AGENDA ITEM NO: 7.0 Meeting Title/Date: Primary Care Commissioning Committee 18 August 2020

Item for: Decision X Recommendation Information AGENDA ITEM NO: 7.0 Meeting Title/Date: Primary Care Commissioning Committee 18 August 2020

Options Appraisal following Notice given on Personal Medical Report Title: Services Agreement: Windermere and Bowness Medical Practice Kay Wilson / Date of Paper Prepared By: August 2020 Kate Hudson Paper: Responsible Executive Sponsor: Hilary Fordham Kate Hudson Manager: Committees where Paper Previously Presented: N/A

Background Paper(s): N/A

Summary of Report: Windermere and Bowness Medical Practice informed NHS Morecambe Bay CCG of its intention to resign from the PMS Agreement with effect from 31 March 2021. The purpose of this report is to set out the steps the Committee needs to consider, in light of this notification, specifically in relation to the future provision of services to patients registered at the practice. Recommendation(s): The Committee is asked to consider the attached report, as well as the options set out in it, with a view to agreeing the future arrangements for providing primary medical care to the registered patient population. Please Select Y/N Identified Risks: (Record Dispersal of the current list of registered related, Assurance Framework patient to neighbouring practices may not be or Risk Register reference an option in this instance due to the number of number) registered patients. The current agreement is due to end on 31 March 2021, which is a short timescale in which to complete a successful Yes procurement exercise. There is a risk that the CCG may need to enter into an ‘emergency contract’ with a provider for a short period of time, which will have financial implications for the CCG.

Impact Assessment: A full impact assessment together with patient (Including Health, Equality, and stakeholder engagement will be N Diversity and Human Rights) undertaken following the Committee’s decision.

Strategic Objective(s) Please Select

Supported by this Paper: (X)

Better Health - improve population health and wellbeing and reduce health X inequalities Better Care - improve individual outcomes, quality and experience of care X

Delivered Sustainably - create an environment for motivated, happy staff and X achieve our control total Please Contact: Kate Hudson Head of Primary Care [email protected] Options Appraisal Notice to Terminate PMS Agreement, Windermere & Bowness Medical Practice ______

MORECAMBE BAY CCG PRIMARY CARE COMMISSIONING COMMITTEE

OPTIONS APPRAISAL FOLLOWING NOTICE GIVEN ON PERSONAL MEDICAL SERVICES AGREEMENT

WINDERMERE & BOWNESS MEDICAL PRACTICE (A82046)

1. INTRODUCTION

1.1 One Medical Group is the holder of a Personal Medical Services (PMS) Agreement for the provision of primary care medical services to patients registered with Windermere and Bowness Medical Practice and provides Essential, Additional and Enhanced Services. The registered list size as at 01 July 2020 was 5,653 patients (weighted population of 5,380.49). Services are provided from Windermere Health Centre, Goodly Dale, Windermere. The practice is a member of the Grange and Lakes Primary Care Network (PCN).

1.2 One Medical Group (the ‘Provider’) notified NHS Morecambe Bay CCG on 15 July 2020 of its intention to resign from the Agreement with effect from 15 January 2021. Following discussion with the Provider and the Head of Primary Care, it was agreed that the period of notice would be extended to 31 March 2021.

1.3 The reasons cited in the resignation letter from One Medical Group for taking this action relate both to the financial aspect of the practice as well as the staffing model.

1.4 This paper sets out information relating to the local area (see Appendix 1 Health Needs Analysis – Windermere and Bowness’) as well options available to the Primary Care Commissioning Committee in order for a decision to be made in respect of the future provision of primary medical services to the patients registered with Windermere and Bowness Medical Practice.

2. BACKGROUND

2.1 One Medical Group has held the contract for approximately 5 years. Latterly, the Provider has worked with both NHS Morecambe Bay CCG and NHS England in relation to problems to staffing the contract. One Medical Group has also highlighted the fact that the practice is ‘significantly loss making and has been for a number of years’1 and that despite the efforts by One Medical Group to address this issue, the Group does not feel that keeping the contract is sustainable in the longer term.

2.2 At the Committee meeting held in February 2019, Members approved a request from a neighbouring practice, St Mary’s Surgery (Windermere), to temporarily close the

1 Extract from letter of resignation ______

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patient list to new patients. This request had been made in view of the number of patients which had left Windermere and Bowness Medical Practice and wished to register at St Mary’s Surgery. Both the CCG and NHS England worked with One Medical Group to assist the Group in addressing the clinical workforce pressures and the CCG has continued to engage with One Medical Group since that time.

2.3 However, One Medical Group wrote to the Morecambe Bay CCG on 15 July 2020 to serve notice of its intention to resign from the Agreement effective from 15 January 2021.

2.4 Following receipt of this notice, Kate Hudson, Head of Primary Care, agreed with the directors of One Medical Group an extension of the notice period until the end of the financial year. Consequently, the Agreement is due to terminate on 31 March 2021. Clause 54 of the standard PMS Agreement states:

“Termination by Serving Notice “58.1 The Contractor or the Board may at any time terminate this Agreement by serving notice in Writing on the other party or parties to the Agreement. The period of notice shall be [six (6) months].

”58.2 The notice given under clause 58.1 must specify the date on which the termination is to take effect (which must be calculated in accordance with the period specified in clause 58.1) and the Agreement terminates on the date so specified.

