Meeting of the NHS Eastern Cheshire Primary Care Commissioning Committee Meeting to be held In Public

Wednesday 10th July 2019 15:00-17:00 Boardroom 2, New Alderley House, Macclesfield, SK10 3BL

A G E N D A

Delivery & Time Agenda item Speaker Decision

15:00 1. PRELIMINARY BUSINESS 1.1 Welcome & Introductions Chair Verbal

1.2 Apologies for absence and quorum check Chair Verbal

1.3 Declaration of any interests relevant to the Chair Verbal agenda items 1.4 Minutes and action log from the previous meeting Chair Papers attached – 8 May 2019 For approval 15:10 2. STANDING ITEMS 2.1 Public Speaking Time Chair Verbal

2.2 Primary Care Risks Chair Papers attached For information 15:20 3. ITEMS FOR DECISION 3.1 Practice Boundary Change Request – Chelford Sally Papers to follow Surgery Williams For decision 3.2 Practice Boundary Change Request – Alderley Sally Papers to follow Edge Medical Practice Williams For decision 3.3 Practice Merger Request – Knutsford GP Sally Papers to follow practices Williams For decision 16:00 4. ITEMS FOR DISCUSSION 4.1 ECCCG Primary Care Report Dean Grice Papers attached For information 4.2 Primary Care Finance Update Niall O’Gara Presentation For information 4.3 Local GP Service Specification Update Report Dean Grice Papers attached For information 4.4 Post-CQC Inspection Engagement Report Dean Grice Papers attached For information 4.5 Update on the Primary Care Committee Annual Dean Grice Verbal Report For information 4.6 Working Together Across Cheshire update Neil Evans Verbal For information 4.7 Development of a Primary Care Committee in Chair Verbal Common For information

PTO

Delivery & Time Agenda item Speaker Decision

16:50 5. AOB 5.1 Any Other Business Chair Verbal - Rescheduling of future meeting dates

5.2 Future Meeting Dates:  Wed 11/09/2019 15:00-17:00 – Board Room 1  Wed 13/11/2019 15:00-17:00 – Board Room 1 17:00 6. CLOSE OF MEETING Version 2 – 03/07/2019

MEETING OF THE NHS EASTERN CHESHIRE CCG PRIMARY CARE COMMISSIONING COMMITTEE

Minutes of Meeting in Public (Unconfirmed) Wednesday 8 May 2019 15:00-17:00 Boardroom 2, New Alderley House VOTING MEMBERS Gill Boston (Chair) (GB) ECCCG Lay Member, Patient and Public Involvement Jane Stephens (JaS) ECCCG Lay Member, Patient and Public Involvement Alex Mitchell (AM) Chief Finance Officer, Deputy Accountable Officer, ECCCG Apologies Neil Evans (NE) Commissioning Director, ECCCG NON-VOTING MEMBERS Laura Beresford (LB) GP Peer Group Representative – Bollington, Disley, Poynton GP Peer Group Representative – Joanne Morton (JM) Chelford, Handforth, Alderley Edge, Wilmslow Dr Victoria Buckley (VB) GP Peer Group Representative – Congleton & Holmes Chapel Apologies Dr Jennifer Lawn (JL) GP Peer Group Representative – Knutsford Apologies Dr Daniel Harle (DH) GP Peer Group Representative – Macclesfield OTHER ATTENDEES Dean Grice (DG) ECCCG Primary Care Commissioning Manager From Dr Mike Clark (MC) Executive GP, Governing Body member during item 2.2 Deputy Head of Medicines Management, ECCCG, South presenting Janet Kenyon (JK) Cheshire CCG & Vale Royal CCG item 4.4 presenting Niall O’Gara (NOG) Head of Finance, ECCCG item 4.3 from Carla Sutton (CS) Senior Contract Manager, NHS England during item 2.2 Katie Mills (KM) Primary Care Quality Manager William Greenwood Chief Executive Cheshire Local Medical Committee Apologies Louise Barry Healthwatch - Cllr Liz Wardlaw Cheshire East Council - Dr Julie Sin (JuS) Public Health, Cheshire East Council - Hazel Burgess Note Taker – ECCCG Members of the Public

Jacquie Grinham HealthVoice QUORACY REQUIREMENTS A quorum shall be three voting members, one of which being a Lay Member and one of which being a CCG Executive. Although not voting members, to facilitate the involvement of General Practice Representation in the discussion, if no General Practice Representatives are available to attend a meeting the chair may consider the rescheduling of the meeting.

MEETING NARRATIVE AND OUTCOMES UNCONFIRMED

1 Preliminary Business 1.1 Welcome & Introductions The Chair welcomed the group. 1.2 Apologies for Absence & Quorum check Apologies for absence were received as noted above. Three voting members were present and the Chair confirmed the meeting was quorate. 1.3 Declarations of interest Laura Beresford updated her declaration of interest, indicating that following the 1.3.1 merger of the Bollington, Disley and Poynton Practices, their staff were now employees of The Middlewood Partnership.

Individual GP Practice Nature of Conflict of Interest (if applicable) Laura Beresford Middlewood Employee of member practice Partnership Joanne Morton Handforth Health Employee of member practice Centre Dr Mike Clark High Street Surgery Partner of member practice All the practice representatives above declared an indirect financial interest in agenda items: 3.1 Local GP Service Specification – 2019-20 3.2 GP Retainer Scheme Application 3.3 Extended Access Service Provision Requirements 2019-20 The Chair noted the declarations and confirmed that the representatives listed above did not need to leave the meeting for these items but should refrain from lobbying for their area/practice. There was independent representation at the meeting and no further mitigating action was deemed necessary. 1.4 Minutes and action log from the previous meeting 1.4.1 The Minutes from the meeting of the NHS Eastern Cheshire CCG Primary Care Commissioning Committee (PCC) held on 13 March 2019 were agreed as an accurate record.

1.4.2 Action Log: 1901-1 – although DG has checked, there remains a question over whether meeting details are being sent to PPG Chairs as well as HealthVoice. DG will check again, it may be that emails are being sent blind copied to both distribution lists at once, and as the distribution lists are not visible to the receivers, this may lead to the assumption from people on both groups that the email is going to only one of the two. 1903-1 and 1903-2 – To be closed on this log and added to the Primary Care Operational Group Log. 1903-3 – Data had showed some opportunities to increase utilisation and this action is to work with Vernova. Work will be on-going until August but this action will be closed on the log, as it will be concluded as part of Action 1903-4.

PCC Minutes 8.5.19 Page 2 of 11

UNCONFIRMED

1903-4 – due September. 1903-5 – On the agenda – complete. 1903-6 – due September. 2 Standing Items 2.1 Public Speaking Time No items had been notified in advance and there were no requests to speak. 2.2 Primary Care Risks This standing item had been missed from the agenda in an oversight; DG gave an update on the three risks. Primary Care premises – risk remains active with some practices/areas needing expansion space going forward. There will be more focus on this during the summer as part of the updated Primary Care strategy document being produced. Annandale Medical Practice Lease – The building has now been sold to a new Landlord. Discussions are taking place between the practice and the new landlord. The CCG and NHS England have yet to see a draft of the new lease, if it is agreed, the GP practice can remain in the building while the wider Knutsford Build project is taken forward. The Committee agreed the risk score could be reduced from 12 to 6. [Dr Mike Clark joined the meeting] Primary Care Workforce – A recently published Nuffield Report (https://www.nuffieldtrust.org.uk/news-item/is-the-number-of-gps-falling-across- the-uk) revealed that nationally primary care workforce numbers are reducing. In the North West the picture is less negative: primary care workforce numbers are static, however they are not increasing to meet the increasing demand for services and therefore the risk is increasing. The risk is scored at 12: GB asked what mitigating actions the CCG could take and whether a Deep Dive of the risk would be helpful. NE commented that the CCG is reliant on other organisations to deliver the risk. Notional ICPs are being asked to develop a strategy. KM is working on a nursing strategy from recruitment to retention to feed into the full workforce strategy being developed for Cheshire East ICP. Funding streams and timely availability are issues: currently funding is not confirmed for a course set to start in Cheshire in September. [Carla Sutton arrived] GB repeated that action needs to be taken to demonstrate the CCG is working to mitigate the risk. NE reported that he understood a report had recently been taken to the Cheshire East Partnership Board. Type ID Detail Who/when Action 1905-1 Invite lead Cheshire East Place Lead for Workforce, DG Rachael Charlton, to attend the next meeting to present an update on workforce planning for the Cheshire East Place 3 Items for Decision 3.1 Local GP Service Specification 2019-20 PCC Minutes 8.5.19 Page 3 of 11

UNCONFIRMED

The specification brought to the last meeting has been discussed with the LMC and had been circulated to the membership for their feedback. The Committee noted a summary of the changes made and that work is being done on finalising a section on ADHD. 3.1.1 It was queried how monitoring information will be reviewed, and it was requested that when it comes to committee, it be made clear what is part of the national contract requirements, and what is part of the local contract. DG gave assurance that anything in the local specification has to be above and beyond what is provided in the national contract. A check is made annually to ensure there is no duplication with any elements of the new the national contract. Review visits have recently taken place with all practices and a dashboard with Red/Amber/Green assurance ratings specific to the local GP Service Specification has been created. Where a practice has scored amber or red there is an action plan. The dashboard will be brought to a future Committee meeting. A second round of visits by the CCG, looking for improvement, is now being scheduled. If necessary formal contract query letters will be issued in cases where there are any concerns about a lack of progress. 3.1.2 It was queried how it can be ensured the contract is aligned with the GP Forward View. DG, LB and MC responded: The GP Forward View is about future sustainability of general practice as a whole, and the direction of travel is towards bringing practices together to work as larger groups and doing things on a larger scale. The local contract was about levelling the service offer across Eastern Cheshire in Phase 1, reinvesting monies from PMS contracts and local enhanced services, reaching a consensus on priorities, and delivering the objectives of the Caring Together Programme. The aim had been to work at larger scale across practices in Phase 3 which is in line with the national direction of primary care networks. Phase 3 was to look at progressing services at a wider Care Community level, not, just primary care. Phase 3 of the local contract was not progressed at the time. There is now a national shift in direction towards a Primary Care Network strategy, getting practices to collaborate over a wider footprint. 3.1.3 DG reported he had not had much feedback on the specification from the practices, which he assumed meant they have no major issues with it. It had been on the agenda for the Locality Meeting on 5th April, time had run out for discussion but the specification had been circulated to practices again immediately after the meeting with a request for comments. 3.1.5 The Committee was asked to approve the changes – mainly refinements to wording - made to the specification since the last Committee meeting. The Committee approved the Local GP Service Specification 2019-20. 3.2 GP Retainer Scheme Application Dr Mike Clark declared an interest as a GP Partner at High Street Surgery. He is not a voting member of the committee. An application for a GP Retainer Scheme at High Street Surgery was recently received via Health Education England and considered by the Primary Care Operations Group (PCOG). The Group found the level of detail in the application to be less than satisfactory but that the criteria for approval appeared to meet PCC Minutes 8.5.19 Page 4 of 11

UNCONFIRMED

national guidelines and the Executive Committee ratified the PCOG’s approval of the scheme. NHS England was made aware of the CCG’s dissatisfaction with the application process. MC commented that from the point of view of High Street Surgery, the process had also been unsatisfactory on this occasion. DG added that the appropriate path for the person concerned, who had returned from abroad, should have been via the GP Returners Scheme, which is run by NHS England, whereas the GP Retainer Scheme is funded by CCGs and should look to retain existing GPs thinking about leaving the NHS. The Committee ratified the recently submitted GP Retainer Scheme for High Street Surgery Type ID Detail Who/when Action 1905-2 Remind the member practices via the Locality Management DG meetings about the GP Returner Scheme and the GP Retainer Scheme and the appropriate processes 3.3 Extended Access Service Provision Requirements 2019-20 It was acknowledged that the “Extended Access” service and the separate “Extended Hours” provision required by the new Primary Care Network DES are confusingly similar names for two discrete requirements. Last year there was a requirement from NHS England that an 30 extra minutes per week per 1,000 head of population would be provided by general practice under the Extended Access contract, potentially rising to 45 minutes per week per 1,000 population in 2019/20 if required. In Eastern Cheshire the Extended Access service is currently provided by Vernova Healthcare CiC on behalf of the member practices. Current utilisation of the service is at 76%. It is not felt that there is a requirement to increase service provision from 30 to 45 minutes at the current time. Historically there was a GP Extended Hours service for provision of an additional 30 minutes per week per 1,000 population, funded by a DES (Direct Enhanced Service). Not all practices had chosen to undertake the national DES. This DES will end on 30th June 2019 but the requirement to provide 30 minutes extended access has now been included as a mandatory requirement in the 2019-20 Primary Care Network (PCN) DES. There is a risk that practices will not have sufficient staff to be able to provide safe provision of both the Extended Access and Extended Hours service requirements. It is proposed that the Extended Access service provided by Vernova continue as 30 minutes for 2019-20 rather than increasing to 45 minutes. In conjunction with the “Extended Hours” additional 30 minutes’ provision required by the PCN DES, in total this will provide an additional one hour per week per 1,000 patients to the local population. Primary Care Networks will work to achieve this additional capacity for the benefit of the local population. DG commended this as a balanced approach which will provide more patient appointments and achieve the position that all member practices will be offering Extended Hours. 3.3.1 In view of the inclusion in the national Primary Care Network DES of a further 30 minutes per week per 1,000 head of population, which will lead to all practices now offering Extended Hours, The Committee approved continuation for 2019/20 of the GP Extended Hours contract at 30 minutes per week per 1,000 head of population.

