Primary Care Commissioning Committee – Part 1 … Care Commissioning Committee – Part 1 Thursday 7 September 2017, 3pm – 4.25pm Bevan Room, Aylesbury Vale CCG, 2 nd Floor The

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Primary Care Commissioning Committee – Part 1 Thursday 7 September 2017, 3pm – 4.25pm

Bevan Room, Aylesbury Vale CCG, 2nd Floor The Gateway, Gatehouse Road, Aylesbury, Bucks HP19 8FF

Agenda Item Desired Outcome(s)

Contributor Papers/Times

1 Welcome and Introductions: Apologies: Helen Delaitre

Graham Smith CHAIR

3.00 – 3.10

Paper A

Paper B

2 Declarations of Interest • Review of CoI Register

Graham Smith CHAIR

3 Questions from members of the public

Graham Smith CHAIR

4 Minutes of the June 2017 meeting and action log

To Approve Graham Smith CHAIR

Assurance Reports 5 Primary Care Risk Register For Assurance Wendy Newton 3.10 – 3.20

Paper C 6 GP Forward View Action Plan To Discuss and

For Assurance Wendy Newton 3.20 – 3.30

Paper D 7 Finance Report M4 For Assurance Alan Overton 3.30 – 3.35

Paper E 8 Quality Report For Assurance Lisa Beaumont 3.35 – 3.45

Paper F Primary Care Commissioning

9 Premises Sub Group Terms of Reference

To Approve Wendy Newton 3.45 to 3.50 Paper G

10 Beaconsfield New Build – Project Initiation Document (PID)

To Approve Nicola Lester / Kate Holmes

3.50 – 4.05 Paper H

11 Transition of Delegated Functions and Small Contracts

To Note Jessica Newman 4.05 – 4.15 Paper I

12 Primary Care 24/7 Access Update To Note Nicola Lester 4.15 – 4.20 Verbal

Any Other Business 13 Any Other Business

- Date of Next Meeting 7 December 2017

Graham Smith CHAIR

4.20 – 4.25

For Information Only 14 Note from Premises Sub-Group –

24/07/2017 Paper for Information Only Paper J

15 Head of Primary Care Report Paper for Information Only Paper K

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MEETING: Primary Care Commissioning Committee PAPER: A

DATE: 7 September 2017

TITLE: Review of Register of Interests

AUTHOR: Wendy Newton, Primary Care Manager

Russell Carpenter, Head of Governance

LEAD DIRECTOR: Nicola Lester, Director of Transformation

Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: To ensure compliance with the CCG’s Conflict of Interest Policy and national NHS England guidance, the PCCC is required to formally circulate a copy of their Conflict of Interest Register with the meeting papers. This is to ensure members have the opportunity to review entries and confirm any changes through the standing Declaration of Interest agenda item. All CCG Boards / Committees / Groups have been asked to undertake this task to ensure that the CCG has evidence, should we be challenged, that registers have been kept up to date. Conflicts of Interest: None Strategic aims supported by this paper :( please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all

Better Care for Bucks – to commission personalised, high value integrated care in the right place at the right time

Better Care for Bucks – to ensure local people and stakeholders have a greater influence on the services we commission

Sustainability within Bucks – to contribute to the delivery of a financially sustainable health and care economy that achieves value for money and encourages innovation

Leadership across Bucks – to promote equity as an employer and as clinical commissioners

Governance requirements: (Please tick each box as is relevant to the paper) Governance Element Y N N/A Comments/Summary Patient & Public Involvement

Equality Quality Financial Risks

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Statutory/Legal Prior consideration Committees /Forums/Groups

Conflict of Interest Register to be formally reviewed by the PCOG every 6 months. Declarations of Interest are a standing agenda item for the PCOG. Declared conflicts are cross-referenced with the agenda in advance of meetings to determine whether a conflict exists.

Membership Involvement Supporting Papers: PCCC Register of Interest NHS Aylesbury Vale CCG & NHS Chiltern CCG Conflicts of Interest Policy

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Bi-Annual Review of Conflict of Interest Register To ensure compliance with the CCG’s Conflict of Interest Policy (Appendix 1) and national NHS England guidance (NHS England’s Managing Conflicts of Interest: Revised Statutory Guidance for CCGs, June 2016 can be viewed here) the PCOG is required to formally circulate bi-annually a copy of their Register of Declared Conflict of Interest with the meeting papers. This is to ensure members have the opportunity to review entries and confirm any changes through the standing Declaration of Interest agenda item. All CCG Boards / Committees / Groups have been asked to undertake this task to ensure that the CCG has evidence, should we be challenged, that registers have been kept up to date. All members of the PCCC are asked to review their declared conflicts of interest and to inform the PCCC Chair of any changes to their recorded status.

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https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/revsd-coi-guidance-june16.pdf

Declared Interest Nature of Interest

(Name of the organisation and nature of business) From To

Graham Smith Lay Member CHAIR 1. None to Declare N/A N/A N/A N/A N/A N/AColin Seaton Lay Member 1. None to Declare N/A N/A N/A N/A N/A N/ARoss Carroll Lay Member 1.Employee of UCB Pharma Ltd,

Director of UCB Pharma ltd Financial Direct Employee and Director Jan-15 current Standing declaration

Robert Parkes Lay Member (Deputy Lay Chair Aylesbury Vale CCG)

1. Chearsley Parish Council Non-financial professional

Direct SFO (Senior Financial Officer) to Oct-16 current Standing declaration

1. East Berkshire College of Further Education

Non-financial personal

Direct Chair Apr-13 current Standing declaration

2. Directorship, Windsor Theatre Ltd

Non-financial personal

Direct Director Apr-13 current Standing declaration

Helen Delaitre Head of Primary Care 1. None to Declare N/A N/A N/A N/A N/A Standing declaration

Alan Overton Finance Analyst 1. None to Declare N/A N/A N/A N/A N/A Standing declarationJessica Newman Assistant Contract Manager,

NHS England1. None to Declare N/A N/A N/A N/A N/A Standing declaration

1 DHL (Logistics) Indirect interest Indirect; spouse Husband holds Global Directorship role

2006 current Standing declaration

2. Teenage Cancer Trust (Charity) Non-financial personal

Direct Volunteer 2012 current Standing declaration

3. Brunel University Non-financial professional

Direct Member of Brunel Business School Strategic Advisory Board


4. Chalfonts Community College Academy

Non-financial professional

Direct Director of Academy, Trustee 2006 Jun-16 Standing declaration

1. Local Medical Committee (LMC)Elected Member - the professional organisation representing individual GPs as providers


Direct 1. Directorship - Bucks Berks Oxon LMC Secretariat Ltd


2. Whitehill Surgery - generalpractice

Financial Direct 2. GP Partner at Whitehill Surgery. 1991 current Leaving any meeting involving discussion (at chair’s discretion) and decision in respect of primary care incentive schemes

3. NHS Clinical Commissioners - the membership organisation of clinical commissioning groups


Direct 3. Board Member 2014 current Standing declaration

4. NHS Clinical Commissioners - the membership organisation of clinical commissioning groups


Direct 4. Co-Chair of NHSCC effective from 1st April 2016


5. Share Holdings - None (Previously in Vale Health untilMarch 2013)

Financial Direct 6. Share Holdings - None (Previously in Vale Health untilMarch 2013)


6. Wellington House Practice,Princes Risborough

Indirect interest Indirect; spouse 7. Wife is salaried GP within a member practice


7. Chiltern Vale Health (provider of community based NHS and private healthcare services in Buckinghamshire)

Indirect interest Indirect; spouse 8. Wife works in the CV health intermediate Gynae service


8. FedBucks - provider of community services

Financial Direct Whitehill Surgery is a member of FedBucks; a GP lead provider company

Jul-16 current Leaving any meeting involving discussion (at chair's discretion) and decision in respect of projects or contracts for which FedBucks may or has bid• 9. NHS Confederation; membership

body that brings together and speaks on behalf of all organisationsthat plan, commission and provide NHS services.


Direct 9. Trustee Feb-17 current Standing declaration; I have no personal pecuniary interest in the organisation and receive no payment for being a trustee, but do have a liability to the financial structure of the Confed (there is insurance in place to cover that liability)

Clinical Chair - Aylesbury Vale CCG by invitation, not a formal vosting member)

Dr Graham Jackson

Action taken to mitigate risk (to be agreed with line manager or a senior CCG manager)

Name

Current position (s) held in the CCG i.e. Governing Body member; Committee member; Member practice; CCG employee or other

Type of Interest

Is the interest direct or indirect (including details of the relationship with the person who has the interest where indirect)

Date of Interest

Lou Patten Chief Officer

Tony Dixon Lay Member (Deputy Lay Chair Chiltern CCG)

Appendix 1 – PCCC Register of Declared Conflicts of Interests

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1. I am a member of a practice that has joined Fed Bucks, a newly formed GP provider organisation

Financial Direct. I am one of 2 partners at Little Chalfont Surgery. The surgery is a member practice of Fed Bucks.

a single practice share holding 1.7.16 current I will declare an interest and absent myself from any and all commissioning decisions pertaining to areas in which Fed Bucks may have a provider interest.

2. 50% ownership of Little Chalfont Surgery.

Financial Direct. I am one of 2 partners at Little Chalfont Surgery

one of 2 equal partners in practice 1.4.2000 current I will declare an interest and absent myself from any and all commissioning decisions pertaining to areas in which Little Chalfont surgery may have a provider interest.

3 On call doctor for Florence Nightingale House Hospice - specialist palliative care service

Financial Direct. I have worked as a palliative care doctor at Florence Nightingale House since 1998.

salaried on call doctor 1.3.1998 31.6.16 I have ceased this work upon my appointment as clinical chair.

4. In the past I have participated in advisory boards and training sessions for pharmaceutical companies. I have ceased all such activity for some time.

Financial Direct. occasional training or advisory work 1.4.2004 27.11.2015 I have ceased all such activity and will not undertake any such work in the future. I have no links with any specific company. All historical work has been compliant with ABPI regulations.

5. University of Oxford Non-financial Professional

Direct Currently a member of the University as an MSc student

1.10.2015 current I will declare an interest and absent myself form any commercial decision involving the university.

Nicola Lester Director of Transformation 1. Buckinghamshire Healthcare NHS Trust

Indirect interest Indirect; son 1. Son works for Trust as Physiotherapy Clinical Support Worker

Dec-16 current Low risk. Will not take part in related discussions.

Lisa Beaumont Associate Director Quality and Nursing

1. None to Declare N/A N/A 1. N/A N/A N/A N/A

David Williams Head of Quality and Patient Safety

1. Buckinghamshire Healthcare NHS Trust, provider of hospital and community services


Direct 1. Staff member previously employed by a provider for whom the CCG is a co-ordinating or associate commissioner - 02/2015-31/12/206

Dec-16 current Individual no longer employed, but having been could be perceived to offer additional positive influence in relation to decisions to commission. To be noted in relation to conflicts of interest in circumstances where individual is advising or recommending in relation to any decision to commission additional services that do not form part of core contract that are subject to formal tender procurement. No contracting or quality activity at BHT

Dr Raj Bajwa Clinical GP Chair - Chiltern CCG (by invitation, not a formal vosting member)

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1. VodaFone Group Indirect interest Indirect; spouse Wife works as Customer Delivery Manager

Sep-15 current Not directly involved in schemes with this provider. Not authorising expenditure with this provider.

2. Oxford Health NHS Trust Indirect interest Indirect; neice Niece worked in finance Apr-13 Jul-15 Standing declaration

Kate Holmes Deputy Chief Finance Officer 1. None to Declare N/A N/A N/A N/A N/A N/AAlan Cadman Deputy Chief Finance Officer 1. None to Declare N/A N/A N/A N/A N/A N/A

1. Vale Health as provider of community based NHS and private healthcare services in Buckinghamshire - Buckinghamshire GP Federation as of 2016 (Buckinghamshire GP Federation as of 2016)

Financial Direct 1. Share Holdings - None (Previously in Vale Health until April 2013)

2009 Apr-13 Standing declaration

2. Haddenham Medical Centre, GP Practice

Financial Direct 2. GP Partner Jun-08 current Leaving any meeting involving discussion (at chair’s discretion)

d d i i i t f i 3. Brain Lab - Medical Software and Hardware Innovators

Indirect interest Indirect; spouse 3. Husband is National Sales Manager


4. FedBucks - provider of community services

Financial Direct 4. Haddenham Medical Centre is a member of FedBucks; a GP lead provider company

Jul-16 current Leaving any meeting involving discussion (at chair's discretion) and decision in respect of projects or contracts for which FedBucks may or has bid

1. Wycombe Heritage and Arts Trust

Non-financial Personal

Direct 1. Chairman 13/10/2014 current Standing declaration

2. Chiltern Business Club Non-financial Personal

Direct 2. Treasurer 13/10/2014 current Standing declaration

3. British Gymnastics Association Non-financial Personal

Direct 3. Trustee 13/10/2014 current Standing declaration

4. Oxfordshire Youth Arts Partnership



5. Bucks County Museum Trust Non-financial Personal


6. Hughenden Valley Parish Council Non-financial Personal

Direct 6. Councillor 13/10/2014 current Standing declaration

7. Oxfordshire University Hospitals NHS Foundation Trust

Indirect interest Indirect; spouse 7. Partner is Deputy Chief Nurse for the Childrens Hospital

13/10/2014 current No involvement in commissioning decisions for this provider

8. Healthwatch Buckinghamshire Indirect interest Indirect; friend 8. Chair is personal friend 13/10/2014 current No involvement in commissioning decisions for this provider

9. Buckinghamshire Healthcare NHS Trust - Adult Community Health Team (ACHT)

Indirect interest Indirect; former spouse 9. Former spouse is District Nurse 13/10/2014 current No involvement in commissioning decisions for this provider

10. Fullflight - private limited company providing general consultancy

Financial Direct 10. Owner 13/10/2014 current Standing declaration

11. DXS clinical decision support system


Direct 11. Friend of chairman of DXS and on same trust board

01/11/2016 current No involvement in commissioning decisions for this provider

12. Chair of Governors Millbrook School - largest primary school in Wycombe


Direct 12. Chair 16/11/2016 current Standing declaration

Wendy Newton Primary Care Manager 1. None to Declare N/A N/A N/A N/A N/A N/A

Robert Majilton Deputy Chief Officer

Dr Karen West Member GP / Clinical Commissioning Director for Integrated Care CHAIR

Simon Kearey Head of Localities

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Sarah Edwards Programme Support Officer 1. None to Declare N/A N/A N/A N/A N/A N/A

1. GP practice; Ivers Practice, Iver Heath Bucks

Financial Direct 1. GP Partner Jul-16 current Leaving any meeting involving discussion (at chair’s discretion) and decision in respect of primary care improvement schemes

2. FedBucks - federation of GP providers; practice is a member

Financial Direct 2. Practice is a member Jul-16 current Leaving any meeting involving discussion (at chair’s discretion) and decision in respect of projects or contracts for which FedBucks may or has bid.

Dr Paul Roblin CEO BBOLMCJane O'Grady Director of Public HealthThalia Jervis Chief Executive, Healthwatch

Bucks

Steve Burr Clinical Locality Lead, Amersham and Chesham

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Appendix 2 – CCGs Conflict of Interest Policy

CONFLICTS OF INTEREST POLICY

Author/s Kate Holmes/Nicola Lester/Russell Carpenter Date of Approval October 2016 Review Date October 2018 Policy Number CHCCGPOL018

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DOCUMENT CONTROL SUMMARY

Title Conflicts of Interest Policy Lead Officer Nicola Lester, Director of Corporate Affairs

Purpose of document This policy sets out how the CCGs will manage conflicts of interest.

Status Final Version No. 2.4 Date September 2016 Author(s) Kate Holmes/Nicola Lester/Russell Carpenter Date of approval by Audit Committee 27/09/16

Date of ratification by Governing Body 13/10/16

Review Date Annual

VERSION CONTROL SUMMARY

Date & Version

Author Comment

Jan 2014 v1.0

Kate Holmes Approved. For review Jan 2015

Dec 2014 v2.0

Nicola Lester Draft. Revised in light of new statutory guidance. For review by Governing Body and Executive Committee on 8th Jan 2015

Jan 2015 v2.2

Nicola Lester Draft. Revisions made by Governing Body and Executive Committee on 8th Jan 2015 included. Recommended for ratification by the Audit Committee on 28th January 2015.

28th Jan 2015 v2.2

Nicola Lester Approved. For review Jan 2018

20th July 2015 v2.3

Nicola Lester Changes proposed to reflect Internal Audit recommendations. For Audit meeting on 29th July.

27th Sept 2016 v2.4

Russell Carpenter

Re-write and changes to reflect new NHS England Guidance

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Introduction 1.1 Purpose and Scope This policy applies to Aylesbury Vale and Chiltern Clinical Commissioning Groups (the CCGs) and sets out how the CCGs will manage conflicts of interest. It will not always be possible to avoid conflicts of interest. However, by recognising where and how they arise, and dealing with them appropriately, commissioners will be able to ensure proper governance and demonstrate that decision-making is appropriate. This policy should be read in conjunction with the CCGs’ constitutions (specifically the relevant section on conflicts of interest), and the policies on standards of business conduct, whistleblowing, gifts and hospitality, counter fraud and bribery, and the disciplinary procedure. This policy applies to all individuals, whether Members, employees or appointed individuals who are working for the CCGs, and persons serving on committees and other decision-making groups established by the CCGs (including representatives of third-party organisations and members of the public). It also applies to any relevant ‘in attendance’ members; that is, any individual who sits on a committee or acts in an advisory capacity. 1.2 Objectives This policy outlines:

• How the CCGs and member clinicians in commissioning roles work within legal frameworks (including the Bribery Act 2010) to demonstrate transparency, fairness and probity in decision making and to ensure that they do not seek advantage.

• How conflicts of interest – personal and business interests that are perceived or actual – must be declared by members of committees, member practices, employees and others such as contractors. This applies declarations at meetings and for inclusion on published registers.

• The processes in place to manage declarations and maintain published registers of interests on CCG websites. 1.3 Legal requirements The consequences of failing to manage conflicts of interest properly could have significant implications both legal and reputational. All individuals impacted by this policy should act in good faith and in the interests of the CCGs. Furthermore, they should reflect the expectations set out in the Standards for Members of NHS Boards and Clinical Commissioning Groups and act in accordance with the Nolan Principles and other internal documents as listed in section 1.1. Non-compliance with this policy will be investigated by the Audit Committee. Any individual failing to comply with the policy may face disciplinary action. 1.4 Review This policy will be reviewed annually, or otherwise when new guidance is published which prompts it earlier. The Audit Committee will review this policy in tandem with annual internal audit of management of conflicts of interest in accordance with guidance provided by NHS England. The Audit Committee will also oversee quarterly self-certification of compliance to NHS England and an annual assessment as part of the NHS England integrated assurance framework for CCGs.

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1. Definition of an interest This is documented in statutory guidance published by NHS England (December 2014, updated June 2016), pages 13 to 17, and in Question and Answer documents for both primary care and CCG employees. https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/revsd-coi-guidance-june16.pdf G:\AVCCG CCCG SCWCSU\Statutory Documents\Conflicts of Interest

• Declarations of Interest – primary care FAQ • Declarations of Interest – CCG employees FAQ

2. Principles A number of principles for good governance to be considered when discharging this policy include:

• The Seven Principles of Public Life (commonly known as the Nolan Principles); • The Good Governance Standards of Public Services; • The Seven Key Principles of the NHS Constitution; • The Equality Act 2010.

3. Declarations 4.1 Requirements National statutory guidance also includes how interests should be identified and managed, and templates for declaration. NHS England’s template declaration form also describes the types of interest to be declared: https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/coi-annx-a.docx GP member practices/GP Partners must also declare any interest that they would be required to declare in accordance with paragraphs 10-13 of the GMC’s Financial and Commercial Arrangements and Conflicts of Interest (2013) or any successor guidance. Any nursing staff must declare any interest that they would be required to declare in accordance with paragraph 21 (Uphold your position as a registered nurse or midwife) of the NMC’s publication Code of Professional Conduct or any successor Code. For CCG lay members of the Governing Body, there is additional criteria that disqualify people from being appointed as per Regulation 12(6) of the NHS Clinical Commissioning group) Regulations 2012. 4.2 At appointment and on six-monthly review All applicants for roles on the Governing Body and Executive Committee should be tested for conflicts of interest before appointment (see section 8 for further detail). All members of CCG committees and employees will also be required to complete a declaration on appointment. These declarations will be transferred to registers published on CCG websites, to be reviewed every six months. Where an individual changes role or responsibility within the CCG any change to the individual’s interest should be declared as soon as they are aware, and in any event within 28 days.