“58.3 This clause 58 does not affect any other rights to terminate this Agreement which the Contractor and the Board may have.” [source: NHS England Standard PMS Agreement, 2019]

3. CURRENT SITUATION

Provision of services / Clinical Workforce

3.1 The Provider is required to continue providing primary medical services to the registered population until the end of the contract. One of the on-going challenges at Windermere and Bowness Medical Practice has been the ability to maintain a consistent number of GPs working at the practice. It is understood that One Medical Group has relied heavily on the engagement of Locum GPs, which as well as being a significant cost to the Group, is also an untenable position in the long term as One Medical Group had highlighted to the CCG that the practice was not generating sufficient income. The Group has also commented that, following the development of PCNs, the practice would benefit from the provider being based within the local geography.

3.2 In July 2020, a GP from the Grange and Lakes PCN contacted the Head of Primary Care to express concerns on behalf of the PCN about the long-term viability of Windermere and Bowness Medical Practice due to the staffing structure. The concerns were: the practice had one full-time GP working at the practice who was on a period of extended sick leave; a second salaried GP had been appointed but ultimately did not take up the position and the long-term locum had left. A meeting between key members of the PCN, One Medical Group and the CCG was held on 03 August 2020; the purpose of this meeting was to explore the support available to One Medical Group from the PCN. At this meeting One Medical Group confirmed its intention to terminate the PMS Agreement; it was, therefore, agreed that a further ______

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meeting would be held with the entire PCN when CCG representatives could attend and explain the situation further.

3.3 At the meeting on 03 August, the Provider confirmed that one member of staff who had been on sick leave had returned to work and that efforts to recruit additional staff would continue. In discussions with Kate Hudson, Head of Primary Care, the Provider also confirmed that it was confident sufficient GP locum cover had been booked to continue providing services until the end of the Agreement. The Provider will be asked to share information relating to staffing rotas with the CCG in order for this situation to be monitored.

Engagement

3.4 Again, following the meeting on 03 August, it was agreed that it was necessary to inform patients of the decision taken by One Medical Group; this was achieved by the publication of a press statement on 10 August 2020. This decision was made in view of the fact that both practice staff and members of the PCN had been informed of the development, albeit on a confidential basis; all parties were in agreement that patients needed to be formally notified of the situation.

3.5 However, on-going patient and stakeholder engagement will need to be undertaken throughout the period to 31 March 2020. This will be achieved by a number of methods, including written correspondence to all patients and stakeholders as well as patient engagement sessions. It is unlikely, in the current situation, that face-to-face patient engagement sessions will take place; the CCG’s Communications Team has been asked to provide advice on a Communications Plan in these circumstances.

4. OPTIONS FOR CONSIDERATION

4.1 The Committee is asked to note the termination notice served by One Medical Group (Windermere and Bowness Medical Practice) to be effective from 01 April 2021 and to consider the options for providing primary medical services to the practice population going forward. The options are:

Option 1: Dispersal of the patient list to other practices (led by patient choice) Option 2: Undertake a procurement exercise to identify a new provider

Option 1: Dispersal of the Patient List

4.2 The registered patient list as at 01 July 2020 was 5,653 patients. If the list was dispersed, this would mean that patients would be asked to register with an alternative GP and Windermere and Bowness Medical Practice would close. The process by which this would be achieved is set out in NHS England’s Primary Medical Care, Policy Guidance Manual. There are a number of steps involved in this process, Table 1 below sets out some of the key steps to be undertaken to disperse the list.

Table 1 - List Dispersal Steps STAGE ACTION Pre-dispersal Obtain list of vulnerable patients from Windermere and Bowness Medical Practice Pre-dispersal Liaise with local practices to: ______

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STAGE ACTION i. advise of dispersal and need to accept registrations ii. understand any significant barriers practices might have in terms of registering additional patients Start of dispersal Write to all patients setting out details of local practices and period and asking patients to register with alternative practice. throughout NB: At least 2 letters should be sent to patients over the dispersal period dispersal period in order to ensure that all patients register with an alternative practice. A third letter should be sent to anyone remaining on the list at the end of the process (see below) Throughout Monitor the number of patients registered with Windermere dispersal period and Bowness Medical Practice to ensure this decreases over dispersal period Throughout Liaise with NHS England / Improvement to ensure that patients dispersal period identified as vulnerable are registered with an appropriate alternative practice End of dispersal Liaise with NHS England / Improvement to determine whether process any patients need to be assigned2 to a practice and write to relevant patients to notify them of the assignment NB: List dispersal does not override the right of patients to choose which practice they wish to register with and any patients who are assigned to a practice must be reminded that they have the option of changing GP practice. End of dispersal Manage closedown of GP clinical system and transfer of NHS process assets (medical records etc) End of dispersal Ensure that all patients at the end of the contract are process registered with / assigned to an alternative provider

4.3 Should the decision be taken to disperse the patient list, there are a number of issues to be considered; these are:

4.3.1 Alternative practices: Table 2 below shows the neighbouring practices together with the list sizes and the approximate distance and travel times between the sites. There is one other practice within Windermere and a practice at Ambleside, both of which are within 10 miles of the current site. However it should be noted that the practice boundary for Central Lakes Medical Practice (Ambleside) does not include Windermere and Bowness. (Copies of the practice boundaries for neighbouring practices are within the Health Needs Analysis document.) Other neighbouring practices within 10 to 15 miles of the current site include practices in Kendal, Haverthwaite, Coniston, Cartmel and Grange-over-Sands. However, due to these sites being within the Lake District National Park (with the exception of Grange- over-Sands) travel can often be disrupted and journeys take much longer than anticipated, especially during peak seasons of tourism.

