Agenda Document for Primary Care Commissioning Committee

PRIMARY CARE COMMISSIONING COMMITTEE - OPEN MEETING

Tuesday, 7 September 2021 9.45 am Microsoft Teams Meeting

AGENDA

Agenda Item Time Presenter Pages/ Action Verbal Required 1 Chairman's Welcome 9.45 am Chair Record

2 Apologies 9.45 am Chair Record

3 Declarations of Interest 9.45 am Chair Record Individuals will declare any interest that they have, in relation to a decision to be made in the exercise of the commissioning functions of Wigan Borough Clinical Commissioning Group, in writing to the Governing Body, as soon as they are aware of it and in any event no later than 28 days after becoming aware. 4 Minutes of Previous Meeting and Actions 9.50 am Chair 1 - 14 Approve

5 Options Appraisal Boundary Change - 10.00 am Gillian 15 - 38 Approve Hawkley Brook Medical Practice (P92647) Watson - SWAN PCN

6 Standing Agenda Items 10.15 am All Receive

Catherine Johnson / 6.1 Finance Update 39 - 50 Receive Kirsty Wilson Primary Care Commissioning Gillian 6.2 51 - 62 Receive Programme Update Watson Debbie Primary Care Quality Improvement 6.3 Szwandt / 63 - 76 Receive Programme Update Alison Foster Primary Care Infrastructure Jonathan 6.4 77 - 88 Receive Programme Update Kerry 6.5 NHS England Update Angela Osei 89 - 98 Receive

7 Local Commissioned Service 10.45 am Gillian 99 - Approve Specification Review Watson 102

103 - 7.1 Influenza Service Specification 112 113 - 7.2 Near Patient Testing 118 7.3 Ring Pessary To Follow 119 - 7.4 Anticoagulation 130 131 - 7.5 End Of Life (Draft) To follow 140 8 Any Other Business 10.50 am Chair Receive

9 Date and Time of next meeting 10.55 am Chair Notes Tuesday 02nd November 2021 10am Minutes of Primary Care Commissioning Committee - Open Meeting Held on Tuesday 6 July 2021 at 10.00 am in Microsoft Teams Meeting.

Present Frank Costello, Lay Member (FC) – Chair Linda Scott, Director of Primary Care (LS) Jonathan Kerry, Associate Director of Primary Care (JK) Debbie Szwandt, Assistant Director Primary Care (DS) Gill Watson, Primary Care Commissioning Manager (GW) Catherine Johnson, Senior Finance Manager (CJ) Dr Nikesh Vallabh, GP Representative (NV) Alison Foster, Lead Nurse for Quality (AF) Ernie Rothwell, Lay Member (ER) Gail Henshaw, NHS England Representative (GH) Mick Hodlin, Healthwatch Wigan and Leigh (MH) Karen Parker, Healthwatch Wigan and Leigh (KP) Anne Burgess, Head of Primary Care Workforce Development and Learning (AB)

In Attendance: Marie Pilling, Corporate support officer

ACTION

1 Chairman's Welcome FC welcomed everyone to the July Primary Care Commissioning Committee meeting.

2 Apologies Apologies received from: Dr Marios Adamou, Governing Body/ Secondary Care Doctor Craig Harris, Accountable Officer Paul McKevitt, Chief Finance Officer Claire Roberts, Associate Director, Primary Care Transformation

3 Declarations of Interest Individuals will declare any interest that they have, in relation to a decision to be made in the exercise of the commissioning functions of Wigan Borough Clinical Commissioning Group, in writing to the Governing Body, as soon as they are aware of it and in any event no later than 28 days after becoming aware.

4 Minutes of Previous Meeting and Actions Minutes The minutes of the previous meeting were approved as a true and accurate record.

Page 1 Actions The actions from the previous meeting were reviewed and updated. 5 Standing Agenda Items

5.1 Finance Update CJ presented an update on the financial position that was reported as of 31st May 2021 for the Delegated and Non-Delegated areas of Primary Medical Care expenditure. The report also includes an update on additional investment money.

As reported at the March Committee meeting, due to the ongoing pandemic, financial plans for 2021/22 have so far been set for the period April to September which is referred to has H1. These have been based on system allocations received in the second half of 2020/21, plus 0.88% programme growth.

CJ referred to the table on page 13 of the agenda pack and made the following observations: Table 1- - Financial plans have only been set for the first 6 months referred to as H1. - Delegated Budget £26m and non- Delegated Budget £8m.

Table 2- PCN and non- PCN - The Delegated budgets include the nationally agreed inflationary increases and includes 3% inflation for Premises costs and estimates for list growth size. - Over £2.2m investment will be made available to PCNs in H1. - The CCGs Delegated budgets exceed the H1 allocation £278k, therefore a negative reserve had been created in order for the plans to balance - this will be a pressure against PC budget if savings aren’t identified. - The ARRS budget represents c56% of the total ARRS funding available in H1 and the remaining funds are held centrally by NHSE and available for draw down by the CCG/ PCN if required.

Table 3- outlines the investment that Wigan is expected to receive a share of. - As at M02 the CCG has been notified that it will receive £710k for Primary Care COVID Support which will support the Hot Clinics and reduce the backlog. - Further £98k has also been made available to Wigan PCN and Community Pharmacy- led COVID Vaccination to provide additional staffing between 16th June to 14th July.

CCG has recently undergone an audit by the Mersey Internal Audit Agency (MIA). MIA were asked to complete an audit of the COVID 2

Page 2 claims process and we can confirm the CCG have received high assurance, stating that there was a strong system in place.

LS added that we have also put in for the extension of the Clinical Director for Leadership and Management across PCNs and it has been put in the finance forecast as this will run until September.

FC referred to the £11.7m which is allocated as GM money and queried, how we access the remaining money available to support staffing models etc.

CJ suggested this is part of the action previously mentioned on the action log and it can be picked up with Angela Osei as part of the Primary Care PCN Funding.

NV stated that we need to know what is held back at GM and how we can utilise that. Then we can look how that will be shared out. NV also queried if the network and practices will be able to identify what support they need or will the money be ring fenced.

LS confirmed that the money received has been ring fenced for the Hot Clinics and supporting phone line booking. This has been discussed with LMC, the other things we have mentioned will be considered but I suspect that this will be supporting Hot Clinics which supports all our practices.

Resolved: The Committee received the report and noted the contents.

5.2 Primary Care Commissioning Programme Update

DS presented an update on the progress of the Primary Care Co- commissioning Programme during 22nd April 2021- 16th June 2021. The report details any contractual changes that have been made during this period in particular those to facilitate the continued scale up of the COVID vaccination programme to include Cohorts 10-12 and requirements of the PCN Network DES for 2021/2022.

On page 20 of the agenda pack the Committee members are asked to note the addition of objective number 4: - Manage all GP contract requests in line with contract regulations and NHSE/I policy book.

On page 21 in the agenda pack is a report on GP Partner retirements/ leavers/ joiners, and merger applications following a recent update with GM. Work is ongoing with GM to ensure communication regarding applications and leavers etc is timely. One of the changes reported was in relation to a PMS contract and this 3

Page 3 will need further work. The local commissioner needs to be involved in decisions when it involves a PMS contract.

The report details the key notifications issued by NHS England during this period and DS highlighted the letter received on the 17th June which updated on GP contract arrangements for 2021/22.

The letter advised on an initial set of funding and contractual arrangement which was supplemented by £120m additional funding for the period April 2021 to September 2021 to support general practice capacity as well as up to £32.5m additional funding for PCN Clinical Director support from April 2021 to June 2021. NHS England have confirmed that it will provide further funding for PCN Clinical Director support for the period from July to September 2021. This funding is temporary and time limited.

PCNs are eligible for this further support payment where at least one Core Network Practice is signed up to the COVID-19 Vaccination Programme Enhanced Service. This funding is to support the leadership and management of the COVID-19 response and may be used by PCNs to enhance the management or support capacity for their clinical leadership.

NHS England is also offering practices the voluntary opportunity to participate in two new enhanced services from 1 July, backed by up to £50m of wholly additional funding for 2021/22. These focus on the priorities to support recovery from the pandemic and Weight Management.

DS advised that the GP enhance specification will be covered under agenda item 6.

NV commented that it was helpful to see all GPs leaving and joining practices and gives a good idea of the number of GPs retiring and new partners. Many GPs will join as a salary GP so these may not be captured, he reassured the Committee that there will be more new GPs than noted in the report.

Committee members were advised that numbers of GPs and timeliness of the GP data is on the agenda for the LMC meeting tomorrow. GH added that they will work on the timeliness of the GP reports and ensure that CCG members receive the reports as appropriate.

FC noted the retirement news of David Valentine and asked about any issues of the closure of Golborne Vaccination Clinic. LS reassured Committee members that we have had a high number of uptakes and LiGA PCN are working in Leigh Sports Village which

Page 4 is working well.

Resolved: The Committee accepted the report and noted the contents.

5.3 Primary Care Quality Improvement Programme Update

DS provided an update on the progress of the Primary Care Quality Improvement Programme, between 22nd April 2021- 16th June 2021, the focus of the work continues to be predominantly to support practices to implement the COVID 19 Vaccination Programme.

Within the report milestone 2 is new and supporting information has been included in the appendix.

Primary Care Assurance Framework (PCAF) has been mobilised following the peak of the COVID Pandemic and fifteen months of an “on hold” position, priority metrics were discussed in April 2021 Primary Care Operations Group.

Care Quality Commission (CQC) update- at the quarterly meeting on the 17th June 2021 a review of all member practices was carried out, CQC confirmed all practices are currently low risk. The CQC have updated that the comprehensive visits have started again and although we do not have any inadequate practices our inspector is being redeployed to support across GM.

Table 2 on page 32 of the agenda pack shows the Wigan Borough CCG GP practice CQC latest inspections by year. This demonstrates a very positive picture.

The COVID Vaccination Programme will be covered as a separate agenda item. Key highlights within the report were noted: - 356,000 vaccinations have been administered. - 80 % of 40-49yrs and 35% of 18- 29yrs have now received their first vaccination. - Work continues to increase capacity of vaccine delivery. - Delivery of the 2nd vaccine has increased to 150,000 up from 66,000 in April 2021.

AF gave an update on the General Practice Nurse Champions: - Previously we had six GPNCs, but we had one step down at beginning of June for the next three months. - The remaining five GPNCs will provide cover during this period. - Continue to develop and deliver the forums for nurses and care assistants. - In future we will be reporting on a review of the GPNC roles 5

Page 5 and aligning it with practice managers so an update will come to the next committee meeting.

AB gave an update on the Additional Roles Reimbursement Scheme: - We have had great success regarding ARRS and the steps taken to implement new roles. - We ended last year on 57 WTE additional roles and look to increase this to 103/4 by end of this year. - Recruitment underway for Care Co-ordinators and the Council will host those roles. - Looking to recruit to 16 of those positions and interviews are taking place this week. - Mental Health Practitioners are a new role, and we are looking to recruit 14. - Working on care navigation scoping in General Practice and enhanced patient experience of accessing services. - Practice manager resilience training- making the role attractive helping us to maintain staff and improve the development of future practice managers.

NV commented on the First Contact Practitioners, we have 18 FTE and from a patient and GP perspective that gave an additional 90 appointments, and we can see patients in 72 hours. 90% of the work is done in house and is delivering a quality of care and improving patient outcomes. These additional roles are a huge benefit to patients and practices.

FC concluded, we need to continue to look at new roles we can develop that will support practices and improve patient quality. Pre- covid one of our ambitions was to ensure good practices reached outstanding, although we have other priorities, we do not want to lose sight of our ambition.

Resolved- The Committee received the report and noted the contents.

5.4 Primary Care Infrastructure Programme Update

JK presented an update on the progress against the CCGs Primary Care Infrastructure Support Programme and highlighted the pertinent points within the report:

Digital: - Continue to dedicate a substantial amount of resource to the support of the Borough Wide Vaccination Hub system which underpins the booking and operations within our COVID vaccination Centre. 6

Page 6 - Supported just over 210,000 vaccinations in local clinics. We want to continue to improve systems. - Work continues to utilise existing technologies to support the introduction of Friends and Family Tests (FFT) to the vaccination programme. - For seven months we have been using multiple systems to support clinics, recently been working with TPP to replace Pinnacle, and working to remove duplication of systems in Hindley PCN and this will allow us to utilise FFT in wider systems and get a strong foundation for the future.

NHS111 and GP connect: - In June 2020 work was completed to implement the capability of direct booking between NHS111 services and General Practice. This created a mechanism through which NHS111 could “triage” calls into a Practice appointment slot, allowing local workflows and processes to then be followed in order to provide the appropriate care to the individual. - Given the continued increasing demand across all health services, work has been progressed to review the setup and configuration of the direct booking slots to ensure they align to the demand being seen through NHS111. - Through this refreshed configuration and approach, we will monitor usage, with the expectation of an increased utilisation of slots, and the right care being delivered at the right time in the right place.

Clinical System Migrations: - Recently moved a step closer to our goal of standardising practice clinical systems locally, with one of the two remaining INPS practices migrating to EMIS Web. - This provides benefits not just to the practice, but also to Central Wigan PCN allowing them to really maximise the benefits of collaboration and integration across practices. - We have had confirmation that the one remaining INPS practice is happy to move to EMIS Web. - We are hoping to commence the 12-week transition process in July and will ensure further updates are brought to the Committee.

Support to Primacy Care Networks: - Work has progressed to understand the developing PCNs and their plans for the ARRS embedding into the existing practice workflows. - Work is ongoing regarding the introduction of a Clinical Services Hub using EMIS and TTP to ensure a seamless approach. - Across the seven PCNs there is a degree of variation in their

Page 7 approach but aim to deliver and achieve the same, aligning to the four core phases as detailed on page 45 of the agenda pack.

Enhanced digital learning sets: - It brought out some interesting learning and feedback from practices. - This approach allows everyone to share experiences. - We want to develop a number of Enhanced Action Learning Sets (EALS) across the PCNs.

Information governance: - Continue to support information governance using the tool kit. - We went through an internal audit, and we have received assurances that we have good tool kit, and this will be reported at the Audit Committee.

Estates: - Approved Boothstown/ Parr Bridge development and conversations are underway regarding the tendering process. We hope to complete by December 2021 and to commence in January 2022. - Aspull Surgery- we have received formal planning approval and the revised image of the building has been included in the agenda pack on page 48. We remain on track to commence during August 2021. - Shevington Surgery remains a commitment we want to progress. The initial Business Case has been reviewed by the Primary Care Committee and subsequently the CCG Finance, Contracting and Performance Sub-committee to gain approval. The business case was supported by both committees, but further work needs to be done to ensure the scheme is financially sustainable for all partners.

Primary Care Network estates: - Started to progress with SWAN PCN to get a mandate in place and we hope to address this further across other PCNs and set a clinical delivery direction and drive forward better utilisation and improving estates in a controlled fashion to provide maximum benefits.

FC confirmed that we will deliver on Shevington Surgery, but we are challenging the finance around the building costs.

NV referred to the 4 phases and asked if this can be developed to allow practices to identify their own phases and identify what support they need to progress through them. JK added, we need to understand where everyone is up to, so we

Page 8 can ensure that our resources are utilised effectively to move this forward. One positive is our relationships with System One/ TTP and Ask my GP as they approach us regarding pilot schemes which should stand us in good stead for the benefits.

FC concluded that we need to recognise that PCNs will progress at different rates through the phases, and we need to identify those progressing slower so we can support them.

Resolved: The Committee received the report and note the contents. 5.5 NHS England Update

GH gave an update on behalf of NHSE: - The Workforce update for July is now available which contains support and resources available to all primary care providers. This will be shared with Committee members following the meeting. - Demand in Primary Care has increased and there has been significant demand due to the consequences of the pandemic. - A task and finish group has been established comprising of Commissioners and Provider colleagues to rapidly mobilise a plan to support Primary Care in managing the rising demand for services. - It was agreed that a system-wide, targeted approach is required to support this programme of work. Taking the learning from the pandemic and using evidence to drive change, so we can identify the areas that will generate the most impact and make a difference for the population in the short, medium, and long term. - The key priorities areas are: Improved access, health, wellbeing and resilience, communications and engagement, workforce, and urgent care. Work is already progressing in individual localities. As part of the programme of work the re- purposed group will look to understand what is happening locally, share best practice and scale up where appropriate. - In the wider context of practices being in demand a letter came out in June to support national funding of £20m that will support primary care providers to draw down additional staff through their lead employer to help deliver the COVID-19 vaccination programme between 16 June and 14 July 2021. - £30m has been made available for covid support and weight management support. - Letter went out from NHSE which outlines phase 3 of the booster programme which should begin in September 2021 to coincide with Flu programme.

Page 9 LS noted that the group that GH referred to is looking at demand in Primary Care and is attended by Dr Tim Dalton as co-chair and Jonathan Kerry. Planning for Phase 3 of the vaccination programme has started, and we will be working with the leadership members of the vaccine programme.

DS confirmed that the letter to Wigan GP services regarding the Enhanced Service Specification will be going out tomorrow.

Resolved: The Committee received the update.

6 Enhanced General Specification 2021/22 JK presented an update on the final detail of the Enhanced Service Specification in 2021/22.

With the updated specification, we have worked with Clinical colleagues and the Local Medical Committee (LMC) to set out a clear direction, supportive but not duplicating, that will ensure that we are able to clearly demonstrate how our investment underpins quality improvement and health promotion to improve the outcomes for our local population, whilst simultaneously reducing inequality.

We are keen to encourage the benefits of working collaboratively, and through Primary Care Network (PCN) Collaboration Priorities we will develop PCN level projects which will compliment ongoing work within the PCN Direct Enhanced Service (PCN DES).

JK outlined the principles as detailed below: - Practice Sign up to scheme- Funding aligned to Practice and PCNs according to the Funding Model - Practices and PCNs to agree 3 “Collaboration Priorities” (Projects highlighted within scheme) to deliver at a PCN level - Practices have the ability to utilise the Collaboration Priorities element of funding to deliver the priority or can opt to fund other practices in the PCN to deliver on their behalf. - All Practices are expected to participate in the Collaboration Priorities, with “Opt-outs” from them being in exceptional circumstances. - Clear specification of expected Outcomes, Deliverables and Metrics to support achievement

JK went through each of the core theme as detailed on pages 56- 61 in the agenda pack. If we deliver the outcomes and the deliverables, we have noted the metrics that we will measure against.

Following approval, we will draft up a contract and will look to commence in Quarter 3.

Page 10 AF asked if we could include the patient feedback/ service user experience in the collaborative section. JK agreed and stated that this will be referenced in the final contract specification.

The Committee was asked to review the finalised detail of the specification to approve it for contract progression.

Resolved- The Committee reviewed the Specification and approved it for contract progression. 7 Options Appraisal - Y00050 Pennington Park Surgery / P92035 Lilford Park Surgery - Leigh PCN DS explained that on the 8th April 2021 Wigan Borough CCG received a formal application from Dr Akalanka Weerasekara and Dr Samaitha Weerasekara; Pennington Park Surgery (Y00050) to merge with Lilford Park Surgery (P92035).

The draft Options Appraisal was reviewed at the Primary Care Operations group on the 21st April 2021, with further information requested to clarify workforce capacity and Leigh PCN engagement and a subsequent updated business case received on the 8th June 2021.

In accordance with the guidelines set out in the Primary Medical Services Policy and Guidance Manual with regards to the merger of two practices, the Primary Care Team from the CCG and the contract holder explored the options available to them. The options were: - Merger of the two contracts. - Retain the existing two contracts.

As part of the options appraisal, we have received some stakeholder feedback and the Local Medical Committee (LMC) LiGA are in support. During the appraisal we found no dis-benefits to the merge of the two contracts.

The purpose of this Options Appraisal is to present all the available facts to the Committee so that an informed decision can be taken.

Recommendations 13.1. The Wigan Borough CCG Primary Care Commissioning Committee are asked to consider the contents of this report and decide the preferred option. 13.2. The Primary Care Team would ask the Committee to consider option 2 as the preferred option subject to the following: - Practice to confirm the formal merge date and provide a detailed plan for the practice merger. - Practice completes a signed variation as directed by Greater Manchester Health & Social Care partnership. - A detailed patient communications plan to be provided by the practice to include the options available to patients regarding patient choice within the area. - Practice to take mitigating actions in response to concerns raised during 11

Page 11 the public consultation by ensuring:  Ensuring services remain on both sites.  Ensuring that neither site is deemed as a branch site. 13.3. The Practice proposed the merger will become Lilford & Pennington Park Surgery (P92035)

FC referenced bullet point 13.2 and suggested an additional point be added regarding maintaining appropriate staffing levels. DS agreed with the suggestion and referred to table 5 on page 73 of the agenda pack which lists the staffing model and provides assurance that no staff will be lost in the merger.

Resolved: The Committee approved the recommendation subject to bullet point being added as agreed. 8 Any Other Business No other business was raised.

9 Date and Time of next meeting Tuesday 07th September 2021 10am

Meeting concluded: Time Not Specified

Page 12 Actions from the WBCCG - OPEN Primary Care Commissioning Committee (PCCC) held on Tuesday 06 July 2021

Agreed Actions September 2020 Item Number Action Action By Progress 5.5 NHS England Update AO to comeback to Committee with a breakdown of AO We have received formal breakdown of the cost and AO the £1m being held centrally and find out how the will share following the meeting with LS. BI and DI are in money will be split and how the CCG will be support and there is a large piece of work ongoing informed about accessing it at a local level and regarding review of PCN’s to offer more support. Most feedback to committee members. recently HR support has been put in place to support the roles and someone has been brought in the support the R’s summary.

Page 13 Page Update 04/05/2021- there have been a few verbal updates following concerns regarding Wigan receiving funding. AO is still awaiting the formal report to share with LS.

Update 06/07/2021- GM team is to request responses to the GP Provider Board and localities regarding the PCN development programme. This will provide a transparent look across both localities and GM and the information will be shared with both the provider board and locality leads. A separate conversation is taking place with the finance leads/Ben Galbraith regarding any further PCN spend.

Action on-going Agreed Actions July 2021 No new Actions This page is intentionally left blank MEETING: Primary Care Commissioning Committee Item Number: 5

DATE: 07th September 2021

Options Appraisal Boundary Change - Hawkley Brook Medical REPORT TITLE: Practice (P92647) - SWAN PCN

1: Commissioning Health and Care Services CORPORATE Commission health and care services that meet the needs of OBJECTIVE local people, delivering high quality, clinically viable, ADDRESSED: affordable, efficient and responsive services that improve the overall experience for each person at every contact, across their life course.

2: Equality and Inclusion - Everyone Counts As a health and social care partnership, ensure that everyone has fair and equitable access to health and care services, in order for each person to fulfil their individual potential to live longer, and have happy and healthier lives.

3: Innovation and Sustainability Develop, implement and sustain effective initiatives that will lead to improvements in quality and experience for local people, whilst ensuring that we make the best use of the 'Wigan Pound'.

4. Financial Affordability Commission high quality health and care services within the allocated financial resources that are available to the Borough.

REPORT AUTHOR: Gillian Watson – Primary Care Commissioning Manager

PRESENTED BY: Gillian Watson – Primary Care Commissioning Manager

RECOMMENDATIONS/ The Committee is asked to receive the report and for Decision DECISION REQUIRED: on the preferred option.

Page 15 EXECUTIVE SUMMARY

On the 27th July 2021, Wigan Borough Clinical Commissioning Group (CCG) received a formal application from Hawkley Brook Medical Practice (P92647) located at Chandler House, Poolstock Lane, Wigan, WN3 5HL to change their boundary area.

