Primary Care Commissioning Committee

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Primary Care Commissioning Committee

AGENDA Thursday 5 December 2019, 3pm – 5pm

Olympic Room, The Gateway, Gatehouse Road, Aylesbury, Bucks HP19 8FF

Agenda Item Action Lead Papers/Duration

1

Introductions and Apologies: Gary Heneage Confirmation of Quoracy

Graham Smith - CHAIR 3.00pm

2 Declarations of Interest Graham Smith - CHAIR 3.02pm

3 Questions from Members of the Public Graham Smith - CHAIR 3.03pm

4 Minutes and Action Log from the meeting held on 5 September 2019 For Approval Graham Smith - CHAIR

Paper A 3.05pm – 3.10pm

5 Conflict of Interest Annual Review For Action Graham Smith - CHAIR Paper B

3.10pm – 3.15pm

Assurance Reports

6 Primary Care Risk Register For Assurance Helen Delaitre Paper C 3.15pm – 3.20pm

7 Head of Primary Care Report For Assurance Helen Delaitre Paper D 3.20pm – 3.30pm

8 Quality Report For Assurance David Williams Paper E 3.30pm – 3.40pm

9 Finance Report For Assurance Alan Overton Paper F 3.40pm – 3.45pm

Primary Care Commissioning

10 Merger Application – Norden House, Wing and Whitchurch Surgeries

For Approval Jessica Newman Paper G

3.45pm – 3.55pm

11 The Future of Complex Care Management

For Information Louise Smith Paper H 3.55pm – 4.05pm

Primary Care Transformation

12 Digital Transformation Update For Information Anna Lewis Paper I (to follow) 4.05pm – 4.15pm

13 Locally Commissioned Services – Proposals for 2020/210

For Approval Simon Kearey Paper J 4.15pm – 4.25pm

14 Primary Care Network Update For Information Simon Kearey Paper K 4.25pm – 4.35pm

15 General Practice Forward View Update For Information Wendy Newton Paper L 4.35pm – 4.45pm

Governance

16 Decision Log for Update For Approval Graham Smith – CHAIR 4.45pm – 4.50pm

17 New Risks Identified by the Committee For Approval Graham Smith - CHAIR 4.50pm – 4.55pm

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Any Other Business

18 Any Other Business Graham Smith - CHAIR 4.55pm – 5.00pm

19 Date of Next Meeting: 5th March 2020, 3pm to 5pm in Olympic Room, The Gateway

For Information

20 Report from the Primary Care Operational Group meetings held on 3 October 2019 and 7 November 2019

For Information Paper M

21 Notes of Premises Sub-Group Meeting held on 18 October 2019 For Information Paper N

22 Aylesbury Primary Care Centre Full Business Case: Executive Summary For Information Paper O

23 Beaconsfield Primary Care Centre Full Business Case: Executive Summary For Information Paper P

24 Threeways Surgery Reconfiguration Full Business Case: Executive Summary For Information Paper Q

25 Contract Variations For Information Paper R

26 Meeting Forward Planner For Information Paper S

Paper A

Primary Care Commissioning Committee

Thursday 5 September 2019, 3-5pm Jubilee Room, The Gateway, Gatehouse Road, Aylesbury, Bucks HP19 8FF

Voting Members: Graham Smith (GS), Lay Member, CCG – Chair of PCCC Present Tony Dixon (TD), Lay Member, CCG Present Louise Patten (LP), Chief Officer, CCG Apologies Gary Heneage (GH), Chief Finance Officer, CCG Present David Williams (DW), Associate Director of Quality and Safeguarding, CCG Apologies Nicola Lester (NL), Director of Transformation, CCG Present In Attendance: Dr Raj Bajwa (RB), Clinical Chair, CCG Apologies Helen Delaitre (HD), Associate Director of Primary Care, CCG Present Robert Majilton (RM), Deputy Chief Officer, CCG Present Phil Thiselton (PT) Healthwatch Bucks Present Thalia Jervis (TJ), CEO, Healthwatch Bucks Apologies Simon Kearey ( SK) Head of Localities, CCG Apologies Alan Overton (AO), Finance Analyst, NHS England Present Jessica Newman (JN), Senior Primary Care Manager, CCG Apologies Peter Redman (PR) Estates and Development Manager, CCG Present Wendy Newton (WN), Primary Care Manager, CCG Present Dr Rebecca Mallard-Smith (RMS), Clinical Commissioning Director, CCG Apologies Colin Hobbs (CB), Assistant Head of Finance – Primary Care, NHS England Apologies Nick Spence (NS), Assistant Head of Primary Care – Medical, NHS England Present Anna Lewis (AL), Associate Director of Digitalisation and IM&T, CCG Present Sharon Hanley (SH) Sustainability and Transformation Manager, CCG Present

1 Welcome & Introductions

Primary Care Commissioning Committee (PCCC) members were welcomed to the meeting. The meeting was declared quorate. It was noted that no members of the public were in attendance.

Apologies Apologies were received from LP, DW, JN, SK, TJ, MM and RB. The meeting remained quorate

2 Declaration of Interests The Chair reminded members of their obligation to declare any interest they may have, on any issues arising at the PCCC meeting, which might conflict with the business of NHS Buckinghamshire Clinical Commissioning Group. Declarations declared by members are listed in the CCG’s Register of Interests. The Register is available on the CCG website through the following link: https://www.buckinghamshireccg.nhs.uk/public/about-us/how-we-make-decisions/registers-of-interests/

https://www.buckinghamshireccg.nhs.uk/public/about-us/how-we-make-decisions/registers-of-interests/


No conflicts of interest were declared. Clinical standing invitees were not in attendance at the meeting, however it was noted that no decisions of a clinical nature were being asked of the Committee and voting quoracy was not affected.

3 Questions From Members Of The Public There were no questions raised from members of the public.

4 Minutes and Action Log from the Meeting Held On 6 June 2019 Minutes were agreed as a true and accurate record of the previous meeting, subject to the following amendments;

• Dr. Rodger Dickson - attendance to be noted as Norden House GP • GH Apologies - initials and job title corrections.

The action log was updated accordingly.

AL entered the meeting

5 Primary Care Risk Register The Committee was asked to review assessment of risk scores on the Primary Care Risk Register and be assured that the risks are mitigated with appropriate actions in place. The Risk Register was included for assurance to the Committee. There were no risks scoring 12 or above. HD highlighted several risks are assigned to NL as the risk owner. The committee discussed whom the new risk owner should be after NL leaves the CCG, RM advised that the corporate risk owner would likely be Jo Cogswell, Director of Transformation and Primary Care. NL queried if the following risks should now be listed, as the risk is now BAU:

• Improved Access to Primary Care • Provision of Primary Care services

RM advised closing the original risks but capturing the newer risks now emerging:

• Chiltern House risk to remain open whilst consultations regarding Holmer Green continue and to bring back to the meeting based on the results.

TD asked if the Committee should review the risk register in light of the Primary Care Networks which may pose their own risks. HD advised that the risk regarding PCN implementation by 1st July 2019 has been closed and any risks that are raised regarding PCNs going forward would be added to the risk register. No risks regarding PCNs have yet been raised.

6 Head of Primary Care Report HD highlighted the main points of report. Primary Care Commissioning Committee Membership As a result of NL leaving next week, there is a need to establish an interim solution for the vacancy with regard to decision making at the Committee. HD volunteered to fill the vacancy, which was supported by the Committee. One CCG Clinical Director has resigned from post since the last PCCC meeting in order to

take up a position as director of a PCN. In order to retain clinical involvement in the delegated committee and to ensure the unique benefits of clinical commissioning are maintained, the CCG Clinical Chair is in the process of confirming future membership arrangements. Meeting Forward Planner The planner was noted for adoption. Proposed Merger of Norden House, Wing Surgery & Whitchurch Surgery in North Buckinghamshire Merger is planned from April 2020 and will be named ‘3W Health’. There is a patient engagement piece of work underway which will allow the practices to submit an application to the CCG for decision at PCCC in December 2019. PT queried if the application required the merging practices to identify how they will manage patient access via telephone. HD advised that the practices will maintain the practices as they currently are, and it is the back office functions that would merge. ACTION: HD to check future arrangements for telephony following merger. Chiltern House Medical Centre - award of APMS Contract Primary Care Management Solutions now hold the APMS Contract and are exploring options to establish a base in Holmer Green to deliver some basic services and act as an information point and it is hoped that this could be provided jointly with community pharmacy in the area. Positive discussions have taken place, with the hope that a task and finish group will be set up and a model established over the next few months. Two more patient engagement events are planned to take at the end of September aligned with Flu clinics. Buckinghamshire Special Allocations Service ( SAS) Single Tender Waiver At its May meeting, PCOG received a review of the first year of the Buckinghamshire SAS which is provided by Bassett Road Surgery in Leighton Buzzard. At the same meeting, PCOG also approved the proposal to award a 3 year Enhanced Service to Bassett Road Surgery using a Single Tender Waiver and publish a Notice of Intent to mitigate the risk of challenge. The STW application will be submitted to Audit Committee for sign off after the 30th September. Premises Developments Two new builds located in Beaconsfield and Aylesbury, funded by the Estates and Technology Transformation Fund are both at the planning application stage and both sets of developers have now submitted tender specifications. Both are experiencing issues with gaining planning permission due to new planning regulations for surface water drainage. PR explained that the 2018 Building Research Establishment Environmental Assessment Methods (BREEAM) building standards regarding energy efficiency are now more onerous and costly per square meter, and in order to achieve the ‘excellence’ rating required for new builds, planning has to encompass 1 in 1000 years events as opposed to the 1 in 100 previously. Threeways Reconfiguration Tender returns have now been returned for this reconfiguration. It is hoped the full business case will be submitted to the October Finance Committee and then to NHS England, with a view to the building work being undertaken over the winter months.

HD

7 Primary Care Quality Report PCCC received the Quality Report which focused on patient safety, clinical concerns, safeguarding, infection prevention control (IPC) and quality oversight. Highlights of the report were noted. The Quality and Primary Care teams have worked together to review the results of the GP Patient Survey, which showed most indicators were above the National average. Work will be undertaken around the areas indicated as below the average. PT queried the higher number of significant events reported by Unity Health in section 2.1. ACTION: HD to feed back to the Quality Team for more detail to be provided. TD asked if the Outstanding Clinical Concerns for BHT were completed at the end of August as the BHT Medical Director had advised these would be. HD advised that concerns have been raised that reports are not being received back from BHT in a timely manner and this would be raised on the Quality risk register. ACTION: The Quality Team would be taking this forward to discuss at the Quality Committee meetings.

HD

DW

8 Finance Report (M4) The PCCC was asked to note the financial position of the primary care delegated budget for month 4. AO reported in Month 4 there was £6k overspend with the overall YTD position at month 4 being £28k underspend. The underspend was on two levels:

• GP Contract payment £27k underspend, Global Sum below plan, under review. • GP Enhanced Services £1k underspend, Extended Hours below plan.

All other areas, on plan.

The Forecast Outturn 2019/20 was reported as on plan. AO highlighted the contracting and procurement activity along with the risks and opportunities, detailed within the report.

9 Primary Care Commissioning Audit Report The report was presented for assurance that the CCG’s delegated primary care commissioning functions have been through internal audit for 2019/20. Overall the audit reported that there is ‘reasonable assurance that the controls upon which the organisation relies to manage the identified area(s) are suitably designed, consistently applied and operating effectively.’ The report noted that the CCG had significant strengths in operation of Governance, formation of PCN’s and commissioning of new services. Three low risks were identified and one medium risk for action regarding:

• review of the Buckinghamshire CCG Primary Care Strategy, in order to consistently detail the organisational vision and objectives. This will be addressed via the implementation of the BOB Primary Care Strategy which will be completed later in the year

• enhancing the administration of some CCG sub-groups, such as the introduction of recorded meeting minutes, in order to assure that defined responsibilities are undertaken

• Procurement Policy requires review to ensure Primary Care Procurement is in line

with CCG policy. ACTION: GH to review the BCCG Procurement Policy. • A review of the terms of reference of the Premises Sub Group. This would be

undertaken at the Premises Sub Group taking place on 6.9.19.

GH

10 Primary Care Network - Highlight report The report was submitted to PCCC for information and provided an update on the establishment of PCNs across Buckinghamshire in line with the requirements of the Long Term Plan with effect from 1st July 2019. Point to note:

• Accountable Clinical Directors are in place for all 12 PCNs and groups are established to help support PCNs around transformation through the ICP Network Steering Group.

• PCN managers meeting now established, which will focus on practical aspects of PCN management such as governance, recruitment and workforce planning.

• The CCG business support managers will support PCNs initially (each PCN one day per week).

• Progress on Transformation is reported though the ICP Integrated Care Delivery Board and in highlight reports to the ICP Partnership Board.

• The ICP is coordinating a programme of events for information to emerging PCNs, aimed at ACDs and wider PCN staff.

HD will continue to report to Committee on PCN progress.

11 Locally Commissioned Services for 2020/21 A report was submitted to the PCCC for information which updated on work to-date to establish recommendations for future commissioning of services currently commissioned via the LCS scheme. A clinically led task and finish group has been set up to look at the best approach to service delivery with recognition that networks are optimally located to deliver some of these services. Discussions underway are in tandem with discussions at BOB ICS level to develop a consistent set of principles and specifications. Further discussions are required as there are suggestions that bundles of services are offered in order to achieve more complete coverage of service delivery. Discussion from the group:

• Does the task and finish group include further feedback from patients? ACTION: HD advised she would relay this to SK who is leading on this work.

• NL queried if it is correct to offer to practices or PCN’s. NL advised this could be offered to a lead practice on behalf of a PCN and that due diligence would need to be undertaken.

• RM agreed with principles set out in the paper but was unclear how the task and finish group and its localised membership fitted in with delivering the principles of approach across the ICS. A consistent framework is required at ICS level in order to achieve consistent service. ACTION: HD advised she would relay this to SK who is leading on this work.

Further update paper to be presented to PCOG in November, with recommendations coming to PCCC in December 2019.

HD

HD

12 ICS Primary Care Strategy HD provided a verbal update: The Primary Care Strategy is in development and will pull together themes regarding having a consistent approach to commissioning that benefits patients. An early draft strategy was submitted to the June PCCC and also NHS England for review. The approach taken is that the Strategy will become a chapter within the system Long Term Plan up to 2023/24. The latest version is awaited and will be shared with ICP partners.

13 Digital Transformation and GP IT Update RM raised a point of clarification regarding the Data Protection Officer role. Practices are required to have their own DPO; the CCG is only required to provide some ad-hoc support in the interim. The support requirements are not yet set out and further guidance is awaited. Report submitted to PCCC for information, AL highlighted that the paper focuses on primary care digital projects in three groups: 1. The projects that are necessary to maintain business as usual in general practice 2. The projects in place to support practices in meeting the GMS contract requirements and to deliver Digital First Primary Care 3. Supporting the development of Primary Care Networks and Bucks ICP wide projects.

Business as usual

• Ensuring the infrastructure meets the GP IT Operating Model, which is under review. • Working closely with ICP partners, looking at the strategy for the infrastructure. It is

hoped there will be an initial draft in order to begin liaising with practices within the next month.

Work with PCNs - Highlights

• PCNs implementing Clarity TeamNet, a data sharing tool which allows PCNs to have their own shared IT which operates similarly to a shared drive which is IG compliant. Good feedback has been received so far.

• Online consultations - the benefit is having tools to be able to re-route people to Self-Care, where appropriate.

• EMIS Clinical Services has been implemented in Buckinghamshire to assist in the development of local community services, providing care closer to home. EMIS Clinical Services shares information for direct care without the requirement for additional consent.

GS enquired as to whether full medical records were still to be uploaded onto EMIS. AL advised that there is a target for GP Online to do this, however the target also requires policies and procedures to be in place in order to do this and not all are in place at the moment. SH advised that the CCG and CSU are looking to hold a workshop at the end of October 2019. The1st April next year is the contract start date for this requirement. TD queried how we would upgrade practices from Windows 7 to Windows 10 software and avoid the potential issues that this can cause. AL advised this would be upgraded amongst other updates/projects and would be tested at one location first before roll out to all to avoid disruption. PT queries if the CCG is able to verify that “All practices will ensure at least 25% of all appointments are available for online booking” as indicated in the table Section 2.1. SH advised that this is why there is the move to Ask NHS, as this tool allows for appointments to

be triaged and be visible to the GP on the appointment book to ensure better use of the Doctors time. PT asked if there was any concern that patients will miss important information about their practice if they bypass the GP website and only use Patient Access or Ask NHS. SH advised that there are Service Finder links within both apps which provide information on services, however there is a gap for updates at a local practice level. SH advised this may be something to feedback to see if there is something that could be linked through to the websites.

14 Buckinghamshire GPFV Update The report is provided for information, the PCCC is asked to note progress on delivering the GPFV in Buckinghamshire. WN reported that the Buckinghamshire GP Forward View Oversight Group has met and agreed the GPFV Plan is in need of update. This piece of work has been undertaken which has produced a large document. The proposal is to bring a highlight report of some of the key projects to update PCCC and that the full report will be managed by the oversight group. Report Highlights:

• The Training Hub is hosting its inaugural Bucks Paramedic forum in October. This forum will make it easier for the Hub to identify future training and development needs for paramedics.

• The Wessex Workforce tool (a workforce planning tool) which acts as a skills

calculator has been funded by the ICS to be developed so that it can report on ICS and PCN levels as well as practice levels. The tool launches at the PCN workforce event on 5th November 2019 and PCNs are asked if they want to pilot the tool beforehand.

• GP Mentorship Scheme (one of the 3 workstreams under the GP retention scheme) is

a BOB wide scheme which has been piloted in Oxford. 8th October is the first meeting of the recruited mentors under the Buckinghamshire scheme. 7 mentors are recruited thus far, with the plan to recruit 9 in total. Those recruited already work as GPs and have received additional training. Oxford feedback has been positive.

• Next wave of Time for Care Productive General Practice Programme starts 10th

September with 8 practices across Bucks taking part.

• Recognition of a need for HCA’s across general practice in Bucks to acquire basic standards. The Training Hub has been working with BHT to adapt their HCA care certificate to meet the needs of general practice, with the course content being fit for Primary Care. Working with BHT to roll out a joint training programme across primary and secondary care going forward.

• Thames Valley Leadership programme, which was successful last year, has been rolled out again with 8 places being taken by Buckinghamshire staff.

HD added that the training Hub is commissioned through Health Education England and hosted by FedBucks. There have been discussions with BHT to relocate the training HUB into the new Bucks Health and Social Care Academy. One of the faculty’s within this will be the

Primary Care Faculty which will be established April next year as a not for profit organisation with charitable status.

15 Decision Log for Update HD to be listed as an interim voting member for the PCCC until a decision has been made regarding committees in common.

16 New Risks Identified by the Committee HD advised the risks had already been identified earlier in the meeting. Noted.

17 Any Other Business The Chair praised NL, wished her farewell and thanked her for all her support.

18 Date of Next Meeting 5 December 2019, 3pm – 5pm, Olympic Room, The Gateway, Aylesbury

For Information 19 Report from the Primary Care Operational Group

Noted

20 Notes from Premises Sub-Group Noted

21 Contract Variations (for information) Noted

22 BCCG Primary Care Forward Planner 2019/20 Noted

Action Log – from Primary Care Commissioning Committee-05.09.19

Date Action Raised Action Description Responsibility / Owner Status Progress Details / Comments

05/07/2018

Practice Opening Hours - Following concerns raised by CQC re access to primary medical services in the Central Aylesbury Locality.

Jessica Newman On-going

Update August 2019 Primary Care and Quality Teams to prioritise review of practices showing below average GPPS scores as part of the Quality Assurance Process.

05/06/2019 & 05/09/2019

Quality Report – Update on improvements to clinical concern process with BHT as a result of delayed timeframes for resolution. Quality Team looking for themes between FFT data and patient feedback. Quality Team to ensure Healthwatch are kept informed of outcomes and findings of this review.

David Williams David Williams

On-going Due 05/12/2019

December Update: A follow up meeting has been planned with BHT on 3/12/19 to understand the difficulties with the process, a recovery plan will be requested to improve the position.

December Update: The CCG does not have sight of FFT feedback from GP Practices and therefore it has not been possible to review FFT data to identify themes.

05/09/2019

Item 7: Primary Care Quality Report PT queried the higher number of significant events reported by Unity Health in section 2.1. ACTION: HD to feed back to the Quality Team for more detail to be provided.

Helen Delaitre

Due 05/12/2019 December Update: The Quality Team has done some follow up with the practice and those concerns linked to BHT will be followed up at meeting with BHT on 3.12.19.

The other incidents were all “no harm incidents” and it’s positive that the practice are reporting incidents as many don’t.

Date Action Raised Action Description Responsibility / Owner Status Progress Details / Comments

05/09/2019

Locally Commissioned Services 2020/2021-

RM agreed with principles set out in the paper but was unclear how the task and finish group and its localised membership fitted in with delivering the principles of approach across the ICS. A consistent framework is required at ICS level in order to achieve consistent service. ACTION: HD advised she would relay this to SK who is leading on this work.

Helen Delaitre Due 05/12/2019 December Update: Action complete.SK incorporating further detail into paper submitted to December PCCC.

05/09/2019

Procurement Policy requires review to ensure Primary Care Procurement is in line with CCG policy. ACTION: GH to review the BCCG Procurement Policy.

Gary Heneage Due ASAP

Primary Care Commissioning Committee : Abbreviations and Acronyms Glossary

A&E Accident and Emergency K Thousand ACHT Adult Community Health

KLOE Key Lines of Enquiry

ACO Accountable Care

LMC Local Medical Committee AF Atrial Fibrillation LPF Lead Provider Framework AGM Annual General Meeting M Million APMS Alternative Provider Medical

MAGs Multi Agency Groups

AO Accountable Officer MCA Mental Capacity Act AQP Any Qualified Provider MCP Multi-specialty Community Provider AT Area Team MIG Minor Improvement Grant AVCCG Aylesbury Vale Clinical

MK Milton Keynes Foundation Trust

BAF Board Assurance

MusIC Musculoskeletal Integrated Care BCC Buckinghamshire County

NHSE NHS England

BCF Better Care Fund NHSi NHS Improvement BAF Board Assurance

NOAC New Oral Anticoagulants

BHT Buckinghamshire

OCCG Oxfordshire Clinical Commissioning BME Black and Minority Ethnic OOH Out of Hours BPPC Better Payment Practice

ORCP Operational Resilience & Capacity

C4Q Commissioning for Quality

OUH Oxfordshire University Hospitals Trust CCCG Chiltern Clinical

PACS Primary & Acute Care Systems

CDIF Clostridium Difficile PAS Patient Administration System CEPN Community Education

PB Programme Board

CFO Chief Finance Officer PBR Payment by Results CHC Continuing Health Care PIRLS Psychiatric In Reach Liaison Service CIP Cost Improvement

PLCV Procedures of Limited Clinical Value

COI Conflict of Interest PMS Personal Medical Services COPD Chronic Obstructive

PCCC Primary Care Commissioning Committee

CPA Care Programme Approach PCOG Primary Care Operational Group CQC Care Quality Commission POD Point of Delivery CQRM Contract Quality Review

POG Programme Oversight Group

CQUIN Commissioning Quality &

PPA Prescriptions Pricing Authority CSCSU Central Southern

PPE Patient & Public Engagement

CSIB Children’s Services

QIPP Quality, Innovation, Productivity & CSP Care & Support Planning QIS Quality Improvement Scheme

CSR Comprehensive Spending

QOF Quality & Outcomes Framework CSU Commissioning Support Unit RAG Red, Amber, Green DES Directly Enhanced Service DGH District General Hospital RBH Royal Berkshire Hospital DOLS Deprivation Of

Liberty Safeguards

RCA Root Cause Analysis

DST Decision Support Tool (CHC)

REACT Rapid Enhanced Assessment Clinical Team

EDS Equality Delivery System RRL Revenue Resource Limit EOL End of Life RTT Referral to Treatment ETTF Estates and

Technology Transformation Fund

SCAS South Central Ambulance Service

F&F Friends and Family SCN Strategic Clinical Network FHFT Frimley Health

Foundation Trust SLA Service Level Agreement

FOT Forecast Outturn SLAM Service Level Agreement Monitoring FPH Frimley Park Hospitals

NHS Foundation Trust SRG Systems Resilience Group

GB Governing Body STP Sustainability & Transformation Planning GMS General Medical Services SUS Secondary Uses Service GPFV General Practice Forward

View TDA Trust Development Authority

GPRP General Practice Resilience Programme

TOR Terms of Reference

HASU Hyper Acute Stroke Unit TV Thames Valley HETV Health Education

Thames Valley TVN Tissue Viability Nurse

HWBB Health & Wellbeing Board UECN Urgent Emergency Care Network ICE Integrated Clinical

VuPS Vulnerable Practice Scheme

ICS Inhaled Corticosteroids YTD Year to Date ICU Intensive Care Unit 5YFV 5 Year Forward View IFR Individual Funding Request PCN Primary Care Network IG Information Governance ACD Accountable Clinical Director

MEETING: Primary Care Commissioning Committee PAPER: B

DATE: 5 December 2019

TITLE: Review of Register of Interests

AUTHOR: Wendy Newton, Primary Care Manager Russell Carpenter, Head of Governance

LEAD DIRECTOR: Louise Smith, Interim Director of Primary Care and Transformation

Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: Each member and standing invitee of the Committee or group is asked to:

1. REVIEW their declaration of conflicts of interest (stated in the register at appendix 1) and provide any new or updated signed declarations as required.

Introduction As you will be aware, there is ever present scrutiny of how conflicts of interest are declared and mitigated in public services. At any time there is a risk that any commissioning decision made and the process followed to make it could be challenged; by internal or external audit, a losing applicant in a procurement process or the media. This includes localities when making suggestions or recommendations from which a commissioning decision results. Guidance and published registers Knowledge of conflicts which exist should never be assumed. Guidance on identification and management of conflicts of interest for CCG’s is very clear. https://www.england.nhs.uk/commissioning/pc-co-comms/coi/ Our policy and registers are clearly published on our website https://www.buckinghamshireccg.nhs.uk/public/about-us/how-we-make-decisions/registers-of-interests/ Individual responsibilities It is individual responsibility to ensure their declaration is accurate. In accordance with our policy, this is undertaken at least annually. Declarations of interest should be made as soon as reasonably practicable and by law within 28 days after the interest arises (this could include an interest an individual is pursuing). Any breaches of policy will be investigated and reported to NHS England Governance Cover sheets (especially where there are commissioning decisions required) must be clear on conflicts identified and mitigating actions. If we follow the right process, the potential for confusion at meetings as to whether or not people should or should not be participating and possibly leaving a meeting would be clear in advance.

https://www.england.nhs.uk/commissioning/pc-co-comms/coi/


We also have an easy to use checklist which all meeting chairs must ensure is used to identify, manage and mitigate conflicts. To ensure compliance with the CCG’s Conflict of Interest Policy and national NHS England guidance, the PCCC is required to formally circulate a copy of their Conflict of Interest Register with the meeting papers. This is to ensure members have the opportunity to review entries and confirm any changes through the standing Declaration of Interest agenda item. All CCG Boards / Committees / Groups have been asked to undertake this task to ensure that the CCG has evidence, should we be challenged, that registers have been kept up to date. The PCCC is requested to review the Conflict of Interest Register for members of the Primary Care Commissioning Committee and inform Gemma Richardson, Corporate Governance Manager of any changes to their recorded status. [email protected] Conflicts of Interest: No conflict identified Conflict noted, conflicted party can participate in discussion and decision (see below) Conflict noted, conflicted party can participate in discussion but not decision (see below) Conflict noted, conflicted party can remain but not participate in discussion (see below) Conflicted party is excluded from discussion (see below) Governance assurance (see below) None identified. Strategic aims supported by this paper :( please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all

Better Care for Bucks – to commission personalised, high value integrated care in the right place at the right time

Better Care for Bucks – to ensure local people and stakeholders have a greater influence on the services we commission

Sustainability within Bucks – to contribute to the delivery of a financially sustainable health and care economy that achieves value for money and encourages innovation

Leadership across Bucks – to promote equity as an employer and as clinical commissioners

Governance requirements: (Please tick each box as is relevant to the paper) Governance Element Y N N/A Comments/Summary Patient & Public Involvement

Equality/ Equity Quality Financial Risks Statutory/Legal Prior consideration Committees /Forums/Groups

Conflict of Interest Register to be formally reviewed by the PCCC annually. Declarations of Interest are a standing agenda item for the PCCC. Declared conflicts are cross-referenced with the agenda in advance of meetings to determine whether a conflict exists.

Membership Involvement Supporting Papers: Primary Care Commissioning Committee Conflict of Interest Register – November 2019 NHS Buckinghamshire CCG Conflicts of Interest Policy

mailto:[email protected]

Review of Conflict of Interest Register To ensure compliance with the CCG’s Conflict of Interest Policy (Appendix 1) and national NHS England guidance (NHS England’s Managing Conflicts of Interest: Revised Statutory Guidance for CCGs, June 2016) the PCCC is required to formally circulate a copy of their Register of Declared Conflict of Interest with the meeting papers. This is to ensure members have the opportunity to review entries and confirm any changes through the standing Declaration of Interest agenda item. All CCG Boards / Committees / Groups have been asked to undertake this task to ensure that the CCG has evidence, should we be challenged, that registers have been kept up to date. All members of the PCCC are asked to review their declared conflicts of interest and inform Gemma Richardson, Corporate Governance Manager of any changes to their recorded status. [email protected] Appendix 1 – Register of Interests- Primary Care Commissioning Committee The PCCC Register is available on the CCG websites and through the following insert:

Conflict of Interest Policy https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2015/03/2016-09-28-Conflicts-of-Interest-Policy-ANNUAL-REVIEW-SEPTEMBER-2017-clean-MERGER-UPDATE.pdf


https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2015/03/2016-09-28-Conflicts-of-Interest-Policy-ANNUAL-REVIEW-SEPTEMBER-2017-clean-MERGER-UPDATE.pdf

https://www.buckinghamshireccg.nhs.uk/wp-content/uploads/2015/03/2016-09-28-Conflicts-of-Interest-Policy-ANNUAL-REVIEW-SEPTEMBER-2017-clean-MERGER-UPDATE.pdf

MEETING: Primary Care Commissioning Committee PAPER: C

DATE: 5 December 2019

TITLE: Primary Care Risk Register

AUTHOR: Wendy Newton, Primary Care Manager

LEAD DIRECTOR: Louise Smith, Interim Director of Primary Care and Transformation

Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: The CCG has reviewed the way in which it manages risks and how these are reported to the Governing Body. A risk management software tool called Verto has been introduced and each sub-group of the Governing Body reviews the way it monitors and manages risks. This includes the Primary Care Commissioning Committee (PCCC). The Primary Care Operational Group (PCOG) review the Primary Care Risk Register on a monthly basis and escalate any items scoring 12 or above to the PCCC. Currently the only risk scored 12 or above is Improved Access to Primary Care. The PCCC is asked to:

- Review assessment of risk scores on the Primary Care Risk Register - Be assured that the risks are mitigated with appropriate actions in place.

Conflicts of Interest: None identified. Strategic aims supported by this paper: (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all






Equality Quality Financial Risks CCGs have a responsibility to ensure proper

governance which will in turn enable the CCGs to be compliant with statutory obligations and ensure aims/goals and objectives are met. Every activity that the CCGs undertake, or commissions others to undertake on its behalf, brings with it some element of risk that has the potential to undermine or prevent the organisation achieving its strategic aims/goals. Therefore it is vital that appropriate governance is applied to manage and mitigate this.

Statutory/Legal

Prior consideration Committees /Forums/Groups

The management of the risk register has been considered and agreed by the PCCC and the PCOG at monthly meeting since March 2017.

Membership Involvement

Supporting Papers: Primary Care Risk Register.

Risk Detail

Risk Title Raised On

Risk Causes Risk Description (IF & THEN) Consequence (LEADING TO) Project Risk Owner

Delegated Risk Owner

Corporate Risk Owner

Risk Baseline

Score Risk Score

After Mitigation

Corporate Risk Score

Reasoning for Current Score

Risk Proximity

Controls & Assurances in

Place Actions Required Last

Review Date

Update Next Review

Date STPProg01 : Primary Care Resilience within General Practice

02/03/17 Several practices in Bucks are experiencing difficulty in sustaining core primary care services. The reasons for this are varied and each practice is affected differently. The collective impact risks destabilising current delivery of primary care across a wider area.

A practice informs the CCG that they are experiencing difficulties or are identified as being at risk. Resilience of practices in the Wycombe Locality is a particular risk. There may be difficulties in sustaining core primary care services.

Unsustainability of individual practice leading to difficulties in delivering primary medical services.

Instability of the individual practice impacts on other local practices creating further instability.

CCG not fulfilling statutory responsibility. Ability to deliver transformation agenda

hindered by resources being diverted to address resilience issues.

Loss of reputation. Poor patient outcomes.

Louise Smith

Helen Delaitre 20 9 9 Risk score after mitigation reflects that, depending on the severity of resilience issues identified, a practice, patients and surrounding practices may be affected in a moderate (3) way and the likelihood of the risk occurring in possible (3). Although the Corporate Risk Score was and still is 9 (and below routine escalation threshold), this risk has been res-escalated as a means of assurance that the current score has reduced.

Immediate Controls: CCG to identify and work with at risk practices using GPRP to improve resilience. Appointment of Locality Co-ordinator for Wycombe. To assess risk across the locality and advise PCOG. Assurances: Completion of Primary Care risk register using E-Declaration responses and quality indicators including CQC liaison. Response to highlighted risks via CCG support processes.

Gaps in controls and assurances: On-going liaison between practices and primary care / BSM team to support resilience

31/10/19 GPRP funding now confirmed for 2019/20 on an ICS basis with proportional split for CCG use Review of Wycombe Locality submitted to PCOG in November 2019

31/03/20

Quality in Primary Care

02/03/17 All practices in Bucks have now been inspected by CQC. 49 out of 50 practices have been rated good or with elements of outstanding. 1 practice ranked as requires improvement.

If practices rated as good or outstanding are re-inspected and fail to maintain their rating then surrounding member practices will be subject to added / additional pressure. If practices rated as requires improvement or inadequate fail to improve leading to CQC enforcement action then the sustainability of practices is at risk if CQC use enforcement action. Surrounding member practices will be subject to added/additional pressure. Sustainability of practices is at risk if CQC use enforcement action.

