Primary Care Commissioning Committee Part I – 2.30pm – 3.30pm Wednesday 30th October 2019

Committee Rooms, 4th Floor Unex Tower, 5 Station Street, London E15 1DA

Agenda

No Time Item Action Required

Page Presenter

1. Administration and updates

1.1

2.30pm

Welcome, introductions and apologies Chair

1.2 Declarations of interests Monitor Chair

1.3 Minutes of previous meetings:

28 August 2019

Approve Page 2Chair

1.4 Action log Monitor Page 7 Chair

1.5 Matters Arising – update on Newham Health Report

Monitor Verbal L Greco

1.6 NEL Primary Care Commissioning Committee in Common

Information Verbal J Mazarelo

2 Decision Items

2.1 2.50pm Proposal to Sub-Contract Primary Care Medical Services – The Project Surgery

Decision Page 8J Lee

3. Any other business

3.1 3.00pm Any Other Business

3.2 Next meeting: 2.30-3.30pm Wednesday 27 November (discussion meeting), Committee rooms 4th Floor, Unex Tower, 5 Station Street, London E15 1DA

Primary Care Commissioning Committee Part I meeting: 2.30-3.30pm Wednesday 28th August 2019

Committee rooms, 4th Floor, Unex Tower, 5 Station Street, E15 1DA

Minutes

Voting members present:

Phil Horwell (Chair) Lay Member

Ellie Robinson Lay Member

Steve Collins Executive Director of Finance, WEL CCGs

Nadeem Faruq GP Board Member, NCCG

Non-voting members present:

Jenny Mazarelo Deputy Director of Primary Care, WEL CCGs

Fiona Hackland Head of Commissioning, Public Health – Adults, LBN

Alison Goodlad Head of Primary Care Commissioning, NELCA

Leonardo Greco Healthwatch Newham

Councillor Susan Masters Lead for Health and Adult Social Care, LBN

In Attendance:

Jason Clarke (minutes) Risk and Information Governance Officer

Apologies:

Fiona Smith Board Nurse, NCCG

Chetan Vyas Director of Quality & Safety, WEL CCGs

Greg Cairns Director of Primary Care Strategy, Londonwide LMC

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No Item

1.1 Welcome, introduction, apologies for absence and declarations of interest

The Chair welcome everyone to the meeting and noted the apologies above. There were no new

declarations of interest.

1.3 Minutes of last meeting

Action Log – page two of the minutes referred to Commissioning Intentions for the ‘New’ Transitional Team, rather than the ‘Newham’ Transitional Team.

This section also stated that other actions were ‘no’ rather than ‘not’ due.

Page three of the minutes referred to NHS England when it should have referred to Newham CCG.

Subject to the above correction, the Committee agreed that it was an accurate account of the meeting that took place on 29th May 2019.

1.4 Action log

PCCC94 Review of Roma Community Access to Primary Care

The Committee agreed to close this action as the review was carried out by Jennifer Kezia who

presented to the Committee in June 2019.

PCCC108 Revised AQP Minor Surgery Specification

The revised specification was presented to the Committee in May 2019 and it was agreed that the action

should be closed.

PCCC111 Strategic Estates Plan

The action was not due until November 2019.

PCCC112 Commissioning Intentions – Newham Transitional Team

This was discussed in Part 2 of the meeting.

PCCC119 Practice Core Opening Hours

This was discussed in Part 1 of the meeting.

PCCC120 Community Minor Surgery

An update would be presented to the Commissioning Committee; however, the date would be moved

back to 3rd October 2019.

PCCC121 Review of Roma Community Access and other seldom held groups access to primary

care.

A review was being undertaken and was initially to be presented the Quality, Performance and Finance

Committee. However, this Committee has been stood down as part of the move to WEL based

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Committees. A Goodlad stated that she would consult with Satbinder Sanghera and report at the next

meeting of the Committee.

PCCC121 Health Newham Report

This was discussed in Part 1 of the agenda.

1.5 Primary Care Networks

Presented by Jenny Mazarelo

A new arrangement for Stratford PCN had to be drawn up as Dr Knight and Dr Asher’s practice could

not be included in the PCN. As a result, the Stratford PCN did not have the minimum 30,000 patient

requirement. Two local practices were invited to move from their existing PCN to Stratford PCN. One

had declined and discussions are ongoing with another.

From 1st October 2019, practices shall have a duty to cooperate, however at the LMC meeting held on

27th August, there were concerns that one PCN had still not been approved. NHSE has also been

concerned at the continuing issues.

The Committee noted the update.