The draft Options Appraisal was reviewed at the Primary Care Operations group on the 18th August 2021, with further information requested to clarify how will the practice ensure that the patients living in the new widened “outer boundary” will receive wider health and social care services such as; First Contact Physiotherapy and District Nursing and what impact does the practice foresee on the “place-based working” approach for those patients living in neighbourhoods outside SWAN PCN/SDF area?.

Under Level Three Delegated Commissioning Wigan Borough Clinical Commissioning Groups (the CCG) Primary Care Commissioning Committee (PCCC) is responsible for making decisions on the future of Primary Medical Services within the Borough, which includes taking decisions on the merging of contracts.

The CCG must consider any application having regard to but not limited to: impact on patients, patient choice, impact on other primary care providers, premises and leases, financial implications and primary care strategies.

The CCG and NHS England (GM Health & Social Care Partnership) are required to carry out an Options Appraisal to support the commissioning decision regarding the Primary Medical Services for the respective registered patient list.

It is therefore the purpose of this Options Appraisal to present all of the available facts to the Committee so that an informed decision can be taken.

FURTHER ACTION None REQUIRED:

EQUALITY AND DIVERSITY: Confirmed that any changes to service or procedure introduced as a result of this report do not impact adversely on any of the protected groups covered by the Equality Act 2010.

Page 16 Primary Care Commissioning Options Appraisal:

The proposed boundary change for Hawkley Brook Medical Practice (P92647)

1. Introduction

1.1. On the 27th July 2021, Wigan Borough Clinical Commissioning Group (CCG) received a formal application from Hawkley Brook Medical Practice (P92647) located at Chandler House, Poolstock Lane, Wigan, WN3 5HL to change their boundary area.

1.2. Under Level Three Delegated Commissioning the CCG Primary Care Commissioning Committee (PCCC) is responsible for making decisions on the future of Primary Medical Services within the Borough. This includes taking decisions on any alterations to a practice boundary.

1.3. The underlying principle for the PCCC is to consider; when any such proposal is made, what the benefits are for patients and what the financial implications are to the CCG. The CCG must consider any application having regard to but not limited to: impact on patients, patient choice, impact on other primary care providers, financial implications and primary care strategies.

1.4. The CCG and NHS England (GM Health & Social Care Partnership) are required to carry out an Options Appraisal to support the commissioning decision regarding the Primary Medical Services for the respective registered patient list.

1.5. The role of the PCCC is to ensure that due process has been followed and that all of the information presented to them is of a standard that allows them to make a fair and balanced decision.

1.6. Two options will be assessed:

 Approve the application and allow the boundary changes to be made.  Reject the application meaning that the primary medical services continue as is and providing a rationale to the provider.

2. Background

2.1. On 27th July 2021, the CCG received an application from Hawkley Brook Medical Practice (P92647) to extend the outer practice boundary. Any approved change would constitute a contract variation.

2.2. Hawkley Brook Medical Practice is situated within SWAN PCN in Worsley Mesnes, Hawkley Hall , Poolstock, Newtown and Winstanley Neighbourhoods.

1 Page 17 2.3. The practice holds a GMS contract and has 2 partners. The practice has highlighted their workforce in the below table.

Number of GPs and clinical sessions 3 GP / hours (provide breakdown) 2 x Partners – 6 sessions

1 x Salaried 5 sessions

Number of hours of nursing time 45 hours per week

(provide breakdown) Practice Nurse – 25hrs HCA – 20 hrs Number of other practice staff 1 Practice Manager 30hrs 1 Reception manager 35 hrs (provide breakdown) 1 GP Asst 35hrs 1 Qof Lead / Administrator 25hrs 4 x reception / admin = 89hrs Table 1 – Clinical and Non-Clinical Workforce – P92647

2.4. Core hours are 8am – 6.30pm Monday to Friday and Extended Access hours Monday to Friday, 6.30am – 8am.

2.5. The practice list size was 3063, weighted list size of 3667 as at April 2021.

3. Practice boundary change application

3.1. The practice has indicated that the revised outer boundary will be an extension to the current inner boundary. The practice propose the below change to the inner / outer boundary.

3.2. Figure 1: Current boundary area

2 Page 18 3.3. Figure 2: Proposed boundary change

Hawkley Brook Practice

3.4. The practice have indicated all postcodes below except WN7 / WN8 and exclude Wrightington from WN6 postcode. Table 2

Postcode Coverage Area Local Authority Area WN1 Haigh, Ince, Swinley, Wigan Wigan WN2 Abram, Aspull, Bamfurlong, Bickershaw, Wigan Haigh, Hindley, Hindley Green, Ince, Platt Bridge WN3 Goose Green, Ince, Winstanley, Worsley Wigan Mesnes, Hawkley Hall WN4 Ashton-in-Makerfield, Garswood Wigan & St Helens WN5 Billinge, Newtown, Higher End, Orrell, Wigan & St Pemberton, Winstanley, Worsley Hall, Helens

3 Page 19 Marsh Green. WN6 Appley Bridge, Shevington, Standish, Wigan Standish Lower Ground,

3.5. Figure 3 – outlines the area of the above (Appendix

3.6. The practice has highlighted several reasons for the boundary change request within the application, and these are summarised as follows:

 New partnership in place at the practice, which has resulted in the practice revising current polices.

 Due to Covid-19, the practice has changed the way that they deliver care to their patients with the introduction of digital platforms that allow patients to access their healthcare services remotely.

4 Page 20  The practice has developed strong working relationships with patients that can move from the practice boundary and with the advent of remote consulting the practice wishes to give patients the option to continue the working relationship with the practice.

 The practice also has additional capacity to take on newly registered patients and would like to support areas where practices are being overwhelmed with new patients.

 Continuity of care - Increased requests to remain registered at the practice when changing address outside of the current practice boundary

 The practice works closely with community services that provide great support with patients being seen at their residence if they are acutely unwell. The practice does not want to disadvantage any patients by not offering home visits.

4. Patient and stakeholder engagement

4.1. In line with the Policy & Guidance Manual (PGM), a consultation letter as detailed in Appendix 1 has been circulated to potentially affected parties as follows:

 Healthwatch Wigan  Wigan Local Medical Committee (LMC)  Clinical Director for SWAN PCN  Clinical Director for Wigan North PCN  Clinical Director for Wigan Central PCN  Clinical Director for Hindley PCN  Neighbouring Wigan Borough GP practices  Wigan Community Services at WWL  Mental Health Trust  Local Councillors (41) – Abram / Ashton / Bryn / Worsley Mesnes / Orrel / Winstanley / Aspull / Hindley / Ince / Pemberton / Standish / Wigan Central & Wigan West Wards

4.2. Neighbouring Wigan GP practices within a 2-mile radius. Table 3

Name of Practice Distance from WN3 5HL The Chandler Surgery 0 miles away Marus Bridge Practice 0 miles away Dr Zaman Practice 0 miles away Shakespeare Surgery 0 miles away Winstanley Medical Centre 1.2 miles away Pemberton Surgery 1.2 miles away Newtown Medical Practice 1.2 miles away Claire House Surgery 1.3 miles away Lower Ince Surgery 1.3 miles away The Dicconson Group Practice 1.4 miles away Mesnes View Surgery 1.5 miles away Wrightington Street Surgery 1.6 miles away Sullivan Way Surgery 1.6 miles away

5 Page 21 Marsh Green Medical Practice 1.7 miles away Longshoot Medical Centre 1.7 miles away Beech Hill Medical Practice 1.8 miles away Higher Ince Surgery 1.9 miles away Bradshaw Medical Centre 1.9 miles away Bryn Cross Surgery 2 miles away Platt Bridge Medical Centre 2 miles away Platt House Surgery 2 miles away Alexander House Surgery 2 miles away

4.3. Full detail of the responses received is included within Appendix 6.

4.4. The responses received were supportive of the application and did not raise any objections to the proposal.

5. Practice Profile – Access

5.1. Appendix 4 shows the location of the practices registered list.

6. Considerations

6.1. There are a number of factors that should be considered in relation to this application, and these are articulated below.

6.1.1. Local housing developments

In September 2018, Wigan Council were given permission to redevelop five sites across the Worsley Mesnes estate. Taking the views of residents, community groups and organisations within the local community formed a vital part of this project and have helped shape the regeneration proposals. Almost 95 per cent of residents who took part in the consultation supported the proposals, which included the demolition of five sites to make space for new housing, retail and landscaping improvements.

The five sites identified for development include (Map detailing this Appendix 3):

 Site A: Site of the former Hindley House Sheltered Accommodation (already demolished)  Site B: The site of the former Wheel Pub, the shopping parade, adjoining parking areas and a number of Council owned block flats off Dryden Close.  Site C: The site of Huxley House Council flats and former site of Blake Close Council flats (demolished)  Site D: Area of open land at Elliot Drive between Eliot Gardens extra care scheme and Mesnes Avenue  Site E: Site of former Victoria Labour club, and area of open land to the north

In June 2020 Wigan council selected Keepmoat Homes as their preferred development partner to regenerate the area. The proposal of 184 new homes, of which 45 are affordable homes/apartments for rent and 139 homes for private sale, along with a new shopping parade. Delivered across the five

6 Page 22 priority development sites offers the potential to create a truly balanced and integrated community that will support the sustainable growth of the estate over the longer term.

6.1.2. The size/shape of the proposed boundary

The practice have specified in Figure 2 and Table 2 their intended practice boundary. The practice wishes to keep the inner boundary and expand on the outer boundary.

Appendix 4 demonstrates where the current patient list resides. GMS Regulations prevent the practice from removing patients unless specific criteria are met, however the proposed change to the boundary would mean that new residents would be able to join the practice and be entitled to all services within the practice.

6.1.3. Impact on service users

A decision to approve the application would mean that the current patients who reside within the outer boundary will have access to all services including home visits.

The practice have highlighted that due to the Covid pandemic new ways of working have been introduced, such as the use of digital platforms. This has changed the way the practice delivers care to patients by allowing patients to access healthcare services remotely recognising some patients prefer this access, which means there are no geographical limitations now.

6.1.4. Stakeholder Engagement

Stakeholder engagement has been undertaken by the CCG as described in Section 4 of this paper, with the responses received detailed in Appendix 6.

A question was asked from 1 GP Practice – “Is the practice planning to service these patients in all the suggested areas with home visits? If they are not, how are they going to manage these patients? If a patient deteriorates, are they going to manage them remotely?

Practice Response: We want to provide the highest quality of care for all of our patients irrespective of where they reside. We provide visits for all of our registered patients of which the majority lie within the practice internal boundary. This includes visits for flu and covid vaccinations for those that are housebound.

The request to extend the practice boundary with an outer boundary would allow the practice to take more patients on. These patients may be at a further distance from the practice and this could make house visits very challenging due to the distances and often the time it would take to make these visits. This would be very clear to those patients who wish to remain registered with the practice in the outer boundary. We would want to be clear that these patients are not then expected to see acute services or place unnecessary pressure on

7 Page 23 the wider system. We would suggest the following for patients in the outer boundary that wish to remain with the practice:  House visits may not be possible due to the distance from the practice and the practicalities of visiting.  If patients are likely to need home visits (due to age, mobility, advanced disease) then we would suggest not to remain with the practice and to register locally with a practice so their needs can be met.  With the integration of digital patients would be able to access the practice much more easily and can be supported with remote support.  Our average time for dealing with requests is now 57 minutes on average. We therefore deal with patient requests very quickly and have seen a massive reduction in home visits as patients are managed much more effectively.  We work closely with community partners such as community react teams who have supported us with patients who are acutely unwell and have provided much quicker responses than we can provide in practice during busy clinics.  For patients who are acutely unwell we will still utilise existing acute services as appropriate.

6.1.5. LMC Feedback

The LMC provided the following response to the application:

The LMC admires the ambition of the practice to extend the practices outer boundary however expresses the following concerns:  Potential to leave a substantial number of chronic patients without the provision of home visits.  The practice would struggle provide a range of service services such as Flu Vaccinations to those patients in the outer boundary.  Travel for those patients within the outer boundary – it could take some patients requiring F2F appointments up to 2 bus rides to get to the GP Practice i.e., those without a car.  Potential to de-stabilise the coherence of other services provided by practices and PCNs in the outer reaches.  Future proofing of the practice – a stable partnership is currently in place, but circumstances may change and could the practice then still be able to support the needs of all their patients.  Query the ability in managing positive patient’s expectations at the outer reaches of the in the extensive boundary .  Impact on place-based working for those patients living in neighbourhoods outside SWAN PCN.

The LMC have received concerns from other practices and therefore doesn’t recommend for the outer boundary to be amended to the scale proposed.

6.1.6. Feedback from Primary Care Operations Group

The options appraisal for the boundary change application was presented to the Primary Care Operational Group members on the 18th August 2021, and received the following questions:

8 Page 24 1. How will the practice ensure that the patients living in the new widened “outer boundary” will receive wider health and social care services such as; First Contact Physiotherapy and District Nursing?

2. What impact does the practice foresee on the “place-based working” approach for those patients living in neighbourhoods outside SWAN PCN/SDF area?

The practice provided the following response:

For patients living in the new ‘outer boundary’ will still have access to all services provided to patients in the inner boundary. The examples given of the First Contact Physiotherapists, and any other PCN services will continue to be available for all patients registered to practices in SWAN PCN. The boundaries will not affect their access to these services. The PCN services are delivered from multiple sites across the PCN to ensure easier access for patients. No PCN services as visiting services. District nursing is a separately commissioned service to PCN services and is already available to all patients across the borough. The boundaries will not affect access to community services for any patients.

Place based working is the using the knowledge, assets and expertise of the local area to develop services for local populations. This is not defined purely by geographical lines but as we have seen with PCNs, defined also by the practice they are registered with. We continue to be committed to deliver place based care as a practice within a mature PCN to patients registered at our practices, but we are also keen not to fragment services offered to patients because of geographical boundaries. With the embodiment of digital into primary care, the ability for patients to access services across the borough has widened. For example patients access Extended Access via the Alliance and the Hot clinics at sites outside of their neighbourhood. The widening of the outer boundary offers choice to patients to be able to access services outside of their direct neighbourhood. It provides choice to access services we offer as a practice and as a PCN. We have capacity in practice to increase our list size, where many practices are struggling with patient numbers. This will help to reduce pressure on other practice already at capacity and their services.

6.1.7. Equality Assessment (EA)

Approval of this proposed new boundary will not affect patients who reside in Wigan Borough.

6.1.8. Impact on and risks for other primary care providers

The proposal will have an affect on neighbouring practices and those practices outside the Wigan Borough with a WN4 / WN5 postcode. Residents of Wigan within the postcodes listed in Table 2 will be able to request registration at Hawkley Brook Medical Practice.

All practices within the Wigan have open lists.

6.1.9. List size

9 Page 25 Upon receipt of the application, information was gathered in relation to list size at the practice. The list size was reviewed over a period of months, and is displayed under Appendix 5 which shows a slight decrease in registered patients since April 2018 – 0.94% Reduction over a 3 year period (174 patients)

The practice noted that this was due to the impact of COVID and also the elderly population at the practice.

6.1.10. GP Survey – Access results

Table 4 shows access results taken from the latest GP survey results (July 2021)

Question GP CCG Survey Average Overall, how would you describe your 98% 86% experience of your GP practice? Percentage of patients saying ‘good Generally, how easy is it to get through to 84% 70% someone at your GP practice on the phone? Percentage of patients saying it is ‘easy’ to get through to someone on the phone How helpful do you find the receptionists at 99% 91% your GP practice? Percentage of patients saying receptionists at the GP practice are ‘helpful’ How easy is it to use your GP practice’s 90% 78% website to look for information or access services? - Percentage of patients saying it is ‘easy’ to use their GP practice’s website On this occasion (when you last tried to 82% 76% make a general practice appointment), were you offered any of the following choices of appointment? - Percentage of patients saying ‘yes’ they were offered a choice of appointment Were you satisfied with the appointment (or 95% 86% appointments) you were offered? Percentage of patients saying ‘yes’ they were satisfied with the appointment offered Overall, how would you describe your 84% 74% experience of making an appointment? Percentage of patients saying they had a ‘good’ experience of making an appointment How satisfied are you with the general 81% 72% practice appointment times that are available to you? Percentage of patients saying they are ‘satisfied’ with the appointment times available

6.1.11. QOF Achievements

10 Page 26 Table 5 - QOF Achievement

2017/18 2018/19 2019/20 2020/21 96% 99.1% 99.95% 99.94%

6.1.12. CQC Rating

Reported as GOOD Overall in April 2018

6.1.13. COVID 19 Impact

The impact of COVID-19 has resulted in Hawkley Brook Practice changing the way that they deliver care to their patients, it has open the opportunities to introduce a new way of working with the introduction of digital platforms that allow patients to access their healthcare services remotely / virtually.

6.1.14. General practice in England is under significant strain, facing pressure from a range of supply, demand and health service factors. At the same time, it is being asked to do more to relieve increasing pressures on emergency and out-of-hours services, support the development of better integrated care for people with long-term conditions, and play a central role in commissioning and more recently manage the new demand following the COVID Pandemic.

6.1.15. The strategic direction for primary care within the Borough, as detailed in the ‘Happy, Healthy People’ Wigan Borough’s Locality Plan (2020-25) for radically improving residents’ health and wellbeing sets out the vision for to have in place high quality and resilient primary care services that form the basis of our integrated model for health and care services in communities. Empowering people to be in control of their own health and offer co-ordinated, person- centred care when it is needed.

6.1.16. National and Local peer review, GM H&SC P confirmed that other GP providers have requested to increase their boundary. In 2019 Greater Manchester objected a request from GP at Hand (Babylon) to have an additional location in Manchester. GP at hand have over 10,000 patients registered and provide a 24/7 online services and 8 locations (7 in London and 1 in Birmingham) the contract is held by Hammersmith and Fulham CCG.

https://www.gpathand.nhs.uk/our-nhs-service

6.1.17. Furthermore, the strategic direction for Primary Care within the Borough is for Primary Care Networks (PCN’s) will provide the basis for enabling general practice to work at scale, improve the ability of practices to recruit and retain staff, to manage financial and estates pressures and to provide a wider range of high quality, resilient services to patients. They also provide the foundation for general practice to strengthen joint working with dentists, community pharmacies, opticians and other partners in PCN’s to improve the health of their populations.

11 Page 27 7. Financial Implications

7.1. If permission was granted to amend the surgery’s practice boundary there would not be any significant anticipated changes to the cost of the service. The weighted list size is projected to stay within expected growth.

7.2. The practice may benefit from increase list size and global sum, however the CCG isn’t expected to see any financial changes unless there is an increase in patients from out of borough CCG catchment area.

8. Options Appraisal

The following options are available:

8.1. Option 1: Decline application to change practice boundary - with this option the application would be rejected and the practices would be required to continue to provide primary medical services within the practice boundary outlined in their contract.

The benefits of this option are:

 The risk to patients would be minimal as service would continue as normal.

The dis-benefits of this option are:

 Current patients residing in the outer practice boundary won’t have access to all the services.

8.2. Option 2: Agree to amend the practice boundary -with this option the application would be approved and the services will be delivered on a larger footprint

The benefits of this option are:

 The practice has developed strong working relationships with patients that can move from the practice boundary and with the advent of remote consulting the practice wishes to give patients the option to continue the working relationship with the practice.

 The practice has additional capacity to take on newly registered patients and would like to support areas where practices are being overwhelmed with new patients.

 Continuity of care - Increased requests to remain registered at the practice when changing address outside of the current practice boundary

12 Page 28  Patients are able to access healthcare services remotely which means there are no geographical limitations now.

The dis-benefits of this option are:

 Patients from neighbouring practices may wish to deregister from their current practice

 Cash flow from other CCG’s from NHS England

9. Recommendations

9.1. The Wigan Borough CCG Primary Care Commissioning Committee are asked to consider the contents of this report and decide the preferred option.

10. Next steps

10.1. The PGM details the next steps in responding to an application for a boundary change, as follows:

7.14.8 If the Commissioner accepts the proposed changes to the practice area, the contractor should be notified, as soon as possible, in writing of:

• the acceptance; • the date upon which the changes will take effect; and • a requirement of the contractor to publish the details of the new practice area within their patient information leaflet and on their website (if they have one).

7.14.9 If the Commissioner declines the proposed changes to the practice area, the contractor should be notified, as soon as possible, in writing of that decision and to include:

• the reasons for the decision; • the right of the contractor to appeal and the process for doing so; and • specify any period within which the Commissioner would not consider a further application from this contractor to vary its practice area.

7.14.10 Practices who are intending to reduce their practice area must be advised that registered patients who subsequently fall outside of the new agreed area, but who are within the original practice area (main and outer boundary) can

13 Page 29 only be removed from the list if one or more of the provisions of the relevant regulations / directions that relate to removal of patients from the practice's patient list apply.

14 Page 30 Appendix 1

Application received by the CCG to amend the practice boundary Application for revised boundary.pdf

Current practice boundary

Current boundary.pdf New proposed practice boundary

Revised boundary.docx Stakeholder Letter

20210802 LMC 20210802 Letter to Letter - notification oPfr ipmrarcyt iCcea rbeo Sutankdeahryo lcdhearns gre B- oPu92n6d4a7r.yd Cohcxanges P92647.doc

15 Page 31 Appendix 2

16 Page 32 Appendix 3

17 Page 33 The Hub

This will be the ﬁrst site to start with the construction of a brand new shopping parade for Worsley Mesnes. Located next to the school and opposite the site of the existing shops and former public house.

Five retail units of varying sizes will be provided with car parking for customers to be accessed from Worsley Mesnes Avenue with a service yard and staﬀ access to the rear from Cornwallis Road. Any retailers wishing to move across into the new units from the existing shops will be accommodated and moved once the build is completed along with opportunities provided for new retailers in the parade.

The Drive

The site opposite the existing shops will provide a new shopping parade. The shops and remaining buildings on this site will be demolished and the site redeveloped for 63 quality new homes.

There will be 6 x 2 bed houses, 41 x 3 bed houses, 4 x 4 bed houses. 12 homes are to be oﬀered for aﬀordable rent and shared ownership.

The Place

Site to be redeveloped for 40 new homes. All are two storey in height but with semi- detached and mews houses. New tree planting is proposed in front gardens to create tree lined streets. 5 x 2 Bed homes and 21 x 3 Bed homes are proposed to be built with 12 oﬀered for aﬀordable rent or shared ownership.

Huxley Green

The site is to be developed for 42 new homes set around public open space. The layout has been designed to retain as many trees as possible and where trees are to be removed they will be replaced elsewhere on site. A children’s play area will be available for all to use. There will be 12 x 2 bed houses, 26 x 3 bed houses and 2 x 4 bed houses. There will be 12 x 2 bed houses and 20 x 3 bed houses. 10 homes will be provided for aﬀordable rent or shared ownership.

Victoria Fields

Redevelopment of the site to provide 28 new two storey homes.

This development will offer 2 x 2 bed houses, 16 x 3 bed houses and 1 x 4 bed house. 9 homes will be offered for affordable rent or shared ownership.

18 Page 34 Appendix 4

Hawkley Brook Practice

19 Page 35 Appendix 5

P92647 - Hawkley Brook Medical Practice

4,000 3,800 3,600 3,400 3,200 3,000 2,800 2,600 2,400 2,200 2,000

4/1/2018 7/1/2018 1/1/2019 4/1/2019 7/1/2019 1/1/2020 4/1/2020 7/1/2020 1/1/2021 4/1/2021 10/1/2018 10/1/2019 10/1/2020 PRACTICE NORMALISED WEIGHTED LIST SIZE RAW PRACTICE LIST SIZE

Appendix 6

Stakeholder Feedback Patient Feedback from Practice We did complete 20 patient feedback the results of which are below:

20 completed 14 patients would prefer the opportunity to remain registered 6 didn’t express a preference either way

The reasons given were

 Continuation of care with the same GP / Clinicians

 Excellent service that they receive from the practice

Healthwatch Wigan Seems pretty straight forward and I can see that an opportunity has been given to patients to comment should they wish so no further comments from Healthwatch Wigan Local Medical Committee (LMC) Comments within the body of the report Clinical Director for SWAN PCN No comments received

20 Page 36 Clinical Director for Wigan North PCN No comments received Clinical Director for Wigan Central PCN Dr Humphreys Unable to comment as the revised boundary only gives a map of Wigan so we don’t know which practices it will affect.