Individual practice unsustainability Locality resilience at risk Loss of reputation Poor patient outcomes Patient access compromised

Karen West David Williams (CCG) 16 6 9 Rating reflects that

49 out of 50 practices are rated 'green' by CQC. One practice requires improvement. Score based on likelihood of this happening is low (2) but if it did, the impact would be moderate. (3)

Immediate Expertise available to support practices should re-inspections result in adverse ratings.

Continued oversight and monitoring with input from the Quality and Primary Care teams where practices are re-inspected and rated Inadequate or Requires Improvement by CQC. QIAF being piloted, subject to LMC comment in Autumn 2019. QIAF will further mitigate risk around practice and system resilience.

31/10/19 Risk reviewed and updated

31/03/20

Delegated Responsibility for Primary Care

02/03/17 Evolution of delegated responsibility functions for primary care commissioning in light of Long Term Plan, ICS and STP development

If increased responsibilities and functions sit within Primary Care as a result of LTP, then the CCG will have insufficient resource to deliver delegated functions

impact of ICS and STP development unknown and outside the control of the CCG

Then the CCG will be non-compliant with the delegation agreement and not able to fulfil its responsibilities with regard to delegated commissioning functions.

The CCG will be unable to support member practices in their delivery of primary medical services.

The CCG will not meet its statutory duties in relation to delegated Primary Care Commissioning.

Sustainability and stability of general practice will be at risk.

Loss of reputation Poor patient outcomes

Louise Smith

Helen Delaitre 12 6 The risk of delegated functions not being fulfilled is minor (2) although it is possible it could happen (3).

Immediate CCGs in BOB to agree how best to share limited primary care resources. Solution may involve commissioning some services at scale across the ICS and outsourcing some transactional functions to other organisations. ICS Primary Care Transformation Board established.

Internal review of roles to meet primary care transformation and commissioning work programme in 2019/20. Initial review of areas for joint working across BOB complete and action plan of initial areas agreed. Regular meetings established with senior managers across BOB.

31/10/19 Internal review to be complete 31/12/19. Development of joint working using action plan and monthly meetings.

31/01/20

Provision of Primary Care Services

02/03/17 A new APMS contract was awarded on 1 September 2019 for the provision of primary medical services to the patients at Chiltern House Medical Centre

If the new provider is unable to meet the requirements of the APMS contract, then the practice will be in breach of contract, and the CCG will not be meeting its statutory duties around the provision of care

Poor reputation Poor patient outcomes Local unsustainability

Louise Smith

Helen Delaitre 12 6 The new provider has been operating the service on an interim basis and therefore the risk of being unable to provide service is low. The score after mitigation is therefore 6 given it is unlikely this would happen (2)

3-6 months Mobilisation meetings will continue weekly for first month. Contract review meetings to take place thereafter, monthly for 6 months and then quarterly

Continued oversight on plans for service delivery particularly the establishment of a clinic at a local pharmacy to provide access for patients in Holmer Green. To open early in 2020.

31/10/19 Mobilisation meetings completed and monthly contract reviews planned. Monitoring of pharmacy plans in Holmer Green.

01/02/20

but the impact would be moderate (3)

Improved Access to Primary Care

02/03/17 Improved Access to General Practice. The contract for provision of this service ends on 31 March 2020

If the CCG does not agree commissioning plans for this service from April 2020 then the CCG will be unable to meet government expectations on 24/7 access. Patients will not have access to 24/7 primary care

Poor reputation Poor patient outcomes Local unsustainability

Louise Smith

Helen Delaitre 16 12 12 Risk score after mitigation reflects that the CCG is engaging with providers to determine commissioning plans for 2020/21. The impact would be major (4) with the possibility (3) that the risk might occur

3-6 months Contract in place until 31 March 2020 and quarterly CRMs taking place. Confirmation that arrangements for Extended Hours DES to be provided at PCN level.

National Access Review outcome delayed. Workshop on 19.11.19 agreed extension of current IA contracts for 2020/21. Single Tender Waiver Action to be prepared and submitted to Audit Committee January 2020.

26/11/19 Securing of IA contract for 2020/21. Development of specification for the service using IA steering group – to be reconvened 25.2.20

31/03/20

MEETING: Primary Care Commissioning Committee PAPER: D

DATE: 5th December 2019

TITLE: Head of Primary Care Report

AUTHOR: Helen Delaitre, Associate Director of Primary Care

LEAD DIRECTOR: Louise Smith, Interim Director Primary Care and Transformation

Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report:

To inform the Primary Care Commissioning Committee of local and national developments within primary care between September and November 2019 in the context of NHS Buckinghamshire CCG. Conflicts of Interest: None to note. Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all






Equality

Quality

Financial

Risks

Statutory/Legal



Supporting Papers: Head of Primary Care Report.

Head of Primary Care Report Primary Care Commissioning Committee

5th December 2019 Primary Care Commissioning Committee Membership Following Nicola Lester’s retirement in September 2019, the Terms of Reference for the Primary Care Commissioning Committee and the Primary Care Operational Group have been amended to reflect Louise Smith, Interim Director, Primary Care and Transformation as a voting member on both these groups.

To ensure appropriate clinical representation, Dr Rashmi Sawney, Clinical Director for Health Inequalities and Primary Care Networks and Dr Rebecca Mallard-Smith, Clinical Commissioning Director for Community Care are now standing invitees for both meetings, alongside Dr Raj Bajwa, Clinical Chair for the CCG.

Improved Access to General Practice In line with the national commitment to deliver seven day services, the CCG commissioned “improved access to general practice” in October 2018. The key components of this service are:

• Capacity – an additional 30 minutes per 1,000 weighted population. • Timing – Weekday evenings until 8pm and availability of appointments at weekends

based on patient need. • Advertising – the service is widely advertised and included on all practice websites. • Measurement – quarterly data reporting to NHS England. • Digital – use of digital approaches to offer a range of consultation types. • Inequalities – service model addresses identified local need. • Effective access to wider whole system – ensuring access from and to other primary

care and GP services (e.g. links with NHS 111). Recurrent funding to commission additional capacity to improve patient access has been provided by NHS England and in 2019/20, the CCG received £6 per weighted patient. This funding is in addition to the existing primary medical service allocation.

The CCG awarded an APMS contract for this service to FedBucks Limited, as a member of the wider Buckinghamshire provider collaborative for a period of 18 months (1st October 2018 to 31st March 2020). An 18 month contract was deemed prudent given at the time, national negotiations were already underway regarding GP contract reform.

A Primary Care Network (PCN) contract was introduced on 1st July 2019.A core component of this is a requirement for PCNs to ensure that all their population is able to accessExtended Hours provided under the Extended Hours DES.

At the same time, a national review of access to general practice services was announced with the objective of improving patient access both in-hours and at evenings and weekends and to reduce unwarranted variation in experience. The key output being the development of coherent access to general practice appointments, ready for full implementation by 2021/22.

In light of the ongoing review with the likelihood that the national contract specification would change from 2021/22, the formation of PCNs in July 2019 and the existing contract ending on 31st March 2020, the CCG held a workshop with providers in November 2019 to consider options for continuation of the Improved Access service during 2020/21. The workshop also reviewed service provision to-date.

All PCNs were represented at the workshop and they were invited to provide staff and patient feedback as well as report on what had worked well, and not so well. It was noted that this service had provided the opportunity for many practices to innovate and expand the range of services offered to patients, examples being the introduction of video consultations, paramedic home-visiting and first contact physiotherapy. Group consultations and piloting 111 making direct bookings into the weekend service were agreed as future service developments as well as further promotion of the Sunday service operating out of Stoke Mandeville Hospital. In view of provider willingness to continue with the service, the difficulty and cost associated with reprocuring a contract for only 12 months and the likelihood of a new national specification being introduced from 2021/22, the CCG has taken the pragmatic view that the best option is to extend the current contract with FedBucks. The current APMS contract includes provision to extend the contract for up to 3 years (Clause 2.3) and a single tender waiver application will be presented to the CCG’s Audit Committee on 29th January 2020 with the recommendation that this contract is extended until 31st March 2021. Once approved, the CCG intends to hold a further workshop with providers at the end of February 2020 to confirm service arrangements from April 2020. Beaconsfield and Aylesbury Primary Care Centres: New Build Projects The full business cases associated with these schemes were approved by the CCG’s Finance Committee on 30th October and have now been submitted to NHS England for Panel review on 16th December 2019. If approved, work will start on site in early 2020. The Executive Summary for each scheme is provided for information as Papers O and P. Threeways Surgery Reconfiguration The full business case for reconfiguring the existing Threeways Surgery in Stoke Poges was approved by the CCG’s Finance Committee on 30th October and was also approved by NHS England on 28.11.19. The Executive Summary for this scheme is provided for information as Paper Q. Chiltern House Medical Centre – One Year On In December 2018, the PCCC agreed that following an options appraisal and public engagement exercise, Buckinghamshire CCG should undertake a procurement process to identify a new provider for Chiltern House Medical Centre. The procurement exercise ran from January to June 2019 and resulted in the award of a 7 year (5 years with the option to extend for a further 2 years) APMS contract to Primary Care Management Solutions (PCMS). A requirement of the new contract is that local services are provided in Holmer Green to provide access to services for Chiltern House Medical Centre patients who live in the village. The branch surgery at Dragon Cottage closed in September 2018 and as part of the public engagement exercise, local services for that population were requested. The attached diagram (Appendix 1) shows the service model being developed by PCMS to deliver care to the patients registered at Chiltern House Medical Centre. Of particular interest is a joint project with the community pharmacy in Holmer Green to provide some services and consultations in the community.

The practice’s Patient Participation Group (PPG) has been very active in supporting the procurement process and shaping the service model. PCMS will continue to work closely with the PPG in the development of the practice and in particular services in Holmer Green. Long Term Plan The Buckinghamshire, Oxfordshire and Berkshire West Integrated Care System (BOB ICS) has developed a five year plan. The five year, one system plan describes how partners in the ICS will work together and with people in their communities to deliver the ambitions of the NHS Long Term Plan and address the specific priorities, opportunities and challenges within the BOB ICS area.

As per NHS Operational Planning and Contract Guidance 2019/20, ICSs must also include a primary care strategy as part of the system response and this strategy must set out how the ICS will ensure the sustainability and transformation of primary care and general practice as part of the overarching strategy to improve population health.

This plan was submitted to NHS England in November 2019 and will be made public by the end of December 2019.

Primary Care Delegated Commissioning Functions Work has been taking place across the CCGs in the BOB ICS (Buckinghamshire, Oxfordshire and Berkshire West) to identify areas where delegated commissioning functions could be done jointly and experience shared. A list of tasks to start this joint working has been drawn up including developing a common approach to locally commissioned services, contract variations and monitoring and administration of the Primary Care Networks DES. Senior primary care managers at each CCG have agreed to meet on a regular basis to promote working together and identify further areas where joint working could be developed. GIS Mapping After careful consideration, PCOG has approved the procurement of the Geographic Intelligence Service (GIS) mapping tool from the SCW CSU. This service already supports 31 CCGs across the South of England and four regional NHS England teams: South West, Wessex, South Central and South East. Berkshire West CCG already commissions this service. HD 22.11.19

Appendix 1

Primary Care Quality Report November 2019

1

MEETING: Primary Care Commissioning Committee PAPER: E


TITLE: Primary Care Quality Report

AUTHOR: Asela Ali, Quality & Patient Safety Manager

LEAD DIRECTOR: David Williams, Acting Associate Director of Nursing and Quality

Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information

Summary of Purpose and Scope of Report:

Conflicts of Interest:

Strategic aims supported by this paper:(please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all





Governance requirements: (Please tick each box as is relevant to the paper) Governance Element Y N N/A Comments/Summary Patient & Public Involvement Equality Quality Financial Risks Statutory/Legal Prior consideration Committees /Forums/Groups

None


Supporting Papers: Primary Care Quality Report.

This report provides a progress update of the work being completed by the Quality Team within Primary Care in Buckinghamshire CCG.

N/A


2

Primary Care Quality Report 1. Introduction

This report provides a progress update of the work being completed by the Quality Team within Primary Care in NHS Buckinghamshire CCG.

• Patient Safety – Incidents and Clinical Concerns • Safeguarding • Infection Prevention Control • Quality oversight

2. Patient Safety

2.1 Incidents

As of the 1stApril 2017 Buckinghamshire CCG became fully delegated. This means that the

CCG is responsible for tracking and supporting practices as and when they log Significant Events. Due to this new responsibility the CCG developed a database similar to the Serious Incident Management System (SIMS) which it uses to monitor secondary care providers’ Serious Incidents (Significant Events). Following a review we have found using the NRLS as a standalone system is not viable as the e-reports that are generated when an incident is reported, only last for 30 days before they are removed. The new system has been developed as a means to support GP Practices to investigate and learn from Significant Incidents.

Since the previous report in September 2019, the CCG has not been made aware of any further incidents occurring at GP Practices in Buckinghamshire. However we know that through other sources of information practices are conducting Significant Event reviews. 2.2 – Clinical Concerns

Of the 124 Clinical Concerns that have been reported to the CCG since 1st October 2017, 75 have been closed to the satisfaction of the original reporter, 49 remain open. Of these, 44 are overdue with the remainder still within the 30 working day timeframe. Of these 44 overdue, 33 are concerns related to our main Acute and Community provider Buckinghamshire Healthcare NHS Trust (BHT), the CCG quality team are following up on these outstanding concerns with the provider as no responses have been received since August 2019, this has been escalated to the Medical Director and the Interim Chief Nurse at BHT. A meeting has been planned with the lead for the management of the clinical concerns processes at BHT to understand what the barriers are to responding to these identified quality issues.


3


4

As illustrated in the charts above and below, the majority of concerns raised have been directed to BHT (68%). This is a minor shift from the previous report (where 65% of concerns related to BHT.

The most frequent type of Clinical Concern raised relates to medication or prescription issues where there were 26 instances, this is 3 more than in the previous report.

Overall, the most common “theme”, when all concerns are looked at as a whole continues to be a lack of or delayed communication/understanding between secondary and primary care. This may be in the form of Secondary Care clinicians’ awareness of the formulary (prescribing issues) or in Primary Care receiving results from Secondary Care. A common issue within this theme appears to be that Primary Care are not aware of the contractual obligations of Secondary Care and so their expectations are not managed adequately. Work conducted by SCAS with a number of GP Practices meant that practices were able to better understand the prioritisation categories for ambulance callouts and fewer incidents relating to SCAS have been reported. Those that have been raised with the CCG do not relate to timeliness of callouts but rather staff attitudes and are being investigated separately. This lack of awareness on the part of Primary Care HCPs compounded with some elements of Secondary Care not being aware of their contractual obligations results in an all-round lack of communication and frustration from both Primary and Secondary Care.


5

3. Complaints

In the last quarter there were 29 complaints received for Bucks:

Of the partially upheld and upheld complaints the emerging themes identified were:

The CCG has only recently obtained access to complaints data from NHSE and will be monitoring these themes and practices over a period of time as part of the Primary Care Quality Improvement and Assurance Framework.

4. Infection Prevention & Control (IPC) IPC activity Jul-Sep 2019 Bucks IPC Lead Nurse assisted with Oxford CCG’s Infection Prevention & Control training day for primary care link staff in July as part of Bucks/Oxon cross area working. IPC audits have been carried out in three practices during this period. All of them scored as compliant and the audits were carried out because the IPC Lead in the practice had changed and audit acts as a training process and preparation for the IPC lead role. In liaison with the Primary Care Lead Nurse and the CSU a guide for conducting flu searches was developed to provide support for practices in accurately identifying patients for flu vaccination, particularly of pregnant women as this risk group can change throughout the flu season. This work was also shared with colleagues in NHSE and across BOB.

17

6

1 2

Not Upheld

Partially

Upheld

Still Open

2

2

2

1 Subject GPD07 - Communications

GPD06 - Clinical Treatment(inc Errors)

GPD27 - Prescription Issues

GPD24 - PracticeManagement


6

5. Safeguarding

Children:

• In July, the exploitation work across Buckinghamshire was reviewed, and the Exploitation Hub was formed, to replace the Swan Unit. The location of the service remains the same, and the staff remain the same, however, the Terms of Reference have been updated and amended to ensure flow of cases to frontline teams. The revised ToR allow for wider considerations of the exploitation agenda as a whole and facilitate multi agency working in a more efficient and therefore effective framework. The impact of this for children and young people is that they receive targeted, bespoke support in a more timely manner.

• The plans for safeguarding activity in the BOB ICS are progressing with 4 options being considered.

• An audit of the Looked After Children health summaries was undertaken, with learning identified. The learning accounted for greater input from the Looked After Children themselves, and greater emphasis on the responsibility for who should ensure that dental and eye sight screening/treatment should take place, not simply state it is a need.

• The joint CDOP arrangements are progressing with the first themed review planned and an electronic database being used by both Oxon and Bucks. The aim is that with a greater pool of cases reviewed that this will support learning across both systems.

• The Serious Case Reviews continue to progress, none are published yet. • The SEN and LAC review process are being considered to try to identify any streamlining

opportunities. • A new Independent Chair has been appointed to the safeguarding children partnership as

well as the safeguarding adult’s board. This will offer improved consistency and connectivity in the future.

Adults:

• The CCG lead nurse for safeguarding adults left the CCG in August. Safeguarding adults activity continued with support from members of the Quality Team and peer support from BOB safeguarding colleagues.

• The Domestic Homicide Reviews and Safeguarding Adults Reviews all continued with 2 SAR’s now ready for their respective executive summaries ready for publication. We are seeing an increase in the number of cases, which impacts both primary care and the CCG teams. Support is being provided into practices by the Named Doctors and the wider Safeguarding team.

• The sub groups to the Safeguarding Board have not been meeting as they were not quorate, these are also under review due to new chairing arrangements. The Safeguarding Adult Lead and Associate Director for Quality and Safeguarding are meeting with the Board Chair imminently.

• A steering group for the forthcoming Liberty Protection Safeguards (LPS) has met to discuss future models for compliance with the LPS. In doing so the group will impact assess implementation of this new legislation across all health providers. The group is meeting every 2 months and we are expecting further guidance to be released in January 2020.

6. Quality Oversight

Following the CQC inspections that took place in the quarter, as at November 2019, 49 of our practices are rated as good (47) or outstanding (2), with 1 practice rated as requires improvement, an action plan and regular supportive visits are in place for the practice requiring improvement. This is a positive sign of the general quality of primary care in Buckinghamshire.


7

We are reviewing the Primary Care Quality Improvement & Assurance Framework with the LMC with a view to full implementation in 2020.

7. Friends and Family Test

The completion and submission of FFT data is a contractual requirement. There remain a number of Practices that remain non-compliant and are monitored by the Primary Care contracts team.

Aylesbury Vale M Sep-19 91%

Chiltern M Sep-19 92%

Combined M Sep-19 91%

National Average M Sep-19 90%




National Average M Sep-19 5%

Aylesbury Vale M Sep-19 7

Chiltern M Sep-19 16

Combined M Sep-19 23

Aylesbury Vale M Sep-19 0

Chiltern M Sep-19 1

Combined M Sep-19 1




Friends and Family TestGP Practices

% Recommended

Percentage of Practices with unpublished FFT

No. Practices Returning Zero Results

No. Practices Returning <5 Results

Friends and Family TestGP Practices

% NOT Recommended

Aylesbury Chiltern

Combined National Average

5 7 7 6 5 8 7 10 6 6 7 7

13 19 22 15 14 12 14 15 15 12 13 16

18 26 29 21 19 20 21 25 21 18 20 23

1 1 0 0 2 1 2 2 1 7 1 0

0 0 0 1 1 1 1 1 1 1 1 1

1 1 0 1 3 2 3 3 2 8 2 1

33% 44% 39% 33% 39% 50% 50% 67% 39% 72% 44% 39%

38% 56% 65% 47% 44% 38% 44% 47% 47% 38% 41% 50%

37% 52% 56% 42% 42% 42% 46% 54% 44% 50% 42% 46%

Aylesbury Chiltern

Combined National Average

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MEETING: Primary Care Commissioning Committee PAPER: F

DATE: Thursday 5 December 2019

TITLE: GP Delegated Budget, financial position month 7

AUTHOR: Alan Overton, Finance Analyst Primary Care, NHS England

LEAD DIRECTOR: Director of Transformation

Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: To note the financial position of the GP delegated budget for month 7 Conflicts of Interest: Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all





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Equality

Quality

Financial

Risks

Statutory/Legal



Supporting Papers: M7 Finance Report

of 8

Buckinghamshire Primary Care Commissioning Committee

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Report to the Primary Care Commissioning Committee – NHS Buckinghamshire CCG

Prepared by: Alan Overton, NHS England South East (Thames Valley), Finance Analyst Primary Care.

Classification: OFFICIAL

The National Health Service Commissioning Board was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the National Health Service Commissioning Board has used the name NHS England for operational purposes.

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1. Introduction

This paper sets out the financial position for month 7 of 2019/20 for the NHS England delegated primary care GP Services commissioning budget of Buckinghamshire CCG.

Buckinghamshire CCG Month 7 Year to Date Full YearGP Services 19/20 Plan Actual Variance Plan Actual Variance Plan FOT Variance £k £k £k £k £k £k £k £k £k GP Contract payment 4,005 4,010 (5) 28,032 28,017 15 48,055 48,055 0 QOF payments 534 534 0 3,741 3,741 0 6,414 6,414 (0)GP Seniority and Locums 165 165 (0) 1,156 1,156 (0) 1,982 1,982 (0)GP Drug payments 190 190 0 1,327 1,327 0 2,276 2,276 0 GP Premises 629 629 0 4,402 4,402 0 7,548 7,548 (0)GP Enhanced Services 124 116 8 867 818 49 1,488 1,488 (0)GP Primary Care Networks 191 191 (0) 1,336 1,336 0 2,290 2,290 (0)GP Other Items 3 3 (0) 21 21 (0) 36 36 0 Collaborative Fees 6 6 0 45 45 0 78 78 0 GP Premises other 5 5 0 35 35 0 59 59 0 GP General Reserves 0 0 0 0 0 0 568 568 0

Total 5,852 5,849 3 40,962 40,898 64 70,792 70,792 0

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2.0 Month Position The month position at month 7 is £3k underspend. 2.1 Year to Date Position Overall the YTD position at month 7 is £64k underspend.

• GP Contract payment £15k underspend Global Sum below plan, under review.

• GP Enhanced Services £49k underspend Extended Hours £16k below plan, Minor Surgery £33k below plan.

• All other areas on plan

2.2 Forecast Outturn 2019/20 The forecast outturn for 19/20 is on plan. 3.0 Budget 2019/20 The delegated GP Services budget for 2019/20 is £70,792k. This includes the new Primary Care Network payments for 2019/20. 4.0 Assumptions on reporting The figures have been prepared in accordance with the following national guidance:

• Accruals are as per accounting standards and in the year end outturn position.

4.1 Contracting and procurement activity

Chiltern House Medical Centre – New APMS contract in place from 1 September 2019 with PCMS.

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5.0 Risks and Opportunities Risks and opportunities are reviewed on a regular basis. A table of costs is shown below based on a review at M7. Reserves £'000'sGeneral 355

Total Reserves 355

Risks -Potential Commitments against Other Reserves Notes

GP Practice late claims 0 tbc

GP Dispensing Fees (243) Fee increase

Locum cover (Parental/Sickness Leave) 0 tbc

GP Retainer Scheme (100) Budget £50k, costs £150k

Seniority (159) Review of costs

GP Practice Support Rent Hanover House (60) Additional rent 18/19

Total Risk (561)

Potential Slippage/Opportunities

Contract Payments 0 Est Population Growth tbc

PMS Premium reinvestment 60 PMS premium

Extended Hours Des 30 <100% sign up

Locum cover (Parental/Sickness Leave) 0 tbc

Premises Rates 0 Refunds for 18/19 tbc

Prior Year unutilised accruals 116 tbc

Total Gain 206

Net Gain/(Risk) (355)

Net Gain/(Risk) after inclusion of Reserves (0)

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Risks

• Section 96 support for practices in financial difficulty.

• Increased Premises reimbursements for premises developments/rent reviews.

• Locum cover for Parental/Sickness Leave.

• GP Retainer Scheme - nationally funded incentives are increasing the number of GP's in post.

Opportunities

• Enhanced Services slippage

• Population Growth – Impact on Contract Payments of growth below the planning assumption.

• Premises Rate Rebates following national appeal process.

Net Risks will be funded from reserves

MEETING: Primary Care Commissioning Committee PAPER G


TITLE: Merger Application: Norden House, Wing and Whitchurch Surgeries, North Buckinghamshire

AUTHOR: Jessica Newman, Senior Primary Care Manager


Reason for presenting this paper (Please tick relevant boxes): For Action For Approval For Decision For Assurance For Update Summary of Purpose and Scope of Report: NHS Buckinghamshire CCG has received an application from 3 practices in the north of the county to merge; Norden House Surgery in Winslow, Wing Surgery and Whitchurch Surgery. The merged practice will be known as 3W Health. The 3 practices wish to merge on 1 April 2020 with the aim of improving their resilience and sustainability by sharing back office functions and creating one, larger practice team. However, the intention is to maintain the existing 3 surgery buildings so that the impact on patients is minimised. The practices’ application, details of a comprehensive public engagement and a paper setting out the commissioning issues to be considered is attached. PCCC to requested to consider the application made by Norden House, Wing and Whitchurch Surgeries to merge as of 1 April 2020 and to approve. Authority to make a decision – process and/or commissioning (if relevant) Under delegated commissioning arrangements it is the responsibility of the PCCC to approve practice mergers. When carrying out such actions, the CCG is required to act in accordance with the Delegation Agreement which includes but is not limited to: • undertaking all necessary consultation when taking any decision in relation to GP practice mergers, including those set out under section 14Z2 of the NHS Act (duty for public involvement and consultation). The consultation undertaken must be appropriate and proportionate in the circumstances and should include consulting with the LMC; • prior to making any decision, clearly demonstrating the grounds for such a decision and fully considering any impact on the GP practice’s registered population and that of surrounding practices. The CCG must be able to clearly demonstrate that it has considered other options and has entered into dialogue with the GP contractor as to how any merger will be managed; and

• in making any decisions, taking account of the CCG's obligations as set out in the Delegation Agreement in relation to procurement, where applicable. Conflict of Interest (Please tick relevant boxes): No conflict identified Conflict noted, conflicted party can participate in discussion and decision (see below) Conflict noted, conflicted party can participate in discussion but not decision (see below) Conflict noted, conflicted party can remain but not participate in discussion (see below) Conflicted party is excluded from discussion (see below) Governance assurance (see below) None known. No member GPs who are Partners at either practice are either voting members of the PCCC or in attendance in a commissioning role. No further action required. Strategic aims supported by this paper (please tick relevant boxes) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all Better Care for Bucks – to commission personalised, high value integrated care in the right place at the right time Better Care for Bucks – to ensure local people and stakeholders have a greater influence on the services we commission Sustainability within Bucks – to contribute to the delivery of a financially sustainable health and care economy that achieves value for money and encourages innovation

Leadership across Bucks – to promote equity as an employer and as clinical commissioners n/a Governance requirements: (Please tick each box as is relevant to the paper) Governance Element Y N N/A Comments/Summary Patient & Public Involvement The practices have undertaken a

comprehensive public engagement process. Equality

The merger application considers how access will be maintained for patients. An EIA has been completed as part of this paper.

Quality The merger application describes how quality services will be sustained by the merger.

Financial

The financial aspects of merging the 3 current contracts are considered within this paper.

Risks

This paper considers the risk of challenge from other providers should PCCC agree to the merger without offering the contract out to a wider market.

Statutory/Legal

The CCG is required to consider applications for practice merger as part of its delegated primary care commissioning responsibility.

Prior consideration Committees / Forums /

Groups Membership Involvement Member practices have been consulted as

part of the engagement process. Supporting Papers: Merger application report Annex 1 – Practice Boundary map Annex 2 - Application to Consider a Practice Merger Annex 3 – Public and Patient Consultation report Annex 4 – 13Q Duty Public Involvement Assessment Form Annex 5 – Equality Impact Assessment

Merger Application to form 3W Health Norden House Surgery, Winslow Wing Surgery Whitchurch Surgery

1. Background The 3 practices are members of North Bucks PCN together with The Swan Practice, Ashcroft Surgery, Waddesdon Surgery and Edlesborough Surgery. All these practices also work together as the Medicas Federation to provide extended access.

The 3 practices are partnerships holding GMS contracts with dispensing rights. Dispensing aspects of GMS contracts are managed by NHS England, via the local Prescribing Services Regulations Committee (PSRC), so the merger has been considered by the Committee in this regard.

All practices are rated as ‘Good’ by CQC.

The current practice boundaries, which will merge to form the 3W Health boundary is shown at Annex 1.

Norden House Surgery

Avenue Road, Winslow MK18 3DW Number of partners: 4 Registered patient list as at 01.09.19: 9,688 Norden House Surgery is going through the process of becoming a training practice.

Wing Surgery 46 Stewkley Road, Leighton Buzzard, LU7 0NE Number of partners: 2 Registered patient list as at 01.09.19: 5,432

Whitchurch Surgery 49 Oving Road, Whitchurch, Aylesbury, HP22 4JF Number of partners: 2 Registered patient list as at 01.09.19: 4,002

NHS Buckinghamshire CCG has received an application from the practices requesting approval for a merger with effect from 1 April 2020. The practices’ application is shown at Annex 2.

The merged practice will be known as 3W Health although each practice will retain its current identity and surgery site. The merged list will be approximately 19,000 patients. The organisational K code for Wing Surgery will be retained.

2. CCG Responsibilities The NHS England Primary Medical Care – Policy and Guidance Manual (PGM) sets out the process that should be followed when considering a merger: The PGM advises that “practice mergers can be complex matters which should not be approached lightly by either the contractors or the Commissioner. Where a practice merger requires amendments to the practice contracts, the final commissioning decision on whether contracts should be amended to effect the proposed merger, lies with the Commissioner and there are a number of important issues that would need to be considered, prior to giving consent”. The following are highlighted as items which should be considered by the CCG, although this is noted not to be an exhaustive list: To be Considered by the CCG Comment Benefits to Patient How patients would access a single service. The merged practice will continue to operate

from the 3 existing sites. Patients will be able to visit their current site, or any of the other 2 surgeries. Telephony will eventually be accessed via one number but this will run in parallel to the existing 3 practices’ telephone numbers whilst current contracts are in place.

What would the practice boundary be (inner and outer).

The inner and outer boundary of the merged practice is shown at Annex 1 which is formed from the 3 existing practice boundaries combined.

Assurances that all patients will access a single service with consistency across provision i.e. home visits, booking appointments, essential and additional services, opening hours, extended hours, and so on, single IT and phone system.

Assurance received from the practices. There will be a merged clinical system and a single point of access for patients. Services for patients will initially reflect current arrangements in each practice. Where there are inconsistencies the practices will work together to align services.

Premises arrangements and accessibility to those premises to patients.

The merged practice will continue to operate from the 3 existing sites who will maintain their current opening hours.

Proposed arrangements for involving patients about the proposed changes, communicating the change to patients and ensuring patient choice throughout.

Full patient consultation has been undertaken. A summary of this and outcomes is shown at Annex 3. The 13Q Duty Public Involvement Assessment Form has been completed (Annex 4).

The impact on health inequalities and patient choice.

An Equality Impact Assessment has been completed (Annex 5) and does not reveal any significant impact on any protected groups. The Health Inequalities Group will consider the EIA at their meeting in December 2019. The merged practice area will cover a large

geographical area. As part of its application, the 3 practices have been asked to identify where patient choice will be limited and agree how patient removals will be accommodated.

Costs/Value for Money Costs / value for money - a contract merger is likely to merge contracts with differing values, this would have an ‘averaging’ effect, possibly resulting in a higher cost per head of population under a single contract than the Commissioner would have expected.

The contract merger will merge 3 practices with differing contract values and costs per head of population to the sum of the 3 single contracts. The global sum is calculated using the national Carr-Hill formula. 2020/21 is the last year of phasing out the Minimum Practice Income Guarantee (MPIG) and the combined MPIG allowance for this final year will be included in the contract price for the merged practices. The 3 practices will need to do their own due diligence to satisfy themselves of the affordability of the merged contract.

Other financial arrangements – the impact of Directions under the Statement of Financial Entitlements, or any specific terms included in the individual contracts.

The SFE is a national directive which underpins the way payments are made to practices. Financial arrangements for the merged practice would remain in line with the SFE and would be equitable with other practices within the CCG. There are no adverse financial implications for either the practice or the CCG that we are aware of.

Premises reimbursements The newly merged practice would continue to operate from the existing three premises. Rent reimbursement and pass through costs are expected to remain the same and continue to be based upon the current square footage.

Locally commissioned services and out of hours opt-outs/improved access arrangements.

It is anticipated that additional services and extended hours will continue in line with current arrangements.

Enhanced services. It is the responsibility of the 3 practice to consider the impact on payments for the merged practice in relation to QOF, enhanced services etc. However, the CCG expectation is that current commissioning arrangements will be carried over. As the commissioners for primary medical services, the CCG has the right to amend future commissioning arrangements however; these would be equitable across all CCG practices and would not be varied for the new merged practice. The merged practice will be expected to maintain membership of the North Bucks PCN.

Patients from the terminating contract are included under the remaining contract through bulk transfer where possible to

PCSE will be notified of the proposed merger using the prescribed process to ensure that patients are transferred to the one practice

avoid additional cost pressure. list without disturbance to the patient or the practice.

Competition The commissioner should clearly articulate the benefits of delivering Primary Care at scale in its Primary Care strategy and should always consider whether a proposed merger will benefit patients.

Although the merged practices cover a large geographical area, the merged practice list will be 19,000 which is not considered to be significantly ‘at scale’. The application shows clear benefit to patients from the merger, in terms of ensuring sustainability of general practice in the area.

Other Considerations Strategic fit The proposed practice merger is in line with

the CCGs Primary Care Strategy, local delivery of the 5YFV and LTP which prioritises practices coming together to work across larger geographical areas, enabling the sharing of clinical expertise in specialist areas and increased resilience. By working at scale, integrated community services can be wrapped around the larger patient populations enabling increased out-of-hospital services.

Dispensing Regulations NHS England’s PSRC are assured that the Practices’ intentions fulfil the requirements of Regulation 59 and as such will be able to amend the dispensing doctor list from the date of the merger, should it go ahead.

3. Summary and Recommendation

Norden House Surgery Winslow, Wing Surgery and Whitchurch Surgery have applied to merge practices to become 3W Health from 1 April 2020. The application describes how the merger will benefit patients by creating sustainability for the 3 practices. Impact on patients will be minimal with the 3 surgery sites remaining open. The practices have considered how they will maintain patient choice. A comprehensive patient consultation has taken place which reports patient support for the merger. Therefore it is recommended that PCCC approve the merger Norden House Surgery Winslow, Wing Surgery and Whitchurch Surgery to become 3W Health from 1 April 2020.

