AGENDA NHS Leeds CCG Primary Care Commissioning …

AGENDA

NHS Leeds CCG Primary Care Commissioning Committee

Date: Thursday 28 March 2019

Time: 14:00 – 17:00

Venue: Hinsley Hall, 62 Headingley Lane, Leeds LS6 2BX

Item Description Lead Paper Time

PCCC 18/113

Welcome and Apologies Purpose: To record apologies for absence and confirm the meeting is quorate.

Chair N

14:00

PCCC 18/114

Declarations of Interest Purpose: To record any Declarations of Interest relating to items on the agenda: a) Financial Interest

Where an individual may get direct financial benefit from the consequences of a decision they are involved in making;

b) Non-financial professional interest Where an individual may obtain a non-financial professional benefit from the consequences of a decision they are involved in making;

c) Non-financial personal interest Where an individual may benefit personally in ways that are not directly linked to their professional career and do not give rise to a direct financial benefit, because of the decisions they are involved in making; and

d) Indirect Interests Where an individual has a close association with another individual who has a financial interest, a non-financial professional interest or a non-financial personal interest who would stand to benefit from a decision they are involved in making.

Chair

Y

PCCC 18/115

Questions from Members of the Public Purpose: To receive questions from members of the public

Chair N 14:05

PCCC 18/116

Minutes of the Primary Care Commissioning Committee meeting held on 31 January 2019 Purpose: To approve the minutes

Chair Y 14:15


PCCC 18/117

Matters Arising Purpose: To consider any outstanding matter arising from the minutes that is not covered elsewhere on the agenda

Chair N

PCCC 18/118

Action Log Purpose: To note the items on the outstanding action log

Chair Y

PCCC 18/119

Chief Executive’s Update

Purpose: To receive the Chief Executive’s update for information

Phil Corrigan N 14:20

PCCC 18/120

General Practice Forward View (GPFV) Delivery Plan Update

a) Confederation Update

Purpose: To receive an update for discussion

Kirsty Turner/ Gaynor Connor

Y 14:30

PCCC 18/121

Equitable Funding Review Purpose: To approve the proposal

Kirsty Turner Y 14:40

PCCC 18/122

Chair’s Summaries from the Primary Care Operational Group in February and March 2019 Purpose: To receive the summaries for information


PCCC 18/123

Health Inequalities Audit – Access to General Practice Purpose: To receive the audit for discussion


PCCC 18/124

Quality Improvement Scheme – Year 2 Purpose: To approve the proposed Year 2 Quality Improvement Scheme


BREAK FOR 5 MINUTES

PCCC 18/125

Chair’s Summary from the Quality and Performance Committee meeting of 13 March 2019 Purpose: To receive the summary for information

Dr Stephen Ledger

Y 15:15

PCCC 18/126

Primary Care Integrated Quality & Performance Report (IQPR)

Purpose: To receive the IQPR and consider any issues escalated by the Quality & Performance Committee.

Kirsty Turner

Y 15:20


PCCC 18/127

Primary Care Risk Report

Purpose: To receive an updated risk report


PCCC 18/128

Primary Care Finance Update

Purpose: To receive an update

Visseh Pejhan-Sykes

Y 15:30

PCCC 18/129

Forward Work Programme 2019/20

Purpose: To receive, accept and input to the programme

Chair Y 15:35

PCCC 18/130

Questions from Members of the Public

Purpose: To receive questions from members of the public

Chair N 15:40

PCCC 18/131

Any Other Business Chair N 15:50

Exclusion of the public - it is recommended that the following resolution be passed: "That representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest" PCCC 18/132

Confidential Minutes of the Primary Care Commissioning Committee meeting held on 31 January 2019

Purpose: To approve the minutes

Chair Y 15:55

PCCC 18/133

Enhanced Cover to Care Homes

Purpose: To approve the scheme


PCCC 18/134

Contract Extension - Medical Practice

Purpose: To approve an extension of the current contract


PCCC 18/135

Procurement Update

Purpose: To ratify the Urgent Actions on 27 February 2019, 7 March 2019 and 21 March 2019


Dates and venues of future meetings:

5 June 2019 – The Old Fire Station, Gipton Approach, Leeds LS9 6NL

7 August 2019 - The Old Fire Station, Gipton Approach, Leeds LS9 6NL

2 October 2019 – Hinsley Hall, 62 Headingley Lane, Leeds LS6 2BX

This page is intentionally blank

Title Name Job Title

(where applicable)

Role Practice

B Code

Declared Interest- (Name of the

organisation and nature of

business)

Type of Interest Is the interest

direct or

indirect? Interest From

Interest

Until

Action Taken to Mitigate Risk

Sam Senior Lay Member for

Primary Care Co-

Commissioning

Governing Body Member N/A Lay Member for Primary Care

Bassetlaw CCG

Financial Interests Direct

01/09/2013

Ongoing Declare conflict or perceived conflict within context

of any relevant meeting or project work


Primary Care Co-

Commissioning

Governing Body Member N/A Lay Representative National

School of Healthcare Science


01/05/2016




Primary Care Co-

Commissioning

Governing Body Member N/A Lay Advisor Health Education

England (West Midlands)


01/05/2016




Primary Care Co-

Commissioning

Governing Body Member N/A Patient and Public Panel

Member - National Institute

Health Research


01/04/2017




Primary Care Co-

Commissioning

Governing Body Member N/A Chairperson - Brampton

United Junior Football Club

(S63 6BB)

Non-Financial Personal

Interests

Direct

01/05/2013



Phil AyresGoverning Body

Member

Governing Body Member

N/A

I have personal friendships with

two members of the Rawdon

Surgery


Interests

Indirect

Ongoing

Declare interest at meetings as relevant

Phil Ayres Secondary Care

Consultant

Governing Body Member

N/A

I am a management consultant

and may work with providers in

the city on clinical leadership

development


01/06/2018

Ongoing

Maintain awareness of potential influence over

decisions I may take as independent practitioner. Abide

by GMC code of conduct. Declare this interest at

relevant meetings.

Angela Collins Lay Member for

Patient and Public

Participation

Governing Body Member N/A Nil Declaration N/A

Philomena Corrigan Chief Executive Governing Body Member N/A Nil Declaration

Joanne Harding Director of Nursing

and Quality


Stephen Ledger Lay Member for

Assurance


Peter Myers Lay Member for Audit

and Conflict Matters

Governing Body Member N/A Nil Declaration

Visseh Pejhan-Sykes Chief Finance

Officer


Tim Ryley Director of Strategy,

Planning &

Performance


Sue Robins Director of

Operational Delivery


Simon Stockill Medical Director Governing Body Member N/A Partner at Sleights and Sandsend

Medical Practice, Whitby

(Hambleton, Richmondshire &

Whitby CCG)


01/04/2016 Ongoing

Simon Stockill Medical Director Governing Body Member N/A GP Appraiser, NHS England

(Yorkshire & Humber)


01/12/2013 Ongoing

Simon Stockill Medical Director Employee Non-Decision

Maker

N/A Clinical Lead for Quality

Improvement, Royal College of

GPs

Non-Financial

Professional Interests

Direct

01/09/2016 Ongoing

Kirsty TurnerAssociate Director of

Primary Care

Band 8d and above or

Employee Decision MakerN/A

Husband is the Deputy Chief

Finance Officer

Financial Interests Indirect

01/04/2018 Ongoing

Discussion with line manager. Declare as part of ongoing

discussions,

Oliver CorradoHealthwatch

Representative

Other Committee Member

N/A

Lead Physician for the National

Audit of Dementia


Ongoing

Declare any potential conflict of interest at Governing

Body/Board, sub committees and relevant meetings

Oliver CorradoHealthwatch

Representative

Other Committee Member

N/A

Member of the British Geriatrics

Society

Non-Financial


Direct

Ongoing

Declare any potential conflict of interest at Governing

Body/Board, sub committees and relevant meetings

Dr Julianne Lyons GP Member

Representative

Governing Body Member B86110 GP Partner at Leeds Student

Medical Practice

Financial Interests Direct 01/01/2016Ongoing

Declare any potential conflict of interest at

Governing Body/Board, sub committees and

relevant meetings Dr Julianne Lyons GP Member

Representative

Governing Body Member B86110 Leeds Local Medical

Committee Member





Representative

Governing Body Member B86110 Spouse is a Director of Leeds

Haematology plc

Indirect Interests Indirect 01/05/2013Ongoing




Representative

Governing Body Member B86110 Spouse is a trustee of UK

Myeloma Forum





Representative

Governing Body Member B86110 Spouse is an employee of the

University of Leeds




relevant meetings Julianne Lyons GP Member

Representative

Governing Body Member B86110 GP lead for Leeds Primary

Care Workforce and Training

Hub





Representative

Governing Body Member B86110 Spouse has an honorary

contract with Leeds Teaching

Hospitals NHS Trust

Indirect Interests Indirect 01/01/2015

Ongoing



relevant meetings

Dr Julianne Lyons GP Member

Representative

Governing Body Member B86110 Shareholder of Leeds West

Primary Care Limited




relevant meetings

Sabrina ArmstrongDirector of Corporate

Services

Governing Body MemberN/A

Substantively employed by NHS

England


01/10/2014 Ongoing

Gaynor Connor Associate Director of

Primary Care


Employee Decision Maker

N/A Role embedded within Leeds GP

Confederation

Non-Financial


Direct

01/10/2018 Ongoing

Anna Ladd Senior Primary Care

Manager NHS

England

Other Committee Member N/A Spouse is Contract Lead at

Yorkshire Ambulance Service


Interests

Direct

Ongoing

Not required

Laura Parsons Head of Corporate

Governance and Risk


Employee Decision Maker

N/A Close friend works for Leeds

Teaching Hospitals NHS Trust as

Resourcing Co-ordinator

Indirect Interests Indirect

03/09/2018 Ongoing

Declare any potential or perceived conflict of interest at

relevant meetings/workshops

Karen Lambe Corporate

Governance Officer

Employee Non-Decision

Maker

N/A Spouse works for NHS

England as Senior Knowledge

Manager

Financial Interests Indirect

21/05/2018

OngoingWill declare conflict, or any potential conflict, at

GB/Board Meetings/Committees and relevant

meetings.

1

Minutes NHS Leeds CCG – Primary Care Commissioning Committee

Thursday 31 January 2019 2.00pm – 5.00pm

Pudsey Civic Hall, Pudsey Civic Hall, Dawson’s Corner, LS28 5TA

Members Initials Role Present Apologies

Sam Senior SSe Lay Member – PCCC (Chair)

Dr Phil Ayres PA Secondary Care Specialist Doctor

Angela Collins AC Lay Member – Patient & Public Involvement

Philomena Corrigan PC Chief Executive

Jo Harding JH Director of Quality and Safety

Dr Stephen Ledger SL Lay Member - Assurance

Peter Myers PM Lay Member - Audit

Visseh Pejhan-Sykes VPS Chief Finance Officer (item

18/105 only via phone)

Tim Ryley TR Director of Strategy, Performance &

Planning

Susan Robins SR Director of Operational Delivery

Dr Simon Stockill SSt Medical Director

Kirsty Turner KT Associate Director of Primary Care (on

behalf of Dr Simon Stockill)

Additional Attendees

Councillor Rebecca Charlwood

RC Health & Wellbeing Board Representative

Dr Ian Cameron IC Director of Public Health Medicine

Dr Oliver Corrado OC Healthwatch Leeds Representative

Stuart Morrison SM Healthwatch Leeds Representative

Dr Julianne Lyons JL GP Representative

Sabrina Armstrong SA Director of Corporate Services

Joanne Evans JE Head of Primary Care Commissioning

and GP Forward View

Gaynor Connor GC

Associate Director of Primary Care

(item 18/99a)

Anna Ladd AL Primary Care Manager, NHS England

2

Members Initials Role Present Apologies

Laura Parsons LP Head of Corporate Governance

Karen Lambe (Minutes) KL Corporate Governance Officer

Members of the Public Observing the Meeting – 4

No. Action

PCCC

18/91

Welcome and Apologies The Chair welcomed everyone to the meeting. Apologies had been received from Angela Collins, Dr Simon Stockill, Councillor Charlwood, Dr Oliver Corrado, and Visseh Pejhan-Sykes. It was noted that Kirsty Turner was in attendance on behalf of Dr Stockill. Visseh Pejhan-Sykes would dial into the meeting for agenda item PCCC 18/105.

PCCC

18/92

Declarations of Interest The Chair noted members’ Conflicts of Interests (CoI) and asked members to declare any updates or changes to the COIs which were relevant to the meeting. No declarations were raised.

PCCC

18/93

Questions from Members of the Public There were no questions from the members of the public.

PCCC 18/94

Minutes of the meeting held on 29 November 2018 The minutes of the meeting held on 29 November 2018 were approved as a correct record. The Primary Care Commissioning Committee:

a) approved the minutes of the meeting held on 29 November 2018.

PCCC 18/95

Matters Arising There were no matters arising.

PCCC 18/96

Action Log The Primary Care Commissioning Committee (PCCC) reviewed the action log and noted the following updates: 18/83-1 – Practice A to submit an action plan regarding reducing A&E activity. This was ongoing as KT was liaising with the practice.

3

No. Action

18/83-2 – Discussion with Dylan Roberts regarding IT and Primary Care delivery. VPS reported regular one to one meetings with Dylan Roberts since 1 January 2019, engagement of external support to formulate the Leeds Digital Strategy and discussions regarding the role of digital technology as identified in the NHS Long Term Plan. This item was completed. SS confirmed that all other actions had been completed.

PCCC 18/97

Chief Executive’s Update PC informed the Committee of recent correspondence relating to the New GP Contract which provides additional investment in General Practice including funding for 20,000 more staff to be incorporated into Primary Care. The letter also referred to a state indemnity that would allow Primary Care staff to work across practices. This would be centrally funded for the whole country. There would be an expectation that practices would commit to being part of a Primary Care Network, with payment being allocated accordingly. PC reported that TR was working to incorporate the Long Term Plan into the CCG’s operational plan, to be submitted to NHS England (NHSE) in April 2019. The CCG intended to address all the areas identified in the Long Term Plan. Action: Letter received from the DoH to be circulated with the minutes of the PCCC meeting

KL

PCCC 18/99

General Practice Forward View (GPFV) Delivery Plan Update Summary of the Current Workforce Position GC presented a summary of the current workforce position from the perspectives of primary care at national and city levels, as well as that of the Integrated Care System. The report focussed on a number of issues including recruitment and retention, student nurse placements, clinical pharmacy and the General Practice Nursing Strategy. It was acknowledged that the review had attracted a good response from practices. JH expressed concern that while 43% of practices would be willing to recruit nursing students, there needed to be some further questions raised as to why the remaining 57% would not. GC stressed that recruitment of nursing students could be shared within localities, rather than the responsibility of individual practices. It was recognised however that different skill sets were required for staff working across practices, as opposed to being located in a single practice. There was some discussion regarding the non-clinical workforce and how these roles could be developed.

4

No. Action

SL expressed an interest in the report’s findings on retention of the workforce. With regards to staff over 55 years, there was a concern that staff were retiring prematurely due to the stress of pressures across the system. This raised the question of where responsibility lay for supporting the workforce. GC stressed that the GP Confederation was in a position to produce solutions to mitigate this risk. There were examples of peer support groups being set up for GPs and opportunities being made available to retain older staff outside of a partnership in salaried positions across localities. PM queried to what extent pension considerations mitigated against retired GPs taking on support roles. AL explained that this was recognised nationally as a disincentive. Members agreed the necessity for all new models to be integrated in the Leeds Health and Care Plan and to stay connected with the GP Confederation. The Committee also recognised that staff wanted to be able to work more flexibly, particularly women who represented the majority of the current intake in Primary Care in the city. Action: An update of the workforce position to be brought to the PCCC meeting on 28 March 2019. The Primary Care Commissioning Committee:

a) noted the update provided by the paper and the review of the risks on the Governing Body Assurance Framework and Primary Care Risk Register;

b) commented on the work programmes underway in the Integrated Care System and the city to address the challenge and risk posed in ensuring the right staff and skills are developed and retained within general practice; and

c) agreed to receive a further update on 28 March 2019 containing detailed plans as these develop through regional and local infrastructure.

Update on 111 Direct Booking Capability

KT provided members with an update on extended access (EA) in relation to direct booking capability. During November 2018, the average utilisation of the EA service had increased to 82%. The Committee was informed that the CCG target for the next year would be a minimum of 75%. The paper detailed technical difficulties that were being experienced with the Adastra system used for the 111 service. The difficulties, while being recognised at a national level, had not been resolved and were affecting multiple site practices. The Committee was assured that NHS Digital was progressing the issue nationally, with a number of solutions being tested.

GC

5

No. Action

However, it had been agreed that the current Adastra system could not be enabled due to concerns for patients’ safety. AL informed members that NHSE was under considerable pressure to address this issue. KT assured the Committee that the issue would be brought to future PCCC meetings. The Primary Care Commissioning Committee:

a) noted the update on extended access and direct booking.

PCCC 18/100

Chair’s Summaries from the Primary Care Operational Group in December 2018 and January 2019 The Committee was presented with the summaries from the Primary Care Operational Group (PCOG) meetings held in December 2018 and January 2019. PC queried the reduction in DATIX incidence reporting that had occurred since its removal from incentive schemes. KT explained that it would be beneficial to encourage practices to do this via training sessions. Members were informed that regular meetings were being held with the Care Quality Commission (CQC) to report on this. There were also examples of practices using other incident systems and the need to access their data. SL assured the Committee that the Quality and Performance Committee was aware of this issue and the action being taken by the Primary Care team to address it. The Primary Care Commissioning Committee:

a) noted the Chair’s Summaries from the Primary Care Operational Group meetings in December 2018 and January 2019.

PCCC 18/101

Commissioning Priorities – Practice Update Members were presented with a summary of practice changes. This included a reduction in the number of practices, mostly as a result of mergers, from 104 in April 2018, to 97 by April 2019. Two procurements were underway for The Light and the Safe Haven registered lists. Key commissioning priorities were identified as: medical support for care homes; Year 2 of the Quality Improvement Scheme; estate and workforce; continued support for Local Care Partnerships (LCPs); and an equitable funding review. With regards to the funding review, KT reported that the inequity between GMS practices receiving £88.96 and PMS practices receiving between £91.28 and £95.50 would need to be addressed in order to help the CCG realise its strategic ambition to tackle health inequalities. Action: Funding inequities paper to be brought to next PCCC meeting on 28 March 2019. With reference to the report, TR highlighted the further development of the Primary Care Networks (PCNs) and queried whether members approved of new investment in these in light of the additional non-recurrent £1.9m that had

KT

6

No. Action

recently become available to Primary Care. The Primary Care Commissioning Committee:

a) noted the changes to practice and planned priorities for 2019/2020.