PCC Minutes 8.5.19 Page 5 of 11

UNCONFIRMED

4 Items for discussion 4.1 ECCCG Primary Care Report DG highlighted some of the main points in the report. 4.1.1 CQC Inspections (5.3, 5.4 in the report) Following the CQC’s inspection in March, Toft Road Surgery has been rated as “Requires Improvement”. CQC and the CCG will work with Toft Road on submission of an action plan, and its execution. Manchester Road Medical Centre was also inspected in March and has maintained its rating of “Good”. 4.1.2 Safeguarding Policies GP practice policies should now include guidance on prevention of FGM. Updated national guidance now states that nurses doing immunisations need to have level 3, not level 2, child safeguarding training. 4.1.3 QOF - Post Payment Verification Process (1.4 in the report) As per last year, Eastern Cheshire and South Cheshire CCGs will each visit a practice in the other CCG to verify all data is in order as a check to verify QOF payments are appropriate. 4.1.4 Falsified Medicines Directive (1.5 in the report) A national change in the process for coding and tracking medicines will impact GP practices. The Medicines Management Team will provide a paper to the Committee detailing what actions the CCG should be taking. 4.1.5 NHS Pension Employer Contribution increase NHS England will support the increase in 2019-20, it is not known what will happen in the following years and it was queried whether this should be raised as a risk for the CCG and what the nature of the risk to the CCG would be. NE commented that the CCG has little control over mitigating the risk. It was commented that the Nuffield report on primary care workforce referenced earlier in the meeting included the observation that GPs are being forced out of work by changes to taxation and pensions. Type ID Detail Who/when Action 1905-3 Discuss with Alex Mitchell and the new Cheshire Chief Finance NOG Officer the risk to the CCG arising from the NHS Pension Employer Contribution increase and write a risk for Eastern Cheshire on the potential financial and workforce implications 4.2 2019-20 National GP Contract Changes – key implications and next steps Following a request at the last meeting, an overview of the changes had been prepared. 4.2.1 In response to a query, it was acknowledged that Primary Care Networks with smaller populations might be disadvantaged in relation to funding. 4.2.2 Indemnity costs for clinical negligence are centrally funded under the primary care contract, practices need to make provision for anything which falls outside this

PCC Minutes 8.5.19 Page 6 of 11

UNCONFIRMED

scheme. 4.2.3 The Primary Care Network DES is aimed at encouraging practices to work together at scale. Guidance on what needs to be included in the specification for next year is awaited. The CCG is committed to supporting the development of Primary Care Networks with funding at £1.50 per head of population. A look will be taken at how the local care home scheme LES (Locally Enhanced Service) overlaps with the 2020-21 national scheme. 4.2.4 Nationally there is a big push on digital technology to help patients and relieve pressure on GP practices, with more services being made available online. 4.3 Primary Care Finance Report Niall O’Gara presented the primary care finance report, indicating that as financial planning guidance, including many changes, was gradually clarified over the course of January and March, the CCG’s financial plan was updated and refined accordingly. The two main pressures in primary care are GP Extended Hours and Extended Access. Pending further guidance on funding for this from NHS England, a risk of £1 million and mitigation of £1 million has been included in the Budget Book in anticipation. CS confirmed that guidance for the last cohort of schemes, which started in October 2018, and which include Eastern Cheshire CCG’s scheme, has not yet been finalised. Funding for Primary Care Networks has been set aside from the CCG’s core allocation at a rate of £1.50 per head of population. The original figure envisaged was £862,000 but now is estimated at £578,000 based on what is provided by NHS England. Clarification has been requested from NHS England. Having no headroom in the delegated budget for primary care means difficulty in affording items such as GP Retention scheme applications. DG highlighted that another pressure for the CCG is that a rent review is imminent for several GP practices. Following several years of rents being consistent it is anticipated these will now rise. NOG gave assurance that some provision has been made in the budget for rent increases and he anticipated the position presented is the “worst case scenario”. In answer to a query he said the Finance Committee would review the risks and update the overall CCG’s Finance risk to include the primary care risk. An update was requested for the July meeting. 4.4 Medicines Management Scheme to support cost effective prescribing 2019-20 JK presented the paper which has been presented at other meetings and includes input from discussions at prescribing committees, meetings with GPs and prescribers, CCE, Eastern Cheshire CCG Execs and the Governing Body of South Cheshire & Vale Royal CCGs. The scheme is based on last year’s, with the addition of a section around the STOMP LD programme (STOMP LD stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines). Practices are being asked to do more work on this. The scheme includes a section on medicines optimisation in care homes in PCC Minutes 8.5.19 Page 7 of 11

UNCONFIRMED

response to a successful bid from NHS England, and a review of prescribing for patients with multiple medications and those who do not have cancer but are receiving strong painkillers. The aim is to engage with practices to optimise appropriate prescribing budgets at care community levels and at CCG levels, with the practices and the CCG sharing the financial risk. Practices will receive a set payment for achievement of an agreed underspend. 4.4.1 It was commented that the general public might have concerns relating to the gain share agreement whereby GPs receive payment if they prescribe less. JK gave assurance that the principle is about prescribing more cost effectively and the scheme is to encourage GPs to do additional work to maintain appropriate prescribing for patients when e.g. a patent comes to an end and a generic version of a medicine is cheaper but identical in efficacy, or to explain the rationale for when medicines used in secondary care are not listed for use in primary care and a substitute should be offered. 4.4.2 It was queried why West Cheshire CCG is not part of the system. JK and NE explained that currently there is a single Medicines Management Team for Eastern Cheshire, South Cheshire and Vale Royal CCGs employed by Vale Royal CCG. West Cheshire CCG’s medicines management structure is different and currently operates differently. Historically the two sides of Cheshire have mirrored the patient flow to the respective hospitals in each area. JK and NE explained that this is a year of transition for the Cheshire CCGs, and a national review of prescribing schemes is anticipated, therefore the approach adopted is to make no major changes to last year’s scheme, and as the CCGs continue to work more closely together, harmonisation of plans across Cheshire is expected in 2020. 4.4.3 The decision that an Equality Impact Assessment had been deemed not necessary on the initiative to reduce painkilling medication was questioned, highlighting that this could affect specific demographics and people on low incomes. JK explained that the principle of the scheme is asking practices to continue doing the work they normally do, but in addition, to review medication for some groups of patients. There are nationally agreed indicators of good prescribing practice and the CCGs look at where they are outliers and seek to improve. In line with national guidance, GPs access translators if needed, and use infographics for patients who are less verbal when discussing their medication with them. The point was made that particular groups may be more affected by changes to their medication than others and this will not be identified without carrying out an EIA. There was a discussion about how groups of patients on low incomes with poor health may already be disproportionately affected by the need for strong painkillers and JK gave assurance that decisions on changes to medication are all made in conjunction with the patient, and in the case of chronic pain, for example in line with NICE guidance, there is the option for patients’ medication to be reduced in conjunction with referral into a pain management programme, which may be more beneficial to the individual than remaining on strong medication. GB felt there was still a case for examining how the impact of changes might disproportionately affect people with protected characteristics. It was commented that if patients will not engage with the practice, the practice PCC Minutes 8.5.19 Page 8 of 11

UNCONFIRMED

will not meet its target and be eligible for the incentive payment. JK clarified that the scheme incentivises engagement with the patient on reviewing their medication, there is no target for reduction in medication. The incentive payment is to recognise the additional work in the review. Patients on high opioids may need more frequent reviews and a gradual reduction in dosage. It was commented that the payment allows GPs time to discuss medication with patients, which they would not normally have. Discussing more reliance on self-help is a challenging conversation. JK highlighted that the paper has brought together streams of work supported by NHS England and that the rate of high dose opioids in Eastern Cheshire has reduced to just under the national average. The amount of work done is proportional to the number of people on the medicines, and not to the practice population. EQIAs have been done for elements of the scheme in the past, where it was felt the work was outside the nationally directed programmes of work. 4.4.4 The level of risk to the CCG in the prescribing scheme was queried, and how much in total, what the likelihood is of the risk materialising. NOG said all the risk is built into the budget and the scheme is effectively self- financing. If the prescribing budget is not met, the practices do not receive incentive payments. The likelihood of some, all, or none of the practices being eligible to receive the money was queried. Last year all practices received the payment for quality. NE responded that it is in the CCG’s interest to make the payments to the practices; an overspent prescribing budget would be a financial pressure on the CCG. NOG stated that the real risk lies with factors outside the CCG’s control and it is not possible to quantify in advance the potential impact of NCSO (no cheaper stock obtainable) issues due to manufacturing, import and export factors. Should the risks materialise, the impact will be shared with practices. A proportion of the scheme funding is paid for engagement and quality improvements, e.g. antibiotic stewardship; a proportion of the scheme funding is paid for medicines optimisation / achievement of budget. A contingency has been included in the budget to mitigate against practices not meeting their prescribing budgets. It was requested that a review of progress be presented in September. JK was thanked for the report. 4.5 MIAA Audit of Primary Care Governance

This audit was carried out by MIAA and will be managed through the Governance and Audit Committee. Overall the findings were “substantial assurance”, with a recommendation that it would be good practice for the Primary Care Committee to undertake an annual report of their activity for the Governing Body. Minutes of the meetings and a summary are already provided to the Governing Body after each committee meeting, but national best practice is for an annual report to be produced. This will be scheduled in for future years, with a draft brought to the January meeting.

DG will conduct an on-line survey of committee members asking what they believe works well and what does not. Type ID Detail Who/when PCC Minutes 8.5.19 Page 9 of 11

UNCONFIRMED

ACTION 1905-4 Conduct on line survey of Committee members asking what they DG believe works well about the meetings and the committee, and what does not 4.6 Working Together Across Cheshire Update NE reported that the Cheshire CCGs Executive Directors have recently been appointed. Primary care spreads across a number of directorates. Work on refining portfolios of the new directorates will be taking place over the next few months. Governing Body members present had not seen the announcement of the post holders, this will be circulated.

4.7 Cheshire East Place primary care strategy Amanda Best of South Cheshire & Vale Royal CCGs is the nominated lead for primary care strategy in Cheshire East. NHS England requires a Place-based strategy to be developed by the autumn, with an interim strategy from each CCG to be submitted by 1st June. Eastern Cheshire CCG’s draft has been sent. Engagement with practices, primary care networks, the Place and the public will be necessary to ensure the primary care strategy works locally and this will be progressed over the next few months and brought back to the July meeting before being taken to the Governing Body. NE clarified that full Place strategies, not just primary care strategies, have to be completed by the autumn. Type ID Detail Who/when ACTION 1905-5 Circulate the draft primary care strategy submitted to NHS DG England 5. AOB

5.1 GP Forward View – Releasing Time to Care programme GP members were familiar with the programme. In addition to 10 high impact areas there are a number of different streams. Last year all five care communities tapped into support to release clinical time for quality improvement and leadership. The focus of the scheme is shifting to Primary Care Networks. It was asked how this links to improving workforce and when the inputs and output benefits will be seen in return for the investment. DG responded that practices have looked at areas where efficiencies can be introduced relevant to themselves and have not been asked for a report. GP members talked about the difficulty of quantifying the benefits derived by individual practices; the example was given that signposting patients elsewhere might have provided the benefit of heading off an increase in demand for GP appointments. The outcomes of practices internal reviews have been shared within peer groups. JS and GB were keen to have sight of the reviews. It was emphasised that there is no cost to the CCG and the CCG does not have to manage the local uptake/delivery of the programme. General Practice members gave assurance that the practices have seen and reviewed what the others have done.

4. Future Meeting dates Wed 10 July 2019, 3pm Boardroom 2 Wed 11 Sept 2019, 3pm Boardroom 1 Wed 13 Nov 2019, 3pm Boardroom 1

PCC Minutes 8.5.19 Page 10 of 11

UNCONFIRMED

Meeting closed at 16:50.

PCC Minutes 8.5.19 Page 11 of 11

Key: ECCCG Primary Care Committee OD Overdue ACTION LOG 03/07/2019 BS Behind Schedule but deliverable OS On Schedule C Completed

Action Update Agenda Item Update Log No Date Raised Action Description Due by/ Closed date Owner RAG Status Number Required 1903-4 13.3.19 3.4 Bring update on Extended Access Service back to September 08.05.19 - to be taken to Sep19 PCC meeting. 11.9.19 DG meeting OS 1903-6 13.3.19 4.1 08.05.19 - to be taken to Sep19 PCC meeting. Flu Vaccination Campaign - Circulate achievements and learning from the flu vaccination campaign to Primary Care and bring an 11.9.19 KM OS update back to PCC once data is published. 1905-1 08/05/19 2.2 02.07.19 - Dean Grice met with Rachael Charlton in May to discuss. Rachael to attend a Invite Cheshire East Place Lead for Workforce, Rachael Charlton, future PCC (October meeting now suggested - to have both South and Eastern Cheshire in Oct 2019 DG to attend the next meeting to present an update on workforce the room) to explain what work has progressed; plan for 19/20 and current governance OS planning for the Cheshire East Place. arrangements. 1905-2 08/05/19 3.2 02.07.19 - Information provided to GP practices on the two schemes. Action complete. Remind the member practices via the Locality Management meetings about the GP Returner Scheme and the GP Retainer DG C Close? Scheme and the appropriate processes

1905-3 08/05/19 4.1.5 Discuss with Alex Mitchell and the new Cheshire Chief Finance Officer the risk to the CCG arising from the NHS Pension Employer Contribution increase and write a risk for Eastern Cheshire on the July 2019 NOG OS potential financial and workforce implications.

1905-4 08/05/19 4.5 Conduct on line survey of Committee members asking what they believe works well about the meetings and the committee, and DG OS what does not. 1905-5 08/05/19 4.7 Circulate the draft primary care strategy submitted to NHS England . DG Place based Primary Care strategy to be taken to PCC prior to OS Governing Body.

Eastern Cheshire CCG Primary 02/07/2019 10:47:09 Care Risks

Risks

00016 Primary Care Services Estates

Risk Details

Prev Risk 495 Register Number (Datix) Description The provision of Primary Care services in premises fit for purpose to meet current demand.

Risk Type Strategic

Raised By Dean Grice - Primary Care Manager

Owners Dean Grice

Executive Neil Evans - Executive Director of Planning & Delivery Lead Accountable Primary Care Committee Committee Key Dates

Date Raised 17/01/2018

Target Date 31/03/2020

Risk Closure Date Governing Body Assurance Framework Section Governing No Body Assurance Framework Flag Objectives Investing Responsibly

Review Date

Risk Appetite

Initial Score

Initial Score 6

Rationale for Risk relating to having appropriate: Score - Primary Care premises in place. - Estates expertise within the CCG. - Financial capacity within the CCG to implement strategy.

Current Score Eastern Cheshire CCG Primary 02/07/2019 10:47:09 Care Risks

Current Initial version of the Primary Care Estates Strategy document produced (November 2017). With Controls evolution of STP/HCP and the Cheshire East Place a strategy is needed at 'Place' level. STP/HCP board have asked Cheshire East Place Board to lead on pulling this together. Primary Care estates being monitored at monthly Primary Care Operational Group meetings. Primary Care Team monitoring new housing development being submitted into the Cheshire East Council. Primary Care Team working with South Cheshire CCG to develop a more robust template for requesting Section 106 health funding from developers via the Cheshire East Council Planning Department. NHS England will shortly be confirming the process that CCGs should be following with regards to Section 106 funding requests. Primary Care Team working with GP practices in Knutsford, looking to progress a combined new build for the three GP practices - this will hopefully be part funded by NHSE ETTF funding (up to a max of 40% funding) with the sourse of the remaining funding needed to be identified, e.g. NHS Property Services, 3P, etc. Primary Care Team monitoring ongoing development of the Handforth Garden Village. Primary Care Team working with NHSI and NHS PS estates experts to realise beenfits of their expertise.