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https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/coi-annx-a.docx

4.3 Changing circumstances Wherever an individual’s circumstances change in a way that affects the individual’s interests (e.g. where an individual takes on a new role outside of the CCG or sets up a new business or relationship), a revised declaration should be made to the Corporate Governance Lead to reflect the change in circumstances. This could involve a conflict of interest ceasing to exist or a new one materialising. 4.4 Secondary employment In particular, it is the responsibility of all individuals to inform their line manager if they are employed or engaged in, or wish to be employed or engaged in, any employment or consultancy work in addition to their work with the CCGs, in order to enable the CCGs to be aware of any potential conflict of interest. Members are required to obtain prior permission to engage in such secondary employment and the CCGs reserve the right to refuse permission where it believes a conflict will arise which cannot be effectively managed. 4.5 Reporting declarations Declarations should be reported to Locality Business Support Managers for member practices in primary care and localities, and the Corporate Governance Lead for employee declarations and those of committees other than localities. The Corporate Governance Lead oversees maintenance of registers and publication of these on the CCGs’ websites. 4.6 Additional information Summary guides have also been published by NHS England for:

• GPs in commissioning roles • Conflicts of Interest Guardians • CCG Governance Leads • CCG Lay Members • CCG Admin Teams • Healthwatch Representatives on Primary Care Commissioning Committees

These can be found through the following link: https://www.england.nhs.uk/commissioning/pc-co-comms/coi/

4. Governance arrangements and decision making 5.1 Standing item All CCG committee and sub-committee meetings have declarations of interest as a standing agenda item, with interests to be declared by all members even if the interest has been declared on registers, for an agenda item of potential conflict. These must be recorded in the minutes, as well as the agenda item for which conflict has been declared. All relevant register entries will also be made available for the Chair in advance of the meeting. Where such a declaration is made, the following information shall also be recorded in the minutes of the meeting.

• who has the interest; • the nature of the interest and why it gives rise to a conflict; • how the conflict was agreed to be managed; and • evidence that the conflict was managed as intended.

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https://www.england.nhs.uk/commissioning/pc-co-comms/coi/

5.2 Managing declared conflicts In circumstances where a potential perceived or actual conflict is known to exist, the chair of the meeting has ultimate responsibility for agreeing how to manage any conflict of interest in the meeting. Possible actions may include (but are not limited to):

• Asking conflicted individuals to leave the meeting when the relevant matter(s) are being discussed; • Allowing conflicted individuals to participate in some of the discussion, but asking them to leave the

meeting at the point of decision-making; • Restricting access to papers in advance of the meeting.

Were this to result in an absence of members to the extent that the meeting would no longer be quorate, then the meeting would be unable to make any formal decisions. The Chair reserves the right to adjourn and reconvene the meeting when appropriate membership can be ensured. This would need to be recorded in the minutes. Should it never be possible to have a quorate decision through the need to exclude conflicted voting members for a certain item, such items/decisions will be escalated as described within the committee’s terms of reference. The above will apply not only in relation to formal CCG decision making meetings, but equally at contract monitoring meetings with providers, and also where a contract is held jointly with another organisation such as the Local Authority or with other CCGs under lead commissioner arrangements. Governing Body In the event of the Governing Body needing to make a decision in which a Governing Body member has declared a potential conflict of interest (real or perceived) in accordance with this policy, the conflicted individual may be excluded from all discussions and voting in relation to the matter in question. If a quorum is still present for the discussion and decision, the Governing Body may continue to make decisions. In the event that exclusion renders the Governing Body inquorate due to the number of conflicted individuals, alternative quorum arrangements may be made, as per the Constitution. This may also require co-opting clinical expertise from outside the membership of the CCG or individuals from the Health and Wellbeing Board or escalating the decision to another committee. The management of conflicts of interest will be reported in the minutes of the meeting. Where, having adhered to the requirements of this policy, a Member practice benefits from a decision through payment or benefits in kind, this will be reported in the CCG’s annual report and accounts, as a matter of best practice. See paragraphs 72 to 94 of the guidance (Managing conflicts of interest at meetings) for further details. Advice on conflict management should be sought from the Conflict of Interest Guardian and Corporate Governance Lead. The decision of the Chair of the governing body on questions of order, relevancy and regularity and their interpretation of the constitution, standing orders, scheme of reservation and delegation and prime financial policies at the meeting, shall be final. A template for recording minutes has been published as follows: https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/coi-annx-f.docx

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https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/coi-annx-f.docx

5. Maintaining Registers of Interests Details of which individuals need to declare interests is documented in statutory guidance published by NHS England (December 2014, updated June 2016), pages 19 and 20, and in Question and Answer documents for both primary care and CCG employees. This also refers to review every six months. https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/revsd-coi-guidance-june16.pdf The CCGs will maintain registers, published on both CCG websites, for the following:

• All GP Practices (divided by locality), including GP Partners (or, where the practice is a company, its directors) and any other individual directly involved with the business or decision making of the CCG;

• All members of the Governing Body, the Governing Body’s committees, sub- committees; and • All employees of the CCG, including agency staff and seconded staff.

In respect of employees, only those declarations for employees at Band 8a and above are published on the website. Where an individual believes that substantial damage or distress may be caused to him/herself or somebody else by the publication of information about them, they are entitled to make a written request that the information is not published. The Conflicts of Interest Guardian will make the decision whether or not such information should be published, who may seek independent legal advice if required. The CCGs will always retain a confidential un-redacted version of the relevant register(s).

6. Declarations of gifts and hospitality This is covered by a separate CCG policy and also pages 20 and 21 of the statutory guidance. Updating these declarations will fall within the same timescale as declarations of interest. A definition of a gift is given within statutory guidance. Gifts and hospitality are considered one-off benefits and a different declaration is required. Declarations should also include those offers of commercial sponsorship which could include grants (for which there is also a separate policy), even when such offers have been declined. Under the Bribery Act 2010 it is a criminal offence to accept a bribe, which the offer of a gift or hospitality could be construed as if it is not managed appropriately. A bribe is offering an incentive to someone to perform a relevant function or activity improperly (e.g. to improperly enable the briber to secure or retain a business contract or to gain an advantage over a competitor by obtaining confidential information). A template form for declarations of gifts and hospitality can be found here: https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/coi-annx-c.docx The above provisions for registers of interests shall apply in respect of gifts and hospitality for publication on websites (i.e. in relation to damage or distress from publication).

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https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/coi-annx-c.docx

7. Roles and responsibilities Oversight of the management of conflicts of interest will be provided by the Accountable Officer, supported by the Director of Corporate Affairs and Corporate Governance Lead. A number of additional considerations are also required. Appointment of Governing Body or Committee Members When appointments are being made to the Governing Body or its committees, the CCGs will consider on a case-by-case basis as to whether conflicts of interest should exclude individuals from being appointed. The following will be taken into consideration:

a. The materiality of the interest - in particular whether the individual (or a family member or business partner) could benefit from any decision the Governing Body might take. This will be particularly relevant for any profit sharing member of any organisation but will also be considered for all employees and especially those operating at senior or Governing Body level;

b. The extent of the interest – if the interest is related to an area of business significant enough that the individual would be unable to make a full and proper contribution to the Governing Body, that individual will be excluded from becoming a member of the Governing Body.

c. Any individual who has a material interest in an organisation which provides, or is likely to provide, substantial services to a CCG (whether as a provider of healthcare or commissioning support services, or otherwise) should recognise the inherent conflict of interest risk that may arise and should not be a member of the Governing Body or of a committee or sub-committee, in particular if the nature and extent of their interest and the nature of their proposed role is such that they are likely to need to exclude themselves from decision-making on so regular a basis that it significantly limits their ability to effectively perform that role. The role of lay members CCG lay members play a critical role in CCGs, providing scrutiny, challenge and an independent voice in support of robust and transparent decision-making and management of conflicts of interest. They also chair a number of CCG committees, including the Audit Committee and the Primary Care Commissioning Committee. By statute, CCGs must have at least three lay members; one of whom must have qualifications, expertise or experience such as to enable the person to express informed views about financial management and audit matters and serve as the chair of the audit committee. Another should have knowledge of the geographical area covered in the CCG’s constitution such as to enable the person to express informed views about the discharge of the CCG’s functions. National guidance also stipulates that the primary care commissioning committee must have a lay chair and lay vice chair (page 28). https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/revsd-coi-guidance-june16.pdf To provide appropriate oversight and assurance, and to ensure the CCG audit chair’s position as Conflicts of Interest Guardian is not compromised, the audit chair should not hold the position of chair of the primary care commissioning committee. At present this applies only to Aylesbury Vale CCG which has delegated responsibility for commissioning of general practice. Conflicts of Interest Guardian To further strengthen scrutiny and transparency of the CCGs’ decision-making processes, the CCGs’ audit chairs are appointed Conflicts of Interest Guardians and will be supported in their role by the Corporate Governance Lead.

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The latter will have responsibility for the day-to-day management of conflicts of interest matters and queries, and to keep the Conflicts of Interest Guardians well briefed on conflicts of interest matters and issues arising. The Guardian has the following responsibilities:

• Act as a conduit for GP practice staff, members of the public and healthcare professionals who have any concerns with regards to conflicts of interest;

• Be a safe point of contact for employees or workers of the CCGs to raise any concerns in relation to this policy;

• Support the rigorous application of this policy; • Provide independent advice and judgment where there is any doubt about how to apply this policy in

an individual situation; and • Provide advice on minimising the risks of conflicts of interest.

Page 27 of the national statutory guidance further describes the role of the conflict of interest guardian. Responsibilities of CCG member practices The most obvious area in which conflicts of interest could arise is where the CCGs commission (or continue to commission by contract extension) healthcare services, including GP services, in which a member of either CCG has a financial or other interest. This is inherent when commissioning services in primary care where GPs are current or possible providers. It is the responsibility of all Members to familiarise themselves with this policy and comply with its provisions. Any updates shall be circulated to Members, who will be asked to confirm that they have read this policy on a minimum of an annual basis and that they have completed online training provided by NHS England. CCGs have to report statutorily regulated healthcare professionals to their regulator if they believe that they have acted improperly, so that these concerns can be investigated. Statutorily regulated healthcare professionals should be made aware that the consequences for inappropriate action could include fitness to practise proceedings being brought against them, and that they could, if appropriate, be struck off by their professional regulator as a result. Responsibilities of CCG employees Line managers must ensure their team members are aware of this policy and the processes to be followed to manage conflicts of interest. Furthermore, they must make sure that staff also complete the online training provided by NHS England.

8. Managing conflicts of interest throughout the commissioning cycle Service design Engagement with relevant providers, especially clinicians, in confirming the design of a service specification is entirely permissible, provided it is done fairly, transparently and in a non-discriminatory manner. Conflicts of interest can occur if a commissioner engages selectively with only certain providers (be they incumbent or potential new providers) in developing a service specification for a contract for which they may later bid. Therefore steps should be taken to ensure that any potential providers are all subject to equal process and information.

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The CCGs will, as far as possible, specify the outcomes that they wish to see delivered through a new service, rather than state the way in which these outcomes are to be achieved. As well as supporting innovation, this will help to prevent bias towards particular providers in the specification of services. Procurement The NHS Act and associated regulations set out the statutory rules with which commissioners are required to comply when procuring or contracting for the provision of clinical services. They need to be considered alongside Public Contract Regulations (revised 2015), and where appropriate, EU procurement rules. Other statutory guidance the CCG should abide by is Monitor’s ‘Substantive Guidance on the Procurement, Patients Choice and Competition regulations (2013)’. The above requirements will apply not only to those participating in procurement, but also anyone seeking information in relation to procurement. The CCGs must not award a contract for the provision of NHS health care services where conflicts, or potential conflicts, between the interests involved in commissioning such services and the interests involved in providing them affect, or appear to affect, the integrity of the award of that contract. Where a relevant and material interest or position of influence exists in the context of the specification for, or award of, a contract, then the member will be expected to:

• Declare the interest; • Ensure that the interest is recorded in the register; • Withdraw from all discussion on the specification or award; • Not have a vote in relation to the specification or award.

Members will be expected to declare any interest early in any procurement process if they are to be a potential bidder in that process. Failure to do this could result in the procurement process being declared invalid and possible suspension of the relevant member from the CCG (following due process with ConSultHR for CCG employees/appointees or NHS England for Member Practice representatives). If necessary, the CCGs shall prohibit the award of a contract where the integrity of the award has been, or appears to have been, affected by a conflict. If the contract has already been awarded, the CCGs may, if necessary, seek to terminate the contract, or may remove the relevant individual from their post. Potential conflicts will vary to some degree depending on the way in which a service is being commissioned e.g.:

• Where a CCG is commissioning a service through Competitive Tender (i.e. seeking to identify the best provider or set of providers for a service) a conflict of interest may arise where GP practices or other providers in which CCG members have an interest are amongst those bidding.

• Where the CCG is commissioning a service through Any Qualified Provider a conflict could arise where one or more GP practices (or other providers in which CCG members have an interest) are amongst the qualified providers from whom patients can choose. Statutory guidance published by NHS England (December 2014, updated June 2016), details a number of annexes to be used for procurement related declarations:

• Annex G: Procurement checklist • Annex H: Template Register of procurement decisions and contracts awarded • Annex I: Template Declaration of interests for bidders/ contractors

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Please refer to the following link for these documents: https://www.england.nhs.uk/commissioning/pc-co-comms/coi/ Declarations of external conflicts of interest will be expected from bidders in advance of the PQQ (Pre-Qualification Questionnaire) stage to avoid spending time completing the PQQ in the event that the response would be excluded as a result of an irreconcilable conflict of interest. Register of procurement decisions The CCGs will maintain a register of procurement decisions which will include the details of the decision, who was involved in making the decision, and a summary of any conflicts of interest in relation to the decision and how this was managed by the CCGs. It will also detail the award decision taken. The register will be updated whenever a procurement decision is taken and be made publically available both on the website and by having a copy available in the office for inspection. Once agreed, details of the contract and contract value (including any qualified provider contracts) will also be made available on the CCGs’ websites. These records will be retained for a period of at least three years from the date of award of the contract. The register will form part of the CCGs’ Annual Accounts and will thus be signed off by external auditors.

9. Raising concerns

Where a Member or employee has genuine concerns in relation to this policy and/or any breaches of this policy, they need not investigate their concerns but should report the matter to the Conflicts of Interest Guardian in accordance with the terms of this policy and the CCGs’ whistleblowing policy. Suspicions or concerns relating to acts of fraud or bribery can be reported online via https://www.reportnhsfraud.nhs.uk/ or via the NHS Fraud and Corruption Reporting Line on 0800 0284060.

10. Breach of conflicts of interest policy Non-compliance with this policy may result in civil challenges to the CCGs’ decisions, criminal proceedings for offences such as fraud, bribery and corruption, professional regulatory proceedings and/or disciplinary action. If the situation arises where a contract has been entered into and a breach of this policy has occurred, the CCGs will investigate and take action appropriate to circumstances. The CCGs will view instances where this policy is not followed as serious and may take disciplinary or other relevant action against individuals, which may result in dismissal. Any unwitting failure to declare a relevant and material interest or position of influence and/or to record a relevant or material interest or position of influence that has been declared will not necessarily render void any decision made by the CCGs or their properly constituted committees or sub-committees, although the CCGs will reserve the right to declare such a contract void. Where the breach is reported by an employee or worker of another organisation, it will be investigated with the terms of the whistleblowing policy of the relevant employer organisation. The Conflicts of Interest Guardian will record anonymised details of, and investigate, the alleged breach with support from the Director of Corporate Affairs and act in accordance with all relevant law and CCG policies. Breaches will be reported to the Audit Committee as standing agenda item. The CCGs will publish anonymised details of material breaches of this policy on websites for learning and development purposes.

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https://www.england.nhs.uk/commissioning/pc-co-comms/coi/

https://www.reportnhsfraud.nhs.uk/

19

11. Acknowledgement of external sources Title / Author Institution Link Managing Conflicts of Interest: Statutory Guidance for CCGs

NHS England https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/revsd-coi-guidance-june16.pdf

The Bribery Act 2010 HM Government

http://www.legislation.gov.uk/ukpga/2010/2 3/contents

Health and Social Care Act 2012

HM Government

http://www.legislation.gov.uk/ukpga/2012/7/ contents

Nolan Principles HM Government

https://www.gov.uk/government/publications/the-7-principles-of-public-life/the-7-principles-of-public-life--2

Equality Act 2010 HM Government http://www.legislation.gov.uk/ukpga/2010/15/contents

NHS Constitution NHS England https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/480482/NHS_Constitution_WEB.pdf

UK Corporate Governance Code

Financial Reporting Council

https://www.frc.org.uk/Our-Work/Publications/Corporate-Governance/UK-Corporate-Governance-Code-April-2016.pdf

Good Governance Standards for Public Services (2004)

OPM CIPFA

http://www.cipfa.org/-/media/files/publications/reports/governance_standard.pdf

Procurement, patient choice and competition regulations: guidance (2013)

Monitor https://www.gov.uk/government/publications/procurement-patient-choice-and-competition-regulations-guidance

Support to manage conflicts of interest for CCGs when commissioning primary care (2015)

NHS Clinical Commissioners, Royal College of GPs

http://www.nhscc.org/latest-news/conflicts-of-interest/

Commissioning; Ensuring transparency and probity. Guidance on conflicts of interest for GPs in their role as commissioners and providers (2014)

British Medical Association (BMA)

http://www.bma.org.uk/support-at-work/commissioning/ensuring-transparency-and-probity

Managing conflicts of interest in clinical commissioning groups (2011)

Royal College of General Practitioners Centre for Commissioning/NHS Confederation

http://www.rcgp.org.uk/~/media/Files/CIRC/Managing_conflicts_of_interest.ashx

Financial and commercial arrangements and conflicts of interest (2013)

General Medical Council (GMC)

http://www.gmc-uk.org/guidance/ethical_guidance/21161.asp

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http://www.legislation.gov.uk/ukpga/2010/23/contents









https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/480482/NHS_Constitution_WEB.pdf









https://www.gov.uk/government/publications/procurement-patient-choice-and-competition-regulations-guidance








http://www.rcgp.org.uk/%7E/media/Files/CIRC/Managing_conflicts_of_interest.ashx

http://www.rcgp.org.uk/%7E/media/Files/CIRC/Managing_conflicts_of_interest.ashx



Paper B

Primary Care Commissioning Committee (PCCC) – Part 1

Thursday 1 June 2017, 3.00pm – 5.00pm Bevan Room, Aylesbury Vale CCG, The Gateway, Gatehouse Road, Aylesbury, Bucks

PCCC Voting Members Present Graham Smith (GS), Chair Lay Member, Bucks CCGs Robert Parkes (RP) Lay Member, Aylesbury Vale CCG Kate Holmes (KH) Deputy Chief Financial Officer, Bucks CCGs (Acting CFO) Louise Patten (LP) Chief Officer, Bucks CCGs Nicola Lester (NL) Director of Transformation, Bucks CCGs

In Attendance (non-voting) Dr Graham Jackson (GJ) Clinical Chair, Aylesbury Vale CCG Dr Raj Bajwa (RB) Clinical Chair, Chiltern CCG Helen Delaitre (HD) Head of Primary Care, Bucks CCGs Alan Overton (AO) Finance Analyst, NHS England South (South Central) Tony Dixon (TD) Lay Member, Chiltern CCG Colin Seaton (CS) Lay Member, Bucks CCGs Wendy Newton (WN) Primary Care Manager, Bucks CCGs Jessica Newman (JN) Contract Manager - Medical, NHS England South (South Central) Sarah Ayub (SA) Primary Care Support, NHS England South (South Central) Simon Kearey (SK) Head of Locality Delivery, Bucks CCGs Phil Thistleton (PT) Head of Research and Intelligence, Healthwatch Bucks Sarah Edwards (SE), Notes Programme Support Officer, CCGs

Members of the Public Lesley Munro-Faure (LMF) Managing Partner, Wellington House Surgery Dr Rebecca Mallard-Smith (RMS)

Clinical Director for Unplanned Community Care, Bucks CCGs

Apologies Colin Hobbs Assistant Head of Finance, NHS England South (South

Thalia Jervis Chief Executive, Healthwatch Bucks Jane O’Grady Health & Wellbeing Board Representative Dr Paul Roblin CEO, BBOLMC Louise Smith Associate Director Commissioning & Locality Delivery, Bucks CCGs Dr Karen West Clinical Director for Integrated Care, Bucks CCGs Lisa Beaumont Associate Director of Quality & Safeguarding, Bucks CCGs

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Item No

Agenda Item Actions

1 Welcome & Introductions Members of the PCCC were welcomed to the meeting and introductions given. It was noted that the meeting was quorate.