Annex 1 3W Health Boundary

Annex 2 Merger Application; Norden House, Wing and Whitchurch Surgeries, North Buckinghamshire to form 3W Health

Annex 3 3W Merger summary of public and patient consultation

Results of the Public Consultation Regarding the Potential Merger of Wing Surgery, Whitchurch Surgery and Norden House

Surgery. 1st August 2019 to 31st October 2019.

Modes of communication with Patients and the General Population. Comms materials were developed with the assistance of the Team at Buckinghamshire County Council. (see appx 1 & 2). Commencing from the beginning of August all practices made this information available via their websites and Facebook feeds. In addition it was manually distributed at Reception desks and in drug bags from our dispensaries. Articles were placed in the local press by the Comms Team at the Council and a news piece placed in all the village magazines. (14 contacted – 10 published) A dedicated e-mail address was set up for the merger ([email protected]) and this was distributed widely in all Comms information. A merged Patient Reference Group with a membership of 24 has been in place since March 2019 and has been consulted with extensively on all aspects of the merger including Comms material. (See Appx 3 & 4) Drop in sessions were arranged for the 5th, 12th and 26th of October. These were planned to coincide with Saturday Flu Clinics, one in each surgery. They were advertised online, in village magazines and flyers manually distributed in surgeries and dispensaries. There was a footfall of 675 patients through these clinics and comms material was distributed to the queues, questions answered if necessary and time spent with those who turned up to exclusively talk about the merger. Results of the Consultation. Dedicated e-mail We received a total of 4 e-mails to the dedicated account. One was a simple request for more information which was provided. The second expressed concerns around accessing surgeries that were some distance away for him. He was reassured that he can continue with his surgery as he does now. There is no requirement to attend the other surgeries if he does not wish too. He was provided with the comms material which he had not seen. He wanted to know why the two surgeries in Wing weren’t merging instead and an explanation was given. The third was an enquiry from a patient who was planning to move within the area and wished to know if he needed to re-register with Norden House or whether he would be able to


remain with Whitchurch. He was advised he would be able to continue with Whitchurch Surgery. The final e-mail enquiry was from a patient that runs a voluntary car service between Great Horwood and Winslow and was concerned that he and his drivers might be having to take patients further afield. Re-assurance was given. Facebook Comments There was one comment on Facebook from a Norden House Patient declaring his satisfaction with the service he currently receives and hoping that the merger will not affect this. Drop-in Sessions Drop-in sessions were organised to run alongside Saturday flu clinics. These were advertised online and in village periodicals. (see appx 5). An information board was set up in the waiting room to attract attention and promote discussion.

Wing Surgery – 05/10/19 The first ‘drop-in’ session was held at the Wing Surgery Saturday flu clinic. The session took place between 9am and 12am. The clinic vaccinated approximately 200 patients. 44 of the A4 Patient Information Sheets were handed out. 4 Patients sought discussed the merger further.

3 of the 4 patients were very positive about the merger and felt it was the practical and pragmatic thing to do. 1 Patient was concerned that it might change the atmosphere of the surgery she had visited since childhood. All the patients spoken too were attending for a Flu jab. The majority of patients spoken to felt informed and were comfortable with the merger. Norden House – 12/10/19 The second ‘drop-in’ session was held during a Norden House Surgery flu clinic taking place between 08.30am and 1pm. The clinic vaccinated 375 patients and 75 information sheets were handed out to interested parties. The majority said they were already aware of the merger. 11 patients discussed the merger further and all seemed happy with the proposal as long as they could continue accessing services in the way they currently do. 5 patients attended purely to ask questions about the merger. All seemed happy with the proposal following discussion. Whitchurch Surgery – 26/10/19 The ‘drop-in’ session at Whitchurch Surgery was the quietest of the 3. It coincided with the flu clinic as well as a coffee morning run by the Friends of Whitchurch surgery. Unlike Norden House surgery there is no appointment required for the flu clinic at Whitchurch and the organisers believe that England’s Rugby semi-final had impacted on attendance. 23 information sheets were handed out and again the overriding opinion was that as long as they could continue to use services as they currently do it would be fine. Friends of the Surgery There was some discomfort expressed by the Friends of Whitchurch Surgery about the merger. They are very active and fund raise to purchase equipment for the surgery. They were concerned about what would be expected of them going forward. Norden House has an equivalent group but there is no equivalent at Wing. A meeting was arranged between the Practice Manager at Whitchurch, the Practice Manager at Norden Surgery and the chair of the Whitchurch Friends. Norden House Friends had already expressed a willingness to merge the two groups. Following the meeting there was agreement to recommend this as a way forward to the Friends of Whitchurch with the proviso that representation should be sought from the patient group at Wing. Conclusions

• The proposal to merge is uncontroversial as patients will be able to continue using their surgeries as before.

• Many view the proposal as pragmatic and sensible.

• Good understanding and acceptance of our reasons for the merger (e.g. economies of scale, buying power, sharing staff etc.)

• Inevitably there were one or two patients that have grown up with these surgeries and

do not wish to see them change. Noel Ratcliffe – Practice Manager Norden House surgery. 12/11/19

Appx 1.

Proposed Merger of Wing Surgery, Whitchurch Surgery and Norden House Surgery Winslow

Whitchurch, Wing and Norden House Surgeries are proposing to merge on 1 April 2020. The partnership between these surgeries will be known as 3W Health, however the existing surgeries names will remain the same.

We are sure you are aware that over the past few years there have been increased pressures placed upon General Practice services. All three surgeries have been performing well and have had ‘good’ recent Care Quality Commission ratings. In order to enhance the services we currently provide, we feel that the best way forward is to merge.

All three surgeries share the same commitment to quality and by merging we will be able to share working arrangements and offer improved services to patients.

We have a growing population with increasingly complex healthcare needs. Merging our practices will make us more resilient, giving us a larger pool of staff to draw from, and allow us to work toward bringing services from hospital into the community for the convenience of patients. It will also give us the opportunity to reduce some of our overhead costs due to economies of scale.

Our doctors, practice nurses and other staff will continue to be available to patients under the proposed new arrangements in the same way as they are at present. Due to the size of the area covered by our practices, there are no plans to close buildings.

Patient registration would not be affected and you would not need to do anything should you wish to stay registered with the proposed new practice. Following the proposed merger, you would have the choice of being seen at any of the three surgery sites or continuing to use your current practice only, as you do now.

We are proud of our practices and the personal care we have maintained over the years and have always been encouraged by the positive feedback and support of our patients. By uniting as one like-minded team we can continue to provide this high quality care in a way that allows us to thrive in the future, making best use of available resources, developing new services and providing seamless care for all of our patients.

We understand that you may have questions and comments about the proposal to merge and we intend to listen to your thoughts in a number of ways:

• We have answered some of the questions we think you may have on a list of FAQs (Frequently Asked Questions) and these can be found on all three websites: www.nordenhousesurgery.co.uk

www.wingsurgery.co.uk

www.whitchurchsurgery.co.uk

http://www.nordenhousesurgery.co.uk/

http://www.wingsurgery.co.uk/

http://www.whitchurchsurgery.co.uk/

• We will hold drop in sessions and members of the team will be available to listen to your comments and answer questions. These sessions are currently being planned and will be publicised in due course.

• Updates will be added to the practice websites as and when they are known and will be displayed in our waiting rooms.

• If you have any specific queries or concerns please write to Noel Ratcliffe at Norden House surgery, Avenue Rd, Winslow, Bucks, MK18 3DW , or email [email protected]

Yours faithfully, Dr Beth Peel, Dr Rodger Dickson, Dr Joseph Rizzo-Naudi, Dr Diana Straker, Dr Sara Ronaghy, Dr Ruth Mason, Dr Chris Davies & Dr Satheesh Ramasamy.


Appx 2 FAQS

Proposed practice merger between Whitchurch Surgery, Wing Surgery and Norden House Surgery, Winslow

All three practices are driven by the following important values:

• Trust, integrity, honesty and professionalism • Quality of patient-centred care • Quality of life for our Staff, ensuring work/life balance is maintained • Empowerment and involvement of staff and patients. • Patients: encouraging and promoting self-care and responsibility

1. Why are Whitchurch surgery, Wing surgery and Norden House surgery proposing to merge?

As we are sure you are aware, over the past few years there have been increased pressures placed upon General Practice. The increasing elderly population, the growth in long term illnesses like diabetes and asthma and the need to move more work from hospitals into the community means that General Practice needs to work in different ways to absorb this increased workload. We feel that the best way to continue to offer our patients an innovative, sustainable, quality service into the future is to join together.

2. Is the merger supported by NHS England and NHS Buckinghamshire Clinical Commissioning Group?

NHS Buckinghamshire Clinical Commissioning Group will consider our application to merge at their Primary Care Commissioning Committee meeting in December 2019. A key part of the application process is the views of patients and local stakeholders which we will gather in the coming weeks. For ways that you can express your views and get involved please see FAQ Question 15.

3. When will the merger be completed?

If merger is approved the target date will be 1 April 2020.

4. Will there be a new name for the merged practices?

Yes.

If the plan for merger proceeds, we will have a new Partnership Name - 3W Health. However the individual surgery names will remain the same.

5. Will I still be able to see my usual GP or Nurse?

Yes, the same staff and GPs will still be working at each of the three practices. We are committed to provide continuity of care to our patients.

6. How will the proposed merger benefit patients?

It will strengthen our ability to maintain high quality care for our patients, invest in innovation and create a stable and sustainable GP Practice by sharing the resources and expertise of all three current practices. The new structure will provide greater flexibility for patients and, over time, we hope to provide new patient services. Some of these will come about through our ambition to move certain

services out of a hospital setting and provide them instead at your GP practice or in your community. We would update you on any such plans in due course.

7. How will the merger benefit the GPs, nurses and other healthcare professionals working at the practices?

The clinical team will have a wider pool of knowledge and experience to draw upon. There will be increased opportunities to specialise. Staff will have more robust support in a larger structure.

By working together everyone will have access to a wider pool of knowledge and experience to draw upon. The expansion of the team will create a more robust support structure and give greater development opportunities to staff. We are committed to making 3W Health a great place to work and promoting a culture of lifelong learning.

8. What will change?

Initially there will be little change; however, over time there will be improved access to services and an opportunity to introduce new services, closer to home.

9. Will I have to go to another site for my consultations?

We believe continuity of care is very important and you will continue to see staff in your usual location. In some circumstances it may be more advantageous for you to be seen at another site - for example, if you need to see a healthcare professional who specialises in a particular area. If you wish to take advantage of this you will be able to.

10. Will there be improved access to appointments?

Yes, we will continue to review the availability of appointments regularly to ensure patients have access to the care they need.

11. Currently my prescriptions are dispensed at my Practice, will this change?

No, you will continue to have prescriptions dispensed at your usual surgery.

12. Will the merger affect access to other services such as community nurses, midwives or health visitors?

No, patients receiving care from community based services either at home or in practice will not be affected.

13. Are there plans to close any of the sites?

No, the current sites will remain open.

14. What will happen to my medical record?

All three practices currently use the same computer system and these will be merged into one clinical database. All medical records will be available for any clinician who needs access to them. Patients will to be able to access their medical record, order prescriptions and make appointments on-line.

15. How are you planning to keep patients informed of the progress of the proposed merger and how can I get involved?

Patient Participation Groups from each practice have already met and will continue to meet as one group. We have shared details of the proposed merger with the PPGs and have also discussed with them how we communicate and engage with all our patients in the future.

Updates will be available on the practices’ websites/ Facebook pages, posters in the waiting rooms, leaflets, text alerts, and at patient participation group meetings. We are also planning ‘drop in’ meetings where staff will be available to chat with you about the merger, listen to your views and answer any questions you might have. Dates will be provided in due course. Should you have any comments, questions or concerns you can send us an e-mail to [email protected] and we will respond as soon as possible.

16. Would I have to stay with the merged practice?

We hope that you will want to remain registered at the proposed merged practice and you do not need to do anything if this is the case. However, if you do not wish to remain with the proposed merged practice you are free at any time to register with another GP practice, providing you live within their practice boundary. https://www.nhs.uk/ provides information on other local practices or you can reach NHS England Contact Centre on 03000 311 22 33 or at [email protected]


https://www.nhs.uk/

Appx 3

Meeting of the Patient Reference Group for Whitchurch Surgery, Wing Surgery and Norden House Surgery

Thursday 27th June 2019

Attendance at the meeting:

Whitchurch Surgery Wing Surgery Norden House Surgery Amanda Tofield (AT) Pamela Cruse (PC) Roger Slevin (RS) Linda Gerhardt (LG) Lauren Shepherd (LS) Ian Hook (IH) Michael Nagele (MN) Christine Law (CL) Jill Lord (JL) Pauline Moore (PM) Roy Collis (RC) David Whinyates (DW) Prudence Newman (PN) John Wainwright (JW) Jenny Groom (JG) Ralph Followell (RF) Ann Roberts (AR) Christine Dodds (CD) Debbie Scott (DS) Frank Donlan (FD) Rachel Brice (RB) Mel Abbott (MA) Noel Ratcliffe (NR)

Introduction

NR gave a brief background to the meeting.

Terms of Reference.

NR had pre-circulated Norden House PRG Terms of Reference with a view to revising these for the new bigger group. Numbers on the group. It was agreed that those at the meeting were interested in carrying the role forward. Total number of representatives from each practice agreed pro-rata to the size of the practice population. As Norden house already had 12 members in their group it was agreed that Whitchurch and Wing would have 6 reps each and as this matched the numbers in the room this would define the membership going forward.

Some discussion around retirement. Agreed that each member should serve a term of 3 years but with the agreement of the rest of the group could be increased to 4 years. It was also agreed that should a rep leave the group and wish to re-join in the future they should have left for a period of at least a year.

All reps happy to be e-mailed and for other reps on the group to know their e-mail addresses. NR to create a comprehensive mailing list.

NR to redraft the Terms of Reference and recirculate to the group.

Update on the Merger Plans.

NR gave an update on the progress with the merger to date.

Confirmed that the Memorandum of Understanding has been signed by all the practices and we are now proceeding towards merger. Application has been made to the NHS England and

the CCG for approval of the plans and application to the Pharmaceutical services Committee for confirmation of all practices dispensing status.

We now have a date for the IT Company to merge the patient databases and this will be in April next year.

New name (3W Health) shared with the group.

All 3 practices have started the work of preparing for the merger. Staff are starting to work together on different work streams looking at every facet of how the practices work.

One question asked was whether merger might make it more difficult to get an appointment. This was the experience of some patients in other merged practices. NR commented that it was too early to say what the new practices appointment system might look like. Difficulty getting appointments is not the current experience and all the practices would be very keen to avoid difficulties and will plan to have a system that allows patients good access to appointments while managing capacity as efficiently and effectively as we can.

Primary Care Networks.

NR had pre-circulated a document from the CCG to inform patients about the new primary care network. This is the latest reform which looks to set up networks of GP Practices working together to provide services to a defined population. The network in the North Locality will be based around the practices in Waddesdon, Whitchurch, Wing, Winslow, Buckingham and Edlesborough. All these practices have a good track record of working together and sharing services. These new networks are being set up to introduce new funds to employ workers that can take some of the pressure off GP’s as it is challenging to fill GP vacancies. Such roles are Pharmacists, Paramedics, Advanced Nurse Practitioners, Advanced Physiotherapists and Social Prescribers. Our network is in place and the Clinical Director is Dr Ramasamy from Norden House Surgery.

FD stressed the importance of these new roles and the need to use these staff across the network where they are most needed.

Concern was expressed around who decides which patients see these new practitioners. If it is receptionists are they appropriately trained to do so. Currently this is done differently in each practice and will need looking at as part of the merger planning and work.

Communications Strategy for the Merger.

NR Circulated the Comms plan for the merger. He met this morning with the Comms Team at the council who will coordinate the public consultation. The required consultation runs over 12 weeks and needs to be complete in time for a meeting at the beginning of December. This suggests that the consultation needs to start in the middle of July, completing in the middle of October, and giving us enough time to consider the outcome before the meeting in December. NR feels that news of the merger is starting to leak and that we need to inform patients about the merger as soon as possible.

AOB. No other business.

Appx 4

Meeting of the Patient Reference Group for Whitchurch Surgery, Wing Surgery and Norden House Surgery

Tuesday 17th September

Attendance at the Meeting

Whitchurch Surgery Wing Surgery Norden House Surgery Ralph Followell Roy Collis Jill Lord Amanda Tofield John Wainwright Jenny Groom Linda Gerhardt Ann Roberts Christine Dodds Pauline Moore Christine Lawrence Debbie Scott Prudence Newman Lauren Shepherd Rose Scott Rachel Brice (RB) Pamela Cruse Peter Scott Noel Ratcliffe (NR) Apologies: Melanie Abbott, Michael Nagele, Frank Donlan, Alan Eatwell, Roger Slevin, Ian Hook, David Whinyates, Peter Saxton

Introduction

NR introduced Alison Combe who will be assisting with aspects of merger administration including the taking of minutes for meetings such as this. Members of the PRG group then introduced themselves.

Minutes of the last meeting

Agreed

Matters arising from the minutes of the last meeting

NR was asked as to whether there had been any patient feedback following the public announcement of the merger.

NR reported that there had been 1 email to the dedicated address which he had responded to and 1 person who spoke to him directly seeking clarification.

Update on the Patient Consultation

Several members reported that they were surprised not to have seen the announcement in the local parish magazines.

NR responded that this communication is being managed by the County Council and he will chase up. RF is the editor for the Hardwick magazine and has not been contacted to date, his next publication deadline is Saturday 21st September. RB has all contact details for the parish magazines covering the Whitchurch population. It was decided that AJC will create an A5 version of the announcement and send out to all parish magazines and give the County Council a nudge.

Patient drop-ins will be taking place to coincide with planned Saturday morning flu clinics at each surgery with dates as follows: 5th October Wing

12th October Norden House

26th October Whitchurch

Members reported that conversations had with them to date were felt to be mainly around concern that the practice locations/buildings and doctors themselves would be changing and when reassured that these elements were not to be changed and rather that it was about services, most people were positive. RB reported that there is a concern amongst some of Whitchurch patients due to the possibility of retirement of one of the partners. NR suggested that members should feel they can pass on contact details for any persons having concerns about the merger and he will contact them directly.

NR then introduced guest Thalia Jervis CEO of Healthwatch Bucks describing to Thalia how the new larger PRG has come about through the proposed merger and highlighting that it is important to stay relevant and keep other issues on the table for discussion within the PRG as well as the merger.

Presentation from Thalia Jervis CEO of Healthwatch Bucks

Thalia gave a brief outline of Healthwatch:

• Set up by the government under the Health and Social Care Act 2012 to ensure that health and social care services put the experiences of people at the heart of their work.

• A statutory function funded by Buckinghamshire County Council and run as a not for profit organisation.

• Their aim is to ensure that what everyone in Bucks has to say about health and social care is reflected in the services available.

• 7 people in the team 5 FTE. • 3 objectives are to:

o Listen to the residents of Buckinghamshire, to understand what they think about health & social care through verbal and electronic feedback.

o Influence the right people so that the views make a difference to health and social care services. Feeding in to Healthcare Boards, Trusts and Commissions at a high level.

o Ensure that the feedback makes a difference to the way health and social care services are commissioned and delivered.

• 2 key projects at the moment are: o Signposting people to the relevant health and social care o Dignity and care reporting across care homes as they have ‘enter & view’ powers.

• Another function is to assist patient groups get off the ground in areas where they do not exist. • All feedback is reported and recommendations are published and subsequently followed up to

see what recommendations have been taken forward by the relevant groups creating and managing health and social care services.

• Access to appointments is the main feedback issue from patients as would be expected, Healthwatch has to look very carefully at the smaller issues to ensure all are taken into account in determining what areas of focus should be.

• More recently areas of focus have included: o Mental health o Continuing care o Transitions from discharge o Health checks for those with learning difficulties

General consensus of the group was that this all sounded very good and many were surprised that there wasn’t more awareness of Healthwatch’s existence. It was suggested that there was an opportunity to promote further in the practices and possibly through the flu clinics. Thalia pointed out that there is actually literature in most practices and on the information screens but obviously patients

can become blind through message saturation. The creation of the Primary Care networks will make contact to practices easier for Healthwatch given the small number of people resources they have.

To see the latest projects, health and social care news or to signup for the newsletter see the website www.healthwatchbucks.co.uk .

Update on progress of the Merger

NR reported that we are 2 months into the public consultation and all feedback will be compiled for the CCG prior to the 5th December meeting where it is hoped they will sign off on the merger. The Pharmaceutical committee also has to sign off on the merger. NR believes that there is provision in the rules for a merger as long as the dispensing areas are left as is. The Pharmaceutical committee ruling is a go/no go decision for the Merger Board who will not continue with the merger should the dispensing aspect of the merger not be agreed.

Staff are being introduced to one another team by team, with issues being appeased as much as possible. Most issues have been similar to patient concerns with regard to things staying as is.

NR indicated that there is a Merger Board made up of the partners of each of the practices and NR and a Merger Management Committee made up of an Executive Partner, all Practice Managers and Deputy PMs and key personnel leading on specific areas of integration.

3W Health will be the new the new name of the merged practice but patients will still refer to each practice by its individual name. The benefits will come through additional services and cost savings.

A member queried whether there will be a change in drug products prescribed. RB stated that there may be the odd product change but as the practices already work to a local formulary there shouldn’t be much change.

A.O.B

A member has received a text message asking him to sign up to the ASK NHS App which is unclear as to what it is offering and with what details one should sign up.

NR stated that the 3 practices are rolling it out and patients mustn’t get it mixed up with MJOG which is the text message appointment reminder service. ASK NHS is a service to assist patients in identifying if they need an appointment or an alternative avenue, as a way to reduce the load of the practice where possible. It asks a number of questions and then will refer the patient to a fact sheet, 111, pharmacist or to the surgery for an appointment based on the answers given. It is a service that has been trialled in Buckingham and is a work in progress for the surgeries.

Date of Next Meetings:

Thursday 7th November 1pm Whitchurch Surgery

Thursday 23rd January 1pm Whitchurch Surgery

http://www.healthwatchbucks.co.uk/

Appx 5

Proposed Merger of Wing Surgery, Whitchurch Surgery and Norden House Surgery Winslow

Whitchurch, Wing and Norden House Surgeries are proposing to merge on 1 April 2020. The partnership between these surgeries will be known as 3W Health, however the existing surgeries names will remain the same.

We are proud of our practices and the personal care we have maintained over the years and have always been encouraged by the positive feedback and support of our patients. All three surgeries have been performing well and have had ‘good’ recent Care Quality Commission ratings. By uniting as one like-minded team we can continue to provide this high quality care in a way that allows us to thrive in the future, making best use of available resources, developing new services and providing seamless care for all of our patients. We will become more resilient, have a larger pool of staff to draw from, and can work towards bringing services from hospital into the community for the convenience of patients.

Our doctors, practice nurses and other staff will continue to be available to patients under the proposed new arrangements in the same way and in the same premises as they are at present.

We understand that you may have questions and comments about the proposal to merge and have answered some of these in a list of FAQs (Frequently Asked Questions)which can be found on all 3 websites: www.nordenhousesurgery.co.uk, www.wingsurgery.co.uk, www.whitchurchsurgery.co.uk

We will also be holding drop-in mornings on the following Saturdays:

5th October Wing, 12th October Norden House, 26th October Whitchurch

If you have any specific queries or concerns please write to Noel Ratcliffe at Norden House Surgery, Avenue Rd, Winslow, Bucks, MK18 3DW , or email [email protected]

Annex 4 13Q Public Duty to Consult

Step 1 - Details of the commissioning activity Describe the commissioning activity: Norden House Surgery, Wing Surgery and Whitchurch Surgery intend to merge. The GMS contracts for Norden House and Whitchurch Surgeries will cease and a contract variation will be issued for 3W Health (formerly Wing Surgery) adding Norden House and Whitchurch as additional sites. Emis will bulk transfer all patients currently registered to one clinical system to 3W Health (formerly the patient database for Wing Surgery). A new contract price will be created by merging the previous GMS contract price for the 3 individual surgeries. Step 2 – Identify type of commissioning activity Type of activity: Planning X Proposals for change Operational decision Step 3 – In respect of proposals for change or operational decisions, assess the impact on service users If the plans, proposals or decisions are implemented, would there be:

• An impact on the manner in which the services are delivered to the individuals at the point when they are received by users? Yes X No

• An impact on the range of health services available to users? Yes X No Explain why you have answered yes or no to the above: As the merged practices intend to continue to offer services from the existing 3 sites there should be no issues for registered patients. The practices have committed to continue to provide continuity of care to all of their patients. Patients would be able to continue to attend at the sites they currently utilise and access the existing services. Step 4 – section 13Q duty Does the section 13Q duty apply to the activity? X Yes No Explain why you have answered yes or no to the above: Change in service provider If yes, (a) identify any existing arrangements to involve the public which are already in place (national or local involvement initiatives): A comprehensive public and patient consultation exercise will be run including meetings with each practices’ PPG and open meetings. FAQs have been produced. Information is available on each practice website and in waiting rooms. Update – the methodology for the public and patient consultation exercise can be seen in the report at Annex 3. (b) whether it is considered necessary to make further arrangements for this activity and if so what these will be:

An action plan for the consultation exercise has been agreed in advance with the CCG’s Primary Care and Communications Teams. No further arrangements are considered necessary. Confirm whether a further assessment needs to be carried out in future and, if so, when or in what circumstances that will be carried out: The CCG recommends that the merged practice asks for feedback from patients and the PPG on the impact of the merger for them in future patient surveys and engagement. Name: Jessica Newman Job Title: Senior Primary Care Manager Date: 26th June 2019

If you are unsure as to the answer to any of these questions, seek advice from the relevant team in your region or the Public Participation Team in the national support

centre: [email protected] or telephone 0113 8250861.

Completed assessment forms must be retained and will be required for reporting and

monitoring purposes.


Equality and Health Inequalities Analysis: Standard Template for NHS England

Norden House Surgery, Wing Surgery and Whitchurch Surgery Application to Merge Equality Impact Assessment

September 2019

Annex 5

Equality Analysis

Title: Proposed Merger of Norden House Surgery, Wing Surgery and Whitchurch Surgery to form 3W Health

What are the intended outcomes of this work? Include outline of objectives and function aims Norden House Surgery, Wing Surgery and Whitchurch Surgery intend to merge. The GMS contracts for Norden House and Whitchurch Surgeries will cease and a contract variation will be issued for 3W Health (formerly Wing Surgery) adding Norden House and Whitchurch as additional sites. Emis will bulk transfer all patients currently registered to one clinical system to 3W Health (formerly the patient database for Wing Surgery).

Please outline which Equality Delivery System (EDS2) Goals/Outcomes this work relates to? See Annex B for EDS2 Goals and Outcomes Better Health Outcomes: 1.1,1.2, 1.3, 1.4,1.5 Improved Patient Access & Experience: 2.1, 2.3 A representative and supported workforce: 3.6

Who will be affected by this work? e.g. staff, patients, service users, partner organisations etc. Patients and staff of Norden House Surgery, Wing Surgery and Whitchurch Surgery.

Evidence What evidence have you considered? List the main sources of data, research and other sources of evidence (including full references) reviewed to determine impact on each equality group (protected characteristic). This can include national research, surveys, reports, research interviews, focus groups, pilot activity evaluations or other Equality Analyses. If there are gaps in evidence, state what you will do to mitigate them in the Evidence based decision making section on page 9 of this template. • Registered list data: geographical and demographic spread of registered patients at all 3

surgeries. • Practice boundaries for the local area. • Evidence to be provided by the surgeries through consultation with patients, local

community and stakeholders.

Age Consider and detail age related evidence. This can include safeguarding, consent and welfare issues. As the merged practice intends to continue to offer services from the existing 3 sites there should be no issues for registered patients. The practices have committed to continue to provide continuity of care to all of their patients. Patients would be able to continue to attend at the site they currently utilise.

Disability Consider and detail disability related evidence. This can include attitudinal, physical and social barriers as well as mental health/ learning disabilities. As the merged practice intends to continue to offer services from the existing 3 sites there should be no issues for registered patients. The practices have committed to continue to provide continuity of care to all of their patients. Patients would be able to continue to attend at the site they currently utilise.

Gender reassignment (including transgender) Consider and detail evidence on transgender people. This can include issues such as privacy of data and harassment. No specific impact.

Marriage and civil partnership Consider and detail evidence on marriage and civil partnership. This can include working arrangements, part-time working, caring responsibilities. No specific impact.

Pregnancy and maternity Consider and detail evidence on pregnancy and maternity. This can include working arrangements, part-time working, caring responsibilities. As the merged practice intends to continue to offer services from the existing 3 sites there should be no issues for registered patients. The practices have committed to continue to provide continuity of care to all of their patients. Patients would be able to continue to attend at the site they currently utilise.

Race Consider and detail race related evidence. This can include information on difference ethnic groups, Roma gypsies, Irish travellers, nationalities, cultures, and language barriers. No specific impact.

Religion or belief Consider and detail evidence on people with different religions, beliefs or no belief. This can include consent and end of life issues. No specific impact.

Sex Consider and detail evidence on men and women. This could include access to services and employment. No specific impact.

Sexual orientation Consider and detail evidence on heterosexual people as well as lesbian, gay and bisexual people. This could include access to services and employment, attitudinal and social barriers. No specific impact.

Carers Consider and detail evidence on part-time working, shift-patterns, general caring responsibilities. As the merged practice intends to continue to offer services from the existing 3 sites there should be no issues for registered patients. The practices have committed to continue to provide continuity of care to all of their patients. Patients (and their carers) would be able to continue to attend at the site they currently utilise.

Other identified groups Consider and detail evidence on groups experiencing disadvantage and barriers to access and outcomes. This can include different socio-economic groups, geographical area inequality, income, resident status (migrants, asylum seekers). No specific impact. Engagement and involvement

How have you engaged stakeholders with an interest in protected characteristics in gathering evidence or testing the evidence available? In line with the NHS England SOP all 3 surgeries have consulted widely on their proposal. The practices have run a robust 12 week consultation for patients, including patients and stakeholders and the results have been included with their application to the CCG. This EIA has been drawn up in light of comments received as part of the consultation.

How have you engaged stakeholders in testing the policy or programme proposals? N/A operational change.

For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs: The details of the consultation are outlined in the application to merge. This EIA has been drawn up in light of comments received as part of the consultation. Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impacts, if so state whether adverse or positive and for which groups and/or individuals. How you will mitigate any negative impacts? How you will include certain protected groups in services or expand their participation in public life? The impact of the merger would have minimal impact on patients. Services will continue to operate from the existing sites and the practices have committed to ensure a continuity of care for their patients. Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups.

Eliminate discrimination, harassment and victimisation

Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sexual orientation). No impact.

Advance equality of opportunity Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sexual orientation). No impact.

Promote good relations between groups Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sexual orientation). No impact. Evidence based decision-making

Please give an outline of what you are going to do, based on the gaps, challenges and opportunities you have identified in the summary of analysis section. This might include action(s) to eliminate discrimination issues, partnership working with stakeholders and data gaps that need to be addressed through further consultation or research. The 12 week consultation on the proposed merger of Norden House Surgery, Wing Surgery and Whitchurch Surgery has completed. The EIA has been drawn up in light of the results of the consultation.

How will you share the findings of the Equality analysis? This can include corporate governance, other directorates, partner organisations and the public. Updated Equality Analysis included in the decision-making paper submitted to the Primary Care Commissioning Committee on 5th December 2019. Health Inequalities Analysis

Evidence 1. What evidence have you considered to determine what health inequalities exist in relation to your work? List the main sources of data, research and other sources of evidence (including full references) reviewed to determine impact on each equality group (protected characteristic). This can include national research, surveys, reports, research interviews, focus groups, pilot activity evaluations or other Equality Analyses. If there are gaps in evidence, state what you will do to mitigate them in the Evidence based decision making section on the last page of this template. • What health inequalities currently exist with regard to the health issue that your

policy/procedure aims to address? N/A operational change.

• What factors have created, maintained or increased health inequalities in access to, and outcomes from healthcare services? No impact

• Who will be affected by your work and what are the demographics of the population

affected? No impact

• How is the health issue that your work is aiming to address distributed across different population groups and across different geographical locations? N/A operational change.

Impact 2. What is the potential impact of your work on health inequalities? Can you demonstrate through evidenced based consideration how the health outcomes, experience and access to health care services differ across the population group and in different geographical locations that your work applies to? • How will your work affect health inequalities?

No impact

• Can you demonstrate through evidenced based consideration how the health outcomes, experience and access to health care services differ across the population group and in different geographical locations that your work applies to? N/A operational change.

• Will the work address need across the social gradient or focus on specific groups?

N/A operational change. • Will the policy/procedure have an unintended differential impact on different

population groups and across different geographical locations? N/A operational change.

• Would providing services in an integrated way reduce health inequalities?

N/A operational change. 3. How can you make sure that your work has the best chance of reducing health inequalities? • What can you do to make it more likely that the work reduces health inequalities?

N/A no increased health equalities • What have you done to mitigate against any failure to reduce health inequalities?

N/A no increased health equalities • Are there any dependencies or interdependencies that may impact on the work’s ability

to address health inequalities? For example, are delivery partners sufficiently engaged in addressing health inequalities? Are there any resource implications that may affect the delivery?

N/A no increased health equalities • Will the work be equitably delivered to all population groups, with a scale and intensity

proportionate to the level of disadvantage? N/A operational change.

Monitor and Evaluation 4. How will you monitor and evaluate the effect of your work on health inequalities? • How will you know whether your work has an impact on reducing health inequalities?

The CCG will ask the newly merged practice to monitor and report any impact the merger has had (if the merger is agreed).

• Have you captured the evidence and recorded how the need to reduce health inequalities has been taken into account in the development of this work? Part of practice application.

• Are there any gaps in the evidence that need to be addressed through further

consultation or research? No.

• What will you do based on the gaps, challenges and opportunities you have identified in

the evidence? N/A

• Can you produce both whilst developing this work and at the end of the work, for

assurance and risk mitigation, accessible records of all decisions and the decision making processes? Yes.

