NHS CROYDON CCG PRIMARY CARE COMMISSIONING ... body/Primary...Surrey Street , Croydon CR0 1RG Page 1 of 112 Croydon Clinical Commissioning Group Primary Care Commissioning Committee

NHS CROYDON CCG PRIMARY CARE COMMISSIONING COMMITTEE

Meeting in Public

Tuesday 4 June 2019 12 00 – 13 20

Markee Room, Croydon Conference Centre,

Surrey Street, Croydon CR0 1RG

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Croydon Clinical Commissioning Group Primary Care Commissioning Committee Meeting in Public

Agenda

Meeting: 4 June 2019, 12 00 – 13 20 Location: The Markee Room, Croydon Conference Centre, 5-9 Surrey St, Croydon CR0

1RG Members of the public are welcome to attend this meeting of Croydon CCG’s Primary Care Commissioning Committee meeting. There will be the opportunity to ask questions during the Open Space. Questions will be limited to one question, plus one supplementary question, per person.

Item Time Lead Enclosure

1 12 00

Apologies for absence Chair Verbal

2 Declaration of Interests

Chair Verbal

3 Minutes of the meeting held on 3 March 2019 For agreement

Chair Enclosure 1

4 Matters Arising Chair Verbal

Governance

5 12 05 Chair’s Report

Chair Enclosure 2

6 12 10 Primary Care Finance Report – Month 12 For noting

Mike Sexton Chief Finance

Officer

Enclosure 3

Transformation

7 12 15 Update on Transforming Primary Care For noting

Martin Ellis Director of Out of Hospital and Primary Care

Enclosure 4

8 12 25 Locally Commissioned Schemes For noting and agreement


Enclosure 5

9 12 35 Primary Care Networks For agreement


Enclosure 6 (To follow)

Assurance

10 12 45 Commissioning Update

• Practice Update

• Contractual Update

William Cunningham

Davis, Director of

Enclosure 7

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For noting and agreement

Primary Care, NHS England

11 12 50 Primary Care Quality Update For noting

Dr Mike Simmonds, GP

Governing Body, GP CQRG Chair

Enclosure 8

Open Space for Public Questions

12 13 00

Any Other Business

13 13 10 Any other business

Chair

Date of next Meetings in Public of

14 3 September 2019 12 00 – 13 00 TBC

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Croydon Clinical Commissioning Group Primary Care Commissioning Committee

MINUTES

Date: 5 March 2019 Time: 12 00 – 13 30 Location: Markee Room, Croydon Conference Centre, Surrey House, 5 – 9 Surrey Street,

Croydon CR0 1RG

Present: In Attendance:

▪ Philip Hogan, (PH) Lay Member Governance and COI, Croydon CCG (Chair)

▪ Tom Chan (TC), GP Medical Director, Croydon CCG

▪ Elaine Clancy (EC), Director of Quality and Governance, Croydon CCG

▪ William Cunningham Davis (WCD), Regional Director of Primary Care, NHS England

▪ Roger Eastwood (RE), Lay Member, Finance, Croydon CCG

▪ Andrew Eyres (AE), Accountable Officer, Croydon CCG

▪ Martin Ellis (ME), Director of Primary and Out of Hospital Care, Croydon CCG

▪ Agnelo Fernandes (AF), Clinical Chair, Croydon CCG

▪ Amy Page (AP), Registered Nurse, Lay Member, Croydon CCG

▪ Mike Sexton (MS), Chief Finance Officer, Croydon CCG

▪ Vaishali Shetty (VS), GP Governing Body Member, Croydon CCG

▪ Mike Simmonds (MSi), GP Governing Body Member, Croydon CC

▪ Emily Symington (ES), GP Governing Body Member, Croydon CCG

▪ Paulette Lewis (PL), Lay Member, PPI

▪ Richard Brown (RB), Medical Director, Surrey and Sussex LMC

▪ Gordon Kay (GK), Health Watch ▪ Simon Keen (SK), Head of Estates

and IT, Croydon CCG ▪ Ben Smith (BS), Board Secretary

(minutes)

Apologies ▪ Jon Norman (JN), Secondary Care Consultant,

Croydon CCG

Apologies ▪ Rachel Flowers (RF), Director of

Public Health, Croydon Council

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Ref: 2019/03/01

1 Apologies for absence Action

1.1 Phil Hogan welcomed members to the meeting. Apologies were noted.

Ref: 2019/03/02

2 Declaration of Interests

2.1

GP colleagues declared their conflict of being commissioners as well as providers.

Ref: 2019/03/03

3 Minutes of the Meeting held on 4 September 2018

3.1

The minutes of the meeting held on 6 November 2018 were agreed as a true record.

Ref: 2019/03/04

4 Matters Arising

4.1

Action log The action log was reviewed and updated.

Ref: 2019/03/05

5 Chair’s Report

5.1 Phil Hogan reported that since the Primary Care Commissioning Committee met on 6 November 2018 in public, there had been three meetings in private due to the confidential nature of the items at the time. The meetings discussed the closure of Downland Surgery, the procurement of Edridge Road Community Health Centre and East Croydon Medical Centre to seek assurance on how the practice intended to address the recommendations of the CQC inspection on their current site. The Primary Care Commissioning Committee noted the report.

Ref: 2019/03/06

6 Primary Care Finance Report Month 6

6.1 6.2 6.3

Mike Sexton presented the Primary Care Finance Report and explained that the overall financial position for Primary Care Delegated Commissioning was in line with the year to date plan. The Committee noted that risks and contractual commitments had been robustly managed without recourse to the contingency fund which had allowed for a small underspend to be forecasted. The Committee noted some volatility on practice list sizes and noted that any surplus from this financial year would be carried forward to next year’s budget. Mike Sexton advised that the delegated primary care allocation had received an uplift for 2019/20 to cater for population increase and contract inflation. The Finance Team were trying to understand the financial implications of the new Primary Care Network DES The Primary Care Commissioning Committee noted the report.

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Ref: 2019/03/07

7 Transforming Primary Care

7.1 7.2 7.3 7.4 7.5 7.6

Martin Ellis reported that NHS England had recently released a five-year framework for the GP Contract reform to implement the NHS Long Term Plan. This included additional investment for General Practice to support the development of networks. The framework outlined how GP practices would form Primary Care Networks covering a geographical population of 30 – 50 thousand with emphasis on the need to develop fully integrated community based health care. This would involve developing multidisciplinary teams, including GPs, pharmacists, district nurses, and allied health professionals working across primary care and hospital sites. The NHS Long Term Plan and the GP Contract reforms were complimentary to the CCG’s direction of travel however there was a need to review and align the new requirements and the funding available to maximise the benefits for patients. Agnelo Fernandes reflected that the proposed changes were one of the biggest changes since 2004 and needed significant support to practices. The Primary Care Commissioning Committee noted that the CCG was actively engaging with key partners such as the GP Collaborative, The Local Medical Committee to support practices and disseminate key messages. The CCG was also attending network meetings to ensure continued engagement. William Cunningham Davis advised that NHS England was supportive of the current plans and support was being provided to practices to form their Primary Care Networks. Paulette Lewis sought clarification on engagement with members of the public. Martin Ellis explained that the locality model brought together a range of stakeholders and members of the public were an important partner. The model was in early stages of development and engagement would happen once there was more clarity. There was an opportunity for GP practices to engage with their Patient and Public Groups to jointly develop their primary care networks. Digital Transformation and Workforce had been highlighted as enablers for the successful implementation of the Long-Term Plan and GP Contract. Martin Ellis advised that the New NHS App would be rolled out in April for the Croydon residents. The app would enable patients to book and manage their GP appointments, order repeat prescriptions, amongst other functionalities. Patients will not be required to go to their practice to verify their identity before they could access the service as was the case during the pilot phase. The removal of this extra step would encourage sign up. The CCG was reviewing how this would complement the local Health Help app. Practices in Croydon were additionally participating in a South West London initiative to trial online consultations working with DoctorLink. Martin Ellis provided an update on the various strands of the Primary Care Transformation.

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7.7 7.8 7.9 7.10 7.11

Extended Access All Croydon residents had access to GP appointments from 8 am to 8 pm seven days a week across the five GP Hubs. An improvement plan was being devised to support service improvement and drive usage up. Primary Care at Scale The Primary Care Commissioning Committee noted that practices had approved the GP Collaborative as their delivery partner for primary care at scale. A programme board with representation from each network had been established to oversee the developments. Proposals would be submitted to the CCG for review and sign off. GP Forward View Practices were on track to spend their allocated investments. Locally Commissioned Services (LCS) and Practice Development and Delivery Scheme (PDDS) Review Martin Ellis reported that the review was on going and the existing LCS had been extended for another year and the PDDS for a further three months to allow time for a review in line with the move towards commissioning from networks rather than practices on a population health basis. Estates The Primary Care Commissioning Committee noted that the most suitable option to support an integrated model for health and well-being services in New Addington was the council’s new hub scheme. Construction consultants had been appointed to undertake a design appraisal and feasibility of the proposal put forward for East Croydon through Estates and Technology Transformation Fund. The Primary Care Commissioning Committee noted the progress on transformation work within primary care.

Ref: 2019/03/08

8 Commissioning Update

8.1 8.2 8.3

William Cunningham Davis presented this report to the Primary Care Commissioning Committee. Contractual Update An update on the contractual changes was presented for information. Practice Update Coulsdon Medical Practice Coulsdon Medical Practice closed on 26 October 2018. Patients had been registering with neighbouring practices and as of 8 February 2019, 481 patients were still registered at the practice

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8.4 8.5 8.6 8.7 8.8 8.9

Edridge Road Community Health Centre East Croydon Medical Centre took over the contract to deliver services at Edridge Road Community Health Centre from 1 February 2019. The new providers had carried out a clinical and administrative review of the practice. The Committee noted the continued work in regards to addressing the recommendations of the CQC inspection report. Performance monitoring would be on going to ensure best possible service for patients. Downland Surgery The Committee noted that Downland Surgery closed at the end of January 2019. William Cunningham Davis explained that as previously reported the Selsdon, Warlingham & Caterham (SWC) Medical group of practices which ran Downland Surgery had been facing the possibility of not having access to the Downland premises and closing that site would enable them to consolidate their resources across their remaining sites. Preceding the proposed closure date, patients had been engaged and had been given the option of registering with another practice within the group or at an alternative practice of their choosing. Thus, by January 2019, a very small number of patients remained registered at Downland Surgery. Attention was drawn to the number of patients who had registered to practices outside of the Croydon CCG area in Surrey. Given the low number of patients registered at Downland was not a viable financial decision the CCG and NHS England took forward a decision, to be ratified by this committee, to allow the practice to close at the end of January 2019. The practice had been in direct communication with vulnerable patients on the Downland Surgery list including patients in nursing homes and had discussed their registration options. The practice closed at the end of January 2019 and a closedown plan had been enacted. The Primary Care Commissioning Committee noted the contracting and practice update and ratified the decision to allow Downland Surgery at the end of January 2019.

Ref: 2019/03/09

9 Primary Care Quality Update

9.1 9.2

Martin Ellis introduced this report and reported that the GP Clinical Quality Review Group was well established and included representation from each of the six GP Networks. The GP CQRG provided a platform for discussion on clinical issues, quality of care, performance and monitoring of underperforming areas within General Practices. The Committee noted that the GP Quality Dashboard had undergone further developments since December 2018 to include new tools and functionalities. The new developments had received positive feedback at the recent GP CQRG and had the potential to enable the Variation

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9.3 9.4 9.5 9.6 9.7 9.8 9.9 9.10

team to provide better support to the team. The dashboard would continue to develop and updates would be provided accordingly. Martin Ellis provided a summary from the GP CQRG held on 23 January 2019. Complaints and Incidents reporting There had been a discussion on the need for effective guidance for GPs setting out the process for reporting complaints, incidents, serious incidents and quality alerts. A draft guidance from NHS England’s Patient Safety Team had been drafted and was being reviewed by key stakeholders before this could be disseminated to practices. DOCMAN 10 The CCG was awaiting confirmation that all previously reported performance issues had been resolved. Plans to roll out DOCMAN 10 (a cloud based system that allows remote access) for all practices were being finalised and the CCG’s GP IT team were ensuring the deployment plan was robust. The March GP CQRG would be reviewing these. Cancer Screening Historically there have been low uptake across London including Croydon. The reasons were complex and multifactorial including socioeconomic and cultural factors. The CCG has been working with the local Cancer UK (CRUK) team to visit practices with a view to support as well as helping practice data was presented in a more accessible dashboard to help focus on areas of need. CRUK would be hosting a networking event in March for primary care focusing on bowel breast and gynaecological cancer. A Task and Finish Group had been set up with representation from Public Health, the Acute Trust. Representation from members of the public was also being scoped. Safeguarding statutory requirements The CCG has a requirement to ensure that the quality of safeguarding practice across the Croydon health economy was fit for purpose and to ensure that there were effective means of supporting practitioners to maintain a satisfactory level of safeguarding knowledge and skills. Self- assessments forms had been sent to all practices. To date 37 forms had been returned the safeguarding team. The returns had been reviewed and feedback had been sent to practices to enable them to improve their level of compliance with safeguarding. Care Quality Commission (CQC) Visits/Ratings report Croydon GP Hubs Following a recent CQC visits all the three GP Hubs had been rated as “good” overall in each domain. GP Practices Last year, there were 3 practices, within Croydon Borough rated as ‘Inadequate’ overall:

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9.11 9.12 9.13 9.14

9.15 9.16

9.17

9.18

• Denmark Road Surgery.

• Edridge Road Community Health Centre

• Coulsdon Medical Practice

At this point, only Denmark Road Surgery remains ‘Inadequate’: Denmark Road Surgery The CCG and the GP Collaborative had been supporting the practice to address the concerns raised at the CQC visit. An action plan had been developed and agreed. This was being implemented. Edridge Road Community Health Centre New providers took over the contract from 1 February 2019 and were working to address the recommendations of the CQC inspection report. A new inspection cycle would be starting this year with the new provider. Coulsdon Medical Practice This practice closed on 26 October 2016. There were three practices who the CQC had rated as ‘Requires Improvement’ overall:

• Shirley Medical Centre

• Brigstock and South Norwood Partnership

• East Croydon Medical Centre Whilst the remaining GP Practices within Croydon Borough had been rated as “Good” overall, some practices had been rated as “Requires Improvement” in one of the CQC’s Quality Domains:

• Violet Lane Medical Practice – “Safe” domain;

• Brigstock Family Practice – “Responsive” domain;

• Addiscombe Surgery – “Safe” domain Two practices had been rated as “Outstanding” in one of the CQCs Quality Domains:

• Friends Road Medical Centre – “Well Led”

• Selhurst Medical Centre – “Responsive” The Primary Care Commissioning Committee had a discussion regarding the role of the GP CQRG in supporting practices to prepare for CQC Visits. It was agreed that the dashboard would be able to provide practices with a roadmap to enable practices to transition to improved CQC ratings. The Primary Care Commissioning Committee noted the report.

Ref: 2019/03/10

10 Open Space for Public Question

10.1 Q: Representative for a local Patient Participation Group, reflected that

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10.2 10.3 10.4 10.5 10.6 10.7 10.8 10.9

they had attended a meeting to discuss the NHS Long Term Plan and the PCN model and wanted to understand what that meant for patients. A: Martin Ellis described the Integrated Care Network Huddles and explained that the multi-agency team proactively planned the care of people with complex health and care needs as well as escalating the needs of those at risk of future hospital admissions. Attending meetings with practices to help design the service was an opportunity for PPGs to contribute and provide patient input. Q: A Local Medical Committee representative in attendance referred to the statutory representatives of practices and reflected that it was a change and welcomed the investment. A: Year 1 was still a small increase with a need for further embedment within the community which would help to make appointments easier to be obtained. Q: A member of the public requested that a glossary be shared with papers in future. A: This would be added to future meeting papers. Q: Member of the public referred to MMR vaccination and wondered whether the increase in measles could be attributed to immigrants coming into Croydon from countries with different vaccination schedules. A: Agnelo Fernandes fed back that Public Health had the responsibility for immunisations including MMR and explained that uptake has been an issue since the initial claims of harm since the 1980s. These claims had been thoroughly debunked, however, uptake had been generally poor. The Public Health team was working on increasing uptake; however, this was a complex matter and a further decrease in uptake noted at the time of the second round of immunisations. Q: Representative from Healthwatch, congratulated the GP hubs on CQC rating and PIC extension.

Ref: 2019/03/11

11 Any Other Business

11.1 11.2

Medical Director resignation The Primary Care Commissioning Committee noted Tom Chan, Medical Director had resigned from the CCG and would be leaving at the end of March. The Committee thanked Tom Chan for all his guidance and support in regards to GP CQRG. There was no other business to discuss.

Ref: 2019/03/12

12 Date of Next Meeting

12.1 4 June 2019, 11 30 – 13 00, Venue TBC

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REPORT TO CROYDON CLINICAL COMMISSIONING GROUP PRIMARY CARE COMMISSIONING COMMITTEE

4 June 2019

Title of Paper: CHAIR’S REPORT

Presenter Philip Hogan Chair of Primary Care Commissioning Committee

Report Author Martin Ellis, Director Primary and Out of Hospital Care Vasudha Rai Business Manager, Primary and Out of Hospital Care

Committees which have previously discussed/agreed the report.

None

Committees that will be required to receive/approve the report

Primary Care Commissioning Committee Governing Body

Purpose of Report For noting

Recommendation:

The Primary Care Commissioning Committee is asked to: ▪ Note the Internal Audit Report: SWL CCGs Primary Care Delegated

Commissioning ▪ Note the updates in regards to the Primary Care Policy Guidance Manual ▪ Note the Chair’s report detailing discussion and decisions of recent meetings.

Background:

SWL CCGs Primary Care Delegated Commissioning Audit Report Since April 2017 the CCG has operated with full delegation from NHS England for the commissioning of primary medical care services. In December 2018, as part of its assurance process NHS England commissioned an internal audit of the delegated commissioning arrangements. Within the confines of the review the auditors’ opinion was that the arrangements of Primary Care Delegated Commissioning were effective and operating well. However, a “reasonable assurance” opinion has been received due to the identification of weaknesses. The auditors have raised four medium management actions have been raised in relation to:

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• absence of a Primary Care Strategy to set out the CCG’s vision for improving the health and wellbeing of Croydon’s population;

• out of date Terms of Reference (ToR) of the Croydon Primary Care Commissioning Working Group.

• out of date terms of reference of the Croydon Primary Care Commissioning Committee (PCCC). Also, there is a requirement within the ToR to have an Independent GP as voting a member of the PCCC to attend meetings for decision making to avoid conflict of interest but there was no evidence that meetings are attended by an Independent GP; and

• absence of South West London Primary Care Quality Dashboard to contribute to effective monitoring and common oversight of quality issues across SW London.

The audit was reasonably assured of the controls in place to manage risks. The Primary

Care Commissioning Committee should note that work was underway to develop a

Croydon Primary Care Strategy. An update was on the agenda.

The terms of reference for the Primary Care Commissioning Committee was updated and

approved at the Committee held on 4 September 2018. The audit had not reviewed this.

The inclusion of an independent GP is being reviewed as part of the wider

transformational work across SWL. The terms of reference for the Primary Care

Commissioning Working Group are being reviewed and would be ratified at a future

Primary Care Commissioning Committee.

A Primary Care Quality Dashboard has been developed and is discussed at Primary Care Clinical Quality Review Group as well as Network and GP Open Meetings. An update from the meeting is provided at the Primary Care Commissioning Committee. Primary Care Policy Guidance Manual The Primary Care Commissioning Committee held on 4 September 2018, approved the Primary Medical Care Policy and Guidance Manual. This policy and guidance manual has been updated to reflect the changing landscape in primary care commissioning. The suite of policies should be followed by all commissioners of NHS Primary Medical Care to ensure that all commissioners, providers and most importantly patients are treated equitably and that NHS England and CCG’s meet their statutory duties. Amendments have been made on chapters in regards to National Procurement Support Contract, Premises Running Costs, Service Charges and some smaller amendments. The manual is available online at: https://www.england.nhs.uk/publication/primary-medical-care-policy-and-guidance-manual-pgm/ Meetings Held in Private As per the Terms of Reference, the Committee meets in public at least quarterly, except as otherwise agreed by the members. Since the Primary Care Commissioning Committee met on 3 March 2019 in public, there have been two meetings in private due to the confidential nature of the items at the time. This report provides an update of those items/issues that are no longer confidential and provides a summary of the outcome of discussions.

