Chair: Eleri de Gilbert Enquiries to: ncccg.notts - [email protected]

SHARED AGENDA For the Meetings in Common of:

NHS Mansfield and Ashfield CCG Primary Care Commissioning Committee NHS Newark and Sherwood CCG Primary Care Commissioning Committee NHS Nottingham City CCG Primary Care Commissioning Committee NHS Nottingham North and East CCG Primary Care Commissioning Committee NHS Nottingham West CCG Primary Care Commissioning Committee NHS Rushcliffe CCG Primary Care Commissioning Committee

Meeting Agenda (Open Session) Wednesday 19 June 2019 9:00 – 10:50 Committee Room, Loxley House, Station Street, NG2 3NG

Time Item M&A N&S NC NNE NW R Presenter Action Reference 9:00 Introductory Items 1. Welcome,       Chair Note PCC19/001 Introductions and apologies 2. Confirmation of       Chair Note PCC19/002 quoracy 3. Declarations of       Chair Review/ PCC19/003 interest for any Note item on the agenda 4. Management of       Chair Note PCC19/004 any real or perceived conflicts of interest 5. Questions from the       Chair Receive PCC19/005 Public Protocol 6. Action log and       Chair Comment PCC19/006 matters arising from the meetings in common 9:10 Committee Business 7. Delegation       Lucy Branson Information/ PCC19/007 Agreement – Discussion Delivery and Oversight Arrangements 9:25 Decision Making

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Time Item M&A N&S NC NNE NW R Presenter Action Reference 8. Leen View  Fiona Warren Approve PCC19/008 Boundary Reduction 9. Parkside Boundary  Fiona Warren Approve PCC19/009 Expansion 10:00 For Assurance/Discussion 10. Finance Report at       Stuart Poynor Review PCC19/010 month two 11. Strelley Health  Esther Gaskill Assurance PCC19/011 Centre (verbal) 12. Draft Integrated       Sharon Pickett Review/ PCC19/012 Care System Comment Primary Care Five Year Strategy 10:30 Risk Management 13. Risk Report       Siân Assurance/ PCC19/013 Gascoigne Information 10:40 For Information The following items are for information and will not be individually presented. Questions will be taken by exception. 14. Primary Care       - Information PCC19/014 Network Update 15. 360 Assurance       - Information PCC19/015 Reports: Primary Medical Care Commissioning and Contracting – Primary Care Finance 16. Minutes from - Receive PCC19/016 previous meetings in common held on: 23 May 2019   10:45 Closing Items 17. Any other business       Chair Note PCC19/017 18. Key messages to       Chair Identify PCC19/018 escalate to the Governing Body 19. Date of next       Chair Note PCC19/019 meetings: 18/06/2019 Rooms 2 - 3, Birch House, Ransom Wood Business Park, Southwell Road West, Mansfield, NG21 0HJ

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Time Item M&A N&S NC NNE NW R Presenter Action Reference Confidential Motion: The Governing Body will resolve that representatives of the press and other members of the public be excluded from the remainder of this meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest (Section 1[2] Public Bodies [Admission to Meetings] Act 1960)

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Managing Conflicts of Interest at Meetings

1. A “conflict of interest” is defined as a “set of circumstances by which a reasonable person would consider that an individual’s ability to apply judgement or act, in the context of delivering commissioning, or assuring taxpayer funded health and care services is, or could be, impaired or influenced by another interest they hold”.

2. An individual does not need to exploit their position or obtain an actual benefit, financial or otherwise, for a conflict of interest to occur. In fact, a perception of wrongdoing, impaired judgement, or undue influence can be as detrimental as any of them actually occurring. It is important to manage these perceived conflicts in order to maintain public trust.

3. Conflicts of interest include:  Financial interests: where an individual may get direct financial benefits from the consequences of a commissioning decision.  Non-financial professional interests: where an individual may obtain a non-financial professional benefit from the consequences of a commissioning decision, such as increasing their reputation or status or promoting their professional career.  Non-financial personal interests: where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit.  Indirect interests: where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision. The above categories are not exhaustive and each situation must be considered on a case by case basis.

4. In advance of any meeting of the Committee, consideration will be given as to whether conflicts of interest are likely to arise in relation to any agenda item and how they should be managed. This may include steps to be taken prior to the meeting, such as ensuring that supporting papers for a particular agenda item are not sent to conflicted individuals.

5. At the beginning of each formal meeting, Committee members and co-opted advisors will be required to declare any interests that relate specifically to a particular issue under consideration. If the existence of an interest becomes apparent during a meeting, then this must be declared at the point at which it arises. Any such declaration will be formally recorded in the minutes for the meeting.

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6. The Chair of the Committee (or Deputy Chair in their absence, or where the Chair of the Committee is conflicted) will determine how declared interests should be managed, which is likely to involve one the following actions:  Requiring the individual to withdraw from the meeting for that part of the discussion if the conflict could be seen as detrimental to the Committee’s decision-making arrangements.  Allowing the individual to participate in the discussion, but not the decision-making process.  Allowing full participation in discussion and the decision-making process, as the potential conflict is not perceived to be material or detrimental to the Committee’s decision-making arrangements.

Nottingham and Nottinghamshire CCGs’ Primary Care Commissioning Committees’ Meetings in public - Guidance for members of the public

1. Introduction The Nottingham and Nottinghamshire Clinical Commissioning Groups (NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Mansfield and Ashfield CCG, NHS Newark and Sherwood CCG, NHS Rushcliffe CCG and NHS Nottingham West CCG - hereafter referred to as “the CCGs”) are committed to openness and transparency, and conduct as much of their business as possible in sessions that members of the public, and staff from any organisation, are welcome to attend and observe (subject to available space). As part of the CCGs’ Primary Care Delegation Agreements, we are also required to hold these meetings in public. As part of the alignment of arrangements across the CCGs, meetings of the CCGs’ Primary Care Commissioning Committees will be held ‘in common’. This will enable the Committees to discuss common agenda items, whilst retaining the specific accountabilities of each individual CCG. The meetings, although held in public, are not a public meeting and as such there is no opportunity provided for the public to ask questions in that arena other than that offered at the discretion of the Chair.

2. How do I find out about meetings? Meeting dates, times and the venue, which can be subject to change, are published on each of the CCG’s websites:  NHS Nottingham North and East CCG - http://www.nottinghamnortheastccg.nhs.uk/our- meetings/primary-care-commissioning-commitee/  NHS Rushcliffe CCG - https://www.rushcliffeccg.nhs.uk/your-ccg/primary-care- commissioning-committee/  NHS Nottingham West CCG - https://www.nottinghamwestccg.nhs.uk/about-us/primary- care-commissioning-committee/  NHS Nottingham City CCG - https://www.nottinghamcity.nhs.uk/your-ccg/governing- body/primary-care-commissioning-committee/  NHS Mansfield and Ashfield CCG - https://www.mansfieldandashfieldccg.nhs.uk/about- us/meetings/primary-care-commissioning-committee/  NHS Newark and Sherwood CCG - https://www.newarkandsherwoodccg.nhs.uk/about- us/meetings/primary-care-commissioning-committee/ The Agenda and supporting papers are available on website up to five days before the meeting.

3. Can members of the public ask questions during the meeting? To assist in the management of the agenda and meeting, individuals are encouraged to submit written questions to the Corporate Governance Team at ncccg.notts- [email protected] at least 48 hours before the meeting. This will greatly assist in responding to questions where possible at the meeting. The maximum amount of time for any one individual to raise a question or speak on a topic is five minutes. It is necessary to impose such a timeframe so as to ensure that those who wish to speak are given a fair opportunity to do so while also ensuring the meetings in common runs to time Where possible, a response will be given to questions at the meeting, however if the matter is complex or requires the consideration of further information, a written response to questions will be provided within 10 working days. If the number of questions raised exceeds the time allocated, questions will be taken on a first come, first served basis and any remaining questions subsequently addressed in writing We will not be able to discuss questions if

 They relate to individual patient care or the performance of individual staff members.

 The question does not relate to an item on the agenda.

 The question relates to issues which are the subject of current confidential discussions, legal action or any other matter not related to the roles and responsibilities of the CCGs The Chair reserves the right to move the meeting on if they judge that no further progress is likely to result from further discussion or questioning, or to ensure that the meetings in common can be conducted on time. Any questions submitted may be treated as a request under the Freedom of Information Act and treated accordingly

4. Attendance at meetings. If you have any particular needs with regards to access or assistance, such as wheelchair access or an induction loop please contact the Corporate Governance Team at ncccg.notts- [email protected] and we will do our best to assist you. Please be aware that you will need to sign-in at the venue reception upon arrival, for fire safety and security reasons. A member of staff will escort everyone to the meeting room. Unfortunately, if members of the public arrive after the meeting has already started it may not be possible for them to join the meeting. At the end of meeting, all members of the public will also be escorted back to the main entrance by a member of staff. Please note that the use of mobile phones or other electronic devices during the meeting will not be permitted if their use is deemed disruptive to the meeting. This is for the benefit of all present.

5. Identifying committee members The Chair will ask members to introduce themselves at the beginning of each meeting. A name plate for each member will also be displayed on the table to help you see who is speaking during the meeting.

6. Discussion at meetings The members will have been provided with copies of the agenda and papers at the same time as they are published on the CCGs’ websites and will therefore have had the opportunity to consider the papers prior to the meeting. The Primary Care Commissioning Committees will consider the items on the agenda in turn and each paper includes a summary cover sheet, which makes recommendations for the meeting to consider. For some items there may be a presentation, whereas for others this may not be necessary. The members may not actively discuss each item in detail; this does not mean that the item has not received careful consideration but means that the members have no further questions on the matter and do not wish to challenge the recommendation(s). A formal vote will not be taken if there is a general consensus on a suggested course of action.

7. Minutes A record of the issues discussed and decisions taken at the meeting will be set out in the minutes, which members will be asked to approve as a correct record at its next meeting. Please note that the minutes will not be a verbatim record of everything that was discussed at the meeting. The minutes are presented to the next meeting for approval and will be added to the CCG’s website once approved.

8. Public Order The Chair may at any time require the public or individual members of the public or media to leave the meeting or may adjourn the meeting to a private location if they consider that those present are disrupting the proper conduct of the meeting or the business of the Committees.

Primary Care Commissioning Committees in Common Consolidated OPEN ACTION LOG for the previous meeting(s) of the Primary Care Commissioning Committees

MEETING CCG AGENDA AGENDA ITEM ACTION LEAD DATE TO BE COMMENT DATE REFERENCE COMPLETED

ACTIONS OUTSTANDING

No actions outstanding

ACTIONS ONGOING / NOT YET DUE

No actions ongoing

ACTIONS COMPLETE

12/10/2018 Nottingham City PCCC Any Other Esther will attend in Esther 01/02/2019 Included on the February 2019 18/039 Business/Quality February to present the Gaskill confidential agenda. Update completed Primary Care Quality Dashboard.

12/12/2018 Nottingham City PCCC Any Other Helen Clark to arrange a Helen Clark 01/05/2019 The new cycle of Primary Care 18/051 Business new cycle of meetings. Commissioning Committee meetings in common is due to start on Wednesday 19 June 2019.

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MEETING CCG AGENDA AGENDA ITEM ACTION LEAD DATE TO BE COMMENT DATE REFERENCE COMPLETED

12/12/2018 Nottingham City PCCC Any Other Helen Clark to put a Helen Clark 01/02/2019 An update was provided as 18/051 Business Primary Care part of paper 19 009 Commissioning Joint Integrated Governance Arrangements update Arrangements which went to on the February the January 2019 Governing agenda. Body.

12/12/2018 Nottingham City PCCC Any Other Helen Clark to confirm Helen Clark 01/02/2019 The new terms of reference 18/051 Business Suma Harding’s are in place; they do not make membership as Sue reference to an associate lay Clague was in member role. Membership will attendance as a guest be reviewed as the member. establishment of the meeting's in common progresses.

21/02/2019 Rushcliffe PCCC 19 Terms of To seek clarification Helen Clark 15/03/2019 The terms of reference were 009 Reference from Lucy Branson, reconsidered by the Governing Corporate Director, in Body on 16 May 2019 and no relation to the following further changes were made. points: The inaugural Primary Care • Why there is an Commissioning Committee in imbalance between the common will receive the number of executives revised terms of reference for and non-executive consideration. members of the

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MEETING CCG AGENDA AGENDA ITEM ACTION LEAD DATE TO BE COMMENT DATE REFERENCE COMPLETED Committee; • Whether all members can send a deputy to the meeting as documented in section six of the terms of reference. • If the Committee will still have the option to meet separately within its locality – as suggested by the wording in section two. • Whether there should be a locality management representative present to better inform the discussion.

21/02/2019 Rushcliffe PCCC 19 Terms of To extend an invitation Helen Clark 15/03/2019 This action has been 009 Reference to Lucy Branson to superseded following the present to the revision of the governance Committee on future arrangements. The Greater Nottingham and Mid-

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MEETING CCG AGENDA AGENDA ITEM ACTION LEAD DATE TO BE COMMENT DATE REFERENCE COMPLETED arrangements. Nottinghamshire Primary Care Commissioning Committees will meet in common from Wednesday 19 June 2019.

14/05/2019 Mid- JPC/19/25 Review of risks To add consideration of Kerrie June 2019 This action has been Nottinghamshire a risk relating to poor Woods incorporated into quality primary care conversations regarding risks estate impacting on the associated with Primary Care CCGs’ aim to deliver Commissioning. Please see high quality care to the the Risk Report, agenda item forward plan of the PCC 19/013. This item is Primary Care Quality proposed for closing. Review Group.

23/05/2019 Mid- JPC/19/36 Quality Report To add to the forward Sue 01/06/2019 This item has been included Nottinghamshire work plan a report Wass/Helen on the Forward Work Plan regarding non-elective Brocklebank 2019/20. See the Delegation activity; support for -Clark Agreement – Delivery and Kirkby and engagement Oversight Arrangements with PCNs going paper, agenda item PCC forward. 19/007.

23/05/2019 Mid- JPC/19/38 Transformation To request further Andrea July 2019 Included on the forward work Nottinghamshire Report information from the ICS Brown programme. See the

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MEETING CCG AGENDA AGENDA ITEM ACTION LEAD DATE TO BE COMMENT DATE REFERENCE COMPLETED Workforce Workstream Delegation Agreement – regarding their GP Delivery and Oversight retention activity and Arrangements paper, agenda future plans for mid item PCC 19/007. Nottinghamshire and bring to the July 2019 meeting.

23/05/2019 Mid- JPC/19/38 Transformation To lead on the drafting Lynne Sharp August 2019 This statement will be Nottinghamshire Report of a statement on next incorporated within the steps for the Ollerton Primary Care Estates update feasibility study for the scheduled for August 2019. August 2019 meeting. This item is proposed for closing.

23/05/2019 Mid- JPC/19/39 General Practice To add final approval of Sharon 01/06/2019 Included on the forward work Nottinghamshire Forward View the GPFV funding Pickett programme. allocations to the Committee work plan for June 2019.

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Meeting in Common of NHS Mansfield and Ashfield CCG, NHS Newark and Sherwood CCG, NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG

Meeting Title: Open Primary Care Commissioning Date: 19 June 2019 Committee

Paper Title: Delegation agreement – Delivery and Paper Reference: PCC/19/007 Oversight Arrangements

Sponsor: Lucy Branson, Associate Director of Attachments/ Appendix A – TOR Presenter: Governance Appendices: Appendix B – Work Lucy Branson Programme Appendix C – Aligned Governance Framework Appendix D – Operational arrangements

Executive Summary The purpose of this report is to set out the aligned delivery and oversight arrangements that have been established for the six Nottingham and Nottinghamshire CCGs (“the CCGs”) in order to ensure that the CCGs are able to effectively discharge their delegated functions with regard to Primary Care Commissioning. The report also:  Aims to clarify the role of the Primary Care Commissioning Committees (which will now be meeting in common from June 2019) in relation to the remainder of the CCGs’ newly aligned governance structure; and  Presents an opening work programme for the Committees for 2019/20 for discussion.

Recommendation: ☐To endorse ☒To review ☒To receive/note for assurance and information ☐To approve the recommendations as set out below

Recommendation(s): 1. NOTE the Primary Care Commissioning Committees’ Terms of Reference and the legal requirements for operating ‘in common’. 2. REVIEW the Committees’ draft Annual Work Programme (Appendix B) and note that further work will be required to fully develop this during the Committees’ scheduled development discussion/session. 3. NOTE the Committees’ role within the CCGs’ aligned governance structure 4. CONSIDER and COMMENT on the initial work performed to map out the operational arrangements in place to ensure that the CCGs’ delegated functions (with regard to primary care commissioning) are effectively discharged

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5. NOTE the national policies in place to ensure compliance with the delegation agreement for primary care commissioning and that a local policy is being developed to ensure a robust and consistent approach to the approval of discretionary payments Relevant CCG priorities/objectives: (please tick which priorities/objectives your paper relates to) Compliance with Statutory Duties ☒ Establishment of a Strategic Commissioner ☐ System architecture development (e.g. ☐ Financial Management ☒ ICP, PCN development) Performance Management ☒ Cultural and/or Organisational Development ☐ Service Planning and/or Commissioning ☒ Procurement and/or Contracting ☒ Completion of Impact Assessments: Equality / Quality Impact Yes ☐ Has an EQIA been completed? If the answer is No, please Assessment (EQIA) No ☒ explain why N/A Data Protection Impact Yes ☐ Has a DPIA been completed? If the answer is No, please explain Assessment (DPIA) No ☐ why N/A Risk(s): N/A

Confidentiality:

Is the information in this paper confidential? ☒No

Conflicts of Interest: Please state whether there are any conflicts of interest considerations relevant to paper authors, members or attendees. ☒ No conflict identified ☐ Conflict noted, conflicted party can participate in discussion and decision ☐ Conflict noted, conflicted party can participate in discussion, but not decision ☐ Conflict noted, conflicted party can remain, but not participate in discussion or decision ☐ Conflicted party to be excluded from meeting

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Delegation Agreement – Delivery and Oversight Arrangements

1. Introduction The purpose of this report is to set out the aligned delivery and oversight arrangements that have been established for the six Nottingham and Nottinghamshire CCGs (“the CCGs”) in order to ensure that the CCGs are able to effectively discharge their delegated functions with regard to Primary Care Commissioning. The report also:  Aims to clarify the role of the Primary Care Commissioning Committees (which will now be meeting in common from June 2019) in relation to the remainder of the CCGs’ newly aligned governance structure; and  Presents an opening work programme for the Committees for 2019/20 for discussion.

2. Delegation Agreements 2.1 Delegated Functions As a reminder for the Committees, the following bullet points provide a summary of the functions that have been delegated by NHS England to the CCGs:  Decisions in relation to the commissioning, procurement and management of primary medical services contracts, including but not limited to the following activities: • Decisions in relation to enhanced services; • Decisions in relation to Local Incentive Schemes (including the design of such schemes); • Decisions in relation to the establishment of new GP practices (including branch surgeries) and closure of GP practices; • Decisions about ‘discretionary’ payments; and • Decisions about commissioning urgent care (including home visits as required) for out of area registered patients.  The approval of practice mergers.  Planning primary medical care services in the Areas, including carrying out needs assessments.  Undertaking reviews of primary medical care services in the Areas.  Decisions in relation to the management of poorly performing GP practices, including decisions and liaison with the CQC where the CQC has reported non-compliance with standards (but excluding any decisions in relation to the performers list).  Management of the delegated funds.  Premises Costs Directions Functions.  Co-ordinating a common approach to the commissioning of primary care services with other commissioners in the area where appropriate.

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 Such other ancillary activities that are necessary in order to exercise the delegated functions.

2.2 Delegated Limits The CCGs have certain limitations placed on them in relation to the delegated functions, which need to be kept in mind when decisions are being made. Essentially, any decisions that fall into three specific categories can only be taken following the receipt of prior approval from NHS England. These categories, along with the individuals that need to be involved in the decision-making process, are set out in the table below. As such, the Committees’ Terms of Reference set out that the Accountable Officer or Operational Director of Finance (on behalf of the Chief Finance Officer) must be in attendance for the meetings in common to be quorate.

Decision NHS England Approval CCG Approval Taking any step or action NHS England Head of Legal Accountable Officer or in relation to the Services Chief Finance Officer settlement of a claim, and where the value of the Local NHS England Team settlement exceeds Director or Director of Finance £100,000 Any matter in relation to Local NHS England Team Accountable Officer or the delegated functions Director or Director of Finance Chief Finance Officer which is novel, or contentious or NHS England Region Director repercussive or Director of Finance or NHS England Chief Executive or Chief Financial Officer The entering into any Local NHS England Team Accountable Officer or Primary Medical Services Director or Director of Finance Chief Finance Officer Contract, which has, or is capable of having, a term which exceeds five years

2.3 Reserved Functions For information, the following bullet points provide a summary of the functions that have been reserved by NHS England:  Management of the national performers list.  Management of the revalidation and appraisal process.  Administration of payments in circumstances where a performer is suspended and related performers list management activities.  Capital Expenditure Functions.

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 Section 7A Functions (Public Health Services, including screening programmes, immunisations and vaccinations, health visiting and family nurse partnership services, child health information services, public health services for people in prison and other places of detention, and sexual assault services).  Functions in relation to complaints management.  Decisions in relation to the Prime Minister’s Challenge Fund.  Such other ancillary activities that is necessary in order to exercise the reserved functions. The CCGs will work collaboratively with NHS England and will support and assist NHS England in carrying out the reserved functions.

3. Committees’ Terms of Reference The Committees’ Terms of Reference have been developed from the national model terms of reference, to ensure that the Committees are operating in line with the delegated responsibilities. Each Committee’s Terms of Reference have now been approved by the applicable Governing Body and a copy is provided for the Committees’ information at Appendix A. Members are asked to note that whilst the six individual committees will meet ‘in common’; it is important that they continue to operate within the legal framework and therefore each committee must:  Be able to make its own decisions. The meeting in common approach will facilitate a single discussion but there should still be the ability for each committee in the arrangement to reach a different decision (although this should be unlikely).  Have clear accountability arrangements. Each of the Nottingham and Nottinghamshire CCGs retain individual accountability for the decisions taken on behalf of their local populations.

4. Draft Annual Work Programme and Committee Development Sessions. To further support the Committees in effectively discharging their responsibilities, initial discussions have taken place in order to start developing a comprehensive (shared) annual work programme. This is being developed around the following three key areas:  Items for discussion/assurance (e.g. needs assessments and plans, quality and performance, contract management and finance reports);  Items for decision (e.g. the approval of practice mergers, list closures); and  Items for information (e.g. documents providing contextual information to support the Committees’ role). The draft Annual Work Programme is shown at Appendix B. Further work on finalising the Annual Work Programme, and future reporting requirements, is planned for the Committees’ development discussion following this meeting and a further development session scheduled on 17 July 2019. It is also planned that the development session in July will provide members with a comprehensive overview of each ICP ‘Place’ in order to support the Committees’ understanding of issues pertinent to specific areas and aid

Page 3 of 5 discussions/decisions that are required over the Nottingham and Nottinghamshire CCGs’ footprint. This will include issues around workforce, sustainability, contracting and quality.

5. Delivery and oversight arrangements Responsibilities for operational delivery and governance oversight of the delegated functions have been updated in line with the aligned governance arrangements of the CCGs and the establishment of the single Executive Management and Senior Leadership Team. The remaining staffing structure is currently under consultation but it is anticipated that a single Primary Care Team will be in place, supported by the local Primary Care Hub (“the Hub”). The aligned governance structure and a high-level description of the role of each Committee is provided for information at Appendix C. It is acknowledged that the meeting ‘in common’ approach means that the Committees will now focus across a larger scale than that in the previous arrangements. Therefore, a greater emphasis is needed with regard to the operational arrangements in place for primary care commissioning, along with assurance on the robustness of early warning systems and that issues will be escalated to the Committees’ attention as appropriate. As such, an exercise is now being completed in order to map out where responsibilities for operational delivery sit and an outline of this initial work is shown at Appendix D. This exercise will be completed following the consultation process and when staff/teams have been fully aligned within the CCGs’ joint staffing structure. Members are also asked to note that whilst this exercise defines the role of the Hub, the recent internal audit reviews of the primary care commissioning arrangements for the Greater Nottingham CCGs and Mid-Nottinghamshire CCGs (as provided at agenda item PCC 19/015) highlight that the Memorandum of Understanding (MoU) in place, which sets out the detailed working arrangements between the CCGs and the Hub, dates back to 2016/17. This was assessed by internal audit as low-risk and an action has been agreed to update the MoU by 1 August 2019.

6. Policy and Guidance In November 2017, NHS England published the Primary Medical Care Policy and Guidance Manual (which replaced the previous ‘Policy Book for Primary Medical Services’), a suite of policies that support a consistent and compliant approach to primary care commissioning across England and should be followed by all CCGs. The manual also sets out good practice and guidance for areas not absolutely defined in legislation and law. During 2018/19, the Hub highlighted that decisions regarding GP Retainer Scheme applications, would now come straight to the CCGs (in line with the CCGs’ duties regarding discretionary payments). This highlighted the need for a local policy on payments for this scheme (and other similar schemes that may be in existence) to be prioritised for agreement and the draft policy with be presented to the Committees for approval once developed.

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7. Recommendations The Primary Care Commissioning Committees are requested to:  Note the Primary Care Commissioning Committees’ Terms of Reference (Appendix A) and the legal requirements for operating ‘in common’.  Review the Committees’ draft Annual Work Programme (Appendix B) and note that further work will be required to fully develop this during the Committees’ scheduled development discussion/session.  Note the Committees’ role within the CCGs’ aligned governance structure (Appendix C).  Consider and comment on the initial work performed to map out the operational arrangements in place to ensure that the CCGs’ delegated functions (with regard to primary care commissioning) are effectively discharged (Appendix D).  Note the national policies in place to ensure compliance with the delegation agreement for primary care commissioning and that a local policy is being developed to ensure a robust and consistent approach to the approval of discretionary payments.

Lucy Branson Associate Director of Governance June 2019

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Appendix A

Primary Care Commissioning Committee – Terms of Reference

1. Purpose / Status In accordance with its statutory powers under section 13Z of the National Health Service Act 2006 (as amended), a formal delegation agreement has been issued by NHS England to empower the CCG to commission primary care medical services for the people of [applicable CCG]. The Primary Care Commissioning Committee has been established in accordance with the CCG’s Constitution. The Committee will function as a corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers. Arrangements made under section 13Z do not affect the liability of NHS England for the exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and the duties shown at Annex A (section 14) of these Terms of Reference. The CCG will also need to specifically, in respect of the delegated functions from NHS England, exercise those in accordance with the relevant provisions of section 13 of the NHS Act. The Committee is subject to any directions made by NHS England or by the Secretary of State. The Governing Body has authorised the Committee to create task and finish sub-groups in order to take forward specific programmes of work as considered necessary by the Committee’s membership. The Committee shall determine the membership and terms of reference of any such task and finish sub-groups. The Primary Care Commissioning Committee may meet ‘in- common’ with the other Primary Care Commissioning Committees of the Nottingham and Nottinghamshire CCGs. 2. Duties The Committee has been established in accordance with the above statutory provisions to enable the committee to make collective decisions on the review, planning and procurement of primary care services in the CCG, under delegated authority from NHS England. In performing its role the Committee will exercise its management of the functions in accordance with the agreement entered into between NHS England and the CCG, which will sit alongside the delegation and the Terms of Reference. The functions of the Committee are undertaken in the context of a desire to promote increased co-commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers. The role of the Committee shall be to carry out the functions relating to the commissioning of primary medical services under section 83

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Appendix A

of the NHS Act. This includes the following: a) GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing branch/remedial notices, and removing a contract); b) Newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”); c) Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF); d) Decision making on whether to establish new GP practices in an area; e) Approving practice mergers and/or closures; and f) Making decisions on ‘discretionary’ payments’ (e.g. returner/retainer schemes). g) Making decisions on premises costs directions functions

The Committee will also: h) Assure itself on the effective management of delegated primary care commissioning arrangements; more specifically, the planning, commissioning and procurement, and contract oversight of primary medical services, including arrangements for monitoring the quality of primary medical services. i) Assure itself that effective arrangements are in place to manage the delegated budget for primary care medical services. j) Oversee delivery of the General Practice Forward View. k) Review and approve policies specific to the Committee’s remit. l) Oversee the identification and management of risks relating to the Committee’s remit. 3. Membership The Primary Care Commissioning Committee will have nine members, comprised as follows: Lay Members a) Lay Member – Quality and Performance b) Lay Member – Financial Management c) Associate Lay Member – Audit and Governance Clinical Members d) Independent GP Advisor e) Associate Director of Nursing and Quality Managerial Members f) Accountable Officer g) Chief Commissioning Officer h) Operational Director of Finance

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Appendix A

i) Associate Director of Primary Care

There will be a standing invitation to the following to offer representation in a non-voting capacity on the Committee: a) Member Practice GP Representative b) Healthwatch Nottingham and Nottinghamshire c) Nottinghamshire County Health and Wellbeing Board d) Primary Care Contracting Team of NHS England e) Local Medical Committee Other CCG officers may be invited to attend meetings when the Committee is discussing items that fall within their areas of expertise and/or responsibility. 4. Chair and The Lay Member – Quality and Performance will Chair the Primary Deputy Care Commissioning Committee, with either the Lay Member – Financial Management or Associate Lay Member – Audit and Governance being nominated to deputise in the Chair’s absence. 5. Quorum The Primary Care Commissioning Committee will be quorate with a minimum of five members, to include: a) The Chair or Deputy Chair; b) Either the Independent GP Advisor or Associate Director of Nursing and Quality; and c) Either the Accountable Officer or Operational Director of Finance. To ensure that the quorum can be maintained, Committee members are able nominate a suitable deputy to attend a meeting of the Committee that they are unable to attend to speak and vote on their behalf. Committee members are responsible for fully briefing their nominated deputies and for informing the secretariat so that the quorum can be maintained. If any Committee member has been disqualified from participating in the discussion and/or decision-making for an item on the agenda, by reason of a declaration of a conflict of interest, then that individual shall no longer count towards the quorum. If the quorum has not been reached, then the meeting may proceed if those attending agree, but no decisions may be taken. For the sake of clarity, no person can act in more than one capacity when determining the quorum. 6. Decision-making Generally it is expected that at the Committee’s meetings decisions Arrangements will be reached by consensus. Should this not be possible then a vote of members will be required, the process for which will align to that of the Governing Body’s, as set out in Standing Order 5.9. The Committee will make decisions within the bounds of its remit. The decisions of the Committee shall be binding on NHS England

Page 3 of 7

Appendix A

and the CCG. On occasion, the Committee may be required to take urgent decisions. An urgent decision is one where the requirement for the decision to be made arises between the scheduled monthly meetings of the Committee and in relation to which a decision must be made prior to the next scheduled meeting. Where an urgent decision is required a supporting paper will be circulated to Committee members by the secretary to the Committee. The Committee members may meet either in person, via telephone conference or communicate by email to take an urgent decision. The quorum, as described in section 5, must be adhered to for urgent decisions. A minute of the discussion (including those performed virtually) and decision will be taken by the secretary to the Committee and will be reported to the next meeting of the Committee for formal ratification. 7. Frequency of Meetings of the Primary Care Commissioning Committee will be Meetings scheduled on a monthly basis and the Committee will meet, as a minimum, on a bi-monthly basis. Meetings of the Primary Care Commissioning Committee, other than those regularly scheduled above, shall be summoned by the secretary to the Committee at the request of the Chair. 8. Admission of Meetings of the Primary Care Commissioning Committee will public and the normally be open to the public. press However, the Committee may, by resolution, exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) wherever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time. In the event the public could be excluded from a meeting of the Committee, the CCG shall consider whether the subject matter of the meeting would in any event be subject to disclosure under the Freedom of Information Act 2000, and if so, whether the public should be excluded in such circumstances. The Chair (or Deputy Chair) or the person presiding over the meeting shall give such directions as he/she thinks fit with regard to the arrangements for meetings and accommodation of the public and representatives of the press such as to ensure that the Committee’s business shall be conducted without interruption and disruption. The Committee may resolve (as permitted by Section 1(8) Public

Page 4 of 7

Appendix A

Bodies (Admissions to Meetings) Act 1960 as amended from time to time) to exclude the public from a meeting (whether during whole or part of the proceedings) to suppress or prevent disorderly conduct or behaviour. Matters to be dealt with by the Committee following the exclusion of representatives of the press, and other members of the public shall be confidential to the members of the Committee. Members of the Committee and any member or employee of the CCG in attendance or who receives any such minutes or papers in advance of or following a meeting shall not reveal or disclose the contents of papers marked 'In Confidence' or minutes headed 'Items Taken in Private' outside of the Committee, without the express permission of the Committee. This will apply equally to the content of any discussion during the Committee meeting which may take place on such reports or papers. 9. Secretariat and Secretariat support will be provided to the Primary Care Conduct of Commissioning Committee to ensure the day to day work of the Business Committee is proceeding satisfactorily. Agendas and supporting papers will be circulated no later than five calendar days in advance of meetings and will be distributed by the secretary to the Committee. Any items to be placed on the agenda are to be sent to the secretary no later than seven calendar days in advance of the meeting. Items which miss the deadline for inclusion on the agenda may be added on receipt of permission from the Chair. The Committee agenda will be agreed with the Chair prior to the meeting. 10. Minutes of Minutes will be taken at all meetings and presented according the Meetings corporate style. The minutes will be ratified by agreement of the Primary Care Commissioning Committee at the following meeting. The Chair of the Committee will agree minutes if they are to be submitted to the Governing Body prior to formal ratification. 11. Conflicts of In advance of any meeting of the Primary Care Commissioning Interest Committee, consideration will be given as to whether conflicts of Management interest are likely to arise in relation to any agenda item and how they should be managed. This may include steps to be taken prior to the meeting, such as ensuring that supporting papers for a particular agenda item are not sent to conflicted individuals. At the beginning of each Committee meeting, members and attendees will be required to declare any interests that relate specifically to a particular issue under consideration. If the existence of an interest becomes apparent during a meeting, then this must be declared at the point at which it arises. Any such declarations will

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Appendix A

be formally recorded in the minutes for the meeting. The Chair of the Committee will determine how declared interests should be managed, which is likely to involve one the following actions: a) Requiring the individual to withdraw from the meeting for that part of the discussion if the conflict could be seen as detrimental to the Committee’s decision-making arrangements. b) Allowing the individual to participate in the discussion, but not the decision-making process. c) Allowing full participation in discussion and the decision-making process, as the potential conflict is not perceived to be material or detrimental to the Committee’s decision-making arrangements. 12. Reporting The Primary Care Commissioning Committee will report to the Responsibilities Governing Body through regular submission of minutes from its and Review of meetings. Any items of specific concern, or which require Committee Governing Body approval, will be the subject of a separate report. Effectiveness The Committee will provide an annual report to the Governing Body to provide assurance that it is effectively discharging its delegated responsibilities, as set out in these terms of reference. The Committee will conduct an annual review of its effectiveness to inform this report. 13. Review of Terms These terms of reference will be formally reviewed on an annual of Reference basis, but may be amended at any time in order to adapt to any national guidance as and when issued. Any proposed amendments to the terms of reference will be submitted to the Governing Body for approval. 14. Annex A Arrangements made under section 13Z do not affect the liability of NHS England for the exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and including: a) Management of conflicts of interest (section 14O); b) Duty to promote the NHS Constitution (section 14P); c) Duty to exercise its functions effectively, efficiently and economically (section 14Q); d) Duty as to improvement in quality of services (section 14R); e) Duty in relation to quality of primary medical services (section 14S); f) Duties as to reducing inequalities (section 14T); g) Duty to promote the involvement of each patient (section 14U); h) Duty as to patient choice (section 14V); i) Duty as to promoting integration (section 14Z1); and

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Appendix A

j) Public involvement and consultation (section 14Z2). The CCG will also need to specifically, in respect of the delegated functions from NHS England, exercise those set out below: k) Duty to have regard to impact on services in certain areas (section 13O); and l) Duty as respects variation in provision of health services (section 13P).

Issue Date: Status: Version: Review Date:

June 2019 DRAFT 1.0 May 2020

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Appendix B - Primary Care Commissioning Committees DRAFT Annual Work Programme 2019/20

June Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Notes Items for assurance/discussion General Practice Forward View (GP FV) Further discussion points to x  Funding be determined.  Extended Access Mid-Year Review Primary Care Estates Update x - Quality/Performance Exception x x x x x x x x x x x - Report Contract Management x x x x x x x x x x x - Exception Report Finance Report x x x x x x x x x x x - Meeting date(s) to be Directed Enhanced Services determined. Meeting date(s) to be Local Enhanced Services determined. Risk Report x x x x x x x x x x x x Items for decision (NB. All items for decision cannot be proactively scheduled) Primary Care Hub Memorandum of x - Understanding (MoU) and Handbook Items for information (and discussion where necessary) Integrated Care System x Primary Care Five Year Strategy Primary Care Network x x x x x Update Primary Care Estates Strategy x Half yearly Primary Care Meeting date to be Hub/CCG performance determined. review outputs Page 1 of 2

June Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Notes Committee business Terms of Reference x To be approved at July x x Annual Work Programme meeting following (Draft) (Final) development discussions. Committees’ Annual Report x

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Appendix C – Nottingham and Nottinghamshire CCGs’ Aligned Governance Framework

ALIGNED GOVERNANCE FRAMEWORK

June 2019

Page 1 of 5 Appendix C – Nottingham and Nottinghamshire CCGs’ Aligned Governance Framework

CITY M&A NNE N&S RUSH WEST Member Member Member Member Member Member Practices Practices Practices Practices Practices Practices

Nottinghamshire-wide Nottinghamshire-wide CCGs CCGs Governing Bodies Membership Forum (Meetings in Common) (Joint Advisory Group)

Nottinghamshire-wide Nottinghamshire-wide Mid-Nottinghamshire Nottinghamshire-wide CCGs CCGs CCGs CCGs Patient & Public Strategic Commissioning Clinical Effectiveness Audit & Governance Engagement Committee Committees Committees Committees (Joint Advisory Group) (Committees in Common) (Committees in Common) (Committees in Common)

Greater Nottingham CCGs Nottinghamshire-wide Nottinghamshire-wide CCGs Patient & Public CCGs Quality, Safeguarding & Engagement Committee RATS Committees Performance Committees (Joint Advisory Group) (Committees in Common) (Committees in Common)

Nottinghamshire-wide Nottinghamshire-wide CCGs CCGs Finance & Turnaround Primary Care Statutory Committees Committees Commissioning Committees (Committees in Common) (Committees in Common) Non-Statutory Committees

Page 2 of 5 Appendix C – Nottingham and Nottinghamshire CCGs’ Aligned Governance Framework

Committee Purpose Audit and This Committee exists to: Governance a) Provide the Governing Body with an independent and objective Committee view of the CCG’s financial systems, financial information and compliance with the laws, regulations and directions governing the CCG in as far as they relate to finance. b) Approve the CCG’s Annual Report and Accounts. c) Scrutinise every instance of non-compliance with the CCG’s Standing Orders, Scheme of Reservation and Delegation and Prime Financial Policies and monitoring compliance with the CCG’s Conflicts of Interest Policy and Gifts, Hospitality and Sponsorship Policy. d) Review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the CCG’s activities that support the achievement of the organisation’s objectives. This will include scrutinising compliance with legislative and regulatory requirements relating to information governance. In carrying out this work the Committee will primarily utilise the work of internal audit, external audit and other assurance functions, but will not be limited to these sources. Remuneration and This Committee exists to make recommendations to the Governing Terms of Service Body in relation to: Committee a) The remuneration, fees and allowances payable to employees of the CCG and to other persons providing services to it; and b) Any determinations about allowances payable under pension schemes established by the CCG. The Committee will also: c) Approve all human resources policies for CCG employees. d) Oversee compliance with the requirements set out in the Equality Act 2010 Act (Gender Pay Gap Regulations) 2017, as necessary.

Page 3 of 5 Appendix C – Nottingham and Nottinghamshire CCGs’ Aligned Governance Framework

Committee Purpose Primary Care This Committee exists to carry out the functions relating to the Commissioning commissioning of primary medical services under section 83 of the Committee NHS Act (as delegated by NHS England). This includes the management of GMS, PMS and APMS contracts, newly designed enhanced services and local incentive schemes, establishment of new GP practices, practice mergers and/or closures, discretionary payments (e.g. returner/retainer schemes) and premises costs directions functions. The Committee will also ensure the effective management of delegated primary care commissioning arrangements and the delegated budget for primary care medical services, and oversee delivery of the General Practice Forward View. Quality, Safeguarding This Committee exists to scrutinise arrangements for ensuring the and Performance quality of CCG commissioned services, scrutinise the robustness of Committee This safeguarding arrangements, and to oversee the development, Forum exists to implementation and monitoring of performance management ensure that GP arrangements. membership The Committee also monitors equality performance in relation to engagement, health outcomes, patient access and experience, and promotes a involvement and culture of continuous quality improvement. communication is effective and appropriately maintained Finance and This Committee exists to scrutinise arrangements for ensuring the Turnaround delivery of the CCG’s statutory financial duties, including the Committee achievement of the CCG’s Financial Recovery Plan and QIPP targets. The Committee will review the monthly financial performance and identify key issues and risks requiring discussion or decision by the Governing Body. Strategic This Committee exists to evaluate, scrutinise and quality assure the Commissioning clinical and cost effectiveness of business case proposals for new Committee investments, recurrent funding allocations and decommissioning and disinvestment of services. This will include assessment of any associated equality and quality impacts arising from proposals and feedback from patient and public engagement/consultation activities where necessary. The Committee will also ensure that the CCG’s procurement responsibilities are appropriately discharged, including oversight of annual procurement plans.

Page 4 of 5 Appendix C – Nottingham and Nottinghamshire CCGs’ Aligned Governance Framework

Committee Purpose Clinical Effectiveness The Clinical Effectiveness Committee exists to provide advice in Committee relation to clinical policies, clinical pathways and referral guidelines, with the aim of meeting the health needs of the CCG’s population within limited resources, whilst reducing unwarranted clinical variation and improving consistency of pathways. Patient and Public These Committees exist as strategic groups to ensure that the Engagement patient voice is at the centre of CCG decision-making. Committees Membership Forum This Forum exists to ensure that GP membership engagement, involvement and communication is effective and appropriately maintained.