For your records Name of person(s) who carried out these analyses: Jessica Newman, Senior Primary Care Manager, Bucks CCG

Name of Sponsor Director: Louise Smith, Interim Director Primary Care and Transformation, Bucks CCG

Date analyses were completed: November 2019

Review date: October 2020 (6 months after the proposed merger date)

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MEETING: Primary Care Commissioning Committee AGENDA ITEM: H DATE: Thursday 5th December 2019 TITLE: Complex Care Management AUTHOR: Louise Smith, Interim Director Primary Care and Transformation LEAD DIRECTOR: Robert Majilton, Deputy Chief Officer LINK TO RISKS: Governing

Body Assurance Framework

No direct link to risks

Corporate Risk Register

No direct link to risks

Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information For Ratification Summary of Purpose and Scope of Report: In October 2019 following a request from the CCG Executive Committee a paper was taken to Executive Committee which provided an evaluation of the current complex care services previously known as the ‘over 75s’. The paper included: 1) a clear description of each of the services and the mapping of key components against the ambition for a new community model of care and the anticipated PCN DES requirements. 2) a clear methodology for reviewing these services in the form of a logic model which incorporates both quantitative and qualitative factors. 3) a clear recommendation for the CCG to map the complex care services to the PCN DES contracts as they evolve in order to understand the gaps, and agree transitional arrangements as appropriate to ensure service continuity. The Executive Committee was asked to NOTE the main benefits of the services, which have been:

• The impact on A&E activity which whilst still seen to continue to rise is at a statistically significant slower rate to the rest of the CCG.

• Impact on GP time with fewer consultations as a consequence of the interventions. • Improved general staff satisfaction and resilience in primary care. • Fewer consultations in less acute environments for patients and a positive effect on

satisfaction. The Executive Committee agreed that the mapping of the services against the PCN DES contracts should take place (point 3 above) and this was delegated to the Interim Director Primary Care and Transformation and the Chief Finance Officer. As this relates to the

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commissioning of primary care, the CCG Executive Committee requested that PCCC was given an early indication of the work, and any further progress made since the meeting. The paper that went to Executive Committee is attached for the Primary Care Commissioning Committee’s information. In terms of progress very little has been made due to the absence of detail from NHS England on the Anticipatory Care DES. A further meeting is planned in December with providers to look at the data and how the mapping exercise is progressed. The PCCC is asked to note the following:

1. the content of the paper which was submitted to CCG Executive 2. that relevant practices will continue to receive payments for delivery of the existing

range of services during the subsequent transition period (length to be confirmed dependent upon mapping and subsequent gaps in provision identified)

3. That any subsequent decision to commission (to add value) where there are any gaps identified between current provision and those mapped to the PCN DES (and DES plus opportunity) will be appropriately escalated to Primary Care Commissioning Committee (and Governing Body if required). This will further mitigate conflicts of interest where member GPs as practice partners or shareholders in Federation companies, could apply to deliver such services.

Authority to make a decision – process and/or commissioning (if relevant) N/A – no commissioning decision required – Paper for information only. Conflicts of Interest: (please tick accordingly) No conflict identified Conflict noted, conflicted party can participate in discussion and decision (see below) Conflict noted, conflicted party can participate in discussion but not decision (see below) Conflict noted, conflicted party can remain but not participate in discussion (see below) Conflicted party is excluded from discussion (see below) Governance assurance (see below) CCG Primary Care Commissioning Committee standing invitees, where member GPs and practice partners, are directly and materially conflicted where having a pecuniary interest as both providers of existing services and as members of Primary Care Networks contracted to deliver services through the DES. The following members are directly and materially conflicted: • Dr Raj Bajwa • Dr Rebecca Mallard- Smith • Dr Karen West • Dr Rashmi Sawney Mitigating Action: None The Anticipatory Care DES (including any relevant financial information) has not been withheld from circulation to conflicted standing invitees as it will be nationally published following purdah.

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Any subsequent commissioning decision and further discussion/papers to address gaps in provision though the DES/DES plus (following the mapping exercise) will be taken by the Primary Care Commissioning Committee. The CCG Executive Committee was previously asked on 24 October 2019 to note a planned mapping exercise between existing service provision and nationally published anticipatory care DES. The Executive Committee was also asked to delegate authority to the Interim Director of Primary Care and Transformation and Chief Finance Officer to undertake the required mapping exercise between existing specifications and PCN DES. This was given its direct and material conflict of interest where member GPs are formal voting members rather than standing invitees. Implications for any CCG commissioning decision involving funding, investments, budgets and workload implications

The Chief Finance Officer, as a voting member of the CCG Primary Care Commissioning Committee, Executive Committee and CCG Governing Body, is also directly conflicted where a commissioning decision involves investment of funding, and/or may affect income/expenditure for the CCG, and/or may affect the workload for themselves and/or other members of CCG staff. This is given the purpose of this role to ensure both financial and staff capacity sustainability for the organisation through management of budgets, income/expenditure and staffing resource. The same principle may be deemed to apply to the Accountable Officer, Deputy Accountable Officer or any other management director with responsibility for a budget agreed by the CCG Governing Body against which commissioning decisions are committed. This conflict is equally applicable to any decision that involves a formal external procurement followed by contract award or adoption of a policy that affects CCG income and expenditure. However, if this were to be deemed material to decisions, the CCG would be unable to take any commissioning decision, given the Chief Finance Officer and Accountable Officer roles are statutory appointments. They also form a core part of quorum to take commissioning decisions through both CCG Governing Body and CCG Executive Committee. Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all






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Equality/Equity Quality Privacy Financial The £618k of the service is in current baseline Risks Statutory/Legal Prior consideration Committees /Forums/Groups

CCG Executive Committee.


Members of CCG Primary Care Commissioning Committee, allowing for direct and material conflicts of interest as described above

Supporting Papers: -The Future of Complex Care Management – paper - Complex Care graphs - Complex Care evaluation logic model

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The Future of Complex Care Management

1. Introduction and Context

In May of this year as a consequence of the inequity across the county in service provision of the original ‘over 75’ services (now referred to as Complex Care Management) and the financial position of the Buckinghamshire system, a review was requested. Two outcomes were anticipated, a review of current service provision and secondly a recommendation on future funding.

The NHS landscape has changed significantly since the inception of these services. The long-term plan supports the proactive management of those with complex comorbidities. PCNs are now established and the population health data emphasises the significance of supporting those with complex care needs.

2. Evaluation of Current Complex Care Provision

A review group was established consisting of CCG commissioners, finance, contracting and clinicians with involvement of the service providers. The aim of the group was to

1) Establish a clear description of current service provision

2) Establish a methodology for reviewing these by creating an evaluation logic model with both quantitative and qualitative information to reflect patient and staff experience as well as value for money given the total spend of £618k.

3) Make a recommendation to the CCG Executive.

2.1 Description of Current Service Provision

A summary of each of the services is provided in brief below.

Name & Constituent practices

Core service provision & case load

Patient Group Cost Weighted Population

Staff Compliment

AV Central 1 Meadowcroft Mandeville Whitehill (working as separate practices)

Nurse led complex care assessment and management

Complex care Reactive & proactive No defined case load

£100k 40,434 Nurse 0.8 WTE Nurse 0.6 WTE

AV Central 2 Poplar Grove, Berryfields & Oakfield

Integrated team approach to complex care assessment and management

Complex care - Reactive & proactive requirement No defined case load

£160k 33,450 Band 7 Nurse 0.9 WTE Band 5 Nurse 0.8WTE Band 6 CPN 0.4 WTE Band 4 HCA 1 WTE Band 3 HCA 1 WTE

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AV Central 3 Westongrove


Frail, vulnerable & comorbid complex care 80 active patients

£152K 29,601 Nurse 1WTE Care coordinator 1WTE 2xParamedics 0.8WTE in total 2 x HCA 0.8WTE in total

AV North Norden House, Swan, Wing, Whitchurch, Ashcroft, Edelborough & Waddesdon

Social prescribing - non-medical patient support service & MDT coordination

Frail & vulnerable Active Caseload 88, Av. 8 referrals/wk

£92k 65,629 127.5 hours per week (6 part-time none qualified workers) 1x Befriending Co-ordinator 0.6 WTE 4 x Care Co-ordinators 2.8 WTE

AV South Unity, Haddenham, Cross Keys, Waddesdon


Complex care - Reactive & proactive Case load 64 for single team member

£114k

52,345 GP leadership Admin Band 6 Nurse 1 WTE Social Worker 1 WTE

It is evident that not all services are equally funded or have developed uniformly. It is also evident that the population group which they serve is not the over 75s but those with complex care needs regardless of age.

2.2 Achievement of the original ‘over 75’ objectives

The original expectations of the over 75s pilots are shown in appendix A. The Review Group agreed to assess data captured over the last 5 years against these criteria. There have been a number of challenges to evaluating against these not least because the services no longer provide the service that they were originally set out to. In addition much of the research point to the challenges of evaluating integrated models of care which is what these models did set out to achieve and which have started to become, seen from the service information supplied above. The challenges relevant to these Buckinghamshire models include

• System and practice boundaries • Changes in groupings of practices • Inability to cross reference practice and acute patient identifiable data to track patients • Inability to relate any improvement solely to the service • Changes to acute data coding • Finding a comparison with no over 75 service / intervention as other integration initiatives

started to occur over time in different areas • Difficulty in identifying the total system impact for example in the area in which there was a

social worker what was the impact on social care referrals

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As a consequence the review group developed a logic model for the evaluation (appendix B) based on the quadruple aim which is to

• Improve population health outcomes • Improve patient experience • Improve service provider satisfaction • Resource utilisation

The logic model represents the evaluation criteria which would most suitably apply to the model now and would be used in any further evaluation of integrated services or community model of care in the future. Where relevant data was available the group agreed to use this and also the three core objectives of the original specification. The following was possible.

Measure Data Source Summary Original complex care management expectations Reduction in A&E Attendances

Quantitative SPC – Monthly SUS Q1 14/15 – Q1 19/20

All sites showed A&E activity is increasing at a slower rate than the rest of the CCG (in the majority of sites this was statistically significant, and particularly in AVC2 (Graph A)

Reduction in Non-Elective stay

Quantitative SPC – Monthly SUS Q1 14/15 – Q1 19/20

All sites showed inpatient Activity Rate is increasing at a slower rate than the rest of the CCG.

Improve population health outcomes Optimised length of stay Quantitative SPC –

Monthly SUS Q1 14/15 – Q1 19/20

AVS was the only site to take a focussed proactive approach to acute discharge – from Q1 16/17 we see a statistically relevant reduction in excess bed days (Graph B)

Reduction in readmissions Quantitative SPC – Quarterly SUS Q1 14/15 – Q1 19/20

Change of database – current data had to be written off and is being reviewed

Improve patient experience Reduced patient contact Quantitative (EMIS)

GP interactions pre and post service intervention

All sites who ran the EMIS search saw a net reduction in GP interaction Central 1 – 50% Central 2 - 41% Central 3 - 44% AV North – 19%

Improvement in patient satisfaction

Qualitative - Patient stories

Multiple patient/carer stories / letters from each site all positive.

Identification of gaps in commissioned services

Qualitative - Service summary

Step up beds for those requiring services over the current double handed four times per day domiciliary care commissioned by BCC. Social care capacity Social prescribing & signposting Complex care nursing

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Care coordination Multidisciplinary professional skills

Improve service provider satisfaction Staff working to the top of their licence in a collaborative way within a team. There are appropriate consultation times and hours in the working day. Staff feel valued and empowered

Qualitative – Staff feedback

Positive feedback received from across general practice from many different professional groups.

Resource utilisation Quicker discharge Quantitative SPC –

Quarterly SUS Q1 14/15 – Q1 19/20

AVS was the only site to take a focussed proactive approach to acute discharge – from Q1 16/17 we see a statistically relevant reduction in excess bed days (graph B)

Reduction in admissions for social / non acute care needs

Urgent care team analysis of step up bed costs verses A&E admission

AVC3 only – 13 patients in the year May 18 – April 19 had step up beds at a cost of £34,713.55 versus £112,650.00 in the acute trust. This includes two significant outliers and although step up beds were demonstrated to have prevented acute admission further analysis and consideration would need to be made of system value and criteria for use if this was to be systematically commissioned.

3 Service alignment with the LTP

The core components of the services are listed below. Although not all models have all of these it is evident that they are the elements that the ICP would require in a community model of care which responds to the long term plan and PCN requirements based on differing geographies, services and population health needs.

Patient at the heart of care

• Proactive holistic approach to care • Continuity of care through single team and coordination • Social issues are often are a big element of care and non-medicalised patient care is given

where possible e.g. to reduce social isolation

Team approach

• Contribute to MDT meetings • Work with duty team • Coordination role with other professionals • Multidisciplinary professionals working at the top of their licence • Cover available during leave

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Focus on population health needs

• The services are targeted at two cohorts of patients those with complex care needs and those with social isolation in which services can potentially make the greatest impact

• Patients triaged based on need • Chronic care housebound patients are not excluded

Interoperability

• Use of single clinical system – EMIS clinical services • Access to social care system

Services directly provided • Comprehensive geriatric assessment • Care Planning • CHC assessments • Medicines reconciliation • Clinical monitoring • Social prescribing – care coordination navigation and support • Social care assessment and intervention

Access to appropriate care and services

• Referrals from practice, family & patients • Onward referral to other services as appropriate • Patient can access nurse if subsequently unwell • Access to step up beds • Access to onward specialist care • Support dementia care and early diagnosis • Referral to CCCT, and the independent care sector including facilitating nursing home

admission for urgent respite care

Works with the wider health and care system

• Prevent admission • Automatic alert from acute trust on admission allows for proactive discharge planning

involving primary input • Follow up of complex patients following hospital discharge • Joint assessments with mental health team • Cross boundary working where services are provided differently

There are just a few elements identified that would not be replicated in a future model of integrated community care including:

• Lone practitioners • Absence of an administrative support function • Absence of PHM data in identifying and targeting care

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Mapping of the services against the PCN DES

Service Component

AVC1 AVC2 AVC3 AVN AVS Comments

PCN DES Workforce roles Pharmacist X X Already paid for

through 19/20 DES Social Prescriber X X Already paid for

through 19/20 DES Other Healthcare Professionals

X X Not yet funded in DES - Paramedics / Social workers

Anticipatory Care DES PCN led delivery X X X X X Includes community providers & VCS

X X X

Agreement on delivery model

X X X X

Understand population health data

X X X X X Note in bucks we know that our target cohort is not frailty but comorbidity

Identify population X X X X X Build a register Specify outcomes Logic model Manage care needs - Nurse led complex care management

X X X X AVN starting to bring in BHT complex care manager

Manage care needs- Social care

X Social care is absent except for the secondment site

Manage care needs – social prescribing & isolation

X All sites will now build this with their social prescriber

Offer interventions to reduce risk

X X X X X

Provide care closer to home

X X X X X

Frailty /care co-ordinator

X Duel role of the social prescriber

Service aims Sustain health X X X X X Maintain independence

X X X X X

Reduce reactive healthcare

X X X X X

Increase integration

X X X X X

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Increase support to patients

X X X X X

4 Findings and recommendations

4.1 Finding

The complex care management services have allowed local teams to implement an alternative model of care provision based on the health needs of their population. Incremental changes over time have meant that they have reached a point at which they no longer reflect the original ambition of the service but have none the less added value and influenced elements of the care model that community services should now aspire to. The ‘piloting’ of this service has however been allowed to continue and has evolved ahead of the LTP resulting in short-term extensions.

Recommendation

Piloting a service or proof of concept has its place in healthcare particularly where teams want to innovate and deliver new models of care provision. The CCG or ICP should not seek to stifle this but should be clear on time scales, clear evaluation criteria and exit or roll out strategy depending on outcome. PDSA cycles should be considered where small changes can be incrementally added to the model and the effect can be tracked. The ICP change management documentation currently being drafted as a guide for the Buckinghamshire system must be clear on the expectations of change being introduced to reflect this. This must be considered in the light of new developments in services including BHT ward closure, CAT / Hubs and high intensity user services.

4.2 Finding

Each site chose to provide care in its own way including different professionals, processes and referral criteria etc. This by its very nature introduces differences in care and confusion for other service providers that cover the county.

Recommendation

In commissioning the new model of community based care consideration must be made of the need to provide universal access to services whilst being responsive to population health needs. Commissioners will need to develop a clear framework on which to do so.

4.3 Finding

One of the greatest areas of impact of these services was on GP time and the work load in general practice as demonstrated by the time released and staff satisfaction. As a key strand of our evaluation logic model this emphasises the positive impact on primary care.

Recommendation

As an ICP we need to recognise the value of improved resilience and staff satisfaction in general practice, and this should be built into any future model of community care and incorporated in our planning.

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4.4 Finding

Standalone or services that run on a single individual are not robust or resilient and can cause gaps in care provision and continuity of service. The added value has come from differing and complementary skill sets of the professionals working in a team based approach. Where services are dependent on core individuals any form of leave, retirement or notice can have significant consequences, destabilising the model. Where individuals have strayed too far from their professional group or originating organisation that usually provides such services then the full impact of that skill set, contacts and access to additional services is lost.

Recommendation

In commissioning and constructing the model of community care provision for the future we must maximise the links with key providers that have the required skill sets, contacts, tools and access to services and not seek to in-house everyone at PCN level without strategies to manage how this will work.

4.5 Finding

Although set out at the start evaluation of these services has been persistently difficult due to changing expectations and potential impact on the system not just primary care.

Recommendation

Set out the evaluation criteria at the start using a clear model which reflects the expectations of commissioners and providers and which meets the quadruple aim.

4.6 Finding

The services have been mapped against the PCN and anticipatory care DES. No single model of care provision has all the components of an integrated community model of care. Many of the core components of the services have been implemented as a consequence of the lack of services commissioned from, capacity in, or integration with the existing service providers e.g. step up beds, social prescribers, complex care nurses, mental health capacity, paramedic skills and social workers working at practice level. Many of these will now be prescribed in the new PCN DES contract including additional workforce roles, complex care management and an integrated team.

Recommendation

The elements identified in the services that have been found to add value and are in the community model of care as defined by the ICP must be commissioned. How this would be done and the financial scope to do so is for commissioners to decide. Where service components are mapped against the new PCN DES contract and have direct correlation then services will be commissioned through this route. Where there are gaps consideration must be made for transitional arrangements. No current model has a care coordinator yet this is a vital component and it is not clear if this is included in the PCN funding.

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4.7 Finding

In having a budget and being given the opportunity to work on a project across a defined number of practices with different provider organisations and professional groups the sites that have embraced all of these components have been enabled to take ownership of care provision collectively and deliver on new care models quicker than sites that have not. AV North and AV Central now have MDTs up and running whilst Southern area that was a BIT pilot but no project / service focus or additional funding have not progressed as far.

Recommendation

The recommendation above is honoured and all pilot sites are right sized through alignment with the PCN DES contracts as per the mapping table in this document. In order for sites that have not had the opportunity to progress in this way given that they now have the opportunity to do so with the implementation of the PCN contract that they are given access to the funding pot throughout 20/21 to accelerate delivery. Commissioners and PCNs should explore the shared appetite to give PCNs their integrated community care budgets.

4.8 Finding

In implementing their local models of complex care management leaders have emerged who are knowledgeable in how services could be configured and implemented to ensure maximum benefit to the patient and system.

Recommendation

This expertise and leadership should not be lost and utilised to provide expert support in the design of the system model of community integrated care and to support Buckinghamshire PCNs implementing similar components of care.

5 Equitable Investment

Population health data tells us that there are 15 wards with significant deprivation in which spend could be targeted to address health inequalities. This could be achieved through various different schemes using short term funding and replicating the issues that have arisen with the complex care funding. It is therefore proposed that by systematically facilitating aspects of the described community / complex care model which has population health at its heart it would improve health outcomes in those that would benefit, thereby reducing equality. To quote

'Those covered by national health insurance schemes in various countries (NHS in UK, Medicare in Australia, etc) have access to health services more or less equally once they are in the system, regardless of gender, ethnicity, creed or religion. However the ability to benefit from these services is subject to individual autonomous decision making, socio-economic circumstances, social network; to ensure health equity, extra resources (including affirmative action) are needed to assist those perceived to be disadvantaged to make use of the same service provided by the health scheme. '

https://www.bmj.com/content/356/bmj.j556/rr-8

https://www.bmj.com/content/356/bmj.j556/rr-8

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The focus therefore needs to be on facilitating delivery of the community model within each PCN and not just about inequity between PCNs. It is therefore proposed that after mapping of services against the PCN DES arrangements and the community model of care, any remaining funding is used to facilitate PCNs who have not had access to similar opportunities to use to support delivery of the community model of care at PCN level.

6 Commissioning Options

The CCG has three options for the future commissioning of these services

1) Discontinue provision from April 20 2) Map the services to the PCN DES contracts as they evolve, understanding the gaps, and

agree transitional arrangements as appropriate to ensure service continuity. 3) Continue to fund the model as it presently stands

Option 1 is not considered to be appropriate. These services are expected to be reflected in the PCN DES contracts. As such to stop their provision at this time would be counterintuitive and disruptive given the national expectation to provide over the coming years. It would serve no purpose other than to relinquish what is comparatively a relatively small sum. In addition to the risk around halting our progress as an ICP including MDT development, the following would need to be managed

• Diminished quality of patient care with a negative social, mental and physical impact • Increase in non-elective activity – The service has been shown to free up GP time which

could support access as well as directly reduce non elective care significantly in some sites. • Increase in MK non elective activity – the service in the North of the county has worked to

target patients particularly on the border of the county. • Cost risk of redundancy to each practice / PCN

With the introduction of the PCN DES arrangements option 3, to continue to fund the model as it presently stands, would represent duplication of funding. Given the overlap demonstrated between the services and the expected content of the DES which is open to all, to continue to pay for this service in its present form would not be responsible commissioning.

Option 2 is the recommendation to CCG executives. This allows the models to continue and transition over time to be funded through the PCN DES arrangements. Whilst there may be gaps these are expected to be minimal and the flexibilities in the contract will allow for flexing of the model at the PCNs discretion. The transition may require short-term funding of elements that cannot be covered or are considered vital for all PCN delivery and could be provided to all PCNs not just those sites described in this paper. Any underspend could be utilised to support PCNs not as advanced in their delivery of complex care management.

7 Next Steps

If option 2 is agreed there would be a requirement for the following next steps

• Further analysis of the data to understand the contribution of the model components to inform our future commissioning arrangements

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• Public health involvement to understand the value of the services for particular patient cohorts

• Full mapping of services against the PCN DES as the detail emerges • Development of a framework for integrated community commissioning

8 Conclusion

The Complex Care review group has completed its evaluation of the current services and believes that the three aims originally agreed have been delivered.

1) There is a clear description of each of the services and these components have been mapped against the ambition for a new community model of care and the anticipated PCN DES requirements.

2) A clear methodology for reviewing these services has been developed in the form of a logic model which incorporates both quantitative and qualitative factors. It is recognised that whilst not all of the indicators are collectable and measurable for the services at present, the model can be used in the future to evaluate community integrated services. From the evaluation we have concluded that the main benefits have been

• the impact on A&E activity which is still seen to continue to rise but at a statistically significantly slower rate to the rest of the CCG.

• impact on GP time with fewer consultations as a consequence of the interventions • improvement of general staff satisfaction and resilience in primary care • fewer consultations in less acute environments for the patients and a positive effect on

satisfaction.

3) A clear recommendation has been outlined for the CCG executive taking into consideration service evaluation, the future of integrated community provision (reflecting LTP and PCN requirements) as well as the financial position of the system. This recommendation is to map the services to the PCN DES contracts as they evolve in order to understand the gaps, and agree transitional arrangements as appropriate to ensure service continuity. Any 20/21 funding which remains can be utilised to pump prime support to PCNs not as advanced in their care delivery.

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Appendix A - Original expectations of the over 75s pilot

Following the NHS England planning guidance all over 75 services were originally expected to invest in

• Community services to secure integration with primary care provision • New general practice services that go beyond the GP contract and the new enhanced

service

In order to

• Increase quality of care • Transform the care of the over 75s • Demonstrate integration and be complementary to initiatives through the Better Care

Fund • provide additional services • Support the accountable GP to deliver • Demonstrate how it will be possible to maintain and potentially increase this

investment on a recurrent basis, if the initiative successfully reduces emergency admissions

• Demonstrate patient involvement in designing the service • Demonstrate how equality and diversity has been included in designing the services

Core objectives expected to be monitored by the CCG were

• 3.5% reduction in A&E admissions • 3.5% reduction in A&E attendances • Improvement in patient experience

Measurable objective outcomes by the service could include

• Increase % population reviewed with personalised healthcare plans • Increase % patients recorded with an advanced care plan/DANCPR • Increase number of planned deaths occurring at place of choice • Reduce % avoidable admissions • Reduce % attendance at a/e • Reduce ambulance call outs • Reduce GP attendances

Measurable subjective outcomes were

• Improved satisfaction ratings by patients/families/carers

Key: In order to achieve this aim.. We need to ensure... Which requires... Ideas to ensure this happens

Measurable now Measurable in the future

To robustly evaluate the model of complex care

management in the community to demonstrate improved system outcomes

Improved population health outcomes including a reduction

in health inequalities

Improved patient experience

Improved service provider satisfaction

Resource Utilisation

Reduction in early deaths linked to patients with 2 or more common LTCs

Increased proportion of identified patients receiving proactive care/early intervention

Patient/carer reported improvement in health & wellbeing leading to resilience

and capacity to be independent

Reported improvement in patient/carer centred care - tell my story once

Access to responsive services

Staff satisfaction with the role

Appropriate use of clinical team skills & expertise

Evidencing the Right service, in the Right place for the Right patient

Consistent, equitable and affordable core service model

Improved system partnership working

Reduction in health inequalities across our most deprived wards

Reduction in unplanned hospital admissions for ACS & UCS Conditions

Optimised length of stay

Increased proportion of advanced care plans in the target cohort

Improvement in QALYs

Improvement in patient activation measure (PAM)

Reduction in readmissions

Increased sign posting

Identification of gaps in commissioned services

Reduced patient contacts

Staff work to the top of their licence in a collaborative way within a team. There are appropriate consultation times and hours in the

working day. Staff feel valued and empowered Staff Survey

Reduction in admissions for social / non acute care needs Step up bed utilisation

Quicker discharge - LOS

Improved access to services including MH, dementia services & social care

Reduction in emergency admissions for acute conditions that should not usually require admission

Reduction in unplanned admissions for chronic ACS conditions

Improvement in patient satisfaction / patient stories

Increase in case finding & stabilisation of LTC

Reduction in polypharmacy

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MEETING: Primary Care Commissioning Committee PAPER: J


TITLE: Locally Commissioned Services for 2020/21

AUTHOR: Simon Kearey, Head of Locality Delivery


Reason for presenting this paper: For Action For Approval For Discussion For Assurance For Information Summary of Purpose and Scope of Report:

Buckinghamshire CCG commissions nine Locally Commissioned Services (LCS) on an annual basis from Primary Care (currently directly from individual practices) and the annual budget for these services is £1.813m. This paper reports on work to-date to establish recommendations for future commissioning of services currently commissioned via the LCS scheme and proposes recommendations for future commissioning of these services in the light of input from across the ICS and key stakeholders.

Recommendations • The Primary Care Commissioning Committee is requested to review work

undertaken to date • PCCC is requested to approve the recommendations included in this final report.

Conflicts of Interest: Member GPs where partners in member GP practices would ultimately benefit financially from Locally Commissioned Services (LCS). However they are not formal voting members and therefore do not form part of quorum required to make decisions under delegated authority from the Governing Body.

Member GPs are free to remain in the meeting of the Primary Care Operations Group, and may participate in discussion on the clinical elements of the schemes described at the discretion of the Chair, who as a lay member is not conflicted.

No additional financial information has had to be withheld from conflicted standing invitees, given the decision required relates to the overall funding envelope and not funding related to individual specifications.

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Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all






N/A

Equality N/A

Quality

LCS support practices to deliver high quality services.

Financial

Conflicts of interest with GP and LMC members of PCCC and the Task and Finish Group – not part of decision making arrangements.

Risks

Risks associated in delivering this scheme are not covered by this paper.

Statutory/Legal N/A


A Clinical Task and Finish Group has been formed to considered the development of recommendations included in this report.


Through GPs and LMC representatives who are members of the Task and Finish Group.

Supporting Papers: Locally Commissioned Services for 2020/21.

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Locally Commissioned Services for 2020/21 Primary Care Commissioning Committee

5th December 2019 Background Buckinghamshire CCG commissions nine Locally Commissioned Services (LCS), listed below on an annual basis from Primary Care (currently directly from individual practices) and the annual budget for these services is £1.813m1. Service H-Pylori testing Near Patient Testing Suture Removal Venous & Mixed Aetiology Leg Ulcer Phlebotomy Insulin Initiation Care Home Medical Services Depot Antipsychotics specifications Physical Health Checks for People living with Serious Mental Illness (SMI)

In addition to these services there are other areas of primary care provision which are not contracted for which either have been raised as areas where commissioning of primary care could take place or already does in Oxfordshire and Berkshire West CCGs. (Appendix A shows those services which are commissioned across the three CCGs. A Task and Finish Group has been set up to review all these services and put forward recommendations on commissioning intentions for 2020/21. Over half of the services are bundled together for Aylesbury-facing practices and commissioned on a fixed rate basis (based on practice list size and age profile) whereas these services are all commissioned individually on activity from practices in the former Chiltern CCG area. Whilst addressing a cohesive way forward for all practices within Buckinghamshire in the light of the Primary Care Network (PCN) Directed Enhanced Service (DES) being created and delivering services from July 2019, there may also be opportunities for Networks to take on work currently provided within General Practice under locally commissioned services (LCS).

1 In 2019/20 Prophylactic Flu Provision for Care Homes was partially commissioned through general practice and is being reviewed under a separate stream of work for the 2020/2021 year.

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This paper reports on work to-date to establish recommendations for future commissioning of services currently commissioned via the LCS scheme.

Approach The Task and Finish Group was requested to review the current Locally Commissioned Services in light of Primary Care Network development in 2019/20 and the expectation that national service specifications that form part of the Primary Care Network DES and the NHS Long Term Plan will be delivered by PCNs from 2020 onwards. This needs to be undertaken urgently as practices expect notification of the CCG’s LCS plans for 2020/21 no later than March 2020. The Task and Finish Group will therefore propose a plan for commissioning LCS for 2020/21 by March 2020 including transition to the new commissioning arrangements. Principles of Approach The following principles and assumptions for the work and approach have been adopted:

1) Financial envelope needs to be cost neutral to the CCG 2) Patient outcomes are better supported where possible 3) Any recommendations are in line with CCG and the wider ICP/ICS system objectives 4) The recommendations will cover 2020/21 as well as potentially future years and are

in line with the Long Term Plan. Commissioning Options and Approach The Commissioning approach will take into consideration a number of factors including:

1) Payment methodology e.g. a. Fixed amount or based on activity b. Appropriateness to the service c. Ease of administration d. Promotes the appropriate clinical decisions to be made and is not driven by

income.

2) Service Level e.g. a. Network or Practice b. Resources/capabilities c. Equality of provision d. Appropriateness of place of clinical intervention.

The results of the above will also be cross-checked against a number of criteria:

1) What is happening in the rest of the ICS (Oxfordshire and Berkshire West) 2) What impacts, if any, the proposal has on the financial envelope available,

representing best value in terms of finances and resources 3) Any related work in a specific area or future work planned 4) Whether there are any other services which need to be covered by LCS. 5) Whether the model can be applied to all future locally commissioned services

The proposals made will also come with recommendations as to what payment models will be used e.g. practices invoicing for work done, automation of statements etc. as this currently varies across the ICS.

5

Using the above criteria the list of current services provided across the ICS (Appendix A) has been reviewed in terms of the work required to align services across the ICS, recommendations and timing, LCS were divided into the following categories:

1) Similar specifications exist already – resourcing may need to be reviewed 2) Minor work required on the specifications to bring them into line across the ICS 3) Delivery route of service requires further work 4) Local variances exist which result from legitimate conditions already in place 5) Future national and local work will address this area e.g. new DES specifications.

Governance, Accountability and Reporting Arrangements The BCCG Task and Finish Group is providing this report and recommendations to the Primary Care Commissioning Committee (and has been making regular updates to the Primary Care Operational Group). On a wider scale the ICS comparison and recommendations are being taken to individual CCG Operational Groups/Primary Care Commissioning Committees as well as the ICS Primary Care Programme Board. Decision Making and Delegated Authority The Task and Finish Group has no delegated decision making authority due to the conflicts of interest of all GP members. The Group will provide clinical input in both review and recommendations in a non-conflicted forum. Governance The previously documented task and finish group has met on a fortnightly basis and this report reflects their input. The group has included finance, portfolio leads and managers, primary care lead nurses, GPs, LMC and representation from various Primary Care Networks PCNs. Since the start of the project, the intention has been to align the work fully with Berkshire West and Oxfordshire to ensure a consistent approach to LCS across BOB is achieved. Leads in all 3 CCGs have been identified to take this work forward and this report reflects the thinking from all three CCGs. Findings and Recommendations Commissioning Approach In the past all these services have been contracted directly with practices. With the creation of PCNs this offers another option through which commissioning can be undertaken. Commissioning through PCNs has the following advantages: To General Practice

1) Economies of scale 2) Use of and access to clinical expertise 3) More resource efficient services by providing at scale where appropriate

To patients

1) Locally tailored and responsibly managed services 2) Shared use of local expertise 3) Improved access

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To the CCG 1) Reduced number of contracts - it means that the CCG only has 12 contracts across

the county.

Commissioning from PCNs may have the advantage of encouraging the development of services at both the Practice and Network level where advantage can be made of integrated network working to support delivery and use of non-practice resources where there is a lack of expertise or capacity e.g. Mental health community teams in deport neuroleptics. Proposals for “Network” services are:

1) Insulin Initiation 2) Care Home Medical Services (pending release of Care Home DES specification) 3) Depot Antipsychotics

Opportunistic services will be provided at practice level. Services such as health checks, routine testing and expected after-care may be part of “Practice” Services but could in time be provided in any appropriate location by any appropriate individual. In time, when mature enough, PCNs could make the decision themselves which services to provide at practice or PCN level. Fixed Price (Bundle) vs Variable Tariff Since 2017, Aylesbury Practices have been contracted and paid via the “Bundle” approach. With the development of the “Practice” and “Network” service model it is proposed that the whole of the county be brought under one set of commissioning arrangements. An initial tariff approach is therefore proposed for the whole of the County based on activity, moving to needs based and fixed over time. The main reasons for this are:

1) Whilst PCN level management of LCSs over time develops it encourages practices to cover each other in the provision of services and funding can easily follow delivery.

2) It allows for other service providers to gain activity and be paid in the same way as above.