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The meetings discussed the following: 12 April 2019: Locally Commissioned Schemes: Service Specification for Care Homes and Ear Syringing. 30 May 2019: Primary Care Networks Locally Commissioned Schemes The Committee convened on 12 April 2019 to discuss and approve the service specification for Care Homes and Ear Syringing services. Service Specification for Care Homes The Primary Care Commissioning Committee noted that the current care home LCS incentivised GPs to provide enhanced care on the basis of £200 per patient. This applied only to nursing homes, and the rate has remained flat for several years. It was proposed that the rate be uplifted from £200 per patient to £220 to help improve the distribution of work amongst general practice as well as make the LCS more attractive. It had been recognised that 45% of the acute demand from the care home market came from residential homes, and it had been proposed to expand the LCS to incentivise enhanced care to residential homes. The proposed payment for this would be £120 per patient in line with the differences in the patient cohort. The Committee discussed the funding for the service and noted that £80k of Primary Care contingency (£270k) will be used to support the scheme. The Committee noted the clinical engagement and leadership in developing the specification as well as outcomes that would be delivered. The Primary Care Commissioning Committee approved the service specification for care homes and the proposed payment rates. Ear Syringing All practices are expected to provide essential and additional services that they are contracted to provide to all their patients. Ear syringing is not a contractual requirement and GP practices are not obliged to provide this service and that commissioning this service at a primary care level would be in line with two of the CCG’s strategic objectives; keep care closer to home and support sustainability of the local system. The Committee noted that the CCG had carried out some benchmarking to understand the cost implications and had engaged with the Local Medical Committee to agree a local rate. It was proposed that this would be £14 per patient and an overall budget of £65K would need to be allocated to this service. This would be funded from the primary care growth funding. The Primary Care Commissioning Committee approved the service specification for ear syringing provided through Locally Commissioned Services (LCS) at a cost of £14 per patient.

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Primary Care Networks The Primary Care Commissioning Committee convened on 30 May 2019 to review Primary Care Network (PCN) coverage for the Croydon Population. This is on the agenda for the June meeting. PCNs are groups of GP practices working more closely together with other primary and community care staff and health and care organisations, providing integrated services to their local populations. The PCN Contract Directed Enhanced Service (DES) was included in the five-year GP contract framework from 2019/20. The DES specification states that PCNs will typically serve populations between 30k-50k and as part of the registration process a network agreement setting out the ways of working was required as well as appointment of a clinical director.

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Governance:

Corporate Objective To commission integrated, safe, high quality service in the right place at the right time.

Risks Risk that the quality of GP services delivered deteriorate.

Financial Implications None as a result of this paper.

Conflicts of Interest None.

Clinical Leadership Comments None.

Implications for Other CCGs None.

Equality Analysis

Undertaken as part of the procurement process

Patient and Public Involvement

The CCG is working with its patient and public reference group to identify patient experience and any associated risks to quality and safety.

Communication Plan None.

Information Governance Issues None.

Reputational Issues

Failure to have continuity of GP services for the local population will have an adverse impact on the CCG’s reputation.

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REPORT TO CROYDON CLINICAL COMMISSIONING GROUP PRIMARY CARE COMMISSIONING COMMITTEE HELD IN PUBLIC

04 JUNE 2019

Title of Paper: 2018/19 PRIMARY CARE FINANCE REPORT: PERIOD 12 (MARCH 2019)

Lead Director Mike Sexton, Chief Finance Officer

Report Author Edward Odoi Chief Management Accountant

Committees which have previously discussed/agreed earlier version of this report.

Senior Management Team – 23 April 2019 Finance Committee – 23 April 2019 Governing Body – 07 May 2019 Clinical Leaders Group – 01 May 2019

Committees that will be required to receive the report

Purpose of Report For discussion and noting

Recommendation:

The Primary Care Commissioning Committee is asked:

▪ To note that 2018-19 financial performance for Primary Care is reporting an outturn position of £0.2m overspend. The two component elements of the budget are summarised below:

▪ Primary Care Services (£51.6m annual budget including Prescribing): outturn position of £0.4m overspend.

▪ Primary Care Delegated Commissioning (51.8m annual budget): outturn position of £0.2m underspend.

Background:

Following the publication of the Primary Care Medical allocations as part of the place-based funding for all CCGs, CCGs taking full delegation received the funding direct as a separate Medical Services recurrent allocation. NHS Croydon CCG now has full delegation of primary care medical services from April 2017. The allocation is provided solely for commissioning Primary Care Medical services on behalf of NHS England under delegation therefore cannot be used for other CCG expenditure or vired to another budget area.

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Key Issues:

This finance report reflects 2018-19 Primary Care related expenditure. Cost pressures and benefits identified have been included in the reported position.

Governance:

Corporate Objective To achieve financial surplus of £1.2m in 2018/19

Risks The CCG achieved the £1.2m surplus required.

Financial Implications The CCG achieved the £1.2m surplus required.

Conflicts of Interest No specific conflicts of interest.

Clinical Leadership Comments Clinical Leadership Group is supporting the delivery of the QIPP and transformation programme.

Implications for Other CCGs Croydon CCG works closely with the other SWL

CCGs as part of the SWL Health and Care

Partnership.

Equality Analysis All QIPP and expenditure programmes are

required to have an EIA, compliance monitored

by the PMO.

Patient and Public Involvement All service redesign, QIPP projects and

expenditure reductions must meet the requisite

PPI requirements.

Communication Plan The 2018/19 Financial Position and QIPP Programme have been share in the public domain and with stakeholders.

Information Governance Issues

Restrictions on access to patient level activity data limiting the ability of CCG to review provider performance and to monitor some QIPP schemes.

Reputational Issues Delivery of financial plan. After 2 years, the CCG is no longer in (Financial) Special Measures as a result of the improvement in the annual overall assessment.

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Primary Care Finance Report – 2018/19 Outturn 1. Overview: Croydon CCG is reporting an outturn position of £0.4m overspend for Primary Care Services and £0.2m underspend for Primary Care Delegated Commissioning for 2018/19. 2. 2018/19 Budgets: The combined total Primary Care annual budget of £103.5m includes £51.8m for Primary Care Delegated Commissioning, £42.7m for Prescribing, £5.4m for Community Based Services, £2.3m for Practice Transformation Support (GPFV) and £1.3m for Primary Care IT. The budgets were set based on commitments and to meet all known costs in line with current contractual obligations. The budgets include an allowance for both demographic growth and a 2% increase for premises cost increases. The CCG received £1.9m via South West London Health and Care Partnership (SWL HCP) to fund the Primary Care at Scale (PCAS) and Extended Access programmes. 3. Capitation Report

CCG

Normalised weighted list

as at 01/04/2017


as at 01/04/2018

Year on Year % Movement


as at 01/01/2019

YTD Movement 01/01/2019

% YTD Movement

Full Year budgeted Growth %

Croydon 374,428 377,819 0.9% 379,888 1,873 0.5% 1.1%

Croydon’s normalised weighted population increased by 0.9% (3,391) year on year from April 2017 to April 2018 and a further increase of 0.5% (1,873) from April 2018 to April 2019. 4. Primary Care Expenditure: The 2018/19 full year outturn for all NHS Croydon CCG Primary Care Services is set out in tables below.

2018/19

Annual

Budget

2018/19

Outturn

Var

£000s £ 000s £ 000s

Primary Care

Prescribing 42,655 43,348 693

Community Based Services 5,414 4,661 (752)

Practice Transformation Support 2,268 2,332 64

GP IT Costs 1,289 1,670 382

Total Primary Care 51,625 52,012 386

Primary Care Delegated-Commissioning 51,836 51,600 (236)

FULL YEAR

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Primary Care Services (2018/19 Outturn)

COST CENTRE NAME 2018/19

Annual

Budget

2018/19

Outturn

Var

£000s £000s £000s

Medicines Management 1,810 1,600 (211)

Prescribing:

GP Practice & Specialist Clinics(Inc. IPP-PMd Adj.) 37,248 38,798 1,549

PADM (Cost of Drugs) 1,127 1,206 79

Prescribing Cost Recharge (186) (592) (406)

Community Education Provider Network(CEPNs) 11 (10) (21)

Medicines Optimisation - Community 100 100 -

Minor Ailments 216 200 (16)

Lipid Modification Proj 31 1 (29)

Drugs Met Centrally 1,245 1,237 (8)

New Oxygen Service 522 379 (143)

Scripswitch/Eclipse/Presqipp 195 101 (94)

Prescribing Incentives Scheme 336 328 (8)

Sub Total 40,845 41,748 903

Sub-total: Prescribing 42,655 43,348 693

Local Incentives Schemes:

Urology 16 50 34

Phlebotomy 288 233 (55)

Phlebotomy - CHS 173 173 (0)

Coeliacs 7 14 6

Barretts 39 30 (10)

Spirometry 176 145 (31)

Care Homes 339 379 41

Cardiology 85 117 32

MGUS CLL 5 - (5)

Mental Health LES 32 - (32)

Pre-Op Hernia 6 17 11

Diabetes 175 141 (34)

Basket 519 452 (68)

PDDS & GP E-Referral excluding Prescribing Incentive Scheme 2,464 2,494 30

Prior Year Impact of the LISs Above - (512) (512)

Primary Care - £3 per head (50%) 607 651 44

Planned Care Investment 213 - (213)

Sub Total 5,144 4,383 (761)

Primary Care Other:

Rainbow PCTMS 74 37 (37)

Collaborative/Assessment Fees Claims 195 241 46

Primary Care Other 270 278 9

Sub-total: Community Based Services 5,414 4,661 (752)

GPFV

Reception and Clerical Training 70 75 5

Online Consultations 137 137 (0)

Improving Access to General Practice 1,014 1,073 59

Primary Care at Scale (PCAS) 1,047 1,047 -

Sub Total 2,268 2,332 64

GP IT 1,289 1,670 382

Grand Total 51,625 52,012 386

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Primary Care Delegated Commissioning (2018/19 Outturn)

COST CENTRE NAME 2018/19

Annual

Budget

2018-19

Outturn

Var

£000s £000s £000s

Primary Care Medical Services (PMS,GMS,APMS)

Essential and Additional Services 38,980 39,174 194

Enhanced Services 1,337 1,303 (34)

Quality and Outcomes Framework (QOF) 4,324 4,272 (52)

Premises Payment 4,495 4,416 (79)

Seniority 358 330 (28)

Other Administered Funds (Maternity etc) 534 661 127

Personally Administered Drugs 223 246 23

Other Medical Services 193 240 47

0.5% Contingency 261 - (261)

Prior Year Accruals - 158 158

Primary Care Transformation - OOH 800 800 -

Primary Care Transformation 333 - (333)

Total Primary Care Delegated Commissioning 51,836 51,600 (236)

FULL YEAR

5. Financial Performance Summary The CCG is reporting an outturn position of £0.2m overspend. Essential and additional services costs are reported as £194k over budget. £312k of the overspend is due to the announcement of the increase in the Global Sum value to further fund GP and practice staff salaries, £33k reflects the agreed additional £20 per patient payments made to practices registering patients from a closing practice. These overspends in core contract costs are partially offset by the implementation of Out of Hours deductions on five practices previously not receiving the deduction providing a £100k saving in year. Additional saving on the list size growth reserve is included in the results. There is an under-spend of £34k on budget for enhanced services, this is primarily a reflection of the claw-backs to be applied for the extended hours DES for non-achievement in Quarters 1 and 2. Seniority costs are £28k better than budget. Premises costs are £79k below budget primarily attributable to the rent charge from NHSPS for Impact House being less than last year. The locum costs budget was based on last year’s outturn, but this year the activity has increased, and following an exercise to identify costs that will no longer be incurred the final outturn was a £127k overspend on budget.

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The 2018/19 QOF achievement cost were £52k below budget. Personally Administrated Drugs and Medicines payments are £23k over budget.

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Page 1 of 2

REPORT TO CROYDON CLINICAL COMMISSIONING GROUP PRIMARY CARE COMMISSIONING COMMITTEE MEETING IN PUBLIC

4 June 2019

Title of Paper: Update on Transforming Primary Care

Lead Director Martin Ellis Director of Primary and Out of Hospital Care

Report Author Leilla Thomas Head of Primary Care


None


Primary Care Commissioning Committee


Recommendation:

The Primary Care Commissioning Committee is asked to: ▪ Note the progress against primary care transformation areas, ▪ Consider the proposed approach to transformation in 2019/20

Background:

This paper summarises the investment in primary care transformation during 18/19, and the progress as a result of this in relation to General Practice working at scale. It describes an approach to further support Primary Care Network development, based on the work that has taken place during 18/19 with the existing networks and GP Collaborative, and using feedback from our primary care commissioning workshop, as well as national guidance. We have also included progress against extended access, including feedback from a visit from NHSE and a summary of an improvement plan from providers. There is also a summary of the transformation programmes that are being coordinated by the South West London Health and Care Partnership.

Key Issues:

Croydon CCG has already embarked on a journey to develop integrated care networks, and PCN development needs to be considered alongside this. The paper includes an approach for invested 19/20 transformation funding, in line with the guidance received on PCN development and extended access and includes the requirements for planning.

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Governance:

Corporate Objective To develop as a mature membership organisation To commission integrated, safe, high quality service in the right place at the right time. To have collaborative relationships to ensure integrated approach

Risks

Failure to agree an approach to transformation funding in 19/20 may delay investment available being received.

Financial Implications

Additional funding from the new contract is yet to be confirmed

Conflicts of Interest

All clinical members of the Governing Body, CLG & other clinical leads are eligible to access transformation funds through the agreed process.

Clinical Leadership Comments

Implications for Other CCGs

There are no known implications for other CCGs.

Equality Analysis

The plans to work at scale ensure that general practice is resilience and sustainable in order to deliver services across our c.420k patient population including current and future workforce.


Conversations started with Healthwatch

Communication Plan N/A


N/A

Reputational Issues

Failure to agree plans for transformation in 19/20

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Transforming Primary

Care

May 2019

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Table of Contents

Background ..................................................................................................................... 3

Primary Care Networks ................................................................................................... 4

Transformation Funding ................................................................................. 7

Extended Access ............................................................................................................. 8

LCS Review ............................................................................................................. 9

SWL Primary Care Programme ....................................................................................... 9

Primary Care Strategy …………………………………………………………………………10

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1. Background

This paper gives an update to the committee on key areas of primary care transformation in

Croydon, including an update on Primary Care Network (PCN) development and feedback from a

Primary Care Commissioning Committee (PCCC) workshop. It summarises key areas of investment

in 2018/19 and sets out the approach to developing a local strategy and investing the second year of

transformation monies to deliver the regional plan.

During 2018/19 Croydon Clinical Commissioning Group (CCG) received £1,055,000 to support the

development of primary care at scale, and £1,073,000 to support extended access. In addition to

this the CCG has invested £1,188,700 to support implementation of the 10 high impact actions to

support General Practice identify new ways of working as part of the additional GPFV investment.

The investment has supported practices to explore initiatives in their current network arrangements

to improve population health and reduce workload based on population health need, some of which

are described below as well as providing the national specification for extended access. The

Croydon GP Collaborative have provided the infrastructure to coordinate many of the schemes and

established a programme board to review and monitor the initiatives, with a view to sharing of best

practice and gaining economies of scale.

Initiative Aim Challenges Outcomes

Home Visiting

Service

Increase GP capacity

through providing a network

home visiting service

delivered by paramedics

Developing the network

and federation

infrastructure to plan and

deliver the service

Increase GP capacity, reduction

in LAS call outs from patients.

Establishment of network-based

workforce

Organisational

Development

Strengthen the leadership

from primary care to plan and

implement working at scale.

Managing demand for

attendance at the

programme.

Improved staff satisfaction.

Increased number of primary

care staff in leadership roles.

Cervical

Screening

Reduce Cervical Cancer rate

by early detection/screening

for abnormal cells

Upskilling Nurses;

Proactive pursuit of

patients for screening

80% of patients tested &

adequately signposted based on

outcome of testing. Earlier

Cervical cancer detection.

Clinical

Pharmacist

Medication Management &

Review

Recruitment & Retention This has proven to relieve GP

workload in other networks/areas

Audit and

Analysis

Develop the capacity to

review and monitor primary

care data

Capacity to manage the

analysis

Better intelligence to support

network development

Social

Prescribing

Support and empower

patients to be access self-

care and other support

Coordinating programmes

across Croydon

Improved patient experience and

increased GP capacity

Extended

Access

Provision of extended

primary care to all patients

registered with a Croydon GP

Developing the IT

infrastructure to support

interoperability and direct

booking

Access to primary care services

8-8, 7 days a week

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In addition to the initiatives described in the table, transformation funding has also been used to

support multi-professional leadership development in Croydon CCG through an emerging leaders

programme. As a result of this there have been a number of new clinical and management leads

supporting local transformation. Primary Care at Scale Funding has been used to commission the

course during 19/20, and we have encouraged those involved in leadership of emerging PCNs to

attend. There is scope to expand on any of the above schemes that will support PCN development

through 19/20 transformation funds from NHS England

The new contract guidance sets out a contractual mechanism for PCNs as described in the NHS

Long Term Plan, supported by additional investment through a Directed Enhanced Service (DES).

This will enable the 6 existing networks to develop into PCNs as described in the Long-Term Plan.

The development of PCNs is phased over the next few years, with the responsibilities for networks

in terms of service delivery and engagement increasing. This paper sets out the requirements for

transformation as part of PCN development and sets the context and timelines for the development

of a Croydon Primary Care Commissioning Strategy.

2. Primary Care Networks

The new contract guidance and NHS long term plan place PCN at the heart of delivering place-based care. Primary care networks will need to deliver care to their identified registered population, but also work with the whole system on transformation, with a view to removing the divide between primary care community care, and greater integration with acute services. In future, NHS England will ensure that predictive analytical tools are available to PCNs to set out progress on network metrics, covering population health, urgent and anticipatory care, prescribing and hospital use. This will help the networks to plan and deliver services as well as identify population need. However, this is currently a gap. Each PCN will have a named accountable Clinical Director and a Network Agreement setting out the collaboration between its members. Together, the Clinical Directors will play a critical role in shaping and supporting their Place Based Care System and dissolving the historic divide between primary and community medical services. PCNs will also be funded to recruit additional workforce to support them to deliver population health outcomes. The development of PCNs is a phased approach, that is supported through additional services over the next few years that will help practices to adopt a population health approach and work more closely with the wider system. The Croydon GP Collaborative has started discussions with practices to understand how they can support the PCN infrastructure, including through development of a cabinet of PCN directors to maintain a One Croydon voice. As part of signing up to the DES, practices need to sign a network DES agreement that will describe how they will work together. From 1920/21, the agreement will also need to describe the relationship between PCNs and wider stakeholders. Practices have until the end of June to develop these agreements. The One Croydon Alliance has already started on a journey to integrate health and care systems across the borough and has a vision for how they will plan and deliver services based on population need with primary care at the centre of this model. See the illustration below regarding Integrated Community Networks plus. Once the PCNs are established, the new Clinical Directors will need to influence and lead how the primary care networks become integrated with wider health and care services. In order to support this, the CCG will facilitate discussions with the PCNs and The One Croydon Alliance.

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The success of a PCN will depend on its ability to develop its infrastructure during 2019/20. This will include developing a leadership and delivery model across a group of practices and changing the way practices have worked together historically. While practices have had some experience of this during 2018/19, the requirements for PCNs involve sharing finances, leadership and staffing in a way that has not happened previously. PCN Clinical Leads will be funded based on 0.25 WTE per 50,000 population. Given the requirements to provide leadership to the network, as well as the system, this may need to be supplemented. PCN Directors will need time to develop their relationships to understand how they can work collaboratively, as well as any support they need. As General Practice is the core unit of PCNs, it is important that any perceived weaknesses are addressed as well as any variation to form a standard offer to build upon. It is also important to recognise that PCNs are larger organisations with increased responsibility, and staff need to be supported to develop their capabilities accordingly. Croydon CCG will receive £2,359,624 to support the development of PCNs and deliver extended access in 2019/20 subject to meeting national requirements. A workshop was held in April to allow the PCCC to explore the development of PCNs in Croydon alongside the local primary care team. This was an opportunity to discuss the strengths, weaknesses, opportunities and threats of General Practice, and explored some of the developments needed to support PCN implementation, to identify the gaps. Outcomes of the workshop will be shared at the May GP open meeting and June network meeting to

explore these themes further as part of developing our primary care strategy, and to explore the

opportunities for addressing the gaps with the additional investment to support PCNs and extended

access in 19/20.