PCCC 18/102

Chair’s Summary from the Quality and Performance Committee meeting of 16 January 2019 With regards to the utilisation of community beds, SR informed members that guidance was being developed to clarify GPs’ understanding of admittance criteria for patients. KT reported that some inaccuracies had been identified in the data relating to the Learning Disabilities register and health checks. These were being investigated and it was anticipated that there would be an improvement in performance however further work was needed to increase overall achievement. IC stressed that people with Learning Disabilities represented a specific, disadvantaged group in the Strategic Plan. It was recognised that plans needed to be developed to assess qualitative data in addition to the numbers of reviews being carried out. Members were assured that Learning Disabilities remained a priority for 2019/20. The Primary Care Commissioning Committee:

a) received the Chair’s Summary from the Quality and Performance Committee of 16 January 2019.

PCCC 18/105

Primary Care Finance and Estate Update This item was brought forward on the agenda as VPS dialled in to the meeting. Members were informed that the CCG had received an unexpected additional allocation of £851,000 from NHS England (NHSE) to cover the nationally agreed GP pay increase in November 2018. The money would be specifically for Primary Care. This figure was in addition to £837,000 received from NHSE Yorkshire & Humber to address performance pressures related to Primary Care and the CCG’s current underspend of £300,000. Assurance was given that, while the sum of £1.9m would need to be committed in the current year, the timing of when cash would flow into practices would be finalised once details of the schemes had been finalised. TR shared that the GP Confederation was working on a development plan for the additional funds which would be brought to Executive Management Team meeting (EMT) in February 2019. With regards to estates, members were informed that the CCG would be working with Dayle Lynch, Programme Manager with the Estates

7

No. Action

Health Partnerships Team at Leeds City Council, to develop a city-wide integrated care strategy for Primary Care. VPS emphasised the need for the Primary Care Estates Group to receive the paper, prior to city-wide circulation. With regards to the current inequity of funding across the city between GMS and PMS contracts, work was ongoing to harmonise these in 2019/2020. The Primary Care Commissioning Committee:

a) noted the financial position, including the additional non-recurrent payment of £1.9m; and

b) noted the current inequity of funding across the city between General Medical Services (GMS) and Personal Medical Services (PMS) contracts.

PCCC 18/103

Primary Care Integrated Quality & Performance Report (IQPR) and Quality Improvement Scheme (QIS) KT presented the IQPR to members and emphasised the Quality Outcomes Framework (QOF) high achievements for 2017/2018. In terms of QIS performance targets, both hypertension and atrial fibrillation (AF) showed positive results. Learning disabilities would be included in the IQPR from April 2019 and flagged as a ‘hot topic’. SA queried what actions would be taken to improve current cervical screening rates. The next TARGET session would include this as part of women’s health and the highlighting of innovative examples of awareness raising. There had also been an increase in the number of drop-in sessions through cervical screening week. Cervical screening would also be incorporated into the work of Cancer Screening Champions pending approval of a bid. With regards to mental health, SL queried how this was being addressed. It was acknowledged that there may have been coding inaccuracies relating to the mobile population in Leeds and that the data might not reflect fully the work being carried out in this area. The Committee was assured that mental health remained a priority and that the QIS target would increase in the following year. TR stressed the need for the CCG to work with the Primary Care Networks (PCNs) and the Leeds Care Partnerships (LCPs) to understand populations and their needs, in order to be flexible to address root causes. The Primary Care Commissioning Committee:

a) received the Integrated Quality & Performance Report.

PCCC 18/104

Primary Care Risk Report

8

No. Action

The Committee was presented with the updated Primary Care Risk Report. The risk register contained 49 risks, ten of which were aligned to Primary Care. Risk number 651: General Practice workforce and wider models of care had increased to a high amber (15) risk. Risk number 331, concerning providers not engaging with the CCG’s Medicines Optimisation team, had been realigned to the Quality and Performance Committee due to it covering all providers, not just Primary Care. All risks had been reviewed in light of operational knowledge. The Primary Care Commissioning Committee:

a) reviewed the high scoring amber (15) risk; and b) considered the recommended level of assurance.

PCCC 18/98

Annual Review of Committee Effectiveness The Committee discussed its draft annual report and the results of the self-assessment survey. In response to comments in the survey, it was agreed that Primary Care strategy should be a focus for a future Governing Body workshop. It was also felt that the Committee’s agenda should include items on the GP Confederation. Action: Review Forward Work Plan to ensure inclusion of GP Confederation updates. With regards to comments raised about links with the Quality and Performance Committee and the PCCC, it was felt that soft intelligence was communicated well between the two. Members acknowledged a need for future reports to be concise when submitted to the PCCC. Two amendments were made to the Committee’s Terms of Reference: SA’s role was changed to that of a voting member; and SR’s job title was updated. Action: PCCC’s Terms of Reference to be updated. The Primary Care Commissioning Committee:

a) received the annual report; b) considered ways to improve the effectiveness of the Committee; and c) reviewed and approved minor amendments to the PCCC’s Terms of

Reference.

SSe/PC

KL/LP

PCCC 18/106

Forward Work Programme 2018/2019 It was agreed that an update from the GP Confederation should be included in the Forward Work plan. The Primary Care Commissioning Committee:

9

No. Action

a) received the Forward Work Programme for 2018/2019.

PCCC 18/107

Questions from Members of the Public There were no questions from members of the public.

PCCC 18/108

Any Other Business There was no other business.

The Primary Care Commissioning Committee resolved that representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

Approved and signed by: Sam Senior, Lay Member – Primary Care Co-Commissioning / Deputy Chair Date:


MINUTES ACTION LOG – PRIMARY CARE COMMISSIONING COMMITTEE

UPDATED 18 March 2019

ITEM NO:

ACTION NO:

ACTION: ACTION BY:

COMPLETED/UPDATE

PRIMARY CARE COMMISSIONING COMMITTEE MEETING

OUTSTANDING ACTION LIST

29 November 2018 PCCC 18/83

1. Primary Care Finance and Estates Update Practice A to be requested to submit an action plan re: reducing A&E activity prior to award of the funding.

SS/VPS On-going. KT to feedback from meeting with practice.

31 January 2019

PCCC 18/97

1. Chief Executive’s Update Letter from the Department of Health to be circulated with PCCC minutes to members.

KL Completed.

PCCC 18/98

1. Annual Review of Committee Effectiveness Review Forward Work Plan to ensure inclusion of GP Confederation updates.

KL Completed.

PCCC 18/98

2. Annual Review of Committee Effectiveness PCCC Terms of Reference to be amended re: approved changes.

LP

Completed.

PCCC 18/99

1. GP Forward View Delivery Plan Update AL to forward website link to pension guidance for retiring GPs in supporting roles.

AL Completed.

PCCC 18/99

2. GP Forward View Delivery Plan Update Update on the workforce position to be brought to PCCC meeting on 28 March 2019.

GC In progress. Confederation update to be brought to PCCC meeting on 5 June 2019.

PCCC 18/101

1. Practice Update – Commissioning Priorities Equitable funding review paper to be brought to PCCC meeting on 28 March 2019.

KT In progress. Agenda item 18/121 – Equitable Funding review


1

Leeds Health & Wellbeing Strategy Outcomes – that this report relates to:

1. People will live longer and have healthier lives

2. People will live full, active and independent lives

3. People’s quality of life will be improved by access to quality services

4. People will be actively involved in their health and their care

5. People will live in healthy, safe and sustainable communities

NHS Leeds CCG Strategic Commitments We will focus resources to:

1. Deliver better outcomes for people’s health and wellbeing

2. Reduce health inequalities across our city

We will work with our partners and the people of Leeds to:

3. Support a greater focus on the wider determinants of health

4. Increase their confidence to manage their own health and wellbeing

5. Achieve better integrated care for the population of Leeds

6. Create the conditions for health and care needs to be addressed around local neighbourhoods

Assurance Framework – which risks on the GBAF does this report relate to: 1. Inadequate patient and public engagement results in ineffective decisions and challenge

2. Failure to assure the delivery of high quality services, leading to commissioned services not reflecting best practice and improving care

3. Failure to achieve financial stability and sustainability

4. Lack of provider and clinical support for change will impact on the development and implementation of the CCG strategy

5. Resources are not targeted effectively to areas of most need, leading to failure to improve health in the poorest areas

6. Insufficient workforce capacity, capability and adaptability to deliver the ambitions

7. Failure to enable partners to work together to deliver the CCG commitments

8. Failure of system to be adaptable and resilient in the event of a significant event

Agenda Item: PCCC 18/120 FOI Exempt: N

NHS Leeds CCG Primary Care Commissioning Committee Meeting

Date of meeting: 28 March 2019

Title: Ensuring access to primary care during the Easter bank holiday period 2019

Lead Governing Body Member: Simon Stockill, Medical Director of Primary Care

Category of Paper Tick as

appropriate

()

Report Author: Gaynor Connor, Director of Transformation Leeds GP Confederation

Decision

Reviewed by EMT/Date: N/A

Discussion

Reviewed by Committee/Date: N/A Information

Checked by Finance (Y/N/N/A - Date): N/A

Approved by Lead Governing Body member (Y/N):

2

EXECUTIVE SUMMARY: The report sets out the arrangements for providing urgent and extended access to primary care services in the city over the Easter bank holiday weekend. The report details the learning from similar arrangements over the Christmas holiday period and describes how providers led by the Leeds GP Confederation have responded to ensure people are able to access services in a safe and timely manner.

NEXT STEPS: Confirmation of operational detail between Local Care Direct and the Leeds GP Confederation.

RECOMMENDATION: The Primary Care Commissioning Committee is asked to:

a) receive the report; and b) reflect on the proposed arrangements.

3

1. SUMMARY 1.1 This report sets out the arrangements for the provision of urgent and extended access to

primary care services over the Easter bank holiday weekend. 2. BACKGROUND 2.1 Leeds GP Confederation (the ‘Confederation’) is commissioned to provide extended access

to primary care which it delivers through a number of locality ‘hubs’ across the city. 2.2 This means that 100% of the population has access to evening and weekend

appointments, a proportion of which can be pre booked with the remainder being available for same day consultations.

2.3 Appointments are available with GPs; nurses; pharmacists; phlebotomists and physiotherapists. Across the city, appointments can be available face-to-face or via telephone consultation.

2.4 Local Care Direct (LCD) is commissioned to provide urgent access to primary care during the traditional ‘out-of-hours’ period ie overnight from 6:30pm and weekends.

2.5 It is recognised there is an element of overlap resulting in a clear need for the two providers to work collaboratively to ensure 24 hour access is maximised.

2.6 Prior to the provision of extended access, NHS Leeds CCG commissioned additional primary care activity to support LCD in meeting predicted increased demand on key holiday periods during the year. This was provided by a number of individual GP practices at key locations.

2.7 Christmas 2018/19 was the first time that the two services were both operational. Discussions between the two providers resulted in a number of extended access appointments being made available for direct booking by LCD.

2.8 Concern was expressed by LCD that this provided a lower number of overall appointments than in previous years which could negatively impact on their organisational resilience and result in a poorer patient experience.

2.9 At that point, the impact of a city-wide extended access offer was not fully known. The hypothesis of extending access to primary care is that it results in reduced demand in the out-of-hours period.

3. PROPOSAL 3.1 Learning from the Christmas period, both providers have identified opportunities to improve

access and experience for people who use their services. 3.2 GP Confederation extended access staff have undertaken visits to the LCD call centre to

strengthen relationships and gain a better understanding of systems and processes. 3.3 It is known that LCD experience peaks in demand later in the afternoon and evening.

Extended access was established to offer appointments until early afternoon on weekends. 3.4 The late afternoon and evening period offer therefore needs to include additional capacity

to meet the anticipated demand on Good Friday, Easter Saturday and Sunday.

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3.5 Plans are underway to open up to three specific extended access hubs from 12md to 7pm over the Easter weekend offering direct bookable appointments to LCD.

3.6 The remaining 9 extended access hub locations will be open as usual for pre-booking via GP practices and will also include Bank Holiday Monday.

3.7 The GP Confederation and LCD are currently working through the operational details in doing this with both providers seeking to mitigate the risk in respect of the availability of the additional workforce requirements.

4. NEXT STEPS

4.1 Confirm operational arrangements agreed between LCD and Confederation – a verbal update will be provided to the Primary Care Commissioning Committee as part of the presentation of this paper.

4.2 Ensure the Directory of Service is updated. 4.3 The CCG will continue to seek assurance of improving access to primary care through

ongoing contractual monitoring and discussion with providers.

5. RECOMMENDATION

The Primary Care Commissioning Committee is asked to:

a) receive the report; and b) reflect on the proposed arrangements.

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Title: Equitable Funding for Primary Care

Lead Governing Body Member: Dr Simon Stockill, Medical Director


appropriate

()

Report Author: Joanne Evans, Head of Primary Care Commissioning & GP Forward View

Decision

Reviewed by EMT/Date:

Discussion

Reviewed by Committee/Date: (PCOG) 12 March 2019

Information

Checked by Finance (Y/N/N/A - Date): Y

Approved by Lead Governing Body member (Y/N): Y

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EXECUTIVE SUMMARY: NHS England (NHSE) National team implemented a ‘Review of Personal Medical Services (PMS) contracts’ in February 2014. The purpose of the review was to ascertain what services PMS practices were providing over and above the core contracts to warrant the additional funding they were receiving. NHSE completed the review with all PMS practices supported by the CCG and it was not evident that PMS practices were offering additional services over and above the core General Medical Services (GMS) contract. A reduction of funding to PMS practices then took place over the subsequent four years, reducing the additional funding by a quarter each year. In Leeds this process was completed this year. The expectation of the review was to align both GMS and PMS practices to the same level of core funding (currently £88.96) by 2020/21. If this is not achieved we will need address the reasons why with NHS England. NHS Leeds CCG is in a position now where there is still a discrepancy in the funding of GMS and PMS practices. All GMS practices are currently paid at £88.96 and PMS practices are paid between £91.28 and £95.50. We now need to do a further review to bring all practices in line. In order to support all practices our intention is to not destabilise any practices, as the PMS premium review has already had a significant effect on some practices within the CCG, but to implement a core contract baseline for all practices in line with the GMS rate, and to enhance this for all practices to the rate of the highest paid PMS practices within the CCG. NHS Leeds CCG currently has recurrent funding available and proposes to use this to support practices to all be paid at the same level.

NEXT STEPS: Implement reviews of all PMS practices and align them to the same funding as GMS practices, for April 2019. This will provide assurance around equity to NHS England. The money from these reviews will be reinvested back into the PMS premium already held by the CCG for re-investment into primary care. A working group including Local Medical Council (LMC), confederation, primary care and finance colleagues will review proposals for the use of the funding and utilising recurrent funding available to the CCG.


a) approve the proposal to align all GMS and PMS practices to the same core income; and

b) approve the proposal to implement the quality in general practice scheme.

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1. SUMMARY 1.1 The issue of ‘equity of funding’ in general practice has been discussed at PCCC in previous

meetings with an agreement that this needed to be reviewed as a CCG with the recurrent budget available being prioritised to invest in general practice. In line with the strategic plan for 2018-21, it sets out the vision for ‘Leeds to be a health and caring city for all ages, where people who are the poorest improve their health the fastest’.

1.2 In order to address the issue across the Leeds CCG footprint, a working group was set up,

which included LMC, Leeds GP Confederation, primary care and finance colleagues, to review the current funding to general practice and any further funding available and plan how we can have equity across all general practices.

1.3 A proposal has been worked up which will ensure that we have reviewed all PMS practices

and brought them in line with GMS funding, this will provide assurance to NHS England that we have completed the equitable funding review of PMS practices. In order not to destabilise any practice and to continue to pay all practices at the same level, a scheme has been developed and funding identified, which will be worth £6.54 per patient, and will bring all practices back up to the highest level of funding within the CCG.

2. BACKGROUND

2.1 NHS England completed a review of Personal Medical Service (PMS) contracts in 2014/15; the purpose of the review was to ascertain what PMS practices were providing over and above General Medical Service (GMS) contracts. The review showed that PMS practices were not offering anything over and above the core GMS. A subsequent reduction in funding has taken place over the last four years.

2.2 The purpose of the review was to align both GMS and PMS practices to the same £ per patient. NHS Leeds CCG is now in a position where there is still a discrepancy in funding with GMS being paid £88.96 and PMS paid between £91.28 and £95.50 (based on 2018/19 figures).

2.3 Discussions have taken place with the LMC, Leeds GP Confederation, Finance and Primary Care colleagues with a task and finish group set up to understand the discrepancy and see how we are going to work with practices to bring equity. We want to continue to support and sustain general practice and we do not want to destabilise any practice. The recommendation from the group would be to bring all practices in line by aligning the core baseline and then to make an additional payment to all practices to the highest level of funding across the patch in recognition of a focus on reducing variation.

2.4 We have also engaged with all member practices at members meetings in December 2018

to receive feedback on equity of funding and to start to formulate a plan. 2.5 We have worked closely with our finance colleagues to ensure the finances are available to

implement across the city. The funds will be made up of £1.8 million recurrent primary care

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funding that is already available to the CCG. The additional funding comes from top slicing the PMS premium already available to the CCG.

3. PROPOSAL 3.1 In order to reach equitable funding across the CCG, a final review of all PMS practices

funding has taken place to understand what is needed to bring them in line with GMS. The proposal is to bring all practices in line from April 2019. All practices will be paid at the same core baseline, which is currently £88.96 (based on current GMS). The funding deducted of PMS practices would be added to the current PMS premium pot, which is currently used to support health inequalities.

3.2 PMS practices will remain on their PMS contract, but as the funding will be the same for

PMS and GMS they may wish to invoke their right to return to a GMS contract, if they wish to do so. The primary care team will work with practices who wish to explore this option.

3.3 Our commitment is not to destabilise any practice, as we are aware that the previous PMS

reviews have had a significant effect on some practices within the CCG. We will therefore be implementing a ‘quality in general practice scheme’ (Appendix 1) across all practices which will be worth the equivalent of £6.54 per patient, this will effectively bring all practices up to what the highest PMS practice was paid which is £95.50. This will be inclusive of MPIG, but as MPIG reduces, funding for all practices will remain at an overall £95.50 per patient (figures based on 2018/19), in line with current funding arrangements, Out of Hours (OOH) will be deducted off this figure.

3.4 A letter has gone out to both GMS and PMS practices outlining the proposal for equitable

funding, details of the additional funding and scheme details. This requires practices to sign to express an interest in the scheme for the additional £6.54 for implementation in April 2019. 60% of practices across Leeds will receive an increase in funding from our proposals with almost 50% of those practices being in our most deprived communities.

3.5 The proposal has been reviewed by Primary Care Operational Group who have supported

the recommendation to progress the approach to achieve equitable funding. 4. NEXT STEPS 4.1 Expressions of interest have been received from practices. We will then work with finance

colleagues to make the changes required and ensure that payments are adjusted for the April 2019 payment.

4.2 The Primary Care Team will work with individual practices to identify the key areas of improvements the practice will focus on to ensure value for money for the proposal.

5. STATUTORY/LEGAL/REGULATORY/CONTRACTUAL

5.1 All practices will continue with their current PMS/GMS contract so there will be not

contractual changes, unless a practice wishes to invoke their right to return to GMS from a

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PMS contract. The primary care commissioning team will work with any practice who wishes to do this.

6. FINANCIAL IMPLICATIONS AND RISK 6.1 The CCG already has £1.8 million recurrent funding available in the primary care funds, to

enable us to fund the £6.54 for all practices we will top slice £690k off the PMS premium. This will leave an additional £964k of PMS premium available to be reinvested into health inequalities for practices in the most deprived/high BAME populations.