Page 5 of 5 Appendix D – Operational delivery arrangements for delegated primary care commissioning functions.

Delegated Function Specific Obligation Operational Delivery & Oversight

1) Planning primary Planning the commissioning of primary medical  Primary Care Team, supported* by: medical care services, including:  Public Health services, including  Carrying out primary medical health needs carrying out needs  The Nottinghamshire-wide CCGs Membership Forum, assessments to help determine the needs of the assessments, and local population;  Member GP practices undertaking reviews of primary  Recommending and implementing changes to  ICS Communications & Engagement Team medical care meet any unmet primary medical service’s  Mid-Nottinghamshire CCGs Patient & Public services needs; and Engagement Committee

 Undertaking regular reviews of the primary  Greater Nottingham CCGs Patient & Public medical health needs of the local population. Engagement Committee

* Health needs assessments, including patient and public engagement, and responding to outcomes / developing primary care strategy.

2) Planning the Plan the primary medical services provider  Primary Care Team, supported by the Nottinghamshire- provider landscape landscape, including considering and making wide CCGs Membership Forum and member GP practices decisions in relation to: (reviewing and planning the primary medical services provider landscape)  Establishing new GP practices (including branch  Local Primary Care Hub (list cleansing process) surgeries);

 Managing GP practices providing inadequate standards of patient care;  The procurement of new Primary Medical Services Contracts;  Closure of practices and branch surgeries;  Dispersing the lists of GP practices;

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Appendix D – Operational delivery arrangements for delegated primary care commissioning functions.

Delegated Function Specific Obligation Operational Delivery & Oversight  Agreeing variations to the boundaries of GP practices; and  Coordinating and carrying out the process of list cleansing in relation to GP practices, according to any policy or Guidance issued by NHS England from time to time.

3) Management of the Manage the delegated funds in accordance with Finance Team (financial management) delegated funds business rules and national guidance. 4) Decisions in Actively manage each Primary Medical Services Local Primary Care Hub / Primary Care Team / Quality relation to the Contract by: Team / Finance Team (contract management) commissioning,  Managing quality standards, incentives and the procurement and QOF, observance of service specifications, and Primary Care Performance and Quality Steering Groups* management of monitoring of activity and finance; (operational oversight of delivery) primary medical  Assessing quality and outcomes (including services contracts clinical effectiveness, patient experience and patient safety);  Managing contract variations in accordance with national policy, service user needs and clinical developments;  Agreeing information and reporting requirements and managing information breaches;  Agreeing local prices, managing agreements or proposals for local variations and local modifications;  Conducting review meetings and undertaking contract management including the issuing of

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Appendix D – Operational delivery arrangements for delegated primary care commissioning functions.

Delegated Function Specific Obligation Operational Delivery & Oversight contract queries and agreeing any remedial action plan or related contract management processes; and  Complying with and implementing any relevant Guidance issued from time to time.

5) Decisions in Manage the design and commissioning of enhanced Primary Care Team (design of local enhanced services) relation to services in line with relevant guidance, including re- enhanced services commissioning these services annually where Local Primary Care Hub (management of national and local enhanced appropriate. services) Newly designed enhanced services must consider the needs of the local population and ensure that Primary Care Performance and Quality Steering Groups* value for money is obtained. (operational oversight of delivery)

6) Decisions in Any proposed new Local Incentive Scheme must Primary Care Team (design of local incentive schemes) relation to Local comply with national standing rules and: Incentive Schemes  Be subject to consultation with the Local Medical Local Primary Care Hub (management of local incentive schemes) (including the Committee; design of such  Be able to demonstrate improved outcomes, schemes) Primary Care Performance and Quality Steering Groups* reduced inequalities and value for money; and (operational oversight of delivery)  Reflect the changes agreed as part of the national PMS reviews. 7) Approving GP Undertake all necessary consultation when taking Local Primary Care Hub / Primary Care Team / ICS practice mergers any decision in relation to GP practice mergers or Communications and Engagement Team (managing GP practice and closures GP practice closures, including those set out under mergers and closures) section 14Z2 of the NHS Act (duty for public involvement and consultation). The consultation undertaken must be appropriate and proportionate in

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Appendix D – Operational delivery arrangements for delegated primary care commissioning functions.

Delegated Function Specific Obligation Operational Delivery & Oversight the circumstances and should include consulting with the Local Medical Committee. Decisions are required to clearly demonstrate that:  Any impact on the GP practice’s registered population has been considered and that of surrounding practices.  Other options have been considered; and  A dialogue has been entered into with the GP contractor as to how any closure or merger will be managed.

8) Decisions about Manage and make decisions in relation to the CCGs’ Policy on Discretionary Payments (to be developed to ‘discretionary’ discretionary payments to be made to GP practices ensure a robust and consistent approach to decisions on discretionary payments in a consistent, open and transparent way. The payments). levels of payment to GP practices are required to be determined in accordance with the Statement of Local Primary Care Hub / Primary Care Team (development of Financial Entitlements Directions. proposals for discretionary payments and subsequent management)

9) Decisions about Manage the design and commissioning of urgent Local Primary Care Hub (design and commissioning of urgent care commissioning care services (including home visits as required) for services) urgent care its patients registered out of area (including re- (including home commissioning these services annually where Primary Care Performance and Quality Steering visits as required) appropriate). Groups*(operational oversight of delivery) for out of area registered patients 10) Decisions in Make decisions in relation to the management of Local Primary Care Hub / Primary Care Team / Quality relation to the poorly performing GP practices, including: Team (identification of performance concerns, development and monitoring management of  Ensuring regular and effective collaboration with of improvement plans and implementation of contractual action where

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Appendix D – Operational delivery arrangements for delegated primary care commissioning functions.

Delegated Function Specific Obligation Operational Delivery & Oversight poorly performing the CQC to ensure that information on general necessary) GP practices, practice is shared and discussed in an including decisions appropriate and timely manner; Primary Care Performance and Quality Steering Groups* and liaison with the  Ensuring that any risks identified are managed (identification of performance concerns) CQC where the and escalated where necessary; CQC has reported  Responding to CQC assessments of GP non-compliance practices where improvement is required; with standards (but excluding any  Where a GP practice is placed into special decisions in measures, leading a quality summit to ensure the relation to the development and monitoring of an appropriate performers list) improvement plan (including a communications plan and actions to manage primary care resilience in the locality); and  Taking appropriate contractual action in response to CQC findings.

11) Premises Costs Make decisions concerning: Local Primary Care Hub (development of proposals for payments under the Premises Costs Directions and subsequent management) Directions  Applications for new payments under the Functions Premises Costs Directions (whether such payments are to be made by way of grants or in respect of recurring premises costs).  Revisions to existing payments being made under the Premises Costs Directions.

* Different arrangements are currently in place across the CCGs in relation to the operation of quality and performance steering groups. An exercise is currently underway to determine how these groups now need to work.

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Meeting in Common of NHS Mansfield and Ashfield CCG, NHS Newark and Sherwood CCG, NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG

Meeting Title: Open Primary Care Commissioning Date: 19 June 2019 Committee

Paper Title: Leen View Surgery – Boundary Paper Reference: PCC 19/008 reduction

Sponsor: Kerrie Woods, Contacts Manager Attachments/ Included within NHSE Appendices: paper: A to E Sharon Pickett, Associate Director of Primary Care Presenter: Fiona Warren, Primary Care Manager

Executive Summary This is an application from Leen View Surgery to reduce their practice boundary. The main driver for this application is that the practice, at present, feels they are struggling with workload, patient access and room availability.

The current patient list size for Leen View is 9,555 as at 1 April 2019. The weighted list size was 10,523 at the same date.

The practice has a GMS contract and the contract holder is Dr Bakshi as the only GP partner and a non- clinical partner, Lizzie Brain who is an Advanced Nurse Practitioner at the practice.

Leen View is co-located with another GP practice, Parkside Medical Centre, in the Bulwell Riverside Health Centre. Parkside have recently submitted a request to extend their practice boundary.

Recommendation: ☐To endorse ☐To review ☐To receive/note for assurance and information ☒To approve the recommendations as set out below

Recommendation(s): 1. To consider whether the boundary reduction should be approved and if approved, consider placing conditions in relation to the services provided to the care homes affected. Relevant CCG priorities/objectives: (please tick which priorities/objectives your paper relates to) Compliance with Statutory Duties ☐ Establishment of a Strategic Commissioner ☐ System architecture development (e.g. ☐ Financial Management ☐ ICP, PCN development) Performance Management ☐ Cultural and/or Organisational Development ☐

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Service Planning and/or Commissioning ☐ Procurement and/or Contracting ☒ Completion of Impact Assessments: Equality / Quality Impact Yes ☒ Has an EQIA been completed? If the answer is No, please Assessment (EQIA) No ☐ explain why Data Protection Impact Yes ☐ Has a DPIA been completed? If the answer is No, please explain Assessment (DPIA) No ☒ why Confirmed via email (10.06.2019) by the CCG IG team that a DPIA is not required as patients will be registering with another practice according to boundary lines. Patients registering will be following the usual process for GP registrations and will not have any effect on how their personal data is processed. Risk(s): The practice advises that if the boundary reduction is not approved there are risks to patient safety, experience and the sustainability of the practice. If the list size continues to grow, access to appointments may be compromised as there is a limitation on the number of clinical staff who can be employed at the site. This may result in the practice applying for a list closure in the near future which would pose a higher inconvenience to neighbouring practices and patients.

If the boundary reduction is approved there is a risk that other practices will follow, as per the practice comments received, and this could result in patients registered in this area and in particular at these care homes not having access to primary care services.

Confidentiality: Is the information in this paper confidential? ☒No ☐Yes Conflicts of Interest: Please state whether there are any conflicts of interest considerations relevant to paper authors, members or attendees. ☒ No conflict identified ☐ Conflict noted, conflicted party can participate in discussion and decision ☐ Conflict noted, conflicted party can participate in discussion, but not decision ☐ Conflict noted, conflicted party can remain, but not participate in discussion or decision ☐ Conflicted party to be excluded from meeting

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Primary Care Commissioning Committee June 2019

Request to amend practice boundary

Panel Date: 19 June 2019

Practice: Leen View Surgery

Delegated Function: 4 – Decisions in relation to the commissioning, procurement and management of primary medical service contracts Author(s): Bryony Higgins, Primary Care Contracts Officer NHSE Fiona Warren, Commissioning Manager, Nottingham City CCG

Sponsor: Kerrie Woods, Contacts Manager, NHSE Sharon Pickett, Assistant Director of Primary Care

Summary

On 1 May 2019, Leen View Surgery, situated in Bulwell, Nottingham City CCG applied to reduce their practice boundary area.

The current boundary covers mainly the NG6 postcode area of Bulwell and Bestwood Village. The part of the boundary the practice wishes to reduce is an area of Cinderhill in the NG8 postcode area.

The practice has not reduced their boundary before, but at present feel they are struggling with workload, patient access and room availability. New patient registrations continue to rise at the practice despite operating at maximum workforce capacity. Approximately 120 new registrations are currently being processed each month by the practice whose raw list size was recorded at 9,555 on 1 April 2019 (10,523 weighted).

The surgery has a GMS contract held with Dr Bakshi as the only GP partner and a non-clinical partner, Lizzie Brain who is an Advanced Nurse Practitioner at the practice. Other healthcare professionals are employed by the practice including 5 Salaried GPs, Nurses and Healthcare Assistants.

Leen View is co-located with another GP practice, Parkside Medical Centre, in the Bulwell Riverside Health Centre. Parkside have recently submitted a request to extend their practice boundary.

The decision framework below outlines the key questions for the Primary Care Commissioning Committee to consider as part of their decision-making process. This framework should be read in conjunction with the following appendices:  Appendix A which provides an overview of the practice  Appendix B includes the practice boundary application form as completed by the practice  Appendix C summarises the policy framework relevant to this decision  Appendix D neighbouring practice boundaries  Appendix E feedback from other practices consulted

Decision Framework

This decision framework summarises the key factors for consideration by the Primary Care Commissioning Committee. To aid this process, responses to the key questions have been populated from the practice’s application and commissioner intelligence about the practice and surrounding area.

Key factors for consideration What is the main The practice cites several difficulties they are currently facing as justification

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Primary Care Commissioning Committee June 2019 reason(s) for this for reducing the practice boundary. application? The practice list size has grown steadily since April 2017, increasing by 256 over the course of the 2017/18 financial year and a further 383 over 2018/19. The weighted list size has grown at a similar level. The practice currently reports dealing with around 120 new patient applications each month. Between January 2019 and May 2019, 430 new patients joined the practice and 402 patients have since left the practice.

The practice believe they are currently staffed at maximum capacity for both clinical and administrative staff. The practice is unable to accommodate a larger workforce to service the growing list size due to lack of clinical rooms, patient access and appointment availability. If the boundary area is not reduced they believe patient safety may be compromised in regard to these issues and access to patient appointments will become more difficult. Access to appointments has previously been highlighted in the GP Patient Survey and NHS choices feedback as an area of improvement at the practice. Common areas of comment are long telephone queues and lack of available appointments.

The area of Bulwell where the practice is situated is an area of higher deprivation and patient need. The practice wishes to reduce their boundary area to focus on the patients within the immediate practice area. The area in question sits within a county postcode area whereas the practice is within a city postcode area it can also present difficulties regarding referrals to services.

Has this practice There have been no previous applications to extend or reduce the practice previously submitted boundary. application(s) to change their practice boundary?

How will the proposed The dark yellow highlighted section on the below map shows the area practice boundary proposed for reduction. change?

The map below is focussed solely on the reduction area:

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Primary Care Commissioning Committee June 2019

It shou ld be noted that there are two neighbouring care homes Acer Court and Alder House, which are situated in the area the practice wishes to eliminate from their boundary. The care home patients are currently managed on a rotational basis with other local practices. This has been raised as a concern by neighbouring practices when commenting on this application (see below).

What is the current The practice currently has a GP to patient ratio of 1:2,556 which is slightly staffing position and GP above the normal range of most GP practices which is circa 1: 2,200. (wte) to patient ratio? Around 43% of Nottingham City CCG practices are working over this 1:2,200 range. How does this ratio compare to other applications considered Leen View’s GP:patient ratio is slightly higher than Parkside practice by the panel? (1:2,203) who are co-located in the Bulwell Riverside

Has this practice Please see the table below detailing the quarterly practice list sizes since observed a change in April 2018: its list size in recent months? Month Raw List Quarterly Change in Size list size Is there a high patient April 2018 9,172 -- turnover at this July 2018 9,237 65 practice? October 2018 9,365 128 January 2019 9,483 118 Include reference to April 2019 9,555 72 monthly net changes in list size The practice currently reports dealing with around 120 new patient applications each month. Between January 2019 and May 2019, 430 new patients joined the practice and 402 patients have since left the practice.

Is the practice located The practice is located in a deprived area. The practice has a deprivation in an area of high score of 45.6 (IMD 2015) compared to a City average of 36.9.

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Primary Care Commissioning Committee June 2019 need? The Bulwell area in Nottingham is an area of high deprivation in children and older people, furthermore income deprivation is significantly worse in the area than the England average according to 2015 Public Health data. Incidences of lung cancer and prostate cancer are also significantly worse than England averages, breast and colorectal cancer incidences are not significantly different. Life expectancy for the area is significantly worse for both males and females, averaging at 75 for males and 78.2 for females, there are higher than average levels of premature deaths from circulatory disease, coronary heart disease and cancers.

The practice also noted in their application that they have higher incidences of cancers, diabetes and mental health issues in their practice population. As well as higher incidences of safeguarding issues and patients with complex needs. These patients often require more intensive support from clinical staff and is reflected in the weighted list size.

Is the practice A full list of additional services provided by the practice is included at commissioned to Appendix A. provide any enhanced services for vulnerable The practice provides the following additional enhanced services including: patient groups? . Learning disabilities Health Check Homeless, Asylum . Minor surgery Seekers . Primary Care Patient Offer . Warfarin anti-coagulation and shared care (4 disease areas)

The practice does not provide the Homeless or Asylum seekers enhanced services.

How many practices The following practices are within a 1.5mile radius of Leen View Surgery. are nearby? The highlighted practices below cover some or all of the affected area with their practice boundaries. Do neighbouring practices have capacity Practice Distance from List Size Letter on Map to accept new patients? Leen View (m) Parkside 0.0 7484 A Medical Centre Riverlyn Medical 0.1 2998 C Centre Springfield 0.4 2638 D Medical Centre St Alban’s 0.6 7278 E Medical Centre Southglade 1.0 2929 F Medical Centre Lime Tree 1.1 3521 G Surgery Rise Park 1.3 7439 H Surgery Hucknall Road 1.3 13,204 I Medical Centre The Alice 1.5 3503 J Medical Centre Churchfields 1.5 9427 n/a Medical Practice

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Primary Care Commissioning Committee June 2019

Leen View are in Primary Care Network 1, and the other practices in this PCN are:

 Parkside Medical Centre (co-located with Parkside)  Queensbower Surgery  Rise Park Surgery  Riverlyn Medical Centre  Southglade Medical Practice  Springfield Medical Centre  St Alban’s Medical Centre

Dr Foster from the Parkside practice has been accepted as Clinical Director for the PCN.

Do neighbouring 11 practices were contacted for comment who were identified to cover the practices support this area of reduction or were in a mile radius of the practice. Three practices application? responded, and all raised similar concerns regarding the proposal. There are two neighbouring care homes Acer Court and Alder House, which are situated in the area the practice wishes to eliminate from their boundary. The care home patients are currently managed on a rotational basis with What is the potential other local practices. Lime Tree Surgery, Parkside Medical Practice and impact on neighbouring Riverlyn Medical Centre are concerned this will impact on their capacity practices if this significantly and affect their management of these patients. Parkside boundary extension Medical Practice have also applied to extend their boundary and they are application was concerned of the impact Leen View’s reduction may have on their plans to approved expand.

The area in question is also covered by RHR Medical Centre and Strelley Health Centre who were also invited to comment.

Please see Appendix D for the full comments from the practices who responded. Page 5 of 14

Primary Care Commissioning Committee June 2019

Do patients support the The practice has discussed the reduction with the PPG who did not raise application? any concerns.

Does the LMC support The LMC were invited to comment but did not respond. this application?

What are the risks, as There are risks to patient safety and experience and the sustainability of the described by the practice. If the list size continues to grow, access to appointments may be practice, if the compromised as there is a limitation on the number of clinical staff who can boundary is not be employed at the site. reduced? This may result in the practice applying for a list closure in the near future which would pose a higher inconvenience to neighbouring practices and patients.

If the boundary reduction is approved there is a risk that other practices will follow, as per the practice comments received, and this could result in patients registered in this area and in particular at these care homes not having access to primary care services.

What actions have the The practice has held discussions with the CQC to help increase practice taken to date appointment availability and patient access. This was highlighted from a to manage the growing patient complaint to the CQC, the practice felt this was a positive list size? conversation and was used this to outline strategies to help improve access for patients. The practice currently has a CQC rating of good and achieved a Have they approached rating of good in all domains. commissioners for support? They introduced a telephone triage clinic for GPs and ANPs which aim to increase the flexibility and availability of appointments. The practice is also encouraging patients to use online functions to contact the practice and are now receiving around 10-20 online messages a day from patients.

They are also looking into 420 patients who are registered outside of the boundary area and asking them to consider registering at another practice.

Recommendation

 The committee is asked to consider whether the application for a boundary reduction be approved. If approved, it is recommended that consideration be given to placing conditions which stipulate that the practice should continue to provide a primary care service to care homes within this area under the same arrangements with other practices as previously agreed.

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Primary Care Commissioning Committee June 2019 Appendices

Appendix A – Practice Overview

Workforce The make-up of the clinical staff is as follows:

Type of staff Number Whole Time Equivalent GP Partners 1 1 Salaried GP 5 3.27 Advanced Nurse Practitioner 1 1 Nurse Practitioner 1 0.69 Practice Nurse 2 2 Healthcare Assistant 2 2

Registered list size and patient demographics

List Practice % Date size change

01/01/2016 8711 01/01/2017 8853 1.6% 01/01/2018 9097 2.8% 01/01/2019 9483 4.2%

The breakdown of the practice population by age compared to the CCG figures is demonstrated below.

% of City CCG Age Group practice average list size 0-4 yrs 7.65% 5.45% 5-19 yrs 20.63% 18.91% <19 total 28.28% 24.36% 20-64 yrs 55.87% 64.77% 65-74 yrs 8.3% 5.91% 75-84 yrs 4.87% 3.43% 85+ yrs 2.68% 1.52% 100.00% 100.00%

Local health needs

The practice is located in the Bulwell Forest ward area of Nottingham. The following information is taken from the National General Practice Profile populated by Public Health England:  The life expectancy is slightly lower than the national average (81 years for females, 77 years for males).  The practice has a younger population profile than the CCG and national average with 34% of its patients under 18 years old compared to 21.1% and 207% respectively.  10.9% of the practice patient list is unemployed; this is higher than both the CCG and national average  BME groups form 18.3% of the resident population in Bulwell Forest; this is lower than the city average of 34.6%. Black/African/Caribbean/Black British, Asian/Asian British and Mixed/multiple Page 7 of 14

Primary Care Commissioning Committee June 2019 ethnic groups are the predominant BME groups in the area with 6.0%, 4.8%, 4.4% respectively.  20.7% of Bulwell Forest residents describe themselves as having a limiting longterm illness or disability which is higher than the Nottingham average of 18.1% (2011 census).  6.6% describe themselves as having very bad or bad health compared to the Nottingham average of 6.4% (2011 Census)  2.8% describe themselves as providing 50 hours or more of unpaid care compared to the Nottingham average of 2.4% (2011 Census).  A small proportion (4.0%) cannot speak English well, but this equates to over 1,700 people with poor English

Premises information

 Location: Bulwell Riverside, Main Street, Bulwell, Nottingham NG6 8QJ  Owner: NHS Property Services  Tenure basis: Lease  Rent: N/A  Overall condition: Purpose Built 2012.

Access Opening hours at the surgery is as follows:

The practice has opted to provide the Extended Hours Access Enhanced Service.

Day Leen View Surgery Monday 07:00 – 18:30 Tuesday 07:00 – 18:30 Wednesday 07:00 – 18:30 Thursday 07:00 – 18:30 Friday 07:00 – 18:30 Saturday Closed Sunday Closed

Local primary care provision

The practice provides all essential and additional services as well as the following enhanced services:  Minor Surgery  Extended Hours  Learning Disability Health Check  Primary Care Patient Offer  Warfarin anti-coagulation and shared care (4 disease areas)

Care Quality Commission Leen View Surgery was last inspected in October 2016 and the report was published in December 2016. The practice achieved good in all domains and as the overall rating.

Primary Care Web Tool

The Primary Care Webtool was decommissioned in April 2019 and at present the information and indicators recorded here are not able to be accessed.

NHS Choices feedback

2.5 stars out of 5 from 24 reviews.

GP Patient Survey Results

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Primary Care Commissioning Committee June 2019

 85% of respondents say they have had enough support from local services or organisations in the last 12 months to help manage their long-term condition(s) Local (CCG) average: 77%National average: 79%

 98% of respondents had confidence and trust in the healthcare professional they saw or spoke to during their last general practice appointment. Local (CCG) average: 93%National average: 96%

 89% of respondents felt the healthcare professional recognised or understood any mental health needs during their last general practice appointment Local (CCG) average: 85%National average: 87%

 26% of respondents find it easy to get through to this GP practice by phone Local (CCG) average: 70%National average: 70%  36% of respondents were offered a choice of appointment when they last tried to make a general practice appointment Local (CCG) average: 67%National average: 62%

 39% of respondents describe their experience of making an appointment as good Local (CCG) average: 68%National average: 69%

Appendix B – Practice Boundary Change application form

Application.pdf

Appendix C – Policy Framework

Practice boundary applications will be considered in line with the requirements set out within the NHS England Policy Book for Primary Medical Services Chapter 7, Part 14: Boundary Changes.

 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.  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.  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.  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.  14.5 The contractor and the Commissioner must engage in open dialogue concerning the circumstances that have led to the request to change their boundary and discuss the possible Page 9 of 14

Primary Care Commissioning Committee June 2019 implications of the action, i.e. a reducing patient register, an expanding patient register, the financial implications of both and any possible alternative actions that may be taken by either party to enable the practice to maintain its existing practice area.  14.6 Commissioners must consider the application having regard to other practices’ boundaries, patient access to other local services and in general other health service coverage within a location and may seek to involve the public to seek their views.  14.7 Once a decision is reached on whether to accept or reject the application, the Commissioner should notify the contractor in writing of its decision.  14.8 If the Commissioner accepts the proposed changes to the practice area, the contractor should be notified, as soon as possible, in writing of: 14.8.1 the acceptance; 14.8.2 the date upon which the changes will take effect; and 14.8.3 a requirement of the contractor to publish the details of the new practice area within their patient information leaflet and on their website (if they have one).  14.9 If the Commissioner declines the proposed changes to the practice area, the contractor should be notified, as soon as possible, in writing of that decision and to include: 14.9.1 the reasons for the decision; 14.9.2 the right of the contractor to appeal and the process for doing so; and 14.9.3 specify any period within which the Commissioner would not consider a further application from this contractor to vary its practice area.  14.10 Practices who are intending to reduce their practice area must be advised that registered patients who subsequently fall outside of the new agreed area, but who are within the original practice area (main and outer boundary) can only be removed from the list if one or more of the provisions of the relevant regulations / directions that relate to removal of patients from the practice's patient list apply.

Local CCG principles

For the avoidance of doubt, where a practice requests to reduce their practice boundary the CCG will require that all currently registered patients who reside in the current boundary area but who will be outside the proposed boundary area, will remain as registered patients and will not be removed at any time in the future.

The CCG may wish to apply conditions to the approval of the boundary change. Where this is the case, any conditions will be clearly stated in the notice to the practice.

Appendix D – Practice boundaries of neighbouring practices

The proposed reduction area is covered by; Lime Tree Surgery, Parkside Surgery, Riverlyn Medical Centre and partly by RHR Medical Centre and Strelley Health Centre. As of 9 June 2019, Strelley Health Centre was closed by the CQC. At the time of writing this paper, the practice remains closed for the foreseeable future but the boundary has still been included here.

The boundary areas of these practices are shown below as declared in March 2019.

Lime Tree Surgery (full area covered):

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Primary Care Commissioning Committee June 2019

Parkside Surgery (Full area Covered):

Riverlyn Medical Centre (Full Area Covered):

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Primary Care Commissioning Committee June 2019

RHR Medical Centre (Partial area covered):

Strelley Health Centre (Partial/M ajority of the Area Covered):

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Primary Care Commissioning Committee June 2019

Appendix E – Practice Comments

Below is a summary of the comments received from neighbouring practices on this application.

Parkside Medical Practice (co-located in Bulwell Riverside)

Parkside Medical Practice strongly object to this application, noting that there are two large care homes within the proposed reduction area with an estimated 140 care home beds which they believe could be the highest density of care home beds in the City. Approving this reduction in boundary would deliberately alter the composition of Leen View’s patient list. Leen View is the largest practice in the area and should therefore have a broad range of patients including a fair share of those registered in these care homes.

Parkside state that they have been working towards offering the population of Bulwell a sustainable service and their recent request to extend their boundary has been done so irrespective of patient make-up.

Should Leen View be successful in their application Parkside will consider reviewing their boundary and in particular this area covered. Parkside feel they will be unable to extend their boundary as proposed and risk being able to fulfil their core contract.

Lime Tree Surgery

Lime Tree surgery strongly object to this proposal as they feel that Leen View are proposing a change in geography which only serves to suit them and purposely exclude care homes from their practice area. They have also raised concerns about Leen View allegedly advising complex patients to leave their patient list. This statement is being follow-up by the CCG/NHSE Contracts Team.

Lime Tree advise that they are a small practice yet have continued to be willing to take on patients from these care homes on a rotational basis with other practices in the area. If Leen View are allowed to reduce their boundary this will severely increase the burden on their practice which will force them to consider submitting a similar application. Lime Tree would rather avoid such a situation as this will compound the problem further for these care home patients.

Riverlyn Medical Centre:

Our objection will be that the care homes are not excluded from their boundary.

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Primary Care Commissioning Committee June 2019

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Engrand North Midlands

APPL!CAT:ON FOR PRACTiCE BOUNDARY CHANGE

C84043 PRACTICE CODE

PRACT!CE STAMP

PLEASE COMPLETE THE FOLLOW:NG:

Briefly describe your main reasons for applying to change the practice boundary area. (Please delete where applicable Extend Practice Boundary / Reduce Practice Boundary area Our practice is being inundated by new registrations especially for the past 9- 12months. We are receiving around 120 new applications for registrations every month. We have already registered around 450 new patients from January this year. There are foreseeable issues around patient access, workload and availability of rooms for doing extra clinics .There is also an ongoing disputation with the premises landlord-CHP regarding their proposal to sharply increase the rent and rate of non reimbursables. lf that goes through then it won't be possible for our practice to use the present premises. Negotiations are ongoing and LMC is mediating in this. We have started making contingency plans for the worst case scenario. The proposed area to be reduced falls in the county jurisdiction. lt is well served by county General Practices. Community services associated with that patch are also commissioned by the county. Ours being a city practice, makes referral to county services difficult. Our patients in Bulwell have complex health needs. They have multiple comorbidities but very sparse socio economic support. They need close monitoring and intensive medical care. We want to maintain our high standards of care and feel by redefining our boundary we can provide better quality of service to the residents of Bulwell.

Application to Change Practice Boundary March 2016 What are the WTE for each named Partnerlsalaried GP and any other clinical staff carrvinq out GP work? Dr.P.Bakshi-1ヽⅣTE― Partner SALARIED GENERAL PRACTIT10NERS

Dr HS Pabla… 0.60VVTE

Dr Fatma Elias¨ 0.69ヽ内TE Dr.Mark Graham-0.69 VVTE

Dr.Florian Batstone-0.69WTE Dr.Anubama Ramasamy-0.6 VVTE

Detail other Clinical Staff,ro:es and WTE“ Lizzie Brain- Partner and ANP-1WTE

Susan Redford-Practice nurse and nurse prescriber-0.69wTE

Georgina Rhodes- Practice Nurse-1 WTE

Lisa Hayes- Practice Nurse- 1 WTE

Helen Oliver-HCA- lWTE

Stacey Rookes-HCA- 1 WTE

Detail any Practice future strategy?

Our team is trying to find ways to reduce admin workload and increase clinical capacity of GPs and nurses. We have done exhaustive in-house training and have also booked external training events for the staff to improve their efficiency.

Last month, we had discussions with CQC regarding issues around patient access. We had a very positive discussion with them and have outlined some strategies to increase availability of appointments.

2 Application to Change Practice Boundary March 2016 Our practice has recently started piloting "Doctor First" style telephone triage clinics for GPs and ANP. These are slowly taking shape . They aim to increase flexibility and availability of appointments for our patients. We are also encouraging patients to register with our website. They are shown how to use "Contact Us" option to send messages across to us .We are now receiving around 10-20 online messages every day. We recruited a clinical pharmacist through CPGPE pathway, last year. Unfortunately there were significant shortfalls in his competencies and we had to part ways in February 2019, due to patient safety risk. We are looking into our 420 outliers and are requesting some of them to consider joining a local surgery. Couple of our GPs are considering reducing their sessions due to retirement and other personal reasons. Our further plans and strategies will be dependent on the functioning and structuring of newly established PCN.

Any longer term workforce development plans?

As outlined above, we are training staff to improve workflow management. They have received in house and external training. Our administrative team is booked to go for "Correspondence management course" and some networking events with other teams in Nottingham. We are a training practice and since last year, are training GP registrars and ANP. Hopefully in few years they may consider joining our team .

CQC visit made, and if so date and outcome?

27/10/2016¨ Good in a‖ areas.

3 Application to Change Practice Boundary March 2016 Any other practices in same building?

Park side practice- First Floor, Bulwell Riverside, Main Street, Bulwell. NG6 8Oj.

Any capacity issues (clinical or administrative)?

We are at full capacity staff wise ( admin and clinical). We have employed a new HCA last year and recruited a new administrator this year. We are unable to take on more clinical staff due to national recruitment crises for GPs and ANPs..Some of our GPsare considering dropping few clinical sessions in the near future. We do use locums but they do not provide continuity of care and holistic management (eg Home visits and admin).

Any patient complexitv in this practice i.e. Population demoqraphics?

Bulwel! is one of the most deprived area in Nottingham city. Our patients Iive in poor socio-economic conditions. This is an Ex- mining area. We have higher than norma! prevalence of cancers, COPD, Dementia -Menta! health diseases and Diabetes.

There is high incidence of safeguarding (adult and children) procedures in our population. !n Bulwell, we are looking after very complex housebound patients with multiple chronic diseases, severe frailty and terminal illnesses. Because of relatively Iower literacy and high incidence of unemployment we are constantly faced with patients who fail to take responsibility for their health. These patients require intensive input from clinicians to achieve functionality. We also have substantive number of patients in residential and nursing homes that require frequent visits and assessments.

Discussed with neiqhbourinq practices, and if so outcome?

We have discussed our proposal with Parkside medical practice and they don't seem to have any concerns. They are actually keen to increase their list size and have 4 Application to Change Practice Boundary March 2016 applied for extension of their practice boundary.

Discussed with LMc/other key stakeholders/Patient Participation Group, and if so the outcome?

We have written to LMC last month but have not received any reply yet from their practice liaison officer. They were in the process of recruiting a new personnel for this post. We have discussed this proposa! with CQG and PPG and they don't seems to have any' GOnCerns

Are the practice proposed changes aligned to the CCG future strategy?

Like all other practices, we are participating in formation of our local PCN and are working closely with all stakeholders.

Copy of existing boundary map and proposed boundary map (to be inserted or attached).

Please see attached

Patient turnover to date?

Patient turnover form January 2019 to present Joined practice- 430

5 Application to Change Practice Boundary March 2016 Left practice-402 There is construction underway in our immediate area including a residential development of new flats .We also have a new complex for people for Learning Disabilities develop nearby, all residents have joined Leen View Surgery. We anticipate that any new build developments in the near future will impact on us. There are also concerns regarding the other surgeries in the area, We have had influx of patients joining from St Alban as their surgery is in special measures. GPs are due to retire from other surgeries and this could impact on us. After facing problems with access we were advised to remove Out of Area patients to enable us to focus on those within our area. This was suggested by the CQC and lan Trimble, during the practice visit programme in September 2018.

Anv practice premises issues?

Our practice is currently negotiating with our lease holder- CHP regarding their current proposal to stop a steep increase in rent and reimbursable. This is a national issue and we are aware that there are several other practices in similar situation. LMC is trying to mediate are we are still waiting to achieve a resolution.

Anv NHS Enqland/GCG premise develooment olans?

None

Opening Hours, do you shut half day or offer Extended Hours?

We do not shut on any day of the week, our core hours are 0800-1830 Mon- Fri. We run an extended hours service each morning from 0700.

Any other relevant information relatinq to the application?

We have to concentrate our efforts to improve the wellbeing of Bulwel! residents as

6 Application to Change Practice Boundary March 2016 they have significant deprivation and unmet socio-economic needs.,There have been agonizing cuts in health and social care budgets ( New leaf service, Recovery college, YMVA Gym, physio first, community podiatry etc). As a result, everything is falling back onto us.

Please note that this application does not concert any obligation on the NHS Commissioning Board to agree to this request.

To be signed by all parties to the contract (where this is reasonably achievable):

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Meeting in Common of NHS Mansfield and Ashfield CCG, NHS Newark and Sherwood CCG, NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG

Meeting Title: Open Primary Care Commissioning Date: 19 June 2019 Committee

Paper Title: Parkside Medical Centre – Boundary Paper Reference: PCC 19/009 extension

Sponsor: Kerrie Woods, Contacts Manager Attachments/ Included in paper A Presenter: NHSE Appendices: to C Sharon Pickett, Associate Director of Primary Care

Executive Summary This is an application from Parkside Medical Centre to extend their practice boundary. The main driver for this application is that the practice wishes to grow its patient list size from its current level to 10,000.

The current patient list size for Parkside is 7,508 as at 1 April 2019. The weighted list size was 8,112 at the same date.

The practice has a GMS contract and the contract holders are Dr Amita Deolkar as lead, Dr Andrew Foster and Mr Ben Moorhouse, the practice Advanced Nurse Practitioner.

The practice has recruited extra clinical staff, for which they state they are starting to see the benefits, and want to grow the practice to develop as a quality and sustainable practice.

Recommendation: ☐To endorse ☐To review ☐To receive/note for assurance and information ☒To approve the recommendations as set out below

Recommendation(s): 1. To approve the extension of the practice boundary Relevant CCG priorities/objectives: (please tick which priorities/objectives your paper relates to) Compliance with Statutory Duties ☐ Establishment of a Strategic Commissioner ☐ System architecture development (e.g. ☐ Financial Management ☐ ICP, PCN development) Performance Management ☐ Cultural and/or Organisational Development ☐ Service Planning and/or Commissioning ☐ Procurement and/or Contracting ☒

Page 1 of 2

Completion of Impact Assessments: Equality / Quality Impact Yes ☒ Has an EQIA been completed? If the answer is No, please Assessment (EQIA) No ☐ explain why

Data Protection Impact Yes ☐ Has a DPIA been completed? If the answer is No, please explain Assessment (DPIA) No ☒ why Confirmation received from the CCG IG Delivery Manager that a DPIA is not required because patients will be registering with one practice or another according to different boundary lines. Patients registering will be following the usual process for GP registrations. The boundary changes proposed will not have any effect on how their personal data is processed. Risk(s): No risks have been identified within the paper or by the practice in relation to this contractual request Confidentiality: Is the information in this paper confidential? ☒No ☐Yes (please tick the relevant box to explain why it is confidential) Conflicts of Interest: Please state whether there are any conflicts of interest considerations relevant to paper authors, members or attendees. ☒ No conflict identified ☐ Conflict noted, conflicted party can participate in discussion and decision ☐ Conflict noted, conflicted party can participate in discussion, but not decision ☐ Conflict noted, conflicted party can remain, but not participate in discussion or decision ☐ Conflicted party to be excluded from meeting

Page 2 of 2

Primary Care Commissioning Committee June 2019

Request to amend practice boundary

Panel Date: 19 June 2019

Practice: Parkside Medical Centre

Delegated Function: 4 – Decisions in relation to the commissioning, procurement and management of primary medical service contracts

Author(s): Richard Hobbs, Assistant Contracts Manager, NHS England Fiona Warren, Commissioning Manager, Nottingham City CCG

Sponsor: Kerrie Woods, Contacts Manager, NHSE Sharon Pickett, Assistant Director of Primary Care

Summary

This is an application from Parkside Medical Centre to extend their practice boundary. The main driver for this application is that the practice wishes to grow its patient list size from its current level to 10,000.

The current patient list size for Parkside is 7,508 as at 1 April 2019. The weighted list size was 8,112 at the same date.

The practice has a GMS contract and the contract holders are Dr Amita Deolkar as lead, Dr Andrew Foster and Mr Ben Moorhouse, the practice Advanced Nurse Practitioner.

The practice has recruited extra clinical staff, for which they state they are starting to see the benefits, and want to grow the practice to develop as a quality and sustainable practice.

Parkside is co-located with another GP practice, Leen View Surgery, in the Bulwell Riverside Health Centre. Leen View have recently submitted a request to reduce their practice boundary.

The decision framework below outlines the key questions for the Primary Care Commissioning Committee to consider as part of their decision-making process. This framework should be read in conjunction with the following appendices:  Appendix A which provides an overview of the practice  Appendix B includes the practice boundary application form as completed by the practice  Appendix C summarises the policy framework relevant to this decision

Decision Framework

This decision framework summarises the key factors for consideration by the Primary Care Commissioning Committee. To aid this process, responses to the key questions have been populated from the practice’s application and commissioner intelligence about the practice and surrounding area.

Key factors for consideration What is the main The desire to grow the practice from the current 7,500 to 10,000 patients. reason(s) for this application? Has this practice Not since 2005 when the practice successfully applied to reduce their previously submitted practice boundary to exclude Top Valley. None of the partners from that

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Primary Care Commissioning Committee June 2019 application(s) to change time are still with the current practice. their practice boundary?

How will the proposed The map below shows the current practice boundary in black, the proposed practice boundary extension of the practice boundary in light brown. The Star marks the change? location of Parkside Medical Centre.

Parkside Medical Centre is based in Bulwell Riverside, Main Street, Bulwell, Nottingham which is central to the current boundary. The current practice boundary extends to the north to the east of Hucknall, but excludes Bestwood Village. It also has a spur which includes Nuthall village.

The practice proposal is to extend their current practice boundary in three areas:

1. An area to the north of their current boundary which includes south Hucknall and extends to the M1 to the west. A large part of this area does not comprise of housing, however it includes Hucknall Airfield where over 2,000 homes are planned, and the first phases have been completed. This area includes areas which are within both Nottingham North & East, and Nottingham West CCG boundaries. 2. A small area beyond Nuthall village adjoining the current boundary (within the Nottingham West boundary) 3. A small area to the south of the current boundary, to include

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Primary Care Commissioning Committee June 2019 Melbourne park (within Nottingham City).

Areas 2 & 3 have been included by the practice as a means of offering a tidy boundary; one that they can easily describe to patients and other stakeholders, that staff are able to visualise; and to offer simplicity to patients wanting to know if they fall within the boundary. They feel that offering a clear boundary which is simple and easy to interpret fits with the values of the practice.

The practice has actively considered the question of an “outer” boundary, which allows patients who move a short distance away from the practice boundary to remain with the practice. However they have decided not to have any outer boundaries in addition to their usual practice boundary.

What is the current Parkside Medical Centre has 2 GP partners who work a total of 1.6 WTE. staffing position and GP Additionally, there are 3 other GP’s providing in total 1.8 WTE. This gives a (wte) to patient ratio? ratio of 1 WTE GP: 2,203 patients. This is within the normal range of most GP practices.

The practice also has an ANP working full-time, who is also a partner on the contract.

The practice also employs: . Two full-time Practice nurses – 2 WTE How does this ratio . Health care assistant – 0.8 WTE compare to other . Phlebotomist – 0.4 WTE applications considered by the panel? The GP : patient ratio is similar to that of Leen View Surgery, who is co- located in the Bulwell Riverside building. Leen View ratio is 1:2,556.