The table below summarises the views of the PCCC around the strengths, weaknesses, opportunities and threats to General Practice.

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It was suggested that working together as a collective would help to manage some of the threats

and weaknesses. However, some areas of support would be needed to strengthen management

capabilities and improve the infrastructure.

Due to the timescales of PCN formation, practices have not yet had time to develop their thinking

around their role as part of the PCN. Practices will need to submit further information by the end of

June to describe their operating model, and this will include details around decision making.

Practices will be given time to meet as PCNs in their June network meetings to facilitate this.

Practices in Croydon CCG have grouped themselves into 9 proposed PCNs with list sizes varying from 30,000 to 75,0000. While some of these formations are within current network boundaries, there have been some changes which will need further discussion once approved. Additional support may be needed for those larger PCNs to not disadvantage them in year 1. PCNs will need to set their own agendas and manage their meetings as per the contract guidance.

Croydon CCG has traditionally used network meetings as an opportunity to engage with practices

round transformation and variation. In order to continue to support this, the primary care team will

provide PCN Clinical Directors with information from the quality dashboard and be available to

present when invited.

It is proposed that open meetings are held monthly, so that the CCG has an opportunity to engage

with practices on a regular basis. Representation at CLG will need to be amended to include the

PCN Clinical Directors, and further planning will be needed to support PCNs to have representation

in other relevant forums to allow them to influence transformation and system integration.

The table below sets out areas of development suggested by the PCCC workshop. These are based

on perceived gaps in the General Practice business model, Clinical leadership, Primary Care

Network Capabilities and Extended Access Provision. These domains were chosen due to the

immediate responsibilities of PCNs in these areas. Views from the newly formed PCNs will be

sought as to whether these are the perceived gaps, and how these areas can be supported.

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In addition to local offers for PCN development, the national team will also be providing support

through regional workshops and development programmes. There will also be case studies

produced through accelerator sites chosen nationally to help shape PCN development.

3. Transformation Funding

Croydon CCG has been allocated £ 2,359,624 of Transformation Funding to support PCNs and delivery of Extended Access. The guidance from NHSE states that investment is to be spent on acceleration of at scale transformation work which will build on and be an addition to existing STP/CCG or national funding streams and must directly support the development of general practice working at scale.

Spend plans will be collaboratively defined and monitored, and SWL HCP will need to engage with both CCGs and providers to define plans for investment, and to monitor spend and impact. CCGs will need to engage with all leads of at scale providers during this process. For Croydon, this would be the PCN leads, the GP Collaborative and our extended access providers.

Each initiative will need to have clear and defined measures of success and would need to be based on the Next Steps Guidance around primary care at scale. The first phase of plans will need to be submitted by the end of the first quarter. The table below sets out an example of how transformation funding could be invested in 19/20 to support development of PCNs and delivery of the extended access requirements. The example will be shared at the GP Open Meeting, and proposals will be

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developed through the primary care at scale programme board, which will have representation from the emerging PCNs. Final proposals will be approved by the finance committee prior to investment.

Expansion of roving clinician service across the PCNs £ 212,286.00

Coordination of recruitment activities for social prescribing and pharmacists £ 38,961.08

OD support for each PCN £ 150,000.00

Additional support for super PCNs to support neighbourhood development £ 175,846.00

PCN Development £ 409,530.92

Delivery of extended access £ 1,073,000.00

Extended Access improvements £ 300,000.00

£ 2,359,624.00

Plans for expansion and variation of existing services funded with year 1 of transformation monies

will be developed by the current providers and submitted as improvement plans or variations to

existing contracts with clear outcomes and timescales. Where a new initiative is being proposed,

such as support for PCN development, the primary care team will develop these in partnership with

the LMC, PCN leads, GP Collaborative and other relevant stakeholders.

4. Extended Access

There are 5 GP Extended Access Hubs in Croydon, which means all patients registered with a

Croydon GP have access to primary care from 8am – 8pm, 7 days a week either at their own

practice or from a GP hub site. Appointments are pre-bookable, and there is also direct booking

through 111.

Currently utilisation rates for the extended access hubs is only at 45% against a target of 75%; this

is an improvement from a utilisation rate of 36% in December. The current providers have been

asked to develop a joint improvement plan which will demonstrate how they will improve utilisation

through improving patient engagement, increasing the services available at hubs, and facilitating the

ability to book an appointment at the hub.

Providers have been sharing the data and information around extended access hubs at network

meetings to engage practices and promote the service. Some changes to the infrastructure including

ability for patients to be seen at any site, and telephone access to hubs may help improve the

service. If the joint improvement plan is agreed, any additional resource for improvements would be

sourced through this year’s access and primary care at scale funds.

NHSE visited the Purley extended access hub in March to discuss the service and proposals for improvement and agree with our approach as follows:

1 – Short- to medium-term (March 2019 and into April 2019): providers and commissioners to work collaboratively to develop an action plan to ensure the delivery of all seven Extended Primary Care Service (EPCS) standards by April 2019. 2 – Medium to long-term (throughout 19/20): the current EPCS provider contracts run until March 2020. The commissioning team described their ambition to optimize the opportunities this offered to support their providers in developing a general practice focused, collaborative EPCS provision that aligns with:

• Extended access core standards and 19/20 guidance

• Collaborative working

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• The Long Term Plan

• Other changes in the local provider landscape

As a response to this the providers have shared an improvement plan which describes how they will:

• Agree consistent provision across Croydon that meets the new specification requirements.

• Ensure that hub sites are accessible to all Croydon patients

• Carry out a marketing exercise to promote the availability of extended access

• Improve ability to make and change appointments, including directly bookable by 111

• Develop a single structure for the management and delivery of the service to support further

system integration.

5. LCS Review

An LCS framework has been developed to support the review of existing services, and to support

the commissioning of any new services. The framework ensures that there is a consistent approach

to commissioning of local services, and includes the processes needed to ensure that contracts are

robust with clear outcomes. Each LCS will be reviewed against the framework and

recommendations made for services from the 1st April 2020. The framework also takes into account

the ability for CCGs to commission services from PCNs.

During 19/20 there have been additional services to support patients in residential homes and ear

syringing. The PDDS schemes have also been transferred to LCS from the 1st July 2019 and while

commissioned from General Practice, have scope for development into PCN-based services in

future. There are also plans for a mental health LCS.

The framework supports services that meet any of the CCG commissioning priority areas or population health need, and addresses variation through requiring population coverage. Any services that do not meet the framework will need to be reviewed by the clinical and commissioning leads.

6. SWL Primary Care Programme

There are several programmes that are coordinated and supported by the South West London

Health and Care Partnership (SWL HCP). This includes practice resilience, patient online, and

recruitment and retention. Working across the region for these areas allows us to benefit from

economies of scale in planning and delivery.

The IT solution Doctorlink has been procured for usage across SWL, and 4805 patients have

registered to use this symptom checker function across four practices in Croydon. We have had

positive feedback from those practices that are using the service and aim to have 50% of practices

signed up by the end of July. Merton and Wandsworth have been selected as the digital accelerator

site for SWL and are leading on developing the ‘digital front door’ as part of the NHS app to improve

access. Learning from this will be applied across the region and shared nationally.

SWL HCP are coordinating programmes to support recruitment and retention of primary care staff.

This includes the international GP recruitment programme, implementation of the 10-point nursing

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plan to support practice nurse recruitment and retention and supporting the local training hubs with

schemes such as mentoring, induction and peer support as part of our efforts to retain our

workforce.

There are ongoing discussions around the alignment of commissioning and contracting functions for

primary care to strengthen our ability to manage this across SWL, and to help reduce conflicts of

interest. Primary care transformation would continue to remain at a local level and be part of our

approach to place based care so as not to lose local engagement and leadership.

7. Primary Care Strategy

Croydon CCG is developing a primary care strategy that will set out an approach to commissioning

primary care services that supports the wider vision for place-based care in Croydon. The strategy

will set out the plans for further development of PCNs in the context of ICN+ and the One Croydon

Alliance. The primary care strategy will be presented at the September PCCC for approval.

In addition to the development of the local primary care commissioning strategy, NHSE has asked

each region to develop a strategy that sets out how the key components of the GPFV will be

delivered at a regional level. This will focus on Extended Access, PCN development, Online

Consultations, Practice Resilience and workforce development. Our local strategy will describe how

this will be implemented and reflect our local need.

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REPORT TO CROYDON CLINICAL COMMISSIONING GROUP PRIMARY CARE COMMISSIONING COMMITTEE HELD IN PUBLIC

4 June 2019

Title of Paper: LOCALLY COMMISSIONED SERVICES & FRAMEWORK

Lead Director Martin Ellis Director of Out of Hospital and Primary Care

Report Author Shola Oke Primary Care Programme Lead, Croydon CCG


Procurement Advisory Group – 22 May 2019 Senior Management Team – 28 May 2019 Primary Care Commissioning Working Groups


Primary Care Commissioning Committee

Purpose of Report For noting and approval Recommendation:

The Primary Care Commissioning Committee is asked to:

▪ Approve the draft Locally Commissioned Schemes (LCS) Framework.

The Committee is also asked to note the following specifications:

▪ The Enhanced Care Homes LCS specification ▪ Elective Care Delivery Transformation Programme ▪ Proactive Management LCS ▪ Mental Health LCS

Background:

Following on from the CCG’s Primary Care Committee’s decision to allow the CCG to proceed

with reviewing all the LCS, a new LCS framework has been developed outlining a set of new

requirements that will enable the CCG to complete a robust assessment of all the current LCS

with a view towards:

• Decommissioning the services which are no longer required from April 2020

• Re-commissioning existing services or new services in line with Croydon’s Health and Care Transformation Plan’s priorities

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The Draft LCS Framework has been developed in line with Croydon’s Health and Care

Transformation Plan 2019/2- 2024/25) priority outcomes and also the objectives of NHS Long

Term Plan to allow the CCG to continue to support people to stay well for longer, and delay

and avoid more people from becoming acutely unwell in the first place.

As part of our journey towards delivering better outcomes for our patients we have updated

our Enhanced Care Homes Specification to reflect the previously agreed uplift of

remuneration for nursing homes residents and extension to residential homes, and will be

backdated to 1st April 2019. Our new service specification has been developed for

implementation from 1st July 2019 to formalise these changes. Practices who are not currently

providing this service will be offered the opportunity to sign up to the revised specification.

We have also developed the Elective Care Delivery Transformation Programme and the

Proactive Care Management LCS as replacement specifications following on from the CCG’s

decision to decommission the PDDS contracts from June 2019, these two service

specifications will be funded through a redistribution of the PDDS funding for quarter 2 to

quarter 4 for 2019/20 and will apply from 1st July 2019 and aim to ensure:

• Continuation of peer review and demand management approach

• Continuation of the proactive management through care planning and huddle review for patients with complex needs.

Through our community transformation programme, we intend to continue to ensure that our

patients are at the centre of care, with the registered GP providing, managing and

coordinating the care received. A key part of this is the development of an improved wrap-

round offer in Primary Care for patients who have long-term or complex mental health needs.

We recognise that our GPs are central to coordinating this care and we have now developed

a new Mental Health LCS to provide GPs with appropriate remuneration to deliver care to

patients who have complex needs through proactive engagement and support. The service

will also enable CCGs to meet the requirements set out in the Long-Term Plan to ensure that

patients with mental health needs receive annual physical health checks. This LCS is

supported by the CCG CGP Clinical Lead.

The costing of the service has been benchmarked below with other London CCGs and is in

line with what other CCG’s have rolled out to support this patient cohort.

Benchmarking

CCG Annual

Review Cost

(£)

Follow

up Cost

(£)

Number of

Follow Ups

Total

LCS Cost

(£)

Croydon CCG 90 45 2 180

Central

London, West

London,

93.19 43 1-2

(dependent

on CGG)

136 (1

Follow

up)

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Hammersmith

and Fulham,

Hounslow,

and Ealing

CCGs

£179 (2

Follow

ups)

Brent,

Hillingdon,

Harrow CCGs

90 No

Follow

up

0 90

Recommendation: The Primary Care Commissioning Committee is asked to approve the framework and note the specifications with the following principles:

▪ The LCS review is currently underway to ensure we are in a position to commission services which are fit for purpose from April 2020.

▪ All LCS will be contracted with practices as part of the NHS Standard Contract ▪ The Proactive Management and Care Home LCS represent interim arrangements

for the remainder of 2019/20 only ▪ Discussions are still on-going with LMC relating to the 8% referral reduction outlined

within the Elective Care Delivery Transformation Programme.

Governance:

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Corporate Objective To ensure all LCS are commissioned in line with the priority outcomes of Croydon’s Health and Care Transformation Plan 2019/2- 2024/25).

Risks

• The review is expected to be jointly completed with SME’s and also Commissioners, however most of the existing LCS do not have clinical leads and this could create an issue for some of the future services which need to be redesigned and re-commissioned in line with organisation’s priorities.


• The outcome of the LCS review will result in a new model of care which could potentially have some financial implications that would impact on the current budget.

• Outpatient activity will increase which will be a financial burden for the CCG.

• The Proactive Management LCS is focused on complex patients’ cohorts which is quite costly and these costs could potentially increase if not commissioned via this LCS.

• The increase in funding for the Care Homes LCS has already been approved by SMT and PCC in April 2019.


Conflicts of Interest have been managed where appropriate as per the Conflicts of Interest policy.


None

Equality Analysis

Plan to improve access for all patients which need to access any locally commissioned services closer to home.


Not applicable

Communication Plan Not applicable at this stage


Nil Known

Reputational Issues

1. A decision to not adopt this framework could potentially lead to a reputational risk to the CCG as there will not be a defined process to ensure that all local services are commissioned in an appropriate manner that provides ‘value for money, sustainability and also in line with the needs of the local population.

2. If the new LCS services are not approved as replacement services, we will have to manage the expectations of the GP practices.

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Croydon CCG’s Locally Commissioned Services Framework

1. Background:

As part of our ambition to transform healthcare in Croydon, the CCG is working together with

our local stakeholders to address the challenges that we face to deliver healthcare to a growing

and evolving population. At the heart of our work, is the intention to transform the way services

are provided in primary care to make them more sustainable and to reduce the known variation,

by moving towards a model that is outcomes based and sustainable for our local population.

Our vision to transform our services aligns with the organisational objectives outlined in the

Croydon Health and Transformation Plan (2019/20 – 2024/25) and also the NHS Five Year

Framework for GP Contract Reform to Implement the NHS Long Term Plan 2019 to ensure that

we shift to care that is more planned and population focused whilst exploring the opportunity of

commissioning our local services at a Primary Care Network level. Part of our objectives will be

to continue to develop locality focussed services to enable primary care to collaborate with each

other and other parts of the health and care system to provide greater access when required,

including 7 day services where relevant.

Our area of focus will be on the prevention of ill health, better management of chronic and long

term condition, enhanced self-care and early interventions.

We also intend to continue to work with our local partners (Croydon Council and Age UK

Croydon) to continually review and assess the health and wellbeing needs in the borough of

Croydon as part of our move towards providing a holistic model of care that is seamless at the

point of use.

Working together with our partners, we intend to ensure that all our locally commissioned

services align with our organisational objectives with a focus on:

▪ Prevention and proactive care – to support local people before things become a problem

▪ Unlocking the power of communities – key to helping local people stay fit and healthy for longer is to connect them with their neighbours and communities

▪ Making sure local people have access to integrated services that are tailored to the needs of local communities – locality matters

2. Recommissioning of Locally Commissioned Services:

The Locally Commissioned Services (LCS) applies to the provision of services by General

Practice that are not currently included in the NHS Standard Contract, and were previously

known as Local Enhanced Services. These services were commissioned from General Practice

as they were list based services, relying on access to GP records.

Although the CCG currently commissions 17 LCS in primary care to support the provision of

Primary Care Core services and also our out of hospital services, there are still a number of

practices which have not signed up or are unable to provide a service for a period of time,

resulting in patients being seen in secondary care or not accessing services.

Our current services are also focused on supporting those in crisis or those with the most acute

health and social care needs which makes it difficult to review and evaluate quality along with

the patient experience.

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As we continue along our journey towards delivering the objectives of NHS Long Term Plan,

there will be opportunities for Primary Care Networks to work together to deliver better outcomes

for their local population.

We recognise that in order to achieve our objectives, we need to review all of our locally

commissioned services to identify what’s wrong and not working, with a view to moving away

from the traditional approach of commissioning our local services and moving towards an

outcome based approach and holistic model of care to allow us to support people to stay well

for longer, and delay and avoid more people from becoming acutely unwell in the first place.

To support the review process, we have developed a key set of principles as part of the

framework for evaluating which services are ‘fit for purpose’ to allow the CCG to:

• Decommission services which are no longer required from April 2020

• Continue to commission the existing services in line with our organisation’s

objectives and key LCS principles from April 2020

• Commission a range of new services with a new set of requirements to meet our

objectives and key principles from April 2020

3. Overarching Aims:

To ensure all locally commissioned services are aligned to the priority outcomes outlined in

Croydon’s Health and Care Transformation Plan (2019/20 – 2024/25) and underpinned by the

following key LCS principles.

4. Key Principles:

All Locally Commissioned Services must be underpinned by the following key principles:

• Must be part of an integrated business case which addresses the priorities and

priorities outcomes outlined in Croydon Health and Care Transformation Plan

(2019/20-2024/25)

• Must be considered from the perspective of the patient and provided as close to

home as possible where this is in the best interest of the patient and where value

for money can be demonstrated.

• Must support greater integration of care especially where future models of care are

being developed and services are expected to be provided at scale for patients or

for patients from other practices within or across Primary Care Networks to provide

economies of scale

• Must demonstrate population health need whilst recognising that there may be

some local variations across our population due to their differing needs.

• Must be standardised as far as possible across the areas where they will be

provided.

• Must be accessible to the local population with cross coverage across Croydon

where required.

• Must be affordable and sustainable

• Must meet minimum quality standards for all services provided from practices and

across their Primary Care Networks.

• Must be commissioned in line with recommendations of NICE guidance

/regulations as the approved pathway.

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• Must support Primary Care Networks development and support integration across

other services.

• No adverse impact on One Croydon alliance partners

• Business case is aligned to a transformation programme where possible

The LCS contracts will be offered to general practices and their Primary Care Networks.

However, our local practices will be expected to explore other options to deliver some of these

services either collectively via a Primary Care Network and/or through an appropriate local

primary care provider which is able to provide cross coverage.

As part of the informed decision making process for the delivery of the LCS, the practices will

also be expected to ensure that the delivery vehicle for each LCS has the appropriate

governance arrangements in place and also the required infrastructure to support cross

coverage within the financial envelope.

The CCG aims to move to this new arrangement from April 2020 and has agreed to roll over

all existing LCS contracts till the end of March 2020 with the exclusion of the Care Homes

Contract and the PDDS contract. This will help provide continuity of current services and allow

us to complete the LCS review to ensure that all new LCS support the delivery of the Croydon

Health and Care Transformation Plan (2019/20-2024/25).

5. LCS Governance Process

All commissioners will be expected to adhere to the CCG’s internal governance process for r approving a Business Case prior to the submission of any LCS service specification. All proposed services will be expected to be aligned to a transformation programme and approved through the CCG’s transformation governance process as outlined in the table below. Delegated Matter Lowest Level Authority Delegated to

All requisitions up to £10,000 Budget Manager

All requisitions from £10,000- £25,000 Senior Manager

All requisitions from £25,000- £100,000 Chief Finance Office or Executive Director

All requisitions from £100,000-£250,000 Accountable Officer

All requisitions over £250,000 Governing Body

The outcome of the LCS review will result in services being commissioned differently through

a single service specification from April 2020 and the following critical pathway will be adopted

to ensure all of the relevant groups have provided clinical input, oversight and also approval of

the proposed model and financial envelope.