Asked for more information with a direct comparison showing the current and revised inner and outer boundaries.

Updated Boundary Map shared – no further comments received

Clinical Director for LiGA PCN No comments received Neighbouring Wigan GP practices 1 Practice Feedback Is the practice planning to service these patients in all the suggested areas with home visits? If they are not, how are they going to manage these patients? If a patient deteriorates, are they going to manage them remotely?

Local Councillors Cllr Jim Ellis – Hindley Ward No Comments

21 Page 37 This page is intentionally left blank MEETING: Primary Care Commissioning Committee Item Number: 6.1

DATE: 7th September 2021

REPORT TITLE: Finance Update

4. Financial Affordability CORPORATE OBJECTIVE Commission high quality health and care services ADDRESSED: within the allocated financial resources that are available to the Borough.

REPORT AUTHOR: Catherine Johnson

PRESENTED BY: Catherine Johnson

RECOMMENDATIONS/DECISION For information REQUIRED:

EXECUTIVE SUMMARY

This paper provides an update on the financial position that was reported as at 31st July 2021 for the Delegated and Non-Delegated areas of Primary Medical Care expenditure.

It also provides an update on COVID-19 expenditure and additional investment funding that Wigan is expected to receive a share of in this financial year.

FURTHER ACTION REQUIRED:

Page 39 This page is intentionally left blank Primary Care Commissioning Committee – Finance Update

Tuesday, 7th September 2021

1. Introduction

1.1 This paper provides an update on the financial position that was reported as at 31st July 2021 for the Delegated and non-Delegated areas of Primary Medical Care.

1.2 It also includes an update on COVID-19 expenditure, and on the additional investment funding that is expected to be made available in this financial year.

2. Position Reported at as July 2021 (M04)

2.1 Table 1 shows a summary of the financial position reported as at July 2021 for the Delegated and Non-Delegated areas of Primary Medical Care.

H1 Forecast YTD YTD YTD H1 H1 Forecast Outturn Budget Actual V a r i ance B u dget Outturn V a riance £k £k £k £k £k £k Delegated 16,802 16,607 -196 26,240 26,486 246 Non Delegated 6,089 5,988 -101 9,113 8,953 -160 Total 22,891 22,595 -297 35,353 35,439 86 Table 1. Delegated and Non-Delegated Primary Medical Care Finance Position - as at July 2021 (M04)

2.2 In the year to date, costs were underspent against budget by £297k, however an overspend of £86k was forecast as at the end of H1, split £246k overspent against the Delegated budget and £160k underspent against non-Delegated budgets.

2.3 The £246k Delegated overspend mostly relates to ARRS costs that are due to be funded via a separate, centrally held allocation (see section 4.4). Other off- setting variances arising against the Delegated budget include: -

 Pressure due to the budget plan exceeding allocation - £278k,  Pressure due to an increase in premises costs - £120k,  Slippage against GMS contract funding due to list size growth being less than planned – (£100k), and  Fortuitous prior year favourable variances c(£300k).

Page 41 2.4 The £160k underspend reported against the non-Delegated budget mostly relates to Nursing Home LCS slippage. This scheme is now being re-provided as part of the PCN DES and is therefore funded via the Delegated allocation.

3. COVID-19 Expenditure

3.1 The July financial position includes the following in relation to COVID-19 expenditure.

H1 £k Budget Forecast Variance Total 721 754 33 Table 2. Covid Related Budget and Expenditure - as at July (M04)

3.2 The H1 budget is made up of the General Practice COVID-19 Capacity Expansion Fund - £710k (reported previously) and £11k Inequalities funding to cover Interpreter costs incurred at the Vaccination Centres.

3.3 The £33k overspend relates to Asylum Seeker costs - £13k, and Vaccination text message costs - £20k. An additional top up allocation is expected in H1 to fund these costs.

3.4 Other Vaccination Centre costs continue to be incurred by the CCG on behalf of PCNs, e.g., for rent, cleaning, security, and clinical waste. Once paid, these costs are expected to be transferred to, and accounted for by, NHSE & I, therefore they are excluded from the CCG’s financial position.

3.5 As at July, the total cost of invoices paid by the CCG in relation to the Vaccination Centres was £204k and approval to transfer these costs to NHSE has been requested.

4. Primary Care Investments

4.1 There are several schemes for which additional investment is expected to be made available to Primary Medical Care across Wigan in this financial year, as shown in Table 3 below.

Page 42

Total Wigan Share Wigan Share Available H 1 & H2 H1 H 1 Allocation Held / Scheme £k £k £k Received By PC SR / SDF Funding Workforce Training Hubs 639 tbc tbc GM PCN Development & Support Sysytems 1,554 tbc tbc GM Regional GPFV Implementation 1,171 tbc tbc Region GP IT Infrastructure & Resilience 692 73 36 CCG (incl. Table 1) Improving Access 19,487 2,055 1,028 CCG (incl. Table 1) Practice Resilience Programme 468 tbc tbc GM Online Consultation Software 878 tbc tbc GM PC Covid Support 6,387 711 711 CCG (incl. Table 1) Sub-total PC SR / SDF Funding 31,276 2,839 1,775 Other Expected PC Investments Long Covid Enhanced Service 165 tbc NHSE Weight Management Enhanced Service tbc tbc NHSE Clinical Director increase Q1 (estimate) 180 180 PCNs (rec'd) Clinical Director increase Q2 (estimate) 180 180 PCNs (rec'd) ARRS Centrally Held allocation (maximum available) 1,937 tbc NHSE Additional Staff for Additional Covid Vacc Clinics 96 96 T&G FT IIF (£150m nationally) tbc tbc NHSE PCN Leadership & Management (£43m nationally) tbc tbc NHSE Sub-total Other Expected PC Investments 2,558 456 Total 5,397 2,231 Table 3. Summary of SR / SDF and Other Expected Investments

4.2 This shows the schemes and the corresponding funding that is expected to be received in this financial year, split by H1 & H2 where known. Wigan’s share of this funding is yet to be confirmed for some schemes, and not all funding is expected to flow through the CCG, e.g., the Workforce Training Hub monies are expected to be paid to directly to the Training Hubs, and the Clinical Director increases for Q1 and Q2 have been paid directly to PCNs from NHSE & I.

4.3 The CCG has requested information from GMH&SCP with regards to the value of SR / SDF investment that Wigan is expected to receive.

4.4 GP IT Infrastructure & Resilience, Improving Access, and PC Covid Support funding for H1 has already been received by the CCG and is included in the position reported in Table 1. The ARRS overspend referred to in section 2.3 will be funded from the ARRS Centrally Held allocation - £1,937k, once guidance on how to draw down the funding is made available.

4.5 Details around the IIF and PCN Leadership & Management investment are set out in a recent letter from NHSE & I, see copy in Appendix A.

5. H2 Planning

5.1 Planning guidance for H2 has not yet been published, therefore further details will be shared with the Committee in the November finance update.

Page 43 Appendix A. Copy of letter from NHSE & I re PCN Investment dated c23/08/2021

6.1 B0828_i_GP contract letter re PCNS 21-22 and 22-23_230821.pdf https://www.england.nhs.uk/wp-content/uploads/2021/08/B0828-i-gp-contract-letter-pvns-21-22- and-22-23.pdf

Page 44 Classification: Official Publication approval reference: PAR828_i

To: • Regional EPRR team NHS England and NHS Improvement • Regional directors of primary care Skipton House and public health commissioning 80 London Road • Heads of primary care London commissioning SE1 6LH • ICS primary care leads 23 August 2021 • STP primary care leads • Regional health and justice leads

Dear Colleagues,

Primary Care Networks – plans for 2021/22 and 2022/23

Dear colleagues,

1. Thank you for the ongoing work you and your teams are continuing to do for your patients and communities.

2. The COVID-19 pandemic has clearly demonstrated the value and effectiveness of the primary care network (PCN) model as a basis for local partnership working. A significant part of the COVID-19 vaccination programme was delivered by GP practices collaborating at network level. All care home residents are now benefiting from the Enhanced Health in Care Homes (EHCH) service; and over 73% of those aged 14 and over on practice learning disability registers received an annual health check last year.

3. In January 2021, NHS England and the BMA England General Practitioners Committee (GPC England) agreed to defer the introduction of new PCN service requirements and the majority of new Investment and Impact Fund (IIF) incentives until at least October 2021, recognising the significant workload challenges being experienced, the planning for autumn and winter which is required, and the need to create time to embed new starters in expanding PCN teams. We also took a range of measures to bolster general practice capacity, including the continuation of the planned uplift to Additional Roles Reimbursement Scheme (ARRS) funding from April, a further £120m of general practice capacity funding for the period from April to September, and additional funding for the PCN clinical director role until September.

Page 45

4. General practice continues to be working under pressure to support the response to the pandemic, to improve the health of its registered populations, to provide convenient care for people with urgent needs, as well as to deal with the backlog of chronic disease management. Taking into account the immediate pressures on general practice, and in line with NHS England’s letter to GPC England of 18 August 2021, we are now setting out a plan for the gradual introduction of new service requirements for PCNs and confirming how PCNs will access the significant funding available for their activities through the IIF across the second half of 2021/22 and 2022/23. The main implementation focus is 2022/23 rather than 2021/22, so that PCNs have the maximum possible time to prepare. Funding through voluntary incentives such as the IIF is the principal way in which NHS England will be promoting PCN service improvement goals from the Long Term Plan, reinforced by simple and concise service specifications, as outlined below. As previously set out, the IIF will be worth £150m to PCNs for 2021/22 and £225m for 2022/23. In addition, we can also confirm new funding for PCN leadership and management support, of £43m in 2021/22.

5. NHS England also agrees with GPC that it is primarily for PCN Clinical Directors – rather than commissioners - to ensure that use of the PCN Investment and Impact Fund meets the conditions that it is re-invested wherever possible in services and staff, for example extra GPs and practice nurses. PCNs need to know that if they achieve the goals, they can be certain that the funding will definitely follow.

PCN areas of focus for 2021/22 and 2022/23 6. Our engagement with stakeholders – including representatives of GPs, practice staff, and patients – has identified five areas of focus for PCNs over the coming 18 months. These are:

I) Improving prevention and tackling health inequalities in the delivery of primary care

II) Supporting better patient outcomes in the community through proactive primary care III) Supporting improved patient access to primary care services

IV) Delivering better outcomes for patients on medication V) Helping create a more sustainable NHS.

7. We have consistently heard that to have the maximum impact in all of these areas, widen the participation in PCNs across local partners like community pharmacy and

Page 46 2

community providers and play a key role making a success of ICSs, that PCN Clinical Directors need further support.

8. We will therefore provide new funding to support PCN leadership and management, of £43m in 2021/22. This funding will be allocated on the basis of the clinical commissioning group (CCG) primary medical allocation formula – therefore incorporating a specific adjustment for unmet need in areas of higher deprivation. It will be for clinical directors to recommend how it is deployed to create new capacity in support of the work of PCNs.

PCN services 9. Recognising current pressures in general practice, service requirements will not be introduced in full from October 2021, but phased over the coming eighteen months in a gradual way. The two specifications being introduced in 2021/22 will be introduced in a reduced or preparatory form. Full details are set out in Annex A. In summary:

Requirements in 2021/22 Requirements in 2022/23

Cardiovascular From October 2021, the Requirements on PCNs to disease (CVD) requirements on PCNs will focus increase diagnosis of atrial prevention and solely on improving hypertension fibrillation, familial diagnosis case finding and diagnosis, hypercholesteremia and heart where the largest undiagnosed failure will be introduced from April prevalence gap remains and 2022. where the greatest reductions in

premature mortality can be made.

Tackling PCNs will be asked to work from Continued delivery of the co- neighbourhood October 2021 to identify and designed intervention. health engage a population inequalities experiencing health inequalities within their area, and to codesign an intervention to address the unmet needs of this population. Delivery of this intervention will commence from March 2022.

Page 47 3

Anticipatory care Introduction of requirements for By 30 September 2022, PCNs will this service are deferred. be required to agree a plan for

delivery of Anticipatory Care with their ICS and local partners with whom the service will be delivered jointly – in line with forthcoming national guidance.

Personalised Introduction of requirements for From April 2022 there will be three care this service are deferred. areas of focus for personalised care: further expansion of social

prescribing to a locally-defined cohort which are unable or unlikely to access through established routes; supporting digitised care and support planning for care home residents; and shared decision making training.

Extended access 10. From April 2022, PCNs will deliver a single, combined extended access offer funded through the Network Contract DES. We intend to publish details this autumn to allow planning for service commencement in April 2022. They will allow for collaboration between PCNs and subcontracting to other providers, including GP federations. Commissioners should ensure that PCNs are preparing for this transition, and that they have undertaken good engagement with existing providers.

Investment and Impact Fund (IIF) 11. In order to provide as much clarity and certainty for PCNs as possible, we are setting out full details of the IIF indicators for 2021/22 AND 2022/23. As previously committed in the GP contract agreement, the scheme will be worth £150m in 2021/22 and £225m in 2022/23. It will support PCNs in the delivery of critical clinical objectives, as well as wider system-wide goals where PCNs have a central role alongside other NHS partners. The scheme is aligned to the five areas of focus set out above, with many of the indicators in 2021/22 supporting preparatory work towards the PCN service requirements or the introduction of full performance indicators in 2022/23.

12. Annex C summarises the IIF indicator set for 2021/22 and 2022/23, and how the PCN service requirements and IIF indicators fit together under the five areas of focus

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outlined above. A comprehensive description of the IIF indicator set, together will a full list of the indicators, valuations and thresholds, is set out at Annex B.

Next steps 13. The changes for 2021/22 will be incorporated into a revised Network Contract DES to take effect from 1 October 2021. As is already the case, practices will be auto- enrolled into this revised DES if there are no changes to their PCN details, with one calendar month for practices to opt out if they wish to do so. The 2022/23 changes will be included within the 2022/23 Network Contract DES, alongside the extended access requirements, which will be published later this financial year.

Yours sincerely,

Ed Waller Dr Nikki Kanani Director of Primary Care Medical Director for Primary Care NHS England and NHS Improvement NHS England and NHS Improvement

Page 49 5 This page is intentionally left blank MEETING: Primary Care Commissioning Committee Item Number: 6.2

DATE: 07th September 2021

Primary Care Co-Commissioning Programme Update August REPORT TITLE: 2021

4. Financial Affordability Commission high quality health and care services within the allocated financial resources that are available to the Borough.

REPORT AUTHOR: Gillian Watson – Primary Care Commissioning Manager

Debbie Szwandt, Assistant Director Primary Care

PRESENTED BY: Gillian Watson – Primary Care Commissioning Manager

RECOMMENDATIONS/ The Committee is asked to receive the report and support the DECISION REQUIRED: continued progress of the co-commissioning programme.

Page 51 EXECUTIVE SUMMARY

The report outlines the CCGs progress of the Primary Care Co-Commissioning Programme, during 17th June 2021 to 20th August 2021

It details any contractual changes that have been made during this period, in particular any contractual updates received from General Practice and an update on GP Enhanced Service Specification.

FURTHER ACTION None REQUIRED:

Page 52

Primary Care

GP Co-Commissioning Programme September 2021

Page 53 Primary Care Co-commissioning Programme Highlight Report

Programme Lead/s Gillian Watson, Primary Care Commissioning Manager – Primary Care Commissioning

Will Roberts, Business Manager (GP Team), GM Health & Social Care Partnership

Senior Responsible Linda Scott, Director of Primary Care Officer

Reporting Period 17th June 2021 to 20th August 2021

Purpose and Aims

The purpose of the Primary Care quality commissioning programme is to ensure the CCG carries out its delegated authority to commission high quality Primary Care to General Practice, which will also enable transformation of Primary Medical Services.

Objectives

O1 Implement the PCN Direct Enhanced Service Contract.

O2 Implementation of the Primary Care Commissioning Intentions from Quarter 3 21021/22.

O3 To support GP practices and PCNs to be responsive to COVID – 19, ensuring an appropriate level of service is maintained, and staff and patients are always kept safe.

O4 Manage all GP contract requests in line with contract regulations and NHSE/I policy book.

Milestones

M1 Review all contract and partnerships changes On Track M2 Implement Annual Contract Review 1-3 year rolling On Hold COVID - Programme. 19 M3 Follow up contract management when high and On Track medium risk issues identified M4 Review and Implement any changes to Direct On Track Enhanced Services (DES) and Local Commissioned Services (LCS M5 Ensure process is in place to review all Remedial On Track and Breech notices M6 Monitor and manage any appeals through the On Track Special Allocation Scheme Programme Updates within the Period

Borough Wide / A Review was carried out with the GM Team in June 2021, it was SDFs / PCNs highlighted that there have been a number of changes, which can be Page 54 3

found below.

GP partner Hindley PCN: Retirements/ leavers/joiners  No Updates

Merger LiGA PCN: Applications  1 Incorporation application – Morden Avenue (P92630) Incorporation Applications  1 Practice Name Change – This is on hold (P92030) Boundary change Contract Date applications Date P Code Practice Partner Change Status type Change On List Size closure of Hold Golborne practice applications 03/08/21 P92630 Surgery name GMS

Leigh PCN:  1 GP partner joiner (P92007)

 1 GP Partner Leaver – Retirement (P92602)

 Pennington Park (Y00050) and Lilford Park (P92035) surgeries Merger mobilisation – Go Live Date 28th October 2021.

 1 Incorporation application from 1 GP provider – approved in closed PCCC in July. Start Date to be confirmed. (Y00050)

Contract Date Date P Code Practice Partner Change Status type Dr Wong & 06/07/21 P92007 Partners Dr Clive Nash Joiner Partner GMS Foxleigh Dr Alastair Leaver - Dec 16/08/21 P92602 Surgery Wilson Retiring Partner PMS 21

SWAN PCN:  1 GP partner Retirement

 1 Practice Boundary Change – Hawkley Brook Medical Practice (P92647)

The application and options appraisal is now complete and will be received as Agenda item 5 within the Open meeting of the September Committee.

Contract Date Date P Code Practice Partner Change Status type Marus Bridge 02/10/21 20/07/21 P92642 Practice Dr Robert Kirk Leaver Partner GMS TABA PCN:

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 1 GP Retirement Succession Planning – Meadowview Surgery (P92626)

Wigan North PCN:

 1 GP partner Leaver (P92017)

Contract Date Date P Code Practice Partner Change Status type Shevington Dr Christina 10/08/21 P92017 Surgery Hadjidemetriu Leaver Partner GMS 15/09/21

Wigan Central PCN:

 No Updates

Members to the committee are required to note that the GM H&SC (NHSE/I) and Primary Care team continue to work collaboratively.

Wigan Borough Pennington Park (Y00050) and Lilford Park (P92035) – Leigh PCN CCG The team continue to support the practice on a weekly basis on the mobilisation of the practice merger. The Go Live date is set for the 28th Practice September 2021. Updates High Street Surgery (P92012) – LiGA PCN The team continue to support the practice manager on a weekly / fortnightly basis regarding any outstanding issues.

Marus Bridge (P92642) – SWAN PCN GP Retention application has been received and options appraisal is now complete and will be received as an Agenda item within the closed meeting of the September Committee.

Wrightington Street Surgery (P92030) – Central Wigan PCN Initial meeting with the practice manager took place on 17th August to discuss application to close list size. Further details will be presented to the November committee.

Meadowview Surgery (P92626) – TABA PCN A Succession plan application has been received, however due to the sensitive detail within the application this will be presented within the close meeting of the committee.

Wigan Borough Letter sent to practices 26th July 2021 – Appendix A CCG Update to practices on the new contracts, which are currently being GP Enhanced drafted, and will run from 1st July 2021 to 31st March 2022 and will Service include the updated Enhanced GP Services specification and any Specification, Locally Commissioned Services (LCSs) contracted within practices. including Local commissioned As part of the Enhanced General Practice Specification which got services approved at the Primary Care Commissioning Committee on the 6th

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July, a review of the all Local Commissioned Services that we have in the borough have taken place.

This review was really to look at each specification, ensure that they are still valid and fit for purpose. This has been undertaken by a clinical lead and Commissioning Lead.

A full update on the review will be received as Agenda item 8 within the Open meeting of the September Committee.

Changes to National Priorities Contracts during COVID Key notifications issued by NHS England during the period are 19 and in order summarised below; to manage recovery Extension of temporary changes to GP contract The following temporary changes to the GP contract in England will continue under the pandemic regulations until 30 September 2021:  A suspension of the requirement that practices report to commissioners about the Friends and Family Test returns.

 A temporary suspension of the requirement for individual patient consent in certain circumstances, to encourage increased use of electronic repeat dispensing (eRD).

 A continuation of the temporary increase in the number of appointment slots that practices make available for direct booking by 111 up to 1 slot per 500 patients per day. These slots continue not to be appointments in the traditional sense, but practices should clinically review patient referred by 111 and contact the patient to arrange appropriate follow-up.

Enhanced Service – Long Covid & Weight Management All practices have signed up to both enhanced services.

The national influenza immunisation programme 2021 to 2022 Letter from PHE and DHSC about the roll out of the flu vaccine programme this autumn. Letter dated 17th July 2021 – Appendix B

Primary Care Networks – plans for 2021/22 and 2022/23 Letter from NHS England and NHS Improvement – 23rd August 2021 – Appendix C

The letter details a plan for the gradual introduction of new service requirements for PCNs and confirming how PCNs will access the significant funding available for their activities through the IIF across the second half of 2021/22 and 2022/23.

The letter identified five areas of focus for PCNs over the coming 18 months. These are:

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I) Improving prevention and tackling health inequalities in the delivery of primary care II) Supporting better patient outcomes in the community through proactive primary care III) Supporting improved patient access to primary care services IV) Delivering better outcomes for patients on medication V) Helping create a more sustainable NHS.

New funding will be available to support PCN leadership and management, of £43m in 2021/22. This funding will be allocated on the basis of the clinical commissioning group (CCG) primary medical allocation formula – therefore incorporating a specific adjustment for unmet need in areas of higher deprivation. It will be for clinical directors to recommend how it is deployed to create new capacity in support of the work of PCNs.

Local priorities

Letter Sent to GP Practices – 25th June 2021 re Indicator ACC-01, Investment and Impact Fund 2021/22 The letter detailed changes to the deadline and submission IIF indicator ACC-01, which requires PCNs to provide “Confirmation that, by 30 June, all practices in the PCN have mapped all active appointment slot types to the new set of national appointment categories and are complying with the August 2020 guidance on recording of appointments. The submission deadline had been extended by one calendar month, from 30 June to 31 July 2021 and the payment deadline had been extended by one calendar month, from 30 September to 31 October 2021.

PCN Clinical Directors was asked to complete pro-forma on behalf of member practices confirming compliance with the conditions required by IIF indicator ACC-01

Enhanced General Practice Enhanced Service Specifications for the Services Seasonal Influenza Vaccination Programme 2021/22

Two Enhanced Service Specifications have been published  Seasonal Influenza Vaccination Programme 2021/22.  The Childhood Seasonal Influenza Vaccination Programme 2021/22

The service specifications for 2021/22 are largely based on the 2020/21 flu service specifications, with the exception that the Seasonal Influenza Vaccination Programme specification (covering adults and at-risk groups) will be commissioned as an Enhanced Service this year to enable greater responsiveness to any subsequent JCVI advice or Government policy. The Childhood Seasonal Influenza Vaccination

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Programme 2021/22 was previously commissioned as an Enhanced Service.