Mitigating CCG working with relevant GP Practices to progress the local Estates and Technology Action Transformation Fund (ETTF) submission bids. For the Knutsford ETTF bid, CCG updating PID for final resubmission to NHSE North. For the Holmes Chapel ETTF bid, GP practice progressing planning stages with a hopeful start to the build in summer 2019. Practice aware that ETTF funding window for this project most likely closes April 2020. Working with agencies involved in planning to maximise understanding of health needs in developments. Cheshire CCGs proposing to release staff into ICP to support development of Primary Care strategy; to include estates and technology plans.

Gaps in Further development of Eastern Cheshire CCG Primary Care Estates Strategy on hold pending control or development of Cheshrie East ICP and merger of Cheshire CCGs. assurance Clear plan for development in Knutsford not yet in place. Knutsford ETTF bid still to clear PID stage into OBC stage. Eastern Cheshire CCG lacks an estates expert that other CCG's have in place. For the Knutsford new build project, a part-time estates resource is needed if we are to efficiently drive the project forward.

Assurances Initial version of the Primary Care Estates Strategy document being used in talks with our partners. Primary Care estates position being monitored / actively managed by the CCG Primary Care team and escallated as appropriate.

Current Score 6

Actions

00083 Garden Village

Description Working with planners and local GP practice to ensure development considers future health needs of additional population.

Due Date 31/03/2020

Owners Dean Grice

Completion Date Progress Pending further engagement from The Engine of the North. Update

00084 ETTF

Eastern Cheshire CCG Primary 02/07/2019 10:47:09 Care Risks

Description Work with NHS England and GP Practices to deliver schemes within the ETTF development process (Knutsford, Congleton and Holmes Chapel)

Due Date 31/03/2020

Owners Dean Grice

Completion Date Progress Lawton House - completed Update Knutsford - in PID stage - CCG to respond to queries raised by NHSE North in order to allow the project to move into OBC stage. Holmes Chapel - with GP practice who are progressing building plans and planning permission, with a planned build stage for summer 2019.

00085 Section 106 and CIL processes

Description Ensure CCG processes support the maximium draw down of funding from developers and that processes for the funding to transfer from council to the relevant health body are effective.

Due Date 31/03/2020

Owners Dean Grice

Completion Date Progress NHSE have confirmed that they have reviewed and revisd the Section 106 for Health process and Update will shortly be sharing this guidance with CCGs and GP practices. CCG working with South Cheshire CCG to maximise the sucess rate of Section 106 Health funding requests to Cheshire East Council.

00157 CCG Estates Strategy

Description Development of final CCG (place) estates strategy is required to form a part of the the overall Place Strategy (due Autumn 2019). The Cheshire CCGs are realiging resource in order to develop this document with dedicated resource from CCG Primary Care Teams released.

Due Date 01/08/2019

Owners Neil Evans

Completion Date Progress Update

Actions

Updates

Eastern Cheshire CCG Primary 02/07/2019 10:47:09 Care Risks

00026 Premises Lease Expiration

Risk Details

Prev Risk 494 Register Number (Datix) Description An Eastern Cheshire GP practices (premises leased from a private landlord) received six months notice on their presmises lease, initially requiring the GP practice to find alternative accommodation by the end of the notice period (start of May 2019). Risk of the practice population having reduced access to primary care services; due to limited additional capacity in neighbouring GP practices this could lead to some patients being unable to adequately access primary care services for an extended period of time. Should the GP practice be unable to fulfil its contract and the CCG not have a clear plan in place to mitigate this risk there would be reputational damage across all stakeholder groups.

Risk Type Quality Reputational Strategic

Raised By Dean Grice - Primary Care Manager

Owners Dean Grice

Executive Neil Evans - Executive Director of Planning & Delivery Lead Accountable Primary Care Committee Committee Key Dates

Date Raised 17/01/2018

Target Date 31/08/2019

Risk Closure Date Governing Body Assurance Framework Section Governing No Body Assurance Framework Flag Objectives Investing Responsibly

Review Date

Risk Appetite 12

Initial Score

Initial Score 16

Rationale for Reviewed at Primary Care Committee (Jan 2018 and April 2018) - agreed that the likelihood is high Score and the potential impact is high

Current Score Eastern Cheshire CCG Primary 02/07/2019 10:47:09 Care Risks

Current Building has now be purchased by a new Landlord. GP Practice engaging with new Landlord / Controls negociation underway. Due to be concluded by end of june 2019, now extended to end of August 2019. Maintaining regular dialog with the GP practice. Meeting with GP practice regularly to review options and risks. Keeping NHSI Strategic Estates expert up to date / consulted. Have reviewed potential sites for temporary relocation (portakabins) as part of a plan B approach. GP practice has brought in legal advice to help them with negociations with the landlord.

Mitigating 1) Building has now be purchased by a new Landlord. GP Practice engaging with new Action Landlord. Potential for a new lease to be agreed. 2) Progressing feasibility study with Knutsford GP practices on longer term strategic estates solution. 3) Developing interim solution for the individual practice at risk. 3a) Use of alternative GP practice site - GP practice has engaged with a portakabin supplier in order to understand costs and requirements of housing temporary buildings on a neighbouring GP practice site. 3b) Interim premises could be used, e.g. local East Cheshire Trust premises. 3c) GP practice is looking at alternate local sites for temporary building, e.g. Cheshire East Council land. 3d) The existing site could be purchased by a stakeholder and leased back to the GP practice. A willing stakehold has not been identified. 4) Explore viability of non NHS sourced investment into capital development and lease back. 5) Potential future rent reimburement costs (to the CCG) provisionally looked at in order to provide PCOG and PCC with an awareness of future cost implications.

Gaps in Dependant on negotiations between GP Practice and landlord. control or 1) CCG Primary Care Estates Strategy is not fully formed / needs further development in order that assurance future issues of this nature can be avoided. 2) Full OBC sign off by all financial stakeholders for a preferred long-term solution, ensuring the local population can access Primary Care both in the short and longer term. 3) It is unknown if the GP practice would get planning permission for positioning of the portakabins on the neighbouring GP practice site.

Assurances 1) Longterm plan options appraisal completed and stakeholders agreed next steps. These are pending NHSE signoff of the Knutsford ETTF PID and progression into the OBC stage. 2) Stakeholders are supporting an interim solution and are willing to assist in resolving this issue. 3) Current building being used to maintain services while options appraisal and mitigating actions are put in place, recognising that there is a deadline now set of end of August 2019.

Current Score 6

Actions

00050 Cost analysis of interim solution

Description Cost analysis of various interim solutions to be generated. Meeting took place 19th June 2018 to refine shortlist and now further work is taking place to ensure costings are accurate. A range of options have been considered and a shortlist of options are now being assessed in more detail.

Due Date 01/09/2019

Owners Dean Grice

Completion Date Progress High level costs of the various options discussed. Update For the placement of portakabins on ECT community hospital site, we are pending a costs breakdown from ECT estates team. This option is not the preferred option for the GP practice. GP practice has detailed costs for relating to portakabin costs at a neighbouring GP practice. Action to remain open until risk resolved / costs related to options is an ongoing evolving picture. Eastern Cheshire CCG Primary 02/07/2019 10:47:09 Care Risks

00052 GP Practice exploring viability of non NHS capital options

Description Undertake analysis of private landlord development options, including interim proposals. This includes private landlords and commercial estate agencies.

Due Date 31/01/2019

Owners Neil Evans

Completion 12/04/2019 Date Progress Action with GP practice who are exploring options. Update Not seen as a viable option by the GP practice.

00053 Peer Group estates Options Appraisal

Description For the long term estates solution an outline business case is required, led by NHS Property Services, on the shortlisted options for the wider peer group included the affected GP practices. This work is pending funding being released by NHS England through ETTF. The decision was due in August but has been delayed meaning work has slipped.

Due Date 01/09/2019

Owners Dean Grice

Completion Date Progress Pending funding confirmation from NHS England. CCG to respond to NHSE to clarify a number of Update points on the PID prior to this being signed off and allowing the project to move into OBC stage.

00149 Implementation of short-term solution for accomodation

Description

Due Date 30/04/2019

Owners Dean Grice

Completion 02/07/2019 Date Progress Options are realistically seen to be: Update a) negotiation of a new lease / lease extension at the current location. b) legal challenge from GP practice to landlord / resolution via Courts. c) use of portakabins on land at a neighbouring GP practice. d) use of portakabins on CEC land near the current GP practice site. Option investigation / progression being led by GP practice with CCG support.

Actions

Updates

Eastern Cheshire CCG Primary 02/07/2019 10:47:09 Care Risks

00113 Workforce and Organisational Development

Risk Details

Prev Risk 214 Register Number (Datix) Description If Primary Care and the integrated care system does not attract, train and retain a high quality workforce which is motivated, with the right capability, capacity and behaviours , there is a risk that there will be a negative care and service experience.

Analysis has shown that over 30% of GPs/Practice Nursing personnel are due to retire in the next few years. Challenges in career progression within the current GP Practice model; and in the case of nursing also the differentials in pay and benefits are contributing to the challenge retaining staff. There are similar pressures in Practice Management.

The traditional role of a GP has become more challenging to recruit to reflecting a desire for "portfolio" careers with fewer hours spent in General Practice and the isolated working and work pressures contribution to the recruitment/retention pressures.

Risk Type Clinical Financial

Raised By Neil Evans

Owners Katie Mills

Executive Neil Evans - Executive Director of Planning & Delivery Lead Accountable Primary Care Committee Committee Key Dates

Date Raised 07/11/2018

Target Date 28/03/2019

Risk Closure Date Governing Body Assurance Framework Section Governing No Body Assurance Framework Flag Objectives Quality

Review Date

Risk Appetite 12

Initial Score

Initial Score 12 Eastern Cheshire CCG Primary 02/07/2019 10:47:09 Care Risks

Rationale for  A Cheshire East Place Workforce and OD workstream is in place and has been developed to Score build on the Caring Together workforce workstream.  A Care Communities Delivery Group has been formed to discuss/address workforce issues.  Primary Care Enhanced Training Hub in place ; hosted by Bollington Medical Centre to support student placements in Primary Care for Nurses and Physician Associates and to look at emerging roles  National tools being used to capture workforce data. Processes need to be developed to capture Care Community level and Enhanced Training Hub reviewing this information  Practices have recruited directly to a variety of new roles including Clinical Pharmacists, Advanced Nurse Practitioners. Assistance Practitioners and Physician Associates to diversify and sustain their workforce. There has also been support to Primary Care additional roles within care communities e.g. Direct Access musculoskeletal physiotherapists, care home support services including speech and language, dietetics and pharmacists

Current Score

Current Monitoring of a range of quality and performance indicators highlights issues in current practices Controls deliver of clinical care. This includes monitoring of complaints and incidents. Nursing workforce database developed and maintained in CCG, including training needs analysis.

Mitigating The 2019-20 contract changes to the National GP Contract provide additional Primary Care funding Action to support GP Networks in employing new roles that will support GPs / General Practice. CCG working with the Cheshire East Place to develop a workforce strategy at ICP level. The Enhanced Primary Care Training Hub is continuing to innovate and introduce new roles. External funding is being used to pump prime additional roles in Primary Care e.g. Care Home Pharmacist. GP practices have access to the GP Retention programme which has been reviewed locally and a local policy put in place. Workforce has been identified as a key role in the Primary Care Strategy that is to be developed. The CCG is utilising Health Education England CPD funding which is being utilised to support Health Care Assistants and Practice Nursing to develop/maintain competencies and upskill individuals/services. This aims to ensure Primary Care is able to meet emerging standards and good clinical practice. GP and Lead Nurse meetings put in place to discuss existing service delivery challenges and develop mitigating actions. Congleton GP practices engaged in NHSE International Recruitment Programme. Continued use of national funding streams to pump prime roles with Care Home Pharmacists being recruited in 2018/19. New NHS Long Term Plan looks to provide ongoing funding for the Enhanced Training Hub.

Gaps in Whilst there is significant amounts of work at a Cheshire East Place level, through the GP National control or Contract and the Enhanced Training Hub a detailed workforce strategy needs to be finalised with assurance associated plans developed and resourced. National workforce shortages make addressing vacancies challenging. Current gaps in student placement capacity limits progress in attracting trainees to the area. There is limited capacity in Primary Care to enable people to be freed up to take on leadership roles.

Assurances Primary Care indicators continue to show that Primary Care in Eastern Cheshire is delivering excellent standards of care. This includes the recent GP Survey. Primary Care has been engaged in developing a strategy and they and the Local Medical Committee are committed to working with commissioners on developing solutions to ensure sustainability of Primary Care. CCG actively engaged in Cheshire and Merseyside GP Forward View and General Practice Nursing Leadership Programmes to ensure we maximise any opportunities to benefit from regional/national programmes.

Current Score 12

Actions

Eastern Cheshire CCG Primary 02/07/2019 10:47:09 Care Risks

00125 Primary Care Strategy

Description Development of a strategy and work plan.

Due Date 31/08/2019

Owners Neil Evans

Completion Date Progress Update

00126 NHS England Transformation (GPFV and GPN)

Description NHS England plans on workforce development to be developed regionally and implemented locally.

Due Date 31/08/2019

Owners Neil Evans

Completion Date Progress Update

Actions

Updates

Primary Care Committee Paper

Paper Title Chelford Boundary Change Request

Purpose of paper / report To obtain Primary Care Committee approval for a patient boundary change request from Chelford Surgery Outcome Approve Ratify Decide  Endorse For Required: information

Summary Under part B of the Primary Medical Care Policy and Guidance Manual (PGM) section 7.14 Boundary Changes: 7.14.1 There may be circumstances when a contractor wishes to change their main practice boundary to either expand or contract the practice area for new registrations due to new redevelopment, local authority compulsory purchase schemes and/or road developments. 7.14.2 Most practices will also have within their contracts a defined outer boundary to allow those patients, who move home a relatively short distance outside of the main boundary and who would prefer to stay with their existing practice with whom they may have a well-established relationship, to remain registered. 7.14.3 For the purposes of service provision, the full range of contractual services must be made available to those patients registered with the practice within the outer boundary and the outer boundary area must be treated as part of the practice’s contracted area. 7.14.4 Any changes to the practice area (main and outer boundary) must be considered a variation to the contract and the definitions of these areas amended under a variation notice. The contractor must notify the Commissioner of its intent to vary its area in writing setting out the reasons for the change and full details of the proposed practice area, with any additional supporting evidence that may assist the Commissioner in reaching its decision

On 15th May 2019 Chelford Surgery requested a formal boundary change, citing the following reasons for the application (Appendix 1):

Currently we have two housing developments underway, but yet to be completed, which will increase the number of houses within the village of Chelford itself considerably. There will be 89 homes on the market site with another 18 awaiting approval and 94 on the Stobart site which could rise to 119 with 25 awaiting approval. Estimating that half of the houses will have 4 residents and the other half 2 this would increase our list size by 549 with the approved houses and another 129 with the houses awaiting approval. In addition Cheshire East are looking to safeguard another area of land which if came to fruition would mean a further 200 + homes. This could increase our list by a further 600 patients. In summary, our baseline list, which has been stable for many years is 3778 (January 2018) It has risen to 3968 with partial occupancy of the Stobart site and we anticipate that it will rise to 4400 when all of the developments are complete as approved. If the additional planning permission which is awaited is granted our rise would be to 4500. And in the longer term could rise to 5100 (With the extra 600 included).