2. Discussion Items

2.1 GP Patient Survey Results

Presented by Jenny Mazarelo

The NEL Primary Care Commissioning Committees in Common would be taking place on 1st October

and a paper would be submitted in relation to the survey response result.

J Mazarelo gave a brief overview of the survey and the questions asked noting that there had been a

marginal improvement, however there were considerable variations regarding practices. The survey

looked at overall patient experience, how easy it was to get through on the phone and if they were aware

of online services.

In response to questioning from Cllr Masters, J Mazarelo said that the survey would be shared with the

primary care networks. The Chair stated that the national average, rather than the CCG average, should

be benchmarked noting that 80% of the practices are below the national average.

Dr Faruq and A Goodlad added that that consideration need to be given to the type of patients the

practices serve noting that family run practices tended to rate higher. In addition to this the expansion

of the core hours, which took place earlier this year, may result in the improvement of patient experience

though this would not show through until the next survey.

The Committee discussed the approaches that could be taken to ensure that practices exceed the

national average. S Collins said that the timeline was short as the survey is likely to be rerun in eight

months’ time. Suggestions included practice staff such as receptionists and administrative staff be

embedded in the PCN whilst Cllr Masters noted that the Primary Care Collaborative held a prize

ceremony for well performing practices and suggested a similar system relating to the survey.

The Committee noted the results.

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2.2 Update on Practice Core Opening Hours

Presented Alison Goodlad and Lorna Hutchinson

Previously most practices were open during core hours, however there was a sizeable minority where

this was not the case. A Goodlad confirmed that all practices, with one exception, are now open during

core hours, which means that Newham CCG has the best record in NEL.

The Boleyn Road Practice is now the only practice that does not comply with core hours and the

Committee noted that the Practice was among the five worst performing practices in the patient survey

in every area. The Practice continues to close on Thursday afternoons. The contractual lever to prevent

this was through the PCN networks as the condition of joining was to open during core hours. However

as Boleyn Road Practice is not part of a network, this lever cannot be used.

However, A Goodlad announced that consideration would be given to issuing a breach notice on the

basis that they are failing to meet the reasonable needs of patients. Should Boleyn Road Practice

refuse to act on the Breach notice, then contractual sanctions would be applied. However, A Goodlad

cautioned that this had not been done before and that legal advice would be sought from NHSE to

ensure that any action would withstand a legal challenge.

The Committee noted the update.

2.3 Newham Health Report

Presented by Leonardo Greco

Healthwatch England were given funding from NHSE earlier this year to deliver engagement around the

long term plan. In Newham two focus groups were established; one for persons with physical disabilities

and one for persons with learning disabilities. However, there was no survey taken as the template was

only in English and there was no time to translate them and recruit volunteers from hard to reach

communities. L Greco noted that, England wide, 90% of survey respondents were White and from a

middle class background and thus not representative of Newham.

L Greco highlighted concerns from persons with physical disabilities that GPs appointments were two

short and limited discussion to one issue and that GPs often focused on their main disability at the

expense of other issues. Few focus group participants were aware that they could ask for an extended

appointment and L Greco added that there was no apparent capacity issues relating to extended

appointments.

There was also concern expressed in relation to pharmacists and GPs changing medication or dosage

without explaining why and the possible side effects. This was especially the case with respondents

who had a visual impairment. None of the respondents was aware of the self-care programme indicating

that promotion needed to be improved.

Respondents were aware of what cancer meant and what they need to do reduce the chance of

developing it. However, respondents disclosed that they had not been aware of any type of screening

nor had their GP brought it to their attention. The focus group research also showed that patients where

not always aware of why the GP was examining them in a certain way and that this resulted in some

avoiding screening.

L Greco confirmed, following questioning, that he had liaised with LBN in relation to the recruitment to

the focus groups. L Greco noted that a nurse used to visit vulnerable groups to provide information on

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accessing services. This ceased some years ago and Healthwatch have urged ELFT to reintroduce this

or a similar service.

L Greco made recommendations that included making patients aware of extended appointments,

cancer screening and the process thereof and promoting wellbeing programmes. For patients with

physical disability, it was important for GPs not to make assumptions based on their main disability and

remember that the purpose of the visit may not be connected to it. Clear and concise information should

be given to patients regarding medicine or dosage changes and adjustments made for the visually

impaired.

The Committee agreed with the recommendations in the report and asked that an update be given on

their implementation.

Action: L Greco to update the Committee at the meeting at the end of October.

3. Any Other Business

3.1

A Goodlad confirmed that the NEL Primary Care Commissioning Committees in Common had been

confirmed for Tuesday 1st October 2019. The time and venue would be confirmed.