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Croydon CCG’s Locally Commissioned Services Critical Sign off Process

CCG’s Governance Process for Commissioning LCS

Clinical Input & Oversight Review & Evaluation Recommendation Approval

Clinical Leadership Group /Professional Cabinet To allow the Clinicians and Practice Managers to clinically review service specifications. Meetings: Every 1st Wednesday of the month. Professional Cabinet meetings are held monthly.

Primary Care Quality , Finance & Planning Group To critically review all LCS in line with the CCG’s commissioning priorities, LCS key principles and quality requirements. Meetings: Held every 1st Thursday of the month

Senior Management Team: To grant a decision to recommend approval Meetings Every Tuesday, papers sent on Thursday the week before

Primary Care Committee: To grant a decision in line with SMT’s recommendation. Meetings: Held quarterly on 4th June, 03 Sept, 03 Dec 2019

Surrey & Sussex LMC For Primary Care Review Meetings: Held bi-monthly, the 3rd of every month

Primary Care Working Group: To review details of Service specification and allow to proceed to SMT. Meetings: Every 3rd Thursday of the month

Procurement Advisory Group For information for existing services and to ensure all procurement guidelines are applied for new services. Meetings Every 4th Wednesday of the month

Finance Committee: For approval of funding for all new LCS. Meetings: Every last Monday of the month.

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Phase one: The critical pathway for approving a Business Case to develop an

LCS

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Phase Two: The Governance Process for (Service Specifications) Approval

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SCHEDULE 2 - THE SERVICES

Service Specification – Care Homes LCS 2019/20

1. Purpose

Summary

This service aims to ensure that the best possible enhanced primary care is provided to

people living in both nursing and residential homes in Croydon. It does not replace the

requirement within the GMS core contract for practices to register patients who are

residents of care homes within their catchment area. However, it will operate as part of

a wider, Care Home Transformation programme, spanning secondary care, enhanced

virtual support (telemedicine) and other health and social care services. The overall

aim is to improve outcomes and quality of life for residents, enhance the care delivered

in care homes and reduce avoidable pressures on the wider healthcare system.

Problem statement

Croydon has the highest number of care homes in London, 131 care homes and

approximately 2,700 beds (1517 in nursing homes and 1156 in residential homes).

During 2017/18 demand from unscheduled care from care homes generated the

following pressures on the health and social care system:

• Croydon has among the highest rate of ambulance call out rates in London:

2115 incidents in care homes between March 2017 and March 2018.

• Between March 2017 and March 2018, care home residents accounted for more

than 2,000 non-elective admissions and 2,300 delayed days in 2017/18 (24% of

all delayed days).

Local context

Croydon has good provision of health and social care services which support care

homes; but there are some gaps, inconsistencies and particular issues which need to

be addressed:

• Inequitable split of patient registration and activity across different practices, with

practices registering higher or lower number of care home patients than would

be expected from their local care home population.

• Lack of consistent training and capability framework for care home staff,

compounded by high levels of staff turnover.

• Support services for care homes not consistently well co-ordinated or

understood

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• Evidence that care home staff do not know when and how to refer to care home

support services

• Significant pressure placed on primary care, leading to over reliance on

emergency services for crisis management

• Variable approach to pro-active care in managing chronic disease and medicine

among care homes residents

• Inconsistent approach to care planning, especially around end of life (EOL)

Many of the barriers to good care reflect the national picture: a narrow focus on

medical rather than holistic needs, reactive and inconsistent care and variable access

for care home residents to NHS services. This is compounded by the scale of

Croydon’s care home market and volume of patient need – which has created a

compelling case for change and strong local commitment for the successful delivery of

a significant major multi-sector care home transformation programme.

This programme is now being mobilised and includes a number of work-streams:

1. Enhanced primary care support for care homes through the delivery of this service specification

2. Mobilisation and effective embedding of telemedicine approach to support and enhance the delivery of care across Croydon’s care homes through addressing urgent care needs.

3. The development of the specialist care home support initiative which includes the Complex Care Support Service and enhanced medicines support.

4. The development of delivery of a LA/CCG bed commissioning strategy which seeks to achieve a consistent, streamlined and sustainable commissioning framework.

5. The development and delivery of a workforce development plan for care home staff focused on training and support designed to increase the capacity and capability of staff to support their patients and reduce unnecessary use of health and social care resources.

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Primary care

As part of wider transformation plans, NHS Croydon CCG supports primary care transformation and more resilient and sustainable services to provide a consistent quality service to residents of Croydon. Following the release of the 1NHS Long Term Plan in January 2019, and the associated early guidance on the approach for the 2GP Contract Framework, the requirements within this specification have been aligned where possible to the latest national requirements. This service therefore represents an interim arrangement for the period to 31st March 2020; and aims to support the transition from the current service into the implementation of the national service specification requirements. Key within the NHS Long Term Plan is the development of Primary Care Networks (PCNs). A network based approach to the support and management of Care Home residents has been in discussion across Croydon for some time. Aiming to provide equitable registration, streamline the number of practices supporting each individual Care Home, and continuing to build upon the relationships between care homes and primary care, and facilitate inter- and intra-network working to mitigate against the impact of the geographical spread of care homes and therefore workload for these residents. The approach to network working for care homes will be facilitated through PCNs in line with planning for the implementation of the new National specification for ‘Enhanced Health in Care Homes’. Telemedicine

The implementation of telemedicine to support care homes commenced in winter 2018/19. The aim of this service is to provide support for both nursing and residential

1 https://www.longtermplan.nhs.uk/

2 https://www.england.nhs.uk/publication/gp-contract-five-year-framework/

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homes through remote review of patients and provision of advice during periods of crisis or exacerbation of existing conditions. Early data suggests that over 75% of the telemedicine contacts would have otherwise contacted a GP for support, with only 27% of these requiring onward referrals to a GP service (both in and out of hours). This therefore provides an additional resource to support care homes and reduce the reliance on GPs to respond to urgent requests for assistance. Combined with the ward round and proactive review approach outlined within this specification and the Proactive Management LCS service specification, this aims to provide a robust and effective approach to managing the health needs of care home residents.

Service description: enhanced care home LCS:

The overall aim is to improve outcomes and quality of life for residents, support nursing and residential homes to provide more timely and appropriate care in the home, rather than utilising the LAS and acute trust services. Other aims are to:

• Improve the quality of care delivered to care home residents and reduce avoidable pressures on the healthcare system.

• Provide consistency, co-ordination and a multidisciplinary (MDT) approach with rapid access to specialist advice when necessary.

• Promote independence and self-care for care home residents

• Support nursing and residential homes to provide more care in the home, rather than using emergency services inappropriately

1.3 Objectives

• Enhance access to personalised, high quality primary care for residents of care homes

• Ensure that the majority of care home residents are registered with Croydon practices which are delivering the LCS and located within reasonable proximity to the care home

• Ensure patients have high quality proactive care management plans (full requirements are outlined within the service specification for the Proactive Management LCS)

• Support medical optimisation of patients within nursing and residential homes

• Work with other services as required such as telemedicine, Integrated Care networks and the Complex Care Support Service

• Act as primary care resource for care home staff

• Improve: o Medicines management o Integrated and Proactive management planning o Patient experience; o Shared-care and joint working between health and social care

professionals, and care home teams o Shared Decision Making, including with residents, families and carers; o Self-care;

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2. Outcomes

2.1 NHS Outcomes Framework Domains & Indicators

Domain 1 Preventing people from dying prematurely

Domain 2 Enhancing quality of life for people with long-term conditions ✓

Domain 3 Helping people to recover from episodes of ill-health or

following injury ✓

Domain 4 Ensuring people have a positive experience of care ✓

Domain 5 Treating and caring for people in safe environment and

protecting them from avoidable harm ✓

2.2 Expected (local) outcomes

The Provider is expected to provide an enhanced primary care service for care homes (nursing home and residential homes). This service will deliver the following outcomes: Enhanced primary care service outcomes:

• Improved clinical care • Better co-ordination of services delivered within the care home • Alignment of services • Linkages with pathway development for complex care support • Better integration of proactive management pathway

Support wider Care home Transformation outcomes

• Better experience and outcomes for care home residents • Supported and sustainable care home model • Care home staff have tools, confidence and capability deliver timely and

appropriate care in the home • Reduce levels of inappropriate LAS call outs • Reduced levels of inappropriate A&E attendances • Reduces levels of inappropriate non-elective hospital admissions • Reduced length of stay following admission • Reduced inappropriate and lower acuity demand for unscheduled care

services • Increase in positive CQC inspections • Reassurance for relatives and carers

3. Scope

3.1 Care Pathway and Requirements

The following diagram outlines the relationships and interdependencies between

relevant services:

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Figure 1: Services supporting people with complex health needs

3.1.1 Proactive care management and review

The CCG has developed a proactive care clinical model which aims to ensure that patients with complex and escalating needs receive the best care. Co-ordinate My Care (CMC) is used as the template for the care plan. This approach is fully defined within the Proactive Management LCS service specification. The proactive plan should be a collaborative process between the patients (and

carer/family). The consultation should seek to address how their care will be managed

to:

• Enable effective management of their long-term conditions

• Enable optimum support for self-management

• Provide clear contact points for times of crisis/exacerbation

• Understand the patient’s interactions with other agencies providing support to

them

• Consider the needs of the patient’s carers (this should be done via the Care

home who will have more contact with family on a regular basis)

• Review medications being taken by the patient and support improved

compliance where appropriate

• Reduce their risk of avoidable admission to hospital

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This plan will be regularly reviewed – on an annual basis as a minimum for stable

patents - and updated at key points including

• Unplanned admission

• Following discharge from intermediate care services (such as Living

Independently For Everyone (LIFE) services) (within 3 working days)

• New significant diagnoses,

• Contact with the Telemedicine service,

• Other significant change of circumstances.

This model operates across a joined-up continuum of care spanning enhanced primary care, MDT Huddles and the Complex Care Support Service and is outlined within the above pathway diagram (Figure 1 above). 3.1.2 MDT Huddles

MDT huddles are in place across all practices with Croydon. This multi-agency team aims to discuss the care planning of people with complex health and care needs. The purpose is to proactively plan care so to reduce the need for future hospital admissions or other escalated care needs. Huddles are the cornerstone to the development of effective multi-agency working and the establishment of Integrated Community Networks (ICNs). They provide a platform for all community services to strengthen their working relationships through mutual learning and open communication. The model provides opportunities to avoid delays, complex referral processes and duplications for timely and efficient care for people. Where required, MDT huddles may provide further opportunities to support care planning for care home residents. 3.2 Key intervention points Newly admitted care home residents will be visited within one week of admission to the

care home. The review should cover:

• Information gathering;

• Initial physical and mental health assessment;

• medication reconciliation; with a full medication review supported by a pharmacist

within 1 month

• Completion of co-ordinate my care record (or review and updating if already

developed)

3.3 Care Home Ward Rounds Practices will provide regular routine ward MDT rounds which should include the care

home GP, other key individuals, such as pharmacists and other ICN staff, and senior

care home staff. Ward rounds should be mutually agreed with the care home and the

frequency agreed with the Care Home Manager appropriate to the size and complexity

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of the residents and performance of the Care Home. The purpose of the ward round is

to:

• Co-ordinate clinical activities to enable the provision of timely, quality care for patients and their families – shifting the balance of care from reactive to proactive.

• Update the Co-ordinate My Care (CMC) record and comprehensive geriatric assessment as it develops.

• Identifying residents requiring proactive care to remain healthy • Providing responsive care in a timely way • A whole system approach to care delivery

3.3.1 Frequency of ward rounds

GPs will decide the most appropriate frequency of ward round based on clinical need and in discussion with the Care Home Manager. However, a review on a weekly basis would be recommended for nursing homes. For residential homes, a reduced frequency of ward rounds is likely to be sufficient and is recommended to take place monthly as a minimum. Noting that, as a new service for residential homes, more frequent ward rounds may be required initially.

The time required for a ward round will vary according to the number of patients, their needs and the professional skills required.

3.4 Medication review

GPs will be expected to work with pharmacists to ensure medications are optimised as soon as practically possible. Pharmacists will attend ward rounds until such medications are optimised. Pharmacists may be members of the CCG medicines optimisation team or identified by the practice and accredited by the CCG medicines optimisation team.

Once optimised, medication focussed ward rounds should take place every six months.

3.5 Emergency admissions review

Residents who have had an emergency admission should be reviewed during the agreed

ward rounds, and if further support and review is required, referred into the Complex care

support team

The review will cover:

• what could have avoided the emergency admission

• what will be done differently next time

• to identify gaps in service

3.6 Responsibilities of the GP

In order for the service to be effective participating GPs will be expected to:

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• Work with care home staff and other specialists to prepare patients and

families in advance, when appropriate, to facilitate shared decision making and

review

• Ensure that all relevant actions are implemented/handover over

• Attend best interest meetings

• Develop clear management and clinical protocols to achieve clear

communications with all staff in the care home, including managers, nursing staff

and administrative staff. This could include agreed processes for repeat and

urgent prescriptions, use of the telemedicine service and how to obtain a

telephone opinion or triage in urgent circumstances;

• Liaise with patients previous GP (or current GP if only temporarily registered in Croydon)

where necessary

3.7 Additional responsibilities

Croydon CCG is strengthening specialist palliative care input to the care planning

progress. This includes:

• Expansion of the PEACE (PErsonalised Advisory CarE) planning model to at least

140 patients including 10 care homes. The PEACE plan is a document to help

health care professionals deliver the best care to frail, people with life-limiting

illnesses who are anticipated to be in the last year of their life and reside in a care

home. PEACE will be delivered by specialist nurses with community geriatrician

oversight, the PEACE planning process can indicate how best to deliver care in

the care home, and what support is available in the community to do this. GPs will

not be responsible for the development of this plan but may be requested to

provide information where appropriate.

• EOLC focussed ICN huddles with specialist input from St Christopher’s hospice.

These occur on a 6-weekly basis, depending on GP list size.

3.8 Interdependence with other services/providers

GPs will be expected to work closely with:

• Complex Care Support Service which operates to enhance best practice and improve quality aligned to CQC domains.

• Highly Specialist Speech and Language Therapist which manages and supports patients with swallowing difficulties (dysphagia) and training to Care Home staff and other Health Professionals.

• Croydon Mental Health of Older Adults and Psychological Medicine (CHIT) • St Christopher’s Hospice provides training and education – joint End of Life care

reviews • Integrated Community Networks.

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The service will also be expected to give particular focus to support the effective

delivery of the following services:

Complex care support service which is an extension of the existing Integrated

Community Networks. It comprises specialist staff (e.g. Community Geriatrician, mental

health workers) and will provide specialist advice/consultation; assessment and care

planning support; and training and development to support front line workers to

proactively manage people with complex health and care needs.

Telemedicine service Supporting 80 care homes across Croydon, this new service

provides an accessible single point of access 24/7 365 days per year, and access to a

highly experienced telemedicine clinical team providing timely and responsive

comprehensive “visual” assessments of the resident via HD video links.

3.9 Care home workforce

Responsibilities of Care Home Managers to support the service are set out under

appendix 1.

4. Applicable Service Standards

1. Practices participating in the LIS will be required to provide the following monitoring

information on an annual basis (as per workbook in Appendix 2)

I. Patient ID, and date arrived in care home

II. Dates of urgent / emergency visits or interventions undertaken by the GP to

support residents

III. Frequency of ward rounds undertaken by the GP Practice within the home and

the activity undertaken

IV. Confirmation whether telephone consultations are used to support patients

V. Number of advanced care plans completed (recorded in CMC in line with the

Proactive Management LCS requirements) including resuscitation decisions and

DNaCPR forms as required

VI. Number of medication reviews undertaken including anticipatory prescribing

2. The above monitoring will be performance managed and validated through the Contracting

Team’s returns process from practices to claim their annual payments.

3. Practices are asked to ensure that patient contacts are appropriately recorded and coded

on EMIS / Vision to support the development of automated reporting.

5. Quality and Performance Standards Practices signing up to this scheme will be expected to participate fully in the initiatives and

services describes above to support Care Home Residents, as well as complying with and

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supporting the delivery of, national guidance e.g. Managing Medicines in Care Homes NICE

Guidance3

6. Provider Premises

Not applicable. The service will be delivered from Croydon care homes.

7. Individual Service User Placement

Not used.

8. Payment

Practices signing up to this scheme will receive:

• £220 payment per patient per year for nursing homes

• £120 payment per patient per year for residential homes

NB:

• Workbooks should clearly articulate any changes to individual residents circumstances

(leaving care home or RIP – to be included within the field ‘ date patient no longer

permanent resident at care home’) to support payment on a per patient basis within the

total number of beds for that care home.

3 https://www.nice.org.uk/Guidance/SC1

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Appendix 1: Responsibilities of Care Home Manager

The care home manager will be expected to

• Support proactive GP involvement for their homes and provide feedback to relevant

bodies of any concerns

• Arrange for a patient to be registered with the nominated GP practice under this

scheme as soon as possible upon arrival in the home unless the patient is choosing to

stay with another GP practice.

• Ensure that summary patient information from the patient’s previous practice, including

list of medications, is available to the GP within 3 days of the patient’s arrival

• Make sure that the patient’s medication record and any new any hospital-provided or

community service information is made available to the GP when visiting the patient.

• Provide the GP with a list of patients with queries/issues prior to every ward round visit

using a secure method of communication

• Arrange for the nurse in charge/on duty to be available to discuss patients on the list

with the visiting GP and accompany the GP to see any patients. Drug charts should

be to hand.

• Ensure that key points arising from these visits are communicated to colleagues or

written in nursing notes.

• Work with the GP to address medication issues in order to reduce prescribing errors

and promote high quality and cost effective prescribing.

• Ensure full engagement with the telemedicine service from all staff through training

and identification of a telemedicine champion.

• Make all reasonable efforts to contact the responsible GP practice; or telemedicine

service where an urgent review is required

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Appendix 2: Workbook Template DRAFT

Enhanced GP Care Home LCS 2019-20 (Please submit claims annually at the end of Q4)

Care Home (please state)

Number of Patients Reviewed

(Please state)

Agreed Frequency of ward rounds

Are arrangements for telephone

consultations in place?

Did patent require

contact with urgent

/ emergency care

services? (Yes or No)

If Yes Date reviewed on

discharge

patient number or other anonymous identifier

(do not include person confidential data)

enter all

applicable datesenter all applicable dates

this does not

include extended

hospital stays; but

will include

transfer to other

residential setting

or death

Total Number of Patients xx

Date patient no

longer permanent

resident at care

home

Noting that frequency of patient review and

attendance at the care home will be predicated on

the clinical needs of the residents at that time.

Care home

type -

nursing or

residential

Patient ID

Date

Arrived in

Care Home

(if New

patient)

ACP (via

CMC) in

Place

(Yes or

No)

Date ACP

Agreed (via

CMC)

Date

medication

review

completed with

pharmacist

Contact with emergency services including

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Appendix 3: Assurance process for GP practice pharmacists undertaking

medication reviews.

An assurance process for GP practice pharmacists undertaking medication reviews

in care homes as part of the enhanced care home locally commissioned scheme for

2019/20 is currently in development. This aims to ensure that all medication reviews

are undertaken in line with NICE guidance and other best practice requirements.

Further communication of this process will be circulated once finalised.