2 An assignment is where a patient is automatically placed with a practice to ensure continuity of care ______

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Table 2 - Neighbouring Practices List Size (as at 01 Distance Travel time Practice July (by car) (by car) 2020) St Mary’s Surgery (main practice 1 mile 3 minutes site at Windermere) 6,168 St Mary’s Surgery (branch site at 4.5 miles 8 minutes Staveley) Central Lakes Medical Practice 6 miles 14 minutes (main practice site at Ambleside) 6,223 Central Lakes Medical Practice 10 miles 22 minutes (branch site at Hawskhead)

4.3.2 The CCG would need to enter into discussions with local practices, prior to the start of the dispersal process, regarding the impact registering additional patients would have on the current levels of service. It is likely due to practice contractual boundaries and local travel distances that the majority of patients may disperse to St Mary’s Surgery. The CCG would need to understand the implications for St Mary’s Surgery specifically if a significant number of patients sought to register there.

4.3.3 Open / Closed Lists: Currently all practice lists are ‘open’ and as such practices must register new patients provided that the patient lives within the practice boundary. However, it is possible that practices may apply to close the lists in advance of any dispersal process starting, once the decision of the Committee was known.

4.3.4 Date of dispersal: The list dispersal process can take some months to complete as patients need to be given sufficient time to find an alternative GP practice; guidance from Primary Care Support England suggests that this can take between 1 and 3 months to complete. There is sufficient time, therefore, to undertake the dispersal of the list before the contract end date.

4.3.5 Premises: The premises are owned by Primary Health Properties plc and leased to One Medical Group. If the list was to be dispersed, the premises would no longer be required and the CCG would not incur notional rent costs in line with the NHS Premises Cost Directions.

4.3.6 Patient Choice: There are currently 5,653 patients registered with the Windermere and Bowness Medical Practice. Whilst the CCG has not undertaken a full patient engagement exercise, the CCG believes that registered patients have expressed their choice of GP practice by registering and remaining with the surgery. Table 3 below shows information on the number of patients registered with the practice since 2015. Whilst the list size has dropped by 119 patients, this represents a 2% reduction to the list size. To disperse the list could be perceived as limiting/removing this choice from the patients without clear justification (as alternative provision may be found via a procurement exercise).

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Table 3 – List Size Changes 2015 – 2020 Change % Change from Date List Size from previous previous year year April 2015 5,759 April 2016 5,739 -20 - 0.35% April 2017 5,809 70 + 1.22% April 2018 5,848 39 + 0.67% April 2019 5,626 -222 - 3.80% April 2020 5,640 14 + 0.25% [source: NHS Digital]

Option 2: Undertake a Procurement Exercise

4.4 As explained previously, One Medical Group has confirmed that it intends to withdraw from the PMS Agreement on 31 March 2021. If the Committee took the decision to undertake a procurement exercise, this would ensure that a contract was in place with a new provider which would ensure continuity of services to the registered list.

4.5 It should be noted, however, that in line with procurement legislation, it is not possible for a new PMS Agreement or GMS Contract to be awarded as all new contracts must be Alternative Provider Medical Services (APMS) contracts. The main differences are:

 Length of contract: The CCG must determine the appropriate length of the contract;

 Price: PMS contracts are funded in line with the nationally agreed General Medical Services (GMS) rate whereas APMS contract funding is determined by the Commissioner;

 Contracting party: The Regulations do not stipulate who can hold an APMS contract, but do state who cannot hold a contract; the CCG must ensure that anyone awarded an APMS contract is eligible to hold this; and

 Consideration of KPIs: It is possible for the inclusion of Key Performance Indicators (KPIs) to be within an APMS contract. These would need to be linked to specific pieces of work / issues which needed to be addressed and have measurable targets. If KPIs were included within the contract it would be normal for additional funding to be given to the provider on attainment of the KPIs.

4.6 If this option were chosen, the CCG would need to work with procurement experts to ensure that the process was conducted in line with procurement regulations. For CCGs within the North, procurement expertise is provided through the North East Commissioning Support unit (NECS).

4.7 The specific issues that will need to be agreed in order for a procurement process to commence are:

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4.7.1 Contract price: Whilst the funding for this would be determined by the CCG, it would be usual for this contract to be offered at GMS equivalent funding levels. The successful bidder would have the opportunity to earn additional income through the Quality and Outcomes Framework (QOF), directed enhanced services and local enhanced services.

4.7.2 Contract length: The options can be: an initial contract length of 5 years with the option to extend for a further 5 years; an initial 10 year contract with the option to extend for 5 years etc.

4.7.2 Transitional / Sustainability fund: A transition or sustainability fund is optional but can be offered by the CCG. This would normally be time-limited and could be linked to specific pieces of work (see paragraph 4.5 above). The benefit of considering a Transition or Sustainability fund could help to attract bidders although this will have a financial implication for the CCG.

