, excisions

Yes/ No

Level 3a & b – Invasive procedures e.g. removal of toenail with ablation or sebaceous cysts

Yes/ No

Level 3c – Invasive procedures including the removal of low risk Basal Cell Carcinoma (BCCs)

Yes/ No

Date of last attendance at CPR training: (Please ensure you are able to produce a copy of your certificate of attendance, if requested)

Date:

Relevant Experience: Please give information about all minor surgery experience in the last three years relevant to the level at which you are applying (Please supply references). 1) Name of Organisation : (This may include your own or another general practice)

Position held:

Dates:

Type of Minor Surgery activities undertaken, e.g. joint injections, excision of benign lesions, excision of BCCs:

Activity Levels (annual). Please be specific about the number of procedures of each type performed:

Referee Details:

2) Name of Organisation:

Position held:

Dates:


Activity Levels (Annual)

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Please be specific about the number of procedures of each type performed: Referee Details:

2) Name of Organisation:

Position held:

Dates:


Activity Levels (Annual) Please be specific about the number of procedures of each type performed:

Are you currently on the Performers Register?

Yes/No IF YES, go to Part B

IF NO, please provide referee details:

Relevant Training (for new additions to the Performers Register): Please give information about all minor surgery training attended in the last three years relevant to the level at which you are applying. (Please ensure you are able to produce a copy of your certificate/s of attendance, if requested). Course 1 Name of training course and details of course content:

Venue:

Date Attended: Course 2 Name of training course and details of course content:

Venue:

Date Attended: Course 3 Name of training course and details of course content:

Venue

Date Attended: Course 4

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Name of training course and details of course content: Venue

Date Attended: PART B This Section to be completed by GPs wishing to provide Level 3c Minor Surgery Local Enhanced (LES) Services for low risk BCCs. Direct Observation of Procedural Skills (DOPS) New (and some existing) minor surgery practitioners must be able to evidence competency to perform the designated procedure(s) to a suitably qualified external body using objective evidence and competency based assessment tools, i.e. Direct Observation of Procedural Skills, (DOPS), within the preceding three years. Did any of your training courses that you have entered above include a DOPS assessment?

Please delete as appropriate:

YES/ NO If YES Name of course/s:

If NO Have you evidence of having completed a DOPS assessment in the past 3 years?

YES/ NO

If YES please provide details below:

Name of DOPS Provider:

Venue:

Date Completed: If NO Please confirm that you have booked to attend a DOPS assessment, including name of course, venue and date:

Relevant Training: GPs performing skin surgery on low-risk BCCs are required to demonstrate competency in performing local anaesthesia, punch biopsy, shave excision, curettage and elliptical excision using the direct observation of procedural skills (DOPS) assessment tool in the Department Health Guidance for GPwSIs in dermatology and skin surgery. Please indicate which course detailed in PART A meets this requirement: Name of training course and details of course content:

Reporting Requirements: GPs performing skin surgery on low-risk BCCs are required to meet full reporting requirements as specified in Section 3 of this document and the Minor Surgery LES specification. Please place a tick in the adjacent box to confirm that you will meet these requirements:

PART C – To be completed by ALL applicants

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DECLARATION: I declare that the information provided on this form is correct. Doctors Signature:

Name Printed:

Date:

Appendix 2

Single Use and Reusable Cautery Tips and Devices Practices should note, single use cautery tips and devices are not licensed for use on multiple patients. By reusing a single use device, practitioners may be legally liable for the safe performance of the device. Where possible single use cautery tips and devices should be used, as attempts to sterilise cautery tips by heating them between patients (known as “burning off” or “flaring up”) is not a suitable decontamination process and may compromise patient safety. Only cautery tips and devices labelled reusable should be decontaminated. Guidance on decontaminating medical devices can be found on the gov.uk website. https://www.gov.uk/government/publications/single-use-medical-devices-leaflet https://www.gov.uk/government/publications/management-and-decontamination-of-surgical-instruments-used-in-acute-care

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https://www.gov.uk/government/publications/single-use-medical-devices-leaflet

https://www.gov.uk/government/publications/management-and-decontamination-of-surgical-instruments-used-in-acute-care

https://www.gov.uk/government/publications/management-and-decontamination-of-surgical-instruments-used-in-acute-care


Appendix 2 – Member Practice Engagement Scheme

Member Practice Engagement Scheme

2017/18

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1.0 Introduction

The engagement of our member practices is vital to the success of the Clinical Commissioning Group (CCG). The core purpose of clinical commissioning is to improve the health of our population. To achieve this all GPs, practice managers and their practice teams have a role as commissioners to ensure that their patients are receiving the best care possible.

This engagement scheme has been developed in recognition of practices’ fundamental role in the CCG achieving its aims. It is designed to support commissioning work within GP practices, at locality level and across all 37 member practices that make up the CCG.

This paper will set out the format, content and payment arrangements for the Member Practice Engagement Scheme to run from 1st April 2017 to 31st March 2018.

2.0 Objectives

The objectives of the Member Practice Engagement Scheme are:

• To recognise and incentivise the development of clinical leadership for commissioning at practice level.

• To create explicit links between the clinical commissioning programmes and localities. • To support the development of localities as the building blocks of the CCG by promoting

practice engagement in the commissioning process at locality level. • To give practices the opportunity to engage in and understand the work of the CCG. • To use data and information to provide clinicians with the knowledge they need to identify

and prioritise areas for quality improvement by using the individual practice profile. • To provide an opportunity to share best practice and develop innovative solutions.

3.0 Clinical Engagement Each practice will nominate a GP Commissioning Lead who will act as the CCG contact point for their practice.

The GP Commissioning Lead in each member practice is responsible for:

• Attendance at monthly GP Locality Network meetings (excluding August). Attendance is required from the Commissioning Lead GP. Practice Managers are very welcome to attend. A practice nominated GP may attend as a substitute for the Commissioning Lead GP in the event of sickness or holidays. However, if no substitute is available, apologies for absence should be given in advance of the meeting wherever possible. Practice managers are not able to deputise for GPs at these meetings. Member practices will be paid £300 (for a 3 hour session) to pay for locum cover for attending these meetings. If a GP does not attend payment will not be made.

• Being the link between the practice and the GP Locality Network. Commissioning Lead GPs will act as a conduit between their practice and their locality. They will feedback discussions at the GP Locality Networks and canvas the opinions of their practice colleagues in order to support and influence commissioning decisions. Practices will be paid £85 a month (equating to one hours work within the practice for 11 months) to ensure that

25



colleague’s views are sought and that feedback is given from the GP Locality Network meeting.

• Attendance at Membership Council Meetings four times a year. The Membership Council is the committee where every member practice can both be consulted and has the opportunity to contribute to the CCG’s plans. The membership council holds the governing body to account for the functions that the group has conferred on it through its regular meetings with the chair and the accountable officer. Member practices will be paid £300 for the Commissioning Lead GP’s attendance at these meetings.

4.0 Practice Manager Engagement

Practice Managers will be funded £100 to attend the monthly Practice Managers’ Forum.

This is in recognition of the important role practice managers have in ensuring the success of the CCG’s objectives; and the importance attached to the Practice Managers’ Forum as a place where practice managers as a group can be consulted to support and influence work programmes.

5.0 Payment

Activity Funding

Monthly Annual

GP Commissioning Lead attendance at 11 GP Locality Networks

£300 £3,300

GP Conduit between Locality Networks and their member practice at 11 GP Locality Networks

£85 £935

GP Attendance at Membership Council £300 £1,200

Practice Manager Attendance at Practice Manager Forum £100 £1,100

Practices will be paid for:

• GP attendance following each funded meeting

• GP acting as conduit following each funded meeting

• Practice Manager attendance following each funded meeting

26



Payment will not be made if the GP does not attend the relevant meeting or if the Practice Manager does not attend the Practice Manager Forum.

Cluster Leads Meetings

To support the transformation of primary care it has been beneficial to bring the GP and Practice Manager leads for each of the nine clusters together to share best practice and facilitate new ways of working. Therefore Cluster Lead GPs and Practice Managers will be funded to attend a 2 hour quarterly Cluster Leads meetings. GPs will be funded £200 and Practice Managers £66 per meeting.

For more information contact Sarah Murray on [email protected].

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2. Title of Report: Primary Care Quality Report

3. Key Messages:

• The Primary Care Operational Group met on 16th of February and March 2017 and discussed a number of items in relation to Primary Care Quality. The key messages were:

o The CCG has committed to working closely with its member Practices and the Care Quality Commission to address issues of Primary Care quality that will in turn improve inspection results

o The Clinical Lead for Quality and Safety continues to keep an overview of incidents and themes reported by Primary Care. This has resulted in the CCG entering discussions with Secondary Care due to Datix reports that clinical risk and hospital actions have been inappropriately shifted to General Practice

o The CCG continues to engage and be involved with areas of research that impact upon Primary Care

o The CCG has undertaken an extensive consultation process to develop and agree a Primary Care Commissioning for Quality and Innovation Scheme (CQUIN) for 2017/18. This CQUIN has been linked to the Support and Escalation Process via Supplementary Guidance.

4. Recommendations The Primary Care Commissioning Committee is asked to:

i. Note the work of the Primary Care Operational

Group in relation to Primary Care Quality ii. Approve the Primary Care CQUIN Specification for

2017/18 along with the Supplementary Guidance for the Support and Escalation Process.

5. Report Prepared By: Tanya Jefcoate-Malam

Primary Care Contracting Report 1 NHS West Cheshire Clinical Commissioning Group March 2017


Deputy Head of Primary Care



PRIMARY CARE OPERATIONAL GROUP QUALITY REPORT

PURPOSE 1. The purpose of this report is to provide the Primary Care Commissioning

Committee with an update of the key highlights and progress of the work of the Primary Care Operational Group in relation to Primary Care Quality.

CARE QUALITY COMMISSION 2. The Care Quality Commission (CQC) contacted the CCG within December 2016 in

order to request a meeting with Primary Care Team Members to discuss issues, risks and concerns resulting from Inspections. In addition, the CCG has received feedback from Member Practices around CQC inspections identifying areas of the CQC framework and inspection format that require additional clarity and the need to learn from these inspections by sharing best practice across the patch.

3. CQC attended the Primary Care Operational Group in March 2017 to discuss this feedback and potential next steps. Please see full report of areas identified within Appendix 1.

4. It has been agreed that the CCG will work with Member Practices to develop some “General Practice Quality Standards” that will lead to improved quality of Primary Care delivered within West Cheshire, as well as improved CQC inspection results. Best practice examples for each of these Standards will be shared at quarterly Practice Manager Forum meetings. In addition, the CCG Primary Care Team will meet with CQC on a quarterly basis in order to identify any specific issues or themes that could feed into this discussion.