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Locally Commissioned Service (LCS) Service Specification for Elective Care Delivery and Transformation

Programme

1st July 2019- 31st March 2020

1. Introduction It is acknowledged that patients need to be able to access care in a timely fashion - ‘right care, in the right place and at the right time’. It is also recognised that we need to use resources efficiently and effectively. In order to realise this aim, the CCG and CHS Trust are working on a one-system approach that will ensure sustainability of the local health economy and promote the local Trust as the primary provider of choice for all Croydon patients. 2. Service Outline The scheme continues to recognise the significance of Peer review and Advice and Guidance, and aims to develop this further with the use of the eRS Blue Button for referral to secondary care services. This Locally Commissioned Service (LCS) is designed to offer member practices an integrated scheme that supports the demand management, repatriation and provider of choice initiatives within the Croydon healthcare economy. The initiatives are as follows:

• Peer Review of outpatient activity

• Advice and Guidance via eRS

• Referral Management via eRS Blue Button To support delivery and improved quality of care whilst using resources efficiently and sustaining local services, new services have been developed by our local acute provider (Croydon Health Services NHS Trust). Please note, for the purposes, of this document, Croydon Health Services NHS Trust is referred as Croydon University Hospital as this is the name listed on the eRS Blue Button. The new services include:

• Customer service o Patient helpdesk o GP Hotline

• Booking service (includes Advice&Guidance and referrals)

2.1. Customer Helpdesk

The Customer Helpdesk is for all new patient referrals from 1st April 2019. The helpdesk will take telephone calls from 08:00 to 20:00, Monday to Friday from both new patients and GPs and answer any queries including about being a patient and referring a patient to CHS. Whilst the service will be equipped to pre-dominantly answer/navigate queries that relate to outpatient (including diagnostics) and elective

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care, it is envisaged that other random queries may come through this telephone line and generic email. The staff will re-direct these either to the main hospital switchboard or relevant department. There are two telephone numbers (below), one for patients and a direct hotline for GPs.

• Telephone number for patients is: 020 8401 3800; Email: [email protected]

• Telephone number for GPs is: 0208 401 3808; Email: [email protected]

2.2. Booking Service

The aim of the booking service is to provide one single entry point (“Blue Button”) via e-RS for Croydon GPs across for the list of specialities listed below. GPs will submit a referral which may either seek advice and guidance from a secondary care clinician or propose that the individual may benefit from secondary care intervention. The Booking service will then process the referral based on the outcome of clinical review (See Appendix 1 for Process Map).

1. Integrated Dermatology Service - Croyderm

2. Integrated Gynaecology Service

3. Integrated Gastroenterology

4. Integrated Endoscopy Service

5. General surgery

6. Vascular surgery

7. Colorectal surgery

8. T&O

9. Integrated Urology Service

10. Paediatrics

11. Neurology

12. Cardiology

13. Integrated ENT/ Audiology Service

14. Respiratory

15. Nephrology

16. Endocrinology

17. Rheumatology

18. Haematology

19. Maternity Services

20. Anticoagulation

Follow up appointments will continue to be managed by the relevant POD for the service. Although it is envisaged that the booking, PODs and e-RS teams will all work very closely to support both patient and GP queries.

3. Eligibility criteria

3.1 Inclusion Criteria: All urgent and routine planned care referrals for Services that are on the eRS Blue Button for Croydon University Hospital.

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3.2 Exclusion Criteria:

• 2 week waits which follow the 2ww pathway

• A+E and Emergency Care referrals including services such as Rapid Access Chest Clinic

4 Data Monitoring and Payment

This Locally Commissioned Service (LCS) applies to all new elective services available via the Croydon University Hospital eRS Blue Button for onward care within the health economy. The expectation is that all GP referrals and A+G requests are made via the eRS Blue Button, choosing ‘Croydon University Hospital’ from the eRS list. The LCS currently only covers an individual practice’s patient list and is not extended to cover other practice patients.

4.1 Data Monitoring

In order to ascertain the usage of Blue Button, the practice is required to supply Croydon CCG with weekly monitoring data which outlines the following:

• Patient reference number (non-identifiable information)

• Date of referral

• Specialty

• Referral sent via Blue Button to CHS

• Referral sent to other Providers if not CHS Please see spreadsheet for further information. This weekly data reporting will be monitored and should there be any concerns regarding the usage of Blue Button for Croydon University Hospital, the relationship manager assigned for the practice will work closely with the practice staff to understand and identify issues and support the practice to improve the referral rate via the Blue Button where appropriate.

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4.2 Payment This element is to support the use of eRS Blue Button and choose ‘Croydon University Hospital’ when requesting ‘referrals for review’ or ‘Advice and Guidance’ for all the services described on page 2. Element description

Financial reward

Payment terms Payment

Demand management via Peer Review of outpatient activity

0.28ppt The practice is expected to achieve 8% reduction in referrals compared with their 2018-19 baseline.

On achievement of targets as stated in this document

Note threshold payment where applicable

Advice & Guidance

0.28ppt 0.14ppt for achievement of the minimum expected outcome (1 A&G request per 3,000 registered patient population per month)

Additional 0.14ppt if the practice exceeds the minimum expected outcome by 30% or more

eRS Blue Button usage

0.56ppt Referral Management via e-RS (e-referral system) Blue Button of outpatient activity

Please note there will be a threshold payment for practices if they do not comply with full achievement of stated target.

If practice hits 95% or above referral activity via Blue Button, they will receive £0.56ppt

If practice hits between 70% - 95% of activity via Blue Button, they will receive £0.39ppt

If practice hits less than 70% of activity via Blue Button, there will be no payment made

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5. Service Agreement and Duration 5.1 The service agreement is from 1st July 2019 – 31st March 2019 and the LCS will be reviewed annually.

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Appendix 1 – Booking Service Process Map

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SCHEDULE 2 - THE SERVICES

Service Specification – Proactive Management LCS

4. Purpose

As part of the One Croydon Alliance, Croydon CCG has developed an ambitious out of hospital programme that requires a fundamental change in the way both acute and community services are delivered, how we work with the voluntary and community sector and the people of Croydon. This service aims to ensure that the best possible proactive care is taken up by people with complex and escalating health and care needs. It sets out a joined-up continuum of proactive care management spanning general practice, huddles and complex care support delivered as part of wider Out of Hospital services. Ultimately this approach aims to help people with chronic health conditions to keep as well as they can and more effectively manage acute episodes. The overall aim of the service is to support the role of the registered GP in coordinating an individual’s care, putting people at the centre of their care, to improve their outcomes and quality of life and reduce avoidable pressures on the wider healthcare system. This specification reflects the following principles:-

• Shifting from reactive to proactive care; identifying people with complex and escalating needs

• Assessment of an individual’s objectives to set appropriate goals and development with them (or

carers as appropriate) a jointly owned care plan

• Care planning and coordination operates across a dynamic pathway with the GP at the centre of the

process

• The GP oversees the care planning and care co-ordination for people with complex needs. Where

appropriate, proactively seeks to identify and work with other health and care professionals at

appropriate points

• Empowering individuals, carers and families: provision of a copy of the plan as well as relevant

supporting information such as self-management and links with community groups / organisations

• Improving co-ordination of different areas of health and care: review and update the care planning

in multi-agency meetings (huddles) or in direct liaison with agencies – such as secondary, mental

health, social care and others

• Establishing exemplary governance systems: clear action planning – what we are doing, who is

responsible and when will it be reviewed.

5. Outcomes

2.1 NHS Outcomes Framework Domains & Indicators

Domain 1 Preventing people from dying prematurely

Domain 2 Enhancing quality of life for people with long-term conditions ✓

Domain 3 Helping people to recover from episodes of ill-health or following

injury ✓


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Domain 5 Treating and caring for people in safe environment and protecting

them from avoidable harm ✓

Expected Outcomes

The service will deliver the following outcomes:

• Improved clinical outcomes for people with complex health and care needs • People have the tools, motivation and confidence to take responsibility for their health and

wellbeing • More integrated and effective delivery of proactive management pathway • Reduction in presentations for unscheduled care • Reduction in non-elective admissions • Reduced Length of stay following admission • Reduction in non-elective excess bed days • Reduction in volume and intensity of packages of care

It is anticipated that this service, together with other initiatives and services commissioned and developed by

the CCG and as part of the One Croydon Alliance, will collectively contribute towards the achievement of the

outcomes outlined above. There is evidence that good proactive management plays a key role in keeping

people healthier for longer, but the CCG recognises that it is not possible to attribute a clear causal relationship

between practice-level interventions (undertaken under this specification) and the outcomes outlined above.

6. Scope

This specification sets out a Model of Care for the proactive management of people who are identified as

complex/frail. This population tends to be high users of services and can have a variety of underlying health

and social care needs. This will usually include those people who have complex and escalating needs. For

example, people who:

• Have multiple needs, who are often on different pathways of care to manage their multi-morbidity

and may be at risk of potential interactions between prescribed medications.

• Are becoming increasingly frail and those with high unplanned admissions possibly due to social

factors.

• Experience a combination of Long Term Conditions, particularly Cardiovascular Disease, Hypertension,

Heart Failure, Stroke/TIA, Diabetes, COPD, Depression and Dementia.

• Experience high levels of social care needs which cannot be easily resolved without the input of wider

health and social care professionals.

Proactive Identification

Individuals will be identified using the following framework:

• Clinical system search

• Opportunistic identification

• People recently discharged from hospital

• Peoples recently discharged from the Living Independently for Everyone Service.

• People identified through Sollis risk stratification tool (top 1% of people registered with the practice

who are likely to get admitted to hospital in the next one year).

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Practices will be free to use their own clinical judgement on which people are suitable for proactive

management; however, when identifying people with complex needs, the practice should consider the needs

of the total practice population regardless of age, location of residence or input from other health and social

care teams.

Generating a proactive management plan

The personalised proactive management plan should be generated during a face to face consultation with

the person. The care plan should be a collaborative process between the individual (and carer/family); an

accountable GP or other appropriate and competent registered healthcare professionals. The care planning

consultation should seek to address how their care will be managed to:

• Enable effective management of their long term conditions

• Enable optimum support self-management

• Provide clear contact points for times of crisis/exacerbation

• Understand the person’s interactions with other agencies providing support to them

• Consider the needs of the person’s carers

• Review medications being taken by the person and support improved compliance where appropriate

• Agree the case management approach with the individual, i.e. frequency of review of care plan,

review arrangements in the event of an unexpected admission to hospital etc.

• Reduce their risk of avoidable admission to hospital

Care Plans will be completed via Coordinate My Care to enable accessibility across multidisciplinary teams.

Generating the plan: additional information

• The plan could be generated by another health and social care professional but should be signed off

by the GP

• Proactive management appointments should be flexible to meet the particular needs of the

individual. The GP/healthcare professional will use clinical discretion to determine length of the

appointment – some appointments may last 10 minutes’ others potentially 30 minutes.

• The practice should provide the person with clear information as to the benefits of sharing their

records with other providers and seek to obtain their consent for their medical record to be shared

with other health and care professionals electronically.

Proactive management plan review

The practice will carry out regular care plan review which can either be done face to face or by telephone.

The review does not need to take place during a pre-scheduled appointment, but can take place

opportunistically or during a Long-Term Conditions review.

The frequency of review will depend on risk and should be agreed between the registered healthcare

professional and the individual; but is recommended to be undertaken every 6 to 12 months. All care plans

should be reviewed annually as a minimum for stable patients. In addition, the following should trigger a

care plan review:

• Unplanned admission

• Following discharge from LIFE services (within 3 working days)

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• New significant diagnoses,

• Other significant change of circumstances.

Proactive management: overarching model

The following model reflects the approach for adults with complex needs and the services available for

support. It is however, recognised that some practices may have a considerable cohort of children with

complex needs.

Proactive management can be delivered at across three levels:

• Practice level

• Multi-agency/Huddle level

• Complex Care Support Team

The provider is expected to determine the most appropriate case management approach for each person

receiving proactive management either at the practice level, Integrated community networks / Huddles

(multi agency meetings) or through the Complex Care Support Team which can be accessed via referral to

the huddles.

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Care pathway

Identifying People with complex care

Practices will identify people suitable for proactive management via a range of measures such as clinical

system search, opportunistic identification, people recently discharged from hospital, People recently

discharged from the LIFE services.

GP practice proactive management care plan

The Co-ordinate My Care (CMC) record is the template for the proactive management plan.

Level two: Integrated community network (ICN) / Huddle level

The ICN huddle is a key service within the proactive management pathway. This core team includes the GP,

Community nurse, social worker, Personal Independence Coordinator (PIC) and medicines optimisation

pharmacist. If practices identify that a person would benefit from being managed through a huddle they

should follow this process:

ICN Huddle:

To ensure effective huddles:

• Practice will identify lead(s) who will work closely with the core ICN team in and out of huddles to

support proactive management

• Practice lead(s) will work proactively with members of core ICN team to deliver the pathway

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Identification and referral

• Practice leads are expected to bring appropriate cases for discussion based on clinical judgement

• Practice lead(s) will identify people continually, identify and manage any urgent issues / needs and

use either practice or ICN level to proactively support them.

Supporting effective ICN Huddles

• Attending GPs will play a proactive role within the MDT discussion

• An appropriate member from the practice will attend the Integrated Care Network meetings on

regular basis at practice level

• The practice will ensure that multiagency working in and out of huddles is optimised. Appendix 1.

Shows top characteristics of effective huddles.

• Cases must be submitted a week in advance to the meeting

• Outputs of the meeting should be shared with the wider practice team

• A meeting record should be available for the wider practice team to remain informed of

actions/decision and individual health and care records updated if appropriate. The outcomes from

the ICN meeting should be followed up and care plans amended with the individual as required.

• Learning points from the discussion should be shared at provider level discussions

Level three: complex care

Extending the remit of Integrated Community Networks, the Complex Care Support Team was launched early

in 2019. Comprising existing and new specialist staff (e.g. Community Geriatrician, mental health workers,

specialist community nurses), the purpose of the Complex Care Support Team (CCST) is to improve the

outcomes of adults with complex health and care needs by providing co-ordinated specialist care and support

that will encourage people to be supported at home and so avoiding the debilitating effects of staying in

hospital long term.

The service will be for adults with one or more of the following:

• a high risk of frequent hospital admissions and/or A & E attenders;

• Are frail and complex, who may be in residential care or nursing homes;

• Have multiple physical and mental health co-morbidities; and

• Have previously been brought to a huddle for discussion. However, some cases will be accepted on a

case by case basis where physical health is of a primary concern.

Referral into this service is via the Huddles. The service will be delivered in three segments:

1. Advisory support:

• Attend huddles in ICNs and provide advice and guidance on complex cases. [Note: Complexity of

cases will be subjective to the professionals involved in individuals’ health and care]

• Be available to provide advice and guidance via telephone for ICN and care homes

• Hold virtual network MDTs for complex patients referred from ICN huddles and care homes.

2. Hands on delivery of care:

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• Support development of advanced care plans (ACP) and provide a Comprehensive Geriatric

Assessment (CGA) as required for appropriate cases.

• Provide in-reach assessments to care home residents on admission to care homes and review as

required such as after hospital discharge

• Provide regular medication reviews for care home residents

• Liaise with voluntary and community sector to provide community support where required.

3. Training and development:

• Provide training and development for GPs, ICN core team and care homes staff around identification

and management of complex care

Interdependencies

• LIFE services (re-ablement, rehabilitation and rapid response services)

• Care Support Team operates to enhance best practice and improve quality aligned to CQC domains.

Includes proactive training.

• Highly Specialist Speech & Language Therapist which manages and supports people with swallowing

difficulties (dysphagia) and training to Care Home staff and other Health Professionals.

• CHIT Croydon Mental Health of Older Adults and Psychological Medicine

• St. Christopher’s Hospice provides training and education – joint End of Life care reviews

• Integrated Community Networks.

5. Applicable Service Standards

4.1 Service Requirements

Element description Arrangements for 1st July 2019 to 31st March 2020

Element 1: Review of

Non-elective (emergency)

admissions

Practices will no longer be expected to demonstrate a decrease in NEL activity given this activity is representative of a much wider issue and cohort; however, it would be expected that effective proactive management for patient with complex needs will contribute to a reduction in the need for NEL care. Practices will be asked to:

• Undertake a review of NEL activity in Quarter 2 and Quarter 4 of 2019/20 (see template in appendix 2) and provide notes of practice meetings where this review has been undertaken

• Identify complex cohort for the practice

• Identify actions required to support individual patients, key cohorts of patients

• Provide feedback to PCNs and CCG to support and inform development of future services and approaches to support identified patient cohorts

• Reports on the actions undertaken and impact should be completed in Quarter 4.

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Element 2: Case

Management

Month Number of Huddles Number of patients

discussed

July 2019

August 2019

September

2019

October 2019

November

2019

December

2019

January 2019

February 2019

March 2019

• Number of patients that were discussed at Huddles read coded as case management started (Read code 8CV0)

• Maintenance of CMC plans for 2% of practice population (aged over 18 years)

• Number of patients at the practice with CMC care plans:

TOTAL plans

on CMC

(published)

Number of reviewed CMC

plans (reviews undertaken

within the last 12 months)

Number of

patients

recorded on

CMC as

deceased

• Please provide a brief narrative summary of the benefits of MDT Case Management by providing the specific activity information of how patients were supported via Huddles

• Please provide 2-3 anonymised examples on what benefits patients received as a result of the care planning, demonstrating the impact on patient care, health outcomes and well-being

• Narrative of achievement and action plans with clear timelines

Element 3: Complex

Patients

The approach to the management of patients with complex care needs

(i.e. appointment duration) will not be specified; but will include a

requirement to undertake reviews at least annually for stable patients

as well as identifying and undertaking care plans for a minimum of 2%

of population:

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• Outline of arrangements planned / in place to support identification of patients with complex needs including use of risk stratification tools / Sollis and NEL activity review (as per element 1)

• Outline of arrangements planned / in place to provide sufficient clinical time to support the development of care plans with patients / carers and families as required

• Proportion of patients who have had a review of their CMC care plan within the last 12 months (as per CMC report table in element 2)


Element 4: Huddle

Effectiveness

New requirement linked to the delivery, development of, and referral into, huddles:

• Practice participation in quarterly huddle surveys / reviews (coordinated by Network Facilitator) to include:

o Lessons learnt and approach to sharing learning across the practice team

• Consideration of impact on individual patients

• Consideration of how to increase referrals into huddles

• Work with the Network Facilitator to implement recommendations and support activities to increase referrals into huddles (based upon outcome of workshop on ‘optimising the effectiveness of huddles’ planned for 5th June 2019)

9. Quality and Performance Standards The above service standards will be measure through:

Element description Reporting requirements

Element 1: Review of

Non-elective (emergency)

admissions

Evidence of review of NEL activity during quarter 2 and quarter 4 and practice discussion, through provision of:

• Proactive Management Reporting template: Review of non-elective activity (appendix 2) including actions identified to support people with complex needs, and impact of these actions.

• Notes of practice meetings in quarter 2 and quarter 4

Element 2: Case

Management

Reporting of:

• Number of patients that were discussed at Huddles read coded as case management started (Read code 8CV0)

• Number of care plans on CMC (minimum of 2% of practice population over 18 years)

• 2-3 anonymised examples on what benefits patients received as a result of the care planning, demonstrating the impact on patient care, health outcomes and well-being

• Narrative of achievement, impact and action plans with clear timelines

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Element 3: Complex

Patients

Practices should review and identify their local approach to ensuring

that all patients with complex needs are enabled to take part in

discussions to develop / review their care plans; including:

• Outline of arrangements planned / in place to support identification of patients with complex needs including use of risk stratification tools / Sollis and NEL activity review (as per element 1)

• Outline of arrangements planned / in place to provide sufficient clinical time to support the development of care plans with patients / carers and families as required

• Proportion of patients who have had a review of their CMC care plan within the last 12 months


Element 4: Huddle

Effectiveness

Practices will be required to demonstrate:

• Practice participation in quarterly huddle surveys / reviews (coordinated by Network Facilitator) which will focus on ensuring huddles are delivered in line with the ‘characteristics of successful huddles’ (appendix 1)

• Consideration of impact on individual patients

• Consideration of how to increase referrals into huddles

• Work with the Network Facilitator to implement recommendations and support activities to increase referrals into huddles

10. Provider Premises Services are provided through the GP premises or other suitable alternative location which may include the

patients usual place of residence

11. Individual Service User Placement

Not used

12. Payment

NB the following financial reward represents three quarters of the previous PDDS payment framework given

this service is implemented from July 2019 to March 2020 only.