3) All PCNs will receive a quarterly statement by practice providing them with the activity data for those services. These will be validated by the practice/PCN, therefore making payment and management of these services simpler. It will also encourage better coding of activity.

4) It is expected that other services commissioned by Public Health etc. may be commissioned similarly and arrangements will be flexible enough to cover these. This is likely to happen in future years after 2020/21.

5) All three CCGs in BOB will use activity basis for payments of PCNs/Practices for these services.

6) Future developments of associated services nationally and development of pathways during the year can be supported under this approach with a view to moving to a place based aligned outcomes approach over time.

In addition to the above the Task and Finish group spent some time reviewing the current way that blood tests are both performed and paid for. At this time it was felt that the fixed payment to practices via the PCN would continue however, the wording in the contract would be tightened up to ensure that only patients where appropriate, have access to local primary care services for these tests. The CCG is working closely with BHT to ensure that this is supported through flexible timing of blood test transport and access to local community hospital services where required.

7

Alignment of Specifications/Tariffs Across BOB As can be seen from Appendix A – due to past history of service development or existing current alternative arrangements many of the services looked as across the three CCGs will only be consolidated into the one specification with the same tariff following further pathway work in these areas during 2020/21. However there are a number of areas where we can achieve parity in the 2020/21 commissioning round.

1) Physical Health Checks for People living with Serious Mental Illness (SMI) 2) Venous & Mixed Aetiology Leg Ulcer (not covered by Berkshire West) 3) Near Patient Testing (Oxfordshire and Buckinghamshire same drugs list) 4) H-Pylori testing (not commissioned as an LCS by Buckinghamshire in 2020/21).

All these specifications have been reviewed and going forward these CCGs will share the same specifications for all these areas. Delivery of Services Current delivery of services is undertaken by individual practices and this may continue for those services named as “Practice” level. For “Network” level services, whilst individual practices may continue to deliver these services within the PCN, coverage by other practices within the network and other community organisations may be undertaken, should a practice choose not to participate, e.g. Care Home patients may be covered by other practices and/or providers in the PCN (DES specification pending). Payments As service delivery is paid for on an activity basis, this supports the instances where delivery of these services is undertaken by other local practices and so they will receive the appropriate funding for these services. The activity dashboards produced by PCN/Practice during 2019/20 have been reconciled to claims made and the accuracy of recording was found to be of a good standard during that period. This means that as with OCCG, Buckinghamshire will produce quarterly statements from information obtained from the EMIS system and practices will validate this noting any areas where local records are different. Activity and payment statements will be provided to PCNs. There are options for payments however:

1) At PCN level with the PCN then allocating payment based on activity to practices 2) At practice level directly.

The proposal, as discussed and recommended by PCOG on 7th November is that payments are made to PCNs who will then allocate those funds to practices and also be in a position in the future to cover delivery of “Network” services by other practices in the PCN or other community providers in the PCN. This supports the lead provider direction of travel for PCNs as well as bringing payments in line with commissioning. Financial Implications The current financial envelope for commissioning LCS is £1.813m. The forecast for 2019/20 is suggesting that claims will come within this figure based on activity claims to end of Q2.

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In 2019/20 £555k is planned to be spent with Aylesbury practices as part of the bundle of services commissioned. Reviewing the activity supporting these payments – if paid based on an activity basis then these payments would be £39k more in year and this can be accommodated within the set financial envelope. Local and National Context These recommendations align with NHSE recommendations for PCNs as laid out in the PCN Handbook2

“Locally funded services The network may wish to discuss with the CCG the possibility of providing additional services beyond the national specification in return for appropriate funding. Commissioners may choose to transfer, where appropriate, their locally commissioned services contracts to the network, rather than with individual providers.”

Discussions have taken place with Mental Health and Public Health Commissioners where they would positively support this approach and use the model for future commissioning of these services. In time a portfolio of local services will be both commissioned and delivered via this mechanism. The “Network” and “Practice” split of services is being used by other CCGs across the Country to designate what services will be expected to be provided by local GPs and those that are likely to be delivered at a Network level. This both supports Buckinghamshire’s developing “Hub” model as well as align with previous discussions with practices and clinicians. This is echoed in Dorset CCG’s (amongst others) report3 which supports local services being commissioned and delivered through PCNs. It is expected that PCN local commissioning will also support development of integrated local services as well as being used as a mechanism to address health inequalities as laid out in Public Health reports the PCNs are already receiving and on which they will base their local delivery and development priorities. Patient Engagement Patients will be members of the wider PCN Network governance and therefore will be part of any service provision decisions. BCCG will work closely with Healthwatch Bucks to ensure that patient feedback is encouraged and addressed and supports any quality assurance work undertaken for any of the services provided. 2 https://www.bma.org.uk/-/media/files/pdfs/collective%20voice/committees/gpc/gpc%20england/pcn%20handbook.pdf?la=en 3 https://www.dorsetccg.nhs.uk/wp-content/uploads/2019/01/07.2-PC-Update-060219-1.pdf

9

Due Diligence The CCG will continue to provide monthly activity dashboards for each service at Practice and PCN level. These would be monitored against expected delivery and any inequalities of provision discussed with the relevant PCN. Best practice would be regularly discussed and patient feedback would be used to support commissioning decisions. Summary Proposals

1) All services will be contracted through PCNs. 2) Services will be designated “Practice” and “Network” level Services (see appendix B)

but PCNs will have the ability to influence this based on their individual circumstances.

3) All CCGs in BOB will decommission H Pylori from 2020/21. 4) SMI Health Checks (pending agreement by mental health commissioners), Near

Patient Testing and Leg Ulcer Services will have the same specification and payment across BOB.

5) Services will be paid for based on tariff and activity (with the exception of Phlebotomy – to be reviewed).

6) The CCG/CSU will provide quarterly activity statements to be validated by practices/PCNs and used to generate payments.

7) Payments will be made to PCNs for them to allocate to practices. 8) It is expected that other services commissioned at practice/PCN level will follow the

same principles as set out in this paper. 9) Tariffs remain at current levels.

Next Steps and Future Plans Project Milestone Dates Status ToR for task and finish group agreed August Complete Discussions with OCCG as to approach August Complete Discussions with BWCCG as to approach August Complete Map service specifications, activity and costs August/ September Complete Devise detailed project plan including communications

August/ September Complete

Review linked streams of work and identify interdependencies

September Complete

Approach and plan provided to PCCC September Complete Update report to PCOG October Complete Update report to PCOG November Complete Agree financial assumptions and recommendations Mid November Complete Finalised Recommendations to PCCC December Complete Notify Practices of changes to commissioning of LCS in 2020/21

End December On Track

Issue contracts and specifications to Practices/PCNs January On Track ICS Workstream Dates Status Agree ICS approach October Complete

Agree ICS matrix of services End October Complete

Briefing to Primary Care Programme Board 13 November Complete

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Agree LCS framework with other CCGs across the ICS*

Mid November Complete

Agree ICS conclusions and draft recommendations Mid November Complete

Complete ICS recommendations** End November Complete ICS recommendations approved*** January On Track *Agreed recommendations with Oxfordshire CCG and Berkshire West CCG ** OCCG and BWCCG will sign off recommendations in December 2019/January 2020 *** At the BOB Primary Care Transformation Board Mitigation of Risks

• There are risks around clinical engagement due to changes within the CCG – the project will use the Clinical Care Forum to gain greater clinical engagement where necessary. The project will also engage with PCN Accountable Clinical Directors prior to finalising contracts and specifications – mindful of conflicts of interest which will exist.

• Any jointly agreed solutions will need to be reviewed in the light of financial impact on the individual CCGs as well as the system as a whole.

• Positive engagement will be expected from all parties in the project to ensure timescales are met and joint solutions found.

Recommendations

• The Primary Care Commissioning Committee (PCCC) is requested to review work undertaken to-date.

• PCCC is requested to approve the Summary Proposals included within this report.

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Appendix A - LCS provided across BOB ICS KEY TWO OR MORE CCGS USING SAME SPECIFICATION AND TARIFF REVIEW IN 2020/21 NO CHANGE N/A AS SPECIFIC TO CCG DROP SERVICE

In p

lace

in 2

019/

20

Oxfordshire Buckinghamshire Berkshire West Bucks - WAY FORWARD IN 2020/21

Arrhythmia - patients presenting as suspected

24hr ECG or longer cardiac monitoring referrals into Acute

24hr ECG or longer cardiac monitoring referrals into Acute

AREA OF REVIEW IN THE FUTURE

Aural Toilet at request of 2y care - including blood test - aural toilet £15.30

Some GPs provide - rest advise self care or for specific things secondary eg. Move to not offer it but provide advice

Core contract providing have skills - NICE guidance if complex refer into secondary care - on going project to take activity out of secondary care

NO CHANGE

Completion of an Episode of Surgical Care - suture removal, removal of foreign bodies, wound monitoring

Suture Removal

GPs do this under GMS AREA OF REVIEW IN THE FUTURE - CLOSE BUT FURTHER WORK NEEDED

Community Dermatology Services - no long er done N/A N/A N/A

Deprivation - only for 19/20 - overtaken by national spec N/A N/A N/A

SERVICE DELIVERED AS PART OF LCS

12

Dermatology (Cancer monitoring) - patients already diagnosed - set reviews

Melanomas are followed up by Dermatology acute

Melanomas are followed up by Dermatology acute - there is cancer quality improvement money which may change things

AREA OF REVIEW IN THE FUTURE - - TV INITIATIVE

DVT Diagnosis - assessment and treatment GP tend to do what they can - GP tend to do what they can -

AREA OF REVIEW IN THE FUTURE - basket of community provision going forward

Leg Ulcer Care & Management Venous & Mixed Aetiology Leg Ulcer

GP nurses deliver the service - no separate payments - activity ends up in walk in centre - looking at leg ulcer care

BCCG/OCCG CONSOLIDATE

LTC Insulin Initiation, Monitoring and Re-stabilisation Insulin conversion provided

AREA OF REVIEW IN THE FUTURE - basket of community provision going forward

Minor Injuries - lacerations including suturing

REVIEW - CLOSE BUT FURTHER WORK NEEDED

Near Patient Testing Near Patient Testing DMARD and Denosumab BCCG/OCCG CONSOLIDATE

Newborn Checks COVERED BY ACUTE – Birth Centres/Midwives

First clinical Examination of Newborn Homebirths

NO CHANGE

Phlebotomy at request of 2y care - see spec above Phlebotomy Phlebotomy Service in Primary

Care

AREA OF REVIEW IN THE FUTURE - CLOSE BUT FURTHER WORK NEEDED

Phlebotomy home visits ACHT DO THIS - SHOULD SIT BETWEEN ACHT/PRIMARY CARE

NO CHANGE

13

Primary Care Memory Assessment

Patients are referred to memory clinic - DEDICATED MEMORY SUPPORT TEAM IN PRIMARY CARE

Patients are referred to memory clinic - DEDICATED MEMORY SUPPORT TEAM IN PRIMARY CARE

AREA OF REVIEW IN THE FUTURE -

Proactive GP Support to Care Homes Care Home Medical Service

REVIEW PROVISION IN LIGHT OF QOF AND OTHER INITIATIVES

Warfarin monitoring Sits outside LCS. Yes COVERED IN NEW CONTRACTING ARRANGEMENTS

Administering depot neuroleptics in primary care -

Administering depot neuroleptics in primary care -

AREA OF REVIEW IN THE FUTURE

Diabetes Prevention Programme - Healthier You - GP A4 info Sheet Berkshire

NO CHANGE - YEAR OF CARE

H. Pylori - Decommission

DECOMMISSION

Anti – Coagulation COVERED IN NEW CONTRACTING ARRANGEMENTS

Anticipatory Care 19-20 CONSOLIDATE INTO YEAR OF CARE Pre-diabetes monitoring CONSOLIDATE INTO YEAR OF CARE LHRH Zoladex/Prostap/Decapeptyl

SR SPECIFIC

Monitoring Drug treatment for ADHD

SPECIFIC – NEEDS REVIEW

14

Provision of community annual reviews for Rheumatology patients monitored by DAWN

SPECIFIC

Ravenswood 2019-20 SPECIFIC

SMI Heatlhchecks SMI Heatlhchecks Enhanced physical health checks for people with SMI CONSOLIDATE

Prophylactic Flu management - Care Homes

Prophylactic Flu management - Care Homes

15

Appendix B –“Practice” and “Network” Services Service Practice/Network H-Pylori testing N/A Near Patient Testing Practice Suture Removal Practice Venous & Mixed Aetiology Leg Ulcer Practice Phlebotomy Practice Insulin Initiation Network Care Home Medical Services Network Depot Antipsychotics specifications Network Physical Health Checks for People living with Serious Mental Illness (SMI) Practice

1

MEETING: Primary Care Commissioning Committee PAPER: K


TITLE: Primary Care Network (PCN) Update

AUTHOR: Simon Kearey, Head of Locality Delivery


Reason for presenting this paper: For Action For Approval For Discussion For Assurance For Information Summary of Purpose and Scope of Report:

Buckinghamshire CCG has approved the establishment of 12 Primary Care Networks (PCNs). This paper provides an update covering various workstreams regarding Networks development.

Recommendations

The Primary Care Commissioning Committee (PCCC) is requested to note this paper for information.

Conflicts of Interest: None – paper for information only. Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all





2


N/A

Equality N/A

Quality

Financial N/A

Risks Risks associated in delivery of PCNs are covered

in this paper.

Statutory/Legal N/A


N/A

Membership Involvement N/A

Supporting Papers: Primary Care Network Update

3

Primary Care Network Update Primary Care Commissioning Committee

5th December 2019 Background Further to the report on Primary Care Networks (PCNs) provided to the Primary Care Commissioning Committee on 5th September 2019, detailing the creation of 12 PCNs in Buckinghamshire, this paper provides an update on the progress of PCNs in line with the requirements of the Long Term Plan (list of PCNs attached at Appendix A). NHS England has recommended the use of a Primary Care Network Maturity Index (Appendix B) with which the development of PCNs can be monitored and this report uses elements of this matrix to consider PCNs and their development. Leadership Planning and Partnerships PCN Organisational Development Fund

A more detailed paper regarding this area of work has been drafted and is in the process of being discussed and reviewed by ACDs.

Key points for Bucks are as follows:

• Each PCN is at a different stage of maturity and development needs will vary. • The CCG will aim to work closely with all PCNs to share details of the BOB

development offer and to ensure provision is in line with their needs. • The CCG aims to achieve equality and commonality where possible. • In order to maximise the impact of the funding it is proposed that developmental

support is provided at scale where appropriate. • The first tranche of funding released £51k, £4,250 per PCN which has enabled

o 5 PCNs to have Awaydays where their governance, structure, health inequalities and range of development areas have been explored. From these days, future priorities have been agreed and work begun in a number of areas.

o PCN members to attend the RCGP two day PCN conference.

A number of events have recently been held to support PCN development:

• 22nd October - PCN and Integrated Team Event • 5th November - PCN Workforce Event

A meeting with all PCN network managers is planned for 5th December with the aim of sharing best practice and receiving an update on future developments. Accountable Clinical Directors (ACDs) of the PCNs continue to meet on a monthly basis as a developing group.

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Individuals also had access to a range of webinars across many subjects hosted by NHS England. Use of Data and Population Health Management Public Health has provided all PCNs with a comprehensive set of Health Inequalities and Outcomes data. PCNs are using this data to determine the main focus of their work. In addition, BOB has approved funding to support further work with PCNs on Population Health Management and PCNs will be given the opportunity to be involved in this. Integrating Care This should be a priority for all PCNs especially with the provision of the new Anticipatory Care and Care Homes specifications. PCNs will develop teams of professionals who will work together to provide a range of local services which are pertinent to the patient’s needs. Data sharing agreements in place are allowing GP data to be shared across the PCN with other local partners. Other workstreams fostering integrated arrangements are:

• Continuation of Multi-Disciplinary Team meetings in pilot sites • IT developments as described below:

AskNHS – This Application is being used on mobile phones for advice and also for booking patient appointments with GPs.

TeamNet - Practices/PCNs can use this to share and hold relevant information and data. It is seen as a repository which can hold System information which can be easily accessible by other systems partners.

Graphnet – portal being developed to hold and share personal medical information between partners – and will include social care and other forms of data from a range of systems.

EMIS Clinical Services – This system currently enables referrals to other community services as well as providing them with access to key patient record data.

Managing Resources Wessex Workforce Tool

Building on the work by Wessex Academic Health Science Network and Wessex LMC who in partnership created a workload / workforce planning tool for GP practices, BOB ICS has fully funded the development of the tool so that it can be used by practices, PCNs, CCGs and the ICS to support:

• Workforce development plans • Realisation of the alternative workforce • Workforce resilience planning • Workload planning.

TeamNet can also be used by PCNs to unify, standardise and share their own templates, documents, policies etc. and therefore could be seen as a tool to support Workflow Optimisation.

5

Working with People and Communities There were a number of PCNs who were already working closely with local community groups and patient representatives. The PCNs who have had their own development events invited their patient groups to attend and this was very successful. In addition work with community is further encouraged through the requirement of social prescribers for each PCN and the development of community boards.

Social Prescribing Link Workers (SPLWs)

Social prescribing and asset based community development are highlighted as one of the key developmental support areas for PCNs. SPLWs are expected to play a key role in supporting the delivery of the forthcoming Personalised Care national service specification and therefore it is vital that this new role is fully embedded within PCNs and the wider community. In Bucks we currently have:

• 9 PCNs who have recruited SPLWs • 2 PCNs who are actively recruiting • 1 PCN is not planning to recruit in this financial year.

The majority (8 out of 12) of our PCNs have recruited either via FedBucks / Bucks Charitable Alliance (BCA) or directly from the BCA. 3 PCNs have / plan to recruit their SPLW independently. The SPLWs employed under the BCA umbrella have the advantage of a common and comprehensive induction package and many of those employed come from an experienced background in this field.

Already many PCNs have not only thought about but have developed a wider PCN governance group which includes membership by local community groups and organisations. This wider group will support both the development of services signposted to by social prescribing but also identify gaps in provision and how existing organisations can support coverage of those gaps. Clinical Pharmacists PCNs have access to 70% funding for a WTE Clinical Pharmacist in year 1. In Bucks we currently have:

• 11 PCNs recruiting PCN Clinical Pharmacists in year 1. • 7 PCNs utilising Fed Bucks offer to host employment. • All Clinical pharmacists in post or will have started by the first week of December. • New roles have been recruited from a wide range of Pharmacy backgrounds

including community pharmacy, hospital and CCG pharmacy teams which will give the network a good range of experience on which to build on and share.

Summary The Primary Care Commissioning Committee (PCCC) is requested to note this paper for information.

6

Appendix A Buckinghamshire PCN List

PRACTICE NAME PCN NAMERECTORY MEADOW SURGERY MID CHILTERNSAMERSHAM HEALTH CENTRE MID CHILTERNSJOHN HAMPDEN SURGERY MID CHILTERNSHUGHENDEN VALLEY SURGERY MID CHILTERNSTHE PRACTICE PROSPECT HOUSE MID CHILTERNSTHE NEW SURGERY CHESHAM & LITTLE CHALFONTWATERMEADOW SURGERY CHESHAM & LITTLE CHALFONTGLADSTONE SURGERY CHESHAM & LITTLE CHALFONTLITTLE CHALFONT SURGERY CHESHAM & LITTLE CHALFONTOAKFIELD SURGERY MAPLETHE MANDEVILLE PRACTICE MAPLEPOPLAR GROVE SURGERY MAPLEMEADOWCROFT SURGERY BMWWHITEHILL SURGERY BMWBERRYFIELDS MEDICAL CENTRE BMWWESTONGROVE PARTNERSHIP WESTONGROVETHE SWAN PRACTICE NORTH BUCKSWHITCHURCH SURGERY NORTH BUCKSNORDEN HOUSE SURGERY NORTH BUCKSASHCROFT SURGERY NORTH BUCKSWADDESDON SURGERY NORTH BUCKSWING SURGERY NORTH BUCKSEDLESBOROUGH SURGERY NORTH BUCKSCROSS KEYS SURGERY AV SOUTHHADDENHAM MEDICAL CENTRE AV SOUTHUNITY HEALTH AV SOUTHIVER MEDICAL CENTRE SOUTH BUCKSTHREEWAYS SURGERY SOUTH BUCKSBURNHAM HEALTH CENTRE SOUTH BUCKSSOUTHMEAD SURGERY SOUTH BUCKSDENHAM MEDICAL CENTRE SOUTH BUCKSTHE HALL PRACTICE CHALFONTSTHE MISBOURNE SURGERY CHALFONTSCALCOT MEDICAL CENTRE CHALFONTSMILLBARN MEDICAL CENTRE ARC NETWORKHIGHFIELD SURGERY ARC NETWORKTHE MARLOW MEDICAL GROUP ARC NETWORKCHERRYMEAD SURGERY ARC NETWORKTHE SIMPSON CENTRE ARC NETWORKBOURNE END & WOOBURN GREEN MED ARC NETWORKCHILTERN HOUSE MEDICAL CENTRE DASHWOODWYE VALLEY SURGERY DASHWOODTHE RIVERSIDE SURGERY DASHWOODCARRINGTON HOUSE SURGERY DASHWOODSTOKENCHURCH MEDICAL CENTRE DASHWOODCRESSEX HEALTH CENTRE DASHWOODTOWER HOUSE SURGERY CYGNETDESBOROUGH SURGERY CYGNETKINGSWOOD SURGERY CYGNETPRIORY AVENUE SURGERY BUCKS CYGNET

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Appendix B – NHSE Maturity Matrix Self Assessment

Network

Themes PCN/Systems Foundation X Step 1 X Step 2 X Step 3 X Overall position

The PCN can articulate a clear vision for the network and actions for getting there. GPs, local primary care leaders, local people and community organisations, the voluntary sector and other stakeholders are engaged to help shape this.

The organisations within the PCN have agreed shared development actions and priorities.

The PCN has established an approach to strategic and operational decision-making that is inclusive of providers operating within the network footprint and delivering network-level services. There are local governance arrangements in place within networks to support integrated partnership working.

PCN leaders are fully participating in the decision making at the system and relevant place levels of the ICS/STP. They feel confident and have access to the data they require to make informed decisions.

Clinical directors are able to access leadership development support.

Joint planning is underway to improve integration with broader 'out of hospital’ services as networks mature. There are developing arrangements for PCNs to collaborate for services delivered optimally above the 50k footprint.

The PCN Clinical Director is working with the ICS/STP leadership to share learning and support other PCNs to develop.

There are local arrangements in place for the PCN (for example through the PCN Clinical Directors) to be involved in place/system strategic decision-making that both supports collaboration across networks and with wider providers including NHS Trusts/FTs and local authorities.

Systems are actively supporting GP practices and wider providers to start establishing networks and integrated neighbourhood ways of working and have identified resources (people and funding) to support PCNs on their development journey.

Primary care is enabled to have a seat at the table for system and place strategic planning.

Primary care is enabled to play an active role in strategic and operational decision-making, for example on Urgent and Emergency Care. Mechanisms in place to ensure effective representation of all PCNs at the system level.

Primary care leaders are decision making members of the ICS and place level leadership, working in tandem with partner health and care organisations to allocate resources and deliver care.

Systems have identified local approaches and teams to support PCN Clinical Directors with the establishment and development of networks and for clinical directors in their new roles.

As set out in the LTP, there is a system level strategy for PCN development and transformation funding, with support made available for PCN development. System leaders supports PCN clinical directors to share learning and support development across networks.

PCN Clinical Directors work with the ICS/STP leadership to share learning and work collaboratively to support other PCNs.

Primary Care Network Maturity Matrix

Leadership, planning and partnerships

For the PCN

For Systems

Insert name of network

8

The PCN is using existing readily available data to understand and address population needs, and are identifying the improvements required for better population health.

Analysis on variation in outcomes and resource use between practices and PCNs is readily available and acted upon.

All primary care clinicians can access information to guide decision making, including identifying at risk patients for proactive interventions, IT-enabled access to shared protocols, and real-time information on patient interactions with the system.

Systematic population health analysis allows the PCN to understand in depth their population’s needs, including the wider determinants of health, and design interventions to meet them, acting as early as possible to keep people well and address health inequalities. The PCN’s population health model is fully functioning for all patient cohorts.

Basic population segmentation is in place, with understanding of key groups, their needs and their resource use. This should enable networks to introduce targeted interventions, which may be initially focussed on priority population cohorts

Functioning interoperability within networks, including read/write access to records.

Ongoing systematic analysis and use of data in care design, case management and direct care interactions support proactive and personalised care

Data and soft intelligence from multiple sources (including and wider than primary care) is being used to identify interventions.

Infrastructure is being developed for PHM in PCNs including facilitating access to data that can be used easily, developing information governance arrangements & providing analytical support.

Basic data sharing, common population definitions, and information governance arrangements have been established that supports PCNs with implementation of PHM approaches.

There is a data and digital infrastructure in place to enable a level of interoperability within and across PCNs and other system partners, including wider availability of shared care records

Full interoperability is in place across the organisations within PCNs, including shared care records across providers.

There is some linking of data flows between primary care, community services and secondary care.

Analytical support, real time patient data and PHM tools are made available for PCNs to help understand high and rising risk patients and population cohorts, and to support care design activities.

System partners work with PCNs to design proactive care models and anticipatory interventions based on evidence to target priority patient groups and to reduce health inequalities.

The PCN is starting to build local plans for improving the integration of care for their populations, informed by the Long Term Plan, GP contract framework and locally agreed system/place priorities.

Integrated teams, which may include social care, are working within the network and supporting delivery of integrated care to the local population. Plans are in place to develop MDT ways of working, including integrated rapid response community teams and the delivery of personalised care.

Early elements of new models of care defined at Step 1 now in place for most population segments, with integrated teams including social care, mental health, the voluntary sector and ready access to secondary care expertise. Routine peer review takes place.

Fully integrated teams are in place within the PCN, comprising of the appropriate clinical and non-clinical skill mix. MDT working is high functioning and supported by technology. The MDT holds a single view of the patient. Care plans and co-ordination in place for all high risk patients.

The PCN is aware of the organisations they need to engage to develop multi-agency approaches to integrated care and are beginning to make initial approaches.

Components of comprehensive models of care are defined for all population groups, with clear gap analysis and workforce plans.

The PCN and other providers have in place supportive HR arrangements (e.g. formalised integrated team governance and operational management) that enable multi-agency MDTs to work together effectively.

There are fully interoperable IT, workforce and estates across the PCN, with sharing between networks as needed.

Systems support the PCNs to build relationships across physical and mental health service providers and social care partners to facilitate the delivery of Integrated care.

Systems support the building of relationships across providers of physical and mental health services, and social care partners.

There is continued development of partnerships across primary care, community services, social care, mental health, the voluntary sector and secondary care that are enabling on-going MDT development. Workforce sharing protocols in place.

Systems have developed and implemented integrated care models that meet with objectives of the LTP.

System workforce plans supports the development of integrated neighbourhood teams.

Integrating care

Use of data and population health

management

For the PCN

For Systems

For the PCN

For Systems

9

Primary care, in particular general practice, has the headroom to make change

Steps taken to ensure operational efficiency of primary care delivery, such as delivering the Time to Care programme, and support general practices experiencing challenges in delivery of core services.

The PCN has sight of resource use and impact on system performance and can pilot new incentive schemes where agreed locally.

The PCN takes collective responsibility for managing the resource flowing to the network. Data is used in clinical and non-clinical interactions to make best use of resources.

There are people available with the right skills to make change happen.

System plan in place to support managing collective financial resources that includes PCNs.

Systems have put in place arrangements that support PCNs with improvements in the efficiency of primary care delivery and enable PCNs to make optimum use of their resources.

Systems support networks to have sight of resource use and impact on system performance and that can enable piloting of new incentive schemes.

Systems support PCNs to take collective responsibility for managing the resource flowing to the network and use data in clinical and non-clinical interactions to make best use of resources.

PCN development support funding is being used to address PCN development needs.

Approach agreed to engaging with local communities.

The PCN is engaging directly with their population and are beginning to develop trusted relationships with wider community assets.

PCNs are routinely connecting with and working in partnership with wider community assets in meeting their population's needs.

PCNs have fully incorporated integrated working with local Voluntary, Community and Social Enterprise (VCSE) organisations as part of the wider network.

Local people and communities are informed and there are routes for them contribute to the development of the PCN.

The PCN has undertaken an assessment of the available community assets that can support improvements in population health and greater integration of care.

Insight from local people and communities, voluntary sector is used to inform decision-making.

Community representatives, and community voice, are embedded into the PCNs’ working practices, and are an integral part of PCN planning and decision-making.

The PCN has established relationships with local voluntary organisations and their local Healthwatch.

Community networks are understood and connected to the PCN.

The PCN has built on existing community assets to connect with the whole community and codesign local services and support.

Systems are providing PCNs with expertise to support local involvement of people and communities.

Systems have put in place arrangements to support PCNs to develop local asset maps in partnership with their local community to enable models of social prescribing for personalised care.

Systems are facilitating effective partnerships with local community assets within PCN footprints.

The community assets and partnerships developed by PCNs are being connected in to strategic planning at place and system level.

The system is developing a strategy to support communities to develop and build particularly in those areas that face the greatest inequalities.

Working with people and communities

Managing resources

For the PCN

For Systems

For the PCN

For Systems

MEETING: Primary Care Commissioning Committee AGENDA ITEM: L


TITLE: GPFV Update

AUTHOR: Jessica Newman, Senior Primary Care Manager Wendy Newton, Primary Care Manager


Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: To ensure NHS Buckinghamshire CCG continues to deliver high quality care to its population and aligns with priorities and direction of travel identified in the GPFV, this paper summarises work in progress to help support and drive successful delivery of a number of projects that sit under the following GPFV workstreams:

• Workload • Workforce • Training and Development • Infrastructure – Premises • Infrastructure – GPIT • New Models of Care

The progress of the workstreams within NHS Buckinghamshire CCG is varied: Workforce, Workload and Training and Development workstreams are increasingly delivered on an ICS basis. Others, particularly infrastructure are dependent on national strategy and programmes such as ETTF, availability of improvement grants and roll-out of the NHS App and GP online. In order to ensure progress is being made across all workstreams and to promote co-ordination, a GPFV Steering Group has been established. Members of the group are actively involved in the delivery of work within the key workstreams. In addition, a working group focusing on Buckinghamshire workforce and training initiatives has been created in conjunction with the Bucks Training Hub to co-ordinate activity across the CCG. With the publication of the Long Term Plan in January 2019 and the introduction of Primary Care Networks in July, the GPFV Steering Group has been working to revise the format of the GPFV Workplan, which is available for review upon request. PCCC is asked to note for information progress on delivering the GPFV in Buckinghamshire. Conflicts of Interest: None arising from this paper.

Strategic aims supported by this paper :( please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all





Governance Element Y N N/A Comments/Summary Patient & Public Involvement .

Equality Quality Financial Funding is aligned to some of the actions within

GPFV. Risks

Some of the actions within the GPFV framework contribute towards resilience in primary care thereby mitigating risks around the sustainability of general practice.

Statutory/Legal Prior consideration Committees / Forums / Groups

Updates on the progress of the GPFV workstreams have been regular agenda items for PCOG and PCCC since the inception of the GPFV in 2016.

Membership Involvement Supporting Papers: GPFV Update November 2019.

General Practice Forward View (GPFV) Buckinghamshire CCG Plan Update November 2019

Background The GPFV was published in April 2016 and committed to increasing investment in general practice over 5 years, to 2020/21. NHS Buckinghamshire CCG drew up a plan for delivering the key objectives of the GPFV in 5 workstreams: Workload; Workforce; Training and Development; Infrastructure - Premises and IT - and New Models of Care. The progress of the workstreams within Buckinghamshire CCG is varied with Workforce, Workload and Training and Development being increasingly taken forward on an ICS basis, that is, across Buckinghamshire, Oxfordshire and Berkshire West. Others, particularly infrastructure are dependent on national strategy and capital investment available. In order to ensure progress is being made across all workstreams and to promote co-ordination, a GPFV Steering Group has been established. Members of the group are operationally involved in the delivery of work within the key workstreams. In addition, a working group focusing on Buckinghamshire workforce and training initiatives has been created in conjunction with the Bucks Training Hub to co-ordinate activity across the CCG. With the publication of the Long Term Plan in January 2019 and the introduction of Primary Care Networks in July, the GPFV Steering Group has been working to revise the format of the GPFV Workplan, which is available for review upon request. Changes to GPFV Funding Arrangements For 2019/20, GPFV funding has been allocated across the Buckinghamshire, Oxfordshire and Berkshire West (BOB) ICS instead of to individual CCGs. This is a national change to the spending allocation and is in response to feedback from GPFV leads that “siloed” funding was not able to achieve optimum benefits. The central NHS England finance department has circulated details of each ICS’ allocation for the next 2 years. Unlike previous years, this is based on weighted population rather than registered population. The intention is that allocating at an ICS level will provide greater flexibility on how funding can be spent and assurance that it meets local needs (in line with the BOB ICS Primary Care Strategy). The 4 GPFV programmes currently having their allocations combined at ICS level are: • General Practice Resilience Programme (GPRP) • Reception and Clerical Staff Training • Recruitment and Retention • Online Consultation The following funding allocations have been agreed for 2019/20 for Buckinghamshire CCG:

CCG Allocations 2019/20 2019/20 2019/20 2019/20 2019/20 2019/20

Primary Care (medical) GPFV Weighted population Resilience Reception

& Clerical Online

Consultation GP

Retention NHS Buckinghamshire CCG 530,446 £101,022.65 £126,601.98 £170,000.00 BOB STP 1,759,746 £335,141.00 £425,455.85 £469,685.13 £198,859.03

BOB STP TOTAL £1,429,141.01

GPFV Workplan Revision The GPFV Steering Group agreed the need to revise the GPFV Workplan, to reflect the objectives of the Long Term Plan, creation of PCNs and the ICS. The GPFV Steering Group agreed that the revised document should: • Recognise that work to deliver the GPFV is taking place at national, ICS and local level and the work

plan should cross reference to key initiatives which influence the delivery of the GPFV. Where possible the funding streams associated with relevant initiatives should also be referenced.

• Show inter-dependencies between the workstreams which come together to deliver the GPFV.

• Provide document control and regular review, to keep it relevant to organisational changes which may impact on how and who delivers the GPFV.

The revised document has been reworked on a task basis, allowing for cross-referencing across the previously identified 5 workstreams. Summary PCCC is asked to note for information the Highlight Report for November 2019. Further Highlight Reports will be provided to PCCC on a Quarterly basis.