7. COMMUNICATIONS AND INVOLVEMENT 7.1 Members meetings have been used to communicate with all practices and a workshop

session was held to engage with practices and gain their feedback on the equitable finding review.

7.2 A task and finish group was set up which involved LMC, representatives from the confederation, primary care and finance colleagues to work up proposals.

8. WORKFORCE

8.1 There are no workforce issues associated with this proposal. The proposal aims to support

recruitment and retention at practice level through providing headspace for quality improvement.

9. RECOMMENDATION The Primary Care Commissioning Committee is asked to:

a) approve the proposal to align all GMS and PMS practices to the same core income;

and b) approve the proposal to implement the quality in general practice scheme.

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Quality Improvement in General Practice

Introduction: The Strategic Plan 2018/19-2020/21 sets out the vision for “Leeds to be a health and caring city for all ages, where people who are the poorest improve their health the fastest”. The CCG believes that the first part in achieving this vision is to strengthen access to high quality GP services and primary care. Following feedback from practices, the CCG is providing additional investment in general practice of £1.8 million to address the financial inequity that current exists within our practices. The Service: The focus of this scheme will be to improve the health and wellbeing of practice populations by addressing variation at practice and locality level through embedding a culture of continuous quality improvement. Quality Improvement (QI) is a commitment to continuously improving the quality of healthcare by focusing on the needs of the people who use the services. It is an evidence-based approach that supports primary care to deliver initiatives and embed new approaches more effectively and efficiently into practice. QI helps make the most of systems to deliver better outcomes for patients. The CCG aims to give practices the flexibility to utilise this resource as necessary to improve health outcomes and reduce inequalities, ensuring that services are safe and of a consistent high quality that works well both for staff and patients. Criteria: All practices will be eligible to participate in this scheme providing:

The practice is open 8am – 6.30pm Monday to Friday*

Quality ECG testing and interpretation, quality spirometry testing and interpretation, and phlebotomy is provided

The practice engages with the evolving Primary Care Networks strategy for integrated nursing services in areas such as wound care which is driven by reducing duplication, reducing variation and improving efficiencies

Continues to promote learning from incidents through the use of Datix

The practice participates in regular quality improvement work by identifying and addressing areas of variation.

o Utilising data for improvement through the primary care webtool, RAIDR and the practice quality improvement dashboard

o Review of patient experience through the NHS GP Survey and how this reflects capacity and demand profiling

o Participate in winter communication plans

In 2019/20 a specific focus will be to review the variation of the annual health checks for people with learning disabilities including reviewing the offer from the Health Facilitation Team to achieve the ambition of 75% *Practices can determine how best these services are provided but any subcontracting arrangements (6-6:30pm) should be agreed with the commissioner

Funding: The funding for this element of the scheme will be worth the equivalent of £6.54 per weighted patient. The CCG will discuss with individual practices the key focus for improvement during 2019/20 identified by the practice.

Leeds CCG - Primary Care Operational Group Chairs Summary – February 2019

Commissioning

The group discussed the recent publication of the GP Contract https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf

The following areas were identified as immediate areas to review: o Impact of changes to QOF on QIS o New workforce roles – PCOG needs to take into account the funding flows through this route

on our strategy for clinical pharmacists come up with a proposal based on this recommendation to maximise best value.

o Review the potential implications for current social prescribing procurement starting on 1 September.

o Geographically aligned networks to cover 30,000-50,000. Key action to future meeting is to consider the implications for our localities following further guidance.

Procurements of The Light and Safe Haven are progressing with consensus taken place for The Light. A contract extension for Safe Haven has been actioned to align the contract end date.

Drafts of the Quality Improvement Scheme, care homes and the Equitable Funding scheme were circulated to the group with a request for comments on the papers. These would be presented to members in March to support implementation from 1st April 2019.

Workforce

The group received the recent paper that had been presented to PCCC and the group noted that the risk scores have been increased on the Governing Body Assurance Framework and on the Primary Care Risk Register. PCCC had welcomed the report and requested an update in relation to Primary Care Workforce Group and the Confederation.

The group received an update on the first of the three TARGET events on Women’s health. 20 speakers, including Professor A White, with 2 parallel sessions covering a wide variety of topics were planned. It was agreed choice of session had resulted in an increased a good mix of attendees, including LCH nurses. A recent South and East locality session provided training receptionists on Active Signposting.

The May external TARGET will focus on early diagnosis of sepsis, cancer and heart failure. September will have a focus on health inequalities. The June TARGET session (20 June) is the City wide Primary Care Conference.

Quality, Risk and Performance

The group were updated on the latest QSG meeting where progress against those practices under routine, routine + and enhanced surveillance took place.

Three practices are in enhanced, two of which are progressing well. Eleven practices in routine+ (some because RI in one domain). The group discussed a comment regarding GP practices appear to be not maintaining quality systems and processes and subsequently their ratings have got worse than previous inspections, reflecting national position. It was agreed that this data would be reviewed.

https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf

https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf


Leeds CCG - Primary Care Operational Group Chairs Summary – March 2019

Workforce

The group were updated on the recent TARGET events on Women’s health which appear to have been well received. There had been some feedback on the behaviour of some individuals towards speakers which would be addressed and plans to try and mitigate by ensuring facilitators are available.

Commissioning

The group was updated on the status of The Light procurement which was progressing and entering into the standstill period. Thanks were given to the team who have been working on this.

The latest draft of the care home specification was reviewed in advance of PCCC. The financial position was discussed whereby the risk relating to ensuring 100% coverage has been mitigated through existing primary care expenditure.

In preparation for support the recommendation to PCCC, the group discussed the Shakespeare APMS Contract and agreed to recommend extending the contract as is permitted through the contract.

Year 2 of the scheme was presented of Quality Improvement Scheme, feedback had now been taken into account from clinical leads along with changes relating to QOF. A draft version had been shared with members at the March meetings.

The group received the draft paper setting out the final proposal in relation to Equitable Funding in preparation for PCCC. The group had been supportive of the development of the proposal and therefore recommend approval of the scheme to PCCC.

The group received a paper setting out the arrangements at some practices for Vulnerable Populations. The group discussed the contractual position in relation to accepting registrations within practice boundaries however agreed that a further options appraisal would be brought to the group to identified what further support could be made available to practices.

The group agreed that the CCG in line with the NHS Contract should write out to primary care networks to begin the process of reviewing the position of networks across the City. Whilst further guidance is expected it was agreed that writing out to practices would support further conversations at practice level.

Agreement was given the name change for Pudsey Health Centre to Mulberry Street Medical Centre

The group discussed implications of the Public Health England campaign for cervical screening and implications for practices. Many practices were already utilising the campaign to increase screening and it was agreed to discuss with the Confederation the ability to offer screening through the hub arrangements.

Quality, Risk and Performance

The group were updated on the latest QSG meeting where progress against those practices under routine, routine + and enhanced surveillance took place.

The group received an update on the status of CQC re-inspections particularly following some feedback previously regarding deteriorating position: 25 practices had received a further inspection by CQC – 72% of those either maintained or improved their position with 28% have a reduced position (which may include a reduction in one domain).


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NHS Leeds CCG Strategic Commitments

We will focus resources to:








Assurance Framework – which risks on the GBAF does this report relate to:

1. Inadequate patient and public engagement results in ineffective decisions and challenge











Title: Health Inequalities Audit 2019 - Access to General Practice (part of the NHS England 7 Core Standards)

Lead Governing Body Member: Dr Simon Stockill, Medical Director, Medical Director of Primary Care


appropriate ()

Report Authors: Charlotte Orton, Public Health Specialist Vicky Annakin , Contracts and Commissioning Manager – Primary Care

Decision

Reviewed by EMT/Date: N/A Discussion

Reviewed by Committee/Date: N/A Information



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EXECUTIVE SUMMARY: CCGs were required to commission additional access at evenings and weekends for 100% of the population by 1 October 2018. As part of the seven core standards, CCGs are required to review issues of inequalities in patient experience of accessing general practice services identified by local evidence and produce an appropriate action plan. The CCG has worked with public health colleagues to review patient experience along with a review of the barriers to enable local populations to have the best possible access to primary care services in Leeds.

NEXT STEPS: The CCG will continue to work with the GP Confederation and individual practices to improve the patient experience of accessing services to ensure a continuous improvement is made.


a) note the briefing paper and action plan; and

b) identify any further actions to address inequalities in access to services.

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Background NHS England have identified there are “currently significant inequalities in different groups’ experience of access. Whilst making changes designed to improve access, CCGs should ensure that new initiatives work to reduce inequalities as well as improve overall access”. As part of the NHS Operational Planning and Contracting Guide 2017-19, NHS England set out their 7 core standards for improving access to general practice. As part of these core standards, one relates to inequalities with patients’ experience of accessing general practice. Through the commissioning arrangements there is a real opportunity to improve access to general practice for patients, however funding alone will not deliver our aspirations to improve access particularly for those groups of patients that traditionally have a poorer experience of accessing GP services. NHS Leeds CCG in collaboration with public health has undertaken a review which examines barriers to access that exist for the population of Leeds. Whilst individual patients will each have a different experience of access we want to ensure equality in experience of access for all patients regardless of protected characteristics, personal circumstances or condition. Appropriate access to primary care services is key to supporting the Leeds CCGs high level strategic commitments which are to:

deliver better outcomes for people’s health and well-being

reduce health inequalities across our city Assessing local issues As outlined within NHS England’s “Improving Access for all: reducing inequalities in access to general practice services”, Ford et al outline 6 key factors which may influence a patients ability to access general practice:

1. Identification of health problem – barriers can include: health literacy (including education and health beliefs) and problematic experiencing causing a health issue.

2. Decision to seek help – barriers can include: health beliefs, understanding the local health system, support.

3. Actively seek help – barriers can include: patient and community, use of technology and discrimination.

4. Obtain appointment – barriers can include: registration at a practice, access to an interpreter, navigating the booking process, diversity in patient backgrounds, GP preference,

5. Attending an appointment – barriers can include: waiting room experience, transportation.

6. General practice interaction – barriers can include: the consultation, communication, cultural competency, equality.

Health Inequalities Health inequalities are differences in health between people or groups of people that may be considered unfair. Health inequalities exist across a range of dimensions or characteristics, including personal characteristics, lifestyle factors, social networks, living and working conditions, and socio-economic and environmental conditions.

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By tackling health inequalities we can help ensure everyone has the same opportunities to lead a healthy life, regardless of who they are or where they live. However, despite efforts to address inequalities in health, stark health inequalities remain. Nationally, there has been little change in: the gap in male life expectancy; male and female healthy life expectancy and premature cancer mortality. Life expectancy for females has actually widened between those living in the most and least deprived areas. A key determinant of health is where people live, with poorer health outcomes being closely related to higher levels of deprivation. As some ethnic groups are far more likely to live in more deprived areas than others, this results in further inequalities for some groups. Similarly, those who are considered vulnerable may also experience greater health inequalities. It is widely known that some groups within Leeds have a poorer experience of accessing healthcare services. The following model (developed by Leeds Public Health) is helpful in illustrating the impact of health inequalities for groups who may be considered vulnerable, including highlighting links with ethnicity, where people live and the relationship to healthcare access and experience.

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Current Picture

A review of national evidence in relation to primary care access was undertaken by Public Health and the following provides an overview of the main barriers and access issues experienced, as evidenced nationally:

Accessing a Practice

- Registration i.e. lack of paperwork, lack of capacity to take on new patients

- Understanding of healthcare services i.e. cost

- Staff attitudes acting as a barrier i.e. prejudice, discrimination, understanding needs

- Location i.e. transport links, rural areas

- Building access

Accessing an Appointment

- Ability to make an appointment

- Timeliness of appointments available

- Suitability of appointments available

Patient Experience

- Understanding within the consultation i.e. low health literacy, language barrier

- Communication i.e. respect, listening, appropriate delivery of information

- Satisfaction with consultation i.e. confidentiality, privacy, confidence in advice

provided

- Responsive service i.e. speed of appointment, convenient time, appointment with

preferred member of staff, sufficient time allocated for appointment.

The findings from the evidence review also supported the view that those from vulnerable groups are most likely to report the access and experience issues outlined above. Such groups include those sharing one or more protected characteristic, the result of which is poorer health outcomes than the rest of the population. Target Groups

Someone who may be considered vulnerable may require additional support to help live their lives, including accessing healthcare services. The following groups may be considered vulnerable:

People insecurely housed

Gypsy, Traveller and Roma groups

Refugees and asylum seekers

Migrant populations

Sex workers

Faith groups

Drug and alcohol addiction

Gang/serious youth violence

Harmful sexual practices

Domestic violence

FGM

Poverty Homelessness

Evidence also highlights the following groups may be similarly challenged in relation to primary care access and experience:

- People with mental health problems

- People with learning disabilities

- People with low health literacy

- People with drug and alcohol problems

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Groups who are not registered with a GP practice are also highlighted and may be considered ‘invisible’ in the primary care system. Action is therefore required to reduce the number of Leeds residents who are not registered with a GP practice and to highlight any areas where this is a particular concern for community groups. This is supported by the NHS England report ‘Improving access for all: reducing inequalities in access to general practice services’ (NHSE, 2017). Methodology An action plan has been developed in line with the 6 key factors identified that prevent patients accessing primary care and the factors that have been identified as the main barriers to access. The action plan takes into consideration comments from patients and service users through both the national GP patient survey 2018 and feedback given to the CCG. The action plan identifies current action taken by the CCG to address these barriers and outlines any existing gaps where future insight work is required. This insight work will then inform any future commissioning intentions to support access into primary care. In order to ensure that we do not exclude patients who do not often attend primary care we will also ensure that insight work would seek to engage these groups. Research has led us to identify the elderly, young males and gypsy and traveller community as groups that are less likely to access primary care. As a Leeds system we have committed to focus on our frail population as we move to a commissioning for population health approach. We also are aware that there are particular challenges for this group in terms of cognitive function, mobility and travelling to appointments and complexity of health conditions. A number of patients (young males) attend Accident & Emergency for primary care amenable complaints, often citing access to GP services as the reason for attendance. We have reviewed the cohort of patients who have attended A&E and were streamed to GP services using this as a proxy measure for identifying groups who are struggling to access general practice. This will also be an opportunity to evaluate a scheme we have recently put in place in Leeds aimed at improving access for the gypsy and traveller community. Primary Medical Services – GP Practice Provision Through delegated commissioning arrangements, Leeds CCG is responsible for the commissioning of primary medical services from our 100 GP practices. Each practice has its own way of providing services to the local population which responds to patient feedback and the population demographic and we encourage practices to actively review capacity and demand as part of a quality improvement approach. Access is key indicator of quality and workload and as part of our regular review of quality forms part of our Primary Care Quality Improvement Dashboard including:

Patient Experience o GP Survey o Friends and Family Test o www.nhs.uk ratings

Access o Use of A&E, GP Streaming, Minor Injury Units, Walk in Centre, 111, out of

hours and Extended access hubs o Use of online consultations

Where local intelligence identifies recurring themes, the team will work with individual practices to develop an action plan to address areas of concern.

http://www.nhs.uk/

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Current Service Model for Extended Access The delivery of extended access services is currently provided via the Leeds GP Confederation through 12 physical ‘hub’ locations as well as a virtual access to physiotherapists and pharmacists available in specific areas of the City. The hub locations are identified as: Aire Valley Armley Hyde Park / Burley Park Ireland Wood Leeds Student Medical Centre Morley Otley Pudsey Rutland Lodge Seacroft St Georges Wetherby The physical locations have been identified through discussions locally as to the preferred locations to respond to patient accessibility. Between April 2018 and January 2019 there have been an additional 82,739 appointments available across the City, which reflects a growing number as the roll out of extended access occurred throughout the year to meet the October 2018 target for implementation. Leeds West practices had early access to funding for extended access and therefore the utilisation / awareness of appointments is currently greater in those areas whilst the rest of the City continues to embed the services. Services available through the hubs include appointments with GP, nurse, HCA, physiotherapist and pharmacist. The GP Survey 2018 results The patient demographic results show that out of the 33,034 survey forms distributed, there was a 31% response rate with 10,367 surveys returned. These results in part have been included within the action plan. There are different response rates to each individual question provided by patients and the actual number has been included after the percentage figure to show the number of patients who have responded to that particular question. The male population are slightly under represented with a 49% (5,529) response rate with 51% (5,681) of females replying. Those aged between 25-34 provided the most responses 19% (2,132) with those aged over 75+ provided the least responses. Age Range

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The ethnic origin of respondents demonstrates that from the 11, 141 total responses received, the majority of respondents was predominantly “White – British” with a response rate of over nearly 9,000 as shown in the chart below. The lowest return rate was from “White - Gypsy or Irish Traveller” with only 2 responses received. We know that this cohort of patients are a hard to reach group and have poorer health outcomes due to limited accessibility to health care services and in particular, primary care. To understand why this community struggles to access health services, the CCG visited the local authority Gypsy and Traveller site called Cottingley Springs in a previous exercise. Residents were asked what worked well and what could be improved upon. The feedback provided identified that the majority of people wanted it to be easier to register with a GP practice and that they would also like to be able to choose a practice of their choice. Ethnic origin

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The majority of responses were received from full-time paid work for more than 30+ hours per week. This cohort of patients also experience issues when utilising general practice where improved access or alternative commissioned services would be beneficial. Status

Frail & Elderly and Long Term Conditions As a Leeds system there is a commitment to focus on our frail population as we move to a commissioning for population health approach. There is evidence of particular challenges for this group in terms of cognitive function, mobility and travelling to appointments and complexity of existing health conditions. The ‘What matters to older people living with frailty review’ found that one of the most important things to this group is ‘experience of using healthcare services, in particular whether they feel they have been listened to and treated with dignity’. In relation to end of life care ‘people’s experience of care’ and ‘how people’s wishes are taken in consideration’ were highlighted as most important. This evidence is echoed by the 2017 GP Survey findings for those living with long term conditions which highlighted that whilst the way people are treated with Long Term Conditions in Leeds is generally good, there is a gap in the way local organisations help them to manage their condition and the way plans are discussed and communicated between health care professional and patients. One in 5 patients who responded to the GP Survey felt that they had not had enough support from local organisations to manage their health condition. In addition, more people reported that they had not had a conversation with a healthcare professional around managing their condition than those who had. However, 60% of those who had, had a plan in place to help them manage. 92% of those found this helpful, but 56% had not been given a written copy. Given the high number of patients (1 in 2) living with a long term physical or mental health condition, disability or illness and 1 in 5 using 5 or more types of medication (GP Survey

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Data) there is a clear need for primary care to play a greater role in supporting patients to self-care. Furthermore, 15% respondents felt that the healthcare professional did not understand their mental health needs, suggesting a need for greater awareness among primary care staff. Working Population Of those that do complete the survey young males appear to report poorer experiences of accessing services compared to the Leeds average of 74.9% (males 18-24, 65.2% and males aged 25-34, 67.9%). Those of working age (20-39) also appear to be frequent users of GP Streaming, Walk-in Centres and Minor Injury Units compared to other age groups, with the exception of those aged 0-4 (accessed GP streaming and Walk-In Centres more frequently); and 10-19s (accessed Minor Injury Units more frequently, followed by those age 0-4). However, 10-19 year old accessed Minor Injury Units more often than any other group. This could suggest age-related healthcare needs relating to lifestyle i.e. accidents and sports related injuries rather than lack of access to a GP practice. Findings The action plan pulls together the GP survey results and patient feedback provided to the CCG through engagement exercises. We mapped this against engagement already undertaken for existing work programmes which will enable better access to services. Through our local commissioning arrangements such as through the Quality Improvement Scheme, we have already identified actions for primary care which support improvements in health inequalities, including:

Principle of using the weighted capitation approach to target resources to greatest need

Equitable funding review will providing additional investment in some of our most deprived populations rectifying historic levels of disinvestment

Embedding personalised care through Collaborative Care and Support Planning

Focus on annual health checks for people with serious mental illness and learning disabilities

Ethnicity and first spoken language – focus on improving the coding and review of patients who may experience barriers to healthcare due to language differences

Recommissioning of British Sign Language interpretation services

The implementation of the 10 high impact actions will support improvements in access for patients through the use of alternative modes of consultation, increasing the workforce availability and focusing on improvements on areas such as DNA which should enable patients easier ways of cancelling (and making) appointments.