4.8 However, before the CCG can undertake a procurement exercise, it must apply to NHS England Commercial Executive Group for approval to advertise the APMS contract if the term of the contract, including any extension period, exceeds 5 years. In order to produce a strong case for approval to advertise the vacancy, the CCG could undertake a ‘market engagement’ exercise which alerts potential bidders to the possibility of a contract being advertised and asks a series of questions, including whether the proposed length of contract would attract bidders; whether the contract price would attract bidders etc. This information can then be used to strengthen the case for the procurement exercise to be undertaken. A market engagement process does not commit the CCG to advertising a contract and can be a quick and effective way of gaining information about potential bidders.

4.9 Once approval was given, if the total value of the contract3 exceeded £663,540 the procurement would be advertised on the open market through the Official Journal of the European Union (OJEU); the contract would also be advertised through the Government contracts platform and the e-tendering system (used by NECS). Interested parties would be invited to submit tenders for the contract, which would be evaluated in order for a successful bidder to be appointed. As part of the evaluation process, the CCG would be required to draw-up a list of pertinent questions for bidders to respond to and also to appoint a panel of experts to evaluate the answers.

4.10 Interested bidders would be asked to source premises from which services would be provided. The CCG would not intervene between the owners of the current premises and interested bidders, as this would be a private matter between the two parties should a potential bidder wish to continue using the existing premises. If a bidder chose not to do this, the responsibility for sourcing new premises would remain the bidder’s and again the only involvement of the CCG and NHS England would be to ensure that the premises were fit for purpose; represented value for money and that a suitable lease was in place (if the premises were leased).

4.11 The procurement process can be lengthy and could take up to 6 months to complete. Should the procurement process result in a situation where there was not a successful bidder, or if the process could not be completed before the end of the current PMS Agreement, the CCG would need to consider entering into an ‘emergency contract’ with a local provider.

3 This is calculated over the full term of the contract including any extension period ______

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5. FINANCE

5.1 Table 4 below shows the current payments to Windermere and Bowness Medical Practice.

Table 4 – Contract Payments Monthly Payments Annual Payments

PMS sum £41,032.43 £492,389 Directed Enhanced Services £51,000 (approximate (commissioned through NHS figure dependent on England / Improvement) activity) Local Enhanced Services £1,914.00* £22,970* (commissioned through MBCCG) Quality Improvement Scheme (QIS) £2,299.00* £39,417* £64,028 (includes QOF £3,682.26 annual achievement payment) Notional Rent £4,604.16 £55,250 Rates (reimbursed) - £10,311 (19/20 value) [source: NHS England / MBCCG] *Based on figures for 2019/20

Dispersal

5.2 If it is agreed that the patient list should be dispersed, practices registering new patients will receive a ‘new patient registration fee’ which is equivalent to 46% of the annual global sum figure. This fee is payable in the first year only, the Statement of Financial Entitlement (Annex B) says:

“Analysis of the workload implications revealed 40 – 50% more workload, as measured by aggregate consultation times, within the first year of registration. An average uplift factor, of 1.46, will be applied through the formula in respect of all new registrants in their first year of registration.”

5.3 For 2020 / 21, the global sum per patient per annum is £93.46, the increase in respect of new patients will, therefore, mean an additional £42.99 per patient for the first year. However, there is a deduction of £4.46 per patient from this amount in respect of the opt-out from providing Out of Hours. Additional funding is given to practices in respect of participation in the Primary Care Networks (PCN) Directed Enhanced Service (DES), in 2020 / 21 this equated to core funding of £1.50 per patient per annum with additional amounts payable to the PCN for the employment of additional staff.

Procurement Exercise

5.4 As said in paragraph 4.7.1 above, the CCG would need to determine the value of an APMS contract if it was agreed a procurement exercise should be undertaken. It is usual for the contract value to be at GMS equivalent funding. This would mean that the successful bidder would receive a contract value equivalent to the global sum

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figure shown in Table 3 above with the option of earning additional income through QOF and the provision of enhanced services.

5.5 However, it should be noted that Windermere and Bowness Medical Practice is one of six practices in Morecambe Bay where the ‘weighted list’ is less than the actual list. The weighted list is calculated by applying the Carr-Hill4 formula to the actual patient list size; practices are then funded on the basis of the weighted list multiplied by the Global Sum payment. For Windermere and Bowness, the number of weighted patients is 95.18% of the total number of patients. As said in paragraph 1.1, the actual number of patients registered with Windermere and Bowness Medical Practice is 5,653 patients although the weighted list size is 5,380.49 (95.18%) as at 01 July 2020.

5.6 The cost of undertaking a procurement exercise is approximately £21,000; this is funded by NHS England / Improvement through a contract held with NECS.

6. POPULATION INFORMATION

6.1 The Health Needs Analysis attached as Appendix 1 has highlighted the following issues:

6.1.1 Population information shows that the percentage of residents in Windermere and Bowness aged 65 and over is higher than both the Cumbria and National averages; in the case of the National average it is more than 10% higher. Similarly, the percentage of residents who are retired is higher than both the Cumbria and National averages.

6.1.2 QOF data shows that the prevalence of all indicators counted for Windermere and Bowness Medical Practice are less than the Cumbria averages with the exception of ‘Osteoporosis: secondary prevention of fragility fractures’; ‘Atrial fibrillation’ and ‘Heart Failure’ all of which are slightly higher.