General Practice Forward View: Highlight Report

November 2019

PCN Development Fund – The CCG is working collaboratively with BOB colleagues to develop a plan for the use of £1.2m PCN Organisational Development Support funding which is available in 2019/20. In broad terms the monies are to be used to support the further development and maturation of PCNs in such a way as to enable them to fully deliver their role as set out in the NHS Long Term Plan. Each place will develop plans for use of their share of the monies; however the ICS aspire to achieve commonality, where possible, across all 3 places and to align any offer of support to the domains within the national prospectus. Therefore the CCG will work with PCNs to share information about the development offer, to ensure that provision is in line with their needs and to achieve equality and commonality where possible. In order to maximise the impact of this funding, it is proposed that development support is provided at-scale where appropriate. Inaugural Bucks Pharmacists Forum 20 November 2019 – This Forum provided an opportunity for all pharmacists working in general practice across Bucks to meet and engage. The Forum offered a supportive environment to help identify future training and development needs. Training Needs Assessment – Bucks Training Hub will be undertaking a Training Needs Analysis of primary care staff during November / December 2019. The results of the assessment will help to shape the training provision in Bucks for 2020/21.

Wessex Workforce Planning Tool – The tool was launched at the Bucks PCN Event on 5 November 2019. The BOB ICS has fully funded the development of the tool so that it can be used by practices, PCNs, CCGs and the ICS to support; workforce development plans, realisation of the alternative workforce, workforce resilience planning and workload planning. All practices will be supported to use the tool and to interpret the outcomes. https://gptools.nqminds.com/ Increasing the Number of Student Placements - Bucks Training Hub will be employing a lead to support the development of student placements across BOB. This role will also support the existing Nurse Lead in providing these opportunities to practices. The Lead Nurse has increased her working hours to two days a week to help support nurses who wish to take on students. Lead nurse to visit all practices in Bucks from November 2019. Case study in underway to support practices and provide better understanding of what it’s like to have a student in practice. This case study will look at the benefits and challenges and opportunities available.

GP Mentorship Scheme – The scheme is now running across BOB with mentor and mentees in each area. 36 mentees have been approved to join the scheme, including 10 from Bucks.

Locum Chambers – a BOB-wide Locum Chambers will provide a platform to bring together locums and practices. The chambers will support practices with administrative aspects of locum use as well as helping to source and book locums. Locums will also be supported and linked into education and career development opportunities offered via Bucks Training Hub. The Locum Chambers website is now live and being tested by practices and locums from Oxfordshire and Bucks www.boblocumchambers.org.uk. Locums and practices can now register their interest, and will be transferred to the platform when it goes live in a couple of weeks.

GP Career Support Programme – A meeting is planned to scope the roll out of the Buckinghamshire Flexible Careers Programme. The programme launch is expected in Spring 2020 and will provide a range of career options and support to GPs designed to assist making GP careers more attractive and sustainable.

https://gptools.nqminds.com/

http://www.boblocumchambers.org.uk/

Time for Care PGP Quickstart Programme - Eight practices have completed the ten week programme. PGP Quick Start is an on-site, hands-on, short term support package for practices that aims to help practices release time for care and build improvement capability. The focus is on fast, practical improvement to help reduce pressures and release efficiencies within general practice. Feedback from practices at group sessions has been very positive and the CCG anticipates receiving the impact data reports in early December. Social Prescribing Link Workers – In Bucks 9 PCNs have recruited a SPLW, 2 PCNs are actively recruiting and 1 PCN has decided not to recruit a SPLW in this financial year. The majority (8 out of 12) of our PCNs have recruited via FedBucks / Bucks Charitable Alliance (BCA) or directly from the BCA. 3 PCNs have recruited / plan to recruit their SPLW independently. SPLWs are expected to play a key role in supporting delivery of the forthcoming Personalised Care national service specification and therefore it is vital that this new role is fully embedded within PCNs and the wider community.

Leadership Development – The Thames Valley Leadership Programme is focused on Primary Care staff who have been in post for at least 6 months, as they will be required to demonstrate potential and ability to deliver outcomes ensuring patient safety and positive patient experience in a changing and challenging NHS. This is open to all GP’s Practice Managers, Assistant Practice Managers, Lead Nurses etc. This innovative 5 day programme has been designed to help Primary Care staff to deliver more effective leadership within their practices and the wider healthcare system. It is a personalised approach to developing and strengthening leadership qualities which will give participants competence, confidence and motivation to build on their existing skills. Up to 15 professionals are undertaking this programme and another cohort is scheduled for 2020. HCA Care Certificate - Initial meetings have been held with colleagues at Buckinghamshire Healthcare Trust (BHT) to determine whether they could adapt their current HCA Care Certificate programme to include HCA’s working in general practice. Further work and clinical input is required to consider the variations required to BHT’s current HCA Care Certificate programme to make it fit for purpose for primary care. Bucks Training hub are also looking at the Nursing Associates Apprentice Pathway for our HCA’s. We have 8 places available for Healthcare Assistants in General Practice to go onto the February 2020 intake, fully funded.

Digital Transformation – The digital transformation team are working with general practice to ensure that all requirements of the LTP are met, including:

• Offering online consultations by April 2020. • All patients to access their full digital GP record by April 2020. • All practices offering video consultation by April 2021.

A full update on all digital programmes is provided in Paper I on today’s agenda. Primary and Community Care Staff Training - Bucks Training Hub is pulling together a list of all available training in Bucks together with ICP partners. This will help to reduce the amount of duplication and also allow us to work closely together with ICP partners.

MEETING: Primary Care Commissioning Committee PAPER: M DATE: Thursday 5th December 2019

TITLE: Report from the Primary Care Operational Group: 3rd October 2019 and 7th November 2019



Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information For Ratification Summary of Purpose and Scope of Report: To provide the PCCC with an update from the PCOG meetings held on 3rd October 2019 and on the 7th November 2019. Authority to make a decision – process and/or commissioning (if relevant) N/A- paper for information only Conflicts of Interest: (please tick accordingly) No conflict identified Conflict noted, conflicted party can participate in discussion and decision (see below)

Conflict noted, conflicted party can participate in discussion but not decision (see below)

Conflict noted, conflicted party can remain but not participate in discussion (see below)

Conflicted party is excluded from discussion (see below) Governance assurance (see below) Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all






Equality Quality Privacy Financial Risks Statutory/Legal Prior consideration Committees /Forums/Groups


Supporting Papers: Report from the Primary Care Operational Group’s held on:

• 3rd October 2019 • 7th November 2019

Report from the Primary Care Operational Group (PCOG) Meeting held on 3rd October 2019

Primary Care Risk Register Two items with a risk scoring 12 or above on the Primary Care Risk Register were highlighted: Provision of Primary Care Services: following updates the risk score is revised to a 6. Improved access to primary care in general practice: the risk continues until the outcome of the national Access Review is known and is scored at 12. A workshop is planned for 19th November to discuss the detail of plans. List Closure PCOG was asked to approve the request from a Surgery to apply for a temporary suspension of their patient list for a period of three months, until 31 January 2020, whilst work on resilience is started. The members did not approve the temporary closure at this time. They asked that the surgery maintain business as usual until they reach a patient list of 5900, unless there is an exponential rise. An update will come to the January 2020 meeting. GPRP Funding Request: GIS mapping tool PCOG approved the GIS mapping tool which is provided by the Commissioning Support Unit (CSU) and will be used to help support ongoing commissioning needs (to identify patient gaps in terms of surgery coverage, etc.) and will be useful to PCNs in understanding demographics and planning services going forward. It is estimated that the cost will be c. £40k. Finance Report

• M5 position was £63k underspend in 2 areas: GP contracts and Services. • Forecast outturn is on plan. • Figures to be provided on risks and opportunities for the next report.

Locally Commissioned Services for 2020/21 Buckinghamshire CCG commissions 9 Locally Commissioned Services (LCS), on an annual basis currently directly from individual practices. The budget for these services in 2019/20 is £1.813m. The CCG is undertaking work with colleagues in Berkshire West and Oxfordshire CCGs to align LCS specifications ready for 2020/21.This will also need to consider changing the commissioning of LCS’s at a PCN, rather than individual practice level. A fuller proposal based on recommendations of the Task and Finish Group, was presented to PCOG in November for comment before submission to December PCCC for sign off.

Redevelopment Full Business Case: Update The CCG has been working on the preparation of several full business cases to secure STP capital funding to support primary care-led initiatives. Due to timings regarding submission to NHS England one full business case will have to be signed off retrospectively by the Finance Committee. One of the STP Wave 2 projects aims to create improved access within the Southern locality and the first stage of this is the creation of a hub. The hub location was selected as the preferred site following appraisal of three options. The creation of the hub will provide better access for patients from 8am to 8pm within the CCG area and alleviate pressure on out of hours services at Wexham Park Hospital. Digital Transformation PCOG was shown a demonstration of the Ask NHS app dashboard that is currently live in 36 practices. Communications are promoting the use of the app in practices. There was discussion with regard to alignment of technology across BOB and the group were advised that ICS would decide whether to bring together a unified solution across BOB.

Work is ongoing regarding the development of Emis Clinical Services for use in Children’s Hubs and configuration work is also ongoing on Emis Clinical Services for PCNs.

Report from the Primary Care Operational Group (PCOG) Meeting held on 7th November 2019

Primary Care Risk Register One item with a risk scoring 12 or above on the Primary Care Risk Register was highlighted: Improved access to primary care in general practice: the risk remains at 12 due to the uncertainty around future provision until the outcome of the national access review is known. A workshop is planned for 19th November to discuss the detail of plans. With regard to 2020/21 and arrangements for the Extended Hours DES, the plan is to continue as is, with the ability to cut short contracts with a 6-month notice period as required. It is expected that the DES arrangements will also roll over but would only be confirmed following completion of the National Access Review - not expected before the end of December. Primary Care Commissioning Committee and Primary Care Operational Group Terms of Reference Both sets of TOR are to be amended to reflect the appointment of the Interim Director for Primary Care & Transformation. The Interim Director will attend future PCOG and PCCC meetings. Finance Report (M6)

• The YTD position is £62k underspend. Enhanced services (extended hours and minor surgery) are below plan – the forecast outturn is currently still on plan.

• Risks and opportunities were reviewed and are managed within reserves. • Retainer scheme costs are going to be above budget. • Seniority also reviewed and is above budget. • Slippage on extended hours, • A reduction on rates may be available and will be reviewed monthly to update as required.

GPRP Funding request PCOG were asked to approve the identified package of support for a Surgery by utilising GPRP funding. Several areas were highlighted as a risk to the resilience of the Practice. It was agreed that GPRP funding for the Practice would require agreement on criteria for use of the funding which will be monitored by the CCG. These conditions are to be worked up and presented to Xytal. PCOG agreed to funding, dependant on agreed conditions being met to ensure accountability by the practice. QOF + Scheme PCOG received a presentation on the progress of the QOF+ scheme for 2019/20. PCOG agreed to end the QOF+ scheme in March 2020 but to keep looking for funding opportunities to further the good work it has started. The £200k released from April 2020 is to be directed to Locally Commissioned Services. Locally Commissioned Services A Task & Finish Group conducted a review of all LCSs across BOB, to set out a consistent approach and to make recommendations on commissioning intentions for 2020/21. Analysis of the services currently commissioned across BOB identified several LCSs which can be aligned. Others may need to continue at a CCG level. The Task & Finish Group looked at how LCSs might be commissioned on a PCN and/or practice level from April 2020. As PCNs are not currently legal entities or CQC registered, (and therefore, an LCS cannot be directly commissioned from a PCN), it was suggested that this could be commissioned through a Lead Practice or FedBucks on behalf of PCNs.

PCOG agreed to the approach being taken by the Task & Finish Group. A final report is to be submitted to the Primary Care Commissioning Committee on 5

th December 2019.

Patient Registration and Allocation Ongoing problems were reported to PCOG regarding the allocation of patients who have been removed or wish to leave a practice but have no other practice to register with. There are concerns around gaps in registration boundaries across the county. The CCG had previously agreed to the purchase of the GIS mapping package which will aid the understanding of the issues. A report to PCOG is expected in January or February, showing boundary gaps (if any) and suggestions for a policy/internal process for processing allocations quickly and efficiently. Supporting Resilience in Wycombe An update was presented to PCOG on work to support resilience in Wycombe, informing the group about the potential for a future piece of work that can be done to develop a quality dashboard to support further resilience in Wycombe. PCN development will have a direct impact on resilience in Wycombe. It is proposed that the CCG could benefit from developing a more robust tool/solution to support resilience which can identify practices at risk before they experience crisis. PCOG supported the recommendation to refresh previous pieces of work and the development of a matrix dashboard to look at practices in terms of resilience and revisit proactively. Hampden Fields Project PCOG approved funding up to a maximum of £17,000 to complement the NHSE contribution towards the cost of funding a Strategic Outline Case for Hampden Fields. BOB ICS Long Term Plan: Primary Care Strategy (presented for information) An extract of the ICS Primary Care Strategy was circulated to PCOG, addressing Primary Care concerns, issues and highlighting priorities. PCOG were in agreement that the Primary Care Transformation Board cannot change lines of accountability with regards to delegated authority from NHS England to the CCG Governing Body, on decisions for Primary Care funds. PCN Organisational Development Funds 13% of PCN development funds have been agreed to be released by the BOB Primary Care Transformation Board. Amounting to £51k for BCCG and breaking down to £4,250 for each PCN. NHS England has shared a PCN development support prospectus outlining the main priority areas for PCNs. The CCG has contacted PCNs and asked for a proposal for use of their initial share of the funding. PCNs were asked to consider value for money and longevity. To-date 7 proposals have been submitted and approved. The process will require PCOG to ratify spending –the paper will be submitted to the January PCOG.

Minutes of the Premises Sub-Group 18th October 2019 12.00pm – 1.00pm

Large Meeting Room, Amersham

Voting Members: Tony Dixon (TD) Lay Member and Finance Committee Chair (Chair of this meeting) Kate Holmes (KH) Deputy Chief Finance Officer, CCG Helen Delaitre (HD) Associate Director of Primary Care, CCG Peter Redman (PR) Estates and Development Manager, CCG Simon Kearey (SK) Head of Locality Delivery, CCG Jessica Newman (JN) Senior Primary Care Manager, CCG In Attendance: Vicki Parker (VP) Business Support Manager, CCG Apologies: Gary Heneage (GH) Chief Finance Officer, CCG Dr Matt Mayer (MM) Chief Executive, BBO LMC

Agenda No. Agenda Item Action 1 Welcome and Introductions

• The chair welcomed all to the meeting and apologies were received from GH and MM

• The meeting was declared quorate.

2 Declarations of Interest • No additional declarations other than those standing on published registers.

3 Notes from Last Meeting: • Minutes from the 16th September 2019 meeting were agreed as an accurate

record.

4 Action Log • The action log was updated accordingly.

5 Authorisation to move to dispute: Poplar Grove Surgery

• HD explained the Poplar Grove Practice in Aylesbury wishes to lodge an appeal with the DV over a dispute with the rent reimbursement for car parking spaces. The Agent representing the Practice is suggesting a reimbursement of £300 per car parking space, per annum.

• Action: HD will instruct the CSU to take forward the negotiations.

HD

6 Outstanding Lease Issues • Cressex Health Centre: PR was asked to review Premises Costs Directions to

ensure that the CCG is able to reimburse rent in the absence of a lease. PR felt we need to refer to the DV as where there is a lease, even if classed under common law, the DV needs to be involved before a level of reimbursement is considered. The CCG will need to instruct the DV to look at the reimbursement levels to understand the direction the CCG takes with regard to future payments. This is explained in Direction 31 of the Premises Cost Directions.

• Carrington House: There has been very little progress since the last meeting. JN advised the practice has been awarded resilience funding to provide specialist support and advice on their future business model.

PR

7

Update from the Greater Aylesbury LAF meeting • HD explained the LAF (Local Area Forum) is a community based meeting with 19

taking place across Buckinghamshire. The greater Aylesbury LAF was chaired by

the previous chair of HASC. HD was invited to discuss what we are doing about the developments in Aylesbury, explaining the hurdles we are facing with financial contributions (S106) and the planning restrictions.

• HD was introduced to the new Bucks County Council Assistant Director for Estates.

• It is anticipated the LAFs will be redesigned into Community Boards once the new Bucks Council is in place from April 2020. The CCG and PCNs are being consulted on these so they align to the footprint of the PCNs.

8 PCN Estates Work • SK explained each PCN will be required to score against a national maturity

index. The Primary Care Network (PCN) Maturity Matrix outlines components that underpin the successful development of networks.

• SK highlighted that in time PCNs will need to ensure they have a fully interoperable strategy for IT, workforce and estates across the PCN, with sharing between networks as needed. This is a piece of work that PCNs need to start considering when discussing their estates solutions.

• It was suggested the CCG supports PCNs by mapping the public estates and other resources in the footprint, allowing PCNs to have a foundation to plan for their future growth.

• The CCG has agreed to fund G.I.S mapping software which will be a big benefit to the planning.

9 Hampden Fields Project Support • Back in April 2019, the Premises Sub Group agreed with the principle of funding

pre-project costs for the development at Hampden Fields. • In the first instance VP and NL were asked to explore options with our partner

organisations to support this work within existing budgets. Conversations were held with ETTF, NHSE and STP colleagues with no success.

• The scope of the work will be to model a few options in some detail; size and use of the space and also phasing options, existing capacity / decanting solutions, procurement of the developer, financial modelling of the third party investment (bearing in mind too much 106 monies can undermine third party developers’ interest), and more accurate costings / understanding of exactly the kind of facility we’re looking to deliver here (not least to understand our shortfall in Section 106 funding.

• After discussion it was suggested the funding required for this work (£10k) could be allocated from the GP Resilience funds, subject to approval from the Primary Care Operations Group.

• Action: VP will draft a paper to go to PCOG on 7th November to request a consideration for the funding of this work.

VP

10 Any Other Business • HD advised BHT is taking the lead role in putting together the ICP Estates

Strategy. Assets associated with BHT and CCG have been mapped and work continues with remaining partners to further develop the strategy. It is expected the strategy will be presented at the Governing Body when completed.

• VP is keeping a list of potential projects that could be supported by any MIG slippage from 19/20. Please advise VP of any relevant projects.

• HD explained the CSU is commissioned to support Bucks and Berkshires CCGs with their primary care estates rent reviews. Oxfordshire CCG provides the service within their existing primary care team. Both Bucks and Berks West agree the support from the CSU has been good value, prompt and professional. The Premises Sub Group was asked to support requesting CSU for a quotation for their support in 2020/21. Agreed.

11 Date of Next Meeting

• 29th November 2019, 12.00pm - 1.30pm, Large Meeting Room, Amersham

ALL

MEETING: Primary Care Commissioning Committee PAPER: O


TITLE: Aylesbury Primary Care Centre Full Business Case Executive Summary

AUTHOR: Helen Delaitre, Associate Director of Primary Care LEAD DIRECTOR: Louise Smith, Interim Director Primary Care and Transformation

Reason for presenting this paper: For Action For Approval For Recommendation For Assurance For Information For Ratification


A full business case in support of the development of a new build, fit for purpose Primary Care Centre to serve patients in the town of Aylesbury, Buckinghamshire and its wider catchment area has been submitted to NHS England.

The two practices that are co-locating into this new build (Berryfields Medical Centre and Meadowcroft Surgery) are part of the ICS vision and have demonstrated to the CCG their commitment to delivering services of the highest quality, while at the same time embracing new ways of working at scale and in an integrated fashion.

The new primary care centre will be capable of delivering the following key criteria:

• Increase in capacity for primary care services out of hospital • Primary care working at scale • Capacity to provide for the expected population growth in this part of Aylesbury • Capacity to enable the opportunity to change ways of working by building skill mix

within the workforce and integrating with community services colleagues • Improve seven-day access • Provide increased training capacity. The Primary Care Commissioning Committee is requested to note this paper for information.

Authority to make a decision – process and/or commissioning (if relevant)It should be noted that this scheme has previously been approved by Primary Care Commissioning Committee at Outline Business Case stage where approval to fund was delegated to the CCG’s Finance Committee. Finance Committee approved this scheme in October 2019. Conflicts of Interest: (please tick accordingly) There are no material conflicts of interest for member GPs given they are not voting members of the Primary Care Committee.

No conflict identified Conflict noted, conflicted party can participate in discussion and decision (see below) Conflict noted, conflicted party can participate in discussion but not decision (see below)

Conflict noted, conflicted party can remain but not participate in discussion (see below) Conflicted party is excluded from discussion (see below) Governance assurance (see below) Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all





Governance requirements: (Please tick each box as is relevant to the paper) Governance Element

N Comments/Summary

Patient & Public Involvement

A Stakeholder Workforce Group including patients, has been created with regular public meetings scheduled throughout the build timeline.

Equality An Equality Impact Assessment has been completed for the proposed scheme.

Quality The Quality Team has reviewed the EIA and will be consulted throughout the build phase to ensure quality requirements are met.

Privacy N/A Financial As outlined in the paper. Risks As outlined in the paper. Statutory/Legal N/A Prior consideration Committees /Forums/Groups

The proposed scheme has been discussed at Premises Sub Group, Primary Care Operational Group, Primary Care Commissioning Committee and Finance Committee and reported on at the CCG’s Governing Body.


Proposal involves Berryfields Medical Centre and Meadowcroft Surgery.

NHS Buckinghamshire CCG Aylesbury Primary Care Centre

Executive Summary: FBC

November 2019

V0.4

“

VERSION CONTROL

Version Date Description Created Reviewed

01 06.11.19 First full Draft JB HD

02 08.11.19 Second Full Draft HD/JB PR/HD

03 11.11.19 Third draft with PR Commercial Case

JB/PR HD

04 13.11.19 Final Business Case JB/HD GH

CONTACT DETAILS

SPONSORING NHS ORGANISATION

NHS Buckinghamshire CCG

Executive Offices

Amersham Hospital

Whielden Street

Amersham

HP7 0JD

TITLE OF SCHEME Aylesbury Primary Care Primary Care Centre

CONTACT DETAILS

SRO Gary Heneage; Chief Finance Officer Helen Delaitre; Associate Director of Primary Care NHS Buckinghamshire Clinical Commissioning Group Executive Offices Amersham Hospital Whielden Street Amersham HP7 0JD

Tel: 01494 586773

Mobile: 07769 248733

Email: [email protected]


1. Executive Summary 1.1 Introduction

This full business case is in support of the development of a new build, fit for purpose Primary Care Centre to serve patients in the town of Aylesbury, Buckinghamshire and its wider catchment area. The premises will be held leasehold by two practices co-locating onto the site. The new primary care centre will be capable of delivering the following key criteria:

• Increase in capacity for primary care services out of hospital • Primary care working at scale • Capacity to provide for the expected population growth in this part of Aylesbury • Capacity to enable the opportunity to change ways of working by building skill mix within

the workforce and integrating with community services colleagues • Improve seven-day access • Provide increased training capacity.

The two practices that are co-locating into this new build are part of the ICS vision and have demonstrated to the CCG their commitment to delivering services of the highest quality, while at the same time embracing new ways of working at scale and in an integrated fashion. We are fully supportive of this FBC and will work closely with the practices and their appointed developer to achieve successful conclusion of this exciting new development within timelines stated.

Key points to note

The level of risk associated with this project is substantially reduced due to the following key points:

a. Planning permission is now in place b. Any risk of overspend on capital is underwritten by developer c. The practices will be signing a 25 year lease with the anticipated option to extend

further should they so wish d. A positive District Valuer report which confirms the rental and has been agreed by

the developer e. A facility which offers Value for Money, as confirmed by the DV report and

importantly offers sustainability well into the future with capacity for growth and flexibility of accommodation.

1.2 Strategic Context

NHS Buckinghamshire CCG is responsible for planning and commissioning healthcare services to meet the needs of local people. We are a member of the Buckinghamshire Integrated Care Partnership (ICP). The ICP is creating a place-based care system in which to deliver transformation that improves and integrates care and makes the system operationally and financially sustainable over the long term. The population, health and social care structures and the geography also offer ideal opportunities for delivering outstanding integrated care. The drivers behind transformation can be summarised as:

• The number and proportion of older people in the population is increasing.

• There are more people being diagnosed with long term conditions and a greater proportion of people living with co-morbidity.

• Greater prevalence of mental health needs and co-morbidity of physical and mental health illness.

• A shift in culture towards patient centred care, for all parts of the healthcare system. • The healthcare expectations of the population are changing in line with greater

consumer choice, 24/7 access, faster response times and better-informed consumers. • The approach to healthcare provision is shifting away from a paternalistic model with a

greater onus on patients taking a more active role in the management of their own health.

• Significant differences in health outcomes for different population groups. • Funding levels have decreased in real terms and the same resources are being spread

more thinly requiring more efficient use of funds available. • Greater integration between health and social care teams. • Advances in technology are enabling improved survival rates, more complex conditions

to be managed in a community or home setting and alternative ways of seeing and assessing patients.

• There are significant workforce issues in many parts of healthcare and this is keenly felt in primary care where fewer GPs are entering the profession and more are choosing early retirement; there are too few practice nurses and a lack of dedicated training and career structure.

• A combination of workload and workforce pressures is pushing some general practices to consider closure.

1.2.1 The Case for Change

The ICP is beginning to build a solid foundation on which primary care and PCNs will become central to strong community care integrated teams, resilient enough to face today’s and the future’s healthcare challenges.

Our practices are already struggling to keep up with the increase in population as a result of housing growth, while others are finding it difficult to recruit and retain staff, given the increase in workload in primary care today. Despite these challenges, the staff who are working within Primary Care are as committed as ever to deliver safe, quality services but need space in which to expand and develop more services.

The investment objectives for this project are as follows:

• Improved resilience in primary care services to meet on the day needs of residents

• Care integrated locally to provide better support closer to home

• Whole system approach to transforming health and care to achieve better patient experience and outcomes

• Redesign care model and make best use of clinical, estate and digital resources

• Deliver better value for money for the tax payer.

These objectives are derived from listening to the membership of the CCG who have repeatedly voiced concerns regarding the resilience within primary care, given all the challenges currently being faced. Our solution to these concerns is the development of the care model, with all partners within the ICP who have a stake in ensuring that we have a sustainable future.

Both practices no longer have the physical capacity to offer the services demanded from their combined patient list which is increasing annually in size as new housing is developed in this part of Aylesbury and its demographic profile is ageing in line with national population trends.

The proposal will support the colocation of the two practice teams and bring primary and community care together into a local facility that is aligned to the ICP model of care. This will deliver improved access to care for patients and transform the way care is delivered, through the implementation of digital technology and working in collaboration with other services to meet the health and social care needs of patients. The scheme will also improve local resilience and create capacity to manage future population growth.

Both practices desire to work collaboratively adopting a federated and transformational approach to patient care, sharing best practice and enabling them to improve efficiencies of working together and becoming more cost effective.

The existing practice premises have a number of disadvantages, they are:

• Inadequate in size • Inflexible • Not fit for purpose or capable of being extended • Not fully compliant with modern healthcare standards.

All these issues result in an inefficient way of working. The premises of both practices are thwarting the ambitions of the ICP and the GP practices and their desire to improve the level of service they offer their patients and to increase their training capacity.

The two practices together provide services for just over 24,300 patients and planned housing growth in and around the greater Aylesbury area will see the projected practice lists grow to over 32,000 within the next 10 years which will exacerbate the inadequacies of both existing premises with resultant pressure on accessibility, services and patient care.

1.2.2 Existing surgery premises serving Aylesbury

Meadowcroft Surgery:

This practice is situated on Jackson Road in Aylesbury. The building is traditional masonry construction split across two storeys and is 590m2 NIA in size. Whilst the site does offer discrete areas for expansion, the limiting factor will be the number of parking spaces available which will need to be increased proportionally with any building footprint increase as per local

Planning Authority requirements. The list size at the time of writing is approximately 15,240 with 23 car parking spaces for patients and 8 for doctors, 2 of these are dedicated disabled parking spaces.

According to a Six Facet Survey completed on the premises in December 2016, the report noted that at the time of the survey the practice was advised that storage space and seating/waiting was generally insufficient. Clinical space was noted to be under pressure most of the time due to growing patient numbers (practice built for 10,500 patients, at time of survey (Dec 16) 14,500 patients registered) and 98% of space was deemed to be “over-crowded”.

CATEGORY Rating Action

Provision of Accommodation

Insufficient clinical and admin rooms to building C Improvement required

Seating and Waiting

Seating and waiting space is generally insufficient C Improvement required

Separation of Male/Female Toilets

There are no separate WCs to the building C Improvement required

Storage Facilities

Inadequate space throughout C Improvement required

Table 1: Extract from Meadowcroft 6 Facet Survey Berryfields Medical Centre:

The need for a primary care facility to cater for residents of the Berryfields and Buckingham Park suburbs was identified and approved in 2004 and the Berryfields Medical Centre has been located on a slim parcel of land adjoining some green space, off Colonel Grantham Avenue, Buckingham Park in Aylesbury since 2007. The building is comprised of a number of porta cabins joined together to form a larger space which is in the region of 250m2 NIA in size. Whilst there is some room to expand on the site, there are a number of limitations with regards to adjoining land ownership and suitability of extending this construction type for modern primary care services. The list size at the time of writing is approximately 9,110 with 14 car parking spaces for patients, 2 for doctors, and a further 2 disabled parking spaces.

Buckinghamshire will see significant change in terms of growth over the coming years and the impact of current and expected housing growth will be particularly acute in and around Aylesbury. Practices are already struggling to keep up with the increase in population and some are finding it difficult to recruit and retain staff, given pressures caused by the increasing workload in primary care today.

Fig 1: Catchment areas for Berryfields Medical Centre and Meadowcroft Surgery and Aerial View The proposal will support the co-location of the two practice teams and bring primary and community care together into a local facility that is aligned to the ICS model of care. This will deliver improved access to care for patients and enable transformation of the way care is delivered, through the implementation of digital technology and working in collaboration with other services to meet the health and social care needs of patients. The scheme will also improve local resilience and create capacity to manage future population growth.

This business case has clear evidence of support from: • the PPG Chairs • Councillor for Buckingham Park, Aylesbury and • Joint Letter of Support from the Practices.

1.2.3 Design proposals

The design has been developed based on an agreed schedule of accommodation totaling approximately 2109m2 GIA (1973m2 NIA). There has been clinical engagement in design development, and clinical leads have provided clinical sign off.

The Aylesbury Primary Care Centre will be subject to a BREEAM Assessment in order to drive the eco-credentials of the scheme. The expectation will be BREEAM Excellent which meets NHS standards. The buildings will comply with NHS design and specification standards, infection control standards, BREEAM rating (including energy efficiency measures) and offer future internal flexibility and physical capacity to enable the building to be extended to provide additional clinical, back office and waiting room capacity. The Practices have agreed

their funding requirement in relation to Group 2 and 3 items is not included within the building specification.

The building specifications will include the IT and telephone cabling infrastructure. The practices will be responsible for their telephone systems and the CCG responsible for any upgrading of IT equipment required. The investment in IT will ensure that digital solutions fully support delivery of the new model of care.

1.2.4 Digital Solutions

The CCG is encouraging practices to offer remote consultations as soon as practices are digitally enabled. First contact with patients will also use AI-based models so that when the patient contacts the practice, they will be automatically streamed to the best healthcare professional, online advice or self-help strategy. The software will also speed up the consultation process by enabling the patient to provide some history and other remote examination data so that the time spent in consultation with the healthcare professional is most effectively used. By enabling remote consultation, the practices will find it easier to recruit younger GP's who prefer a more flexible method of working. This offers a practical solution to practices who are struggling to fill their sessions or who may require overflow options when the demand temporarily outstrips supply.

The Berryfields/Meadowcroft build will also provide a digital information hub in the lobby of the building with several terminals to ease the process of registration, care navigation and appointment booking.

1.3 Economic case

1.3.1 Funding Requirement

ETTF funding is sought for £ 3,605k. Pre-project costs have already been signed off at £50k. The breakdown of the funding requirement and the funding being provided by the Development Company is detailed below in Table 2.

Table 2 Capital and Funding Requirement

Developer ETTF TOTAL

£k £k £k

LAND 2,100.0 2,100.0

VAT 420.0 420.0 Total Land 2,520.0 - 2,520.0 BUILD

Capital Split 4,277.1 2,794.4 7,071.5 VAT 836.5 558.9 1,395.4 SDLT 191.8 191.8 Construction Funding 5,113.6 3,545.0 8,658.6 Pre Project Funding 50.0 50.0

GP IT 60.0 60.0

TOTAL PROJECT FUNDING incl. VAT

7,633.6 3,655.0 11,288.6

FBC

CAPITAL

1.3.2 Non Financial Options Appraisal

In accordance with the capital investment manual and requirements of HM Treasury’s ‘Green Book’, an options appraisal has been carried out to consider a range of options to deliver the scope set out in the strategic case.

A non-financial Options Appraisal was undertaken to weight the benefit criteria for their relative importance, and appraise each shortlisted option against them.

Critical Success Factors for the project

The following Critical Success Factors (CSFs) need to be met by all NHS Buckinghamshire CCG Primary Care developments.

• Efficient, Fit for Purpose Environment • Sustainable for the future development of improved and integrated services for delivery

of primary and community care and services associated with general health and wellbeing

• Delivering the Long Term Plan for Health and Social Care.

In order to qualitatively assess the options against the critical success factors, benefit criteria were developed to describe the key deliverables the preferred options should achieve. These were based on the investment objectives and critical success factors.

The criteria and weighting used to assess the options are as follows:

Table 3: Criteria and weighting

Criteria Definition Weight

Access to the facility & services

An assessment of Parking /transport links and geography 20.00

Range of Services for patients

A focus on the Co- location of services and access for Patients 20.00

Transformation in line with National and Local Strategies

16.67

Environment The internal space and design 13.33

Deliverability This area assesses time, risk and challenges in delivering the solution. It also incorporates the GP Practice willingness to support the Option

16.67

Sustainability Fitness for purpose of the development into the future and supporting the growth that is expected in the area

13.33

Total 100.00

1.3.3 Options for Consideration

1 Do Nothing

COMMENTARY Berryfields cannot sustain delivery of services from modular units much beyond 2020. This would lead to closure of their practice list. Meadowcroft is the next closest surgery, but is already 50% under supplied in space standards for its list. Meadowcroft has already advised the CCG that they will be forced to close their list if new premises cannot be found. Other surgeries are geographically too far away and have no capacity to absorb more patients. The Do Nothing option will leave patients looking to register in the area without a GP.