Has this practice As demonstrated below, from 17/18 Q1 to 18/19 Q4 there has been a net observed a change in increase of 455 patients (6.5%). its list size in recent months? Patient turnover figures are not currently available from the primary care Is there a high patient webtool. turnover at this practice? The table below demonstrates the average monthly change in list size from 17/18 to 18/19 Q1. Include reference to Quarterly List monthly net changes in Date Change in size list size list size 01/04/2017 7,035

01/07/2017 7,155 120 01/10/2017 7,210 55 01/01/2018 7,274 64 01/04/2018 7,289 15

01/07/2018 7,360 71

01/10/2018 7,406 46 01/01/2019 7,490 84 How does this compare 01/04/2019 7,508 18 to other applications considered by the The only other recent application to extend a practice boundary was for panel? Southglade Health Centre, which was approved in October 2018. They are a smaller practice and the contract was being managed by a new provider Page 3 of 10

Primary Care Commissioning Committee June 2019 who was keen to grow the patient list, which had become fairly stable over the years.

Is the practice located The practice is located in a deprived area. The practice has a deprivation in an area of high score of 45 (IMD 2015) compared to a City average of 36.9. need? The Bulwell ward has the second highest unemployment rate in the City. One fifth of the working age population claim working age benefit, which is the highest proportion of all the City wards. 4 in 10 households are in receipt of housing benefit or council tax support which is above the City average.

The ward has a higher proportion of children and older people than the City average however less than one fifth of the population are from a BME background compared to the City average of over one third.

There are significantly higher rates of premature deaths from cancer and cardiovascular disease compared to the City average and the ward has the 4th lowest life expectancy at birth in the City.

Source: Bulwell ward profile 2017 by Nottingham City Council for Nottingham Insight and GP practice profiles produced by Public Health England. Is the practice A full list of additional services provided by the practice is included at commissioned to Appendix A. provide any enhanced services for vulnerable The practice provides all essential and additional services and provides all patient groups? additional enhanced services including: Homeless, Care . Learning disabilities Health Check Homes, Asylum . Minor surgery Seekers . Primary Care Patient Offer . Asylum Seekers . Homeless . Warfarin anti-coagulation and shared care (4 disease areas)

Parkside Medical Centre has confirmed they will continue to be involved with the fair allocation of care homes, and the registration of care home patients in the areas where they wish to extend their boundaries. This includes the areas in Nottingham North & East and Nottingham West CCGs, as well as within Nottingham City. They currently hold quarterly meetings with local care homes and will extend this to any new homes as a result of the boundary change.

How many practices There are ten alternative GP practices within 1.5 miles of Parkside Medical are nearby? Centre, all of which have open practice lists. See below.

The table below outlines the ten neighbouring practices within a 1.5 mile radius: List size Letter Practice Distance 01/04/19 on map Leen View Surgery – 0.0 9,555 A C84043 Riverlyn Medical Centre 0.1 2,995 C – C84717 Springfield Medical 0.4 2,636 D Centre – C84138 St Albans Medical Centre 0.6 7,284 E – C84004 Page 4 of 10

Primary Care Commissioning Committee June 2019 Southglade Health 1.0 3,017 F Centre – Y05622 Lime Tree Surgery – 1.1 3,503 G C84694 Rise Park Surgery – 1.3 7,446 H C84129 Hucknall Road Medical 1.3 13,220 I Practice– C84078 Alice Medical Centre – 1.5 3,483 J C84695 Churchfields Medical 1.5 9,384 n/a Practice – C84034

Parkside are in Primary Care Network 1, and the other practices in this PCN are:

 Leen View Surgery (co-located with Parkside)  Queensbower Surgery  Rise Park Surgery  Riverlyn Medical Centre  Southglade Medical Practice  Springfield Medical Centre  St Alban’s Medical Centre

Dr Foster from the Parkside practice has been accepted as Clinical Director for the PCN.

Do neighbouring 18 neighbouring practices have been invited to respond to the proposal, as practices support this well as the Local Medical Committee; only one response has been received application? from these practices, and that was supportive of the proposal. Nottingham

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Primary Care Commissioning Committee June 2019 North & East and Nottingham West CCGs have also been informed.

The proposal to increase the practice boundary will increase choice for What is the potential patients wishing to register in these new areas. This will reduce the impact on neighbouring pressures on other practices in these areas. As there have been no practices if this adverse comments received from any neighbouring practices, it is assumed boundary extension that there is no impact. application was approved Leen View Surgery, who share the same premises as Parkside, have submitted an application to reduce their practice boundary. A separate paper has been produced for the PCCC.

Do patients support the Yes. The PPG Chair is very keen to ensure the long-term sustainability of application? the practice, and supports the boundary extension to achieve this. The PPG as a whole, are also supportive but did seek assurances from the GPs that as the list grows, so will the available appointments. This has been confirmed by the practice and the additional staff which have been recruited.

Does the LMC support The LMC have been invited to comment but no response has been this application? received.

What are the risks, as No risks have been identified, rather the practice sees it as an opportunity to described by the grow and develop the practice. practice, if the boundary is not extended?

Recommendation

The Primary Care Commissioning Committee is asked to approve this boundary extension application subject to:  The boundary extension takes place with immediate effect.

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Primary Care Commissioning Committee June 2019 Appendices

Appendix A – Practice Overview

Workforce The make-up of the clinical staff is as follows:

Type of staff Number Whole Time Equivalent GP Partners 2 1.6 Salaried GP 3 1.8 GP Registrar n/a n/a F2 doctor n/a n/a Advanced Nurse Practitioner 1 1.0 Nurse Practitioner n/a n/a Practice Nurse 2 2.0 Healthcare Assistant 1 0.8

Registered list size and patient demographics

The practice has a raw list size (headcount) of 7,508 as at the 1 April 2019. When weighted for deprivation this increases to 8,112.

The table below shows overall there has been an increase in the number of patients at the practice over the last three years, with a net increase of 726 patients (10.4%).

List Practice % Date size change

01/01/2016 6,782 01/01/2017 7,006 3.3 01/01/2018 7,274 3.8 01/01/2019 7,490 3.0

The breakdown of the practice population by age compared to the CCG figures is demonstrated below.

% of City CCG Age Group practice average list size 0-4 yrs 7.55% 5.45% 5-19 yrs 19.76% 18.91% <19 total 27.31% 24.36% 20-64 yrs 57.48% 64.77% 65-74 yrs 8.27% 5.91% 75-84 yrs 4.74% 3.43% 85+ yrs 2.19% 1.52% 100.00% 100.00%

Local health needs

The practice is located in the Bulwell Forest ward area of Nottingham. The following information is taken from the National General Practice Profile populated by Public Health England and the 2011 Census: . The life expectancy is slightly lower than the national average (80 years for females, 77 years for Page 7 of 10

Primary Care Commissioning Committee June 2019 males). . The practice has a younger population profile than the CCG and national average with 25% of its patients under 18 years old compared to 19% and 20% respectively. . 7.5% of the practice patient list is unemployed; this is higher than both the CCG and national average . BME groups form 18.3% of the resident population in Bulwell Forest; this is lower than the city average of 34.6%. Black/African/Caribbean/Black British, Asian/Asian British and Mixed/multiple ethnic groups are the predominant BME groups in the area with 6.0%, 4.8%, 4.4% respectively. . 20.7% of Bulwell Forest residents describe themselves as having a limiting longterm illness or disability which is higher than the Nottingham average of 18.1% (2011 census). . 6.6% describe themselves as having very bad or bad health compared to the Nottingham average of 6.4% (2011 Census)  2.8% describe themselves as providing 50 hours or more of unpaid care compared to the Nottingham average of 2.4% (2011 Census).

Premises information

 Location: Bulwell Riverside, Main Street, Bulwell, Nottingham, NG6 8QJ  Owner: NHS Property Services  Tenure basis: Leased  Rent: n/a  Overall condition: Purpose built in 2012.

Access Opening hours at the surgery is as follows:

The practice has opted to provide the Extended Hours Access Enhanced Service.

Day Parkside Medical Centre Monday 08:00 – 18:30 Tuesday 07:00 – 18:30 Wednesday 08:00 – 19:30 Thursday 08:00 – 18:30 Friday 08:00 – 18:30 Saturday Closed Sunday Closed

Local primary care provision

The practice provides all essential and additional services and provides all additional enhanced services including: . Learning disabilities Health Check . Minor surgery . Primary Care Patient Offer . Asylum Seekers . Homeless . Warfarin anti-coagulation and shared care (4 disease areas)

Care Quality Commission The last report on the practice was published in August 2016 with an overall good rating and the practice received a good rating across the 5 domain areas.

Primary Care Indicators The national Primary Care web tool has been removed as of 31st March 2019 and is to be replaced by a new primary care indicator dashboard. It is expected that the dashboard will be made available during Q1 2019/20.

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Primary Care Commissioning Committee June 2019

NHS Choices feedback There are a total of 36 reviews left on NHS Choices website for Parkside Medical Centre, and they average 4 stars out of 5.

GP Patient Survey Results The National GP Patient Survey for 2018 highlighted: . 49% of respondents rated their experience of making an appointment as good as opposed to 68% locally and 69% nationally . 72% describe their overall experience of this surgery as good against a local score of 82% and national average of 84%

In general, the areas where Parkside were rated most highly, were only similar in scores to the local and national average.

Where room for improvement was identified included:  Ease of getting through to the practice by phone  Experience of making an appointment  Being offered a choice of appointment

Appendix B – Practice Boundary Change application form

Parkside application.pdf

Appendix C – Policy Framework

Practice boundary applications will be considered in line with the requirements set out within the NHS England Primary Medical Care Policy and Guidance Manual (PGM v2) Chapter 7 Contract Variations. The relevant extract is included below:

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 (a template application notice is set out in Annex 13 A).. 7.14.5 The contractor and the Commissioner must engage in open dialogue concerning the circumstances that have led to the request to change their boundary and discuss the possible Page 9 of 10

Primary Care Commissioning Committee June 2019 implications of the action, i.e. a reducing patient register, an expanding patient register, the financial implications of both and any possible alternative actions that may be taken by either party to enable the practice to maintain its existing practice area. 7.14.6 Commissioners must consider the application having regard to other practices’ boundaries, patient access to other local services and in general other health service coverage within a location and may seek to involve the public to seek their views. 7.14.7 Once a decision is reached on whether to accept or reject the application, the Commissioner should notify the contractor in writing of its decision (a template letter is provided in Annex 13B). 7.14.8 If the Commissioner accepts the proposed changes to the practice area, the contractor should be notified, as soon as possible, in writing of:  the acceptance;  the date upon which the changes will take effect; and  a requirement of the contractor to publish the details of the new practice area within their patient information leaflet and on their website (if they have one). 7.14.9 If the Commissioner declines the proposed changes to the practice area, the contractor should be notified, as soon as possible, in writing of that decision and to include:  the reasons for the decision;  the right of the contractor to appeal and the process for doing so; and  specify any period within which the Commissioner would not consider a further application from this contractor to vary its practice area. 7.14.10 Practices who are intending to reduce their practice area must be advised that registered patients who subsequently fall outside of the new agreed area, but who are within the original practice area (main and outer boundary) can only be removed from the list if one or more of the provisions of the relevant regulations / directions that relate to removal of patients from the practice's patient list apply.

Local CCG principles

For the avoidance of doubt, where a practice requests to reduce their practice boundary the CCG will require that all currently registered patients who reside in the current boundary area but who will be outside the proposed boundary area, will remain as registered patients and will not be removed at any time in the future.

The CCG may wish to apply conditions to the approval of the boundary change. Where this is the case, any conditions will be clearly stated in the notice to the practice.

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Meeting in Common of NHS Mansfield and Ashfield CCG, NHS Newark and Sherwood CCG, NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG

Meeting Title: Open Primary Care Commissioning Date: 19 June 2019 Committee

Paper Title: Finance Report Paper Reference: PCC 19/010

Sponsor: Stuart Poyner Attachments/ PCCC Co- Presenter: Stuart Poyner Appendices: Commissioning Report M2

Executive Summary The paper presents the financial position of each CCG Delegated Primary Care budget plus a consolidated position.

The consolidated position shows a year to date position of broadly breakeven. The combined forecast position of the six CCGs is to remain within budget, with sufficient reserves available to cover all risks that may be incurred during the financial year. Such risks include locum cover, care-taking and list dispersal. Recommendation: ☐To endorse ☒To review ☐To receive/note for assurance and information ☐To approve the recommendations as set out below

Recommendation(s): 1. To note the financial position of the Delegated Primary Care budget Relevant CCG priorities/objectives: (please tick which priorities/objectives your paper relates to) Compliance with Statutory Duties ☐ Establishment of a Strategic Commissioner ☐ System architecture development (e.g. ☐ Financial Management ☒ ICP, PCN development) Performance Management ☐ Cultural and/or Organisational Development ☐ Service Planning and/or Commissioning ☐ Procurement and/or Contracting ☐ Completion of Impact Assessments: Equality / Quality Impact Yes ☐ Has an EQIA been completed? If the answer is No, please Assessment (EQIA) No ☒ explain why Not required. Data Protection Impact Yes ☐ Has a DPIA been completed? If the answer is No, please explain Assessment (DPIA) No ☒ why Not required.

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Risk(s): No risks identified. Confidentiality: Is the information in this paper confidential? ☒No ☐Yes Conflicts of Interest: Please state whether there are any conflicts of interest considerations relevant to paper authors, members or attendees. ☒ No conflict identified ☐ Conflict noted, conflicted party can participate in discussion and decision ☐ Conflict noted, conflicted party can participate in discussion, but not decision ☐ Conflict noted, conflicted party can remain, but not participate in discussion or decision ☐ Conflicted party to be excluded from meeting

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Delegated Co-Commissioning – Finance Report – May 2019

Nottingham & Nottinghamshire CCG’s

The financial position below shows a consolidated overall position for the Nottingham and Nottinghamshire CCGs.

Annual Budget YTD Budget YTD Actual YTD Variance Co-Commissioning Category ('000) ('000) ('000) ('000) Dispensing/Prescribing Drs 2,341 389 386 -3 Enhanced Services 3,890 648 639 -9 General Practice – APMS 5,540 922 900 -20 General Practice – GMS 59,799 9,945 9,915 -29 General Practice – PMS 32,595 5,429 5,593 165 General Reserves 4,552 672 0 -672 Other GP Services 2,115 352 719 367 Other Premises costs 2,914 486 495 9 Premises Cost Reimbursement 15,756 2,622 2,639 17 Primary Care Networks 4,586 763 763 0 QOF 13,723 2,283 2,202 -81 Grand Total 147,811 24,511 24,252 -257

Adjustment back to NHSE Allocation -1,366 -228 0 228 Grand Total after Adjustment 146,445 24,283 24,252 -29

Year to Date

The consolidated position for all 6 CCGs is broadly breakeven, this is a similar picture by individual CCG. For detailed budget line variance review please see the supporting individual CCG reports.

Forecast

Overall, the delegated financial position is forecast to remain within budget. The individual CCGs, with the exception of Newark & Sherwood, all have contingency and other reserves that are expected to sufficiently cover all anticipated expenditure plus also providing cover for risks such as locum, care-taking or list dispersal.

Newark and Sherwood CCG, in isolation, has a current forecast overspend position of £1m. Further information regarding this forecast position were detailed further in the paper sent to PCCC on the 23rd May 2019

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Mansfield and Ashfield CCG (04E)

The financial position for Mansfield and Ashfield CCG at Month 2 2019/20 is £324k underspent. This reduces to an underspend of £188k once the adjustment the CCG made to the delegated commissioning allocation is removed. Below is the summary position by expenditure category.

YTD YTD YTD Annual Co-Commissioning Category Budget Actual Variance Budget ('000) ('000) ('000) ('000) Dispensing/Prescribing Drs 164 27 27 0 Enhanced Services 1,044 173 173 0 General Practice – APMS 1,279 212 212 0 General Practice – GMS 13,227 2,193 2,206 13 General Practice – PMS 3,930 652 651 0 General Reserves 2,033 337 0 -337 Other GP Services 281 47 47 0 Other Premises costs 58 10 11 1 Premises Cost Reimbursement 2,729 452 452 0 Primary Care Networks 858 142 142 0 QOF 2,757 457 457 0 Grand Total 28,359 4,702 4,378 -324

Adjustment back to NHSE Allocation -816 -136 0 136 Grand Total after Adjustment 27,543 4,566 4,378 -188

Key Variances

Dispensing/Prescribing Drs – Currently reporting on plan. This activity is seasonal and may vary during the winter period.

General Practice contracts – Core contract payments are largely on plan with the exception of a slight overspend at month 2 on the GMS contracts relating to changes in list size. As with all contracts this will vary throughout the year.

General Reserves – As in previous years Mansfield & Ashfield CCG has a surplus reserve that is phased evenly throughout the year and is the primary driver of the overall surplus position. However, it should be noted that this is significantly reduced on previous years as a result of the 2019/20 allocation adjustment.

Other GP Services – The key areas of spend in this category relate to CQC reimbursements, Seniority payments and Locum costs. At this stage all areas are performing on plan.

Primary Care Network (PCN) – A new category of spend has been introduced this financial year summarised as the PCN which encompasses the PCN payment, Clinical Director, Clinical Pharmacist and Social Prescriber payments. Page 2 of 8

QOF – Activity is currently on plan however the final 18/19 achievement payment is process in month 3 will adjust the Aspiration payment due this financial year.

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Newark & Sherwood CCG (04H)

The financial position for Newark and Sherwood CCG at Month 2 2019/20 is £70k deficit. This increases to a deficit of £162k once the adjustment the CCG made to the delegated commissioning allocation is removed. Below is the summary position by expenditure category:

YTD YTD YTD Annual Co-Commissioning Category Budget Actual Variance Budget ('000) ('000) ('000) ('000) Dispensing/Prescribing Drs 659 109 109 0 Enhanced Services 632 105 105 0 General Practice – APMS 903 150 150 0 General Practice – GMS 12,131 2,012 2,018 6 General Practice – PMS 0 0 0 0 General Reserves -397 -66 0 66 Other GP Services 290 48 44 -4 Other Premises costs 104 17 20 2 Premises Cost Reimbursement 2,253 374 374 0 Primary Care Networks 596 99 99 0 QOF 1,931 320 320 0 Grand Total 19,101 3,168 3,238 70

Adjustment back to NHSE Allocation -550 -92 92 Grand Total after Adjustment 18,551 3,076 3,238 162

Key Variances

Dispensing/Prescribing Drs – Currently reporting on plan. This activity is seasonal and may vary during the winter period.

General Practice contracts – Core contract payments are largely on plan with the exception of a slight overspend at month 2 on the GMS contracts relating to changes in list size. As with all contracts this will vary throughout the year.

General Reserves – Newark & Sherwood CCG has a financial gap against its allocation as detailed in the report sent to PCCC in May. Work is still ongoing to determine ways in which to mitigate this and achieve a balanced financial position.

Other GP Services – The key areas of spend in this category relate to CQC reimbursements, Seniority payments and Locum costs. At this stage all areas are performing on plan with a non-recurrent benefit of a Locum Year-end accrual no longer required.

Primary Care Network (PCN) – A new category of spend has been introduced this financial year summarised as the PCN which encompasses the PCN payment, Clinical Director, Clinical Pharmacist and Social Prescriber payments.

QOF – Activity is currently on plan however the final 18/19 achievement payment is process in month 3 will adjust the Aspiration payment due this financial year. Page 4 of 8

Nottingham City CCG (04K)

The financial position for Nottingham City CCG at Month 2 2019/20 is £1k overspent. Below is the summary position by expenditure category.

Annual YTD Budget YTD Actual YTD Variance Co-Commissioning Category Budget ('000) ('000) ('000) ('000)

Dispensing/Prescribing Drs 267 45 45 0 Enhanced Services 1,043 174 165 -9 General Practice – APMS 3,359 560 539 -20 General Practice – GMS 19,633 3,272 3,243 -29 General Practice – PMS 10,767 1,794 1,775 -19 General Reserves 1,456 200 0 -200 Other GP Services 763 127 393 266 Other Premises costs 2,122 354 355 1 Premises Cost Reimbursement 5,793 965 982 17 Primary Care Networks 1,569 261 261 0 QOF 3,943 657 651 -6 Grand Total 50,715 8,409 8,409 1

Key Variances

Dispensing/Prescribing Drs – Currently reporting on plan. This activity is seasonal and may vary during the winter period.

General Practice Contracts – GMS currently underspending on Global Sum by £28k. APMS currently underspent by £20k. PMS currently underspent by £20k. All of these underspends are due to fluctuations in practice list sizes since original budgets were set.

General Reserves – The underspend here relates to the Reserves having to be phased in the ledger in 12ths as per the Financial Plan submission at Mth 2, however in Mth 3 this will be rephased into Mth 12.

Other GP Services – The main overspend here relates to Locum costs that have been incurred, but as we have been unable to move budgets from the Plan position at Mth 2 these have been unable to be funded from Reserves, but this will be sorted from Mth 3.

Primary Care Network (PCN) – A new category of spend has been introduced this financial year summarised as the PCN which encompasses the PCN payment, Clinical Director, Clinical Pharmacist and Social Prescriber payments.

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Nottingham North & East CCG (04L)

The financial position for Nottingham North & East CCG at Month 2 2019/20 is Break-Even. Below is the summary position by expenditure category.

YTD YTD YTD Annual Co-Commissioning Category Budget Actual Variance Budget ('000) ('000) ('000) ('000) Dispensing/Prescribing Drs 290 48 49 1 Enhanced Services 449 75 75 0 General Practice – APMS 0 0 0 0 General Practice – GMS 3,945 657 657 0 General Practice – PMS 9,496 1,583 1,791 209 General Reserves 1,141 173 0 -173 Other GP Services 339 56 47 -9 Other Premises costs 164 27 27 0 Premises Cost Reimbursement 1,636 273 273 0 Primary Care Networks 646 108 108 0 QOF 2,051 342 315 -27 Grand Total 20,156 3,342 3,342 0

Key Variances

Dispensing/Prescribing Drs – Currently reporting on plan. This activity is seasonal and may vary during the winter period.

General Practice contracts – There are 2 practices who have moved CCG from 04L Nottingham North and East to 04M Nottingham West CCG; (C84667 Giltbrook Surgery & C84131 Newthorpe Medical Practice). The costs for both of these practices are on the ‘General Practice – PMS’ line and the budget and costs will be adjusted in future periods to Nottingham West once Resource Allocation transfers can be actioned in month 3.

General Reserves – The budget for the two practices that have moved to 04M Nottingham West CCG is in Reserves to be transferred via the Resource Allocation Transfer process.

Primary Care Network (PCN) – A new category of spend has been introduced this financial year summarised as the PCN which encompasses the PCN payment, Clinical Director, Clinical Pharmacist and Social Prescriber payments.

QOF – The underspend here is the QOF Aspiration payments, as the budget has been set based on 30% of what the Achievement for 18/19 was but will be adjusted when the final QOF payments are made in Month 3.

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Nottingham West CCG (04M)

The financial position for Nottingham West CCG at Month 2 2019/20 is Break-Even. Below is the summary position by expenditure category.

YTD YTD YTD Annual Co-Commissioning Category Budget Actual Variance Budget ('000) ('000) ('000) ('000) Dispensing/Prescribing Drs 121 20 20 0 Enhanced Services 358 60 60 0 General Practice – APMS 0 0 0 0 General Practice – GMS 5,542 924 914 -9 General Practice – PMS 2,723 454 439 -15 General Reserves 696 105 0 -105 Other GP Services 163 27 135 108 Other Premises costs 227 38 43 5 Premises Cost Reimbursement 1,372 229 229 0 Primary Care Networks 393 66 66 0 QOF 1,396 233 249 16 Grand Total 12,991 2,154 2,154 0

Key Variances

Dispensing/Prescribing Drs – Currently reporting on plan. This activity is seasonal and may vary during the winter period.

General Practice contracts – GMS £9K underspent and PMS £15k underspent. Both underspends are due to fluctuations in practice list sizes since original budgets were set.

Other GP Services – The main overspend here relates to Locum costs that have been incurred, but as we have been unable to move budgets from the Plan position at Mth 2 these have been unable to be funded from Reserves, but this will be sorted from Mth 3.

General Reserves - The underspend here relates to the Reserves having to be phased in the ledger in 12ths as per the Financial Plan submission at Mth 2, however in Mth 3 this will be rephased into Mth 12.

Primary Care Network (PCN) – A new category of spend has been introduced this financial year summarised as the PCN which encompasses the PCN payment, Clinical Director, Clinical Pharmacist and Social Prescriber payments.

QOF – The overspend here is the QOF Aspiration payments, as the budget has been set based on 30% of what the Achievement for 18/19 was but will be adjusted when the final QOF payments are made in Month 3. Page 7 of 8

Rushcliffe CCG (04N)

The financial position for Rushcliffe CCG at Month 2 2019/20 is £4k underspent. Below is the summary position by expenditure category.

Annual YTD Budget YTD Actual YTD Variance Co-Commissioning Category Budget ('000) ('000) ('000) ('000)

Dispensing/Prescribing Drs 840 140 136 -4 Enhanced Services 365 61 61 0 General Practice – APMS 0 0 0 0 General Practice – GMS 5,321 887 877 -10 General Practice – PMS 5,679 946 937 -10 General Reserves -378 -77 0 77 Other GP Services 280 47 53 6 Other Premises costs 239 40 40 0 Premises Cost Reimbursement 1,973 329 329 0 Primary Care Networks 524 87 87 0 QOF 1,645 274 210 -64 Grand Total 16,487 2,734 2,730 -4

Key Variances

Dispensing/Prescribing Drs – Currently reporting on plan. This activity is seasonal and may vary during the winter period.

General Practice contracts – GMS and PMS both £10k underspent. Both underspends are due to fluctuations in practice list sizes since original budgets were set.

General Reserves – The overspend here relates to the Reserves having to be phased in the ledger in 12ths as per the Financial Plan submission at Mth 2, however in Mth 3 this will be rephased into Mth 12.

Primary Care Network (PCN) – A new category of spend has been introduced this financial year summarised as the PCN which encompasses the PCN payment, Clinical Director, Clinical Pharmacist and Social Prescriber payments.

QOF – The underspend on QOF relates to Achievement and has been based upon what is expected to be paid in June in relation to the advance payment made in March 19. This is only an estimate based on the CQRS forecast and actual figures will be reported in Month 3 after the payments made.

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Meeting in Common of NHS Mansfield and Ashfield CCG, NHS Newark and Sherwood CCG, NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG

Meeting Title: Open Primary Care Commissioning Date: 19 June 2019 Committee

Paper Title: Nottingham and Nottinghamshire ICS Paper Reference: PCC 19/012 Draft Primary Care Strategy

Sponsor: Dr Nicole Atkinson Attachments/ Primary Care Presenter: Sharon Pickett, Associate Director of Appendices: Strategy for ICS Primary Care Board

Executive Summary In a letter dated 26th April 2019, NHS England and NHS Improvement requested that each STP/ICS develop a Primary Care Strategy. As well as needing to respond to the NHS Long Term Plan, the production of an ICS Primary Care Strategy is also a requirement in respect of the allocation of General Practice Forward View funding. Accompanying the letter was a template which included recommended section headings as well as detailed guidance on the expected content of the strategy.

The first draft of the strategy is due for submission to the NHSE/I regional team by 20th June. Following feedback from NHSE/I and other stakeholders the strategy will be further reviewed and updated prior to submission of the final version on 28th June.

Locally, approval of the strategy is the responsibility of the ICS Board and as such the latest draft is to be presented at the meeting of the board on 13th June for comment. At the meeting it is to be proposed that sign off of the final version of the strategy be delegated to the ICS Managing Director.

The draft ICS Primary Care Strategy is therefore submitted to the PCCC for information, and also to provide committee members with an opportunity to review and comment in advance of submission of the final version to NHSE/I.

Recommendation: ☐To endorse ☒To review ☒To receive/note for information ☐To approve the recommendations as set out below

Recommendation(s): 1. Note progress on development of the strategy to date 2. Provide feedback on the draft strategy by 25th June 3. Acknowledge the internal and external approvals process as described Relevant CCG priorities/objectives: (please tick which priorities/objectives your paper relates to)

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Compliance with Statutory Duties ☐ Establishment of a Strategic Commissioner ☐ System architecture development (e.g. ☐ Financial Management ☐ ICP, PCN development) Performance Management ☐ Cultural and/or Organisational Development ☐ Service Planning and/or Commissioning ☒ Procurement and/or Contracting ☐ Completion of Impact Assessments: Equality / Quality Impact Yes ☐ Has an EQIA been completed? If the answer is No, please Assessment (EQIA) No ☒ explain why Not applicable Data Protection Impact Yes ☐ Has a DPIA been completed? If the answer is No, please explain Assessment (DPIA) No ☒ why Not applicable Risk(s): None identified Confidentiality: Is the information in this paper confidential? ☒No ☐Yes Conflicts of Interest: Please state whether there are any conflicts of interest considerations relevant to paper authors, members or attendees. ☒ No conflict identified ☐ Conflict noted, conflicted party can participate in discussion and decision ☐ Conflict noted, conflicted party can participate in discussion, but not decision ☐ Conflict noted, conflicted party can remain, but not participate in discussion or decision ☐ Conflicted party to be excluded from meeting

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DRAFT: Nottingham and Nottinghamshire Integrated Care System (ICS) 2019/20-2023/24 Primary Care Strategy

PLEASE NOTE: Whilst this document is largely complete, this version remains a working draft which is still being developed and written. There are some gaps (identified with placeholders) and further editing to be undertaken. It is being shared at this stage to seek further comment and input. Guidance from the provided template (shown in the blue boxes at the start of most sections) has been left in for information at this stage, but will be removed prior to final submission.

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Version Control Version Date Author Details of Update Number 0.1 08/05/2019 Jon Singfield Early draft collating pre-existing material First draft shared for comments with 1.5 28/05/2019 Jon Singfield stakeholders Second working draft incorporating 2.0 05/06/2019 Jon Singfield initial feedback, shared with ICS Board for further comment and input

Authorisation

Date Name Position

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Table of Contents

1 Executive Summary ...... 7 2 Vision ...... 8 2.1 Context ...... 8 2.2 Primary Care Vision ...... 8 3 Introduction ...... 12 3.1 Map Of Nottingham and Nottinghamshire, Integrated Care Partnerships (ICP) ...... 12 3.2 Composition of System, Place & Neighbourhood ...... 13 3.3 PCN Configuration across Nottingham and Nottinghamshire ...... 13 3.4 ICS Key Partners ...... 15 4 The case for change ...... 16 4.1 Demographics and Health Inequalities ...... 16 4.2 Workforce Challenges ...... 20 4.3 Estates & Infrastructure ...... 23 4.4 Financial Sustainability ...... 24 4.5 Case for change: Conclusion ...... 25 5 Fulfilling the NHS Long Term Plan ...... 27 6 Key element 1 - We will boost ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community health services ...... 31 6.1 Current Situation...... 31 6.2 How services will be integrated ...... 32 6.3 Workforce configuration to deliver integration ...... 33 6.4 Service delivery and technology ...... 33 6.5 Governance and Operational Arrangements ...... 34 6.6 Resourcing and costs ...... 34 7 Key element 2 - The NHS will reduce pressure on emergency hospital services ...... 35 7.1 Current Situation...... 35 7.2 Role of primary care in reducing pressure on emergency services ...... 36

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7.3 Workforce configuration ...... 42 7.4 How services will be delivered ...... 42 7.5 Governance and Operational Arrangements ...... 43 7.6 Resourcing and Costs ...... 43 8 Key element 3 - People will get more control over their own health and more personalised care when they need it ...... 44 8.1 Current Situation...... 44 8.2 Role of Primary Care in Personalising Healthcare Services ...... 45 8.3 Workforce Configuration ...... 46 8.4 Service delivery and implementation ...... 46 8.5 Governance and Operational arrangements ...... 50 8.6 Resourcing and costs ...... 50 9 Key element 4 - Digitally-enabled primary and outpatient care will go mainstream across the NHS ...... 51 9.1 Current Situation...... 51 9.2 Role of Primary Care in delivering digitally enabled healthcare ...... 53 9.3 Workforce configuration ...... 55 9.4 Service delivery ...... 56 9.5 Governance and operational arrangements ...... 57 9.6 Resource requirements ...... 57 10 Key element 5 - Local NHS organisations will increasingly focus on population health – moving to Integrated Care Systems everywhere ...... 59 10.1 Current Situation...... 59 10.2 Primary Care’s role in the ICS and Mental Health agenda ...... 60 10.3 Workforce Configuration ...... 62 10.4 Service delivery and implementation ...... 63 10.5 Governance and Operational arrangements ...... 63 10.6 Resourcing and costs ...... 63 11 Workforce ...... 64 12 Governance ...... 71 13 Estates ...... 72

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13.1 Background ...... 72 13.2 ICS Estates Strategy ...... 72 13.3 Clinical Services and Estates Strategy Alignment ...... 73 13.4 Approach to Primary Care Estates and Emerging Plans ...... 74 14 Measurement ...... 76 14.1 GP Patient Survey ...... 76 14.2 GP Workforce plan ...... 77 14.3 GPFV monitoring survey ...... 78 14.4 Primary Care annual assurance statements ...... 79 14.5 Learning from GPFV MoU Reviews...... 79 14.6 Patient Participation Groups ...... 79 14.7 Governance ...... 80 14.8 Public information ...... 81 15 Finance ...... 82 15.1 Current expenditure ...... 82 15.2 Forecast expenditure ...... 84 15.3 Overall ICS Position, broken down by CCG ...... 84 15.4 Risks and mitigations ...... 84 Appendix 1 ...... Error! Bookmark not defined.

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List of Tables and Figures

Figure 2-1 - ICS Vision Statement ...... 8 Figure 2-2 – Ambitions ...... 10 Figure 3-1 - Map of Nottinghamshire ICS ...... 12 Figure 3-2 - Nottinghamshire ICS- What should happen where ...... 13 Figure 3-3 - PCNs, Practices and Population by CCG area ...... 14 Figure 3-4 - Key system organisations by footprint ...... 15 Figure 4-1 - Workforce key facts and figures ...... 21 Figure 4-2 - Projected 5 year NHS do nothing gap ...... 25 Figure 5-1 - The model of Primary Care Networks across the ICS ...... 28 Figure 5-2 - ICS Priorioties mapped to Long Term Plan priorities ...... 30 Figure 9-1 - Integration of local capabilities with NHS App ...... 54 Table 15-1 – Primary Care developments funded via Delegated Budgets £000's.... 83 Table 15-2 - £1.50 per head (from Core allocation) £000's ...... 83 Table 15-3 - GPFV (Anticipated NR Allocation 2019/20) (£000's) ...... 83 Table 15-4 - Extended Access £000's ...... 84 Table 15-5 - Practice Engagement £000's ...... 84

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1 Executive Summary

This section should summarise the overall approach that your STP is adopting to deliver the GP Forward View especially in light of the new GP Contract and the NHS Long Term Plan.

[To be written once rest of document completed]

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2 Vision

This section should state what is the vision for Primary Care for the STP with endorsement from local stakeholders, for example the Local Authority, and takes The Long Term Plan into consideration.

2.1 Context

This Primary Care Strategy aligns to the overarching vision for the Nottingham and Nottinghamshire Integrated Care System (ICS). The ICS vision, which has full endorsement from key stakeholders, is as follows:

Figure 2-1 - ICS Vision Statement Our Overall ICS Vision Across Nottinghamshire, we seek to both increase the duration of people’s lives and to improve those additional years, allowing people to live longer, happier, healthier and more independently into their old age

The vision for the ICS includes three priority areas which are essential in order to improve outcomes for the population of Nottingham and Nottinghamshire. These include: . effective resource utilisation . independence, care and quality . health and wellbeing.

2.2 Primary Care Vision

Our vision for primary care is aligned with the ICS Five Year Strategy which has been developed in order to deliver against the requirements of the NHS Long Term Plan. The vision is built on the foundations of Primary Care Networks which will enhance integrated care and which will deliver a person-centred (holistic) approach to continuous and proactive lifetime care, rather than the traditional disease focused approach. Our vision for primary care delivers: . Effective Resource Utilisation - fully integrated, primary and community based healthcare, successfully incorporating new models of care and multidisciplinary teams with wide ranging clinical and social care skills and capabilities . Independence, Care and Quality - care organised around individuals and

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populations – as opposed to organisations - delivering the right type of care based on people’s needs . Proactive and Community-Based Health & Wellbeing - providing models of health and care that are more proactive and preventative, ensuring more people are looked after at home, and closer to home, thereby reducing the rising demand for hospital-based care.

Delivery of the ICS vision is based on 10 ambitions and these have been used to frame the priorities for Primary Care. The ambitions are illustrated in the diagram overleaf.

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Figure 2-2 – Ambitions

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In order to deliver our vision and ambitions, the priorities for Primary Care are as follows: i. Delivering clinical and service consistency including access - Localised and centralised clinical services which put care in communities where possible, but concentrate care where clinically necessary to improve patient outcomes and efficiency - Excellent care plans and pathways developed by clinicians and supported by improvement science - Integrated community–based mental health services, which recognise the personal, societal and economic importance of mental health - A scaled-up primary-care system with access to speedy diagnostics and therapeutics provided in suitable facilities and supported through integrated community and pharmacy health teams ii. Workforce resilience, capacity and happiness - Workforce motivation and development that looks at the sensible delegation and demarcation of skills from the patient’s perspective and not just the producer’s iii. PCN development and reorientation to population health - Strong health promotion and illness prevention - A health system that treats patients as active partners in their care (and communities as carers), and allows individuals and carers control over their life, and ultimately, their death - Integrated health and social care provided seamlessly in the home iv. Delivering digital transformation - Excellent population and patient segmentation and stratification techniques to encourage and support citizens and patients to live actively, all supported by the latest technology

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3 Introduction

Nottingham and Nottinghamshire has a resident population of 1.1m people. The NHS annual budget is approximately £1.9bn and a budget of £525m for social care.

3.1 Map of Nottingham and Nottinghamshire ICS

Figure 3-1 - Map of Nottinghamshire ICS

3.2 Composition of System, Place & Neighbourhood

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As part of the move to the new system architecture, Nottingham and Nottinghamshire have established three Integrated Care Partnerships (ICPs) and 20 Primary Care Networks (PCNs). The diagram below provides an illustration of responsibilities in relation to working as a system.

Figure 3-2 - Nottinghamshire ICS- What should happen where

3.3 PCN Configuration across Nottingham and Nottinghamshire

Primary Care Networks provide the local infrastructure that will deliver a person- centred (holistic) approach to continuous lifetime care, rather than the traditional disease focused approach. They comprise integrated, cross organisational and cross professional groups of staff who come together as an integrated community offer.

134 GP Practices have been aligned to 20 PCNs across the ICS. Each PCN has a designated Clinical Director who will provide strategic and clinical leadership for the ongoing development of each network.

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Figure 3-3 - PCNs, Practices and Population by CCG area No of CCG PCN Population practices Ashfield South 8 38,794 Ashfield North 5 51,705 Mansfield & Mansfield South 5 46,587 Ashfield Mansfield North 8 58,425 4 26 195,551 Sherwood 7 59,627 Newark & Sherwood Newark 7 76,147 2 14 135,004 1 – Bulwell & Top Valley 8 44,571 3 – BACHS 12 59,168 4 – Radford & Mary Potter 6 49,503 5 – Bestwood & Sherwood 8 49,390 Nottingham City 6 8 66,474 7 4 36,390 8 5 31,662 U 2 51,549 8 53 388,707 1 - Hucknall 4 36,715 2 – Arnold & Calverton 3 33,778 Nottingham 3 – Carlton & Villages 6 40,969 North & East 4 4 29,647 4 17 141,109 Nottingham Nottingham West 12 106,473 West 1 12 106,473 Rushcliffe 12 128,389 Rushcliffe 1 12 128,389 TOTAL 20 134 1,095,233

3.4 ICS Key Partners

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Our partners are: . Nottingham University Hospitals NHS Trust . Sherwood Forest Hospital NHS Foundation Trust . Nottinghamshire Healthcare NHS Foundation Trust . Nottingham CityCare . NHS Mansfield and Ashfield CCG . NHS Newark and Sherwood CCG . NHS Nottingham City CCG . NHS Nottingham North and East CCG . NHS Nottingham West CCG . NHS Rushcliffe CCG . East Midlands Ambulance Service . Nottingham City Council . Nottinghamshire County Council . 6 District/Borough Councils . Voluntary Sector Organisations

Figure 3-4 - Key system organisations by footprint

ICS Nottingham & Nottinghamshire ICS

Nottingham South ICP Mid Notts City Notts

Commissioner Greater Nottingham Mid Notts group Sherwood Main Acute Nottingham University Forest Provider Hospitals Hospitals Main Nottingham Nottinghamshire Community CityCare Healthcare Trust Provider Partnership Main Mental Health Nottinghamshire Healthcare Trust Provider

Local Nottm City Nottinghamshire County Authority Council Council

Ambulance East Midlands Ambulance Service Service

4 The case for change

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This section should outline the case for change in your STP area typically this should include the following elements: 1. A summary of the current demographic profile and anticipated demographic changes, in your health economy that is determining the demand for primary care services. This should also address health inequalities and equality issues more generally in the local population. 2. The current profile of the primary care workforce in your health economy, the challenges that you face, any anticipated opportunities and/or threats that you consider material to the capacity and capability of the area’s workforce. 3. The current and anticipated challenges to the delivery of primary care services. For example how the condition, location and capacity of the primary care estate is configured and whether it is capable of delivering the changing pattern of demand. 4. What are the key funding issues that the health economy faces and how it is capable of meeting the changing pattern of demand for services? Describe any funding gaps and how you intend to meet them.

4.1 Demographics and Health Inequalities

The populations of Nottingham and Nottinghamshire require health and care services that are of the highest quality and delivered as locally as possible. Our citizens have told us that they want to be supported to take more responsibility for their own health and that if they become ill they want to be cared for at home where-ever possible with a proactive support system wrapping services around them. We have made great strides in improving the health and care that our population receive, but to continue to improve outcomes, meet the rising level of demand and stay within the funding available we recognise we need a transformation programme which will require all sectors – NHS, social care, local authority services, private and voluntary sectors to work collaboratively with our citizens to radically redesign the way we deliver our services. There are a number of reasons why our services need to be re-focused to ensure we can maximise the health and well-being of our population within the available resources. These include;

Changing Demographics There are currently 1.1m people in the Nottingham and Nottinghamshire ICS which is set to increase by 3% by 2024 and by 10% by 2039.