6.1.3 The Cumbria Joint Strategic Needs Assessment shows that the population aged 65 and over is projected to increase over the next 10 to 15 years with one of the highest increases expected in South Lakeland.

6.1.4 Tourism has a significant impact on practices located in the Lake District National Park.

7. OPTIONS APPRAISAL

Option 1: Dispersal of the Patient List

7.1 If the list was dispersed, the Windermere and Bowness Medical Practice contract would end and the practice would close. The benefits and risks associated with this option are:

7.2 Benefits:

7.2.1 Continuity of services for patients as they would be able to register with an alternative GP practice.

4 This is the national funding formula which is calculated centrally; CCGs are then informed of the number of weighted patients each practice has. ______

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7.2.2 Patients would not have a further period of uncertainty whilst a procurement exercise was undertaken; particularly if this was not successful.

7.3 Risks:

7.3.1 Impact on local practices, particularly St Mary’s Surgery, as the paper has highlighted that it is likely most patients will disperse to this practice (paragraph 4.3.2). The practice currently has a list size of 6,168 patients (as at 01 July 2020); if all patients from Windermere and Bowness Medical Practice were to register with St Mary’s Surgery this would represent an increase of almost 92% on the current list size.

7.3.2 There a great many tourists to the Lake District a significant number of which register, on a temporary basis, with a local GP practice. The loss of one practice in the area increases the number of temporary residents registering with the remaining practices.

7.3.3 Patients may have difficulty in travelling to alternative practices, particularly during the tourist season.

7.3.4 Reduction in patient choice. There are currently 5,653 patients that have expressed a choice to be registered with the Windermere and Bowness Medical Practice at the Windermere Health Centre site. Dispersal of the Windermere Health Centre list would remove this choice.

Option 2: Undertake a Procurement Exercise

7.4 A procurement exercise would be undertaken to find an alternative provider, thereby maintaining the current number of GP practices in the area. The benefits and risks associated with this option are:

7.5 Benefits:

7.5.1 Continuity of a practice based within Windermere which would benefit the patients residing in the local area;

7.5.2 Maintains current level of choice for patients in so far as residents of Windermere and Bowness, as well as temporary residents, will have the choice of two practices to register with.

7.6 Risks:

7.6.1 The procurement may not attract any potential bidders, or bidders may not meet the minimum requirements. In this scenario the CCG would need to re- consider whether to pursue a second procurement or to disperse the list. Whilst this was being considered, it would be necessary to enter into an emergency contract to ensure continuity of services to patients whilst the next steps were being considered.

7.6.2 Bidders may feel that the contract value is insufficient to secure the long term viability of the practice and may pull out of the process.

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8. SUMMARY

8.1 One Medical Group holds the PMS agreement for the provision of primary medical services to a registered list of 5,653 patients.

8.2 The Agreement is due to terminate on 31 March 2021.

8.3 Patient Engagement events have not yet taken place; letters have not been sent to all registered patients although a press statement has been made. As said in paragraph 4.3.6, whilst the list size has fluctuated within the normal range, for the last 5 years the list size has remained above 5,600 patients.

8.4 To date, no market engagement exercise has been undertaken to understand whether there are providers who may be interested in submitting a bid should a procurement exercise be undertaken.

8.5 The number of patients aged 65 and over living in South Lakeland is higher than both the Cumbria and National average. List size information for Windermere and Bowness Medical Practice, however, shows that the number of patients aged 65 and over is in line with the National Average (Windermere and Bowness is 18.6% and the National average is 18.4%) and slightly lower than the Cumbria average (24.5%).

9. NEXT STEPS

9.1 The Committee is asked to consider the options presented in the paper to determine whether:

9.1.1 Option 1 should be pursued: the patient list should be dispersed to local practices; or

9.1.2 Option 2 should be pursued: the CCG should undertake a procurement exercise to source a new provider for the patient list.

AUGUST 2020

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Morecambe Bay Clinical Commissioning Group

Health Needs Analysis

Windermere & Bowness

August 2020

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1 Background

1.1 This appendix sets out information in respect of the population of Windermere and Bowness Medical Practice together with the surrounding areas together with information in respect of practices neighbouring Windermere and Bowness Medical Group.

2 Windermere & Bowness-on-Windermere

About the local area

2.1 Bowness-on-Windermere is the older of the two villages; the civil parish of Bowness- on-Windermere merged with that for Windermere in the 1900s. Following the opening of the railway terminus at Windermere, the economy of the area has relied heavily on tourism.

2.2 Windermere and Bowness sit within South Lakeland District Council and are split into the following wards:

 Windermere Applethwaite and Troutbeck  Windermere Bowness North  Windermere Bowness South  Windermere Town

2.3 The wards bordering Windermere and Bowness are: Staveley in Westmorland; Staveley in Cartmel; Ambleside and Grasmere and Hawkshead.

Population Information

2.4 Data from Cumbria Observatory gives the total population for Windermere and Bowness as 8,086 residents. Table 1 below shows the population information for the wards; the table includes the ward of Staveley in Cartmel (as this area is included in the practice boundary for Windermere and Bowness Medical Practice). The number of patients registered with Windermere and Bowness Medical Practice as at 01 July 2020 was 5,653 (weighted population of 5,380.49), which is 57% of the population of the local area.

