PRIMARY CARE COMMISSIONING COMMITTEE
Minutes of Meeting held on Thursday 22 April 2021 between 2:30pm and 4pm
Online Meeting via MS Teams Live
Voting Members Present: Mr Ian Bretman (Chair) Governing Body Lay Member, Patient & Public Engagement and Committee Chair Mr Simon Goodwin Chief Finance Officer Dr Dominic Roberts Independent GP Ms Claire Johnston Governing Body Member, Registered Nurse Dr Subir Mukherjee Governing Body Member, Secondary Care Clinician Mr Arnold Palmer Governing Lay Member, General Portfolio Mr Paul Sinden Chief Operating Officer Ms Karen Trew Governing Body Lay Member for Audit & Governance
In Attendance Dr Peter Christian Governing Body Member, Clinical Representative Ms Tracey Lewis Head of Finance, NCL STP Primary Care Ms Vanessa Piper Head of Primary Care, NCL Primary Care Commissioning & Contracting Team Ms Deborah McBeal Director of Integration, Enfield Mr Simon Wheatley Director of Primary & Community Commissioning (Interim), Camden Ms Colette Wood Director of Primary Care Transformation, Barnet Ms Rebecca Kingsnorth Assistant Director of Primary Care, Islington Mr Owen Sloman Assistant Director of Primary Care, Haringey Ms Noelle Skivington Healthwatch Representative, Enfield Ms Jane Betts Deputy Director of Primary Care, London Wide LMCs Dr Sue Dickie Chair of Haringey LMC, London Wide LMCs Mr Mark Agathangelou Community Representative, Camden Ms Nicola Theron Director of Estates, NCL Cllr Patrician Callaghan London Borough of Camden Cllr Alev Cazimoglu London Borough of Enfield Cllr Nurullah Turan London Borough of Islington Vivienne Ahmad (Minutes) Board Secretary , NCL
Public Attendance Mr Malcolm Souch Healthy Urban Development Unit Mr Ismail Ihahir Practice Manager at Phoenix Practice Mr Kostakis Christodoulou Community Representative, Enfield Dr Louise Jones Healthwatch Representative, Camden Ms Karla Damba Estates Strategic Delivery Lead, NCL Ms Sally Mackinnon Director of Integration, NCL
Apologies: Ms Sarah McDonnell- Executive Director of Borough Partnerships, NCL Davies Page 1 of 10
Ms Jenny Goodridge Director of Quality & Chief Nurse, NCL Cllr Sarah James London Borough of Haringey Cllr Caroline Stock London Borough of Barnet Mr Stuart Lines Director of Public Health, Enfield
1.0 INTRODUCTION
1.1 Welcome & Apologies
1.1.1 The Chair welcomed members and attendees to the meeting.
Apologies were recorded as above.
1.2 Declarations of Interests Register
1.2.1 The Register was noted by the Committee.
The Committee NOTED the Register
1.3 Declarations of Interest Relating to Items on the Agenda
1.3.1 The Chair invited members of the Committee to declare any interests in respect to the items on the agenda. There were no declarations declared.
1.4 Declarations of Gifts and Hospitality
1.4.1 There were no declarations declared.
1.6 Minutes of the NCL Primary Care Commissioning Committee Meeting on 18 February 2021 1.6.1 Prior to approving the minutes, the Chair suggested that an additional sentence be added to the penultimate paragraph in item 1.6.1 on page 13 in regards to AT Medics.
This currently reads – “Councillor James advised that the decision had caused anger and risked trust at a time that the NCL integrated care system was being developed. Although the decision to agree the change of control may have been conducted within due process, it still raised a wider question about ownership of health services in England and Wales. The CCG was urged not to sign this and refer the matter to the Secretary of State and NHS England.”
The suggested additional sentence to be added was – “Councillors Callaghan, Cazimoglu, Turan and Stock all spoke in support of these comments and reiterated the deep concerns among patients and residents about the CCG’s decision and their dissatisfaction with the process by which it was reached”.
The Committee agreed to the additional sentence.
A further point was raised about rephrasing the action of the finance report on page 14 of the papers: Instead of stating ‘to bring back an outturn report to the next meeting’, that it could change to: - ‘Prior year comparatives to be shown on the finance report and a more detailed analysis of the other medical services line’.
The Committee agreed to the action being rephrased.
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Subject to the above amendments, the minutes of the NCL Primary Care Commissioning Committee Meeting on 18 February 2021 were agreed as a true record of the meeting.
Subject to the above amendments, the Committee APPROVED the minutes of the meeting dated 18 February 2021.
