(Public Pack)Agenda Document for Primary Care Commissioning

PRIMARY CARE COMMISSIONING COMMITTEE - OPEN MEETING

Tuesday, 5 November 2019 10.00 am Wigan Borough CCG Boardroom - Wigan Life Centre

AGENDA

Agenda Item Time Presenter Pages/ Action Verbal Required 1 Chairman's Welcome Frank Costello

2 Apologies Frank Costello

3 Declarations of Interest Individuals will declare any interest that they have, in relation to a decision to be made in the exercise of the commissioning functions of Wigan Borough Clinical Commissioning Group, in writing to the Governing Body, as soon as they are aware of it and in any event no later than 28 days after becoming aware. 4 Minutes of Previous Meeting and Actions Frank 1 - 8 Approve Costello

5 Contract Options Appraisal: P92012 Jonathan 9 - 68 Approve Kerry

6 Practice Merger Application: Debbie 69 - Approve P92042/P92652 Szwandt 106

7 Standing Agenda Items

Catherine 107 - 7.1 Finance Update Receive Johnson 118 Primary Care Commissioning Aaron 119 - 7.2 Receive Programme Update Barker 126 Alison Primary Care Quality Improvement Foster / 127 - 7.3 Receive Programme Update Debbie 138 Szwandt Claire Roberts / 139 - 7.4 Primary Care Transformation Update Receive Jonathan 150 Kerry Laura Verbal 7.5 NHS England Update Receive Browse Report 8 Any Other Business Frank Costello

9 Date and Time of next meeting

Tuesday 7th January 2020 – 10am Wigan Life Centre – Meeting Room 17 Minutes of Primary Care Commissioning Committee - Open Meeting Held on Tuesday 3 September 2019 at 10.00 am in Wigan Borough CCG Boardroom - Wigan Life Centre.

Present: Gary Cook Secondary Care Consultant, Governing Body – Chair (GC) Frank Costello Lay Member (FC) Linda Scott Director of Clinical Services and Primary Care (LS) Jonathan Kerry Senior Assistant Director of Primary Care (JK) Margaret Hughes PPG representative (MH) Catherine Johnson Senior Finance Manager (CJ) Ernie Rothwell Lay Member (ER) Laura Browse NHS England Representative (LB) Debbie Szwandt Assistant Director of Primary Care (DS) Jennifer Gammack Senior Assistant Director of Primary Care (JG) Aaron Barker Primary Care Commissioning Manager (AB) Nikesh Vallabh GP Representative (NV) Karen Parker Health Watch Wigan and Leigh (KP) Janet Kay WBCCG Primary Care Support Officer (Notes)

ACTION

1 Chairman's Welcome GC welcomed members to the meeting

2 Apologies  Paul McKevitt  Rebecca Murphey  Claire Roberts  Stuart Cowley  Stef Duerden  Mick Hodlin

3 Declarations of Interest No declarations of interest were raised.

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

Actions 5.3 Completed Actions 5.4 In Progress

Page 1 Resolved: The committee received the report

5 Standing Agenda Items

5.1 Finance Update CJ updated the Committee on the budget and clarifies the finance position to the members. The following was noted:

 CJ stated that Finance must keep an eye on Q3 & Q4 periods.  There is potential a forecast overspend this year.  The reserves are currently showing a negative figure due to funding the PCN budgets resulting in a shortfall; however this will be continually monitored throughout the year.  Network roles issued in the 19th August guidelines from NHS England, there are some queries which will need to be addresses.  A CCG claims form is due to be published.  NHS England has a three- four year programme of work for auditing, Wigan CCG Primary Care Finance is the first to be accurate. More information to be provided to the members for the November meeting.  QOF overspend is a positive outcome, once the QOF results/reports are produced they will be shared at the November meeting, we are hoping for more achievements.

Resolved: The committee received the report.

5.2 Primary Care Commissioning Programme Update AB gave members an update on the Co Commissioning Programme.

The following was noted:  The APMS contracts are being monitored quarterly; there will be a further update for the November meeting.  There is a change of a practice name.  We have updated PCN Guidance.  Updates roles.  The PCN deliver additional winter appointments. There are 16,000 additional appointments from Primary Care Networks so we will see 100% coverage for the winter resilience.  CQC visited Dr Anis there were no improvement’s from the first report. (to be continued in the closed meeting).  Marsh Green has got an outstanding from the CQC Inspection.

It was suggested that Marsh Green practice should be wrote to

Page 2 congratulate them. NV. Raised a concern regarding the additional appointments, make sure the infra structure is in place with the I.T systems and ensure you have coverage, especially for the Winter Resilience. How will we all deliver this when some of us are on different networks?

JG. We will have new AD’s from 1st November to 31st March.

JK. There has been a Q2 review on the Primary Care Specification of the Commissioning Intentions, JK. To pick up with NV. Lessons learnt.

Action: To share results of Q2 Review on the Primary Care JK Specification Commissioning Intentions.

Resolved: The committee received the report

5.3 Primary Care Quality Improvement Programme Update DS provided an update on progress across the Quality Improvement Programme:

September Update: Changes from the last report and areas of work covered.  Linda Scott, Primary Care Director is now the Senior Responsible Officer for this programme of work  Two replacement practice nurse positions have been filled and all SDFs. Have a lead nurse now.

Dr Anis & Anis (P92012) remain in special measures, following the comprehensive re-inspection visit on the 30th May 2019, the CQC published findings on the 5th August 2019 and the practice received a second Inadequate rating.

In addition, the CQC have also published the enforcement decision, which is a notice of proposal for cancellation of registration.

The CQC findings have been escalated and WBCCG continue to work with the practice team and Wigan Local Medical Committee to manage the requirements in line with both primary care contracting and CQC process.

There has also been one other CQC report published in this report period relating specifically to Wigan Borough Locality Practices; Marsh Green Medical Practice (Y02885) received an overall rating of “Outstanding”.

This is one of the six APMS contracts procured in August 2018 and is an improvement from the previous rating of Good.

Resolved: The committee received the report 5.4 Primary Care Transformation Update JK provided an update on to the Committee on the key areas being

Page 3 progressed within the Transformation plan:

Primary Care Networks (PCNs)  As previously reported, the Primary Care Networks align to the 7 Service Delivery Footprints  To support PCNs a development session has been held, supported by Capita & Primary Care Commissioning (PCC), to give support to PCNs on the challenges faced and to give them some space to work through in a collaborative session  The workshop was well attended which we hope will be of benefit to PCNs and Practices in the delivery of specifications in the future, and we will look to hold similar sessions in the future to continue to support PCNs as they mature.

Workforce and Training  Funding that was previously received by the CCG from HEE to support workforce training have now been aligned to the Enhanced Training Practices (ETP)  The ETP is currently Marus Bridge Practice in SWAN PCN, we will work with the practice to ensure that the funding still aligns to the aspirations of the Training Group and to support getting maximum benefits for the Wigan Workforce.  The CCG has also been working with Community Healthcare Partnership (CHCP) to ensure that the opportunity to expand the Community Link Worker/Social Prescriber workforce through the PCN DES is not missed and builds on the current capability of CLWs and links into the Mental health teams too.

Estates There are a number of schemes that are currently progressing:

 Ashton Health Centre is nearing build completion and we will then move onto commissioning and mobilisation of services before Christmas.  Shevington Surgery has a revised set of plans and a Business Case is being developed to support the Practice and CCG understand the potential costs for progressing with the scheme.  Coldalhurst Lane is awaiting confirmation from GM HSCP with regards to the potential extension/refurbishment.

It should also be noted that the potential of a development to support Boothtown Practice has also been progressing, with a new developer engaged in the scheme and some positive conversations happening with appropriate stakeholders.

Digital/Information Technology The work plan is focused on support the day to day requirements of General Practice as well as delivering a number of transformational projects to support future ways of working and getting the most from technology.

Clinical Migration consolidation continues, with plans in place to have all but 2 practices standardised on 2 main clinical systems within the current

Page 4 calendar year. Work continues to support the remaining practices to maximise clinical system potential and work within their PCNs.

The Information Governance Forum has created a revised Information Assurance Statement to underpin sharing across the Borough. We have 50 signatories out of a possible 64 currently which is a positive position having only circulated last month.

We are also looking at how to make the best use of digital records and use less storage space within practices to maximise space for clinical service delivery. This is being piloted in 3 locations and if successful will be developed into a full business case for wider rollout. It is expected that the pilot will run until around December.

Resolved: The committee received the report 6 NHS England Update LB updated the committee on on-going work within the Partnership

 Claire Roberts (WBCCG) is to attend a Task and Finish Group, the intention of the group is to investigate how the monies flow.  There are to be more money contributions towards Pharmacy and Optometrist.  There is to be a Clinical Meeting meeting on the 19th September 2019.  NHS England consultation period of the restructure closes on Friday 6th September 2019, further updates and information regarding the restructure will be brought to the next meeting.  The Primary Care workforce strategy is coming to an end further updates re to be brought to the next meeting.

Resolved: The committee received the report 7 Any Other Business A query was raised with regards the impacts on Clinical Workforce and Pensions that was currently in the media.

LS confirmed that Pensions Guidance had been published, although only circulated in the past 24 hours, and any implications would be brought to the next meeting.

The meeting was brought to a close.

8 Date and Time of next meeting November 5th 2019. 10.00am. Wigan Life Centre

Page 5 This page is intentionally left blank Actions from the WBCCG - OPEN Primary Care Commissioning Committee (PCCC) held on Tuesday 3rd September 2019

Agreed actions September 2019

5.3 To share results of Q2 Review on the Primary Care JK Primary Care Quality Specification Commissioning Intentions. Improvement Programme Update Page 7 Page This page is intentionally left blank MEETING: Primary Care Commissioning Committee Item Number: 5

DATE: 5th November 2019

REPORT TITLE: Options Appraisal GP Practice Exit (Contract Termination): Dr Abu Anis and Dr Yasmin Anis (P92012) 1. Supporting our population to stay healthy and CORPORATE OBJECTIVE live longer in all areas of the Borough ADDRESSED: 2. Commissioning high quality services, which reflect the population's needs, delivering good clinical outcomes and patient experience within the resources available

3. Function as an effective commissioning organisation that puts the patient first.

4. Function as an organisation that puts patients first

5. Functioning as an organisation that consistently delivers its statutory duties and participates fully in Greater Manchester Devolution

REPORT AUTHOR: Debbie Szwandt, Assistant Director Primary Care

Alexia Mitton (Head of Communications)

Jonathan Kerry (Senior Assistant Director of Primary Care)

Debbie Szwandt, Assistant Director Primary Care PRESENTED BY:

RECOMMENDATIONS/DECISION The Committee is asked to receive the report and REQUIRED: make the commissioning decision regarding the delivery of primary medical services to registered patients at High Street Medical Centre from the 1st January 2020.

Page 9 EXECUTIVE SUMMARY

The report outlines the options appraisal carried out against Dr Abu Anis and Dr Yasmin Anis (P92012) GMS contract for the 4,574 registered patients.

Subsequent to WBCCG’s decision to terminate the GMS contract with Dr A Anis and Dr Y Anis (P92012), a commissioning options appraisal has been developed including a programme of engagement.

The two commissioning options are:

Option 1: WBCCG agree to close the practice at a date in the future and support patients to transfer to another practice in the local area. It is likely that this process wouldn’t be finished by 1st January 2020 and therefore a “caretaker GP” would be required to manage this process for approximately 3 months.

Option 2: WBCCG keep the practice open and find a provider to run GP services at the High Street Medical Centre. We would need to find a temporary GP to act as a “caretaker GP” to manage and improve the services delivered at the practice whilst we follow a legally proper process to do this, which could take up to 12 months.

The recommendation is to keep the practice open and find a provider to run GP services at the High Street Medical Centre. We would need to find a temporary GP to act as a “caretaker GP” to manage and improve the services delivered at the practice whilst we follow a legally proper process to do this.

FURTHER ACTION REQUIRED: None

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

Page 10

Primary Care Commissioning Committee (PCCC) 5th November 2019

Options Appraisal GP Practice Exit (GMS Contract Termination):

Dr Abu Anis and Dr Yasmin Anis (P92012)

High Street Health Centre, Kid Glove House, Golborne

1. Introduction

1.1. Dr Abu Anis and Yasmin Anis hold a GMS contract as a partnership and are accountable for the service delivery. There is also an additional GP and non-clinical partner on the contract. However, both roles do not have a partnership agreement or have been operationaly involved in decsions about service, staff and budget.

1.2. On the 24th September 2019 Wigan Borough CCG decided to terminate the contract with Dr Anis and Dr Y Anis who are responsible for the General Medical Services (GMS) contract at High Street Medical Centre (PCCC descision was made on the 3rd September 2019).

1.3. On the 31st December 2019 the GMS contract P92102 will be terminated with Wigan Borough CCG/ NHS England , in line with clause 26.7 of the National General Medical Services Contract.

1.4. The CCG and NHS England (GM health & Social Care Partnership) are required to carry out an options appraisal to support the commissioning decision regarding the Primary Medical Care Services for the registered patients from the 1st January 2020.

1.5. The process for the management of a GP practice closure was approved by the Governing Body meeting held on the 27th September 2016 and the Primary Care Commissioning Committee on the 1st November 2016.

1.6. Although the process refers to GP practice exit, at this stage Wigan Borough CCG working with NHS England (Greater Manchester Health and Social Care Partnership) have not made a commissioning decision.

1.7. A programme of Patient engagement was scheduled and implemented, refer to section 2.

Page 11

2. Patient and Stakeholder Engagement

2.1 Using Patient and Stakeholder engagement to inform commissioning decisions is a Statutory Duty of Wigan Borough CCG.

2.2 A comprehensive programme of engagement was led by the WBCCG Assistant Director of Communications & Engagement. Other WBCCG key roles involved are described in Appendix A.

2.3 WBCCG wrote to all adults and parents/guardians of children who are registered at the practice, to inform them off this decision and ask for their feedback on the options.

2.4 WBCCG also contacted all relevant local stakeholders including neighbouring practices and pharmacies.

2.5 Using a mixture of online, face-to-face and written communications, we had over 800 contacts. The full engagement report which summarises what people and wider stakeholders told us is available as an attachment.

2.6 Members of the committee with have an opportunity to ask questions regarding the engagement report at the PCCC on the 5th November 2019.

2.7 We also gathered lots of insight from people from different protected characteristic groups. We have produced an “Equality Impact Assessment” to sit alongside this report.

2.8 There were a number of recurring themes that came up throughout the engagement with patients.

 Patients were surprised and concerned when they received the letter.

 People who used the practice reported positive experiences of the care they had received over many years.

 People who used the practice raised concerns about their experiences and the quality of care they had received.

 The practice should remain open with new doctors.

 Dr Khan and the practice nurses were uniformly praised and thanked.

 Dr Khan should be allowed to run the practice – petition of 578 supporting this.

 Concern for the elderly and vulnerable who it was felt would be most disadvantaged if it closed.

 Concern that there weren’t enough practices in the area to take on the number of patients and that they would have to travel quite far for GP services.

Page 12

 Patients didn’t want to use the other GP practices in the building – some reported they had previously tried others

2.9 WBCCG also contacted the following types of stakeholders to ask for their feedback on the options: Other Local GP Practices, Local Pharmacies, Local Dentists, Local Opticians, Local Care Homes

2.10 We have had feedback from 5 GP practices and Wigan LMC, with no feedback received from elsewhere to date (29th October).

2.11 All the practices have confirmed who have contacted have indicated that they have capacity to grow their patient list size by taking on more patients and would like to do so.

2.12 One practice has indicated that they would support closing the practice as there are 3 other practices within the building and a further 5 within what they consider to be close proximity”. They comment that this would be a better use of resources at a period of high demand on the NHS.

3. Options Appraisal GP Practice Exit

The following list of criteria is included in the commissioning options.

General (applies to all options)

1. List size 2. Local Capacity 3. Geographical Location 4. Premises ownership / lease arrangements 5. Specialised services commissioned

Specific ( Applies to Options: 1 and 2)

6. Impact on other primary care providers (stakeholder engagement) 7. Financial Implications 8. Impact on patients (Patient Engagement) 9. Impact on wider health and social care providers

Page 13

Table A: GP Practice Options Appraisal (P92012)

Options Appraisal: Dr Abu Anis and Dr Yasmin Anis (P92012) Expected to End – 31St December 2019

Criteria for consideration of commissioning opportunities in relation to the termination of a contract.

ALL OPTIONS NEED TO BE CONSIDERED IN LINE WITH LOCAL AREA STRATEGY DOCUMENTS

Wigan Borough CCG primary care strategy and Locality plan sets out the vision for a greater collaborative, federated, more robust model for general practice operating in an integrated model, which sees larger clusters of practices delivering higher quality services along with a wider range of services to the population.