Chelford Surgery have been adapting their working practices in order to manage the changes in practice and have increased their GP time from 23 to 25 Sessions and the Practice Nurse time from 9 to 11 sessions. There has been an increase in administration hours by 14% to reflect some of the additional workload. The practice currently has 4 GP’s employed with a WTE

equivalent of 3.20 current raw list size of 3968 is 1240 patients per GP which is considered to be low in comparison to peers. However the practice also manage the David Lewis Medical Practice which is a complex service dedicated to residents at the David Lewis Centre, which is wholly for the use of adults and children with a range of complex medical needs including learning disabilities and epilepsy, the list size excludes these patients.

The increase over the past 4 years has been a 10% increase to population size

Practice Contract Q1 Q1 Q1 Q1 Current Q4 Code Practice Name PCN type 15-16 16-17 17-18 18-19 18-19 Increase (CHELFORD N81069 SURGERY) CHAW PMS 3736 3633 3767 3807 3968 (DAVID LEWIS Y05750 CENTRE) CHAW PMS included in above 135 136 10% Total List Size 3736 3633 3767 3942 4,104 368

The practice have consulted with their PPG and have a supporting letter from them (Appendix 4). They have also discussed with Chelford Parish Council and have a supporting letter from them (Appendix 2).

The practice have consulted with their neighbouring practices and have had feedback from two practices as follows ( response from Chelford in Red):

 Will we be removing patients already outside of our new area?– No we will no longer take on patients out of the area but will not be asking patients to move to another surgery.  Will there be any patients in an area not covered by a surgery ?– No  Do you mind if I check with the CCG? – No

The CCG has written to all bordering practices and have received the following responses to date:

 Alderley Edge Medical practice would support this boundary change. The areas of change are appear to well covered by neighbouring practices in Knutsford, Holmes chapel and Macclesfield. Given the latest developments regarding the formation of primary care networks, these changes would also make perfect sense to myself.

 Annandale MP - We don’t have any objections to the boundary change but Chelford allowed our staff to register with them so there wasn’t any conflict with the GPs, will the Knutsford staff who live in Knutsford still be able to/continue to be register(ed) with them?

 Lawton House - Do you know if Chelford are plannig to remove currently registered patients or is this the new boundary going forward?

 Meadowside MC - I do not see any objections

Chelford have confirmed that they do not intend to remove any patients from their list, however as patients move home and remove from the boundary they will be asked to register with another GP practice. If approved all of the area which Chelford have requested to be reduced are already covered by alternative practices.

The Current and proposed Boundary for Chelford Surgery is as per Appendix 3.

There has been some expansion work completed on the Practice recently however there is no further scope to expand the practice to manage an influx of additional patients.

Recommendation(s) The Primary Care Committee is asked to approve Chelford Surgery’s application for a change to their practice boundary area.

Benefits / value to our population / communities Enable the practice to prioritise existing caseloads and patients

Key Implications of this report – please indicate 

Strategic  Consultation & Engagement Financial Equality Quality & Patient Experience  Legal / Regulatory Staff / Workforce  Safeguarding

Governing Body Assurance Framework Risk Mitigation: Not Applicable

Report Author Sally Williams Deputy Head of Contracts Date of report 08.07.2019

Appendices

Appendix One – Chelford Application Boundary Change request Appendix Two – Letter of Support from Chelford Parish Council Appendix Three – Current and requested boundary Appendix Four – Letter of Support from Chelford Patient Participation Group

Dr H Thomas & Dr S Yasin

Associate Doctors: Chelford Surgery Chelford, Macclesfield Dr Sarah Duce Cheshire SK11 9BS Telephone No: 01625 861316 Dr Joanne Harris Fax No: 01625 860075

Chelford has had a GP Surgery since 1936. It was originally based in the garden of the GP’s house- a ‘Green Shed’. In 1983 purpose built premises were acquired and have been in continuous use since this time. Considerable extensions and renovations of the original property have been undertaken on 3 occasions since 1983, the most recent of which were completed in 2016. The current practice area stretches from Alderley Edge in the North, Gawsworth in the East, beyond Goostrey in the South and to Over Tabley- past the M6 in the west. This is a huge geographical area to be served by a small 2 partner practice and has been the same area since the inception of the practice. There have, however, been considerable changes in the population and the way in which health care has been delivered throughout this time period. We have adapted our service to respond to these changes and population needs but are aware that there are currently more changes occurring than ever before. Currently we have two housing developments underway, but yet to be completed, which will increase the number of houses within the village of Chelford itself considerably. There will be 89 homes on the market site with another 18 awaiting approval and 94 on the Stobart site which could rise to 119 with 25 awaiting approval. Estimating that half of the houses will have 4 residents and the other half 2 this would increase our list size by 549 with the approved houses and another 129 with the houses awaiting approval. In addition Cheshire East are looking to safeguard another area of land which if came to fruition would mean a further 200 + homes. This could increase our list by a further 600 patients. In summary, our baseline list, which has been stable for many years is 3778 (January 2018) It has risen to 3968 with partial occupancy of the Stobart site and we anticipate that it will rise to 4400 when all of the developments are complete as approved. If the additional planning permission which is awaited is granted our rise would be to 4500. And in the longer term could rise to 5100 (With the extra 600 included). We have been aware of the changes that were going to occur and have tried to adapt and grow our practice in response to this. We have increased our clinical sessions, GP sessions having increased for 23 to 25 per week and nurse sessions form 9 to 11. We have also started to use locum sessions for holiday cover and top-up sessions as an interim measure to provide service until we are in a position to understand what the clinical demand is so that we can recruit further permanent employees once we know what the clinical demand is and the population numbers have stabilised. In addition we have increased our administration hours by 14% to support the additional patient load. As a supplementary approach we have invested in alternative methods of working. One of the alterations in working patterns we have put in place is called workflow Optimisation, where the administrative burden on clinicians is reduced by directing more clerical work to administration staff. We have also re-structured our entire appointment process, partly in response to contractual changes but also in response to support an expanding population. We have an array of different appointments available including, on line booking, urgent on the day , pre-=booked appointments, telephone appointment as well as early and late appointments- as part of the extended access and extended hours contracts. However, we do feel that at times our services are becoming too thinly spread due to the large geographical area that we serve. The ability to travel from one end of the practice area to the other is much more hampered by traffic than it ever was. This leads to difficulties in providing home support to the increasingly elderly and vulnerable population. We are a small practice with just 2 partners and at times have only 1 doctor on duty to cover this area. We do not wish to leave any area without cover but are seeking to reduce our boundary particularly to the west and South east, areas that have cover readily available from practices much closer to them than Chelford .This would allow us to provide a more robust service within the newly defined area. With this in mind we have contacted all practices in the CCG to inform them that we are looking to bring our boundary nearer Chelford. We have received feedback from only two practices and the questions were:-  Will we be removing patients already outside of our new area?– No we will no longer take on patients out of the area but will not be asking patients to move to another surgery.  Will there be any patients in an area not covered by a surgery ?– No  Do you mind if I check with the CCG? – No

Looking towards the future, the new GP contract looks to us providing care within Primary Care Networks and we are in a care network with Handforth, Wilmslow and Alderley Edge. As this develops we will be sharing services with these practices and potentially expecting our patients to access care from other sites within this area. We are the most southern point of this alliance and it would be logical, therefore, to look to align our area with this network, moving away from our Western and southern borders. In summary a change in boundary would result in more robust, accessible, responsive and aligned care.

Appendix 2

Appendix 3

Appendix 4

Primary Care Committee Paper 3.2

Paper Title Alderley Edge Medical Practice Boundary Change Request

Purpose of paper / report To obtain Primary Care Committee approval for a patient boundary change request from the Alderley Edge Medical Practice Outcome Approve Ratify Decide  Endorse For Required: information

Summary Under part B of the Primary Medical Care Policy and Guidance Manual (PGM) section 7.14 Boundary Changes: 7.14.1 There may be circumstances when a contractor wishes to change their main practice boundary to either expand or contract the practice area for new registrations due to new redevelopment, local authority compulsory purchase schemes and/or road developments. 7.14.2 Most practices will also have within their contracts a defined outer boundary to allow those patients, who move home a relatively short distance outside of the main boundary and who would prefer to stay with their existing practice with whom they may have a well-established relationship, to remain registered. 7.14.3 For the purposes of service provision, the full range of contractual services must be made available to those patients registered with the practice within the outer boundary and the outer boundary area must be treated as part of the practice’s contracted area. 7.14.4 Any changes to the practice area (main and outer boundary) must be considered a variation to the contract and the definitions of these areas amended under a variation notice. The contractor must notify the Commissioner of its intent to vary its area in writing setting out the reasons for the change and full details of the proposed practice area, with any additional supporting evidence that may assist the Commissioner in reaching its decision.

On 17th December 2018 Alderley Edge Medical Practice requested a formal boundary change, citing the following reasons for the application:

This is a written request to reduce the practice boundary for the Alderley Edge Medical Practice. Currently your records show that Alderley Edge Medical Practice’s boundary overlaps with three other medical practices being the Wilmslow Health Centre, Kenmore Medical Centre and Chelford Medical Practice. Therefore by moving the practice boundary towards the Alderley Edge Medical Practice, any patients living nearer to these three practices would be able to register with these practices. According to the data provided by the Edenbridge Apex software, the Alderley Edge Medical Practice has seen its patient registered at the practice increase since the data was collated from 2014. The data has shown that in 2014, 7,490 patients were registered at the practice and to date in 2018, 8,368 patients are registered with the practice. With the new housing development at Alderley Park of additional 250 new homes being built with a mixture of 4/5/6 bedroom houses, the patient list will increase further from 2019, when the homes are constructed and ready for people to move in.

From this request the CCG has worked with the practice to provide some further information and evidence, the application was re submitted 12th February 2019. (See appendix one). There rationale for the request is as follows:

 To give priority to existing patients in near proximity to the practice, requiring new patients outside of their new/proposed boundary to register with other GP Practices who are closer to these residential locations.  There are other GP practices who are closer to some of the areas they wish to remove from their boundary.

The list size has increased over the last 4 years, however not overly excessive with a growth of 6%

Q1 Q1 Q1 Q1 Practice Contract 15- 16- 17- 18- Current Code Practice Name PCN type 16 17 18 19 Q4 18-19 Increase Alderley Edge N81033 Medical Practice CHOC GMS 7,729 7811 7989 8108 8206 6% Total List Size 7729 7811 7989 8108 8206 477

The GP Practice has engaged with their PPG for support on the application, see appendix two, however how this has been represented to the PPG is misleading and inaccurate.

The additional housing being built within the area of the Alderley Park is expected to have a population of 632 and there is plans to build a further 81 apartments on the AstraZeneca campus which will be a possible further increase of up to 186 patients dependent on occupants.

The practice has 6 GP partners and 1 Salaried GP. The practice has increased the number of GP sessions to meet the extra pressure and demands, increasing from 39 to 45 sessions. However on 29 April 2019 a GP retired from the practice and the sessions reduced to 42 (5.25 WTE GPs as 8 sessions per GP appears to be full time at the practice). The list size per WTE GP is low at 1564 patients per WTE GP.

The practice has confirmed that they will not be removing any patients on their current list if the application is approved, however any patients moving out of the area will be required to register with a neighboring practice.

The CCG has written to all bordering practices to confirm whether they have any objections/concerns relating to the application, and have received only one response to date from Chelford Surgery supporting the change.

The CCG has mapped the contractual and proposed boundary, please see appendix three.

Recommendation(s) The Primary Care Committee is asked to approve Alderley Edge Medical Practice application for a change to their practice boundary area.

Benefits / value to our population / communities Enable the practice to prioritise existing caseloads and the practice time to review estate options.

Key Implications of this report – please indicate 

Strategic  Consultation & Engagement Financial Equality Quality & Patient Experience  Legal / Regulatory Staff / Workforce  Safeguarding

Governing Body Assurance Framework Risk Mitigation: Not Applicable

Report Author Sally Williams Deputy Head of Contracts Date of report 08.07.19

Appendix One

Boundary Request Application 12th February 2019.docx Appendix Two

Minutes of the PPG Alderley Edge.doc Appendix Three ( current contractual and proposed boundary)

Alderley Edge Practice Boundaries.pdf

Primary Care Committee Paper 3.3

Paper Title Knutsford Merger

Purpose of paper / report To obtain Primary Care Committee approval for a practice merger for the 3 Knutsford Practices, Manchester Road MC, Toft Road Surgery and Annandale MC Outcome Approve Ratify Decide  Endorse For Required: information

Summary 3 GP Practices within Eastern Cheshire CCG are looking to merge as of 1st April 2020; this is in line with the GP Forward View and vision of NHS England, to ensure GP Practices are more resilient and to work within Hubs of circa 33,000-50,000 patients. There are no intentions to change any of the services or locations of service and patients will still be able to see the GP of their choice. The practices have completed a robust application form using the model application form taken from the Primary Medical Care Policy and Guidance Manual. (See Appendix One).

The merging of the 3 practices will enable a more sustainable Clinical and Administrative workforce, enabling greater resilience as the increased pressure on Primary Care continues. Working together will enable streamlining of process and more efficient services for patients. The future vision of the merging practices is to enable more services to be delivered in primary care locations, providing care closer to home and changing cultures for more integrated working with other medical professionals. As there are no changes to services we have been advised by NHS England that consultation is not required, however the practices are engaging with the populations and regular meetings are being held with the PPG’s to involve and engage them within the process. The 3 Knutsford PPG’s have joined together and have already morphed into a Knutsford PPG which is held currently every 6 months. There is a communications strategy which includes engagement events, posters, messages on patient systems, parish newsletters and information on the 3 websites and the “Knutsford” website, however this is delayed due to requiring a decision from the Primary Care Committee.