The new GP Contract provides additional funding for additional workforce to help support improvements in capacity

There are however a number of developments that are required, which include:

Working with the GP Confederation to ensure extended access services support a focus on health inequalities, this could include:

o Greater focus on preventative measures to improve screening, health checks (LD, SMI and NHS Check)

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o Review of locations to ensure ease of access for patients who may find it difficult to travel

Ongoing training and development of GP receptionists through care navigation

Further development of ‘online’ services including ability to book appointments and availability of other consultation types

RECOMMENDATION The Primary Care Commissioning Committee is asked to:

a) receive the briefing paper and action plan; and b) identify any further actions to address inequalities in access to services.


Improving Access for All: Reducing inequalities in access to general practice services (2019)

Patient Pathway Approach2. Decision to seek helpGP Patient Survey results

(2018)Patient feedback (Leeds CCG) Objective Action Progress

Gain a better understanding of access barriers

experienced by working age males

Scope and commission insight work to gain a better understanding of access barriers

experienced by working age malesReview the recently published State of mens health report to identify specific actions for primary care

Understand the needs of groups who experience

barriers to communicating within the primary care

setting

Actively promote within practices (including practice website):

- Availability of Language Line

- Availability of health information in other languages (NHS Health Choices)

AIS Workgroup

MJOG voice pilot

Notices etc available in different formats and languages for all patients.

Language Line procurement already in place

Engagement exercise undertaken to ascertain opinions on messages and language used for improving early

access to maternity services.

Consider the needs of those on a low income

Call back system as an alternative To putting on hold (reducing cost of phone Call)

- Online appointment system (reducing cost of phone Call)

- easy access To repeat prescriptions (reduce the need for visiting the practice when not

necessary for medication required)

- Consider waiver of fees for those experiencing debt-related ill health

Focussed work with practices who have poor patient experience to support quality improvements in relation to

capacity and demand (making it easier to obtain an appointment)

Roll out of unified communication systems

Overall increase in investment in general practice to help support increase in capacity

Embedding of social prescribing services at practice to support patients with debt issues

Reduce the number of people not registered with a

GP practiceLink with community organisations that can support people to access help

Regular deliberative events are held bringing together a wide range of communities to comment on our plans

and priorities.

Understand population statistics / areas where patients are not registered to consider some targetted approach

58% (3,079) reported condition

reduces ability to carry out day to

day activities

*If not entitled to free rx, cost may deter from seeking

early help

*Women more likely than men to engage with health

providers but cultural issues re male clinicians. May attend

appointments with entire family

*Difficult balancing desire for privacy and to speak to a

same-sex GP with the difficulty they experience getting an

appointment

*Variations in how trans people are treated - e.g. names /

titles etc

*People living in care homes face particular issues

accessing health services


Patient Pathway Approach 3. Actively seek help GP Patient Survey results (2018) Patient feedback (Leeds CCG) Objective Action Progress

Identify practices requiring further engagement with Active Signposting

Active signposting training completed for all practices

From 1 October 2019, commission 1 single Primary Care Mental Health service for patients experiencing

feeling low, vulnerable or anxious.

Explore opportunities to improve the use of other healthcare professionals for

those with complex needs e.g. pharmacist, physio (sharing learning from other

practices)

Other health professionals in practice including physio, paramedic pilot, pharmacists working with local

GPs to support.

Proposals to establish five urgent treatment centres for urgent (non-life threatening), same day care.

New GP Contract provides new workforce models at scale including social prescribing

QIS supports referral/signposting to other prevention services such as One You, NDPP

Identify appropriate action to reduce A & E attendance from those aged 0-15 PQI identifies attendance Practices working on reducing A&E attendances and highlight younger age group.

Ensure practices promote health and wellbeing and prevention of ill-health. For

example:

- Promote and signpost to websites including NHS Choices, Mindwell, MECC

- Support relevant national and local Public Health campaigns, including Health

Harms, Alcohol Awareness Week, Mental Health Awareness Week

- Promote healthy living services, including One You Leeds and Forward Leeds

Signposting in practice

- Ongoing support for local campaigns

- Development of the mental health website MindMate, with involvement from children/young people To

Provide further support To parents and carers.

- health Inequalities Scheme: smoking cessation

78% (3,242) easy for ease of using GP practice website to look

for information relating to accessibility

8% (843) reported feeling isolated from others

2% (158) reported having blindness or partial sight

6% (570) reported having deafness or hearing loss

59 respondents (of 11,171) responded being a deaf person

who uses sign language

11% (1,086) reporting having a mental health condition

*Poor experience with reception staff

*Poor attitude / discrimination, especially at reception

*Some negative reactions / prejudice from staff

*Gatekeeping / discrimination

*Attitude of GPs to young people's issues

*Limited access to interpreters; not taking time to listen /

communicate effectively

*Low literacy rates & language barriers – accessing information is

difficult, including how to take medication, services available etc

*Lack of privacy & confidentiality at reception; may not be

comfortable coming out to health care staff

*May need more time with a GP than usual appts allow - frail/elderly

patients

*Interpreters may not be available at GP appts - can result in lack of

clarity re medication, care etc. Would benefit from information

available in video format (e.g. re long term conditions

*Lack of current / age appropriate information

Empower patients to take control over their own health and

wellbeing

Ensure actions are in place which support patients to self-care, including:

- Peer support programmes (focussing on local population needs e.g. diabetes,

COPD)

- Promote Better Conversations training available to staff

QIS provides resource to implement a collborative care and support planning for patients with LTC ensuring

share decision making occurs through a better conversation and a holistic approach

Support patients to access appropriate services

Improving Access for All: Reducing inequalities in access to general practice services (2019)Patient Pathway Approach 4. Obtain an appointment GP Patient Survey results (2018) Patient feedback (Leeds CCG) Objective Action Progress

Audit use of Language Line

The team has recommended that following initial feedback a wholescale review of

intepretation services is required which will be commissioned from April 2020

Seek the views of GP practice staff and service users on using Language Line As above

Promote opportunities for greater privacy

- Promote opportunity to see a preferred GP (to ensure continuity for those that

would benefit most)

- Identify carers or whether a carer will be attending (to accommodate longer

appointments)

- Recording language spoken (to arrange appropriate translation or

interpretation)

- Identify whether a patient has low literacy levels (to enable letters to be

explained/alternative communication to be used) and consider implementing

Health Help cards

carers identification work underway.

- used in CQC

- Highlighted on team lists To increase Recording of carers.

- Ethnicity and first spoken language (Part of health Inequalities)

- longer appointment where needed To support interpreters

Already working with the 20 practices that received the lowest patient

satisfaction

Actions plans being developed (for each practice)

NHS England tool has been developed to support capacity and demand

Develop tailored action to address areas highlighted within the practice survey,

for example:

- Promote online booking systems where awareness and usage is low

- Raise awareness of alternatives to a GP appointment (active signposting)

"Workload" group established which oversees the improvement in uptake of online booking

systems and increasing the availability of online consultations. The CCG must have 75% of

the population able to access online consultations by April 2020 which will only help improve

satisfaction in terms of appointment availability

- Active Signposting training rolled out across the City

Ensure alternatives to same day appointments exist for those with additional

needs or those who need to make arrangements to be accompanied

Extended access provides additional appointments at weekends and evenings to support

increase in availability.

BSL contract has been procured with a new service specification to support same day and

urgent appointments.

Capacity and demand toolkit - NHSE/APEX

74% (7,990) easy to book appointment

46% (5,142) booked appt in person

76% (8,606) booked appt by phone

12% (1,301) booked appt online

3% (298) booked appt via alternative, ie NHS111

67% (6,962) satisfied with general practice appointment times

44% required same day appt

64% were offered choice of appt

20% (2,099) were not satisfied with appt but took it anyway, of

these,

48% said there were no other appts at time or day suitable to the

pt

Of those that did not accept the appt:

24% (153) decided to contact the practice at another time

29% (187) Didn't see or speak to anyone

46% (4,940) have a preferred GP to see/speak to

48% (2,208) are able to see their preferred GP

25% (2,396) waiting a week or longer for their appt

69% (7,205) had a good experience of making an appt

*Limited ability to make appointments; having to call at certain

times particularly difficult for parents with school age children

*Long telephone waiting times, not aware of online booking /

problems logging on; lack of appointments outside of working

hours

*Cost of contacting the surgery - don't always have credit for

phone calls

*Problems making appointments, especially urgent ones; not

being able to get appointments with chosen GP or for more

than one issue

*Less likely to understand how to use different booking

systems

*Physical access, transport etc an issue for frail & elderly with

restricted mobility. May experience problems phoning for

appts at set times & using automated systems

*Problems making appointments by phone– text service would

be useful

*Usual difficulty getting appointments when needed. People

with LD may have to rely

*Tend not to plan ahead so experience problems getting appts

Explore experience and acceptability of the Language Line service

Ensure systems are in place that allow

appropriate appointments to be made

Improve patient satisfaction in obtaining an

appointment


Patient Pathway Approach5. Get an appointment

GP Patient Survey results (2018) Patient feedback (Leeds CCG) Objective Action Progress

Agree actions which support vulnerable groups to navigate the healthcare

system, with a focus on: Refugees, Asylum Seekers and Migrants, Gypsy &

Traveller groups, Roma groups, ex-offenders and homeless people. For

example:

- Consider signing up to Safer Surgeries, including engagement with training

and assessing improvements for targeted groups

- Seek learning from MAP project+

TT to advise on wording to include in relation to costs for different groups

- Develop staff awareness and understanding of different health care

cultures

Work ongoing through proactive care team.

Outreach Worker working among Gypsy/traveller community and raise

awareness in local practices.

Deliberative event has taken place and a 'you said, we did' list of actions

has been developed to be included on the website

Support patient groups less likely to access primary care due to

lack of understanding or confidence in the health care system

*Little understanding of system; different expectations of

health care

*People with LD may have to rely on others to navigate

system, make appts etc

*Lack of knowledge about services available

12% (1,319) experienced physical mobility and

problems getting around the home

5.1. Access to primcary care. A public (deliberative) event to look at how

we can implement the Five Year Forward View - Ten impact Actions. These

are things GP practices need to do to free up clinical time for the people

who need it most.


Patient Pathway Approach 6. General practice interaction and experience GP Patient Survey results (2018) Patient feedback (Leeds CCG) Objective Action Progress

53% (2,741) have not had a conversation with their healthcare professional at their GP

practice to discuss what is important to them when managing their condition(s)

60% (1,296) have an agreed plan with a healthcare professional from their GP practice to

manage their condition(s)

*Single issue / fixed appointment slots / seeing different clinicians perceived as a barrier by many

*General lack of trust in authority organisations, including health services – less likely to try to

register / make appointments.

*Lack of continuity of care & short appts can be an issue

Ensure the waiting area environment supports a

positive patient experience

Ensure waiting areas reflect the diversity of the patient

population. For example:

- Confidentiality and privacy policy displayed (all notices

should be displayed in line with CQC).

- Cues for deaf and blind patients to ensure appointments

are not missed

- Dementia Friendly

- Breastfeeding Friendly Scheme

Previous training given to Practice Manager re deaf and blind patients and

need for interpretation and working with staff to support patients.

This will be addressed through the AIS pilot

Primary Care Team to identify a Dementia Friendly champion to link with

the Dementia team to ensure GP practices are updated


1
























NHS Leeds CCG Primary Care Commissioning Committee


Title: Quality Improvement Scheme: Year 2

Lead Governing Body Member: Simon Stockill, Medical Director of Primary Care


appropriate

()

Report Author: Deborah McCartney, Head of Primary Care Commissioning & GP Forward View

Decision

Reviewed by EMT/Date: N/A Discussion

Reviewed by Committee/Date: PCOG 12 March 2019

Information



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EXECUTIVE SUMMARY: In 2018, the CCG approved additional funding for a three year single Quality Improvement Scheme (QIS) for General Practice. The scheme was developed with Clinical Leaders working alongside commissioning and improvement managers. It took into consideration the three historic CCG schemes, a review of the CCG priorities and ambitions and data from Rightcare data and other national benchmarks. The scheme was released part way through the year to practices and we can confirm 100% uptake of participating practices. The team have continued to work in partnership with colleagues and practices to support the delivery of the scheme. This work is progressed and reviewed through a CCG-led QIS Operational Group and a QIS strategy group. Reports have been provided to PCCC throughout the year; these are supported with a purpose built dashboard which provides data at practice, locality and CCG level. This will be adapted to reflect the changes both locally and nationally. The development of the scheme for Year 2 has been led by the Primary Care team, with input and validation from Clinical leaders and the Local Medical Council (LMC). The clinical aspect was presented to Members meeting in March. It builds on Year 1 and has taken into account the recently released NHS Long Term Plan and the GP Contract reform. It is positive to note that many of the initiatives and priorities outlined in the NHS plan are established within the QIS; however the ambition in the plan over the next 5 years pushes progress further. The Year 2 scheme is presented to PCCC for approval

NEXT STEPS: Subject to the approval from Primary Care Commissioning Committee, the Primary Care team will:

a) Work with colleagues in the CCG, through the QIS working groups to support the release of the scheme, operational delivery and continuous monitoring

b) Release the scheme and supporting information in readiness for 1 April 2019 c) Support Practices and CCG/Confederation colleagues in the delivery of QIS d) Continuous quarterly uptake and monitoring reports


a) note the changes to the Quality Improvement Scheme; and b) approve the proposed Year 2 Quality Improvement Scheme to PCCC.

3

1. SUMMARY

1.1 In 2018 Leeds CCG approved additional funding for a three year single Quality Improvement Scheme for General Practice. The scheme was developed with Clinical Leaders working alongside commissioning and improvement managers. It took into consideration the three historic CCG schemes, a review of the CCG priorities and ambitions and data from Rightcare data and other national benchmarks.

1.2 The scheme was released part way through the year due to the complexity and challenge of bringing together the member practices within one CCG and the respective local incentive schemes. 100% of participating practices have signed up to the scheme, this was presented to PCCC in September 2018

1.3 The team have continued to work in partnership with colleagues and practices to support

the delivery of the scheme. This work is progressed and reviewed through a CCG led QIS Operational group and a QIS strategy group.

1.4 To support Practice delivery and CCG performance monitoring requirements, the

Business Intelligence team in conjunction with the Primary care team released searches and reports, built within the clinical system. These reports have provided a level of assurance regarding progression and delivery of the scheme, although it should be acknowledged that the teams have continued to receive ongoing feedback regarding the searches and responded accordingly. Work continues in this area, and the reports will be adapted to incorporate the changes within year.

1.5 Reports have been provided to PCCC throughout the year, these are supported with a

purpose built dashboard which provides data t a practice, locality and CCG level.

1.6 The development of the scheme for Year 2 has been led by the Primary Care team, with input and validation from Clinical leaders and LMC. The clinical aspect was presented to Members meeting in March.

1.7 It builds on Year 1 and has taken into account the recently released NHS Long Term

Plan and the GP Contract reform. It is positive to note that many of the initiatives and priorities outlined in the NHS plan are established within the QIS and known to Practices; however the ambition in the plan over the next 5 years pushes progress further.

2. PROPOSAL

2.1 The Year 2 scheme has built on Year 1 priorities, taking into consideration feedback from Practices, colleagues and Clinical Leaders in its development.

2.2 Following the release NHS Long Term Plan and GP Contract Reform Investment and

Evolution (BMA/NHSE 2019), the team has reviewed these in conjunction with the QIS. It has resulted in the following amendments:

4

2.2.1 a realignment of the locality focus to Primary Care Networks 2.2.2 Review of the Quality and Outcomes Framework (QOF) changes including the

Quality Improvement (QI) modules 2.2.3 Removal of the End of Life section, as this is now supported through the QOF: QI

module End of Life Care 2.2.4 Facilitates the QI module Peer review requirements within the Members and

Prescribing Leads meetings 2.2.5 Prescribing section reflects the QOF: QI module Prescribing Safety 2.2.6 Engagement and network plan reflects the workforce areas

2.3 Member Practices have found the targeted prevention priorities a challenge in Year1,

with some practices being demotivated by a specific target (number/ %) achievement. This has resulted in the removal of the overall target, taking into consideration that reducing the prevalence gap requires the system to be working as whole and the numbers of people that General Practice would need to screen to reduce the gap to national requirements is unworkable.

2.4 We are working with Public Health and Planned care colleagues to present an alternative approach, whilst recognising all providers have a part to play in reducing the prevalence gap, diagnosing long term conditions in a quality assured way.

2.5 The scheme has incorporated additional long term conditions into both Section 1: Targeted prevention of Long Term Conditions and Section 2: Better Management of Long Term Conditions with the following:

2.5.1 Section1 seeing the introduction of High Risk of Diabetes incorporating gestational

Diabetes 2.5.2 Section 2 seeing the introduction of Heart Failure and COPD and a more detailed

description of the requirements of the Physical Health Check of people living with a SMI. The latter will align to the requirements of the CCG IQPR from 2019/20

2.6 It should be recognised that the changes within the GP contract and QOF do present the CCG with some reporting challenges that may want to be considered as risks, an example of this relates to: 2.6.1 Section 2: Diabetes. The target set relates to the Treatment to target ambitions set

out in the National Diabetes Audit (NDA), however QOF has now removed the requirements relating to cholesterol level and as such there is no longer a requirement by practices to continue to request this level. The Scheme request practices continue to request the Cholesterol level to support the CCG and also highlights that patients may wish to continue receiving their cholesterol levels to support their individual approach, as a way of mitigation.

2.7 The scheme will incorporate the QI service provision, which is being funded through the equitable funding initiative and will address financial inequity that has existed within Leeds practices. It will be monitored through the QIS operational group.