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The age profile of our populations in Nottingham and Nottinghamshire are relatively similar to that of the England average, whilst our Nottingham City population has a smaller proportion of those aged 50+ and a higher proportion of younger people even when we discount for its large student population. People are living far longer with 13% of the ICS population currently aged 70+ which is set to rise to 18% by 2039.Deprivation is a strong driver of illness and poor levels of health. Our ICS has large variations in the levels of deprivation, for example Nottingham City and Mansfield and Ashfield are some of the most deprived districts in England compared to Rushcliffe which has significantly lower levels of deprivation.

Deprivation and socio-economic factors significantly affect a person’s life expectancy. Nottingham City and Mansfield & Ashfield are affected by higher levels of unemployment, lower qualifications and less healthy lifestyle choices (healthy eating, smoking, overweight/obesity, low physical exercise) resulting in poorer health and wellbeing outcomes. Across the ICS we have a differential pattern in overall life expectancy with male life expectancy ranging between 77yrs – 80.7yrs and females ranging between 81.1yrs - 83.4yrs.

The healthy life expectancy, ie the number of years a person lives in ‘good health’, also shows a pattern of inequity – a male in Nottingham City lives 57 years in good health compared to a male in the rest of Nottinghamshire who lives 62.5 years. The pattern is similar for females with 53.3 years compared to 61.6 years.

The number of people living with multi-morbidity prevalence will also rise dramatically across our population significantly increasing the complexity of those people who do need health and care support. The number of people with 4+ diseases will more than double in the next 20 years and 2/3 of these will have mental ill-health as well as physical ill-health. By 2039 moderate frailty will increase by 96% and severe frailty by 117%.

Childhood obesity is a further key indicator of the impact our lifestyle choices have on the health of our population. It is associated with a higher chance of premature death and disability in adulthood. Overweight and obese children are more likely to stay obese into adulthood and to develop long term health (LTC) conditions such as diabetes and cardiovascular diseases at a younger age.

For most LTCs resulting from obesity, the risks depend partly on the age of onset and on the duration of obesity. Obese children and adolescents suffer from both short-term and long-term health consequences. The most significant health consequences of childhood overweight and obesity, that often do not become apparent until adulthood, include cardiovascular diseases (mainly

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heart disease and stroke); diabetes; musculoskeletal disorders, especially osteoarthritis; and certain types of cancer (endometrial, breast and colon).

At the age of 4-5yrs Nottingham City children are already significantly less likely to be a healthy weight that those in Nottinghamshire and the rest of England. By age 10-11yrs the gap has grown further with only 57.8% of Nottingham City children being a healthy weight compared to 64.3% in England as a whole. By 10-11yrs 2in 5 children and 1in 15 children in Nottingham City are severely obese and this is increasing year on year for both age categories.

Changing Public Expectations We therefore have a growing population with increasingly complex care needs that are placing different demands on the health and care services. However, they also want to be able to receive services in a very different way to that which their parents and grandparents did. Our citizens tell us they want easier access to services closer to home, increased use of technology and other ways that enable them to take greater control of their health and well-being. Much of our estate was established over 50 years ago to meet a very different health need. Our health and care services need to adapt and change to provide high quality care for people at home or in the community (where appropriate) and to ensure everyone can benefit from modern day medicine, technological advances, and new models of care.

Clinical Sustainability The current healthcare system is clinically unsustainable driven by demand pressures, insufficient levels of out of hospital services and staff shortages. From an activity perspective we have seen: . Increase in demand for primary care appointments . Outpatient appointments have increased by 15% in the last 3 years (17/18 vs 14/15) with a 20% increase in age 70+ Outpatient appointments. . A&E attendances have seen a 4% increase in the last 3 years (17/18 vs 14/15) with a 17% increase in age 70+ A&E attendances in last 3 years. . Inpatient episodes have increased by 7% over the last 3 years but we have seen a corresponding decrease in bed days by 9% and an increase in day case activity of 10%. There has been a 17% increase in inpatient episodes in those age 75+. . Currently 13% of the ICS population is aged 70+ and this population accounts for; . 20% A&E attendances,

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. 27% outpatient appointments, . 31% of emergency inpatients, . 33% of elective and 33% of day cases Circulatory disease (including stroke, coronary heart disease), cancers and respiratory diseases currently account for 60% of the diseases that cause the gap in life expectancy between the most and least deprived areas in Nottingham and Nottinghamshire and these are set to rise. For example over the next 20 years stroke will increase to 84%, respiratory diseases to 101% and cancer to 179%. Evidence has confirmed that these diseases can be prevented by improving lifestyle choices. For example; . 9 out of 10 strokes are caused by risk factors that can be modified . 40 - 45% of cancers are caused by risk factors that can be modified

Current data suggests that we still have significant areas of unhealthy lifestyle choices as demonstrated below;

Smoking  Mansfield and Ashfield > 1 in 5 people  Rushcliffe 1 in 12 people Exercised for 30 mins for  Nottingham City and Mansfield and Ashfield - 1 in 3 people 12 out of 28 days  Rushcliffe - 1 in 2 people

With the population growing, ageing and spending a higher proportion of time in poor health, there will be an ever increasing need for carers. Informal carers need more support, they are 2.5 times more likely to experience psychological distress than non-carers; working carers are two to three times more likely to suffer poor health than those without caregiving responsibilities. Dementia carers particularly struggle and dementia is due to increase 86% in the next 10 years.

The pressures on our current services are unsustainable and require a radical re-think in not only how and where services are delivered to ensure efficient and effective delivery, but also how we shift to a more proactive model of care that focuses on preventing the population developing the disease burden in the first place.

Clinical sustainability also requires us to review and consider how and where we deliver services from. Treatments are becoming increasingly specialised offering the potential to improve quality of care further by enabling access to the latest treatments and techniques. This will enable specialist staff to build their

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skills and capabilities, and to ensure all patients have access to specialist skills and equipment.

4.2 Workforce Challenges

Across the ICS

Workforce is a key driver for change within our system. Having staff with the right skills and expertise in the right locations is fundamental if we are to achieve our goals and ambitions as a system and we currently face a number of significant challenges in being able to achieve this.

The ICS has developed a 10 year People and Culture strategy which articulates the challenge and puts forward some of the mitigations in terms of recruiting and retaining high quality staff to deliver the care needs of our population. We employ a wide range of talented and dedicated staff across our system who provide excellent care and services to our populations. The profile of staff is as follows;

Figure 4-1 - Workforce key facts and figures

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Our local analysis indicates that based on current demand trajectories our ICS will have a shortage of at least 1,500 clinical staff over the next five years. Our system is currently running with a high vacancy rate at 18.19% with turnover at 11.4%. This is exacerbated by a reduced supply of graduates and an ageing workforce with a significant number of staff reaching retirement age. In terms of primary care, modelling has highlighted significant workforce challenges including a shortage of General Practitioners (77 FTE short by 2020) along with a general shortage of practice nurses and other primary care based staff. Additionally, there are 2000 (9%) social care/ residential care staffing vacancies, with turnover in Nottingham and Nottinghamshire in line with the England average of 30.1%. Our People and Culture strategy outlines a range of initiatives and actions that need to be taken for us to address this significant workforce challenge. These are aligned to four strategic workforce objectives: . Recruitment & retention supporting our current workforce; . Supporting and retaining our students; . Developing and supporting emerging new roles; . Preparing the workforce for new ways of working.

Staff engagement is a key enabler to delivery of both our People and Culture strategy and to this Primary Care Strategy. It is essential that we listen and respond to our workforce to shape the delivery of our priorities. Evidence tells us that an engagement and committed workforce leads to improved patient outcomes and increased staff satisfaction which will assist with recruitment and retention challenges. Developing our Primary Care Strategy will also identify where we will deliver

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services differently and how we can use enablers such as technological advances to mitigate some of the workforce challenges. We need to ensure that staff are empowered to work at the top of their licence and that we maximise their valuable contribution by developing new and innovative roles where appropriate to ensure we continue to focus on high quality patient outcomes. Additionally, we recognise that the current roles and workforce structures are not fit for purpose. We need to develop a flexible workforce that is not constrained by organisational or professional boundaries. In order to achieve this we will need to link with education providers and review the approach to training our future workforce to focus on the skills we need rather than the roles themselves.

Primary Care and GP Practices In engaging with our GP Practices across Nottingham and Nottinghamshire GP practices they have outlined that they: . are struggling to recruit both salaried GPs and partners on a permanent basis, particularly GP partners. Given the number of GPs anticipated to retire over the next 5 years, practices are concerned that this will further exacerbate existing workforce challenges and pose risks to continuity of provision locally . are concerned that a reduction in the number of general practice trainees will result in an increased risk to workforce capacity over than next 5-10 years . are concerned that difficulties in recruiting doctors and nurses is reducing available capacity within the system, compounded by closing practices . often have to manage vacancies through the use of temporary or locum GPs . are finding it increasingly difficult to source locum medical cover for gaps in frontline general medical services provision . are finding it challenging to maintain continuity of care and clinical quality with the need to use more temporary locum medical staff . have concerns that financial austerity will introduce further financial challenges to sustaining frontline services . recognise particular challenges in recruiting to practices that serve our most deprived populations, where workload is typically higher and more challenging whilst pay is often lower . are aware of the need to develop and support primary care leadership and to encourage more inclusivity and greater diversity of leaders.

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4.3 Estates & Infrastructure

The quality of the existing primary care estate provides both a challenge and an opportunity. Across the ICS area there is £168m of backlog maintenance required across the key provider organisations much of it critical for ongoing service delivery. The healthcare estate infrastructure in the ICS costs circa £172 million per annum of which £78 million p/a is Private Finance (PFI) or LIFT payments. Nottingham & Nottinghamshire Estate (Health) has: . High number of NHS Property Services inherited from Nottingham City and Nottinghamshire County PCTs . LIFT and PFI Estate across the system – high quality, commercial estate Key challenges and issues: . We do not have a single system long-term plan, historically estates plans produced at an organisational level for short/medium term . There is underutilisation of high quality, commercial estate i.e. PFI and LIFT . Clinical space is used for administrative purposes in many of these buildings. . We have an aging primary care estate with growing levels of backlog maintenance and inadequate space to meet future requirements. . There are 316 health buildings across the ICS including 115 GP owned buildings . £171 million annual running costs . £168 million backlog maintenance requirement (£110 million is high risk)

It is therefore essential that our strategy for primary care estates over the next five years supports and enables . Better use of our primary care estate, especially PFI and LIFT building where there are long term contractual commitments, using the estate more effectively for the whole health and care system, looking beyond traditional organisational boundaries. . The development of new primary care estate where required in order to deliver against the requirements of the NHS Long Term Plan.

4.4 Financial Sustainability

The Nottingham and Nottinghamshire ICS currently spends £3.2 billion on health and care services and for a number of years has been spending more money than it receives. Without change, the situation will get worse.

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The system faces a gap of £159.6 million in 2019/20 representing 4.9% of the total system resources. This gap is expected to increase to in excess of £500 million by 2023/24 for NHS services alone if we do not change the way in which we design services and work with our populations to improve their health and well-being to prevent them entering ill-health in the first place. The improved NHS Long Term Plan funding settlement will result in system resources increasing by circa 20% over the next five years but this will not keep pace with cost increases which are projected at 35% for the same period if we don’t do anything differently. To address the financial and operational challenges the system needs to focus on how services are transformed to be delivered within available resources (finance, workforce and capacity). Five-Year Plan: Finance & Efficiency Gap . An initial indicative figure (more detailed analysis is ongoing) for the health system’s do nothing five year gap has been identified as £510 million (increasing gap) - NHS system resources expected to increase by 20% over 5 years to £3 billion - NHS system costs expected to increase by over 35% over 5 years to £3.5 billion . ICS has higher levels of fixed costs in comparison to other systems due to PFI costs . NHS is implementing a new financial framework for providers and commissioners and it is expected that in future years we will move away from control totals and sustainability funding. However, for 2019/20 control totals remain in place, for individual organisations and ICSs. . The five-year plan will need to deliver within available resources.

Figure 4-2 - Projected 5 year NHS do nothing gap

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4.5 Case for change: Conclusion

We have a compelling need for change, driven by the changing needs of our local population and by the need to ensure we are consistently offering the best evidence based services for all of our citizens. We are faced with a current health and care system that has a number of challenges, ranging from  an inability to recruit and retain the key skills and workforce we require to deliver care,  rising costs that mean our current services are costing more than the income we receive  a primary care estate that is aging and does not have adequate space to support the delivery of new models of care. These issues are very real and we need to address them in a way that will improve outcomes for individuals, our communities as well as all of our staff working across the system. Experiences locally and nationally from testing alternatives through Vanguards and other developments tell us that primary care has a vital role to play in improving population health and helping to drive the system forward, including relieving pressure on A&E departments and offsetting winter spike demands. But our Primary Care provision also needs to find ways to address its own pressures and challenges in order to be able to fulfil its role effectively.

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5 Fulfilling the NHS Long Term Plan

The following sections should outline, in summary how the strategy meets the five key elements as set out in Chapter 1 of the Long Term Plan (LTP): 1. We will boost ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community health services (section 5) 2. The NHS will reduce pressure on emergency hospital services (section 6) 3. People will get more control over their own health and more personalised care when the need it (section 7) 4. Digitally-enables primary and outpatient care will go mainstream across the NHS (section 8) 5. Local NHS organisations will increasingly focus on population health – moving to Integrated Care Systems everywhere (section 9) When addressing each element the strategy should note each of the following: 1. The role that PCNs will play in achieving each element of the LTP 2. How the workforce will be configured to achieve each of the elements 3. What changes will be required to the location and function of the estate in achieving each element. 4. How the increased use of new technology will support the delivery of primary care services. 5. What the pattern of funding will be to ensure this can be achieved within the limits of budgetary allocations. Particular reference to how you intend to manage the delegated funds for this year and the outcomes you intend to achieve with the delegated funding, should be included.

This section should provide your statement of intention to meet the key five elements of the NHS Long Term Plan (LTP) in primary care.

How we intend to fulfil the ambitions of the NHS Long Term Plan for primary Care Our overarching aim for Primary Care Networks is that;- “PCNs will be at the heart of health and care provision; improving the wellbeing of our local populations through proactive, accessible, coordinated, and integrated health and care services.” Our vision therefore is an integrated, place-based care approach developed

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around natural communities. Key characteristics of each PCN will be: . An integrated and collaborative primary care workforce, with a strong focus on delivering quality services through partnership – ‘primary care’ is defined as first line services such as; general practice, community providers, secondary care, mental health, voluntary sector and social care; . A supported and integrated workforce with a combined focus on prevention and personalisation of care with shared and improved qualitative health and care outcomes utilising population health management data; . Citizens that are taking personal responsibility for their own well-being and are actively engaged in the development of their local Primary Care Network and in strengthening their local community; . A proactive model of care, utilising risk stratification and targeted interventions to eliminate hospital admissions as a default for people who are not acutely unwell but do need some degree of help and support to prevent further deterioration.

Figure 5-1 - The model of Primary Care Networks across the ICS

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In addition to core general practice and associated services, it is anticipated that all PCNs will incorporate the following services within their scope: . Population health management for risk stratification of the population. Phase 1 will focus on 100% of patients with a long term condition but will ultimately cover 100% of the local population . Proactive and self-care . Enhanced care to care homes . Planned care - secondary care consultations, procedures and outpatient appointments . Urgent and unplanned care - access to GP-led urgent care through GP surgeries, OOH, integrated urgent care and urgent care centres, including access to diagnostics imaging and x-ray . Step-up and step down care - to avoid hospital admissions and support early discharge, including mental health crisis teams

A great deal of progress has already been made within the system in implementing the ten ‘High Impact’ changes set out in the General Practice Forward View to improve efficiency and resilience, and work continues across these areas. The Long Term Plan provides opportunity for our Primary Care to go further and build upon the foundations established to date, playing a critical role in the delivery of the new care models described in the following sections.

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In addition to the priorities set out in the Long Term Plan, Nottingham and Nottinghamshire ICS has a set of priorities focussed on the particular needs of our population and the challenges in our system. As the table below demonstrates, these complement and support the Long Term Plan whilst helping to direct effort and resource where it is most needed.

Figure 5-2 - ICS Priorities mapped to Long Term Plan priorities ICS Priorities Long Term Plan Priorities ICS1 Redesign the urgent and emergency care system, LTP1 LTP1 We will boost ‘out-of-hospital’ care, and finally ICS1 including integrated primary care models, to ensure LTP2 dissolve the historic divide between primary ICS3 timely care in the most appropriate setting LTP5 and community health services (section 5) ICS2 Improve support to people at risk of and living with LTP3 LTP2 The NHS will reduce pressure on emergency ICS1 single and multiple long term conditions and disabilities LTP4 hospital services (section 6) ICS3 through greater proactive care, self-management and personalisation ICS3 Re-shape and transform services and other interventions LTP1 LTP3 People will get more control over their own ICS2 so they better respond to the mental health and care LTP5 health and more personalised care when the ICS5 needs of the population need it (section 7) ICS4 Deliver increased value, resilience and sustainability LTP4 LTP4 Digitally-enables primary and outpatient care ICS2 across the system (including estates) will go mainstream across the NHS (section 8) ICS4

ICS5 More action on and improvements in the upstream LTP3 LTP5 Local NHS organisations will increasingly focus ICS1 prevention of avoidable illness and its exacerbations LTP5 on population health – moving to Integrated ICS3 Care Systems everywhere (section 9) ICS5

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6 Key element 1 - We will boost ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community health services

This section should demonstrate the role primary care will play, in your health economy to develop the integration of primary and community health services. This should address the following areas: 1. A summary of the current situation regarding the integration of primary and community services, including any developments that have already been implemented or that are underway. 2. A description of how services will be integrated 3. How the workforce will be configured to deliver the proposed integration, the new and/or additional roles that will be needed and the implementation timeframe. 4. How services will be delivered, what role new technology might play and the timeframe for implementation any proposed solutions. 5. The section should also describe the governance and operational arrangements that will be required to deliver and implement the proposed changes. 6. The resourcing of the proposed changes should also be addressed, detailing both the set up and anticipated ongoing costs of delivering the proposed changes.

6.1 Current Situation

A great deal of work has already been undertaken across Nottinghamshire to integrate Primary and Community Services. There are strong examples of good practice already in place, including the award winning Vanguard in Rushcliffe, and a well-established Care Delivery Group model. Over the last twelve months work has been underway to build on the learning from the four Vanguard programmes: urgent care, care home, multi-specialty community provider, and integrated primary and acute care systems. The four New Models of Care work programmes have provided extensive learning and insights that support the continuation of work to progress and develop care close to home, supported by the integration of general practice, community provision, and social care. More recently work has focussed on the development of Primary Care Networks across Nottingham, South Nottinghamshire and Mid Nottinghamshire. This work has been supported by all key health and care partners across the

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ICS. The publication of the NHS Long Term Plan and Investment and Evolution: a five-year framework for GP contract reform to implement The NHS Long Term Plan have provided added impetus to progress the work to formally establish Primary Care Networks across the ICS area.

6.2 How services will be integrated

PCNs need to embrace a much wider approach than the traditional model of general practice. The approach will focus on the prevention agenda with the aim of reducing the need for complex care in future years. This will be achieved through; . Robust risk profiling and targeted, outcome based interventions . 100% coverage of population health management data that links into the wider community to enable people to proactively take control of their health and well-being . General Practice stratifying and proactively targeting at risk people in their locality . Patient choice and self-care, supporting patients to make choices about their care and look after their own health by connecting them with the full range of statutory and voluntary services.

Prevention needs to be seen to have an equal level of importance as treatment modalities and be implemented at scale. It should be accessed at all levels, from an individual GP consultation, right through to accessing the wider community assets. This will be achieved through: . An expansion of social prescribing and health coaching aligned and navigated through dedicated care co-ordinators. . Promotion and access to screening programmes will continue to have their profile raised with the aim that national priorities and targets are surpassed. . A focus on ‘what is important to you’ rather than ‘what is wrong with you’. . A focus on personalisation and personal health budgets which will also enable a more proactive approach to maintaining well-being.

Care co-ordination needs to take place across all levels of the health and care system from the individual consultation within the GP practice, through to coordinating with wider services across a number of PCN’s. This will be achieved through; . Shifting the response of care co-ordination to a more proactive focus so that

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care co-ordinators are able to actively contact patients and work alongside social prescribers and health coaches to proactively signpost and motivate people to promote their well-being. . A well-developed JSNA at an ICS level and clear implementation plans developed through the ICPs. Local authority and voluntary sector organisations – housing, education, fire and police services, leisure, and environmental health services, along with engagement with local businesses and voluntary organisations will be key to

Addressing the wider determinants of health through engagement with the wider social network is vital. Issues such as debt, poor housing and social isolation can have a negative impact on a person’s health and wellbeing. This will be addressed through: . Giving children and young people a good start in life by engaging with education providers in local communities and focusing on healthy families . Development of local strategies that will provide training and job opportunities, good quality housing and keep people connected to their local community by enabling people to create and engage with local community assets . Ensuring that parity of esteem is delivered between physical and mental health problems, and that a holistic approach is delivered to support patients and their families.

6.3 Workforce configuration to deliver integration

The workforce will move away from service specific care to a more generalist role and will be trained to treat the patient, not the disease, recognising that most patients may have one or more health or social care need.

6.4 Service delivery and technology

The use of technology and effective information sharing will be critical. Utilising technology and information patients will have the ability to book their appointments online, re-order prescriptions, access their GP medical records and access online consultation services. Patients will be empowered by giving them the tools to support their own self-care as well as offering more telephone advice/video consultation appointments.

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6.5 Governance and Operational Arrangements

[To follow]

6.6 Resourcing and costs

[To follow]

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7 Key element 2 - The NHS will reduce pressure on emergency hospital services

This section should demonstrate the role primary care will play, in your health economy to reduce pressure on emergency hospital services. This should address the following areas: 1. A summary of the current situation regarding the integration of primary and community services, including any developments that have already been implemented or that are underway. 2. A description of the role primary care will play in reducing pressure on emergency services, providing an estimate of the potential impact and how this might develop over time. 3. How the workforce will be configured to reduce pressure on emergency services, the new and/or additional roles that will be needed and the implementation timeframe. 4. How services will be delivered, what role new technology might play and the timeframe for implementation any proposed solutions. 5. The section should also describe the governance and operational arrangements that will be required to deliver and implement the proposed changes. 6. The resourcing of the proposed changes should also be addressed, detailing both the set up and anticipated ongoing costs of delivering the proposed changes.

7.1 Current Situation

Our emergency care services are under huge pressure and it is recognised that any sustainable solutions require whole system transformation, including leveraging the role of Primary and Community services to a greater extent. PCNs are seen as a key enabler in helping with this transformation. General practice is already meeting the core national requirements in respect of GP extended access which includes: . 100% population coverage . Monday to Friday 8am to 8pm . Saturday and Sunday/Bank Holiday pre bookable appointments There are also a number of other initiatives being delivered which are targeted at reducing pressure on emergency services. These include: . Acute Home Visiting Service – proactively completes ‘on the day’ requests

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for a home visit. Leading to reductions in hospital attendance; increase utilisation of single point of access and earlier arrival times at hospital, allowing secondary care to turn patients around on the same day. . Enhanced Care Home Service which manages patients in a community setting . Community monthly Multi-Disciplinary Team (MDT) risk stratification meetings by PCN identifying those at risk of admission or deterioration. . High intensity user MDT meeting focussing on proactive care planning for people deemed high volume service users . Non clinical navigators using E-healthscope to identify patients who have triggered demand on secondary care services such as ED. . Practice level information used to performance manage individual practice secondary care utilisation . Local public engagement through Patient Participation Groups, including education

7.2 Role of primary care in reducing pressure on emergency services

A key priority for the ICS is to transform the urgent and emergency care system, including integrated primary care models, to ensure timely care in the most appropriate setting. This is being addressed through four strategic areas, each supported by a series of initiatives, with Primary Care playing a key role in many of these: i. Out of hospital urgent care ii. Pre hospital urgent care iii. Hospital care - Flow and right place iv. Home First Integrated Discharge

i) Out of hospital urgent care Primary care is core in the delivery of this strategic area and all four initiatives:

Initiative Description

Same Day Each PCN will provide same day access to an appropriate Access to health or social care professional via a GP led multi-disciplinary Primary Care service model which includes therapists, pharmacists, community physical and mental health nurses and social workers. Delivery will be through a network of practices and/or hubs within PCNs with services available from early morning into the evening, 7 days a week. Out of Hours services will be either

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aligned or integrated with the daytime same day access service.

Single Point of In circumstances where patients do deteriorate community Access (Call for based urgent response and recovery support will be readily Care) available with the aim of preventing unnecessary admission to hospital. Access to these services will be via a single point of access, known locally as Call for Care. Health and social care referrers will hand over the patient, and often complex family, care needs to Call for Care who will assess the patients’ needs and mobilise appropriate services and equipment, including a two hour response and support (both social and health care support). Call for Care will be accessible to all health professionals and provide other services, like EMAS, with support so patients can remain at home where clinically appropriate. Call for Care will also be able to access step up bedded capacity should a patient require a period of rehabilitation. The Strategic Commissioner will agree with each of the ICPs the optimal hours the service will operate , the pathways, and how it will integrate with its PCNs.

Community Out of hospital crises response will centre around an integrated Crisis rapid response service that will: Response . Respond within two hours (accessed by the single point of access) of referral in line with NICE guidelines, where clinically judged to be appropriate, thereby preventing A&E attendances and unnecessary admissions to hospitals and residential care; . Provide a ‘pull approach’ by supporting the active management of patients at the front door to prevent A&E attendance and admissions by ensuring urgent response pathways are utilised appropriately to prevent decision to admit; and . Support and accelerate complex discharges into the community from hospital. This urgent response and recovery support will be delivered by flexible joint health and social care teams that include GPs, allied health professionals, district nurses, mental health nurses, therapists and reablement, and will be fully integrated with Primary Care Networks and local hospitals.

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The integrated rapid response service will deliver holistic assessments and short term interventions based on an acute medical health condition within the patient’s usual place of residence wherever possible, or refer into a ‘step-up’ bed. The integrated rapid response service will make appropriate referrals and have direct access to other community providers and closely align with the Acute Home Visiting Service (AHVS), which are staffed by experienced Advanced Nurse Practitioners who visit patients that GPs would normally visit at home. The Strategic Commissioner will agree with each of the ICPs the optimal hours the community crisis response service will operate, based on needs, the duration of care packages provided, how the service supports the active management of patients at the hospital front door and how it integrates with step- up beds, specialist teams (e.g. falls), AHVS and the voluntary sector.

Community Even when primary and community care professionals identify ‘step-up’ beds the need for an in- patient stay it is still be possible to avoid an acute admission by using ‘step-up’ beds. Step-up beds will be used when it is not safe to support people in their usual place of residence, an assessment is needed and patients are likely to benefit from a short term bed based in patient stay. They will be accessed through Call for Care. The Strategic Commissioner will determine with the three ICPs the location and number of step- up beds on an ongoing basis including in community hospitals, a ward on an acute site and / or in the independent sector to ensure they meet local need. Local PCNs will be looked to for medical cover to the beds

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ii) Pre Hospital Urgent Care Primary care has a key role in the delivery of two of the four initiatives within this area.

Initiative Description

Integrated The Strategic Commissioner will commission an Integrated Urgent Care Urgent Care Service that operates across all three ICPs and is Service comprised of two elements; an integrated Clinical Assessment Service (CAS) and Urgent Primary Care Treatment Services.

The CAS will move from a ‘hear and refer’ to a ‘consult and complete’ model, with the aim to close the majority of calls within its services or make a direct booking into another service for example a GP surgery within a PCN or Urgent Treatment Centre. This consult and complete model would move towards reducing reliance on A&E referral and ambulance conveyance unless clinical presentation indicates this is the only appropriate course of action. A single entry point via NHS 111 either by phone or internet based NHS 111 online applications.

These calls (or online referrals) will be received and triaged by 111 call handling staff with appropriate calls be passed to a Clinical Assessment Service for further clinical assessment. Patients who then require treatment face to face (rather than telephone) will be directed to an appropriate service which may be accessed via a booked appointment. One of these options for patients with a minor injury or illnesses will be an Urgent Treatment Centre.

The Strategic Commissioner will agree the pathways and conditions that are managed by the CAS and how it integrates with PCNs with the three ICPs to ensure they meet the needs of the population.

In addition the Strategic Commissioner will procure an out of hours service across Nottingham and Nottinghamshire to a single specification that provides face to face treatment and home visits.

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Ambulance This initiative is predominantly aimed at the Ambulance Service, Conveyance although it does draw upon services such as Call for Care and and Arrivals Community Pathfinder. Front Door When patients present at an A&E there are still opportunities to Triage and provide alternative care rather than assessment within A&E and Divert potential onward admission.

Triage and divert will be supported by Primary Care Streaming that is integrated with the CAS and a multi-disciplinary front door team who are experts in signposting and finding alternative care, where needed, in the community.

The team will include nurses, therapists, mental health specialists, social care professionals and social prescribers. Professionals will work to the same thresholds, providing an appropriate response across the spectrum of urgent care.

This team and service will be part of or integrated with the Community Crisis Service depending on the model agreed between the Strategic Commissioner and the ICPs.

Senior decision makers are key to the success of the A&E. When patients enter the A&E a decision making clinician will see new patients on or as close to arrival as possible. The A&E team will not admit a patient likely to be able to go home just to avoid a breach of the emergency care four hour standard.

Mental Health All age mental health liaison services will be available in all Liaison Service acute trusts 24/7 providing direct support into A&E as well as wards to support admission avoidance and early discharge

iii) Hospital Care – Flow and Right Place The initiatives within this strategic area are predominantly around practices within the acute hospitals, although improved management and utilisation of community bed capacity is needed to support this.

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iv) Integrated Discharge

Initiative Description

Discharge to The vast majority of patients (approximately 85%) will leave the Assess and hospital with no ongoing care needs. These patients will be Manage discharged in a timely manner with appropriate transport planned in advance. The remaining 15% of patients will need to leave the hospital with ongoing support. The provision of high quality reablement care will reduce the dependence of patients upon on going care and in many cases eliminate the need for support after the first few weeks of discharge. When a patient is declared to be medically optimised a full Discharge to Assess process will be implemented. When an intensive level of care (daily and/or 24 hour care) is agreed the patient will be admitted to either: . Urgent response/intensive rehabilitation at home for home based daily rehabilitation; or . Intensive rehabilitation within a bedded facility When a less intensive level of care is agreed, the patient will be supported either: . Within their usual place of residence with health and/or social care support; or . Within a bedded facility to receive rehabilitation, if they are non-weight bearing and their needs can not be met in an alternative setting or if they are requiring a DST CHC assessment. The Strategic Commissioner will determine with the three ICPs the location type (intensive vs. less intensive) , duration of care package and number of step-down rehabilitation beds on an ongoing basis, supported by bed utilisation reviews, including in community hospitals, a ward on an acute site and / or in the independent sector to ensure they meet local need. Similarly the Strategic Commissioner will determine with the three ICPs the required capacity for intensive rehabilitation and less intensive rehabilitation, and the duration of care packages to be provided within patients homes on an ongoing basis. Local PCNs

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will be looked to for medical cover to the beds.

7.3 Workforce configuration

One Clinical Pharmacist per PCN - in line with the national GP contract Social Prescriber – one per PCN – in line with the new National DES

7.4 How services will be delivered

Each ICP will undertake work to understand demand and capacity in secondary care.

GPs will continue to offer extended access and will focus on improving the utilisation of pre bookable appointments.

PCNs will continue to work with community provider partners in identifying those most at risk of hospital admission and will proactively put in place plans to manage the particular issues identified; this will be far and wide reaching to include ill health, social care needs and determinants wider than health such as housing and debt.

The CCG expects that a common set of outcomes is adopted across PCNs within the ICPs in Nottingham and Nottinghamshire. Where appropriate, a consistent model for delivery will be adopted by all geographies. Primary care, community services and local authorities will be key partners in providing proactive case management.

Each practice population will be reviewed using a common risk stratification tool that will identify the patients who are most at risk of attendance at or admission to hospital. Once identified some patients may only require a simple intervention that reduces their risk and will not require a full care plan and regular review. For practical reasons only those most complex patients who remain high risk will have regular reviews of their care plans. Other patients will be reviewed as the data iteratively escalates them back into the risk thresholds.

Interventions and care plans agreed should concentrate on managing the patient’s needs in the community. If patients do attend A&E or require admission to hospital the care plan will be available to hospital staff and will detail jointly agreed “ceilings” of treatment (as well as care), including a

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comprehensive social history to allow for effective discharge planning at the point of admission.

The NHSE new care model - Enhanced Health in Care homes framework is being rolled out and the framework aims to enhance 7 core elements and 18 sub elements to maximise benefits of existing works to improve the quality and safety of care for residents living in care homes. Many of these elements will support hospital avoidance.

7.5 Governance and Operational Arrangements

The assurance and monitoring of this will be carried out through the ICS Primary care steering group and the ICP A&E Delivery Board The Joint Primary Care Commissioning Committee (JPCCC) will provide oversight

7.6 Resourcing and Costs

[To follow]

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8 Key element 3 - People will get more control over their own health and more personalised care when they need it

This section should demonstrate the role primary care will play, in your health economy to personalise care and should address the following areas: 1. A summary of the current situation regarding the personalisation of healthcare services, including any developments that have already been implemented or that are underway. 2. A description of the role primary care will play in personalising healthcare services. 3. How the workforce will be configured to deliver personalised care, the new and/or additional roles that will be needed and the implementation timeframe. 4. How services will be delivered, what role new technology might play and the timeframe for implementation any proposed solutions. 5. The section should also describe the governance and operational arrangements that will be required to deliver and implement the proposed changes. 6. The resourcing of the proposed changes should also be addressed, detailing both the set up and anticipated ongoing costs of delivering the proposed changes.

8.1 Current Situation

NHS England named the Nottingham and Nottinghamshire ICS as a demonstrator site for the comprehensive model of personalised care. The vision of personalised care in the Nottingham and Nottinghamshire ICS is to maximise independence, good health, and wellbeing throughout people’s lives, shifting the focus from ‘what is the matter to you’ to ‘what matters to you’.

The ICS is working to give people access to a range of services that enables them to make choices that will focus on self-care without unnecessary intervention, developing access to an array of appropriate choices to support this. For those who need more assistance, people are offered personal budgets, personal health budgets or integrated budgets in order to ensure meaningful choice and control, resulting in both health and social care that meets the person’s needs. A person-centred approach is used to empower all people using health and social care services in order for them to build their own knowledge, skills and confidence to self-care.

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In 2018/19, after signing a memorandum of understanding in 2018/19 with NHS England, the ICS and partner organisations have delivered:

. A clear vision for implementing personalised care in line with the NHS Long Term Plan and Universal Personalised Care: Implementing the Comprehensive Model . System ownership, especially at senior level within ICS organisations, with many starting to see personalised care as a solution . Shared leadership across health and social care, working as a team . 2,321 PHBs/integrated budgets, 18,519 personalised care and support plans, and 14,662 self-management and community support plans in 2018/19 . 199 looked-after children and young people with a PHB, with 100% reporting that they feel better about their quality of life . Patient Activation Measures implemented within pulmonary rehab (resulting in learning to guide further roll-out in 19/20) . Programmes of workshops including personalised care and support planning, health coaching, and expansion of social prescribing . A common quality framework and guidance for personalised care and support planning . Strategic co-production involved in all stages of project planning, delivery, and service development via the My Life Choices group of people with lived experience Primary care has been a key part of delivering these achievements in 2018/19 and will continue to play a strong role as we move forward in 2019/20 and beyond toward the ambitions of personalised care.

8.2 Role of Primary Care in Personalising Healthcare Services

The focus will be on ‘what is important to you’ rather than ‘what is wrong with you’ and will be achieved through patient engagement and activation being fully embedded within each PCN. There will be a focus on personalisation and personal health budgets which will also enable a more proactive approach to maintaining well-being.

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8.3 Workforce Configuration

To successfully deliver personalised care, the ICS is working to train and equip staff involved in the delivery of all people’s care to identify self-care needs and take a flexible, holistic approach to people’s needs with a strong prevention focus, encompassing person-centred approaches. This will develop a workforce which is trained, equipped, and supported to deliver preventative and person- centred approaches and includes: . Production of a toolkit to provide the ICS workforce with the knowledge and skills to understand and deliver personalised care . Embedding personalised care in induction, training, supervision and appraisals . Developing professional skills and behaviours to deliver PCSP as fundamental ways of working across health and social care staff . Establishing support networks for link workers, navigators, health coaches or community connectors . Carrying out a train-the-trainer programme to empower members of the workforce to help spread the personalised care approach with their teams and colleagues In 2018/19, 53 colleagues across the ICS, including those from primary care, received training in health coaching conversations. By 2020, the ICS personalised care team will increase this to 250. The ICS will embed at least one link worker in every primary care network (PCM) in 2019/20; these link workers will support primary care by signposting people and connecting them with groups and organisations within their community alongside work toward developing local organisations and groups within the community

8.4 Service delivery and implementation

A multi-disciplinary approach to care coordination, reflecting the outputs of segmentation/stratification, will be embedded that breaks down the traditional silos between primary and community services and supports greater integration between health and social care. Each ICP and its PCNs will agree a standard operating model (including capacity requirements) and shared accountability structure for care coordination with the commissioner, with clearly defined responsibilities for each person involved, including the individual receiving the care, the GP and other members of the integrated health and care teams. This will include the frequency and focus of care coordination reviews, the presence of coordinators in practices outside of review meetings, the use of real time

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information outside of coordination reviews and referrals to disease/condition management programmes. This responsibility and accountability structure will be transparent across organisations and the performance and results (KPIs) of the approach within each PCN defined, monitored and shared. .

Building on the successes of 2018/19, the ICS is discussing a subsequent MOU with NHS England for 2019/20 with further targets toward the embedding of personalised care: . 1,615 people completing the Patient Activation Measure (PAM) . 15,000 people referred for self-management support, health coaching and similar interventions . 15,000 people referred for social prescribing community groups, peer support and similar activities . 19,580 personalised care and support plans or reviews . 2,900 personal health budgets or integrated budgets across a range of cohorts Primary care plays an important role in working toward these targets and developing a culture where a different, person-centred conversation is the norm and people are recognised as equal partners.

i. Personalised Care and Support Planning and Personal Health Budgets The ICS will build on the successes in 2018/19 to continue the expansion of personalised care and support planning and budgets. This includes expanding both within existing cohorts (such as continuing healthcare, looked-after children, NHS and direct payment carers’ breaks, joint-funded budgets, Section 117 aftercare, and personal wheelchair budgets) and expanding to additional cohorts, such as neuro-rehabilitation in Mid-Nottinghamshire, further areas of mental health (including the personality disorder cohort), fast track, and cancer (in partnership with Macmillan). In 2019/20, the personalised care team will continue working toward a digital solution for sharing the information in the personalised care and support plans between teams across the ICS, building on current work to increase interoperability between primary care systems (such as SystmOne) and other systems across the other health and social care organisations in the ICS. Alongside this, the All About Me one page profile document is an important element in the shift to personalised care. It forms the first page of a personalised care and support plan and is the starting point to summarise what matters to a person and how they would like to be supported. In 2019/20, the

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personalised care team will continue to expand the use of the All About Me, including with primary care colleagues. ii. Health Coaching The ICS will train 250 staff in health coaching by 2020, including those from primary care. This will be evidence-based and include primary and secondary prevention approaches which have an initial focus on delivering outcomes over a short-term timescale. This training will support staff in all interactions with people to have brief conversations on how they might make positive improvements to their health or wellbeing, seeking to have a significant impact on population health through supporting people and their families to live healthier lifestyles.

iii. Patient Activation Measure (PAM) The ICS personalised care team will continue to drive rollout of the Patient Activation Measure (PAM) tool across the ICS through an action plan identifying specific cohorts to roll out to each quarter, building on learning from the initial cohort of pulmonary rehabilitation in 2018/19 and working with Sheffield, who have implemented PAM on a wide scale, as a mentor site. The ICS aims to complete 1,615 PAM assessments in primary care in 2019/20. Through PAM, primary care staff can support people to manage their health in a way that empowers them and suits them best, tailored to their activation level (a person’s knowledge, skills, and confidence). This includes those with long- term conditions. Using the results of PAM, primary care colleagues can then support people to build their knowledge, skills, and confidence, leading to improved self-management.

iv. Shared Decision Making (SDM) Shared decision making (SDM) involves working with clinicians and practitioners to ensure they involve people more fully in designing support around individual needs, meaning equipping people with the knowledge that they need to then be an equal partner in care and treatment decisions. The ICS personalised care team aims to extend SDM to at least two further clinical situations in primary and secondary care and at the primary/secondary care interface, targeting areas where it will have the greatest impact.

v. Community Connectivity and Community Development Community connectivity programmes are already in place in some areas of

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Nottingham and Nottinghamshire; in 2019/20, the ICS will extend this capability ICS-wide through establishing at least one link worker per PCN while creating and embedding a social prescribing and community connecting model within ICP and PCN areas. This approach will aim for people to be easily referred to these link workers from a wide range of local agencies, including primary care, local authorities, pharmacies, multi-disciplinary teams, hospital discharge teams, allied health professionals, fire service, police, job centres, social care services, housing associations and voluntary, community and social enterprise (VCSE) organisations. Alongside the advent of these link workers, the ICS will work to strengthen and increase capacity to support this community connecting, encouraging a vibrant and active community and self-care sector. This will allow primary care professionals to have confidence when connecting people to neighbourhood and community groups and local organisations. The ICS will work in partnership with Community and Voluntary Service (CVS) organisations to establish clear KPIs for community development in the VCSE sector to work to ensure a safe referral system is in place, meaning that primary care colleagues can feel assured when referring people to link workers for community connectivity. This work will support community groups with all relevant aspects to ensure both people and link workers are safe. This includes, but is not limited to, insurance, safeguarding, lone working, first aid, data protection, DBS checks, food safety, and working with vulnerable citizens. Through this work, referral agencies and statutory bodies have an honest and transparent relationship with VCSE organisations, allowing innovative community initiatives to establish themselves without being prevented by barriers around risk aversion in statutory agencies. The ICS personalised care team will work with VCSE organisations to create reasonable and safe referrals, based on what matters to people while minimising bureaucratic controls and working to overcome an overly risk-averse approach to local community development. The ICS will also work to further develop digital resources that primary care colleagues can point people toward such as Nottinghamshire Help Yourself and Ask LION for signposting and community support.