Minor Surgery

Request to widen the appropriate clinician to register to deliver minor surgery in view of ARRS roles (currently GP only) – Appendix D- Proforma

Recommendation to approve to include qualified clinicians such as advanced physiotherapist to administer joint injections as part of the minor surgery along with GP’s.

Other Contract GMSS Meetings The last Greater Manchester Shared Service (GMSS) contract meeting was held on the 22/07/2021, at this stage the team had commenced the contract due diligence with 58 GP Provider/practices and a contract expected sign up summary in anticipation for the changes from Quarter 2 2021/2022. GMSS have received 54/58 practice contract information in order to draw up this year’s contract.

Wigan GP Extended Access Contract

The last Contract meeting with Wigan GP Alliance was held 27/07/2021.

Special Allocation Scheme (SAS)

The monthly SAS contract meetings have continued (23/06/2021 & 28/07/2021) with development work in the three priority areas;

A. Identify a new suitable and safe location for the service.

B. Implement the annual review / discharge process using a standardised template and working with PCSE where discharge from the scheme is approved.

C. Future contract negotiations.

Broomwell ECG Interpretation Services

The last contract meeting will be held on the 6th July 2021, with development of the 2021/22 contract in place.

Local Medical The CCG continues to have fortnightly meetings regarding COVID and Committee monthly operational/contracting meetings with Wigan Local Medical (LMC) Committee (LMC).

The LMC is the elected, statutory body representing and supporting

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local member GPs in the borough of Wigan. Wigan LMC is divided into six constituencies. Members of the Committee are registered General Medical Practitioners who provide primary care medical services within Wigan, who pay a statutory and voluntary levy, or a special levy in the case of sessional GPs.

Outcomes Achieved

Ou 1 Compliance with NHS England’s Single Operating Framework, Primary Care Policy and Guidance manual

Ou 2 Completion of the Options appraisal for the boundary application for Hawkley Brook Medical Practice (P92647)

Ou 3 Completion of the Options appraisal for GP Retention application for Marus Bridge Surgery (P92642)

Ou 4 Review of the Local Commissioned Services specifications

Plan for Next Period

1. Review commissioning applications; 1 incorporation, 1 boundary changes, 1 list size closure, 1 PMS retirement & 1 PMS change.

2. Contribute to the COVID-19 recovery / management.

Risk Register

Risk Number Risk Description Risk Rating

PCR2 Failure to manage Primary Care Co- 8 Commissioning could lead to GP practices not delivering the optimum services for the resources available.

PCR4 Failure to engage with Stakeholders, patients and 6 public could lead to a breach in the duty to consult

PCR5 Failure of the practice that has been placed into 6 special measures to improve in the areas set out by the CQC. The practice could lose their CQC registration and would no longer be able to deliver the primary medical services contract.

PCR12 Failure to respond to national COVID priorities in 12 the short / demanding timescales could lead to contract non-compliance.

PCR13 Failure to respond to practices requirements / 12 requests during COVID crisis could lead to contract non-compliance.

Page 60 Healthy People, Healthy Place 9

Appendix A: Appendix B: Appendix C: Appendix D

Letter for Practices Annual_National_Fl 6.1 B0828_i_GP DES minor surgery 16th July v2 JK All.pd f u_Programme_2021_t o _ 2 0c2o2n_tlreatctet rl.eptdtefr re PCN Su 2p1d-a2t2e a fnodrm 2 2A-p2r3i_l 223002812.d1o.pcdxf

Page 61 Healthy People, Healthy Place This page is intentionally left blank MEETING: Primary Care Commissioning Committee Item Number: 6.3

DATE: 07 September 2021

REPORT TITLE: Primary Care Quality Improvement Programme: update August 2021

1: Commissioning Health And Care Services CORPORATE OBJECTIVE Commission health and care services that meet the ADDRESSED: needs of local people, delivering high quality, clinically viable, affordable, efficient and responsive services that improve the overall experience for each person at every contact, across their life course.

4. Financial Affordability

Commission high quality health and care services within the allocated financial resources that are available to the Borough.

REPORT AUTHOR: Debbie Szwandt, Assistant Director Primary Care

Alison Foster, Lead Nurse for Quality, Primary Care

Anne Burgess, Head of Primary Care Workforce Development and Learning

Debbie Szwandt, Assistant Director Primary Care PRESENTED BY: Alison Foster, Lead Nurse for Quality, Primary Care

RECOMMENDATIONS/DECISION The Committee is asked to receive the report and

Page 63 REQUIRED: support the continued implementation and development of the primary care quality improvement programme.

EXECUTIVE SUMMARY

The report outlines the CCGs progress of the Primary Care Quality Improvement Programme, between 17th June 2021 – 18th August 2021, the focus of work continues to be predominately to support practices to implement the COVID 19 Vaccination programme.

The report details the range of GP Primary Care Quality workstreams that have been escalated as priorities in order to minimise the spread of the pandemic and keep staff and the public safe and support the COVID-19 response directed by NHS England/ Improvement and Public Health England.

The Key Priority quality workstreams are:

 COVID – 19 Vaccination programme, second and first dose all adults aged 16 years and over  Workforce- COVID response  Review of National GP Survey 2021

FURTHER ACTION REQUIRED: None

Page 64 Primary Care GP Quality Improvement Programme Update September 2021

Page 65 Primary Care Quality Improvement Programme Highlight Report

Programme Lead/s Debbie Szwandt (DS), Assistant Director Primary Care

Alison Foster (AF), Lead Nurse for Quality in Primary Care

Anne Burgess (An B), Head of Primary Care Workforce Development and Learning

Senior Responsible Linda Scott (LS), Director of Primary Care Officer

Reporting Period 17th June 2021 – 18th August 2021

Aim

The aim of the Primary Care Quality Improvement programme is to ensure the CCG carries out its statutory duty to “continuously improve” the quality of Primary Care, General Practice, which will also enable transformation of Primary Medical Services.

Objectives

O1 Implement the Primary Care Assurance Framework (PCAF) CCG monitoring tool including a programme of “follow up” and learning.

O2 Ensure CCG specialist support is assessed & planned/provided following all CQC Inadequate and Requires Improvement ratings within 1 month of publication.

O3 Support the implementation of the Primary Care Enhanced Service Specification 2021/22 (formerly Primary Care Standards), including GM Primary Care Standards & local priorities.

O4 To support GP practices and PCNs to be responsive to COVID – 19, ensuring an appropriate level of service is maintained, and staff and patients are kept safe at all times.

Milestones

M1 Planning PCAF review and follow up medium risk GP (delayed due practices to COVID -19)

M2 Review of the CQC GP Dashboard as at 2020 On Track

M3 Implementation of COVID-19 NHS E/I and Public Health England guidance and Standard Operating On Track Procedures (SOPS)

M4 Planning Review and follow up GP Survey 2019 / re schedule (delayed due to July 2021 publication to COVID -19

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M5 Continue to Deliver phase two of the Borough wide On Track COVID Vaccination programme

M6 Develop plans for post COVID-19 recovery (long On Track Covid managing demand, capacity and activity)

Programme Updates within the Period

Primary Care During the reporting period, the system of virtual strategic and Network operational meetings have continued with Clinical Leads, PCN Delivery teams, Lead Practice Managers and Lead Practice Nurses on a regular basis, although reduced to a two weekly cycle.

The CCG leads continue to facilitate the receipt of national policy changes, translation, communication and implementation since the mobilisation of WBCCG Emergency planning and response policy in March 2020 due to the COVID-19 pandemic.

Demand on GP practices is continuing to increase and workforce staff illness and self-isolating has increased during the summer period.,.

Work is continuing to progress to make best use of new ways of working and avoid service inequalities through; the scaled use of remote triage, assessment and collaboration, being responsive to; feedback from patients, priorities and opportunities from the PCN Network DES.

The examples of new ways of working are;

 COVID -19 Vaccination Programme at scale, second and first dose

 First contact Physiotherapists, increasing capacity and improving access

 Mental Health practitioner

Personal In order to keep staff and patients safe, GP practices are continuing Protective to implement the Public Health England policy and guidance Equipment regarding PPE and lateral flow testing, including the advice to staff (PPE) and the public to continue to wear face coverings in health and social care settings.

Practices continue to see more patients face to face, with sustained implementation of a range of measures to support social distancing and hand hygiene across all GP practice locations.

The CCG has been proactive in sharing as much learning as possible, and has kept this up to date as lessons are learnt from any outbreaks that have occurred.

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Care Quality There have been no CQC Inspection reports published in the Commission reporting period relating specifically to Wigan Borough locality (CQC) The new inspection process will involve a range of remote working and the practice visit will therefore be targeted to assess face to face assurances,

https://www.cqc.org.uk/guidance-providers/gps/what-we-will-inspect- types-inspection-gp-practices

A summarised position has been included for reference, WBCCG dashboard is in Appendix 1.

WBCCG has six practices rated as Outstanding by the CQC across four of the Primary Care Networks (PCN).

Table 1. Wigan Borough CCG GP practice CQC rating, August 2021

CQC overall rating Number % of GP practices of GP practices Outstanding 6 10.35 Good 51 87.93 Requires Improvement 0 0 Inadequate 0 0 New Inspection Triggered 1 1.72

Table 2. Wigan Borough CCG GP practice CQC latest inspections by year, August 2021

CQC latest onsite Number Number of years inspection of GP since last practices inspection 2016 16 5 2017 17 4 2018 10 3 2019 11 2 2020 3 1

Learn from A new national NHS Learn from patient safety events service patient safety (previously called the patient safety incident management system – events (LFPSE) PSIMS – during development) has been launched. service LFPSE replaced the National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS), to offer better support for staff from all health and care sectors.

All healthcare staff in England, including those working in primary care, are encouraged to use the system to record any events where:

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 a patient was harmed, or could have been harmed

 there has been a poor outcome but it is not yet clear whether an incident contributed or not

 risks to patient safety in the future have been identified

 good care has been delivered that could be learned from to improve patient safety

Healthcare staff can register for a LFPSE account via the web-based service. Details of patient safety events can then be submitted to LFPSE by completing a responsive online form;

https://record.learn-from-patient-safety-events.nhs.uk/

National GP The National GP survey was published in July 2021, results can be Survey 2021 found at the following location;

Statistics » GP Patient Survey 2021 (england.nhs.uk)

The GP Survey results have been shared and discussed at the Primary Care Operations Group and practice manager leads group in July 2021.

Key metrics have been included in the Primary Care Assurance Framework and the Business Intelligence Team have developed a benchmarking tool to enable comparisons across multiple groups.

The next step is to target follow up work with practices and or PCNs to drive Service improvement.

COVID -19 The PCN Groupings aligned to Robin Park Leisure Centre and Leigh Vaccination Sports Village Leisure Centre, and Hindley Pavilion are operational Programme and continuing to deliver vaccines depending on supply from NHS E. Golborne Parkside delivery stopped in the June at the request of the landlord in order to return to business as usual.

Nearly 437,500 vaccinations have been administered to Wigan Borough residents, with 83% of 40-49yrs and 69% of 18-29yrs having now received their first vaccination, please see the infographic below for further information;

Page 69 Healthy People, Healthy Place 6

Work is continuing to increase the capacity of vaccine delivery to expand the numbers of vaccinations being administered to the local population, including the increased delivery of the second vaccine, which is now at 280,000 (from 150,000 in June 2021) and delivery to Cohort 13 (16-17yrs).

Primary Care The Primary Care Assurance Framework (PCAF) has been Assurance refreshed, see chart below and the draft WBCCG PCAF Framework benchmarking monitoring report, Quarter 2 2021-2022 has been (PCAF) developed and a period of engagement has commenced.

The good practice guide is also being refreshed with a focus on “Ensuring Quality Together” and a clinical review of the QOF indicator achievement will be scheduled following the national publication in October 2021.

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Additional PCNs were required by NHSE to submit ARRS planning intentions to Roles the CCG by 31st August for 21/22. All PCNs have submitted these Reimbursement and indicate that by March 2022 there is an intention for a total of Scheme 130 WTEs to be employed via this scheme across the seven PCNs. There is also a requirement to then submit ARRS planning intentions for 22/23 and 23/24 by 31st October. To support PCNs with the introduction of new roles there are workshops in the planning to consider Trainee Nurse Associates with support from Greater Manchester Training Hub and also the Allied Health Profession roles of Dietitian, Podiatrist and Occupational Therapist.

Care Co-ordinator recruitment has taken place, with two rounds of recruitment yielding the 16 Care Co-ordinators that PCNs requested. All PCNs will have at least one Care Co-ordinator and they will be commencing from the end of September and during October. These roles will be employed within the council on behalf of PCNs within the same team as the Community Link Workers and Healthy Routes Advisors, forming a holistic team for PCNs.

Mental Health Practitioners recruitment is underway with GMMH for one band 7 post in all PCNs. Band 5 recruitment will follow.

Training and PCN Education Clinical Leads are now in place, working together Education and planning programmes of education for PCN workforce. This programme will include key topics and areas that will support practices in delivering various requirements (e.g. QoF, DESs, IIF and enhanced specification) and in linking in support from partner organisations across the health and care system. These Leads are working closely with the CCG Workforce Leads and the locality Training Hub to ensure offers and opportunities are reaching the workforce.

A HEE funded locality CPD offer has been planned for our Nursing/AHP workforce with the Lead Nurses, Lead Nurse for Quality and Head of Primary Care Workforce. This planning was submitted to Greater Manchester Training Hub in July and has now been approved by HEE. The programme will be delivered between September 2021 and March 2022.

Workforce A project focusing on Practice Manager Development and Resilience Development is now underway. Lead Practice Managers are engaging with Time for Care Productive General Practice Quick Start programme (PGPQS) to understand, scope out and develop a consistent and robust Appraisal system for Practice Managers. This quality improvement work will also link with GM offers and has attracted interest from GP Excellence.

CCG Quality and Primary Care teams have been facilitating a collaborative approach between WWL and Greater Manchester Training Hub in bidding under the Clinical Placement Expansion Programme. This will expand student placements across various learning environments in Wigan, including Primary Care by

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increasing the number of student placements available within the locality and offer them across the different settings.

Care Navigation work is progressing with the Lead Practice Manager to understand the demand and processes within a GP surgery. This is closely linking with the Digital Learning Sets work with Jonathan Kerry and Ask My GP.

An Employee Assistance Programme has been procured and will be available for general practice as part of the Health and Wellbeing offer. This will be live from 1st September and will be promoted during September.

General 5 active General Practice Nurse Champions (GPNC) continue to Practice Nurse provide support for nursing colleagues within their Primary Care Champions Network (PCN). They maintain cover for all 7 PCN’s. (GPNC) A review of the role has been undertaken to ensure we have dedicated Nurses / AHP’s who will support the development and implementation of quality improvement and transformation programmes across the health and care system.

The transfer of the GPNC’s to a Lead Practice Nurse (LPN) role and recruitment of the 2 vacant positions for either LPN or Lead Allied Health Professionals (LAHP) will be commenced in September 2021.

The LPN / LAHP role will:

 Strengthen and maintain the clinical and professional voice for nursing and AHP’s and act as advocates for the patient/resident ensuring all voices are heard.

 Support Peer engagement ensuring the Practice Nurse, AHP and associated workforce feel they are involved informed and engaged.

 Develop consistency of approach across Primary Care Nursing

 Support the Wigan system to deliver its ambition for population health improvement.

 Tap into the LPN’s / LAHP’s experience, insight, expertise and knowledge to support the development, implementation and delivery of the locality transformation programmes.

 Gain perspectives from the Practice Nurses / AHP’s to ‘tell us how it really is’ and what will work on the ground.

 Promote professional role models, providing Nursing and AHP Leadership and acting as positive influencers for change.

 Act as an advocate for supporting the current and future

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development and resilience of the nursing and AHP workforce

Practice Nurse With the support of the CCG Lead Nurse for Quality, the 5 Practice Forum / Nurse Champions continue to provide virtual communication Newsletter approaches, to: - ensure connectivity for isolated practitioners across the Borough - cascade important update information - provide learning and development opportunities

Key methods are: Virtual monthly Practice Nurse forums - these continue on the 2nd Wednesday of every month and have provided the opportunity in July and August 2021 for further education and discussion re: Contraception and Sexual Health Services and Chronic Kidney Disease

Quarterly Health Care Assistant forums – these sessions continue once per quarter. The collaborative work with Primary Care, Wigan Borough CCG, Wigan Council and Health First continues to support this cohort of staff. The September 2021 will provide the opportunity to develop knowledge and skills in relation to Pre diabetes checks and Lifestyle Specialist Services for weight management and exercise in relation to pre- diabetes.

Quarterly electronic newsletter – these continue to provide a wealth of information for all nursing staff within General Practice. A wide range of information is provided to update and educate colleagues. Contributions are gained from Primary Care colleagues and specialist services.

Outcomes Achieved

O1 Implemented national COVID-19 priorities across 58 GP practices aligned to 7 PCNs

O2 Reviewed and responded to GP practices requirements during COVID crisis, including planning the recovery phase.

O3 Delivered against the national targets for COVID Vaccination Cohorts 1-12.

Plan for Next Period

1. Monitor and implement quality priorities related to the COVID- 19 National and local requirements.

2. PCAF 2021/22 implementation and review/follow up as necessary

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3. Enhanced service specification 2021/2022 implementation

4. To re-establish effective Clinical supervision for nurses within General Practice, a Lead for Clinical Supervision and one supervisor per PCN will be developed from September 2021.

Risk Register

Risk Number Risk Description Rating PCR1 Failure to implement a Primary Care Assurance 10 Framework could lead to quality issues in GP practices being undetected.

PCR4 Failure to conduct Patient & staff engagement and 6 respond to feedback will reduce the impact of service development.

PCR5 Failure to share and respond to learning lessons will 6 reduce the rate of implementation of Continuous Improvement.

PCR6 Failure to share and respond to learning lessons will 9 reduce the rate of implementation of Continuous Improvement. PCR14 Failure to respond to national COVID priorities in the 12 short / demanding timescales could lead to reduced quality.

PCR15 Failure to respond to practices requirements / requests 12 during COVID crisis could lead to reduced quality.

PCR23 Failure to implement co-commissioning support fairly 9 and consistently could lead to reputational harm.

PCR24 Failure to work closely with GP providers regarding 10 their business plans, viability and resilience may lead to a lack of contract holder/s to deliver Primary Medical Services

Page 74 Healthy People, Healthy Place Appendix 1: CQC Inspection Dashboard, August 2021

Current Practice List Date Last GP Practice SDF CQC

Code Size Site Visit SAFE

Rating CARING WELL-LED EFFECTIVE RESPONSIVE P92001 Medicentre SWAN 5423 22 September 2016 G G G G G G P92005 The Grange Practice (Dr Zaman) SWAN 4119 04 December 2019 O G G O G O P92024 The Chandler Surgery SWAN 4110 10 March 2016 G G G G G G P92034 Bryn Cross Surgery SWAN 5832 04 April 2017 G G G G G G P92642 Marus Bridge Practice SWAN 5208 05 September 2016 O O O O G O P92647 Hawkley Brooke Medical Practice SWAN 3332 11 April 2018 G G G G G G P92653 Shakespeare Surgery SWAN 2981 01 June 2016 G G G G G G P92038 Winstanley Medical Centre SWAN 3109 01 August 2018 G G G G G G P92007 Dr Wong & Partners L 6854 25 March 2020 G G G G G G P92023 Brookmill Medical Centre L 7972 05 April 2019 G G G G G G P92029 Westleigh Medical Centre L 4091 11 May 2017 G G G G G G P92035 Lilford Park Surgery L 3691 25 April 2017 G G G G G G P92607 Grasmere Surgery L 8202 17 January 2020 G G G G G G P92615 Dr Esa (The Avenue) L 4901 14 June 2016 G G G G G G P92621 Premier Health Team L 2779 19 October 2016 O G G G O O P92602 Foxleigh Family Surgery L 2320 24 October 2017 G G G G G G Y00050 Pennington Park Surgery L 2040 21 February 2017 G G G G G G Y02322 Leigh Family Practice L 7873 20 February 2019 G G G G G G Y02886 Leigh Sports Village L 3496 27 September 2019 G G G G G O P92010 Beech Hill Medical Practice NW 13000 17 May 2016 G G G G G G P92014 Standish Medical Practice NW 11937 06 June 2018 G G G G G G P92015 Aspull Surgery NW 5382 2nd November 2017 G G G G G G P92017 Shevington Surgery NW 12700 20 November 2018 O O G G G O P92003 The Dicconson Group Practice CW 8440 30 August 2016 G G G G G G P92008 Bradshaw Medical Centre CW 8865 27 October 2017 G G G G G G P92011 Sullivan Way Surgery CW 7531 15 November 2018 G G G G G G P92019 Pemberton Surgery CW 9676 22 August 2016 G G G G G G P92021 Newtown Medical Practice CW 6287 14 January 2016 G G G G G G P92026 Longshoot Medical Practice CW 7875 03 March 2016 G G G G G G P92030 Wrightington Street Surgery CW 4288 08 March 2017 G G G G G G P92634 Mesnes View Surgery CW 4360 25 May 2016 G G G G G G Y02885 Marsh Green Medical Practice CW 2735 14 August 2019 O G G O G O P92635 Dr Vasanth and Partners TABA 2433 22 January 2019 G G G G G G P92020 Dr Sivakumar and Dr Gude TABA 4330 27 November 2018 G G G G G G P92028 Elliott Street Surgery TABA 4621 18 December 2018 G G G G G G P92033 The Surgery (Dr CP Khatri) TABA 4670 19 July 2017 G G G G G G P92042 Dr KK Chan & Partners* TABA 10,110 14 July 2016 G G G G G G P92605 Boothstown Medical Centre TABA 5916 02 December 2016 G G G G G G P92626 Meadowview Surgery (Dr Atrey) TABA 4674 09 October 2017 G G G G G G P92633 Bee Fold Lane Surgery TABA 1973 30 August 2019 O G G O O G P92637 Astley General Practice TABA 2776 23 May 2017 G G G O G G P92646 The Surgery Astley (Dr Vardhan) TABA 3102 18 February 2020 G G G G G G

Page 75 Y02321 Nelson St & Poplar St Surgery TABA 4568 31 May 2019 G G G G G G P92016 Pennygate Medical Centre H 16729 28 April 2016 G G G G G G P92004 Dr Tun & Partners H 8052 31 October 2016 G G G G G G P92006 Dr Ahmad & Partners H 6172 07 December 2017 G G G G G G P92031 Platt House Surgery H 3402 26 April 2018 G G G G G G P92616 Higher Ince Surgery H 3280 20 June 2017 G G G G G G P92620 Lower Ince Surgery H 3944 31 July 2017 G G G G G G Y02274 Claire House & Rivington Surgery H 3490 25 April 2019 G G G G G G P92002 Braithwaite Surgery Li 5159 06 June 2017 G G G G G G P92012 High Street Surgery* Li 4574 5th August 2019 NI NI NI NI NI NI P92041 Ashton Medical Centre Li 7543 26 September 2017 G G G G G G P92630 Dr M Pal* Li 2718 08 January 2019 G G G G G G P92639 Dr Syed Shahbazi Li 3134 14 July 2016 G G G G G G P92648 Slag Lane Medical Centre Li 2354 21 June 2018 G G G G G G P92651 Lowton Surgery Li 4738 06 December 2018 G G G G G G Y02378 Bryn Street Surgery Li 6088 13 June 2019 G G G G G G

Key

*= This practice has been identified for a new comprehensive inspection because of a new provider/ partnership since the last inspection.