QUALITY AND SAFETY INCIDENTS 5. The Clinical Lead for Quality and Safety continues to keep a brief on all quality and

safety incidents that will impact upon Primary Care. Key themes in February related to secondary care shifting clinical risk and responsibility to GP Practices via written hospital communication. This shift of clinical risk and the request of GP action has not in all cases demonstrated an appropriate or clear transfer. The Clinical Lead has collected examples of these issues from Primary Care and has met with senior clinicians within Secondary Care to agree a way forward. Further updates on Primary Care incidents will be given to the Quality Improvement Committee as agreed.

RESEARCH



6. The Clinical Lead for Quality and Safety continues to drive forward research projects that will lead to improved outcomes for Primary Care. The Clinical Lead is currently working on a thematic review project of GP reported patient safety incidents, and is also involved in research work with the Bradford Institute of Healthcare Research regarding earlier diagnosis of cancer within Primary Care. The Clinical Lead will ensure progress of this is reported to the CCG via Primary Care Operational Group.

PRIMARY CARE CQUIN 2017/18 WITH SUPPLEMENTARY GUIDANCE

7. The Primary Care CQUIN was drafted in December 2016 following an internal steering group attended by the Heads of each CCG programme (bar Mental Health who were not able to attend), Director of Commissioning, Medical Director and former chair of the CCG. At this meeting, the key outcomes within each Chapter and programme were identified with guidance given as to how the scheme could be drafted to achieve these. This guidance was reviewed and inputted into by each Programme’s Clinical Lead.

8. In addition, the previous Local Enhanced Services considered to be included within this scheme were identified as follows: a) Nursing Homes LES b) Intermediate Care LES c) Minor Injuries LES d) Primary Care CQUIN (including Over 75s budget) e) PMS reinvestment funding f) ECG LES g) Spirometry LES h) Diabetes LES i) Mental Health LES

9. The objective of including these schemes within the CQUIN is to reduce the

bureaucracy for Practices in claiming for multiple schemes and submitting process measure level data, reduce the demand on the CCG to assess and validate process measure level data, to incentivize Practices to contribute to the outcomes set out within the West Cheshire Way and encourage Cluster working where relevant.

10. At this meeting, immediate timescales around CQUIN development and consultation were set. These have now been completed as follows:: a) 22nd December 2016 – All programmes inputted into draft CQUIN that was

shared with the Local Medical Committee for comment and feedback b) 29th December 2016 – The Draft CQUIN was circulated to the Ellesmere Port

& Neston Network and on 3rd and 5th January, was circulated to Rural and City Networks

c) Feedback was gathered at the January Networks leading to a number of internal CCG meetings involving the Chair, Director of Commissioning, Director of Finance and Heads of Programmes. The outcome of these meetings as the CQUIN Chapters were developed were shared with Programme clinical leads



d) Due to “Chapter 1” (relating to Urgent and Intermediate Care) being the section with the most queries, the Unplanned Care Team were asked to attend February Networks to listen to further feedback and consult on future developments

e) Following this, the CCG met with the Local Medical Committee on 15th February 2017 to discuss further developments and amendments that could be made to the scheme to make this compatible with CCG outcomes and Practice deliverables. Through this time, further feedback was received at the CCG from individual Practices, Clusters and Cluster Leads

f) An updated Specification (taking into account this feedback) was shared with the Local Medical Committee on the 2nd March 2017, with a revised version also being circulated to the Local Medical Committee and all Practices on 9th March. This revised CQUIN was discussed with all Networks within March

g) At the Primary Care Operational Group on 16th March 2017, the CQUIN Specification for 2017/18 as contained within Appendix 1 was recommended for approval at the Primary Care Commissioning Committee

h) If approved, the scheme will launch in participating Practices from Monday 3rd April, 2017.

11. In summary, the CQUIN requests Practices to deliver General Practice Standards

that will contribute to the health economy outcomes monitored and agreed through the West Cheshire Way. The Specification is broken down into three chapters. A summary of these and key changes made owing to feedback received is detailed as follows: a) Chapter 1 of the CQUIN continues to take a focus on frailty, however due to

frailty assessments now being a requirement of the GP contract, slight changes have been made. In summary, this Chapter now requires the following: • Practices to carry out care planning for patients who are vulnerable within

their own home or residential homes • Practices to continue to deliver the current Nursing Homes and / or

Intermediate Care Scheme for six months, but to work with the CCG to engage with and develop a new scheme providing equitable care for vulnerable patients whatever their care setting

• Practices who currently provide Minor Injuries to continue to claim on an activity basis. Engagement will take place throughout the year to ensure the Specification is reflective of Practice and CCG need, and to consider the situation for City Practices within year

• For Practices to work with the CCG to look at the need for direct booking from 111 (once clinically assessed) into General Practice appointments

• For Practices to utilise Step-Up bed facilities It should be noted that requirements to complete prophylaxis anti-virals has been removed and passed back to NHS England.

b) Chapter 2 focuses on patients with long-term conditions, children and elements of Primary Care Access. In summary: • Requiring the continued use of self-management tools and services • Working towards rolling out the Year of Care approach for all long-term

conditions and engaging with the Acute to Community process



• Carrying out an audit to look into Primary Care Access • Engaging with relevant Starting Well initiatives It should be noted that as this section requires previous activity base services to be claimed as block based on 2016/17 activity, PMS reinvestment funding has been added here to allow a rise in funding to be seen equitably for every Practice.

c) Chapter 3 creates a key focus on Mental Health, updating the current Local

Enhanced Service and ensure patients with mental health conditions achieve parity of esteem and are viewed holistically.

12. The outcomes that Practices are asked to contribute to throughout the CQUIN as

per the West Cheshire Way will be monitored via the Primary Care Dashboard.

13. However, payment will not depend upon achievement of these outcomes. Incentive or disincentive will be based upon engagement with the Support and Escalation Process, as detailed within the Supplementary Guidance. Entire “traditional” CQUIN and over 75s funding could be reduced as follows (on reaching Stage 4 of the process):

Severity Reduction (quarterly) Minor breach e.g. the Practice have completed all actions as agreed with the CCG between Stages 1-3 however they are not able to demonstrate any improvement or evidence that improvement is not necessary

10% reduction

Moderate breach e.g. the Practice have completed over half of the actions as agreed with the CCG between Stages 1-3 and they are not able to demonstrate any improvement or evidence that improvement is not necessary

25% reduction

Severe breach e.g. the Practice has completed less than half of the actions as agreed with the CCG between Stages 1-3 and they are not able to demonstrate any improvement or evidence that improvement is not necessary

50% reduction

Total breach e.g. the Practice has not completed any actions agreed with the CCG between Stages 1-3 and they are not able to demonstrate any improvement or evidence that improvement is not necessary

100% reduction

14. Due to concerns raised by Practices throughout March as to the impact of the

Support and Escalation Process and linking this to the Primary Care CQUIN, a Supplemental Guidance document has been created to clarify and alleviate some of these concerns. in summary, this Guidance provides further information around the following: a) What are the main triggers that may result in a Practice entering the process b) What are the stages c) What the Practice can expect as support from the CCG within each of these

stages d) What the CCG can expect from the Practices within each of these stages e) What are the potential incentives and disincentives in a case of non-

compliance that Practices can expect from the escalation and support process.



15. Concerns have been raised from Practices and the Local Medical Committee around the use of CQUIN funding to incentivise or dis-incentivise Practices. Therefore, the Primary Care Operational Group has recommended the following changes to the Support and Escalation Process: a) To change the focus of the Escalation Policy to “Support” and Escalation b) To ensure Stages 1 and 2 are termed as “support” with only stages 3 and 4

being considered “escalation” c) To only ask a Practice to enter this process formally when they are at

statistically significant variance to average (both above and below). Practices within one standard deviation from average may still be asked to enter the process informally

d) To change the one month time frame between stages to six weeks e) To enable Practices to submit evidence to demonstrate that no change or

improvement is necessary due to an independent and clinically reviewed audit.

16. Please see Appendix 2 of the Primary Care CQUIN Specification for 2017/18 for full Guidance.

RECOMMENDATIONS

The Primary Care Commissioning Committee is asked to:

i. Note the work of the Primary Care Operational Group in relation to Primary Care Quality

ii. Approve the Primary Care CQUIN Specification for 2017/18 along with the Supplementary Guidance for the Support and Escalation Process

Written by: Tanya Jefcoate-Malam, Deputy Head of Primary Care Date: March, 2017



APPENDIX 1 – CARE QUALITY COMMISSION WEST CHESHIRE FEEDBACK REPORT CQC Feedback Report March 2017


https://www.westcheshireccg.nhs.uk/document_uploads/documents/Care%20Quality%20Commission%20Feedback%20Report%20March%202017.pdf


APPENDIX 2 – DRAFT PRIMARY CARE CQUIN SPECIFICATION FOR 2017/18 Draft Primary Care CQUIN Specification for 2017/18


https://www.westcheshireccg.nhs.uk/document_uploads/documents/Draft%20Primary%20Care%20CQUIN%20Specification%202017-2018.pdf


PRIMARY CARE COMMISSIONING COMMITTEE 1. Date of Meeting: 30 March 2017 2. Title of Report: Repeat Prescribing Wastage Report 3. Key Messages:

• This paper provides the Primary Care Commissioning Committee with information on the Repeat Prescribing Wastage work undertaken in practices, its impact and also sets out details regarding the investment and return on investment associated with funding additional administration hours in practices for this work.

• The Repeat Prescribing Wastage project started in 1 November 2016 with additional work undertaken by practice admin staff in 7 practices, funded by the Clinical Commissioning Group.

• On 16 January 2017 the Clinical Commissioning Group

asked Medicines Managers in all practices to dedicate 20% of their allocated time to focus on this work, 10% from the CCG’s allocation and 10% from the practice’s allocation.

• The Medicine Managers input into this work had a

significant impact in the savings made, with approximately an additional £6k net savings reported each week.

4. Recommendations The primary care commissioning committee is asked to:

a) receive the report and agree which option to support.

b) The Clinical Commissioning Group’s preferred

option is Option 3 - Increase the percentage of the allocated Medicines Managers’ hours used for this work to 30% and also continue to fund those practices who are undertaking monitoring work in addition to the Medicines Managers hours by administrators

5. Report Prepared By: Sarah Murray Head of Primary Care

Repeat Prescribing Wastage Report 1 NHS West Cheshire Clinical Commissioning Group Primary Care Commissioning Committee 30 March 2017




REPEAT PRESCRIBING WASTAGE REPORT

PURPOSE 1. This paper provides the Primary Care Commissioning Committee with information

on the Repeat Prescribing Wastage work undertaken in practices, sets out details regarding the investment and return on investment associated with funding additional administration hours in practices for this work and the results of this work. It also explores the potential to use additional medicines management hours, in addition to the 20% currently being used.