Consideration should also reasonably relate to:-

 Acceptability to stakeholders  Value for Money (includes efficiency, best outcomes)  Access (Capacity and Choice)  Suitable available premises in relation to the services intended to be provided  Impact assessment (GP practices within 1 mile / 2miles / within LiGA PCN)  Wider health economy  GM Primary Care Strategy  Consultation and engagement

General Criteria – appllies to all Options

1.Registered List size AGE 0-4 AGE 5-64 AGE 65-74 AGE 75-+ Total Oct 2019 181 3,354 549 490 4,574

2. Local Capacity There are currently 3 GP practices within a 1 mile radius, 5 GP practices within 2 miles of High Street Medical Centre and 6 within LiGA Primary Care Network (PCN), Appendix B.

None of the practices are currently operating a closed list.

NHS England (Greater Manchester) and Wigan Borough CCG recognises that a number of practices are already actively managing their capacity and face ongoing challenges to meeting new patient requests to register. 4

Page 14

3. Geographical Location Please see Appendix C, Geographic location of High Street Medical Practice and registered patient population (patient postcode map).

4.Premises Premises are owned by Eric Wright Health and Care, and is one of 8 Ownership/lease facilities built by Private Finance Funding (PFI) in 2002 arrangements Occupancy is by tenancy lease with Community Health Partnerships (CHP).

The current premises are suitable for provision of future services. CHP have confirmed no issues with tenancy changes to ensure continuation of services from the 1st January 2020.

The strategic direction for all PFI premises is to improve utilisation.

5.Specific specialised The practice delivers a range of National DES and the Locally services currently Commissioned Services (LCS). commissioned No additional specialised services have been commissioned from High Street Medical Centre.

Page 15

OPTION 1 – List Dispersal

NHS England would write to all patients registered at High Street Medical Practice informing them that the practice will close on a specified date.

The letter will request patients to register with an alternative local GP Practice.

Issues for Comments Consideration 6. Impact on other Dispersal of the practice registered list following the contract termination primary care providers is possible.

However, list dispersal would mean that the registered patients would be required to re-register with another local GP practice under the Patients right to choose a GP practice and to be accepted by that practice unless there are reasonable grounds to refuse.

This could provide for significant risk to local practices that may be inundated with new registrations, as there would be no control over where patients registered.

Furthermore, there may be limitations on their surrounding practice boundaries which could restrict registration, and patients may live outside a practice boundary.

Moving to dispersal could destabilise local practices, which may lead to practices requesting immediate list closures.

The list size of 4,574 is a large number of patients to disperse. There are 3 practices with a 1 mile radius, 5 within a 2 mile radius and 7 members of LiGA primary Care Network, see Appendix B.

Patient choice of registering will apply and General Practice’s cannot discriminate on the basis of: race; gender; social class; age; religion; sexual orientation; appearance; disability or medical condition in making that decision.

WBCCG would recommend that any patient letter includes a clause that explains that some practices may have a limited capacity to accept new patients, which would breach patient choice.

Page 16

7. Financial There are no known financial implications to WBCCG/NHSE regarding Implications deiverying the core contract.

The caretaker practice will be required for a period of 3 months and is unlikely to create any additional costs.

8. Impact on Patients Refer to the feedback in the engagement report, this is not a preferred option for almost 900 patients.

Refer to Appendix D: Health needs Assessment 9.Impact on wider High Street Medical Centre is part of LiGA Service Delivery Footprint health and social care (SDF) dispersal would mean one less GP provider in that SDF. providers

OPTION 2: PROCUREMENT

Full details of consideration and processes for procurement are as set out in NHSE ‘Policy for managing procurement for primary care services’.

Issues for Comments Consideration

6.Impact on other Procurement of services recognises the need for a provision for the primary care providers registered population; procurement would result in services continuing but being opened to the market because of a material change in what and how services are commissioned.

The timescale for an effective procurement process is around 12 months; this includes for example pre engagement, service specification development, tendering processes and effective mobilisation of services.

Any new procurement would be through an Alternative Provider Medical Services (APMS) contract or General Medical Services contract (GMS).

APMS can be used to provide essential services, additional services, under APMS the NHS Commissioning Board (NHSE) is able to contract for primary medical services with a wide range of providers and would allow existing GMS, PMS and new providers the opportunity to establish a practice within the locality.

Wigan Borough CCG primary care strategy and locality plan set out the vision for a greater collaborative, federated, more robust model for general practice operating in an integrated model, which sees larger size practices delivering higher quality services along with a wider range of services to the population.

This would have the least impact on local primary care providers in

Page 17

the long term, but there may be short term impacts if the patient population is destabilised and patients decide to change practice.

7. Financial Implications Additional procurement costs

Consideration of pass through costs for TUPE of staff

8.Impact on patients Re-procurement could ensure value for money and improved equity of service for patients.

Patients will still have a new management team and at least 1.4wte new GPs.

This is the preferred option for patients.

Refer to Appendix D: Health needs Assessment

9.Impact on wider There would be a limited impact on the wider health and social care health and social care providers in the long term, but there may be short term impacts if the providers patient population is destabilised and seeks support from alternative services.

Page 18

4. Recommendations:

4.1. The Primary Care Operations Group met on the 16th October 2019, discussed and debated the commissioning options for P92012, High Street Medical Practice.

4.2. There are two options available to us:

4.3. The recommendation is to keep the practice open and find a provider to run GP services at the High Street Medical Centre. We would need to find a temporary GP to act as a “caretaker GP” to manage and improve the services delivered at the practice whilst we follow a legally proper process to do this.

4.4. The introductory letter a for the appointment of a Caretaker GP is described in Appendix F.

Page 19

Page 20

Appendix A: Members of the Commissioning and Engagement programme team

Name Role Responsibility Tel Calls Stakeholder letters Emails Survey Monkey Follow up Engagement

15.10.19 17.10.19

Alexia Mitton Assistant Director Communications and Yes Yes Yes Yes Yes Yes Communications and Engagement lead Engagement, WBCCG

Page 21 Page Rachel Engagement Arrange, run and required Yes Yes Richardson stakeholder activities

Linda Scott Primary Care Director Senior Responsible Officer Yes

Debbie Assistant Director Lead Commissioner Yes Yes Yes Szwandt Primary Care WBCCG

Gillian Head of Project Support Project management Yes Yes Watson

Aaron Barker Head of Commissioning Commissioning process No Yes WBCCG advice

Jonathan Senior Assistant Director Senior manager, Contracts, Yes Yes Kerry Primary Care WBCCG IM&T, Estates and Business Inteligence

Lynn Hogan Business Transformation PCN relationships No Yes Manager, WBCCG

Alison Foster Lead Nurse for Quality Quality and Practice Nurse Yes Yes

WBCCG advice

Janet Kay Primary Care Support Admin Yes Yes Assistant

Nicky Communications Support Admin Yes Ainscough

Page 22 Page

Appendix B: Practices within; 1 mile / 2 miles of High Street Medical Centre and member practices of LiGA Primary Care Network (PCN)

Family Medical Practice Kid Glove House, Kid Glove Road, Golborne, Warrington. WA3 3GS 0 miles

Dr Pal Kid Glove House, Kid Glove Road, Golborne, Warrington. WA3 3GS 0 miles Railway Street (Branch to Bryn Street, Ashton) Kid Glove House, Kid Glove Road, Golborne, Warrington. WA3 3GS 0 miles Slag Lane Surgery 216, Slag Lane, Lowton, Warrington. WA3 2EZ 1.5 miles Braithwaite Road Surgery 36 Braithwaite Road, Lowton, Warrington. WA3 2HY 1.6 miles Lowton Surgery The Surgery, 208C Newton Road, Lowton, WA3 2AD 2.1 miles

Page 23 Page Bryn Street* (main to Railway Street Ashton Clinic, Queens Road, Ashton In Makerfield , Wigan, Lancashire, WN4 3.8 miles Golborne) 8LB Bryn Street, * New Build expected to be Council Avenue, Ashton In Makerfield , Wigan, Lancashire WN4 9AX 3.5 miles operational December 2019 Ashton Medical Centre 120 Wigan Road , Ashton-in-Makerfield, Wigan, Lancashire WN4 9SU 4.1 miles

Appendix C: Geographic location of High Street Medical Practice and registered patient population (patient postcode map) Page 24 Page

Appendix D : Health Needs Assessment for existing Service

High Street Medical Centre

Kid Glove House, Kid Glove Road, Golborne, Warrington, WA3 3GS

High Street Medical Centre Patients Registered Q2 4,574 2016/17 Levels of Deprivation Index of Multiple Deprivation (IMD) Page 25 Page Dr Anis’s, High Street Medical Centre is ranked 7,703 out of 32,844 LSOAs in England; where 1 is the most deprived LSOA.

This is amongst the 30% most deprived neighbourhoods in the country.

Page 26 Page

Type of Building Modern purpose built Health facility post 2002 Practices in the Same 4 Building Practices within 1 Mile 3 (Including 1 branch site, Main site is in Ashton, WN4 9AU. New build expected opening Oct 2019 ) See Appendix A for list

Practices within 2 Miles 5 (Including 1 branch site, Main site is in Ashton, ) See Appendix A for list

Practices within LiGA 7 primary Care Network (Including 1 branch site, Main site is in Ashton, ) See Appendix A for list Opening Hours Monday 08:00 – 18:30 Tuesday 08:00 - 18:30 Wednesday 08:00 – 18:30 Thursday* 08:00 – 19:30 Friday 08:00 – 18:30 Saturday CLOSED Sunday CLOSED

Training Weekly Thursday 11am – 1pm QOF Achievement in Page 27 Page 2018/19 94% (WBCCG Average= 98%) New Houses by 2035 2,533

GP Patient Survey in 2019 = 72% Page 28 Page

Appendix E: Health Needs Assessment Practices within; 1 mile/ 2 miles and LiGA Primary Care Network of High Street Medical Centre, Dr Anis and Dr Anis Health Needs Assessment Supporting Information Template

Name of GP Practice:

Name of contact person if any points need clarifying:

(1)Are there any changes in workforce capacity such as retirements which may reduce the capacity of your GP practice in the next 1-5 years?

(2) Do you have the ability and/or willingness to grow your practice list size in the next 1-5 years?

(3) Are there any planned changes to your deliver site location or plans to provide new branch site(s) in the next 1-5 years?

(4) Are there any planned changes to the services offered to your registered or non - registered patients?

(5) Any other information

Please return this template by Monday 28th October to: [email protected]

Page 29 Appendix F: Caretaker Letter

Caretaking Arrangements:

NHS Wigan Borough CCG Wigan Life Centre College Avenue Wigan WN1 1NJ

Date: 1st November 2019 Dear Doctor,

NHS Wigan Borough CCG is seeking expressions of interest from interested practices within Wigan Borough CCG to provide caretaking arrangements for the P92012 (Dr Anis and Anis) practice as a result of the current GMS contract terminating with effect from 31st December 2019.

The arrangement is being offered under the terms of an APMS contract for a minimum period of 3 months from the 1st January 2020 to 31st March 2020, during which time the contract will be part of an Options Appraisal, and a potential subsequent EU Tender procurement exercise.

In the event of a full procurement being initiated it is expected that the caretaker arrangements would be extended until 30th September 2020.

The caretaker practice will be expected to operate from the existing premises based at the Kidglove House, Golborne and TUPE arrangements will apply in respect of the staff currently providing the service.

NHS Wigan Borough CCG is seeking a caretaking provider with the necessary capacity and capability to ensure the delivery of high quality, patient-centred services.

Practice Information

 Practice Population: 4,574  QOF Achievement 18/19: 94%  Full CQC registration  Range of enhanced services  TPP SystmOne clinical system  Approximate Financial Breakdown

Enclosed are a Letter of Intent, which details the APMS contract specification, service expectations and contract value, as well as an Expression of Interest Application form, which interested practices should utilise in order to demonstrate their interest, capability and capacity to deliver the caretaker arrangements.

Expressions of Interest should be addressed to Jonathan Kerry, at the above address or emailed to [email protected] by no later than 6pm on Friday 15th November.

Page 30

Yours sincerely

Jonathan Kerry NHS Wigan Borough CCG Senior Assistant Director of Primary Care

Page 31 This page is intentionally left blank ENGAGEMENT FEEDBACK REPORT

Page 33 Page The Future of High Street Medical Centre (Drs Anis’ Practice) Author: Alexia Mitton, Assistant Director of Communications & Engagement

If you would like help translating this information into another language, or you would like this information in Braille, large print or audio format, please get in touch with us. Call: 01942 482711 or Email: [email protected] Contents Section Page Section 1: Introduction How did we engage with people Section 2: Patient Engagement Feedback Key Themes Option 1: Keep the practice open under new management

Page 34 Page Option 2: Close the practice and support patients to find an alternative practice Improvements and Experiences Further Comments Equality Monitoring Section 3: Stakeholder Feedback Stakeholder Feedback Section 4: Equality Impact Assessment Equality Impact Assessment Section 5: Recommendation and next steps Recommendations Next steps & contact details

Page 1 Section 1: Introduction, background and overview Page 35 Page

Page 2 Introduction

In December 2018 and August 2019, the Care Quality Commission (CQC), who visit all GP practices to check the quality of care, published reports on the quality of care being delivered at the High Street Medical Centre. On both occasions, the practice was rated as ‘Inadequate’ Following this, the CQC issued a ‘Notice of Proposal for Cancellation of Registration’ for the registered manager (Dr Anis) at the practice. For more information on this, please visit the CQC website, www.cqc.org.uk.

Page 36 Page After reading the report in December 2018, we at Wigan Borough Clinical Commissioning Group began our own review in to the care at this practice. As a result of the evidence from our review and the information provided by the CQC, on 24th September 2019, the CCG decided to terminate the contract with Drs Anis and Anis who deliver services within High Street Medical Centre. This decision was made in the best interests of patient safety and care and is part of our plan to make sure that all patients get high quality GP services. This decision means that from 1st January 2020, the partners at High Street Medical Centre, including Drs Anis and Anis, will no longer be responsible for managing the delivery of services at the practice. There are two options available to us: • We can keep the practice open and find a provider to run GP services at the High Street Medical Centre. We would need to find a temporary GP to act as a ‘caretaker’ GP to manage and improve the services delivered at the practice whilst we follow a legally proper process to do this. (continued on next page)

Page 3 Introduction (cont..)

• We can agree to close the practice at a date in the future and support patients to transfer to another practice in the local area. It is likely that this process wouldn’t be finished by 1st January 2020, and so we would again need to find a ‘caretaker’ GP to manage the practice until it closed. We wrote to all adults and parents/guardians of children who are registered at the practice, to inform them of this decision and ask for their feedback on the options. We also contacted all relevant local stakeholders including neighbouring practices and pharmacies. Page 37 Page Using a mixture of online, face-to-face and written communications, we had over 800 contacts. This report summarises what people and wider stakeholders told us. We also gathered lots of insight from people from different protected characteristic groups. We have produced an “Equality Impact Assessment” that is included within this report. The feedback from this engagement work will be shared with the Primary Care Committee to support their decision on the next steps for the future of the practice. Thank you to everyone who took the time to speak to us and share with us their opinions, concerns and experiences.

Page 4 How did we engage with people

APPROX 450 FACE- 327 COMPLETED TO-FACE 97 PHONECALLS Letter to patients SURVEYS Letter to stakeholders CONVERSATIONS Posters in the practice 4 RESPONSES 2 drop-in sessions 18 EMAILS 7 LETTERS FROM

Page 38 Page Local Press – Leigh Journal & Wigan Post STAKEHOLDERS Petition led by Practice Patient Group: 578 signatures

When we contacted people, we gave them different ways to engage with us and share their feedback, including writing to us, completing an online survey, ringing us, emailing us and attending one of two face-to- face drop in sessions. We had an overwhelming response to our letter, with 899 contacts from patients and 5 responses from stakeholders. We returned all the phone calls (except one where the number was incorrect), responded to all the emails and wrote back to all the letters with an address provided. The petition was submitted by the practice on behalf of the Patient Group. We engaged with people from Monday 7th October, when the posters went up in practices, until 29th October when the final phone calls were made.

Page 5 Section 2: Patient Engagement Feedback Page 39 Page

Page 6 Key Themes There were a number of recurring themes that came up throughout the engagement with patients.

Patients were surprised and concerned when they received the letter.

People who used the practice reported positive experiences of the care they had received over many years. 2 3 People who used the practice raised concerns about their experiences and

thepractice the quality of care they had received. Themes about about Themes Page 40 Page Dr Khan and the practice nurses were uniformly praised and thanked. 4

5 The practice should remain open with new doctors.

Dr Khan should be allowed to run the practice – petition of 578 supporting this. 6

Concern for the elderly and vulnerable who it was felt would be most disadvantaged 7 if it closed. Concern that there weren’t enough practices in the area to take on the number of 8 patients and that they would have to travel quite far for GP services.

theoptions Patients didn’t want to use the other GP practices in the building – some reported Themes about about Themes 9 they had previously tried others. Another option should be that everything remain the way it is now. 10

Page 7 Feedback on Option 1: Keeping the practice open with a new

Page 41 Page provider

Page 8 The Response We wanted to know what people thought of the option to keep the practice open with a new provider. This was captured in all of the surveys, but wasn’t included in all of the wider conversations as they were patient- led. This is captured in the below diagrams. Responses: Method Number who Percentage of gave feedback total number 100 Survey 327 100% 80 Happy Phone 39 40% Unsure 60 Email 15 83% Page 42 Page Concerned % 40 Letter 5 71% 20 Face-to-face 0 (conversations 83 83% , not people) NB. Some people contacted us to find out more information or to share their experiences, so not everyone shared their opinion of this option.