Page 76 Healthy People, Healthy Place MEETING: Primary Care Commissioning Committee Item Number: 6.4

DATE: 7th September 2021

REPORT TITLE: Primary Care Infrastructure Support Programme Update September 2021

1: Commissioning Health and Care Services CORPORATE OBJECTIVE Commission health and care services that meet the ADDRESSED: needs of local people, delivering high quality, clinically viable, affordable, efficient and responsive services that improve the overall experience for each person at every contact, across their life course.

4. Financial Affordability Commission high quality health and care services within the allocated financial resources that are available to the Borough.

REPORT AUTHOR: Jonathan Kerry (Associate Director Primary Care)

PRESENTED BY: Jonathan Kerry (Associate Director Primary Care)

RECOMMENDATIONS/DECISION The Committee is asked to receive the report and REQUIRED: support the direction of the Primary Care Infrastructure Support Programme.

Page 77 EXECUTIVE SUMMARY

This paper provides an update on the progress against the CCGs Primary Care Infrastructure Support programme.

The paper illustrates the CCGs commitment to ensuring that all elements of underpinning infrastructure provide a firm foundation for Primary Care Transformation.

The key areas of work in the Primary Care Infrastructure Support programme have been;

 Estates,  Information Governance,  Information Technology,

There are a number of local and national initiatives which are being supported by the single programme of work; making best use of resource and ensuring that Wigan Borough is delivering the highest levels of care possible.

Work is also progressing to support our forward thinking approach to technology and innovation; with our focus being to support practices to work smarter and deliver high quality care to all patients across Wigan Borough.

FURTHER ACTION REQUIRED: None

Page 78 Primary Care Infrastructure Programme Update September 2021

Page 79 Primary Care Infrastructure Programme Highlight Report

Programme Lead/s Jonathan Kerry - Associate Director of Primary Care

Senior Responsible Linda Scott – Director of Primary Care Officer

Reporting Period July – August 2021

Purpose and Aims

We want to ensure that we create the right environment and foundation to support General Practice Transformation, both within Practices and the CCG, to allow change to be driven at pace and scale.

We will ensure that services delivered to Primary Care are resilient and responsive to the needs of local practices, and flexible to cater for the developing transformation agenda, so that they can build upon these services to deliver high quality and innovative models of care.

We will support Service Delivery Footprints and Primary Care Networks in understanding opportunities for new ways of working and organisational implications through the use of technology and innovation.

Objectives

O1 To support and facilitate the development of Primary Care Networks (PCNs) as the basis for delivering high quality, sustainable and resilient general practice.

O2 To support and facilitate the development, capability and capacity of PCNs to operate at the heart of an integrated place-based health and care system

O3 To work with member practices and other key stakeholders to design and implement schemes that provide the conditions and infrastructure to enable primary care transformation and development.

Milestones

M1.1 Consolidation of GP Clinical Systems On track

M2.1 Expansion of Video Consultation capabilities across General Practice to support Care Home Locally On track Commissioned Services

M2.2 Secured Record Storage Pilot to expand opportunities Delayed for premise utilisation and service expansion.

M3 Expansion of Online and Video Consultation capabilities across the Practices and Primary Care On track Networks

Page 80 Programme Updates within the Period

A number of projects are underway to ensure that we can use digital services to support all practices, and through innovation, Digital / drive forward the transformation agenda at pace throughout the Information current COVID outbreak. Technology Vaccination Centres

We have continued to dedicate a substantial amount of resource to the support of the Borough Wide Vaccination Hub system which underpins the booking and operations within our covid vaccination centres.

57/58 practices are now utilising the GP Connect remote booking capabilities to allow them to directly book their patients into a shared rota of appointments.

We also continue to provide onsite technical support to ensure that we can quickly respond to any issues with the mobile workstations. The mobile workstations have provided a stable platform allowing for connectivity to the full clinical system, with Infection Prevention and Control approved peripherals, so that practice staff have access to the right tools and information to ensure the highest levels of quality patient care are delivered.

The Wigan GP Alliance continue to deliver the Boroughwide call handling service 7 days per week, allowing for a central capability for patient communications, support for booking/arranging vaccinations and ensuring that additional pressures are not added to individual practice systems/processes and workload.

The use of online booking of appointments has also continued to be incredibly popular, giving those patients with access online a quick and easy option of booking into the correct clinics at a convenient time. Where patients do not take up the offer of online booking, or don’t have mobile contact details recorded, we continue use the call handling service to ensure patients are booked in.

Over 250,000 appointments and vaccinations have been handled to date using our local configuration.

NHS111 / GP Connect

We continue to monitor the capability of direct booking between NHS111 services and General Practice. This is a mechanism through which NHS111 could “triage” calls into a Practice appointment slot, allowing local workflows and processes to then be followed in order to provide the appropriate care to the individual.

Given the continued increasing demand across all health services, a revised setup and configuration of the direct booking slots has

Page 81 Healthy People, Healthy Place been implemented to ensure they align to the demand being seen through NHS111.

This refreshed configuration has seen an improvement in slot utilisation, meaning that NHS 111 are being able to successfully book patients more often into General Practice. The weekly average is currently circa 50-60%.

GM Care Record (Graphnet)

The Graphnet platform continues to be expanded to ensure that across all care settings the right information to support care delivery is available.

This builds on previous capabilities, being able to share General Practice Data wider, to be able to bi-directionally share General Practice, Acute, Community, Mental Health and Social Care data, for the purposes of direct care.

To ensure we maximise the potential, we are linking with colleagues across Greater Manchester and Health Innovation Manchester to share training materials and good practice for how the system can be used to best support care delivery.

Support to Primary Care Networks

Work has progressed to continue to support Primary Care Networks, and specifically their aspirations with regards to have the additional roles being recruited as part of the ARRS will interact and embed with existing practice workflows.

Our local consolidation and usage of standardised systems helps to provide insight and opportunities to support the work, and there is now a clear direction of travel across each of the Primary Care Networks (PCNs) that we are looking to support.

At present we are supporting work to implement central hubs in a number of PCNs whilst also progressing work to streamline the referral/signposting processes to support First Contact Physio and Community Link Worker roles.

This flexibility in roles and approach has shown early signs that this approach to configuration and developing maturity in capabilities will support future roles and PCN led service developments.

Digital First Primary Care

The introduction of new approaches to supporting patient access was rapidly introduced at the start of the pandemic, with uptake being so rapid that it did not allow for the normal adoption and transformation process to occur.

Recognising that this rapid implementation has brought with it

Page 82 Healthy People, Healthy Place challenges for practices and patients, we have commenced with an approach of “Enhanced Action Learning Sets” (EALS) in order to break down the challenges and complexities of the new approaches with a view of sharing opportunities for improvement and ensuring an equitable level of access is achieved for all.

The EALS commenced in June with an initial group of 6 practices, each at a different stage in the transformation journey and with different experiences of adoption and utilisation. Supported by colleagues from within the CCG and specialists from AskmyGP, we have started to come up with a series of recommendations and processes for the practices to test and feedback upon.

Taking the learning from this initial group we are now looking to create an additional 3 groups and include wider input from the Production General Practice Programme and Healthwatch to further advance our learning and sharing of benefits to practice operations.

Our goal through the EALS is to create an “ecosystem” of shared learning that will help to not only embed digital services but also recognise the ways in which we can ensure inclusive and accessible services for patients.

Secure Record Storage

Working with colleagues from across Greater Manchester CCGs, we have been successful in securing funds from NHS England to allow us to progress with the Digitisation of Patient records (predominantly historic elements), in line with the national programme of work.

We have recently (26th Aug) received approval to utilise a GM based approach to procurement, given only limited progress in the national procurement. This will allow for the phase 1 of the programme to progressing, aiming to digitise approx. 10% of local historic records, utilising a mini competition approach across GM.

It is hoped that the mini competition can be progressed during September to allow for digitisation to commence from October.

Technology Deployments

We have been continuing to support remote and agile working across practices to ensure that we can keep the workforce operational during the current times.

To support an increased number of practice staff either self- isolating, or working remotely to ensure business continuity, we have deployed additional laptops.

We have also been looking to maintain Business As Usual operations, with a project underway to delivery upgrades to Primary Care hardware to ensure that the minimum warranted

Page 83 Healthy People, Healthy Place specification is maintained, and that practices have fit for purpose technologies to support efficient use of time and resources.

Information The CCG is responsible for the delivery of Information Governance Governance services to support the requirements to comply with information legislation, data protection and the NHS Information Governance (Data Security Assurance Framework across General Practice. and Protection) This provides a significant level of assurance to the CCG and has allowed us to have much more focus on local needs and to ensure that we have robust and focused resource in place to meet the needs of Practices and Primary Care Network developments.

Work has continued to gain approval and embed Data Protection Impact Assessments along with a refresh of the Confidentiality Code of Conduct to ensure it can be used by an increasing volunteer and subcontracted workforce across the vaccination sites.

There has now been confirmation that the Data Security and Protection Toolkit submission for 2021/22 will be due on the 30th June 2022, so workplans are being developed and consistency ensured through the upcoming commissioning changes.

It is essential that support is given to practices, and Service Delivery Footprints, to identify assets and opportunities for assets Estates to ensure that services can be delivered within the community.

Work is continuing to ensure that we maximise the utilisation of our LIFT buildings, support practice developments, and also look to identify and support new developments in the future, aligned to funding opportunities and patient need. This has been supported by all stakeholders, including Community Healthcare Partnerships (CHP), which is ensuring that we have tactical flexibility in locations rather than getting caught up in formal agreements and licenses for usage.

Work is continuing to progress across a number of areas:

Boothstown/Parr Bridge

Work has been continuing at a pace on the Parr Bridge Health and Wellbeing Centre, following on from formal approval gained through the CCG and Wrightington, Wigan and Leigh Teaching Hospitals Foundation Trust committee structures.

The project is continuing along the projected timeline which is currently focussed on stakeholder engagement, plan refinement, legals, tendering, construction and mobilisation.

During September and October we will be completing an extensive piece of work to support the stakeholder engagement, focussing

Page 84 Healthy People, Healthy Place on staff, patients and wider public groups to ensure that the scheme meets all the needs of its service users.

We remain on track for the contractual elements of work being completed by December 2021, allowing for the build to be completed during 2022 and occupation to occur from around January 2023.

Aspull Surgery

Formal planning approval has now been received which is allowing the scheme to progress to the next phase of refinements, legals and contractor selection.

Work has also continued with the local stakeholder group which will aim to meet at least quarterly during the build stage, and more frequently as we get closer to completion and mobilisation of services.

The programme remains on track to commence the build work imminently, with an estimated build duration of 12 months.

Shevington Surgery

There remains a commitment to progress with a scheme to maximise the estates opportunities covering the Shevington Surgery and Clinic location.

An initial Business Case has been reviewed by the Primary Care Committee and subsequently the CCG Finance and Performance Committee in order to gain approval.

Whilst supported in principle by both Committees, further work is required to ensure that the scheme is financially sustainable for all partners. A further update will be brought to the November Committee meeting.

Primary Care Network Estates Programme

We have also continued with the creation of more formal

Page 85 Healthy People, Healthy Place approaches to our support of PCNs and their estates requirements linked to Service Delivery Footprints.

The approach has started to introduce governance at a PCN level, allowing for the agreement of a Project Mandate overseen by a project board and agreed by all partners which will set out the direction of travel and aspiration of the PCN/SDF.

Utilising this we are then able to instigate task and finish groups, reporting to the project board, which will progress the necessary reviews, discussions and/or work to meet the direction set in the mandate.

Early examples have started to describe and progress with alternative approaches to reception services, back-office administration, training and collaborative working space.

It is expected that the initial mandates will be in place to bring together a single programme of work to the November Primary Care Committee for support and oversight.

We also continue to work with colleagues from Wigan Council as part of the Strategic Estates Group to ensure that the future provision of estate for health and social care services aligns to the ambitions of our Locality Plan as well as being able to forecast for the potential increases in our local population.

Outcomes Achieved

O1 Deployment of technologies to support remote working across the CCG and General Practice.

O2 Deployment of technologies and software solutions to support the Covid Vaccination programme.

O3 Maintained a high level of governance with regards to Data Protection and Security.

Plan for Next Period

 Ensure the continued adoption of a Digital First Approach.

 Continue to support the operational and implementation element of the Vaccination programme.

 Progress with Records Digitisation programme.

 Continued support to active estates developments and progress schemes coming through the pipeline.

Page 86 Healthy People, Healthy Place  Respond to the requirements of Practices and PCNs to support service changes and consolidation in response to the Covid-19 pandemic.

Risk Register

R1 Failure of Primary Care Networks to develop deliver models and organisational structures to support new ways of working restricts the opportunities to support 12 patients and maximise the potential of funding available.

R2 Risk of Virus and/or Ransomware attack is increased if Operating System and Antivirus patching is not kept up 5 to date. R3 Competing operational and project pressures threatening overall aims and objectives across IM&T 9 programme.

R4 Limited capital funding available across Greater Manchester restricts the opportunities available to 8 support estates developments.

R5 Significant financial penalties could be incurred through information breaches in practices if GDPR and Information Governance process are not properly 4 embedded, maintained and monitored.

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PRIMARY CARE NETWORK DEVELOPMENT FUNDING - SUMMARY

Update to Wigan Borough Primary Care Commissioning Committee

1. Purpose The following provides an overview of utilisation of Primary Care Network (PCN) development funding at a GM level and in localities. The purpose is to share details with GM and locality colleagues to reduce any duplication, identify gaps and contribute to planning of 20/21 activities.

2. Introduction/Background As part of the of PCN Directed Enhanced Service (DES), Greater Manchester received £2.3m funding to support PCN development in 2019/20; in 2020/21 GM received a further £2.1m In 2019, a Task & Finish group was established to agree the best approach for utilisation of the funding. The group, comprising of CCG primary care commissioners, GP providers, PCN Clinical Directors, GM primary care team and GM workforce team agreed that £1.3m should be delegated to localities, and £1m retained centrally for GM wide initiatives. The same approach was taken in 2020/21. National guidance set out that resources should be used to:  Support recruitment  Enhance integration  Continue to improve access  Reduce health inequalities In August 2020 responsibility for the GM level PCN Development programme transferred to the Primary Care Provider Board (PCB) as part of a Memorandum of Understanding between the Greater Manchester Health and Social Care Partnership and Primary Care Board.

Page 89 3. GM Level Programmes 3.1 Business Intelligence Business intelligence support including the development of PCN dashboards, provision of Investment and Impact Fund (IFF) reports to support contract management, health inequalities reports and support, business intelligence and analysis and 1:1 support for PCNs. Progress to date A dedicated Business Intelligence specialist has been in post since April 2020, working with the GM BI team and locality teams to develop a series of Tableau reports for PCNs. All PCNs have access to Tableau which contains IIF and health inequalities information. At the request of PCNs, dashboards and operational information have been and are being developed in the following areas:  Outputs to assist PCNs in understanding their populations – for example prescribing data, childhood immunisation, workforce information, digital outcomes, social prescribing, disease prevalence measures, wider determinants/social issues  Outputs to assist PCNs in delivering the requirements in the GP contract agreement / PCN service specification, for example structured medicine reviews, enhanced health in care homes, early cancer diagnostics and IIF metrics  Additional outputs to be agreed by the PCNs (ongoing) The primary focus is on health inequalities. Scoping work was undertaken to understand the breadth of work already underway across GM, including work within the combined authority, hospital trusts and other stakeholders This work is being delivered in partnership with the Utilisation Management Team at Health Innovation Manchester and the GM Business Intelligence team. From August 2021 a dedicated BI programme commenced specifically aimed at supporting health inequalities. This programme is being delivered through Health Innovation Manchester and will be available to all localities and PCNs across GM on an interest first basis. The health inequalities work has commenced in Tameside and Glossop and is about to start in Bolton, closely followed by Wigan. The remaining localities will be involved over the course of the next 12 months. The data collected will be presented back to localities through a series of workshops. The outputs of the observational review have been used as a baseline to underpin the digital first programme. A podcast has been developed to summarise the key learning which will be shared in October

3.2 Observational Review This includes the provision of reports for each PCN providing recommendations and insights from PCN business practices. More detailed reports were available for PCNs that wanted them. There was also an overarching report and podcast of key findings.

Page 90 Progress to date There was an observational review for each PCN focusing on business set up, management and efficiency. This programme was delivered in partnership with Interdigitate working alongside locality leads and Clinical Directors. The initial review concluded in May 2021. There was good engagement from the PCNs, with some preferring to go later after the vaccination programme was more established and others keen to complete early. As part of this programme Interdigitate have produced website reviews for all PCNs and bespoke reports with PCNs that worked with them more closely. In the final few weeks of the project Interdigitate worked intensively with two PCNs (SWAN in Wigan and the Heatons Group Network in Stockport) to review their detailed business data and produce case studies to demonstrate the value of understanding business processes within their PCN and opportunities for sharing processes across practices. Interdigitate also produced an ‘Ask my GP’ report for the Wigan locality.

The learning from this programme has been shared with all PCNs. It highlighted a number of key priority areas including access, working together across PCNs, improved ways of working such as networked appointments and navigation, improving and increasing the data culture (promoted through the development of the health inequality tools) and maximising the opportunities of the ARRS roles.

3.3 Additional Roles Reimbursement Scheme (ARRS) Working closely with and on behalf of PCNs including negotiation with NWAS and mental health trusts and ensuring economies of scale for recruitment and negotiation. This includes the easing of arrangements for funding from CCGs down to PCNs as well as supporting PCNs with the onboarding and management of staff alongside the GP Federation Group. Progress to date Working closely with CCG finance leads to understand the process for approval and access to ARRS funding. Senior HR support has been commissioned to work with PCNs regarding recruitment, release of funding and working closely with the GM primary care workforce team to ensure new roles are primary care ready. With this additional HR capability, the Primary Care Board have been able to offer professional HR support to PCNs as well as support with team management. Work continues in 2021/22 to enable PCNs to make best use of the ARRS funding within current arrangements. The focus has been on the recruitment of paramedics and mental health workers, due to the complex interdependencies with NWAS and Mental Health trusts.

3.4 Digital Developments The Primary Care Board has been able to provide a unified voice for primary care in regard to digital developments. The board has representation on the Primary Care Digital Board, encouraging attendance from primary care providers. Membership of the digital board ensures primary care is consulted on any digital developments as well as testing of new market opportunities roll out and proof of concept opportunities. Examples include Safe

Page 91 Steps, Linus cognitive tool for detection of early dementia, ‘Sleepio’ and other health and wellbeing tools Progress to date Primary Care Board have been working closely with Health Innovation Manchester to develop digital solutions for primary care, with PCNs involved in supporting this work and contributing to future developments. PCNs are represented on the Primary Care Digital board via interested GPs, with an open invitation to all PCNs. Up to 10 PCNs are actively involved in the digital first work with Health Innovation Manchester. The Primary Care Board have recently identified a Digital GP Lead (from Salford locality) who will be working one day a week to support this programme of work. There is also a broader piece of insight work being led by Health innovation Manchester which will include up to 50 practices. Proofs of concept are under development, particularly to support community diagnostics and other emerging tools. This includes testing of a digital dementia and cognition tool.

3.5 Business as Usual The Primary Care Board has established a weekly Tuesday night meeting for PCNs. This is open to all PCNs and has good attendance across all PCNs. It is an opportunity for PCNs to discuss and debate current priorities. PCNs are also able to bring topics for discussions. This work is a central part of collaboration and involvement for the COVID vaccination programme as well as bringing current issues for discussion.

3.6 Future Developments 3.6.1 CLEAR Programme An opportunity has been made available through Heath Education England. The programme focuses on anticipatory care and development of a model for the identification and management of vulnerable people. This is a direct opportunity for two PCNs (TABA in Wigan and Hyde in Tameside and Glossop). The outcomes and learning will be shared across all PCNs. Both PCNs will receive executive leadership ad hands on support.

3.6.2 Working with Boehringer Boehringer Ingleheim is a pharmaceutical company keen to understand more about PCNs and their development needs. The PCB have secured a mutually beneficial support programme for a small number of PCNs. This includes a ‘buddying’ arrangement with members of the Boehringer team to problem solve and with on particular PCN issues. This may include customer engagement, digital navigation etc or work to establish best practice in clinical pathways. This programme will commence in the autumn with TABA PCN in Wigan (subject to CLEAR programme) and Gorton & Levenshulme and Clayton Beswick & Openshaw PCNs in Manchester. The programme will provide proofs of concept for wider sharing.

Page 92 3.7 PCN Engagement There has been good engagement from PCNs across all initiatives. The Primary Care Provider Board is working in a need’s basis in some cases. For example, the PCB is working with Pennine Care to recruit on mass for the Bury PCNs. Attendance at the digital board and the weekly PCN meeting is voluntary. The PCN weekly meeting is well represented by all PCNs.

4. Locality Level Programmes The following provides a summary of local activity, based on information provided by localities.

4.1 Recruitment and retention Additional Roles Reimbursement Scheme A number of PCNs have focused on supporting the recruitment and embedding of the ARRS roles. This includes the development of staff inductions, training and upskilling, development, supervision, mentorship of new staff and HR and legal support. PCNs have also been working to integrate ARRS roles including administrative and pastoral support. Leadership and OD Several PCNs have focused on creating time for Clinical Director development – including CD meetings, as well as development of business managers, lead practice managers and nurse leads. In Oldham, three GPs are being supported to complete to complete their GP trainer qualifications. A number of PCNs have invested in team building and team organisational development, such as the development of informal professional networks in Trafford, PCN business manager and wider team development in Tameside and Glossop and establishment of a nurse forum in Stockport. Workforce development In Salford, work is progressing to develop portfolio roles. They have also explored the development of an electronic workforce management tool and workforce development plan. In Wigan PCNs are developing employment models to enable them to employ more PCN and ARRS staff, supported by the CCG. A number of localities have focussed on wellbeing and resilience support including the increase of appointment times in Trafford and resilience and wellbeing training for practice managers in Salford. In Wigan, PCNs have been prioritising working together on back office functions such as workflow and telephony PCNs have utilised funding for backfill and additional support to ensure CDs and other PCN workforce have protected time to fulfil their roles. A number of localities have employed PCN managers and/or co-ordinators to support PCNs and recruited additional staff to support COVID related increases in workload.