BACKGROUND

2. As part of the Financial Recovery Plan it was agreed that significant savings could be realised by reviewing repeat prescription requests on a weekly basis in practices and, where the medication was either no longer required or not yet required, these requests would be stopped.

3. The Financial Recovery Plan has a target of £400k saving for 2016/17 and will be

rolling on into the recovery plan for 2017/18 with a further target for the next financial year of £500k.

4. The Repeat Prescribing Wastage project started on 1 November 2016 with 7 practices checking and challenging repeat prescription requests, with additional administration funding from the Clinical Commissioning Group.

5. By the end of December, 22 practices were undertaking this work with additional funding from the Clinical Commissioning Group. The average net savings for this per practice was £400 per week.

6. From 16 January 2017, it was agreed to incorporate repeat prescribing check and challenge within 20% of their Medicines Manager’s allocated hours. (10% from the Clinical Commissioning Group’s allocation and 10% from the practice’s allocation). in addition to the additional administrative time funded by the Clinical Commissioning Group

7. The average net savings generated by practices per week once the medicines managers’ hours were used was £21,216 (or £606 per practice).

8. The majority of practices are now only using the 20% Medicines manager’s hours to undertake this work, however a number of practices (14) feel that having the additional administrative funding is providing additional capacity and being translated into additional savings, as well as recouping the initial investment from the Clinical Commissioning Group. These are:

Practice Return on Investment (average) Boughton 74%



City Walls 85% Garden Lane 87% Great Sutton x 3 86% Heath Lane 90% Helsby 70% Neston Medical 92% Old Hall 94% Park 84% Upton Village 66% Western Avenue 81% York Road 85%

9. The investment from the Clinical Commissioning Group for this additional admin work is £1,473 per week for all 14 practices. This would be approximately £70k for 2017/18, although to date practices have not always taken up their full allocation of these hours. If it is agreed to continue to fund this work in 17/18 then a Return on Investment lower limit could be set, i.e. only those practices achieving a Return on Investment of 65% or more would be able to access additional funding. The Clinical Commissioning Group’s initial investment of £70k would be saved plus an additional amount of between £45,550 for a ROI of 65% and £65,800 for a ROI of 94% (based on work undertaken to date in these practices).

10. On 8 March, Dr Andy Dunbavand, Clinical Lead for Medicines Management, wrote to all community pharmacists explaining the work being undertaken by the Clinical Commissioning Group and practices, asking for their support in delivering more cost effective and safer repeat prescribing. As this work has progressed a number of practices have reported a change in the prescriptions being requested by community pharmacies.

11. As at 24 March 2017, net savings for 16/17 of £229,851 have been reported.

12. The potential to increase the proportion of the Medicine Managers’ hours used to undertake this piece of work has been raised. This would ensure that repeat prescribing becomes a core part of the Medicines Managers role going forward and would also enable the Clinical Commissioning Group to direct the Medicines Managers to undertake focused repeat prescribing reviews on particular themes e.g. care homes. The Commissioning Support Unit has undertaken a piece of work to understand what impact this may have on delivery of the medicines management QIPP savings. They have reported that the Medicines Manager work accounts for approximately 49% of the total medicines management QIPP savings, therefore any changes to current work allocation could potentially affect the QIPP targets.

13. Work is underway to update the Service Level Agreement between the Clinical Commissioning Group and the Commissioning Support Unit.



OPTIONS FOR FUNDING ARRANGEMENTS

Option 1 Continue to use 20% of the Medicines Managers hours to undertake the repeat prescribing monitoring work

This option would involve the Clinical Commissioning Group continuing to direct practices to use 20% of their Medicines Managers hours to work on monitoring repeat prescription requests, as currently.

The benefits:

• The practices would continue to realise the savings, average net savings of

approximately £10,000 a week. • Unnecessary waste would be reduced. The cons:

• The Medicines Managers would have 10% less of their allocated work to

undertake tasks for the practice. • The Medicines Managers would have 10% less of their allocated work to

undertake tasks to achieve the Clinical Commissioning Group’s medicine management QIPP (which may then need to be absorbed by working with other individuals within the practices and/or by the Commissioning Support Unit team).

Option 2 Continue to use 20% of the Medicines Managers hours to

undertake the monitoring work and also continue to fund those practices who are undertaking monitoring work in addition to the Medicines Managers hours by administrators

This option would involve funding 14 practices for their administrators to undertake additional monitoring work as well as the Medicines Managers’ hours. A Return on Investment lower limit could be set, i.e. only practices achieving 65% or more of a Return on Investment would be able to access additional funding. The benefits:

• The CCG would be maximising its opportunity for realising savings. • Practices would feel engaged as they have asked to continue this work.

The cons:

• There would be additional initial investment of £1,473 per week from the Clinical

Commissioning Group which would be recouped as well as additional savings made with a minimum Return on Investment target of 65%.

Option 3 Increase the percentage of the allocated Medicines Managers’

hours used for this work to 30% (20% from CCG allocation and 10% from practice allocation) and also continue to fund those practices who are undertaking monitoring work in addition to the Medicines Managers hours by administrators



The benefits:

• The CCG would be maximising its opportunity for realising savings. • Practices would feel engaged as they have asked to continue this work. • It may increase the level of savings realised without any further investment

required by the Clinical Commissioning Group • Ensures a continued sustainable focus on repeat prescribing

The cons:

• May have an adverse effect on delivery of the wider medicines management

QIPP target. RECOMMENDATIONS

c) The primary care commissioning committee is asked to receive the report and agree which option to support.

d) The Clinical Commissioning Group’s preferred option is Option 3 - Increase the

percentage of the allocated Medicines Managers’ hours used for this work to 30% and also continue to fund those practices who are undertaking monitoring work in addition to the Medicines Managers hours by administrators

Sarah Murray Head of Primary Care March 2017





2. Title of Report: Primary Care Contracting Report

3. Key Messages:

• The Primary Care Operational Group met on 16 February 2017 and 16 March 2017 as well as discussing a number of items virtually and made a number of recommendations for approval at the Primary Care Commissioning Committee. These relate to:

o The reinvestment of the majority of the Personal Medical Services (PMS) funding via the Primary Care CQUIN for 2017/18. It is recommended that PMS funding continues to be stabilised for 12 months in one Practice due to patient demographics

• In addition, the following key issues were discussed: o The draft PMS key performance indicators

(KPIs) for 2017/18 and progress update on achievements within 2016/17

o An update was given around the Practices that are currently within the CCGs Escalation Process

• Details are provided of the changes agreed to the GMS contract for 2017/18.

4. Recommendations The Primary Care Commissioning Committee is asked to: a. Note the contents of the report.

b. Approve the recommendations of the Primary Care

Operational Group as follows: i. Approve the use of PMS reinvestment funding with

the Primary Care CQUIN for 2017/18 with one Practice having their premium funding stabilised due to patient demographics

b. Note the progress on other key issues relating to Primary Care contracting.

5. Report Prepared By: Tanya Jefcoate-Malam, Deputy Head of Primary Care

Laura Jones, Primary Care Project Delivery Manager





PRIMARY CARE CONTRACTNG REPORT

PURPOSE 1. The purpose of this report is to provide the Primary Care Commissioning

Committee with an update of the key highlights and progress of the work of the Primary Care Operational Group and request approval for the recommendations made by that group.

DECISION 1 – PRIMARY MEDICAL SERVICES REINVESTMENT FUNDING 2. As discussed at the last Primary Care Commissioning Committee, the CCG is

required to reinvest the Personal Medical Services premium that is being removed from six Practices over a four year period within General Practice. To this end, the CCG has already taken the decision through this forum to reinvest the majority of this within the Primary Care Commissioning for Quality and Innovation Scheme (CQUIN) for 2017/18. This funding has been split equitably across all Practices based on population size. This is a slight amendment to the previous decision of the Primary Care Commissioning Committee to reinvest a small proportion of this funding within Practices who are currently signed up to the Nursing Homes Local Enhanced Service (LES). This change has been made owing to this now being subsumed within the CQUIN scheme for 2017/18 and in year being the subject of a holistic review. By September 2017, it is expected that requirements for this service and funding levels will be different. PMS funding of circa £198k will be reinvested via the CQUIN to uplift all Practices delivering the CQUIN for 2017/18, which now has additional requirements.

3. It is recommended that the PMS Premium aligned to Western Avenue Practice, currently at circa £175k annually, is not reduced within 2017/18. This funding has not been reduced within year one due to evidence submitted before the commencement of the financial year 2016/17 to demonstrate a significant difference in population demographics and the risk of significant destabilisation for the Practice.

4. Western Avenue Practice have submitted to the CCG data that they have obtained

from Cheshire West and Chester Council demonstrating the health inequalities within this population:

5. Residents with bad or very bad health:

Blacon: 8.4% Cheshire West: 5.5%

6. Day to day activities limited: Blacon: 22.9% Cheshire West: 18.5%



7. Life expectancy: Blacon: Male 75.1 Female 78.9 Cheshire West: Male 79.1 Female 82.6

8. Obesity: Blacon: 27.9% Cheshire West: 22.7%

9. In addition, Cheshire West and Chester Council have published a map

demonstrating areas of significant deprivation. As can be seen, the Blacon community suffers significant deprivation, at a level which is much higher than other Practices within West Cheshire. It is therefore likely to create significant health inequalities:



10. Western Avenue Practice contend that near 100% of patients registered at this Practice are from the Blacon community. Please see the quote below taken from Cheshire West and Chester’s Health Inequalities report:

11. By retaining this funding, the Practice has implemented a number of key services in order to address some of these health inequalities. These can be seen in detail in Appendix 1, but in summary, include: a) Staffing the Practice at an increased level in order to offer acute services to

patients within the community – including same day access to appointments for all patients. Additional staffing costs are broken down as follows: • 7 Salaried GP sessions = £86,380 per annum (inc. on costs) • 8 Nurse Practitioner sessions = £42,280 (inc. on costs) • 1 full time practice nurse = £45,720 (inc. on costs) • Part-time employment of an in-house pharmacists = £4,000 • Direct mental health service = £9,000 • Total = £187,380

12. Positive outcomes at Western Avenue have continued to be achieved for patients

within an area of significant health inequalities, as per the PMS KPIs. In summary: a) Although A&E attendances are above average, every patient who has

attended at A&E with a condition that could have been dealt with within Primary Care at a time when the Practice is open is contacted to promote the Practice services. The Practice have seen a reduction in A&E attendances compared to the previous year of 5.22%

b) The Practice are high achievers for QOF, and continue to be within the top quartile of Practice performers for flu vaccination uptake in the over 65s and cervical screening

c) The Practice were identified as a “Chlamydia testing champion” within 2016 due to their increasing and high performance in offering and completing these tests for patients.