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3 NEXT STEPS 3.1 Subject to the outcome of the Primary Care Commissioning Committee the team will:

a) Work with colleagues in the CCG, through the QIS working groups to support the release of the scheme, operational delivery and continuous monitoring

b) Release the scheme and supporting information in readiness for 1 April 2019 c) Support Practices and CCG/Confederation colleagues in the delivery of QIS d) Continuous quarterly uptake and monitoring reports

4 STATUTORY/LEGAL/REGULATORY/CONTRACTUAL

4.1 This scheme is a voluntary local enhanced service, offered to all GMS/PMS practices.

APMS practices and practices with bespoke/ unique populations will be required to review their population needs and propose a revised scheme which meets those needs, provides value for money and supports the NHS Long Term Plan and direction of travel for General Practice and communities.

4.2 This scheme does not impact on the GMS/PMS contracting arrangements.

5 FINANCIAL IMPLICATIONS AND RISK

5.1 The CCG approved recurrent funding for the three year Quality Improvement scheme. No additional funding is required for Year 2.

6 COMMUNICATIONS AND INVOLVEMENT

6.1 Members meetings have been used to communicate with all practices.

6.2 LMC was provided with a draft version in February 2019, this was discussed at the February liaison meeting and their comments have been considered. A FAQ document has been developed, which will be shared with the release of the scheme

7 RECOMMENDATION The Primary Care Commissioning Committee is asked to:

a) note the changes to the Quality Improvement Scheme; and b) approve the proposed Year 2 Quality Improvement Scheme to PCCC.

Primary Care Quality Improvement Scheme 2018-2021 – Year 2

Introduction and Funding:

The NHS Long Term Plan sets out a clear path for Primary Care, enabling it to be leaders in the emerging system, with a specific focus around populations and provide a framework for the GP services contract over the next 5 years. It recognises that Primary Care Networks are the essential building blocks of the Integrated Care System (locally known as Local Care Partnerships), these will be supported through the new national Primary Care DES Contract. In Leeds our direction of travel to date supports this strategic approach and can be built upon to meet the NHS Long Term Plan and its ambitions. 2019/20 is the second year of the Leeds Primary Care Quality Improvement Scheme (PCQIS) which is a three-year scheme providing additional financial resource into primary care as the foundation stone of the NHS to support practice resilience, service transformation and most importantly improving outcomes for patients. The scheme has been reviewed in line with the NHS Long Term Plan and the GP Contract reform “Investment and Evolution”, in many areas including the proposed service agreements align to the CCG priorities and outcomes. The scheme remains funded around the registered list at practice level but encourages practices to work collaboratively within Primary Care Networks supported by the Leeds GP Confederation. The benefits for general practice of working in a network are seen as:

Stability – helping the GP partnership model survive and evolve over the coming decade;

Workforce – easier to create different and more varied roles across 30 – 50,000 patients than at individual practice level;

Investment – PCNs can use this to offer services not reasonable to ask of every practice;

Better health and care – PCNs as the natural unit for integrating most NHS care and the footprint for other NHS community-based services. By serving a defined place, the PCN brings a geographical focus to improving health and wellbeing;

Community leadership – the PCN Clinical Director will provide strategic and clinical leadership to support change across primary and community health services.

The scheme has been developed by clinical leaders working alongside commissioning and improvement managers using the latest data on how we, in Leeds, perform against national benchmarks and the nature of variation in clinical outcomes and resource use within Leeds. The scheme has drawn on best available evidence of good practice. The scheme now addresses the historic financial inequity within practices to enable them to:

undertake quality improvement (QI) activities which improve patient outcomes and experience of care in key clinical areas and optimises value for money;

reduce unwarranted variation between practitioners, practices and localities;

contribute to reducing health inequalities.

Support personalised care using examples such as shared Decision Making, Personalised care and support planning, increased use of signposting to Social prescribing and community based support (as appropriate for individual patients) and supported self-management

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Remuneration is based on practice total weighted population, which is calculated based on the Carr-Hill formula and follows the principles of funding for other areas such as Quality and Outcomes framework. Practices will receive the funding for their own patient population however in some instances we are encouraging Primary Care Networks to consider how they can support initiatives that deliver the strategic outcomes for the local population for example sharing financial resources to deliver components of the scheme. Payments will be made quarterly in advance. A value to the equivalent of £1.50 will be withheld as an achievement payment of provision of evidence of the identified outcomes. Please see Appendix II. The Leeds Health and Care Informatics Service will provide practices with local data including a locality and a city profile, as well as individual practice data. This data will be extracted monthly/ quarterly from a set of citywide reports and searches within the clinical systems and be available to the CCG and practices through RAIDR. This will enable the CCG, and practices to review progress on the delivery of the scheme automatically with minimal reporting work required of practices. The CCG will determine achievement based on the outcomes and processes as recorded on the informatics tool RAIDR. Where a practice is not able to demonstrate achievement on RAIDR, the CCG will meet with the Practice to request further supporting evidence. A CCG panel consisting of members of CCG managers, clinicians and lay representatives and the LMC will review the Practice submission and determine the final payment decision.

£8

8.9

6

£1

6.5

4

£1

05

.50

Total price per patient

Equitable

Funding & QIS

GMS Price per patient

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Section 1 - Targeted Prevention of Long Term Conditions

NHS RightCare data for Leeds identifies a significant gap between expected and reported prevalence of Atrial Fibrillation, COPD, High Risk of Diabetes and Hypertension. Closing the prevalence gap provides an opportunity for the identification and treatment of people at risk of respiratory and cardiovascular disease, which has a proven impact for both individual patients and the health and care system through reduced risk of complications and improved population outcomes. Rather than set a series of practice or locality targets, the scheme encourages practices to work using quality improvement (QI) approaches and methodologies to review how they could work with their locality and wider local care partnership to identify additional patients on the register. Primary Care Networks are encourage to review the public health profile and look at opportunities for peer review .The CCG will also continue to work with partners to support the identification of patients.

Targeted Prevalence Gap Rationale

Atrial Fibrillation Estimated Prevalence Gap for AF in Leeds is 4624 people NICE guidance (NNT) for AF supports the identification and treatment to reduce risk of stroke

COPD Estimated Prevalence Gap for COPD in Leeds is 11711 people Being accurately identified with COPD allows improved management and to reduce morbidity and mortality from COPD including avoidable hospital admissions.

High risk of diabetes Estimate prevalence for high risk of diabetes is 64,277 (compared with the current identified population of 36,413) with an estimate prevalence gap of 27,864 Identifying those at high risk of diabetes, including those with gestational diabetes and supporting them with an effective and appropriate intensive lifestyle-change programme to prevent or delay the onset of type 2 diabetes

Hypertension Estimated Prevalence Gap for Hypertension in Leeds is 80000 people. To identify and optimise treatment of people with undiagnosed hypertension would reduce the risk of stroke and cardiovascular disease

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Section 2 – Better Management of Long Term Conditions

Primary care is central to good management of long term conditions. The QOF process has enabled practices to develop systematic ways of recalling and reviewing patients to support their better care. Increasingly many practices in Leeds have adopted a new approach to supporting patient-focussed goals and improved self-care as part of improving patient experience, clinical outcomes and focusing clinical resources and expertise in people with greatest need. This approach, known as Collaborative Care and Support Planning (CCSP) facilitates a change in the annual review process already being undertaken, ensuring that the patient is better prepared for the consultation and received relevant information in advance of the review to aid the collaborative discussion between professional and the patient and “what matters most to me”. For further information see the Leeds CCSP (Building on the National Year of Care programme and training delivered in Leeds) Leeds Collaborative Care and Support Planning Process: Adapted from Diabetes Year of Care Programme

Further information available: http://www.rcgp.org.uk/getting-started This approach is supported as the basis for improving clinical outcomes and experience of care for people with long term conditions. As in the section on Targeted Prevention of LTCs – the impact of the scheme on changing clinical practice (monitored through process measures) and improving clinical outcomes (measured through available recorded data) will contribute to the 20% achievement element of payment. Clinical leads have offered suggestions for practice / locality actions, however the adoption of the principles of CCSP is a required component, but how the outcomes, including how the process for working with better informed patients are achieved remains the decision of practitioners. Collaborative Care and Support Planning is the principle change Practices are required to introduce, with the longer term aim of providing one annual review for people with multiple long term conditions. Where practices are currently implementing CCSP for more than one long term condition or providing one review for people with multiple long term conditions we encourage you to continue with this approach.

http://www.rcgp.org.uk/getting-started

5

YEAR 2 Priorities

Rationale Key Outcomes / Process Measures

Suggested actions that practices / localities may wish to consider to achieve the outcome targets

CVD: AF

Increasing the number people with known AF who are assessed and appropriately managed. Anticoagulation reduces the risk of stroke, premature deaths and chronic disability. In Leeds there is a current recorded treatment gap of 24% or approx. 3000 people with AF but not anticoagulated and at higher risk of stroke.

Target- the CCG to achieve 85% high risk AF cohort on treatment by end of year 2 (current citywide achievement is 76%); whole locality to achieve 90% on treatment by end of year 3 Reduce the Practice level of exception reporting year on year to achieve CCG mean

Continue to engage and collaborate with CCG funded pharmacy team in AF treatment gap and act upon any recommendations from the team including enacting prescribing Review of patients with CHADS2VASc >=1 who are not on appropriate treatment Review exception reporting for people not on appropriate treatment and explore treatment options Conduct a peer review at Practice level as outlined below and discuss the findings at Practice and locality level to share best practice and learning. Findings supported in the locality action plan For all people with a current diagnosis of Atrial Fibrillation who are not on appropriate treatment and subsequently experienced a TIA/CVA review their medical records to understand reason for not being on appropriate treatment, when last reviewed and what action had been taken.

CVD: >20% risk

To reduce morbidity and mortality associated with known higher risk of CVD. Note: Practices to continue using Qrisk 2 tool and transition to Qrisk 3 tool when it is available within clinical systems

75% of patients with Qrisk >=20% taking or declined Atorvastatin (20mg) (in the previous 12 months) by the end of Year 3

Use CCSP approach for all people identified as having >20% risk in annual review to include medication review, self-care, lifestyle behaviour goals Identify patients at >20% risk through NHS Health Check NICE recommends that cholesterol is checked again 3 months after starting statin to see if non HDL has fallen by at least 40%. The statin dose may need adjustment but should be continued long term. There is no reason to repeat the CVD risk assessment.

NICE guidance Cardiovascular disease: risk assessment and reduction, including lipid modification (CG181) point 1.1.28 Page 13 of 44 does state: If the person's CVD risk is at a level where intervention is recommended but they decline the offer of treatment, advise them that their CVD risk should be reassessed again in the future. Record their choice in their medical notes. https://www.nice.org.uk/guidance/cg181/resources/cardiovascular-disease-risk-assessment-and-reduction-including-lipid-modification-pdf-35109807660997

https://www.nice.org.uk/guidance/cg181/resources/cardiovascular-disease-risk-assessment-and-reduction-including-lipid-modification-pdf-35109807660997



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If however we are looking at motivating individuals to address CVD risk factors the best way to undertake this is through the Heart Age Tool, as changing certain risk factors can reduce heart age for example stopping smoking and can support behaviour change. https://www.nhs.uk/conditions/nhs-health-check/check-your-heart-age-tool/

High risk of Diabetes (Hba1c 42-- 47mmol/l)

Reduce the number of people developing diabetes by targeting prevention on those already known to be high risk (HbA1c 42-47mmol/l)

Increase the number of people participating in the NDPP and other Lifestyle Activities

Invite all patients using the CCSP approach, at High Risk of Diabetes aged > 17 yrs for an annual review (face to face or telephone conversation), to include HbA1c monitoring, goals set and achieved relating to lifestyle and the option of referral to the NDPP – practices may wish to consider risk-stratifying this cohort (eg by HBA1c or comorbidities) to phase the roll-out of these reviews. To note where people return to have a normal HBa1C they still remain in the cohort for annual reviews and need annual HbA1C

Diabetes

Reduce morbidity and mortality associated with poor control of diabetes and associated risk factors.

NDA: review and increase the number of people treated to target for HbA1c, on statin therapy and BP. Three areas 40% Reduce the Practice level of exception reporting year on year to achieve 2017/18 CCG mean

Invite all patients, using a CCSP approach aged >17 yrs and over for an annual CCSP review. Review exception reporting for people on the three treat to target areas Guidance for the Treated to Target areas are as follows: HbA1c targets: Oral medication: <59mmol Insulin “target”: 64mmol is set as an audit target, in recognition that people should have an individual target and their aim is to have as low as possible home glucose readings without hypos CCG recognises that a series of changes to reduce the potential harm to individuals has been introduced within QOF 2019/20 which creates a personalised approach. We don’t believe this will have a negative impact on achieving the key outcomes BP targets Aim for a target clinic blood pressure below 140/90 mmHg in people aged under 80 years with treated hypertension. [2011] Aim for a target clinic blood pressure below 150/90 mmHg in people aged 80 years and over, with treated hypertension. [2011] In people with CKD and diabetes, and also in people with an ACR of 70 mg/mmol or more, aim to keep the systolic blood pressure below 130 mmHg (target range 120–129 mmHg) and the diastolic blood pressure

https://www.nhs.uk/conditions/nhs-health-check/check-your-heart-age-tool/

https://www.nhs.uk/conditions/nhs-health-check/check-your-heart-age-tool/

7

below 80 mmHg[3]. [2008] Cholesterol: In line with the proposed QOF changes, the QIS will enable practices to record those people who receive statin treatment in place of the Cholesterol level , this is captured within the NDA (2019/20) Practices to review all simvastatin prescribing, and aim to switch from simvastatin to Atorvastatin 20mg as per NICE guidance to support the reduction below 4 mmol/l

Mental Health: SMI

People living with severe mental illness (SMI) face one of the greatest life expectancy gaps- 15-20yrs lower than the general population and deaths are largely due to preventable or treatable physical health problems. NHS England have committed to ensure that by 2020/21 people living with SMI have their physical health needs met by increasing early detection and expanding access to evidence based physical care assessment and intervention each year.

60% of people on the SMI register receiving a full and comprehensive physical health check to include:

Measurement of weight

BP and pulse check

Blood lipid including cholesterol test

Blood glucose test

Assessment of alcohol consumption

Assessment of smoking status

Assessment of nutritional status, diet and level of physical activity

Assessment of illicit substance

Access to screening (cytology / breast / bowel)

Medicines reconciliation and review

Develop a practice or locality action plan in conjunction with CMHT colleagues to improve joint working across the primary/ secondary care interface and validate the disease register. Conduct an annual review for people with SMI conditions over the age of 17yrs, incorporating screening programmes and medicines reviews – practices may wish to consider a risk stratified approach to phase the roll out of these reviews. For further information: Lester tool https://www.rcpsych.ac.uk/docs/default-source/improving-care/ccqi/national-clinical-audits/ncap-library/ncap-e-version-nice-endorsed-lester-uk-adaptation.pdf?sfvrsn=39bab4_2

https://www.rcpsych.ac.uk/docs/default-source/improving-care/ccqi/national-clinical-audits/ncap-library/ncap-e-version-nice-endorsed-lester-uk-adaptation.pdf?sfvrsn=39bab4_2




8

General physical health enquiry including sexual health and oral health

CVD: Hypertension

To reduce morbidity and mortality associated with undertreated hypertension.

Treatment to target increase the proportion of patients achieving treatment to target by 5% Reduction in the number (%) of people who are not receiving appropriate treatment by 2% Under 80 140/90 (general population) Over 80 150/90

Conduct an annual review for those people in the following cohorts: Stage 1 with target organ damage Stage 1 with QRisk >20% Stage 2 with BP >= 140/90 ( under 80) (equal to or above) To optimise treatment and encourage self-care and lifestyle changes Review exception reporting for people not on appropriate treatment and explore treatment options

CVD: Heart failure

Patients who do not receive optimum treatment are likely to have poorer outcomes and unplanned admissions

Completion of CCSP reviews in all diagnosed patients and management to NICE guideline standards.

All patients with Heart Failure under the care of General Practice require 6 monthly reviews in practice as per NICE guidance. https://www.nice.org.uk/guidance/ng106 Chronic heart failure in adults: diagnosis and management

COPD

Reducing risk of exacerbations reduces unplanned admissions and quality of life

Increase (from baseline) number of patients offered and annual review (prioritising those at highest clinical risk/history of acute presentation)

Invite all patients aged >17 yrs for CCSP review Cost effective interventions are: flu vaccination, pneumococcal vaccination, standby medications. Reduction/ cessation in smoking Using a QI approach to consider how you will provide a high quality management of COPD. Practitioners support people with COPD are able to access the ICST E learning platform and they are encouraged to complete COPD modules: provide evidence of similar update learning Increased numbers of referrals and attendance at Pulmonary Rehabilitation for MRC scale 3 and above Onward referrals to Breathe Easy following annual review and / or completion of Pulmonary Rehab Link to breathe easy groups

https://www.nice.org.uk/guidance/ng106

9

Frailty Improving outcomes

for people living with

frailty continues to

be a priority for the

city and forms part

of the NHS Long

Term Plan.

A proactive frailty

model has been

developed by

care Providers in

Leeds. The model is

underpinned by the

identification of

people living with

moderate frailty.

Please see attached

frailty fulcrum video

which was shared at

the November

TARGET events

https://www.youtub

e.com/watch?v=Wzq

_MzWQhwo

Increase in the

number of

patients

identified as

moderately frail

having received a

clinical review

using a CCSP

approach in the

last 12 months.

(Target aim is

60% however if

this is

unmanageable

for your

population please

discuss with your

locality team)

Increase in the number of patients with Enhanced Summary Care Record (eSCR).

Through the GP contract, practices will already use an appropriate tool e.g. electronic Frailty Index (eFI) to identify patients from their practice population aged 65 and over who are living with moderate and severe frailty All patients with a severe/ moderate eFI should undergo a verification of the frailty diagnosis by reviewing the eFI score in conjunction with a face to face clinical review. This should be read coded and added as a major problem for those people diagnosed with severe and moderate frailty. The Rookwood Clinical Frailty Scale can support practices with diagnosis, the link is: https://www.cgakit.com/fr-1-rockwood-clinical-frailty-scale For those patients identified as living with moderate frailty, the practice will deliver a clinical review using a CCSP approach (which can be combined as part of other LTC reviews) providing, as a minimum, an annual medication review and where clinically appropriate discuss whether the patient has fallen in the last 12 months and provide any other clinically relevant interventions. A template is available to support practices and further frailty-related training and education opportunities will be offered in-year.

https://www.youtube.com/watch?v=Wzq_MzWQhwo



10

Section 3 – Healthy Practices Scheme

Introduction: The Strategic Plan 2018/19-2020/21 sets out the vision for “Leeds to be a health and caring city for all ages, where people who are the poorest improve their health the fastest”. The CCG believes that the first part in achieving this vision is to strengthen access to high quality GP services and primary care. Following feedback from practices, the CCG is providing additional investment in general practice of £1.8 million to address the financial inequity that current exists within our practices. The Service: The focus of this scheme will be to improve the health and wellbeing of practice populations by addressing variation at practice and locality level through embedding a culture of continuous quality improvement. Quality Improvement (QI) is a commitment to continuously improving the quality of healthcare by focusing on the needs of the people who use the services. It is an evidence-based approach that supports primary care to deliver initiatives and embed new approaches more effectively and efficiently into practice. QI helps make the most of systems to deliver better outcomes for patients. The CCG aims to give practices the flexibility to utilise this resource as necessary to improve health outcomes and reduce inequalities, ensuring that services are safe and of a consistent high quality that works well both for staff and patients. Criteria: All practices will be eligible to participate in this scheme providing:

The practice is open 8am – 6.30pm Monday to Friday*

Quality ECG testing and interpretation, quality spirometry testing and interpretation, and phlebotomy is provided

The practice engages with the evolving Primary Care Networks strategy for integrated nursing services in areas such as wound care which is driven by reducing duplication, reducing variation and improving efficiencies

Continues to promote learning from incidents through the use of Datix

The practice participates in regular quality improvement work by identifying and addressing areas of variation. o Utilising data for improvement through the primary care webtool, RAIDR and the practice quality

improvement dashboard o Review of patient experience through the NHS GP Survey and how this reflects capacity and demand profiling o Participate in winter communication plans

In 2019/20 a specific focus will be to review the variation of the annual health checks for people with learning disabilities including reviewing the offer from the Health Facilitation Team to achieve the ambition of 75% of patients receiving an annual health check

Practices can determine how best these services are provided but any subcontracting arrangements (6-6:30pm) should be agreed with the commissioner

Funding: The funding for this element of the scheme will be worth the equivalent of £6.54 per weighted patient. The CCG will discuss with individual practices the key focus for improvement during 2019/20 identified by the practice. .