1.6 Action Log
1.6.1 The Action Log was reviewed and updated.
The Committee NOTED the updates to the action log
1.7 Matters Arising
1.7.1 There were no matters arising.
1.9 Questions from the public relating to items on the agenda received prior to the meeting 1.9.1 No questions from the public had been received.
2.0 BUSINESS
2.1 Primary Care Finance Update
2.1.1 The Committee was asked to note: The month 11 report was presented and the out-turn position for 2020/21 would be available at the next meeting in June 2021; The forecast for the year remained as break even against plan; The budget for Other Medical Services was currently fully shown against Barnet resulting in an under spend in Barnet and a corresponding over spend in the other four localities. The budget would be redistributed for the year-end report to show the correct values against the individual Boroughs respectively.
2.1.2 The Committee NOTED the report.
2.2 Quality & Performance Report
2.2.1 The following was highlighted to the Committee: The Quality report covered all practices in NCL and the metrics included the Care Quality Commission (CQC) ratings, patient experience data, complaints, the quality outcomes framework and the demographic data; Section 3 of the report set out how the data was used to improve performance including formal contract notices where the practices receive an inadequate or requires improvement CQC, quality improvement support from borough teams where practices were getting lower quality outcome framework results than their peers; Deprivation - practices were segmented into five categories with the highest level of deprivation in NCL recorded in Enfield, Haringey and Islington, although all boroughs have areas of deprivation; Care Quality ratings – most practices in NCL had a good rating with a single practice rated as inadequate with the rating relating to the previous contract holders. Three practices recording an inadequate rating at the last meeting had moved up to requiring improvement, but these practices would still need to continue with remedial action plans until they receive a good rating;
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The Quality Outcomes Framework for 2021 – had a new focus on early diagnosis for cancer and also physical health checks for people with severe mental illness and learning disabilities; Patient Experience measures were drawn from the GP Patient Survey and the Friends and Family Test. These indicators would be used in the forthcoming access review including for the impact to a total triage model for access introduced as a response to the covid pandemic; Practice Appointments – fell in January 2021 due to the second peak of Covid but they fell by about 5 to 6% which was a lot less that 30% reduction seen in the first wave of the pandemic in April / May 2020. The switch to virtual appointments was still apparent and this would also be picked up in the access review; Early Warning System – identifies struggling practices as summarised in section 6. A primary care recovery plan was being prepared as we moved out of the second wave of Covid. This will be developed during April / May 2021 focussing on: practice workforce and resilience; access and patient experience; clinical prioritisation (how to remove the planned care backlogs and how to support people with long term conditions including long term Covid); and the development of networks and neighbourhoods.
2.2.2 In consideration, the Committee noted: When e-consult was introduced at the start of the pandemic there was more uptake in Enfield compared to other boroughs. This would be investigated through the access review; The impact of Medicus Health Partners merger on the uptake of on-line appointment bookings and repeat prescriptions in Enfield should be investigated, as well as included in the access review; Patient Participation Groups (PPG) would make a valuable contribution to the access review, in Enfield and across NCL, building on work on access agreed to be undertaken at the April 2021 Voluntary and Community Stakeholder Reference Group meetings in Enfield; Digital – work was being done on telephony systems as some practices had older systems which required improving to support access; At the peak of the pandemic, practices provided weekly reports on capacity, picking up on the ability to see people with Covid, access to personal protective equipment (PPE) and ability carry out face to face appointments. The frequency of the reports has been stood down but could be brought back at points of peak demand; Practice capacity had been supported locally with the resilience package and supporting funds, and there had also been national capacity funding for practices to maintain business as usual as well as undertake the covid vaccination programme; Workforce capacity was being addressed through skill mix in practices via the additional roles reimbursement scheme augmenting the traditional clinical mix of GPs and nurses. The specifics on nursing capacity would be included in the next report. Training hubs were supporting the work on workforce development in primary care. It was agreed that a slide would be useful to circulate about the priorities in NCL around workforce, training and nursing; Information on the role of patient participation groups (PPGs) in Care Quality Commission (CQC) inspections was requested.
2.2.3 Action: To circulate a slide about the priorities in NCL around workforce, training and nursing. (Sarah Mcilwaine)
The Committee NOTED the report.