13. It is therefore recommended that the PMS premium is not reduced for Western Avenue within 2017/18.

PRIMARY CARE CONTRACTING ISSUES PMS KPI ACHIEVEMENT AND DEVELOPMENTS FOR 2017/18 14. Quarter 3 KPI evidence templates have been received by the CCG for all PMS

Practices. The following Practices had submitted returns and their progress is noted below: a) Garden Lane: Provided evidence to demonstrate that they have continued to

work closely with the university to implement changes to their service that will



improve the outcomes for university students. They have taken a proactive role in using E-Consult, have commenced social medial communication with patients and updated the university website to provide additional information about Primary Care. The Practice has also arranged a meeting with other Practices within City who take on the registration of University students to share best practice and discuss whether a more collaborative approach to managing students across a wider foot-print might be possible. The Practice continues to use the WEBWEMs mental health assessment tool, however are yet to discover any significant improvement in outcomes from its use. This continues to be analysed.

b) Bunbury: Have also submitted their return demonstrating their continued work with self-management alternatives to Primary Care and the leisure sector. The Practice continue to work on their frailty (as do other Practices via the CQUIN) but have instigated internal processes to make use of local step-up beds and daily A&E / discharge data sent from the Countess to Practices. This has resulted in direct contact to the ward being made and discharges supported. The Practice continue to carry out their men’s health checks and have had 47 dedicated appointments within this quarter.

c) Western Avenue: The Practice has been unable to attend Starting Well meetings in month due to clinical needs. However, they have continued to support and promote the Starting Well programme projects where required and have given EMIS support to a project. The Practice continue to achieve positive outcomes through their high use of screening, and have supplied evidence to the CCG around their use of Practice Pharmacists and Mental Health workers collaboratively with CWP. The Practice continues to audit and discuss A&E attendances with patients and will supply the CCG with information to take to contract meetings where required.

d) Tarporley Adey: The Practice continues to instigate proactive homes visits to prevent admission and achieve patient outcomes. These are generally for patients within their last stages of life and have decreased over recent months. The Practice have also worked with the CCG to provide feedback and useful information to aid discussions with the Countess about the development of this data. Use of EPACCs (End of Life EMIS templates) have also increased, and although the Practice have not been able to attend meetings relating to this due to short notice, have provided relevant feedback. The Practice are also working closely with their carers link and have increase the numbers of patients recorded as being a carer. Finally, the Practice has committed to working closely with the CCG as we develop electronic care plans.

e) Fountains Medical Practice: The Practice within quarter three has continued to make their GP Partner available to attend CCG meetings to discuss the development of the Nursing Homes LES. In addition, the GP Partner has provided CCG advice with regards to a Practice Survey to gauge the outcomes of the current scheme and to provide advice around the prescribing of flu anti-virals for patients within care homes. Quarter 4 KPIs for this Practice will be dealt with separately.

15. The CCG expect to receive completed quarter 4 evidence templates from the above Practices by 31st March, 2017. It should be noted that the Village Surgeries no longer have a PMS Premium or KPIs.

16. Work has now commenced within the CCG to draft KPIs for 2017/18. These will be agreed with PMS Practices by 31st March 2017 where possible and will be entered



into the PMS Contracts by NHS England in April 2017. A table setting out the expected content of these KPIs is set out below:

Practice Name PMS Q1 KPI - Year 2 Tarporley Adey • Continuing to record of end of life care on EPACCs and share feedback

across other practices in West Cheshire. • To act as the link practice with the CCG for the CQUIN, by providing support

and feedback on an ad-hoc basis to the CCG. Bunbury • To share expertise and good practice with the CCG gained from delivering

the Well Man Clinic, with particular focus on sharing best practice for management of patients with erectile dysfunction.

• To act as the link practice with the CCG for the CQUIN Care Plan, by providing support and feedback on an ad-hoc basis to the CCG.

Western Avenue

• To continue to work with the CCG to pilot, test and audit any relevant Starting Well work including use of technology by helping to develop, support and pilot new ways of working and be a key contact to other Practices as these roll out (e.g. by sharing tips, providing practical advice and case studies in how to make these work in practice) and to continue to support the evaluation of those initiatives implemented

• To continue to take a proactive approach to managing the health inequalities within the community via relevant screening, A&E attendance follow-ups, QOF and innovation

• To work with CWP to devise new mental health pathways appropriate for the local community.

Garden Lane • To demonstrate the sharing with other practices in West Cheshire CCG of good practice and knowledge around caring for students and young people and in particular the usage of e-Consult, feeding back to the CCG on its use and acting as a key point of contact for other Practices wishing to use this tool

• To work with other practices to consider developing a cluster based service for students and young people. Also to provide feedback to the CCG on best practice for young people mental health.

Fountains Medical Centre

• To be confirmed.

PRIMARY CARE ESCALATION PROCESS 2016/17 17. Within 2016/17, the CCG has approved and implemented a Support and Escalation

Process. Although this does not currently link to the Primary Care CQUIN Incentive Scheme, the CCG has been working with a number of Practices who are at significant variance to CCG average. A progress report of this work to date can be seen below:

• Whitby Warren (Stage 2 – Planned Care)

CCG Officers linked to this Practice have spoken with the new Practice Manager to give an update on the situation and advise on the relevant indicators via the dashboard. A meeting was arranged with the partners from the Whitby Practices on 8th March, 2017. The CCG managers linked to this work were in attendance, as well as the clinical lead assigned to this Practice. An information pack has been pulled together that details the main areas for support, along with a template agenda to ensure the meeting is



effective. At this meeting, a patient level audit was agreed with feedback to be received from the Practice by 31st March, 2017

• Neston Surgery (Stage 2 – Planned and Emergency Care)

The Practice met on the 10th February with senior CCG Managers. At this meeting, the Practice fed-back on their roll-out of dedicated second opinion clinics to reduce the number of unnecessary dermatology referrals. The Practice has found that 80% of patients that have passed through this clinic that would have traditionally been referred have now been managed within Primary Care. The Practice are also working with the CCG to look at redesigning pathways such as paediatric hearing tests in order to achieve a more efficient solution. The Practice has been asked to complete a retrospective audit of emergency admissions and are due to be sent patient level data to facilitate this. It is hoped that this will support the work of the Cluster (a nurse has been recruited to carry out additional admissions avoidance care within residential homes). The Practice have also agreed some specific actions around their Medicines Management over performance focusing on respiratory and antibiotics. Although the outcome of this work will not be seen until the release of the March 2017 Primary Care Dashboard, initial reports from the contracting team have shown a reduction in activity within the main provider utilised by these Practices.

• Malpas (Stage 2 – Planned Care)

The Practice are continuing to monitor their internal data and report back to the CCG where required. The Practice has been sent a data sharing agreement in order to release the patient level data that will support a further internal audit. This agreement has now been signed and the results of the internal patient level audit will be shared with the CCG within agreed timescales. The CCG can then offer any additional support as per agreed actions, or independent clinical peer review if identified as helpful.

• Westminster (Stage 2 – Planned and Emergency Care)

A CCG Manager has now met with the Practice to detail the dashboard indicators that have resulted in the Practice being recommended to enter the process. The Practice have also carried out an internal referral audit that has been external peer reviewed. This audit has demonstrated some specialty areas that could be focused on to avoid unnecessary referrals. The Practice have written to the CCG with recommendations for internal pathways to be implemented that should lead to improvement. The Practice has also signed a data sharing agreement to enable the release of patient level emergency admission data to allow a similar audit to be completed for these patients. The expected completion date for audits and pathways is set for 24th March, 2017. In the meantime, the Practice are working to internally promote such services as the Geneo Portal and the Accenda virtual basket.

a. Primary care quality:



i. The three Great Sutton Practices have previously been contacted due to their performance for friends and family test, GP survey and CQC. The Practice have provided assurance that this work is taking place and have been offered additional CCG support. The Practice are due to be re-inspected by CQC imminently.

ii. Helsby Practice have also had discussions with the CCG around their CQC status and assured of additional support from the CCG if required. The Practice has approached the CCG to discuss the Support and Escalation Process – further contact with the Practice is in the process of being made.

iii. Bunbury Practice will be contacted as soon as capacity is available via the Locality Project Manager to provide any additional support required. Additional support around the Practices claiming process has already been supplied by the CCG and NHS England.

b. Primary care CQUIN:

i. As at end of February 2017, all bar three Practices have achieved their targeted frailty assessments cumulatively. Three Practices are currently “amber” and therefore further contact will be made to ensure they are on target to achieve KPIs by year end.

c. Primary care clinical quality:

i. Frodsham (via the Knoll), York Road and Westminster have all been contacted in order to ensure that their screening and immunisation levels are improving. This work is ongoing.

d. Medicines management

i. Old Hall, Great Sutton McAlavey and Neston Surgery are all being provided with additional support via the CSUs Medicines Management Team. Updates around the work taking place with Neston Surgery was given at the last meeting. More support will now commence with Old Hall and Great Sutton.

18. The CCG will continue to work informally with the Practices noted above. The formal link between the Primary Care CQUIN from April 2017 is detailed within a separate paper.



GMS Contract Changes for 2017/18 Introduction 19. Agreement has been reached with the General Practitioners Committee (GPC) regarding

changes to the General Medical Services (GMS) contract for 2017/18 which seeks to address concerns of the profession in relation to workload and increasing expenses and other agreed changes. The agreement reflects commitments made as part of the General Practice Forward View (GPFV) and continues to make significant investment in primary care.

20. The NHS Employers contract website www.nhsemployers.org/gms provides details of the

agreement and NHS England’s dedicated GP contracts page https://www.england.nhs.uk/gp/gpfv/investment/gp-contract/ will give details of the implementation guidance, links to supporting legislation and standard contract documentation in time for these new arrangements to take effect from 1 April 2017. Given the timing of this announcement NHS England will be implementing the changes to the Regulations from July 2017 at the earliest. The contract for 2017/18 will see a national investment of £238.7 million.