2 Declarations of Interest. The Chair reminded committee members of their obligation to declare any interest they may have, on any issues arising at the PCCC meeting, which might conflict with the business of NHS Aylesbury Vale and NHS Chiltern Clinical Commissioning Groups. Declarations declared by members are listed in the CCG’s Register of Interests. The Register is available on the CCG websites through the following links: Aylesbury Vale CCG: https://www.aylesburyvaleccg.nhs.uk/about-us/conflict-of-interest-pol/ Chiltern CCG: https://www.chilternccg.nhs.uk/public/about-us/how-we-make-decisions/registers-of-interests/ Trinity Health /Wellington House Practice Merger - Item 7 RP and GJ declared a conflict in relation to the above item as they are both patients at Wellington House Practice. The Chair gave permission for RP and GJ to remain in the room for this item as neither were voting members. However GJ decided he would leave the room for this item. Primary Care Development Scheme - Item 9 The clinicians present declared a conflict of interest for Item 9. The Chair acknowledged the conflict and agreed to allow them to stay in the room for the discussion to provide clinical guidance. It was noted that none of the conflicted clinicians were voting members of the PCCC.

3 Questions from Members of the Public No questions were directly submitted from members of the public.

The Chair gave a brief outline following the submission of a petition to the Governing Body by Mr Trevor Snaith of Ryemead Forum. Mr Snaith is lobbying the CCG for a new “state of the art” Health Centre for the east of High Wycombe to be delivered within the next 2 years. The petition stated that funds “can be made available but we need some focus and urgency from the Chiltern Clinical Commissioning Group (CCG) to ensure a quick delivery”. The proposed Health Centre should cover the areas Bowerdean, Totteridge, Ryemead and Micklefield which are areas of deficiency. He stated funds were available via CIL and S106 funding with land available to purchase from developers.

The Governing Body accepted the petition and agreed to ensure that it is subject to the core CCG Governance process. Regular updates on this work will be presented to this Committee, with a full review being presented to the Committee on 7 December 2017.

4 Minutes and Actions of Committee Meeting 2 March 2017 Minutes of the PCCC meeting held on 2 March 2017 were approved as a true record of the meeting. The action log was reviewed and updated accordingly.

5 PCCC Terms of Reference (ToR) and Scheme of Delegation The PCCC were asked to note the latest iteration of the PCCC’s ToR which were formally approved by the Governing Body. The ToR were updated as a result of: • NHS Chiltern CCG being formally delegated the responsibility for commissioning

Primary Care Medical services from NHS England on 1st April 2017. • Internal reconfiguration of Programme Boards within the Buckinghamshire CCGs. The PCCC were asked to review the appropriateness of the scheme of reservation and delegation and recommend to the Governing Body any potential amendments

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https://www.aylesburyvaleccg.nhs.uk/about-us/conflict-of-interest-pol/

https://www.aylesburyvaleccg.nhs.uk/about-us/conflict-of-interest-pol/

https://www.chilternccg.nhs.uk/public/about-us/how-we-make-decisions/registers-of-interests/

https://www.chilternccg.nhs.uk/public/about-us/how-we-make-decisions/registers-of-interests/

which would assist the Committee to undertake its duties. The current scheme sets the PCCC’s approval limit at £50k per item per CCG. RB informed the meeting that £50k was a historic threshold. The PCCC debated the value of contracts which would likely be reviewed by the PCCC e.g. direct awards with a contract value of circa £2m. LP supported the proposal to increase the PCCC’s approval limit as the PCCC is a public meeting with a significant number of lay representatives and clinicians present together with the AO and CFO. Decision: Voting members of the PCCC recommended that the approval limit stated within the scheme of reservation and delegation is reviewed by the Audit Committee. Any amendments will require ratification by the Governing Body. In the meantime the current approval limits remain.

Action: HD to provide the Audit Committee with examples of potential contracts and their values which may be reviewed by the PCCC.

HD

6 Primary Care Risk Register HD advised that the first draft of the Primary Care Risk Register came to the PCCC in March 2017. Mitigating factors and actions have been added at subsequent Primary Care Operational Group meetings (PCOG). The complete risk register was presented for review and approval by the PCCC. The risk register will be monitored by the PCOG with risks scored at 12 and above being escalated to the PCCC. Action: HD to raise with Corporate Governance Lead the suggestion that risk owners should be referred to by role within the organisation rather than their name. Decision: Voting members of the PCCC noted and approved the Primary Care Risk Register.

HD

7 Trinity Health / Wellington House Practice Merger GJ left the room for this item due to a personal conflict of interest in the subject matter. HD gave an overview of the proposed practice merger between Wellington House Practice and Trinity Health. • The two practices serve approximately 21,000 patients across five sites. • The practices have jointly undertaken a full 12 week patient consultation and

feedback from this was appended to the application. No significant concerns were raised during the consultation process.

• Patients would continue to access all five premises. • The financial impact of the merger had been considered by looking at the associated

costs and value for money. In previous merger applications, practices have not been disadvantaged by the merger.

• No adverse effect to QOF known and the newly merged practice will still have the opportunity to participate in the new Primary Care Development Scheme (which is voluntary).

• If the merger is approved PCSE will be notified and asked to merge the patient lists. • JN confirmed that to date the application to merge process has been conducted in

line with the process set out in the NHSE Primary Care Policy Handbook. • A Quality Impact Assessment has been completed. The PCCC was asked to: • Review the application to merge Trinity Health and Wellington House Practice. • Approve the merger to take effect from 1 October 2017. • Approve to carry over MPIG into the merged budget. • Offer assurance that current enhanced services, commissioned from the two

practices would continue to be commissioned on the same, or improved, terms from the merged practice.

Trinity Health holds rural dispensing rights and the newly merged practice would like to retain these rights. The CCG is not delegated to make decisions regarding dispensing rights and an application for the retention of these rights will be presented to NHS

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England’s Pharmacy Services Regulations Committee (PSRC). However as there is no change to the dispensing rights being proposed it is unlikely the PSRC will make any changes to the existing dispensing rights. Decision: Voting members of the PCCC approved the application for merger.

8 Premises Sub-Group HD outlined the rationale for the establishment of the Premises Sub-Group following the loss of advisory support from NHS England. The proposal is for the Sub-Group to review premises matters in advance of PCOG, PCCC or Governing Body (GB) meetings. The PCOG have reviewed and recommended to the PCCC the draft Premises Sub-Group ToRs which the PCCC are now asked to formally approve. The Sub-Group will be chaired by a Lay Member of the Governing Body and membership will include a Clinical Lead, Estates Advisor, Head of Primary Care, Head of Localities, LMC and a Deputy Chief Finance Officer.

The PCCC agreed that it would be beneficial to have a complete baseline of primary care estate as well as a number of people who understand the intricacies of funding flows. However felt that the draft ToR did not outline the scope of the Sub-Group or offer assurance that the Sub-Group would be aligned to the One Public Estate and wider plans. Action: HD agreed to divide ToR into transactional and transformational and then re-circulate. ToRs to be brought back to the PCCC for approval on 7 September 2017. Decision: Whilst the ToRs are amended to reflect the comments from the PCCC, the Sub-Group should continue to meet as required.

HD

9 Primary Care Development Scheme SK delivered a presentation on the Primary Care Development Scheme (PCDS) which covered the background to the scheme. The draft specifications have been reviewed by a group of practice managers and their feedback has been incorporated into the specifications. The PCCC were asked to approve the PCDS including the clinical scope and financial model. KH advised that the financial envelope has increased and now stands at £7.7m. A sliding payment scale has been incorporated following consultation with practices. Some practices have recommended that payments are not related to practice’s QOF achievements in 2016/17 as they had not met their usual level of achievement. Practice’s projected income has been calculated and the CCGs are not expecting any practice to be financially worse off than they were under QOF. The meeting agreed that it would be beneficial for the scheme to be measured in terms of the impact on patient care and benefit to practices. The PCCC were reassured that a year-end report on the scheme will be presented at a future meeting. Across the two CCGs there are currently 7 practices that do not use EMIS as their chosen clinical system. Individual discussions are being held with these practices. It is recognised that non-EMIS practices would need to develop their reporting mechanisms until they switch to EMIS. The PCCC were reminded that sign up to the local PCDS is optional and that the National QOF is still available to practices that may not wish to sign up. Decision: The voting members of the PCCC approved the launch of the PCDS and the service specification pack will be circulated to practices on Friday 2 June. Practices have until 30 June to return their signed contracts.

10 Hawthornden Surgery In Flackwell Heath - Branch Closure HD presented the paper on the decision to close the Hawthornden Branch Surgery in

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Flackwell Heath. Hawthornden Surgery has circa 6,800 patients of which approximately 1,700 patients attended the Flackwell Heath branch which is only open four mornings per week. Following a CQC inspection at the end of last year significant concerns were raised by CQC, including lone working at the branch surgery. The practice made the decision to temporarily close the branch and applied for a permanent closure. In line with the process, a twelve week public consultation has been undertaken. Chair’s action was taken at the PCOG and the decision to close the branch surgery approved based on the fact that this has a low impact on patient services and appointments offered at the branch surgery have been reprovided at the main practice. There is also a bus route from outside Flackwell Heath branch to the main surgery in Bourne End. Decision: The voting members of the PCCC ratified the decision to close the Hawthornden Surgery’s branch in Flackwell Heath.

11 Any Other Business The Finance report has been received for Month 1 and will be circulated to the PCCC. Date of Next Meeting Thursday 7 September 2017, 3pm – 5pm, Bevan Room, Aylesbury Vale CCG

For Information Only Reports from the Primary Care Operational Groups held in April and May 2017

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Primary Care Commissioning Committee Abbreviations and Acronyms Glossary A&E Accident and Emergency K Thousand ACHT Adult Community

Health Team KLOE Key Lines of Enquiry

ACO Accountable Care Organisation

LMC Local Medical Committee

AF Atrial Fibrillation LPF Lead Provider Framework AGM Annual General Meeting M Million APMS Alternative Provider

Medical Services MAGs Multi Agency Groups

AO Accountable Officer MCA Mental Capacity Act AQP Any Qualified Provider MCP Multi-specialty Community Provider AT Area Team MIG Minor Improvement Grant AVCCG Aylesbury Vale

Clinical

MK Milton Keynes Foundation Trust

BAF Board Assurance Framework MusIC Musculoskeletal Integrated Care BCC Buckinghamshire

County Council NHSE NHS England

BCF Better Care Fund NHSi NHS Improvement BAF Board Assurance Framework NOAC New Oral Anticoagulants BHT Buckinghamshire

Healthcare Trust OCCG Oxfordshire Clinical Commissioning

BME Black and Minority Ethnic OOH Out of Hours BPPC Better Payment Practice

ORCP Operational Resilience & Capacity

C4Q Commissioning for Quality Committee

OUH Oxfordshire University Hospitals Trust

CCCG Chiltern Clinical Commissioning Group

PACS Primary & Acute Care Systems

CDIF Clostridium Difficile PAS Patient Administration System CEPN Community Education

Provider Network PB Programme Board

CFO Chief Finance Officer PBR Payment by Results CHC Continuing Health Care PIRLS Psychiatric In Reach Liaison Service CIP Cost

Improvement

PLCV Procedures of Limited Clinical Value

COI Conflict of Interest PMS Personal Medical Services COPD Chronic

Obstructive

PCCC Primary Care Commissioning Committee

CPA Care Programme Approach PCOG Primary Care Operational Group CQC Care Quality Commission POD Point of Delivery CQRM Contract Quality

Review Meeting POG Programme Oversight Group

CQUIN Commissioning Quality & Innovation

PPA Prescriptions Pricing Authority

CSCSU Central Southern Commissioning Support

PPE Patient & Public Engagement

CSIB Children’s Services

QIPP Quality, Innovation, Productivity & Prevention

CSP Care & Support Planning QIS Quality Improvement Scheme CSR Comprehensive

Spending Review QOF Quality & Outcomes Framework

CSU Commissioning Support Unit RAG Red, Amber, Green DES Directly Enhanced Service

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DGH District General Hospital RBH Royal Berkshire Hospital DOLS Deprivation Of

Liberty Safeguards RCA Root Cause Analysis

DST Decision Support Tool (CHC)

REACT Rapid Enhanced Assessment Clinical Team

EDS Equality Delivery System RRL Revenue Resource Limit EOL End of Life RTT Referral to Treatment ETTF Estates and

Technology

SCAS South Central Ambulance Service

F&F Friends and Family SCN Strategic Clinical Network FHFT Frimley Health

Foundation Trust SLA Service Level Agreement

FOT Forecast Outturn SLAM Service Level Agreement Monitoring FPH Frimley Park Hospitals

NHS Foundation Trust SRG Systems Resilience Group

GB Governing Body STP Sustainability & Transformation Planning GMS General Medical Services SUS Secondary Uses Service GPFV General Practice Forward

View TDA Trust Development Authority

GPRP General Practice Resilience Programme

TOR Terms of Reference

HASU Hyper Acute Stroke Unit TV Thames Valley HETV Health Education

Thames Valley TVN Tissue Viability Nurse

HWBB Health & Wellbeing Board UECN Urgent Emergency Care Network ICE Integrated Clinical

VuPS Vulnerable Practice Scheme

ICS Inhaled Corticosteroids YTD Year to Date ICU Intensive Care Unit 5YFV 5 Year Forward View IFR Individual Funding Request IG Information Governance

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Previous Meeting Date (or Date raised/ added)

Minute ref Action Description Open/ Closed

Responsibility/ Owner

Due Date Update on action Completed date

01/06/2017 Scheme of Delegation

HD to provide the Audit Committee with examples of types of contracts and their contract values. The Audit Committee have been asked to consider this information and to review the scheme of delegation.

Closed Helen Delaitre

07/09/2017 Audit Committee met on 26/07/17 and will make the following recommendation to Governing Bodies on 14/09/17

26/07/2017

Recommendation to Governing Bodies for approval and ratification on 14 September 2017 Delegation threshold £100K across both CCGs with 3 agreed exceptions.

a. Approve and ratify Direct Awards up to annual composite value per annum except where brand new which needs to be approved by Governing Bodies

b. Approve and ratify practice improvement schemes up to £1m per annum except where brand new which needs to be approved by Governing Bodies.

c. Award of GMS, PMS and APMS contracts up to £1m contract value per annum unless new which needs to be approved by Governing Bodies.

Delegations relate both to price increases on existing contracts as well as award of new contracts. Scheme also to be amended to specify all delegated decision making must be within agreed and approved budgets.

01/06/2017 Primary Care Risk Register

Amend Risk Register to insert job titles and remove post holder's names


07/09/2017 Russell Carpenter has discussed concerns over removing names from Risk Register and recommended that this is not done.

02/06/2017

01/06/2017 Premises Sub-Group

HD to amend the draft Premises Sub-Group ToR to include transactional and transformational responsibilities and alignment to the One Public Estate and wider strategic plans. ToRs to be brought back to PCCC on 07/09/2017 for approval.


07/09/2017 Agenda item . 07/09/2017

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1

MEETING: Primary Care Commissioning Committee PAPER: C


TITLE: Primary Care Risk Register

AUTHOR: Wendy Newton, Primary Care Manager


Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: The CCG has reviewed the way in which it manages risks and reports them to the Governing Body. A new risk management software tool called Verto has been introduced and each sub-group of the Governing Body is being asked to review the way it monitors and manages risks. This includes the Primary Care Commissioning Committee (PCCC). Primary Care Risk Register The Primary Care Operational Group (PCOG) review the Primary Care Risk Register on a monthly basis and escalate any items scoring 12 or above to the PCCC. The PCCC is asked to:

- Review items on the Primary Care Risk Register scoring 12 or above. - Be assured that the risks are mitigated with appropriate actions in place.

Conflicts of Interest: None identified. Strategic aims supported by this paper: (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all





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2


Equality Quality Financial Risks CCGs have a responsibility to ensure proper governance

which will in turn enable the CCGs to be compliant with statutory obligations and ensure aims/goals and objectives are met. Every activity that the CCGs undertake, or commissions others to undertake on its behalf, brings with it some element of risk that has the potential to undermine or prevent the organisation achieving its strategic aims/goals. Therefore it is vital that appropriate governance is applied to manage and mitigate this.

Statutory/Legal

Prior consideration Committees /Forums/Groups

The management of the risk register has been considered and agreed by the PCCC and the PCOG at monthly meeting since March 2017.

Membership Involvement

Supporting Papers: Extract from Primary Care Risk Register of risks scoring 12 or above.

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15 Stability of General Practice

2.3.17

Many practices in Bucks are experiencing difficulty in sustaining core primary care services. The reasons for this are varied and each practice is affected differently. The collective impact risks destabilising current delivery of primary care.

A practice informs the CCG that they are experiencing difficulties or are identified as being at risk

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• destabilising current delivery of primary care

• loss of reputation

• poor patient outcomes

Nicola Lester

Helen Delaitre

20

15

Phase 1 of the programme to build resilience in primary care through GP clustering is complete although all localities need further support to develop. Two practices placed in special measures by CQC.

Immediate CCG to identify

and target at risk practices.

Utilise GPRP and VPS funding to encourage practices to build locality-wide resilience. Commissioned FedBucks / KPMG to lead on building resilience within Primary Care.

FedBucks to draft project plan outlining key support needed in Phase 2 of the programme

16

Primary Care Transformation

2.3.17

Lack of appetite by member practices to change current ways of working. A key driver for delegated commissioning is to instigate innovation and redesign services to improve patient outcomes and drive transformation. CCG

Member practices are not effectively engaged in primary care transformation

CCG will be unable to meet the requirements and expectations of FYFV

• Unable to

instigate innovation and re-design services to improve outcomes and drive transformation

• Member practices do not embrace change or see the advantages of doing so

• local

Karen West

Helen Delaitre

16

12

Practice engagement and commitment to the project has been positive. However, due to the infancy and importance of this project the score after mitigation has been set at 12 with escalation to the Corporate Risk Register deemed appropriate by the PCCC.

Immediate

Clear engagement with the membership will identify the appetite for change. First discussions with localities regarding community hubs and collaborative working beginning to take place. FedBucks / KPMG to lead on building

Support FedBucks to continue working with practices to extract value from the new ways of working and to continuously improve, scale and sustain change.

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4

member practices need to embrace change and see the advantages to them in doing so.

unsustain-ability

• loss of reputation


primary care resilience.

18

Quality in Primary Care

2.3.17

All practices in Bucks have now been inspected by CQC. Still practices which “require improvement” while 2 practices are in “special measures”. If a practice fails re-inspection, it creates added pressure on the remaining practices in the surrounding area.

Member practices already inspected by CQC but in CQC “requires improvement” or “special measures” categories fail future re-inspection

Surrounding member practices will be subject to added/additional pressure

• local

unsustain-ability

• Loss of reputation


• Patient registration difficulties

Karen West

Lisa Beaumont

16

12

As two practices within Buckinghamshire CCGs are rated as Inadequate by CQC and under Special Measures the PCCC felt that even with all possible mitigation the current risk score should remain at 12 with escalation to the Corporate Risk Register. Practice engagement and commitment to working to address concerns previously highlighted by CQC is paramount for a successful reinspection. The practices concerned are in Wycombe and Aylesbury and the risk of the practice failing at re-inspection will add pressure to all neighbouring practices.

Immediate

All practices in Bucks have now been inspected by CQC. 2 practices are in “special measures”. If a practice fails re-inspection, it creates added pressure on the remaining practices in the surrounding area.

CCG and NHSE Quality Teams to continue working with the practices to ensure that they are working through a comprehensive and robust action plan which will address all concerns previously raised by CQC. The CCGs to offer practices support through the process utilising the RCGP package and other resilience funding as appropriate.

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5

ST0008 : My Care Record - GP Access Centre

Sustainability within Bucks - to contribute to the delivery of a financially sustainable health care economy that achieves value for money and encourages innovation.

3

Full potential and benefits may not be realised

6.4.17

The Community Programme and the SMT are currently in the process of deciding on whether the GPAC Proof of concept should be ended or be given an extension of 3 months.

If the GPAC Proof of Concept is not given an extension for the implementation of EMIS Clinical Services (Cross Org appointments & Cross Org Tasks)

Then the implementation of EMIS Clinical Services (Cross organisational Appointments and Tasks will be wasteful of resources and ETTF funding.