All three practices are using EMIS as their clinical systems and there will be a cost to the CCG to support the merge of the clinical systems:

GPSoc Maintenance Contracts initial costs for merger of £1125 per merger x 2 EMIS Enterprise- £825 + vat per annum EMIS Remote Consultation Docman Share £5-£10k initial merge costs

The GPSoc costs are being funded under the GP IT monies, and the support for the practices during the merger from the Commissioning Support Unit are under the LPF and will not incur additional costs.

The Practices are already working to standardise the process’s within EMIS which supports greater achievement within QoF as not all of the practices currently undertake all indicators, 17-18 Achievement was as follows ( please note 18-19 data is not yet finalised):

Service Provider Id Service Provider Name Parent Organisation Name Achievement Date QOF1718 QOF1718 Full Achievement N81049 ANNANDALE MEDICAL CENTRE NHS EASTERN CHESHIRE CCG 31/03/2018 543.61 559 MANCHESTER ROAD MEDICAL N81042 NHS EASTERN CHESHIRE CCG 31/03/2018 547.85 559 CENTRE N81026 TOFT ROAD SURGERY NHS EASTERN CHESHIRE CCG 31/03/2018 536.45 559

There is a potential financial impact on the QoF funding to practices, however until the practices have merged on Open Exeter this will be an unknown quantity as QoF is calculated using a complex formula using the patient demographics. There is the request that the CCG will support QoF for the first year of merger if there is a detrimental impact financially, as previously agreed with the Middlewood Merger, thus guaranteeing the Aspiration payments, although final achievement will be as per actual achievement.

The CCG will undertake a QEIA assessment as per governance process, however similarly to the Middlewood Merger, there is not expected to be a detrimental impact on patients.

The Knutsford practices are engaging with the CCG around the estates strategy of having one Health & Wellbeing Centre single site for all three practices. There has previously been some concerns around the estates, in particular with Annandale Medical Centre, however they have just agreed a lease with the landlord for 5 years, with a break clause at the three year point. It is hoped the future single site would be in progress by then.

There are no changes to the Boundary by enacting a merger, and the 3 contractual boundaries and the Knutsford boundary is as appendix two.

Recommendation(s)

The Primary Care Operational Group has provided recommendations on the following areas:

1) Agreement on the formal Merger 2) Effective patient engagement 3) Highlight any financial impact on the CCG/Practice 4) Confirm Financial Support for QoF in the first year for the merged practice at 18-19 levels ( guarantee expected aspiration level as per 18-19 if required) 5) Confirm funding for IT changes 6) Highlight any risk factors in approving/rejecting the application

Benefits / value to our population / communities More robust and resilient General Practice for the population of Knutsford area.

Key Implications of this report – please indicate 

Strategic  Consultation & Engagement Financial Equality Quality & Patient Experience  Legal / Regulatory Staff / Workforce  Safeguarding

Governing Body Assurance Framework Risk Mitigation: Not Applicable

Report Author Sally Williams Deputy Head of Contracts Date of report 08.07.2019

Appendix One

Appendix Two

Knutsford Practice Boundaries inc merged.pdf

NHS Eastern Cheshire Clinical Commissioning Group

Primary Care Commissioning Manager’s Report

Date: 3rd July 2019

CCG Representative: Dean Grice

Report to: Primary Care Committee

1 Primary Care Risks

Risk ID: 00016 Title: Primary Care Services Estates Description: The provision of Primary Care services in premises fit for purpose to meet current demand. Current Risk Score: 6 Status: Risk remains active with some practices/areas needing expansion space going forward. There will be more focus on this over the coming months as part of the development of the Cheshire East Place Primary Care strategy.

Risk ID: 00026 Title: Premises Lease Expiration Description: An Eastern Cheshire GP practices (premises leased from a private landlord) received six months notice on their premises lease, initially requiring the GP practice to find alternative accommodation by the end of the notice period (start of May 2019). Risk of the practice population having reduced access to primary care services; due to limited additional capacity in neighbouring GP practices this could lead to some patients being unable to adequately access primary care services for an extended period of time. Should the GP practice be unable to fulfil its contract and the CCG not have a clear plan in place to mitigate this risk there would be reputational damage across all stakeholder groups. Current Risk Score: 6 Status: The building now has new Landlords. Discussions are taking place between the GP Practice and the new Landlords regarding a new lease. The CCG and NHS England have yet to see a draft of the new lease prior to it being signed by the GP practice. If it is agreed, the GP Practice will be able to remain in the current building while the wider Knutsford Build project is taken forward. The Committee agreed the risk score could be reduced from 12 to 6.

Risk ID: 00113 Title: Workforce and Organisational Development Description: If Primary Care and the integrated care system does not attract, train and retain a high quality workforce which is motivated, with the right capability, capacity and behaviours, there is a risk that there will be a negative care and service experience. Analysis has shown that over 30% of GPs/Practice Nursing personnel are due to retire in the next few years. Challenges in career progression within the current GP Practice model; and in the case of nursing also the differentials in pay and benefits are contributing to the

Page 1 of 5

challenge retaining staff. There are similar pressures in Practice Management. The traditional role of a GP has become more challenging to recruit to reflecting a desire for "portfolio" careers with fewer hours spent in General Practice and the isolated working and work pressures contribution to the recruitment/retention pressures. Current Risk Score: 12 Status: Primary Care Workforce – A recently published Nuffield Report (https://www.nuffieldtrust.org.uk/news-item/is-the-number-of-gps-falling- across-the-uk) revealed that nationally primary care workforce numbers are reducing. In the North West the picture is less negative: primary care workforce numbers are static, however they are not increasing to meet the increasing demand for services and therefore the risk is increasing. There will be more focus on this over the coming months as part of the development of the Cheshire East Place Primary Care strategy.

2 Contracts

2.1 The CCG continues to work with the GP practices / Primary Care Networks to progress the contractual aims outlined within NHS England’s five-year framework for GP contract reform to implement The NHS Long Term Plan (https://www.england.nhs.uk/publication/gp-contract-five- year-framework/). The 2019-20 GP contract changes are the current priority for the Primary Care Team.

2.2 All five Eastern Cheshire GP Networks have successfully formed Primary Care Networks as of the 01 July 2019. The next steps for the PCNs are: 2.2.1 PCNs to start the provision of PCN DES Extended Hours as of 01 July 2019. 2.2.2 PCNs to implement the requirements of the 2019-20 PCN DES specification guidance.

2.3 Five Care Communities are defined (on the same footprint as the GP Networks) with each working to develop and implement their transformation plan. Progress and pace varies across the five Care Communities.

2.4 The CCG is putting into action the QOF Post Payment Verification process, whereby a nationally agreed proportion of GP practices have their QOF submission verified. The CCG is working with the other Cheshire CCGs to facilitate this, with a South Cheshire CCG GP Clinical Lead being asked to review and verify the Eastern Cheshire GP practice data via a practice visit (accompanied by an Eastern Cheshire CCG Officer), and vice versa. The Eastern Cheshire GP practice randomly selected (at the April 2019 GP Provider Development Meeting) is the Chelford Surgery.

2.5 Funding allocation has now been received from NHS England for the provision of the 2019-20 Extended Access Service. The overall funding value for 2019-20 is £1,191,000.

3 Medicines Management Prescribing Scheme – 2018-19 Sign Off

3.1 The CCG has now received the March 2019 Medicines Management prescribing data allowing for the final position to be agreed for the Eastern Cheshire GP practices.

3.2 Eastern Cheshire Prescribing Data (excluding Stoma, NCSO and Influenza): Peer Group End of Year Position Eligible for £1/pt Payment CHAW £140,349 Yes BDP -£115,684 No

Page 2 of 5

CHOC -£230,576 No Knutsford £66,515 Yes Macclesfield -£90,418 No

The GP practices in CHAW and Knutsford are eligible for the £1 per patient payment.

3.3 The CCG has met all of the 2018-19 antibiotic targets set and therefore all of the Eastern Cheshire GP practices are eligible for the £0.15p per patient payment.

3.4 The 2018-19 Medicines Management Prescribing Scheme was approved with allocated budget by the Governing Body earlier on in 2018-19. Consequently, the outcome does not need to go back to Governing Body in order for payment to be approved and made to the eligible GP practices. The above end of year position has therefore been signed off by the Executive Director of Finance & Contracting (CFO) Lynda Risk and the CCG Finance Team asked to progress relevant payments.

4 Falsified Medicines Directive

4.1 The Falsified Medicines Directive (FMD) technically came into effect 09/02/19 (https://www.gov.uk/guidance/implementing-the-falsified-medicines-directive-safety-features). The Directive introduces tougher rules to ensure medicines are safe and that the trade in medicines is rigorously controlled. This is a reaction to a reported significant increase of false medicinal products detected within the legal supply chain of the Member States. Counterfeiting high-price medicines is perceived as a growing illegal business and a threat to public health worldwide.

4.2 All GP practices will need to have the infrastructure and processes in place to decommission medicines, even non-dispensing practices that prescribe and administer vaccines. They will also need to decide whether they decommission medicines at the point of dispensing or in advance, although practices should take into consideration the proposed 10-day window in which they will be able to recommission the medication into the system.

4.3 GP practices await further clarification from NHS England, following the release of an NHS England FMD Advice Notice to Primary Care Leads.

4.4 CCG actions taken / queries: 4.4.1 Already on the radar of the CCG’s Medicines Management Team. 4.4.2 Noted at CQ&P, PCOG and Primary Care Committee. 4.4.3 Meds Mgt Team asked to prepare a brief paper for PCC on what actions are to be taken over the next 12 months concerning the FMD – pending further guidance from NHS England. 4.4.4 NHS England asked for further national guidance.

5 CQC

5.1 All 24 GP practices have been inspected by CQC over the last five years. One Eastern Cheshire GP practice is rated Outstanding, 20 are rated Good and two are rated Requires Improvements.

5.2 Meadowside Medical Centre has been inspected on the 09/01/2019, with a published rating of Requires Improvement. The CCG Primary Care Team has engaged with the GP practice and reviewed progress against the CQC areas of concern. Report to be taken to PCC and then CQ&P.

Page 3 of 5

5.3 Toft Road Surgery has been inspected on the 07/03/19, with a published rating of Requires Improvement. The CCG Primary Care Team has engaged with the GP practice and reviewed progress against the CQC areas of concern. Report to be taken to PCC and then CQ&P.

5.4 Manchester Road Medical Centre has been inspected on the 14/03/19, with a published rating of Good.

6 Primary Care Quality and Performance

6.1 The Primary Care Contractual and Performance Dashboard is up and running, pulling together metrics previously known and/or monitored but displaying these within one dashboard, enabling greater profiling and trending to be assessed. Monthly operational update / review meetings taking place with Primary Care Team and CCG Analysts.

6.1.1 Escalations to Primary Care Committee – none identified at the current time.

6.2 Dashboard data is being used to provide part of the GP Practice Visit narrative and enabling key points of discussion, e.g. practice strengths, points of interest, CCG concerns.

6.3 The dashboard is available for review by CCG Primary Care Team and Quality Team here: S:\ECCC\Business\Primary Care\Dashboard\Published Version

6.4 The dashboard has been made available to GP practices via IntraDoc.

7 GP Practice Visits / Local GP Service Specification

7.1 The Local GP Service Specification provides an equitable and enhanced level of patient care across General Practice within Eastern Cheshire. Between December 2018 and April 2019 the CCG’s Primary Care Team undertook visits with each Eastern Cheshire GP practice in order to review the level of assurance against each of the scheme’s indicators. Based on available data, the level of assurance for each indicator was assessed. The bandings used were as follows: - Green CCG Assured - Amber CCG Partly Assured, Action with GP Practice - Red CCG Not Assured, Action with GP Practice

7.2 GP practice visits were productive and practices demonstrated many areas of good practice. A number of GP practices and/or indicators were given an assurance rating of Amber or Red. A number of indicators were identified where the majority of GP practices could not demonstrate the required level of assurances. Where further assurances were required, action plans were agreed with the GP practice. A number of deep dive workshops are being put in place utilising future GP Provider Development Meetings.

7.3 The CCG Primary Care team are currently arranging the second round of GP practice visits. Following these further visits, where required, the CCG will issue formal contract breach letters and look to withhold / claw back relevant and proportional scheme funding.

7.4 The CCG Primary Care Team will continue to monitor the scheme performance and continue to seek and maintain CCG assurances for the life of the Local GP Service Specification scheme.

7.5 The CCG has finalise the 2019-20 Local GP Service Specification which has been updated in light of visit outcomes / refinement of the existing indicators, along with a review of any duplication arising out of the 2019-20 national GP contract changes. GP practices and the

Page 4 of 5

LMC have been engaged with this process. The final 2019-20 version of the specification to be shared with the GP practices.

8 General Practice Forward View

8.1 The Cheshire East Place has been tasked with providing an updated Primary Care Strategy document, to cover the agreed direction of Primary Care Development over the next five years, including Primary Care workforce and premises. The Primary Care Team are working collaboratively with the South Cheshire CCG Primary Care Team to develop this updated strategy.

9 Primary Care Estates

9.1 NHS England have responded to our Knutsford ETTF PID submission, with a small number of clarifications required. The Primary Care Team will work with the GP practices to develop a response, which will go back to NHS England and hopefully result in approval of this project to an Outline Business Case stage.

9.2 Holmes Chapel Health Centre is planning an extension (utilising ETTF and Section 106 funding) during 2019-20 to add additional capacity to the existing building.

9.3 Annandale Medical Centre’s lease with the private landlord is outstanding. The GP practice is currently in ongoing negotiations with the new landlord over a new lease. Transfer of ownership of the premises has potentially mitigated the risk of the GP practice needing to relocate premises.

9.4 Readesmoor Medical Centre has expressed an interest in the purchase of a neighbouring terrace house in order to expand provision of GMS services (purchase costs to be covered by Readesmoor Medical Centre). The CCG await a formal business case submission from Readesmoor Medical Centre in order that this can be reviewed by the Primary Care Committee at a future date for their endorsement (with the CCG being required to cover any increases in notional rent, as defined independently by the District Valuer).