3.2 Next meeting: Wednesday 25th September 2019 (discussion meeting)

2.30pm-3.30pm Committee rooms 4th Floor, Unex Tower, 5 Station Street, London E15 1DA

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Action

referenceMeeting date Action Owner Deadline Update

PCCC111 31/10/2018

Strategic Estates Plan

Strategic Estates Plan approved by PCCC on 31.10.18 on an annual

review cycle J Kelder Nov-19 Not due

PCCC122 28/08/2019Newham Health Report

An update to be providedL Greco Oct-19 On agenda

item 1.4 - 30 October 2019 Primary Care Commissioning Committee - Action Log Part I

Highlighted items represent a recommendation to close action

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Primary Care Commissioning Committee Part I meeting: 2.30pm – 4.00pm Wednesday 30 October 2019 The Committee Room, 4th Floor Unex Tower, 5-7 Station Street, London E15 1DA

Title Proposal to Sub Contract Primary Medical Services – The Project Surgery

Agenda item 2.1

Author Joseph Lee, Senior Transformation Manager, Newham CCG

Presented by Joseph Lee, Senior Transformation Manager, Newham CCG

Contact for further information

Joseph Lee, Senior Transformation Manager, Newham CCG, josephlee@nhs.net 020 3688 2227

This paper is for ☒ Decision ☐ Monitor ☐ Discussion ☐ For Information

Action required The Committee is requested to approve the practice’s request to establish sub-contracting arrangements to cover maternity leave of practice clinical staff from [date] to [date]..

Executive summary

The Project Surgery comprises a sole Personal Medical Services (PMS) contract holder. The practice is located in Plaistow with a registered population of 5,052 patients with a Good CQC rating.

The contract holder has requested approval to partially sub contract primary medical services provision to a third party provider due to maternity leave within the practice.

The practice comprises five GPs (headcount) and currently has one GP on maternity leave, with two more due to commence maternity leave from mid-November, as a result of which it has a clinical capacity issue at the practice.

Supporting papers Appendix A – The Project Surgery Business Case

Appendix B – Practice GP Patient Survey Results

Appendix C – Clinical Provision

Next Steps/ Onward Reporting

No planned further presentation or reporting

Where has the paper been already presented?

Not previously presented

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How does this fit with NHS Newham CCG strategic Priorities?

Strategic Priorities • To commission a Newham-based integrated health and care system which

delivers high quality services for the residents of Newham, in accordance with statutory requirements

• To commission and develop GP services that are modern, accessible and fitfor the future in caring for our residents

Enabling Priorities • Ensuring we maintain our performance across the key business areas

Outcomes • We will improve access to, and, the quality of, Primary Care• We will clearly be able to demonstrate how we have improved outcomes for

our residents

Commissioning Priorities • To implement the five-year framework for GP contract reform to implement

The NHS Long Term Plan.

Risk BAF.05– Failure to effectively monitor the quality, performance and activity ofcommissioned services, with a focus on ensuring the delivery of better clinicaloutcomes.

BAF.07.01 Failure to effectively deliver a primary care strategy that isadequately resourced to service Newham residents

Equality impact There is no anticipated adverse impact to patients, as the proposal is that some current service provision is sub-contracted resulting in no loss of face to face services for patient access. The proposal aims to increase clinical capacity in the short term to negate any possible negative impact.

Stakeholder engagement Presented at Practice September PPG

If approved will be further patient engagement on the roll out andimplementation

Financial Implications

The financial implications would be present in the reimbursement of maternity locum costs to the practice in line with the GMS Statement of Financial Entitlements (SFE). The paper outlines an increase in hours contracted versus what is currently contracted. The reimbursement to the practice will be a fixed specified amount per week as per the SFE.

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1. Introduction and background

1.1

1.2

The practice has 5052 registered patients and five GPs (headcount) delivering twenty one sessions currently provides online consultations and telephone consultations to its patients along with face-to-face appointments. The practice has contacted the CCG to request the approval to sub contract primary medical service provision due to a clinical capacity issue as a result of three salaried GPs due to be on maternity leave.

One salaried GP within the practice is currently on maternity leave, who provided 3 sessions within the practice. These sessions have been covered by the existing salaried GPs within the practice. From mid-November two further salaried GPs within the practice, who provide a total of 9 sessions within the practice, will be going on maternity leave and as such presents the practice with a severe clinical capacity shortage

2. Sub-Contracting Request

2.1

2.2

2.3

2.1.3

2.1.4

The practice are seeking approval to subcontract 20 clinical hours per week to MD International Limited, trading as Docly, who are a CQC registered provider of digital consultations, to provide additional clinical capacity for the practice. This is set out in the business case at Appendix A

The sole contract holder, Dr Farzana Hussain, is the Primary Care Network (PCN) Clinical Director (CD) for Central One PCN. She has approached colleagues within the PCN to ascertain if there is further clinical capacity within the Network to support but has been unsuccessful due to the amount of clinical capacity required.