How happy would you be to stay at the practice under new management? (survey only, 308 responses)

0 1 2 3 4 5 6 7 8 9 10

Page 9 Comments The comments repeated throughout the feedback were: • The community needs this practice to stay open - a loss to the neighbourhood if the practice closed. • We need to keep a family practice. • It would be unsettling and difficult to go to a new practice, even in the same building – this was raised a number of times with specific mention to people with dementia, autism, learning disabilities and older people. • Don’t want to lose my practice. • Don’t want to have to travel further for my practice. • This practice is on a bus route.

Page 43 Page • All the local GPs are oversubscribed, with one patient saying they had been told by a local practice that they would have to go on a waiting list if they wished to transfer. • Too many patients for the other practices to handle. • Number of people in the area growing with lots of houses being built, so GP capacity needs to grow, not shrink. • Want to keep the relationship with the staff and doctors they know and trust and who understand their medical history. This is raised with particular reference to older people and those more vulnerable. • The practice needs some new, young doctors. • The practice needs modern methods introducing.

In a significant number of responses, the answer was caveated with: • Only if Dr Khan takes this over and the nurses and other staff remain. • Don’t want a corporation, consortium or business to take over, want it to remain a family practice. • Don’t run the practice with locum doctors.

Page 10 Feedback on Option 2: Close the practice and support

Page 44 Page patients to move to an alternative practice

Page 11 The Response We wanted to know what people thought of the option to close the practice. Responses: Method Number who Percentage of gave feedback total number 100 Survey 320 98% 80 Happy 60 Unsure Phone 25 26% 40 Concerned Email 10 56% 20 Letter 5 71%

Page 45 Page 0 Face-to-face % (conversations 44 57% , not people) NB. Some people contacted us to find out more information or to share their experiences, so not everyone shared their opinion of this option. How happy would you be to use a different practice in the building? (survey only, 311 responses)

0 1 2 3 4 5 6 7 8 9 10 How happy would you be to use a different practice in your area? (survey only, 303 responses)

0 1 2 3 4 5 6 7 8 9 10

Page 12 Comments The comments repeated throughout the feedback were: • It is convenient near the town centre, concerned about travelling further, especially those who don’t have transport. • Too many patients for other practices to take – cause oversubscription and make it more difficult to get an appointment. • New houses being built. • People with complex needs will struggle to change and might cause safeguarding issues, e.g. dementia, long term conditions, etc. • It would cause continuity of care issues; these doctors and nurses know our history and needs. • I have been at the practice a long time.

Page 46 Page • Difficult for people with disabilities and on low incomes to travel elsewhere. • It would cause people upset and sadness. • Difficult for the elderly. • Might not get the doctor of our choice. • Not convinced the alternative would be as good. • Drs Anis looked after several generations in our family. • Concerned about the reputations of other GPs in the area. • Tried (an)other GP(s) in the building and moved to this practice. • It would cause anxiety, especially for those who already have mental health issues. • Concerns about the future of the staff.

In a small number of responses, the answer was caveated with: • Would depend where the alternative practice was.

Page 13 Improvements and Experiences:

Page 47 Page We asked people if there was anything they would change and if they had any experiences they would like to share.

Page 2 Page 14 Improvements The comments repeated throughout the feedback were: • Appointments – the system of ringing to get an appointment at 8am in the morning caused people concern and issues • Long waiting times to see the GP of choice or sometimes any GP • New, young GPs needed • More doctors and appointments • System for ordering prescriptions seems to change regularly • Phones and phone lines were mentioned a lot. People couldn’t get through or got through and got an answer phone message. They want more people answering the phones at busy times.

Page 48 Page • Longer appointments; people felt rushed in and out. • Refurbish the building and use it to its full potential, putting more services in. • Complaints system needs review. • Better communication between practice and pharmacy. • The CCG should offer more support. • Patient records need keeping up-to-date and information needs recording accurately at time of consultation. • More evening and weekend appointments. • Better follow up after tests with results. • Continuity of GPs, particularly for people with long term conditions. • More patient input. • More training for staff. • Online consultations.

A lot of people took the opportunity to say that they had had no issues with the practice. People once again asked for Dr Khan to be allowed to run the practice and work more hours.

Page 15 Experiences

Throughout the process, people felt able to share with us very personal stories. Some of these praised the response of the practice and thanked them for saving their lives or the lives of their loved ones. It is important to remember that lots of people are very happy with the care they have received. However, some people also shared experiences with us that were not so positive and were more concerning. Medication and prescribing concerns, specifically, came up regularly throughout the face-to-face discussions. It is not necessary for this report to contain the experiences, positive or negative, that people shared with us. Page 49 Page Those comments that are directly relevant to the future options have been included in the above sections. Please don’t think that any of these comments are being ignored though. Your feedback regarding personal experiences are being reviewed separately to see if any further action needs to be taken, particularly those experiences regarding patient safety, safeguarding and quality of care. Thank you to those people who felt able to share personal stories with us, both positive and negative.

Page 16 Further Comments:

Page 50 Page Any further information people wanted us to take note of.

Page 2 Page 17 Comments There were a number of additional things people wanted us to take note of:

Repeal Decision to Terminate Contract: Some people would prefer us to leave the contract with Dr and Mrs Anis alone and allow them to continue with CCG support. Decision to terminate contract: A number of patients questioned why the decision to terminate the contract had not been taken sooner. Evidence we should consider: People referenced things we needed to consider when making the decision, including the number of houses, the number of Page 51 Page practices and whether they can take on new patients, the ease of access of the practice for people with a disability and wider impact on vulnerable populations. The letter: The letter was both praised and called disgraceful. Whilst people were glad to have been informed and invited to comment, it did also worry people. Reputation: People commented that we were damaging the reputation of Dr and Mrs Anis after their many years of service to the community. Minimise Change and Disruption: There were requests for us to minimise change and disruption for patients. The Future: People want to know what is happening as soon as possible.

Page 18 Equality Monitoring:

Page 52 Page Characteristics of the people filling the survey in

Page 2 Page 19 Characteristics Postcode Age

WN7 75+ WN6 65-74 WN5 55-64 WN4 45-54 WN2 35-44 WA12 % % WA5 25-34 WA3 18-24

Page 53 Page WA1 0-18 0 20 40 60 80 100 0 10 20 30 Gender Gender Identity Same as at Birth

Yes Female

% No %

Male Prefer not to say

0 20 40 60 80 0 20 40 60 80 100

Page 20 Characteristics Ethnicity

White British White Irish White Polish White Gypsy or Irish Traveller Indian Pakistani Chinese White and Black Caribbean % White and Black African White and Asian African Carribean Page 54 Page Arab 0 10 20 30 40 50 60 70 80 90 100

Religion / Faith

Atheist/none Buddhism Christianity Hindism Islam Judaism % Sikhism Prefer not to Say Other 0 10 20 30 40 50 60 70 80

Page 21 Characteristics Relationship Sexual Orientation

Civil Partnership Heterosexual / Straight

Co-habiting Lesbian / Gay Woman Married Bisexual Woman Single % Gay Man % Seperated or Divorced Widowed Bisexual Man

Page 55 Page Prefer not to say Prefer not to say

0 20 40 60 80 0 20 40 60 80 100 Disability Disability

Mobility or physical Yes Communication Mental ill health Impaired memory No Learning % Long term illness % Visual Prefer not to say Hearing Other 0 20 40 60 80 0 20 40 60 80

Page 22 Characteristics British Resident Employment

Student

Yes Retired Employed / Self… % Apprenticeship /… % Unemployed No Prefer not to say

Page 56 Page Other

0 50 100 150 0 10 20 30 40 50 Serving Personnel Carer

Reservist or part time Yes serving person

No Prefer not Family of Serving % to say person or veteran No Prefer not to say Yes Serving in forces or veteran 0 20 40 60 80 100

0 50 100 Page 23 Section 3: Stakeholder Feedback Page 57 Page

Page 24 Stakeholders We contacted the following types of stakeholders to ask for their feedback on the options: • Other Local GP Practices • Local Medical Committee • Local Pharmacies • Local Dentists • Local Opticians Page 58 Page • Local Care Homes

We have had feedback from 5 GP practices and from the Local Medical Committee. All the practices who have responded have indicated that they have capacity to grow their patient list size by taking on more patients and would like to do so. Further comments: One responder indicating that they would support closing the practice as there are 3 other practices within the building and a further 5 within what they consider to be “close proximity”. They comment that this would be a better use of resources at a period of high demand on the NHS. One responder highlighted the need to keep the practice community (LIGA Service Delivery Footprint) stabilised, and is therefore pleased that keeping the practice open remains an option.

Page 25 Section 4: Equality Impact Assessment Page 59 Page

Page 26 Equality Impact Assessment

For each of the options, we explore what the impact might be on people with protected characteristics (P) and three other characteristics we consider important in the Borough. This Equality Impact Assessment supports the Primary Care Committee to understand the impact of their decision on these people with these characteristics. Characteristics:

Page 60 Page Age (P) Ethnicity / Race (P)

Carers Marriage & Civil Partnerships (P) Deprivation Pregnancy & Maternity (P) Disability(P) Religion / Faith (P) Gender (P) Sexuality (P) Gender Reassignment (P) Veterans

Feedback from patients Practice data (limited) & English Indices of Deprivation Sources of data Feedback from previous engagement, including APMS review – from 2016-17, but valid for this patient population as included practice within building /area and proposal similar.

Page 27 Equality Impact Assessment

Option 1: Keep practice open Option 2: Close practice Protected Is there an impact? How can it be Is there an impact? How can it be Characteristic mitigated? mitigated?

Age (P) Older people expressed a Older people were highlighted Transfer those patients preference for this option due to as potentially disadvantaged to practices within the it being better around continuity under this as they are most building or nearer to of care, travel and trust. It is on likely to use the GP practice their home if possible. a bus route and easy to get to and will be most affected. They Page 61 Page on a mobility scooter. are more likely to find it harder to travel, due to mobility issues or no car. They are more likely than the general practice population to have a named GP, so continuity of care will be interrupted. Carers Carers of people with autism, Carers of people with autism, Transfer those patients children, older members of the children, older family members to practices within the family and dementia preferred and dementia raised that this building to minimise this as an option due to it being would cause the people they impact. better for the people they care care for considerable distress for. and potentially set back their Work closely with these illness. Some agreed this could patients to help them be mitigated if a practice in the choose the best same building was available to practice for their needs. them, but this would still interrupt relationships and continuity of care The travel for carers with limited time, could cause issues for attendance. Page 28 Equality Impact Assessment

Option 1: Keep practice open Option 2: Close practice Protected Is there an impact? How can it be Is there an impact? How can it be Characteristic mitigated? mitigated?

Deprivation No known impact The additional cost of travel to Transfer those patients an alternative practice was to practices within the mentioned for people on low building or nearer to incomes. The practice is their home if possible amongst the 40% most Page 62 Page deprived in the country. Disability (P) People with disabilities, People with disabilities, Work closely with these particularly mental ill health, particularly mental ill health, patients to help them long term conditions and long term conditions and choose the best mobility issues highlighted that mobility issues were concerned practice for their needs. this was a better option for that changing practice and them. It is on a bus route and travelling to a new practice Transfer those patients easy to get to on a mobility could be difficult for them, to practices within the scooter. interrupt continuity of care and building or nearer to exacerbate illnesses such as their home if possible anxiety/depression. Autism and dementia was raised several times with concerns that it will cause them distress. Gender (P) Under current staffing levels The new provider Local practices have both male this would leave the practice would need to consider and female GPs, so there with only 1 female GP, which that both male and should be no impact based on could be difficult for men female GPs may need gender. requiring a male GP or to be made available. chaperone. Page 29 Equality Impact Assessment

Option 1: Keep practice open Option 2: Close practice Protected Is there an impact? How can it be Is there an impact? How can it be Characteristic mitigated? mitigated?

Gender This is likely to be the best People going through or who Work closely with these Reassignment (P) option for people going through have been through gender patients to help them or who have gone through reassignment are more likely to choose the best gender reassignment, due to benefit from continuity of care practice for their needs. minimising disruption. and experience significant Page 63 Page mental ill health. It is possible that this could be exacerbated by changing practice. Ethnicity/ Race (P) Under current staffing levels, The new provider Local practices have both male this would leave the practice would need to consider and female GPs, so there with only 1 female GP, which that both male and should be no impact based on could be difficult for men of female GPs may need race or ethnicity. some cultures who can’t be to be made available. examined by a female outside the family. Marriage & Civil No known impact. No known impact. Partnerships (P) Pregnancy & No known impact. Pregnant women have certain Carefully manage the Maternity (P) appointments at certain times transfer of these and this may be disrupted by patients. the transfer.

Page 30 Equality Impact Assessment

Option 1: Keep practice open Option 2: Close practice Protected Is there an impact? How can it be Is there an impact? How can it be Characteristic mitigated? mitigated?

Religion/ Faith (P) Under current staffing levels, The new provider Local practices have both male this would leave the practice would need to ensure and female GPs, so there with only 1 female GP, which that both male and should be no impact based on could be difficult for men of female GPs are religion or faith. some cultures who can’t be available. Page 64 Page examined by a female outside the family. Sexuality (P) No known impact. Lesbian, Gay, Bisexual, Work closely with these Transgender and Questioning patients to help them people are more likely to suffer choose the best from mental ill health. This practice for their needs. could possibly be exacerbated by changing practice. Veterans No known impact. Veterans are more likely to Work closely with these suffer from mental ill health. patients to help them This could possibly be choose the best exacerbated by changing practice for their needs. practice.

Page 31 Section 5: Recommendations & Next Steps Page 65 Page

Page 32 Recommendations

On the back of this report, it is recommended that the primary care committee carefully reviews the feedback, with particular reference to the Equality Impact Assessment and the feedback regarding the two options. It was requested by some patients, but we weren’t provided with any overriding information that could be deemed as requiring a full review of the process so far or any decisions taken, and nor

Page 66 Page were we provided with any new options to consider. It would be helpful to publish further information on the reason the decision to terminate the contract to help patients understand. Once the decision has been made, it is recommended that further engagement work is done with patients to help them understand and be involved in the next steps. It is also recommended that further work be done to examine the experiences that have been shared with the CCG and action take as appropriate.

Page 33 Next steps & Contact Details

This report will be shared with the Primary Care Committee to support them to make a decision on the future of the practice. It will also be published online and we will share it with our local patient groups / engagement membership. After the decision is made on the future of the practice, we will write again to patients at the practice to explain what the decision means and what will happen next.

Page 67 Page If you have any questions or if you would like the report in a different format please don’t hesitate to contact us:

Call: 01942 482711

Email: [email protected]

Website: www.wiganboroughccg.nhs.uk

Facebook: Wigan Borough CCG

Twitter: @wiganboroughccg

Post: FREEPOST RTRA-BXKR-CTTT, Shape Your NHS, Wigan Borough CCG, Wigan Life Centre, College Avenue, Wigan, WN1 1NJ

Page 34 This page is intentionally left blank MEETING: Primary Care Commissioning Committee Item Number: 6

DATE: 5th November 2019

REPORT TITLE: Options Appraisal

The proposed merger of Seven Brooks Medical Practice (P92652) with Dr KK Chan and Partners (P92042)

2. Commissioning high quality services, which CORPORATE OBJECTIVE reflect the population’s needs, delivering good ADDRESSED: clinical outcomes and patient experience within the resources available

REPORT AUTHOR: Rob Wilson – Assistant Director of Primary Care

Jonathan Kerry – Senior Assistant Director of Primary Care

Jonathan Kerry – Senior Assistant Director of PRESENTED BY: Primary Care

RECOMMENDATIONS/DECISION For Decision on preferred option REQUIRED:

Page 69 EXECUTIVE SUMMARY

On the 2nd October 2019 Wigan Borough CCG received a formal application from Dr KK Chan & Partners (P92042) to merge with Seven Brooks Medical Practice (P92652).

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

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

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

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

FURTHER ACTION REQUIRED: None

Page 70 Primary Care Commissioning Options Appraisal

The proposed merger of Seven Brooks Medical Practice (P92652) with

Dr KK Chan and Partners (P92042)

1. Introduction

1.1. On the 2nd October 2019 Wigan Borough CCG received a formal application from Dr KK Chan & Partners (P92042) to merge with Seven Brooks Medical Practice (P92652).