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8.5 Governance and Operational arrangements

The ICS personalised care team is working toward ensuring personalised care is a golden thread throughout all work at the ICS, ICP, and PCN level and is included as a strategic priority throughout ICS key system and planning processes, working to embed system-wide leadership through a shared understanding of the relationships between the social determinants of health, lifestyles, and health behaviours. Wording around key elements of personalised care will be included for all new or revised service specifications. The ICS will work in 2019/20 to build a personalised care approach into all commissioning, contracting, and payments, joining up commissioning across primary care and other organisations and providers to maximise funding and reduce duplication. This will maximise funding, reduce duplication, and provide greater flexibility within contracts to provide choice and control.

8.6 Resourcing and costs

The majority of resourcing and cost in 18/19 and 19/20 have been managed through the use of NHSE MOU monies. Moving into 2019/20 CCGs and provider organisations will need to look at more sustainable plans for releasing resource to manage personalise care.

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9 Key element 4 - Digitally-enabled primary and outpatient care will go mainstream across the NHS

This section should demonstrate the role primary care will play, in your health economy to enable the introduction of digitally enabled primary care. 1. A summary of the current situation regarding the introduction and adoption of digitally enable primary healthcare services, including any developments that have already been implemented or that are underway. 2. A description of the role primary care will play in delivering digitally enabled healthcare. 3. How the workforce will be configured to deliver digitally enabled services, the new and/or additional roles that will be needed and the implementation timeframe. 4. How services will be delivered and the timeframe for implementation any proposed solutions. 5. The section should also describe the governance and operational arrangements that will be required to deliver and implement the proposed changes. 6. The resourcing of the proposed changes should also be addressed, detailing both the set up and anticipated ongoing costs of delivering the proposed changes.

9.1 Current Situation

Primary Care in Nottinghamshire has made significant progress in the delivery of overall the strategic digital plans to support the 19/20 contract requirements and foundations for the Long Term Plan. The deployment of numerous technological solutions supports improved information sharing, infrastructure and digital maturity. These key enablers deliver the ambitions set out in Nottinghamshire’s Local Digital Roadmap and the emerging Integrated Care System digital strategies. Clinical Information Sharing The CCGs, in agreement with other organisations has successfully rolled out the Medical Interoperability Gateway (MIG) which is used to deliver information to the Nottinghamshire Health and Care Portal. This allows data from GP practices operating to be viewed in other agencies such as emergency departments, community and social care enabling them to make better, informed decisions about care.

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The Medical Interoperability Gateway (MIG) also supports information sharing across Out of Hours, Community Services, GP Federation(s) and Mental Health Services. In addition, an End of Life care dataset bought on line through the Electronic Palliative Care Co-ordination System (EPaCCS) is available to all primary and community care providers as well a number of third party care providers across Nottinghamshire. Use of Information to support care The GP Repository for Clinical Care (GPRCC) has been developed to support clinical workflows across the community. Data is received nightly from GP, community, mental health, acute provider and social care systems. Over 100 workflows aimed at clinical coordinators, pharmacists, GPs, community teams and mental health are derived in keeping without our clinically led strategy. Risk stratification and the Electronic Frailty Index are used to prioritise our response to acute workflows. A dashboard informs practices, PCNs and CCGs about how it is performing over hundreds of indicators monitoring key outcomes. Data standardisation and digital library F12 is a locally built solution for standardising the collection of data across Long Term Conditions and referrals. All local guidelines and forms are accessible from a central library that is referenced by our other projects along with references to key National guidelines. Information from standard templates is extracted into a database, hosted by eHealthScope. These can be used to populate other data collection templates used elsewhere in the community. Information governance The CCGs have achieved an acceptable level of IG toolkit compliance (including partners) and several pieces of additional assurance work have taken place, relating to shared information tools, in the last 12 months. Nottinghamshire is also engaged with accredited independent third party suppliers to conduct exercises such as PEN/Vulnerability testing when delivering or changing technical infrastructure and Privacy and Security Impact Assessments are undertaken on new technology implementations. Cyber security remains an important consideration in all technology enabled projects. Nottinghamshire adopt robust processes in data security and IT security. NHS App Nottinghamshire is a pilot area for the national NHS App which has now been deployed across the whole GP estate in Nottinghamshire and Nottingham. This is a significant step in modernising GP services, and should make life easier for patients and for practices, with the ability to book and manage appointments online, order repeat prescriptions, view your medical history and access 111 Online, among other services.

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UEC As part of the UEC services redesign Nottinghamshire Practices have already completed the technical enablement to allow appointment booking into GP appointments. Following this work is underway to release appointment slots in line with the redesign planning and capacity requirements. GP IT Futures The end of the GPSoC contract represents both a challenge and an opportunity to General Practice and the PCNs. The move to a GP IT Futures compliant system will enable new models of digital exploitation and ensure data sharing can be achieved in line with the aspirations of the wider health and care system for the Nottinghamshire ICS. In order to achieve this Nottinghamshire Health Informatics Service will be a key partner and will be commissioned to support practices. Assistive Technology Several pieces of work are underway that use technology to support care delivered outside of traditional care settings and that support self-care by patient/citizens. Nottinghamshire has a number of projects underway utilising TeleCare devices in patients’ homes in the Greater Nottingham area which include self-care applications and a Tele-dermatology service. Alongside this another initiative using ‘Flo’ (which is a text messaging ‘Telehealth’ service to patients) is used widely in the Mid Nottinghamshire area is supporting key cohorts of patient such as those with early heart failure and COPD diagnosis.

9.2 Role of Primary Care in delivering digitally enabled healthcare

The vision is to transform the way people experience access General Practice and Primary Care services across Nottinghamshire. By providing digital health tools and services that connect them to the information and services they need, when they need them it enable people to access care in a convenient and coordinated way, promoting independence through the digital tools they are familiar with in other aspects of daily life. General Practice across Nottinghamshire will support the NHS England commitment to become much better at involving patients and their carers by: . empowering people to manage their long term conditions and make informed decisions about their care and treatment . supporting people to improve their health, giving the best opportunity to lead the life that they want Public Facing Digital Services

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In order to support this transformation in the way GP services are delivered practices will need to give people the tools they need to assist them in managing their own health condition, improve their wellbeing and provide information to enable them to live healthier lifestyles and prevent the development of ill health. This includes the deployment of digital tools to support Self Care and Management, Active Signposting, Community Connectivity and New Types of Consultations (including online and video consultation).

Figure 9-1 - Integration of local capabilities with NHS App

We shall procure a local Application to deliver this functionality. This App will be linked to the NHS App, to provide identity management via a single sign on, and in time it will enable patients to manage their interaction with some secondary care services as well as general practice. This will be rolled out across Nottinghamshire by April 2020, with further development beyond that. This will enable patients to: . adopt preventative approaches within their lifestyles

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. have easier and more convenient access to key information to enable them to better support themselves at home . manage and control long term conditions better . access more convenient methods of consultation (and thereby reduce the number of missed or avoidable appointments) The intention is that by promoting self-care and signposting to appropriate services this initiative will reduce reduce demand on general practice as well as supporting more flexible working patterns. This in turn will link to GP retention plans and attracting clinicians back to general practice. The intention is that by promoting self-care and signposting to appropriate services this initiative will reduce reduce demand on general practice as well as supporting more flexible working patterns. This in turn will link to GP retention plans and attracting clinicians back to general practice. Population Health Management (PHM) The development of Primary Care Networks (PCN) will require service transformation based on this neighbourhood unit of delivery. This work is interwoven with other plans to support the PCN digital requirements and will require clinical and managerial input at all practices. Building on the leading PHM work across GP Practices in Nottinghamshire identification of proactive care interventions has already surpassed 7,700 per month in 2019. Linking into the ICS led work to segment and identify cohorts of patients in the priority multi-morbidity groups primary care teams will further develop and refine the technology that is used in the GPRCC and eHealthscope tools described above. In plain terms, this analytical approach will enable care to be delivered to those patients that need it most.

9.3 Workforce configuration

Implementing the Public Facing Digital Services described above will require significant change management. An implementation plan has been produced with a timeframe from mid-2019 for 18 months. The plan identifies the requirement for GP Fellows, GP digital leads, practice nurse digital champions and practice managers to work with general practices. Funding has been identified from the GP Forward View programme. It is anticipated that this will lead to some changes in clinical work patterns within each general practice as they adapt to digital working but this will be within existing resources. It is hoped that, as described above, this may help alleviate some of the current level of demand in primary care.

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Effective organisations are underpinned by successful, resilient and well- supported IT systems. For Nottinghamshire CCGs to continue their success they must be supported by high quality, resilient, responsive and cost-effective IT services. The increased reliance on IT and the probable extension to the hours within which primary care services are accessible to patients means that the CCGs’ IT service providers must respond to cover the broader scope and time required and meet the rising customer expectations. The CCGs will review the arrangements for IT support and ensure fit for purpose, appropriate and cost effective user support is in place to underpin the ambitions of this strategy. CCGs recognise the importance of training and its vital contribution towards best and efficient use of clinical systems and IT. Through the revised GP IT Futures contracts, the Primary Care Development Centre and local provider arrangements, the CCGs will ensure appropriate training is provided to all Nottinghamshire practices. In addition, PCNs will require additional capabilities to support their new functions and allow greater sharing between individual GP practices. Much of the technology to deliver this is already in place. A review of the analytic support function is currently underway to determine the resources, including workforce, required for this.

9.4 Service delivery

The CCGs hold a Service Level Agreement (SLA) between their informatics service provider and the GP practices. This SLA identifies and details all the elements necessary to maintain IT services. It provides a framework for the provision of specified services including operational support, desktop support, network support, application support, programme management and business change, training and telecommunications, where locally agreed and funded. The CCGs will continue to review this service against national guidance within the GP IT operating model to ensure value for money in GP IT investment. Arrangements for GP IT funding are changing as the current GPSoC arrangements are due to end in December 2019. Funding for GP systems will be allocated directly to CCGs on a per capita basis. Guidance is still awaited on future procurement arrangements. The other elements of the primary care digital landscape are at varying stages of development and implementation. Data sharing via the Medical Interoperability Gateway (MIG) is already live. GPRCC is already working, and the functionality is constantly reviewed and upgraded - Phase 4 implementation will occur during 2019/20. The Public Facing Digital Services (PFDS) App will be procured in 2019, with implementation across Notts phased through 2019/20

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with the aim of every practice being able to offer online consultation by April 2020. Additional functionality, including video consultation, intelligent management of long term conditions, and links to secondary care and mental health services should be in place by October 2020.

9.5 Governance and operational arrangements

Delivery of the strategic aims will be overseen by the IT Management Board, which reports to the ICS Board. A number of working subgroups report to the IT Management Board, covering records and information governance, technical issues, and project delivery, such as PFDS and GPRCC. Operational oversight will be provided by the Primary Care IT team, within the Finance directorate of the CGG, who will manage the SLA with the informatics service provider. Currently, work across the health community is facilitated by a team called Connected Nottinghamshire, but his will be succeeded by different substantive arrangements in 2020. Across Nottinghamshire we have a diverse population including individuals with specific language or communication requirements. Quality Impact Assessment (QIA) and Equality Impact Assessment (EIA) are undertaken for all projects and are a key consideration at every stage of the project lifecycle.

9.6 Resource requirements

Future funding for primary care IT clinical systems will be allocated on a per capita basis, currently projected to be £1.26 per patient per annum. However, this funding stream alone is insufficient to deliver our vision for digital transformation in primary care. To support delivery of this strategy and drive efficiencies there is a requirement for new funding and innovative use of existing funding for both capital and revenue investment. Where possible joint procurements will be utilised through the use of the Midlands Accord, procuring systems and solutions exploiting scales of economy in order to reduce the financial burden on individual organisations and maximise cost savings. It is anticipated that applications for funding will be submitted against a number of national, regional and local finance schemes. These include but are not limited to; GP Forward View funding, Health Service Led Investment fund, Local Digital Roadmap/National Technology fund, Developing Digital Maturity Fund, Academic Health Science Network funding and other opportunities as they arise.

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As part of the controls for each project, identification of finance and controls on expenditure will be managed by the project lead and reported to the appropriate programme board or IGM&T meeting. In addition to this each project will have a benefits evaluation, including return on investment and value for money calculation (where appropriate). These controls will provide assurance to each project board attributed to the individual CCG area. With national policy changing to move more responsibility for IGM&T to the CCGs it is recognised that additional financial pressure will need to be considered. The Health and Social Care Network (HSCN) and GP Public Wifi projects are examples of projects that have to be implemented but that only have limited financial support (two years). This approach must be balanced against limited revenue locally. In order to ensure IM&T projects are affordable and linked to transformation and improvement locally projects will be prioritised annually with CCGs.

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10 Key element 5 - Local NHS organisations will increasingly focus on population health – moving to Integrated Care Systems everywhere

This section should demonstrate the role primary care will play, in moving your health economy to becoming an Integrated Care System. 1. A summary of the current situation regarding the development of your health economy becoming, or already having become and Integrated Care System. 2. A description of the role primary care plays or will play in the Integrated Care System and how you intend to ensure that it supports key facets of patients’ mental health. 3. How the workforce will be configured to deliver services as Integrated Care System, the new and/or additional roles that will be needed and the implementation timeframe. 4. How services will be delivered, what role new technology might play and the timeframe for implementation any proposed solutions. 5. The section should also describe the governance and operational arrangements that will be required to deliver and implement the proposed changes. 6. The resourcing of the proposed changes should also be addressed, detailing both the set up and anticipated ongoing costs of delivering the proposed changes.

10.1 Current Situation

Nottingham and Nottinghamshire have a fully operational Integrated Care System that includes all statutory NHS organisations, Local Authorities in Nottingham and Nottinghamshire and includes: Clinical Commissioning Groups (CCGs) and a unitary and two-tier local government structure with a City Council, and a County Council with seven District Councils as well as the two major hospital trusts, a large mental health, learning disabilities provider and number of community providers that serve the Nottingham and Nottinghamshire population. The ICS Board meets monthly and is chaired by a Non Exec Director and provides system leadership, oversight and assurance of successful delivery of the whole systems objectives and outcomes. It brings together all Chief Executives and Non-Executive Chairs along with Clinical Leads from statutory health and social care organisations across Nottingham/Nottinghamshire. The Board is committed to strengthening its approach to providing greater transparency to key stakeholders and will continue to embed a unified

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leadership and governance approach with partners, clinicians, Public Health expert’s patients and citizens that affiliates and meets national targets within each organisations strategic objectives. As an ICS we are currently working with a wider group of representatives from other organisations that deliver local services such as the voluntary (third) and community sector, giving them a forum to contribute to the development of an integrated health and care system where local people will receive better, more joined-up care, closer to home. Local organisations will be better able to keep pace with the growing and ageing population and address some of the current problems in the NHS, while making it sustainable for the future. Benefits will include: . Those who are largely well today will be helped to stay well. . Those with complex or advanced long-term conditions will be supported to manage their own care, with a system to escalate care quickly in the event of exacerbations. . People will remain independent thanks to prevention programmes and proactive rather than reactive care. . People will receive care at home and in the community as much as possible. . Multi-disciplinary teams will work across organisational boundaries to deliver integrated care as simply and effectively as possible. . The social value that health and social care can add to communities will be maximised.

10.2 Primary Care’s role in the ICS and Mental Health agenda

Nottingham and Nottinghamshire ICS has recently published an integrated Mental Health and Social Care Strategy, aiming to transform mental health and wellbeing across the footprint. This strategy is to be factored into all relevant aspects of other ICS work if true integration is to be enabled. This includes the parallel clinical services strategy work around acute, community and primary care services. This strategy represents our system’s commitment to the re- shaping of services and other interventions so that they better respond to the needs of our population. We now need to plan together how to achieve this, including where to focus our combined efforts in the short, medium and longer term. We are seeking a seamless service and a step change in people’s mental health and wellbeing. Our strategy seeks to recognise that everyone is different and care and support needs to be personalised accordingly, yet everyone deserves equality (with parity of esteem in all situations and scenarios).

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In order to meet the strategic vision of the ICS, The Population Health Management programme will be at the heart of driving this transformational approach forward. The programme will bring key partners together in primary, secondary, social care and third sector providers to fully integrate not just a medical model but an all-encompassing integrated whole system, all-age, person-centred approach, driven by access to physical and mental health and social care in the same place at the same time, with no wrong door, where prevention is at the heart of all we do. The Nottingham and Nottinghamshire ICS has identified a significant level of unwarranted variation across our region due to a lack of joined-up services, and a lack of real insight and actionable intelligence about both the needs of our population and standardised interventions to address these. This has led to gaps in health and care outcomes for our population and is a key driver for our system’s £230m financial deficit. We have already undertaken significant work to identify, articulate and quantify the specific gaps and unwarranted variation in health and wellbeing; care and quality; and our baseline financial position. Our aim is to help people to be, stay or regain good health and wellbeing. To do this we must take a preventative approach and build strong and joined-up community services. Working together in this way will allow us to look across the system at how services are provided and identify opportunities to add value, improve outcomes and eliminate duplication and reduce costs. Our current approach is underpinned by a rigorous PHM programme structure, utilising a wide range of experts, internal and external, both clinical and non- clinical, to understand our population’s current needs, activity, cost and outcomes. Our initial focus will be on the population segment of people with Long Term Conditions. Through further sub-segmentation and risk stratification of this segment, the programme will lead the delivery of standardised, evidence-based pathway/journey redesign approach, with appropriate interventions to achieve the aims of the ICS outcomes framework, and in turn to meet the needs of our population at a Primary Care Network level. There will be a clear process for monitoring and evaluating change within the programme framework. We will quantify the financial impact of the interventions proposed by the programme as part of the evaluation criteria for agreeing these. The approach taken will identify opportunities to address gaps in care, reduce acute emergency activity which is avoidable and which does represents the optimal value-for-money, and shift resource into proactive, targeted out-of-hospital interventions to keep our population well. Ultimately this will underpin our system strategy to achieve financial sustainability and reduce pressure within the hospitals acute sector.

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10.3 Workforce Configuration

Redesigning health and care delivery around the needs of our population will require our teams to work in new ways and have new skills as well as offering exciting career and development opportunities to people working in Nottinghamshire. Our People and Culture Strategy sets out our vision for future capacity, capability and behaviours and how we will work with our colleagues to embed our planning into wider system plans to ensure care is delivered in the appropriate setting by people with the right skills. We have set a 10 year strategic horizon to align with the national Long Term Plan and the Nottinghamshire Clinical Services Strategy. However, we will focus on the development of a five year delivery plan (in line with national planning guidance) with the opportunity to review and refresh at regular intervals. Through the PHM programme we will be able to develop a population health- led approach to shape the skills and future skills that we will need to deliver future models of care using system dynamics modelling. This approach engages clinicians and managers across the system in developing a range of scenarios to bridge the gap between supply and future demand for skills and provides the opportunity to test the impact of new ways of working and new and innovative roles. Our approach will continue to take a system wide and population health based view of role and team design and cultural aspects of change and includes improvements to our workforce information and intelligence, integrated workforce planning, recruitment and retention, role redesign, attracting the right people with the right skills, career development, training, development and leadership at all levels. By working together as a system and with our population we will strengthen current teams by supporting them to develop new skills and work in new ways, enable smooth introduction of new roles, developing solutions to support areas where there are shortages, improving integration across sectors and organisations, embedding approaches to prevention, promoting independence, self-care, community resilience and personalisation and enabling change through system wide organisational development and sharing of resources. Delivering good health and care outcomes will require citizens and communities to understand and take responsibility for their own health and wellbeing. As an ICS we have a role in supporting people, families, carers, communities and voluntary organisations to have the skills and capacity to build that resilience in our communities. The ICS People and Culture Strategy will support development of both our paid workers, volunteers, families and carers.

10.4 Service delivery and implementation

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A multi-disciplinary approach to care coordination, reflecting the outputs of segmentation/stratification, will be embedded that breaks down the traditional silos between primary and community services and supports greater integration between health and social care. Each ICP and its PCNs will agree a standard operating model (including capacity requirements) and shared accountability structure for care coordination with the commissioner, with clearly defined responsibilities for each person involved, including the individual receiving the care, the GP and other members of the integrated health and care teams. This will include the frequency and focus of care coordination reviews, the presence of coordinators in practices outside of review meetings, the use of real time information outside of coordination reviews and referrals to disease/condition management programmes. This responsibility and accountability structure will be transparent across organisations and the performance and results (KPIs) of the approach within each PCN defined, monitored and shared.

10.5 Governance and Operational arrangements

The ICS Board meets monthly and provides system leadership and oversight to assure successful delivery of the objectives and outcomes agreed in the STP through the two transformation programmes and supporting workstreams. It brings together all Chief Executives and Non-Executive Chairs along with Clinical Leads from statutory health and social care organisations across Nottingham/Nottinghamshire. The ICS Board is committed to strengthening its approach to providing greater transparency to key stakeholders.

10.6 Resourcing and costs

[to be added]

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11 Workforce

Workforce and workload are key issues facing general practice and the pressures experienced both nationally and locally have been detailed earlier in this strategy. These pressures are acknowledged in both the GPFV and ‘Investment and Evolution: a five-year framework for GP contract reform to implement The NHS Long Term Plan’.

The NHS Long Term Plan sets out the objective to develop and deliver a national workforce implementation plan in which there are requirements to: . ensure we have enough people, with the right skills and experience, so that staff have the time they need to care for patients well . ensure our people have rewarding jobs, work in a positive culture, with opportunities to develop their skills and use state of the art equipment, and have support to manage the complex and often stressful nature of delivering healthcare . strengthen and support good, compassionate and diverse leadership at all levels – managerial and clinical – to meet the complex practical, financial and cultural challenges a successful workforce plan and Long Term Plan will demand. A Nottinghamshire clinical services strategy is currently in development across the ICS, based on a place based model of care. The aim of the overarching strategy is to shift the focus of our health and care delivery from reactive, hospital based treatment models to a pro-active approach of prevention and early intervention, delivered in people’s homes or in community locations where this is appropriate. The final primary care workforce strategy will therefore need to respond to the workforce implications of this strategy. The six design principles for the clinical services strategy include the following: . Care will provided as close to home as is both clinically effective and most appropriate for the patient, promoting equality of access . Prevention and early intervention will be supported through a system commitment to ‘make every contact count’ . Mental health and wellbeing will be considered alongside physical health and wellbeing . The model will require a high level of engagement and collaboration both across the ICS and neighbouring ICSs . The models of care to be developed will be based on evidence and best practice, will ensure that pathways are aligned and will avoid un-necessary duplication . They will be designed in partnership with patients and the public and will

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operate across the whole healthcare system to deliver consistent outcomes for patients through standardised models of care except where the variation is clinically justified The primary care workforce strategy will reflect the primary care ICS priority objectives which include: . a systematic approach to primary care delivery across the ICS to develop local primary care networks . a more integrated and collaborative primary care workforce . a supported and integrated workforce with a combined focus on prevention and personalisation of care with shared and improved qualitative health and care outcomes utilising population health management data . implementation of the new GP contract . to build on the network of clinical pharmacists and the value they bring . to implement social prescribing . the key workforce aim to ensure there are 5,000 more doctors alongside 5,000 other clinical professionals working in primary care . 2 year post-CCT GP and graduate nurse fellowships in primary care to support entry to practice and retention . extended access to GP appointments . increased access to talking therapies in general practice

Across Nottinghamshire, great progress has been made in developing and implementing a range of initiatives to support the recruitment and retention of GPs and the wider general practice team. It is expected that the full benefits of these will be realised as the various schemes become more firmly embedded. However, as a system, we recognise that there is much more to be done. Our draft primary care workforce strategy for the next five years will therefore respond to the challenges identified, and addresses five key areas: . Planning, attracting and recruiting our future workforce . Retaining staff and trainees, promoting career paths and talent management . Role redesign and development of new roles . Preparing and supporting people to work in new ways, including digital skills development . Enabling cultural change and leadership development to maximise system effectiveness

The strategy includes: . a range of GP retention schemes targeting each stage of career (via the

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Phoenix Programme) including GP Trainee Transition, Preceptorship and Fellowship . general practice nurse 10 point plan delivery . implementation of the nursing associate role . embedding clinical pharmacists in general practice (national schemes transition to PCN) . development of advanced practice skills in the wider team . roll-out of the medical team administrator/GP assistant role and extended skills for other administrative/support staff . development of other new roles such as physician associate, paramedics, mental health professionals and physiotherapy in PCNs . a greater role for the Training Hub working alongside primary care networks to support the expansion of clinical placements, improve quality of education and training, establish shared learning opportunities, roll out bespoke education programmes . robust training needs analysis across primary care . joint training across health and social care to understand different conditions and the impact on wellbeing and promote better outcomes . the use general practice simulation tools to consider the workforce transformation possibilities . working with the Training Hub

Our work programme will be based on the following principles: . Securing supply . Enabling flexibility . Providing broad pathways for careers . Widening participation . Inclusive, modern, attractive employers . Integration of financial, service and workforce planning around population need . Active focus on diversity and inclusion and teams that represent our local population

A number of primary care workforce initiatives currently being developed and/or implemented across Nottingham and Nottinghamshire are briefly described below.

i. General Practice Phoenix Programme

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The Nottingham and Nottinghamshire ICS is in the privileged position of having an excellent relationship with the Local Medical Committee who have taken a key role in the development and implementation of the primary care workforce strategy. The Nottinghamshire General Practice Phoenix Programme was created in January 2019 to provide a single point of access for workforce schemes in Nottinghamshire. This is hosted by the Nottinghamshire LMC and includes seven workforce schemes: . The GP Trainee Transition Scheme . Preceptorship . Fellowship Lite . Special Interests . Clinical Network Leaders . GP Portfolio Plus . Practice manager development

ii. International GP recruitment This is a national programme to recruit international GPs, currently from six European Union countries. Initially mid-Notts submitted a bid for 26 international GP recruits. Greater Nottingham submitted a bid to a later tranche for a similar number. However the scheme was heavily oversubscribed and therefore the total Nottinghamshire bid has been limited to 36. Progress has been slow and to date there is only one GP working in Nottinghamshire as a result of the international recruitment scheme. However it is hoped that numbers will increase over the coming months/years as the initiative gains momentum.

iii. Targeted Education Recruitment Scheme (TERS) TERS is a joint venture between NHS England, Health Education England (HEE), the British Medical Association (BMA) and the Royal College of General Practitioners (RCGP) to support recruitment in areas to which it has traditionally been hard to recruit. NHS England is funding a £20,000 salary supplement to attract GP trainees to work in areas of the country where GP training places have been unfilled. TERS funding of £240k has been utilised in Mansfield and Ashfield CCG to support full take up of GP trainee placements in 2017/18 and 2018/19.

iv. GP Trainee Transition Scheme

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This scheme will provide third year GP trainees with support based on individual needs. This might include coaching, mentoring, portfolio careers advice, brokering of discussions with potential employers (mainly GP practices).

v. Nottinghamshire post-CCT fellowships This involves the development of a Nottinghamshire-specific post-CCT Fellowship scheme, building on the successes of the scheme currently managed by Health Education England (HEE) which has been scaled back in 2018/19. As per the established approach newly/recently qualified GPs would spend approximately 40% of their time in clinical practice and the remainder on project work, supported by the Nottinghamshire Training Hub Alliance. This scheme enables participants to develop portfolio careers which may be of more interest than working as a GP on a full-time basis. A Fellowship helps trainees to access a more flexible career, improve networks, and increase project management skills. Under the existing HEE Post CCT Fellowship Scheme six Fellows were funded and appointed in September 2018. All chose practices in Greater Nottingham for their clinical sessions.

vi. Nottinghamshire Portfolio Plus Scheme This established initiative, led by Nottinghamshire Local Medical Committee (LMC) is available to support GPs at any stage of their career. It aims to help GPs to enjoy a better working life thereby improving GP recruitment and retention. Expert facilitators and clinical champions work with GPs to explore the development of flexible working and extended career options. GP Portfolio Plus also has a specially created peer support network. It is supported by the GP-S Mentoring Service and has links to the GP Training Transition Scheme. This scheme originated from a survey of GPs approaching retirement. 30 GPs responded to the LMC stating an intent to leave the profession within two years, in the main because of workload, workforce problems and finance. The average age of those known was 52 with the youngest at 35 and oldest at 67. The Scheme launched in May 2018 and has supported 18 GPs to date (as of 1 November).

vii. GP-S Mentoring Service This service provides GPs with a free and confidential structured mentoring and coaching programme of up to four sessions of two hours each. GPs are seen by a trained peer on a one-to-one basis and supported to work on areas of their

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choice. The service was launched in 2015 and is hosted by Nottinghamshire Local Medical Committee working with Derby and Derbyshire Local Medical Committee. It has seen approximately 240 GPs access support across Nottinghamshire, Derbyshire, Lincolnshire and Telford & Wrekin.

viii. GP Retention (Retainers) Scheme This long-standing scheme is aimed at doctors who are seriously considering leaving or have left general practice due to personal reasons, approaching retirement, or requiring greater flexibility. The scheme supports both the retained GP and the practice employing them by offering financial support in recognition of the fact that this role is different to a ‘regular’ part-time, salaried GP post, offering greater flexibility and educational support. Retained GPs may be on the scheme for a maximum of five years with an annual review each year to ensure that the doctor remains in need of the scheme and that the practice is meeting its obligations.

ix. Tier 2 Scheme This scheme supports the retention of overseas doctors or international medical graduates (IMG) that have completed their GP training in the UK and are looking for a practice to sponsor them for the remaining two years (after five years doctors get indefinite approval to remain in the UK). There has been some interest in this scheme from practices across Nottingham and Nottinghamshire and practices that express an interest in applying are receiving visits from NHS England staff to support them with the process including accessing funding. There are xx practices across Nottinghamshire who are signed up as Tier 2 sponsors, with additional practices who have expressed interest in becoming sponsors.

x. Medical assistants Medical assistants/doctors’ assistants/medical team administrators are all similar job titles for staff trained especially to support their GPs with administrative and in some cases, basic clinical work. Nottinghamshire Local Medical Committee is working with the training hubs to financially support a practice from each of the CCG areas to form a working group and start a pilot scheme based on experiences of early working with this new role in the north- west of England, West Midlands, and London. The first meeting of the pilot steering group took place in early December 2018 with the aim to start the roles early in 2019/20.

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In addition there are a number of schemes being progressed locally that relate to recruitment and retention of other primary care professionals e.g. the General Practice Nurse 10 Point Plan, the development and local implementation of the nurse associate role, and recruitment of additional pharmacists into general practice via the Clinical Pharmacist Programme. Early engagement with service redesign leads across the ICS will be essential to ensure we take a proactive and long term approach to understanding and reshaping the capacity and skills we will need in the future.

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12 Governance

Fig 12.1 – Proposed Governance for Strategic Primary Group

[Further content to follow]

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13 Estates

13.1 Background

With the development of integrated care systems, a significant change to the way planning and resourcing estates is required. Rather than the organisation based approach to planning and managing assets there has to be a collective direction of travel across a wider area involving several partner organisations, including local authorities. The Nottinghamshire ICS Estates Strategy represents a combined system-wide approach to estates including key priorities and a pipeline of emerging developments. For primary care it incorporates all of the outstanding priorities identified from the previous individual CCG estates strategies approved by Governing Bodies in 2016.

13.2 ICS Estates Strategy

The first Nottinghamshire ICS estates strategy has been assessed as Improving. Detailed feedback has been received to improve the assessment to Good or Strong which is currently being reviewed by system partners ahead of re-submission in June 2019. An estates group with key individuals from the ICS team and partner organisations has been established reporting into the ICS Planning Group and ultimately the ICS Board. This group will work on the recommendations and refine the estates strategy accordingly. In relation to primary care, two key areas were identified: . the link between capital and estates plans and the system’s overarching clinical and service strategies was not always clear. This needs to become clearer as the plans evolve and in particular they need to facilitate the system plans for moderating demand and preventing avoidable hospitalisation . although all strategies set out their approach to primary care estate in general this was less well developed and this will be a key priority for future development. The final estates strategy will be received by the ICS Board as part of the five- year plan 2019-24.

13.3 Clinical Services and Estates Strategy Alignment

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The ICS Clinical Services Strategy is progressing well and will effectively influence the Estates Strategy development, and in particular primary care estate, against a background where there is: . a system- wide need to have a smaller acute estate footprint but also address very high levels of infrastructure risk . a requirement to have a more developed community service offer, particularly in relation to providing services closer to home; and the requirements of the emerging PCNs for local network hubs. . a need to utilise PFI estate capacity which is tied to long term commitments in the ICS; recognising fixed points – some service locations will not change in the future clinical model and recognising these allows them to be determined as fixed points around which future care models can be built. It is also important to recognise the need to effectively use PFI and LIFT estate. Fixed points have been agreed by the ICS Clinical Services Strategy Programme Board to reflect these issues and support planning.

Clinical pathway reviews are being considered against the twenty service areas of highest activity volume in the system. Six initial areas of priority have been identified:

1. Cardiovascular Disease – Stroke 2. Maternity and Neonatal 3. Respiratory (COPD and Asthma) 4. Frailty 5. Children and Young People 6. Colorectal

The Clinical Service Strategy service review work aims to develop improved models of care with strong emphasis on prevention and education and system sustainability. Service reviews will also be evidence based. Evidence shows that many of the services can have an increased offer of care closer to home, if not in the home setting itself through advances in assistive technology, self- care and monitoring. Collectively this work should deliver the opportunity to consolidate the care needed in the acute hospital setting by transforming pathways to provide many of these services locally within primary and community hubs.

The Clinical Services Strategy work has a clear connection to the estate requirements in the ICS and as the service models develop will look to the Estate work to help inform the available options that will enable these new care models.

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13.4 Approach to Primary Care Estates and Emerging Plans

An estates strategy that focuses entirely on the technical aspects of the location, size and funding of buildings, which seeks to fit an off-the-shelf solution to a complex local problem, is doomed to failure. A strategy with a much greater chance of success will be one developed by system leaders who truly connect with the needs and potential of the population they serve and the staff they employ, who have a deep understanding of the benefits that can be realised through partnerships with local authorities and industry, and who are able to work with advisors that bring creative solutions to well understood challenges. Strategic estates plans should be developed in an integrated and inclusive way at a more local level with a bottom up approach. It is at local community levels where there is the right level of detailed understanding of population needs, and the most productive opportunities to align the political, civic, institutional, professional and personal interests involved. To this end the immediate priorities are: i. To understand the emerging requirements of Primary Care Network hubs: . For each PCN configuration, map out the current primary and community facilities and provide a reference document for each PCN; meeting with Locality Directors and Clinical Directors to identify key risks and vulnerabilities . Recognising and identifying requirements for population health management and working with a range of stakeholders in a place based manner . Linking the development of digitally enabled initiatives with the future requirements for face to face contacts and the impact on estates assets. . Obtain funding for and commission 6 facet surveys in Greater Nottingham and re-visit surveys done more recently in Mid-Notts . Identify gaps and further priorities for ICS capital, ETTF and business as usual capital with particular emphasis on: - Quality of estate - Housing growth - Opportunities for consolidating and disposing of estate including co- locating with partner organisations - Opportunities for integrating health and social care staff

ii. To link in with the Clinical Services Strategy service reviews at a service level to quantify the impact on primary and community

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facilities of shifting activity from acute hospital facilities: . Immediate connection with the existing Outline Business Cases being developed in anticipation of Wave 5 ICS capital bids in 19/20: - Eastwood - Hucknall - Strelley - East Leake - Newark . Scope the fixed points and identify ‘true’ vacant space and options for better utilisation . Continue to support the feasibility of revenue funded schemes through 3PD or GP led funding. iii. To maximise the potential of working with partners: . Develop a joint strategy with Nottinghamshire Healthcare Trust for primary and community hubs . Continue to actively engage with the N2D2 One Public Estate work, including multi-agency locality reviews and linking this work with PCNs; explore opportunities for local government borrowing as a potential funding option. . Develop a consistent operating model with council planners to be actively consulted/informed of major housing developments, building on successful work with Rushcliffe, Ashfield, Gedling and Newark and Sherwood Borough Councils; maximising the potential for Section 106 contributions iv. To ‘get our house in order’: . Ensure that data is accurate and up to date across the 200+ primary care properties and tenancy agreements . Simplify or remove complex historical arrangements which are often costly and incur unnecessary management fees . Explore the opportunities highlighted through the ICS Estates Rationalisation work, including where there are opportunities to dispose of properties whilst not making short term decisions where there may be a longer term need. . Rationalise the CCGs’ Headquarters requirements following the merger and restructure, being mindful of the need to preserve a locality presence for PCN facing teams.

14 Measurement

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This section should demonstrate how the system will use existing methods to monitor the delivery of local priorities through published reports and provide enablers for PCNs to deliver to their local populations. 1. A confirmed baseline to measure from and how the STP will measure change in the GP patient survey 2. Monitoring the workforce plan through the general practice workforce publications from NHS Digital 3. Monthly assessment when completing the GPFV monitoring survey 4. How the Primary Care annual assurance statements (https://www.england.nhs.uk/wp-content/uploads/2019/02/Annex-B- guidance-for-operational-and-activity-plans-assurance-statements-v2.pdf) and technical definitions (https://www.england.nhs.uk/publication/preparing- for-2019-20-operational-planning-and-contracting-annex-f/) will hold the system to account. 5. Describing how any learning from the GPFV MoU mid and end of year reviews will influence future plans. 6. How will the system be making sure that Patient participation groups are engaged throughout the process so that the patients voice is heard. 7. A description of the role a primary care commissioning committee, or similar, plays or will play in the Integrated Care System and how you intend to ensure that it supports PCNs in their development. 8. It must also include information on how the STP/ICS plans to provide data for a PCNs local population to allow them to understand, in depth, their populations’ health and care needs for symptomatic and prevention programmes such as screening and immunisation.

14.1 GP Patient Survey

The baseline data will be taken from the GPPS 2018 Practice results data file. This gives a practice level breakdown for each question at response level as well as the calculated % question result. It is proposed that the CCG will use the baseline data from the 2018 GP Practice Survey to provide the Primary Care Networks with the ability to monitor their performance against agreed priorities. This will provide the CCG with a robust tool for measuring patient satisfaction to be reported to the Primary Care Commissioning Committee. The CCG will undertake an analysis of the baseline results to identify areas for improvement or focus. This will include benchmarking results against

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organisations with a similar demographic profile, against the National results; and presenting results over an historical timeline. As well as the GP Patient Survey, we have access to a rich mine of information from areas such as Patient Participation Groups; Friends and Family test results; CQC inspections. Additionally, we have the capacity to overlay the GP Patient survey results with the GP Workforce plan. This will indicate whether there is a correlation between staffing levels and rates of patient satisfaction. The aim will be to build a comprehensive picture of overall satisfaction levels at GP practice level which can be aggregated up to PCN level. The intention is that the CCG will commission GP practices to undertake a patient survey that focusses on the priorities that have been agreed. This will be carried out on a quarterly basis. The results will then be made available to PCNs. The CCG will deliver the GP Practice survey results aggregated to a PCN level via interactive dashboards and infographics, which will allow users to drill through to row level data. The dashboard tools will allow PCNs to benchmark performance against local and national results; provide a timeline series that can help identify changes in performance. Wider PCN Reporting Each PCN will be provided with a “point of contact” so that ongoing needs for analytics and performance data are addressed. We will establish routine reporting of all the relevant, identified metrics. There will be a range of aggregations including drill-down to PCN level. We are currently planning how these dashboards will be developed and they will include in-depth demographic, epidemiological and other data sets that will enable population and health care needs to be proactively identified at PCN level. The data sets will be comprehensive and will draw on data expertise across the full range including local authority and public health analytics expertise.

14.2 GP Workforce plan

The baseline data at CCG level will be taken from the December 2018 GP Workforce files: GP Workforce GP CCG level data GP Workforce Nurses CCG level data GP Workforce Admin_NonClinical CCG level data GP Workforce Direct Patient Care CCG level data

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In addition we have access to anonymised row level data covering the demographics of the workforce. This allows analysis at NHS England and HEE Region, STP, and CCG level. GP Workforce Practice level data This file gives anonymised demographic and qualification data at practice level. This will allow analysis at PCN level. All of the data sources listed above will be available on a quarterly basis. The baseline data allows analysis at NHS England Region, HEE Region, STP and CCG level. Data is published as both a headcount and FTE. In addition we have access to quarter on quarter changes at GP Practice level. It is proposed that the CCG will use the baseline data from the December 2018 GP Workforce datasets to provide the Primary Care Networks with the ability to monitor their staffing levels on a quarterly basis. All this helps to provide, alongside organisational Strategic Business and Workforce Plans, indicators on what the workforce will look like in the future. The better the information and its quality the more sound the judgements will be on commissioning the workforce for the future The CCG will undertake an analysis of the baseline results to identify areas for improvement or focus, such as clinical staff / patient ratio. The data will help PCNs by building and understanding the: . Age profile of the workforce which can then be related to understanding turnover, retention (stability) and retirement data; . Effect of gender on working patterns – for example the increasing numbers of GP’s who are female and the impact that this may have on training numbers. . Staff movements - understanding the workforce data within this area provides essential information on how the shape of the historical and current workforce has ebbed and flowed.

14.3 GPFV monitoring survey

[to follow]

14.4 Primary Care annual assurance statements

[to follow]

14.5 Learning from GPFV MoU Reviews

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The Nottingham and Nottinghamshire ICS has completed a process to determine how to utilise GPFV funding in order to achieve maximum impact and benefit. A number of schemes have been prioritised which focus on the four key programme areas – GP retention, practice resilience, reception and clerical staff training and online consultation. Although GPFV funding allocations have been confirmed for 2019/20 and 2020/21 a decision has been made locally that the initial focus will be on 2019/20 only. This is in the context of the emerging PCNs and recognises that the workforce, training and organisational development needs of PCNs are likely to become clearer during 2019/20. The schemes for 2019/20 will be supported by clear measurable outcomes/outputs. Achievement against these will be assessed via mid and end of year reviews. These reviews will be used to inform investment priorities for 2020/21 and future years. Progress and delivery will be monitored via the Nottingham and Nottinghamshire Primary Care Strategic Commissioning Steering Group.