Leading to reduced data for evaluation of the benefits of the Clinical Services which are required to inform other EMIS Clinical Services projects and prevent further proposed implementations of EMIS remote consultations to support remote urgent on the day cross organisational appointments (overspill clinics)

Nicola Lester

Helen Delaitre, Anna Lewis

15

12

1

At an SMT meeting a one month extension was approved for the GPAC, enabling the implementation of the Cross organisational Appointments and Tasks (expected 3rd May 2017). This will allow for 6 weeks of data and benefits measuring. This has slightly reduced the likelihood of not getting any measurable outcomes but the impact on the CCG Primary Care strategy is still moderate.

Immediate

Controls and assurances are embedded into the project management of the projects that are linked to the Clinical services project for GPAC The project board consists of GPAC members, practice managers, GP's, CCG managers and EMIS The Community Programme Board is currently reviewing an extension of 3 months to the GPAC and has full over sight of this and the GPAC project. SMT are informed of the Community Programmes decisions and request for any approvals required.

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MEETING: Primary Care Commissioning Committee

AGENDA ITEM: D

DATE: 7th September 2017

TITLE: GP Forward View Action Plan

AUTHOR: Helen Delaitre, Head of Primary Care


Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: The challenges faced in Primary Care today in Buckinghamshire are no different to other parts of England: difficulties recruiting clinical and non-clinical staff, lack of investment, increased workload and premises that are becoming cramped mean that CCGs must support primary care providers to ensure that a sustainable model of primary care can be developed for the future. NHS England has acknowledged that action is needed to accelerate the support offered to general practice and has set out a number of funded actions contained within the GP Forward View to help make a tangible difference to both practices and their patients. CCGs are expected to implement these actions and develop a plan for doing so. The final version of this plan was represented to the PCCC on1st June where it was approved and recommended to Governing Body. Following Governing Body sign off on 8th June 2017, the plan was uploaded to the CCGs’ websites. The Primary Care Commissioning Committee is requested to review the GP Forward View Action Plan and be assured that CCG is actively monitoring delivery against plan. Conflicts of Interest: None in respect of this paper. Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all



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Service redesign described in the Plan will be subject to patient engagement during 2017/18.

Equality Service redesign described in the Plan will be subject to full EIA.

Quality The CCG will quality assure the quality of primary care services it commissions as part of delivering the GPFV Action Plan.

Financial The plan does not include financial information – please refer to main GPFV Plan.

Risks The PCCC will be responsible for reviewing any risks associated with the delivery of this Plan.

Statutory/Legal None. Prior consideration Committees /Forums/Groups

The PCCC reviewed and approved the draft plan in December 2016 and the final plan in June 2017. Primary Care Operational Group: May 2017.

Membership Involvement Members have been involved in designing the service models described in the action plan.

Supporting Papers: GP Forward View Action Plan.

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GP FORWARD VIEW ACTION PLAN Workforce Key Deliverables Actions Action

Owner Timescales Comment

Improving Recruitment into General Practice Address the current shortfall in GPs and practice nurses and utilise other clinical skills in innovative ways

Investigate new ways of working and new roles in primary care (paramedic practitioners, physician associates, pharmacists in primary care). Participate in STP wide bid to recruit international GPs for practices who have particular difficulty in recruiting GPs.

CCG CCG

Throughout 2017/18 and 2018/19 Throughout 2017/18

Successful bid to second wave of clinical pharmacist programme bring the total to 4 posts in Bucks. Practices throughout Bucks considering whether they would benefit from participation in this scheme.

Increase the number of practices becoming training practices (GP and Nurse Placements)

Work with HEE to provide greater opportunities for GPs to train locally. Evidence suggests that trainees are more likely to take permanent jobs locally when they finish training.

CEPN Throughout 2017/18 and 2018/19

CCG to link HEE with CEPN to forward this work through GP Education Lead within the CEPN.

Develop supportive environment for newly qualified staff

The CCGs will promote the First 5 Forum that exists across Thames Valley for newly qualified GPs within the first 5 years of general practice.

CEPN Throughout 2017/18 and 2018/19

CCG to promote links between GP Education Lead and newly qualified GPs.

Promote Nurse Forum Through the Primary Care Lead nurses, the CCGs will continue to promote the Nurse Forum for

CCG Throughout 2017/18 and 2018/19

The Primary Care Lead Nurse is working to establish a formal nurse

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nurses at all levels and stages of their career.

forum. To continue the current Tissue Viability Nurses’ leg ulcer forums. Continue to organise nurse break-out sessions at educational PLT sessions.

Retaining Doctors within General Practice Explore training opportunities (e.g. Leadership courses), working across primary/secondary care interface (delivery of community and primary care services). Talent management and succession planning schemes to safeguard leaders for the future

New guidance issued on Retained Doctor Scheme outlines increases in funding for practices employing a retained GP and an increase in the annual payment to the GP towards professional expenses. CEPN, working within the wider workforce project across STP to consider rotations across primary, community and acute sectors.

NHS England / CCG CEPN / LWAB

2017/18 2017/18

The CCG advertises any training opportunities for staff training through the GP Newsletter and the CEPN will be developing its own website that will also contain information on all training opportunities. Once integrated teams are established, this could provide the opportunity for staff rotations.

Supporting those who wish to return to General Practice Encourage doctors to consider joining General Practice in Bucks

Support the drive to recruit returning GPs.

NHS England/ HEE TV/CCG

2017/18 The CCG will support and advertise any opportunities provided through NHSE/TV HEE.

Encourage more retirees to consider providing sessions in the local area

Encourage practices to be more flexible in their approach to recruiting GPs so that part time hours and flexible working arrangements can be accommodated.

CEPN/CCG 2017/18 CEPN to co-ordinate opportunities for retired staff to continue to work within general practice on a flexible basis.

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Training Inform future workforce requirements and draft Workforce Strategy that links with service redesign plans which include new ways of working in integrated teams and delivery of 24/7 access to primary care

Build on local audit findings and training needs analysis completed by Bucks New University in 2015. Ensure GPs and GPNs are included in the workforce modelling being undertaken for Bucks by GE Healthcare Finnamores as supported by HEE TV.

CEPN 2017/18 Bucks Training Hub has recently sent out a survey to capture training needs. This survey lists a wide range of different courses and training for wider workforce. The aim of this is to identify the top priority training that is required within Bucks, in order for Training Hub to Commission in 2017/18. Have contacted different education providers to find out training they are currently offering.

Develop primary care workforce strategy

Draft strategy to be developed in line with wider STP work on workforce and signed off by CEPN Board.

CEPN 2017/18 Workforce Strategy being developed at STP level by LWAB.

Look to develop training opportunities for non-clinical staff to play a greater role in patient navigation and processing clinical paperwork

Planned roll out of training to all practices in Bucks using GPFV funding for non-clinical training.

CCG 2017/18 – 2018/19

Training already underway with practices in Aylesbury Vale CCG, Chiltern practices to follow Autumn 2017.

Continue to support Protected Learning Time (PLT)

There are 10 PLT sessions per year, the CCGs host 4 sessions with the remaining sessions being practice-led.

CCG 2017/18 The CCG is committed to continuing to support PLT.

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Workload Key Deliverables Actions Action Owner Timescales Comment General Practice Workload Increase public awareness of where to go to get help for both routine and urgent health care needs

Use training funds to upskill GP receptionists to become care navigators. More emphasis on local publicity campaigns to ensure patients make use of the most appropriate service to meet their needs. Develop materials to explain redesign of primary care access.

CCG 2017/18 The CCG is organising training in care navigation for receptionists. 4 practices currently road-testing training. In early 2018, the CCG will develop new resources for patients advising of new 24/7 primary care pathways.

Develop training packages for non-clinical staff on workflow optimisation

Use training funds to commission workflow optimisation training for non-clinical staff.

CCG Started Spring 2016/17

Training already underway and will be completed by end 2017/18.

Work with patients, GPs and secondary care to cut inappropriate demands on primary care

Support FedBucks to establish regular liaison meetings between primary and secondary care clinicians.

FedBucks Starting 2017/18

Forging stronger links within provider collaborative as part of developing the ACS.

Reduce unnecessary workload requests

Use the existing contract monitoring process to challenge inappropriate workload requests from secondary care.

CCG Starting 2017/18

Working with CSU Contracting Team to determine best way to highlight these with secondary care.

Support patients to self-care Continue to promote and develop “Live Well, Stay Well” and “Health Help Now” to support patients with long term conditions and/or minor illness needs.

CCG Ongoing - started 2016/17

Live Well Stay Well has been running for one year and has supported over 4,000 patients to find support to change their

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lifestyle behaviours. The service has been commissioning for a further 5 years and will hope to enhance the existing service with social prescribing, exercise referral, pre-diabetes education and further digital options for support.

Locality Integrated Teams Roll out integrated teams in all localities to support patients in the community who have complex needs

Evaluate current pilots operating in two localities to inform the development of the service model for integrated teams wrapped around ‘clusters’ of GP practices.

CCG/BHT/local stakeholders

2017/18 and 2018/19

The CCG is currently working with practices to establish GP clusters that will work together with integrated teams. Development of the Buckinghamshire Integrated Teams (BITS) model across multiple care providers. Investigation of technology to support secure real time communication and sharing (akin to Skype / WhatsApp but appropriate for patient data).

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Single Point of Access (SPA) to a range of services

Following the GP Access Centre proof of concept in Aylesbury, look at how a SPA could be used to provide consistent triage and access to a number of community and primary care services, including general practice.

CCG 2017/18 – 2018/19

Following evaluation, the CCG has concluded that the SPA was a successful proof of concept. Work to establish consistent triage within GP clusters is part of the commissioning model for 24/7 primary care access. SPA concept supported by “My Care Record” phase 2 initiative looking at Shared Record of patient data across all care settings.

Explore how LITs can work with Care Homes to reduce GP workload

Preparatory work to support strategy of improving health in care homes.

CCG 2017/18 CHIS pilot ran with some learning. West Berks have run a 12 month ‘enhanced’ service which is being reviewed. West Berks to share review report in September.

Explore the value and benefits of LITs becoming more multi-disciplinary

Learn from paramedic practitioner pilot how this role could become an integrated part of the LIT.

CCG 2017/18 Pilots in Wooburn Green and AV South have shown the benefits of paramedic involvement. This approach could be useful across the county and included into the BITs. To be discussed with BHT.

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Practices working Together Encourage practices to work together to produce “at scale” working across a larger geographical area.

Commission external provider to facilitate discussions and provide expertise to practices looking to work at scale.

CCG 2017/18 Successful first stage of building primary care resilience is complete. Decisions regarding priorities for at-scale working will form part of the second stage of this project.

Encourage practices to work together to share clinical expertise in specialist areas

Localities or “like minded” practices to consider areas where they might share clinical expertise across a wider area.

CCG 2017/18 Part of the clustering work being promoted by FedBucks and the CCGs.

Encourage practices to work together within networks/clusters to develop resilience

Localities to consider areas where they might work at scale i.e. back office functions, 24/7 primary care access.

CCG 2017/18 Part of the clustering work being promoted by FedBucks and the CCGs.

Primary Care Resilience Support individual practices who are identified as being vulnerable

Develop and agree action plan and funding to support practices at risk of becoming vulnerable.

CCG/NHS England

Ongoing from 2016/17

The Primary Care Team liaises with practices and updates the PCOG at monthly meetings on support offered to individual practices.

Develop a programme of support for all practices

Use the GPRP to foster collaboration between GP practices and to develop concept of locality community hubs to build resilience.

CCG/FebBucks Ongoing from 2016/17

The first stage of this support has been completed. Stage 2 is under discussion.

Explore the establishment of a Locum Chambers

GPs have indicated that one of the biggest drains on resources is finding and affording GP

FedBucks Ongoing from 2016/17

To be explored by FedBucks during 2017/18.

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locums. FedBucks to explore how a Locum Chambers might help address this.

Infrastructure Key Deliverables Actions Action Owner Timescales Strategic Estates Planning Development of Community Hubs Working in tandem with emerging

GP clusters, undertaking assessments at locality level of all primary care infrastructure to understand estates opportunities and needs with regard to delivery of new service models.

CCG Ongoing from 2016/17

This is currently underway with Localities Team leading on 1:1 discussions with practices.

Member of the Bucks Estates Group

Forum to identify what public sector assets exist and whether their utilisation can be maximised to the benefit of the health and social care system i.e. One Public Estate.

CCG as member of this group

Ongoing from 2016/17

The outputs from the OPE workshops currently underway will be drawn into an Estates Strategy for Primary Care.

Secure support and funding from key stakeholders to deliver infrastructure needed to accommodate growth in Buckinghamshire population via Local Plans and Infrastructure Delivery Plans

Work with district and county councils to establish a methodology for CIL/S106 contributions from developers concentrating on the Wycombe Plan, Vale of Aylesbury Plan and also the Chiltern and South Bucks Plan.


Ongoing through regular discussions with colleagues in both district and county councils.

Work across BOB STP Footprint Ensure that proposed developments are in line with STP strategic priorities and are


Bucks wide plans are shared at STP level to ensure they are aligned to

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affordable. overall objectives within the STP.

Operational Estates Management Estates and Technology Transformation Fund

Support practices that have been successful in their application for funding from ETTF.

CCG Ongoing Support offered through the Primary Care Team in conjunction with NHS England lead for ETTF. Additional ETTF Extension Bid (new monies) submitted in August 2017 for secure communications (CareFlow) and Single Sign On to support multidisciplinary teams operating on BHT network.

Support General Practice plan for future service delivery

Six facet survey of all general practice premises to be undertaken.

CCG 2016/17 Completed for all practices that participated in this programme.

Support Quality in Primary Care Work to support general practice so that by 2018 no GP practice has an overall inadequate rating from CQC due to poor premises.

CCG Ongoing No practice in Bucks has been rated as inadequate by CQC due to poor premises.

Improve fabric of premises within primary care

Work to secure funding and improvements for individual practices through the minor improvement grant (MIG) process.

Ongoing MIGs currently awarded to 4 practices in Bucks. Process for approval being led by NHSE.

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Key Deliverables Actions Action Owner Timescales Strategic Technology Planning Implementing the local Digital Road Map in order to deliver a fully interoperable health and care system by 2020.

Bucks LDR development complete with further work to combine with Berks West and Oxon to form BOB LDR to support delivery of STP. Workstream leads identified to deliver universal capabilities across BOB footprint.

CCG Ongoing My Care Record Phase 2 and Buckinghamshire Interoperability Programme formed and operating with engagement across all care settings and GP Federations. Shared Care Record (based on Graphnet CareCentric) contract nearing signature. ETTF Extension Bid submitted for use of CareFlow across ACS.

By 2016/17 minimum of 10% of patients actively accessing primary care services and/or consultations online or through apps (i.e. Health Help Now). Trajectory and plan for achieving a significant increase by 2020.

Continuation of access and supported self-care pilots to increase the use of digital access to services and care. Evaluation of pilots and development of plans for wide scale rollout if successful.

CCG 2016/17 2017/18 onwards

Buckinghamshire CCGs asked to pilot direct booking into Primary Care from 111, SCAS and Patient Apps / Websites. Work integrated into the Buckinghamshire Interoperability Programme.

Every patient has access to digital health records that they can share with their families, carers and

To be delivered through Patient Online Programme and GP Access pilots

CCG Ongoing Patient Online is being delivered by the CSU on behalf of the CCG.

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clinical teams. GP Access Pilot (GPAC) concluded successfully and next steps are being planned. Buckinghamshire Interoperability Programme will look at patient access to records in the future.

By 2020, 95% of GP patients to be offered e-consultation and other digital services and 95% of tests to be digitally transferred between organisations

Continuation of GP Access pilot to include integrated capability to offer e-consultation. Investment in technology to allow wider offering of e-consultation across both CCGs in all practices STP wide workstream identified to deliver 95% of tests to be digitally transferred between organisations.

CCG CCG STP

2016/17 onwards 2016/17 onwards Ongoing

CCG decision not to continue with GPAC pilot (as stated above). eConsultation options being investigated by SCW CSU.

CCGs will promote EMIS as GP system of choice.

100% coverage to support inter-operability to be achieved by 2020.

CCG Ongoing Discussions underway with GP practices wishing to move to EMIS.

GPs will hold and be able to share electronic patient records (with the patient’s consent) with GP practices and other providers.

Information Sharing Agreements already in place to support sharing of GP held patient records with OOH, Acute and Adult Social Care through the My Care Record programme. Phase 1 (MIG) to be completed in 2016/17 with additional capability to be implemented to allow

CCG

2016/17

Information Sharing Agreements extended. New BOB STP Information Sharing Agreement drafted by BOB Information Governance Group. MIG / My Care Record

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access for Mental Health teams in support of STP aims. Sharing of EOL patient information in place using Summary Care Record with Additional Information. EMIS Clinical Services and wider interoperability to be implemented as Phase 2 of My Care Record to support the development of integrated teams and new ways of working in Primary Care

CCG

2016/17 onwards

Phase 1 implemented and live. MIG access for Mental Health (OHFT) funded by CCG and implementation underway. SCR AI implemented. My Care Record Phase 2 programme up and running. Contract for new shared care record close to signature.

Operational Matters CCGs will increase online offer to patients beyond repeat prescriptions and GP appointment booking. Increase in % of patients accessing and using their electronic health record.

Patient Online Programme in place with resources from within the Digital transformation team and CCG Localities team to increase services available and usage levels.

CCG 2016/17 onwards

Patient Online is being delivered by the CSU on behalf of the CCG. Presentations to Locality meetings to help increase awareness of patient online programme.

80% of referrals made using e-referral service.

Work programme in place to increase usage by 20% by end Mar 2017 with further increases throughout 2017/18.

CCG Ongoing Bucks CCG leads on a cross organisational working group including BHT, Frimley Health, OUHT and Milton Keynes to oversee the development of services on eRS and management of slots to support

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increased utilisation of eRS across Bucks. BHT and Bucks CCG recently completed a programme of work to set up all 2ww services on eRS. GP’s and practice admin staff are updated regularly about new services , training and can report issues via the ‘lets talk health’ communication tool for eRS

Provide clinical decision support to GPs.

Work programme underway building on current use by GP practices across Chiltern CCG.

CCG Ongoing A workshop was held in July 17 to review the current decision support aids available to GP’s. A paper has been presented to the Executive team with recommendations.

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New Ways of Working Key Deliverables Actions Action Owner Timescales Improving Access 100% of the population has access to weekend/evening routine GP appointments by March 2019.

Procure improved primary care access to ensure that all patients have access to routine and urgent appointments in the evenings and on Saturdays and Sundays (according to need). Different localities will require different approaches.

CCG Developing the model in 2017/18 with phased implementation expected in 2018/19

The commissioning model for roll out has been approved. CCG is working with providers to implement phased introduction starting in 2018.

Resolve issues of inequality in patients’ experience of accessing general practice

Evaluate Vanguard sites and other pilots and engage with patients to ensure that suggested improved access scheme meets patient requirements.

CCG/local stakeholders

2017/18 NHSE released a resource entitled “Improving access for all: reducing inequalities in access to general practice services” in August 2017. The CCGs will work through this to undertake an assessment.

New Ways of Working Roll out integrated teams in all localities to support patients in the community who have complex needs.

Evaluate current pilots to inform the development of the service model for integrated teams wrapped around groups of GP practices.

CCG/local stakeholders

2017/18 A proposed core model has been developed and will be rolled out to GP clusters in phases from October 2017.

New Models of Care New care model programme covering at least 50% of population

Introduce new models of care i.e. MCP or PAC. Support localities using the GPRP fund to consider

CCG Ongoing and during 2017/18

The CCG is working with practices to establish resilience through cluster

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which (if any) new model of care they wish to adopt and to develop business case. The CCGs submitted an expression of interest to transition to an Accountable Care System from April 2018 and have been successful in this.

working. Each cluster has different priorities in terms of implementing different ways of working which will be progressed throughout 2017/18.

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PAPER: E


TITLE: Finance Report: M4 of 2017/18

AUTHOR: Alan Overton, NHS England LEAD DIRECTOR:

Colin Hobbs, NHS England

Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: The purpose of this paper is to set out the financial position at month 4 of 2017/18 for the delegated primary care services commissioning budget of Aylesbury Vale CCG.

Conflicts of Interest: No conflict of interest.

Strategic aims supported by this paper: (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all






Equality Quality

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Page 2 of 14

Financial Risks Statutory/Legal Prior consideration Committees /Forums/Groups


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Page 3 of 14

Joint Commissioning Primary Medical Services Committee

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Page 4 of 14

Report to the Primary Care Commissioning Committee – Aylesbury Vale CCG and Chiltern CCG

Prepared by: Alan Overton, NHS England South (South Central), Finance Analyst

Classification: OFFICIAL

The National Health Service Commissioning Board was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the National Health Service Commissioning Board has used the name NHS England for operational purposes.