The practice currently provide online consultations to its registered patients and therefore there is no proposed change to the access model. The practice has also recruited an additional Advanced Nurse Practitioner (ANP) to provide clinical face-to-face appointment, which will result in an increase in clinical capacity during the maternity cover, as shown by the table in Appendix C.

The practice currently provide both telephone triage and online consultations in conjunction with face-to-face appointments as their access model. To date that the practice has had good patient feedback in response, with the latest GP Patient Survey Scores showing that the practice has comparable score for appointment times and types with the Newham average, as shown within Appendix B.

The employment of the ANP is outside any reimburseable income but has been contracted to ensure that the clinical face to face appointments available to practices remains at the Band A level required for delivery of the PMS Outcome Measures of 16.5 clinical hours per thousand patients per week.

The practice are proposing to initiate these arrangements with immediate effect.

3. Recommendation

3.1 It is recommended that given the extra-ordinary circumstances of this practice, the Committee approve the sub-contracting of services provided under the PMS agreement with immediate effect until 31 October 2020.

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Appendix A – The Project Surgery Business Case

The Project Surgery Subcontracting arrangement

Context: From mid-November 2019, the Project Surgery will face a clinical capacity challenge due to three of the salaried GPs who currently work within the practice being on maternity leave concurrently. One of the salaried GPs is currently on maternity leave, with two more going on leave in mid-November. To help address this challenge, the Project Surgery has decided to subcontract a proportion of its clinical capacity to MD International Limited, a CQC registered provider of digital consultations. MD International Limited, known as Docly, provides a solution to the capacity challenge through the deployment of technology, which enables a locum GP workforce to deliver digital consultations. This solution will provide GP cover for the GPs on maternity leave.

Support from the Primary Care Network (PCN): As Clinical Director of the Newham Central One PCN, Dr Farzana Hussain has explored whether there is clinical capacity locally to support The Project Surgery’s challenge. Unfortunately, the PCN is unable to assist. In addition to this, The Project Surgery attempted to recruit traditional maternity locum GP cover but has been unable to find a satisfactory solution.

What is the practice’s current and proposed capacity?

Clinical Resource Current Capacity (Hours) Proposed Capacity (Hours)

GP 44.5 37.5 (including 20 digital locum GP hours)

Nurse 30 30

Advanced Nurse Practitioner 0 24

Healthcare Assistant 34 34

Total 108.5 125.5

When maternity leave starts in mid-November, the capacity of the practice will reduce by a further 9 GP clinical sessions, on top of the 3 sessions the practice has currently lost to maternity leave. These sessions are 4 hours 10 minutes in length, with 3 hours of this spent on consultations, 27 hours in total. This will leave one GP remaining in the practice workforce, who delivers 7 sessions each week for a total of 17.5 hours consultation time.

To ensure that there is sufficient GP time available to support patient care and meet the contractual KPI to have 16.5 hours of GP time per 1000 registered population, the Project Surgery proposes subcontracting 20 hours of locum GP time a week from MD International Limited. In addition, to help address this shortfall, the Project Surgery has also recruited an advanced nurse practitioner (ANP), who will work in the practice for 4 days a week, delivering 24 consulting hours face to face. The opportunity to increase the skill mix within the practice is

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important and aligned with national policy to increase the usage of a variety of healthcare professionals within primary care.

The Project Surgery already uses a telephone first methodology to its appointments, so its patients are used to accessing care remotely. The Docly digital locum GPs will be able to convert digital consultations to telephone calls if necessary, ensuring that there is a not a reduced service for patients.

The proposed proportion of appointments subcontracted

The proposed portion of GP consultation hours to be subcontracted is 20 of 37.5 GP hours, which represents 53% of GP consultation hours. The expectation is that digital consultations will achieve efficiencies when compared with face-to-face consultations and that the 20 hours of subcontracted digital locum GP clinical time is able to deliver up to 170 appointments per week.

The Project Surgery currently delivers 290 appointments a week, so the proportion of appointments to be subcontracted could be up to 58%.

Outline the delivery model going forward and if the sub-contractor will be covering all three absent Salaried GPs with yourself providing clinical appointments?