14.6 Patient Participation Groups

A new communications and engagement strategy is under development with the objective of demonstrating that the newly merged CCG will have effective engagement of its population in place. The strategy is being developed as part of the merger process. Its content will be informed by the following: . Patient and public participation in commissioning health and care: Statutory guidance for clinical commissioning groups and NHS England (https://www.england.nhs.uk/wp-content/uploads/2017/05/patient-and- public-participation-guidance.pdf) . The Patient and Community Engagement Indicator in NHS England’s Improvement and Assessment Framework (https://www.england.nhs.uk/wp- content/uploads/2019/01/ccg-iaf-patient-community-engagement-indicator- guidance-v1.pdf). To provide assurance around PPI the strategy will set out how the merged CCG will manage engagement in relation to the following: . Governance - Involving the public in the CCG’s decision making bodies - Providing a patient committee structure that assures the CCG that the voice of its population is informing its commissioning decisions on a continuous basis - How providers will be held to account for their own public

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involvement activities . Engagement in commissioning - How engagement will be embedded in commissioning activity - How the CCG will determine the appropriate level and approach for engagement e.g. formal consultation . Equalities and health inequalities - Ensuring engagement takes account of equalities and health inequalities - Providing assurance that the CCG has mechanisms in place to engage across its populations, including those that are seldom heard and those protected by a characteristic under the Equalities Act 2010. The above focus is aligned to the guidance for CCGs on meeting their statutory duties for PPI. A single patient group for Greater Nottingham will be established by the end of June 2019. This group will replace the Greater Nottingham CCGs’ existing patient committees. It will sit alongside the Mid Notts Patient and Public Engagement Committee (PPEC) as one of two patient groups providing assurance around PPI for the Nottinghamshire-wide Governing Bodies.

14.7 Governance

Going forward the Nottingham and Nottinghamshire Primary Care Strategic Commissioning Steering Group will be the overarching forum that will monitor and ensure delivery of the ICS Primary Care Strategy. This will be supported by a number of workstreams leading on core areas including general practice, primary care networks, estates, workforce and population health. The steering group will also provide the governance around GPFV funding.

14.8 Public information

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15 Finance

This section should set out how much the STP estimates implementing the strategy is likely to cost, and identify how the STP might be able fund the increased expenditure on workforce, estates and other enablers. It is important to include: The current levels of expenditure using the current model of care Forecast levels of expenditure using new models of care across all workstreams (workforce, PCNs, estates, digital technology and other enablers) The overall STPs financial position with a breakdown by CCG available The risks associated with the strategy and how they will be mitigated Please ensure this section also accounts for all funding available.

15.1 Current expenditure

The CCGs in Nottingham and Nottinghamshire ICS are facing significant financial pressures. The financial challenge for 2019/20 is £53 million in Greater Nottingham and £25 million in mid Nottinghamshire. CCG programme budgets are therefore under significant pressure and the level of investment in to Primary Care should be seen in this context. Discretionary areas, funded from core/programme allocations will need to be reviewed to ensure that they are aligned with the PC investment strategy.

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Table 15-1 – Primary Care developments funded via Delegated Budgets £000's

Rush- City NNE NW M&A N&S Total cliffe

£1.761/head to practices £672 £270 £166 £225 £370 £257 £1,960 for engagement

New workforce re- £721 £270 £185 £194 £488 £339 £2,197 imbursement scheme

DES changes: . extended hours -£544 -£219 -£135 -£182 -£167 -£98 -£1,345 DES finishes

. network contract £415 £167 £103 £139 £216 £150 £1,190 DES access

Table 15-2 - £1.50 per head (from Core allocation) £000's

£1.50 per head (from Rush- Core allocation) City NNE NW M&A N&S Total cliffe £000's

£1.50/head network £572 £230 £142 £192 £293 £204 £1,633

Table 15-3 - GPFV (Anticipated NR Allocation 2019/20) (£000's)

Anticipated Allocation £854 (NB. Covers all 6 CCGs) Current Plan Practice Resilience £254 GP Retention Programme £200 Reception & Clerical Staff Training £125 On Line Consultation £297 Req'd Reduction to match Allocation -£22 Total Plan £854

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Table 15-4 - Extended Access £000's

Rush- Extended Access £000's City NNE NW M&A N&S Total cliffe from Programme Allocation £2,250 £0 £0 £676 £1,169 £767 £4,862

anticipated Allocation 19/20 £0 £920 £568 £0 £0 £0 £1,488 ( *estimate £6/head )

Table 15-5 - Practice Engagement £000's

Practice Engagement Rush- City NNE NW M&A N&S Total £000's cliffe opening PC budgets / BCF £2,133 £1,124 £793 £826 £0 £0 £4,876

15.2 Forecast expenditure

[to follow]

15.3 Overall ICS Position, broken down by CCG

[to follow]

15.4 Risks and mitigations

[to follow]

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Meeting in Common of NHS Mansfield and Ashfield CCG, NHS Newark and Sherwood CCG, NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG

Meeting Title: Open Primary Care Commissioning Date: 19 June 2019 Committee

Paper Title: PCCC Risk Report Paper Reference: PCC 19/013

Sponsor: Siân Gascoigne, Corporate Attachments/ PCCC Risk Report Presenter: Governance & Assurance Manager Appendices: PCC Risk Register Siân Gascoigne, Corporate (Extract) Appendix Governance and Assurance Manager A

Executive Summary Work is currently underway to align the risk management framework and develop a joint risk register across the six CCGs. Discussions are being held with relevant CCG officers and ‘new’ risk owners to support this work. The purpose of this paper is to present the Primary Care Commissioning Committees with the operational risks from the CCGs’ joint risk register relevant to the Committees’ responsibilities. This paper will be a standing agenda item, presented to each meeting of the Committee. As work is ongoing in relation to the risk management framework, views from members both in terms of the content and format of this report, as well as the current risk profile of the Committee are welcomed.

Recommendation: ☐To endorse ☐To review ☒To receive/note for assurance and information ☐To approve the recommendations as set out below

Recommendation(s): 1. NOTE the work being undertaken to align the operational risks from Greater Nottingham and Mid Nottinghamshire CCGs. 2. COMMENT on the risks shown within this paper (including the high/red risk) and those at Appendix A. 3. HIGHLIGHT any risks identified during the course of the meeting for inclusion within the Corporate Risk Register.

Relevant CCG priorities/objectives: (please tick which priorities/objectives your paper relates to) Compliance with Statutory Duties ☒ Establishment of a Strategic Commissioner ☐ System architecture development (e.g. ☐ Financial Management ☐ ICP, PCN development) Performance Management ☐ Cultural and/or Organisational Development ☐ Service Planning and/or Commissioning ☐ Procurement and/or Contracting ☐ Page 1 of 2

Completion of Impact Assessments: Equality / Quality Impact Yes ☐ Has an EQIA been completed? If the answer is No, please Assessment (EQIA) No ☒ explain why Purpose and content of report does not require EQIA. Data Protection Impact Yes ☐ Has a DPIA been completed? If the answer is No, please explain Assessment (DPIA) No ☒ why Purpose and content of report does not require DPIA. Risk(s): Report contains all risks from the CCGs’ Corporate Risk Register which fall under the remit of the Primary Care Commissioning Committees. Confidentiality: Is the information in this paper confidential? ☒No ☐Yes Conflicts of Interest: Please state whether there are any conflicts of interest considerations relevant to paper authors, members or attendees. ☒ No conflict identified ☐ Conflict noted, conflicted party can participate in discussion and decision ☐ Conflict noted, conflicted party can participate in discussion, but not decision ☐ Conflict noted, conflicted party can remain, but not participate in discussion or decision ☐ Conflicted party to be excluded from meeting

Page 2 of 2

Primary Care Commissioning Committees Monthly Risk Report

1. Introduction Work is currently underway to align the risk management framework and develop a joint risk register across the six CCGs. Discussions are being held with relevant CCG officers and ‘new’ risk owners to support this work. The purpose of this paper is to present the Primary Care Commissioning Committees with the operational risks from the CCGs’ combined risk register relevant to the Committees’ responsibilities. One of the Committees’ duties, as outlined within its Terms of Reference, is to ‘oversee the identification and management of risks relating to the Committees’ remit’. Risks relevant to the Primary Care Commissioning Committees may include, for example, risks associated with the merger and/or closure of GP practices or shortages in primary care workforce and/or capacity concerns. This paper will be a standing agenda item, presented to each meeting of the Committee. As work is ongoing in relation to the risk management framework, views from members both in terms of the content and format of this report, as well as the current risk profile of the Committees are welcomed. The purpose of this is to provide assurance that risks relating to the Committees are being systematically captured across the Nottingham and Nottinghamshire CCGs and that sufficient management actions are in place and being actively progressed.

2. Alignment of Greater Nottingham and Mid Nottinghamshire Risks Work to align the operational risks from the Greater Nottingham and Mid Nottinghamshire CCGs is being undertaken in two stages. Stage 1 consisted of bringing the risk registers together to form a single document and ensuring responsibility for each of the individual risks aligns with the new Executive and senior management team and committee structures. This stage is complete.

Stage 2 of the process consists of reviewing each individual risk within the combined risk register to determine its relevance in the new organisational structure. Consideration is being given as to whether risks are relevant to the CCGs in their entirety, or whether they are specific to certain CCGs and/or localities. The format of the new Corporate Risk Register enables these distinctions to be made.

As part of this work, the narrative of the risks is being reviewed to ensure it is clearly articulated and addresses the ‘so what’ (or consequence) of the risk identified. Focus is also being given to addressing whether the risks are in line with the roles and responsibilities of a commissioning organisation.

Page 1 of 3

As expected, there is some duplication of risks across the patch as described in Section 3 below. Where appropriate, work is being undertaken to amalgamate the narrative of these risks and determine an appropriate risk score. Members should note the previous risk matrices used across Greater Nottingham and Mid Nottinghamshire CCGs were the same (e.g. 5 x 5 impact vs. likelihood). Work in relation to target risk scores will be undertaken once the CCGs’ risk appetite statement has been agreed by the Governing Bodies.

3. Risk Profile

Following Stage 1, there are currently seven risks pertaining to the Committees’ responsibilities (as detailed in Appendix A). Future reports will outline whether there is an increase or decrease in the number of risks from the previous month. The movement of risks is described in Sections 4 and 5 of this paper.

The table to the right shows the current risk Risk Matrix profile of the seven risks. 5 - Very High 1

4 – High 1 3 Risks have been reviewed by the Corporate 3 – Medium 2 Governance and Assurance Manager in Impact 2 – Low

conjunction with relevant CCG officers from 1- Very low

Mid-Nottinghamshire. A meeting is scheduled

with the Associate Director of Primary Care on

Rare

Likely

Almost Almost

-

unlikely

Possible

-

18 June to review the entirety of the risks. - - Certain

-

1 1

4 4

5 5 2 2 3 From the initial review, it has been identified Likelihood the risks within the Committees’ remit fall until three clear ‘themes’:

- Increased demands / referrals (RR 022, RR 023, RR 032, RR 055 and RR 065); - Primary Care workforce (RR 032 and RR 061); and - Primary Care estate (RR 066).

It has been agreed that new risks will be articulated across the above themes, bringing together the current risks which have elements of duplication. Work can then be undertaken to formally define the controls and mitigating actions.

A further draft risk is being developed in relation to potential loss of locality focus within the new Committee structure following discussions at the last Mid-Nottinghamshire and Greater Nottingham PCCC meetings.

At present, there is one high / red risk in the Committees’ remit as outlined below. The narrative and scoring of this risk will be reviewed as part of the process referenced above.

Risk Current Risk Risk Narrative Reference Score

Overall Score 20: RR 061 There is a risk that general practice workforce required to deliver sustainable services during 2019/20 will not be in a sustainable position Red (I5 x L4)

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to deliver the system requirements.

This means the delivery of system benefits including population health outcomes and reduction in practice vulnerability will not be delivered.

4. Risk Identification

In future meetings, this section will highlight if there have been any additional risks identified for inclusion within the Risk Register which fall under the Committees’ remit.

Risks may be identified through a variety of means, for example, via risk assessments, external assessments and/or audits, complaints and/or claims, changes to legislation or through business as usual activities, such as annual business planning. The Corporate Governance and Assurance Manager will attend Committee meetings to contribute, identify and capture any new risks arising during discussions.

5. Archiving of Risks In future meetings, this section will identify any risks that are being proposed to the Committees for archiving.

6. Amendments to Risk Narrative/Score In future meetings, this section will draw members’ attention to any changes made to the wording and/or changes to risk scores since the previous meeting.

7. Recommendations

The Committees are asked to:

 NOTE work being undertaken to align the operational risks from Greater Nottingham and Mid Nottinghamshire CCGs;  COMMENT on the risks shown within this paper (including the high/red risk)and those at Appendix A; and  HIGHLIGHT any risks identified during the course of the meeting for inclusion within the Corporate Risk Register.

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Corporate Risk Register for Greater Nottingham and Mid-Nottinghamshire CCGs (June 2019)

Risk Ref Oversight Committee Directorate Relevance to Risk Source / Risk Description Existing Controls Mitigating Actions Current Risk Mitigating Actions Progress Update: Last Review Next Review due (as per June 2019 (as per April 2019 Statutory CCG Previous Risk Ref Initial Risk Rating Date

Governance Structure) Joint CCG structure) (e.g. GN or MNs) LeadExecutive Rating

Risk Owner

(Relevant committee in the (Risk relevant to all (Previous risk (These risks are by-products of day-to-day business delivery. They (The measures in place to control risks and reduce the likelihood of them occurring). (Actions required to manage / mitigate the identified risk. Actions (To provide detailed updates on progress CCGs' governance six statutory CCGs or register ref if arise from definite events or circumstances and have the potential should support achievement of target risk score and be SMART (e.g. being made against any mitigating actions structure responsible for specific CCGs, as applicable) to impact negatively on the organisation and its objectives.) Specific, Measurable, Assignable, Realistic and Time-bound). identified. Actions taken should bring risk

monitoring risks relating to noted). to level which can be tolerated by the

Score Score

Impact Impact Likelihood their delegated duties) Likelihood organisation).

RR022 Primary Care Commissioning TBD GN068 There is a risk that reductions in unwarranted clinical variations in 12 • Role and remit of the Primary Care Commissioning Committee (and supporting governance structures) Specific SMART mitigating actions in development. 3 3 9 01/11/18 30/01/19 Commissioning primary care may not be achieved in order to deliver better value Committees for money and better outcomes for patients • Role and remit of Primary Care Performance and Quality Steering Group

SharonPickett

LucyDadge • Primary Care performance and quality reporting processes

• Activity monitoring via e-Health Scope tool.

• GP Practice Quality Visits programme

RR023 Primary Care Commissioning TBD GN070 As practices have seen an increase in charges for reimbursable and 3 3 9 • CCG meetings with NHS Property Services and Community Health Partnerships (quarterly). Specific SMART mitigating actions in development. 3 3 9 30/11/18 28/02/19

LynneSharp

Commissioning non-reimbursable costs for premises from Property Services and LucyDadge Committees from CHP (Community Health Partnerships), there is a risk that for some practices this increase could mean that it is no longer viable to continue providing primary care services at the location leading to service disruption

RR032 Primary Care Commissioning TBD GN089 Increase in demand and workforce challenges may adversely impact 4 4 16 • Role and remit of the Primary Care Commissioning Committee (and supporting governance structures) Specific SMART mitigating actions in development. 4 3 12 Commissioning capacity and capability within General Practice. This presents a risk Committees that GP practices may be unable to deliver core services and • Appointment of Locality Directors (and supporting teams) transformation requirements, which in turn, may impact the quality of services provided (including patient access, for example). • Development of Primary Care Networks (PCNs) (and/or other collaboration/federation activities)

SharonPickett LucyDadge • Delivery of the Nottingham and Nottinghamshire STP Primary Care Workforce Plan

• Implementation of the GP Enhanced Delivery Scheme (South County CCGs) and Primary Care Patient Offer (City CCG)

• Ensuring the best use of funding via the GP Forward View, targeting resources to areas of need e.g. GP Resilience Funding, Practice Manager training and development funding.

RR055 Primary Care Commissioning TBD MN Risk No. SR1 There is a risk that GP elective referrals will increase beyond the 4 3 12 • The demand management centre (DMCC) will refresh and revise the approach taken in 2018/19 to Action: Tactical discussions in the primary care team occur to agree 4 3 12 11/06/2019 09/09/19 Commissioning planned levels and this will cause overspend against the acute ensure it remains fit for purpose especially considering the emerging PCN structure. the approach based on practice intelligence. Committees contract for both CCGs. • The meetings will be chaired by the SRO with a core team in attendance and relevant ad hoc members pertinent to the topic area. Action: The CCG has a member practice agreement with the CCG The consequence would lead to financial challenge putting further • A log of issues, actions and outcomes is recorded as part of the governance approach. which is reviewed two yearly. strain on the control total leading to additional mitigating actions to • Weekly communication and messages are agreed and shared with the system including general ensure the CCGs meet regulatory and legal requirements. practice. Action: The programme is working towards the contractual drivers • Appropriate clinical leadership is provided to ensure clinical conversations are happening not only with expected in the new GP contract from 2020/21 where incentive identified practices and also between primary and secondary care. payments will be made for best use of NHS resources into PCNs. • Analyst support has been dedicated.

SharonPickett

LucyDadge • A revised escalation process is in place and has been effective when implemented during 2018/19 financial year. • Quality and Performance are formally reviewed through the primary care dashboard and discussed at the primary care quality group; formally reporting into the CCG Quality and Risk Committee. • Information is shared with practices to encourage engagement through practice packs as part of practice visits. • Referral reviews are undertaken and the referrals facilitation team visit practices to ensure a common approach is adopted including peer review. • A number of 2019/20 transformation schemes are being led by the CCG, designed to reduce secondary care demand, these include; HVSU, Frailty, EOL, EMAS non conveyance, DVT pathway, enhanced care homes service, call for care, intensive home support phase 2, GU clinical pathway, ambulatory care expansion, integrated urgent care pathways. • As part of the wider QIPP delivery programme, a governance structure of delivery boards is in place and reports into the alliance transformation board. Risk Ref Oversight Committee Directorate Relevance to Risk Source / Risk Description Existing Controls Mitigating Actions Current Risk Mitigating Actions Progress Update: Last Review Next Review due (as per June 2019 (as per April 2019 Statutory CCG Previous Risk Ref Initial Risk Rating Date

Governance Structure) Joint CCG structure) (e.g. GN or MNs) LeadExecutive Rating

Risk Owner

(Relevant committee in the (Risk relevant to all (Previous risk (These risks are by-products of day-to-day business delivery. They (The measures in place to control risks and reduce the likelihood of them occurring). (Actions required to manage / mitigate the identified risk. Actions (To provide detailed updates on progress CCGs' governance six statutory CCGs or register ref if arise from definite events or circumstances and have the potential should support achievement of target risk score and be SMART (e.g. being made against any mitigating actions structure responsible for specific CCGs, as applicable) to impact negatively on the organisation and its objectives.) Specific, Measurable, Assignable, Realistic and Time-bound). identified. Actions taken should bring risk

monitoring risks relating to noted). to level which can be tolerated by the

Score Score

Impact Impact Likelihood their delegated duties) Likelihood organisation).

RR061 Primary Care Commissioning TBD MN Risk No. SR25 There is a risk that general practice workforce required to deliver 5 4 20 • Mid-Nottinghamshire’s Primary Care Commissioning Committee has delegated authority on behalf of Action: Local plans for retention have been developed to mitigate the 5 4 20 11/06/2019 09/09/19 Commissioning sustainable services during 2019/20 will not be in a sustainable the Governing Body through standard finance instruction changes for the oversight and assurance of all anticipated gap in supply. Plans are on track and submitted through Committees position to deliver the system requirements. aspects of primary care including the new GP contract, the establishment of Primary Care Networks and NHSE assurance route. There was a further retention funding the remaining GP Forward View schemes. opportunity from NHSE in January 2019 with bids to be submitted This means the delivery of system benefits including population supporting existing and new retention schemes. The Primary Care health outcomes and reduction in practice vulnerability will not be • A primary care workforce group has been established as part of the ICS workstream governance Commissioning Committee received The Phoenix Programme in March delivered. approach with good representation from Health Education England, Local Medical Committee, Clinical 2019 to review and confirm.

SharonPickett

LucyDadge Commissioning Groups, and NHS England project teams. Action: The working group are developing a narrative that highlights • Local workforce plan is in place, with agreed trajectories currently showing the project is on track the unique opportunities available in the Mid Notts area with ICP overall and ahead for non-medical personnel. partners.

• GP and non-medical workforce trajectories are agreed as part of the programme management approach.

• There is now a nursing lead for the GP practice nurse 10-point plan.

• A successful bid for slippage funds to establish The Phoenix Programme through the Local Medical Council. RR065 Primary Care Commissioning TBD MN PC RR SR01 There is a risk that GP referrals will increase beyond the 19/20 4 3 12 Specific SMART mitigating actions in development. 4 3 12 11/06/2019 09/09/19 Commissioning planned levels and this will cause overspend against the acute Committees contract for both CCGs.

SharonPickett

LucyDadge

• Optimising Health Project - helps to control/reduce GP referrals

RR066 Primary Care Commissioning TBD MN QPRG 01 There is a risk that four practices have unmanageable debt relating 4 2 8 4 2 8 11/06/2019 09/09/19 Commissioning to NHSPS estate rental costs (both reimbursable and non •CCG primary care lead identified to act as project manager and key practice liaison officer (C).

LynneSharp Committees reimbursable). In the short term this could lead to practices being LucyDadge •Working group set up for each practice with representatives from NHSE, the practice, LMC and the CCG unable to plan (i.e. recruit, invest, etc.) and weaken their resilience (C). and in the long term this could result in practice collapse. • Relevant experts in estates and NHS finance identified and project resource protected (C). Action: Periodic update meetings with CO, CFO and DoPC (C). • Quality and Performance Group (QPG) own and oversee progress and risk (C). • QPG receives update at each meeting (C). • LMC supporting all practices (I)

Meeting in Common of NHS Mansfield and Ashfield CCG, NHS Newark and Sherwood CCG, NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG

Meeting Title: Primary Care Commissioning Date: 19 June 2019 Committee

Paper Title: Confirmation of the Primary Care Paper Reference: PCC 19/014 Network Configurations for Nottingham and Nottinghamshire

Sponsor: Helen Griffiths/Lucy Dadge Attachments/ Appendix 1 – Presenter: For Information only Appendices: Primary Care Configurations Appendix 2 – Clinical Directors for the Primary Care Networks Appendix 3 – Comparison of CCG Activity

Executive Summary

At the 9 May 2019 ICS Board meeting, members considered a paper on the development of Primary Care Networks (PCN) across Nottingham and Nottinghamshire, which included a position statement (April 2019) on the proposed configurations of the developing formations of the PCNs for Nottingham and Nottinghamshire.

At the ICS Board meeting, the members approved and agreed the vision and aspirations of the Primary Care Networks, as well as noting and endorsing the progress to date on the PCN configurations.

The final approval of the PCN configurations was delegated to the Managing Director of the ICS in time for the submission to NHSE&I, by the deadline of 31 May 2019.

This paper will:  Outline the Clinical Commissioning Group’s and NHSE’s governance process for approval of the PCN registrations  Confirm the final PCN configurations for Nottingham and Nottinghamshire, as signed off by the Managing Director of the ICS  Detail the rationale for the PCN configurations  Confirm the Clinical Directors for each PCN  Outline the next steps for the development of the PCNs

Recommendation:

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☐To endorse ☐To review ☒To receive/note for assurance and information ☐To approve the recommendations as set out below

Recommendation(s): 1. To note the report 2. To confirm support for the PCN configurations and newly appointed Clinical Directors for each PCN for Nottingham and Nottinghamshire 3. To note the next steps for the development of the PCN’s Relevant CCG priorities/objectives: (please tick which priorities/objectives your paper relates to) Compliance with Statutory Duties ☐ Establishment of a Strategic Commissioner ☐ System architecture development (e.g. ☒ Financial Management ☐ ICP, PCN development) Performance Management ☐ Cultural and/or Organisational Development ☒ Service Planning and/or Commissioning ☐ Procurement and/or Contracting ☐ Completion of Impact Assessments: Equality / Quality Impact Yes ☐ Has an EQIA been completed? If the answer is No, please Assessment (EQIA) No ☒ explain why To be completed now PCN configurations confirmed. Data Protection Impact Yes ☐ Has a DPIA been completed? If the answer is No, please explain Assessment (DPIA) No ☒ why To be completed now PCN configurations confirmed. Risk(s): No risks identified. Confidentiality: Is the information in this paper confidential? ☒No ☐Yes Conflicts of Interest: Please state whether there are any conflicts of interest considerations relevant to paper authors, members or attendees. ☒ No conflict identified ☐ Conflict noted, conflicted party can participate in discussion and decision ☐ Conflict noted, conflicted party can participate in discussion, but not decision ☐ Conflict noted, conflicted party can remain, but not participate in discussion or decision ☐ Conflicted party to be excluded from meeting

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ENC. F Meeting : ICS Board Report Title: Confirmation of the Primary Care Network Configurations for Nottingham and Nottinghamshire Date of meeting : Thursday 13 June 2019 Agenda Item Number: 9 Work -stream SRO: Nicole Atkinson Report Author: Helen Griffiths/Lucy Dadge Attachments/Appendices: Appendix 1 – Primary Care Configurations Appendix 2 - Clinical Directors for the Primary care Networks Appendix 3 – Comparison of CCG Activity Report Summary:

At the 9 May 2019 ICS Board meeting, members considered a paper on the development of Primary Care Networks (PCN) across Nottingham and Nottinghamshire, which included a position statement (April 2019) on the proposed configurations of the developing formations of the PCNs for Nottingham and Nottinghamshire.

At the ICS Board meeting, the members approved and agreed the vision and aspirations of the Primary Care Networks, as well as noting and endorsing the progress to date on the PCN configurations.

The final approval of the PCN configurations was delegated to the Managing Director of the ICS in time for the submission to NHSE&I, by the deadline of 31 May 2019.

This paper will: • Outline the Clinical Commissioning Group’s and NHSE’s governance process for approval of the PCN registrations • Confirm the final PCN configurations for Nottingham and Nottinghamshire, as signed off by the Managing Director of the ICS • Detail the rationale for the PCN configurations • Confirm the Clinical Directors for each PCN • Outline the next steps for the development of the PCNs

Action: To receive To approve the recommendations Recommendations: 1. To note the report 2. To confirm support for the PCN configurations and newly appointed Clinical Directors for each PCN for Nottingham and Nottinghamshire 3. To note the next steps for the development of the PCNs

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Key implications considered in the report: Financial Value for Money Risk Legal Workforce Citizen engagement Clinical engagement Equality impact assessment Engagement to date: Finance Partnership Planning Workstream Board Directors Forum Group Network Group

Performance Clinical Mid South Nottingham Oversight Reference Nottingham- Nottingham- City ICP Group Group shire ICP shire ICP

Contribution to delivering the ICS high level ambitions of: Health and Wellbeing Care and Quality Finance and Efficiency Culture Is the paper confidential? Yes No Note: Upon request for the release of a paper deemed confidential, under Section 36 of the Freedom of Information Act 2000, parts or all of the paper will be considered for release.

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Confirmation of the Primary Care Network Configurations for Nottingham and Nottinghamshire

13 June 2019

Introduction

1. The purpose of this report is to provide the ICS Board with an overview of the confirmed Primary Care Networks (PCNs) for Nottingham and Nottinghamshire, including the approval requirements, governance process and rationale. The paper will also detail the newly appointed Clinical Directors for the PCNs, as well as outline the next steps for the development of the PCNs across the ICS.

Background

2. In the NHS Long Term Plan, Primary Care Networks (PCNs) are described as an essential building block of every Integrated Care System, with general practice taking the leading role in each PCN.

3. The PCN model is intended to dissolve the historic divide between primary care, community health services and social care. PCNs are centred on provision not commissioning. It is acknowledged that there are many benefits of this model including:

• Better health and care: a PCN is a natural unit for integrating most NHS care and aligning with other local services. Collectivised general practice can become the footprint on which other NHS and local authority community- based services can then align. By serving a defined population, PCNs bring a clear geographical locus for improving health and wellbeing.

• Stability: many individual practices face increased daily operational pressure and being part of a PCN may be able to help avoid a practice closure, removing the need to consider alternative provision. It is intended that the PCN model is a way of helping GP partnerships survive and evolve over the coming decade and provide a means of mutual support for better workload management.

• Different roles: it is easier to sustain advanced GP, nurse and allied health professional roles for patients at a larger scale rather than at an individual practice level. The PCN will operate at a size where clinicians able to build effective working relationships being sufficiently large enough to run an extensive multi-disciplinary team.

• Investment: by creating the PCN as a dedicated joint investment and delivery vehicle, GP practices can offer services that the NHS could not reasonably ask of every individual practice to deliver.

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• Community leadership: PCN clinical directors will provide strategic and clinical leadership to help support change across primary and community health services.

4. The contract mechanism for PCNs is a Directed Enhanced Service (DES). A DES is an extension of the core GP contract (February 2019) and is established in accordance with Directions given to NHS England.

5. All Clinical Commissioning Groups (CCGs) (through delegated functions from NHS England) are required to offer participation in the Network Contract DES to all practices. Eligibility applies to all existing and future holders of in-hours (essential) primary medical services contracts.

NHSE Guidance for Primary care Networks

6. NHS England (NHSE) guidance on the establishment of PCNs started to be published from January 2019 with NHSE policy guidance on emerging models being issued up to and including May 2019.

7. The NHSE guidance on PCNs provides the following key directions for consideration during the approval process:

• A PCN will typically serve a population of at least 30,000 people . Low population density across a large rural and remote area could be a permissible exception for a slightly smaller network list size.

• Although the population size of a PCN will not tend to exceed 50,000 people, this is no longer a strict requirement and commissioners may agree to larger PCNs. In such circumstances, the PCN may organise itself operationally into smaller neighbourhood teams that cover population sizes between 30,000 to 50,000 (Revised NHSE guidance, May 2019).

• Each PCN must have a boundary that makes sense to its constituent practices and to other community-based providers , who configure their teams accordingly and to its local community.

• While it is possible that a single geography could be served by more than one PCN (building on current multi-practice arrangements) most areas are likely to have a single PCN.

• Normally a practice will only join one network .

• It is likely that most network areas will not overlap , but this is not an absolute rule: for example, a large town of 100,000 population could have two different 50,000 networks operating on exactly the same footprint. They would have to collaborate on wider place-based goals. And a practice’s catchment area may continue to span more than one network, just as it can currently span across more than one CCG.

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Approval Process

8. Nationally, delegated co-commissioning CCGs were responsible for confirming that the PCN registration requirements had been met by Friday 31 st May 2019. The CCGs Primary Care Commissioning Committees (PCCCs) were required to approve that the registration requirement had been met by all PCNs.

9. CCGs were specifically asked to consider and approve all PCN contracts within its CCG at the same time. This was to ensure that every constituent practice was included, and 100% of the CCG’s own boundary was covered.

10. As part of confirming its support, the CCG was required to secure an explicit pledge of support from the leadership of the local Integrated Care System / Sustainability and Transformation Partnership. A paper was presented to the ICS Board on 9 th May. The Board approved the vision and an aspiration for PCNs. Initial progress to date on the configurations was noted and endorsed, and final approval of the submission to NHSE&I was delegated to the ICS Managing Director on behalf of the Board.

11. It is noted that any subsequent changes to network areas require CCG approval. Boundaries will require active support from both the local CCG and NHS England.

PCN Registrations

12. A total of twenty applications were submitted to the relevant CCGs to meet the NHSE deadline of 15 May 2019. The submissions and approvals can be summarised as follows:

ICP/CCGs Number of applications Approvals Process received

Mid Nottinghamshire CCGs:

Mansfield and Ashfield CCG 3 MN PCCC meeting 23 May Newark and Sherwood CCG 3 2019

Mid Nottinghamshire Total 6

Nottingham City CCG 8 GN PCCC (virtual approval) 30 May 2019

Nottingham City Total 8

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South Nottinghamshire:

Nottingham West CCG 1 GN PCCC meeting 31 May Rushcliffe CCG 1 2019 Nottingham North and East 4 CCG South Nottinghamshire 6 Total Grant Total 20

13. Each PCN submission was assessed against the NHSE criteria. 100% of the Nottingham and Nottinghamshire population is covered by a PCN, and every constituent practice across the CCGs has applied to register in a PCN

14. A summary of the PCN registrations is included in Appendix 1.

15. A list of the Clinical Directors for each PCN is included in Appendix 2.

16. The agreed and confirmed PCN applications were submitted to NHS England to meet the 31 May 2019 following consideration by the relevant PCCCs.

Rationale for PCN Configurations - South Nottinghamshire

17. The three CCG locality teams worked closely with all GP practices, GP partnerships, and the LMC to propose the final configurations of the PCNs.

Areas to note on the submissions received by Nottingham West CCG and Rushcliffe CCG

18. Both CCGs each received an application which described an overarching PCN for both Nottingham West and Rushcliffe, these proposed an operational model of delivery whereby each overarching PCN worked across three defined and well established PCN neighbourhoods.

19. For both PCN submissions, further to the revised NHSE regulatory parameters (May 2019) consensus emerged that the practices were able to apply as an overarching Network. Practices had concluded that this enabled the best contribution to the Integrated Care System (ICS) and future South Nottinghamshire Integrated Care Partnership (ICP).

20. It was determined that clinical practice would continue to be arranged with a focus on neighbourhoods, with the overarching PCNs providing the benefits of working across populations, which have historically be constituted as Care Delivery Groups (CDGs), to deliver the economies of scale in the supporting infrastructure.

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21. Further detail and consideration were sought in relation to both submissions to understand further how operationally working at a neighbourhood level would be delivered in both localities.

22. Detail and rationale include:

Relationships with other providers

23. Service delivery has been well established and successfully delivered at a neighbourhood level in both Rushcliffe and Nottingham West since 2010 when CDGs were first established. CDGs bring together groups of GP practices and community teams, interfaced with social care, and aligned to the borough/district council boundaries (Rushcliffe BC, Gedling BC, Ashfield BC, Newark and Sherwood DC, Broxtowe BC). Of note, both Nottinghamshire Healthcare Trust and Nottinghamshire County Council also configure their service delivery teams in these delivery units.

24. Excellent working relationships across community services and social care have enabled significant service transformation. Over the last four years, practices in Rushcliffe have worked collectively to deliver an exemplar vanguard programme of New Models of Care – the Principia MCP, in partnership with community services, social care and the voluntary sector.

25. Nottingham West continues to be one of the top performing CCGs nationally in terms of quality and safety of primary care services, with eight out of 12 GP practices achieving a CQC rating of ‘outstanding’. Practices are within a boundary that will support the development of expanded MDTs.

26. See Appendix 3 which outlines a comparison of Nottingham and Nottinghamshire CCG’s activity for out-patient activity, emergency admissions, and elective admission for March 2018 to February 2019.

Operating effectively at a Neighbourhood Level

Integrated service delivery

27. The neighbourhoods will provide the ‘docking’ points of community provision for all providers across health, social care and the voluntary and community services. This will be the building block around which integrated care systems are built.

Population Health Management

28. An overarching network for Rushcliffe and Nottingham West enables the practices to maximise population health management whilst making the best contribution to the ICS and future South Nottinghamshire ICP. The proposed Networks will balance the need for working at scale with a focus on neighbourhoods where appropriate. The proposed PCNs are natural communities

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and contiguous with the population boundaries of health and social care, local authority services, with natural flows of populations who live, work and use community assets across these areas. To support patient flow and choice consideration of transport links has been reviewed when proposing the PCNs as it is recognised patient behaviour is a key determinant in how healthcare is accessed.

29. There will be a coordinated shared view and understanding of the system’s priorities and what they mean for the PCN and a neighbourhood sensitive population health management delivery model.

30. Clear understanding of patient demographics, patient flow, transport links, public sector infrastructure and planned future housing developments characterise how the PCNs will ensure appropriate neighbourhood working.

Performance Management

31. A local PCN dashboard is currently being developed, which will be followed by the national PCN dashboard in April 2020. This will provide information at a neighbourhood level to ensure focus is placed on the right priorities, management of clinical variation, highlight opportunities and drive performance at a neighbourhood level. Review of performance via the dashboard will ensure the PCN configurations are appropriate and optimise outcomes.

Emerging system architecture

32. The configuration of Rushcliffe and Nottingham West PCNs is considered within the overall principles of the ICS recognising the accelerator status of the ICS and using this as a framework for the transformational development of the proposed PCNs. This approach recognises the level of maturity of collaboration and integration at a neighbourhood level across the ICS footprint.

33. The proposed Networks would balance the need for working at scale with a focus on neighbourhood where appropriate. This consensus is based on a number of factors:

• The long-established common ground between all practices and partners on fair and reasonable partnership terms and collective outcomes • The nature of provider networks operating in the configuration of PCNs is able to balance general practice at scale with neighbourhood sensitivities where appropriate • The existing shared business and clinical operations via both Partners Health and the Principia new model of care for Rushcliffe, and Primary Integrated Community Services Nottingham West • An already established and shared expertise in network management which provides an efficient infrastructure to manage the administration of the network • A track record of good financial stewardship

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• The opportunities this presents to form the basis of the ICP structure and governance, to be established between providers and between providers and commissioners

34. Both applications sought to build on the relationships and improvements made over years through Partners Health and Principia in Rushcliffe, and, in Nottingham West, Primary Integrated Community Services, and a continuously evolving business model which includes infrastructure, finance, and healthcare delivery.

35. Operating on a small-enough scale to make relationships work is an essential facet of the ‘Primary Care Home’ sites, whose experiences have informed these plans. Some individual practices are already bigger. If a large ‘super-practice’ (e.g. 200,000 patients) meets all the other registration requirements, it can serve as a single very large Primary Care Network. In reality, it will be organising itself into four separate neighbourhood teams, each covering a mean of 50,000 people. (Kings Fund 2019)

36. There is administrative efficiency to be found by not registering each as a PCN, and this was highlighted by The Kings Fund (2019)

Accountable clinical leadership model

37. Primary care representation is stronger through accountable clinical directors and neighbourhood clinical leadership teams from each network being the link between general practice and the wider system.

38. South Nottinghamshire CCGs have worked closely with Nottinghamshire LMC on the appointment process of the clinical director for each of the six PCNs. For Rushcliffe and Nottingham West, a total of eight applications were submitted to a panel for review. The panel consisted of colleagues from the wider partners including Nottinghamshire Healthcare Foundation Trust, the chair of the LMC, and patient representatives.

39. From the eight applications two named clinical directors, with accountability for the purposes of NHSE registration, were agreed by the PCNs for the registration purposes. For Rushcliffe this was noted on the PCN registration form as an interim arrangement until 30 June 2019. Each clinical director will work alongside a clinical leadership executive team made up of the remaining six applicants who will engage and lead each PCN neighbourhood. There is representation of GP clinical leads from each of the PCNs neighbourhoods. The clinical leadership team will work with practices, patients, the leaders of local providers and community assets in an inclusive executive operating at a neighbourhood level. This approach will also enable newly appointed Clinical Directors to be supported and mentored and ensure succession planning.

Collectivised General Practice

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40. Collectivised general practice is well established and mature in South Nottinghamshire. In Rushcliffe collectivisation is coordinated by Partners Health, a limited liability partnership solely owned by the Rushcliffe practices. In Nottingham West and Nottingham North and East, GP practices are supported by two federations set up through Primary Integrated Care Services. There is established and shared expertise in network management, shared business and clinical operations successfully delivered via both Partners Health and Primary Integrated Community Services (PICS).

41. GP Partnerships and federations have played a key part in supporting GP resilience. A key task for PCNs will be to improve overall performance, by leading service transformation and reducing clinical variation. The experience in Rushcliffe and Nottingham West is that this can best be achieved by working collectively working at scale.

42. Evidence shows that collaboration in general practice is most successful when it has been generated organically by general practices over a number of years, underpinned by trust, relationships and support, and where there was a clear focus and agreement on the role of the collaboration (for example, whether it was to share back-office functions, provide community services or for quality improvement) (Kings Fund 2019).

43. All practices have a PCN perspective and commit to the principles of collectivism, participation, mutual accountability, commitment, and collaboration. There is a track record of good financial management with financial vehicles already established without the need for unnecessary bureaucracy.

44. The GP partnerships, on behalf of its member practices, will act as the lead point of contact with the commissioning CCG, receive and distribute PCN funding, and recruit and manage additional PCN workforce, reducing the administrative burden if several PCNs are established to do this

Areas to note on the submissions received by Nottingham North and East CCG

45. When assessed against the NHSE criteria two key concerns were identified which required for further consideration : • the ability of other service providers to align themselves with PCN 3 and PCN 4 given the overlaps between their practice populations; • the ability of PCN 3 to offer services in a way that makes geographical sense to their patients, in particular the patients registered with Daybook Medical Practice.

46. The CCG locality team facilitated a meeting of the practices in PCN 2, 3 and 4 on 29 May 2019; 11 out of the 12 practices were represented. As well as the LMC, NHS England and Local Partnerships were also represented at the meeting.

47. Following discussions, it was agreed that PCN 3 and PCN 4 would adopt a consistent approach to the commissioning of community services delivered in

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both PCNs and that this agreement would be written into the relevant network agreement Schedules.

48. Further consideration as to the proposal from PCN 3 concluded that Daybrook Medical Practice should be included as a core member of the network, due to good working relationships similar practice populations; and remedial actions being taken to ensure patients can access services from the nearest ‘hub’

49. The population of PCN 4 is currently below the 30,000 threshold by 353 patients. Housing developments in the area mean that the PCN will reach the 30,000 threshold during 2019/20. The practices within PCN 4 have stated that if they are not supported to establish a PCN of their own at this point in time because of their population size, as soon as they reach a population of 30,000 they will apply to leave PCN 3 and resubmit an application to form their own PCN.

50. After much discussion, and consideration, on order to ensure good working relationships and to avoid the disruption of practices leaving a PCN soon after it has formed it was agreed to not reject the PCN 4 proposal on the grounds of population size.