Table 1 – Population [Data: 2018] Male Female Total

Windermere Applethwaite & Troutbeck 923 1,004 1,927

Windermere Bowness North 992 988 1,980

Windermere Bowness South 947 958 1,905

Windermere Town 1,116 1,158 2,274

Staveley in Cartmel 915 879 1,794

Total 4,893 4,987 9,880 [source: Cumbria Observatory / Office for National Statistics]

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2.5 Information from Cumbria Intelligence Observatory shows the number of households living in fuel poverty is in line with both the Cumbria and National averages with the exception of Staveley in Cartmel where this is higher. The percentage of children living in low income families is less than these averages (Table 2 below).

Table 2 – Fuel Poverty / Low Income Families Percentage of Households children living in Area experiencing fuel low income poverty (2107) families (2016)

Windermere Town 10% 7.4%

Windermere and Bowness South 11% 5.7%

Windermere and Bowness North 10% 9.0%

Applethwaite & Troutbeck 12% 4.2%

Staveley in Cartmel 14% 7%

Cumbria average 12% 12.1%

National average 11% 17% [source: Cumbria Observatory / Office for National Statistics – 2011 Census]

2.6 The Public Health Profile for South Lakeland, published by Public Health England [data as at July 2020], shows that:

 The health of people in South Lakeland is generally better than the England average;  Approximately 6.9% (980) of children live in low income families;  Life expectancy for both men and women is higher than the England average;  Life expectancy is not significantly different for people in the most deprived areas of South Lakeland to those in the least deprived;  In Year 6, 14.3% (128) of children are classified as obese, better than the England average;  The rate of alcohol-specific hospital admissions among those under 18 is 56 [rate per 100,000 population], worse than the average for England. This represents 10 admissions per year;  Levels of GCSE attainment (average attainment 8 score) are better than the England average;  The rate of alcohol-related harm hospital admissions is 539 [rate per 100,000 population], better than the average for England; this represents 140 admissions per year;  Estimated levels of excess weight in adults (18+), smoking rates in adults (18+) and physically active adults (19+) are better than the England average;  The rates of new sexually transmitted infections and new cases of TB are better than the England average;  The rate of killed or seriously injured on roads is worse than the England average;  The rates of violent crime (hospital admissions for violence); under 75 mortality rate from cardiovascular diseases and under 75 mortality rate

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from cardiovascular disease; under 75 mortality rate for cancer and employment (aged 16 – 64) are all better than the England average [source: Public Health England, Health Profile data]

2.7 Cumbria Intelligence Observatory shows, that for ‘self-reported health’ the number of residents across the four wards in Windermere who considered they had ‘very good health’ is 48.1% which is in slightly higher than the National and Cumbria averages; see Table 3 below.

Table 3 – Self-Reported Health [2011 Census] Very bad Bad health Fair health Good health Very good health health

Count % Count % Count % Count % Count %

Apple’waite & 32 1.5 70 3.8 286 13.8 691 33.3 986 47.5 Troutbeck

Bowness 15 0.7 60 2.9 302 14.7 729 35.4 955 46.3 North

Bowness 7 0.4 53 2.7 193 9.8 700 35.4 1022 51.7 South

Wind’mere 17 0.8 82 3.6 300 13.3 738 32.8 1112 49.4 Town

Staveley in 20 1.2 64 3.7 232 13.4 625 36.2 786 45.5 Cartmel

Cumbria 6481 1.3 23604 4.7 71966 14.4 172789 34.6 225018 45.0 average

National 660749 1.2 2250446 4.2 6954092 13.1 18141457 34.2 25005712 47.2 average [source: Cumbria Observatory / Office for National Statistics]

2.8 Data from Cumbria Intelligence Observatory shows that South Lakeland District Council has a higher percentage of residents aged 65 and over (28.5%) which is higher than both the England and Cumbria averages; see Table 4 below.

Table 4 – Population Estimates of People by Broad Age Group (2018) South Lakeland Cumbria England District Council Count % Count % Count % Persons aged 0 - 15 15,572 14.8 82,265 16.5 10,816,669 19.2 Persons aged 16 – 64 59,580 56.7 295,387 59.1 35,116,566 62.4 Persons aged 65+ 29,936 28.5 122,360 24.5 10,353,716 18.4 [source: Cumbria Observatory]

2.9 It is expected that this percentage will increase over the next few decades at a higher rate than the national average:

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“By 2037, the proportion of residents aged 65+ is projected to increase to 32.9% across Cumbria; this is the third greatest projected proportion of all counties in England and much higher than the projected national proportion (24%). All of Cumbria’s districts are projected to have greater proportions of residents aged 65+ than the national average by 2037. South Lakeland and Eden are projected to have the greatest proportions of residents aged 65+ (37.2% and 36.2% respectively by 2037).” [source: Cumbria Joint Strategic Needs Assessment 2015-2017, Introduction]

2.10 In respect of the patients registered at Windermere and Bowness Medical Practice 1,055 (18.6%) are aged 65 years and over; this is less than the Cumbria average but in line with the average for England5.