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Page 5 of 14

1. Introduction

This paper sets out the financial position for month 4 of 2017/18 for the delegated primary care services commissioning combined budget of Aylesbury Vale CCG and Chiltern CCG.

Aylesbury Vale & Chiltern CCGs Month 4 Year to Date Full YearGP Services 17/18 Plan Actual Variance Plan Actual Variance Plan FOT Variance Prior yr £k £k £k £k £k £k £k £k £k £k GP Contract payment 3,746 3,754 (8) 14,984 15,004 (20) 44,954 44,954 0 0 QOF payments 519 516 4 2,078 2,063 15 6,235 6,235 0 0 GP Seniority and Locums 143 138 5 572 563 9 1,716 1,716 0 0 GP Drug payments 188 186 2 753 729 24 2,259 2,259 0 0 GP Premises 635 644 (8) 2,542 2,536 6 7,626 7,626 0 0 GP Enhanced Services 143 149 (6) 573 538 35 1,721 1,721 0 0 GP Other Items 7 7 0 29 29 0 88 88 0 0 Prior Year Balance AV 0 12 (12) 0 12 (12) 0 0 0 0 CCG Prescribing 0 (0) 0 0 (0) 0 0 0 0 0 Collaborative Fees 15 15 (0) 59 59 0 178 178 0 0 GP Premises other 5 5 0 20 19 1 59 59 0 0 GP General Reserves 0 0 0 0 0 0 1,953 1,953 0 0

Total 5,403 5,426 (23) 21,611 21,552 58 66,788 66,788 0 0

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Page 6 of 14

1.0 Year to Date Position Overall the YTD position for the combined Aylesbury Vale and Chiltern CCGs at month 4 is variance of £58k underspend.

1.1 Forecast Outturn 2017/18 The forecast outturn for 17/18 at month 4 is on plan.

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Page 7 of 14

2. Aylesbury Vale CCG

This paper sets out the financial position for month 4 of 2017/18 for the delegated primary care services commissioning budget of Aylesbury Vale CCG

Aylesbury Vale CCG Month 4 Year to Date Full YearGP Services 17/18 Plan Actual Variance Plan Actual Variance Plan FOT Variance Prior yr £k £k £k £k £k £k £k £k £k £k GP Contract payment 1,441 1,438 3 5,765 5,755 10 17,295 17,295 0 16,508 QOF payments 201 200 2 806 798 8 2,418 2,418 0 2,316 GP Seniority and Locums 58 51 7 233 224 9 698 698 0 417 GP Drug payments 148 152 (5) 590 581 9 1,770 1,770 0 1,756 GP Premises 246 249 (3) 984 984 1 2,953 2,953 0 3,125 GP Enhanced Services 57 57 (0) 229 208 21 688 688 0 1,175 GP Other Items 3 3 0 11 11 0 33 33 0 26 Prior Year Balance AV 0 12 (12) 0 12 (12) 0 0 0 0 CCG Prescribing 0 0 0 0 (0) 0 0 0 0 0 Collaborative Fees 5 5 (0) 20 20 0 61 61 0 60 GP Premises other 2 2 0 7 7 1 21 21 0 25 GP General Reserves 0 0 0 0 0 0 518 518 0 0

Total 2,161 2,169 (8) 8,645 8,599 46 26,455 26,455 0 25,408

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2.0 Budget Changes

Potential Budget Changes Additional in year monitoring will be required to assess the impact of the 2017/18 GMS contract settlement as follows: • Reimbursement of Indemnity Fees paid by GP Practices- This is currently budgeted at 2016/17 prices as the inflation uplift is

not yet available. • Reimbursement of Business Improvement District (BID) Levy fees paid by eligible practices – There are currently no

practices eligible for reimbursement, however, additional BID areas may be approved during the year. • A new NHS England protocol has been introduced to clarify the reimbursement of GP Locum cover payments for Sickness

and Parental Leave and the impact of this is not yet quantifiable due to the ad-hoc nature of cover requirements and subsequent practice claims.

• In relation to the extended hours access DES new conditions will be introduced from October 2017 which will mean that

practices who regularly close for a half day, on a weekly basis, will not ordinarily qualify for the DES 3.0 Month Position The month position as at month 4 is a £8k overspend.

3.1 Year to Date Position Overall the YTD position at month 4 is a £46k underspend.

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9

• GP contract payment £10k underspend • QOF payments £8k underspend • GP Seniority and locums £9k underspend • GP Drug payments £9k underspend • GP Premises £1k underspend • GP Enhanced Services £21k underspend Extended Hours – not all practices have signed up to the service. • GP Other £0k on plan • Prior Year balance £12k overspend Prior year 16/17 costs have exceeded the prior year accrual • Collaborative Fees £0k on plan • GP Premises other £1k underspend • GP General Reserves £0k on plan

3.2 Forecast Outturn 2017/18 The forecast outturn for 17/18 is on plan.

3.3 Assumptions on reporting The figures have been prepared in accordance with the following national guidance:

• Accruals will be as per accounting standards and will be to the expected year end outturn position.

3.4 Contracting and procurement activity Mandeville Surgery, Aylesbury –Interim provider commenced 1st April 2016 and contract extended to 31st March 2018 to allow adequate time for a full re-procurement. Wellington House/Trinity Health – proposed merger 1 October 2017.

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10

3,5 Risks and Opportunities Risks Indemnity Fees Inflation Population Growth – Impact on Contract Payments Section 96 support for practices in financial difficulty Increased Premises reimbursements for premises developments Locums cover (Parental/Sickness Leave) Prior Year costs in excess of accrual. Opportunities Enhanced Services slippage e.g. <100% sign up for Extended Hours DES Premises Rate Rebates following national appeal process.

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3. Chiltern CCG

This paper sets out the financial position for month 4 of 2017/18 for the delegated primary care services commissioning budget of Chiltern CCG.

Chiltern CCG Month 4 Year to Date Full YearGP Services 17/18 Plan Actual Variance Plan Actual Variance Plan FOT Variance Prior yr £k £k £k £k £k £k £k £k £k £k GP Contract payment 2,305 2,315 (11) 9,219 9,249 (30) 27,659 27,659 0 0 QOF payments 318 316 2 1,272 1,265 7 3,817 3,817 0 0 GP Seniority and Locums 85 87 (2) 339 339 1 1,019 1,019 0 0 GP Drug payments 41 34 7 163 148 15 489 489 0 0 GP Premises 389 395 (6) 1,557 1,552 5 4,673 4,673 0 0 GP Enhanced Services 86 92 (6) 344 330 14 1,033 1,033 0 0 GP Other Items 5 5 0 18 18 0 54 54 0 0 CCG Prescribing 0 (0) 0 0 (0) 0 0 0 0 0 Collaborative Fees 10 10 0 39 39 0 117 117 0 0 GP Premises other 3 3 0 13 13 0 38 38 0 0 GP General Reserves 0 0 0 0 0 0 1,435 1,435 0 0

Total 3,241 3,257 (15) 12,965 12,953 12 40,333 40,333 0 0

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2.0 Budget Changes Potential Budget Changes Additional in year monitoring will be required to assess the impact of the 2017/18 GMS contract settlement as follows: • Reimbursement of Indemnity Fees paid by GP Practices- This is currently budgeted at 2016/17 prices as the inflation uplift is

not yet available. • Reimbursement of Business Improvement District (BID) Levy fees paid by eligible practices – There are currently no

practices eligible for reimbursement, however, additional BID areas may be approved during the year. • A new NHS England protocol has been introduced to clarify the reimbursement of GP Locum cover payments for Sickness

and Parental Leave and the impact of this is not yet quantifiable due to the ad-hoc nature of cover requirements and subsequent practice claims.

• In relation to the extended hours access DES new conditions will be introduced from October 2017 which will mean that

practices who regularly close for a half day, on a weekly basis, will not ordinarily qualify for the DES 3.0 Month Position The position as at month 4 is a £15k overspend.

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3.1 Year to Date Position Overall the YTD position at month 4 is a £12k underspend. • GP contract payment £30k overspend Additional MPIG not budgeted for – to be reviewed. • QOF payments £7k underspend • GP Seniority and locums £1k underspend • GP Drug payments £15k underspend • GP Premises £5k underspend • GP Enhanced Services £14k underspend Extended Hours – not all practices have signed up to the service. • GP Other £0k on plan • Collaborative Fees £0k on plan • GP Premises other £0k on plan • GP General Reserves £0k on plan 3.2 Forecast Outturn 2017/18 The forecast outturn for 17/18 is on plan. 3.3 Assumptions on reporting The figures have been prepared in accordance with the following national guidance:

• Accruals will be as per accounting standards and will be to the expected year end outturn position.

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3.4 Contracting and procurement activity .None to report 3,5 Risks and Opportunities Risks Indemnity Fees Inflation Population Growth – Impact on Contract Payments Section 96 support for practices in financial difficulty Increased Premises reimbursements for premises developments Locums cover (Parental/Sickness Leave) Opportunities Enhanced Services slippage e.g. <100% sign up for Extended Hours DES Premises Rate Rebates following national appeal process.

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MEETING: Primary Care Commissioning Committee PAPER: F


TITLE: Primary Care Quality Report

AUTHOR: Asela Ali, Quality & Patient Safety Manager

LEAD DIRECTOR: Debbie Richards, Director of Commissioning & Delivery

Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: This report is a picture of current quality status of Primary Care in the Bucks CCGs and details Quality Team engagement. Conflicts of Interest: None known. Strategic aims supported by this paper:(please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all






Equality Quality Financial Risks Statutory/Legal Prior consideration Committees / Forums / Groups

The Primary Care Quality Report is a standing agenda item for the PCOG


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Primary Care Quality Report 1. Introduction This report is a picture of current Quality Team work with Primary Care in the Bucks CCGs. Patient Safety – Incidents, Safeguarding, and Infection Control

• Patient Experience – Complaints, Friends & Family Tests, GP Surveys • Progress towards Primary Care Quality Premium measures • CQC rating.

2. Patient Safety 2.1 Incidents As of the 1st April 2017 Aylesbury Vale CCG and Chiltern CCG became fully delegated (with Chiltern having a year of shadowing). This means that the CCGs are responsible for tracking and supporting practices as and when they log Significant Events. Due to this new responsibility the CCGs have developed a database similar to the Serious Incident Management System (SIMS) which it uses to performance manage secondary care providers’ Serious Incidents. The new system has been developed not as a means of performance managing GP Practices but as a way of supporting them to investigate and learn from Significant Incidents. From April to August 2017 there have been 12 incidents reported. The majority of these were no (5) or low (2) harm. However, one was reported in May following a death at home in November 2016. One logged in July involved a patient who was discharged from Milton Keynes University Hospital with no follow up after being prescribed Warfarin but not given any medication information. This was picked up by one of our practices and the CCGs have contacted MKCCG to investigate with the Trust. Other recent incidents include a vaccination error and whilst this resulted in no harm, there was a delay in reporting as the practice was not familiar with the reporting processes. As a result of this, the Quality Team will be attending Practice Managers Meetings to raise awareness of the NRLS reporting portal and show the Practice Managers how incidents are logged and monitored. 2.2 Infection Prevention & Control July & August 2017

• There were two audits this period, Threeways Surgery – with a score of 91% and The Simpson Centre with a score of 93%.

• An IPC training session was provided at Threeways Surgery and an interactive hand hygiene training session was carried out at Cressex Health Centre. The UV lightbox hand inspection cabinet has also been loaned to the Little Chalfont Surgery and Gladstone Road Surgery for their IPC leads to carry out hand hygiene sessions in their own practices.

• Practices are supporting the IPC lead to carry out enhanced surveillance of E-coli bacteraemia cases to gather information to guide strategies in reducing gram negative blood stream infections.

The IPC nurse is able to come to GP practices to provide an educational session if required, this will be dependent on other workload commitments, email [email protected] for details. 2.2 Safeguarding Audit on Information Sharing by GPs for Case Conference Following discussions at the Buckinghamshire Safeguarding Children Board regarding attendance and reports for Child Protection Case Conferences concerns were raised that GPs were not engaging well with the child protection process. The CCG designated professionals and the Bucks County Council Conferencing Manager carried out a dip sample audit to review the engagement of GPs in Child Protection Conferences and to review whether information was shared with Social Care prior to Case Conference as part of the S47 enquiry.

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mailto:[email protected]

3

Evidence from the audit demonstrates that although GPs are not attending initial case conferences they are responding to requests for information sharing in the investigation leading up to an initial case conference. It is also apparent that in some cases where there has been significant medical/health input from other health professionals that the GP is not being asked to contribute to the S47 investigation. Our conclusion is that that GPs are involved in the child protection process and have shared recent information within weeks of the conference but often this is not evident at initial child protection conference. In an attempt to avoid duplication of reports for information sharing and conference purposes, we are introducing a report template for GP practices that can be used for both purposes. 3. Patient Experience 3.1 Complaints NHS England are retaining oversight of all Primary Care Complaints and will share the information they gather with the relevant CCGs. 3.2 FFT results The Quality Team is currently undertaking a piece of work to establish an accurate response rate of the GP FFT. Currently the average number of responses per practice is 192 with a range of 1145 and a standard deviation of 225. As it stands this information is not useful as it is too sporadic. Without knowing the number of patients who were eligible for the FFT, i.e. the number of patients who were seen in the calendar month, it’s difficult to establish the level of engagement from patients. 3.3 GP Surveys The GP Patient Survey (GPPS) is an England-wide survey, providing practice-level data about patients’ experiences of their GP practices. In NHS England – South Central (South), 106,324 questionnaires were sent out, and 46,618 were returned completed. This represents a response rate of 44%. This compares with a national response rate of 37%. The survey has limitations:

- Sample sizes at practice level are relatively small. - The survey does not include qualitative data which limits the detail provided by the

results. - The data are provided once a year rather than in real time.

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3.4 CQC Ratings and visits The Quality Team are in direct contact with the Inspection Manager, Thames Valley. Chiltern: Chiltern House Medical Centre – re-inspected earlier following concerns on 6/6/17 rated ‘Inadequate’. The follow-up inspection is due mid –September. Aylesbury Vale: The Mandeville Practice - re-inspected 5/4/17 rated ‘Inadequate’. Follow-up inspection took place in August and we are awaiting feedback. Visits log reported to PCOG by Wendy Newton, Primary Care Manager on a monthly basis. 4. Quality Team 4.1 Quality Dashboard The CCG is redesigning the Quality Dashboard because the data sources are not regularly updated. Further data sources have been considered such as QOF and the Primary Care Web Tool, however there are a number of issues around the usefulness and accuracy of this data for PCOG and for supporting GP practices, because the data is potentially very out of date. A further meeting to discuss the necessity of the dashboard with the Head of Primary Care, Clinical Director Integration and Clinical Locality Directors is planned. 4.2 Quality Visits A Quality Visits schedule is being created to link in to Locality visits. Meetings with Locality managers are being arranged.

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4.3 Clinical Concerns The Clinical Concerns GP feedback tool reporting system has had limited engagement from both GPs and providers. The reasons for this have been reviewed and are being picked up with relevant parties. The Clinical Concerns webinar at the end of June was used for information exchange which is informing the process and better engagement going forward.

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1

MEETING: Primary Care Commissioning Committee PAPER: G


TITLE: Premises Sub Group



Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: Aylesbury Vale and Chiltern CCGs have a challenging Primary Care Strategy to deliver over the next two years. The strategy is closely aligned to the 5 Year Forward View and the GP Forward View and underpins delivery plans across the wider Buckinghamshire, Oxfordshire and Berkshire (BOB) STP footprint. In order to deliver the primary care strategy, a number of key enablers need to be recognised and built into delivery plans:

• Premises development and in particular the development of community and primary care hubs

• IT development and infrastructure • Workforce development • Development of Primary Care led provider clusters • System wide integration.

With the advent of delegated responsibilities for primary care commissioning, decision-making regarding premises development now rests with CCGs. So that the CCG can discharge its duties in an informed way, support was given by the PCOG to establish a Premises Sub Group of the Primary Care Commissioning Committee and terms of reference were drafted to be approved by the PCOG before final sign off by the PCCC at the June 2017 meeting. At the meeting in June 2017 the PCCC commented on the draft terms of reference requesting that the responsibilities for the premises sub-group are divided into transactional and transformational responsibilities. The terms of reference have now been amended to reflect the comments of the PCCC. PCCC is asked to approve the draft Terms of Reference.

Conflicts of Interest: None in respect of approval requested.

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Strategic aims supported by this paper:(please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all






Equality Quality Financial Risks Statutory/Legal Prior consideration Committees /Forums/Groups

Establishment of a Premises Sub Group previously discussed at PCOG on 6th April and 4th May 2017 and at PCCC on 1st June 2017.


Supporting Papers: Draft Terms of Reference.

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Premises Sub Group Terms of Reference

1. Background

Aylesbury Vale and Chiltern CCGs have a challenging Primary Care Strategy to deliver over the next two years. The strategy is closely aligned to the 5 Year Forward View and the GP Forward View and underpins delivery plans across the wider Buckinghamshire, Oxfordshire and Berkshire (BOB) STP footprint. In order to deliver the primary care strategy, a number of key enablers need to be recognised and built into delivery plans:

• Premises development and in particular the development of primary care hubs, which could include community services

• IT development and infrastructure • Workforce development • Development of Primary Care led provider clusters • System wide integration.

With the advent of delegated responsibilities for primary care commissioning, decision-making regarding premises development that are regulated by the Premises Cost Directions, now rests with CCGs. So that the CCG can discharge its duties in an informed way, a Premises Sub Group of the Primary Care Commissioning Committee will be established with the following objectives and responsibilities. 2. Objectives

The objectives of the Premises Sub Group are to:

• Prepare a Primary Care Estate Strategy • Ensure primary care premises are developed in Buckinghamshire to support the

implementation of CCG commissioning plans and in particular the Primary Care Strategy and STP and aligned to One Public Estate.

• Ensure primary care premises are developed to provide the capacity and quality of premises required to meet needs associated with population growth and new housing.

3. Responsibilities The responsibilities of the Premises Sub Group are divided into: Transformational

• Review plans for Estates, Technology Transformation Funding (ETTF)/Minor Improvement Grant (MIG) funded developments as well as improvements funded through other sources.

• Assess capacity requirements for delivering the CCGs’ Primary Care Strategy and develop appropriate premises plans based on GP cluster formations.

• Oversee responses to local district and county councils regarding the development of Local Housing Plans, Infrastructure Delivery Plans, Neighbourhood Plans and major planning applications.

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• Make recommendations on the application of S106 and Community Infrastructure Levy (CIL) funding.

Transactional

• Review all premises matters and where required, make recommendations to the Primary Care Commissioning and Finance Committees based on informed opinion.

• Review rent review management service reports and approve CSU to instigate the local dispute resolution process with practices that appeal their rental assessment. Where this happens the Sub Group will approve increased costs per case up to £5,000.

• Ensure appropriate communication and alignment with other key enabler work streams (e.g. GP IT).

• Provide regular progress and update reports to the Primary Care Commissioning and Finance Committees (and any other committee or board as required).