Report End

Page 5 of 5 Primary Care Committee Paper 10/07/2019 Item 4.3

Paper Title Local GP Service Specification Update Report

Purpose of paper / report To provide the Committee with an update on CCG assurances against the Local GP Service Specification. Outcome Approve Ratify Decide Endorse For information  Required:

Summary The Local GP Service Specification provides an equitable and enhanced level of patient care across General Practice within Eastern Cheshire. Between December 2018 and April 2019 the CCG’s Primary Care Team undertook visits with each Eastern Cheshire GP practice in order to review the level of assurance against each of the scheme’s indicators. Based on available data, the level of assurance for each indicator was assessed. The bandings used were as follows: - Green CCG Assured - Amber CCG Partly Assured, Action with GP Practice - Red CCG Not Assured, Action with GP Practice

The GP practice visits were productive and practices demonstrated many areas of good practice. A number of GP practices and/or indicators were given an assurance rating of Amber or Red. A number of indicators were identified where the majority of GP practices could not demonstrate the required level of assurances. Where further assurances were required, action plans were agreed with the GP practice. A number of deep dive workshops are being put in place utilising future GP Provider Development Meetings.

The CCG Primary Care team are currently arranging the second round of GP practice visits. Following these further visits, where required, the CCG will issue formal contract breach letters and look to withhold / claw back relevant and proportional scheme funding.

The CCG Primary Care Team will continue to monitor the scheme performance and continue to seek and maintain CCG assurances for the life of the Local GP Service Specification scheme.

Recommendation(s) The Primary Care Committee is asked to note for information: - The level of assurance being provided by the GP practices against the Local GP Service Specification. - The next steps being put in place as part of the ongoing monitoring process of the Local

GP Service Specification.

Benefits / value to our population / communities Continued provision of a Local GP Service Specification, providing the residents of Eastern Cheshire with an equitable and enhanced level of patient care across General Practice locally, contributing to improved health services and health outcomes locally.

Key Implications of this report – please indicate  Strategic Consultation & Engagement Financial Equality Quality & Patient Experience  Legal / Regulatory Staff / Workforce Safeguarding

Governing Body Assurance Framework Risk Mitigation: Not Applicable

Report Authors Dean Grice Primary Care Commissioning Manager Date of report 03/07/2019

Page 2 of 6

Local Eastern Cheshire GP Service Specification Update Report - July 2019

1. Background

1.1 The Local GP Service Specification has been in place since January 2015, providing an equitable and enhanced level of patient care across General Practice within Eastern Cheshire.

1.2 The local enhanced service consists of 42 indicators. Between December 2018 and April 2019 the CCG’s Primary Care Team undertook visits with each Eastern Cheshire GP practice in order to review the level of assurance against each of the indicators.

1.3 Prior to each visit the CCG Primary Care Team reviewed a collection of data from both EMIS and Secondary Care SLA Monitoring (SLAM) data.

1.4 Prior to each visit the GP practice was asked to complete a ‘Practice Return’ (Appendix 1). This document covered any indicators where no EMIS or SLAM data is available.

1.5 Based on the assessment of the available data, prior to each visit the CCG Primary Care Team rated the level of assurance for each indicator. The bandings used were as follows: - Green CCG Assured - Amber CCG Partly Assured, Action with GP Practice - Red CCG Not Assured, Action with GP Practice

1.6 The initial bandings formed the basis of the discussion with each GP practice, with the practice able to provide supportive evidence to allow for potential refinement of the allocated banding.

1.7 Following each visit, each GP practice’s banding was added to a Local GP Service Specification Dashboard.

1.8 Following each visit, each GP practice was provided with a copy of the dashboard and where required an action plan of agreed areas where further evidence and/or improvements were needed.

1.9 During May 2019 the underlying data was refreshed and, along with assessment of feedback from GP practices on their action plans, the dashboard updated accordingly.

1.10 The dashboard and findings from the GP visits was shared with the GP practices during June, utilising the GP Provider Development meeting.

Page 3 of 6

2. Findings

2.1 The GP practice visits were productive and practices demonstrated many areas of good practice. A copy of the dashboard can be reviewed in Appendix 2.

2.2 A number of GP practices and/or indicators were given an assurance rating of Amber. The most common reasons for this banding is as follows:

2.2.1 Where a GP practice could demonstrate that the requirements of the indicator were being met but the specific clinical coding identified within the Service Specification were not being used. The majority of Amber ratings fell into this category. In these instances the GP practice was asked to review their coding practice and conform to the requirements of the Service Specification so that their efforts could be identified and acknowledged by the CCG data analysts.

2.2.2 Where a GP practice was meeting some aspects of the indicator but could not provide assurances against other aspects within the indicator. In these instances the GP practice was asked to review the indicator in full and put an action plan in place to cover all aspects of the requirements.

2.2.3 Where a GP practice could demonstrate having the required processes in place but could not demonstrate achievement against the majority of the relevant patient cohort. In these instances the GP practice was asked to review the indicator in full and put an action plan in place to cover all aspects of the requirements.

2.3 A number of GP practices and/or indicators were given an assurance rating of Red. This rating was applied where a GP practice could not provide adequate assurances of achievement / compliance. In these instances the GP practice was asked to review the indicator in full and put an action plan in place to cover all aspects of the requirements.

2.4 A number of indicators were identified where the majority of GP practices could not demonstrate the required level of assurances. The CCG will look to provide support to GP practices to facilitate progression in these areas, e.g. deep dive workshops as part of the bi-monthly GP Provider Development Meetings:

2.4.1 2b.18 End of Life Care – deep dive review of data undertaken with GP practices at the May 2019 meeting 2.4.2 2a.1 Obesity Management – deep dive review of data undertaken with GP practices at the June 2019 meeting 2.4.3 2a.2 Pre-diabetes – deep dive review of data undertaken with GP practices at the June 2019 meeting 2.4.4 2b.10 Multiple Sclerosis Support 2.4.5 2b.12 Functional Condition Management

Page 4 of 6

2.5 Other areas for further discussion at a GP Locality level are:

2.5.1 2b.2 Heart Failure 2.5.2 2b.4 Asthma / COPD 2.5.3 2b.5 Urology 2.5.4 2b.8 IBD Management 2.5.5 2b.9 Coeliac Disease Management 2.5.6 2b.11 Parkinsons Disease Support 2.5.7 2b.19 Coordinating Complex Community Care

3. Next Steps

3.1 GP practices with action plans provided with an agreed period of time to implement the required changes / improvements.

3.2 As indicated above, a number of deep dive workshops to be put in place utilising future GP Provider Development Meetings.

3.3 The CCG Primary Care team are currently arranging the second round of GP practice visits.

3.4 Following the second round of GP practice visits, where required, the CCG will issue formal contract breach letters and look to withhold / claw back relevant and proportional scheme funding.

3.5 The CCG Primary Care Team will continue to monitor the scheme performance and continue to seek and maintain CCG assurances for the life of the Local GP Service Specification scheme.

4. Requirements of the Primary Care Committee

4.1 The Primary Care Committee is asked to note for information:

4.1.1 The level of assurance being provided by the GP practices against the Local GP Service Specification. 4.1.2 The next steps being put in place as part of the ongoing monitoring process of the Local GP Service Specification.

5. Access to further information 5.1 For further information relating to this report contact:

Page 5 of 6

Name Dean Grice Neil Evans Designation Primary Care Commissioning Executive Director of Planning & Delivery Manager Telephone 01625 661601 01625 663469 Email [email protected] [email protected]

Page 6 of 6 NHS Eastern Cheshire Clinical Commissioning Group - 2018 Caring Together GP Service Specification APPENDIX 1 NHS Eastern Cheshire Clinical Commissioning Group - 2019-20 Local GP Service Specification - GP Practice Pre-Visit Submission

GP Practice:

Please enter a true and accurate response to the monitoring measures listed below.

Item Monitoring Measure Monitoring Measure Options Supporting Monitoring Notes Expected Response Supportive Information (please also refer to service descriptor documents) Response 1.1 Patients can use online tools to contact the practice using NHSmail email address Yes / No appropriate tools and protocols, e.g. arrange an appointment, e-Consult Yes / No discuss with a doctor or reply. Patient Online Services, e.g. EMIS Access Yes / No GP practice website feedback functionality Yes / No Other, please specify Yes / No 1.2 Patients can access pre-bookable appointments? Yes / No Average number of pre-bookable appointments per week / 1000 patients? In order to look at variation between GP practices. Value Pre-bookable appointments available how many weeks in advance? Value 1.4 Out of Hours service able to book for urgent appointments, follow up appointments, or early morning telephone call appointments via Yes / No EMIS cross organisational appointment booking? Number of OOH bookable appointments made available daily? GP practices will offer at least 1 appointment per 5000 Value registered population in their morning clinics. 1.5 Practice website contains up to date links to / information on self-care options? Yes / No 1.6 Practices offers telephone appointments? Yes / No Time (in hours) that a patient will be called back for telephone appointments deemed urgent? Value Average number of telephone appointments per week / 1000 patients? In order to look at variation between GP practices. Value 1.9 Practices confirms that CCG endorsed patient forms are completed and returned in a timely manner? Yes / No 2b.1 Practice confirms that good management procedures are in place for the prescribing of warfarin? Yes / No 2b.1 Practice confirms that they have a stock of vitamin K in practice? Yes / No 2b.2 What Read Code(s) do you use to code that a patient has been seen for a Heart Failure (annual) review in Primary Care? Please add code(s) in supportive information box. Codes What Read Code(s) do you use to code that a patient has been seen for a Heart Failure (annual) review in Secondary Care? Please add code(s) in supportive information box. Codes 2b.8 What Read Code(s) do you use to code a medication review done for your IBD patients? Please add code(s) in supportive information box. Codes Number of IBD patients under the care of Secondary Care? Value Number of self-managing / stable IBD patients not actively seen by the GP practice in the last 12 months? Value Number of IBD patients actively managed by the GP practice who have been seen for annual review in the last 12 months? Value 2b.14 Near Patient Testing - GP practices to self-certify that an auditable annual review of the service has been undertaken. Provide copy of service annual review. Yes / No Near Patient Testing - GP practices to self-certify that shared care arrangements in place for specified conditions in line with local Yes / No protocols. 2b.15 Mental health “bridging” and management service - self-certification that key interventions and standards are being followed/applied. Review of patients referred to mental health consultant but not Yes / No yet seen. Have patients been adequately managed by GP practice during interim? Suggestion of randomly selecting a small number of relevant patient notes for review.

2b.16 Referral refinement service - GP practices self-certifies compliance with local protocols for the NHS Eastern Cheshire CCG Referral Yes / No Assistance Service. 2b.18 Number of patients on the GP practices palliative care register? Expected to be approximately 1% of the GP practice Value population. Number of palliative care meetings held/scheduled for the calendar year? Provide evidence of dates and meeting attendance sheets. Value

GP practice self-certifies that EPaCCS template is updated as part of palliative care meetings. Yes / No Number of palliative care patients with an EPaCCS template completed for preferred place of death. Aim for 60%+ Value Number of palliative care patients with an EPaCCS template completed for CPR status. Aim for 60%+ Value Percentage of deceased palliative care patients in the last 12 months coded with an actual place of death read code. % Value 2b.19 GP practice self-certifies that they are undertaking ongoing proactive case management of the top 5% of patients at risk of unplanned This would normally be within 3 working days of discharge Yes / No hospital admission and targeted management of patients post discharge following admission with complex needs. notification being received, excluding weekends and bank holidays). GP practice self-certifies that they are undertaking risk stratification using relevant data sources. e.g. Aristotle Report. Yes / No GP practice self-certifies that they include a Named Usual GP on care plans. Yes / No GP practice self-certifies that they have a Proactive Care Administrator in place. Provide details of how role is provided, including weekly hours Yes / No dedicated to this role. GP practice self-certifies that they are providing an enhanced frailty management service as per service indicator. Yes / No 2c.1 Ring pessary fitting and change - GP practice to self-certify that the key interventions and standards identified within the service Consider clinical audit as optional additional evidence. Yes / No descriptor have been undertaken. 2c.3 Routine dressings, complex dressings, lower limb dressings, post operative dressings /stitch + clip removal - GP practice to self-certify that Consider clinical audit as optional additional evidence. Yes / No the key interventions and standards identified within the service descriptor have been undertaken. 2c.5 Hormone / other injections - GP practice to self-certify that the key interventions and standards identified within the service descriptor Consider clinical audit as optional additional evidence. Yes / No have been undertaken.

Page 1 of 2 NHS Eastern Cheshire Clinical Commissioning Group - 2018 Caring Together GP Service Specification 3b.2 Clinical Liaison with Secondary Care - GP practice to self-certify that the key interventions and standards identified within the service Yes / No descriptor have been undertaken. 3b.3 GP practices to have in place, by 1 October each year, a Practice Winter Plan. Using an agreed standard Eastern Cheshire template. Provide Yes / No copy of completed GP Practice Winter Plan. 3c.1 PPG/patient engagement and education - GP practice to self-certify compliance with indicator requirements. Provide details of PPG meeting arrangements and frequency. Yes / No

3c.2 Participation in GP, Practice Nurse and Practice Manager Development programmes - GP practice to self-certify compliance with indicator Yes / No requirements. 3c.3 MDT meetings - leadership and participation - GP practice to self-certify compliance with indicator requirements. Provide details of MDT meeting arrangements and frequency. Yes / No

3c.4 Carer advocacy/support/care - GP practice to self-certify compliance with indicator requirements. Yes / No 3c.6 Clinical supervision and support for staff employed by the practice / Clinical advice to staff not employed by practices - GP practice to self- E.g. are Practice Nurses receiving clinical supervision as per the Yes / No certify compliance with indicator requirements. GPN 10 point plans? 3c.7 Safeguarding leadership - GP practice to self-certify compliance with indicator requirements. Yes / No 3c.8 Commissioning participation - GP practice to self-certify compliance with indicator requirements. Yes / No

Page 2 of 2 APPENDIX 2 - NHS Eastern Cheshire CCG - Local GP Service Specification - GP Practice Monitoring RAG Rating Key: Green CCG Assured 02/07/2019 Amber CCG Partly Assured, Action with GP Practice Red CCG Not Assured, Action with GP Practice 0 CCG monitoring process pending Indicator Description Practice 1 Practice 2 Practice 3 Practice 4 Practice 5 Practice 6 Practice 7 Practice 8 Practice 9 Practice 10 Practice 11 Practice 12 Practice 13 Practice 14 Practice 15 Practice 16 Practice 17 Practice 18 Practice 19 Practice 20 Practice 21 Practice 22 1.1 Patients can use online tools to contact the practice using appropriate tools and protocols, e.g. arrange an appointment, discuss with a doctor or reply. Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green

1.2 Patients can access pre-bookable appointments. Practices to continue to provide a number of pre-bookable appointments per week. Practices to provide pre-bookable appointments between 2 and 4 weeks (this can be extended beyond 4 weeks in advance, if the practice chooses) so that Green Green Green Green Green Amber Green Green Green Green Green Green Green Green Amber Green Green Green Green Green Green Green patients are able to book for follow up appointments as instructed by their clinician (GP, Nurse Practitioner, Practice Nurse).