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2.3 Primary Care in Planning Guidance for 2021/22
2.3.1 The following was highlighted to the Committee: The guidance for 2021/22 was set in the context of the need to continued recovery from the impact of Covid on services, managing future transmission of Covid, addressing the inequalities impact of Covid, and returning to the delivery of the NHS Long Term Plan priorities; Guidance had a focus on the health and wellbeing for staff in the context of the demands of recovery following the impact of addressing the covid pandemic. Many primary care staff working hard in Covid services and the vaccination programmes, would also be asked to support primary care recovery; For the delivery of the Covid vaccination programme, 900,000 vaccinations had been delivered in NCL to date with over half a million of these delivered from the primary care network sites; Restoration of planned care services (Cancer, Electives, Mental Health and Primary Care) would need to be prioritised for return in order of clinical need; The guidance prioritised expanding primary care capacity to support access and address health inequalities, and expanding community and urgent care capacity to support hospital flow including introducing a two-hour community rapid response service and maintaining integrated discharge teams; Maintaining the collaborative work developed during the pandemic and the development of integrated care systems; Priorities for primary care were: (a) improving access; (b) getting appointments back to pre-pandemic levels; (c) population health management to address poor health outcomes; (d) continued delivery of the vaccination programme including the potential booster programme in the Autumn; (e) the renewed focus on early cancer diagnosis; (e) physical health checks for people with learning disabilities and serious mental illness; and finally (f) further development of primary care networks and their alignment to health and care services in neighbourhoods; Appointments in primary care had fallen less than elsewhere in the system. At the height of the second wave in January, appointments were 5 to 6% below where they were in the previous year; Nationally there had been 1 million fewer referrals in the last 12 months compared to the previous year and within that about 37,000 less cancer referrals.
2.3.2 In consideration, the Committee made the following comments: The low uptake of the vaccine by staff in Enfield care homes and some population groups was being addressed by the CCG and the London Borough of Enfield working with stakeholders. GP surgeries had been working alongside the Council, Public Health and community groups to provide advice to patients to help overcome vaccine hesitancy. The GP led PCN sites remained ready to vaccinate health and social care workers. There was also access via the national booking system for eligible patients to book into the vaccination site at the Dugdale Centre and approved local pharmacy sites. When vaccinating registered care home patients GPs and partners had also encouraged care home staff to have their vaccination at the same time. Outside of these care home visits, staff were still able to access the numerous local options for the vaccination; Similar work was underway across all of the Boroughs in NCL to improve vaccine uptake, and it would be useful for future Committee meetings to receive an update on progress. This would be added to the forward planner and recovery plan; A System Inequalities Fund was being developed to target resource and investment in the most deprived parts of the population to support both access and population health management. Proposals for the fund would be developed through integrated borough partnerships.
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2.3.3 Action: To provide an update on how the Primary Care in Planning Guidance for 2021/22 is being implemented at a future meeting. (Paul Sinden) The Committee NOTED the paper.
2.4 NCL Improvement Grant Process
2.4.1 The following was highlighted to the Committee: The improvement grant process was designed to ensure that the CCG was supporting local strategic priorities including Primary Care Network (PCN) development in a consistent manner across NCL, and that premises directives were followed; Funding for improvement grants was held by London Region and NCL would bid for the funds according to local priorities and estates strategies; Improvement Grants were not there for major new capital developments, with these sourced through Estates and Technology Transformation Funds (ETTF) or through Section 106 monies held by Local Authorities; Practices would submit expressions of interest for estates improvement to Borough Primary Care teams, the proposals were then prioritised by the Local Estates Forum. The prioritised list would then go to London Region for approval; The Committee was asked to approve the standardised NCL Improvement Grant Process but noting the process had already been presented and signed off by the NCL Local Care infrastructure Board and the NCL Estates Board.
2.4.2 In consideration, the Committee noted: The CCG Estates team worked very closely with the borough primary care teams to ensure that expression of interest were received from practices with the greatest need, and proposals were aligned to longer-term primary care development needs; The Improvement Grants process, and supporting premises directions, needed to support the recruitment of Primary Care Network (PCN) additional roles as an integral part of primary care development and delivery of the core contract; The need for priorities for funding ICS strategic priorities to align with population health need and the strategic priorities of the Borough or PCN; Estates development and improvement grants should balance the needs of physical requirements (including face-to-face appointments being given where required) and digital requirements, the need for covid compliance, PCN development, and the impact of the strategic reviews for community and mental health services; Patient Engagement would be developed by borough primary care proposals being part of borough partnership delivery plans; The consolidated NCL estates team provided the strategic oversight team to support the development of borough plans, and align plans into common themes across Boroughs.
The Committee APPROVED the process, with further work requested on the incorporation of Primary Care Network additional roles reimbursement scheme into the process in the future.