2 Develop Standalone solutions for each practice

COMMENTARY Although Berryfields could separate and find a location within the catchment area in isolation, the alternatives for Meadowcroft are extremely limited. Meadowcroft’s on-site schemes to extend accommodation provide insufficient space. Redevelopment of the site requires consent of the Freeholder which is likely to be withheld. Redevelopment would require a decanting alternative for services in order to phase a new build whilst maintaining service provision. Development of standalone solutions negate any of the potential advantages of transformation and are not capable of responding to the NHS Long Term Plan.

3 A new build single site but with 2 completely separate practices

COMMENTARY Completely detached yet parallel development offers few benefits to patients. This approach is economically expensive, requiring duplication of every aspect of development. It is considered regressive and leads both Practices into uneconomic methods of working. This option would not enable transformation nor would it provide the 24/7 access anticipated.

4 A new build single site with maintained independence for the 2 practices

COMMENTARY Retention of organisational and functional separation reduces risks of cultural change. Delivery of transformational healthcare would be challenging and probably impossible. Duplication will add cost at both development stage and operationally.

5 Single Site, integrated working potentially leading to merger of the 2 practices

COMMENTARY This is the confirmed preferred Option It is the most operationally economical, for its flexibility and as the only opportunity to provide the best integration and transformational service.

This is the only Option that can deliver the shared Vision of both Practices. Integrated working can involve training ahead of occupation but the speed of and extent of complete merger can be controlled to suit cultural, technical and business practices of each organisation. Initially there would be separate Patient Lists, but working increasingly closely to share resources. By centralising back office functions, integrating IT systems, combining waiting areas for streamlined care navigation, immediate efficiencies are created. Both will have identical ‘Care Team’ systems and mirrored ‘Care Zones’. This will enable the transformational care which is the vision of both Practices but will allow each surgery to keep its own identity, providing reassurance for existing patients. The Practices would share meeting and education spaces, and anticipate a natural migration towards becoming a single entity.

Table 4: Options for Consideration

1.3.4 Options Appraisal

Summary of Qualitative Options Appraisal

SUMMARY OF SCORING OPTION WEIGHTED Max

Category Weighti

ng 1 2 3 4 5

A: Access to the facility and services 20.00 20.0 23.3 60.0 73.3 80.0 100.0

B: Choice for patients 20.00 23.3 23.3 56.7 93.3 100.0 100.0

C: Transformation in line with National and Local Strategies

16.67 16.7 16.7 16.7 50.0 83.3 83.3

D: Modern Inspirational environment 13.33 17.8 26.7 53.3 64.4 66.7 66.7

E: Deliverability 16.67 25.0 16.7 50.0 66.7 75.0 83.3

F: Sustainability 13.33 13.3 13.3 40.0 35.6 66.7 66.7

100 116.1 120.0 276.7 383.3 471.7 500.0

23% 24% 55% 77% 94%

Table 5: Summary of Qualitative Options Appraisal

Option 5: Single Site, integrated working potentially leading to merger of the 2 practices.

This option achieved the highest scores for qualitative benefits and was the preferred option at OBC. The option is preferred as the most operationally economical, for its flexibility and as the only opportunity to provide the best integration and support a transformational service.

The preferred option was confirmed at OBC panel and has been taken forward to develop the Full Business Case. The build cost has increased from the original estimates but this has been absorbed by the developer. The rental and abatement figures have been agreed by the District Valuer, the Developer and the CCG.

The Site identified at OBC to deliver this option – the Berryfields site is therefore confirmed as the development to proceed to award of funding and contract.

1.3.5 Economic Appraisal

1.3.5.1 Funding Requirement

Table 6: Funding requirements

1.3.5.2 Generic Economic Model (GEM)

(NHS England Generic Economic Model for projects requiring under £5m capital investment).

For GEM purposes, only the following options are expressed below with financials: • Option 1 – Do Nothing • Option 5 - Single site, integrated working leading to potential merger of the practices For completeness we are showing the OBC and the updated FBC figures

Indicative Build costings were provided by the developers for all options but only Option 5 was pursued for full financials and DV assessment as the Qualitative outcome was so overwhelming.

1.3.5.3 Outcome of GEM Process

Summary NPV AEC Points £ per

£000s £000s

Point

Do Nothing Do Nothing 3,314 194 23 144.1

OBC APCC Berryfields - Aylesbury Site 9,332 547 94 99.3

FBC APCC Berryfields - Aylesbury Site 9,546 560 94 101.6

Table 7: Summary of GEM outcomes

1.3.5.4 Key Assumptions • The discount factor applied to all Options is 3.5% • Assessment is over 25 years • Capital investment by ETTF in the build at £ 2,794.37k net of VAT

Mont pelier

NHS Net VAT TotalMont pelier

NHS Net VAT Total

£k £k £k £k £k £k £k £k £k £k £k £k

Land 2,100.00 2,100.00 420 2,520.00 2,100.00 - 2,100.00 420.00 2,520.00 - - TOTAL Land 2,100.00 - 2,100.00 420 2,520.00 2,100.00 - 2,100.00 420.00 2,520.00 - - BUILD

NHS 2,685.00 2,685.00 537.00 3,222.00 2,794.37 2,794.37 558.87 3,353.24 131.24 109.37 Montpelier 4,557.50 4,557.50 911.50 5,469.00 4,277.10 4,277.10 836.52 5,113.62 - 355.38 - 280.40 SDLT 78.00 78.00 15.60 93.60 191.76 191.76 191.76 98.16 113.76 Total Build Cost 4,557.50 2,763.00 7,320.50 1,464.10 8,784.60 4,277.10 2,986.13 7,263.23 1,395.39 8,658.62 - 125.98 - 57.27 GPIT 300.00 300.00 300.00 60.00 60.00 60.00 - 240.00 - 240.00

Pre Project costs 55.00 55.00 55.00 50.00 50.00 50.00 - 5.00 - 5.00

Optimism BIAS - - - - - - - - - Total Project Cost 6,657.50 3,118.00 9,775.50 1,884.10 11,659.60 6,377.10 3,096.13 9,473.23 1,815.39 11,288.62 - 370.98 - 302.27

FBC Movement from OBC Incl VAT

Movement from OBC Excl VAT

CAPITAL

OBC

• GP IT investment is estimated at £60k • VAT is excluded from the build investment and from the rental calculations

1.3.5.5 Optimism Bias In the early stages of a project, GEM requires the application of “Optimism Bias” (OB). This applies a percentage of risk or “Optimism” to the Financials in assessing the options that have been considered. The Full Business Case is in place and therefore Optimism Bias is no longer required.

With regard to the Berryfields site, the maximum ETTF capital funding in respect of the build is assumed at £2.794m plus VAT with the developer bearing the risk on any capital overspend.

The developer has agreed the rental figure.

1.3.5.6 GEM Summary

The table below is the GEM extract for the life of the initial Lease period in respect of the preferred Option:

The capital is assumed to be paid over in Year 0.

Capital funding for GEM purposes of £2,904 is made up as follows:

ETTF Build Investment (excluding VAT) £ 2,794.37k ETTF Pre-project Costs £ 50.00k ETTF GP IT £ 60.00k Total £ 2,904.37k

We are also using £ 191.76k to support the potential SDLT.

The Capital risk sits with the Developer. The economic case has reflected a 5% optimism bias to reflect the potential for any resultant increase in revenue which might accrue as a result of increased Capital cost.

However, although this has been included the market rent has been identified by the District Valuer and has prevailed regardless of the development cost. This is a key restriction in place to ensure that the developer will manage the cost of development.

Table 8: GEM Summaries Preferred Option at FBC and OBC stage compared with Do Nothing

FBC : Aylesbury PPC - BerryfieldsYEAR

0 1 2 3 4 5 6-10 11-15 16-20 21-25 TOTAL 25£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Opportunity Costs 0 0 0 0 0 0 0 0 0 0 0 0Land Transactions 0 0 0 0 0 0 0 0 0 0 0 0Capital Costs 2,904 0 0 0 0 0 0 0 0 0 2,904 0Service Costs 0 391 391 391 391 391 1,957 1,957 1,957 1,875 9,703 391Transition Costs 192 0 0 0 0 0 0 0 0 0 192 0Optimism Bias

Capital 0 0 0 0 0 0 0 0 0 0 0 0Service 0 0 0 0 0 0 0 0 0 0 0 0

Total Optimism Bias 0 0 0 0 0 0 0 0 0 0 0 0TOTAL 3,096 391 391 391 391 391 1,957 1,957 1,957 1,875 12,799 391Discounted Total 9,546Annual Equivalent Cost 560

YEAR

The overall revenue cost has moved from that presented at OBC due to the following key changes:

• Increase in Rental from £204 per m2 to £230 per m2 • Reduction of rental abatement return to 3.5%

These increases are mitigated by:

• Reduction in space from 1,994m2 to 1,973m2 • Optimism Bias provided for at OBC has been released

The net impact is therefore £ 14.30k pa

OBC FBC Movement

£k £k £k Building rental (including Parking spaces) 428.06 479.55 51.49 Repairs 21.51

(21.51)

Abatement (171.87) (169.55) 2.32 Building rates (estimate) 81.36 81.36 (0.00) TOTAL 359.06 391.36 32.30 Optimism Bias 18.00 - (18.00) TOTAL COST TO CCG including Optimism Bias 377.06 391.36 14.30

Table 9: Net Impact of Changes between OBC and FBC

OBC : Aylesbury PPC - BerryfieldsYEAR

0 1 2 3 4 5 6-10 11-15 16-20 21-25 TOTAL 25£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s

Opportunity Costs 0 0 0 0 0 0 0 0 0 0 0 0Land Transactions 0 0 0 0 0 0 0 0 0 0 0 0Capital Costs 3,040 0 0 0 0 0 0 0 0 0 3,040 0Service Costs 0 359 359 359 359 359 1,795 1,795 1,795 1,714 8,895 359Transition Costs 78 0 0 0 0 0 0 0 0 0 78 0Optimism Bias

Capital 0 0 0 0 0 0 0 0 0 0 0 0Service 0 18 18 18 18 18 90 90 90 72 431 18


YEAR

Do Nothing YEAR0 1 2 3 4 5 6-10 11-15 16-20 21-25 TOTAL 25

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000sOpportunity Costs 0 0 0 0 0 0 0 0 0 0 0 0Land Transactions 0 0 0 0 0 0 0 0 0 0 0 0Capital Costs 0 0 0 0 0 0 0 0 0 0 0 0Service Costs 0 201 201 201 201 201 1,006 1,006 1,006 804 4,826 201Transition Costs 0 0 0 0 0 0 0 0 0 0 0 0Optimism Bias

Capital 0 0 0 0 0 0 0 0 0 0 0 0Service 0 0 0 0 0 0 0 0 0 0 0 0

Total Optimism Bias 0 0 0 0 0 0 0 0 0 0 0 0TOTAL 0 201 201 201 201 201 1,006 1,006 1,006 804 4,826 201Discounted Total 3,314Annual Equivalent Cost 194

YEAR

1.3.6 Project Benefits

1.3.6.1 Cash Releasing

This investment is primarily driven by the need to bring the GP practice estate up to todays’ standards for health facilities and the need for additional capacity in the future to ensure that the estate supports primary care services that are sustainable.

The upfront investment delivers an annual abatement of some £170k. Without this upfront investment, the CCG would not have sufficient funding to support the revenue stream going forward. Therefore although not directly cash releasing in terms of savings it is a key contribution to a sustainable Primary Care service

1.3.6.2 Non Cash Releasing

This section describes the objectives and benefits associated with the project and how these benefits will be delivered. It ensures that the project will be designed and managed in the right way to deliver quality and value benefits to patients, staff and local communities.

The practices have worked together to demonstrate how the proposal will produce tangible benefits to the system and meet collective objectives. These are non-cash releasing efficiency benefits delivering practical benefits for patients accessing healthcare services through a primary care hub.

The Vision Practice Deliverables

Improving the wellbeing of local people by helping them to stay healthy, manage their own care and identify health problems earlier

• We are going to improve access to health care by providing self-care promotion information on the website, in the lobby, on the telephone, and providing care navigators.

• We will work in multidisciplinary micro-teams to speed access to the correct clinician or service.

• We are already working in multidisciplinary teams (consultants, specialist nurses, practice nurses, GPs) to improve diabetes home care and will work to expand this model to other long term conditions.

• We are discussing with the ICS about ways to work on a population level to promote health and avoid hospital admissions.

• We are engaging with stakeholders and community leaders to formulate joined-up services. The new building will be used for community group sessions to promote healthy living.


Organising urgent and emergency care so that people are directed to the right services for treatment, such as the local pharmacy or a hospital A&E department for more serious and life-threatening illnesses

• Our clinicians have very robust experience of telephone triaging so that each person can be seen by the correct service at the correct time.

• We are looking at the use of IT to enhance and streamline this service.

• Our flexible ‘Care Zones’ allow for observation of children or adults who could be actively managed on site, after a GP consultation, rather than referred to A&E.

Prioritising initiatives that reduce health inequality and maximise the role of prevention in improving health

• Our over-75s nurse proactively manages our more frail patients while they are still well, and we plan to expand this model of care.

• We have a case manager who works with our more needy patients in order to engage them more in self-care and understand how to navigate the NHS.

• We have approached the ICS for funding for a transformation manager who can use population health data to identify the medical needs of the population.

• We will need to work with other GP practices and the hospital trust to target that population and improve their health care access, understanding and self-management, or to provide hub services on site e.g. CATS service or outpatient clinics.

• Our building plans identify the prioritisation that we have given to communal space for care navigation kiosks, voluntary agencies and social prescribing support groups.

Integrating health and care services by bringing together health and social care staff to organise treatment and deliver patient centred care

• Our newly combined communal space will afford the opportunity for peripatetic staff to regularly meet with us and our patients.

• This joint working will improve safeguarding of the most vulnerable groups and facilitate efficient inter-team working.


Significant increases in population due to new housing growth which could not be accommodated if the practices do not move to new premises.

• Currently, we are at absolute capacity with no room for expansion.

• Our patient list size projections (31,000) provide the case for requesting this proposal be approved.

Working with general practice to make sure it is central to delivering and developing new ways of providing services in local areas

• The new health hub will be specifically designed to host our new way of providing primary care services to the local population.

• The Care Zones are strategically arranged to maximise use and efficient workflow whilst maintaining a culture of “usual doctor lists” and dedicated continuity of care.

• We will work to make the health centre a hub for local services and develop a real sense of community amongst our patient group.

An increase in demand for services, especially for frail older people who often have more than one health and care need

• As mentioned above, we plan to increase our collaboration with the community Nurses and to actively support our complex, elderly, frail or vulnerable patients.

• Our care navigators are trained to help patients with complex health needs access services promptly and ensure appropriate professional input from an increasingly wide range of local options.


Difficulty in recruiting and retaining staff due to the high cost of living, which leads to inconsistent levels of care and unsustainable services

• The new health premises will be designed to provide a comfortable workplace, sensitive to staff needs. By regularly consulting our current staff on the design, we expect to include all the practical requirements that a cohesive workforce needs to thrive.

• Our newly proposed models of working will attract naturally ambitious staff keen to share learning and support the team.

• Working at scale, with a rapidly growing patient population, will afford opportunity to promote and train in house, thereby encouraging staff retention.

• A stable workforce creates resilience and ultimately sustainable, consistent patient care.

Ensuring that the amount of money spent on management and administration is kept to a minimum so that more money can be invested in health and care services for local communities

• By combining the back office functions of the two practices, we will achieve economy of scale for the business whilst freeing up valuable floor space that will be diverted to patient engagement areas.

Developing our workforce, improving recruitment and increasing staff retention by developing new roles for proposed service models

• Working at scale will attract a workforce that can be subsequently challenged and promoted in-house. This stimulation will give opportunity to create new roles and services that would not normally be viable in a smaller working environment.

Using new technology so patients and their carers can access their medical record online and are supported to take greater responsibility for their health.

• Digital technology will be incorporated at all levels to promote efficiency.

• Our Care Navigators will be specifically trained to empower patients to access these platforms and therefore help manage own their health.


Ageing NHS buildings which are not fit for modern use

• Berryfields Medical Centre is currently housed in a selection of ageing portakabins that are highly inefficient for heat and light and noise pollution. The main cabin is now 11 years old and literally falling apart at the seams.

• Meadowcroft Surgery was built in 1992 and is now just over half the size it should be to house the current patient population. Further to exploration of options, we cannot rebuild or extend the building. Each clinical room is 13 m2

or less in size (standard size 16m2).

Table 10: Tangible Benefits for Patients

The practices have also used the core criteria for ETTF Schemes (2016) taken from ETTF Guidance for CCGs to match expectations with deliverables.


Improved access to effective care • We believe that our new clinical model of working will revolutionise primary care team working.

• Whilst supporting staff we have designed the service to integrate patients into the heart of primary care, encouraging ownership of ‘their’ practice.

• Continuity will be maintained through the careful ‘Care teams’ and the dedicated, accountable and accessible support staff.

• Incorporation of digital platforms through every level of care navigation will foster efficient, safe work at scale.

Increased capacity for primary care services out of hospital

• Multifunctional Care Zone rooms will be efficiently rostered to aim for 80% occupancy at all times. This will be facilitated by ‘hot desks’ for clinicians to practice telephone or on-line consulting thereby increasing capacity for primary care services out of hospital.


Commitment to a wider range of services as set out in the CCG’s commissioning intentions to reduce unplanned admissions to hospital

• We have entered into conversations with the CCG and Bucks Healthcare Trust and will willingly offer space to a variety of health services as per commissioning intentions.

• We have also committed to o extended hours, o 8-8 working and o Out of Hours service teams.

Increased training capacity • The Care Zones are specifically set up to engender a supportive training environment for clinicians of all grades.

• ‘First 5’ GPs will all be offered an experienced GP mentor with clear pathways to career progression.

• GP trainees and F2s will be mentored by their named trainer,

• Medical students will be encouraged. • Nursing students will continue to be

placed with our practice and • The Paramedics already in place will lead

their teams with multidisciplinary support from other clinicians.

• Clinical Pharmacists will add to the support and learning on offer, and in turn mentor the newer members of their team.

• The non-clinical staff will experience the same supportive guidance with

o personalised inductions, o clear protocols, o regular appraisal and o feedback sessions. • Placements will be made available to

work experience students from the Aylesbury area.

Table 10: Meeting core ETTF criteria

1.3.7 Sensitivity

The results of the economic appraisal illustrated above show that there is only one viable option, the alternatives do not deliver the key criteria.

1.3.8 Risk

District Valuer Report

The District Valuer’s Report outlines that use of the Market rent manages the revenue risk for the life of the lease and encourages cost efficient behaviours in the developer.

1.4 Commercial case

1.4.1 Ownership Structure and Procurement Decision

The chosen ownership structure for establishing a new health Primary Care Centre is through a Third Party Development.

A Memorandum of Understanding (HOTs) has been drawn up between the three parties concerned being:

• The Developer: Montpelier Estates • The Practices:

o Meadowcroft and o Berryfields.

This specifies that land will be purchased and buildings will be procured through the letting of a JCT Management Contract following a full competitive tender process. The practices and the GP’s and staff of both practices have been offered the opportunity to buy into the ownership of the third party development.

The practices have chosen not to be part of the ownership model however some of the GP’s may do so as individuals. The default position is that Montpelier Estates will fund the development in full should the individual GPs choose not to participate.

A 25 year Lease will be granted to the two practices. Other healthcare providers may also occupy the building on similar rental terms excluding occupation of any of the GMS space.

Montpelier Estates will act as developer and procure the new building via the traditional 3PD process. Montpelier will take full responsibility for the entire development process including managing the programme and being fully responsible for all project costs including the construction cost.

The construction work has been robustly and competitively tendered over a 10 week period to three contractors with the appropriate experience in the Primary Care market and financially capable of undertaking the project , to ensure a market price is achieved that reflects best value for money and will be subject to scrutiny by Pick Everard.

Upon completion of the building, each practice will enter a 25 year lease reflecting the agreed leasing terms; the agreed proportion of the abated GMS rental will be paid under the Premises Cost Directions and be fully reimbursed. The rent reimbursement, the payment of VAT on the rental and building rates will be the responsibility of the CCG. The running costs of the building will be responsibility of the GP practices (paid proportionally to their accommodation space), an indication of the projected operating costs has been provided to each practice.

Montpelier will lead the project team, chair and record all meetings and regularly communicate progress and actions to the project participants, stakeholders and their advisers and the consultant delivery team appointed by Apollo. The development programme will be actively managed to ensure that the target date for completion of the new building (February

2021) is achieved so that this new facility will be available to patients within the agreed timeframe for ETTF funding.

The proposed development programme dates are: Milestone Date CCG Finance Committee 30 October 2019 Submission of FBC November 2019 NHS E Panel 16 December 2019 GP’s exchange Agreement for Lease January 2020 Appoint Contractor January 2020 Commence Construction March2020 Construction Complete February 2021 Handover of Building and lease completion February 2021

Table 11: Milestones

The detailed arrangements for the utilisation of NHS capital within the project structure have been discussed with the NHSE ETTF lead Jo Fox (via Teresa Donnelly). In the absence of revised Premises Cost Directions (PCDs) which may provide direction, it has been agreed to use Direction 6 of the PCDs which will allow the capital to be paid to the developer/investor, via the GP practices at the point the building reaches practical completion.

We are aware that NHSE/I are engaged in an exercise reviewing the legal wording and conditions to be incorporated in the Project Agreement which will support the funding transfers and that the final documents are imminent. These will be incorporated into all the legal agreements between the Practice, the developer and NHSE/I if required.

1.4.2 FM services

The owning company will set up a management committee to take care of the facilities management role. The GP Practices will be represented on the management committee. This will ensure the continued, direct involvement and mutual benefit of the interests of the landlord and tenant.

1.4.3 Workforce

It is the intention of the practices to merge the Meadowcroft partnership and the Berryfields Company (BK Health Ltd) into a single employing organisation and the practices will apply to the CCG to novate both contracts into the new organisation.

The new organisation will be run by a board consisting of the partners and directors of the existing organisation. It is a similar process to the one carried out successfully in Oxford where the Berryfields practice leaders already have experience and expertise in managing this process.

All staff from both organisations will move across into the new organisation under TUPE regulations.

The practices do not anticipate any redundancies and indeed anticipate that with the expected growth in the area they will need to employ more staff.

1.4.4 Equipment

Existing equipment will be re-utilised wherever possible. Any additional equipment required will be the responsibility of the practices to fund.

1.4.5 Planning consent

The detailed planning application was lodged and registered by the Planning Authority, Aylesbury Vale District Council (AVDC), on 8th May. The developer, Montpelier, exchanged a conditional contract to purchase the site from Taylor Wimpey on 11 October 2019; the purchase being conditional on planning.

A Delegated Officer Report from AVDC Planners dated 11 October 2019 has been received that conditionally approves the planning application subject to a completed Section 106 Agreement. The wording of that Agreement is agreed and requires signatures from Taylor Wimpey (vendor), Montpelier Estates (purchaser), AVDC and Buckinghamshire County Council. The full planning consent is anticipated in late November and will be provided in due course.

1.4.6 Exit Strategies for each practice from their current premises

Berryfields Surgery is accommodated in temporary Portakabins on Parish council land on a short lease. NHSPS manage the facility for Berryfields and are fully apprised of this project. When Berryfields move to the new facility the Portakabins will be removed and the land returned to the Parish council.

Meadowcroft own their surgery and will dispose of the building when they move to the new facility. The Ground Lease is held by Aylesbury Vale District Council.

The Practices have been awarded ETTF Pre-project costs to provide legal advice on initial HOTs and subsequently to negotiate agreement to lease and the final lease conditions with the developer’s solicitors.

1.5 Financial Case

1.5.1 The financial case reflects the strategic direction set out in the strategic case and the economic options appraisal.

1.5.2 Key Financial Assumptions

The key financial assumptions are:

• The route to transfer funds to the Developer has been agreed between the parties under advice by NHS England and will be a payment under Direction 6 to the GP practices for onward submission to the developer as a payment on invoice.

• The Practice will enter into a long term lease for the property – 25 years.

• VAT treatment:

- The developer is able to reclaim VAT on its building costs

- The Practice will be required to pay VAT on the invoice from the developer. At this stage it is assumed the VAT is not recoverable but further tax advice is being sought. This would increase the benefit and potential rent abatement.

- Rental will attract VAT as the developer is opting to tax and reclaiming VAT for the build.

1.5.3 The Funding requirement

The table below sets out the total funding requirements for the Aylesbury Primary Care Centre build and sets out the ETTF contribution required for the scheme:

Table 12: Funding Requirement for Preferred Option

1.5.4 Consequences of funding not being made available

The advance of ETTF funding will abate a proportion of the market rent of the new building. This abatement makes the project affordable to the CCG and without it the project will not go ahead and primary care services in this area will be severely impacted in the future.

1.5.5 Interim source of funding pre completion

The full development cost of £9,709.4m plus VAT will be funded initially by the developer. Under the 3PD model, the speculative costs to develop the project have been and will continue to be funded by the developer.

The CCG has no further capital funding requirement with the transaction costs either funded via the ETTF capital or directly by NHSE (DV and Pick Everard fees).

The ETTF funding figure that has been applied to the project is £3,605k plus £50k Pre-project costs.

The remainder of the capital is confirmed as being provided by the developer.

1.5.6 Current and Future Revenue Expenditure

The net capital contribution to the build sum has been agreed by the District Valuer to be amortised to derive a rental stream over 25 years. This figure is £170k pa which has been applied as the amount of abated rent.

There is no capital asset held in the CCG account there is purely a movement on current and future rent and rates which are the sums the CCG is responsible for reimbursing to the Practices.

The practices are responsible for the day to day cost of operations within their GMS contact payment. They have been advised to take independent advice to ensure that the costs in

Developer ETTF TOTAL

£k £k £k

LAND 2,100.0 2,100.0

VAT 420.0 420.0 Total Land 2,520.0 - 2,520.0 BUILD

Capital Split 4,277.1 2,794.4 7,071.5 VAT 836.5 558.9 1,395.4 SDLT 191.8 191.8 Construction Funding 5,113.6 3,545.0 8,658.6 Pre Project Funding 50.0 50.0

GP IT 60.0 60.0

TOTAL PROJECT FUNDING incl. VAT 7,633.6 3,655.0 11,288.6

CAPITAL

relation to the increase in space are affordable and in line with anticipated incremental patient registration.

A comparison of current and future revenue is detailed in the table below:

AYLESBURY PCC - Berryfields

REVENUE CURRENT OBC FBC VAR FROM OBC

VAR FROM CURRENT

SQM 840 1,994 1,973 (21.00) 1,133 £ £ £ £ £ Rent pa 213.65 204.00 230.00 26.00 £k £k £k £k £k 179.47 406.78 453.79 47.01 274.32 Car parking 21.28 25.76 4.48 25.76 Abatement (171.87) (169.55) 2.32 (169.55) VAT 51.24 62.00 10.76 62 Repairing 21.51 - (21.51) 0 Rates 21.64 81.36 81.36 - 59.72 Gross 201.11 410.30 453.36 43.06 252.25 Optimism Bias 21.00 - (21.00) 0 Net 201.11 431.30 453.36 22.06 252.25 Table 13: Current and Future Revenue

The increase compared to current costs is some £252.25k per annum and is an increase of some 225%. This should be viewed in the light of the increased capacity being provided which is comparable at 235%.

The revenue costs for this scheme have increased since the OBC by some £43.06k pa. However this is mitigated by the provision of optimism bias in the OBC such that the increase is only £22.06kpa. The increase is due to a £26 per m2 increase in rental and a reduction in the return percentage to 3.5%

1.5.6.1 Future Revenue Expenditure

Revenue costs with ETTF Support OBC FBC Movement

£k £k £k

Building rental (including Parking spaces) 428.06 479.55 51.49

Repairs 21.51 (21.51)

Abatement (171.87) (169.55) 2.32

VAT 51.24 62.00 10.76

Building rates (estimate) 81.36 81.36 (0.00)

TOTAL 410.07 453.36 43.07

Optimism Bias 21.00 (21.00)

TOTAL COST TO CCG including Optimism Bias 431.07 453.36 22.07

Revenue costs without ETTF support: OBC FBC Movement

£k £k £k Building rental (including Parking spaces) 428.06 479.55 51.49

Repairs 21.28 (21.28)

VAT 85.61 95.91 10.30

Building rates (estimate) 81.36 81.36 (0.00)

TOTAL 616.54 656.82 40.28

Optimism Bias 21.00 (21.00) TOTAL including Optimism Bias 637.54 656.82 19.28

Table 14: Revenue Costs with and without ETTF support

The cumulative impact over the 25 years is some £6.7m this is a net increase of some £553k from the OBC. It should be noted that this figure is inclusive of VAT and therefore is subject to any changes in the VAT rules. At this point it has been assumed that inflationary costs will be met by increased revenue resource. The growth in patient numbers will also increase over time and will go to mitigate the increase by increasing resource.

Table 15: Future Revenue Expenditure

1.5.7 Risk

The initial and future revenue risks are managed by terms in the lease as agreed with the District Valuer. The DV report has been reflected in this business case. and will be finalised once the planning consent is given and the exact design and square meterage is known.

1.5.8 Affordability

The Chief Finance Officer for NHS Buckinghamshire CCG has agreed that the sum of money for the Berryfields site is affordable.

The sum of money required has been noted against the future financial plans for CCG delegated Primary Care budgets. A letter from the CCG to this effect accompanies this OBC.

1.6 Management case

1.6.1 Project Delivery Robust arrangements are in place for the delivery, monitoring and evaluation of this scheme using Prince 2 methodology.

1.6.2 Project Board

The Aylesbury Primary Care Centre Project Board meets on a regular basis with support from the appointed consultants responsible for the design and construction of the new building together with independent advice from the practices appointed Monitoring Surveyor. The Board is responsible for:

• Ensuring that the NHS Policies and building guidance have been taken into account in the design of the new build

• Agreeing with the developer how best to implement plans to deliver the required building

• Mitigation of risk associated with the project.

Financial Impact FBCYear 0 1 2 3 4 5 6-10 11-15 16-20 21-25 TOTAL 25

RevenueNew costs 453 453 453 453 453 2,267 2,267 2,267 2,267 11,334 453 Optimism Bias -0% - Less current costs (186) (186) (186) (186) (186) (930) (930) (930) (930) (4,650) (186)

Increase from Current - 267 267 267 267 267 1,337 1,337 1,337 1,337 6,684 267

Cumulative - 267 535 802 1,069 1,337 2,674 4,010 5,347 6,684

INCREASE FROM OBC 42 42 42 42 42 213 213 213 213 1,066Release of Optimism bias (21) (21) (21) (21) (21) (103) (103) (103) (103) (513)Net increase from OBC 22 22 22 22 22 111 111 111 111 553

Cumulative 22 44 66 88 110 220 331 442 553 -

Years

The developer, Montpelier, will be fully responsible for every aspect and delivery of the project. The project lead, John Horsman (Development Director) will take overall responsibility throughout the entire life of the project, including signing off the 12 months defects liability period. He will be supported by his colleagues with the project management of the construction and snagging/ post completion phase of the project.

The Practices monitoring surveyor, Brown and Lee Clifford Billings, will be included in all meetings and decision making to ensure the building fully meets the requirements of the building specification. The CCG’s Estates Development Manager and Project Managers from Pick Everard, who NHS England use to monitor delivery of ETTF schemes, will be monitoring the construction including the tendering process to ensure the building is compliant.

1.6.3 CCG Governance

The CCG Responsible Officer for overseeing delivery of this project is Gary Heneage, Chief Finance Officer, supported by Helen Delaitre, Associate Director of Primary Care. The Project Board reports into the CCG’s Premises Sub Group, which is a sub group of the statutory CCG Primary Care Commissioning Committee (PCCC). Updates on this scheme have been received by the Premises Sub Group periodically, and any financial variations are approved by the Chief Finance Officer and reported to the Finance Committee in line with current SFIs/Scheme of Delegation. The business case was approved by Finance Committee on 7h November 2019 and will be presented to the PCCC on 5th December 2019. The Primary Care Commissioning Committee is also chaired by a CCG Governing Body lay member, and the committee was established in accordance with statutory provisions to enable its members to make collective recommendations and decisions on the review, planning and procurement of primary care services under delegated authority from NHS England.

1.6.4 Project Risks and mitigation measures

The Project Board will oversee risk and risk mitigation. Risks will be escalated as appropriate to relevant bodies by the Project Board as and when necessary.

The following risks have been identified:

• The time limited availability of the ETTF funding The project stakeholders are aware that should the development fail to be delivered, there is a high risk that the practices would not be able to develop and increase their service provision in line with patient need. There is no potential for further expansion at their existing sites, little development opportunity available in this part of Aylesbury and ever decreasing prospects of securing capital funding via the NHS to make this an affordable scheme for the CCG.

The project risks and mitigation measures are set out below:

Table 16: Project Risks and Mitigation AREA PROJECT RISK MITIGATION

Programme Delays The overall project programme is the responsibility of Montpelier as the developer.

The programme will be actively managed to ensure key milestone events are achieved on programme. In the event of any slippage, the programme will be assessed to establish how to absorb the delay by potentially considering undertaking tasks in parallel to gain the lost time.

The risk is that the project is delivered beyond the ETTF date. Completion date is currently February 2021.

The programme whilst the responsibility of Montpelier will be owned by all the project participants and their respective consultants who will collectively have an impact on the delivery of the project.

Planning Consent Planning application lodged. Planning consent has been granted

1.6.5 Post Project Evaluation The CCG and NHS England are committed to ensuring that a thorough and robust post project evaluation is undertaken at key stages in the project, to ensure that positive lessons can be learnt. The lessons learned will benefit future capital schemes both in the local and wider area. Post Project Evaluation (PPE) will set in place a framework within which the benefits realisation plan can be tested to identify which benefits have been achieved and which have not – with the reasons for these understood in a clear way. The key stages of PPE that will be evaluated are: • Implementation • Shortly after the new service has been brought on line • Once the service is well established.

1.7 Conclusion and Recommendation

1.7.1 Conclusion

This document provides a compelling case for investment in a new primary care centre in Aylesbury. This business case demonstrates that this project will deliver the following substantial benefits at an affordable cost: • An increase in clinical capacity to provide greater access to GP services, cater for

predicted population growth and provide extended hours by becoming a ‘hub’ for use by the practices and the wider PCN.

• The building will lend itself to the potential formal merger of both practices in the future with minimal physical alteration and disruption to patient care.

• It offers clinical space capable of bringing more services within the community and away from a hospital setting and encouraging GPs within the practices with special interests and other qualified providers to offer clinics.