2.11 In respect of disease prevalence, data from the Quality and Outcomes Framework (QOF) (see Table 5 below6) shows there is a significantly lower prevalence of patients with asthma, COPD, depression and diabetes than both the Cumbria and National averages. These figures are derived from the practice’s clinical system and are based on the number of patients placed on the appropriate register by GPs expressed as a percentage of the total practice population. The prevalence of asthma, chronic kidney disease, and depression are all below the Cumbria and National averages, whilst osteoporosis is slightly higher.

Table 5 – Disease Prevalence (QOF) 2018/19 [A cell coloured red indicates prevalence at a significant variance to the CCG average, ie either significantly below or above the CCG average.] Clinical Prevalence (% of National Disease area CCG Average practice Average population)

Asthma 5.87 6.95 6.05

Atrial fibrillation 2.01 2.45 1.98

Cancer 3.25 3.55 2.98

Chronic kidney disease 3.68 4.05 4.09

Chronic obstructive pulmonary 1.55 2.27 2.17 disease

Dementia 0.64 1.06 0.78

Depression 9.75 12.60 10.74

Diabetes mellitus 5.57 6.76 6.93

Epilepsy 0.63 0.92 0.79

Heart failure 1.12 1.09 1.07

Hypertension 13.90 14.97 13.96

Learning disability 0.46 0.49 0.50

5 Source: NHS Digital – June 2020 patient list sizes 6 Reference: https://qof.digital.nhs.uk/search/index.asp ______

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Clinical Prevalence (% of National Disease area CCG Average practice Average population)

Mental health 0.69 0.94 0.96

Osteoporosis: secondary 0.94 0.37 0.79 prevention of fragility fractures

Palliative care 0.53 0.77 0.40

Peripheral arterial disease 0.52 0.87 0.60

Rheumatoid arthritis 0.61 0.93 0.76

Secondary prevention of 3.02 3.85 3.1 coronary heart disease

Stroke and ischaemic attack 2.12 2.30 1.77 [source: NHS Digital]

Local Developments

2.12 The Local Plan for South Lakeland District Council (2013) sets out plans for the development of Bowness Bay and The Glebe:

“Bowness Bay and The Glebe: We have identified the site as a strategic location for a long term development opportunity. An exemplar regeneration project could enable comprehensive redevelopment of the lake frontage, together with improved traffic management, improved public access to the lakeshore and strengthening the role of the Glebe open space.” [source: Lake District National Park – Core Strategy]

Travel

2.13 Windermere and Bowness are located close to the main A591 road between Kendal and Keswick, which follows the north-eastern bank of Lake Windermere.

2.14 Travel between Windermere and Bowness to the nearest hospital at Kendal is approximately 12 miles (20 minute journey)7. The distance between the current practice site and the nearest practice located at St Mary’s Surgery, Applethwaite, Windermere is approximately 1 mile. Table 6 below shows the number of cars or vans per household. The number of households without a car or van is slightly below both the Cumbria and National averages.

Table 6 – Number of Cars / Vans per Households Windermere & Bowness (including Cumbria England Staveley in Cartmel) Count % Count % Count % 1 car or van 2,048 45.3 99,389 44.8 9,301.776 42.2

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Windermere & Bowness (including Cumbria England Staveley in Cartmel) Count % Count % Count % 2 cars or vans 1,271 28.1 57,798 26.0 5,441,593 24.7 3 cars or vans 278 6.1 12,825 5.8 1,203,865 5.5 4 or more cars 132 2.9 4,452 2.0 424,883 1.9 No cars 796 17.6 47,578 21.4 5,691,251 25.8 [source: Office for National Statistics]

Employment

2.15 Windermere and Bowness are within the Lake District National Park; statistics for the National Park shows that unemployment across the National Park is lower than the regional and national averages. Table 7 below shows that the number of retired people living in the area is slightly higher than the Cumbria and National averages.

“Unemployment in the national park is lower than regional and national average. In 2012-13 only one per cent of residents were claiming Jobseekers Allowance which is just over 300 people.

“Levels of self-employment are almost double the national rate at almost one in five of the economically active population.” [source: Lake District National Park]

Table 7 - Economic Activity By Type Windermere & Bowness (including Cumbria England Staveley in Cartmel)

Count % Count % Count %

F/T employee 2,523 37.7 136,835 37.1 15,016,564 38.6

P/T employee 1,047 15.7 59,570 16.1 5,333,268 13.7

Full time student 160 2.5 9,170 2.5 1,336,823 3.4

Self-employed 1,366 20.4 39,234 10.6 3,793,632 9.8

Unemployed 177 2.6 12,346 3.3 1,702,847 4.4

Retired 1,404 21.1 66,857 18.1 5,320,691 13.7 [source: Office for National Statistics]

2.16 Information from the Lake District National Park says that “Tourism is the main source of income for the Lake District economy.” For 2018 the number of visitors to the area was:

“Visitor numbers: In 2018, 19.38 million tourists visited the Lake District “Tourist Days: In 2018, there were 28.55 million tourist days in the Lake District” [source: Lake District National Park – figures STEAM 2018 Cumbria Tourism]

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3 Current Primary Medical Services Provision

3.1 Windermere and Bowness Medical Practice provides Essential, Additional and Enhanced services in line with the Agreement. These are8:

Additional Services Childhood Immunisations and Vaccinations Immunisations and Vaccinations Cervical Screening Maternity Medical Services Contraceptive Services Minor Surgery Child Health Surveillance