Element description Financial reward (1st July

2019 to 31st March 2020)

Payment terms

Element 1: Review of Non-

elective (emergency)

admissions

£0.74 ppt

NEL reviews during quarter 2

and quarter 4. and delivery of

action plans. Submission of

review template and meeting

notes

Element 2: Case Management £1.66 ppt

Multidisciplinary Huddles

&

Care Planning using CMC

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Please note there will be a

threshold payment. If practices

achieve no less than 1.5% rather

than the full 2% initiated onto

CMC they will receive £1.12

Element 3: Complex Patients £2.16 ppt

Confirmation of practices plans

for delivery of sufficient clinical

time to support the

development and review of care

plans with patients / carers and

families

Element 4: Huddle

Effectiveness £0.37 ppt

Participation in huddle reviews,

including sharing learning and

implementing agreed actions to

improve referrals to, and

effectiveness of, huddles.

Any issues with achievement of identification of the practice complex cohort (2%) should be escalated to the

CCG for discussion. Noting that review of all NEL activity, huddle activity, and Sollis (i.e. element 1 of this

LCS) should have been completed prior to escalation to inform both the identification of complex patients

and meeting the 2% threshold, as well as supporting identification of actions / support required.

Appeals and disputes resolution processes are outlined within the NHS Standard Contract and will be

reviewed through the Primary Care Working Group.

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Appendix 1:

Characteristics of Successful Huddles Characteristic Detail and Description

1. Commitment to attendance at

meetings

Core ICN team members prioritise attendance of huddle meeting, arrive on time and provide cover when

unable to attend.

2. Equal and effective participation Core ICN team members come prepared and contribute to discussions. There is equity and respect

between members and individuals take ownership of actions allocated to them. All members understand

roles and responsibilities.

3. Well chaired There is a clearly identified chair person who ensures discussions are focused, that all voices are heard and

that meetings run to time.

4. Right people selected with consent The Huddles select people to be reviewed that have complex needs that are escalating and require a multi-

agency discussion. These will be sourced from multiple sources according to the framework. This will

include risk stratification, recent hospital discharges including people seen by the LIFE team and Careline’s

telecare responses. Any member of the core ICN team can refer people.

5. Use of shared care planning Core ICN team members ensure that people with complex needs have a multi-agency care plan that has

been co-designed with the person and their family/carer.

6. Timely delivery of person centred

actions

Core ICN team members identify and allocate clear actions with time frames. Decisions are recorded, coded

and monitored.

7. Key worker role is used effectively

to support the care planning for

people with the most complex care

needs

Core ICN team members understand the purpose and value of the ICN care lead (previously known as key

worker role) and use it effectively to manage more people with complex health and care needs, including

the use of shared care plans.

8. Members use the dashboard to

assess impact on outcomes

Members review the dashboard of KPIs and take mitigating actions to address any adverse indicators.

9. Multi agency working also takes

place outside the meeting

Members don’t leave urgent and simple issues for the huddle meeting. Members routinely communicate and

work collaboratively together to improve care for people with complex health and care needs.

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Appendix 2: NEL Admissions Review (element 1)

Element 1: Proactive Management Reporting template: Review of non-elective activity

This template should be completed following practice review and discussion of the previous 12 months NEL activity which should be discussed at a Practice meeting and during quarter 2 and quarter 4 2019/20. This review should also build upon learning from huddles, case reviews and clinical experience.

Results should be used to inform:

1. Identification of patients with complex needs to support development of care plans (in conjunction with the use of risk stratification and other tools)

2. Identification of practice action plans to develop local processes to supporting patients with complex needs and delivery of population based health services

3. Feedback to PCNs (at the appropriate time – route to be confirmed) to support understanding of network population needs and development of network-based approaches to address these needs

4. Feedback to the CCG – particularly the Out of Hospital and Urgent Care teams – to support development of commissioning intentions and services to address the needs of local residents

Practice name and ODS code

Date of Review and practice meetings:

Diagnosing the issues

What issues did the practice identify?

Include here a summary of the findings of the review considering:

• Experience of specific case examples

• Patient cohorts identified through Sollis, case reviews etc

• Discussions at huddles

• Key learning from review of NEL activity data e.g. for individual patients; and for cohorts of patients e.g. based on age, social issues, specific conditions

What changes did the practice make to try to address issues identified for supporting people

with complex needs?

Include here any actions undertaken which may not have had the intended impact and learning

from these actions

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Results

What did the practice achieve? To be completed during second review in Quarter 4

This could include:

• examples of key changes to support individual patients with a high volume of NEL activity and how these case studies have changed practice for the wider patient population

• consider and comment on changes in NEL activity identified – either for the total practice population, key cohorts or individual patients

What changes will/ have been embedded into practice systems to support patients with

complex needs in the future?

Outline any areas identified which cannot be addressed by practice actions alone and require

PCN or CCG review / input.

Please attach the results of the NEL review (as appendices)(minutes of practice meetings)

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NHS Standard Contract 2019/20 Particulars Proactive Case Management of Serious Mental Illness (SMI)

and Complex Non-Psychotic Mental Health Needs SCHEDULE 2 – THE SERVICES A. Service Specification

Service Specification No. TBC

Service Proactive Case Management of Serious Mental Illness (SMI) and Complex Non-Psychotic Mental Health Needs

Commissioner Lead Stephen Warren, Director of Commissioning, NHS Croydon CCG

Provider Lead GP Practices & Networks in NHS Croydon CCG

Period 3 years, commencing Q2 2019/20

Date of Review March 2020

1. Population Needs 1.1 National/local context and evidence base

Croydon is a large London Borough with a GP-registered population of 406,309 across 56 practices (QOF

2017/18). Prevalence of long-term, complex mental health needs is higher than the national average,

with an NHSE mental health needs index of 1.21 (where 1.0 is the national average), making it

comparable to many inner-London, high-prevalence Boroughs.

The CCG has a registered Serious Mental Illness Population of 4,610 people, or 1.11% of the adult

population (ibid). In addition, whilst no formal GP register exists, there is a significant group of people

with complex non-psychotic conditions such as severe anxiety, depression and personality disorders

who would also benefit from additional GP services.

The majority of these people will be under the care of their GP alone at any point in time. Many will

present to their GP experiencing distress related to social factors (debt, benefits, housing, social

isolation) as well as for their physical and mental health needs. An audit of 438 randomly-selected

patients on the SMI QOF in West London CCG identified over 2000 appointments, 46% of which related

to such social issues and locally GPs in Croydon report similar if not higher levels. Such social factors can

and do lead to rapid deterioration and loss of control: a potential ‘crisis in the making’, well-evidenced

in the Citizen’s Advice Bureau’s 2018 publication “Roadblocks to Recovery”.

Additionally, the physical health of those with complex mental health needs is demonstrably poorer

than the wider population on average, with markedly shorter life-expectancy. For this reason, the NHSE

5YFV for Mental Health sets out an ambition to extend physical health checks for the SMI population.

This LCS incorporates these requirements but sets them in the real-life context for GPs and their

patients, providing a ‘whole person’ care planning process that attends with equal weight, and

according to the individual, to the physical, mental and social ‘health’. In so doing it observes consistent

findings from co-production, nationally and locally.

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This service recognises that GPs need to go ‘above and beyond’ GMS care levels to effectively respond

to the needs of these individuals and be appropriately remunerated for so-doing. Critically, this LCS is a

bedrock to a wider transformation programme for community mental health services in Croydon that

is set out below.

Developing an integrated mental health & well-being service for Croydon

Over the past year the CCG has been working with partners in commissioning, delivery and users of

services to identify ways to strengthen community service provision, support more care to be

delivered in community and primary settings where the GP is the accountable clinician by providing

health & social care assessment, case management and structured social support (e.g. navigation

services, expert welfare, housing and employment advice, peer support and a range of activities that

promote well-being, closer to General Practice and increasingly locality-based in line with Croydon’s

Health & Care Strategy.

Underpinning this systematic, proactive approach is this new Enhanced Locally Commissioned Primary

Care Service. It aims to ensure that the standard of care provided by GPs to those with long-term

complex mental health needs is consistently delivered. Further, where needed, GPs can call down case

management support (clinical or navigator according to needs) and the full wrap-round offer that the

Hubs will provide through its integrated delivery approach. Crucially, GPs will have access when they

need it to expert advice from community-facing Psychiatry, supporting care to stay in the community.

All those under this ‘Enhanced’ offer will receive a proactive annual bio-psycho-social (“Well-Being”)

plan and provision for up to 3 extended appointments (according to needs) with their named GP each

to review that plan and measure progress.

Key benefits for GPs, their patients and carers of this new approach will be a dedicated GP psychiatric

advice line, support to proactively manage practice lists of those referred in by GPs to this LCS, named

linked workers per Practice and a ‘one stop’ route in to access case management, talking therapies

and social support.

It is recognised that need profiles vary markedly across Croydon and between Practices, from more

affluent areas to more deprived, with attendant presenting mental health needs. This Locally

Commissioned Service can be used flexibly by Practices to respond to their local needs.

This service is aimed at adults (aged 18 and over) with:

(1) Serious Mental illness (SMI) on the QOF register (2) Complex Non-Psychotic mental health needs

All patients on Practice Lists who meet these criteria can be registered for this service, whether under Primary care alone or managed jointly with Secondary care. Appendix 1 sets these values out at 2017/18 QOF out-turn levels. The service is expected to be delivered to a minimum of 80% of patients on practice SMI QOF registers. In addition, practices are expected to deliver a service to the most complex patients with non-psychotic mental health needs.

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The range of indicated conditions for this service is set out in section 3.4 of this specification. In this first year, a ‘Top 10%’ approach is being taken for this complex non-psychotic group. Guidance on ways to systematically identify this group is included at Appendix 2. Indicated numbers are shown in Appendix 1.

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2. Outcomes 2.1 NHS Outcomes Framework Domains & Indicators

Domain 1 Preventing people from dying prematurely ✓

Domain 2 Enhancing quality of life for people with long-term conditions

✓

Domain 3 Helping people to recover from episodes of ill-health or following injury

✓


Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm

✓

2.2 Principles of Care

Individual Empowerment and Self Care

Working with the wider community network in helping people to recognise their own condition and seek support through available services at the time, and in the way, best suited to their needs. The service will support people to access care that is compliant with national standards and meets appropriate care guidelines to give the greatest opportunity for recovery

Access, Convenience and Responsiveness

The specification requires the provider to deliver the service as close to a patient’s home as possible.

Care Planning and Multidisciplinary Care Delivery

The specification requires the service to be provided in a setting where the patient is also receiving other aspects of care at the same time. Individuals will experience coordinated, seamless and integrated services using evidence-based care pathways, case management and personalised care planning. Effective care planning and preventative care will anticipate and avoid deterioration of conditions.

Population- and Prevention-oriented

The specification sets out the requirement for the provider to proactively engage with the patient, as appropriate, to support uptake for screening, medical review, attendance at forthcoming appointments and prevent infection/complications. The CCG expects the service provider to ensure that the service is accessible to all patients registered with GP providers within the CCG.

Safe and High Quality

The provider should have access to the whole patient records, where clinically indicated and with patient consent, so they can contextualise patient results and advise on next steps.

3. Scope 3.1 Aims and objectives of service The CCG is commissioning a service for the enhanced Case Management of patients on the SMI QOF register and patients with complex mental health needs. This includes patients who are under secondary care where GPs are actively involved in their care and those under the sole care of their GP (with or without support from Primary Mental Health Services), in order to:

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• Provide proactive case management for these patients, supported by an Annual Bio-Psycho-Social ‘Well-Being Plan’ and patient contact throughout the year to review progress.

• Ensure that the patient benefits from high quality care, delivered as close to their home as appropriate

• Prevent or reduce unnecessary referrals and admissions to specialist services and Secondary Care.

This service is in addition to those services that GMS, PMS and APMS providers are contracted to provide to their registered patients. The specification of this service is designed to cover the enhanced aspects of clinical care of the patient, which are considered beyond the scope of essential services and additional services within the GMS, PMS and APMS contract. 3.2 Service description/care pathway CASE FINDING The service provider will:

• Update their SMI QOF list and proactively invite the patients on the reviewed list for an Annual Mental Health review

• Proactively identify, from their registered list, patients with Complex Non-Psychotic Mental Health Needs, who are more likely to benefit from a proactive case management approach (see Appendix 2).

PROACTIVE CASE MANAGEMENT The service provider will:

• Carry out an Annual Mental Health Review as defined in Appendix 2 (a duration of 30 minutes for each patient) comprising of a bio-psycho-social assessment, baseline outcome measure (see Appendix 4) and resulting in a jointly agreed Care Plan given to the patient.

• Offer a minimum of one extended follow-up appointment (a duration of 20 minutes for each patient), during the financial year (i.e. April 1st - 31st March), to review progress and make adjustments against the plan where necessary.

• Undertake all required prescribing, monitoring, administration and annual review of

medication, including depot, as appropriate.

Appointment Guidance Notes:

• All consultations should be recorded on the primary care clinical system using the appropriate EMIS template.

• Where appropriate, and with the consent of the patient, carers may be involved in any appointments in primary care. If carers are involved, they will have the opportunity to have an individual appointment with the patient’s GP to discuss any issues they may have. If the carer has legal responsibility for the patient, they must be involved in all review appointments.

• The Annual Review consultation and at least one of the follow-up appointments must be carried out by a registered GP. Please see Section 3.5 on Workforce requirements.

The service provider will also:

• Ensure each patient has a named Case Manager. This should be a registered GP.

• Ensure adequate follow-up and engagement of all patients who Did Not Attend (DNA). Practices must have a protocol for the follow-up and engagement with patients who DNA.

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• Assess whether the patient requires on-going proactive case management after 12 months of entry to the service; this can be discussed with the patient as part of the annual review. However, the expectation is that patients with on-going SMI will remain with the service long term.

• Draw on the services of the new Integrated Mental Health & Well-Being Service for case management, advice and social support where this is needed for the patient to complete their ‘Well-being Plan’ goals.

3.3 Population covered This service must be delivered by an individual Practice or group of Practices to all patients registered with these practices ensuring equitable access and quality of service to the entire CCG population group. Where there is more than one group of GP providers within the geographical boundaries of their CCG, the groups may operate collectively to ensure equitable access and quality of service to the entire CCG population group. The GP provider grouping and location(s) of delivery of the service (number of delivery points) must be agreed with the commissioning CCG. It is recommended that this specification is delivered at practice specific level as this ensures the most holistic care for the patient and closest to their home. Practices and Networks will ensure that the service is offered between 08:00 and 18:30 Monday to Friday, excluding Bank Holidays, as a minimum requirement. 3.4 Any acceptance and exclusion criteria and thresholds Acceptance:

• Adult patients (aged 18 years and over) who are on the QOF SMI register.

• The most complex 10%4 of Adult patients (aged 18 years and over) with the following mental health needs whose condition is any of those listed below with recurrent, chronic, severe or treatment resistant conditions and with moderate functional impairment. Diagnoses in this category may include:

o ADHD (Attention deficit hyperactivity disorder) or ASD (Autism spectrum disorder)

with significant mental health co-morbidities o Anxiety and/or depression o Eating disorders o Obsessive compulsive disorder o Perinatal mental health needs o Personality disorders o Post-traumatic stress disorder

o Sexual and gender identity disorders

o Sleep disorders

o Somatization, somatoform or conversion disorders (Somatic Symptom Disorders)

o Substance related disorders with co-morbidities

These would include patients who:

4 As discussed in Appendix 2

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• Have needs above those that would ordinarily be provided for under the GMS core contract, or the Quality Outcomes Framework, and require the additional pro-active support

• Are under Secondary Care and have no anticipated changes to their current treatment plan and, where applicable, are prepared to receive medication from their GP.

• Require minimal assistance with medication concordance and must be stable on medication but requiring regular review and monitoring

If patients have co-morbid substance misuse needs, ADHD or ASD they will be assessed for their suitability and can be included in this service only if they have dual diagnosis with a mental health co-morbidity. With substance misuse, they must be either stable or being actively managed by substance misuse services. Exclusions:

• Patients with Mild to Moderate CMI whose conditions respond well to first line treatment specified in NICE guidance

• Patients under 18 years of age

• Patients with organic illness

• Patients registered for other LCSs in Croydon - no additional payment for these patients can be made under this LCS.

3.5 Workforce Requirements

• The service provider must ensure that the staff delivering the service meet the requirements outlined in Croydon’s LCS contracts.

• The GP service lead must attend a local or online education session on the delivery of the service.

• The GP must deliver the comprehensive bio-psycho-social face-to-face consultation that is part of the Annual Review and review the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) and the Well-Being Plan, and provide a copy of this for the patient.

• Other clinicians may support the GP in providing lifestyle and physical health information which informs the Annual Review, as set out in the Minimum Data Set (MDS) – please see Appendix 1.

• This is a GP-delivered service; and the GP must carry out both the Annual Review consultation and at least one follow-up appointment. Where a second follow-up appointment takes place, this may be carried out by an Allied Health Professional (AHP), employed by the service provider, with appropriate mental health knowledge, skills and competencies.

3.6 Clinical governance requirements

• The service provider will need to be able to deliver, manage and report on service performance in line with the contractual requirements outlined in Appendix 1.

• Within the GP provider grouping, if not all practices are delivering this specification, there will need to be a mechanism for referring and receiving clinical information about patients between the referring practices and the service delivery points that will need to be supported by robust governance processes.

• The service provider must ensure that there are robust governance processes in place to ensure clinical services are delivered safely in each delivery point and are coordinated across the GP provider grouping.

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• The service provider should ensure that all delivery points meet CQC requirements for the delivery of medical services which as a minimum should be those required for the delivery of general medical services.

• The service provider should ensure that all standards of communication should adhere to Caldecott and Data Protection guidelines.

• Data generated in the course of delivering the service should be available to the commissioner on request. The commissioner will give due regard to data protection and confidentiality requirements.

• If required to ensure that the service is operating effectively, the commissioner can interview the service provider's staff.

• The service provider must comply with commissioner requests for clinical audit. 3.7 Interdependence with other services/providers This service is part of a wider integrated care pathway: both the new Integrated Community Offer and secondary mental health services primarily delivered by SLaM but also cross-border with St George’s and Surrey & Borders NHS Trusts. The provider will support an integrated approach between services and providers, ensuring that patient records are transferred appropriately to support a seamless patient transfer and service provision. The service provider will be expected to work in close partnership with a range of health and social care providers, including:

• Local Primary Care Mental Health Services, which increasingly bring together psychiatric support, case management, health and social care navigators and peer support services.

• Local employment, housing services and benefits services, which are increasingly accessible through Primary Mental Health Services.

• Secondary Mental Health Services in the case of an acute exacerbation and for shared care liaison

• Providers of primary care or secondary care based psychological therapies

• Local Authority commissioned services supporting wellbeing

• Other acute providers delivering physical health care

• Other community provider services including community nursing and specialist nursing and therapy teams

• Community Champions and other community based networks

• Care Navigators and PICs. 4. Applicable Service Standards 4.1 Applicable national standards (e.g. NICE) NICE Guidance Common Mental Illness (CG123) NICE Guidance Anxiety: (CG113) NICE Guidance Depression (CG90) NICE Guidance: Borderline Personality (CG78) NICE Guideline: Eating disorders: recognition and treatment (NG69) NICE Guidance Obsessive Compulsive Disorder (CG31) NICE Guidance Post Traumatic Stress Disorder (CG 26)

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4.2 Applicable standards set out in Guidance and/or issued by a competent body (e.g. Royal Colleges)

• World Health Organisation: The Mental Health Context http://www.who.int/mental_health/policy/services/3_context_WEB_07.pdf

• Guidance issued by Royal College of General practitioners: meeting the competences set out in the new RCPsych curriculum -www.rcgp-curriculum.org.uk

• The RCPsych website provides general advice and guidance for the management of mental health conditions in general practice www.rcpsych.ac.uk.

• Improving physical healthcare for people living with severe mental illness (SMI) in primary care: Guidance for CCGs – 9 February 20185. Please note, this guidance was issued shortly after the present document was finalised. In consultation with the Croydon CCG GP Mental Health Leads, trhe CCG is taking a progressive approach in addition to the 6 required standards by NHSE and the lower levels of adherence nationally prescribed (10% for patients under secondary care and 50% of patients not under secondary care. This is an evidence-based approach and in practice the small number of additional requirements are readily met during the extended appointments that are being remunerated within this specification.