11

Following the release of the NHS Long Term Plan in January 2019, NHSE and the BMA published the new GP contract1. This new GP contract contains a number of features that underpin the role that general practice will play in delivering The Long Term Plan, recognising general practice ‘as the bedrock of the NHS’ without which the ‘NHS could not survive or thrive’. The direction of travel nationally is to have a model of multidisciplinary integration through expanded primary care teams based on neighbouring GP practices that work together typically covering 30-50,000 people; known as Primary Care Networks (PCNs). These expanded community multidisciplinary locality-based teams will comprise a range of staff such as GPs, pharmacists, district nurses, community geriatricians, dementia workers and allied health professionals (AHPs) such as physiotherapists and podiatrists/chiropodists, joined by social care and the voluntary sector. In Leeds, we have been working with locality based networks of general practice for some time – our ‘localities’. To truly deliver the ambition of reducing our city’s health inequalities, it is recognised that a broader (than health and care services) perspective has to be considered; that wider determinants play a central role in maintaining individual and community health and wellbeing. In this context we need to describe and deliver on 2 fronts:

Primary Care Networks (PCNs) formalising the established collaborations between local practices across 18 geographical localities in Leeds delivering integrated community and primary care services. Through the PCNs we are developing models to deliver clinical pharmacy; MSK first contact practitioners; social prescribing; and IAPT.

Local Care Partnerships (LCPs) forming around the PCNs bringing together leaders from statutory health and care services with third sector; housing; employment; planners; elected representatives; and local people to deliver the ambition of the Leeds Health and Wellbeing Strategy.

Practices will be able to participate in the Direct Enhanced service for Primary Care Networks, this will be through the national arrangements as outlined in the GP contract reform. The membership and engagement section of the PCQIS should be read in conjunction with the Primary Care Network DES to enable member practices to be aware of their requirements within each scheme For the purposes of the PCQIS, this will include: • Individual member practices will be required to provide and evidence their engagement and involvement in

shaping the Primary Care Network Leadership voice and future service delivery in the key ways identified below:

Attendance and participation at 4 Members Meetings’ per annum. Expectation of attendance by GP, PM and Lead Nurse for each practice within a named PCN. These will enable continued conversations around key commissioning questions, and maintain direction of travel with the GP Confederation and Citywide providers. Additionally, these meetings will house the QI elements of the Quality and Outcomes Framework outlined in the GP Contract, including participation in 2 Peer Reviews for the End of Life Care module.

Attendance and participation at 4 quarterly Prescribing Leads’ meeting per annum: Expectation of attendance by the prescribing lead GP, practice employed pharmacists’ and/or advanced nurse practitioner. Practice employed pharmacist to meet with Medicines Optimisation team at least twice a year. GP to attend Post Infection Review (PIR) meetings as required Housing QI elements of the Quality and Outcomes Framework outlined in the GP Contract, including participation in 2 Peer Reviews for the Prescribing Safety Module

1 Investment and evolution: a five-year framework for GP contract reform to implement The NHS Long Term Plan. BMA / NHSE.

January 2019

Section 5 - Membership and Engagement: Continuing the Journey

12

Attendance and participation at PCN based Meetings - GP, PM and PN from each practice to attend Primary Care Network meetings, which will be facilitated by the Primary Care Network Leadership Team and supported by Primary Care Development Team. This will assume a minimum of 8 meetings per year to enable members of PCNs to work together and support production of a Network plan* that demonstrates outcomes against keynote topics including and not limited to:

o Continue upholding the direction of the GPFV. This invokes elements of the 10 High Impact Changes for capacity creation and resilience of Primary Care. Ensuring every practice should consolidate against the two actions in 2018/19 and identify, plan and implement a further two of the high impact ‘time to care’ actions in 2019/20. The high impact “time to care” actions are outlined in the NHS England Planning Guidance 2018/19: https://www.england.nhs.uk/wp-content/uploads/2018/02/refreshing-nhs-plans.pdf (DMC link doesn’t work)

o Workforce: The NHS plan sets out an ambitious approach to workforce across primary care including

Clinical Pharmacists, First Contact Practitioner, Paramedics and Social Prescribing link workers. Networks should give specific consideration and contribution of a Primary Care Workforce Plan with Locality Leaders across the City. The purpose is to develop a Primary Care Workforce Plan, which incorporates a local approach to address workforce needs specific to their local population (and core workforce plan or NHSE workforce tool). This plan should incorporate a network review as to how these additional roles and staff funded, in the main, through the GP Contract will be allocated, developed, integrated with the Practice and wider network team in 2019/20 and planning for future years in line with the increase funding.

o Population Needs – PCNs should use their population profiles to review variation in practice. Practices

and localities can use RAIDR, Practice Quality Dashboard and Primary Care Webtool as resources to support and understand why variance might occur, the impact on their population, sharing of approaches and the development of an action plan that reflects a Network Approach.

o Aspects of the Quality Improvement Scheme such as networks focus for Frailty, Peer reviews and Clinical

Audits that support a collaborative review to reducing variation and share best practice to increase patient outcomes.

The prescribing element of the PCQIS will aims to improve quality in prescribing and ensure value for money and secure better outcomes for patients. Practices will be required to:

Complete specified clinical audits of Antibiotics, Asthma, COPD and Diabetes

Participate in Individual Practice Prescribing Reviews with the Leeds GP Confederation Clinical Pharmacy team.

Agree a tailored Practice Prescribing Improvement Plan to ensure evidence based, safe prescribing and to support practices to come within their allocated budget, by reducing waste, optimising medicines and improving quality.(Plans may include review of traffic light drugs, branded to generic switches and other practice specific QI areas identified at prescribing meetings.)

Ensure that any Pharmacist/ Pharmacy technician employed by the practice/locality meets with the Leeds GP Confederation Clinical Pharmacy team at least twice a year.

GP to attend Post Infection Review (PIR) meetings as required

Submit a quarterly audit report that documents their actions and progress in each area as required in the audit tool.

Section 6 –Prescribing

https://www.england.nhs.uk/wp-content/uploads/2018/02/refreshing-nhs-plans.pdf

13

The Leeds GP Confederation Clinical Pharmacy team will:

Send out prescribing information to practices on the following areas via the MOT dashboard and support practices with improvement plans:

Practice prescribing spend against allocated budget on a monthly basis.

Practice level – Antibiotic prescribing trends

Practice level – clinical audit progress

Practice level – Black light spend.

Practice level – Anticoagulation prescribing levels vs AF diagnosis

Progress against the agreed practice action plan and summary of the work to date every quarter

Through the prescribing leads meetings support the QOF Quality Improvement Prescribing Safety Peer review discussions QOF details on next page. Prescribing leads meetings will be held quarterly and Peer view will be held during two of these sessions.

14

Appendix I NHS Leeds CCGs Partnership Primary Care Quality Improvement Scheme 2018/2019

Practice Name: Address: Preferred Contact email address: Preferred Telephone Number:

GP Lead for Commissioning Name and Contact Email Address

Nominated GP Prescribing Lead (can be the same person)

Name and Contact Email Address

Practice Manager


Lead Practice Nurse


Long Term Conditions

If Practices are not able to participate fully in all aspects of the Long Term Condition components:

Targeted prevention: AF, COPD, High risk of Diabetes and Hypertension

Management and the use of CCSP approach for annual reviews for COPD, Diabetes, Heart Failure, High risk of Diabetes, Frailty

Management for people with AF, CVD20% risk and Hypertension

Practices should contact the Primary Care Commissioning team to discuss this and enable an appropriate plan linked to the payment structure.

On behalf of the practice:

Signature Name Date

On behalf of Leeds CCGs Partnership:

Signature Name Date

Please return to the Primary Care Team: [email protected]

mailto:[email protected]

15 *CCG has the right to veto offers to practices based upon quality markers such as CQC reports, NHSE core contract compliance and other mitigating circumstances **CCG reserves the right to recoup monies related to the scheme if practices are unable to deliver against the programme

Appendix II - Scheme Summary and Financial Schedule

Introduction

The CCG has made a 3 yearly investment available to practices for the delivery of key clinical outcomes. Practices will need to demonstrate a year on year improvement in order to secure the ongoing investment. The total funding available to individual practices is £16.54 per weighted patient:

Payments to practices will be made on a quarterly basis at the beginning of each quarter with the first payment in April 2019**

£6.54 relates to the equitable funding scheme and is NOT subject to any achievement payment

£2.64 of the scheme is to support the frailty section and will link to the development of an integrated care approach to the identified population cohort.

The remaining £7.36 of the scheme will be to support the overall delivery of the scheme and associated engagement and clinical audits

The CCG has held a reserve of 15% of the total funding (equivalent to £1.50 per patient) which will be paid on achievement following an end of year report and review of data. The 15% is attributed across the various elements of the scheme and further detail can be found below.

FURs will continue to be made available in accordance with the previous Freed up Resources (FUR) scheme

Data Tools and Reporting

The CCG has commissioned a specific information system to support practices in using data for improvement. Practices should individually perform a regular review (at least quarterly) of the RAIDR system, which will help support the delivery of the scheme and identify any areas for improvement. The CCG will be utilising both RAIDR and the Quality Improvement dashboard, which will draw on data extracted from practices clinical systems to monitor performance against the scheme on a quarterly basis.

There is no requirement for a practice plan to be submitted at the start of the year. However localities will be required to produce a locality plan with support from the Primary Care Development Team.

A mid year review of progress will be made based on RAIDR and the Quality Improvement Dashboard and practices should review to understand progress and if necessary be required to discuss any areas of non-progress and provide mitigation.

Practices will be required to submit an end of year report, where a practice is not able to demonstrate achievement on RAIDR, the CCG will meet with the Practice to request further supporting evidence. A CCG panel consisting of members of CCG managers, clinicians and lay representatives will review the Practice submission and determine the final payment decision.

Any practice that is unable to continue to deliver the scheme should discuss this with the primary care team to determine what support may be available.

Scheme Detail

Achievement Value

Notes

Targeted Prevention

3% Achievement of the target prevention element will be measured at a primary care network level. The CCG will review activity across AF, COPD and hypertension at the end of the year to monitor improvements/maintain the baseline position

Long term conditions

4% SMI 5% Remainder

Achievement will be measured at practice level. Any practices who are unable to deliver all components of the scheme from the commencement date may receive a prorated element of funding. Practices who are in this position should contact the CCG Primary Care team to discuss the situation.

Frailty 3% Achievement will be measured at practice level.

Membership Practices that do not engage in locality or member meetings will have a value of £400 deducted from their next payment for each non-attendance at meetings.

16

*CCG has the right to veto offers to practices based upon quality markers such as CQC reports, NHSE core contractcompliance and other mitigating circumstances**CCG reserves the right to recoup monies related to the scheme if practices are unable to deliver against theprogramme


NHS Leeds CCG – Primary Care Commissioning Committee


Title: Chair’s Summary of Quality & Performance Committee Meeting held on 13 March 2019

Lead Board Member: Dr Steve Ledger, Lay Member, Assurance and Chair – Quality & Performance Committee


appropriate

()

Report Author: Sam Ramsey, Corporate Governance Officer

Decision

Discussion

Information


EXECUTIVE SUMMARY: 1. This report provides the Primary Care Commissioning Committee with a summary of the

primary care items discussed, outcomes and risks identified at the Quality & PerformanceCommittee meeting held on 13 March 2019.

RECOMMENDATION: The Primary Care Commissioning Committee is asked to: (a) RECEIVE the report.

Description of key items of business discussed

1. Please note that this is a brief summary of the primary care items considered at themeeting of the Quality & Performance Committee on 13 March 2019. Further informationcan be obtained by reference to the minutes of that meeting.

Action Log 2. The Committee received an update in relation to Cervical screening and recognised the

current national awareness campaign which should support an increased uptake. TheCommittee agreed that screening should be built in to the Governing Body position inrelation to tackling health inequalities

Integrated Quality Performance Report 3. The IQPR highlighted the low levels of flu vaccinations undertaken, however it was

recognised that there had been issues with the ordering of vaccinations. Members wereinformed that Leeds was in a similar position to the rest of West Yorkshire. The Committeewas assured that work was underway with the screening and immunisations team inpreparation for next year’s flu campaign.

Patient Experience Update Q3 4. The Patient Experience Update highlighted a potential gap in collating feedback from

practice staff of their own experiences with patients. It was recognised that staff surveyresults were collated from secondary and community care, however this was not currentlytaken from Primary Care.

2

5. The Quality team agreed to liaise further with the primary care team as to whether this could be incorporated in to the quality visits within practices.


1


























Title: Primary Care Integrated Quality & Performance Report (IQPR)

Lead Governing Body Member: Dr Simon Stockill, Medical Director


appropriate

()

Report Author: Kirsty Turner, Associate Director of Primary Care

Decision


Discussion

Reviewed by Committee/Date: N/A

Information



2

EXECUTIVE SUMMARY: The Primary Care IQPR reflects a number of strategic priorities and schemes including the overview of the Quality Improvement Scheme(QIS). The presentation of the data is to support improvements at practice level and the City wide view continues to show the variation between the lowest and highest values at practice level. The Practice Quality Improvement (PQI) Dashboard for Quarter 3 has now been circulated including a hard copy provided to all practices at the March member meetings. Highlights identified for Quarter 3 include:

Continued positive improvements in the MMR programme with the % not vaccinated decreasing by 1.6 percentage points from March 2018

Ethnicity and First Language coding continues to rise as well. Increase of 7.4 percentage points in First language recorded from Q1 to Q3 2018-19

QIS achievement is showing overall increases in AF, Hypertension and COPD prevalence. o AF treatment gap has reduced again, 23.8% compared to 24.5% in Jan 18 o Diabetes - % achieving target for 3 treatment across 3 treatment areas – currently at

27.4% (with target of 35%) o End of Life - % of deceased patients where actual place of death recorded – increased

by 2.8 percentage points in the last quarter o End of Life - % of deceased patients with LTC registered on EPaCCs – exceeding the

target of 40% and a rise to 44.3% in Q3

Datix recording continues to decline with 836 LESS incidents recorded this year compared to the same point in 2017/18. Learning from incidents continues to be a key line of enquiry for CQC and practices are encouraged to request support from the team if required. The focus on incident learning has been included in the QI scheme for practices for 2019/20.

Many practices participated in cervical cancer prevention week and provided additional clinics to support an increase uptake and many practices are utilising the materials recently shared by Public Health England. The overall Leeds position currently shows a drop of 0.9% percentage points from July 2017, 73.9%, to July 2018, 73.0%, but hopefully when more recent data is available this will show an increasing trend.

The Quality Surveillance/Support Group continues to monitor quality at practice level and there have been some changes to the categories of practices under surveillance and the CQC rating: CQC Overview

CQC Rating Number of Practices

Outstanding 5 (5%)

Good 92 (93%)

Requires improvement 1 (1%)

Inadequate 1 (1%)

The Primary Care and Quality teams continue to support practices to achieve improvements in their ratings. 25 practices have now been re-inspected by CQC with 72% maintaining or improving their rating with 28% reducing their rating (which may be in one domain rather than an overall rating). Surveillance Update

Surveillance Number of Practices

Routine 85

Routine+ 9

Enhanced 5

3

NEXT STEPS: The IQPR will be presented to Quality & Performance Committee on 13 March 2019.


a) receive the Integrated Quality and Performance Report.