Page 93 4.2 Enhanced Integration Working with Vulnerable Groups Many PCNs have built on exiting work and relationships built through the delivery of the Care Homes DES and delivery of the vaccine programme. HMR locality has developed a dashboard to support delivery of the Care Homes DES. Trafford facilitated a training programme for care home staff with the aim of involving community and secondary care clinicians to develop relationships and enhance integrated working. There are examples of PCNs establishing dedicated Care Home vaccination teams. Oldham have facilitated PCN Patient Participation Groups (PPGs) and commissioned a PPG co-ordinator to support the PPGs including better links with the BAME community. Stockport have facilitated local groups in the community, for examples mental health, fibromyalgia and MSK A number of localities and PCNs have utilised ARRS roles such as community paramedics, clinical pharmacists and social prescribing link workers to support the most vulnerable populations including those in care homes or that are housebound. System Collaboration Some localities have facilitated wider collaboration with local systems to improve patient care including local authorities, local care organisations, acute trusts, voluntary sector and wider primary care providers. Bolton PCNs have established an exercise referral scheme with Bolton Council. In Wigan, community service teams are providing neighbourhood update reports and feedback on practice referrals. This information is then shared with practices. In turn the PCNs have invited teams to join their PCN meetings. There are examples of collaboration with wider primary care. In Wigan, community pharmacies and PCNs are working together to increase flu uptake in the over 65s. they are also co-ordinating business continuity plans should there be a temporary closure of a pharmacy or GP practice. In Tameside and Glossop there are ‘partnership’ locally commissioned services in place. There is innovation funding available to test projects that are focused on partnership working. There is work taking place in several localities to support Clinical Directors to work along the new ICP

4.3 Improved Access Remote Consultations and Digital First Many localities and PCNs are improving access by building on the total triage and remote consultation models developed in response to Covid-19. This includes supporting integration between practices and PCNs, reducing waiting times, helping reduce staff workload and pressures by supporting the interface between primary, community and secondary care. In HMR they are facilitating training and development of a consistent triage process across all practices and PCNs In Salford, they identified GP Extended Access as being inequitable for Swinton patients through the city-wide model. They are in discussions to deliver extended access as a PCN to improve access by offering evening and weekend appointments. Two full time paramedics

Page 94 will also be recruited to support practices in the PCN. All of this work continues alongside face to face access that some people would prefer or need. Workforce Development Some localities are focusing on utilisation of the ARRS roles to improve access. Tameside and Glossop have increased the use of Care Co-ordinators to support proactive identification and contact with patients. Trafford is in the process of revising their social prescribing offer. Salford are supporting the development of newly qualifying staff by providing supervision and mentoring as a way to attract and retain more permanent staff

4.4 Reducing Health Inequalities Population Health Management PCNs are being supported to develop bespoke/population specific projects and quality improvement priorities. Population health management techniques are being developed and embedded in most localities, with local data routinely reviewed at PCN level. PCNs are being supported to understand their data. In Salford a task and Finish group has been established between PCNs, Local Authority and NHS Salford CCG to triangulate population health data to understand the population to ensure they can communicate and target care to their health needs. Working with the Local Community Many PCNs and localities are working with patients and local community groups, specifically working to support ‘harder to reach’ communities. In Stockport specific training has been provided for PCNs focusing on BAME and LGBT communities and people living with dementia. In Trafford PCNs are working directly with BAME communities to dispel myths related to the Covid-19 vaccine. The Trafford team are also working closely with the voluntary sector to increase uptake to cancer screening programmes. Work is ongoing in Trafford to deliver a communications campaign to promote health initiatives in a variety of languages focusing (but not limited to) vaccine programme, cervical screening and diabetes. Many localities are bringing care closer to home. Oldham PCNs are exploring a mobile ultrasound service and specialist mental health support at PCN level. Salford PCNs are working with the acute trusts to pilot dieticians in PCNs. Wigan plan to fund a nurse per PCN for a session per week to support the most vulnerable patients. Protected Learning Time Some localities are ensuring they retain protected learning time. In November, protected time in Tameside and Glossop will focus on developing implementation plans from local information and data to determine the ‘so what’ and drive change. Stockport are planning engagement sessions within the whole PCN and wider neighbourhood teams including mapping and involvement with 3rd sector and local business to promote physical or virtual community hubs. Wigan are using protected learning time to free up time for MDTs to get together to review national and local audits and Significant Event Analysis to address variation and benchmark against best practice across GM and nationally.

Page 95 4.5 Other Digital Wigan locality is developing PCN websites which will offer patients a directory of services, self help guidance for common conditions, links to health TV and an accessibility reader and translation engine. Salford will launch new PCN website in August 2021. Stockport is working to update and standardise practice websites. Trafford are exploring the possibility of a separate platform for their extended access service. Trafford have also obtained Florey Plus for their practices which enables practices to collect information about and monitor patients remotely. Salford have mobilised EMIS Federated and Docman Share to facilitate at scale working across PCNs. Wigan is also working to have PCN level agreed data, templates and protocols which will be stored on a PCN level database. The locality is supporting PCNs to have a digital lead to drive digital changes with examples of good work being shared across all PCNs TABA PCN in Wigan, is aiming to provide clinical services on behalf of member practice, to enable core services to be maintained while practice workforce delivers the Covid-19 vaccine on behalf of the PCN population. The PCN funding would potentially be used as top up money in recruitment of the ARRS roles to ensure a more experienced workforce across the 11 practices. This will reduce workload pressure on general practices. It would also provide an administrative service liaising with practices around quality and KPI monitoring to support our robust management system with financial oversight providing assurance that the PCN would be fulfilling our quality requirements and maintaining robust governance. In addition, funding is being requested to align Clinical Champions for ARRS clinical supervision and to pay practices a nominal backfill payment to attend a protected learning time meeting once a month. Structure and Form Localities are working with PCNs to help develop their structure and organisational form. This includes supporting clinical directors to form cohesive leadership groups, development of network visions, standardisation of clinical decision support, data collection and workflow optimisation. A number of localities are working with ‘Ardens’ to support this work.

5. Considerations Sharing of Learning and Best Practice There is considerable work taking place at GM and localities, however this information is not shared regularly. There needs to be a better mechanism for collating and sharing information across localities, between localities and GM and across commissioners and providers. Links with Workforce A number of initiatives described above are directly linked to workforce developments. Consideration is needed of how the workforce and PCN development programmes align as a strategic level.

Page 96 Wider PCN offers The NHS Leadership Academy and Health Education England have provided a number of leadership and organisational development opportunities for PCNs and primary care providers. These offers may not have been captured by the locality and Greater Manchester level submissions.

6. Next Steps More in-depth analysis of the information provided by localities and GM. Further clarity will be sought on areas that were light in details. The GM primary care team will work with the Primary Care Provider Board and the 10 localities to agree an approach for a robust process for collating and sharing information to understand how PCN development money is being utilised across the whole system and within each locality.

7. Recommendations The Wigan Primary Care Commissioning Committee is asked to:  Note the contents of the paper  Note the next steps

Page 97 This page is intentionally left blank MEETING: Primary Care Commissioning Committee Item Number: 8.0

DATE: 07th September 2021

Local Commissioned Services Specification Review REPORT TITLE:

4. Financial Affordability Commission high quality health and care services within the allocated financial resources that are available to the Borough.

REPORT AUTHOR: Gillian Watson – Primary Care Commissioning Manager

PRESENTED BY: Gillian Watson – Primary Care Commissioning Manager

RECOMMENDATIONS/ The Committee is asked to receive the updated service DECISION REQUIRED: specifications and approve for implementation 01st October 2021.

Page 99 EXECUTIVE SUMMARY

As part of the Enhanced General Practice Specification which got approved at the Primary Care Commissioning Committee on the 6th July, a review of the all Local Commissioned Services that we have in the borough have taken place. Each specification was reviewed to ensure they are still valid and fit for purpose.

Reviews have been undertaken by a clinical lead and Commissioning Lead.

The PCCC is asked to review and approve the service specifications for the following services:

1. Influenza 2. Near Patient Testing 3. Ring Pessary 4. Anticoagulation 5. End of Life – Draft Service specification

Roll out and implementation will commence on 01st October 2021

FURTHER ACTION None REQUIRED:

Page 100 Local Commissioned Service review

• GP Enhanced Service Specification submitted to the Primary Care Commissioning Committee on the 6th July. • Review meetings have taken place with commissioning and clinical leads to review Local Commissioned Services (LCS’s) within the enhanced service for implementation in October 2021. • Reviewed at Primary Care Operation meeting – 18th August 2021

• LCS’s Service Specifications: 1. Influenza – Cross referencing specification against the new enhanced service Page 101 Page 2. Near Patient Testing – No Change 3. Ring Pessary – T&F group with clinical lead have reviewed the specification and relevant changes made. 4. Initiation & Maintenance of Anticoagulation Phase 1 – Specification amended to reflect removal of initiation and link to the annual review transfer as per NICE Guidance. Phase 2 – Quality Review with the Trust and develop Integrated approach (October 2021) 5. End of Life – T&F group with clinical lead have reviewed the specification and changes made. 6. Influenza outbreak in care homes (GP Alliance)– No Change 7. Gynaecology – Pilot in Hindley PCN currently, potential roll out to all PCN’s next financial year

• Other LCS’s (previously in place) • Next Steps: 1. Winter Pressures - Decommissioned – No funding available 1. Approval at Primary Care Commissioning Group – 2. Asylum Seekers / Homelessness – Decommissioned March 2019 07th September 2021 3. Minor Surgery / Care Home – Now Direct Enhanced Service 2. Implementation – 01st October 2021 This page is intentionally left blank SCHEDULE 2 – THE SERVICES

A. Service Specifications

Mandatory headings 1 – 4: mandatory but detail for local determination and agreement Optional headings 5-7: optional to use, detail for local determination and agreement.

All subheadings for local determination and agreement

Service Specification No. Service Influenza and Pneumonia Vaccination Service Commissioner Lead Director of Primary Care Provider Lead GP Practice Service Lead Period 1st October 2021 – 31st March 2022 Date of Review 31st March 2022

1. Population Needs 1.1 National/Local Context and Evidence Base 1.1.1 Flu is a key factor in health and social care resilience. It impacts on those who become ill, the NHS services that provide direct care as a result, and on the wider health and social care system. The annual immunisation programme helps to reduce unplanned hospital admissions and pressure on A&E and Primary Care; improving resilience to seasonal flu is also important in maintaining the delivery of key Council services and supporting service continuity. It is therefore a critical element of the system-wide approach for delivering robust and resilient health and care services during winter months and is an integral element of Wigan’s Winter Wellness programme. 1.1.2 This service aims to supplement the national NHS England Seasonal influenza and pneumococcal immunisation enhanced service to support delivery of an effective flu programme across Wigan Borough CCG. 1.1.3 The service specification is designed to support influenza and pneumonia vaccination within the following eligible groups:  At risk housebound patients plus household contacts where they are eligible for the vaccine  Severely immunosuppressed patients plus household contacts where it is safer for the patient to be vaccinated in their own home.  GP practice staff 1.1.4 The seasonal influenza programme offers an opportunity (using the same call and recall system) to provide PPV23 alongside seasonal influenza to unvaccinated people in risk groups and those who have just turned 65. As pneumococcal infection is a recognised complication of influenza, providing the two vaccines together early in the season will increase the level of protection to vulnerable individuals over the winter period. Page 103 1.1.5 The locally commissioned service (LCS) will be offered by GP practices already delivering vaccination and immunisation services in Wigan Borough Clinical Commissioning Group. 1.1.6 The LCS will support protecting those who are most at risk of serious illness or death should they develop influenza or pneumonia, by offering protection against the most prevalent strains of the virus. 1.1.7 This document has been developed based on the best available knowledge at the time of publishing. Clinicians should remain alert to new developments and the possibility that guidance may change. Clinicians should use the drug's summary of product characteristics to inform decisions made with individual patients.

2. Outcomes 2.1 NHS Outcomes Framework Domains & Indicators

Domain 1 Preventing people from dying prematurely Domain 2 Enhancing quality of life for people with long-term conditions  Domain 3 Helping people to recover from episodes of ill-health or following injury Domain 4 Ensuring people have a positive experience of care  Domain 5 Treating and caring for people in safe environment and  protecting them from avoidable harm

2.2 Local Defined Outcomes 2.2.1 Increase the vaccination levels for housebound patients, immunosuppressed patients, patients on the shielded list plus any household contacts that are eligible against Influenza and Pneumonia.

2.2.2 Increase uptake in Black, Asian, Minority Ethnicity (BAME) and Learning Disability populations

2.2.3 Increase the vaccination levels for frontline GP practice staff and care home staff against Influenza.

2.2.4 Reduce the rates of Influenza and Pneumonia within Wigan Borough Clinical Commissioning Group.

3. Scope 3.1 Aims and Objectives of Service 3.1.1 The overall aim of the service is to provide a high quality Influenza and Pneumonia vaccination service for patients and health and social care staff. This aim will be delivered by:  Ensuring a consistent approach to immunisation.  Improving overall population coverage of patients within the eligible at risk groups.  Ensuring frontline GP Practice Staff are immunised against influenza and do not pose a threat to patients that may be vulnerable to risk of influenza visiting the GP Practice.

3.1.2 The target timeframe for the influenzaPage programme 104 is 1 September to 31 March 2022 however, practices are asked to complete the programme by 30 November 2021 if possible in order to achieve maximum impact of the programme before influenza starts to circulate. Payments will be made under this LCS for eligible patients/staff until 31 March 2022. 3.1.3 Pneumococcal Vaccinations can be provided at any time. Funding under this LCS will be provided where patients eligible under the National NHS England Seasonal influenza and pneumococcal immunisation enhanced service are given a pneumococcal immunisation when visited to provide the influneza vaccine between 1 September 2021 and 31 March 2022. 3.1.4 There are a number of different flu vaccines available and the national guidance published by NHS England and Public health England must be followed regarding which vaccine to offer to ensure patients and staff receive the most effective vaccination. 3.1.1 The national PGD’s for Influenza and Pneumococcal immunisation should be used where PGD’s are necessary.

3.2 Service Description 3.2.1 Practices will be expected to provide the service where consent is given to all eligible patients plus household contacts and staff working in their own practice

3.2.2 Practices can provide the service to non-registered patients, with agreement from the patients registered practice via inter practice referrals from practices who are part of Wigan Borough CCG.

Provider Accreditation: 3.2.3 Only those providers’ providing Seasonal Influenza and Pneumococcal immunisation direct enhanced service will be able to provide this LCS.

3.2.4 The provider is responsible for ensuring that staff providing the service are competent to immunize and meet the PHE national minimum standards and Core Curriculum for Immunisation and have been assessed as competent to immunise.

3.2.5 The national standards for registered healthcare professionals are available here: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_d ata/file/679824/Training_standards_and_core_curriculum_immunisation.pdf 3.2.6 The national standards for healthcare support workers are available here: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_d ata/file/464033/HCSW_Training_Standards_September_2015.pdf 3.2.7 Recommended training requirements by workforce group for flu vaccination are available here: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_d ata/file/906537/Flu_immunisation_training_recommendations_appendix_A.pdf 3.2.8 A competency checklist is available here: https://www.rcn.org.uk/-/media/royal-college-of- nursing/documents/publications/2018/april/pdf-006943.pdf

3.2.9 Training will be organised and funded by the practice to ensure all provider staff or those contracted by the practice to provide the service have the necessary skills and knowledge to administer vaccinations, manage anaphylaxis, provide basic life support and use the equipment supplied.Page 105 3.2.10 Arrangements must be in hand for Continuing Professional Development of the staff delivering the service, with regular training updates and review of the Patient Group Direction (PGD) where this is used.

3.2.11 A summary of the key operational delivery aspects of the service that are required to be provided are outlined below:

3.2.12 The development and maintenance of a register. Practices should be able to produce an up to date register of all housebound patients, indicating patient name and date of birth.

3.2.13 Professional links. To work together with other professionals where appropriate. Any health professionals involved in the care of patients should be appropriately trained.

3.2.14 Infection Prevention and Control (IPC). Practices must ensure that the current guidance on IPC, PPE and hand hygiene are followed. They must ensure a process is in place to ensure that staff members do not visit a house where someone is currently self-isolating for COVID 19.

3.2.15 Education of people immunised. Ensure that all patients (and/or their carers and support staff where appropriate) receive appropriate information on Influenza and/or Pneumonia vaccination, the risks of these diseases and the benefits and risks of vaccination to enable informed consent. Where a patient lacks capacity and is unable to provide informed consent then a person with power of attorney should be contacted to provide consent/dissent. Where there is no power of attorney in place a best interest decision should be made and documented.

3.2.16 Record keeping. To maintain a record of the vaccination including processing of inter practice referrals (notification to buddy practice). Where necessary, update written procedures and clinical protocols for vaccination to ensure they reflect safe practice, and that staff are trained in these procedures. Take all reasonable steps to ensure that the medical records of patients receiving the influenza and pneumococcal vaccinations are kept up to date with regard to the immunisation status. Where Practice staff are being vaccinated records should be kept as part of the practices occupational health / employment records. Any staff vaccinated should be advised to notify their GP practice that they have received a flu vaccination and, where required, written information should be provided to support this transfer of information.

3.2.17 Vaccine Transportation. Providers must ensure an up-to-date Vaccine Carrying policy and procedure are in place and adhered to by their staff. Validated cool boxes/bags and cool packs from a recognised medical supply company should be used in conjunction with validated maximum– minimum thermometers when transporting vaccines. Any breeches of the ‘cold chain’ must be reported to the Greater Manchester Screening and immunisation team ([email protected]).

3.2.18 Untoward events. It is a condition of participation in this service that practitioners will give notification to the CCG Quality team of all emergency admissions or deaths of any patient covered under this service, where such admission or death is or may be due to usage of the drug(s) in question or attributable to the relevant underlying medical condition. This must be reported within 72 hours of the information Page 106 becoming known to the practitioner. This is in addition to a practitioner’s statutory obligations. Advice must be sought from Greater Manchester Screening and immunisation team for any vaccine incidents such as administering an out of date vaccine, patient that has received a double dose, patient receives the wrong vaccine.

3.2.19 Indemnity / Insurance – Practices must ensure that they have appropriate insurances in place to vaccinate their own staff, care home staff and non-registered patients.

3.3 Population covered 3.3.1 At risk housebound patients plus household contacts where they are eligible for the vaccine. This service includes inter-practice referrals which can be used to allow GP practices to vaccinate household contacts who are registered with another practice within Wigan Borough CCG. Housebound Classification Patients that cannot physically get to the Practice/surgery. Patients are not classed as being housebound if they can get on ring and ride, taxi, lift or public transport; go to the hairdressers, shops, practice etc.

3.3.2 Severely immunosuppressed patients plus household contacts where it is safer for the patient to be vaccinated in their own home. This service includes inter-practice referrals which can be used to allow GP practices to vaccinate household contacts who are registered with another practice within Wigan Borough CCG.

3.3.3 GP practice staff are eligible for flu vaccination as frontline healthcare workers. In order to maximise flu vaccine uptake amongst health and social care staff funding is provided under this LCS to support provision of flu vaccination to GP practice staff as part of the Practices occupational health offer. Practices must ensure they have insurance in place to cover this provision.

3.4 Any acceptance and exclusion criteria and thresholds 3.4.1 Provide seasonal influenza and/or pneumonia vaccination in line with national guidance to all eligible people as detailed above. 3.4.2 National guidance should be followed with regards to which vaccine should be given. 3.4.3 Summary of product characteristics (SPC) should be checked for full list of contra indications for each vaccine. Vaccination must be given by a suitably trained member of the GP practice staff. Pneumonia vaccines can be given when visiting the housebound patients if eligible under the National NHS England Seasonal Influenza and Pneumococcal immunisation enhanced service.

3.5 Interdependence with other services/providers The service provider should liaise with the District Nursing teams to check their housebound caseload patients. The service provider will be expected to liaise with community pharmacies and other flu vaccination providers to ensure patients/staff are not vaccinated by both the Practice and another provider.

The service provider will be expected to liaise with Care Homes to maximise Page 107 uptake amongst residents and staff.

3.6 Payment and Claims

Housebound patients plus eligible household £5 per vaccination members registered with the practice - (Claim vaccine via usual NHSBSA influenza and/or pneumonia vaccination route) Immunosuppressed patients plus household £5 per vaccination contacts registered with the practice - (Claim vaccine via usual NHSBSA influenza and/or pneumonia Vaccination route) Household members/contacts of the above £5 per vaccination plus £5 to cover cost and care home residents registered with a of vaccine different Wigan Borough CCCG practice - influenza and/or pneumonia Vaccination (inter-practice referral) Staff member registered with the practice £5 per vaccination they work and are receiving the vaccination (Claim vaccine via usual NHSBSA from - influenza vaccine only route) Staff member not registered with the practice £5 per vaccination plus £5 to cover cost they work and are receiving the vaccination of vaccine from - influenza vaccine only 4. Applicable Service Standards Applicable National Standards (eg NICE)

Public Health England - The national flu immunisation programme for the relevant year: https://www.gov.uk/government/publications/national-flu-immunisation-programme- plan

Influenza: The Green Book, Chapter 19: https://www.gov.uk/government/publications/influenza-the-green-book-chapter-19

NICE guidance. Flu vaccination: Increasing Uptake: https://www.nice.org.uk/guidance/ng103 Public Health England Increasing influenza immunization uptake among children https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attac hment_data/file/807069/Flu_GP-best-practice-guidance_2019.pdf

Public Health England – Flu vaccinations: supporting people with learning disabilities https://www.gov.uk/government/publications/flu-vaccinations-for-people-with- learning-disabilities/flu-vaccinations-supporting-people-with-learning-disabilities

Written instruction for registered nurses to administer inactivated seasonal influenza vaccine as part of an occupational health scheme, which may include peer to peer immunisation (2020/21) have been produced and it is recommend Practices use this template: https://www.sps.nhs.uk/articles/written-instruction-for-the-administration-of- seasonal-flu-vaccination/ A fact sheet on the administration of seasonal influenza vaccination for staff is available here: Page 108 https://www.sps.nhs.uk/wp-content/uploads/2019/05/Factsheet-supporting- seasonal-flu-final-2020.docx.pdf

Additional advice for GP practices on vaccinating staff is available here: https://www.sps.nhs.uk/wp-content/uploads/2020/07/Additional-advice-to-GP- practices-on-the-administration-of-the-seasonal-final-V2-2020.docx.pdf

The national standards for registered healthcare professionals https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attach ment_data/file/679824/Training_standards_and_core_curriculum_immunisation.pdf The national standards for healthcare support workers: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attach ment_data/file/464033/HCSW_Training_Standards_September_2015.pdf Recommended training requirements by workforce group for flu vaccination https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attach ment_data/file/906537/Flu_immunisation_training_recommendations_appendix_A.p df

To be provided by Greater Manchester Public Health Team: Patient Group Direction (PGD) For the supply and administration of Inactivated Seasonal Influenza Vaccine

Patient Group Direction (PGD) For the supply and administration of Fluenz Tetra®

Patient Group Direction (PGD) for the Administration of Immunisations for Pneumococcal (PPV)

Applicable standards set out in Guidance and/or issued by a Competent Body (eg Royal Colleges) Guidance within Enhanced services specification Seasonal influenza and pneumococcal immunisation enhanced service NHS England gateway reference: 06601. Practitioners are advised to register for the PHE “Vaccine Update” electronic newsletter via the www.gov.uk website, which will assist signposting to the latest information. E-learning programme: https://www.e-lfh.org.uk/programmes/flu-immunisation/

General guidance The patient/staff should receive advice and information on Influenza immunisation and Pneumonia. A variety of posters, letter templates, and easy read leaflets are available here: https://www.gov.uk/government/publications/flu-vaccination-leaflets-and-posters

Patient Information Leaflet https://www.gov.uk/government/publications/flu-vaccination-who-should-have-it- this-winter-and-why

Page 109 Applicable local standards

5. Applicable Quality Requirements 5.1 Applicable Quality Requirements (See Schedule 4 Parts [A-D]) The Service Provider will: • Demonstrate compliance with all current regulatory requirements and relevant national standards including the National Institute of Clinical Excellence (NICE) Quality Standards, PGD, PHE national minimum standards and Core Curriculum for Immunisation and staff have been assessed as competent to immunise in line with Clinical Governance requirements. • Ensure that all Provider Staff are suitably qualified and competent and that PGD’s and PSD’s are followed. When vaccinating staff PSDs must be used and the national template should be used. • Internal arrangements must be in place for maintaining and updating relevant skills and knowledge base; that also incorporates and supports the arrangements for staff supervision. • Ensure a lone worker policy is in place with an emergency policy and equipment for offsite working. • Ensure staff have received appropriate training and updates on basic life support and management of anaphylaxis and demonstrate competence in this area. • Ensure that lines of professional and clinical responsibility and accountability are clearly identified. • Ensure that all equipment used for the provision of the enhanced service are at all times suitable for the delivery of those services and sufficient to meet the reasonable needs of patients or clients. • Providers must follow infection control policies and procedures that are compliant with national and local guidelines. All infection control and decontamination measures must meet the standards within the Health and Social Care Act (2008) “Code of Practice for Health and Social Care on the Prevention and Control of Infections and related guidance”. • Providers must ensure that there is a robust system in place for the reporting of incidents (including serious incidents) and near miss events. All incidents must be documented, investigated and followed up with the required corrective action/s. Any lessons learnt from incidents should be shared internally and across the Primary Care Networks (PCNs) to enhance wider learning from incidents, and with the service commissioners. • Providers must ensure that there is an effective complaints procedure in place that can demonstrate compliance with the current regulatory requirements for the management of complaints in relation to the provision of the enhanced service. Evidence of compliance must be available for audit purposes. • Ensure that treatment, care and information provided is culturally appropriate and is available in a form that is accessible to people who have additional needs, such as people with physical, cognitive or sensory disabilities, and people who do not speak or read English. • All providers are required to adhere to quality NHS guidelines on confidentiality Page 110 and consent. • All providers are required to adhere to the updated guidelines for General Data Protection Regulations (GDPR). 5.2 Applicable CQUIN goals None applicable

6. Location of Provider Premises 6.1 Practices within WBCCG. The Provider’s Premises are located at: <> 7. Inter Practice Referral/Collaborative Model A single provider may provide the LCS on behalf of another GP practice(s) subject to the following additional criteria being met: • A signed Inter-Practice agreement between all participating GP practices. • A system in place that ensures all patients of participating practices who receive the Influenza and Pneumonia vaccination or are read coded as vaccinated or declined. • The provider will ensure all necessary clinical information is exchanged with the referring GP practice in a safe manner e.g. NHS Mail. • Referring GP practice that is not under taking the vaccination cannot claim for the patients vaccinated by another GP Practice. • Patient consent (or suitable alternative if patient lacks capacity) must be sought for all patients referred to the service from other GP practices.