Rationale for PCN Configurations - Mid Nottinghamshire CCGs

51. Mid Nottinghamshire CCG worked closely with the LMC throughout the process to allow PCNs to own, engage and drive their own nomination of key leaders and agree their terms of business.

Areas to note on the submissions received by the Mid Nottinghamshire CCGs

52. Four of the PCNs in Mid Nottinghamshire have a total list size over 50,000 : The practices within these PCNs have established collaborative working over recent years and are based on appropriate geography.

Rationale for PCN Configurations - Nottingham City CCG

53. Nottingham City CCG Locality Team and Nottinghamshire LMC worked closely with all the GP practices across Nottingham City to propose the final configurations of the PCNs.

Areas to note on the submissions received by Nottingham City CCG:

54. The creation of a University Practice PCN (currently known as PCN U) : PCN U was developed with the two University practices. Both practices in the PCN have list sizes comprised primarily of the student population. Despite the practices being in different geographical locations they are still contiguous, overlapping with PCN 4, PCN 7, and PCN 8. Joining together in a PCN for this defined population makes sense for commissioned services and the needs of the student community.

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55. Three of the PCNs in Nottingham City have a total list size over 50,000 : in each of the three cases the population demographics and needs are similar. PCN 3 and PCN 6 are largely unchanged from their original established Care Delivery Group configurations; these groups of practices have a well-established and proven track record of successful working relationships

Rationale for PCN Configurations

56. The model in Figure 1 was presented in the 9 May paper to demonstrate the range of core services that have been locally identified to be delivered through the PCN configurations further to the PCN workshops Figure 1

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57. This table has been developed to further demonstrate how the PCNs will deliver services at Practice level, across a PCN neighbourhood, and across PCNs:

Practice level PCN Neighbourhoods Overarching PCN/PCNs 2 – 30k 50 – 100k 100 – 250k Access to GP and practice Social prescribing; self- Specialist community nurses management and services prevention Proactive care/MDTS Clinical and community Other NHS services e.g. pharmacy dentistry; optometry MDT meetings Community health teams Housing Near patient testing Specialist health teams Locality hubs Social care Urgent Care Centres Outreach secondary care Local Authority services teams Public Health Services Outreach outpatient departments Diagnostic and tertiary near patient testing

Next Steps

58. All Schedules which support the PCN Network Agreement DES to be developed and enacted by 30 June 2019.

59. From 1 July 2019 PCNs across the country will go live.

60. Organisational development and leadership to support the newly formed PCNs is being determined at a national, regional and local level.

61. Half day workshops are scheduled across the three PCN ICP footprints for July 2019.

62. Consistent approach to workforce development to support the emerging roles for Social Prescribers, Community Pharmacists, First Contact Physiotherapists; Physician Associates and Community Paramedics.

63. Continue to build upon existing and develop new relationships with community teams, social care, voluntary sector, acute providers, district councils and community assets.

64. Determine how PCNs will be represented at both the ICS and ICPs.

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65. Ensure a systematic communication and cascade of information through PCNs.

66. Engagement activities to the wider workforce.

67. Engage with patients and the public and members to build the emerging narrative and service offer to local communities

Recommendations

68. The Board are asked to:

• Consider this report • Confirm support for the PCN configurations and newly appointed Clinical Directors for each PCN for Nottingham and Nottinghamshire • Note the next steps for the development of the PCNs

Helen Griffiths Associate Director of Primary Care Networks Mid Notts and Greater Notts CCGs June 2019

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Appendix 1: Nottingham City and Nottinghamshire PCN application summary, May 2019

Nottingham City Practice Criteria Formation PCN of PCNs structures Network cannot must make Contract result in a geographic DES Size – practice(s) PCNs can only No al sense to Registration between being left cross upper tier practice patients Form 30,000 out or not local authority can be and for completed in and Geographical contiguity – contiguous areas in excluded commissio line with 50,000 practice boundaries must with other exceptional from a ned Accountable clinical PCN ODS Name guidance patients overlap or be adjacent patients circumstances PCN services director Nottingham City CCG PCN 1 C84043 Leen View Surgery Yes 44,571 Bulwell, Highbury Vale, Rise Complete Complete – all Complete Yes Dr Andrew Foster, Bulwell & Top C84064 Parkside Medical Practice Park, Top Valley practices within Parkside Medical Valley Nottingham City Practice C84135 Queens Bower Surgery Council C84129 Rise Park Surgery C84717 Riverlyn Medical Centre Y05622 Southglade Medical Practice C84138 Springfield Medical Centre C84004 St Albans Medical Centre/Nirmala PCN 3 C84091 Aspley Medical Centre Yes 59,168 Aspley, Beechdale, Complete Complete – all Complete Yes Dr Jonathan Harte, BACHS C84704 Beechdale Surgery Bilborough, Broxtowe, practices within Aspley Medical Centre Cinderhill, Old Basford, Nottingham City C84647 Bilborough Surgery Strelley Council Y06356 Bilborough Medical Centre C84650 Boulevard Medical Centre C84034 Churchfields Medical Practice C84104 Greenfields Medical Centre C84694 Limetree Surgery C84676 Mayfield Medical Practice C84116 Melbourne Park Medical Centre C84680 RHR Medical Centre C84698 Strelley Health Centre

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Practice Criteria Formation PCN of PCNs structures Network cannot must make Contract result in a geographic DES Size – practice(s) PCNs can only No al sense to Registration between being left cross upper tier practice patients Form 30,000 out or not local authority can be and for completed in and Geographical contiguity – contiguous areas in excluded commissio line with 50,000 practice boundaries must with other exceptional from a ned Accountable clinical PCN ODS Name guidance patients overlap or be adjacent patients circumstances PCN services director PCN 4 C84105 The Fairfields Practice Yes 49,503 Hyson Green, Radford, Complete Complete – all Complete Yes Dr Josephine Guha, The Radford & C84103 The Forest Practice Forest Fields, Bobbers Mill, practices within Forest Practice Mary Potter The Park Nottingham City C84691 High Green Medical Practice Council C84117 Radford Medical Practice/NTU C84096 Radford Health Centre - Phillips C84136 St Luke’s Surgery PCN 5 C84695 The Alice Medical Centre Yes 49,390 Bestwood, Carrington, New Complete Complete – all Complete Yes Dr Michael Crowe, Bestwood & C84011 Elmswood Surgery Basford, Sherwood, practices within Hucknall Road Medical Sherwood Sherwood Rise Nottingham City Centre C84078 Hucknall Road Medical Centre Council C84682 Sherrington Park Medical Practice C84628 Sherwood Rise Medical Centre C84151 The Medical Centre - Irfan C84619 Tudor House Medical Practice C84664 Welbeck Surgery PCN 6 C84693 Bakersfield Medical Centre Yes 66,474 Lace Market, Mapperley, Complete Complete – all Complete Yes Dr Hussain Gandhi, C84018 Family Medical Centre Mapperley Park, St Ann’s, practices within Wellspring Surgery; Sneinton Nottingham City Dr Margaret Abbott, C84063 GreenDale Primary Care Centre Council Windmill Practice C84602 Mapperley Park Medical Centre Y02847 NEMS - Platform One Practice C84085 Victoria and Mapperley Practice C84072 Wellspring Surgery C84683 Windmill Practice

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Practice Criteria Formation PCN of PCNs structures Network cannot must make Contract result in a geographic DES Size – practice(s) PCNs can only No al sense to Registration between being left cross upper tier practice patients Form 30,000 out or not local authority can be and for completed in and Geographical contiguity – contiguous areas in excluded commissio line with 50,000 practice boundaries must with other exceptional from a ned Accountable clinical PCN ODS Name guidance patients overlap or be adjacent patients circumstances PCN services director PCN 7 C84044 Deer Park Family Medical Practice Yes 36,390 Old Lenton, Wollaton Complete Complete – all Complete Yes Dr Katherine O’Connor, C84039 Derby Road Health Centre practices within Wollaton Park Medical Nottingham City Centre Y03124 Grange Farm Medical Centre Council C84122 Wollaton Park Medical Centre PCN 8 C84092 Bridgeway Practice Yes 31,662 Clifton, The Meadows, Complete Complete – all Complete Yes Dr Heetan Patel, Clifton C84046 Clifton Medical Practice Wilford practices within Medical Practice Nottingham City C84081 John Ryle Medical Centre Council C84144 Meadows Health Centre - Larner C84060 Rivergreen Medical Centre PCN U C84023 Cripps Health Centre Yes 51,548 Clifton, Dunkirk, Lenton Complete Complete – all Complete Yes Dr Matthew Litchfield, C84714 Sunrise Medical Practice Abbey, New Lenton practices within The University of Nottingham City Nottingham Health Council Service

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Mid-Nottinghamshire Practice Criteria Formation PCN of PCNs structures Network cannot must make Contract result in a geographic DES Size – practice(s) PCNs can only No al sense to Registration between being left cross upper tier practice patients Form 30,000 out or not local authority can be and for completed in and Geographical contiguity – contiguous areas in excluded commiss- line with 50,000 practice boundaries must with other exceptional from a ioned Accountable clinical PCN ODS Name guidance patients overlap or be adjacent patients circumstances PCN services director Mansfield & Ashfield CCG Ashfield C84077 Brierley Park Medical Centre Yes 51,705 Sutton in Ashfield, Harlow Complete Complete – all Complete Yes Dr Andrew Pountney, North Wood, Huthwaite, Fackley, practices within Woodlands Medical C84061 Kings Medical Centre Teversal, Skegby Nottinghamshire Practice C84114 Skegby Family Medical Centre County Council C84012 Willowbrook Medical Practice C84014 Woodlands Medical Practice Ashfield C84067 Ashfield House (Annesley) Yes 38,794 Kirkby-In-Ashfield, Annesley, Complete Complete – all Complete Yes Dr Junaid Dar, Family South Underwood, Jacksdale, practices within Medical Centre (Kirkby) C84074 Family Medical Centre (Kirkby) Barrows Green, Selston Nottinghamshire C84629 Health Care Complex Green, Hall Green County Council C84654 Jacksdale Medical Centre C84076 Kirkby Health Centre Y05690 Kirkby Community Primary Care Centre C84140 Lowmoor Road Surgery C84142 Selston Surgery Mansfield C84710 Bull Farm Primary Care Resource Centre Yes 58,425 Meden Vale, Church Warsop, Complete Complete – all Complete Yes Dr Khalid Butt, Oakwood North Warsop Vale, Spion Kop, practices within Surgery C84658 Meden Medical Services Mansfield Woodhouse, Nottinghamshire C84016 Oakwood Surgery Ravendale, Mansfield, County Council C84051 Orchard Medical Practice Pleaseley C84057 Pleasley Surgery C84127 Riverbank Medical Services C84637 Sandy Lane Surgery C84031 St Peters Medical Practice (Dr Sharma)

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Practice Criteria Formation PCN of PCNs structures Network cannot must make Contract result in a geographic DES Size – practice(s) PCNs can only No al sense to Registration between being left cross upper tier practice patients Form 30,000 out or not local authority can be and for completed in and Geographical contiguity – contiguous areas in excluded commiss- line with 50,000 practice boundaries must with other exceptional from a ioned Accountable clinical PCN ODS Name guidance patients overlap or be adjacent patients circumstances PCN services director Mansfield C84679 Acorn Medical Practice Yes 46,587 Mansfield, Newton Town, Complete Complete – all Complete Yes Dr Milind Tadpatrikar, South Ladybrook, Bleak Hills, Berry practices within Roundwood Surgery C84020 Churchside Medical Practice Hill, Forest Town Nottinghamshire C84036 Forest Medical County Council C84106 Mill View Surgery C84069 Roundwood Surgery

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Practice Criteria Formation PCN of PCNs structures Network cannot must make Contract result in a geographic DES Size – practice(s) PCNs can only No al sense to Registration between being left cross upper tier practice patients Form 30,000 out or not local authority can be and for completed in and Geographical contiguity – contiguous areas in excluded commiss- line with 50,000 practice boundaries must with other exceptional from a ioned Accountable clinical PCN ODS Name guidance patients overlap or be adjacent patients circumstances PCN services director Newark & Sherwood CCG Newark PCN Y05369 Balderton PCC (C84648) Yes 76,147 Newark-on-Trent, Southwell, Complete Complete – all Complete Yes Dr James Cusack, Balderton, Collingham, practices within Lombard Medical Centre C84009 Barnby Gate Surgery Sutton-on-Trent, Norwell, Nottinghamshire C84045 Collingham Medical Centre Caunton, Oxton, Fernwood County Council C84019 Fountain Medical Centre C84660 Hounsfield Surgery C84029 Lombard Medical Centre C84049 Southwell Medical Centre Sherwood C84037 Abbey Medical Group Yes 59,627 Ravenshead, Oxton, Complete Complete – all Complete Yes Dr Kevin Corfe, Abbey PCN Farnsfield, Bilsthorpe, practices within Medical Group C84123 Bilsthorpe Surgery Ollerton, New Ollerton, Nottinghamshire C84656 Hill View Surgery Edwinstowe, Kirton, County Council C84113 Major Oak Medical Practice Boughton, Walesby, Perlethorpe, Kings Clipstone, C84021 Middleton Lodge Practice Clipstone, Newlands, C84087 Rainworth HC Rainworth, Blidworth C84059 Sherwood Medical Partnership

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South Nottinghamshire Practice Criteria Formation PCN of PCNs structures Network cannot must make Contract result in a geographic DES Size – practice(s) PCNs can only No al sense to Registration between being left cross upper tier practice patients Form 30,000 out or not local authority can be and for completed in and Geographical contiguity – contiguous areas in excluded commiss- line with 50,000 practice boundaries must with other exceptional from a ioned Accountable clinical PCN ODS Name guidance patients overlap or be adjacent patients circumstance s PCN services director Nottingham North and East CCG PCN 1 C84095 Oakenhall Medical Practice Yes 36,715 Hucknall, Bestwood Village, Complete Complete – all Complete Yes Dr Adam Connor, Hucknall Linby, Papplewick practices within Whyburn Medical Y00026 Om Surgery Nottinghamshire Practice C84053 Torkard Hill Medical Centre County Council Y06443 Whyburn Medical Practice PCN 2 Arnold C84047 Calverton Practice Yes 33,778 Arnold, Calverton Complete Complete – all Complete Yes Dr Kate Evans, & Calverton practices within Stenhouse Medical C84055 Highcroft Surgery Nottinghamshire Centre C84026 Stenhouse Medical Centre County Council PCN 3 C84066 Daybrook Medical Practice Yes 40,969 Carlton, Daybrook, Complete Complete – all Complete No Dr Umar Ahmad, Carlton & Mapperley, Burton Joyce, practices within Plains View Surgery C84646 Ivy Medical Group Villages Lowdham Nottinghamshire C84133 Peacock Healthcare County Council C84115 Plains View Surgery C84150 Unity Surgery C84033 Westdale Lane Surgery PCN 4 C84613 Jubilee Practice Yes 29,647 Carlton, Netherfield, Not Complete – all Complete No Ian Campbell, Bakersfield, Colwick, Gedling, contiguous practices within Park House Medical C84709 Park House Medical Centre Woodthorpe, Lambley, Nottinghamshire Centre C84010 Trentside Medical Group Burton Joyce, Lowdham, County Council C84696 West Oak Surgery Woodborough, Epperstone, Gunthorpe, Gonalston, Bleasby, Thurgarton, Oxton, Hoveringham, Caythorpe, Mapperley

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Practice Criteria Formation PCN of PCNs structures Network cannot must make Contract result in a geographic DES Size – practice(s) PCNs can only No al sense to Registration between being left cross upper tier practice patients Form 30,000 out or not local authority can be and for completed in and Geographical contiguity – contiguous areas in excluded commiss- line with 50,000 practice boundaries must with other exceptional from a ioned Accountable clinical PCN ODS Name guidance patients overlap or be adjacent patients circumstance s PCN services director Nottingham West CCG Nottingham Yes 106,473 Complete Complete – all Complete Yes Dr Nicole Atkinson, West PCN practices within Eastwood Primary Care PCN Neighbourhood - Beeston: 47,476 Beeston, Bramcote, Chilwell Nottinghamshire Centre C84065 Abbey Medical Centre County Council C84112 Bramcote Surgery C84120 Chilwell Valley and Meadows Practice C84080 Manor Surgery C84030 Oaks Medical Centre PCN Neighbourhood – Eastwood/Kimberley : 37,159 Eastwood, Newthorpe, Giltbrook, Kimberley C84032 Eastwood PCC C84667 Giltbrook Surgery C84624 Hama Medical Centre C84131 Newthorpe Medical Centre PCN Neighbourhood – Stapleford : 21,337 Stapleford C84705 Hickings Lane Medical Centre C84107 Linden Medical Group C84042 Saxon Cross Surgery 501 Not re-registered from practice closure

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Practice Criteria Formation PCN of PCNs structures Network cannot must make Contract result in a geographic DES Size – practice(s) PCNs can only No al sense to Registration between being left cross upper tier practice patients Form 30,000 out or not local authority can be and for completed in and Geographical contiguity – contiguous areas in excluded commiss- line with 50,000 practice boundaries must with other exceptional from a ioned Accountable clinical PCN ODS Name guidance patients overlap or be adjacent patients circumstance s PCN services director Rushcliffe CCG Rushcliffe Yes 128,389 Complete Complete – all Complete Yes Dr Stephen Shortt, PCN practices within East Leake Medical PCN Neighbourhood – North : 39,770 East Bridgford, Bingham, Nottinghamshire Group Radcliffe-on Trent C84017 Belvoir Health Group County Council C84025 East Bridgford Medical Centre C84084 Radcliffe On Trent Health Centre PCN Neighbourhood – Central: 48,129 West Bridgford, Wilford, Gamston C84605 Castle Healthcare Practice C84703 Gamston Medical Centre C84090 Musters Medical Practice C84086 St George's Medical Practice C84621 West Bridgford Medical Centre PCN Neighbourhood – South: 40,490 Keyworth, East Leake, Kegworth, Ruddington C84005 East Leake Medical Group C84048 Keyworth Medical Practice C82040 Orchard Surgery C84028 Ruddington Medical Centre

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Appendix 2: Clinical Directors for the Primary care Networks

ICP PCN Clinical Director Deputy Clinical Director Mid Notts Ashfield South Dr Junaid Dar Dr Deepa Balakrishnan Ashfield North Dr Andrew Poutney Dr Gavin Lunn Mansfield South Dr Milind Tadpatrikar Mansfield North Dr Khalid Butt Dr James Mills Sherwood Dr Kevin Korfe Newark Dr James Cusack City PCN 1 Dr Andrew Foster PCN 3 Dr Jonathan Harte PCN 4 Dr Jo Guha PCN 5 Dr Mike Crowe PCN 6 Dr Hussain Gandhi Dr Margaret Abbott PCN 7 Dr Katherine O’Connor PCN 8 Dr Heetan Patel PCN U Dr Matthew Litchfield South Notts Eastwood and Stapleford Dr Nicole Atkinson Neighbourhood deputies TBC Bramcote and Beeston Clinical Executive to support Rushcliffe North neighbourhoods: Dr Stephen Shortt (Chair until Rushcliffe Central 30.6.19) Dr Matt Jelpke Rushcliffe South Dr Richard Stratton Dr Lynn Ovenden Dr Nigel Cartwright Dr Gurvinder Sahota NNE PCN 1 Dr Adam Connor NNE PCN 2 Dr Kate Evans NNE PCN 3 Dr Umar Ahmad NNE PCN 4 Dr Ian Campbell

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Appendix 3: Comparison of CCG Activity - March 2018 – February 2019

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Internal Audit

Mid- Nottinghamshire CCGs*

Primary Medical Care Commissioning and Contracting – Primary Care Finance

Final Report

*comprising: NHS Mansfield and Ashfield CCG NHS Newark and Sherwood CCG

June 2019 Reference: MACCG/1819/20 NSCCG/1819/20

Table of Contents

Heading Page Executive Summary 1 Findings & Recommendations 6

Appendix A – Risk Matrix & Opinion Levels 16

Distribution

Name For Action For Information Amanda Sullivan, Accountable Officer x  Sharon Pickett, Associate Director of Primary Care  x Mick Cawley, Operational Director of Finance x  Ian Livsey, Deputy Chief Finance Officer  x Lisa Cannon, Assistant Chief Finance Officer x  Ross Tomsett, Acting Head of Finance x  David Ainsworth, Locality Director (Mid-Nottinghamshire) x  Lucy Branson, Associate Director of Governance x 

Key Dates

Report Stage Date Discussion Draft Issued: 3rd May 2019 Client Response and Approval Received: 30th May 2019 Final Report Issued: 3rd June 2019

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Contact Information

Name / Role Contact details Tim Thomas, Director [email protected]  0116 225 6114 Glynis Onley, Assistant Director [email protected]  0115 883 5304 Claire Page, Client Manager [email protected]  0115 883 5307 Paul Hutchings, Associate [email protected]  0115 883 5307

Reports prepared by 360 Assurance and addressed to Mid-Nottinghamshire CCGs* directors or officers are prepared for the sole use of the Mid-Nottinghamshire CCGs, and no responsibility is taken by 360 Assurance or the auditors to any director or officer in their individual capacity. No responsibility to any third party is accepted as the report has not been prepared for, and is not intended for, any other purpose and a person who is not a party to the agreement for the provision of Internal Audit between Mid- Nottinghamshire CCGs and 360 Assurance dated 1st April 2018 shall not have any rights under the Contracts (Rights of Third Parties) Act 1999. The appointment of 360 Assurance does not replace or limit Mid-Nottinghamshire CCGs’ own responsibility for putting in place proper arrangements to ensure that its operations are conducted in accordance with the law, guidance, good governance and any applicable standards, and that public money is safeguarded and properly accounted for, and used economically, efficiently and effectively. The matters reported are only those which have come to our attention during the course of our work and that we believe need to be brought to the attention of Mid-Nottinghamshire CCGs. They are not a comprehensive record of all matters arising and 360 Assurance is not responsible for reporting all risks or all internal control weaknesses to Mid-Nottinghamshire CCGs. This report has been prepared solely for your use in accordance with the terms of the aforementioned agreement (including the limitations of liability set out therein) and must not be quoted in whole or in part without the prior written consent of 360 Assurance.

* Comprising: NHS Mansfield and Ashfield CCG NHS Newark and Sherwood CCG

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Executive Summary

Introduction and Background NHS England became responsible for the direct commissioning of primary medical care services on 1 April 2013. Since then, following changes set out in the NHS Five Year Forward View, primary care co-commissioning has seen CCGs invited to take on greater responsibility for general practice commissioning, including full responsibility under delegated commissioning arrangements. In 2018/19, 96% of the 178 CCGs had full delegated responsibility for the primary care budget. The Mid-Nottinghamshire CCGs1 assumed full delegated responsibility under these arrangements as of 1st April 2015. Since that time, the CCGs have been supported by existing NHS England (NHSE) primary care contracting and finance teams through a Primary Care (PC) Hub arrangement. Although NHSE has delegated functions to CCGs, it retains overall accountability and is, therefore, responsible for obtaining assurances that its functions are being discharged effectively. In order to facilitate the provision of these assurances, correspondence was sent to CCG Chairs, by NHSE, on 27th February 2018, which included a detailed, and now mandatory, Internal Audit Framework2 (the “Framework”), designed to provide independent assurance to NHSE that delegated functions are being appropriately discharged. The Framework requires the independent completion of assessments across four domains, on a cyclical basis, over the next three to four years. While NHS England’s CCG Improvement and Assessment Framework reports CCG performance in key areas, including primary care, it does not provide specific assurance on the management of delegated primary medical care commissioning arrangements. In agreement with NHS England’s Audit and Risk Assurance Committee, NHS England requires the following from 2018/19:

The Annual Governance Statement to incorporate PMC outcomes including innovative approaches Self assessment of Internal Audit of compliance with delegated PMC published PMC policies commissioning via annual Primary Care arrangements reported Activity Report to CCGs for onward (Collection 1) assurance to NHSE

Assurance to NHSE for Primary Medical Care (PMC)

1 NHS Mansfield and Ashfield CCG, NHS Newark and Sherwood CCG 2 NHS England Primary Medical Care Commissioning and Contracting: Internal Audit Framework for delegated Clinical Commissioning Groups version 1.0 published August 2018

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The Delegation Agreement entered into between NHS England and CCGs sets out the terms and conditions for how delegated primary medical care functions are to be exercised. The scope of the Framework is designed around this by mirroring these functions through the natural commissioning cycle:  Commissioning and procurement of services;  Contract oversight and management functions;  Primary Care finance; and  Governance (common to each of the above areas). The Framework is to be delivered as a 3-4 year programme of work to ensure this scope is subject to annual audit in a managed way and within existing internal audit budgets. Follow up audits for areas of no assurance, should there be any, also need to be incorporated into internal audit plans. CCGs are required to tailor their approach to take account of the findings from any previous or related audit work, and make use of local assessment of risk to determine appropriate focus within the scope of work detailed. Our 2018/19 Internal Audit Plan included a separate review of governance arrangements. Given this, and the organisational changes taking place over the next 12 months in Nottinghamshire, it was proposed that the internal audit focus for 2018/19 was on primary care finance; this was in order to provide consistency of coverage across the 6 Nottinghamshire CCGs in this first year of audit. The Mid-Nottinghamshire CCGs set an annual budget of just under £0.5 billion for 2018/19 that included a £57 million allocation for primary care activities. Of this, £45 million was for delegated (co-commissioned) budgets and was just below 10% of the CCGs’ overall budget.

NHS England expects that the Framework will provide a comprehensive baseline for assurance of delegated CCGs’ primary medical care commissioning and provide the basis for moving to a more risk-based approach in future years. The Framework requires that the outcome of each annual internal audit is reported to the CCGs’ Audit and Governance Committees using the opinion levels specified in the Framework that is provided at Appendix A. It also requires that the CCGs’ Primary

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Care Commissioning Committees have a lead role in discussing and taking forward the report. Other relevant sources of assurance that the CCGs receive in relation to finance include a third party assurance report from NHS Digital. This provides an independent assessment of the control environment at NHS Digital of the GP payments system used by the CCGs. Our Post Payment Verification (PPV) service for 2018/19 within Mid-Nottinghamshire consisted of three practice visits where the accuracy of a sample of claims made by each practice was reviewed. These reviews found no significant matters indicative of weak controls over payments.

Audit Objectives and Scope The objective of our audit was to assess whether the Mid-Nottinghamshire CCGs have a robust, efficient and effective control environment in respect of primary care finance relating to the provision of primary medical care commissioning and contracting. Our assessment excluded all controls and functions that are the responsibility of the local NHSE PC Hub. Our review:  Determined whether relevant policies, procedures and guidance have been authorised, and communicated to relevant personnel;  Determined whether roles and responsibilities for activities have been clearly defined;  Documented and assessed the arrangements for the overall management and reporting of delegated funds, incorporating processes for forecasting, monitoring and reporting;  Reviewed financial controls and processes for approving payments to practices;  Determined whether local processes established by the CCGs are aligned to NHS England policies and guidance;  Determined whether processes are in place to confirm compliance with policies and procedures;  Reviewed compliance with coding guidance on a sample basis;  Documented and assessed processes to approve, and decisions regarding, ‘discretionary’ payments (e.g. Section 96 funding agreements, Local Incentive Schemes);  Assessed implementation of the Premises Costs Direction; and  Confirmed documentation is retained, including records of decisions, that show evidence that decisions were exercised in accordance with NHS England’s statutory duties.

Limitations of scope: The scope of our work was limited to the systems and controls identified in the Terms of Reference agreed with the MNCCGs’ Director of Primary Care and Chief Finance Officer in March 2019. Excluded from the scope was the management of conflicts of interest which is subject to a separate mandated internal audit framework. We have not provided assurance on the controls in place within the Primary Care Hub as that is subject to separate internal audit arrangements through NHS England.

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It should be noted that 360 Assurance provides a Post Payment Verification (PPV) service to the CCGs which verifies the accuracy of claims for additional/enhanced services, on a sample basis, made by GP practices. We have taken account of the work undertaken in assessing the robustness, efficiency and effectiveness of the control environment in place in relation to primary care finance. In carrying out our work, and in reporting our findings, we have satisfied ourselves that any common arrangements in place are operating consistently across all the CCGs and have reported where that was found not to be the case.

Audit Opinion

Substantial Assurance The controls in place do not adequately address one or more risks to the successful achievement of objectives; and / or one or more of the controls tested are not operating effectively, resulting in unnecessary exposure to risk. Our opinion is limited to the controls examined and samples tested as part of this review.

This Audit Opinion follows that specified by the NHSE Framework. The assurance levels differ from the standard assurance levels used by 360 Assurance for other reviews. The assurance levels are included at Appendix A for information.

Summary Findings Our review found that the:  Local NHSE Primary Care Hub is responsible for the design and operation of most key financial controls relating to primary care finance; and  Role of the CCGs’ finance team in respect of the financial control environment is relatively limited. Given this, our review has focussed on the nature and extent of support provided by the CCG finance team and financial reporting processes to the Primary Care Hub. Our observations on this are detailed in the Findings & Recommendations section of this report with all control objectives that we reviewed assessed as being effective. Although there is a formal Memorandum of Understanding (MOU) in place between the Derbyshire and Nottinghamshire CCGs and the Primary Care Hub that sets out detailed working arrangements, this dates back to the 2016/17 financial year and requires updating. The MOU is supported by a supplementary Primary Care Handbook issued by the Primary Care Hub for the 2017/18 financial year. This also requires an update. Additionally, the MOU sets out that NHS Mansfield and Ashfield CCG was the CCG lead for the Primary Care Hub in 2016/17; current arrangements are not formally defined and may no longer be appropriate given the significant organisational changes across the Nottinghamshire CCGs since then.

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Summary of Recommendations

High Medium Low Total Findings and Agreed 0 0 4 4 Actions

Follow-Up A follow-up exercise will be undertaken during January 2020 to evaluate progress made in respect of issues raised. This will include obtaining documentary evidence to demonstrate that actions agreed as part of this review have been implemented.

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The following sections of the report summarise the findings of our review. Each section highlights areas of good practice identified. Where relevant, any control weaknesses identified are outlined, including actions that have been agreed in order to address the associated risks. The matrix used for scoring risks is compliant with the ISO 31000 principles and generic guidelines on risk management. This risk matrix, along with definitions of different opinion levels, is provided at Appendix A. These opinion levels have been specified by NHSE within the mandated Framework.

Internal Audit Framework The scope of the primary medical services audit defined in the mandated Framework3 relating to primary care finance comprises: I. Overall management and the reporting of delegated funds – processes for forecasting, monitoring and reporting; II. Review of financial controls and processes for approving payments to practices; III. Review of compliance with coding guidance on a sample basis; IV. Processes to approve and decisions regarding ‘discretionary’ payments (e.g. Section 96 funding arrangements, Local Incentive Schemes); and V. Implementation of the Premises Costs Directions. Our findings in this report have been mapped to these five scope areas. In addition, we have also reviewed the overall governance arrangements in place to support primary care finance and where responsibility for primary care core commissioning functions has been assigned.

3 NHS England Primary Medical Care Commissioning and Contracting: Internal Audit Framework for delegated Clinical Commissioning Groups version 1.0 published August 2018

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Overall Governance Our review confirmed that:  There is a Memorandum of Understanding (MOU) in place dating back to 2016/17 between the then ten Derbyshire and Nottinghamshire CCGs4 and the North Midlands Primary Care (PC) Hub. The stated purpose of the MOU is to set out the principles and detailed working arrangements between the Primary Care Hub and CCG commissioners, and covers: o Ways of working; o Primary Medical Services Commissioning Functions; o Governance; o Interfaces; o Accountability; and o CCG lead arrangements.  Further detailed working arrangements are set out in the Primary Care Hub Handbook which is a supplement to the MOU. This consists of a series of method statements to support key functions. There are two method statements relating to governance that cover decision making, and reporting and information sharing. The Handbook also defines communication and engagement arrangements between the PC Hub and the ten Derbyshire and Nottinghamshire CCGs.  The MOU has a local list of primary care core commissioning functions and sets out the respective responsibilities of the PC Hub and CCG teams. All these core commissioning functions fall within one of the following four categories: o Commissioning high quality and continuously improving services; o Local service planning, delivering transformation and service improvement; o Contracting, contract management and budgetary control; and o Miscellaneous.  Core commissioning functions defined in the MOU list cover primary care finance under detailed financial (i.e. contracting, contract management and budgetary control) and miscellaneous categories.  The MOU confirms that the CCG Primary Care Co-Commissioning Committees (PCCCs) have oversight and decision making responsibilities for primary care commissioning including finance. This is consistent with current PCCC terms of reference for both of the Mid-Nottinghamshire CCGs. The role of each CCG PCCC includes looking at arrangements to manage delegated primary care budgets.

4 Nottinghamshire CCGs include the two Mid Nottinghamshire CCGs: NHS Mansfield and Ashfield CCG and NHS Newark and Sherwood CCG

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Three areas relating to Overall Governance requiring action are detailed below:

Risk and Score No. Findings Agreed Action (Impact x Likelihood)

1 Memorandum of Understanding Agreed detailed working Put in place an agreed MOU with Although the Mid-Nottinghamshire CCGs has agreed working arrangements for arrangements between the the North Midlands PC Hub for the primary care co-commissioning with the North Midlands Primary Care (PC) Hub CCGs and the North Midlands 2019/20 financial year. our review found that these are not up to date. PC Hub may not reflect current Responsible officer: Sharon requirements. We found that the Memorandum of Understanding (MOU) for the 2016/17 financial Pickett, Associate Director of year between the Derbyshire and Nottinghamshire CCGs and the North Midlands Low (2 x 2) Primary Care PC Hub issued in April 2016 was rolled forward to the 2018/19 financial year. In Implementation date: 1st August addition, although this MOU was published as a final agreed version, we found 2019 that the respective descriptions of PC Hub and CCG primary care commissioning functions defined in it were stated as being provisional. Management Response: The MOU has not been updated since 2016 and may not fully reflect the current This recommendation is agreed. working practices of the PC Hub and CCGs. The process of updating the MOU for 2019/20 has commenced. The content of the revised MOU will need to be jointly agreed between the North Midlands PC Hub and the CCGs prior to formal approval via the relevant PCCCs. 2 Primary Care Handbook Agreed detailed working Request the North Midlands PC We found that the Primary Care (PC) Handbook for the 2017/18 financial year arrangements between the Hub to review and refresh the issued by the North Midlands PC Hub in June 2017 was rolled forward to the CCGs and the North Midlands Primary Care Handbook for the 2018/19 financial year. It may not fully reflect the current working practices of the PC Hub may not reflect current 2019/20 financial year. PC Hub and CCGs. requirements. Responsible officer: Sharon Low (2 x 2) Pickett, Associate Director of Primary Care Implementation date: 1st August 2019 Management Response: This recommendation is agreed. The process of updating the Primary Care Handbook for 2019/20 has commenced. The content of the revised Primary Care Handbook will need to be jointly agreed between the North Midlands PC Hub and the CCGs prior to formal approval via the relevant PCCCs.

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Risk and Score No. Findings Agreed Action (Impact x Likelihood)

3 Primary Care Hub Arrangements Formal working arrangements Review and update CCG hosting Our review of the Memorandum of Understanding (MOU) in place between the between the PC Hub and the arrangements with the Primary Derbyshire and Nottinghamshire CCGs confirmed that NHS Mansfield and Mid Nottinghamshire CCGs Care Hub and include in an Ashfield CCG was the lead CCG for the Primary Care (PC) Hub for both the may no longer be appropriate. updated MOU for the 2019/20 2015/16 and 2016/17 financial years. Low (2 x 2) financial year. As the MOU has not been updated since 2016 it is not clear what the formal Responsible officer: Sharon arrangements are for the PC Hub. Given the significant organisational changes Pickett, Associate Director of across the Nottinghamshire CCGs since then, current governance arrangements Primary Care may no longer be appropriate. Implementation date: 1st August 2019 (for MOU) update), 31st December 2019 (for review of governance arrangements post CCG/NHSE reorganisation). Management Response: This recommendation is agreed. Both the CCGs and NHSE are currently undergoing significant reorganisation. The existing timescales suggest that the restructure process across the system is unlikely to be fully complete until later in the financial year (Q3 or Q4). The MOU will therefore be updated to reflect the current situation (by 1 August 2019) and reviewed again following completion of the reorganisation (estimated to be completed by 31 December 2019 but subject to change depending on reorganisation timescales).

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Primary Care Core Commissioning Functions The following table, taken from the MOU, sets out the respective core commissioning functions of the PC Hub and CCGs relating to primary care finance.

Commissioning Area PC Hub Functions CCG functions

Contracting, contract  Review authorisation of manual finance payments via claim forms  Support PC Hub as necessary. management and  Provide financial support and review of tendering process budgetary control - financial  Enact financial changes as a result of contract reviews  Enact financial changes to premises changes  Support the contract team in managing disputes relating to finances  Monitor and provide trend analysis for contract changes  Enact payments from VTS and pension changes  Calculate and implement payments for APMS changes aligned to KPI achievement  Approve PCS recommendation for local payments and financial adjustments  Ensure payment is aligned to delivery of contracts including VPS, clinical waste, occupational health, translations services, PPV and GP retainer payment process  Ensure payment is aligned for LMC levies on price per patient  Financial management of the whole primary care budget and non-recurrent programmes such as Challenge Fund and winter pressures  Financial management of Community Health Partnerships (previously LIFT) and NHS Property Services contracts

Miscellaneous  Provide regular comprehensive contracting reports for CCGs  Submit and present reports in CCG governance processes (with support from PC Hub team).

This shows that the PC Hub is responsible for the design and operation of most key financial controls relating to primary care finance. The agreed functions of the Mid-Nottinghamshire CCGs’ finance team under the MOU are relatively limited. Given this, our review has focussed on the nature and extent of support provided by the CCGs’ finance team and financial reporting processes.

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The following tables provide our observations on, and the effectiveness of, the support provided by the CCG finance team and financial reporting processes.

Objective PC Hub Function Observation on CCG support and reporting Effective?

Framework: I. Overall management and the reporting of delegated funds – processes for forecasting, monitoring and reporting

Relevant policies, procedures - Both the PC Hub and CCGs have financial policies and procedures in Yes and guidance have been place that cover delegated funds. authorised, and communicated They also have access to: to relevant personnel.  Standard NHS SBS Oracle operating and systems notes; and  User manuals for the national NHS GP payments system (Exeter). Roles and responsibilities for - The roles and responsibilities for overall management and reporting of Yes activities have been clearly delegated primary care commissioning delegated funds are defined as defined. part of the MOU between the PC Hub and the Derbyshire & Nottinghamshire CCGs (including the two Mid Nottinghamshire CCGs). Arrangements are in place for Financial management of the The PC Hub prepared detailed annual budgets for each CCG setting out Yes the overall management and whole primary care budget and primary care co-commissioning expenditure for the 2018/19 financial year reporting of delegated funds, non-recurrent programmes such with approval of the budgets by the CCGs’ PCCCs incorporating processes for as Challenge Fund and winter Monthly finance reports including information on delegated co- forecasting, monitoring and pressures. commissioning budgets are routinely presented to the CCGs for scrutiny reporting. Monitor and provide trend by the Governing Bodies and Primary Care Co-Commissioning analysis for contract changes. Committees which both hold meetings in common.. Support provided to PC Hub by the CCG finance team comprises monthly telephone and/or email discussions with NHSE accounting staff at the PC Hub after receipt of financial information. These include confirmatory emails from the Head of Finance to the PC Hub. Support could be strengthened by offering the PC Hub the option of a formal sign-off process for monthly financial information (refer finding 4 below) . Local processes established by - CCGs have financial reporting processes that include delegated co- Yes the CCGs are aligned to NHS commissioning budgets. These are aligned to NHSE reporting and England policies and guidance. monitoring requirements.

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Objective PC Hub Function Observation on CCG support and reporting Effective?

Framework: I. Overall management and the reporting of delegated funds – processes for forecasting, monitoring and reporting

Processes are in place to Produce regular comprehensive See above. Yes confirm compliance with policies contracting reports for CCGs. and procedures. Sufficient documentation is - Both CCGs follow national NHS record keeping guidance. Yes retained to support payments In practice, this means that documents (including financial documents) made from delegated funds. relating to GMS and PMS payments are scanned and that specific destruction dates are used. Information is held on the national NHS GMS and PMS payments (Exeter) system in a standard format.

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Objective PC Hub Function Observation on CCG support and reporting Effective?

Framework: II. Review of financial controls and processes for approving payments

Financial controls and Review authorisation of manual CCG finance team provides support to PC Hub as all Local Medical Yes processes are in place for finance payments via claim Committee (LMC) levy payments are approved by CCG staff. We approving payments. forms. checked and confirmed that LMC invoices are authorised by the CCG Enact payments from Vocational Head of Finance before payment. Training Scheme and pension All delegated primary care payments5 that pass through PCSE (Primary changes. Care Support England) are authorised by the PC Hub on behalf of the Ensure payment is aligned to CCGs. We were informed that PCSE does not recognise CCG staff as delivery of the contracts authorised signatories. including violent patient services, clinical waste, occupational health, translations services, Post Payment Verification and GP retainer payment process. Ensure payment is aligned for LMC levies on price per patient. Support the contract team in managing disputes relating to finances.

5 Primary care payments include the following delegated functions: General Medical Services (GMS), Personal Medical Services (PMS), Alternative Provider Medical Services (APMS) enhanced services, local incentive schemes, discretionary payments, Quality and Outcomes Framework (QOF) payments and premises payments.

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Objective PC Hub Function Observation on CCG support Effective?

Framework: III. Review of compliance with coding guidance

Financial payments are Review authorisation of manual CCG finance team reviews monthly trial balance provided to it by the PC Yes correctly coded. finance payments via claim Hub. This includes a line by line review, by subjective code and forms. associated expenditure category, for reasonableness and accuracy.

Objective PC Hub Function Observation on CCG support Effective?

Framework: IV. Processes to approve and decisions regarding ‘discretionary’ payments

All ‘discretionary’ payments are - Requests for financial support from Primary Medical Services (PMS) Yes controlled with decision making contractors are considered and processed by the PC Hub. Decision and authorisation processes in making and due diligence review requirements have been defined by the place. PC Hub in a formal principles document. We were informed by the CCG Head of Finance that there were no payments to PMS contractors in 2018/19 as a result of requests for financial support.