21. The details have been circulated to all GP Practices, Clinical Commissioning Groups and

Local Medical Committees. Delegated Commissioning Groups will receive the budget uplifts and will implement the changes for their GP Practices

22. The 2017/18 GMS contract changes are welcomed and will support the commitments

made as part of the General Practice Forward View (GPFV). The agreement will introduce measures to address concerns of the professions in respect of increasing workload and expenses and makes a significant investment in primary care.

Summary of the changes agreed 23. The changes include:

a) A pay uplift of one per cent and general expenses uplift of 1.4 per cent.

b) Funding to cover expenses relating to Care Quality Commission (CQC) costs

(estimated £22.5 million), indemnity fee increases (£30 million) and Business Improvement District (BID) levies (estimated £1 million). CQC and Business Improvement District levy costs will be reimbursed directly and indemnity costs will be reimbursed based on practice list size.

c) The global sum per weighted patient will rise from £80.59 to £85.35 (5.9%

increase). The increase in the global sum takes into account: • Increased superannuation costs of 0.08% pension admin charges • Workload associated with overseas administration changes • Workload involved in the workforce survey • Workload involved in bagging and labelling of medical records • Population growth

d) Sickness leave reimbursement - An increase in the maximum amount payable from

£1,131.74 to £1,734.18 per week. Payments will no longer be discretionary and the qualifying criteria based on list size will be removed. This means more practices will be able to claim.


https://www.england.nhs.uk/gp/gpfv/investment/gp-contract/


e) An increase in the payment for Learning Disabilities Health Check Scheme from £116 to £140 per health check

f) A change in the value of a Quality and Outcomes Framework (QOF) point as a

result of a Contractor Population Index (CPI) adjustment. There will be no changes this year to the number of QOF points, indicators or thresholds. The value of a QOF point will increase from £165.18 to £171.20

g) The Avoiding Unplanned Admissions Directed Enhanced Service (DES) will be

discontinued as of 31 March 2017. The 2016/17 spend of £156.7 million will be transferred into global sum, without the out of hours (OOH) deduction applied, and used to support work on frailty. Practices will not be performance managed regarding this.

h) Changes to the GP Retention Scheme with an additional £1 million investment open

to all GPs who are seriously considering leaving or have left general practice due to personal reasons, approaching retirement or who require greater flexibility.

i) Funding to cover expenses relating to submission of data for the NHS Digital

Workforce Census (£1.5 million), contractual changes relating to overseas visitors (£5 million) and pensions administration levy (estimated £3.8 million). This funding will be added to the global sum allocation without the out-of-hours (OOH) deduction applied.

j) A recurrent payment of £2 million for workload related to transfer of patient records.

This figure will be reviewed from time to time with regards to workload issues. It will be added to the global sum allocation without the OOH deduction applied.

k) There are also new contractual requirements around the following:

o Identification and management of patients with frailty. Practices will code clinical interventions for this group appropriately and data will be collected regarding the patients

o Registration of prisoners before they leave prison. This will allow the timely transfer of information from prison to practice with an emphasis on medication history and substance misuse management plans to enable better care when the patient presents at the practice.

o Access to healthcare. Contractual changes will help to identify European Economic Area patients who may be subject to NHS (Charges to Overseas Visitors) Regulations 2015. New recurrent investment of £5 million will be added to the global sum allocation to support this requirement.

o Vaccination and immunisations and data collection. Changes to the specifications for seasonal flu, childhood seasonal flu, MenACWY, Pertussis and Shingles programmes will be introduced.

l) Changes will be made to the Extended Hours Enhanced Service specification which

will make practices who close for half a day each week ineligible to provide this service.

RECOMMENDATIONS

24. The Primary Care Commissioning Committee is asked to:

a) Approve the recommendations of the Primary Care Operational Group as follows:



i. Approve the use of PMS reinvestment funding with the Primary Care

CQUIN for 2017/18 with one Practice having their premium funding stabilised due to patient demographics

ii. Note the other key issues relating to Primary Care contracting.



APPENDIX 1 – WESTERN AVENUE SUBMITTED EVIDENCE REPORT

PMS Review – Western Avenue Medical Centre

Impact of reduction in PMS funding: Points previously raised in earlier report: The only realistic way to cover the reduction in PMS funding is to lose clinical staff. The practice is currently staffed as follows: 17 GP sessions per week (12 partner sessions and 5 salaried sessions) 8 Nurse Practitioner sessions 1 full time practice nurse Staff costs: 7 Salaried GP sessions = £86,380 per annum (inc. on costs) 8 Nurse Practitioner sessions = £42,280 (inc. on costs) 1 full time practice nurse = £45,720 (inc. on costs) The Practice cannot operate without these staff. The ‘Practice Index’ guide to clinical staffing levels indicates that a practice of 4,000 patients should operate with 2.7 GPs and 1 Practice Nurse. With the combination of GPs and Nurse Practitioners, we are operating at the level of 2.7, and would argue that because of the deprivation factor and additional work that this creates, our workload is greater than that of a usual 4,000 patient practice. The removal of the salaried GP and Nurse Practitioners would leave 12 GP sessions per week, which is clearly insufficient and unsafe for a practice of 4,000 patients. The impact on services within the practice, and on external services and other care departments, would be disastrous. Deprivation & health inequalities: Blacon is an area of deprivation, and the workload of the practice is impacted upon by the increased health and social needs attached to residents from a deprived background. As such, our patients access our service more regularly than those from a less deprived background. As a result, we need to staff the practice accordingly, despite only receiving funding for a list size of 4,000. It is acknowledged that other practices in West Cheshire have Blacon residents registered as patients. Blacon residents at other practices will be in the minority, whereas almost 100% of our patients reside in Blacon. In a recent Cheshire West and Chester Council Blacon Ward Snapshot, the health inequalities between Blacon residents, and residents from other Cheshire West areas, were highlighted: Residents with bad or very bad health: Blacon: 8.4% Cheshire West: 5.5% Day to day activities limited: Blacon: 22.9% Cheshire West: 18.5%



Life expectancy: Blacon: Male 75.1 Female 78.9 Cheshire West: Male 79.1 Female 82.6 Obesity: Blacon: 27.9% Cheshire West: 22.7% Safeguarding: The practice currently has 187 patients coded as a safeguarding concern. During our CQC visit, the inspectors were astounded by this figure, especially for such a small practice. These patients generate a considerable amount of additional work for both GPs and admin staff; preparing reports, attending meetings, meeting with the Health Visitor, and updating our records. Requests for information and reports: Due to the large number of patients who are seeking employment or claiming benefits, the practice receives over 30 requests per month for GPs to provide reports and complete forms such as ESA, Universal Credit, and PIP. This work takes a considerable amount of GP time, in addition to their usual day to day duties. Providing rooms to external organisations: The practice provides rooms free of charge to offer patients services specific to their needs e.g. Stonham Housing Support and Remploy Employment Services. Registrations: Although the practice patient list size remains fairly consistent, due to the high levels of social housing in Blacon, there are a large number of new patient registrations and patient deductions. In 2016, 245 patients registered at the practice, and 340 moved away. These changes in registration generate considerable additional work for administration staff, and add additional pressure on clinical time for New Patient Health Check appointments. New ways of working: In-house pharmacist – Due to the poor health of our patient population, a large number of patients are in receipt of multiple medications. The practice has employed a pharmacist to manage these patients, tasked with reducing polypharmacy and the risk of falls in the elderly. (cost: 2 sessions per week = £4,000 per annum) Direct access mental health service – There is a clear link between deprivation and poor mental health. A large number of our GP appointment time is allocated to seeing patients with mental health conditions. The practice has employed a Mental Health Nurse and Psychological Wellbeing Co-ordinator, allowing patients to access mental health services without the need to see a GP, or wait several weeks for a referral. The service has proved extremely successful, with excellent patient outcomes, and releasing pressures on the GP clinics to see other patients. During Q3 of 2016, the number of referrals to the Mental Health Team has halved compared to the same period in 2015 (2015: 37 referrals 2016: 19 referrals) (cost: 1 MH Nurse session and 1 PWP session per week = £9,000) GP 5 year forward view: The practice is highly innovative, and already carries out much of the work highlighted in the 10 high impact actions:



1. Active signposting: A huge amount of time has already been invested in coaching and mentoring the reception team to ensure that patients are signposted to the service that best meets their needs. This includes services such as Pharmacy First, Physio First and NHS11, as well as the range of internal services that we provide, such as Pharmacist, Mental Health Practitioners, GPs and Nurse Practitioners. The practice also promotes self-help initiatives, such as providing RCGP ‘When to Worry’ leaflets, the Cheshire Child Health app, and organising a patient education event for parents of young children. 2. New consultation types: The practice offers patients the option of telephone appointments, and has recently developed an information letter for patients with low vitamin D levels to avoid the need to attend the practice. The practice also uses MJog messaging service for text message follow ups, and offers patients the option to complete asthma reviews forms and travel vaccination questionnaires online. The practice did consider E-Consult, but felt that as a small practice this would prove to be more disruptive. Following a recent patient survey, 76% of patients were aware of Patient Access online services, but only 16% of those used the service. One of the main reasons for the low use was that patients couldn’t use a computer, or didn’t have access to a computer. It was felt that the uptake for E-consult would be very low. 3. Reduce DNAs: Over the past 12 months, the practice has reduced DNAs by 31%. This has been achieved by introducing a more robust system for contacting patients following a DNA, installing MJog as an appointment reminder service, which also allows patients to cancel their appointments via text and outside of practice hours. 4. Develop the team: The practice workforce has been expanded, to include a pharmacist and mental health practitioners. ANPs have been sent on RCPG training, and received GP mentoring, to increase their working knowledge, to improve appointment availability. 5. Productive work flows: Patients with multiple chronic diseased attend one annual health review. This helps to reduce the patient journey, and reduces clinical and admin working time. Direct access to mental health services, employment services and housing support. Change in system for reviewing bloods has reduced the number of patients requested to attend to review their results. 6. Personal productivity: All administration functions will be process mapped using LEAN principles, to ensure that we are working in the most efficient way possible. The process for managing prescription requests has already been reviewed, resulting in more efficient and safer working systems. 7. Partnership working: The practice already operates in a highly effective cluster, with three other City practices. A frailty service has already been established, and involves a Nurse Practitioner from this practice. The practice has also carried out joint recruitment campaigns with one of the cluster practices. 8. Use social prescribing: The practice utilises the services of the cluster wellbeing co-ordinator, as we all as providing accommodation for housing and employment services. 9. Support self-care and management: See ‘Active signposting’