The Project Surgery will supplement its on-site clinical capacity with digital-first primary care provision of 20 GP locum hours per week. The combination of these service elements and an ANP will cover the clinical capacity of the three GPs on maternity leave.

As well as being able to access face to face care and telephone appointments as they do currently, Project Surgery registered patients will be able to access care digitally via a mobile app/web-based platform. Digital consultations begin with the completion of a guided questionnaire for their symptoms. Over 40 of the most commonly occurring conditions presenting to primary care are included in the platform. The questionnaires have been developed by GMC registered GPs and are based on best practice guidelines, e.g. NICE. Patients do not need to book an appointment to access care digitally and can submit questionnaires in their own time.

Once patients have submitted a questionnaire, GPs access the information from a digital waiting room where they are able to review a patient's responses before taking action or seeking further information from the patient. Communication between the GP and patient is predominantly text-based, with images, telephone and video technology all available if required during the consultation. GPs also have access to the full patient record to enable decision-making and allow them to request diagnostic tests and issue prescriptions. GPs will arrive at a diagnosis, decide on any treatment and follow up with the patient, replicating the steps in conventional care but all through a digital experience. If a GP decides that a patient needs a face-to-face consultation in the Project Surgery to manage their condition, then they will arrange this for the patient. At the end of each consultation, the GP will update the patient eHR to ensure a complete record. Patients can also revisit consultations in their Docly app ensuring information and guidance given is not lost.

In summary, the subcontractor provides: 1. The technology for patients to seek care digitally - an app and website

2. Locum GPs to manage digital consultations

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3. Implementation team to work alongside the Project Surgery to communicate with and

support patients to seek care digitally

What patient engagement/consultation has the practice done to ensure that this meets the needs of its population?

The Project Surgery has already adopted online access services with positive feedback from its population and is therefore assured that the subcontracting arrangement will meet the needs of its population. It has also considered feedback from other practices that work with Docly and the positive responses from their patients. The Project Surgery has also consulted its patient participant group about the subcontracting arrangements.

The NHS Long Term Plan commits that all patients will have the right to digital-first primary care over the next five years. Furthermore, the new five-year framework for GP contract reform describes the areas in which we expect early progress to be made in general practice. For example, by April 2021 all patients should have the right to online and video consultations.

A key way this will be achieved is by supporting existing general practice to expand and develop its digital-first offer, as some practices are already doing by partnering with suppliers of digital technology to deliver a digital offer to their patients. The Project Surgery subcontracting to a digital-first locum provider represents an opportunity to learn from application of digital first solutions, sharing best practice across the PCN and Newham CCG.

The approach taken by the Project Surgery aligns with the Digital-first primary care online consultation outcome paper presented at the NHS England and NHS Improvement Board Meeting held on 26th September and particularly the need to focus on under-doctored areas, which is the case for both the Project Surgery and Newham CCG.

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Appendix B – GP Patient Survey Summary

Question Project Surgery CCG Average National Average

Describe their overall experience of this GP practice as good 67% 76% 83%

Find it easy to get through to this GP practice by phone 56% 58% 68%

Find the receptionists at this GP practice helpful 75% 82% 89%

Satisfied with the general practice appointment times available 66% 63% 65%

Usually get to see or speak to their preferred GP when they would like to 34% 40% 48%

Were offered a choice of appointment when they last tried to make a general practice appointment

65% 64% 62%

Were satisfied with the type of appointment they were offered 67% 67% 74%

Took the appointment they were offered 88% 92% 94%

Describe their experience of making an appointment as good 64% 62% 67%

Say they have had enough support from local services or organisations in the last 12 months to help manage their long-term condition(s)

74% 68% 83%

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Appendix C – Clinical Provision

Clinical Resource Current Capacity* (Hours) Proposed Capacity (Hours)

GP 44.5 37.5 (including 20 digital locum GP hours)

Nurse 30 30

Advanced Nurse Practitioner 0 24

Healthcare Assistant 34 34

Total 108.5 125.5

*Hours listed relate to clinical face to face hours and have not taken into account the administration time accounted for within GP sessions

Name Role Clinical Face to Face Hours Pre November 2019

Clinical Face to Face Hours Post November 2019

Farzana Hussain Lead GP 6 6

Ruth Russell** Salaried GP 0 0

Rebecca Islam Salaried GP 18 0

Aklima Khatun Salaried GP 9 0

Iram Ali Salaried GP 21 21

Michelle Stanton ANP 0 36

Total 54 63

**Dr Ruth Russel went on maternity leave in March 2019 and these sessions are currently being reimbursed in line with the SFE

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