5. Membership Chair – nominated Lay Governing Body Representative. Deputising duties will be undertaken by the Director of Transformation as and when required. GP Lead Estates Advisor Head of Primary Care Head of Locality Delivery Deputy Chief Finance Officer LMC Other ad hoc members may join the Sub Group as non-voting members as and when required. Ad hoc members will not count towards quoracy. 6. Quoracy A quorum will be the Chair (or their deputy), Estates Advisor, GP Lead (as long as not conflicted) and either the Head of Primary Care or Deputy Chief Finance Officer. Deputies will absolutely be required to cover absences and will be noted in these Terms of Reference. 7. Frequency of Meetings The sub group will meet on an ad hoc basis to ensure the responsibilities of the group are fulfilled. However, at the very least, the group will meet quarterly. 8. Governance

Primary Care Commissioning Committee

Health and Wellbeing Board

Premses Sub Group

CCG Governing Body

Finance Committee

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Document Control

Version control and review date Signatures (approval and review) Date of approval (by who/which committee) These terms of reference will be reviewed annually. Version (author and date)

Review date (by group/committee)

Reason for amendments

Signature (chair) and date to confirm acceptance and adoption

V 1.0 Helen Delaitre

04/05/2017 First draft, reviewed at Primary Care Operational Group

Graham Smith 04/05/2017

V2.0 Helen Delaitre

23/05/2017 Amendments required following review by Premises Sub-Group

Nicola Lester 23/05/2017

V3.0 Helen Delaitre

18/07/2017 Amendments required following review by Primary Care Commissioning Committee

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MEETING: Primary Care Commissioning

Committee AGENDA ITEM: H


TITLE: Beaconsfield New Build: project initiation document (PID)



Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: In 2015, the two practices in Beaconsfield (Simpson Centre and Millbarn Medical Centre) started working on a joint project to relocate their existing practices in Beaconsfield to a new, purpose-built building accommodating both practices. Note: The Simpson Centre will retain its branch in Penn. The practices appointed a third party developer to help them build plans and applied for Estates and Technology Transformation Funding (ETTF) (formerly Primary Care Transformation Fund) that was made available by NHS England to bidders in 2016. The scheme was successful in being allocated to Cohort 2 of the ETTF (subject to project initiation document (PID) and outline and full business cases being approved) whereby they are potentially eligible to receive up to £3.4 million capital funding towards build costs. Projects in Cohort 2 need to be completed by no later than March 2020. A site for the new build has been identified on the A40 belonging to the Town Council which the developers are hoping will be accepted for community use. ETTF schemes are subject to due diligence carried out by NHS England at both regional level and at national level (the Project Appraisal Unit (PAU)). Part of this process includes the PAU reviewing the CCG’s intention to cover the revenue costs attached to this new build. The PID provides details of the proposed scheme, the site and floor plans as well as costing assumptions. The PID is also in the process of being reviewed by the District Valuer (DV). The DV is a specialist property arm of the Valuation Office Agency (VOA) and provides independent valuation and professional property advice to bodies across the public sector where public funds are being used to support premises development. The outcome of the DV’s assessment will be included in the Outline Business Case. The PID was presented to the Premises Sub Group on 24th July 2017 where the group noted the scheme and agreed it should be recommended to the PCCC subject to knowing the outcome of the land purchase proposals, the DV’s assessment and the inclusion of caveats

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on a phased approach to funding based on evidence of growth in list size. If the PCCC approve this scheme, the next steps and timescales are as follows:

• Detailed planning and Outline Business Case completed before the end of 2017 • Full business case approved Spring 2018 • Contractor to commence work in September 2018 • Build complete by Christmas 2019, in line with ETTF timeframes.

The PCCC is asked to note the information contained within the PID and approve subject to the outcome of the due diligence process carried out by NHS England and the work up of the outline and full business cases. Conflicts of Interest: Although member GPs present may have no material conflict with the proposed scheme, the PCCC should consider requesting any GPs present to leave the room before any decision is made. This mitigation was agreed in advance with the Chair of the Committee. Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all






PPG meeting combined with both practices; held on 21/4/16. Introduction to scheme. PPG & staff workshop, both PPG’s and staff members attended a 2 hour workshop with a Q&A session, held on 25/4/17. Plans of the building design and preferred site have been on display for comment. Town Council presentation by Apollo and both lead GP’s from each practice; held on 28th June 2017. Audience was 15 Town Councillors and Mayor to brief them on the scheme and to seek support to sell the preferred site on Parkway to Apollo. Briefing for Beaconsfield MP on 3rd March 2017 (Dominic Grieve). He was supportive and happy to help if required.

Equality An EIA will be undertaken once detailed proposals are drawn up.

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Quality A QIA will be undertaken once detailed proposals are drawn up.

Financial The estimated financial implications of this scheme are detailed in this paper.

Risks Risks include: - Developer unable to purchase land. - Planning objections raised that cannot

be resolved. - Scheme is unaffordable to the CCG. - Scheme delayed beyond end point for

Cohort 2. Statutory/Legal Prior consideration Committees / Forums Groups

Approved by the Premises Sub Group on 24th July 2017.

Membership Involvement Early involvement with both Pound House & Hawthornden surgeries (they attended the Project meetings for 4 months during summer 2015). Both practices decided to pursue their own plans and not join this project.

Supporting Papers: Project Initiation Document Proposed Site Layout Proposed Floor Plans

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NHS England South Project Initiation Document (ETTF Programme)

1. TITLE OF SCHEME

Beaconsfield Primary Care Centre, Beaconsfield, Buckinghamshire. NEW BUILD

2. SCHEME

REFERENCE

ETTF code: 50903

3. SPONSORING NHS

ORGANISATION (S)

Chiltern CCG federated with Aylesbury Vale CCG.

4. CONTACT DETAILS

Helen Delaitre, Head of Primary Care Tel: 01494 586773 Mobile: 07769 248733 Email: [email protected] NHS Chiltern & Aylesbury Vale Clinical Commissioning Groups Ground Floor, Chiltern District Council, King George V Road, Amersham, Bucks, HP6 5AW

5. DCO

NHSE South Central

SECTION 1: Description and rationale

6. BRIEF SCHEME DESCRIPTION

The project is to develop a purpose built, fit for purpose Primary Care Centre (PCC) for Beaconsfield and its wider catchment area, capable of delivering the key NHS project criteria, namely to increase the capacity for primary care services out of hospital, a commitment to providing a wider range of services, improving seven-day access and providing an increased training capacity. The new building would enable both the Simpson Centre and the Millbarn Medical Centre (the only two NHS GP practices in Beaconsfield) to co locate and work together at greater scale and in a more economic manner, offering greater resilience and efficiencies in serving a combined patient list of almost 20,000. Both practices wish to work collaboratively adopting a federated and transformational approach to patient care, sharing best practice and enabling them to improve efficiencies of working together and becoming more cost effective. The proposed size of the new facility is 2,003m2 GIA to include core GMS accommodation over 2 floors totalling 1,863m2 GIA (1,693m2 NIA) together with an integral Pharmacy of 140m2 (which does not form part of the required rent

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mailto:[email protected]

reimbursement). The building will be served by 98 car parking spaces on a site of 1.8 acres and include drop off points, ambulance parking and services to operate mobile diagnostic units. The proposed development cost for the project is £7.8m (excluding VAT) with an anticipated ETTF grant of 40% of the development cost being £3.12m. Including VAT the total development cost is £9.23m (40% grant is £3.69m). The size of the building has been calculated using the NHS guidance HBN 11-01 and is agreed with the NHS area team. The building design will provide accommodation to service 25,000 patients (an increase of 5,000 patients derived from 2,100 new homes) and offer both medium and long-term expansion capabilities. It is expected that the patient list will increase in line with planned new housing developments both within Beaconsfield and the wider catchment areas of each surgery. The building is designed to be capable of being extended to the rear (within the site boundary) to comprise 4, 8 or 16 additional clinical rooms thus protecting the long-term flexibility of the facility. The South Bucks Local Development Framework Core Strategy Plan (2011) recognises the strong demand for housing in the area which will be directed towards the 3 principle centres of Beaconsfield, Gerrards Cross and Burnham. It is forecast that up to 2,200/2,800 new dwellings will be developed to 2026, 80% of which will be developed in the principal centres; this being 1,760/ 2,240 dwellings equating to a population increase of 4,224 /5,376. This forecast in housing growth excludes any housing developments from outside the core catchment area. This 2011 Strategy Plan is being developed into a Chiltern & South Bucks Local Plan (plan period 2014 – 2036) which will provide greater guidance on housing need and the potential of developing in part of the Green belt surrounding Beaconsfield. It is likely that the continued strong demand for housing combined with good economic growth will further increase the demand and speed of delivery of additional housing in the area. This housing and population growth is a significant factor when sizing the new building and ensuring that in the short and medium term there will be capacity to service the inevitable increase in the collective patient list size towards 25,000. The building design was selected following consideration of the architects’ site and building form analysis which led to the rejection of 3 other potential building designs. The agreed building design solution offers 46% shared space (34% shared excluding corridors and circulation space); the shared facilities to include - Reception, waiting areas, patient facilities , interview room, Minor surgery suite, Health promotions room, meeting/training suite and all the staff facilities including IT/server and staff records. The building design allows for the merger of both practices to occur with only minimal alteration to the building and thereby minimising disruption to patient care. The operation and use of all the rooms within the building will be actively managed by a single point of contact representing both practices to ensure the best room utilisation to satisfy patient demand and the type and frequency of services being provided. Both practices would cooperate under a “Joint Working“ arrangement to ensure that the building is used and managed as effectively and efficiently as possible to maximise patient’s access to a wider range of services. The main reception would be jointly staffed to principally signpost patients to the most appropriate waiting zone. The building floor layout design would enable the ground floor clinical rooms to be used for GP consultations with the first-floor rooms principally for use by the nurse and community teams with a focus on treatments and clinics. Staffing cover between practices (clinical and non-clinical) would be managed subject to governance compliance to prevent interruptions to service due to illness or absence and would include providing access out of normal operational hours in a cost-efficient manner. The meeting rooms would be bookable and actively managed and be available to each practice and to other providers or third-party groups. The minor surgery suite would be available for use by each practice, the GP Federation and visiting clinicians to ensure maximum utilisation.

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The use of a common IT system (with each practice having their own protocols) would enable streamlining of communication including patient calling and access to patient records. All the staff and administrative accommodation would be shared with private “office pods” for each practice to use when appropriate. Both practices would form a Building Management Group to meet quarterly to review the joint working policy and find ways of continually improving the ways of sharing the building for the benefit of the collective patient list and the wider community and to ensure its operational costs are minimised. Practice managers would meet weekly for operational efficiency and the GP’s would share clinical and PLT sessions to capture best practice and cascade it within the collective patient group. There will be a 50% increase in the number of clinical rooms available, increasing from 20 to 30 rooms including the shared Minor surgery suite on the first floor. The clinical rooms are all designed to a standard size, 16m2 for consulting and 18m2 for treatment rooms and all equipped to a standard specification to allow multiple uses and users and the delivery of a consistent approach to care. It is proposed to provide a removable dividing wall between 2 standard consulting rooms thus being able to offer a large clinical room of 32m2 which could be suitable for a variety of group treatments (leg ulcers, inoculations etc) The preferred site option (The Parkway) is located to the south of the town fronting the A40 close to its junction with Walkwood Rise. The site is therefore very accessible to both the Old and New town and to patients from outside the town’s boundary. Terms are agreed in principle to purchase the 1.8 acre site from the Beaconsfield Town Council and the planning prospects to develop the site are considered favourable. Both practices PPG’s and staff members have attended a Building Design Workshop hosted by the Developer Apollo Capital Projects Development Ltd in April 2017 and are fully in support of the location of the site and the proposed building facilities. The building construction will be fully in accordance with the current NHS specification and standards, based on the principle of natural ventilation, adopt a BREEAM standard of Excellent including a range of energy saving features such as Photovoltaic panels, LED lighting and a building management system (BMS) all of which will help to minimise the utility and overall operating costs of the building. The building will also include the latest digital technology and IT features including Wi-Fi internet access throughout the building for patient use. The design and building environment created would offer a positive experience of care for patients and offer benefits of health and well-being to both patients and staff within a safe and secure setting. The agreed project plans are: Site location plan ……………………………. Plan ref PD 003D Ground floor room layout plan……………… Plan ref PD 005D First floor room layout plan ………………… Plan ref PD 006D

7. STRATEGIC NEED

Fundamentally both practices no longer have the physical capacity to offer the services demanded from their combined patient list which is increasing annually in size as new housing is developed in and around the town and its demographic profile is ageing in line with national population trends. Both practices and the CCG recognise that to do nothing is not a viable option to improve delivery standards of patient care.

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Furthermore, the capacity demands must be met to enable a sustainable and resilient model of care to be provided which can offer greater efficiencies and the ability to expand services. The One Public Estate study into Beaconsfield has not yet been commissioned but based on the extensive site search carried out by the developer Apollo, it is considered unlikely that a more suitable site to the preferred site option on The Parkway would be available within the timescale of this project. The Simpson Centre is a converted 1920’s house with parking for 32 cars. The building was extended in 2002; there is no further opportunity to extend the building due to planning and site restrictions. The premises are inadequate in size and the clinical and administrative rooms are too small to enable the practice to offer the quality of care they desire. The accommodation being a converted dwelling is inflexible, not fit for purpose and not fully compliant with modern healthcare standards which all lead to an inefficient way of working. Significant amounts of money will be required to be spent just to maintain the status quo. The premises are thwarting the ambitions of the partnership and their desire to improve the level of service they offer their patients and to increase their training capacity. The Millbarn Medical Centre lease their surgery premises from a private investor (RT Warren Investments) and lease a first-floor store room above adjoining premises owned by Hallbarn Estates. The premises are a converted office building over 2 floors. There are insufficient car parking spaces; a situation which has recently become exacerbated as a number of parking spaces have been surrendered to Hallbarn Estates to facilitate a new office/residential development to the rear of the surgery. The main surgery building lease is due to expire in December 2017 and negotiations are currently in progress to either extend or renew the surgery lease with an appropriate break clause to facilitate a relocation to the proposed new building. The building was extended in 2003 and more recently a consulting room was created within the waiting area to avoid the regular use of the first-floor clinical room which has stair access only. There are no more options to extend the building without the loss of parking and with the landlord’s approval. The premises are not fit for purpose and the accommodation is too small and inflexible to cater for the existing patients; this situation will only get worse with the planned housing growth in the town and surrounding areas. The building will require significant investment soon to maintain the status quo. There is a risk to the continuity of service if a lease renewal or extension to the lease cannot be agreed with the landlord before December 2017. As with the Simpson Centre, the existing premises are limiting the ambitions of the practice to increase their training capacity and consider additional services for their patients. Both practices consider it essential to join and combine resources to offer greater scale of clinical excellence, clinical training and provide streamlined administration, all of which will bring efficiencies, greater resilience and the ability to expand services. The buildings accommodation and facilities will allow neighbouring GP colleagues to benefit from sharing of resources and skills making full use of the flexibility of space including meeting and clinical rooms to respond to the changing demands of the local community and GP practices.

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The need for investment in new premises for both practices fully aligns with the STP’s plans which is supported and endorsed by the CCG’s Estates Plan which prioritised this project for Beaconsfield as their main new build investment. This priority is driven by the current physical inadequacies of each surgery premises and the projected 22% increase in the local population over the plan period to 2026. Between 2001 and 2011 in Beaconsfield the population growth was 13.1% (cf 5.5% for Buckinghamshire) 10.5% of the population in Beaconsfield are aged over 75 (cf 7.8% in Buckinghamshire) The population of South Buckinghamshire is an older population than the national average with a predicted increase over the next 10 years of;

• 39% in the over 65’s • 38% in the over 80’s • 18% reduction in the under 20’s.

More than 16% of the local population is aged over 65 and this will increase to 20% by 2025. This is reflected in the demographics for each practice. The number of older people with care needs will increase by 60% over the next 20 years. The resident population is living longer with a consequential increase in the rate of long term conditions. The identified site offers a strategic, accessible and prominent new facility with the flexibility to provide more services and deliver new models of care as promoted by the 5 Year Plan and increase accessibility to GP services. The new building would enable the GP practices to be at the heart of the wider system of integrated out of hospital care working in collaboration with community teams, other GP practices in the area and service providers offering flexible and improved access to patients. With both practices working together in one building would enable best practice (clinical and non-clinical) to be cascaded to a wider patient group and enable staff to become more responsive to the individual needs of patients especially those with long term conditions. The benefits that will be derived from this investment will include:

• An increase in the clinical capacity by 50% to provide greater access to GP services and offer a way to provide extended hours by becoming a regional hub for use by the federated practices.

• Bring together two sets of professionals to work together under one roof in a transformational, collaborative and more efficient way with the aim to have community and practice nurses working flexibly and interchangeably to broaden their skills and cross over.

• Provide the opportunity to share the use of the new facilities to improve patient services and level of care as well as reducing operating and revenue costs.

• The building will lend itself to the potential merging of both Practices in the future with minimal physical alteration and disruption to patient care.

• Brings the benefit of a pharmacy operator fully integrated within the building with its own consulting rooms and working closely with the practice staff.

• Having had experience of working with Paramedics through the Winter Resilience Funding over the past two years, both practices are keen to work with SCAS to establish an early intervention visiting service. The aim being to start assessment and treatment early in the community so when a hospital admission is required the patient can be admitted in the early part of the day when routine hospital departments are open. The practices are keen to establish the possibility of a training rota for Paramedics for them to maintain their skillset. The building allows this to be carried out.

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• To enable the building to become a Training Centre of Excellence for GPs, Nurses and management training; this leading to greater staff retention and increasing the opportunity for recruitment. Each practice would initially have 2 Training consulting rooms, doubling their current capacity. There will be a minimum of three approved GP Trainers. Learners from our practices as well as other training practices will be able to attend joint tutorials and learning sessions in the flexible spaces with the possibility of Skype interactions from remote sites. The intention would be to cater for GP trainees at different stages in their training to include ST1 & 2 and not just ST3 as at present.

• The federated way of working will improve lines of communication leading to improvement in patient care and the management of long term and chronic conditions. Pooling expert knowledge in Diabetes, Asthma, COPD, CKD, hypertension and Epilepsy management will provide good quality of care for not only our patients but could be part of collegiate working for patients from other practices if there was a need identified for these types of services.

• Offer a Minor Surgery suite capable of bringing more services within the community and away from a hospital setting and encouraging GPwSI’s and other qualified providers including Consultant Dermatologists.

• Diagnostic services (based around ultrasound and Near Patient Testing) and specialist services for the elderly and frail, mentally ill and for those with urgent complex health needs. These services taking pressure off the acute sector and limiting the number of A&E admissions (emergency and planned).

• The buildings’ design and security facilities will enable a range of rooms to be opened up independently from the whole building to offer MIU/Triage facilities, out of hours or extended hours of operation in conjunction with Bucks Urgent Care thereby reducing A&E attendances. These facilities may be utilised by other agencies for example PPGs, Carers associations, Dementia charities and Active Bucks both in and out of work hours. The size of some of the rooms can be altered to provide the correct ambience for small and larger meetings.

• The building is designed to be capable of being extended without the need to purchase any more land to provide either a single or two storey building extension (offering between 4, 8 or 16 clinical rooms) to accommodate other users to provide a greater range of services.

• The building technology will enable simultaneous and multiple Skype consultations as part of a virtual service. • Extend the counselling service currently provided by Healthy Minds to both individual and group therapy. • Offer a dedicated Sexual Health& Midwifery clinic/drop in centre for the town. • Provide an increased phlebotomy service. • Provide an increased ENT, dietician, podiatry, travel clinic services. Millbarn have recently invested and expanded

the Community ENT service which would benefit for the 2 dedicated ENT consulting rooms in the new building providing an improved working environment.,

• Work with the current MSK provider to offer a full range of physiotherapy services. • To offer a base for the Integrated Community teams thereby significantly improving communication between primary

care staff within practice and within the community at large. Development of a multitasking Nursing team that is responsive to day to day patient and staffing needs. This allows fuller integration of all members of the Primary care team.

• To provide improved accessibility to the nearby Travellers community. • To offer support and to work collaboratively with other charitable organisations such as Chiltern Counselling, YES,

Way In and the Citizens Advise Bureau. • Provide accommodation to work with the Public Health and Bucks County Council.

The planned and projected housing developments in Beaconsfield and the immediate area will provide an opportunity for the Council to negotiate s.106 capital contributions for the benefit of the general health economy which could potentially help

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offset the revenue implications for the CCG from this investment. The identified housing development at Wilton Park to the east of Beaconsfield provides the first opportunity to secure s.106 funding to support this project subject to the timing of the planning application and its outcome. The design principles of the CCG’s Primary Care Strategy can be addressed within the proposed new Primary Care Centre for Beaconsfield, namely; • Safe and high quality care – a purpose built and secure facility including a centre of excellence for training and multidisciplinary teams handling primary, social and mental health issues. • Comprehensive access to a wide range of healthcare staff - including charitable organisations offering wider access to the local community’s needs. • Making the patient and their carers at the centre of the decision making about their care and treatment. • Focus on the needs of the locality • Maximising care in the community • Provide a co-ordinated health service across all providers – capable of being accommodated within this regional Hub. • Increased accessibility to meet patients demands – prominent and accessible facility. • Future sustainability and flexibility - it being recognised that services should be capable of being delivered more cost effectively away from the acute sector setting within a purpose built facility that can physically be adapted to meet future demands and changes within primary care.