10. Build QI expertise: No formal team has been developed, but our good practice for the management of prescribing Z drugs and hypnotics has been shared with the other practices within our cluster, and we are currently assisting with implementation and rollout. The removal or reduction of our PMS funding would undo all of this good work, and have a huge impact on our patients, the level of care that we can offer, and other Primary and Secondary Care services. It will also have an impact on screening levels, appointment access, DNAs, patient satisfaction, and A&E attendances. The PMS funding is used to staff the practice at a sufficient level to deal with all of the additional work generated by a patient population based in an area of deprivation. To demonstrate the staffing levels that are required to manage the additional workload, our accountant has produced some staffing cost comparisons. The figures below are for the financial year ending 2016, and are Western Avenue Medical Centre costs compared to other similar sized GP practices who instruct our accountant: Admin & nursing costs per patient: WAMC: £67.69 Others: £43.80 Salaried GP cost: WAMC: £37.02 Others: £8.13


PRIMAY CARE OPERATIONAL GROUP

Thursday 19 January 2017

Room B, 1829 Building

PRESENT: Dr McAlavey, Andy (AMcA) – Chair

Medical Director for NHS West Cheshire CCG, GP Great Sutton Medical Centre

Murray, Sarah (SM) Head of Primary Care, NHS West Cheshire CCG Jefcoate-Malam, Tanya (TJM)

Deputy Head of Primary Care, NHS West Cheshire CCG

Green, Brian (BG) Head of Quality and Safety, NHS West Cheshire CCG Dr Riley, Julia (JR) Clinical Lead Quality and Safety, NHS West Cheshire CCG Gregson, Jonathan (JG) GP, Helsby and Elton Practice and Primary Care Cheshire

Representative Salter, Ken (KS) Patient Representative Goldsbrough, Tim (TG) Practice Manager, Hope Farm Medical Centre Suckley, Lynn (LS) Managing Partner, Malpas Surgery In Attendance: Agenda Item: Hardy, Cheryl (CH) Business Administrator

Agenda no.

Agenda Item Action by

2017-032 Welcome and Apologies The Chair welcomed everyone to the meeting and noted that apologies were received on behalf of Hayley Pashley, Louise Barry, Pauline Finlay, Ellie Ennis.

2017-033

a. Previous notes of Primary Care Operational Group 22nd December 2016

The minutes of the meeting on 22nd December 2016 were accepted and agreed as an accurate record with the following amendments. Lynn Suckley to be added to the attendance list. Page 3 - Procurement Update – change to the new contract starting on 1 November 2017. b. Action Tracker

• 6. Multispecialty Community Provider Contract for Princeway Cluster SM provided an update and advised we are still waiting for the MCP contract, although this is now more aligned to primary care home models.

• 2016-013 – Safeguarding Audit Tool

TJM will provide an update after April 2017.

Minutes of Primary Care Operational Group 19.01.17 NHS West Cheshire Clinical Commissioning Group 1

Agenda no.


• 2016-020 - Terms of Reference a. Amended Dates for 2017 – These dates have been circulated. b. Updated Terms of Reference – This item was covered under the

agenda. c. GP Incidents - It was agreed the GP incidents would be covered

on the Quality Improvement agenda and any primary care quality issues would come to this meeting on a bi-monthly basis.

• 2016-022 - Primary Care Programme Update

a. Summary Care Record – TJM raised this issue with the IT department at the Countess of Chester Hospital who agreed to speak to JR, TJM agreed to chase this as JR confirmed they have not been in contact with her. AMcA informed the group he has alerted John Glover to the training issues.

b. E-prescribing – The group discussed the issue of patients not receiving a printed list of their medications TJM agreed to raise this with NHS England.

• 2016-024 - Primary Care Monitoring Report

a. Escalation process – TJM advised she has not asked Neston Surgery to share their learning from this as the process has not been completed yet. It was agreed this would be brought back to the February meeting.

b. CQUIN Update – TJM confirmed this action has now been completed.

• 2016-025 – Incidents Update

a. Audit re Access LES – SM confirmed this action has now been completed.

b. Written Communication – This item will be discussed on the agenda.

c. Human Factors Issues around samples – JR confirmed an alert has now gone out to practice managers regarding this. It was agreed this would continue be discussed at Practice Managers meetings.

d. CQC Visits – It has now been agreed CQC will attend the March meeting. This was discussed at practice managers meetings and agreed practice managers would meet before the March meeting to discuss the format of the presentation. JR offered to help practices prepare for this she noted a lot of concerns have been raised and asked if these could be sent to her to review, SM confirmed she has raised this with Practice Managers and asked them to send concerns to JR.

e. Significant Event Analysis – JR confirmed this action has now been completed, and agreed to find out when the SEAs need to be reported to CQC.

• Primary Care Services

a. Outstanding Issues with Capita – TJM confirmed that Capita will be contacting practices regarding any outstanding issues.

b. Briefing Document – TJM agreed to chase SS as she has not yet received a copy of this.


Agenda no.


2017-034 Declarations of Interest There were no new declarations to declare.

2017-035 Terms of Reference SM provided an updated Terms of Reference to the group which confirms the meetings will now be held monthly and GP quality items will be reviewed at this meeting bi-monthly. The group agreed Terms of Reference with these changes.

2017-036 Primary Care Programme Update SM provided a primary care programme update to the group and noted the following: Enhanced Extended Hours Service Two of the three nurse prescriber roles have now gone out to advert. Physio First SM advised the physio first service is going very well. Wellbeing Service Wellbeing sessions have now started and are being booked by Age UK. The CCG is holding an engagement event this afternoon which will help inform the service spec with 17 organisations registered to attend. A project team will be pulled together and a tender will be issued in two weeks. Technology Infrastructure SM informed the group the funding for IT infrastructure for practices and estates has now been applied for and she has heard verbally we are likely to get this but is still awaiting official confirmation, SM agreed to confirm this as soon as it is agreed. Medicines Management Repeat Prescribing Project SM confirmed this project has made significant savings with 25 practices undertaking extra hours, however some practices have been asked to reduce this service as it is not delivering sufficient savings. Practice Clinical Pharmacist The group discussed these and wondered whether community teams can take part in this service, SM agreed to liaise with them around this. The group discussed the issues around providing staff and who would hold their employment contract to support this as at the moment only PMS or GMS contract organisations are able to take part in this. SM agreed to look into this. Practice Update SM informed the group as of last week 5 local GPs have become partners at Old Hall Surgery. Also Frodsham Medical Centre are looking to work collaboratively with Helsby practice.

SM

SM


Agenda no.


2017-037 Procurement Update SM provided a procurement update and noted the St Werburghs market engagement event is taking place and the CCG are in the process of writing the service specifications. Following the patient engagement exercise they are hoping to start the new contract in September 2017. The Chair expressed his disappointment that NHS England did not attend the meeting and it was agreed to note this disappointment.

2017-038 PMS Highlight Report and Reinvestment Proposal TJM provided an update on the process of this year’s KPIs and advised although the CQUIN reinvestment was approved at the Primary Care Commissioning Committee, since then two practices have proposed that their reinvestment will be dealt with differently rather than through the CQUIN. The report proposes to reinvest a proportion of the PMS funding differently due to population demographics and the requirement to improve funding for the Nursing and Care Home scheme. TJM advised the majority of this funding will be used equitably across practices some however could be based on nursing home beds. The group discussed if they were comfortable with distributing funding in this way JR noted patients in nursing homes do create a lot of work and therefore agreed if a practices is signed up to the primary care LES and look after all the patients in a nursing home they should receive the funding for this. It was therefore recommended that funding for this would be reinstated as agreed with the nursing home networks on the basis of nursing and care home beds. The second recommendation in the report was to continue the same funding at Western Avenue due to the health inequalities in this practice. TJM advised she has met with Western Avenue to discuss concerns around funding as they have a different population compared to other practices and can demonstrate all funding is used on staff to provide services therefore they have asked that their PMS funding is not reduced this year. They have submitted evidence that this would destabilise the practice due to deprivation and other issues. The group highlighted other areas are also deprived however TJM suggested although other areas are deprived Western Avenue is more concentrated in one practice. TJM advised that Western Avenue have stated that they would hand in there contract if this funding was taken away and advised if it was agreed they could keep the funding the next step would be to work with them to set some stretched outcomes specific for that population. The group voted on this with the following results JG, LS and TG abstaining and JR, BG, SM, AMcA and TJM agreed to these recommendations.

2017-039 Primary Care Monitoring Report TJM provided an update to the group on the primary care monitoring report and noted the following.


Agenda no.


TJM informed the group that additional work is being done with the practices that have moved into stage 2. The report provides an update on where the CQUIN is up to. TJM confirmed this year all bar one practices has achieved the CQUIN this is due to coding issues and is currently being looked into. The group agreed the recommendations made in the report. AMcA thanked TJM for this report and the group agreed it was very useful.

2017-040 CQUIN and Primary Care Quality Update TJM provided an update on the Primary Care Quality and advised the report gives an overview of what is going to be covered in the draft CQUIN for 17/18. She noted the following. Previous local enhanced service specifications will be subsumed by this CQUIN, there should be a small increase in funding to each Practice. As we try to move to a more outcomes based contract Practices will receive their funding as a lump sum each quarter to help them re-divert funding to where it is best needed and for some practices to work together as a cluster. This report has been presented at Cluster Leads and Locality Network meetings. Chris Ritchieson has now asked for a meeting to work out next steps and look at the best way to move forward based on feedback received. This document will continue to be developed in February 2017 with a more final document being presented to practices in March. Primary Care Operational Group agreed that waiting for a more final document in March would be more helpful and asked that TJM communicated this decision with practices in advance of the February networks.

2017-041 Incidents Update JR provided an incidents update to the group and advised there have been lots of issues around poor communication from the Countess of Chester Hospital. The group reviewed some anonymised examples of these which JR advised have been datixed, she noted these have raised some safety concerns as there were lots of errors and contradictions regarding the patients. The group agreed there were no incentives for hospital staff to complete forms correctly although it is in the contract, JR noted she has sent a copy of the datix report to the hospital and has arranged to meet with Nick Lanley to discuss this issue.

2017-042 Planning for CQC session in March 2017 This item was covered earlier in the agenda.


Agenda no.


2017-043 Update on delegated commissioning SM confirmed the Clinical Commissioning Group will not be going to delegated commissioning in April 2017.

2017-044 Any Other Business There was no other business to be discussed.