Objective PC Hub Function Observation on CCG support Effective?

Framework: V. Implementation of the Premises Costs Directions

Financial payments relating to Enact financial changes to Although the financial management of CHP schemes and NHS Property Yes premises are consistent with the premises changes. Services contracts is a function of the PC Hub, in practice the CCGs lead Premises Costs Directions. Financial management of this with a dedicated member of staff in the CCG finance team. There is Community Health Partnerships close working between the CCG finance team and the PC Hub. (previously LIFT) and NHS Property Services contracts.

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One area relating to Primary Care Core Commissioning Functions requiring action is detailed below:

Risk and Score No. Findings Agreed Action (Impact x Likelihood)

4 Monthly Financial Information Inconsistent feedback of Agree a formal sign-off process Our review confirmed that the CCG finance team receives monthly financial comments on monthly financial with the PC Hub for monthly information from the Primary Care (PC) Hub in the form of a detailed trial balance, information to the PC Hub. financial information. and a summary analysis of primary care expenditure with brief comments on Low (2 x 2) Responsible officer: Ian Livsey, financial performance. Deputy Chief Finance Officer This information is reviewed by the CCG Head of Finance with feedback provided Implementation date: 1st July back to the PC Hub. In our view, there is scope to strengthen this process through 2019 having a formal sign-off process between the CCG finance team and the PC Hub. Management Response: This recommendation is agreed. A formal sign-off process will be agreed between the CCGs and the North Midlands Primary Care Hub. This will be implemented across all GN CCGs by 1st July 2019.

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 Risks contained within this report have been assessed using the standard 5x5 risk matrix below. The score has been determined by consideration of the impact the risk may have, and its likelihood of occurrence, in relation to the system’s objectives. The two scores have then been multiplied in order to identify the risk classification of low, medium, high or extreme. 

Score Impact Likelihood Impact

1 Negligible Rare 1 2 3 4 5

2 Low Unlikely 1 L L L L L

3 Medium Possible 2 L L L M M 4 High Likely 3 L L M M H

5 Extreme Almost Certain 4 L M M H H Likelihood 5 L M H H E

The audit opinion has been determined in relation to the objectives of the system being reviewed. It takes into consideration the volume and classification of the risks identified during the review. 

Assurance level Evaluation and testing conclusion The controls in place adequately address the risks to the successful Full achievement of objectives; and the controls tested operate effectively The controls in place do not adequately address one or more risks to the Substantial successful achievement of objectives; and/ or one or more of the controls tested are not operating effectively, resulting in unnecessary exposure to risk. The controls in place do not adequately address multiple significant risks to Limited the successful achievement of objectives; and /or a number of controls are not operating effectively, resulting in exposure to a high level of risk. The controls in place do not adequately address several significant risks leaving the system open to significant error or abuse; and/or the controls No Assurance tested are wholly ineffective, resulting in an unacceptably high level of risk to the successful achievement of objectives.

The assurance levels defined here:  Are not comparable with ISAE 30006 and as such a Full assurance level does not imply that there are no risks to the stated control objectives; and  Differ to the standard assurance levels used by 360 Assurance for other reviews completed as part of the agreed internal audit programme of work, instead being those specified by NHS England.

6 International Standard on Assurance Engagements (ISAE) 3000 Assurance Engagements Other than Audits or Reviews of Historical Financial Information issued by the International Audit and Assurance Standards Board

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Internal Audit

Greater Nottingham Clinical Commissioning Partnership*

Primary Medical Care Commissioning and Contracting – Primary Care Finance

Final Report

*comprising: NHS Nottingham City CCG NHS Nottingham North and East CCG NHS Nottingham West CCG NHS Rushcliffe CCG

June 2019 Reference: 1819/GNCCP/18

Table of Contents

Heading Page Executive Summary 1 Findings & Recommendations 6

Appendix A – Risk Matrix & Opinion Levels 17

Distribution

Name For Action For Information Amanda Sullivan, Accountable Officer x  Sharon Pickett, Associate Director of Primary Care  x Jonathan Bemrose, Chief Finance Officer x  Ian Livsey, Deputy Chief Finance Officer  x Andrew Morton, Operational Director of Finance x  Audrey McDonald, Assistant Chief Finance Officer x  Sarah Szubert, Head of Finance x  Lucy Branson, Associate Director of Governance x 

Key Dates

Report Stage Date Discussion Draft Issued: 30th April 2019 Revised Discussion Draft Issued: 20th May 2019 Client Response and Approval Received: 30th May 2019 Final Report Issued: 3rd June 2019

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Contact Information

Name / Role Contact details Tim Thomas, Director [email protected]  0116 225 6114 Glynis Onley, Assistant Director [email protected]  0115 883 5304 Claire Page, Client Manager [email protected]  0115 883 5307 Paul Hutchings, Associate [email protected]  0115 883 5307

Reports prepared by 360 Assurance and addressed to Greater Nottingham Clinical Commissioning Partnership* directors or officers are prepared for the sole use of the Greater Nottingham Clinical Commissioning Partnership, and no responsibility is taken by 360 Assurance or the auditors to any director or officer in their individual capacity. No responsibility to any third party is accepted as the report has not been prepared for, and is not intended for, any other purpose and a person who is not a party to the agreement for the provision of Internal Audit between Greater Nottingham Clinical Commissioning Partnership and 360 Assurance dated 1st April 2018 shall not have any rights under the Contracts (Rights of Third Parties) Act 1999. The appointment of 360 Assurance does not replace or limit Greater Nottingham Clinical Commissioning Partnership’s own responsibility for putting in place proper arrangements to ensure that its operations are conducted in accordance with the law, guidance, good governance and any applicable standards, and that public money is safeguarded and properly accounted for, and used economically, efficiently and effectively. The matters reported are only those which have come to our attention during the course of our work and that we believe need to be brought to the attention of Greater Nottingham Clinical Commissioning Partnership. They are not a comprehensive record of all matters arising and 360 Assurance is not responsible for reporting all risks or all internal control weaknesses to Greater Nottingham Clinical Commissioning Partnership. This report has been prepared solely for your use in accordance with the terms of the aforementioned agreement (including the limitations of liability set out therein) and must not be quoted in whole or in part without the prior written consent of 360 Assurance.

* Comprising: NHS Nottingham City CCG NHS Nottingham North and East CCG NHS Nottingham West CCG NHS Rushcliffe CCG

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Executive Summary

Introduction and Background NHS England became responsible for the direct commissioning of primary medical care services on 1 April 2013. Since then, following changes set out in the NHS Five Year Forward View, primary care co-commissioning has seen CCGs invited to take on greater responsibility for general practice commissioning, including full responsibility under delegated commissioning arrangements. In 2018/19, 96% of the 178 CCGs had full delegated responsibility for the primary care budget. The Greater Nottingham CCGs1 assumed full delegated responsibility under these arrangements as of 1st April 2015. Since that time, the CCGs have been supported by existing NHS England (NHSE) primary care contracting and finance teams through a Primary Care (PC) Hub arrangement. Although NHSE has delegated functions to CCGs, it retains overall accountability and is, therefore, responsible for obtaining assurances that its functions are being discharged effectively. In order to facilitate the provision of these assurances, correspondence was sent to CCG Chairs, by NHSE, on 27th February 2018, which included a detailed, and now mandatory, Internal Audit Framework2 (the “Framework”), designed to provide independent assurance to NHSE that delegated functions are being appropriately discharged. The Framework requires the independent completion of assessments across four domains, on a cyclical basis, over the next three to four years. While NHS England’s CCG Improvement and Assessment Framework reports CCG performance in key areas, including primary care, it does not provide specific assurance on the management of delegated primary medical care commissioning arrangements. In agreement with NHS England’s Audit and Risk Assurance Committee, NHS England requires the following from 2018/19:

The Annual Governance Statement to incorporate PMC outcomes including innovative approaches Self assessment of Internal Audit of compliance with delegated PMC published PMC policies commissioning via annual Primary Care arrangements reported Activity Report to CCGs for onward (Collection 1) assurance to NHSE

Assurance to NHSE for Primary Medical Care (PMC)

1 NHS Nottingham City CCG, NHS Nottingham North and East CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG 2 NHS England Primary Medical Care Commissioning and Contracting: Internal Audit Framework for delegated Clinical Commissioning Groups version 1.0 published August 2018

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The Delegation Agreement entered into between NHS England and CCGs sets out the terms and conditions for how delegated primary medical care functions are to be exercised. The scope of the Framework is designed around this by mirroring these functions through the natural commissioning cycle:  Commissioning and procurement of services;  Contract oversight and management functions;  Primary Care finance; and  Governance (common to each of the above areas). The Framework is to be delivered as a 3-4 year programme of work to ensure this scope is subject to annual audit in a managed way and within existing internal audit budgets. Follow up audits for areas of no assurance, should there be any, also need to be incorporated into internal audit plans. CCGs are required to tailor their approach to take account of the findings from any previous or related audit work, and make use of local assessment of risk to determine appropriate focus within the scope of work detailed. We met with the then Chief Operating Officer, Director of Primary Care and Corporate Director for the Greater Nottingham Clinical Commissioning Partnership (GNCCP) in February 2019 to discuss the scope of the review. Our 2018/19 Internal Audit Plan included a separate review of governance arrangements. Given this, and the proposed changes in governance structures and now organisational changes taking place over the next 12 months in Nottinghamshire, it was proposed that the internal audit focus for 2018/19 was on primary care finance. The Greater Nottingham CCGs set an annual budget of just over £1 billion for 2018/19 that included a £212 million allocation for primary care activities. Of this, £96 million was for delegated (co-commissioned) budgets and was just below 10% of the CCGs overall budget.

NHS England expects that the Framework will provide a comprehensive baseline for assurance of delegated CCGs’ primary medical care commissioning and provide the basis for moving to a more risk-based approach in future years.

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The Framework requires that the outcome of each annual internal audit is reported to the CCGs’ Audit and Governance Committees using the opinion levels specified in the Framework that is provided at Appendix A. Other relevant sources of assurance that the CCGs receive in relation to finance include a third party assurance report from NHS Digital. This has an independent assessment of the control environment at NHS Digital of the GP payments system used by the CCGs. Our Post Payment Verification (PPV) service for 2018/19 within Greater Nottingham consisted of five practice visits where the accuracy of a sample of claims made by each practice was reviewed. These reviews found no significant matters indicative of weak controls over payments.

Audit Objectives and Scope The objective of our audit was to assess whether the GNCCP has a robust, efficient and effective control environment in respect of primary care finance relating to the provision of primary medical care commissioning and contracting. Our assessment excluded all controls and functions that are the responsibility of the local NHSE PC Hub. Our review:  Determined whether relevant policies, procedures and guidance have been authorised, and communicated to relevant personnel;  Determined whether roles and responsibilities for activities have been clearly defined;  Documented and assessed the arrangements for the overall management and reporting of delegated funds, incorporating processes for forecasting, monitoring and reporting;  Reviewed financial controls and processes for approving payments to practices;  Determined whether local processes established by the CCGs are aligned to NHS England policies and guidance;  Determined whether processes are in place to confirm compliance with policies and procedures;  Reviewed compliance with coding guidance on a sample basis;  Documented and assessed processes to approve, and decisions regarding, ‘discretionary’ payments (e.g. Section 96 funding agreements, Local Incentive Schemes);  Assessed implementation of the Premises Costs Direction; and  Confirmed documentation is retained, including records of decisions, that show evidence that decisions were exercised in accordance with NHS England’s statutory duties.

Limitations of scope: The scope of our work was limited to the systems and controls identified in the Terms of Reference agreed with the GNCCP Director of Primary Care and Chief Finance Officer in March 2019. Excluded from the scope was the management of conflicts of interest which is subject to a separate mandated internal audit framework. We have not provided assurance on the controls in place within the Primary Care Hub as that is subject to separate internal audit arrangements through NHS England.

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It should be noted that 360 Assurance provides a Post Payment Verification (PPV) service to the CCGs which verifies the accuracy of claims for additional/enhanced services, on a sample basis, made by GP practices. We have taken account of the work undertaken in assessing the robustness, efficiency and effectiveness of the control environment in place in relation to primary care finance. In carrying out our work, and in reporting our findings, we have satisfied ourselves that any common arrangements in place are operating consistently across all the CCGs and have reported where that was found not to be the case.

Audit Opinion

Substantial Assurance The controls in place do not adequately address one or more risks to the successful achievement of objectives; and / or one or more of the controls tested are not operating effectively, resulting in unnecessary exposure to risk. Our opinion is limited to the controls examined and samples tested as part of this review.

This Audit Opinion follows that specified by the NHSE Framework. The assurance levels differ from the standard assurance levels used by 360 Assurance for other reviews.

Summary Findings Our review found that the:  Local NHSE Primary Care Hub is responsible for the design and operation of most key financial controls relating to primary care finance; and  Role of the GNCCP CCG finance team in respect of the financial control environment is relatively limited. Given this, our review has focussed on the nature and extent of support provided by the CCG finance team and financial reporting processes to the Primary Care Hub. Our observations on this are detailed in the Findings & Recommendations section of this report with all control objectives that we reviewed assessed as being effective. . Although there is a formal Memorandum of Understanding (MOU) in place between the Derbyshire and Nottinghamshire CCGs and the Primary Care Hub that sets out detailed working arrangements, this dates back to the 2016/17 financial year and requires updating. The MOU is supported by a supplementary Primary Care Handbook issued by the Primary Care Hub for the 2017/18 financial year. This also requires an update. Also, the MOU confirms that NHS Mansfield and Ashfield CCG was the CCG lead for the Primary Care Hub in 2016/17, current arrangements are not formally defined and may no longer be appropriate given the significant organisational changes across the Nottinghamshire CCGs since then.

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Summary of Recommendations

High Medium Low Total Findings and Agreed 0 0 5 5 Actions

Follow-Up A follow-up exercise will be undertaken during January 2020 to evaluate progress made in respect of issues raised. This will include obtaining documentary evidence to demonstrate that actions agreed as part of this review have been implemented.

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The following sections of the report summarise the findings of our review. Each section highlights areas of good practice identified. Where relevant, any control weaknesses identified are outlined, including actions that have been agreed in order to address the associated risks. The matrix used for scoring risks is compliant with the ISO 31000 principles and generic guidelines on risk management. This risk matrix, along with definitions of different opinion levels, is provided at Appendix A. These opinion levels have been specified by NHSE within the mandated Framework.

Internal Audit Framework The scope of the primary medical services audit defined in the mandated Framework3 relating to primary care finance comprises: I. Overall management and the reporting of delegated funds – processes for forecasting, monitoring and reporting; II. Review of financial controls and processes for approving payments to practices; III. Review of compliance with coding guidance on a sample basis; IV. Processes to approve and decisions regarding ‘discretionary’ payments (e.g. Section 96 funding arrangements, Local Incentive Schemes); and V. Implementation of the Premises Costs Directions. Our findings in this report have been mapped to these five scope areas. In addition, we have also reviewed the overall governance arrangements in place to support primary care finance and where responsibility for primary care core commissioning functions has been assigned.

3 NHS England Primary Medical Care Commissioning and Contracting: Internal Audit Framework for delegated Clinical Commissioning Groups version 1.0 published August 2018

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Overall Governance Our review confirmed that:  There is a Memorandum of Understanding (MOU) in place dating back to 2016/17 between the then ten Derbyshire and Nottinghamshire CCGs4 and the North Midlands Primary Care (PC) Hub. The stated purpose of the MOU is to set out the principles and detailed working arrangements between the Primary Care Hub and CCG commissioners, and covers: o Ways of working; o Primary Medical Services Commissioning Functions; o Governance; o Interfaces; o Accountability; and o CCG lead arrangements.  Further detailed working arrangements are set out in the Primary Care Hub Handbook which is a supplement to the MOU. This consists of a series of method statements to support key functions. There are two method statements relating to governance that cover decision making, and reporting and information sharing. The Handbook also defines communication and engagement arrangements between the PC Hub and the ten Derbyshire and Nottinghamshire CCGs.  The MOU has a local list of primary care core commissioning functions and sets out the respective responsibilities of the PC Hub and CCG teams. All these core commissioning functions fall within one of the following four categories: o Commissioning high quality and continuously improving services; o Local service planning, delivering transformation and service improvement; o Contracting, contract management and budgetary control; and o Miscellaneous.  Core commissioning functions defined in the MOU cover primary care finance under detailed financial (i.e. contracting, contract management and budgetary control) and miscellaneous categories.  The MOU confirms that CCG Primary Care Co-Commissioning Committees (PCCCs) have oversight and decision making responsibilities for primary care commissioning including finance. This is consistent with current PCCC terms of reference for each of the four Greater Nottingham CCGs. The role of each CCG PCCC includes looking at arrangements to manage delegated primary care budgets.

4 Nottinghamshire CCGs include the four Greater Nottingham CCGs

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Four areas relating to Overall Governance requiring action are detailed below:

Risk and Score No. Findings Agreed Action (Impact x Likelihood)

1 Memorandum of Understanding Agreed detailed working Put in place an agreed MOU with Although the Greater Nottingham Clinical Commissioning Partnership has agreed arrangements between the the North Midlands PC Hub for the working arrangements for primary care co-commissioning with the North Midlands CCGs and the North Midlands 2019/20 financial year. Primary Care (PC) Hub our review found that these are not up to date. PC Hub may not reflect current Responsible officer: Sharon requirements. We found that the Memorandum of Understanding (MOU) for the 2016/17 financial Pickett, Associate Director of year between the Derbyshire and Nottinghamshire CCGs and the North Midlands Low (2 x 2) Primary Care PC Hub issued in April 2016 was rolled forward to the 2018/19 financial year. In Implementation date: 1st August addition, although this MOU was published as a final agreed version, we found 2019 that the respective descriptions of PC Hub and CCG primary care commissioning functions defined in it were stated as being provisional. Management Response: The MOU has not been updated since 2016 and may not fully reflect the current This recommendation is agreed. working practices of the PC Hub and CCGs. The process of updating the MOU for 2019/20 has commenced. The content of the revised MOU will need to be jointly agreed between the North Midlands PC Hub and the CCGs prior to formal approval via the relevant PCCCs. 2 Primary Care Handbook Agreed detailed working Request the North Midlands PC We found that the Primary Care (PC) Handbook for the 2017/18 financial year arrangements between the Hub to review and refresh the issued by the North Midlands PC Hub in June 2017 was rolled forward to the CCGs and the North Midlands Primary Care Handbook for the 2018/19 financial year. It may not fully reflect the current working practices of the PC Hub may not reflect current 2019/20 financial year. PC Hub and CCGs. requirements. Responsible officer: Sharon Low (2 x 2) Pickett, Associate Director of Primary Care Implementation date: 1st August 2019

Management Response: This recommendation is agreed. The process of updating the Primary Care Handbook for 2019/20

Advisory | Counter Fraud | Internal Audit and Assurance | IT Risk Management and Assurance | PPV | Security Management Services | Training 8 Findings & Recommendations

Risk and Score No. Findings Agreed Action (Impact x Likelihood) has commenced. The content of the revised Primary Care Handbook will need to be jointly agreed between the North Midlands PC Hub and the CCGs prior to formal approval via the relevant PCCCs. 3 Primary Care Hub Arrangements Formal working arrangements Review and update CCG hosting Our review of the Memorandum of Understanding (MOU) in place between the between the PC Hub and the arrangements with the Primary Derbyshire and Nottinghamshire CCGs confirmed that NHS Mansfield and Greater Nottingham CCGs Care Hub and include in an Ashfield CCG was the lead CCG for the Primary Care (PC) Hub for both the may no longer be appropriate. updated MOU for the 2019/20 2015/16 and 2016/17 financial years. Low (2 x 2) financial year. As the MOU has not been updated since 2016 it is not clear what the formal Responsible officer: Sharon arrangements are for the PC Hub arrangements. Given the significant Pickett, Associate Director of organisational changes across the Nottinghamshire CCGs since then, current Primary Care governance arrangements may no longer be appropriate. Implementation date: 1st August 2019 (for MOU) update), 31st December 2019 (for review of governance arrangements post CCG/NHSE re-organisation). Management Response: This recommendation is agreed. Both the CCGs and NHSE are currently undergoing significant re- organisation. The existing timescales suggest that the restructure process across the system is unlikely to be fully complete until later in the financial year (Q3 or Q4). The MOU will therefore be updated to reflect the current situation (by 1st August 2019) and reviewed again following completion of the reorganisation (estimated to be completed by 31st December 2019 but subject to change depending on re-organisation timescales). 4 Monthly Finance Reports PCCC has ineffective Each CCG PCCC to regularly Each CCG Primary Care Commissioning Committee (PCCC) has an oversight assurance arrangements to scrutinise delegated budgets for role defined in its Terms of Reference that includes finance. This is a requirement manage delegated budgets for primary care medical services via for the PCCC to assure itself that effective arrangements are in place to manage primary care medical services. monthly finance reports. the delegated budget for primary care medical services. Low (2 x 2) Responsible officer: Ian Livsey,

Advisory | Counter Fraud | Internal Audit and Assurance | IT Risk Management and Assurance | PPV | Security Management Services | Training 9 Findings & Recommendations

Risk and Score No. Findings Agreed Action (Impact x Likelihood) Our review found that the PCCC at three CCGs5 did not receive monthly finance Deputy Chief Finance Officer reports during 2018/19 and as such did not receive sufficient information to fully Implementation date: 1st July scrutinise the delegated budget for primary care medical services. 2019 Looking ahead, we recognise that the operation of PCCCs is due to change with the establishment of committees in common for all six Nottinghamshire CCGs and Management Response: that financial reporting arrangements may change as a result of this. This recommendation is agreed. Monthly finance reports will be presented to the committee in common for all six Nottinghamshire CCGs once this committee is established. In the interim, finance reports will be provided to each CCG PCCC meeting commencing 1st July 2019.

5 NHS Nottingham City CCG, NHS Nottingham West CCG and NHS Rushcliffe CCG

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Primary Care Core Commissioning Functions The following table, taken from the MOU, sets out the respective core commissioning functions of the PC Hub and CCGs relating to primary care finance.

Commissioning Area PC Hub Functions CCG functions

Contracting, contract  Review authorisation of manual finance payments via claim forms  Support PC Hub as necessary management and  Provide financial support and review of tendering process budgetary control - financial  Enact financial changes as a result of contract reviews  Enact financial changes to premises changes  Support the contract team in managing disputes relating to finances  Monitor and provide trend analysis for contract changes  Enact payments from VTS and pension changes  Calculate and implement payments for APMS changes aligned to KPI achievement  Approve PCS recommendation for local payments and financial adjustments  Ensure payment is aligned to delivery of contracts including VPS, clinical waste, occupational health, translations services, PPV and GP retainer payment process  Ensure payment is aligned for LMC levies on price per patient  Financial management of the whole primary care budget and non-recurrent programmes such as Challenge Fund and winter pressures  Financial management of Community Health Partnerships (previously LIFT) and NHS Property Services contracts

Miscellaneous  Provide regular comprehensive contracting reports for CCGs  Submit and present reports in CCG governance processes (with support from PC Hub team).

This shows that the PC Hub is responsible for the design and operation of most key financial controls relating to primary care finance. The agreed functions of the GNCCP CCG finance team under the MOU are relatively limited. Given this, our review has focussed on the nature and extent of support provided by the CCG finance team and financial reporting processes.

Advisory | Counter Fraud | Internal Audit and Assurance | IT Risk Management and Assurance | PPV | Security Management Services | Training 11 Findings & Recommendations

The following tables provide our observations on, and the effectiveness of, the support provided by the CCG finance team and financial reporting processes.

Objective PC Hub Function Observation on CCG support and reporting Effective?

Framework: I. Overall management and the reporting of delegated funds – processes for forecasting, monitoring and reporting

Relevant policies, procedures - Both the PC Hub and CCGs have financial policies and procedures in Yes and guidance have been place that cover delegated funds. authorised, and communicated They also have access to: to relevant personnel.  Standard NHS SBS Oracle operating and systems notes; and  User manuals for the national NHS GP payments system (Exeter). Support provided to the PC Hub by Greater Nottingham Clinical Commissioning Partnership includes journal approval. Review of system journal lists for each CCG for all journals posted in 2018/19 confirmed that these were approved by a senior member of the CCG finance team. Roles and responsibilities for - The roles and responsibilities for overall management and reporting of Yes activities have been clearly delegated primary care commissioning delegated funds are defined as defined. part of the MOU between the PC Hub and the Derbyshire & Nottinghamshire CCGs (including the four Greater Nottingham CCGs). Arrangements are in place for Financial management of the The PC Hub prepared detailed annual budgets for each CCG setting out Yes the overall management and whole primary care budget and primary care co-commissioning expenditure for the 2018/19 financial year reporting of delegated funds, non-recurrent programmes such with sign-off by the CCGs. incorporating processes for as Challenge Fund and winter Monthly finance reports including information on delegated co- forecasting, monitoring and pressures. commissioning budgets are routinely presented to the CCGs for scrutiny reporting. Monitor and provide trend via the Greater Nottingham Clinical Commissioning Partnership Finance analysis for contract changes. Committee and Joint Commissioning Committee. One CCG6 also scrutinised these monthly finance reports at meetings of its Primary Care Commissioning Committee (PCCC). Support provided to PC Hub by the CCG finance team comprises monthly telephone and/or email discussions with NHSE accounting staff at the PC

6 NHS Nottingham North and East CCG

Advisory | Counter Fraud | Internal Audit and Assurance | IT Risk Management and Assurance | PPV | Security Management Services | Training 12 Findings & Recommendations

Objective PC Hub Function Observation on CCG support and reporting Effective?

Framework: I. Overall management and the reporting of delegated funds – processes for forecasting, monitoring and reporting Hub after receipt of financial information. These include confirmatory emails from the Head of Finance to the PC Hub. Support could be strengthened by offering the PC Hub the option of a formal sign-off process for monthly financial information. Local processes established by - CCGs have financial reporting processes that include delegated co- Yes the CCGs are aligned to NHS commissioning budgets. These are aligned to NHSE reporting and England policies and guidance. monitoring requirements. Processes are in place to Produce regular comprehensive See above. Yes confirm compliance with policies contracting reports for CCGs. and procedures. Sufficient documentation is - CCGs follow national NHS record keeping guidance. Yes retained to support payments In practice, this means that documents (including financial documents) made from delegated funds. relating to GMS and PMS payments are scanned and that specific destruction dates are used. Information is held on the national NHS GMS and PMS payments (Exeter) system in a standard format.

Advisory | Counter Fraud | Internal Audit and Assurance | IT Risk Management and Assurance | PPV | Security Management Services | Training 13 Findings & Recommendations

Objective PC Hub Function Observation on CCG support and reporting Effective?

Framework: II. Review of financial controls and processes for approving payments

Financial controls and Review authorisation of manual CCG finance team provides support to PC Hub as all violent patient Yes processes are in place for finance payments via claim service invoices are approved by CCG staff. We checked and confirmed approving payments. forms. that VPS invoices are authorised by CCG staff. Enact payments from Vocational All delegated primary care payments7 that pass through PCSE (Primary Training Scheme and pension Care Support England) are authorised by the PC Hub on behalf of the changes. CCGs. We were informed that PCSE does not recognise CCG staff as Ensure payment is aligned to authorised signatories. delivery of the contracts The GNCCP Director of Primary Care authorises all budget requests for including violent patient GP retainer payments. services, clinical waste, occupational health, translations services, Post Payment Verification and GP retainer payment process. Ensure payment is aligned for LMC levies on price per patient. Support the contract team in managing disputes relating to finances.

7 Primary care payments include the following delegated functions: General Medical Services (GMS), Personal Medical Services (PMS), Alternative Provider Medical Services (APMS) enhanced services, local incentive schemes, discretionary payments, Quality and Outcomes Framework (QOF) payments and premises payments.

Advisory | Counter Fraud | Internal Audit and Assurance | IT Risk Management and Assurance | PPV | Security Management Services | Training 14 Findings & Recommendations

Objective PC Hub Function Observation on CCG support Effective?

Framework: III. Review of compliance with coding guidance

Financial payments are Review authorisation of manual CCG finance team reviews monthly trial balance provided to it by the PC Yes correctly coded. finance payments via claim Hub. This includes a line by line review, by subjective code and forms. associated expenditure category, for reasonableness and accuracy.

Objective PC Hub Function Observation on CCG support Effective?

Framework: IV. Processes to approve and decisions regarding ‘discretionary’ payments

All ‘discretionary’ payments are - Requests for financial support from Primary Medical Services (PMS) Yes controlled with decision making contractors are considered and processed by the PC Hub. Decision and authorisation processes in making and due diligence review requirements have been defined by the place. PC Hub in a formal principles document. We were informed by the CCG Head of Finance that there were no payments to PMS contractors in 2018/19 as a result of requests for financial support.

Objective PC Hub Function Observation on CCG support Effective?

Framework: V. Implementation of the Premises Costs Directions

Financial payments relating to Enact financial changes to CCG finance team has worked with the PC Hub during 2018/19 to review Yes premises are consistent with the premises changes. and update GMS other premises costs. Premises Costs Directions. Financial management of Community Health Partnerships (previously LIFT) and NHS Property Services contracts.

Advisory | Counter Fraud | Internal Audit and Assurance | IT Risk Management and Assurance | PPV | Security Management Services | Training 15 Findings & Recommendations

One area relating to Primary Care Core Commissioning Functions requiring action is detailed below:

Risk and Score No. Findings Agreed Action (Impact x Likelihood)

5 Monthly Financial Information Inconsistent feedback of Agree a formal sign-off process Our review confirmed that the CCG finance team receives monthly financial comments on monthly financial with the PC Hub for monthly information from the Primary Care (PC) Hub in the form of a detailed trial balance, information to the PC Hub. financial information. and a summary analysis of primary care expenditure with brief comments on Low (2 x 2) Responsible officer: Ian Livsey, financial performance. Deputy Chief Finance Officer This information is reviewed by the CCG Head of Finance with feedback provided Implementation date: 1st July back to the PC Hub. In our view, there is scope to strengthen this process through 2019 having a formal sign-off process between the CCG finance team and the PC Hub. Management Response: This recommendation is agreed. A formal sign-off process will be agreed between the CCGs and the North Midlands Primary Care Hub. This will be implemented across all GN CCGs by 1st July 2019.

Advisory | Counter Fraud | Internal Audit and Assurance | IT Risk Management and Assurance | PPV | Security Management Services | Training 16 Appendix A – Risk Matrix & Opinion Levels

 Risks contained within this report have been assessed using the standard 5x5 risk matrix below. The score has been determined by consideration of the impact the risk may have, and its likelihood of occurrence, in relation to the system’s objectives. The two scores have then been multiplied in order to identify the risk classification of low, medium, high or extreme. 

Score Impact Likelihood Impact

1 Negligible Rare 1 2 3 4 5

2 Low Unlikely 1 L L L L L

3 Medium Possible 2 L L L M M 4 High Likely 3 L L M M H

5 Extreme Almost Certain 4 L M M H H Likelihood 5 L M H H E

The audit opinion has been determined in relation to the objectives of the system being reviewed. It takes into consideration the volume and classification of the risks identified during the review. 

Assurance level Evaluation and testing conclusion The controls in place adequately address the risks to the successful Full achievement of objectives; and the controls tested operate effectively The controls in place do not adequately address one or more risks to the Substantial successful achievement of objectives; and/ or one or more of the controls tested are not operating effectively, resulting in unnecessary exposure to risk. The controls in place do not adequately address multiple significant risks to Limited the successful achievement of objectives; and /or a number of controls are not operating effectively, resulting in exposure to a high level of risk. The controls in place do not adequately address several significant risks leaving the system open to significant error or abuse; and/or the controls No Assurance tested are wholly ineffective, resulting in an unacceptably high level of risk to the successful achievement of objectives.

The assurance levels defined here:  Are not comparable with ISAE 30008 and as such a Full assurance level does not imply that there are no risks to the stated control objectives; and  Differ to the standard assurance levels used by 360 Assurance for other reviews completed as part of the agreed internal audit programme of work, instead being those specified by NHS England.

8 International Standard on Assurance Engagements (ISAE) 3000 Assurance Engagements Other than Audits or Reviews of Historical Financial Information issued by the International Audit and Assurance Standards Board

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Ratified Minutes of the Mansfield & Ashfield CCG and Newark and Sherwood Primary Care Commissioning Committees

Thursday 23rd May 2019 9.00-11.00 Birch House Rooms 2 and 3

Representing both CCG Primary Care Commissioning Committees Mr Jon Towler, Chair Mr Mick Cawley, CCG Chief Finance Officer Dr Nigel Marshall, CCG Clinical Advisor Mr Shaun Beebe, CCG Governing Body Lay Representative Mr Andrew Morton, Deputy Chief Finance Officer Mr Stuart Poynor, CCG Director of Turnaround Mr David Ainsworth, CCG Director of Primary Care

In attendance Dr Hilary Lovelock, Local GP (Mansfield and Ashfield) Dr James Cusack, Local GP (Newark and Sherwood) Ms Paula Longden, CCG Assistant Director of Primary Care Ms Julie Kent, Assistant Contracts Manager, NHS England North Midlands Ms Annie Meakin, Nottinghamshire Local Medical Committee Ms Sue Wass, CCG Corporate Governance Officer (minutes)

Apologies representing both CCG Primary Care Commissioning Committees Dr Amanda Sullivan, CCG Chief Officer Mrs Lucy Dadge, CCG Chief Commissioning Officer Mrs Eleri de Gilbert, Independent Lay Representative Ms Dawn Jenkin, Director, Nottinghamshire Public Health Mrs Elaine Moss, CCG Chief Nurse Mr Peter Clay, CCG Governing Body Lay Member and Chair of the Audit Committee

Apologies in attendance Mrs Cathy Quinn, CCG Deputy Director of Primary Care Ms Kerrie Woods, NHSE GP Contracts Manager, North Nottinghamshire Ms Joe Lunn, Head of Primary Care, North Midlands, NHS England

JPC/19/31 Welcome a) Introductions b) Apologies for absence c) Declaration of interest

The Chair welcomed members to the meeting and a round of introductions was undertaken. Apologies for absence were noted as above and the meeting was declared quorate.

The Chair noted the following potential conflicts of interest:  Dr Lovelock (Brierley Park) and Dr Cusack (Lombard) as GPs of practices referenced in item JPC/19/36 were conflicted. It was agreed that they would remain in the meeting, contributing to the discussion, but not contribute to any discussion relating to their practices. Mr Towler (Sherwood Medical Practice and Major Oak), declared an interest as a patient in a practice referenced in the same report. It was agreed that he would remain in the meeting, but not contribute to any discussion 1

relating to that practice.  Dr Lovelock and Dr Cusack were conflicted for item JPC/19/39 as potential recipients of funding and it was agreed that they would remain in the meeting, contributing on matters of fact.

No other interests were declared on any of the other items on the agenda.

The Chair asked the Committees to note that this was the last meeting in its current format prior to the Committees meeting in common with the south Nottinghamshire CCGs. He reflected on the positive impact that the Committees had made over the previous four years, having responded to a number of difficult and / or urgent issues, ensuring patient safety was maintained. A clear transformation strategy had been developed and practices had been encouraged to work together prior to the national policy shift. A robust dashboard had been developed to monitor quality, performance and unwarranted clinical variation. The Chair urged the Committees going forward to continue to focus on dynamic and innovative solutions to local needs and thanked members for their contributions.

Dr Lovelock noted the huge undertaking to ensure all practices (bar one yet to be inspected) passed their CQC inspections. Also the positive move to partnership working and the focus on tackling unwarranted clinical variation. Dr Lovelock noted her disappointment in lack of progress in Kirkby, which was acknowledged as a priority going forward.

Mr Ainsworth thanked the CCG teams behind the work the Committees oversaw and it was agreed that a thank you note should be circulated.

 ACTION: DA to draft a thank you note to CCG teams for the work they had undertaken on primary care.

JPC/19/32 Questions from members of the public No questions had been received.

JPC/19/33 Minutes of the meeting held on 14 March 2019 The minutes of the meetings held on 14 March were agreed as an accurate record of discussions.

JPC/19/34 Actions arising from the meeting held on 14 March 2019 Regarding item JPC/19/25: poor quality primary care estate, The Chair queried whether there was a date for information from NHS England. Ms Kent noted there was not, although the Area Team continued to pursue it. It was agreed to keep this risk open on the action log.

All other actions were noted as complete.

JPC/19/35 Forward plan The forward plan was noted.

JPC/19/36 Primary Care Quality and Performance Report Dr Lovelock (Brierley Park) and Dr Cusack (Lombard) as GPs of practices referenced in this item were conflicted. It was agreed that they would remain in the meeting, contributing to the discussion, but not contribute to any discussion relating to their

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practices. Mr Towler (Sherwood Medical Practice and Major Oak), declared an interest as a patient in a practice referenced in the same report. It was agreed that he would remain in the meeting, but not contribute to any discussion relating to that practice.

Mr Ainsworth reported that of the 40 practices in the mid Nottinghamshire area, three practices were receiving intense support and four practices were receiving intermediate support. The remainder were under routine monitoring.

The Chair queried the increase in non-elective activity, which was cited as being above alert limits. Mr Ainsworth referenced the work of the Urgent Care Workstream to drive activity through ambulatory pathways and proactive treatment of patients with long term conditions. Work was also taking place to investigate this issue at practice level. Mr Beebe noted that the trend would be monitored at the Finance, Performance and Turnaround Committee. Dr Lovelock noted that there was a need to focus on prevention and to focus on the Kirkby practices, as four were rated red for activity. Mr Ainsworth reported that a social prescribing workshop would be held that afternoon, noting the potential impact to the prevention agenda these roles would bring. It was agreed that an assurance report would be brought to the next meeting on actions to mitigate the increase in non-elective activity.

In the context of discussion regarding Kirkby, the Chair queried how the CCG and this Committee would engage with Primary Care Networks (PCNs) and their Clinical Directors going forward. In relation to Kirkby, Dr Marshall noted the importance of having local information.

 ACTION: SW to add to the forward work plan a report regarding non-elective activity; support for Kirkby and engagement with PCNs going forward.

Mr Cawley queried the infection prevention and control audit red ratings for five practices. It was noted that in all cases patient safety was not compromised. However it did indicate that further work needed to take place to meet certain standards.

The Primary Care Quality and Performance Report was NOTED.

JPC/19/37 Primary Care Strategic Risk:  Risk 25 – Primary Care Workforce  Feedback from March Review of Primary Care Risks Mr Ainsworth proposed that risk 25 remained at its current rating of 20. The only gap in control related to mid Nottinghamshire being in direct competition with other areas in the region and nationally to attract trainees to the area, which was difficult to influence.

There was a discussion on this issue, with the Committees emphasising the need for the future Committee to ensure continued emphasis on workforce issues, how to ensure an equitable split of trainees between north and south Nottinghamshire, and to continue to drive forward activity to produce a mixed workforce. It was noted that PCNs would in time need to drive this agenda and would need to be supported to do this.

It was agreed to maintain risk 25 at its current rating.

JPC/19/38 Primary Care Transformation Programme update Ms Longden reported that in addition to the formal establishment, PCNs had become responsible for whole population coverage of the enhanced hours DES, agreeing 100% coverage for this service. Regarding Extended Access, priorities for the coming year

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were to attain 85% utilisation and provide direct booking from the 111 service. The rollout for this was on track.

A summary of the new governance arrangements was given, as requested at the last meeting.

Regarding the Phoenix Programme, Ms Longden reported that 48 doctors had registered, 10 from mid Nottinghamshire. The programme manager was attending network meetings to promote the programme.

With reference to the request to include dynamic workforce modelling at the last meeting, Ms Longden noted that statistics from NHS Digital were not directly comparable and Andrea Brown was undertaking work to set a new baseline.

A project group had now been established to develop the outline business case for Fountain Medical Centre and a separate working group had been established for the Balderton project. Work on the Ashfield South project had been re-started and the post PID options appraisal was being finalised. Regarding Ollerton, it was reported that the local authority had stepped back from leading the project. However the CCG was keen to improve estate in Ollerton and Edwinstowe; and were now utilising estates expertise from the south CCGs to take the feasibility study forward.

Regarding the Phoenix Programme, Mr Cawley queried whether there was a mechanism to keep GPs in the area once trained. After discussion on the issues involved in trying to retain trained GPs, it was agreed that Mr Ainsworth should request further information from the ICS Workforce Workstream on this issue.

 ACTION: DA to request further information from the ICS Workforce Workstream regarding their GP retention activity and future plans for mid Nottinghamshire and bring to the July meeting.

The Chair requested that a short statement be drafted for the next meeting on the Ollerton feasibility study to clarify how the project could be taken forward, detailing barriers to delivery.

 ACTION: PL to lead on the drafting of a report on next steps for the Ollerton feasibility study for the August meeting.

The Primary Care Transformation Programme update was NOTED.

JPC/19/39 GP Forward View Funding Plan Dr Lovelock and Dr Cusack were conflicted for this item as potential recipients of funding and it was agreed that they would remain in the meeting, contributing on matters of fact.

Mr Ainsworth reported that following feedback, NHS England had devolved funding for the four specific elements of the GP Forward View programme 2019/20 to the ICS as one pot of money. Work had already commenced on engagement over the allocation.

It was agreed that once the allocation was agreed it should be presented to this Committee for final approval and the Committee should monitor performance for assurance purposes.

 ACTION: SW to add final approval of the GPFV funding allocations to the Committee

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work plan for June.

The GP Forward View Funding Plan was NOTED.

JPC/19/40 Year End Finance Reports: a) MACCG b) NSCCG Mr Morton reported that Mansfield and Ashfield ended the year with a 1.6m underspend. Within the total budget, overspend occurred in the premises costs reimbursement budget; and a switch of three practices to GMS contracts resulted in additional spend.

Newark and Sherwood ended the year with a £410k overspend relating to over performance in activity and GMS contracts.

Mr Cawley noted that both final positions were in line with forecasts, with the underspend within the Mansfield and Ashfield budget supporting the overall primary care position.

The Year End Finance Report was NOTED.

JPC/19/41 New risks or issues identified at the meeting for escalation to the Governing Body and/or other committees Dr Lovelock queried whether a risk relating to variation in Primary Care Network performance should be raised. It was agreed that at the current time it was too early to draw conclusions.

JPC/19/42 Any Other Business There was no other business.

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