1.2. The two surgeries are located in the same building, 21 Church Street, Atherton, M46 9DE.

1.3. Dr KK Chan and Partners has a second location, Elmfield Surgery, Ormerod House - Atherton Health Centre, Nelson Street, Atherton, M46 0LE. Ormerod House, Atherton is 0.7 miles from 21 Church Street, Atherton.

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

1.5. The underlying principle for the PCCC is to consider when any such proposal is made, is what the benefits are for patients and what the financial implications are to the CCG.

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

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

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

1.9. Two options will be reviewed:

 Approve the application and allow the two surgeries to merge.

1 Page 71  Reject the application meaning that the primary medical services continue under two contracts.

2. Background

2.1. Initial discussions regarding the potential merger of contact between Dr KK Chan & Partners and Seven Brooks Medical Practice were discussed with the CCG as a result of actions that arose from the Contract Management meetings with Seven Brooks Medical Practice.

2.2. The contractors stated the following reasons for looking at a potential merger:

 To protect patient’s experience of primary care and develop improved access to services whilst absorbing projected growth.  To ensure the sustainability of a larger practice whilst protecting the values of traditional general practice in the changing NHS environment.  The merged practices will provide economy of scale and stability for both sites that will allow investment in front line services.

2.3. In accordance with the guidelines set out in the Primary Medical Services policy book with regards to the merger of two practices, the Primary Care Team from the CCG and the contract holders explored the options available to them. The options were:

 Merger of the two contracts  Retain the existing two contracts

2.4. Following a series of meetings with the CCG, the contractor decided to progress the application to merge the contracts.

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

2.6. GPs and their teams are responding to pressures by forming new organisations to allow care provision at greater scale meaning fundamental changes to the organisation and delivery of general practice and primary care become necessary, including the linking together of practices in federations, networks or merged partnerships, in order to increase the scale.

2 Page 72 2.7. The strategic direction for primary care within the Borough, as detailed in the Locality Plan ‘Further Faster Towards 2020’ sets out the vision for greater collaboration between general practice and other providers utilising a neighbourhood type model, whereby practices are grouped into Primary Care Networks representing populations of around 30,000 to 50,000.

2.8. Furthermore, the strategic direction for Primary Care within the Borough is for patients to have access to the very best primary medical services delivered from premises that are of the required standards.

2.9. Whist it was the contractor that initiated the surgery merger the CCG has a statutory duty to ensure that patient voices are taken into account when making and significant changes to services.

2.10. The CCG Communications and Engagement Team ensured that due process was followed in an appropriate and proportionate manor and in accordance with section 13Q of the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012).

2.11. Engagement work was conducted by the practice to obtain initial views which consisted of meeting with the Patient Participation Group of Dr KK Chan & Partners and interested patients from 7 Brooks Surgery.

2.12. The practice, with support from the CCG, then undertook a period of active patient engagement during May and June of 2019, the key points from this engagement are discussed later in this report.

2.13. During the 4 weeks engagements over 138 contacts were recorded, a summary of the findings can be viewed in Section 11.

2.14. On the 30th July 2019, Greater Manchester Health & Social Care Partnership (GMHSCP) notified local stakeholders with regards to the received application. The purpose of this was to attain stakeholder responses on the proposed merger; a summary is highlighted in Section 11.

3. Demographics of Atherton

3.1. The Office of National Statistics Subnational Population Estimates for 2017 indicates that there are 15,023 patients living in the Atherton electoral ward, which represents 4.6% of the total Wigan resident population of 323,060. Atherton is made up of approximately 50% females and 50% males. 16.7% of residents in Atherton are aged 65+ below the Wigan average of 17.6%

3.2. With 15,023 residents living in Atherton electoral ward and the combined practice population of the two practices is 10,110 this would represent roughly 67% of the population of Atherton if all the registered patients were resident within Atherton.

3 Page 73 3.3. There are currently six GP contractors within a one mile radius of Atherton town centre. The total registered list size of these six practices is 24,919 therefore the proposed combination of the two practices would represent roughly 40% of the registered population.

3.4. The registered populations by postcode are shown in Appendix 1 and highlight the wider catchment area of these two practices.

3.5. A third of Atherton’s communities are ranked within the top 10% most deprived in England. These include the communities of Hag Fold (North, South, East and West) and Westleigh East.

3.6. 60% of residents either own their homes outright or have a mortgage, 26% of households live in social rented accommodation.

3.7. Atherton has its own train station and can access Manchester and Bolton direct. Atherton can also access by bus, Leigh and Bolton.

KK Chan

Seven Brooks Medical Practice

1.Atherton Library 2.Ormerod House 3.Seven Brooks Medical Centre 4.Hatikakoty 5.Atherton St. George's CE Primary School 6.St Richard's Catholic Primary School, Atherton 7.Meadowbank Primary & Nursery School 8.Parklee Community School 9.Chowbent Primary School 10.St Philip's CE Primary School, Atherton 11.St Michael's CE Primary School, Howe

4 Page 74 Bridge 12.Atherton Community School 13.New Greenhall School 14.Howe Bridge Sports Centre 15.Atherton Life Centre 16.Boots The Chemists Limited 17.Cohens Pharmacy Ltd 18.Lloyds Pharmacy 19.Lloyds Pharmacy 20.Atherton Children's Centre 21.Green Grass Centre 22.Hag Fold Community Centre 23.Chowbent Church & Church Hall 24.Formby Hall 25.Atherton Parish Church 26.Trussell Trust

3.8. Figure 1 highlights a map of Atherton with the location of both the contractors’ surgeries.

Practice Profiles

4. Access, Capacity and Choice

4.1. One Clinical Partner holds the GMS contract for Dr KK Chan & Partners, based at Seven Brooks Medical Centre and Elmfield Surgery. The practice operates with two salaried GP’s and two Advanced Nurse Practitioners.

4.2. Dr KK Chan & Partners practice is well-run receiving a ‘good’ rating in all of the domains in their last CQC inspection in August 2018.

4.3. Seven Brooks Medical Practice has not had a recently CQC inspection and the new registration occurred in December 2018.

4.4. The practice list sizes as at 1st July 2019 were 6,179 for Dr KK Chan & Partners and 3,931 for Seven Brooks Medical Practice.

4.5. Figure two highlights the practice boundary for the contractor’s two surgeries, the map overlays the location of the practices registered list. There is no proposed change to the inner or outer boundaries of the combined list.

5 Page 75 Figure 2- The contractors practice boundary with the overlaid registered patients residential locations

4.6. Table 1 highlights the accessibility of services for the both locations. Seven Brooks Medical Practice only sees patient from the Church Street location. Disability access, practices within a one mile radius, other practices where the contractors registered list can register, opening hours and transport links are all highlighted.

Dr K K Chan and Partners Elmfield Surgery & Seven Brooks Medial Practice Nelson Street 21 Church Street Atherton Atherton M46 0LE M46 9DE  Disabled Parking  Disabled Parking Disability Access  Step free access  Step free access  Disabled WC  Disabled WC  Wheel chair on site

P92626 Atrey P92626 Atrey Practices within 1 P92635 Vasanth P92635 Vasanth mile radius P92633 Beefold Lane Surgery P92633 Beefold Lane Surgery Y02321 Nelson St Surgery Y02321 Nelson St Surgery

Practice boundaries P92626 Atrey 0.7 miles that includes the P92635 Vasanth 0.7 miles branch surgery’s P92633 Beefold Lane Surgery 0.7 miles location (where Y02321 Nelson St Surgery 0.7 miles P92033 CP Khatri 1.9 miles patients can P92028 Dr Shah 1.9 miles hypothetically re- P82015 The Unsworth Group 2.5 miles register if they P92637 Astley General Practice 2.4 miles choose to do so) P92035 Lilford Park Surgery 2.9 miles P92607 Grasmere Surgery 2.9 miles P92615 Esa Surgery Ltd 2.9 miles P92623 Khaing 2.9 miles P92029 West Leigh Medical Practice 3.2 mile

Monday to Friday 8.00 am – 6.30 pm Monday to Friday 8:00 am – 6:30 Opening Hours pm Extended access – early morning Wednesday Full access to Atherton bus links within 2 buses to choose from every 30 Transport Links walking. minutes that goes to (bus stops) Atherton.

Table 1- Accessibility, Disability, Location, Opening Hours, Transport Links and Patient Choice.

6 Page 76 4.7. The disabled access that is available at both sites includes parking, step free access, disabled W/C and access to a wheelchair on site.

4.8. The four practices within a one mile radius of both sites, Dr Vasanth, Beefold Lane Surgery, Meadowview and Nelson Street Surgery all of which have open lists. There was no indication as part of the patient engagement that patient’s would want to move if the practices merged but there is adequate choice should it arise.

4.9. There is a variety of patient choice available to the contractors registered list in its entirety. There are fourteen practices that patients from the contractors list could register with (practice boundary’s overlay, Table 1). There are currently no closed practice lists within the Borough.

4.10. A breakdown of both the practice opening hours for the two sites can be viewed in Table 1. Both sites are open between 8.00 am to 6.30pm Monday to Friday. Only the Seven Brooks Medical Centre (Church Street) location offers extended access (early openings) on Wednesday morning. Both Dr KK Chan & Partners and Seven Brooks Medical Practice have aligned there extended access times to allow both practices to deliver with support from Dr KK Chan.

5. Services and Staffing

5.1. The staffing mix and availability of appointments are integral to the delivery of primary medical services, critical to meeting the needs of patients. Table two highlights the number of available face to face appointments during a typical week by skill mix at both sites.

5.2. Quality and Outcomes Frame (QOF) attainment in 2018/19 was 543 out of a possible 559 (97% achievement) for Dr KK Chan & Partners, for Seven Brooks Medical Practice it was 382 (68% achievement).

5.3. In 2019/20 the two practices signed up to deliver the same additional enhanced services with Dr KK Chan & Partners supporting Seven Brooks Medical Practice in their delivery. Table 2 highlights which additional services are delivered.

Appointments and additional services signed up to deliver in 2019/20 KK Chan 7 Brooks GP average appointments per week 230 250 ANP average appointments per week 170 0 Practice nurse average appointments per week 94 67 Health Care Assistant average appointments per week 60 0 Telephone Consultations Yes Yes Enhanced Services Extended Hours DES Yes Yes Learning Disability DES Yes Yes

7 Page 77 Childhood Flu Yes Yes Men ACWY (age 18) Yes Yes Men ACYW fresher Yes Yes Men B Infants Yes Yes Pertussis Pregnant Women Yes Yes Seasonal Flu Yes Yes Pneumococcal Yes Yes Shingles Catch up Yes Yes Shingles routine Yes Yes Hep b New Born Babies Yes Yes HPV Yes Yes MMR 16 plus Yes Yes Rotavirus Yes Yes Men C completing dose Yes Yes Table 2- List of Additional Enhanced Services being delivered across each Practice and the sites

5.4. Staffing at the two surgeries and the proposed combined can be seen in Table 3. This proposed merge will increase the number of staff and WTE, and enable greater flexibility of the workforce.

KK Chan & Partners Seven Brooks Medical Church Street and Church Street and Practice Ormerod House Ormerod House Church Street

Current Provision – Current Provision – Merged Practice Practice 1 Practice 2

Number of GPs and Dr K K Chan 9 Sessions/ Dr G Gangully 9 Dr K K Chan 9 Sessions/ clinical sessions Partner Sessions/ Partner Partner (provide breakdown) Dr M Malook 6 Sessions/ Dr N Choudry 8 Sessions/ Dr G Gangully 9 Salaried GP Salaried GP Sessions/ Partner Locum 6 sessions Dr N Choudry 8 Sessions/ Salaried GP Dr M Malook 6 Sessions/ Salaried GP New starter 6 sessions November

Number of other Practice Manager Practice Manager practice staff 2 Operation Manager 1 receptionist supervisor 2 x Operation Manager (provide breakdown) 2 Data input clerk 4 receptionist 2 x Data input clerk 1 Secretary 1 Secretary 1 Administrator 2 Senior Receptionist

8 Page 78 1 Senior Receptionist 11 Receptionist 7 Receptionist

Number of hours of Practice Nurse 37.5 hours Practice Nurse 37.5hours Practice Nurse 4 total nursing time hours 110 Practice Nurse 20 hours (provide breakdown) HCA 37.5 HCA 37.5 ANP 3 staff 101 hours ANP 3 staff 101 hours Advert for new ANP 30 hours Advert For new Practice Nurse 37.5 Advert for new HCA

Table 3. shows the current and proposed staffing levels

6. Premises

6.1. 21 Church Street Surgery is a converted house, which is part owned by the contractors and is already shared with Seven Brooks Medical Practice. The site has under gone renovation within the past 12 months to increase the clinical capacity and provide appropriate access to the front of the building.

6.2. Becoming one practice will reduce any potential conflicting demands on clinical space and enable Seven Brooks Medical Practice patients to also be seen in the Ormerod House location (Elmfield Surgery).

7. Future Estates Strategy

7.1. Wigan Borough CCG are actively working with colleagues from Wigan Council as part of the Strategic Estates Group to ensure that the future provision of estate for health and social care services aligns to the ambitions of our Locality Plan.

7.2. As part of this work we are building a picture of potential developments as well as the needs of patients to ensure that the right services are delivered from the right locations as part of a single Wigan Borough Estates Strategy.

7.3. As part of this estates strategy, the CCG and partners will be ensuring that there is estate suitable for the delivery of future services, aligned to local demographic need, population growth and to support the transformation of services aligned to Service Delivery Footprints.

9 Page 79 8. Impact on the Local Pharmacy in Atherton

8.1. If the proposed merger of the contractor’s site was approved there is unlikely to be any impact on the local Pharmacy within Atherton.

9. Contract and Regulation

9.1. There is nothing specifically stipulated within the GMS Contract or Regulations with regard to the Merging of contracts. However, 7.11.5 requires the provider to obtain agreement from the commissioner in relation to changes to the services provided. Therefore agreement must be sought and a variation issued before any changes can be made to contract.

9.2. There are a number of important issues described within this heading that have been addressed within this document

10. Financial Implications

10.1. If permission was granted to merge the surgery’s there would not be any anticipated changes to the cost of the service. The weighted list size is projected to stay the same.

10.2. It is expected that QOF achievement will increase as a result of improvement in working practices and integrated processes, which will be managed within the delegated Primary Care budget.

11. Patient Engagement

11.1. A patient engagement process was undertaken by the practices throughout May and June 2019. The practices discussed the potential merger with:

 Patients  Pharmacies  District Nurses  Midwives  Health Visitors and Community Workers  BOC Community Based Respiratory service  Local Medical Committee  Greater Manchester Shared Services - IT services

11.2. The key points from the public engagement:

 In total there have been 138 face to face contacts and a further 2 written responses.

10 Page 80 Key points around the potential benefits:

 Patients identified a range of benefits to the merger and these were similar between patients of both practices.  Having more choice of doctors and nurses was a more popular comment for patients registered at Seven Brooks Medical Practice.  Some patients with Seven Brooks Medical Practice identified it as a benefit that they would be able to visit either the Church Street or Elmfield Surgery locations in the future which gave them more options.

Key points around concerns:

 Patients had a range of concerns about the merger but they were generally the same between patients of both practices  After availability of appointments, the most common issue raised was around continuity of care.  Some patients with Dr KK Chan & partners raised concern about the impact the merge would have on the quality of clinical care.

12. Options Appraisal

The following options are available:

12.1. Option 1: Decline merger of the two contracts - with this option the application would be rejected and the practices would be required to continue to provide primary medical services from for two separate contracts.

The benefits of this option are:

 The benefits would be minimal as service would continue across both sites.

The dis-benefits of this option are:

 The patients at Seven Brooks Medical Practice would continue to not receive services from the wider health care team.  Staffing the surgeries would remain separate and would restrict the contractor from achieving benefits related to the proposed merger.  Patients at both sites would not receive the enhanced option of accessing services across both locations.  Potential risk with the current management support provided to Seven Brooks Medical Practice by Dr KK Chan & Partners, who may not be able to continue the arrangements longer term, and so the services that have improved at Seven Brooks Medical Practice would not continue.

11 Page 81 12.2. Option 2: Agree to the merger of the two contracts - with this option the application would be approved and the services will be delivered as one contract from both sites.

The benefits of this option are:

 All Patients would benefit from an enhanced staffing and the full range of primary care services currently only available to Dr KK Chan & Partners patients.  Patients from both practices would benefit from being able to be seen on either site which ever was most convenient in both time and location.  The consolidation of back office function would enable economies of scale to redirect some current expenditure towards more front line patient facing services.  There will be minimal impact on neighbouring practices if patients chose to reregister with an alternative practice. No practices have raised concerns.  The risk associated with back office provision to Seven Brooks Medical Practice would be removed.

The dis-benefits of this option are:

 There are no perceived dis-benefits to the proposed merger.

13. Recommendations

13.1. The Primary Care Commissioning Committee are asked to consider the contents of this report and decide the preferred option.