8. PROPOSED

PROCUREMENT PLAN

The Simpson and Millbarn practices appointed Apollo Capital Projects Development Ltd as their development partner in April 2015. Apollo is a specialist 3rd Party developer within the Primary Care market and has over 20 years’ experience of developing, investing and managing Primary Care buildings throughout the UK and has all the necessary professional skills in house to assist the practices and the wider project team to deliver their new premises. Apollo operates nationally and recently completed a new surgery development in Ipswich for the Two Rivers Practice which is a very similar project to this proposal. It involved the co-location of two practices (who subsequently merged); the building was designed to service a similar patient population of 25,000 and the overall building size and patient/staff facilities are similar. Both Millbarn & Simpson practices have had the opportunity to visit this building which enabled them to better understand the way a purpose-built building can operate more efficiently and offer a wider range of services. A testimonial from the lead GP from Two Rivers (Dr Jonathan Knight) is available together with other testimonials from other recently completed projects. Apollo’s experience includes other ETTF new build and extension projects which are currently in the design stage across the country. Additionally, Apollo project managed the construction last year of two combined Health & Social Care centres in Glasgow with a combined value more than £32m with another two buildings of similar value currently under construction in the city. Apollo therefore has the skill, experience and in-depth knowledge of healthcare development and funding to successfully deliver this project. Apollo would act as lead developer and procure the new building via the traditional 3PD process. Apollo would therefore become the Landlord and owner of the new building with the 2 GP practices and the pharmacy operator becoming tenants.

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Apollo as the project developer would take full responsibility for all the projects costs and associated risks through the entire development process. This includes all the feasibility project costs associated with achieving FBC approval by early 2018. This 3PD procurement route is well established and historically proven to offer value for money. Upon completion of the building each practice would enter a 25-year lease reflecting the national DV leasing terms; the GMS rental would be paid under the Premises Cost Directions and be fully reimbursed. The increased rent reimbursement, the charging of VAT on the rental and building rates would be the responsibility of the CCG subject to an affordability check and DV sign off for Value for Money. The running costs of the building will be responsibility of the GP practices (paid proportionally to their accommodation space); an indication of the projected operating costs has been provided to each practice. The proposed ETTF Capital Grant would be used to abate the market rent for an agreed period of years thereby limiting the revenue costs for the CCG. Millbarn & Simpson have jointly appointed solicitors and a Monitoring surveyor; their solicitor has reviewed the Heads of Terms for the building lease and agreed that the principles of the lease are acceptable. Apollo would lead the project team, chair and record all meetings and regularly communicate progress and actions to the project participants, stakeholders and their advisors and the consultant delivery team appointed by Apollo. The development programme would be actively managed to ensure that the target dates for each key milestones event is maintained (site purchase, planning, building leases and financial close etc) so that this new facility will be available to patients before March 2020 as agreed by Teresa Donnelly of NHSE. The proposed Development programme dates are:

• Building design sign off June 2017 • PID submission/approval September 2017 • Secure site purchase Sept/Oct 2017 • Prepare OBC October 2017 • Submit planning application November 2017 • Submit OBC November 2017 • OBC approval January 2018 • Secure planning consent March 2018 • Agree occupational building leases Nov/Mar 2018 • Submit FBC April 2018 • Obtain FBC approval May/June 2018 • FINANCIAL & LEGAL CLOSE July 2018 • Commence construction September 2018 • Complete construction December 2019

9.

1. SITE ; Apollo carried out an extensive site search exercise which identified 6 potential sites of which 4 were rejected due to size constraints , planning obstacles (Green Belt issues) and site values (residential values which were

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prohibitive). That left the preferred site (The Parkway) and an option of developing within Wilton Park, a residential led scheme to the east of the town. Apollo has agreed terms in principle for the purchase of the preferred site with the site owner, Beaconsfield Town Council and the sale is subject to the approval from the Full Town Council Committee. Development of the site for a Primary Care Centre requires the release of two restrictive covenants on the land, the beneficiaries being Taylor Wimpey and Hallbarn Estates. The Town Council has the responsibility for negotiating commercial terms for the release of these covenants. To date Hallbarn Estates has agreed to the release of their covenant and Taylor Wimpey has agreed to release their covenant but subject to a commercial payment, the quantum of which is currently being negotiated. The Town Council will convene a special meeting in September to make a final decision regarding the sale of the site to Apollo. Clearly if terms to release the Taylor Wimpey covenant cannot be successfully agreed, the site would not be capable of development and an alternative site would need to be identified. A potential alternative site would be one of the originally identified sites located within the Wilton Park development which has been earmarked for a community building of up to 2,000m2. Meetings have been held with the Wilton Park developer (Inland Homes) which could be reactivated should the subject site fail to be deliverable. This potential switching of sites would possibly have an adverse impact on the overall development programme and put the building operational date at risk of not being achieved.

2. PLANNING CONSENT; the subject site is currently zoned as Open Space. The Town Council held a pre-planning

application consultation with the Planning Authority last year and identified the single planning policy which needs to be satisfied to permit the sites development for Primary Care. The same policy was successfully satisfied on an adjoining site which last year received planning consent for residential use. Therefore, the precedent has recently been set for satisfying the planning policy and therefore the chances of successfully negotiating a planning consent for the project are good. The planning strategy is to only develop on 1.8 acres of the 2.2 acre site owned by the Town Council; the remaining 0.4 acre portion of the site would be left as Open Space to help mitigate the loss of open space and assist the planning case.

3. VALUE FOR MONEY; achieving this test is critical to the overall financial viability of the project. Apollo along with

the NHS team has engaged with the District Valuers office to agree the project costs and the current market rent for the new facility. A financial methodology would be agreed with the NHS/DV to ensure the ETTF capital contribution is correctly utilised to maximum effect which is anticipated to go towards abating the market rent for the new building for an agreed period of years. The DV’s report is due to be issued during September. The release of the ETTF funding would be scrutinised and controlled by the NHS’s consultant (Pick Everard) who has been part of the project team from day one. The main construction works for the building would be tendered, the process and results disclosed by Apollo to the NHS’s consultant to ensure VFM.

4. COST OVER RUN; this risk is the responsibility of Apollo as the project developer. Any cost overrun or

additional/unforeseen costs will not be borne by the NHS or the CCG. Apollo has the experience and commercial skills to manage the project risks and the associated costs.

5. PROJECT DELAY; the overall project programme is the responsibility of Apollo as the project developer. The programme will be actively managed to ensure key milestone events are achieved on programme. In the event of any slippage, the programme will be assessed to establish how to absorb the delay by potentially considering undertaking tasks in parallel to gain the lost time. The programme whilst the responsibility of Apollo will be owned by

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all the project participants and their respective consultants who will collectively have an impact on the delivery of the project.

6. PHARMACY LETTING; the pharmacy letting is the responsibility of Apollo and will be intrinsically linked to the

project financial viability. The letting will be contingent upon the selected pharmacy operator securing a relocation of their pharmacy license which is a process outside the control of Apollo. To mitigate this risk Apollo will employ a specialist Pharmacy consultant to monitor the operator’s application and potential appeal process. By carefully selecting the right operator will also mitigate the risk of not securing a relocation license.

7. PUBLIC AND PATIENT SUPPORT; early consultation with the public will begin with an open public consultation event to be held in Beaconsfield during the lead up to the lodging of the planning application. This will enable the project team to demonstrate to the public the benefits of the new building and to ensure there is no misunderstanding of the projects details. Prior to that event the respective PPG’s have already been formally briefed on two occasions to gauge their level of support which to date has been unanimous. Comments and ideas from the PPG’s and the public will be addressed throughout planning phase.

10. FINANCIALS – Please include full details of financial requirements in APPENDIX A of this PID using the finance template

provided in Accompanying document 3

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SECTION B: Endorsements Note: By endorsing the Project Initiation Document below the project sponsor(s) commits to reimbursing project costs incurred by a third party if the sponsor(s) subsequently decides not to proceed with a viable project.

ENDORSED BY: SPONSOR ORG 1 DIRECTOR OF FINANCE / CHIEF FINANCIAL OFFICER

Organisation

Name

Signature

Date

SPONSOR ORG 2 DIRECTOR OF FINANCE / CHIEF FINANCIAL OFFICER

Organisation

Name

Signature

Date

NHS PROPERTY SERVICES REGIONAL DIRECTOR

Name

Signature

Date

OTHER (Please specify) Organisation

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Name

Signature

Date

NHS ENGLAND REGIONAL DIRECTOR OF FINANCE

Region

Name

Signature

Date

Please name and save this file with the reference above (using format XXX – YY - XXXXX (Org Code – 16 – ETTF ref). These PIDs must be signed off by the CCG Director of Finance, and then passed to the DCO for DCO Director of Finance sign off, and then submitted to the Regional team for Regional and/or National sign off as appropriate. Scanned electronic signatures are acceptable.

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APPENDIX A

COST ESTIMATES and ANTICIPATED CAPITAL FUNDING SOURCES

Capital and Revenue requirements to deliver this scheme. The costs for each main item/class of item, as well as the project management costs, should be separately identified in the table below (please use Excel template provided and copy in).

ETTF Financial summary

Scheme Ref: 54321

2016/17 2017/18 2018/19 TotalCost of scheme Capital £k Revenue £k Total £k Capital £k Revenue £k Total £k Capital £k Revenue £k Total £k Capital £k Revenue £k Total £k

Item 1 - - - - - -Item 2 - - - - - -Item 3 - - - -Item 4 - - - -Item 5 - - - - - -Total Cost of Scheme - - - - - - - - - - - -

Source of Funding Capital £k Revenue £k Total £k Capital £k Revenue £k Total £k Capital £k Revenue £k Total £k Capital £k Revenue £k Total £k %

NHS England - - - - - - -NHS property services - - - - - - -Community Health Partnership/LIFT Co - - - - - - -Other (specify) - - - - - - -Total - - - - - - - - - - - - -

GPIT costs for New Build/Improvement Schemes:2016/17 2017/18 2018/19 Total

GPIT costs Capital £k Capital £k Capital £k Capital £k

Item 1 -Item 2 -Item 3Total - - - -Source of Funding

NHS England 0

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REVENUE AFFORDABILITY

The CCG is currently providing rent and rates reimbursement to both practices totalling £214,500 pa. The proposed capital grant will abate the impact of the market rent for this new building for an agreed number of years, depending on the size of the grant. The CCG’s revenue impact from the new building will therefore be limited to:

• The increase in building rates (Total rates estimated at £172,000 pa - net increase of £132,500 pa) • VAT payable on the existing rent reimbursement of £175,000 (£35,000 pa.)

So, the CCG’s net revenue impact will be £167,500 pa. The market rent for the building will only become payable upon the expiry of the abatement period. The rent reimbursement at existing levels (£175k pa) would remain liable to 3 yearly rent reviews as currently provided for. The CCG is aware of the revenue costs derived from this project which remain provisional and subject to agreement with the District Valuer and further due diligence on the valuation methodology. The proposed market rent of £430,320 pa has been used to calculate the abatement period and therefore the market rent for the building will only become payable upon the expiry of the agreed abatement period. The existing revenue costs (rent and rates reimbursement) for each practice is: Simpson Rent £100,000 ( £250/m2) Rates £23,000 Sub total £123,000 pa. Millbarn Rent £75,000 (£250/m2) Rates £16,500 Sub total £91,500 pa TOTAL £214,500 pa Projected revenue costs ( rent and rates + VAT ) for each practice: NOTE; these are estimate figures only and subject to DV verification. No temporary accommodation is required. GIA for GMS 1,863m2 / NIA 1,693m2 The market rent for the building is estimated as £430,320pa ( £240/m2 plus parking at £250 per space)

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Simpson (55% of the NIA ) Rent £236,676 pa VAT £47,335 Rates £ 94,600( estimate) Sub total £378,611 pa Millbarn ( 45% of NIA ) Rent £193,644 pa VAT £38,729 Rates £77,400 ( estimate) Sub total £309,773 pa TOTAL £688,384 ( NET increase of £473,884 pa) The intention is to utilise the ETTF capital sum ( 40% of the projected development cost of £7.8m excluding VAT) to abate the market rent leaving the CCG to be responsible for the following net increase in revenue costs for an agreed number of years: The new building revenue costs would be: Continuation of paying the existing rent reimbursement £175,000 VAT on rent reimbursement £35,000 New building rates £172,000 ( estimate only) TOTAL REVENUE COST £382,000 pa NET REVENUE INCREASE OF £167,500 pa ( £382,000 less £214,500 ) Rent abatement model (provisional) Apollo has produced informal guidance around the potential way the ETTF capital grant could abate the market rent based on a number of assumptions regarding the development, its costs and market rental levels. This approach requires the agreement of both the NHS and the DV. The Capital grant (ETTF ) required to abate the market rent ( £430,320 pa estimate) would be: 15 years £2.4m 21 years £2.95m 25 years £3.25m Based on an assumption that the ETTF could fund up to 40% of the Development costs of the project which

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are :

• Estimated at £7.8m (excluding VAT) would result in an ETTF grant of £3.12m • Estimated at £9.23m (including VAT) would result in an ETTF grant of £3.69m

Therefore depending on the VAT assumptions of the Development costs and therefore the size of the grant, the abatement period could potentially be between 21 and 25 years.

CAPITAL COSTS Non recurrent costs (to be paid from the Pre project allocation ) GP solicitor fees ( Gordons LLP) £12,000 + VAT GP monitoring surveyor ( AR Group) £15,000 +VAT IT £20,000 ( estimate) SDLT £90,000 ( estimate) TOTAL £137,000 Timing - 2017/18 Surveyor £3,000 Legal £11,000 2018/19 Surveyor £12,000 Solicitor £1,000 IT £20,000 2019/20 SDLT £90,000 Capital cost of the development £9.23 m ( including VAT where applicable) and £7.8m excluding VAT. Includes the following development costs:

• Site cost and Stamp duty • Legal fees ( Apollo’s and Funders) • Funding arrangement and Agents fees • Site survey and planning costs

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• Consultant fees including Breeam • Building costs • Financing costs

ESTIMATED PROJECT DEVELOPMENT COSTS (Inc. VAT) If further project development are required, please include in financial model

Already incurred by Project Sponsor(s) ZERO

Further estimate to achieve OBC ZERO

Further estimate to achieve FBC approval ZERO

Note for schemes greater than £1m: please ensure you have included the following information:

STRATEGIC CASE: Provide a summary of the key strategic drivers and service requirements that support the case for investment; confirmation of the support of all relevant stakeholders; Confirm the extent to which the scheme delivers on high priority NHS capital investment requirements, e.g. improving patient safety and the patient environment, reducing backlog maintenance (% of total); enabling QIPP delivery, etc; Confirm the support of key clinicians and the way in which the scheme supports delivery of local commissioning priorities. ECONOMIC CASE: Confirm that any premises subject to the investment will not be disposed of within 5 years of their completion; Confirm other options considered to achieve the scheme’s objectives; Confirm the scheme benefits – including financial (cash releasing and non-cash releasing) and non-financial (quantifiable and non-quantifiable) and how the scheme delivers value for money; Provide supporting value for money analysis as appropriate (attach tables to show workings). FINANCIAL CASE: Confirm the capital costs of the scheme and anticipated dates of capital deployment (and any associated disposals) split between 2013/14, 2014/15 and 2015/16 (as required).If a lease is proposed, confirm the whole life cost of the lease. Confirm the recurrent revenue costs of the scheme. Where these are anything other than revenue neutral or revenue saving, confirm the source of additional revenue. Confirm and demonstrate that the recurrent revenue cost of the scheme is affordable; Confirm any non-recurrent (e.g. transitional costs) of the scheme; Confirm the source of non-recurrent funds to meet these costs. Provide supporting income and expenditure analysis that sets out clearly the recurrent and non-recurrent costs of the scheme, the sources of funds to meet these costs, and which demonstrates clearly that the scheme is affordable. COMMERCIAL CASE

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Confirm the commercial arrangements for delivery of the proposed capital investment, e.g. procurement approach and proposed contract type (If not using NHS Procure21+ for new build or refurbishment projects explain why not) Confirm when any necessary full planning consent will be achieved. Confirm status of legal documentation and what (if anything) remains to be agreed For new build and refurbishment projects confirm: i) compliant with DH guidance (HBN & HTM); ii) compliant with eliminating mixed sex accommodation; iii) compliant with an approved infection control strategy; iv) in alignment with an approved estate strategy, or equivalent; v) intention to undertake BREEAM assessment and target outcome. Confirm any contribution to carbon reduction plan (if applicable). Where appropriate, attach site plans and design drawings for the preferred option.

PID ENDS

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Proposed Site Layout

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Proposed Ground Floor Layout

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Proposed First Floor Layout

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AGENDA ITEM: I

DATE: Thursday 7 September 2017

TITLE: Delegated Primary Care Commissioning – Transition Update

AUTHOR: Jessica Newman, Contract Manager, NHS England


Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: Buckinghamshire CCGs have fully delegated responsibility for the commissioning of primary medical services. During 2017/18 the CCGs are working with NHS England to achieve the transition of all associated functions by March 2018. A transition plan tracks progress and is reviewed quarterly. The transition of responsibility is also supported by a Memorandum of Understanding between NHS England and the CCGs for 2017/18. This paper updates the PCCC on progress with the transition of the delegated functions from NHS England to the CCGs. The PCC is asked to note the progress being made. Conflicts of Interest: None Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all





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Equality Quality Financial Delegated commissioning status means that

the CCGs have assumed responsibility for the primary care budgets.

Risks Risks associated with the capacity and knowledge of CCG staff to be able to fully deliver all delegated functions.

Statutory/Legal Not a statutory or legal requirement for the CCG to take on delegated commissioning for primary care.


Membership Involvement The membership were fully engaged in the CCGs decision to apply for delegated commissioning status

Supporting Papers: Delegated Primary Care Commissioning – Transition Update

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DELEGATED PRIMARY CARE COMMISSION – TRANSITION UPDATE

Purpose of the Paper Aylesbury Vale and Chiltern CCGs will take on fully delegated responsibility and associated functions for the commissioning of primary medical services from April 2018. This paper updates the Committee on progress with the transition of the delegated functions from NHS England to the CCGs. Background For 2017, the CCGs are working with support from NHS England on a transition plan covering both CCGs and progress is reviewed quarterly. The transition of responsibility is also supported by a Memorandum of Understanding between NHS England and the CCGs for 2017/18. Capacity has been increased in the Primary Care Team with the appointment of a Senior Primary Care Manager to enable full delegation from April 2018. From October 2017 to March 2018 functions will transition from NHS England. Arrangements are also being made for transition within the Finance and Quality teams. There are a small number of functions which due to their nature, activity and/or budget may need to be dealt with across CCGs. Further discussion is needed with colleagues in neighbouring CCGs about how these functions might be managed. This might be either by one CCG taking a lead on behalf of others or CCGs commissioning the CSU to manage the function on their behalf. Summary of Transition of Primary Care Functions Only those functions not already completed are included in this summary. A significant number of functions have already been incorporated into the CCGs’ workplan. Function Timeline Comment Revise content of primary care section of website.

After April 2018 Revise as part of website for merged CCG

Confirm arrangements for access and storage of contracts.

As per NHS England time line - transfer of files is needed.

NHS England is pursuing a technical solution for transfer of all primary medical services files.

Access to Primary Care Web Tool and CQRS.

From October 2017

Management of violent patient process.

From October 2017 Agreement needed across CCGs on how the service might be managed. At CCG level for interim.

Develop relationship and embed processes of Primary Care Support England (PCSE).

From October 2017

Management of discretionary funds process (locum reimbursement for maternity, paternity and sickness).

From October 2017 New allocation rules have made processing of requests easier from April 2017. Payments to remain with NHS England until March 2018.

Management of clinical waste process.

From January 2018 NHS England is embedding the new contract.

Implementation of local Quality Dashboard.

From September 2017

Rather than establish a Quality Dashboard that is not

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fit for purpose, the Quality Team will produce monthly reports to PCOG.

Arrangements for discussion and follow-up of individual GP performance issues.

Quality team lead Retained function of NHS England, CCG input needed.

Arrangements for information sharing and contractual input into patient complaints.

Quality team lead Retained function of NHS England, CCG input needed.

Liaison arrangements with NHS England on vaccination and immunisation and screening programmes.

Primary care team Retained function of NHS England

Recommendation / Action The Primary Care Commissioning Committee is asked to note the progress being made in the functions to achieve fully delegated responsibility by March 2018.

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1

Paper J – For Information Only

Premises Sub-Group 24 July 2017, 1pm – 2.30pm

Small Meeting Room, Chiltern CCG

Attendees: Tony Dixon (TD), Deputy Lay CCG Chair and Audit Committee Chair, Chiltern CCG (Chair), Helen Delaitre (HD), Head of Primary Care, Bucks CCGs Vicki Parker (VP), Central Aylesbury Business Support Manager, Bucks CCGs Paul Rowley (PR), Estates Advisor (via telephone) Richard Drew (RD), Development Director, Apollo Capital Projects Development (Simpson / Millbarn New Build agenda item only) Kate Holmes (KH), Deputy Chief Finance Officer, Bucks CCGs Simon Kearey (SK), Head of Locality Delivery, Bucks CCGs Nicola Lester (NL) Director of Transformation, Bucks CCGs Wendy Newton (WN), Primary Care Manager, Bucks CCGs (notes) Apologies: Dr Stephen Burr (SB), Clinical Locality Director, Bucks CCGs

Welcome and Introductions The Chair welcomed all attendees to the meeting and noted apologies from SB.