1.4 The Out of Hours/Primary Care Streaming Service will be able to arrange appointments for patients at their GP practice through cross organisational booking (using EMIS when technically available). The practice will make arrangements with the Out of Hours service for them to be able to book for urgent appointments, follow up appoinments, or early morning telephone call appointments. The practice will have protocols in place for booking and monitoring of this service, and develop clinical criteria for referral into a practice. Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Practices will offer at least 1 appointment per 5000 registered population in their morning clinics. OOH must have seen the patient and undertaken a clinical assessment before arranging/booking an appointment for review/follow up with the patient's practice.

1.5 Practices will, through their website, have a range of self-care options available to patients with long term conditions through utilisation of NHS Choices ‘Your health, your way’ NHS guide to long term conditions and self-care and will regularly monitor content to ensure it is up to date and relevant. Green Green Green Green Green Green Green Green Green Green Amber Green Green Green Green Green Green Green Green Green Green Green

1.6 Practices will continue to offer telephone appointments. Following triage, the practice will ensure that a clinician will call a patient within 2 hours if deemed urgent (in line with NWAS pathfinder standard). Green Green Green Amber Green Amber Green Green Green Green Green Green Green Green Amber Green Green Green Green Green Green Green

1.9 Practices will, in a timely manner, complete and return CCG endorsed patient forms, including but not limited to Learning Disability, Mortality Reviews, C.Diff Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Root Cause Analysis reports, Fostering medical reports. 2a.1 1. Obesity management Pro-active case finding (in line with NICE QOF Indicators) for patients who fulfil the criteria in the service descriptor and compliance with NICE Guidance (CG189) Amber Amber Amber Amber Amber Green Green Amber Amber Green Amber Green Green Amber Green Green Green Green Amber Amber Green Amber including making referrals to relevant optimisation or dietetics services as appropriate. 2a.2 To identify patients at risk of developing diabetes: 2. Pre-diabetes service to include:- -Identification; -Counselling; -Support and management through health life style advice; Amber Amber Amber Amber Green Amber Amber Green Green Green Green Amber Green Green Amber Amber Amber Green Green Amber Green Amber -Referral into Cheshire and Merseyside Diabetes Prevention Programme; -Annual Review; -Monitor Cardiovascular Risks.

2b.1 To continue with Level 1 National Enhanced Service and in addition: 1. Anti-Coagulation Monitoring Service: a. Identification and management of AF using appropriate protocols for:- i. Counselling/education of patients. ii. Investigation of cause, discussion about warfarin/ACC referral or NOAC, rate control, appropriate referral based on protocol to the INR clinic. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 iii. Ongoing management. iv. Receive and manage onward referrals from other agencies undertaking case finding activities e.g. Cheshire Fire and Rescue.

2b.2 2. Heart Failure Service: a. Identification and management of HF, including counselling/education, investigation of cause, initiation of medication, appropriate referral based on protocol. Amber Amber Amber Amber Amber Amber Green Green Green Green Amber Amber Green Green Amber Green Green Green Amber Amber Green Green b. Referral into cardiac rehabilitation. 2b.3 To continue with existing locally commissioned service for Initiation of Insulin and in addition: 3. Diabetes service: Identification and management of patients with Diabetes a. Counselling/education. b. Investigation of cause and risk factors. c. Initiation of advanced oral medication (based on formulary). Green Green Green Green Green Green Green Green Green Green Amber Green Green Green Green Green Green Green Amber Amber Green Green d. Appropriate referral based on protocol, BM monitoring where appropriate, regular support and the use of assistive technology. e. Referral and coding of patients to structured education programme (including coding of those who accept/decline). f. Record read code within notification letters confirming patient has completed a structured education programme.

2b.4 4. COPD/Asthma service: Identification and management of patients with Asthma and COPD in adults and children (asthma) a. Including counselling/education, investigation of causes/triggers. b. Education and Self-care (individualised care plan). c. Initiation of inhalers and medication, nebuliser loan and education. d. BTS step protocol, exacerbation management, inhaler technique. Green Green Amber Amber Green Amber Green Green Amber Amber Amber Amber Green Green Green Amber Green Amber Amber Amber Green Amber e. Appropriate referral based on protocol, steroid counselling. f. Personal care plan that includes contingency/crisis plan for exacerbation of systems and cold weather plan including rescue packs of meds where appropriate and cold weather texting – especially those in the top 5% cohort.

2b.5 5. Urology service: Identification and management of BPH, ED, urge, mixed and stress incontinence, bladder instability and other common urological presentations. Include: a. Appropriate investigation (USS, PSA, etc.). b .Initiation and titration of medication. Green Green Green Green Amber Green Green Green Green Green Amber Amber Green Amber Amber Green Green Amber Amber Green Red Green c .Appropriate referral based on local protocol. d. Prostate cancer management: Post diagnosis and treatment support and management for stable patients, including PSA monitoring and Zoladex/Prostap injections and support.

2b.6 6. Gynaecology service: a. Identification and management of common gynaecological conditions including dysmenorrhea, menorrhagia, IMB, PCB, infertility, endometriosis and menopause. Green Green Green Amber Amber Green Green Green Green Green Amber Amber Green Green Green Green Green Amber Green Green Amber Green b. Appropriate investigation (e.g. USS, swabs, bloods. semen analysis, etc.) according to local protocol. c. Counselling and medication initiation, including Prostap injections. 2b.7 7. Dermatology Service (Community Based Skin Clinic): identification and management of common chronic skin conditions including eczema and psoriasis. Appropriate referral following agreed protocol for management. Prescription of ‘specials’ remains the responsibility of secondary care. Green Green Amber Amber Amber Green Green Green Green Green Green Amber Green Amber Green Green Green Green Green Amber Green Green

2b.8 8.IBD Management: Identification, referral/work up and management of IBD, including exacerbations, according to local protocol Crohns disease support investigation, diagnosis awareness and investigation before appropriate referral. Green Amber Amber Amber Amber Amber Green Green Green Green Amber Amber Green Amber Amber Amber Green Green Amber Amber Green Green 2b.9 9.Coeliac disease management- investigation, diagnosis, appropriate referral and support. Green Green Amber Amber Amber Amber Amber Green Green Green Amber Amber Green Green Red Amber Green Green Amber Amber Green Green 2b.10 10. MS support – as defined in the CCG's original enhanced service specification to include investigation, diagnosis, appropriate referral and support. Amber Green Amber Amber Amber Amber Amber Green Amber Amber Red Red Amber Amber Red Amber Red Amber Amber Amber Amber Green

2b.11 11. Parkinson Disease- support for diagnosis, investigation, appropriate referral onwards. Amber Green Amber Amber Green Amber Green Green Green Green Amber Green Green Green Red Amber Green Amber Green Red Green Green 2b.12 12. Functional condition management. Following exclusion of pathological disease (via possible referral/investigation), the ongoing support, counselling, education and management of conditions including: - Fibromyalgia. Amber Green Red Red Red Amber Amber Green Amber Green Red Red Green Green Red Red Green Green Red Red Green Green - Chronic fatigue/post viral fatigue/ME. - IBS.

2b.13 13.Pain management: The identification, investigation and management of common pain conditions such as sciatica, osteoarthritis, spondylosis, neuralgia, migraine, post herpetic pain, and other appropriate conditions. Clear adherence to investigation, treatment and referral protocols / formularies. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2b.14 To continue with National Enhanced Service for Near Patient Testing: 14. To provide a service within the primary care setting for the class of drugs known as DMARD. This will include initiation and maintenance, following secondary care assessment and advice, including education. Practices will be expected to initiate and monitor under agreed guidance/protocols approved by the Area Prescribing Committee for:- Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Amber Green Green Rheumatology. Dermatology. Bowel conditions. (Except where clinically the patient is required to be in secondary care). 2b.15 15. Mental health “bridging” and management service – the ongoing diagnosis, counselling, support, medication and advocacy for people awaiting or receiving mental health support or those discharged from the service. Practices will support patients with mental health care needs: ADHD – supporting, prescribing. GP/IAPT – support before and during treatment. Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green LD/PD/ASD/CAMHS/Dementia/ – provide support and ongoing management.

Clinicians will refer patients into specialist mental health services where they assess this is appropriate for the individual patient.

2b.16 Referral refinement service. -Onward referral management will include the support of the wider health care team to improve patient experience and reduce the number of unnecessary referral steps and inappropriate secondary care referrals. -From April 2018 Practices will follow the CCG wide referral assistance service when making a referral and will act upon feedback from clinical triagers to optimise management of the patient. Green Green Green Green Green Green Green Green Green Green Amber Green Green Green Amber Green Green Amber Green Amber Green Green -Patients will be optimised before referral when clinically appropriate. -Practices will utilise data to review referral patterns and identify/address areas where referral levels vary significantly from peers. -Practices will provide feedback where Secondary Care clinicians request the GP, or initiate, a "Consultant to Consultant" referral assessed as inappropriate.

2b.17 17. Ambulatory care management. General practice will make maximum use of the ambulatory care facility at Macclesfield General Hospital for the following conditions: Chest pain, Gastroenteritis, First seizure, TIA, PE, DVT, Headache, UTICAP, DSH, Simple Jaundice, AKI, Syncope, AF ,Low risk fractured pubic rami. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Practices will be part of the ambulatory care project. Practices will work to locally agreed protocols. Practices are aware of how to refer to ambulatory care and existing pathways. 2b.18 18.EOL – enhanced level of support Practices will demonstrate appropriate care co-ordination for patients at the end of life. To include: Medication including sub cut fluids where appropriate. Participation in Palliative Care meetings, to a minimum level of six meetings per annum. Amber Amber Amber Amber Amber Amber Green Amber Amber Amber Amber Amber Amber Amber Red Amber Amber Amber Amber Amber Amber Amber Practices to have processes in place to ensure all relevant parties are notified appropriately when a patient is approaching end of life. Patients identify their preferred place of care which is recorded in their care plan. Practices can access EPaCCS on the end of life care partnership website.

2b.19 Coordinating complex community care - Maintain/improve performance activity for Accident and Emergency attendances and unplanned hospital admissions. - Ongoing proactive case management of the top 5% of patients at risk of unplanned hospital admission and targeted management of patients post discharge following admission with complex needs (this would normally be within 3 working days of discharge notification being received, excluding weekends and bank holidays). - Risk stratification using relevant data sources e.g. Aristotle Report. - Named Usual GP on Care Plan. - Proactive Care Administrators to coordinate this process and determine the most appropriate multi-disciplinary team member to support the individual. - Home visits by a clinician as required. - Medication compliance review. Amber Amber Amber Amber Green Green Amber Green Green Green Red Amber Green Green Amber Amber Amber Green Green Amber Amber Green - Where a patient has been identified with severe frailty through the processes included in the national contract requirements for management of frailty. The service requirement is for enhanced frailty management over and above the core requirements of the national contract, i.e. for patients identified as being aged 65 and over and living with severe frailty, where appropriate: - Inclusion on GP practice’s top 5% high risk / proactive care list; - Document and implement care plan; - DNAR discussion and recording; - Anticholinergic Cognitive Burden Scoring; - Anxiety and depression screening.

2c.1 Your GP Practice will provide (at or by arrangement with another provider) 1. Ring pessary fitting and change. Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Amber

2c.3 Your GP Practice will provide a dressing service for your non housebound patients to include (at or by arrangement with another provider): Routine dressings, complex dressings, lower limb dressings, post operative dressings /stitch + clip removal Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green (excluding vacuum dressings, compression and larvae therapy). Patient care will be supported by TVN as clinically appropriate. 2c.5 Your GP Practice will provide (at or by arrangement with another provider) Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green - Hormone / other injections. 2d.1 1. Ambulatory BP monitoring. Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green

2d.2 2. ECG reading and interpreting. Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green 2d.5 5. Vascular dopplers service (no ulcer) triage referral refinement. Arrangements may need to be made to access a doppler machine as required. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3b.2 Clinical Liaison with Secondary Care. Practices to: Facilitate preoperative investigations using existing protocols and optimising patients both before referral and in advance of proposed surgery by: -Supporting their patients pre/post OPA. Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green -Cooperating with secondary care clinicians.

3b.3 GP practices to have in place, by 1 October each year, a Practice Winter Plan (using an agreed standard Eastern Cheshire template), covering: -capacity/processes put in place to accommodate expected increased/surges in patient demand and to ensure patients do not inappropriately engage with A&E. Green Green Green Green Green Green Green Green Green Green Green green Green Green Green Green Green green Green Green Green Green

3c.1 1. PPG/patient engagement and education – to a greater level, coordinating our PPGs to network with Healthvoice, and play a more pro-active part in the design and review of services. Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green 3c.2 2. Participation in GP, Practice Nurse and Practice Manager Development programmes (AQuA etc). Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green 3c.3 3. MDT meetings - leadership and participation – recognising the leadership role the GP plays, and will play – in the support for community based teams and professionals including nurses, matrons, AHPs, SWs and other health care professionals. Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green

3c.4 4. Carer advocacy/support/care – including carers health checks, carer support and signposting, carer identification. Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green 3c.6 6. Clinical supervision and support for: a. Staff employed by the practice. Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green b. Clinical advice to staff not employed by practices.

3c.7 7. Safeguarding leadership – attendance at safeguarding meetings. Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green 3c.8 8. Commissioning participation – locality/peer group attendance and participation in relevant audits, data collection etc to help commissioner role. Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Green Red Green Green Primary Care Committee Paper 10/07/2019 Item 4.4

Paper Title Post CQC-Inspection Engagement Report

Purpose of paper / report To provide the Committee with an update on two recent CQC Inspections that resulted in a CQC rating of requires Improvement. Outcome Approve Ratify Decide Endorse For information  Required:

Summary All 24 Eastern Cheshire GP practices have been inspected by CQC over the last five years. One Eastern Cheshire GP practice is rated Outstanding, 20 are rated Good and two (Meadowside Medical Centre and Toft Road Surgery) have recently been rated Requires Improvements. The CCG Primary Care Team has engaged with these two GP practice and reviewed progress against the CQC areas of concern.

Both GP practices have provided assurances against the points of concern noted from the CQC Inspection reports.

1.1 A followup review date has been agreed for one of the two GP practices, to assess assurances following completion of an external Health & Safety risk assessment being arranged by the practice. 1.2 1.3 No further action is required by the CCG beyond the ongoing routine monitoring undertaken across all Eastern Cheshire GP practices. 1.4 1.5 CQC will undertake follow-up inspections to reassess the two practices (inspection date to be agreed between GP practices and CQC).