13.2. The Primary Care Team would ask the Committee to consider option 2 as the preferred option subject to the following:

 Practice to confirm the formal merge date and provide a detailed plan for the practice merger.  Practice completes a signed variation as directed by Greater Manchester Health & Social Care partnership  A detailed patient communications plan to be provided by the practice to include the options available to patients with regard to patient choice within the area.  Practice to take mitigating actions in response to any concerns raised during the public consultation.

12 Page 82 Appendix 1 – Postcode maps of KK Chan and Seven Brooks Medical Practice

KK Chan Patient Postcode Map

Seven Brooks Medical Practice Patient Postcode Map

13 Page 83 Appendix 2 - Various documents to support the Options Appraisal

Application received by the CCG to merge the contracts Practice Merger Business p92042.docx

Atherton Equality Impact Assessment

Equality Impact Assessment Template.doc

Map of Future Housing Developments SHLAA and GMSF with SDF compressed.pdf

14 Page 84 Appendix 3 – Engagement Report

15 Page 85 This page is intentionally left blank 7Brooks Medical Practice and Dr KK Chan & partners Proposal to merge the practices

Page 87 Page Engagement Report June 2019

If you would like help translating this information into another language, or you would like this information in Braille, large print or audio format, please get in touch with the practice. Contents

Section Page

Background 2

How did we engage with people? 3

Number of contacts 4

Page 88 Page Summary of results 5

What did people tell us? Potential benefits – results 6 - 7 Concerns – result 8 - 9 Additional comments 10 Patient Participation Group (PPG) meeting 11

Equality Monitoring Information 12 - 15

You Said, We Listened – response from the practice 15 - 17

Next steps 18

Page 1 Background

Between 7th May 2019 and 18th June 2019 we spoke to patients at 7 Brooks Medical Practice and Dr KK Chan & partners about a proposal to merge the practices into one larger practice. This engagement work was supported by the Engagement Team at NHS Wigan Borough Clinical Commissioning Group (CCG) who is responsible for funding the practice.

7Brooks Medical Practice and Dr KK Chan & partners in Atherton currently share the same building on Church Street but run as two separate practices. Dr KK Chan & partners also have a practice in Ormerod House called Page 89 Page Elmfield Surgery. When several key members of staff left 7Brooks Medical Practice last year, Dr KK Chan & partners stepped in to help manage the back office functions. This has been working well and the practices have started to adopt some of the same processes and procedures.

As a next step they are going to apply to formally merge the two practices into one larger practice. This would see them have a combined list size of 10,100.

The aim of the engagement work was to talk to patients about the proposed merger and to gather their feedback about potential benefits or any concerns.

Page 2 How did we engage with people?

We produced an information leaflet and a survey which we used to gather feedback from patients. We undertook a number of online and face to face activities to gather views.

Online activities: • The leaflet and survey was made available on the practice and Wigan Borough Clinical Commissioning Group (CCG) website • The leaflet and survey was sent out to local patient groups via the CCG Engagement Team

Page 90 Page • Links to the leaflet and survey was posted about on CCG social media pages

Face to face activities: • We held 3 drop in sessions across Church Street and Elmfield Surgery • We held a Patient Participation Group (PPG) meeting • Reception handed out the leaflet and surveys to patients

Page 3 Number of contacts

Activity Number Completed surveys: Patients registered with Dr KK Chan & partners 74 Patients registered with 7Brooks Medical Practice 38

Drop in Session/s:

Page 91 Page Church Street 15 Elmfield Surgery 9 Other: Letter 1 Social media comment 1 Total 138

Page 4 Summary of results

In total there were 138 contacts with patients. The comments about potential benefits (103) outweighed those about concerns (78) which suggests more patients were in support with the merger.

Some patients said they could see the benefits of the merger without being specific about why. Patients we spoke to in person at the practices commented that it would be nice to see the practices in Church Street working together with one reception.

The most common issue patients mentioned was the availability of appointments and staff. Those who supported the merger thought it would mean there would be more appointments whilst those who had concerns thought

Page 92 Page there would be less. This is one of the points the practice has responded to within the “you said, we listened” section on pages 15 - 17.

Key points around the potential benefits: Key points around concerns: • Patients identified a range of benefits to the merger • Patients had a range of concerns about the merger and these were similar between patients of both but they were generally the same between patients practices of both practices • Having more choice of doctors and nurses was a • After availability of appointments, the most common more popular comment for patients registered at issue raised was around continuity of care 7Brooks Medical Practice • Some patients with Dr KK Chan & partners raised • Some patients with 7Brooks identified it as a benefit concern about the impact the merge would have on that they would be able to visit Church Street or the quality of clinical care Elmfield Surgery in the future which gives more options

Page 5 Potential Benefits - results

Overall responses

There were 103 different comments relating to benefits of merging the practices. We have put them into the following themes: • Having more appointments / staff available • Getting quicker appointments • Getting a better quality service • Getting more ideas • More choice of doctors and nurses • Reduce running costs of the practice/s • Better working reception / between staff • Having 2 sites to choose from

• 93 Page Being able to offer more services • Non specific comment (e.g. yes will benefit)

0 Better Quicker Reduce More None Better More choice Better working Offer more 2 sites to appointment More ideas running appts/staff specific quality of Dr/Nurse reputation reception/st services choose s costs aff Series1 25 18 9 14 2 14 3 11 1 3 3

Page 6 Responses broken down by practice

7Brooks patients 10 9 8 7 The top 3 themes from patients registered 6 with 7Brooks Medical Practice are: 5 4 1. More choice of doctors and nurses (7) 3 2. Better working reception and between 2 1 staff (6) 0 3. Quicker appointments (5) More Better More choice Better Offer Quicker Reduce 2 sites None Better working More appts/st of reputati more appoint running to specific quality recepti ideas

Page 94 Page aff Dr/Nurs on services ments costs choose on/staff e Series1 49470615023 Dr KK Chan & partners 25

The top 3 themes from patients registered 15

with Dr KK Chan & partners: 10 1. More availability of appointments and staff (21) 5 2. Better working reception and between 0 Better More staff (8) workin Offer Quicke More choice Better Reduce 2 sites None Better g more r More 3. More choice of doctors and nurses (7) appts/s of reputat runnin to specific quality recepti service appoin ideas taff Dr/Nur ion g costs choose on/staf s tments se f Series1 219 5 7 2 8 2 6 1 1 0 Page 7 Concerns - results

Overall responses There were 78 different comments relating to concerns about the merger. We have put them into the following themes: • Impact on the availability of appointments • A patient who has moved from the other practice • Concern about clinical care • Attitude of reception • Concern about the impact on continuity of care and • If they lose any staff because of the merge having to see different clinical staff • If they lose the personal touch if they merge • Concern about there not being enough clinical staff to • If the quality drops because of the merge

Page 95 Page deal with the amount of patients

40 35 30 25 20 15 10 5 0 Availability of Continuity of Not enough Moved from the Attitude of If lose personal Clinical care If lose any staff If lose quality appts. care clinical staff other practice reception touch Series1 37 6 19 2 4 3 1 2 4

Page 8 Responses broken down by practice

7Brooks patients 9 8 7 6 The top 3 themes from patients registered 5 with 7Brooks Medical Practice are: 4 1. Concern about the impact on availability 3 of appointments (8) 2 2. Concern about the impact on continuity 1 of care (6) 0 Not Moved Attitude Availabili If lose 3. If they lose any staff or quality (1 each) Clinical Continuit enough from the of If lose If lose ty of personal care y of care clinical other receptio any staff quality

Page 96 Page appts. touch staff practice n Series1 806000101

Dr KK Chan & partners 35 30 The top 3 themes from patients registered 25 with Dr KK Chan & partners: 20 1. Concern about the impact on availability 15 of appointments (29) 10 2. Concern about the impact on continuity 5 of care (13) 0 Not Moved Attitude 3. Concern about the impact on clinical Availabili If lose Clinical Continuit enough from the of If lose If lose ty of personal care (6) care y of care clinical other receptio any staff quality appts. touch staff practice n Series1 29 6 13 2 4 3 0 2 3 Page 9 Additional comments

These are some of the additional comments that were made relating to the proposed merger: • A small number of patients who responded raised concern about the clinical care at 7Brooks Medical Practice they had either experienced or heard of. There was concern that the quality of care for patients at Dr KK Chan & partners would be negatively affected • Some patients commented frustration about the availability of Dr KK Chan. Dr Chan is very popular and patients like to see him • There were questions about how the appointment system would work across Church Street and Elmfield Surgery

Page 97 Page • Would the practice be able to offer blood tests or more extended hours services in the future? • Some patients commented that it would be nice to see the practices working together again as they did in the past and that the current set up of reception being separate feels silly to some • Some patients commented that it is hard to get an appointment

Page 10 Patient Participation Group (PPG) Meeting

10 people attended the PPG meeting held at Church Street on Monday 10th June 2019.

Overall, the patients were supportive of the practices merging and expressed an interested in helping to communicate the change to patients if it goes ahead.

There were some minor concerns which the practice discussed and addressed at the meeting:

Page 98 Page • Concern about continuity of care particularly if you have a Long Term Condition (LTC) • The number of doctors and nurses that would be available in the practice • How the appointments system would be managed across Church Street and Elmfield Sites

We have included these points within the “you said, we listened” summary at the end of this report so you can see the response from the practice.

24 people who completed the survey said that they would be interested in joining the PPG and they will be contacted by the practice team in due course.

Page 11 Equality Monitoring Information We collected equality monitoring information with the surveys (112 in total)

Age? – 70 answers Gender Identity? - (72 answers) 20 80 18 70 16 14 60 12 50 10 40 8 6 30 4 20 2 10 Page 99 Page 0 Under 18-24 25-34 35-44 45-54 55-64 65-74 75+ 0 18 Yes Didn't want to say Series1 0 2 12 18 18 4 13 3 Series1 70 2

Ethnicity? – 72 answers Gender? - (72 answers) 80 60 70 50 60 50 40 40 30 30 20 20 10 10 0 0 1 Female Male Didn't want to say White British 72 Series1 56 12 4 Page 12 In a relationship?– 71 answers Religion? – 71 answers

60 60

50 50

40 40

30 30

20 20

10 10

0 0 No Yes Didn't want to say Christian Didn't want to say Other Series1 10 53 8 Series1 48 8 15 Page 100 Page

Disability or long term condition? – Sexuality? – 72 answers 72 answers 70 45 40 60 35 50 30 40 25 30 20 20 15 10 10 0 5 Didn't want to Bisexual Lesbian Straight 0 say Yes No Didn't want to say Series1 1 7 1 63 Series1 27 41 4

Page 13 Currently working? – 71 answers In education? – 71 answers

60 70 50 60

40 50 40 30 30 20 20 10 10 0 0 Yes No Didn't want to say Yes No Didn't want to say Series1 4 64 3 Series1 48 21 3 Page 101 Page

Retired? – 71 answers Carer? – 72 answers

60 70

50 60 50 40 40 30 30 20 20 10 10 0 0 Yes No Didn't want to say Yes No Didn't want to say Series1 15 53 3 Series1 8 60 4

Page 14 Currently serving in army, navy or air Veteran?– 71 answers force? – 71 answers

80 70 70 60 60 50 50 40 40 30

Page 102 Page 30 20 20 10 10 0 0 Yes No Didn't want to say Yes No Didn't want to say Series1 1 68 3 Series1 2 66 3

Page 15 You Said, We Listened

You Said We Listened (Feedback from patients) (Response from practice) The majority of patients think the merge is a positive Since October 2018 we have worked together to step and would be beneficial to the patients in some continually improve standards in Dr Ganguly’s Practice way. Some commented that it would be nice to see (7Brooks Medical Practice). Our Management has been the practices working together as they used to in the working with both Practices to ensure a smooth transition. past. It has been 21 years since Sevenbrooks was one Practice and hopefully we can go from strength to strength as once Practice. Page 103 Page Would the merge impact negatively or positively on The merge can only bring positivity to the workforce and the availability of appointments and clinical staff? open up a different range of appointments to the Practice Some patients have reported that the practice is busy population. We are hoping to increase capacity. and it can be difficult to get an appointment. A concern was raised about the quality of clinical care We would like to assure patients that the Practice will and if the standards would be maintained? How would continue to maintain its high standards of care and this will clinical staff be managed across both practices? be managed by the current management team of Dr K K Chan & Partners. This will be done by monitoring including, continuous audits and patient feedback. Some patients would prefer to see the same Ideally as a Practice this is something we would aspire, doctor/nurse for continuity of care, especially if they however we do have sickness, holidays and training to have a Long Term Condition (LTC). contend with so its is not always possible to see the same clinician.

Page 16 You Said, We Listened

You Said We Listened (Feedback from patients) (Response from practice) Would there be enough clinical staff to look after all the We would like to assure patients that the practice will have patients if the practices merge? enough clinical staff. The Practice will have 5 GP’s, 3 Advanced clinical Practitioners, 3 Practice Nurse’s and 2 Health Care Assistants. What changes would happen at Church Street to the The reception will become one reception desk with all the reception if the practice merge? staff working together. Page 104 Page

Concern about losing the “personal touch” if the The will not be an issue as the Reception staff will continue practice becomes bigger to work as before to the same standards and goals under the Management team of Dr K K Chan and Partners. Many patients spoke positively about Dr KK Chan and It is really great to get such positive comments for Dr K K prefer to see him if they can which is difficult. Chan and this has been shared with him. Unfortunately there is only 1 Dr Chan and he does have limited appointments. How would the appointment systems work if the The appointment system will continue as it is now and this merger goes ahead and how would patients be notified will be reviewed continuously to met patient demands. which site to go to (Church Street or Elmfield Surgery) Patients will be informed by reception staff of which site the appointment will be at or in the text reminder. Would it be possible for the practice to offer blood tests Blood test is something the Practice is hoping to provide in or extended hours in the future? the future and the Practice already offers extended hours. Page 17 Next Steps

• The practices will be moving forward with an application to merge the practices • The application will be made to NHS Wigan Borough Clinical Commissioning Group (CCG) and NHS England • This report will be included within the application so the decision makers can see what patients said about the proposal • The practice will also use some of the information within this report to complete an equality analysis to look Page 105 Page at how the change would negatively or positively impact on different protected characteristic groups • A decision will be made by the CCGs Primary Care Commissioning Committee which members of the public are able to attend • Once a decision is made the practices will arrange a Patient Participation Group (PPG) meeting to keep people up to date and review next steps. • If the application is successful members of the PPG will be asked to help communicate the change to patients within the practice.

If you have any questions at all please do not hesitate to contact or pop into the practice and ask to speak to a member of the practice management team.

Page 18 This page is intentionally left blank MEETING: Primary Care Commissioning Committee Item Number: 7.1

DATE: 5th November 2019

REPORT TITLE: Finance Update

2. Commissioning high quality services, which CORPORATE OBJECTIVE reflect the population’s needs, delivering good ADDRESSED: clinical outcomes and patient experience within the resources available

REPORT AUTHOR: Catherine Johnson

PRESENTED BY: Catherine Johnson

RECOMMENDATIONS/DECISION For Information REQUIRED:

EXECUTIVE SUMMARY

This paper provides an update on the finance position that was as at September 2019 (M06) against the CCG’s Primary Care budgets.

It also provides an update on the Delegated internal audit and includes a copy of a letter that was sent to GP Practices from GM H&SCP regarding premises reimbursements.

FURTHER ACTION REQUIRED: None

Page 107 This page is intentionally left blank Finance Update - Primary Care Commissioning Committee

Tuesday, 5th November 2019

1. Introduction

1.1 This paper provides an update on the financial position that was reported for the six month period ending 30th September 2019 (M06) against the CCG’s Primary Medical Care budgets. This includes the Delegated (Co- Commissioning) budget and also budgets that are funded from the CCG’s allocation e.g. Locally Commissioned Schemes, Primary Care IT and Transformation.

2. Finance Position – September 2019 (M06)

2.1 A summary of the financial position that was reported for the six month period ending 30th September 2019 (M06) is shown in Table 1 below.

YTD YTD YTD Annual Forecast Forecast Budget Actual V a r iance B u dget O utturn V a r ia nce Expenditure Type £k £k £k £k £k £k

Delegated 23,671 22,945 -726 47,900 46,516 -1,384 Primary Care Team 388 270 -118 783 595 -188 Locally Commissioned Schemes 513 492 -21 1,339 1,324 -15 Primary Care IT 910 870 -41 1,921 1,921 0 GP Out of Hours 1,257 1,257 0 2,034 2,034 0 Transformation… Primary Care Standards 2,698 2,645 -54 5,397 5,344 -53 GP Extended Access 1,082 1,076 -6 1,600 1,588 -12 Community Link Workers 231 234 3 435 435 0 Nursing Home ES 277 201 -77 555 478 -77 PCN Infrastructure (£1.50/head) 247 247 1 493 493 0 Clinical Pharmacists 25 38 13 50 38 -12 Surplus 61 14 -47 123 14 -108

Total 31,362 30,290 -1,073 62,629 60,781 -1,848 Table 1. 2019/20 Primary Care Financial Position - As at September 2019 (M06)

2.2 This shows that the Primary Care budgets were underspent by £1,073k in the year to date and were forecast to underspend by £1,848k at the end of the financial year.