Date and Time of the next meeting 2.30pm – 4.00pm Thursday 16th February 2017 Conference Room D, 1829 Building


Meeting Notes GP Access Fund Steering Group

Wednesday 16th November 16; 09:00 – 10:30; Helsby Health Centre

Present: • Brian Yorke

Chief Operating Officer, Primary Care Cheshire • Nicola Daniels

Business Operations & Delivery Manager, Primary Care Cheshire (PCC)

• Kerry Winsland ICT Relationship Manager, MLCSU

• Sarah Murray Programme Lead Primary Care, NHS West Cheshire CCG

• Kevin Carbery Interim Project Manager, NHS West Cheshire CCG

Apologies: • Shana Tam

Acting Chair, Primary Care Cheshire

• Lynne Blackhall Head of Finance, NHS West Cheshire CCG

No. Subject Action Who 1. Notes from previous meeting

The Steering Group approved the notes.

2. Update on all PMCF projects Kevin presented a brief summary of all revenue and capital projects including the RAG rating. All actions completed.

MPLS: The group were updated that Malpas was scheduled to migrate to MPLS on the Rolling Half Day on 15th Dec 16.

To progress project Kevin

3. Summary of current financial position Revenue budget:

Kevin shared the latest budget spend and forecast for the

revenue budget. To continue to monitor the spend.

Kevin

4. Summary of current financial position Capital budget: Kevin provided the Steering Group with a detailed breakdown of actual, committed and forecasted spend for this budget.

To progress relevant orders when appropriate.

Kevin

5. Update on Committee papers Planned papers: Paper regarding revenue costs for projects relating to Estates & Technology & Transformation Fund (ETTF) to be presented to Primary Care Commissioning Committee in December 2016.

To write the paper with CSU colleagues & present to committee

Kevin

6. Sustainability Plans Updated Sustainability Plans. To be updated to no longer

include areas not linked to GP Access Fund.

7. Risk Register Kevin highlighted the revised risks from the risk register. There was one new risk PMCF 29 regarding delays to spending capital funding due to delays to project.

To continue to update the Risk Register, as appropriate

Kevin

8. Any other business Brian asked for an update regarding the roll-out of the Cross Organisational Appointment diary for GP Extended hours. Kevin provided Brian with the present position and planned roll-out.

To deliver the Cross Org project for all GP practices

Kevin

To arrange dates for future meetings. To review availability

and book dates until March 17.

Kevin

9. Next meeting: Wednesday 18th January 2017; 13:00 – 14:30.

Meeting Notes GP Access Fund Steering Group

Wednesday 18th January 2017; 14:00 – 15:30 Helsby Health Centre

Present: • Brian Yorke

Chief Operating Officer, Primary Care Cheshire • Dr. Catherine Wall, Primary Care Cheshire • Nicola Daniels

Business Operations & Delivery Manager, Primary Care Cheshire (PCC)

• Kerry Winsland ICT Relationship Manager, MLCSU

• Sarah Murray Programme Lead Primary Care, NHS West Cheshire CCG

• Kevin Carbery Interim Project Manager, NHS West Cheshire CCG

• Lynne Blackhall Head of Finance, NHS West Cheshire CCG

No. Subject Action Who 1. Notes from previous meeting

The Steering Group approved the notes. The actions were completed including: Planned migration of Laurel Bank Surgery at Malpas to the Cheshire Shared IT network on 15th Dec 16 was successful. Paper regarding revenue costs for projects relating to Estates & Technology & Transformation Fund (ETTF) was presented to Primary Care Commissioning Committee in December 2016.

2. Update on all GPAF projects Kevin presented a brief summary of all revenue and capital projects including the RAG rating.

Kevin updated the group regarding the roll-out of the

Cross Organisational Appointment diary for GP Extended hours.

To continue to progress project

Kevin

3. Summary of current financial position

Revenue budget:

Kevin shared the latest budget spend and forecast for the

revenue budget. To continue to monitor the spend.

Kevin

4. Summary of current financial position Capital budget: Kevin provided the Steering Group with a detailed breakdown of actual, committed and forecasted spend for this budget.

To progress relevant orders when appropriate.

Kevin

5. Update on Committee papers Planned papers: Kevin stated that as the Estates & Technology Transformation Fund work also required CCG to agree to commit to significant revenue cost. Paper required to be presented to the Finance, Performance & Commissioning Committee on 2nd February 2017.

To write the paper & present to committee

Kevin & Kerry

6. Risk Register Kevin highlighted the revised risks from the risk register including 2.0, and 3.6. There were new risks 2.10; 2.11 and 3.7 and agreed to close Risk 7.4.

To continue to update the Risk Register, as appropriate

Kevin

7. Any other business The group agreed to Kevin’s proposal for Steering Group to revise its Terms of Reference that it will also have responsibility to monitor spend on GPAF ‘improved access’ budget and for Memo of Understanding between CCG and Primary Care Cheshire to be extended to cover rest of the financial year and the ‘improved access’ GP Access Fund.

To arrange for MOU to be signed and update the Terms of Reference

Kevin

8. Next meeting:

Wednesday 15th February 2017; 09:30 – 11:00 Room 1, First Floor Meeting Room, 1829 Building

IT Infrastructure Board Project Board Meeting

04/10/2016 – 1829 Building Chester

Present: Name: Organisation: Kevin Carberry (KC) WCCCG Ian Hart (IH) MLCSU Kerry Winsland (KW) MLCSU Andy Gaskell (AG) MLCSU Ian Bradbury (IB) MLCSU

Apologies

Name: Organisation: Phil Eagle (PE) MLCSU Sarah Murray (SM) WCCCG Ben Foster (BF) MLCSU

Item: Notes: 1 Apologies received as above – Board is quorate 2 Previous minutes were confirmed as accurate

Review of actions from previous meeting Action comments –

1. AG confirmed he has met with the consultant leading the project in Cumbria. The project has encountered issues with one of the suppliers and has been placed on hold. Closed

2. KW has spoken to Garden Lane and they are happy with their involvement in the

project. Closed

3. KC confirmed that the PO for the CDW days utilised has been raised. Closed

4. AG confirmed that a paper has been provided to KW outlining the costs to design and deploy NWSIS. This needs to be confirmed by MLCSU Finance before being issued to the CCG. KW will issue to Finance and provide proposals. Carry forward

5. Action carried forward and costs have yet to be provided to KC/SM. Carry forward

6. BF provided quote to KC. KC happy with quote and PO will now be raised. Carry over

7. KC confirmed that costs and estimates had been reviewed. Closed

8. KC confirmed that PO for Lakeside deployment was with PCC. Closed

9. AG confirmed he has agreed the process with CDW to approve and monitor call

down days Closed

10. BF issued the risk log after the previous meeting. Closed

11. It was agreed that practice discussions will be linked in with the visit by/to NECS to demo their live implementation. Carry Forward

12. BF had scheduled Board meeting. Closed

3 CSU Project Management Resource IB confirmed that BF has now taken up his new post within the CSU and will no longer be managing the project. The CSU is unable to recruit a replacement on a permanent basis whilst undergoing the organisational restructure currently under consultation. As a result it has been agreed that: - Interim agency resource will be brought in for an initial 3 month period - IB and AG will pick up the project management responsibility until the agency

resource has been secured. In addition, Gray Hewitt has been assigned to project manage the NWSIS domain work stream.

4 Overall Project Position Summary See work package updates below

5 BDS Update AG confirmed that the BDS design has been completed. He has requested some amendments to their PID and is awaiting a revised copy for review and sign-off. AG’s team have reviewed the designs and completed the associated costs for delivery. AG has walked through these with KW who will send to CSU Finance for sign-off before issuing proposals to the CCG/PCC. The proposals will outline; 1/ migration of corporate CCG including 2 pilot sites, 2/ migration of remaining pilots sites & 3/ migration of the remaining practices. AG met with the consultant running the Cumbria project. Due to an issue with a supplier (not being used within this project) the Cumbria project has been placed on hold pending a formal review. As such, further meetings with Cumbria will not be pursued.

AG has also attended a presentation and demonstration held by NECS in conjunction with VMWare and EMIS. NECS have deployed a similar solution to practices and following talks with AG agreed to provide a further demonstration to the CCG/PCC and practices. AG will arrange a meeting. Once AG has signed off the PID, the design from BDS will be provided by AG to CDW and they will progress the HLDs

6 MPLS Update

Operational Readiness Testing completed with BT at both Eagle Bridge and 1829. It wasn’t possible to complete the testing at the Undercroft due to time constraints. One issue was found in a gateway on BTs side which is now being investigated. Retesting has been provisionally scheduled for 13th October alongside completion of ORT at the Undercroft.

The change to the Palo Alto firewalls could not be deployed on the 4th Oct and had to be rolled back due to an issue with Horizon View which is the software used to deliver VDI sessions to user devices. This is being investigated and a new change request will be raised once a solution has been identified.

VOIP telephony testing is scheduled for 11th October.

Resource is also in place to begin testing the sites already commissioned by BT to ensure that the circuits are working prior to scheduling the migration dates with those sites.

7 Overview of current financial PMCF position KC presented the current financial situation for the project. Based on current projections the project will be £18k over budget. However, the estimates for CDW resource were originally done before BDS were commissioned for the domain work and prior to the CSU securing funding towards the domain work. As such it was agreed that a review of anticipated resource needs to be carried out and fed back into the financial review. AG will lead the initial review of resource days required. KC confirmed that submissions had progressed to the next stage of the Estates and Transformation bid process

8 CDW Resource authorisation – previous & future process

AG confirmed that a process is now in place. All work is to be agreed in advance on a weekly basis and reported back to AG on completion. Andy Bland has agreed to this mechanism.

KC confirmed that it had been written into the PO that CDW must document their work

9 Milestone project plan (Estimated)

It was agreed that a PID for the CSU project delivery was required. IB will produce a PID for review including a revised milestone plan.

10 Review of Key Risks and Issues

Risk 7 – to be closed

Risk 5 – add NECS deployment as mitigating action

Risk 6 – space now exists in the data centre to install hardware. AG to arrange delivery and installation prior to agreed storage deadline.

Issue 9 – to be closed

11 Communications (General and practices) & timescales

It was agreed that further comms to the practices would be beneficial at this stage to re-iterate the objectives and provide an update. AG to draft some wording to explain in simple terms what the Lakeside deployment does and why it is being installed. KC will then arrange a communication to practices.

12 AOB

KC – asked if, as a result of the new VDI solution, if there would be any cost savings for the CCG with regard to the IT support services commissioned from MLCSU. IH suggested that we would need some time following deployment to understand what if any savings there were for the CSU. AG will ask NECS what model they have employed.