4.3 Applicable local standards: Please see Mental Health Contractual Requirements document embedded on p.12 5. Applicable quality requirements and CQUIN goals 5.1 Applicable Quality Requirements (See Schedule 4 Parts [A-D]) 5.2 Applicable CQUIN goals (See Schedule 4 Part [E]) Not applicable 6. Location of Provider Premises The service provider’s delivery points should be from sites where GMS/PMS services are delivered or where APMS services are delivered, where the primary function of the APMS contract is for the delivery of primary medical services.

5 https://www.england.nhs.uk/publication/improving-physical-healthcare-for-people-living-with-severe-mental-

illness-smi-in-primary-care-guidance-for-ccgs/

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Appendices Appendix 1: SMI QOF by Practice (2017/18)

The ‘Top 10%’ most complex Non-Psychotic Mental Illness is estimated at 5.5% of Croydon’s Adult

(18+) population of 290,062 (ONS Mid-Year Estimate) = 1,595 people across the CCG.

Practice code Practice Name List Size SMI Register Prevalence (%) 80% Threshold

H83001 PORTLAND MEDICAL CENTRE 12,038 163 1.35 130

H83004 THE FARLEY ROAD MEDICAL PRACTICE 11,681 65 0.56 52

H83005 UPPER NORWOOD GROUP PRACTICE 12,907 160 1.24 128

H83006 PARKWAY HEALTH CENTRE (02) 6,759 112 1.66 90

H83007 VIOLET LANE MEDICAL PRACTICE 10,809 158 1.46 126

H83008 THE ADDISCOMBE SURGERY 3,020 52 1.72 42

H83009 NORBURY HEALTH CENTRE (02) 10,484 92 0.88 74

H83010 SOUTH NORWOOD HILL MEDICAL CENTRE 6,392 48 0.75 38

H83011 NORTH CROYDON MEDICAL CENTRE 5,082 74 1.46 59

H83012 ST.JAMES'S MEDICAL CENTRE 9,600 87 0.91 70

H83013 OLD COULSDON MEDICAL PRACTICE 13,662 112 0.82 90

H83014 QUEENHILL MEDICAL PRACTICE 7,202 63 0.87 50

H83015 PARKSIDE GROUP PRACTICE 13,031 122 0.94 98

H83016 KESTON MEDICAL PRACTICE 15,823 207 1.31 166

H83017 BRIGSTOCK & SOUTH NORWOOD PARTNERSHIP 16,181 227 1.40 182

H83018 SELSDON PARK MEDICAL PRACTICE 11,515 100 0.87 80

H83019 FRIENDS ROAD MEDICAL PRACTICE 8,674 87 1.00 70

H83020 EVERSLEY MEDICAL CENTRE 10,863 179 1.65 143

H83021 LONDON ROAD MEDICAL PRACTICE 5,945 86 1.45 69

H83022 THORNTON HEATH HEALTH CENTRE 6,903 112 1.62 90

H83023 MORLAND ROAD SURGERY 7,026 103 1.47 82

H83024 WOODCOTE MEDICAL 15,547 153 0.98 122

H83027 PARKWAY HEALTH CENTRE (01) 5,906 44 0.75 35

H83028 ADDINGTON MEDICAL PRACTICE 3,422 34 0.99 27

H83029 HARTLAND WAY SURGERY 4,348 29 0.67 23

H83030 BROOM ROAD MEDICAL PRACTICE 3,279 45 1.37 36

H83031 THE HALING PARK PARTNERSHIP 3,526 51 1.45 41

H83033 ASHBURTON PARK MEDICAL CENTRE 3,437 51 1.48 41

H83034 THE WHITEHORSE PRACTICE 7,600 132 1.74 106

H83037 AUCKLAND SURGERY 7,299 77 1.05 62

H83039 STOVELL HOUSE SURGERY 7,377 92 1.25 74

H83040 MITCHLEY AVENUE SURGERY 3,824 28 0.73 22

H83042 LEANDER ROAD SURGERY 7,497 89 1.19 71

H83043 SHIRLEY MEDICAL CENTRE 7,798 58 0.74 46

H83044 EAST CROYDON MEDICAL CENTRE 18,543 169 0.91 135

H83048 DOWNLAND SURGERY 1,832 30 1.64 24

H83049 HEADLEY DRIVE SURGERY 2,612 20 0.77 16

H83050 THE MOORINGS MEDICAL PRACTICE 6,097 42 0.69 34

H83051 THORNTON & VALLEY PARK SURGERY 10,546 97 0.92 78

H83052 BRAMLEY AVENUE SURGERY 2,519 21 0.83 17

H83053 PARCHMORE MEDICAL CENTRE 14,032 179 1.28 143

H83608 BRIGSTOCK FAMILY PRACTICE 4,385 44 1.00 35

H83609 MERSHAM MEDICAL CENTRE 3,854 42 1.09 34

H83611 SELHURST MEDICAL PRACTICE 3,595 46 1.28 37

H83620 COULSDON MEDICAL PRACTICE 3,648 31 0.85 25

H83622 SOUTH NORWOOD MEDICAL PRACTICE 2,788 44 1.58 35

H83624 FAIRVIEW MEDICAL CENTRE 7,868 71 0.90 57

H83625 BROUGHTON CORNER MEDICAL CENTRE 3,739 48 1.28 38

H83626 THE ENMORE PRACTICE 1,928 32 1.66 26

H83627 BIRDHURST MEDICAL PRACTICE 6,525 74 1.13 59

H83631 GREENSIDE MEDICAL PRACTICE 9,513 99 1.04 79

Y02962 THE PRACTICE SURGERIES LTD 5,737 63 1.10 50

Y05317 COUNTRY PARK PRACTICE 5,937 81 1.36 65

Y05318 DENMARK ROAD SURGERY 6,199 85 1.37 68

WHOLE CCG 408,354 4,610 1.13% 3,688

Croydon CCG SMI QOF & Complex Non-Psychotic MH Needs by Practice 2017/18

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Appendix 2: MENTAL HEALTH LOCALLY COMMISSIONED SERVICES – ‘AT A GLANCE’: Requirements and Payment Arrangements, the Annual Mental Health Review, Minimum Data Set (MDS) Requirements, and Key Performance Indicators (KPIs)

1. Requirements and Payment Arrangements

What is required? Number of Payable Appointments per year

All patients

Annual Mental Health Review

including the MDS below 1

Mental Health Review Follow-

Up 1 or 2 according to clinical needs

In one financial year the service provider is required to provide the Annual Mental Health Review described below, and a minimum of one follow-up appointment and a maximum of two. The Annual Review and Well-Being Plan Meeting (30 minutes) attracts a payment of £90, with the maximum of two in-year Reviews (20 minutes) paid at £45 per appointment. This is a GP-delivered service. However, where appropriate, the second follow up appointment can be carried out by an Allied Health Professional (AHP) employed by the service provider, with appropriate mental health knowledge, skills and competencies. The Annual Review Consultation, the Recovery and Stay Well Plan and a review of the Short Warwick-Edinburgh Mental Well-being Scale, must be carried out by the GP, and the GP must also create a Care Plan which should be given to the patient on the same day. Other clinicians in the practice team may support the GP in providing lifestyle and physical health information as part of the MDS. However, it is expected that a majority of the MDS information will be available to the GP when carrying out the Annual Review and that the GP will carry out at least one follow-up appointment. All non-face-to-face time for liaison with Psychiatry, CPNs and other mental health service staff involved in a patient’s care, telephone calls, DNA follow-up and depot injections as appropriate, is included in the tariff price paid for each appointment, apportioned as set out above. Payment will be made in the following circumstances:

• If only the Annual Mental Health Review has been completed: full payment for the Annual Mental Health Review

• If the Annual Mental Health Review and at least one follow-up appointment are carried out within a year: full payment for the Annual Review and full payment for the follow-up appointment.

• A second follow-up appointment, if it takes place, will be payable in accordance with specific CCG policy, and only if the annual review and the first follow-up have already taken place.

No payment will be made in the following circumstances:

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• If a follow-up appointment takes place in one financial year, but no Annual Review has taken place in the same financial year.

• If two follow-up appointments take place in one financial year, but no Annual Review has taken place in the same financial year.

NB: it is not mandated that these follow-up appointments must necessarily sequentially follow an annual review as it is recognised that patient-specific circumstances will dictate the most appropriate type of consultation to take place at any given time.

2. The Annual Mental Health Review The Annual Mental Health Review is a comprehensive bio-psycho-social face-to-face consultation with a GP, that considers the MDS detailed below and results in an agreed, documented, and printed Care Plan that the Patient takes away. The Annual Review is deemed complete when all aspects of the MDS have been completed within that financial year, and these have been reviewed by the GP. The Well-Being Plan and SWEMWBS must be completed by the GP, who must also generate a Care Plan and give this to the patient. Other clinicians in the practice team may support the GP in providing lifestyle and physical health information which informs the MDS.

3. The Minimum Data Set (MDS) For every patient registered, all 13 MDS items below (which include the Well-Being Plan and Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS)) must be completed by financial year-end. Failure to complete all 13 items and to carry out the comprehensive bio-psycho-social consultation comprising the Annual Review will result in non-payment.

What is required? National or Local Number Per Year Carried out by

BMI NR 1 GP or HCA6 or Nurse BP NR 1 GP or HCA or Nurse

Pulse Rhythm LR 1 GP or HCA or Nurse

QRisk/unsuitable/declined NR 1 GP or HCA or Nurse

Smoking status NR 1 GP or HCA or Nurse

Alcohol intake NR 1 GP or HCA or Nurse

Substance misuse NR 1 GP or Nurse Employment LR 1 GP or Nurse

Finances LR 1 GP or Nurse Accommodation LR 1 GP or Nurse

Type of Carer/No carer LR 1 GP or Nurse

SWEMWBS7 LR 1 GP

Well-Being Plan8 LR 1 GP

6 Health Care Assistant

7 Short Warwick-Edinburgh Mental Well-being Scale, see Appendix 4

8 Well-Being Plan – consisting of four items: 1) Patients Goals and Priorities; 2) Signs of becoming unwell; 3) Anticipatory Care Plan; 4) Health Action Plan

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4. KEY PERFORMANCE INDICATORS FOR General Practice

Overall outcome: Enhanced case management of patients with long-term mental health needs.

Outcome Indicator

Improved access to self-care and lifestyle support including accessing stop smoking, weight management, alcohol/substance misuse services, support around physical activity, diet, finances, accommodation for people registered on this LCS.

% of patients registered on LCS with an Annual Review completed and Well-Being Plan created

Improved access to self-care and lifestyle support (as above) for people with SMI

% of SMI patients on the QoF Register seen under the service: target of 80% of QOF.

All patients have undertaken the SWEMWBS questionnaire where appropriate

% of patients with a Wellbeing Score (SWEMWBS) recorded a minimum of once and maximum of twice in a year.

Patients on mental health medication have at least one annual medication review

% patients with Mental health medication that have a medication review recorded on EMIS.

Improved recording of clinical markers with co-morbid health problems Including: Diabetes, CVD, COPD, Alcohol and/or Substance misuse, Smoking

a) % of patients with Q risk, BMI, BP**

b) % of patients with appropriate Blood tests: HbA1c or Glucose, Lipids, LFT and UE**

c) % of patients who are smokers (in the last 12 months) offered smoking cessation advice x 2 per year

d) % of patients who are smokers (in the last 12 months) with Cough/MRC recorded

e) ECG is offered annually to patients on anti-psychotics with high risk of cardiovascular disease and patients with high risk of prolonged QT

f) % of patients seen with alcohol intake recorded

g) % of patients seen with substance use recorded

Proactive management of patients in a year of care

% of patients who have completed a year of care (i.e. have attended an annual review and one follow up appointment, not necessarily sequentially)

NB: A dashboard will be developed that can be run at Practice, Cluster and CCG levels to show the extent of MDS completeness (predicating payment). This will support data quality and core quality standard management. In addition, the above KPIs will be developed into a dashboard to monitor impact against the anticipated outcomes of the LCS.

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Appendix 3: Guidance to Support CCGs and Practices in targeting the ‘Top 10%’ Background Unlike SMI, for which there is a QOF Register, equivalent to ‘known prevalence’, there is no such Register for complex non-psychotic mental illness. The Depression QOF Register covers only patients with depression and anxiety, the vast majority of who would not meet the ‘complexity’ test. Non-psychotic mental health conditions include a range of conditions such as Eating Disorders, Personality Disorders, PTSD as well as Anxiety and Depression. Within these conditions, many patients are often well-functioning, or responsive to treatment (talking therapies and medications). Some however are particularly hard to engage with, may not function well, and may be poor responders to treatment. It is for this group that this LCS is intended: The Top 10% who are the most complex, that would benefit from the extra time and structure that the LCS brings in terms of detailed review, care planning, and follow-up throughout the year to improve or maintain their physical and mental health and social well-being. How were the population estimates arrived at? In the absence of a QOF register, a Clinical Review Group of CCG Mental Health Lead GPs in North West London undertook a literature review of non-psychotic mental health conditions to establish evidence-based estimates for their 8 CCGs. This review determined that prevalence of all common mental health was on average indicated to be 5.5% of the adult registered population. As described above however, this will include a majority of patients whose level of health and functioning would not necessitate the enhanced services. The ‘Top 10%’ of these patients would be the most complex, and this equates therefore to 0.55% of the adult practice population. Croydon CCG’s adult registered population was 290,062 (ONS mid-year estimates), equating to a ‘top 10% most complex’ estimate of 1,595 at CCG level. How can practices systematically target the most complex 10%? To support Practices some guidance has been developed on ‘markers’ of complexity that GPs and Practices can use to help systematically search for patients from their lists that may benefit. It should be stressed that this is not an exhaustive or ‘water-tight’ search strategy. The value of the Mental Health specification is that it strongly encourages individual clinical decision-making. GPs’ knowledge and clinical judgement of their own patients and whether they would benefit from the proactive case management approach of the LCS may be a far more reliable predictor than a list of ‘markers’ or search strategies. The markers set out below may act as a prompt for new ways of considering risk and complexity amongst this group. The following guidance is provided as potential ‘ways in’ for Practices to establish their ‘Top 10%’: (a) Diagnoses: The ‘in scope’ conditions for the specification are:

o ADHD or ASD with significant mental health co-morbidities as discussed above o Anxiety and/or depression o Eating disorders o Obsessive compulsive disorder o Perinatal mental health needs o Personality disorders o Post-traumatic stress disorder o Sexual and gender identity disorders

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o Sleep disorders o Somatization, somatoform or conversion disorders (Somatic Symptom Disorders) o Substance related disorders with co-morbidities

The availability of reliable information on this on the primary care system will depend on the quality and consistency of coding and existence of a pre-existing diagnosis (which for some conditions will be less likely and less accurate than for others that have been included in QOF). In addition, of course, the specification is not intended for universal registration of all patients with such conditions, but only the top 10% most complex (e.g. recurrent and or, chronic, and/or severe, and/or treatment resistant, with poor levels of functioning, poor engagement in mental health and physical health treatments, multiple long-term conditions, repeated DNAs). Nonetheless, we would recommend such ‘global’ searches are carried out as it will foster a better understanding at Practice level of the scale and scope of needs in their population, and use that as a basis for exploring a targeted approach, considering the factors set out in the rest of this section. (b) Patients being prescribed anti-psychotic medication who are not on the SMI QOF. Anti-psychotic medication may well have been initiated for some patients who do not have an SMI, but who have a Personality Disorder or Severe Depression and Anxiety with psychotic symptoms, to control those symptoms, and often at low doses. Whilst patients who experience psychosis related to schizophrenia and bipolar disorder should be registered on then SMI QOF, those outside of those conditions from the list in (a) might well be receiving anti-psychotic medication and would benefit from the enhanced bio-psycho-social review and care planning provided under this LCS. Practices could cross match all anti-psychotic prescribing against their SMI QOF list and consider whether any of these patients might benefit from this LCS. (c) Frequently changing depression/anxiety prescribing. A search could be conducted looking at any patients on the Depression QOF who have had frequent changes to the drugs they have been prescribed, which might be an indicator of treatment resistance, risk and hence complexity. (d) Co-morbidities e.g. drug and alcohol, ADHD, ASD Long Term Conditions (LTCs), Chronic Pain and other mental illnesses. The presence of one or more co-morbidity will be a key marker for escalated risk and lower functioning, indicating the need for an enhanced level of care. A search for patients with these illnesses, or individual GP insight into their patients, could quickly identify patients who may benefit from the service. (e) Patients who are pregnant. Pregnancy greatly escalates the risk factors for those with mental illnesses. Searching for patients with known pregnancy and who have one (or more) of the conditions set out under (a) would identify another at risk group who could be considered for the specification. (f) Frequency of ED/UCC attendance Amongst the patients identified under (a), have any attended ED/UCCs at elevated levels and for reasons that would not otherwise necessitate ED/UCC attendance. This might include physical reasons such as self-harm, or excess presentation due to their mental ill health. Either could be markers of complexity that would benefit from enhanced support under the specification.

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(g) Frequent DNAs Those who DNA multiple GP or Out-Patient appointments may be at excess risk, notably if they have LTCs or other co-morbidities. Such poor engagement in health care and support is likely a marker of poor levels of functioning and ability to self-care. This specification is designed to give Practices the extra resource to support them in the additional work that will be required to engage with those patients who are inherently difficult to engage. (h) Safeguarding Children and/or Adults. Those patients with Read Codes related to safeguarding including domestic abuse and with one or more of the conditions under (a) may be a marker for referral in to the specification. (i) History of childhood or familial mental health difficulties. Whilst this may not be Read-Coded, any patients who are known to have had a childhood mental health issue, or have a family history, may be at elevated risk. Consider in children who are reaching age 18 who had had a mental health issue. Consider cross-checking notes of parents of children who have a mental health issue.

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APPENDIX 4: The Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) SWEMWBS can be completed by the client prior to their appointment (i.e. in the Waiting Room) and be used as discussion guide when you see them for their extended appointment, or be done jointly with the client. Scores need entering on the template on EMIS. Ideally, to track changes, two measures in 12 months would be undertaken. Payment will be based on one valid questionnaire alongside the other 12 MDS items. Where 2 SWEMWBS are completed, a period of 3 months should be left between repeat measures.

------------------

Below are some statements about feelings and thoughts. Please tick the box that best describes your experience of each over the last 2 weeks

Statements None of the time

Rarely Some of the time

Often All of the time

I’ve been feeling optimistic about the future

I’ve been feeling useful

I’ve been feeling relaxed

I’ve been dealing with problems well

I’ve been thinking clearly

I’ve been feeling close to other people

I’ve been able to make up my own mind about things

“Warwick Edinburgh Mental Well-Being Scale

© NHS Health Scotland, University of Warwick and University of Edinburgh, 2006, all rights reserved.”

NB: Exemption is permitted where completion of SWEMWBS is not applicable, such as in cases when:

• No suitable translation of the tool, or translation services, are available

• A patient has a Learning Disability or Autistic Spectrum Disorder

• A patient has severe lack of insight into their condition

• Where completion of the tool would cause significant distress

In these circumstances, please enter N/A on EMIS. No more than 5% of payment claims per practice

can have this code.

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REPORT TO CROYDON CLINICAL COMMISSIONING GROUP PRIMARY CARE COMMISSIONING COMMITTEE IN PUBLIC

4 June 2019

Title of Paper: Commissioning Update

Lead Director William Cunningham-Davis Head of Primary Care, SWL

Report Author SWL Primary Care Team


Primary Care Commissioning Working Group, 16th May 2019


Primary Care Commissioning Committee – 4th June 2019


Recommendation:

The Primary Care Commissioning Committee is asked:

▪ to note the contractual changes update.

▪ to note the update in for Edridge Road Community Health Centre / Special Allocation

Scheme.