2.3 Further information is included in Sections 3 and 4 below.

Page 109 3. Delegated Budget - £726k u/s YTD, £1,384k u/s FOT

3.1 The Delegated budget was expected to underspend by £1,294k at the end of the financial year as a result of the savings achieved following the re- procurement of the APMS contracts, however, as at September, a forecast outturn underspend of £1,384k was reported, as analysed in table 2 below.

Forecast YTD YTD YTD Annual Forecast O u tturn Budget Actual V a r iance B u dget O utturn V a r ia n ce Expenditure Type £k £k £k £k £k £k

GMS 9,519 9,526 7 19,037 19,121 84 PMS 4,538 4,529 -9 9,076 9,086 10 APMS 1,386 1,369 -17 2,771 2,725 -46 QOF 2,264 2,341 77 4,529 4,640 111 DES 1,068 822 -246 2,356 1,999 -357 Premises 1,310 1,349 39 2,621 2,616 -5 Prescribing Drs 80 86 6 255 261 6 Other 383 372 -11 766 724 -42 Void & Subsidy 2,539 2,552 13 5,078 5,104 26 Sub-total (excl. Reserves) 23,087 22,946 -141 46,489 46,276 -213 Contingency 0 0 0 240 240 0 QIPP 648 0 -648 1,294 0 -1,294 Reserves - PRESSURE -62 0 62 -123 0 123 Total (incl. Reserves) 23,673 22,946 -726 47,900 46,516 -1,384 Table 2. Delegated Finance Position - As at September 2019 (M06)

3.2 The GMS, PMS and APMS forecast overspend of £48k net is due to list size growth forecasts being higher than plan (£29k), and APMS contract reconciliations from prior years being under estimated (£19k).

3.3 The QOF forecast overspend is due to actual achievement relating to 2018/19 but paid in 2019/20 being £55k higher than the amount accrued. In addition, the plan for 2019/20 was based on the prior year accrual, therefore the overall pressure for 2019/20 totals £111k.

3.4 The underspend forecast against the DES budget relates to a number of areas including: -

 PCN DES Additional Roles scheme surplus due to budgets being calculated for twelve months, instead of being pro-rated over nine months commencing July (£126k);  PCN DES Additional Roles scheme slippage due to posts not being filled from the July scheme start date (126k);  Minor Surgery DES claims re prior year that were accrued but are no longer expected to materialise (£86k); and  Extended Hours DES slippage re a small number of Practices not delivering the ‘old’ scheme in Quarter 1.

Page 110 3.5 ‘Other’ costs include Seniority, CQC fees, Locum and translation costs. The £42k forecast underspend relates to slippage against CQC fees and Seniority costs.

Capita has recently informed NHSE that a number of Seniority reconciliations are still outstanding, some of which date back to 2011/12. It is not yet clear if any of these will impact the CCG, but Wigan will only be liable to pick up adjustments for the period in which they took on Delegated responsibility (2015/16).

3.6 The £26k Void and Subsidy forecast overspend relates to CHP costs which have increased by more than the 3% inflation that was included in the plan.

The CCG has received details of NHS PS costs for 2019/20, however this has resulted a number of queries and whilst these are being looked into, a breakeven position continues to be reported.

3.7 As part of NHSE’s planning guidance, the CCG had to commit 0.5% of its Delegated budget as a contingency. This has been actioned and totalled £240k.

3.8 The £1,294k QIPP target relates to the recurrent savings that were achieved following the re-procurement of the APMS contracts.

3.9 Funding all of the above budgets resulted in a shortfall against the Delegated allocation of £123k, as reported on the Reserves line at the bottom of the table.

4. Other (Non-Delegated) Primary Care Budgets - £347k u/s YTD, £464k u/s FOT

4.1 As shown in Table1, underspends are forecast against some non-Delegated Primary Care budgets including: -

4.2 Primary Care Team - £188k u/s – due to slippage against the previous team structure. Budgets are expected to be realigned once the CCG’s restructure has been finalised and these savings will be used to contribute to the CCG’s admin savings programme, as mandated by NHSE.

4.3 Primary Care Standards - £53k u/s – due to prior year accruals not being utilised.

4.4 Nursing Home Enhanced Service - £77k – due to prior year accruals not being utilised.

4.5 Primary Care transformation funding uncommitted - £120k.

Page 111 5. Other Issues

5.1 GP Practice Premises Reimbursement letter

GM H&SCP has recently written to all Practices to remind them about a number of premises reimbursement requirements in relation to: -

 The use of GP Practice accommodation for non-GP contract purposes;  Recent contract changes around privately paid-for GP services that fall within the scope of NHS funded Primary Care services;  Maximum levels of service charge that may be charged, and a CCG’s ability to clawback any amounts incorrectly charged;  Different types of rent reimbursement;  Changes to premises agreements / occupation which must be brought to the attention of the CCG; and  Practices having to complete a declaration on a triennial basis.

For information, a copy of the letter is included in Appendix A.

5.2 Delegated Internal Audit (Finance)

As reported at the last Committee meeting, NHSE requested that an internal audit should be performed across all Delegated CCGs to provide information to CCGs that they are discharging NHSE’s statutory primary medical care functions effectively, and in turn to provide aggregate assurance to NHSE and facilitate NHSE’s engagement with CCGs to support improvement.

Wigan’s review of Primary Care Finance took place in July and August, and Mersey Internal Audit Agency’s final report was received in September. This confirmed a high assurance rating on the effectiveness of controls put into place, with no recommendations required.

Page 112 Greater Manchester Health & Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN

T: 0113 825 4796 E-mail: [email protected]

Date: 5th August 2019

Dear Practice

GP Practice Premises Reimbursement

Greater Manchester Health & Social Care Partnership (GMHSCP) manages GP practice premises reimbursement under the terms and conditions of the Premises Costs Directions 2013 (PCD 2013) and other statutory requirements. GMHSCP is writing to you in relation to the following:

1. The use of GP practice accommodation for non-GP contract purposes; 2. The different types of rent reimbursement; and 3. The Declaration form.

1. Use of GP practice accommodation for non-GP contract purposes

Background

The Premises Directions 2004 allowed practices to undertake up to 10% private work from the GP practice premises without having an effect on the level of reimbursement. However, the PCD 2013 removed this flexibility and private work cannot now be undertaken from practice premises without an adjustment to the reimbursement amount being made.

In order that patients benefit from services that support a GP practice being delivered from practice premises the PCD 2013 allows some services outside of the GP contract to be delivered to the patients of the practice from the GP practice premises. Examples of such services include counselling, midwifery, voluntary services (CAB, Welfare Rights, social prescribing sessions). The amount of non GP contract sessions must not be excessive and core contract hours should not be diminished due to the use of the accommodation by other providers. In addition, some GP practices are allowing other providers, such as private therapy providers, ultrasound, etc to utilise the GP practice accommodation. If that is the case then the GP practice must inform the CCG, prior to the other provider occupying the GP practice premises, of the intention to allow such use of the practice accommodation along with details of the occupational charges the practice intends to impose on the other provider.

Issues have been highlighted whereby GP practices are charging the provider a sessional rate for the use of the practice premises. It is acceptable for the practice to charge another provider costs that are not already being reimbursed by the NHS, such as heating, lighting, wear and tear on furniture, consumables, staffing and building management. However, it is considered to be a double benefit where practices are charging other providers a level of occupational cost described

Page 113 as a ‘service charge’ but is at such an amount it can be considered to include costs the practice is already reimbursed for by the NHS. Those costs already reimbursed by the NHS include rent, business rates, clinical waste disposal and water/sewerage standing charge. GP practices must be reminded that NHS reimbursements are based on 24/7 exclusive occupation of the approved GP practice accommodation rather than just for core contract hours.

In accordance with 2019/20 GP contract (Annex D, Part 3), from 2019 it will no longer be possible for any GP provider either directly or via proxy to advertise or host private paid-for GP services that fall within the scope of NHS-funded primary medical services. NHS England will consult in 2019 on expanding this ban on private GP services to other providers of mainly NHS services.

Premises Costs Directions 2013

In accordance with section 48 of the PCD 2013 (extract below), the GMHSCP is required to equitably offset any income received by the GP practice against the reimbursement of premises costs.

“48. Where a contractor’s practice premises, or any part thereof, are or form part of premises that are owned or rented by any person other than the contractor, and that person –

(a) Is required by any agreement (which includes a licence or a lease) to make or makes any contribution towards any recurring premises costs in respect of which the Board is providing financial assistance to the contractor in accordance with the Part; or

(b) Is required by any agreement (which includes a licence or a lease) to pay or pays to the contractor any amount – (i) by way of rent in respect of the practice premises or any part thereof, or (ii) in respect of the running costs of the practice premises, the Board must set off that contribution or that amount, equitably, against the payments made to the contractor pursuant to this Part.”

NHS Property Services (NHS PS) and LIFT/Community Health Partnerships (CHP) apply a daily room usage charge of between £60-£70 plus VAT. Those sessional rates include all services within NHS PS and LIFT/CHP premises, including the items of cost that are reimbursed to GP practices in relation to their core GP contract, reflected in the PCD 2013.

A number of GP Practices are charging similar or higher amounts of ‘service charge’ as LIFT and NHSPS for the same use of their premises. This is not considered appropriate and cannot be justified and, although it is referred to as a service charge, it must include all or part of the PCD 2013 reimbursable expenses and is therefore considered by GMHSCP to be a ‘double’ benefit to the GP practices from NHS funded sources.

Non NHS Commissioned Services

In respect of non NHS commissioned services, the maximum level of service charge that a GP practice is permitted to charge is £60 per day or £30 per 4-hour session, i.e. £7.50 per hour. This is to cover all non-reimbursable expenses such as heating, lighting, reception etc. The maximum level of service charge is fixed for all premise’s types, irrespective of the size and condition of the building/room being rented and irrespective of the number of service providers renting the accommodation that day.

All income generated above the maximum level, will be recovered from the practice in accordance with the PCD 2013. The recovery will be transacted as a deduction from the practices monthly reimbursement payment.

Page 114 Alternatively, your practice may decide to exclude the room rented to the 3rd party from your District Valuer Services (DVS) current market rent (CMR) and business rates assessment, this would be on the basis that the income generated for that room is greater than the expected CMR for that space. Every practice must make that decision prior to the scheduled DVS valuation and this would need to be formally recorded on the CMR in advance of the assessment. However, it is important to highlight that if a practice chooses to exclude a room from the next scheduled valuation, it would be excluded for the full 3-year cycle even if the 3rd party rental arrangement ceases within that time.

NHS Commissioned Services

The same principles apply to NHS commissioned services as to non NHS commissioned services. However, where a practice believes this maximum level is causing a financial disadvantage to the practice, the practice can contact their local CCG for advice.

In exceptional circumstances your CCG may agree to review the £60 daily income threshold. However, this would only be considered on completion of a formal business case, incorporating all evidence in support of your claim. It is strongly advised that you verbally discuss with your CCG prior to making a formal case so it is not a waste of your time.

In advance of permitting NHS commissioned services use of the GP practice premises, the terms of occupancy should be agreed with the CCG and the service. This will avoid potentially putting the practice at a financial disadvantage.

NHS PS and CHP Premises

We are advised by NHS PS and CHP that GP practices housed within their buildings are not permitted to allow other service providers to utilise practice accommodation without first approaching their landlord.

2. Different types of Rent Reimbursement

GMHSCP have recently been made aware of a couple of instances where practices circumstances have changed which has led to a change in the legal interest held in relation to the practice premises. The CCG must be informed of any material change in the legal interest held by the GP practice in relation to its premises as this may affect the CMR reimbursement entitlement for the practice.

As a refresh we would like to draw your attention to the 3 different types of rent reflected in PCD 2013 reimbursement terms that are available to a practice. GMHSCP ask that all GP practices familiarise themselves with the details and requirements of each type of rent and its entitlement.

Actual Rent

This is where the practice holds a formal lease of its premises with an unconnected third-party landlord and the rent passing under the terms and conditions of that lease is the ‘actual rent’ passing.

The terms and conditions of occupation will have been agreed and reflected in the completed lease between the parties. These terms and conditions are considered when the reimbursement rent is assessed by the DVS. The DVS, will consider the rental figure agreed by the parties to the lease agreement at either the commencement of the lease or upon review of the rent during the lease term (The rent is not considered to be reviewed unless there is a fully completed Rent

Page 115 Review Memorandum) but is also required to provide an opinion of rental. The lower of the two rental figures will be reimbursed to the practice in accordance with s32 of the PCD 2013. It is therefore advised that a practice agrees lease terms and conditions that mirror those reflected as part of the PCD 2013 as this will ensure the DVS does not have to adjust his or her opinion of rental value for reimbursement purposes..

The terms of the lease will highlight the responsibilities of the landlord and those of the tenant. It is extremely important that the tenant does not agree terms and conditions that are considered unreasonable and too onerous when entering a lease. The PCD 2013 in relation to the assessment of notional rent (where the premises are owner occupied and no lease exists) reflect the following assumptions:

- A lease term of 15 years (but this is one area that can be altered without too much issue), - Rent reviews every 3 years. - Tenant responsible for internal repairs and decoration only, and - Landlord is responsible for the cost of external repairs and maintenance along with building insurance and must not recharge as service charge.

Ideally, a GP practice, when entering into a lease agreement, should try to include similar main terms and conditions (acknowledging that the length of the lease may differ) as those reflected in the PCD 2013 for the purpose of assessing notional rent. This will reduce the risk of having to adjust the rental for reimbursement purposes.

Where a practice leases its premises from an unconnected third-party landlord but does not have a formal lease in place, it may put the reimbursement at risk as there has to be a formal lease in place or the owner of the premises being a connected party to the GP practice in order that a rental can be reimbursed.

In order to receive reimbursement, practices in receipt of actual rent are required to provide GMHSCP with a copy of the lease and copies of rent invoices from the landlord or proof of payment.

Notional Rent

This is where the owner of the practice premises is connected to the practice or is related to a member of the practice.

Under these circumstances a formal lease could exist, but it would be considered as a not at ‘arm’s length’ agreement. The DVS when assessing the reimbursement rental would consider the terms and conditions of such a lease but would also assess the notional rental value. The lower of the two rental values would then be reimbursed.

If no lease exists, then the DVS would assess the notional rent reflecting the PCD 2013 assumptions, which are noted above.

If a GP practice is considering entering into a sale of its premises and lease back agreement involving a third party it must obtain the support of the CCG to ensure that the premises costs reimbursement is not put at risk. An issue may arise if the landlord decides to increase the rent or levy VAT on the rental, for example. Without prior approval from the CCG to cover any additional costs relating to the leaseback rental the additional cost over and above the original rental will fall to the practice to cover if the CCG is not able to agree the higher figure.

To receive reimbursement, practices in receipt of notional rent are required to complete an electronic CMR form on a triennial basis. The CMR form must be completed and returned in a

Page 116 timely manner to GMHSCP. GMHSCP may choose to inspect the practice premises to ensure the CMR form is completed correctly, so the DVS can be instructed to carry out a rent review.

Cost Rent

This type of reimbursement reflects the payment of mortgage interest on the GP practice self-built premises loan, the payment excludes the cost to purchase the development site itself. The interest is paid at the level reflected in the initial loan. However, if changes are made to the loan arrangement and the interest charged by the lender, then the cost rent must be adjusted accordingly.

Any change to the financial loan arrangements that are not approved by the Commissioner may put the reimbursement at risk.

If the loan is paid off or, if the parties to the initial loan change, then Cost Rent reimbursement will not be available to the practice from that moment. The type of rent reimbursement will then be changed to either notional or actual rent depending upon the circumstances surrounding ownership of the premises.

A practice may choose to change from cost rent reimbursement to notional rent reimbursement at any time, but it is not possible for practice to change back to cost rent reimbursement thereafter.

To receive reimbursement, practices in receipt of cost rent are required to provide confirmation on an annual basis that the loan arrangements have not changed and they are still eligible to receive cost rent reimbursement.

It is the practices responsibility to inform GMHSCP immediately of any change in practice circumstances that would lead to a change in reimbursement entitlement. For example, a change in ownership or reduction in landlord charges.

3. Declaration

Practices will be required to complete a declaration on a triennial basis. This will either be in the form of the electronic Current Market Rent (CMR) form or as a separate declaration form.

The CMR form is completed by practices at the time of an actual rent review where a lease is in place or at the time of the triennial notional rent review where the owner of the premises is connected to the practice.

If the practice is not required to complete a CMR form because the practice is in a Health Centre or is in receipt of cost rent, a separate declaration form will be issued.

Both the CMR form and the separate declaration form require the practice to confirm whether any of the accommodation is used by anyone other than the GP practice in the form of an ‘informal arrangement, sessional arrangement, letting or subletting and if so, state the amount of all income received from the non GP contract provider and provide details of the services to which this income relates. Practices must ensure that the details reflected in the form are fully and truly stated to the best of their knowledge and that any information which GMHSCP may need to calculate the appropriate amount of reimbursement will be made available.