3.0 ITEMS FOR DECISION
Contract Variations 3.1 All Boroughs – Personal Medical Services (PMS) Changes
3.1.1 The Committee was asked to note that all contract variations and change requests were subject to review by the NCL Primary Care Commissioning Team to ensure that all clinical staffing levels were in line with the British Medical Association (BMA) guidance, and that GP and nursing appointment levels were in line with benchmark levels.
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Capacity was also monitored after agreed changes were made to contracts to ensure capacity was retained.
Barnet – The Speedwell Practice The Committee was asked to approve the addition of a new partner to the Personal Medical Services (PMS) agreement from 1 April 2021. The practice was providing above the recommended level of GP and nurse appointments.
The Committee APPROVED the recommendation.
Barnet – Millway Medical Practice The Committee was asked to approve the resignation of a GP from the PMS agreement with effect from 26 April 2021. The practice was providing above the recommended level of GP and nurse appointments.
The Committee APPROVED the recommendation.
Barnet – Ravenscroft Medical Centre The Committee was asked to approve the addition of a partner to the PMS agreement with effect from 27 April 2021. The appointment would support delivery of the benchmark level of GP appointments.
The Committee APPROVED the recommendation.
Barnet – Torrington Park Group Practice The Committee was asked to approve the addition of a partner to the PMS agreement with effect from 1 April 2021. There was a shortfall of 46 GP appointments and 124 nurse appointments per week. The practice has been advised that there was a requirement to improve patient access, and that their progress towards minimum target appointments will be supported and monitored.
The Committee APPROVED the recommendation.
Barnet – Langstone Way Surgery The Committee was asked to approve the 24-hour retirement of a partner from the PMS agreement with effect from 30 March 2021, re-joining 5 May 2021. A locum would be engaged to cover the partner’s sessions in his absence. Otherwise, the practice was providing above the recommended level of appointments.
The Committee APPROVED the recommendation.
Barnet – Hodford Road Surgery The Committee was asked to approve the addition of a partner to the PMS agreement with effect from 1 July 2021. The practice has been advised there was a requirement to improve patient access and their progress towards minimum target appointments will be supported and monitored.
The Committee APPROVED the recommendation.
Camden – Daleham Gardens Surgery The Committee was asked to approve the addition of a partner to the PMS agreement and at the same time the removal of a partner both with effect from 17 May 2021. The practice was aware of the shortfall in appointments and planned to increase appointments to meet the recommendation by adding 1 additional GP session and 2 nursing sessions.
The Committee APPROVED the recommendation.
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Enfield – Arnos Grove Medical Centre The Committee was asked to approve the removal of a partner from the PMS agreement with effect from 20 March 2021. There was a shortfall of 228 GP appointments, 7 GP sessions, 108 nurse appointments and 6 nurse sessions per week. The practice had stated that from 4 April 2021, a new salaried GP would offer one session per week increasing to 4-6 sessions per week over the course of the year. The practice also had a healthcare assistant working three hours per week, but longer-term nursing solutions were required.
The Committee APPROVED the recommendation.
Haringey – Rutland House Surgery The Committee was asked to approve the addition of partner to the PMS agreement with effect from 1 May 2021. There was a shortfall of 49 GP appointments, 2 GP sessions, 44 nurse appointments and 3 nurse sessions per week. The practice was aware of the shortfall and is reviewing ways to increase provision.
The Committee APPROVED the recommendation.
Haringey – Tynemouth Medical Practice The Committee was asked to approve the retrospective removal of a partner from the PMS agreement with effect from 1 August 2019. The practice was providing above the recommended guide in both GP and nursing provision.
The Committee noted that the retrospective request was required due to a delay in the forms being completed by the practice accruing from historic performance problems and previous GP resignations from the contract.
The Committee APPROVED the recommendation.
3.1.2 The Committee APPROVED the contract variations requested in 3.1.1 above.
3.2 Barnet - Ravenscroft Medical Centre - Request for relocation and increase in rent
3.2.1 The Committee was asked to approve the relocation and increase in rent on the following basis; a) Relocation of the practice to Olympia House on the basis of using 6 clinical rooms in line with calculated estates requirements and allowing for population growth; b) The contract holder has evidenced that a lease will be in place; c) That the District Valuer confirms the new rent and plans; d) The landlord will meet the costs of capital work, as currently indicated; e) A relocation plan was developed and implemented with relocation likely in quarter two of 2021.
3.2.2 In Consideration, the Committee noted: The revised case addressed the fit of clinical rooms with estates calculators raised by the Committee in February 2021, with the increase in rent (£12,654 per annum) based on the use of six clinical rooms; The patient survey showed that the practice had received 374 responses from patients with 93% in favour of re-location; The new site was across the road (0.2 miles) from the existing one; A second GP was being added as a partner improving practice resilience.