Background:

Contractual Changes An end of year report for 2018/19 is provided for contractual changes across Croydon Practice Updates As detailed in the report

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Key Issues:

Practice Updates Edridge Road Community Health Centre / Special Allocation Scheme New national requirements were recently introduced for Special Allocation Schemes, set up for patients who have been immediately removed from practice lists as a result of an act of violence or behaviour that led to those at the practice premises fearing for their safety. Service requirements as per the national guidance are:

• The patients on the scheme should be able to access full primary care medical

services during core hours (8.00 – 6.30 Monday to Friday)

• The premises where the service is being provided from should not be the same as

the provider’s normal working place

• Patients should be able to book an appointment or get clinical advice during core

hours and they should not have to call the surgery’s main telephone number

• Security service should be available 30 minutes before and after the appointment to

escort the patient out of the building (if necessary) and ensure the safety of the

clinician

These requirements mean that commissioners have to consider their commissioning options for the scheme. There are currently two schemes in South West London - the Croydon Safe Haven service for Croydon patients only and the Primary Care Extra Service in Wandsworth which was commissioned to deliver SAS services to patients from Kingston, Richmond, Merton, Sutton and Wandsworth. The Croydon service is delivered from Edridge Road Community Health Centre, as part of the recently procured contract there. There is no need to recommission this service due to the recent procurement. However, further financial input is required to ensure consistency of services across SWL, and the same service specifications need to be in place for the two services. The additional yearly financial input required is £3700, to make an annual contribution from Croydon CCG of £22000 – the same contribution as the other five CCGs in SWL. This was agreed at the last Primary Care Commissioning Working Group on 16th May 2019. For the service currently based in Wandsworth and covering the rest of South West London, it is proposed to commission an enhanced service – this proposal is being put to the other SWL CCG PCCCs for approval.

It is recognised that the enhanced service model and commissioning using the recently procured contract in Croydon may not fully meet the national specifications in regards to premises but with appropriate risk assessments and mitigation in place as part of the contract, the safety of the practice staff and other patients can be managed to a high level.

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Governance:

Corporate Objective To commission integrated, safe, high quality service in the right place at the right time. To have collaborative relationships to ensure integrated approach To achieve financial balance over five years

Risks Need to ensure consistent quality of service for Special Allocation Scheme across SWL, and that scheme meets the necessary requirements. Need to ensure access to best possible GP services to patients registered with the scheme. As above, risks relating to premises requirement need to be mitigated.

Financial Implications Additional yearly contribution of £3700 for Special Allocation Scheme

Conflicts of Interest N/A

Clinical Leadership Comments

N/A


Joined up approach across SWL CCGs required for commissioning of Special Allocation Scheme

Equality Analysis

N/A


N/A

Communication Plan

N/A


N/A

Reputational Issues N/A

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2018-19 Year End Contract Variations

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2018-19 Year End Contractual Variations and Notices

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REPORT TO CROYDON CLINICAL COMMISSIONING GROUP PRIMARY CARE COMMISSIONING COMMITTEE IN PUBLIC

4 June 2019

Title of Paper: Primary Care Quality Update

Lead Director Martin Ellis Director of Out of Hospital and Primary Care

Report Authors Bobby Miles Quality Improvement Manager Helen Goodrum Primary Care Commissioning and Quality Lead (CQC Update)


Primary Care Commissioning Working Group


Primary Care Commissioning Committee Quality Committee

Purpose of Report For noting Recommendations:

The Primary Care Commissioning Committee is asked to:

▪ Note the on-going and developmental work to deliver the CCG’s statutory duties in regards to ensuring quality in General Practice

▪ Discuss, comment and support the continued proactive approach to understanding and improving quality in General Practice

▪ Note the CQC status of practices in Croydon and the CCG input and actions to support practices

Background:

A high quality and safe healthcare system is at the heart of the CCG’s ambition as delegated commissioners of General Practice and as a clinically led organisation actively supports providers to go beyond national standards towards safe care on the ground. The CCG’s role is to be assured of the care quality of its providers but more importantly lead their improvement. Croydon CCG has established a number of measures and support mechanisms which are outlined in this report, together with details of future work planned to monitor quality, safety and performance and ensure that commissioned services deliver the best health outcomes for Croydon residents. The General Practice Clinical Quality Review Group (GP CQRG) has been established and includes Clinical lead representation from each of the six GP Networks. The GP CQRG discusses and monitors clinical issues, quality of care and performance.

GP Clinical Quality Review Group (GP CQRG) report

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This report is a summary of the contents of the CQRG meeting on 21 March 2019, the minutes of which were approved at the 15 May 2019 meeting. Medication Incidents reporting It was noted that incidents were often not being reported until several weeks after an incident had taken place (see chart below for detail).

The CQRG discussed the process of the reporting of incidents. An action was agreed for the quality to investigate ways to increase reporting and to reduce the time between occurrence and reporting. It was agreed that in preparation for the next meeting (May 2019) Ursula Madine, Head of Quality Assurance and Claudette Allerdyce, Associate Chief Pharmacist will be clarifying the necessary actions to improve timely reporting. There is a plan to continue incident reporting in the Prescribing Incentive Scheme for 2019/20. Update from May meeting:

• Draft NHS incident report guidance to be distributed to GPs

• Additional guidance setting out how to identify non-medication incidents

• Development of plan to engage, support and train GPs in effective incident reporting Immunisations The group discussed whether a clinical lead for Immunisations was needed. Following detailed discussions, the CQRG agreed that there was no need for a named clinical lead as this falls within the remit of Public Health and would be expected to liaise as necessary with the Primary Care lead; additionally, Agnelo Fernandes (Governing body chair) advised that the Public Health team could contact him in regards to immunisation queries. Diabetes Prevention Programme It was noted (from the GP quality dashboard) that 23 practices had made no DPP referrals to ICS Health and Wellbeing for the period from June 2018 to February 2019. A key supportive action was ICS Health & Wellbeing (the DPP provider) to attend each of the GP network meetings in February and March 2019, which they did. Update from May meeting:

• Number of practices that have made zero DPP referrals has fallen to 10.

35

22

7 4 6 7

118

3 7 4 2 5

10 20 30 40 50 60 90 120 150 180 210 240 300

Nu

mb

er

of

inci

de

nts

Days - difference between data of incident and date report submitted

Number of incidents reported within the stated number of days

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Diabetes Prevention Programme Jun 18-Apr 19

Number of practices with >5 referrals to ICS H&W 23

Number of practices with <=5 referrals to ICS H&W 17

Number of practices with zero referrals to ICS H&W 10

Total 50

Cancer Screening It was confirmed that discussions had been held with nurses and GPs and actions were already in train in regards to cancer screening. In light of the poor figures with regard to cancer screening at Croydon GP Practices this issue has been explored with Primary care clinicians and actions agreed to improve.

Cancer screening - Dec 2018 CCG

performance Standard

# achieving standard

Bowel Cancer Extended Age (60-74) Uptake 50.2% 60.0% 6

Bowel Cancer Extended Age (60-74) 2.5Y Coverage 52.0% 60.0% 7

Breast Cancer Standard Age (50-70) Uptake 66.9% 80.0% 0

Breast Cancer Standard Age (50-70) 36M Coverage 69.5% 80.0% 0

Cervical Cancer Lower Age (25-49) 3.5Y Coverage 66.6% 80.0% 0

Cervical Cancer Higher Age (50-64) 5.5Y Coverage 76.6% 80.0% 10

Update from May meeting:

• A comparison between Q3 and Q2 data showed the following: o Breast Cancer (50-70) – 30 x GPs had a worse rate from Q2 o Cervical Cancer (25-49) – 38 x GPs had a worse rate from Q2 o Cervical Cancer (50-64) – 31 x GPs had a worse rate from Q2

• It was agreed that quarterly comparisons were potentially problematic, but that further analysis could be undertaken before conclusions are reached

Respiratory It was confirmed that the Variation support managers will continue to support the Community Respiratory Team to help improve diagnosis rates for COPD, for example, as well as improved care planning for Respiratory patients. Severe Mental Illness (SMI) Physical Health Checks The decision on SMI Physical health checks becoming a Locally Commissioned Service was discussed amongst the group. The group stressed the importance of knowing when the SMI health checks LCS was going to be launched along with the ongoing practice support on the roll out of SMI health checks. Safeguarding Self assessments Following a discussion between the CCG safeguarding team and the LMC, adjustments have been made to safeguarding self-assessments, namely, practices will now be responsible for RAG rating their own self-assessments. The CCG Safeguarding team will continue to support practices with any challenges that they might face with respect to safeguarding governance matters. The group noted that a core number of practices (11) had not returned their self-assessments despite repeated requests. This would be brought back to the May meeting. Update from May meeting:

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• Mike Simmonds as chair of the GP CQRG to send email to the 11 practices asking them to return their self-assessments

GP Quality Dashboard It was suggested that the GP Quality dashboard data should be added to each GP network meeting agenda as a short item in order to highlight particular themes, areas for learning and further actions. Update from May meeting:

• Dashboard to be presented at the GP open meeting in June New items of note raised at the May meeting (in brief):

• Practice support visits – GP CQRG meeting to receive the approved GP Collaborative proposal for the improvement of quality across Croydon GP practices when it is sent and to discuss

• Variation team workplan - to include project outcomes, and for a highlight type report to be presented to the GP CQRG meeting as a matter of routine

• Risk Register – Primary care related items from the corporate risk register to be brought to the next GP CQRG meeting (in July)

• CQC – Emma Dove (CQC) to be invited to the July meeting

• LD healthchecks has shown sustained improvement in numbers completed each quarter has been noted in 2018-19.

o An increase of 237 checks on the 2017-18 total of 1182 has been reported with a total of 1419 checks for the year.

o Overall this represents 67% of people benefiting from a Learning Disability Health Check, an increase from 56% of people in the previous year.

Care Quality Commission (CQC) Visits/Ratings report The CQC are the independent regulator of health and social care in England and inspect General Practices on a five-yearly cycle or whenever ‘alert’ is received. From 2019-20 a new process of Annual Regulatory Review (ARR) is being used to supplement the inspections, it should be noted that practices will not be able to change a rating unless a full inspection is undertaken. Croydon CCG Primary Care, Variation, Medicines Management and Safeguarding teams are working actively to support Practices who are not rated as “Good” by the CQC. Regular supportive visits are undertaken by CCG representatives, including Clinical Leads, to understand the progress against their action plans and to assess and provide support to manage any risks. This is done in collaboration with the South West London NHS team. There is currently no practices within Croydon Borough who the CQC have rated as ‘Inadequate’ overall. There are three practices who the CQC have rated as ‘Requires Improvement’ overall: 1. Denmark Road 2. Brigstock and South Norwood Partnership 3. East Croydon Medical Centre

Whilst the remaining GP Practices within Croydon Borough are rated as “Good” overall, some

practices are rated as “Requires Improvement” in one of the CQC’s Quality Domains:

1. Violet Lane Medical Practice – “Safe” domain; 2. Brigstock Family Practice – “Responsive” domain; 3. Addington Medical Centre - “Safe” domain;

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Two practices have been rated as “Outstanding” in one of the CQCs Quality Domains:

• Friends Road Medical Centre – “Well Led”

• Selhurst Medical Centre – “Responsive” The table below shows details of inspections undertaken by the CQC as part of their scheduled programme, return visits, other changes or where we are awaiting publications of reports since the previous at the November PCCC meeting. Appendix 1 reflects the position of all the practices at the end of March 2019 (Q4 report).

CQC Reports Published since February 2019 Denmark Road Surgery – Overall Rating: Requires Improvement The Denmark Road Surgery were rated as ‘Inadequate’ overall following their CQC inspection in August 2018. The CQC re-inspected practice on 5 March 2019, and published the report on 7th May 2019, rating the practice as Requires Improvement in the “safe”, effective” and “responsive” domains, as well as Inadequate in the “well led” domain. The Inspectors reported the following: The CQC determined that the practice “Must” make improvements in the following areas:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The CQC determined that the practice “Should” make improvements in the following areas:

• Take action to improve how young patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

The service remains in special measures, since insufficient improvements have been made such that there remains a rating of inadequate for a key question.

Location Type Date of

CQC visit

Date report

published

Current Overall

Rating

Change to last visit

Denmark Road Surgery

Comprehensive 05/03/2019 Published 07/05/2019

Requires Improvement.

↑

Previously IA overall

Shirley Medical Centre

Comprehensive 23/01/2019 Published 22/03/2019

Good ↑

Previously RI overall

Addiscombe Road Surgery

Focused 24/01/2019 Published 11/03/2019

Good

Previously RI in the safe domain, now good.

Addington Medical Centre

Comprehensive 12/02/2019 24/04/2019 Good ↓

RI in safe domain, previously good in all

domains.

Country Park / Greenside

Comprehensive 08/05/2019 Awaiting publication

Unrated / Good

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The practice is taking further actions to address and remedy the issues identified in the CQC report. The CCG have scheduled regular meetings with the practice to provide support and to ensure delivery against the identified actions. Shirley Medical Centre – Overall Rating: Good The CQC inspected the practice on 23rd January 2019, and published the report on 22nd March 2019. It is rated as “Good” overall, and has now been rated as “Good” in all domains, having previously been rated as “Requires Improvement overall” as a result of being rated requires Improvement in the CQC’s Quality Domains of “safe”, “effective” and “well led”. The CQC found no breaches of regulations, however the inspectors determined the provider “should” make improvements in the following areas:

• Review practice procedures for completing health checks for patients with learning disability.

• Review practice procedures regarding issues of repeat prescriptions. Addiscombe Road Surgery - Overall Rating: Good The CQC inspected the practice on 24th January 2019, and published the report on 11th March 2019. It continues to be rated as “Good” overall, and has now been rated as “Good” in all domains, having previously been rated as “Requires Improvement” in the CQC’s Quality Domain of “safe”. The CQC found no breaches of regulations, however the inspectors determined the provider “should” continue to make improvements in the following areas:

• Review processes for exception reporting for patients with long-term conditions

• Continue to develop plans to ensure the practice operates only from suitable premises. Addington Medical Centre – Overall Rating: Good The CQC inspected the practice on 12th February 2019, and published the report on 24th April 2019. It continues to be rated as “Good” overall, however it has been rated as “Requires Improvement” in the CQC’s Quality Domains of “safe”. The Inspectors reported the following: The CQC determined that the practice “Must” make improvements in the following areas:

• Ensure that care and treatment is provided in a safe way

• Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.

The CQC determined that the practice “Should” make improvements in the following areas:

• Review how patients with caring responsibilities are identified and recorded on the clinical system so their needs can be identified and met,

• Review newly-implemented systems so patients without an address can register

• Review complaints process and arrangements so patients receive details of the action they could take if unhappy with the practice’s response.

Future CQC Visits and Quality Assurance The CQC have introduced annual regulatory reviews (ARR) to monitor practices rated as good and

outstanding. This includes all GP practices rated good or outstanding being sent an email

explaining that annual regulatory reviews were being rolled out and that the next step will be a

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phone call from an inspector, to set a date four weeks later. Further details on the process can be

found here: https://www.cqc.org.uk/guidance-providers/gps/how-we-monitor-gp-practices

It is anticipated that the CQC will continue to undertake return visits for practices rated as “Requires Improvement” within the next 3-6 months. The CQC are in regular contact with Croydon CCG Primary Care Team and have been invited to attend a future General Practice CQRG meeting. Croydon CCG Primary Care, Variation and Medicines Management teams are continuing to support Practices who are not rated as “Good” by the CQC, to manage risks. As well as supporting those practices rated as “Requires Improvement”, Croydon CCG are keen to see practices rated as “Good” move to ‘Outstanding’. The GP Quality Dashboard, designed by Croydon CCG, captures various quality data for all Croydon GP practice including CQC results. The Dashboard is presented at the bimonthly Primary Care CQRG meeting and has been designed to assess overall quality within Practices and Localities.

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Governance:

Corporate Objective To develop as a mature membership organisation

To commission integrated, safe, high quality service in the right place at the right time.

To have collaborative relationships to ensure integrated approach

To achieve financial balance over five years

Risks

Risk relate to assuring consistent clinical services to the patient population


Financial costs in line with allocation.


Conflicts of Interest have been managed where appropriate as per the Conflicts of Interest policy.

Clinical Leadership Comments This document has been discussed at Clinical


N/A

Equality Analysis

N/A


Patient and Public involvement will be sought where appropriate.

Communication Plan The new arrangements for monitoring quality will be communicated to Practices through a number of channels.


Discussions around specific quality issues will be undertaken within the boundaries of the CCG’s Information Governance policy.

Reputational Issues

Failure of the CCG to have oversight of the quality of care in General Practice could have an adverse effect on the reputation of the CCG.

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Summary of Infection Control Visits - Croydon CCG 15/16 16/17 17/18

18/19

Practice Code Practice Name Contract

Type Branch/ GP Led/ Walk in Centre

Date of Audit Overall

Compliance Score

RAG Date of Audit

Overall Compliance

Score RAG Date of

Audit Overall

Compliance Score

RAG Minor

Surgery 2018/19

2018/19 Priority

Date of Audit

Overall Compliance

Score RAG

H83001 Portland Medical Centre PMS Main Practice 11/01/2016 95% Green No H83004 The Farley Road Surgery PMS Main Practice 08/07/16 96% Green Yes H83004 The Farley Road Surgery

(Holmbury Grove Branch) PMS Branch 01/07/16 99% Green Yes H83005 Upper Norwood Group Practice PMS Main Practice 01/07/16 98% Green Yes H83006 Addington Group Practice APMS Main Practice 20/07/16 95% Green No H83006 Addington Group Practice

(Fieldway Medical Centre) APMS Branch 12/07/16 97% Green No H83007 Violet Lane Medical Practice PMS Main Practice 22/10/2015 99% Green Yes H83008 The Addiscombe Road Surgery GMS Main Practice Yes ==> 11/09/18 14/14 H83008 The Addiscombe Road Surgery GMS Branch Yes H83009 Norbury Health Centre PMS Main Practice 22/02/2016 96% Green Yes H83010 South Norwood Hill Medical

Centre PMS Main Practice 22/09/16 97% Green 25/07/2017 88% AMBER Yes H83011 North Croydon Medical Centre PMS Main Practice No ==> 18/09/18 10/14 LOW H83012 St James' Medical Practice PMS Main Practice 30/11/2015 100% Green Yes H83012 St James' Medical Practice PMS Branch 30/11/2015 99% Amber Yes H83013 Old Coulsdon Medical Practice PMS Main Practice 18/07/16 98% Green Yes H83014 Queenhill Medical Practice PMS Main Practice 26/02/2016 98% Amber Yes H83015 Parkside Group Practice PMS Main Practice 21/07/16 95% Green Yes H83016 Keston Medical Practice PMS Main Practice 15/11/2017 98% GREEN Yes H83017 Brigstock and South Norwood

Medical Partnership PMS Main Practice 19/10/2015 86% Green Yes H83018 The Selsdon Park Medical Practice PMS Main Practice 07/01/2016 97% Green Yes H83019 Friends' Road Medical Practice PMS Main Practice 12/11/2015 95% Amber Yes H83020 Eversley Medical Practice PMS Main Practice 11/07/16 93% Amber Yes ==> 19/09/18 11/15 LOW H83021 London Road Medical Practice PMS Main Practice 26/11/2015 96% Green Yes H83022 Thornton Heath Medical Centre PMS Main Practice 21/11/2017 79% RED Yes 15/05/18 12/14 LOW H83023 Morland Road Surgery PMS Main Practice 23/11/2015 92% Amber Yes ==> H83024 Woodcote Medical PMS Main Practice 13/09/16 95% Green Yes 02/10/18 14/15 LOW H83024 Woodcote Medical PMS Branch 13/09/16 94% Amber Yes ==> 15/10/18 14/14 LOW H83027 Parkway Health Centre (Dr B

Baskaran) PMS Main Practice 17/03/2016 94% Amber Yes ==> 11/0918 11/14 LOW H83028 Addington Medical Practice

(PARKWAY HEALTH CENTRE) PMS Main Practice 01/09/16 97% Green No H83028 Gravel Hill Surgery PMS Branch 15/03/2016 99% Green No H83029 Hartland Way Surgery PMS Main Practice 14/12/2015 92% Amber Yes H83030 Broom Road Medical Practice GMS Main Practice 15/09/16 96% Green No

Summary of Infection Control 2018/19

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Summary of Infection Control 2018/19

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Summary of CQC 2018/19

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Summary of CQC 2018/19

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Documents

NHS CROYDON CCG PRIMARY CARE COMMISSIONING ... body/Primary...Surrey Street , Croydon CR0 1RG Page 1 of 112 Croydon Clinical Commissioning Group Primary Care Commissioning Committee