Page 111 This page is intentionally left blank SCHEDULE 2 – THE SERVICES

A. Service Specifications

Mandatory headings 1 – 4: mandatory but detail for local determination and agreement Optional headings 5-7: optional to use, detail for local determination and agreement.

All subheadings for local determination and agreement

Service Specification No. Service Near Patient Testing Commissioner Lead Primary Care Director Provider Lead GP Practice Service Lead Period 1st October 2021 – 31st March 2022 Date of Review 31st March 2022

1. Population Needs

1.1 National/local context and evidence base

The treatment of several diseases within the fields of medicine, particularly in rheumatology, is increasingly reliant on drugs that, while clinically effective, need regular blood monitoring. This is due to the potentially serious side-effects that these drugs can occasionally cause. It has been shown that the incidence of side – effects can be reduced significantly if this monitoring is carried out in a well- organised way, close to the patient’s home.

2. Outcomes

2.1 NHS Outcomes Framework Domains & Indicators

Domain 1 Preventing people from dying prematurely x

Domain 2 Enhancing quality of life for people with long-term x conditions

Domain 3 Helping people to recover from episodes of ill-health or x following injury

Domain 4 Ensuring people have a positive experience of care x

Domain 5 Treating and caring for people in safe environment and x protecting them from avoidable harm

Page 113 2.2 Local defined outcomes  Increase the number of patients taking prescribed medication who are able to receive near patient testing in a community setting.  Reduce the number of patients who have adverse clinical complications as a result of taking prescription medications.

3. Scope

3.1 Aims and objectives of service

The overall aim of the service is to provide a high quality Near Patient Testing service for Wigan patients within a primary care setting. This aim will be delivered by ensuring:

 Ensuring therapy is only started for recognised indications and treatments for specified lengths of time (as specified in relevant shared care guidelines or protocols).  Maintenance of patients initiated on drugs following secondary care recommendation is properly controlled  The service to the patient is convenient  The need for continuation of therapy is reviewed regularly  The therapy is discontinued when appropriate  The use of resources by the National Health Service is efficient

3.2 Service description/care pathway

This specification requires a shared care drug monitoring service in respect of the following specified drugs:  Penicillamine  Sulfasalazine  Methotrexate  Sodium Aurothiomalate

The provider is responsible for providing the service according to one of the three levels identified below.

Table 1.

Level 1 – Organise Bloods to be taken at an outreach site (e.g. Thomas Linker or Bridgewater clinics), practice reviews blood test results and prescribes in accordance with specialist advice and shared care agreement.

Level 2 – CCG, Trust or other externally funded professional takes sample in practice, laboratory testing, practice reviews blood test results and prescribes in accordance with specialist advice and shared care agreement.

Level 3 – Practice funded Professional takes sample in practice, laboratory testing, practice reviews blood test results and prescribes in accordance with specialist advice and shared care agreement.

Domiciliary Visits

- In addition to the above service levels, where the sampling requires a domiciliary visit to a housebound patient on or behalf of the practice, and not by a member of staff employed by an NHS body to provide community health services, an additional fee would be paid for each separate address visited on that day.

A summary of the key operational delivery aspects of the service that are required to be provided are

Page 114 outlined below:

1. A register. Practices should be able to produce and maintain an up-to-date register of all Near Patient Testing service patients, indicating patient name, date of birth and the indication and duration of treatment and last hospital appointment. 2. Call and recall. To ensure that systematic call and recall of patients on this register is taking place in the general practice setting. 3. Education and newly diagnosed patients. To ensure that all newly diagnosed / treated patients (and / or their carers when appropriate) receive appropriate education and advice on management of and prevention of secondary complications of their condition and the importance and frequency of blood test monitoring. This should include written information where appropriate. 4. Continuing information for patients. To ensure that all patients (and / or their Carers and support staff when appropriate) are informed of how to access appropriate and relevant information. 5. Individual management plan. To ensure that the patient has an individual management plan, which gives the reason for treatment, the planned duration and the monitoring timetable. Ensure a copy of the relevant shared care guideline is available. 6. Professional links. To work together with other professionals when appropriate. Any health professionals involved in the care of patients in the programme should be appropriately trained. 7. Referral policies. When appropriate to refer patients promptly to other necessary services and to the relevant support agencies using locally agreed guidelines and in accordance with the shared care guideline. 8. Record keeping. To maintain adequate records of the service provided, incorporating all known information relating to any significant events e.g. hospital admissions, death of which the practice has been notified. 9. Training. Each practice must ensure that all staff involved in providing any aspect of care under this scheme has the necessary training and skills to do so. 10. Annual review. All practices involved in the scheme should perform an annual review which could include:

(a) brief details as to arrangements for each of the aspects highlighted in the LCS (b) details as to any near-patient testing equipment used and arrangements for internal and external quality assurance (c) details of training and education relevant to the drug monitoring service (d) details of the standards used for the control of the relevant condition (e) assurance that any staff member responsible for prescribing must have developed the necessary skills to prescribe safely. (f) Systems in place for those patients failing to attend for blood monitoring

Untoward events It is a condition of participation in this service that practitioners will give notification to the CCG clinical governance lead of all emergency admissions or deaths of any patient covered under this service, where such admission or death is or may be due to usage of the drug(s) in question or attributable to the relevant underlying medical condition. This must be reported within 72 hours of the information becoming known to the practitioner. This is in addition to a practitioner’s statutory obligations.

3.3 Population covered

All patients registered with a Wigan Borough CCG GP practice prescribed one of the relevant medications will be eligible for the primary care Near Patient Testing service. This includes domiciliary visits as well as in-practice clinics.

3.4 Any acceptance and exclusion criteria and thresholds

None 3.5 Interdependence with other services/providers

The service provider will be expected to liaise with the provider organisation initiating therapy and supplying the shared care guideline for each patient receiving the service.

Page 115 3.6 Payment and Claims

Please refer to schedule 3 of the contract.

4. Applicable Service Standards

4.1 Applicable national standards (eg NICE)

 QS33 Nice Quality standard for rheumatoid

4.2 Applicable standards set out in Guidance and/or issued by a competent body (eg Royal Colleges)

 None applicable

4.3 Applicable local standards Accreditation Those doctors who have previously provided services similar to this enhanced service and who satisfy at appraisal and revalidation that they have such continuing medical experience, training and competence as is necessary to enable them to contract for the enhanced service shall be deemed professionally qualified to do so.

5. Applicable quality requirements and CQUIN goals

5.1 Applicable Quality Requirements (See Schedule 4 Parts [A-D])

The Service Provider will:

 Demonstrate compliance with all current regulatory requirements and relevant national standards including the National Institute of Clinical Excellence (NICE) Quality Standards; in line with Clinical Governance requirements.

 Ensure that all Provider Staff are suitably qualified and competent. Internal arrangements must be in place for maintaining and updating relevant skills and knowledge base; that also incorporates and supports the arrangements for staff supervision.

 Ensure that lines of professional and clinical responsibility and accountability are clearly identified.

 Ensure that all premises and equipment used for the provision of the enhanced service are at all times suitable for the delivery of those services and sufficient to meet the reasonable needs of patients or clients.

 Providers must follow infection control policies and procedures that are compliant with national and local guidelines. All infection control and decontamination measures must meet the standards within the Health and Social Care Act (2008) “Code of Practice for Health and Social Care on the Prevention and Control of Infections and related guidance”.

 Providers must ensure that there is a robust system in place for the reporting of incidents (including serious incidents) and near miss events. All incidents must be documented, investigated and followed up with the required corrective action/s. Any lessons learnt from incidents should be shared internally and across the localities to enhance wider learning from incidents, and with the service commissioners.

 Providers must ensure that there is an effective complaints procedure for place that can

Page 116 demonstrate compliance with the current regulatory requirements for the management of complaints in relation to the provision of the enhanced service. Evidence of compliance must be available for audit purposes.

 Ensure that treatment, care and information provided is culturally appropriate and is available in a form that is accessible to people who have additional needs, such as people with physical, cognitive or sensory disabilities, and people who do not speak or read English.

 All providers are required to adhere to quality NHS guidelines on confidentiality and consent.

For further information please refer to the quality requirements as detailed within schedule 4 parts A – D.

5.2 Applicable CQUIN goals (See Schedule 4 Part [E])

 None applicable

6. Location of Provider Premises

The Provider’s Premises are located at: <>

7. Individual Service User Placement

 Not applicable

Page 117 This page is intentionally left blank SCHEDULE 2 – THE SERVICES

A. Service Specifications

Mandatory headings 1 – 4: mandatory but detail for local determination and agreement Optional headings 5-7: optional to use, detail for local determination and agreement.

All subheadings for local determination and agreement

Service Specification No. Service Maintenance of Anti – Coagulation Service (Vitamin K Antagonists Only) Commissioner Lead Director of Primary Care Provider Lead GP Practice Service Lead Period 1st October 2021– 31st March 2022 Date of Review 31st March 2022

1. Population Needs

1.1 National/local context and evidence base

Wigan Borough CCG has a population of approximately 330,000. It consists of 58 GP member practices that are working together to ensure the local population has high quality healthcare services which are sustainable.

All practices are expected to provide essential and those additional services they are contracted to provide to their patients.

The role of anticoagulation in the primary and secondary prevention of ischaemic stroke and other conditions is well established. Warfarin is used in the management of significant numbers of patients for conditions including atrial fibrillation, Deep vein thrombosis/Pulmonary Embolism and other disorders. While it is a very effective drug in these conditions, it can also have serious side effects, e.g. severe haemorrhage.

Within Wigan Borough CCG anticoagulation monitoring has been provided for a number of years in a community setting.

This specification aims to deliver the Monitoring of anticoagulants in a primary care setting by the patients GP Practice or via interpractice referral

2. Outcomes

2.1 NHS Outcomes Framework Domains & Indicators

Domain 1 Preventing people from dying prematurely 

Page 119 Domain 2 Enhancing quality of life for people with long-term  conditions

Domain 4 Ensuring people have a positive experience of care 

Domain 5 Treating and caring for people in safe environment and  protecting them from avoidable harm

2.2 Local defined outcomes  Improved access through the implementation of integrated and coordinated approaches into primary care services that reduces the reliance on secondary care services.  Enhance the ability for patients and their families to improve their own health through the provision of up to date information.  Reduce the number of patients who have to go to hospital for anti-coagulation (Vitamin K Antagonists Only, such as Warfarin), management  Reduce the number of patients who have clinical complications as a result of taking Warfarin medication.  Ensure patients achieve a time in therapeutic range (TTR) of at least 65%

3. Scope

3.1 Aims and objectives of service

The overall aim of the service is to provide a high quality anti-coagulation service within a primary care setting (Vitamin K Antagonists Only). Practices sign up to provide on-going monitoring aspect of the service. This aim will be delivered by:  Ensuring a consistent approach to testing, sampling and dosing across primary care providers  Providing increased capacity in the community to meet the rising demand for anticoagulation monitoring enabling the Haematology Department to focus on unstable and more complex cases.  Providing services to patients which are more accessible Ensuring the maintenance of patients is properly controlled and the need for continuation of therapy is reviewed regularly and discontinued where appropriate.  To educate patients in understanding their treatment both in terms of their condition and holistic risk management.  To identify patients who are persistently outside of therapeutic range  To maintain a register of all patients receiving Vitamin K Antagonists medication and have a treatment plan for each patient that is reviewed at least annually and consider appropriate transfer to DOAC in line with NICE guidance(KTT16).  To communicate results and treatment plans to the patient’s own GP practice as necessary.  To have a robust system in place to ensure DNAs (did not attend) are followed up and

Page 120 monitored effectively including advising the patient’s own GP practice of patients who frequently DNA to ensure prescriptions are not continued inappropriately. It must be stressed to the patient that careful monitoring of Vitamin K Antagonists therapy is essential in order to avoid complications. Where patients repeatedly fail to attend, then the risks of continuing therapy should be considered against the benefits.

3.2 Service description/care pathway

Practices will be expected to provide the service to all eligible patients from their own practice and accept interpractice patients. In addition providers are expected to make domiciliary visits to patients assessed as housebound. Where the sampling requires a domiciliary visit to a housebound patient on behalf of the practice and not by a member of staff employed by an NHS body to provide community health services, an additional fee would be paid for each separate address visited on that day

This specification requires anti-coagulation monitoring to be provided according to the below:

 To provide the service to all eligible patients within the Wigan Borough.  To effectively monitor and dose the patient.  To maintain a register of all patients receiving Vitamin K Antagonists medication and have a treatment plan for each patient that is reviewed at least annually and consider appropriate transfer to DOAC in line with NICE guidance(KTT16).

Practices should work on a Primary Care Network (PCN) model to ensure that provisions are met; this could be done via the individual practice, PCN Collaboration or subcontracting to a GP federation.

3.2.1 Maintenance of anticoagulation (Vitamin K Antagonists Only).

To ensure that all patients using the service have their INR maintained within an appropriate range in accordance with national guidance. All patients must be monitored at an appropriate frequency in accordance with national guidance. Time in therapeutic range (TTR) must be maintained above 65% for all patients. Where patients fail to achieve this appropriate steps are taken to achieve an improvement. If despite appropriate steps TTR remains <65% patients are reviewed and considered for an alternative anticoagulant, patients are involved in all decisions regarding potential alternative therapy. To ensure that all patients using the service receive the appropriate counselling to ensure on-going safe use of anticoagulation. To ensure that at initial transfer to the service, and at least annually, an appropriate review of the patients health is carried out, including checks for potential complications and, as necessary, a review of the patient’s own monitoring records. For patients with AF review the need for anticoagulation and the quality of anticoagulation at least annually or more frequently if clinically relevant events occur affecting anticoagulation or bleeding risk. Where patients repeatedly fail to attend for monitoring appropriate steps are taken in liaison with the patient’s own GP to ensure the patient is reviewed and anticoagulant stopped if appropriate with alternative options discussed/referral to specialist.

3.2.2 Patient Self-Monitoring

Page 121

Patients taking long term anticoagulants for AF or heart valve disease requiring INR monitoring may also be given the option to self-monitor their INR NICE has assessed 2 point- of care coagulometers (CoaguChek XS and InRatio2 PT/INR) and both are recommended as an option for use if patients prefer and are able to effectively use this type of monitoring.

The provider should ensure that:

 People (and their carers) who will be using self-monitoring are be given training, and are regularly assessed. This will cover the use of coagulometer meter and practice of obtaining blood sample, how the telephone access and on line access works. The patient will then be given time to practice using the coagulometer meter before a further session, where the clinician assesses competence of patient. Patients will be asked to return after 6 months with the meter. At this meeting the clinician will check the patients INR readings and also the technique used. The clinician then may want the patient to return in further 6 months or annual checks thereafter.

 Equipment for self-monitoring is regularly checked using reliable quality control procedures in accordance to the manufactures guidance, and by testing patients' equipment against a healthcare professional's coagulometer which is checked in line with an external quality assurance scheme.

 Accurate patient records are kept and shared appropriately.

 Patients are able to source their own ‘Point-of Care Coagulometer’

The payment tariff for Patient Self-Monitoring is the same as for patients who are monitored by the provider directly in the community setting.

Providers must notify the CCG of their intention to provide Patient Self - Monitoring in advance of providing this service component.

3.2.3 Managing raised INR

Where a patient’s INR requires the use of Vitamin K to reverse the anticoagulant effect the service provider must ensure timely access to this medication either through direct provision, eg using PGD or issuing a prescription to the patient. It should be noted that vitamin K used to reverse Warfarin may not be readily available in community pharmacy and it is the provider’s responsibility to liaise with pharmacies as necessary to ensure the patient receives the medication within the appropriate time frame. It may be necessary to liaise with the pharmacy at RAEI to facilitate supply to ensure access within the appropriate time frame.

3.2.5 Safety indicators for patients initiating oral anticoagulant treatment

Different loading protocols are used depending upon the urgency to achieve a therapeutic level of anticoagulation, see section 4 of the 2005 update of guidelines on oral anticoagulation (Baglin et al, 2006).

1. Percentage of patients following a loading protocol appropriate to indication for anticoagulation.

Page 122 2. Percentage of patients developing INR > 5·0 within first 2 months of therapy. 3. Percentage of patients in therapeutic range at discharge (for patients being transferred to other outpatient care). 4. Percentage (incidence) of patients suffering a major bleed in first month of therapy and percentage suffering major bleed with INR above therapeutic range. 5. Percentage of referrals to other anticoagulant service (hospital or community- based) with incomplete information, e.g. diagnosis, target INR or inappropriate target with reference to BCSH guidelines, stop date for anticoagulant therapy, dose of warfarin on discharge, list of other drugs on discharge. 6. Percentage of patients that were not issued with patient held information and written dose instructions at start of therapy. 7. Percentage of patients that were discharged from service without an appointment for next INR measurement or for consultation with appropriate health care professional to review and discuss treatment plan, benefits, risks and patient education. 8. Percentage of patients with subtherapeutic INR when heparin stopped (fast loading patients only, e.g. treatment of acute VTE).

3.2.4 Safety indicators for patients established on oral anticoagulant treatment

1. Proportion of patient-time in range (if this is not measurable because of inadequate decision/support software then a secondary measure of percentage of INRs in range should be used). 2. Percentage of INRs > 5·0. 3. Percentage of INRs > 8·0. 4. Percentage of INRs > 1·0 INR unit below target (e.g. percentage of INRs < 1·5 for patients with target INR of 2·5). 5. Percentage of patients suffering adverse outcomes, categorised by type, e.g. major bleed. 6. Percentage of patients lost to follow up (and risk assessment of process for identifying patients lost to follow up). 7. Percentage of patients with unknown diagnosis, target INR or stop date. 8. Percentage of patients with inappropriate target INR for diagnosis, high and low. 9. Percentage of patients without written patient educational information. 10. Percentage of patients without appropriate written clinical information, e.g. diagnosis, target INR, last dosing record.

3.3 Population covered

Page 123 All patients registered within Wigan Borough will be eligible for the primary care Anti - Coagulation service. This includes domiciliary visits as well as community clinics.

3.4 Any acceptance and exclusion criteria and thresholds

Patients with the following conditions/problems should be excluded from the primary care service:

- Children under 18 - Expectant Mothers

3.5 Interdependence with other services/providers

The service provider will be expected to liaise with the Haematology Department/Anticoagulant Team at Wrightington, Wigan and Leigh NHS Foundation Trust.

3.6 Payment and Claims

Please see schedule 3 within the contract.

4. Applicable Service Standards

4.1 Applicable national standards (e.g. NICE)

NICE QS AF

Statement 3. Adults with atrial fibrillation who are prescribed anticoagulation discuss the options with their healthcare professional at least once a year.

Statement 4. Adults with atrial fibrillation taking a vitamin K antagonist who have poor anticoagulation control have their anticoagulation reassessed.

Statement 6 (developmental). Adults with atrial fibrillation on long-term vitamin K antagonist therapy are supported to self-manage with a coagulometer

NICE Clinical Guidelines 138 Patient experience in adult NHS services: improving the experience of care for people using adult NHS services

Page 124 No. Quality statements

1 Patients are treated with dignity, kindness, compassion, courtesy, respect, understanding and honesty.

2 Patients experience effective interactions with staff who have demonstrated competency in relevant communication skills.

3 Patients are introduced to all healthcare professionals involved in their care, and are made aware of the roles and responsibilities of the members of the healthcare team.

4 Patients have opportunities to discuss their health beliefs, concerns and preferences to inform their individualised care.

5 Patients are supported by healthcare professionals to understand relevant treatment options, including benefits, risks and potential consequences.

6 Patients are actively involved in shared decision making and supported by healthcare professionals to make fully informed choices about investigations, treatment and care that reflect what is important to them.

7 Patients are made aware that they have the right to choose, accept or decline treatment and these decisions are respected and supported.

8 Patients are made aware that they can ask for a second opinion.

9 Patients experience care that is tailored to their needs and personal preferences, taking into account their circumstances, their ability to access services and their coexisting conditions.

10 Patients have their physical and psychological needs regularly assessed and addressed, including nutrition, hydration, pain relief, personal hygiene and anxiety.

11 Patients experience continuity of care delivered, whenever possible, by the same healthcare professional or team throughout a single episode of care.

Page 125 12 Patients experience coordinated care with clear and accurate information exchange between relevant health and social care professionals.

13 Patients' preferences for sharing information with their partner, family members and/or carers are established, respected and reviewed throughout their care.

14 Patients are made aware of who to contact, how to contact them and when to make contact about their ongoing healthcare needs.

Anticoagulants, including direct-acting oral anticoagulants (DOACs) Key therapeutic topic Published: 26 February 2016 www.nice.org.uk/guidance/ktt16

Atrial fibrillation: diagnosis and management

NICE guideline [NG196]Published: 27 April 2021 Last updated: 30 June 2021 https://www.nice.org.uk/guidance/ng196

4.2 Applicable standards set out in Guidance and/or issued by a competent body (e.g. Royal Colleges)

Patient self-testing and self-management of oral anti-coagulants with vitamin K antagonists, British Committee for Standards in Haematology (2014)

Improving cardiovascular outcomes: strategy, Department of Health (2013)

Guidance on management of bleeding in patients on antithrombotic agents – British Committee for Standards in Haematology (2012)

Guidance on oral anticoagulation on warfarin – fourth edition - British Committee for Standards in Haematology (2011)

Actions that can make anticoagulation therapy safer – National Patient Safety agency Patient Safety Alert No. 18 (2007)]

Recommendations from British Committee for Standards in Haematology and National Patient Safety Agency (2006)

BSH 2008 Guidelines for point-of-care testing: haematology

Page 126 BSH Safety indicators for inpatient and outpatient oral anticoagulant care

BSH Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency

4.3 Applicable local standards

4.3.1 Provider Accreditation

Providers should ensure continuation of medical experience, training and competence as is necessary to enable them to contract for the local commissioned service shall be deemed professionally qualified to do so.