CurrentLowest

Value

Highest

ValueTrend

Hot Topic

58.8% 36.5% 76.5%

9.4% 3.0% 28.0%

5.9% 0.0% 32.1%

23.1% 1.1% 64.5%

79.1% 52.9% 93.5%

75.0% 74.8% 25.0% 87.4%

55.0% 47.9% 21.4% 66.6%

55.0% 49.0% 15.7% 71.4%

40‐65% 46.3% 13.8% 77.9%

Mar‐18 11.8% 73.6% 30.0% 96.0% n/a

96.0% 95.6% 32.6% 100.0%

6.0 5.6 2.5 13.5

10.1 10.1 2.8 23.2

Contractual Requirements

10.0% 27.8% 0.8% 55.3%

3.5% 4.5% 0.0% 17.8%

2.0% 2.6% 0.0% 13.3%

56.0% 65.1% 0.0% 92.0%

10.0% 17.3% 0.0% 43.0%

PreventionPrenatal Pertussis vaccine uptake (2017‐18) Dec‐18 79.3% 78.7% 0.0% 100.0%

Shingles Vaccine Uptake (coverage for the Routine Cohort since 2013 ‐ 2018/19)2018/19

Q248.3% 44.6% 14.7% 100.0%

HPV (Two doses) CCG level only 2017‐18 83.8% 88.0% n/a n/a

Prevalence 16+ 18.79 7.8 58.8

% patients with smoking status recorded 94.60% 82.3% 98.6%

% of smokers offered smoking cessation advice in the last 24 months 87.0% 79.1% 47.0% 99.3%

Referrals to Smoking Service 2,444 0 165

Referrals of eligible patients 1,317 0 148

% of GP registered population with an Audit C score 58.0% 22.1% 96.6%

Audit C Score >8 11.5% 1.1% 23.9%

Cervical ‐ 3.5/5.5 yr coverage % ‐ Target age range (25‐64) 80.0% 73.0% 23.7% 88.3%

Breast ‐ 3 coverage % ‐ Standard age range (50‐70) 80.0% 71.3% 14.8% 83.3%

Bowel ‐ Uptake % ‐ Extended age range (60‐74) 60.0% 59.2% 21.1% 71.5%

Patient Experience34.1% 31.4% 6.0% 55.7%

68.6% 68.9% 31.7% 100.0%

67.3% 70.8% 34.9% 100.0%

85.0% 84.9% 55.0% 97.7%

2018 89.8% 89.6% 0.0% 100.0%

Number of ratings 2,198 1 479

Number of stars (out of ) 3.4 1 5

AccessAccident & Emergency Dec‐18 212.5 132.0 1552.6

GP Streaming Dec‐18 12.7 1.0 85.1

Minor Injury Unit Nov‐18 37.6 1.1 139.1

Shakespeare Walk‐in Centre Dec‐18 30.8 2.1 309.8

111 225.1 91.1 318.2

Out of hours 63.3 20.7 123.6

Extended Access ‐ Hub Dec‐18 63.7 0.0 394.9

Online Consultations Nov‐18 6.7 n/a n/a

Health Inequalities95.3% 51.0% 100.0%

83.1% 28.6% 100.0%

Safe

2,491 0 142

1,303 0 83

1,188 0 65

1,054 0 91

E. coliDec‐18 397 0 13 n/a

Flu vaccinations

(only to be included in

Q3/Q4)

Pneumococcal Polysaccharide Vaccine (PPV) Uptake 2017‐18 Only

Primary Care

National

Target or

Average

Period

Dec‐18

Information &

Technology

Leeds

Performance Measures (1 of 2)

Dec‐18

Jan‐19

MMR Vaccinations

Jan‐19

Group Name

Incident Reporting

2017/18

QOF

(only to be included in

Q2/Q3)

Jan‐19

Jul‐18

2018/19

Q3

Jan‐19

Overall achievement

Exception reporting rate ‐ All Domains

Exception reporting rate ‐ Clinical Domain

Number of patients accounts registered for online services as % list

Electronic Repeat prescription requests as % accounts

Electronic Appointments booked online as % accounts

Electronic Prescription Service Utilisation (EPS)

(80% of repeat prescriptions)

EPS Repeat Dispensing Utilisation

GP Survey response rate

Jan‐Apr

18

2018/19

Q3

Smoking

Weight Management

Alcohol

Cancer ‐ Uptake for screening programmes

www.nhs.uk ratings

Attendances/Calls 2018‐19 YTD

(Rate per 1,000 Patients ‐ Weighted List Size)

Dec‐18

Vaccinations

Number of patients not vaccination ‐ Aged 25+

Flu vaccinations over 65

Flu vaccinations at risk clinical group

Flu vaccinations pregnant women

Flu vaccinations all children (Aged 2‐8)

Number of patients not vaccination at any age %

Number of patients not vaccination ‐ Aged 1 to 5

Measure



Collection and reporting of a core primary care data set for all E coli BSI ‐ 2018‐19 YTD

Total Incidents reported on Datix (2018‐19)

Non‐medication Incidents reported on Datix (2018‐19)

Medication related incident reported on Datix (2018‐19)

Number of Significant Event Audits (SEA) completed (2018‐19)

Overall experience of making an appointment (Good)

Ethnicity ‐ % recorded

First Language ‐ % recorded

Ease of getting through to someone at GP surgery on the phone (Easy)

Overall experience of GP surgery (Good)

Respondents are likely to recommend the GP Practice

CurrentLowest

Value

Highest

ValueTrend

Effective

1.91 1.64 0.01 3.63

1.91 1.99 0.00 5.20

13.94 12.46 0.21 21.03

AF – Management plans in place (Treatment gap) (WY Ave) Oct‐18 21.0% 23.8% 7.4% 100.0%

Exception reporting rate 2017‐18 5.69 8.17 0.00 33.33

>20% risk ‐ % recieved CCSP review or annual review in the last 12mQ3 17/18‐

Q3 18/1924.6% 0.0% 77.8%

NHS Health Checks % of patients with a CVD Risk Score (Qrisk) of > 20%2018/19

Q33.6% 0.0% 50.0%

Hypertension ‐ Management plans in place (Treatment gap) (WY Ave) 14.3% 13.8% 4.4% 62.9%

Hypertension ‐ On repeat Amlodipine/Felodipine, not on the register (WY Ave) 19.61,110

(Ave 11.1)0 88

Hypertension ‐ Register changes (increases) 1,168 ‐29 382

% high risk of developing 6.9% 0.1% 11.8%

Referrals to NDP programme (CCG quarter target) 975 1,458 0 59

% achieving target for 1 treatment across 3 treatment areas 75% 94.1% 86.7% 98.5%



Exception reporting rate 2017‐18 12.24 12.43 2.85 27.13

Mental Health:SMI % patients who have had all six physical health checks in the last 12 months2018/19

Q350% 28.2% 0.0% 71.7%

COPD Emergency admissions in the last 12 months (Rate per 1,000 patients) Nov‐18 1.98 0.00 6.27

% of deceased patients with LTC registered on EPaCCs 44.3% 0.0% 100.0%

% of deceased patients where actual place of death recorded 90% 79.0% 0.0% 100.0%

Severely Frail (65 years old+) (From practice systems) 7,131 0 327

Moderately Frail (65 years old+) (From practice systems) 17,233 0 674

Summary Care Record ‐ Additional information consent (SCR‐Al)

(65 years old+ Moderate/Severe Fraility)6,311 0 437

31.2% 1.7% 88.9%

43.5% 0.0% 111.2%

2018/19

Q219.0% 17.26% 0.0% 81.5%

Caring99 of 99

practices

16.65 0.00 100.85

Well Led42 of 99

practices

0.36 0.00 8.00

Primary Care

NHS Health Education

Workforce Tool

Performance Measures (2 of 2)

Group Name Period National

Target or

Ave

Leeds

2018/19

Q3

2018/19

Q3

2018/19

Q3

Year of Care

Collaborative Care and

Support Planning

(CCSP)

AF ‐ % Prevalence

COPD ‐ % Prevalance

Hypertension ‐ % Prevalance

Targeted Prevention of


Q3

2018/19

Completed the workforce tool for current quarter

GP vacancies within practice

Quality Improvement

Scheme

All eligible adults 40‐74 against target (100% by year end) cumulative position

All eligible adults 40‐74 against target within latest quarter

NHS Health Checks

Feb‐19

Measure

Practices implementing CCSP

Reviews undertaken in latest quarter per 1,000 population

2018/19

Q3

AF

Cardiovascular Disease

Hypertension

Dec‐18Frailty

End of Life Care Planning & use of EPaCCs

Diabetes

Better Management of


Learning disabilities ‐ % completed

2018/19

Q3

Period Target Leeds Leeds (YTD) Trend

Jan‐19100% by Oct

2018100.0%

2018

(Jan‐Apr 18)71.9% 68.9%

Dec‐18No more

than 481 in 357

12 months to

October 20189,181 5,973

12 months to

October 2018

0.965 or

below0.960

2018/19 Q3 58% 58.5%

Number

6

94

1

Action

Continue to work with practices to ensure the QIS is implemented.

Complete project planning and mobilisation of AF Treatment Gap

Medicines Optimisation project to achieve project milestones set by NHS

England by end of March 2019. Project delivery is on track.

Continued review and challenge of Leeds Cancer Screening performance at

Leeds Cancer Prevention, Awareness and Increasing Screening Uptake and

Leeds Integrated Cancer Services Board

Roll‐out of cervical screening to the Cancer Screening Champion model in

Leeds (across 50 GP practices)

Continued work‐up of locality screening model project.

Report is currently being reviewed.

Performance and Quality Summary

Physical health checks for people with severe mental illness

The data shows a 1% increase since the last IQPR return. This continues to be addressed through the Quality Improvement Scheme for

2018/19.

Practices are being asked to conduct:

Physical health checks for people who are on the SMI register with a current diagnosis

Cardio‐metabolic risk assessments completed ‐ target of 30% of Practice SMI register

Follow‐up lifestyle interventions i.e. smoking, obesity

There is still further work to do to align and understand the data between the IQPR and QIS dashboard however data on the December

return for the QIS show 46.79% achievement which is an increase from the October position.

Practices will have access to a bespoke QIS RAIDR dashboard which will support them in reviewing their current position.

With regards to Mental Health providers delivering physical health checks for this cohort of patients we have learnt that some of the

screening assessments do not transfer to the practice clinical system (i.e. blood tests). As a team we are discussing this with colleagues to

rectify the issue.

Atrial Fibrillation (AF)

The CCG continues to work collaboratively with the Yorkshire & Humber Academic Health Science Network to target and support practices

with the greatest number of identified patients in treatment gap in order to risk assess and treat appropriately.

The Quality Improvement Scheme continues to monitor AF. The target for practices is to achieve 80% of high risk AF cohort on treatment

by end of March 2019. A CVD Operational Delivery Group has been established to reduce the risk of CV events by improving the

identification and management of patients with or at risk of Atrial fibrillation, hypertension and hypercholesterolemia in line with best

practice and take into consideration NICE guidance.

At the beginning of December, the CCG received the opportunity to receive £190,000 from NHSE to participate in the AF Medicines

Optimisation Demonstrator project. Leeds CCG have confirmed that we wish to participate in the project and have signed and returned the

MOU. Project mobilisation is now underway to recruit pharmacy roles and commence the project by April 2019 – the project shall include

the provision of virtual clinics with Primary Care to support the above QIS targets. The project and approach has been discussed with the

Leeds LMC in December who are supportive of the approach.

Cancer Screening

The CCG is not currently achieving compliance against the national screening targets for Breast, Bowel and Cervical Screening.

Performance is monitored closely via our Leeds Cancer Prevention, Awareness and Increasing Screening Uptake meeting which includes

representation from CCG cancer commissioner, Public Health, Primary Care and NHS England Screening leads (commissioners).

Collectively we have worked to increase Bowel Screening uptake via the provision of a bowel screening champion model within Primary

Care, which aims to increase bowel screening uptake. Working with these practices, the locality development team are ensuring the

scheme continues to be embedded with the practical elements being worked through i.e. SystmnOne and EMIS templates have been

developed and all practices are now able to record/evidence increased uptake following multiple contacts with patients who haven’t

accepted screening. We are currently planning to roll‐out the screening champion model to cervical screening from 1st April 2019, to target

an increase in screening performance in the age cohort 25‐49.

Due to reporting/flow of information restrictions into primary care systems for breast screening from the national programme we are

unable to currently replicate the cancer screening champion model for Breast screening.

Increased focus shall therefore be placed on local awareness for breast screening along with cervical and bowel via a project proposal that

is currently being worked up by commissioners to explore the implementation of Locality Screening Coordinators working within primary

care to raise awareness of cancer screening.

Quality Assurance and Improvement

Serious incident: One serious incident was reported in December 2018, categorised as a screening incident, resulting in delayed treatment

for diabetes which has impacted on the patient’s sight.

CQC GP Inspection Rating ‐ Outstanding

CQC GP Inspection Rating ‐ Good

CQC GP Inspection Rating ‐ Requires improvement

Quality Indicators

Performance and Quality

Constitution/Planning Measure

(QP) Whole health economy ‐ E. coli blood stream infections (12 months)

(QP) Antibiotic prescribing for UTI in primary care ‐ no. of trimethoprim items prescribed to patients aged ≥70 years

(QP) Prescribing in primary care ‐ items per STAR‐PU

(QP) Reported to estimated prevalence of hypertension (%)

Extended access at GP services (Full Provision)

Overall experience of making a GP appointment

Kirsty Turner / Sally Bower

Primary Care & Medicines OptimisationResponsible Body Medical Director Director of Nursing and Quality Lead Manager

Primary Care Commissioning Committee Simon Stockill Jo Harding


1


























Title: Primary Care Risk Report

Lead Governing Body Member: Dr Simon Stockill, Medical Director of Primary Care


appropriate

()

Report Author: Kirsty Turner, Associate Director of Primary Care

Decision


Discussion

Reviewed by Committee/Date: N/A

Information



2

EXECUTIVE SUMMARY: The CCG utilises Datix as an internal risk management system which enables risks to be recorded and managed by all members of staff. Each risk is aligned to a CCG committee for overview and scrutiny. The risks are included on the CCG operational risk register and reviewed within individual directorates and by the executive management team on a regular basis. The CCG committees receive and review the risks rated as high amber (12) and risks that are scored at 15 or above. The CCG Governing Body receives the corporate risk register (all red risks scored at 15 and above) for review at each meeting in association with the CCG Governing Body Assurance Framework. The risk register contains 49 risks, 10 of which are aligned to the CCG Primary Care Commissioning Committee (further details of the risks, including controls and assurances, can be seen in Appendix A). Active Risks All risks have been reviewed in light of operational knowledge and progress on specific schemes and this is provided in the synopsis section of Appendix A. There are currently no red risks (corporate risks) but there remains one high amber risk (amber 15) aligned to the Committee on Datix. The high amber risk relates to Risk 651: General Practice workforce and wider models of care which was covered in a paper to the Committee in January 2019 and a further update will be presented to the Committee at a future date. A risk the Committee should be aware of is with regard to risk 653 Primary Care Infrastructure. Whilst the score has not necessarily changed (amber 9), there is a growing risk in relation to Windmill Health Centre and ability to progress the scheme (despite approval from the Primary Care Commissioning Committee). The CCG has escalated this to NHS England (NHSE) with an amendment business case and supporting letter.

NEXT STEPS: All risks will be reviewed as per the bi monthly cycle in accordance with the CCG Risk Management Strategy.


a) review the high scoring amber (12) risk as presented to the Committee; and b) consider the recommended level of assurance.

ID

Rev

iew

dat

e

Title Description Secondary Risks

Co

nse

qu

ence

(in

itia

l)

Like

liho

od

(in

itia

l)

Rat

ing

(in

itia

l)

Controls Gaps in controls

Co

mm

itte

e

Res

po

nsi

ble

Acc

ou

nta

ble

Dir

ecto

r

Man

ager

Costs Assurance Gaps in assurance Synopsis

Co

nse

qu

ence

(cu

rren

t)

Like

liho

od

(cu

rren

t)

Rat

ing

(cu

rren

t)

65

1

05

/03

/20

19

General Practice

workforce

There is a risk that the quality of

and access to general practice

services in Leeds is compromised

due to local and national

workforce shortages resulting in

the inability to attract, develop

and retain people to work in

general practice roles.

Maj

or

Exp

ecte

d t

o o

ccu

r at

leas

t d

aily

. M

ore

like

ly t

o o

ccu

r th

an n

ot.

20

GP Confederation is taking a lead

in general practice workforce

development

Reported through practice quality

improvement dashboard. Will

now include HEE return as well as

NHS Digital return

Leeds participating in the

international recruitment

programme

Work with planned care team on

development of new approaches

to workforce such as first contact

practitioner model

The Quality Improvement Scheme

(QIS) places an ask for localities to

engage in a locality workforce

plan

A city wide primary care

workforce group has been re-

established with wide stakeholder

involvement to oversee the

workforce plan for Leeds and links

to wider West Yorkshire

approach.

Lack of consistently robust data

from general practices about

current and future workforce

plans

As GPs are independent

contractors, the CCG has limited

control over their workforce

practices

Pri

mar

y C

are

Co

mm

issi

on

ing

Co

mm

itte

e

Dr

Sim

on

Sto

ckill

- M

edic

al D

irec

tor

Co

nn

or,

Gay

no

r

Performance against trajectories

is reported via GPFV and

WY&HICS via Primary and

Community Care Workforce

Steering Group

Primary Care Workforce Steering

Group meets bi-monthly chaired

by CEO of GP Confederation with

membership from all stakeholders

CCG QIS includes requirement to

provide workforce data formally

via nationally mandated tool plus

via locality plans which are

monitored on a regular basis

Gaps exist relating to workforce

data and therefore no accurate

picture of workforce

Agreement to hold Primary Care

Workshop for Primary Care

Commissioning Committee to

update on the outcome of the

BDO assessment and the recent

publication of a Workforce for

Leeds report. Establishment of a

workforce group for Leeds.

Exploring one off data collection

exercise to accurately assess

workforce position for Leeds

Risk reviewed in relation to

known current position and risk

score increased as a result.

Mo

der

ate

Exp

ecte

d t

o o

ccu

r at

leas

t d

aily

. M

ore

like

ly t

o o

ccu

r th

an n

ot.

15

66

0

05

/03

/20

19

Delivery of high quality

primary care services

There is a risk that patients are

unable to access high quality

services; including those services

that are rated as requires

improvement or inadequate by

CQC.

Patient satisfaction with GP

services deteriorates

Mo

der

ate

Exp

ecte

d t

o o

ccu

r at

leas

t w

eekl

y. L

ikel

y to

occ

ur.

12

Quality session delivered to

member practices to raise

awareness of support available

and promote 'self-referral' for

support

Use of various of sources of

intelligence for improvement to

help identify themes and trends

and areas for quality

improvement i.e. primary care

web took, PQI

QRP processes in place where

quality issues are identified

Quality surveillance processes to

monitor themes and trends

Clinical lead for Quality identified

Proactive schedule of quality visits

planned

Practices may not pro-actively

engage with the CCG in raising any

concerns around quality

Pri

mar

y C

are

Co

mm

issi

on

ing

Co

mm

itte

e

Dr

Sim

on

Sto

ckill

- M

edic

al D

irec

tor

Turn

er, M

rs K

irst

y

Quality Surveillance Group to

monitor progress against action

plan

Multi team approach to review

approach (Medicines

Optimisation, Quality, Primary

Care, Clinician)

Regular meeting planned with

LMC to share approach to quality

surveillance

Report to PCCC and Quality and

Performance Committee

Systematic sharing of information

through PQI now established

across the City.

Current position of CQC ratings

compared to national position

Practices may not enagage in

quality improvement approaches

98% of practices rates good or

outstanding. Continue pro-active

visits to practices. Continue to

raise awareness through member

meetings and PM sessions.

Continued implementation of

systems and processes. Good

communication between CCG and

CQC.

Increased investment in general

practice to support quality

improvements

Mo

der

ate

Exp

ecte

d t

o o

ccu

r at

leas

t m

on

thly

. R

easo

nab

le c

han

ce o

f o

ccu

rrin

g.

9

66

8

05

/03

/20

19

Failure to appoint a

preferred provider

The CCG has a number of current

and proposed procurements to

support the delivery of primary

medical services either directly or

indirectly. There is a risk that the

CCG fails to appoint a suitable

provider.

That patients are not able to

access high quality care either

through the direct award of a

provider or due to significant

workload challenges.

Maj

or

Exp

ecte

d t

o o

ccu

r at

leas

t w

eekl

y. L

ikel

y to

occ

ur.

16

The CCG has developed a

procurement policy to support

decision making around

procurement

PCCC has supported the practice

support policy which outlines the

commissioning strategy in

relation to local procurements

A primary care procurement

steering group has been

established to operationally

manage procurements

Learning from previous

procurements helps support the

future processes

Bidder events are being planned

to support procurements

Ability for general practice to

respond to local opportunities

due to market immaturity

Pri

mar

y C

are

Co

mm

issi

on

ing

Co

mm

itte

e

Dr

Sim

on

Sto

ckill

- M

edic

al D

irec

tor

Turn

er, M

rs K

irst

y

Procurements known and added

to the procurement log

External procurement advice is

commissioned to support

individual procurements

Ongoing market development

through bidder events

Regular updates through primary

care operational group and PCCC

There is a risk that there is a

challenge to the procurement

decision which may result in

delayed mobiisation

Continue to progress

procurement process.