Directed Enhanced Services HPV completing dose (booster) Meningococcal ACWY freshers Meningococcal B PCV Hib/ Men C MMR (aged 16 and over) Pertussis (Pregnant Women) Pneumococcal Polysaccharide (PPV) Rotavirus Shingles (Catch up) Shingles (Routine) Childhood Seasonal Influenza Seasonal Influenza Learning Disabilities Health Check Scheme Extended Hours Access (now as part of the Primary Care Network DES) Minor Surgery

Local Enhanced Services [NB: all practices have the option of providing these] Morecambe Bay CCG Quality Improvement Scheme (QIS) Anti-coagulation monitoring Minor Injuries Shared Care Post-Operative Dressings Prostate Cancer / Zoladex

3.2 Table 8 below shows the opening times for Windermere and Bowness Medical Practice.

Table 8 – Opening Times Opening Hours Monday 08:00 – 18:30 Tuesday 08:00 – 18:30 Wednesday 08:00 – 19:00 Thursday 08:00 – 18:30 Friday 08:00 – 18:30

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Opening Hours Saturday Closed Sunday Closed

3.3 The national GP Patient Survey shows that patients are less satisfied with the opportunity to speak to their named GP when they choose to do so, as well as having less confidence in the healthcare professional, than both the CCG and national averages. It may be that this is due to the fact that the practice has had staffing issues in the past (see Table 9 below).

Table 9 – Windermere and Bowness Medical Practice: GP Patient Survey Results % of patients % of patients who said they % of patients % of patients % of patients offered a had who found it satisfied with who speak to choice of confidence/ easy to the their appointment trust in the contact the appointment preferred GP when they healthcare practice by times when they last made an professional ‘phone available want to appointment at last appointment

Windermere & Bowness Medical 86 69 16 72 93 Practice

MBCCG average 66 69 48 67 97

National average 65 63 45 60 95 RAG rating: Green = above national and CCG average; Amber = above national but below CCG average; Red = below national and CCG average [source: National GP Patient Survey]

3.4 The nearest A&E department is located at Furness General Hospital which is approximately 24 miles distance and takes 45 minutes by car. The Royal Lancaster Infirmary is a distance of 31 miles but is a slightly quicker journey being 42 minutes by car. Westmorland General Hospital is a distance of 12 miles; the hospital does not have A&E facilities but does have an Urgent Treatment Centre.

Neighbouring Practices

3.5 Windermere and Bowness Medical Practice is one of two GP surgeries located within the area; the other GP practice in Windermere, St Mary’s Surgery, is located close to Windermere and Bowness Medical Practice (approximately 1 mile distance). The area is also served by Community Pharmacies, Dentists and Optometrists.

3.6 St Mary’s Surgery has a branch site in Staveley; this falls within the ward of Staveley in Westmorland. The population for the ward of Staveley in Westmorland is 2,1559. The total patient list size for St Mary’s Surgery (as at 01 July 2020) was 6,168 registered patients (weighted list size: 7,041.55).

3.7 The results of the national Patient Satisfaction Survey for neighbouring practices are shown in Table 10 below.

9 Source: Cumbria Observatory; data as at 2018 ______

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Table 10 – GP Patient Survey (2020) % of patients % of patients who said they % of patients % of patients % of patients offered a had who found it satisfied with who speak to choice of confidence/ easy to the their appointment trust in the contact the appointment preferred GP when they healthcare practice by times when they last made an professional ‘phone available want to appointment at last appointment

St Mary’s Surgery 88 64 68 74 97

Central Lakes Medical Practice, 95 84 78 83 99 Ambleside

Insufficient Insufficient Wraysdale House 100 99 data for this data for this 100 Surgery, Coniston question question

Cartmel Surgery, 100 99 91 97 100 Cartmel

Haverthwaite Surgery, 100 88 86 83 100 Havertwaite

MBCCG average 66 69 48 67 97

3.8 A review of the neighbouring practices’ boundaries shows that St Mary’s Surgery has a similar boundary to Windermere and Bowness Medical Practice. Of the remaining neighbouring practices, Cartmel Surgery’s practice boundary extends to just beyond Bowland Bridge, but does not extend as far east as the A5074. Haverthwaite Surgery also includes Bowland Bridge. However, the boundaries for the two practices (Cartmel Surgery and Haverthwaite Surgery) do not extend as far as Crosthwaite.

3.9 In respect of the map for Central Lakes Medical Practice, it should be noted that the practice was given approval to change its boundary and, therefore, the thick red line (right hand side of page) indicates the new boundary. This excludes the areas of Windermere and Bowness from the boundary for Central Lakes Medical Practice; although these are retained as an outer boundary. The area highlighted in yellow on this map indicates an outer boundary and, therefore, Central Lakes Medical Practice is not obliged to register new patients living in this area. An extract from a letter to the practice from NHS England (Cumbria and the North East) says:

Approval is, therefore, given to reduce the boundary to remove the areas of Bowness and Windermere east of the A591 provided that the practice agrees to retain patients currently registered within these areas. Consequently the parts of Windermere and Bowness which were previously part of the boundary will now be classed as an outer boundary.

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ANNEX 1 – PRACTICE BOUNDARY – WINDERMERE AND BOWNESS

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ANNEX 2 – PRACTICE BOUNDARIES – NEIGHBOURING PRACTICES

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