Both the CMR form and the separate declaration form will will draw your attention to the Fraud Act 2006 along with the Bribery and Corruption Act 2010 and the contents therein. It will also highlight the fact that if any details are subsequently found to be false or misleading then the practice will be liable to be investigated and dependent upon the findings civil or professional sanctions and/or additionally criminal proceedings may follow.

Page 117 Failure to complete the declaration will result in the suspension of rent payments.

Thank you for your cooperation with this matter.

Yours Sincerely

Geoff Jackson Finance Manager Greater Manchester Health & Social Care Partnership

Page 118 MEETING: Primary Care Commissioning Committee Item Number: 7.2

DATE: 5th November 2019

Primary Care Co-Commissioning Programme REPORT TITLE: Update November 2019

1. Supporting our population to stay healthy and CORPORATE OBJECTIVE live longer in all areas of the Borough ADDRESSED: 2. Commissioning high quality services, which reflect the population's needs, delivering good clinical outcomes and patient experience within the resources available

3. Function as an effective commissioning organisation that puts the patient first.

4. Function as an organisation that puts patients first

5. Functioning as an organisation that consistently delivers its statutory duties and participates fully in Greater Manchester Devolution

REPORT AUTHOR: Aaron Barker (Head of Primary Care Commissioning)

PRESENTED BY: Aaron Barker (Head of Primary Care Commissioning)

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

Page 119 EXECUTIVE SUMMARY

The report outlines the CCGs progress of the Primary Care Co-Commissioning Programme during 2019/20.

During September and October 2019 the focus of work has been to continue to engage and work through the new GP Contract with practices.

The team have also been working with Drs Anis & Anis (P92012) practice and their patients to determine the best course of action following the Committees decision to terminate the contract. Patient facing events have taken place and all of the information gathered will be fed into the options appraisal that the Committee will be reviewing.

FURTHER ACTION REQUIRED: None

Page 120 Primary Care

GP Co-Commissioning Programme November 2019

Page 121 Primary Care Co-commissioning Programme Highlight Report

Programme Lead/s Debbie Szwandt, Assistant Director Primary Care – Primary Care Commissioning

Aaron Barker, Head of Primary Care Commissioning

Ann Gough, Primary Care Manager, GM Health & Social Care Partnership

Senior Responsible Jonathan Kerry, Senior Assistant Director of Primary Care Officer

Period September - October 2019

Objectives

1 Implement the PCN Direct Enhanced Service Contract.

2 Implementation of the Primary Care Commissioning Intentions for 2019/20

Contractual Updates

Borough Wide There has been seven changes to the partnership workforce & SDF’s during the reporting period:

P92016-Two New GP Partners (Hindley PCN)

P92011-GP Partner left and New GP Partner Joined (Wigan PCN)

P92623-GP Retirement (Leigh PCN)

P92007-GP Partner Joined (Leigh PCN)

P92642-Salaried GP to Partner (SWAN PCN)

P92038- GP Partner Joined (SWAN PCN)

P92029- 24 hr Retirement Partner (Leigh PCN)

Primary Care As part of the development of Primary Care Networks (PCNs), Networks (PCN) Greater Manchester is in receipt of £2.3m funding to support the Development development of PCNs. National guidance has been developed to sit alongside the funds and sets out that the resource this year should be used for two purposes:

(a) PCN development

(b) Clinical Director development

Funding can be used to free up clinical time as well as to commission support from a range of organisations. The funding Page 122 3

cannot be used for anything already covered in the contract or work that is not related to PCNs. It has been agreed that GM will retain £1m to develop training that can be delivered at a GM level and £1.3m will be cascaded to each localities PCNs. PCNs have submitted high level proposals to GM to obtain their funding which will be reviewed at the end of October 2019.

Further updates will be brought to the Committee.

PCN Extended By the 1st July 2019 PCN submitted and started to deliver a Hours DES combination of 9,844 additional appointments (30 minutes per 1000 population) across the borough.. This is outside Core hours

Previously this have been a practice based service, however responsibility has now shifted to each of the PCNs.

WBCCG Primary Care Team will be seeking assurances that the additional appointments are being delivered by each of the PCNs, this will be reported back to members at the next Committee meeting.

Winter The Urgent Care Board has now agreed the funding for additional Resilience: GP winter appointments. Additional GP appointments. There will be an additional 16,448 appointments delivered across General Practice between October 2019 and March 2020 to support winter pressures.

All practices have now signed up to deliver the additional appointments to support winter resilience.

Merger P92042 and P92652 have submitted a formal request to merge. Application A detailed options appraisal will be presented to the Committee today.

Quality and The objective of the Quality and Outcomes Framework (QOF) is to Outcomes improve the quality of care patients are given by rewarding Framework practices for the quality of care they provide to their patients, 2018/19 based on a number of indicators across a range of key areas of clinical care and public health.

The 2018/19 QOF results have indicated that all but two practices achieved above 90% of the total points available (97% CCG average). Two practices, P92652 Seven Brooks Practice (68.3%) and P92031 Ullah (80.6%) failed to hit the 85% minimum target.

Further work will be carried out with these practices in the coming months and a full report based on the latest data will be brought to the next Committee for review.

Page 123 Healthy People, Healthy Place 4

Contract The CQC revisited P92012 (Dr Anis and Anis) on 30th May 2019 Termination and the outcome of the visit was published on the Monday 5th August 2019. The Practice received a further overall rating of ‘inadequate’.

Based on the practice having had previous opportunities to improve and not doing so, the CQC are also moving to cancel the provider’s registration of the registered manager via the non-urgent route thus giving the provider 28 days to appeal the decision. If no appeals are received within the 28 days the CQC will progress with the notice of removal. This process could take a further 28 days to progress the notice and at this point the contract will terminate.

Wigan Borough CCG has also been running a separate contract compliance process with the contractor due to them not being contractual compliant within a number of areas (outstanding remedial notices).

At the September PCCC the Committee moved to terminate the provider’s contract due to non-compliance (the provider was given three attempts to remedy this). The contract will therefore terminate on the 31st December 2019.

A detailed options appraisal is being presented to the Committee today which will outline a series of recommendations for consideration.

Further updates will be brought to the Committee regarding this contract.

APMS quarterly The final quarter 4 contract review of the 6 APMS contracts first contract year of operation was carried out on the 19th November 2019. monitoring The provider as made a range of significant improvements and a case study will be presented to the next PCCC meeting.

The APMS contract review management will now be included in the planning for all GP contract management from 2020-2021.

GP-Annual The next General Practice Annual Electronic Declaration (eDEC) Electronic for 2018/19 has been finalised and will be opened to receive Declaration submissions for general practice over a six week period between November and December 2019.

Outcomes

O1 Compliance with NHS England’s Single Operating Framework; Primary Care Policy and Guidance manual

O2 Implement Annual Contract Review 1-3 year rolling Programme.

O3 Implement the new five year GP contract.

Page 124 Healthy People, Healthy Place 5

Risk Register – Risk Description

R1 Failure to manage Primary Care Co-Commissioning could lead to GP practices not delivering the optimum services for the resources available.

R2 Failure of the practice that has been placed into special measures to improve in the areas set out by the CQC. The practice could lose their CQC registration and would no longer be able to deliver the primary medical services contract.

Page 125 Healthy People, Healthy Place This page is intentionally left blank MEETING: Primary Care Commissioning Committee Item Number: 7.3

DATE: 05 November 2019

REPORT TITLE: Primary Care Quality Improvement Programme Update November 2019

3. Function as an effective commissioning organisation that puts the patient first.

4. Function as an organisation that puts patients first

5. Functioning as an organisation that consistently delivers its statutory duties and participates fully in Greater Manchester Devolution

REPORT AUTHOR: Debbie Szwandt, Assistant Director Primary Care

Alison Foster, Lead Nurse for Quality, Primary Care

Debbie Szwandt, Assistant Director Primary Care PRESENTED BY:

RECOMMENDATIONS/DECISION The Committee is asked to receive the report and REQUIRED: support the continued implementation and development of the primary care quality improvement programme.

Page 127 EXECUTIVE SUMMARY

Care Quality Commission (CQC)

Dr Anis & Anis (P92012) remain in special measures, following the comprehensive re- inspection visit on the 30th May 2019, the CQC published findings on the 5th August 2019 and the practice received a second Inadequate rating.

In addition, the CQC have also published the enforcement decision, which is a notice of proposal for cancellation of registration and are continuing to manage this process.

There has also been two other CQC reports published in this report period relating specifically to Wigan Borough Locality Practices; Bee Fold Lane Surgery (P92633) received an overall rating of outstanding in August 2019 and Leigh Sports Village (Y02886) received an overall rating of good in September 2019, with an outstanding in the well led domain.

This now means WBCCG has five practices rated as Outstanding by CQC across four Primary Care Networks (PCN)

FURTHER ACTION REQUIRED: None

Page 128 Primary Care GP Quality Improvement Programme Update November 2019

Page 129 Primary Care Support Programme Highlight Report

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

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

Senior Responsible Linda Scott (LS), Director of Primary care Officer Sally Forshaw (SF), Director of Nursing and Quality

Reporting Period 21st August 2019 – 16th October 2019

Aim

The aim of the Primary Care Quality Improvement programme is to ensure the CCG carries out its statutory duty to “continuously improve” the quality of Primary Care, General Practice

Objectives

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

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

O3 Support the implementation of the Primary Care Enhanced Service Specification 2019/20 (formerly Primary Care Standards), including GM Primary Care Standards & local priorities.

Milestones

M1 Quarter 2 – 2019/20 PCAF review Delayed

M2 Completion CQC improvement plan High Street Medical Centre following second inadequate rating Completed August 2019

M3 Completion of patient and stakeholder engagement to Completed support High Street Medical Centre Options appraisal

M4 Review and follow up GP Survey 2019 Delayed

Programme Updates within the Period

Care Quality There have been two CQC Inspection reports published in the Commission reporting period relating specifically to Wigan Borough Locality (CQC) Practices.

A summarised position has been included for reference in Appendix 1 and WBCCG dashboard is in Appendix 2.

Bee Fold Lane Surgery (P92633) received an overall rating of

Page 130 3

Care Quality outstanding in August 2019. Commission (CQC) This now means WBCCG has five practices rated as Outstanding by CQC across four Primary Care Networks (PCN)

Leigh Sports Village (Y02886) received an overall rating of good in September 2019, with an outstanding in the well led domain.

This is one of the six APMS contracts procured in August 2018 and is an improvement from the previous rating of Good in the well led domain.

One practice, Dr Anis (P92012), remains in special measures following the comprehensive re-inspection visit on the 30th May 2019, the CQC published findings on the 5th August 2019 and the practice received a second Inadequate rating, the first Inadequate rating was published in December 2018.

In addition, the CQC have also published the enforcement decision, which is a notice of proposal for cancellation of registration and are continuing to manage this process.

The following quality improvement actions have been completed as a response to the CQC Inadequate rating in the last reporting period.

1. The CQC improvement plan against the safety domain from the August report has been developed, led by the Head of Primary Care Commissioning with; 3 GPs, medicines management, quality and data quality.

2. Formal Contract review meetings have continued and included the monitoring of the CQC Improvement plan. The last meeting was held on the 4th October 2019 and the next was scheduled for the 18th October 2019 following the engagement drop in sessions.

3. The last report to Greater Manchester Quality Board was completed in September 2019.

Page 131 Healthy People, Healthy Place 4

Table 1. Wigan Borough CCG GP practice CQC rating at 16th Care Quality October 2019 Commission (CQC) CQC overall rating Number of GP % of GP practices practices Outstanding 5 8.3 Good 54 90 Requires 0 0 Improvement Inadequate 1 1.7

The quarterly meeting with the CQC Lead inspector was completed on the 10th October 2019.

30 annual regulatory reviews have been carried out, with three practices being identified for an inspection visit in 2019/20.

The CQC lead inspector is scheduled to provide a development session at WBCCG Practice Manager Conference on the 30th October 2019.

Friends and The latest FFT data (published in October 2019) for August 2019 Family Test identified that in terms of outcomes Wigan have a 91% recommended rate which is above both GM (90%) and National (90%) rates. The recommended rate has been reported consistently at or above 88% for the year to date.

47 out of 60 Practices have submitted FFT data = 78%

22% (13/60) Wigan Borough practices failed to submit in August 2019, which has increased slightly from 20% in May 2019

National GP The results of the National GP survey have been shared with lead survey roles within the Primary Care Network, however analysis and follow up has been delayed due to competing priorities.

The relevant metrics within the Primary Care Assurance Framework has also been delayed and the quarter two review will now be completed in November 2019.

https://www.gp-patient.co.uk/analysistool?trend=0

Lead Nurse for Alison Foster, commenced in post on the 16th September 2019, Quality (Primary 0.6wte. Care) The purpose of Alison’s role is to:

 Provide support and advice on; Quality matters to all practices, CCG contractual quality, CQC compliance and

Page 132 Healthy People, Healthy Place 5

quality peer reviews

 Direct and support the activity of the local Practice Nurse Champions

 Represent the Quality team in Primary Care Group and Forums

Practice Nurse There are now 7 established Practice Nurse Champions in place, Champions one for each Service Delivery Footprint (SDF). (PNC) The Champions continue to raise the profile of nursing in General Practice. They assist in driving improvement in the delivery of care and treatment by providing leadership and support for the professional development of nurses and are supported by the Lead Nurse for Quality.

The PNC’s continue to arrange and facilitate the Practice Nurse Forums and produce a bimonthly newsletter.

Practice Nurse The forum takes place once per month to provide the opportunity Forum for practice nurses to network, receive support and professional educational updates.

August / September 2019 – Immunisation updates

October – Autism and Learning Disability

Practice Nurse A number of practice nurses are trained clinical supervisors and Clinical provide the opportunity for all nurses to access regular group Supervision supervision across the borough.

Outcomes Achieved

O1 Completion CQC improvement plan High Street Medical Centre following second inadequate rating August 2019

O2 Completion of patient and stakeholder engagement to support High Street Medical Centre Options appraisal

Plan for Next Period

1. Monitor implementation of CQC Improvement plan High Street Medical Centre

2. Quarter 2 – 2019/20 PCAF review and plan follow up

3. Review and follow up GP Survey 2019

Page 133 Healthy People, Healthy Place 6

Risk Register

Risk Number Risk Description Rating R1 Failure to implement a Primary Care Assurance Framework could lead to quality issues in GP practices 9 being undetected.

R2 Failure to share and respond to learning lessons will reduce the rate of implementation of Continuous 6 Improvement.

R3 Failure to conduct Patient & staff engagement and respond to feedback will reduce the impact of service 3 development.