Initiation should only be done by accredited practitioners who have successfully completed training. Training can be done via BMJ module – ‘Starting patients on anticoagulation: how to do it’

Training protocols must be established and all potential operators must achieve an adequate level of competence. The content of the training programme and the knowledge/skill level assessment should be documented in a training manual.

This should include:

1. Sample requirement and specimen collection, 2. Sample preparation, 3. Stability of sample and reagents, 4. Analyte measurement, 5. Maintenance, calibration and cleaning of instruments, 6. Appropriate use of equipment and consequences of inappropriate use, 7. Reporting of results, 8. Knowledge of normal and abnormal results and actions in the event of an abnormal result, 9. Performance of quality control, 10. Documentation of test and quality control results.

All providers will ensure they have the facilities, medical experience, training and competence as is necessary to enable them to provide anticoagulation initiation and/or monitoring.

Training will be organised and funded by the practice/service provider to ensure all provider staff or those contracted by the provider have the necessary skills and knowledge to conduct anti-coagulation initiation and/or monitoring.

Arrangements must be in place for Continuing Professional Development of the staff delivering the service, with regular training updates.

A summary of the key operational delivery aspects of the service that are required to be provided are outlined below:

(a) The development and maintenance of a register. The provider should be able to produce an up to- date register of all anti-coagulation initiation/monitoring service

Page 127 patients, indicating patient name, date of birth, the indication for, and length of, treatment, including the target INR.

(b) Call and recall. To ensure that systematic call and recall of patients on this register is taking place in a primary care setting; at an appropriate frequency for each individual patient.

(c) Professional links. To work together with other professionals where appropriate. Any health professionals involved in the care of patients should be appropriately trained;

(d) Referral policies. When appropriate, to refer patients promptly to other necessary services and to the relevant support agencies, using locally agreed guidelines where these exist;

(e) Education of newly initiated patients. To ensure that all newly initiated patients (and/or their carers and support staff where appropriate) receive appropriate management of their condition, understand the risks and benefits of anticoagulant, are aware of the potential side effects and action to take should these be experienced, the importance of compliance with the prescribed dose instruction, including the provision of a patient-held booklet. The patient information leaflet to be used is available via the NPSA.

(f) Individual management plans. To prepare with the patient an individual management plan which gives the diagnosis, planned duration, and desired therapeutic range. This should be clearly recorded in the patient’s yellow anticoagulant record book and also within the providers’ computerised clinical record.

(g) Clinical procedures. To ensure that effective procedures are in place to ensure the safe initiation and/or maintenance of anticoagulant therapy in accordance with national guidance. To ensure that all clinical information relating to the Local Commissioned Services is recorded in the patient’s record and appropriate information is communicated to the patient’s own GP. At a minimum the service provider should inform the patients GP of patient’s initiation on therapy the desired INR range, any significant complications and patient’s failure to attend for monitoring. Ideally the provider should advise the patient’s own GP of all INR results via electronic communication.

(h) Record keeping. To maintain adequate records of the performance and result of the service provided including processing of inter practice referrals (notification to buddy practice). This should include the number of ‘bleeding episodes’ requiring hospital admission and deaths caused by anti-coagulants. The provider is responsible for making arrangements with any referring practice to ensure the referring practice shares relevant information.

(i) Audit. To carry out clinical audits of the care of patients against the above criteria. This should also review the success of the service provider in maintaining its patients within the designated INR range as part of quality assurance. See safety indictors included in sections 3.2.5 and 3.2.6.

(j) Training. The provider must ensure that all staff involved in providing any aspect of care under this scheme have the necessary training and skills to do so.

Page 128 5. Applicable quality requirements and CQUIN goals

o Applicable Quality Requirements

The Service Provider will:

 Be registered with the appropriate statutory body and must ensure that the CCG is informed of any registration issues within one week of notification.

 Demonstrate compliance with all current regulatory requirements and relevant national standards including the National Institute of Health and Care Excellence (NICE) Guidelines and Quality Standards; in line with Clinical Governance requirements.

 Report details of any areas for escalation, such as non-compliance with NICE guidance, safety alerts and clinical incidents internally and take steps to resolve issues. Ensure that there is a robust system in place for the reporting of incidents (including serious incidents) and near miss events. All incidents must be documented, investigated and followed up with the required corrective action/s. Any lessons learnt from incidents should be shared internally and where appropriate, across the SDF and with the CCG to enhance wider learning from incidents.

 Ensure all Serious Incidents and Never Events should be managed in line with the NHS England; Serious Incident Framework and the Revised Never Events Policy and Framework (March 2015). Report all Serious Incidents or Never Events to the CCG within 48 hours of becoming aware of the incident. This should be submitted to the Quality Team within the CCG.

 Ensure that lines of professional and clinical responsibility and accountability are clearly identified.

 Ensure referral processes for patients who require secondary care anti coagulation management are in place.

 Ensure that all premises and equipment used for the provision of the local commissioned service are at all times suitable for the delivery of those services and sufficient to meet the reasonable needs of patients or clients.

 Follow infection control policies and procedures that are compliant with national and local guidelines. All infection control measures including cleanliness and decontamination must meet the standards within the Health and Social Care Act (2008) “Code of Practice on the Prevention and Control of Infections and related guidance, Department of Health 2015

 Ensure that there is an effective complaints procedure for place that can demonstrate compliance with the current regulatory requirements for the management of complaints in relation to the provision of the local commissioned service. Evidence of compliance must be available for audit purposes.

Page 129  Ensure that treatment, care and information provided is culturally appropriate and is available in a form that is accessible to people who have additional needs, such as people with physical, cognitive or sensory disabilities, and people who do not speak or read English.

 Adhere to quality NHS guidelines on confidentiality and competence to consent.

 Ensure compliance with GDPR requirements.

 Ensure appropriate safeguarding procedures are in place.

 Undertake an annual patient satisfaction survey and participate in the Friends and Family Test.

o Applicable CQUIN goals

 None applicable

6. Additional Inter-practice collaborative model requirements section

A single provider may provide the service on behalf of a collective group of individual GP practices subject to the following additional criteria being met:

 A signed Inter - Practice agreement between all participating GP practices outlining the patient registered population covered.  An appointment call and recall system in place that is able to operate across GP practice boundaries for all registered patients of participating practices  Clinic sites must be provided that allow easy access for patients registered with any practice in the GP collaboration.  There should be sufficient appointment capacity to manage all patients referred to the service from participating practices.  The provider will ensure all necessary clinical information is exchanged with the referring GP practice at point of referral and as required. 7. Location or provider premises section

Communication will be sent detailing the providers details.

8. CCG Contact Details

Page 130 SCHEDULE 2 – THE SERVICES

A. Service Specifications

Mandatory headings 1 – 4: mandatory but detail for local determination and agreement Optional headings 5-7: optional to use, detail for local determination and agreement.

All subheadings for local determination and agreement

Service Specification No. Service End of Life Care (General Practice) Commissioner Lead Director of Primary Care Provider Lead GP End of Life Clinical Lead Period 1st October 2021 – 31st March 2022 Date of Review 31st March 2022

1. Population Needs

1.1 National/local context and evidence base End of Life is described when people reach a time when they are likely to die within the next 12 months from a life limiting illness, cancer multiple health issues or frailty. It also includes unexpected deaths for example suicide, sudden infant death syndrome and dementia.

There has been a steady increase in the number of people aged 65+ within Wigan Borough as a result of increasing life expectancy. The proportion of people aged 65+ in 2017 was 18.8%. This is projected to rise to 20.9% by 2025, to 23.0% by 2030, and to 26.2% by 2040. Maintaining the health and resilience of older people is important both for the individuals themselves and in ensuring the sustainability of local health and adult social care services.

Life expectancy is increasing and mortality from cardiovascular disease in people aged under 75 has halved over the last decade.

1.2 Local Demography Wigan is home to 330,000 people and while overall there has been a marginal improvement in life expectancy deprivation is higher than average in specific areas of the borough. In the most deprived areas of life expectancy is 12 years lower for men and 10 years lower for women than in the least deprived areas.

Over the last 10 years, early death rates from cancer and cardiovascular disease have fallen, however when combined continues to account for a significant proportion of deaths. Lung cancer remains the most common cause of cancer death in both males and females. However, smoking prevalence has fallen from over 25% a decade ago to 17.7% in 2016. As the effect of the continued reduction in smoking prevalence feeds through this should result in further reductions in cardiovascular and lung cancer mortality rates and result in increased life expectancy.

In a number of cancer disease pathways Wigan have a higher proportion of people wo are diagnosed with cancer at stage three and four (palliative stage) rather than stage one and two (which is likely to have a curative / survivor outcome).

Another contributing factor is the much higher proportion of people aged 75+ dying where the underlying cause is Dementia compared to those less than 75 years old. Given that more people are likely to survive well past the age of 75 than ever before there will be an increasing number of

1 Page 131 people living and dying with Dementia. This will also have an increased impact on social care e.g. accommodation and other types of support. Loneliness and depression are also increasing concerns amongst the elderly.

The majority of people in the borough die in hospital but there has been a reduction from 60% in 2010 to 52% in 2015. This reflects an increase in people dying in their home (23% in 2015 compared to 20% in 2010) or care home setting (17% in 2015 compared to 13% in 2010). The latter reflects the increase in the proportion of people aged over 75 in the borough and the higher prevalence of conditions in this age group such as Dementia that necessitates a move to a care home.

In order to support patients preferred place of care / death each patient should be recorded on the GSF register and have Advance Care Plan, Community Care Plan (CCP) and Do Not Attempt Cardiopulmonary Resuscitation (uDNACPR) and anticipatory medicines in place (then it is deemed appropriate for each individual person) in primary care. This can only assist in Health and Social Care providers working collectively throughout the patient pathway.

All primary care staff contributes to delivering EoL Care to the people of Wigan but GP’s play an integral part in planning and delivery of appropriate patient centred Palliative and EoL care. The delivery of appropriate education to enhance knowledge, skills and attitudes related to care for the dying is critical to the maintenance and improvement in EoL care locally.

For this to happen, end of life care needs to be embedded in training curricula at all levels. EoL care should be included in induction programmes, continuing professional development and form part of G.P appraisal.

2. Outcomes

2.1 Outcomes To develop the quality experience for patients with a Palliative and End of Life (EoL) diagnosis, promoting clinically effective services in all settings across organisational boundaries and Primary Care Networks (PCN’s). Engaging with patients, carers and the public while complying with NICE guidance, National, Greater Manchester and Wigan borough EoL strategies and financial standards. Maintain EoL resilience within primary care by identifying G.P education priorities to enhance existing professional skills. Clinical leadership skills working to bridge gaps across Wigan borough and Greater Manchester Cancer boundaries. Support the implementation of a structures approach to safe evidence based prescribing.

The Six Ambitions for Palliative and End of Life Care: A national framework for local action 2015 - 2020 focuses around the individual and those important to them and requires local leadership and G.P practice support to deliver across all communities.

2 Page 132 NHS Outcome Framework Domains and Indicators related to EoL Care

Domain 2 Enhancing quality of life for people with long-term conditions x Domain 4 Ensuring people have a positive experience of care x Domain 5 Treating and caring for people in safe environment and protecting x them from avoidable harm

2.2 Local defined outcomes

Wigan borough Enhanced General Practice Service Specification 2021/22 looks at ensuring that people across the borough can gain access to high quality general practice in their local community. The approach focuses on collaborative working across Wigan borough bringing G.Ps together in Primary Care Networks (PCN) to reduce unwarranted variation in quality care and patient experience. Additional outcomes include reducing duplication, complicated processes and increasing equal access to all while communicating effectively to compliment multi agency working.

The refreshed Wigan borough CCG End of Life Strategy ratified in June, 2018 identified six priority areas identified following extensive patient, public and staff engagement:

 Advance Care Planning (ACP)  Robust processes to communicate and share information  Easy access to services to support preferred place of death  Aligning Children's and Adult End of Life Services  Joined up approach to Spiritual and Faith support  Peer support and Education for communities and the workforce

The Greater Manchester Commitments to Palliative Care Individuals Approaching or within the last year of life (April 2019) also highlights the need to:

 Identify individuals proactively who may be approaching the last year of their life, and discuss this with an appropriate individual  Plan Person Centred Care  Communicate and coordinate information sharing, including use of electronic record sharing and Advance Care Plan sharing (with appropriate consent)  Identify Dying (after assessing for reversible causes) and discuss this with the patient and those important to them  Care for Individuals in the last days of life in accordance with their wishes  Access appropriate Bereavement support https://www.england.nhs.uk/north-west/wp-content/uploads/sites/48/2020/06/Commitments-document-.pdf

There has been an increase in the number of patients who have an Advance Care Plan (ACP) discussions and their wishes recorded on the Gold Standard Framework (GSF) register in practice. But unfortunately there still remains considerable variation across Wigan borough. There remains much disparity across the borough in the numbers of patients recorded on the GSF register and these need to be addressed. At a time when patients are living longer with many more complex co-morbidities requiring palliative and specialist palliative and end of life support, the numbers of patients recorded on the GSF register should be growing year on year. The impact of COVID-19 may have had an effect on GSF / supportive care registers, but also has highlighted the need to have proactive discussions around care.

GP Practices have also been working towards national and local Enhanced Services around enhanced health in care homes, and as a result are now aligned to care/ nursing homes. This also gives an opportunity to proactively identify patients who are in the last year of life and have

3 Page 133 appropriate discussions around future care.

COVID-19 may have paused GSF meetings in GP practices, but remote / virtual working does open up opportunities to have GSF meetings or include the discussion of GSF patients in other MDT type discussions

The COVID-19 pandemic has also accelerated the use of the GM Shared Care record (via use of the Graphnet System). As a result a functional Electronic Palliative Care Coordination System (EPACCS) is available (and is in use in neighbouring CCG localities) , therefore this system should now be used to share appropriate end of Life Care plans across the borough.

GSF meetings in GP practices across Wigan currently coordinate high quality palliative and end of life care on a quarterly minimum basis. The GSF meetings now need to focus on identifying patients not only with cancer but with other Long Term Conditions (LTC) alongside using the risk stratification tool to identify this cohort of patients. The use of prognostic indicators is helpful in identifying patients with deteriorating symptom’s, however this is not indicative and other tools such as the frailty score will also be important in highlighting patients for inclusion on the GSF register.

3. Scope

3.1 Aims and objectives of service The purpose of this Enhanced Service for End of Life care is to provide high quality care to patients approaching the last year of life, up to and including the end of their lives. The implementation of the Wigan borough CCG EoL Strategy and monitoring progress via the Cancer and EoL Wigan Borough Palliative and End of Life Care Strategy Meeting will support the Wigan borough five year EoL plan.

This will be achieved by: 1. Raising the profile of EoL across Wigan borough prioritising the individual patient EoL requirements within each PCN and monitor progress at Cancer and EoL Wigan Borough Palliative and End of Life Care Strategy meeting. 2. Facilitate education to GP leads for EPACCS training and a further education event (i.e. EPACCS training plus further education event in 2021-22) 3. Improve the experience of patients and their families / carers during the patients EoL care. 4. Use the Wigan DEAL approach to encourage health and social care and voluntary organisations to work in different ways to further increase completion of Advance Care Planning (ACP). 5. Proactively promote effective communication between all NHS, local authority and third sector health care providers. 6. Reduce the numbers of A/E admissions for patients at end of life, by ensuring a coordinated approach to the delivery of end of life care meets the needs of the patient and wherever possible achieves the patients preferred place of care (PPC) and ultimately death – the use of the EPACCS system can help facilitate this

Direct Service Delivery

 The practice must have one named GP / ANP co-ordinator for Palliative and End of Life Care – practices are required to provide this information by 30th September 2021 as it is appreciated named leads may have changed.  A list of named GP / ANP co-ordinators will be held by the CCG.  Practices should look at existing GSF / supportive care registers within their practice, and compare numbers to practices within their PCN, and look to increase numbers on GSF/ Supportive care registers where appropriate. Practices can use appropriate search tools to improve the early identification of patients who may be suitable for inclusion on supportive care / palliative care register.  Practices should create EPACCS care plans once training in the use of the system

4 Page 134 has been attended. The GP / ANP co-ordinators can cascade training back to other practice members.  Practices should aim to create EPACCS records on all patients who are on the supportive care / palliative care register. Exceptions to this could be where patients do not consent or not enough clinical information is not available.  The practice will continue to identify patients approaching the last year of life and continue to add patients with deteriorating life limiting conditions to the palliative care register, this includes frail elderly patients.  The practice will regularly review patients against the prognostic indicators at least 6- monthly.  The practice will review the register and remove patients who have died.  The practice will initiate ACP discussions with all patients at an earlier stage including patients identified on the risk stratification where appropriate.  The named GP / ANP co-ordinator for Palliative and End of Life Care must attend a minimum of two EoL education events per year (one of which will be EPACCS training).

Data Collection  Accurately record data for all patients with life limiting palliative care condition.  Ensure that all clinical information related to EoL Care is recorded in the patient’s own GP held lifelong record, including the completion of any Adverse Incidents.  The appropriate Codes, must be used minimum data set entries in order to allow accurate data collection.

Staffing and support

 The expertise of clinicians, support services, frameworks and best practice should be drawn on where necessary to achieve Gold Standard Services.  Any healthcare professional involved in the care of patients as part of end of life care should be appropriately trained including the introduction of non-clinical champions.  Leadership and implementation of research based evidence and new ways of working to support patient choice at EoL.

3.2 Population covered All patients who have been identified as being at EoL irrelevant of diagnosis who are registered with a G.P practice of Wigan borough CCG.

3.3 Any acceptance and exclusion criteria and thresholds If a request is made to the practice Homeless people should have access to services. Temporary residence should also have access to the same level of services as regular registered patients.

3.4 Interdependence with other services/providers Primary Care Networks and health and social care providers both across the borough and within Greater Manchester conurbation.

3.5 Payment and Claims Please refer to schedule 3 of the contract.

4. Applicable Service Standards

4.1 Applicable national standards (e.g. NICE) End of life care for adults: service delivery (NG142), 2019

5 Page 135 https://www.nice.org.uk/guidance/ng142 People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care. Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding. End of life care includes the care and support given in the final weeks and months of life, and the planning and preparation for this. For some conditions, this could be months or years. This includes people with:  advanced, progressive, incurable conditions  general frailty and coexisting conditions that mean they are at increased risk of dying within the next 12 months  existing conditions if they are at risk of dying from a sudden acute crisis in their condition  life-threatening acute conditions caused by sudden catastrophic events.

NICE End of life care for adults (QS13), 2011 https://www.nice.org.uk/guidance/qs13/chapter/Introduction-and-overview • Statement 1. People approaching the end of life are identified in a timely way. • Statement 2. People approaching the end of life and their families and carers are communicated with, and offered information, in an accessible and sensitive way in response to their needs and preferences. • Statement 3. People approaching the end of life are offered comprehensive holistic assessments in response to their changing needs and preferences, with the opportunity to discuss, develop and review a personalised care plan for current and future support and treatment. • Statement 4. People approaching the end of life have their physical and specific psychological needs safely, effectively and appropriately met at any time of day or night, including access to medicines and equipment. • Statement 5. People approaching the end of life are offered timely personalised support for their social, practical and emotional needs, which is appropriate to their preferences, and maximises independence and social participation for as long as possible. • Statement 6. People approaching the end of life are offered spiritual and religious support appropriate to their needs and preferences. • Statement 7. Families and carers of people approaching the end of life are offered comprehensive holistic assessments in response to their changing needs and preferences, and holistic support appropriate to their current needs and preferences. • Statement 8. People approaching the end of life receive consistent care that is coordinated effectively across all relevant settings and services at any time of day or night, and delivered by practitioners who are aware of the person's current medical condition, care plan and preferences. • Statement 9. People approaching the end of life who experience a crisis at any time of day or night receive prompt, safe and effective urgent care appropriate to their needs and preferences. • Statement 10. People approaching the end of life that may benefit from specialist palliative care, are offered this care in a timely way appropriate to their needs and preferences, at any time of day or night. • Statement 11. People in the last days of life are identified in a timely way and have their care coordinated and delivered in accordance with their personalised care plan, including rapid access to holistic support, equipment and administration of medication. • Statement 12. The body of a person who has died is cared for in a culturally sensitive and dignified manner. • Statement 13. Families and carers of people who have died receive timely verification and certification of the death.

6 Page 136 • Statement 14. People closely affected by a death are communicated with in a sensitive way and are offered immediate and ongoing bereavement, emotional and spiritual support appropriate to their needs and preferences. • Statement 15. Health and social care workers have the knowledge, skills and attitudes necessary to be competent to provide high-quality care and support for people approaching the end of life and their families and carers. • Statement 16. Generalist and specialist services providing care for people approaching the end of life and their families and carers have a multidisciplinary workforce sufficient in number and skill mix to provide high-quality care and support.

Improving support and palliative for adults with cancer NICE guidelines [CSGSP] Published date: 2004 http://www.nice.org.uk/guidance/csgsp • People affected by cancer should be involved in developing cancer services • There should be good communication and people affected by cancer should be involved in decision making • People affected by cancer should be offered a range of physical, emotional, spiritual and social support • There should be services to help people living with the after effects of cancer manage these for themselves • People with advanced cancer should have access to a range of services to improve their quality of life. • There should be support for people dying from cancer

The needs of family and other carers of people with cancer should be met • There should be a trained workforce to provide services.

Care of dying adults in the last days of life NICE guideline Published: 16 December 2015 www.nice.org.uk/guidance/ng31 NICE recommendations relate to: • Recognising when a person may be in the last days of life • Communication • Shared decision-making in the last days of life • Providing individualised care • Maintaining hydration • Pharmacological interventions • Managing pain • Managing breathlessness • Managing nausea and vomiting • Managing anxiety, delirium and agitation • Managing noisy respiratory secretions • Anticipatory prescribing

4.2 Applicable standards set out in Guidance and/or issued by a competent body (e.g. Royal Colleges) Treatment and care towards the end of life: good practice in decision making (GMC, 2010)

Good Medical Practice (GMC, 2014)

Gold Standard framework prognostic indicator guidance (supported by RCGP)

7 Page 137 There are three triggers that suggest that patients are nearing the end of life are: • The Surprise Question: ‘Would you be surprised if this patient were to die in the next few months, weeks, days’? 1. General indicators of decline - deterioration, increasing need or choice for no further active care. 2. Specific clinical indicators related to certain conditions.

4.3 Applicable local standards  Local Formulary and Anticipatory Prescribing Guidance.

5. Applicable quality requirements and CQUIN goals

5.1 Applicable Quality Requirements (See Schedule 4 Parts [A-D])

The Service Provider will:

 Ensure that lines of professional and clinical responsibility and accountability are clearly identified.

 Providers must ensure that there is a robust system in place for the reporting of incidents (including serious incidents) and near miss events, including delayed diagnoses. All incidents must be documented, investigated and followed up with the required corrective action/s. Any lessons learnt from incidents should be shared internally during the quarterly GSF meetings and across the localities to enhance wider learning from incidents, and with the service commissioners.

 Providers must ensure that there is an effective complaints procedure in place that can demonstrate compliance with the current regulatory requirements for the management of complaints in relation to the provision of the enhanced service. Evidence of compliance must be available for audit purposes.

 All providers are required to adhere to quality NHS guidelines on confidentiality and consent.

 For further information please refer to the quality requirements as detailed within schedule 4

8 Page 138 parts A – D.

5.2 Applicable CQUIN goals (See Schedule 4 Part [E])

 None applicable 6. Location of Provider Premises

The Provider’s Premises are located at: <>

7. Individual Service User Placement

 Not applicable

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