Declarations of Interests RD declared his interests with regards to the Simpson / Millbarn New Build. The meeting noted that Apollo Capital Projects Development had a financial interest in this agenda item; however RD remained in the meeting for this discussion in order to provide information to the group. SB is a GP Partner at Little Chalfont Surgery and therefore declared a conflict of interest in respect of agenda item 8.

The Simpson Centre / Millbarn Medical Centre New Build The Simpson / Millbarn New Build Scheme was successfully submitted for the Estates and Technology Transformation Fund (ETTF) last year. The Project Initiation Document / Outline Business Case for the proposed development is now almost ready for formal approval by the CCGs. The Premises Sub-Group have been asked to review the proposed plans in order to help inform the CCG decision making process. RD was invited to attend the Premises Sub-Group to present the proposed plans and to answer any questions that the Group may choose to raise. RD informed the meeting that he had been working with The Simpson Centre and Millbarn Medical Centre for more than 2 years. Apollo Capital Projects Development specialise in developing purpose built general practice facilities. The Simpson Centre and Millbarn Medical centre are looking to co-locate and are considering a practice merger in the longer term. The two practices currently serve a patient population of approximately 20k however the planned new building would have capacity for 25k patients and incorporate a private pharmacy. The Simpson Centre will retain their branch surgery in Penn. The two storey building will allow for flexible use e.g. retractable walls to allow for larger clinical space to accommodate small, medium and larger groups.

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2

Total cost of the new build is estimated at just under £8m (excluding VAT). The combined rent reimbursement is dependent on current markets however capital injected into the scheme via ETTF should abate the rent for 21 – 22 years. Therefore current rent reimbursement is expected to increase by approx. £167k per annum bearing in mind the CCG has indicated a staged rent reimbursement increase in line with increase in patient list size. A site for the new build has been identified on the A40 and is 2.2 acres of which, 1.8 acres will be purchased from the Town Council. The site is deemed as open space and is not designated greenbelt land and the developers are hoping the plans will be accepted for community use. The site has two covenants: Hallbarn Estates and Taylor Wimpey. Hallbarn Estates have indicated that they are happy for the land to be used for general practice. Taylor Wimpey’s covenant states that the land should remain as open space however Apollo are hoping that Taylor Wimpey will take a pragmatic approach for the site to be developed for community use. Apollo Capital Project Development has an open valuation price for this site and therefore should Taylor Wimpey request more money this will not need to be paid by the NHS. The CCGs have indicated to the practice that their design was not transformational enough to meet the criteria for ETTF as the design replicated two separate practices operating in the building. RD reported that the primary constraint on the building design is 3 houses which front onto the site and therefore the medical centre needs to be built away from these houses. There will be a single “meet and greet” area and single reception area and back office. 35% of the building will be shared space. The clinical rooms on the ground floor with additional services (including ENT) and nurses housed on the 1st floor. Shared Practice administration, meeting rooms, staff room and medical records storage will be shared space utilised by both practices. As the new building will be built with additional capacity there will be the potential to house additional services as aspired to by the practices and the CCGs. Additional services have the potential to allow for different income streams outside of GMS. Further, the site allows for potential future expansion and hence future proofs the building. RD expressed his confidence that part of the building can be rented out to a private pharmacy subject to licencing rules. Terms have already been agreed with the Council and Apollo has secured a conditional contract which means that they will only purchase the land once planning permission has been granted. Apollo estimates a moderate risk to objections being received to their planning permission application. To mitigate this risk Apollo will offer to improve the overgrown area on the corner of the plot and in order to return this land to community use. The new premises will offer significant parking spaces (96 spaces for the practices and 2 for the pharmacy) and there is a nearby bus stop. Apollo plan to undertake a study of how patients currently travel to the existing surgeries and how they plan to get to new surgery. Timeframes:

• Approval by CCG September / October 2017 • Detailed planning completed by the end of 2017 • Full business case approved Spring 2018 • Contractor to commence work in September 2018 • Build complete by Christmas 2019, in line with ETTF timeframes.

Outcome:

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The Group noted the scheme and agreed that the scheme should be submitted to PCCC for recommendation subject to knowing outcome of land purchase. Actions: Await outcome of meeting with Town Council on 27 July 2017 to ensure plans for the land are approved [post meeting note: The Town Council failed to make a decision on 27 July 2017, reason being they do not want to commit to a conditional sale until the outcome of the Taylor Wimpey covenant is known. The Council have placed a 2 week time period on TW to make a decision as they recognise that this delay isn’t helpful]. Plans to be reviewed by DV to gain an understanding of the financial implications for the CCG and HD to explore potential for Section 106 funding. To be added to the PCCC agenda (public meeting) on 7 September 2017 once outcome of intention to purchase land is known – this item will be for recommendation to the Governing Body. To be added to the Governing Body agenda on 14th September for formal CCG approval.

HD

HD

HD

HD

Berryfields Medical Centre Berryfields Medical Centre is currently housed in temporary portakabin accommodation. The building of permanent premises was the leading ETTF priority for Aylesbury Vale CCG when submissions were made to NHS England in 2016. The ETTF bid was initially rejected by NHS England however due to slippage from elsewhere and CCG lobbying, this scheme has now been agreed for ETTF and will be taken forward and fast tracked. The practice has already employed a third party developer, drawn up floor plans and a schedule of accommodation. The practice has indicated that they would prefer not to use ETTF money as they do not want the scheme delayed by having to go through NHS England as well as CCG sign off process. However, this would result in significant financial loss to the CCG and appropriate due diligence would still be required which could result in similar delays. Berryfields Medical Centre has previously received significant financial investment from the CCG and therefore the CCG will request that they reconsider their request, given the reasons stated. The practice has identified land on the Berryfields site for their permanent medical centre. NHSPS is working with the practice to review their current ground lease which expires in January 2018. Outcome: Update noted by the Sub-Group. Actions: HD to write to the practice to request that they continue with their application for ETTF investment into the new building.

NHSPS

HD

Notes of the Last Meeting The notes of the last meeting were agreed as an accurate reflection of the meeting.

Action Log ToR – Closed Rent Review Management Service - Closed Financial accountability – Closed Berryfields – Closed Burnham Health Centre – open Kate to close Cressex Health Centre / Wye Valley Surgery – remains open

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Void Costs – open KH to advise VPS Accommodation – Closed Terms of Reference (ToR) The ToR for the Premises Sub-Group were reviewed at the PCCC when they met on 1 June 2017. The PCCC requested that the responsibilities for the Sub-Group were divided into transformational responsibilities and transactional responsibilities. HD has since updated the ToRs in line with the PCCC’s recommendations. The ToR will be an agenda item for the next PCCC on 7 September 2017. Outcome: ToR approved by the Sub-Group. Action: HD to ask the PCCC to approve the ToR when they next meet on 7 September 2017.

HD

Lynton House Refurbishment When CV Health was awarded the APMS contract for Cressex Health Centre their financial plans included closing Lynton House branch surgery. The practice undertook a formal consultation process however their application was rejected by NHS England. The CCG was tasked by NHS England to work with the practice to consider alternatives to the branch surgery closure. Various options have been explored, unsuccessfully, including the use of alternative public owned buildings in the East of High Wycombe. Therefore the CCG negotiated with the landlord of Lynton House and have agreed that the practice could rent a reduced footprint (which reduces ongoing revenue costs to CCG) which would also allow the landlord to sell off the remaining building for flats. The part of the building leased by Cressex Health Centre could then be refurbished. Negotiations with the Landlord have now concluded and the Landlord’s Agent has agreed the DV rental value. Final heads of terms have been agreed for Lynton House as a 10 year lease with break clauses in 3 and 5 years and a rent review in 5 years. This would provide the CCG with the flexibility to opt out of the lease if current contract runs out with CV Health and the CCG is unable to award the contract to another provider. This is deemed a good arrangement for the CCG with notice on the lease only able to be served by the occupier not landlord. The CCG has been formally served with two petitions requesting a new Health Centre to be built to serve the population of East High Wycombe. This will be an agenda item for the PCCC in December 2017. The CCG considers the refurbishment of Lynton House with a reduced footprint to be an interim measure to ensure that adequate services remain in that part of High Wycombe. The reduced footprint of the surgery will lead to a reduction in rental reimbursement. The current rent reimbursement is £45,020 and the revised reimbursement is £23,000. EDTS have drawn up plans for the refurbished building and a tender process has been carried out to appoint the building contractor. The estimated cost for the refurbishment work is £126,460 which will be paid for as follows: Contributor Amount NHS England £ 83,483 (representing 66% of the cost) Landlord Contribution £ 12,450 Wycombe District Council CIL £ 30,000 Total £125,933

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Some additional minor improvement grant funding has been made available which will be kept as a small contingency. Actions: HD to include in her Head of Primary Care Report for the PCCC in September.

HD

Rent Review Management Service Bedgrove Surgery Rent Review Bedgrove Surgery has appealed the outcome of their recent rent reimbursement review. The practice is requesting rental reimbursement for 4 shared car parking spaces (shared with other services) at £200 per parking space. The DV has suggested that a compromise may be to offer the practice £100 rental reimbursement per shared space, which the practice has rejected. Following full local dispute resolution, the practice has the right to take their case to the Litigation Authority, which could be potentially time consuming and expensive for the CCG. Outcome: The Group agreed that it should accept the DV’s opinion in this matter. Actions: HD to inform CSU that the CCG concurs with DV’s opinion. John Hampden Surgery Rent Review In 2016 the Landlord for John Hampden Surgery raised the rent from £4625 to £4975; this increase was agreed by the DV and the increased rent reimbursement confirmed by the CSU back to the practice. Prior to this rental increase the practice received a separate payment of £350 per quarter towards repairs and insurance costs. Following the change in rental value the practice received £4,975 per quarter in one payment and assumed the top up of £350- would continue to be paid separately however NHS England had changed their process so that only one payment was received by the practice and omitted to tell the practice. The CSU have admitted the error in an email to the practice but this has left the practice out of pocket by £1400 per annum. Actions: HD to ask CSU to pay the practice the £1400 per year for costs incurred starting April 2017. HD to advise the practice to appeal to NHSE/CSU to reimburse any costs for previous years. Little Chalfont Practice Rent Review Little Chalfont Practice has built an extension since last rent review which has resulted in an increase in the CMR valuation from £80,300 to £83,500 p.a. However the CSU is not aware of permission being granted by NHSE for the extension prior to when it was built. Additionally the practice is disputing the level of rent reimbursement for their parking. They are currently being reimbursed for 23 spaces however have requested reimbursement for 28 parking spaces which includes tandem spaces. The meeting agreed that this has not been agreed in the Premises Cost Directions so this should be refused. Actions: CSU to ask Practice to provide evidence that permission was granted by NHS England for the extension. CSU to advise the practice that tandem car parking spaces will not be funded.

HD

HD

HD

HD

HD

One Public Estate

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SK updated the meeting on the recent One Public Estate meeting which focused on High Wycombe. The meeting discussed the potential “hub” for the Locality along with the proposed relocation of Wye Valley Surgery and Cressex Health Centre. Wycombe Locality to develop a locality based estates strategy which can be used to help inform decision making for the 3 local development plans. AOB Wye Valley Practice The current lease for the Wye Valley Surgery premises is due to expire in September 2017. Discussions have been held with Buckinghamshire Healthcare NHS Trust regarding the practice relocating to the Wycombe Hospital site. Paul Rowley to chase for an update from BHT. Practice to explore potential to lease 1st floor at Hanover House for a short lease from TPG. The Practice Manager has reported that their current Landlord has notified them of dilapidations to the value of £136k. Lou Patten has suggested that the CCG may be able to assist the practice with the dilapidation costs. Further the current landlord is unwilling to negotiate an extension to the current lease whilst the practice is considering moving elsewhere. Ultimately it is the practice’s responsibility to have premises from which they can fulfil their GMS contract. A move of premises may require a full staff and public consultation. Actions: Paul Rowley to chase BHT for rental and service charges along with terms. HD to ensure that the Executive Committee and Governing Body are briefed. The Swan Practice The CCG has received a business case from The Swan Practice to build a new health centre on the Lace Hill development. This has not yet been formally considered as no costings were available. A public meeting was held in Buckingham last week at which the proposed health centre was discussed. The public appeared to be satisfied with the health centre being built on the Lace Hill Development however they were also in favour of a health facility remaining in Buckingham town centre. The CCG are also aware that Norden House has plans to build a new health facility and therefore it is important that a locality estates strategy can be drawn up that acts as the rationale for future investment in estates and infrastructure. Kingsbrook Barratt Homes are building 2500 new homes on the Kingsbrook Estate. Poplar Grove Surgery has indicated that in order to accommodate the increase in patients they aim to accommodate a temporary facility when the 500th home is build and a new health centre when the 1500th home is built. Poplar Grove practice has made a statement of intent that they are willing to accept the incoming patients and that they may be able to structurally alter their current premises to enable them to accommodate more patients. Actions: VP and NL to discuss with Barratts Homes the potential for acquiring Section 106 funding to fund an extension to the existing Poplar Grove premises. Primary Care Estates Strategy

PR HD

VP/NL

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The CCG needs to prepare a Primary Care Estates Strategy however they do not have the capacity or technical expertise to undertake this work. The CCG will need to commission this service or utilise the necessary skills from partners within the ACS. Actions: HD / NL to discuss the requirement for specialist support to write this strategic plan at SMT. Date of Next Meeting: 25 September 2017, 1pm – 2.30pm

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MEETING: Primary Care Commissioning Committee AGENDA ITEM: K


TITLE: Head of Primary Care Report



Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report:

To inform the Primary Care Commissioning Committee of local and national developments within primary care in the context of NHS Aylesbury Vale and NHS Chiltern CCGs. Conflicts of Interest: None to note. Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all






Equality

Quality

Financial

Risks

Statutory/Legal

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Supporting Papers: None.

1. GP Forward View The GP Forward View Plan is now available on the CCGs websites at https://www.aylesburyvaleccg.nhs.uk/primary-care-joint-commissioning-meetings-in-public/. The Primary Care Operational Group will monitor progress against deliverables within the Plan on a monthly basis and escalate any issues to the Primary Care Commissioning Committee.

2. Primary Care Development Scheme The primary care development model has been designed to enable primary care to transition to new models of care in line with the 5 Year Forward View while maintaining the clinical quality of services. This model is supported by a multi-year development scheme which:

• Encompasses the Quality and Outcomes Framework (QOF) and the current Quality Improvement Schemes (QIS)

• Reduces inappropriate workload, that does not add clinical value • Is built on evidence-based care • Is responsive to the population health needs of localities and adds value to patient

care • Does not disadvantage practices that take up the proposed scheme • Aligns to national, STP and CCG strategies.

This is an entirely new scheme that has been well supported by the CCG Programme Boards as well as the Localities to ensure that its implementation is as smooth and effective as possible for practices. 49 out of 52 practices had signed up to the scheme (as at 31.8.17) which effectively started on 1st July 2017. A comprehensive dashboard has been produced showing current position, by practice and locality for all elements of the scheme. The Project Team involved in developing and implementing this scheme are now looking at how patient outcomes can be measured and will be working with the Commissioning Support Unit (CSU) to develop this concept further. The Project Team will also continue to meet regularly to monitor progress and to start developing recommendations for Year 2 of the scheme.

3. Building Resilience in Primary Care In April 2017, the CCGs commissioned KPMG and FedBucks to provide an intensive support programme to all localities across Buckinghamshire to develop an evidence-based case for change upon which to develop collaborative arrangements for the formation of primary care clusters within Buckinghamshire. The programme aimed to:

- Encourage collaborative locality working in clusters; - Develop a model of care with respect to primary care services in Buckinghamshire;

and

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https://www.aylesburyvaleccg.nhs.uk/primary-care-joint-commissioning-meetings-in-public/

- Develop a turnaround team/support package by working with clinical and management leaders from FedBucks to help build capacity and skills for working with individual practices.

The first stage of this programme is now complete and the full report is attached to this update. The CCG is now working with FedBucks to build a plan for Stage 2 of the programme.

4. 24/7 Primary Care Access In line with the CCGs’ Primary Care Strategy and aligned with the 5 Year Forward View and GP Forward View requirements, the CCGs intend to commission a fully integrated 24/7 primary care service where providers are encouraged to collaborate so that a truly seamless service can be commissioned on the basis of outcomes for the local population. This procurement signals a new way of commissioning services and the Governing Bodies have agreed the use of a novel Assurance Framework to support the process. The assessment of applications to provide this service will be conducted in the following stages:

1 Compliance review 2 Capability Assessment Stage One (CA1) 3 Recommendation to proceed 4 CCG Approvals 5 Capability Assessment Stage Two (CA2) An evaluation group has been established that is responsible for assessing applications against a set of Pass/Fail criteria. The evaluation group has now independently assessed all responses submitted by the due date of 25th August 2017 and a meeting was held on 30th August to moderate and agree the final assessment outcomes. On 7th September, the Steering Group will be asked to review and accept the evaluation group’s final assessment and to make recommendations ready to go to the CCGs Governing Body meetings on 14th September 2017. CA2 stage will start on 15th September and end on 30th November 2017 and will include the requirement for a full service solution with transformation, workforce and benefits realisation plans to be fully described by the preferred Provider Collaborative. Investment and reimbursement models as well as a detailed commercial model will also be required.

5. Chiltern House Medical Centre Following the publication of the CQC Inspection Report dated 3 August 2017 and Warning Notices issued to the practice by CQC dated 22 June 2017, the CCG has served notice to the practice that the CCG considers the practice in breach of its GMS contract. In accordance with schedule 6 part 8, regulation 115 of the NHS (GMS Contract) Regulations 2004, the practice is required to remedy the breach by drawing up and implementing an action plan to achieve compliance with the warning notices and the regulatory breaches identified in the CQC Report. The practice’s progress in taking the required action will be reviewed at the monthly CQC Oversight Meetings which are overseen by the NHS England Quality Team. Failure to comply with the Remedial Breach Notice may result in further breach notices being issued or the CCGs taking steps to terminate the contract or consider the imposition of a contract sanction.

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6. Premises and Estates

Lynton House Branch Surgery, High Wycombe: the CCGs have been working closely with the practice and the landlord for Lynton House to agree a date to start the refurbishment works needed to upgrade the premises. The practice will be giving patients prior notice of commencement of works, which are due to take approximately 6 weeks to complete. Wye Valley Surgery, High Wycombe: this practice has expanded significantly since it originally leased their premises in Desborough Avenue and there is now the need to find alternative accommodation so that the practice can provide additional patient services. The CCG is supporting the practice in exploring the limited options available. Estates and Technology Transformation Fund: Two new build schemes were successful in being awarded capital (in principle) from NHS England towards the build costs of new practice premises. The first scheme is a new build in Beaconsfield that will accommodate both the Simpson Centre and Millbarn practices. The Project Initiation Document (PID) for this scheme is being presented to Committee on 7th September. The second scheme is a new build for the Berryfields Medical Centre in Aylesbury. The Berryfields practice is currently situated in modular accommodation and is planning to move to a new site within the Berryfields development. The PID for this scheme will be presented to Committee in due course. Premises Sub Group: Since April 2017, both CCGs have held delegated status with regard to primary care commissioning and an increasing number of decisions regarding primary care premises are also now being delegated to the CCG. To that end, a Premises Sub Group (a sub group of the PCCC) has been established and the notes of the meeting held on 24th July 2017 have been circulated with the PCCC Agenda and Papers for information. Estates Strategy: A gap analysis conducted against the 5 Year Forward View requirements has highlighted that the CCGs are ragged red due to the absence of an up to date primary care estates strategy. Given the CCGs are now part of the Accountable Care System (ACS), this provides us with the opportunity to link the estates review to the wider health and social care economy through the One Public Estates workstream in partnership with BHT and Bucks County Council. The Committee will in future receive regular Estates update reports. Patient Registrations Since delegation, the CCGs have been responsible for helping patients to register with a practice where they encounter difficulties. Although NHS England has issued guidance on the process to follow1, this guidance does not cover instances where the patient lives in an area only covered by one practice. This situation has arisen recently and the CCG has only been able to fulfil its duties as commissioner by assigning the patient to a practice. To ensure that the CCGs have a fair and equitable process in place should this situation arise again, the CCGs are proposing to draft a local policy in consultation with our GP localities and the LMC. The draft policy will be presented to the Primary Care Operational Group in October 2017.

Helen Delaitre 31st August 2017

1 Policy Book for Primary Medical Services

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