Page 134 Healthy People, Healthy Place Appendix 1: CQC Inspection Reports published between 21st August 2019 and 16th October 2019

CQC INSPECTION REPORTS PUBLISHED Q3 - 18/19

Are services Overall rating Date Report Are services Are services Are services responsive to Are services GP Practice for this Published safe? effective? caring? people’s well-led? service? needs? Bee Fold Lane Surgery 30 August 2019 Good Good Outstanding Outstanding Good Outstanding P92633 Inspected 01 August 2019 Leigh Sports Village 27 September 2019 Good Good Good Good Outstanding Good Y02886 Inspected 12 September 2019 Page 135 Page Appendix 2: CQC Inspection Dashboard as at 16th October 2019

Current Practice List Date Last GP Practice SDF CQC

Code Size Site Visit SAFE

Rating CARING WELL-LED EFFECTIVE RESPONSIVE P92001 Medicentre SWAN 5423 22 September 2016 G G G G G G P92005 Dr Saira Zaman SWAN 4119 26 January 2016 G G G G G G P92024 The Chandler Surgery SWAN 4110 10 March 2016 G G G G G G P92034 Bryn Cross Surgery SWAN 5832 04 April 2017 G G G G G G P92642 Marus Bridge Practice SWAN 5208 05 September 2016 O O O O G O P92647 Hawkley Brooke Medical Practice SWAN 3332 11 April 2018 G G G G G G P92653 Shakespeare Surgery SWAN 2981 01 June 2016 G G G G G G P92038 Winstanley Medical Centre SWAN 3109 01 August 2018 G G G G G G Y02378 Bryn Street Surgery SWAN 6088 16 August 2016 G G G G G G P92007 Dr Wong & Partners L 6854 10 January 2018 G G G G G G P92023 Brookmill Medical Centre L 7972 05 April 2019 G G G G G G P92029 Westleigh Medical Centre L 4091 11 May 2017 G G G G G G P92035 Lilford Park Surgery L 3691 25 April 2017 G G G G G G P92607 Grasmere Surgery L 8202 12 April 2017 G G G G G G P92615 Dr Esa (The Avenue) L 2792 14 June 2016 G G G G G G P92621 Premier Health Team L 2779 19 October 2016 O G G G O O P92623 The Avenue Surgery (Dr Khaing) L 1942 05 May 2016 G G G G G G P92602 Foxleigh Family Surgery L 2320 24 October 2017 G G G G G G Y00050 Pennington Park Surgery L 2040 21 February 2017 G G G G G G Y02322 Leigh Family Practice L 7873 20 February 2019 G G G G G G Y02886 Leigh Sports Village L 3496 27 September 2019 G G G G G O P92010 Beech Hill Medical Practice NW 13000 17 May 2016 G G G G G G P92014 Standish Medical Practice NW 11937 06 June 2018 G G G G G G P92015 Aspull Surgery NW 5382 2nd November 2017 G G G G G G P92017 Shevington Surgery NW 12700 20 November 2018 O O G G G O P92003 The Dicconson Group Practice CW 8440 30 August 2016 G G G G G G P92008 Bradshaw Medical Centre CW 8865 27 October 2017 G G G G G G P92011 Sullivan Way Surgery CW 7531 15 November 2018 G G G G G G P92019 Pemberton Surgery CW 9676 22 August 2016 G G G G G G P92021 Newtown Medical Practice CW 6287 14 January 2016 G G G G G G P92026 Longshoot Medical Practice CW 7875 03 March 2016 G G G G G G P92030 Wrightington Street Surgery CW 4288 08 March 2017 G G G G G G P92634 Mesnes View Surgery CW 4360 25 May 2016 G G G G G G Y02885 Marsh Green Medical Practice CW 2735 14 August 2019 O G G O G O P92635 Dr Vasanth and Partners TABA 2433 22 January 2019 G G G G G G P92020 Dr Sivakumar and Dr Gude TABA 4330 27 November 2018 G G G G G G P92028 Elliott Street Surgery TABA 4621 18 December 2018 G G G G G G P92033 The Surgery (Dr CP Khatri) TABA 4670 19 July 2017 G G G G G G P92042 Dr KK Chan & Partners TABA 6179 14 July 2016 G G G G G G P92605 Boothstown Medical Centre TABA 5916 02 December 2016 G G G G G G P92626 Meadowview Surgery (Dr Atrey) TABA 4674 09 October 2017 G G G G G G P92633 Bee Fold Lane Surgery TABA 1973 30 August 2019 O G G O O G

Page 136 P92637 Astley General Practice TABA 2776 23 May 2017 G G G O G G P92646 The Surgery Astley (Dr Vardhan)* TABA 3102 11 October 2016 G G G G G G Y02321 Nelson St & Poplar St Surgery TABA 4568 31 May 2019 G G G G G G P92652 Seven Brooks Medical Practice* TABA 3931 20 September 2017 G G G G G G P92016 Pennygate Medical Centre H 16729 28 April 2016 G G G G G G P92004 Dr Tun & Partners H 8052 31 October 2016 G G G G G G P92006 Dr Ahmad & Partners H 6172 07 December 2017 G G G G G G P92031 Platt House Surgery H 3402 26 April 2018 G G G G G G P92616 Higher Ince Surgery H 3280 20 June 2017 G G G G G G P92620 Lower Ince Surgery H 3944 31 July 2017 G G G G G G Y02274 Claire House & Rivington Surgery H 3490 25 April 2019 G G G G G G P92002 Braithwaite Surgery Li 5159 06 June 2017 G G G G G G P92012 Dr Anis & Anis Li 4574 5th August 2019 I I I RI RI I P92041 Ashton Medical Centre Li 7543 26 September 2017 G G G G G G P92630 Dr M Pal Li 2718 08 January 2019 G G G G G G P92639 Dr Syed Shahbazi Li 3134 14 July 2016 G G G G G G P92648 Slag Lane Medical Centre Li 2354 21 June 2018 G G G G G G P92651 Lowton Surgery Li 4738 06 December 2018 G G G G G G

Key

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

Page 137 Healthy People, Healthy Place This page is intentionally left blank MEETING: Primary Care Commissioning Committee Item Number: 7.4

DATE: 5th November 2019

REPORT TITLE: Primary Care Transformation Support Programme Update November 2019

3. Function as an effective commissioning organisation that puts the patient first.

4. Function as an organisation that puts patients first

5. Functioning as an organisation that consistently delivers its statutory duties and participates fully in Greater Manchester Devolution

REPORT AUTHOR: Claire Roberts (Senior Assistant Director Primary Care)

Jonathan Kerry (Senior Assistant Director Primary Care)

PRESENTED BY: Jonathan Kerry (Senior Assistant Director Primary Care)

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

Page 139 EXECUTIVE SUMMARY

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

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

The key areas of work in the Primary Care Transformation Support programme are;

 Primary Care Networks,  Workforce,  Estates,  Information Technology.

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

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

FURTHER ACTION REQUIRED: None

Page 140 Primary Care Transformation Programme Update November 2019

Page 141 Primary Care Support Programme Highlight Report

Programme Lead/s Claire Roberts - Strategic Lead for Primary Care & Integration

Jennifer Gammack - Senior Assistant Director of Primary Care

Jonathan Kerry - Senior Assistant Director of Primary Care

Senior Responsible Linda Scott – Director of Primary Care Officer

Reporting Period September – October 2019

Purpose and Aims

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

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

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

Objectives

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

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

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

Milestones

M1.1 Learning and support programme for PCNs On track developed for 2019-20

M1.2 PCN Clinical Directors supported to recruit to new roles and put in place relevant contractual On track arrangements and governance

Page 142 M1.3 The GP Collaborative is developed as a vehicle for supporting PCN Clinical Directors to share learning On track and develop delivery plans to support at scale delivery where appropriate

M1.4 Consolidation of GP Clinical Systems

M2.1 Awareness raising undertaken with key stakeholders to clarify the role and purpose of PCNs and to explore On track opportunities for collaboration

M2.2 Mobilisation of services into Ashton Health Centre Delayed

M2.3 Expansion of Video Consultation capabilities across General Practice to support Care Home Locally Delayed Commissioned Services

M2.4 Secured Record Storage Pilot to expand opportunities On track for premise utilisation and service expansion.

M3.1 Workforce Development Plan in place On track

M3.2 Additional staffing capacity in place to support Completed implementation of the workforce development plan

Programme Updates within the Period

The main focus of PCN development during September and October has been: Primary Care Network  Developing a borough-wide Learning & Support programme Development for PCNs  Supporting PCNs to recruit to the new roles which are included in the reimbursement scheme  Future planning to support the delivery of new service specifications which will be a requirement of the PCN DES from April 2020

NHSE has allocated funding to support the development of PCNs. GM has received the allocated budget of £2.3m for 2019-20. National guidance has been developed to sit alongside the funds which set out that the resource this year should be used for PCN development and a specific Clinical Director (CD) programme in each STP. The intention is to help PCNs make early progress against their objectives, for example supporting much closer and practical collaboration between PCNs and their community partners, including preparatory activity for the forthcoming national service specifications.

Wigan Borough’s proposal to draw down its allocation of £139,000 has been developed with PCN CDs includes the following elements:

Page 143 Healthy People, Healthy Place  Supporting full practice engagement in PCN Development  Promoting Collaboration in Service Delivery Footprints (SDFs)  Access to Technical Advice & Guidance  Leadership & Development  Workforce Development in PCNs  Development of shared IT platform for PCNs  Improving access to and utilisation of Business Intelligence  Patient and Community Engagement

A ‘PCN diagnostic session’ has been arranged for the 27th November which will be facilitated by the national ‘Time for Care’ team. All PCN CDs will be attending with their lead Practice Managers. This session will be used to further design the programme by identifying specific development and learning needs at a borough wide and individual PCN level.

PCNs have been focusing on recruiting to the new roles which will be fully or partially funded through the PCN role reimbursement scheme. In 2019-20 these include Social Prescribing (Community) Link Workers and Clinical Pharmacists. An offer has been developed with City Healthcare Partnership for PCNs to become partners to the current Community Link Worker contract. PCNs are approaching the employment of Clinical Pharmacists in different ways. There will be a discussion at the GP Collaborative meeting on the 12th November to share learning and approaches.

The GP Collaborative meeting in October focused on planning ahead for delivery of GP Extended Access services, which will become the responsibility of PCNs from 1st April 2020. A workshop will be held on the 12th December to work through risks and opportunities and to develop plans for delivery with relevant stakeholders. We are still awaiting the revised national service specification.

A number of projects are underway to ensure that we can use digital services to support all practices, and through innovation, Digital / drive forward the transformation agenda at pace. Information Technology Clinical System Alignment

Clinical System migrations remain a focus to ensure that practices have the right tools to support both individual practice working as well as provide the foundation to collaboration at an SDF level.

All but two practices are now operating on either EMIS Web or TPP SystmOne, which gives a really strong foundation for Primary Care Networks to collaborate and look at new ways in which services can be delivered.

The ability to integrate records directly between EMIS and TPP to support PCNs has also been progressing, with initial pilots aligned

Page 144 Healthy People, Healthy Place to flu vaccination campaigns to support the delivery of services at a PCN level.

This capability will start with the sharing of records, but will progress over the quarter to also enable the ability to deliver appointment booking and workflow/tasking between practices, which are seen to be the core components to facilitate inter- practice working and new models of care.

Secure Communications Platform

We are continuing to encourage practices to utilise NHS Mail v2 to deliver video consultations, participate in huddles and MDTs virtually, and connect to other care professionals via Skype.

The Digital Offer to Care Homes pilot has been expanded to 8 locations, although there are some delays with infrastructure installations, and we are working with a number of PCNs to link the pilot with the Care Home Locally Commissioned Service to ensure the maximise benefits can be gained from the opportunity to link services.

Records Storage and Digitisation

The 3 practices are now fully running with the secure records storage service, and initial feedback has been extremely positive.

A report is being generated to document the benefits realised, lessons learnt and will act as the start of a business case to look at securing additional funds to expand the capability.

We hope that through this work we will be able to compliment the ongoing estates developments to optimize the usage of space within clinical settings, whilst creating a cost effective, secure and sustainable approach to the secure storage of records.

Enhanced Shared Record

The platform is expected to go live during November, having overcome the delays in accessing the nationally held mast patient index. This will give Wigan Borough the capability of creating a single shared record, with future potential to link across Greater Manchester, focused on sharing the right information in the right places to support care delivery.

The feeds of information are being actively progress across all local care providers, and those across Primary and Acute Care will be the first to go live. Clinicians and professionals will have access to high quality information to provide the best possible care.

As part of the project we will also be deploying the “patient portal” module, which will allow individuals to have access to the same

Page 145 Healthy People, Healthy Place single shared record and be in full control of their care.

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

Focus is being given to ensure that we maximise the utilisation of our LIFT buildings, support practice developments and also look to identify and support new developments in the future, aligned to funding opportunities and patient need.

Work is continuing to progress across a number of areas:

Ashton Health Centre

Work has now completed on the build, with the building now handed over to Wigan Council and the final snags being resolved.

Mobilisation has been slightly delayed due to complications with network infrastructure installations, but plans are now being amended to aim to complete mobilisation during November.

The Project Co-Ordinator from One Partnership continues to work with the CCG and is ensuring that all tenant queries, issues and requirements are resolved to ensure a smooth mobilisation.

Operational meetings are continuing fortnightly to ensure that all stakeholders are engaged and clear on roles and responsibilities within the building.

Higher Folds

A number of surveys have been completed on the proposed build location which has highlighted some additional build considerations.

The developer is currently working with architectures and structural surveyors to revise the plans and cost model to ensure the scheme is affordable for all parties.

A deadline of 2nd December has been set for the revised works to be completed so that we can look to progress the scheme as quickly as possible.

Coldalhurst Lane Surgery

Funding has been secured from the Greater Manchester Health and Social Care Partnership (GM HSCP) to support the extension of Coldalhurst Lane Surgery.

This will create more clinical space within the Astley area, with the current 3 GP premises being at capacity (6 facet survey classified as “over-crowded”), and allow for additional services to be

Page 146 Healthy People, Healthy Place delivered closer to patients.

The practice is looking to progress with the chosen developer as soon as possible with completion expected during Q1 of 2020/21.

Boothstown

The practice has continued to meet with the developer to allow for the creation of a proposal and business case.

It is anticipated that initial high level plans, will be available by December, which will allow for a functionality and affordability review to be completed in order to allow for both the Practice and CCG to take a view on progressing further.

The Practice and Patient Participation Group have shown really positive interest in the scheme, which has the potential provision of a Health and Wellbeing Centre for the local area.

Pennygate

Plans have been finalised for the scheme, with a view to utilising the “shell space” within the existing build to allow for the creation of an additional 10 consulting rooms. This would support practice expansion as well as wider service delivery within the Primary Care Network.

With the expected increases in patient population and current overcrowding within Hindley Health Centre, this scheme could deliver real benefits for the Hindley SDF.

GM HSCP has been supportive of the scheme, and the affordability is currently being reviewed to look at whether it is a viable option for the CCG to progress.

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

Recruitment & Retention

Workforce We have recently appointed 4 new GP Fellows who have now taken up the role. 3 of the Fellows will be focusing on workforce development within their CCG funded sessions, and in particular supporting some of the development and implementation work around retention and practice resilience. One of the Fellows has expressed an interest in working on urgent care and we are in discussions to support the development of a work programme.

Page 147 Healthy People, Healthy Place We have been successful in attracting additional funding from GM to deliver schemes that encourage GPs to remain in practice and to attract clinicians to work in general practice in Wigan Borough. This includes investment in creating high quality learning environments and mentorship.

We have recently submitted a proposal to access a further £57k which will enable us to:

 Develop a consistent and scaled health & wellbeing offer for practices  Contribute to an digital platform which will facilitate shared learning across practices and quick access to learning and development resources  Further development of trainers and mentors in practice (this will include building the infrastructure to support the new roles in PCNs  Funding Quality Improvement leads in general practice to support the scaled delivery of effective initiatives that improve care and reduce the administrative burden on clinicians

Learning, Development & Education

The GP podcasts that have been developed by two of our GP Fellows under the brand of Primary Care Knowledge Boost have recently been awarded a highly commended rosette from RCGP at their recent conference. The podcast continue to be an important method of increasing awareness and understanding of a range of pathways and wider themes for clinicians.

We received confirmation in September that HEE funding that had previously allocated to the CCG, would be managed via Enhanced Training Practices (ETPs). We have submitted 4 bids on behalf of local practices to obtain funding to respond to learning and development needs that have been identified. These areas include:

 Mental Health awareness and upskilling  Coding and note summarising  Chaperoning  Immunisation train the train programme

We are working closely with partners to respond to training and development needs that support primary care transformation and quality improvements. This includes joint working with North West Boroughs to develop a programme on Incident Response Support and with public health colleagues on mental health resilience and response.

A Practice Managers Conference was held on the 30th October, which focused on practice resilience and individual wellbeing. The

Page 148 Healthy People, Healthy Place event was extremely well received with over 80 practice representatives attending.

We have accessed funding from GM to develop the role of care navigators in general practice. We will be targeting reception staff initially to develop their skills and understanding in helping to connect patients to wider support and appropriate services. We are working with the training provider, Striding Edge, to develop a bespoke programme that draws on elements of the Wigan Deal, Healthier Wigan Partnership Experience and existing roles such as the Community Link Worker.

Development of new roles in general practice

We are working closely with PCNs and our local ETP to facilitate discussions and identify opportunities to develop new roles in general practice. The initial focus is on Social Prescribing (Community) Link Workers and Clinical Pharmacists. Future roles to be cover by the roles reimbursement scheme include Physician Associates; First Contact Physios and Paramedics.

As part of the PCN Development Programme we have proposed investment in PCN nominated workforce champions who can support the implementation of key workforce schemes in each of the SDFs and connect with the Borough wide workforce group. This will enable us to deliver more systematic change and capitalise on opportunities where we can benefit from economies of scale.

Outcomes Achieved

O1 Workforce funding being secured to support local initiatives.

O2 Clinical System Migrations successfully completed.

O3 Ashton Health Centre build completed and mobilisation progressing.

Plan for Next Period

 Continue support to Primary Care Networks

 Await outcome of funding proposals to support workforce and training opportunities

 Complete the mobilisation of Ashton Health Centre

 Generate the Business Case to support the expansion of the Secure Records Storage service

Risk Register

R1 Failure to secure funding to support workforce 12

Page 149 Healthy People, Healthy Place developments results in not having appropriately skilled workforce to develop new models of care or handle the additional demands of services being delivered within the community

R2 Failure of Primary Care Networks to develop deliver models and organisational structures to support new ways of working restricts the opportunities to support 12 patients and maximise the potential of funding available.

R3 Risk of Virus and/or Ransomware attack is increased if Operating System and Antivirus patching is not kept up 5 to date. R4 Competing operational and project pressures threatening overall aims and objectives across IM&T 9 programme.

R5 Limited capital funding available across Greater Manchester restricts the opportunities available to 8 support estates developments.

R6 Significant financial penalties could be incurred through information breaches in practices if GDPR and Information Governance process are not properly 4 embedded, maintained and monitored.

Page 150 Healthy People, Healthy Place