Continued engagement with

patients and stakeholders. 3

procurements currently live /

going live in respect of Special

allocation service, The Light and

BSL translation support.

Mobilisation underway following

recent procurement in relation to

the Grange practices ready for

implementation on 1st April.

Mo

der

ate

Exp

ecte

d t

o o

ccu

r at

leas

t m

on

thly

. R

easo

nab

le c

han

ce o

f

occ

urr

ing.

9

Appendix A

65

5

05

/03

/20

19

Member Engagement

There is a risk that engagement

with member practices may

deteriorate following strategic

changes within the CCG Mo

der

ate

Exp

ecte

d t

o o

ccu

r at

leas

t w

eekl

y. L

ikel

y to

occ

ur.

12

Primary care engagement scheme

funding provides support through

investment

senior leadership team

representation at member events

to ensure transparency and

visibility

In accordance with the CCG

constitution and scheme of

delegation, members will

continue to be involved in

decision making and consultation

processes

New approach to member

meetings with the first meeting in

June 2018

Locality leads in place and have

developed strong working

relationships to enable good

engagement and support

Development of confederation

strategic and exec board

Development of locality

leadership teams and alignment

of locality managers underway

Pri

mar

y C

are

com

mis

sio

nin

g C

om

mit

tee

Dr

Sim

on

Sto

ckill

- M

edic

al D

irec

tor

Co

nn

or,

Gay

no

r

Attendance at members events

Feedback presented to primary

care operational group

Primary care operational group

reports to Primary care

commissioning committee

Delivery against primary care

engagement scheme is reported

to Primary care operational

group.

Feedback as part of the annual

360 process

March 2019 meetings have taken

place. Reviewing feedback but

good engagement in some of the

topics particularly around

priorities for primary care

commissioning. Proposal for

2019/20 meetings is to reduce the

number of meetings to 2 (there

are current 3 meetings over the

old footprint but the proposal is

to reduce to 2 and hold all on one

day with localities choosing which

session they will attend).

Mo

der

ate

Exp

ecte

d t

o o

ccu

r at

leas

t m

on

thly

. R

easo

nab

le c

han

ce o

f o

ccu

rrin

g.

9

65

3

05

/03

/20

19

Primary Care

Infrastructure

There is a risk that the Leeds CCGs

are unable to support the wider

transformation of primary care

and support out of hospital care

due to the limitations of the

current primary care estate and

technology.

New developments in primary

care may result in increased

recurrent costs such as rent and

reimbursable costs

Maj

or

Exp

ecte

d t

o o

ccu

r at

leas

t m

on

thly

. R

easo

nab

le c

han

ce o

f o

ccu

rrin

g.

12

The CCG is currently supporting a

number of existing ETTF

submissions and supporting

practices through the process

Primary care estates needs are

linked to the strategic estates

group and 3 priority geographical

areas have been identified

Localities will be supported to

identify individual locality

development plans with a focus

on estates.

An independent primary care

premises stocktake was

commissioned to assess the

current condition of all premises

and priorities have been agreed.

CCG has made appropriate links

with LCC site allocation planning

team to ensure that future

housing growth is factored into

our plans and priorities for future

estate needs

Practices may not engage with

the CCG in discussions relating to

premises i.e. sale and leaseback

Whilst some ETTF sites are

identified as priorities this is part

of a national process and some

practices are in urgent need of

development

Pri

mar

y C

are

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mm

issi

on

ing

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mm

itte

e

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on

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ckill

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edic

al D

irec

tor

Turn

er, M

rs K

irst

y

Recurrent costs current identified

as £1m (not all approved)

Strategic estates group is in place

with membership from the wider

health and social care economy

Primary care estate group has

been established to oversee all

primary care estate matters to

ensure consistency

PCCC has regular update on

primary care estate

EFFT process is nationally led and

dependent on timescale and

process set out by NHSE

Limited resource to dedicate to

infrastructure

Inability to progess Windmill

development due to requirement

to continue to awaiting NHSE

approval

Ensure all estate related matters

are taken to the primary care

estate group. Discussions to be

taken forward through localities

on the impact of the site

allocation plan and increased

housing to inform future

prioritisation.

Recurrent risk of developments

causing financial pressure.

Hillfoot Surgery has now

completed through ETTF with

Kippax Hall and LSMP now on site

Mo

der

ate

Exp

ecte

d t

o o

ccu

r at

leas

t m

on

thly

. R

easo

nab

le c

han

ce o

f o

ccu

rrin

g.

9

67

0

05

/03

/20

19

Changes to general

practice

There is a risk that patients are

unable to register with GP

practices due to the capacity of

current practices

Maj

or

Exp

ecte

d t

o o

ccu

r at

leas

t w

eekl

y. L

ikel

y to

occ

ur.

12

Practices need to formally apply

to close the practice list in line

with the NHS Policy

Primary Care Operational Group

will monitor list closures and will

continue to monitor the risk,

supported through the quality

surveillance process

Encourage practices to discuss

early any issues affecting capacity

CCG is not always notified of

pressures affecting practice at an

early stage

Pri

mar

y C

are

Co

mm

issi

on

ing

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mm

itte

e

Dr

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on

Sto

ckill

- M

edic

al D

irec

tor

Turn

er, M

rs K

irst

y

Terms of reference for PCOG

recent changed to support the

effective management of these

list closures

2 practices currently have closed

lists in 2 different areas across

Leeds

In one instance the physical

constraints of the premises has

necessitated the need to close the

list

Need to ensure that practices are

aware of the need to formally

request list closure and not

determining locally

Terms of reference and revised

process being consider at Primary

Care commissioning committee.

2 practices (in 2 separate

localities) have recently applied to

close their list and no other issues

identified in those localities.

QSG to keep a watching brief on

those practices.

Mo

der

ate

Exp

ecte

d t

o o

ccu

r at

leas

t an

nu

ally

. U

nlik

ely

to

occ

ur.

6

67

2

05

/03

/20

19

Delivery of online

consultations

There is a risk that not all practice

will implement online

consultations by March 2020

That the budget allocation is not

utilised

Mo

der

ate

Exp

ecte

d t

o o

ccu

r at

leas

t m

on

thly

. R

easo

nab

le c

han

ce o

f

occ

urr

ing.

9

Development of regional

programme team to support the

delivery

Support for roll out of 10 high

impact actions

Overseen by GP Workload group

Sharing of learning from existing

users

Ability for provider to respond to

developments

Pri

mar

y C

are

Co

mm

issi

on

ing

Co

mm

itte

e

Dr

Sim

on

Sto

ckill

- M

edic

al D

irec

tor

Bel

l, L

ynse

y Monthly GPFV return to NHS

England

Regional team to be implemented

Inability to fully understand

appetite for implementation.

Due diligence completed and

contract awarded. Webinars

established for those interested

practices. Clinical meeting

scheduled to confirm clinical

templates. Trajectory announced

in the planning guidance by

March 2020 75% of practices will

offer online consultations

Awaiting final due diligence

associated with the procurement

and appointment of project team.

Concern expressed relating to

timescale for mobilisation.

Min

or

Exp

ecte

d t

o o

ccu

r at

leas

t m

on

thly

. R

easo

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le c

han

ce o

f

occ

urr

ing.

6

67

5

05

/03

/20

19

Development of at scale

organisation

There is a risk that not all

practices will be part of an 'at

scale' organisation by March

2019.

That the Leeds GP Confederation

will not achieve all of the

deliverables. Maj

or

Exp

ecte

d t

o o

ccu

r at

leas

t m

on

thly

. R

easo

nab

le c

han

ce o

f

occ

urr

ing.

12

Continued engagement with

member practices

Alignment of Primary Care

Development Team in progress

through the business case

100% coverage of the GP

confederation

18 identified localities and 13

local care partnerships which

encompasses all 100% of

practices

Development plan in place for

evolving LCPs including OD

approach

LCP strategy and operational

group

Capacity and capability of team to

drive change

Impact of relationships and

morale as move through

significant change

Capacity of leadership teams (at

locality level)

Communication difficulties in

reaching all staff groups

Pri

mar

y C

are

Co

mm

issi

on

ing

Co

mm

itte

e

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on

Sto

ckill

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irec

tor

Co

nn

or,

Gay

no

r

18 localities in place

13 identified LCPs

Monthly return to NHSE

LCP governance structure

Changes in practice in one locality

resulting in unsustainable locality

and no natural fit

Operational commitment from

across the system

New GP contract now issues

which sets out the establishment

of Primary Care Networks.

Timescale for formally approving

Primary Care Networks set out

with practices confirming their

network by 15 May 2019 - Leeds

starting from a good position

from the previous work in

localities.

Support to localities through

Primary Care Development Team

being embedded with GP

confederation (along with

medicines optimisation provider).

Min

or

Exp

ecte

d t

o o

ccu

r at

leas

t m

on

thly

. R

easo

nab

le c

han

ce o

f

occ

urr

ing.

6

65

2

05

/03

/20

19

Delivery of Extended GP

Access Service

There is a risk that patients will

not be able to access routine and

extended access to primary care

services across 7 days.

That the patient experience of

making an appointment is

perceived as difficult and results

in a reduction in satisfaction in the

annual patient survey (which may

further affect the Quality

Premium performance).

Maj

or

Exp

ecte

d t

o o

ccu

r at

leas

t an

nu

ally

. U

nlik

ely

to

occ

ur.

8

Regular contract meetings now in

place

Revised trajectory agreed for the

City providing assurance as to the

delivery

Monthly performance return to

track progress

Current performance at 70%

(City)

50% of the total Leeds population

must have access by March 2018

and 100% by October 2018

Pri

mar

y C

are

Co

mm

issi

on

ing

Co

mm

itte

e

Dr

Sim

on

Sto

ckill

- M

edic

al D

irec

tor

Turn

er, M

rs K

irst

y Primary care operational group

monitor delivery against

trajectories

The CCGs report against

trajectories and submit to NHSE

Continue to monitor monthly

activity. Contract management

approach established however

some contract issues identified.

All practices can now access a

face to face service at both

evenings and weekends.

Regular reporting now

established.

Min

or

Exp

ecte

d t

o o

ccu

r at

leas

t an

nu

ally

. U

nlik

ely

to

occ

ur.

4

60

9

05

/03

/20

19

Primary Care Payments

There is a risk that there is

insufficient 'cash' available errors

made by PCSE when processing

GP payments that flow from the

CCG Bank Account or result in the

practice not being paid by the

contractual date.

Min

or

Exp

ecte

d t

o o

ccu

r at

leas

t m

on

thly

. R

easo

nab

le c

han

ce

of

occ

urr

ing.

6

Increase communication with

NHSE to ensure the CCG is aware

of all payments that will be made

from

Pri

mar

y C

are

Co

-co

mm

issi

on

ing

Co

mm

itte

e

Vis

seh

Pej

han

-Syk

es -

Ch

ief

Fin

anci

al O

ffic

er

Turn

er, M

rs K

irst

y

We now have increased

communication with NHS England

colleagues who alert us if there

are any significant unexpected

payments due. We also have

access to CQRS where we can see

certain variable payments on the

system before they are due. This

is the reason we have reduced the

significance of the Risk.

Min

or

Exp

ecte

d t

o o

ccu

r at

leas

t an

nu

ally

. U

nlik

ely

to o

ccu

r.

4


1


























Title: Primary Care Finance and Estate Update

Lead Governing Body Member: Visseh Pejhan-Sykes, Chief Finance Officer


appropriate

()

Report Author: Carl Smith, Head of Commissioning Finance & Kirsty Turner, Associate Director of Primary Care

Decision

Reviewed by EMT/Date:

Discussion

Reviewed by Committee/Date:

Information

Checked by Finance (Y/N/N/A - Date):


2

EXECUTIVE SUMMARY: The purpose of this paper is to update the Primary Care Commissioning Committee on the Primary Care and Prescribing Budgets that are in place in 2018/19. The paper will also update the Committee around the Primary Care Estates position.

NEXT STEPS: The CCG Finance and Primary Care teams along with NHS England have worked closely together to understand and mitigate any known risks in the system throughout the year.


a) note the financial position for 2018/19; b) note the contract changes in finance terms in 2019/20; and c) note the estates update.

3

1. SUMMARY

This is the 1st year of NHS Leeds CCG bringing together the three former CCGs in Leeds. The CCG now has a budget of £1.2 Billion, £132.8 Million of which is allocated to Primary Care.

2. FINANCE UPDATE

Of the £134.4 Million budget held for Primary Care £112.4 is allocated to the Co-Commissioning budget held with NHS England. The remaining £22M are locally commissioned budgets including £2.6M for GP IT. NHS Leeds CCG 2018-19 Co-Commissioning Budget

The nationally agreed GP pay increase was paid in October 18 and was covered within the original budget. At the end of December the CCG received an unexpected additional allocation of £851K to cover this payment from NHS England. As the funding had already been covered from the co-commissioning budget the £851K is now been released to show an underspend position. The remaining budget is expected to be fully spent at year end.

NHS Leeds CCG 2018-19 Locally Commissioned Primary Care Budget

In December 2018 NHS England Yorkshire & The Humber provided an additional non-recurrent allocation of £1 per head to support CCGs in West Yorkshire and Harrogate to address performance pressures related to primary care and address specific ‘hotspots’

NHS Leeds CCG 2018-19 YTD Budget YTD Actual

YTD

Variance

2018-19

Budget

Forecast

Outturn

Forecast

Variance

£'000 £'000 £'000 £'000 £'000 £'000

GMS 22,824 22,865 41 24,899 24,914 14

PMS 44,157 44,296 139 48,171 48,196 25

APMS 3,945 3,985 40 4,303 4,301 -2

Premises cost reimbursements 14,124 14,086 -39 15,249 14,933 -316

Other premises costs 204 209 6 222 222 0

Enhanced Services 2,632 2,522 -111 2,873 2,873 0

QOF 8,713 8,719 5 9,507 9,923 416

Other GP Services(inc PCO) 6,619 5,756 -862 7,220 6,232 -988

Total Primary Care Co-Commissioning 103,218 102,437 -780 112,444 111,593 -851


YTD

Variance

(Under)/

Overspend

2018-19

Budget

Forecast

Outturn

Forecast

Variance

(Under)/

Overspend

£'000 £'000 £'000 £'000 £'000 £'000

Primary Care Schemes 17,706 17,186 -520 19,316 18,748 -567

Primary Care - GP IT 2,416 3,131 714 2,636 3,360 724

Confederation Costs:

Prescribing staff 1,431 1,384 -47 1,561 1,526 -36

Primary Care Staff 717 658 -59 782 719 -63

GP Confederation Staff 345 361 16 398 398 1

Total Primary Care Services 22,615 22,719 104 24,692 24,751 59

4

related to financial, performance and workforce challenges. This equated to £837K for Leeds CCG. After liaising with the GP Confederation to develop a plan for this further investment in primary care, it has been concluded that the work will not be undertaken until the 2019/20 financial year. As the £837K can’t be used in this financial year the funding is shown as an under spend in 2018/19 and will be provided in 2019/20 by being added (non-recurrently) to the baseline budgets. The locality funding discussed within the previous finance paper of £2 per head of population led to an expected overtrade of £270K within the Primary Care Schemes cost centre; all localities have signed up for this scheme. The Primary Care GPIT cost centre is forecasting an overspend of £724K, this is due to the Provision for the VAT payment of the GPIT element of the Embed contract, this has been provided backdating to 2015/16. Previously the CCG has recovered VAT for the Embed contract, due to various changes within VAT rules the CCG has decided to make a provision against the loss of the previously recovered VAT. Discussions are ongoing between HMRC and NHS England to clarify the VAT status of all transactions between CCGs across Yorkshire and Humber and eMBED over the 3 year lifespan of the contract. NHS Leeds CCG 2018-19 Prescribing Budget

December data has now been received; based on this information we have reduced the under trade position by £0.7M to show a forecast under spend of £3.7M for 2018/19. There has been a further reduction in forecast spend due to £2M of unmet accruals from 2017/18 which have been released against the forecast increasing the overall underspend expected to £5.7M.

3. The five year framework for GP contract reform

On 31January 2019, new guidance for the GP contract was received. The contract increases funding to Primary Care significantly over the next five years. This equates to a £31.5M increase to the Leeds CCG co-commissioning allocation over the next five years. The main areas this increased funding will apply to include:

Funding for Additional Roles within Networks

Network Participation Payments

Funding for 0.25WTE Clinical Director roles within each Network


YTD

Variance

(Under)/

Overspend

2018-19

Budget

Forecast

Outturn

Forecast

Variance

(Under)/

Overspend

£'000 £'000 £'000 £'000 £'000 £'000Prescribing 115,350 110,113 -5,237 125,836 120,123 -5,713

Ex centrally funded drugs 3,130 3,185 55 3,414 3,474 60

Oxygen contract 1,071 1,096 26 1,168 1,196 28

Total Prescribing 119,550 114,394 -5,156 130,418 124,793 -5,625

5

After working through the new costs and including this in the plan the new contract is affordable for the CCG in 2019/20.

4. Estates Update

The CCG continues to review progress against Estates schemes through the primary care estate group. At the last meeting, the group reviewed a number of proposals against the criteria and provided support for schemes to be worked up further. Windmill Health Centre remains the highest priority for the organisation and despite PCCC providing approval for the full revenue costs the scheme has not been able to be progressed as we still await NHS England approval.

5. RECOMMENDATION

The Primary Care Commissioning Committee is asked to:

a) note the financial position for 2018/19; b) note the contract changes in finance terms in 2019/20; and c) note the estates update.


Primary Care Commissioning Committee– Work Programme 2019/20

June Aug Oct Dec Feb April Notes

STANDING ITEMS

Welcome & apologies X X X X X X

Declarations of interest X X X X X X

Questions from Members of the Public

X X X X X X

Minutes of previous meeting

X X X X X X

Matters arising X X X X X X

Action log X X X X X X

Forward Work Programme

X X X X X X

Chief Executive’s Report X X X X X X

GOVERNANCE ITEMS

Terms of Reference X

Assessment of Committee Effectiveness

X

PCCC Annual Report X

Delegation agreement

COMMISSIONING AND STRATEGY

GP Forward View Delivery Plan (includes Primary Care Estates & Technology Transformation Fund update, Workforce, Workload, Estate, Access, Core Re-design, New Models of Care)

X X X X X X

GP Confederation Update

PPGs/Primary Care Engagement

Local Primary Care Schemes

Includes delivery and prescribing schemes

Quality Improvement Scheme

Approve newly designed enhanced services (LDS/DES)

As required

Chair’s Summary from Primary Care Operational Group

X X X X X X

General Practice Nursing Strategy

Health Inequalities Audit X Review of Action Plan

NHSE National Policies As required

QUALITY, PERFORMANCE AND RISK AND SUMMARY REPORTS

Integrated Quality and Performance Report

X X X X X X

Summary from Quality and Performance Committee

X X X X X X

Corporate Risk Report X X X X X X

FINANCE

Finance update X X X X X X

Approve ‘discretionary’ payments

As required

OTHER

Approve contractual action e.g. branch/remedial notices, contract variation GMS, PMS and APMS contracts

As required

Approve new GP practices and practice mergers

As required

Documents

AGENDA NHS Leeds CCG Primary Care Commissioning …