IB to send invitations to next board meeting (1st Nov @ 10:30, Egerton Room)

AP Owner New Action Points: 1 KW Issue NWSIS costs for CSU Finance sign-off and provide proposal(s) to the

CCG/PCC 2 KC/SM Review proposals and provide sign-off 3 KC Ensure PO raised for wireless cabling work 4 AG Review and sign-off revised BDS PID then provide BDS domain design to

CDW to commence the CDW design process 5 AG Progress with NECS to book in a visit for a demonstration of their solution 6 AG To review original CDW resource estimates (in light of the BDS work and

funding) and provide updates to KC so that the financial position can be reviewed

7 IB Produce PID, inc. milestone plan 8 IB Update and distribute the risk and issue log 9 AG Provide some written narrative to KC outlining the Lakeside deployment 10 KC Draft and circulate comms to practices providing an update on the project 11 AG Speak to NECS with regard to any differences they apply to the costing

model for centralised VDI ‘v’ traditional desktop 12 IB Schedule next board meeting

IT Infrastructure Project Board Meeting

Mtg Rm 1, 1829 Building Chester 11:30 – 12:30, 19/01/2017

Present:

Name: Organisation: Kevin Carberry (KC) WCCCG Kerry Winsland (KW) MLCSU Andy Gaskell (AG) – from 11:50 MLCSU Ian Bradbury (IB) MLCSU Sarah Murray WCCCG Dan Jones WC Primary Care

Apologies

Name: Organisation: Phil Eagle (PE) MLCSU Ian Hart (IH) MLCSU

Actions in italics.

Item: Notes: 1 Apologies received as above – Board is quorate 2 December Board was not quorate and minutes were not taken.

3 MPLS Update

IB informed group that Helsby and Elton would need to be rescheduled as Brian had not confirmed that the 26th Jan was OK. To ensure the BT slot was not lost Garden Lane has been booked in for the 26th instead. SM & KC stated that they had seen Brian yesterday and he had said all was well for the 26th migration. IB to pick up with Gray to ensure both practices are aware and resolve any conflicts re the 26th. There is an issue with regard to asbestos at Blacon where contractor will not re-instate the walls following work. Gray is exploring other options to progress.

4 NWSIS Update

WCCCG have signed off the proposal for the corporate CCG and 2 pilot practices. KC has provided Gray with names of staff for the proof of concept from Malpas. KC to confirm names of staff from CCG and Frodsham MP to Gray so that BDS can progress

the project

5 Wireless Cabling LineWire have contacted the practices and booked in for next week, starting with Malpas on the 26th to lay the cables and fit the brackets.

6 Low Level designs

Workshops with CDW are continuing. Sessions booked for Data Centre 27th Jan and VDI (30th & 31st Jan). Low level design documents will be produced within 10 days of each workshop allowing CSU to prep for work. DJ asked what provisions were in the solution for future changes in technology such as Skype appointments. AG confirmed that in terms of bandwidth the new solution was like for like in terms of capacity. Each new technology would need to be reviewed on a case by case and practice by practice basis.

7 Timeframes Following the project definition workshop with CDW on 12th Jan it became apparent that the project would not be completed before 1st April. As such the VDI proof of concept required to provide the assurance required for WC CCG to procure further hardware and implementation resource cannot be done in time to make those purchases in 2016/17. Exact timeframes will not be known until the LLD workshops are completed and the PID provided by CDW.

8 VDI Proof of Concept

Proof of concept will be with Frodsham MP. IB to liaise with Frodsham to understand what they would like to see within a test environment.

As the PoC will not be possible before April on the new WC CCG infrastructure, IB has contacted both NHS Digital and EMIS to ask if they know of any sites that are operating VDI in a live primary care environment. Currently awaiting a response before hopefully opening channels for dialogue between practices.

AG will liaise with NECS re building a test virtual desktop using the requirements gleaned from Frodsham MP.

9 Financial Position

IB outlined the overall position as

Sep 2015 projection £1,600k; Jan 2017 projection £1,500k; PMCF budget allocation

£1,250k; Deficit of £250k. KC provided a copy of the detail for review.

Options to cover deficit include:

- Using ETTF funds if approved. Several options exist in ETTF funding including targeted rollout of iGel terminals to replace PCs rather than a blanket swap, possibility of number of staff being less than estimated at time of ETTF bid so less hardware and software required.

- Using some of the GP IT budget. This is likely to only cover £50k of the shortfall

100% completion of this project will be dependent on ETTF bid being approved. SM to speak to David Scannell at meeting on 20th Jan to press the issue

IB raised the subject of the pending CDW invoices required to continue the project. PO1 includes delivery of the core data centre and some consultancy to start VDI and wireless. If the ETTF is not approved then this is all PCC can afford from the PMCF monies.

KW asked the group whether to was better to focus on a wider centralised storage rollout than just having practices on VDI. SM asked for a paper outlining the costs and savings of doing centralised storage as opposed to VDI at the 3 practices. IB to work with AG & KC to produce the paper.

In order to keep the project moving and minimise additional risk to delivery SM agreed that PO1 could be raised. KC to agree with CDW that the days could be used interchangeably between VDI and wireless should the ETTF funding not be approved and then raise the PO.

10 Review of Key Risks and Issues

SM left the meeting. Risks reviewed. IB to update risk 8 review date to Feb 17 re GP IT Leads and what tasks they’ll be able to perform. Set review date for Feb and follow up with paper that KW has compiled re FAQs. IB to downgrade risk 12 to medium given that SM has approved PO1.

11 AOB

KC asked Board whether they felt the same personnel should comprise the project Board for the ETTF project given the similarities and to ensure continuity. All broadly agreed but it was noted that there may be some changes in CSU attendees due to the recent restructure. IB suggested that it was likely that IH would be replaced by Julie Murdy.

DJ asked if there could be provision made for GPs to have a voice. It was agreed that the Board should be for strategic and budgetary decisions and therefore the attendees should not be increased but that a separate operational working group should be included within the project.

Future IT Infrastructure Boards to be scheduled. 4th Thursday of the month best for DJ but 1st and 2nd Thursdays also OK. Due to other commitments the next Board is to be scheduled for 16th Feb at 11:30.

Any immediate decisions around finance will be picked up directly with SM outside of the formal Board.

IT Infrastructure Project Board Meeting

Egerton Room, 1829 Building Chester 11:30 – 12:30, 16/02/2017

Present:

Name: Organisation: Kevin Carberry (KC) WCCCG Kerry Winsland (KW) MLCSU Andy Gaskell (AG) – from 11:40 MLCSU Ian Bradbury (IB) MLCSU Sarah Murray (SM) WCCCG Dan Jones (DJ) WC Primary Care Paul Ingham (PI) MLCSU

Apologies

Name: Organisation: Ian Hart (IH) MLCSU

Actions in italics.

Item: Notes: 1 Apologies

Apologies received as above – Board is quorate Paul Ingham introduced as Project Manager for the wireless, datacentre and VDI work streams.

2 Review of minutes and actions from previous meeting Minutes were approved as a true reflection of the January meeting. IB met with David Scannell in January and highlighted that 100% completion of the project was dependant on ETTF bid being approved. IB confirmed that ETTF bid had been approved.

3 MPLS Update KC provided update on MPLS sites migrated since last meeting. Sites migrated are:

Meadowside Medical Centre Bollington Surgery Princeway Medical Centre (Frodsham, Knoll) Kingsley (branch site to Knoll) Garden Lane Surgery Kenmore Medical Centre Mcllvride Medical Practice The Oaklands

Rope Green Medical Centre KC to provide update on further progress at next meeting.

IB confirmed that following confirmation from NHS England regarding the ETTF bid, funding is in place to roll out to remaining West Cheshire sites.

4 NWSIS Update Gray booked to go to Malpas to facilitate full deployment to the NWSIS domain on the 21st-23rd Feb. Frodsham are also due to migrate but have requested to see how Malpas goes before committing to a date. Update to Malpas & Frodsham to be provided at next meeting. DJ provided feedback on the floor walkers for previous migrations. The floor walkers have been positively received by practice managers and have helped in speeding the migration process and reducing business impact on the practices.

5 Wireless Cabling IB confirmed that Linewire have completed work. All cabling & Access Point frames are in place, the next step is dependent on the datacentre work & wireless controllers being commissioned.

PI to update on progress at next meeting

6 Proof of Concept (VDI Testing) CDW have booked in resource to start building a temporary VMware environment, however this will be on a trial license and so will be time limited (30 days). CDW have requested that the PID is signed to ensure CDW resources are released. Group discussed the signing of the CDW PID. AG confirmed he is happy with the PID from a technical perspective. KC to review PID on behalf of CCG and meet with PI to discuss any queries. Update further to meeting – KC & PI met following day to discuss changes and PID was signed by AG and SM on 17/2. IB updated that Bradford have a similar solution. Dr Welford is the contact and IT clinical lead. CSU to open dialogue with them to discuss what they have in place. There are questions marks over how close Bradford’s solution is to the proposed solution but there may be some value in having the conversation with them. PI to provide update at next meeting. CDW to build time bombed VMware environment. AG to start planning the testing of applications (to be tested internally and by within a GP practice). PI/AG to provide update at next meeting.

PI also provided update on a compatibility matrix that had progressed over the last week. PI is using the list generated from Lakeside of the most common in use applications to investigate application VMware compatibility and contacting suppliers where question marks exist over compatibility. PI to share with engineers.

7 User Group Not discussed due to time constraints. PI and KC will set up a weekly update meeting to discuss progress so this will be taken forward to these meetings. PI/KC to update at next meeting.

8 Financial position

KC shared overview of planned spend against ETTF budget. Budget overspend - KC detailed initiative to address budget pressure:

• Potential further savings from competitive procurement process. • Incorporate LPF days from 17-18 into CSU resource costs. • Utilise GP IT capital funding for 17-18 • Utilise 10% contingency that NHS England allocate to each project. • Purchase iGels when funding is available and store ahead of installation. • Utilise any potential underspend from NHS England. • Potential to reclaim VAT against bespoke cloud based technology – this could

case accounting issues with NHS England.

KW queried the approximate cost for converting a PC to an iGEL thin client.

Review of Key Risks and Issues

Not discussed due to time constraints. DJ requested risk adding via email prior to the meeting. The risk concerned the retention of current software functionality on the proposed solution. This has been added to the risk register. PI to raise risk at next board.

10 AOB

None noted. PI to take responsibility for running the Infrastructure board and will produce meeting documentation ahead of next meeting.

Date of next meetings:

11:30 – 12:30 30th March 2017 - Egerton Room, 1829 Building Chester 11:30 – 12:30 27th April 2017 - Egerton Room, 1829 Building Chester 11:30 – 12:30 25th May 2017 - Egerton Room, 1829 Building Chester 11:30 – 12:30 29th June 2017 - Egerton Room, 1829 Building Chester 11:30 – 12:30 27th June 2017 - Egerton Room, 1829 Building Chester

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