Recommendation(s) The Primary Care Committee is asked to note for information: - the actions taken by the CCG following notification of Required Improvement CQC ratings for two Eastern Cheshire GP practices

Benefits / value to our population / communities Continued provision of safe, effective, caring, responsive and well-led GP practices within Eastern Cheshire.

Key Implications of this report – please indicate  Strategic Consultation & Engagement Financial Equality Quality & Patient Experience  Legal / Regulatory  Staff / Workforce Safeguarding 

Governing Body Assurance Framework Risk Mitigation: Not Applicable

Report Authors Dean Grice Primary Care Commissioning Manager Date of report 03/07/2019

Page 2 of 4

Post-CQC Inspection Engagement Report July 2019

2. Background

1.1 All 24 Eastern Cheshire GP practices have been inspected by CQC over the last five years. One Eastern Cheshire GP practice is rated Outstanding, 20 are rated Good and two are rated Requires Improvements.

1.2 Meadowside Medical Centre was inspected by the CQC on the 09/01/2019, with a published rating of Requires Improvement on the 27/02/2019 (www.cqc.org.uk/location/1- 559443479).

1.3 Toft Road Surgery was inspected by the CQC on the 07/03/19, with a published rating of Requires Improvement on the 01/05/2019 (www.cqc.org.uk/location/1-583365286).

1.4 The CCG Primary Care Team has engaged with the two GP practice and reviewed progress against the CQC areas of concern.

3. Review Findings

3.1 For Meadowside Medical Practice, 31 points were noted from the CQC Inspection report. On review with the GP practice (see Appendix 1), the CCG was assured that all 31 points have been adequately addressed by the practice. Review undertaken by Dean Grice (CCG Primary Care Commissioning Manager) and Katie Mills (CCG Primary Care Quality Manager).

3.2 For Toft Road Surgery, 27 points were noted from the CQC Inspection report. On review with the GP practice (see Appendix 2), the CCG was assured that 23 of the 27 points have been adequately addressed by the practice, with four of the points, flagged as partly assured pending completion of an external Health & Safety risk assessment being arranged by the practice (a CCG follow up review date has been noted for September 2019). Review undertaken by Dean Grice (CCG Primary Care Commissioning Manager) and Juliet Thomson (CCG Primary Care Support Manager).

4. Next Steps

4.1 No further action to be taken by the CCG with regards to Meadowside Medical Practice beyond the routine monitoring undertaken across all Eastern Cheshire GP

Page 3 of 4

practices. CQC will undertake a follow-up inspection to reassess the practice (inspection date to be agreed between GP practice and CQC).

4.2 A follow up review will take place between the CCG and Toft Road Surgery in September 2019 to assess progress against the four points which were flagged as partly assured. CQC will undertake a follow-up inspection to reassess the practice (inspection date to be agreed between GP practice and CQC).

5. Requirements of the Primary Care Committee

5.1 The Primary Care Committee is asked to note for information:

5.1.1 The actions taken by the CCG following notification of Required Improvement CQC ratings for two Eastern Cheshire GP practices.

6. Access to further information 6.1 For further information relating to this report contact:

Name Dean Grice Designation Primary Care Commissioning Manager Telephone 01625 661601 Email [email protected]

Page 4 of 4 Meadowside Medical Centre - CQC Inspection Jan 2019 - GP Contract Breaches

CQC Domain Sub Domain CQC Area of Concern Reviewed with Evidence Seen? Adequate Assurances Follow Up CCG Provided to CCG? Date Safe Safeguarding One GP had not undertaken level 3 safeguarding training. The practice was 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A not aware that clinicians who treated children needed to have undertaken level 3 safeguarding training. Safe Safeguarding Staff had not received Mental Capacity Act 2005 training to support and 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A protect patients’ rights as citizens. Safe Safeguarding The safeguarding policy did not include information and guidance with regard 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A to female genital mutilation (FGM), modern slavery and child sexual exploitation. Safe Safeguarding Meetings with health visitors were not minuted to effectively signpost 13/05/2019 Available for review by Primary Care Committee on request. Assured that all Practice N/A clinicians to relevant patient records. meetings will now be minuted. Safe Health and safety The practice had an external company carry out a fire risk assessment and 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A management plan in 2008 this identified actions that needed to be actioned. There was no evidence of action plans in place to address these issues. The practice carried out an annual risk assessment however the designated person to carry out the fire risk assessment did not have the appropriate training to carry out the assessment.

Safe Health and safety The practice had not carried out a premises/ security risk assessment. 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A

Safe Health and safety Health and safety risk assessments were in place however the person 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A designated to carry out the assessments had not received appropriate training to their role and responsibilities.

Safe Health and safety We noted that the blood monitoring machines had not been calibrated. 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A

10/06/2019

Safe Infection prevention and The infection prevention and control policy and procedure was limited and did 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A control not include information and guidance on the following issues: - The programme for cleaning medical equipment and the designated person responsible for this work. - Anti-microbial arrangements such as alcohol gel and where these would be placed and the arrangements for ensuring appropriate stock was available in all areas of the practice were not included. 10/06/2019

Safe Infection prevention and There were no cleaning schedules in place. 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A control 10/06/2019

Safe Infection prevention and We discussed with the practice the need to review the training/specialist 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A control support provided to the member of staff who was the designated infection prevention control lead. This was to ensure that they had the necessary skills and competencies to carry out this role effectively and safely. 10/06/2019

Safe Risks to patients We discussed with the practice that a quick reference guide for receptionists 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A with regard to actions to be taken if they encountered a deteriorating or acutely unwell patient should be placed in the reception area for ease of access. The practice told us they had this type of guide in clinical rooms and would place one in the reception area.

Safe Medicines Management Six Patient Specific Directives (PSD) were examined we found they had not 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A been appropriately authorised. There was no recorded information to show that GPs had reviewed patient records to determine it was safe and appropriate for them to receive these medicines such as B12 injections and flu 10/06/2019 vaccinations from healthcare assistants and assistant practitioners.

Safe Medicines Management The practice was unable to provide documentary evidence as to how they had 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A assessed the competency of the healthcare assistants and assistant practitioners to administer medicines.

Safe Medicines Management There was a medicines policy in place however this document needed to be 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A reviewed to include guidance and information with regard to the use of PGDs and PSDs. Safe Medicines Management There was no system in place to ensure blank prescriptions held in printers 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A were logged and secured when the practice was closed. Safe Medicines Management The current system used to monitor vaccine/medicine fridge temperatures 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A was not effective. The practice monitored and recorded the actual daily temperatures of the fridges. However, there was no minimum or maximum temperature recorded to enable staff to know when action was needed to reset the fridges to ensure vaccines and immunisations were stored at the correct temperature.

Safe Medicines Management The rooms/areas where two of the vaccine/medicine fridges were stored were 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A not locked and the fridges were unlocked. This resulted in vaccines not being securely stored and monitored. 10/06/2019 Safe Medicines Management We noted that a patient’s medicine was being stored in one of the 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A vaccine/medicine fridges this medicine had not been recorded as a medicine being stored by the practice. The practice told us this issue would be addressed. Safe Significant Events We noted that the practice did not take minutes of clinical and nursing 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A meetings. The practice did not have a standing agenda for meetings to ensure issues such as significant event, complaints, safeguarding and revised guidance were discussed. The practice told us these issues were discussed.

Safe Significant Events The practice did not have a policy and procedure in place to inform and guide 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A staff about how to report and document a significant event.

Page 1 of 2 Effective Families, children and The practice did not automatically offer children an appointment on the day if 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A young people they were unwell. The practice told us they were clear when a request for an emergency appointment was made for a child the information would be reviewed by a clinician and a decision made as to whether an appointment was required. We discussed with the practice the need to document the rationale for this approach and ensure all clinicians were aware of this.

Effective Consent to care and During discussions with staff we noted that not all clinical staff understood 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A treatment their role and responsibility with regard to assessing a person’s capacity to agree to treatment. There was a lack of understanding with regard to best interest decision making. Effective Consent to care and The consent policy did not include information on the Mental Capacity Act 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A treatment 2005. Effective Consent to care and The practice had not added alerts to patient records to provide information 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A treatment with regard to capacity and consent issues. Well-led Governance The governance systems in place required improvement for example, policy 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A arrangements and procedures were not being effectively reviewed.

Well-led Governance Staff training needs were not being identified. 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A arrangements Well-led Managing risks, issues The practice had limited systems in place to manage risks and performance. 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A and performance Meetings took place however all but the Gold Standard Framework meeting were not minuted. Well-led Managing risks, issues There was no evidence that audit programme was in place to support service 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A and performance improvement and mitigate risks. Well-led Continuous There was limited documentary evidence to show how the practice shared 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A improvement and learning from significant events and complaints. innovation Well-led Continuous There was limited evidence to show how the practice monitored the services 13/05/2019 Available for review by Primary Care Committee on request. Assured N/A improvement and provided to support improvement. innovation

Page 2 of 2 Toft Road Surgery - CQC Inspection Mar 2019 - CCG Review List

CQC Domain Sub Domain CQC Area of Concern Reviewed with Evidence Seen? Adequate Assurances Follow Up CCG Provided to CCG? Date Safe Safeguarding Not all clinicians who treated children had undertaken level 3 safeguarding 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A training. Safe Safeguarding The safeguarding children’s policy did not include information and guidance 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A about female genital mutilation (FGM), modern slavery and child sexual exploitation. Safe Safeguarding The practice did not have a robust safeguarding adults’ policy in place. 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A

Safe Safeguarding The practice systems to process and monitor safeguarding information being 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A received or requested was not effective. We reviewed five records and found on three occasions information held in paper form had not been scanned onto patients’ electronic records. This resulted in alerts being placed on patient records with limited information as to why the alert had been activated.

Safe Health and safety The practice had not undertaken detailed health and safety risk assessments 18/06/2019 Available for review by Primary Care Committee on request. Partly Assured - pending 18/09/2019 with regard to the building. For example, the building had a steap staircase to completion of H&S risk access the consultation rooms on the first floor. No formal risk assessment had assessment been carried out to ensure patient safety when accessing the first-floor consultation rooms. The practice told us that the reception staff asked elderly patients or people with mobility issues if they would prefer to be seen in a ground floor consultation room however this increased the waiting time as clinicians needed to change rooms.

Safe Health and safety The practice had not carried out a risk assessment about the ability of 18/06/2019 Available for review by Primary Care Committee on request. Partly Assured - pending 18/09/2019 wheelchair users to exit the building in an emergency. completion of H&S risk assessment

Safe Infection prevention and An annual audit of infection control was undertaken however there were no 18/06/2019 Available for review by Primary Care Committee on request. Partly Assured - pending 18/09/2019 control recorded checks to ensure infection control standards were being maintained internal meeting with in between these audits. A record was not made of spot checks of the cleaning PNs undertaken by the cleaners or of when equipment such as nebulisers were cleaned. Safe Infection prevention and The practice had not developed an action plan following the infection control 18/06/2019 Available for review by Primary Care Committee on request. Partly Assured - pending 18/09/2019 control audit. internal meeting with PNs Safe Infection prevention and There was a cleaning schedule for cleaning toys kept in consultation rooms. 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A control However, there was no schedule for cleaning carpets in consultation and communal areas of the practice. Safe Infection prevention and Sharps boxes were not anchored to a wall or fixed to furniture to mitigate the 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A control risk of them falling or being pulled. There was no needle stick injury procedure in clinical rooms. Safe Medicines Management There was a system for repeat prescribing however this needed to be 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A improved to ensure it was robust. We noted that for one patient a medicine had been authorised over twenty times with no audit trail to show this had been brought to the attention of a GP. We looked at a sample of monitoring of patients on high risk medications. Two patients were significantly overdue blood monitoring.

Safe Medicines Management We noted that administration staff were responsible for making changes to 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A medication from outpatient department letters that had been highlighted on electronic records by GPs. The staff made the changes to the record and printed off a prescription with the letter for the GP to sign and to check if the item was needed. However, there was no documented record in the patient record to show this check by the GP had taken place. We asked the practice for evidence of competency for the staff undertaking this extended role. This was not provided by the end of the inspection.

Safe Medicines Management We noted that the system to monitor uncollected prescription required 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A improvement to ensure vulnerable patients not collecting their medication regularly were referred to the GPs for review. Safe Significant Events We looked at a sample of significant events. Records did not demonstrate that 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A robust investigations had taken place and the learning and actions identified were reviewed to offer assurance that the learning and actions taken were imbedded. Safe Significant Events We noted that following a sudden death and subsequent investigation the 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A practice had not used audit as a tool to identify possible actions and learning and to mitigate future risk. Safe Significant Events There was no evidence provided to show that feedback from the telephone 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A triage course attended by one GP had been discussed at clinical meetings. There was no evidence that work had been undertaken to benchmark and standardise practice with regard to the triage/ telephone consultation system.

Safe Significant Events The provider had not informed CQC of two patient deaths that may have been 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A a result of the regulated activity or how it was provided. Effective People experiencing The practice clinical domains exception rates were higher than the national 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A poor mental health and local averages. The practice was aware of their higher exception reporting domains and were working to engage with those patients who were not engaging with the practice to manage their health.

Effective Effective staffing The practice could not demonstrate that appropriate training for 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A administration staff undertaking extended roles had been carried out.

Responsive Complaints We discussed with the practice the need to review where complaint forms 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A were stored to ensure patients had access to them without having to ask at the reception desk. Well-led Governance Staff had responsibility for different areas. For example, there was a lead 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A arrangements member of staff who monitored the quality indicators, lead for safeguarding, medicines management, carers and complaints. There was also a management team with responsibilities for different areas, however the issues we identified at this visit indicates that the oversight needs to be improved.

Well-led Governance We found improvements were needed to how significant events were 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A arrangements investigated, the information from investigations was recorded and learning and actions were shared and monitored. Well-led Governance We found improvements were needed with regard to medicines management 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A arrangements within the practice. Well-led Governance We found improvements were needed to with regard to the processes and 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A arrangements systems used to monitor and act on safeguarding concerns.

Well-led Governance We found improvements were needed regarding how information was 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A arrangements recorded following community MDT meetings to ensure patient records reflected the discussions that took place, even if the decision was to take no further action. Well-led Managing risks, issues Significant events needed to be more consistently managed to ensure that the 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A and performance actions and learning were documented, shared with all relevant staff and reviewed. Well-led Managing risks, issues Audits and quality monitoring activity took place, however, a structured 18/06/2019 Available for review by Primary Care Committee on request. Assured N/A and performance approach to this was not in place.

Page 1 of 1