The Committee APPROVED the recommendation subject to the timeline of the build.
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3.3 Enfield – Winchmore Hill Practice and Park Lodge Medical Centre – Request to merge contracts 3.3.1 The Committee was asked to approve the following: a) The merger by varying the Winchmore Hill Practice PMS contract and terminating the Park Lodge Medical Centre GMS Contract. b) Existing remedial notices were retained and transferred to the merged contract and evidence that both practices sign this agreement; c) Retain the existing practice catchment areas for Park Lodge Medical Centre to ensure that no patients were de-registered following the merger.
The practices already shared premises, partners and IT systems, and the merger would address IT issues accruing from a common system being used for two separate contracts. There was no change in service provision.
The Committee APPROVED the recommendation.
3.4 Enfield – Brick Lane Surgery & East Enfield Medical Practice – Merger & Relocation 3.4.1 The Committee was asked to approve the following: a) The merger of the two contracts by varying the East Enfield Medical Practice PMS contract and terminating the Brick Lane Surgery GMS contract; b) Relocation of merged practiced into new premises – the Electric Quarter building in Ponders End, with an increase in rent of £42k per annum.
The request for the merger was made in the following context: The new premises would provide capacity to meet population growth and remove the risk of the 12-month rolling lease for Brick Lane Surgery; The merger would take effect from July 2021 and the relocation by the end of the year; The new premises would also house a pharmacy and dental practice and was 0.2 miles from East Enfield Medical Practice and 0.9 miles from Brick Lane Surgery; The two practices already shared joint contract holders; The practices had already commenced engagement with 90% of patients in favour of the merger and relocation.
The Committee APPROVED the recommendation.
3.5 NCL – Direct Payments for practices for reimbursable premises costs
3.5.1 The Committee was asked to approve the setup of direct payments from the CCG to community health partnerships (CHP) for reimbursable premises costs for the following four practices: a) Hanley Road Primary Care Centre – Islington b) The Partnership Practice – Islington c) Queens Medical Centre – Haringey d) The Morris House Group Practice – Haringey
3.5.2 In Consideration, the Committee noted: Currently 12 practices in NCL were tenants in the community health partnerships (CHP) buildings. Direct payments could only be considered under premises directions for those practices that did not hold any premises debt and had signed a lease. The four practices above had agreed a switch to direct payments form the CCG to CHP;
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Negotiation was underway with a fifth practice (in Camden) with resolution of negotiations on non-reimbursable costs required before direct payment of reimbursable costs could be considered; The CCG could revoke direct payments if a practice did not comply or agree to a new lease, and if a practice was taken over the new practice would have to sign a new lease with CHP. At the point of the change, the payments would stop and it would come back for re-approval.
The Committee APPROVED the recommendation in principal subject to the above conditions.
4.0 ITEM TO NOTE – URGENT DECISION TAKEN SINCE 18 FEBRUARY 2021
4.1 Primary Care Networks – Proposals for Organisational and Membership Changes 4.1.1 The Committee was asked to note that the urgent decision-making process had been used to confirm the proposed changes to Primary Care Network (PCN) configurations in Camden and Islington with effect from 1 May 2021.
The Committee NOTED the report.
5.0 GOVERNANCE AND COMMITTEE ADMINISTRATION
5.1 PCCC Risk Register
5.1.1 The Committee was asked to note: The risk register picks up many of the issues discussed today including support for struggling practices, addressing variation in performance through the development of Primary Care Networks, the quality improvement Focus through the Quality Outcomes Framework, pressures accruing from the response to Covid and the mitigating resilience package put in place for General Practices, and workforce development The highest risk score on the register is with Capita (Perf 9) which had been undertaking the list cleansing programme. The Committee asked the risk to be reviewed to see whether the risk rating could be reduced; Primary Care Workforce Development (Perf 18) – The Committee asked the risk to be reviewed and to include actions to address nurse development.
5.1.2 Action: To review two risks: Perf 9 (Inadequate support from primary care support England – Capita contract) and Perf 18 (Primary Care Workforce development) to see whether their risk ratings could be reduced. (Paul Sinden & Vanessa Piper) The Committee NOTED the risk report.
5.2 PCCC Forward Planner
The Committee NOTED the forward planner.
6.0 ANY OTHER BUSINESS
7.1 None. 7.0 DATE OF NEXT MEETING
Thursday 17 June 2021 – 2:30pm to 4pm
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