• The development site has the capacity to enable the building and the car parking to be extended in the future without the need to buy any additional land. The building design can accommodate a single or two storey extension by extending existing clinical corridors to provide between 4 and 16 additional clinical rooms to accommodate other users to provide a greater range of services.

These benefits enable sustainable transformation for the immediate area but will also have a wider impact across the PCN and ICP. It is an essential part of the CCG Primary Care Strategy and ICS Long Term Plan.

1.7.2 Recommendation

This development supports the delivery of primary care and PCN services and is seen as an essential enabler to the successful delivery of new ways of working to patients and staff living and working in the Aylesbury areas. In summary, our recommendation is supported by:

• The District Valuer report confirming Value for Money • The results of the Options Appraisal exercise • The benefits that a new building can offer, and • the overriding economic benefit that the ETTF capital support will provide

Gary Heneage Chief Finance Officer and SRO for this Project NHS Buckinghamshire CCG

MEETING: Primary Care Commissioning Committee PAPER: P


TITLE: Beaconsfield Primary Care Centre Full Business Case Executive Summary




A full business case in support of the development of a new build, fit for purpose Primary Care Centre to serve patients in the town of Beaconsfield, Buckinghamshire and its wider catchment area has been submitted to NHS England.

The two practices that are co-locating into this new build (Millbarn Medical Centre and The Simpson Centre) are part of the ICS vision and have demonstrated to the CCG their commitment to delivering services of the highest quality, while at the same time embracing new ways of working at scale and in an integrated fashion.

The new primary care centre will be capable of delivering the following key criteria:

• Increase in capacity for primary care services out of hospital • Primary care working at scale • Capacity to provide for the expected population growth in this part of Aylesbury • Capacity to enable the opportunity to change ways of working by building skill mix

within the workforce and integrating with community services colleagues • Improve seven-day access • Provide increased training capacity. The Primary Care Commissioning Committee is requested to note this paper for information.

Authority to make a decision – process and/or commissioning (if relevant)It should be noted that this scheme has previously been approved by Primary Care Commissioning Committee at Outline Business Case stage where approval to fund was delegated to the CCG’s Finance Committee. Finance Committee approved this scheme in October 2019. Conflicts of Interest: (please tick accordingly) There are no material conflicts of interest for member GPs given they are not voting members of the Primary Care Committee.

No conflict identified Conflict noted, conflicted party can participate in discussion and decision (see below) Conflict noted, conflicted party can participate in discussion but not decision (see below)

Conflict noted, conflicted party can remain but not participate in discussion (see below)

Conflicted party is excluded from discussion (see below) Governance assurance (see below) Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all





Governance requirements: (Please tick each box as is relevant to the paper) Governance Element

N Comments/Summary

Patient & Public Involvement

The Patient Participation Groups (PPGs) for both practices fully support the proposed scheme.

Equality An Equality Impact Assessment has been completed for the proposed scheme.

Quality The Quality Team has reviewed the EIA and will be consulted throughout the build phase to ensure quality requirements are met.




Proposal involves Millbarn Medical Centre and The Simpson Centre in Beaconsfield. Meadowcroft Surgery.

NHS Buckinghamshire CCG Beaconsfield Primary Care Centre

Executive Summary: FBC

November 2019

V0.6

VERSION CONTROL


01 19.08.19 First draft – strategic and management cases JB HD

02 11.10.19 Second draft – economic, financial and commercial cases

JB PR

03 17.10.19 Third draft – amends to full business case PR HD

04 18.10.19 Fourth draft – amends to full business case HD PR

05 22.10.19 Fifth draft – addition of executive summary and appendices

HD/PR GH

06 06.11.19 Final for Submission JB HD

CONTACTS Sponsoring NHS Organisation NHS Buckinghamshire CCG Executive Offices Amersham Hospital Whielden Street Amersham HP7 0JD SRO Gary Heneage; Chief Finance Officer Contact details Helen Delaitre; Associate Director of Primary Care NHS Buckinghamshire Clinical Commissioning Group Executive Offices Amersham Hospital Whielden Street Amersham HP7 0JD Tel: 01494 586773 Mobile: 07769 248733 Email: [email protected]


1. Executive Summary

1.1 Introduction This full business case is in support of the development of a new build, fit for purpose Primary Care Centre to serve patients in the town of Beaconsfield, Buckinghamshire and its wider catchment area. The premises will be held leasehold by two practices co-locating onto the site. The new primary care centre will be capable of delivering the following key criteria:

• Increase in capacity for primary care services out of hospital • Primary care working at scale • Capacity to provide for the expected population growth in Beaconsfield • Capacity to enable the opportunity to change ways of working by building skill mix

within the workforce and integrating with community services colleagues • Improve seven-day access • Provide increased training capacity.

The two practices that are co-locating into this new build are part of the ICS vision and have demonstrated to the CCG their commitment to delivering services of the highest quality, while at the same time embracing new ways of working at scale and in an integrated fashion. We are fully supportive of this FBC and will work closely with the practices and their appointed developer to achieve successful conclusion of this exciting new development within timelines stated.

1.2 Strategic Context

NHS Buckinghamshire CCG is responsible for planning and commissioning healthcare services to meet the needs of local people. We are a member of the Buckinghamshire Integrated Care Partnership (ICP). The ICP is creating a place-based care system in which to deliver transformation that improves and integrates care and makes the system operationally and financially sustainable over the long term. The population, health and social care structures and the geography also offer ideal opportunities for delivering outstanding integrated care. The drivers behind transformation can be summarised as:

• The number and proportion of older people in the population is increasing. • There are more people being diagnosed with long term conditions and a greater

proportion of people living with co-morbidity. • Greater prevalence of mental health needs and co-morbidity of physical and mental

health illness. • A shift in culture towards patient centred care, for all parts of the healthcare system. • The healthcare expectations of the population are changing in line with greater

consumer choice, 24/7 access, faster response times and better-informed consumers. • The approach to healthcare provision is shifting away from a paternalistic model with a

greater onus on patients taking a more active role in the management of their own health.

• Significant differences in health outcomes for different population groups. • Funding levels have decreased in real terms and the same resources are being spread

more thinly requiring more efficient use of funds available. • Greater integration between health and social care teams.

• Advances in technology are enabling improved survival rates, more complex conditions to be managed in a community or home setting and alternative ways of seeing and assessing patients.

• There are significant workforce issues in many parts of healthcare and this is keenly felt in primary care where fewer GPs are entering the profession and more are choosing early retirement; there are too few practice nurses and a lack of dedicated training and career structure.

• A combination of workload and workforce pressures is pushing some general practices to consider closure.

1.2.1 The Case for Change

The ICP is beginning to build a solid foundation on which primary care and PCNs will become central to strong community care integrated teams, resilient enough to face today’s and the future’s healthcare challenges.

Our practices are already struggling to keep up with the increase in population as a result of housing growth, while others are finding it difficult to recruit and retain staff, given the increase in workload in primary care today. Despite these challenges, the staff who are working within Primary Care are as committed as ever to delivering safe, quality services but need space in which to expand and develop more services.

The investment objectives for this project are as follows:

• Improved resilience in primary care services to meet on the day needs of residents • Care integrated locally to provide better support closer to home • Whole system approach to transforming health and care to achieve better patient

experience and outcomes • Redesign care model and make best use of clinical, estate and digital resources

• Deliver better value for money for the tax payer.

These objectives are derived from listening to the membership of the CCG who have repeatedly voiced concerns regarding the resilience within primary care, given all the challenges currently being faced. Our solution to these concerns is the development of the care model, with all partners within the ICP who have a stake in ensuring that we have a sustainable future.

Both practices no longer have the physical capacity to offer the services demanded from their combined patient list which is increasing annually in size as new housing is developed in and around the town and its demographic profile is ageing in line with national population trends.

The Simpson Centre and the Millbarn Medical Centre are the only two NHS GP practices in Beaconsfield. This project will enable them to co-locate and work together at greater scale and in a more economic manner, offering greater resilience and efficiencies in serving an existing combined patient list of 25,300. The population is expected to grow to just over 29,000 by 2027 and the existing facilities are not able to support this level of growth in their current form.

Both practices desire to work collaboratively adopting a federated and transformational approach to patient care, sharing best practice and enabling them to improve efficiencies of working together and becoming more cost effective.

The existing practice premises were not purpose built and have a number of disadvantages, they are:

• Inadequate in size • Inflexible • Not fit for purpose or capable of being extended • Not fully compliant with modern healthcare standards.

All these issues result in an inefficient way of working. Significant amounts of money will be required to be spent on the premises just to maintain the status quo. The premises of both practices are thwarting the ambitions of the ICP and the GP practices and their desire to improve the level of service they offer their patients and to increase their training capacity.

The planned housing growth in both Beaconsfield and the patient catchment area (1,560 new homes; estimated 3,750 population growth) over the plan period to 2027 will exacerbate the inadequacies of both existing premises with resultant pressure on accessibility, services and patient care.

1.2.2 Existing surgery premises serving Beaconsfield

The Simpson Centre is a converted 1920’s house situated in the heart of new Beaconsfield and is owned by the GP partnership. The building, which is approx. 450m2 GIA (400m2 NIA) was extended in 2002 and offers parking for 32 cars. There is no further opportunity to extend the building due to planning and site restrictions. The premises are inadequate in size and the clinical and administrative rooms are too small to enable the practice to offer the range of services they wish to provide. The accommodation, being a converted dwelling, is inflexible and not fully compliant with modern healthcare standards, which leads to an inefficient way of working. The premises are thwarting the ambitions of the partnership and their desire to improve the level of service they offer their patients and to increase their training capacity.

The Millbarn Medical Centre lease their surgery premises from a private investor and lease a first-floor store room above adjoining premises from a local investor, Hallbarn Estates. The surgery premises are approx. 350m2 GIA (300m2 NIA) over 2 floors and were purpose built around 1980. There are just 15 car parking spaces; a situation which became exacerbated in 2018, as parking spaces had to be surrendered to Hallbarn Estates to facilitate a new office/residential development to the rear of the surgery.

The Millbarn partners have negotiated a new 15 year lease with a break clause to take effect in December 2021. The building was extended in 2003 and more recently a consulting room was created within the waiting area to avoid the regular use of the first-floor clinical room which has stair access only. There are no more options to extend the building without the loss of parking and with the landlord’s approval. The premises are not fit for purpose and the accommodation is too small and inflexible to cater for the existing patients; this situation will only worsen with housing growth in the town and surrounding areas. As with the Simpson

Centre, the existing premises are limiting the ambitions of the practice to increase their training capacity and consider additional services for their patients.

1.3 Economic Case This development was previously the subject of an outline business case. The OBC was conditionally approved by NHS England and the CCG in January 2019. The conditions of the OBC were met and the project has now moved to FBC.

1.3.1 Move to Full Business Case

The following actions have been completed to support the Full Business Case:

• The Parkway site has been legally secured under a conditional contract by the Developer

• The site’s restrictive covenants will be removed to permit development of the site • Detailed planning has been lodged and a decision is due on 11th December 20191. • The two GP practices have agreed their respective occupational building leases • The building works have been tendered and the costs approved by Pick Everard • The DV has provided an updated report dated 10th October 2019, confirming the

abatement, rental and ETTF payments.

1.3.2 Options Appraisal Initially the following three options were considered:

1. Do nothing 2. Extend the existing surgery premises 3. Develop a new surgery building.

To support the third option and develop a new surgery building, an extensive site search exercise was undertaken by the developer, Apollo Capital Projects which identified 10 potential sites as illustrated in Figure 6.

The majority of sites were rejected by the project stakeholders as they were considered not to be deliverable within the ETTF timeframe and would not allow for development until 2022 at the earliest. There were only 2 possible sites both of which were put through the full options appraisal process together with the earlier two options identified.

Points W’ting OPTION

1 2 3.1 3.2

Access to the facility and services 5 15.0 38.6 36.4 64.3 55.7

Choice for patients 5 15.0 36.4 42.9 66.4 62.1

Transformation in line with National and Local Strategies 5 12.5 12.5 16.1 62.5 60.7

Modern Inspirational environment 5 10.0 10.0 10.0 50.0 50.0

Deliverability 5 48.2 41.1 51.8 28.6

Sustainability 5 10.0 14.3 15.7 41.4 31.4

1 https://pa.chilternandsouthbucks.gov.uk/online-applications/simpleSearchResults.do?action=firstPage

https://pa.chilternandsouthbucks.gov.uk/online-applications/simpleSearchResults.do?action=firstPage

Timescale to serve ETTF Funding 5 12.5 26.8 26.8 51.8 30.4

TOTAL 87.5 186.8 188.9 388.2 318.9

PERCENTAGE 43% 43% 89% 73%

RANKING 4 3 1 2 Table 1: Summary of Options Appraisal

As approved in the OBC (Option 3.1), and confirmed under this FBC, the site for the new build primary care centre is situated at the junction of the A40 London Road and Walkwood Rise and is known locally as the Parkway Site. The site is currently open space and owned by Beaconsfield Town Council who have agreed a sale to the Developer.

The accommodation in the new building is as follows.

SPACE GIA m2 NIA m2

Car parking Spaces

GMS Space 1,665.6 1,511.6 108 Additional Private Rooms (2) 50.0 40.0 - Pharmacy 140.0 140.0 2

TOTAL 1,855.6 1,691.6 110 Table 2: New Build Accommodation

The GMS accommodation has been designed for core services with room utilisation of 80%. This will ensure some capacity both for growth and for the accommodation to be available to the Primary Care Network and potentially other primary care health professionals.

Both practices are committed to working together to ensure that the building is used and managed as effectively and efficiently as possible to maximise patients’ access to a wider range of services. Both practices consider it essential to join and combine resources to offer greater scale of clinical excellence, clinical training and provide streamlined administration, all of which will bring efficiencies, greater resilience and the ability to expand services.

The building’s accommodation and facilities will allow neighbouring GP colleagues, local voluntary groups and charitable organisations to benefit from sharing of resources and skills, making full use of the flexibility of space including meeting and clinical rooms to respond to the changing demands of GP practices and the local community.

The building construction will be in accordance with the current NHS specification, HBN’s, HTM’s and its design is based on the principle of natural ventilation. A BREEAM Rating of Excellent will be achieved, including a range of energy saving features such as Photovoltaic panels, LED lighting and a building management system (BMS) all of which will help to minimise the utility and overall operating costs of the building. The design and building environment created will offer a positive experience of care for patients.

1.3.3 Funding required for the Parkway Site new build development

The project has increased in cost since the OBC was submitted but as agreed at OBC stage, this does not result in an increase in the overall ETTF funding requirement as the increase is borne by the Developer.

NOTE: revised anticipated build cost of £8.389m (excluding VAT).

The ETTF funding of £3.423m provides a contribution of £2.605m to the actual construction build cost. £214k of this has already been committed under pre project funding arrangements agreed with NHS England. The remainder will meet VAT and SDLT liabilities that arise from the transaction, the already committed pre project costs and the GPIT cost estimates not covered by the build.

Table 3: Cost of Development for Parkway

Table 4: Funding sources

1.3.4 GEM Summary

Optimism Bias is at zero % as the Developer is taking all risk with regard to the capital outlay and the rent and abatement has been agreed with the Developer by the District Valuer.

NPV AEC Points Point

£000s £000s

Do Nothing 3,386 199 43 78.7 New Build - ETTF Funding 8,018 470 89 90.1 FBC - Parkway 8,142 477 89 91.5

Table 5 GEM Summary

OBC FBCCost of

BuildRevised

BUILD £k £k £kConstruction 7,500.0 700.00 8,200.00 Advanced fees 188.96 188.96 VAT 1,500.0 177.79 1,677.79 Build cost 9,000.0 1,066.75 10,066.75 SDLT 78.0 104.00 205.10 Pre Project Funding 62.0 20.00- 42.00 GP IT 361.0 311.00- 50.00 Total Cost of Project 9,501.0 839.75 10,363.85

MovementCAPITAL PARKWAY DEVLOPEMENT

FUNDING

Funded By Apollo NHS Capital TOTAL Apollo NHS Capital TOTAL

£k £k £k £k £k £k

Construction 5,065.00 2,435.00 7,500.00 5,784.04 2,604.92 8,388.96

VAT 1,013.00 487.00 1,500.00 1,156.81 520.98 1,677.79

SDLT 78.00 78.00 205.10 205.10

Pre Project Funding 62.00 62.00 42.00 42.00

GPIT 361.00 361.00 50.00 50.00

TOTAL FUNDING 6,078.00 3,423.00 9,501.00 6,940.85 3,423.00 10,363.85

OBC FBC

Table 6 FBC GEM 25 year

Rent Rates Total

£k £k £k Current

Millbarn 78.55 20.87 99.42 Simpson 100.00 29.48 129.48 Total 178.55 50.35 228.90 Future

Parkway 237.89 77.00 314.89 Movement - inc./ (dec) 59.34 26.65 85.99

Table 7 Current and Future Revenue impact

Over 25 years the incremental cost to the CCG: £ 2.378.6m

For Comparison purposes the revenue costs without ETTF support:

Building rental £ 395,941 Building rates (estimate) £ 77,000 Total £ 472,941 This reflects the loss of the abatement

NB For the economic case these calculations exclude the impact of VAT, BUT it needs to be recognised that as this is not reclaimable by the practice or the CCG under the current VAT rules there is a further 20% cost to the CCG budget. This is recognised in the Financial Case.

1.3.5 Project Benefits

Cash Releasing

This investment is primarily driven by the need to bring the GP practice estate up to todays’ standards for health facilities and the need for additional capacity into the future to ensure that the estate supports a Primary Care service that is sustainable.

FBC PARKWAY0 1 2 3 4 5 6-10 11-15 16-20 21-25 TOTAL 25

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000sOpportunity Costs 0 0 0 0 0 0 0 0 0 0 0 0Land Transactions 0 0 0 0 0 0 0 0 0 0 0 0Capital Costs 2,697 0 0 0 0 0 0 0 0 0 2,697 0Service Costs 0 315 315 315 315 315 1,574 1,574 1,574 1,574 7,872 315Transition Costs 205 51 0 0 0 0 0 0 0 0 256 0Optimism Bias 0

Capital 0 0 0 0 0 0 0 0 0 0 0 0Service 0 0 0 0 0 0 0 0 0 0 0 0


Year

FBC Parkway- 1.0 2.0 3.0 4.0 5.0 6-10 11-15 16-20 21-25 TOTAL 25

Service Costs £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000sCurrent Costs - 228.9- 228.9- 228.9- 228.9- 228.9- 1,144.5- 1,144.5- 1,144.5- 915.6- 5,493.6- - Future - 314.9 314.9 314.9 314.9 314.9 1,574.4 1,574.4 1,574.4 1,574.4 7,872.2 - TOTAL - 86.0 86.0 86.0 86.0 86.0 429.9 429.9 429.9 658.8 2,378.6 -

Year

The upfront investment delivers an annual abatement of some £158k pa for the life of the Leasehold i.e. 25 years. In addition to reducing the revenue costs to the CCG on an ongoing basis the abatement is calculated to deliver a 3.5% return on the investment to the NHS.

Without this upfront investment, the CCG would not have sufficient funding to support the revenue stream going forward.

Non Cash Releasing

Outcomes and benefits will be measured as outlined in the following table:

Benefit How benefit will be delivered

Strengthen capability of current extensive service provision across core and non-core services

Provide modern facilities that meet modern standards to ensure current services are being delivered to a high standard.

Improved quality of care Reconfigure services and staff teams to reflect new model of care in new facilities

Clean and modern building Design of new facilities fully involved service users and providers.

Increase the capacity of service provision to meet demand from an increased local population; and a growing list of patients

Facility allows for an increase in capacity of service provision to meet growing demography in the area locally in short, medium and long term. Match the new models of care for all patient groups. Allow flexible use of rooms for provision of services.

Provide facilities that encourage the integration of health and social care, allowing for new working practices and subsequently providing working efficiencies

Improve functional relationships/adjacencies and increase operational efficiency to deliver better quality care. Reconfigure services including developing primary and community services to support the new service model. Good signposting to other local services essential.

Design incorporates flexible facilities Facilities can be adapted for alternative future medical use. Allocation of shared and flexible space within the facility to encourage shared working and resources. Design flexibility to support foreseeable changes in service provision or need.

The facilities meet the needs of the local population, therefore providing appropriate care and catering to increase in number of patients including, children, adolescents, vulnerable adults and the elderly

Waiting areas with appropriate facilities are provided to cater for all groups.

Benefit How benefit will be delivered

Address "legacy" estates issues to provide a safe patient environment, i.e. statutory compliance.

Allocation of shared and flexible space within the facility to encourage shared working and resources. Design flexibility to support foreseeable changes in service provision or need.

Ensure access to the facility remains "all inclusive", removing barriers to access and ensuring patients feel comfortable with their surroundings

The services offered from the premises will be all inclusive and every attempt will be made to ensure specific groups are catered for.

The facilities provide a high degree of independence and self-care for those with special needs and disabilities.

Patient facilities accommodate the needs of independent wheelchair users. Access between related services is not an impediment to people with disabilities.

Improved facilities for staff and patients, assisting in recruitment and retention

Maintain and improve wider care in the community. Provide better staff working environment.

Improved patient experience Increase in access to a range of GMS services in one location with high staff awareness of local services and signposting for patients. Links with other services such as Social Services and mental health services. Providing health related sessions to the community utilising the community facilities being provided as part of the development. A holistic approach to the community where the service provider participates with other agencies in delivering good additional services to the community.

A place the local community can identify with and have a sense of ownership of

Good use of facilities by .

Effective care delivered by well trained staff Sufficient numbers of medical/clinical staff required in order to deliver appropriate service.

Deliver the appropriate capacity and service requirements within necessary timescales and cost estimates

Agree brief with key stakeholders and ensure that project is delivered on time and to budget. Continued engagement throughout design phases of project with stakeholders.

Table 8: Benefits and Outcomes

1.4 Commercial case

This project is being part-funded through NHS England Estates Technology and Transformation Funding (ETTF). The addition of £3,423,000 ETTF funding will give the practices access to a purpose-built building for the initial lease period of 25 years. The agreement can then be renewed until the building is no longer fit for purpose or the parties mutually agree.

The Outline Business Case for this development was approved by the Primary Care Commissioning Committee in September 2018, with subsequent updates being provided to the committee and to the Premises Sub Group while preparing the FBC. Full and final sign off of the Economic and Financial cases for this FBC will rest with the CCG’s Finance Committee prior to submission to NHS England.

Full responsibility for the build lies with the developer, Apollo Capital Projects Development who will forward fund the development to a specialist Primary Care investor who will become the buildings Landlord. The practices have retained Gordons LLP to provide legal advice. The building leases (for both Millbarn and Simpson) are in an agreed form and based on the agreed Heads of Terms as set out in the OBC. In addition, these agreed-form leases will eventually be part of an Agreement for Lease that will also set out the specification of the build and contain conditions precedent that will provide the necessary assurances to NHS England that the development will meet their objectives.

1.4.1 The Developer

Apollo is a specialist 3rd Party developer within the Primary Care market and has over 20 years’ experience of developing primary care buildings throughout the UK and has the necessary professional skills in house to assist the practices and the wider project team to deliver the new premises.

Apollo’s development experience includes other ETTF-funded projects across the country and delivering Health & Social Care Hubs in Scotland within a development framework called Hub West Scotland, where Apollo is one of the private sector partners. Apollo therefore has the skill, experience and in-depth knowledge of healthcare development and funding to successfully deliver this project.

1.4.2 Procurement

Apollo will act as developer and procure the new building via the traditional 3PD process. Apollo will take full responsibility for the entire development process including managing the programme and being fully responsible for all project costs including the construction cost. The construction work has been robustly and competitively tendered over a 10 week period to four contractors with the appropriate experience in the Primary Care market and financially capable of undertaking the project , to ensure a market price is achieved that reflects best value for money and which has been subject to scrutiny by Pick Everard.

The proposed development programme dates are:

Milestone Date CCG Finance Committee 30 October 2019 Submission of FBC By 15 November 2019 NHS E Panel 16 December 2019 GP’s exchange Agreement for Lease January 2020 Appoint Contractor January 2020 Commence Construction March 2020

Construction Complete February 2021 Handover of Building and lease completion February 2021

1.4.3 ETTF

It has been agreed by NHS England to use Direction 6 of the Premises Cost Directions which will allow the ETTF capital to be paid to the developer/investor, via the GP practices at the point the building reaches practical completion and the building leases are completed which is forecast to be February 2021. The ETTF capital is paid by way of a lease premium and each Practice has a proportional element of the net capital payment which is based on their demised floor space which reflects their current list size. A legal mechanism (including a Project Agreement and a Grant Agreement) will be agreed to enable the ETTF to be made available and to be fully secured before the ETTF deadline of February 2021.

1.4.4 Planning

The detailed planning application was lodged on 6th June and registered by the Planning Authority, South Bucks District Council, on 18th June 20192. The developer, Apollo, exchanged a conditional contract to purchase the site from Beaconsfield Town Council on 8th July; the purchase being conditional on planning and the Town Council clearing restrictive covenants that prevent the development of the site.

There were a number of objections from local residents as well as objections on highways, the loss of trees, urban design and one of surface water flooding risk. These objections are in the process of being addressed and the application is due to be heard by the Planning Committee on 11th December 2019.

1.4.5 Leasing terms

Both Practices have agreed the form of their building lease as approved by their joint solicitor Gordons LLP; the TIR leases will be for a 25 year term and conform with the Heads of Terms as sanctioned by the District Valuer and set out in the OBC. The pharmacy tenant (Pyramid Pharmacy) has agreed to enter a 25 year FRI lease.

1.4.6 Building Specification

The building will comply with NHS design and specification standards, infection control standards, achieve BREEAM Excellent rating and offer future internal flexibility and physical capacity to enable the building to be extended to provide additional clinical, back office and waiting room capacity. The building specification will include the IT and telephone cabling infrastructure.

1.4.7 Value for Money

The District Valuer was commissioned to agree the building rental, development costs and the mechanism to convert the ETTF capital into rent abatement. The District Valuer has produced a final report dated 10 October 2019 for NHSE and the CCG confirming that the rental,

2 https://pa.chilternandsouthbucks.gov.uk/online-

applications/simpleSearchResults.do?action=firstPage



development costs and rental abatement based on the ETTF capital support offer value for money.

FBC Lease term 25 Years Development costs (excluding advance fees) £8.2 Abatement rate on net ETTF capital 3.5% Rent abatement £158,048 Building initial rent reimbursement (excl VAT) £237,893

Table 9: Summary Rental Details

1.5 Financial case

1.5.1 The Funding Requirement

The table below, sets out the total capital requirement for the Parkway build and identifies the ETTF capital contribution required for the overall scheme:

Table 10: Capital Requirement

As explained in the Economic and Strategic cases, this investment in estate will support services into the future for the Beaconsfield population.

1.5.2 Consequences of funding not being made available

This project is key to the overall Buckinghamshire plan for the delivery of healthcare services in the future. If funding is not made available, this project will not be able to continue as the additional funding required would not be affordable.

1.5.3 Key Financial Assumptions

The key financial assumptions are:

• The route to transfer of funds to the Developer has been discussed with NHS England. The business case reflects the assumption of transfer via GPs under Direction 6 for ETTF funds

• VAT treatment

- The developer is able to reclaim VAT on their building costs but will charge the practices for the work funded by ETTF which will attract VAT. The GP practices cannot reclaim the VAT which therefore needs to be funded.

- In reclaiming VAT on the build the developer is opting to tax and therefore VAT is chargeable on the rental.

FUNDING

Funded By Apollo NHS Capital TOTAL Apollo NHS Capital TOTAL

£k £k £k £k £k £k

Construction 5,065.00 2,435.00 7,500.00 5,784.04 2,604.92 8,388.96

VAT 1,013.00 487.00 1,500.00 1,156.81 520.98 1,677.79

SDLT 78.00 78.00 205.10 205.10

Pre Project Funding 62.00 62.00 42.00 42.00

GPIT 361.00 361.00 50.00 50.00

TOTAL FUNDING 6,078.00 3,423.00 9,501.00 6,940.85 3,423.00 10,363.85

OBC FBC

• Inflation for business rates has been applied at 1.5%. • Rent and abatement is assumed as flat although the rent will be subject to review on a

three yearly basis. • The practices will enter into a long term lease for the property. All options were assessed

over 25 years.

• Capital investment in the build is assumed as £2.605m.

1.5.4 Capital Contribution

The total construction costs of the project have been advised to the District Valuer by the Developer. For cash flow purposes the project is funded initially by Apollo, the 3PD who will invoice on completion. ETTF capital abates a proportion of the market rent of the development.

1.5.5 Information Management and Technology (IM&T)

The new building specification will provide the necessary IT infrastructure to support the services required. Existing equipment will be transferred from the practices where it is fit for purpose and the detailed list of equipment to be purchased is incorporated in GEM. The sum being set aside for this work is £50k.

Any further development required will form part of the wider Buckinghamshire GP IT development programme and will be funded under BAU grants and will be applied for when the facility is operational in 2021.

1.5.6 Revenue Impact

The impact of the project amounts to a Net Annual Revenue Increase of £118k for the current comparable practice reimbursement.

Location

Rent VAT Rates Total

£k £k £k £k

Current Millbarn 78.55 15.71 20.87 115.13

Simpson 100.00 29.48 129.48

Total 178.55 15.71 50.35 244.61

Future Parkway 237.89 47.58 77.00 362.47

Movement 59.34 31.87 26.65 117.86

Table 11: Revenue Impact

A key assumption driving this project is an expectation of increased demand as a direct result of increases in the registered population. This will increase the RRL for the delegated Primary Care Budget which will go some way to offset the increased costs. Any balance is expected to be resourced from the CCG Primary Care Delegated Budget.

Table 12: Financial Model over 25 years

1.5.7 Risk

The Developer is responsible for all risk in respect of capital expenditure.

1.5.8 Sensitivity

This option is the only viable option to deliver the critical success factors.

1.5.9 Affordability

The Chief Financial Officer for NHS Buckinghamshire is also SRO for this project. He approved the future increase in rent reimbursement compared to current reimbursement and confirmed it as affordable. The Revenue impact is now reduced by some £24.67k (see Table 13 below).

The sum of money required has been included in the future financial plans for CCG delegated Primary Care budgets.

Table 13: Key Movement from OBC to FBC

1.6 Management case

1.6.1 Project Delivery

Robust arrangements are in place for the delivery, monitoring and evaluation of this scheme using Prince 2 methodology.

Project Board

The Beaconsfield Primary Care Centre Project Board meets on a regular basis with support from the appointed consultants responsible for the design and construction of the new building together with independent advice from the practices appointed Monitoring Surveyor.

OBC FBC Movement£k £k £k

CMR Rent 390.20 395.94 5.74

Abatement (158.10) (158.05) 0.05Net 232.10 237.89 5.79VAT 78.04 47.58 (30.46)Initial Rent 310.14 285.47 (24.67)Rates 77.00 77.00 -TOTAL 387.14 362.47 (24.67)

Increased Capital Contribution offset by Reduction in return from 4% to 3.5%

VAT calculated on Gross in OBC

The Board is responsible for:

• Ensuring that the NHS Policies and building guidance have been taken into account in the design of the new build

• Agreeing with the developer how best to implement plans to deliver the required building

• Mitigation of risk associated with the project.

The developer, Apollo, will be fully responsible for every aspect and delivery of the project. The project lead, Richard Drew (Development Director) will take overall responsibility throughout the entire life of the project, including signing off the 12 months defects liability period. He will be supported by his colleagues Rob James and Campbell Halliday with the project management of the construction and snagging/ post completion phase of the project.

The Practices monitoring surveyor, AR Group, will be included in all meetings and decision making to ensure the building fully meets the requirements of the building specification. The CCG’s Estates Development Manager and Project Managers from Pick Everard, who NHS England use to monitor delivery of ETTF schemes, will be monitoring the construction including the tendering process to ensure the building is compliant.

CCG Governance

The CCG Responsible Officer for overseeing delivery of this project is Gary Heneage, Chief Finance Officer, supported by Helen Delaitre, Associate Director of Primary Care.

The Project Board reports into the CCG’s Premises Sub Group, which is a sub group of the statutory CCG Primary Care Commissioning Committee (PCCC). Updates on this scheme have been received by the Premises Sub Group periodically, and any financial variations are approved by the Chief Finance Officer and reported to the Finance Committee in line with current SFIs/Scheme of Delegation. The business case was approved by Finance Committee on 30th October 2019 and will be presented to the PCCC on 5th December 2019.

The Primary Care Commissioning Committee is also chaired by a CCG Governing Body lay member, and the committee was established in accordance with statutory provisions to enable its members to make collective recommendations and decisions on the review, planning and procurement of primary care services under delegated authority from NHS England.

1.6.2 Project Risks and mitigation measures

The Project Board will oversee risk and risk mitigation. Risks will be escalated as appropriate to relevant bodies by the Project Board as and when necessary.

The following risks have been identified:

• The time limited availability of the ETTF funding

• Obtaining planning consent; target decision date 11th December 2019 • Clearing the title covenants; being negotiated by the Town Council.

The project stakeholders are aware that should the development fail to be delivered, there is a high risk that the practices would not be able to develop and increase their service provision in line with patient need. There is no potential for further expansion at their existing sites, little development opportunity available in the Beaconsfield area and ever decreasing prospects of securing capital funding via the NHS to make this an affordable scheme for the CCG.

The project risks and mitigation measures are set out in the following table:

AREA PROJECT RISK MITIGATION

Programme Delays The overall project programme is the responsibility of Apollo as the developer. The programme will be actively managed to ensure key milestone events are achieved on programme. In the event of any slippage, the programme will be assessed to establish how to absorb the delay by potentially considering undertaking tasks in parallel to gain the lost time. The risk is that the project is delivered beyond the ETTF date. Completion date is currently February 2021.

The programme whilst the responsibility of Apollo will be owned by all the project participants and their respective consultants who will collectively have an impact on the delivery of the project.

Site acquisition/clean title

Exchanged conditional contract in July 2019. Town Council to clean title contractually within six months of exchange (8th Jan 2020).

Development Director actively working with Town Council to secure clean title for the land by the latest legal long stop date of 8th Jan 2020.

Planning Consent Planning application lodged June 2019. Objections discussed with Planners on 29th August 2019. Planning Committee dates set for 11th December 2019 and 15th January 2020.

Development Director and Procurement Team working through issues such as surface water flooding survey, highways and urban design queries.

Table 14: Project Risks and Mitigation

1.6.3 Post Project Evaluation

The CCG and NHS England are committed to ensuring that a thorough and robust post project evaluation is undertaken at key stages in the project, to ensure that positive lessons can be learnt. The lessons learned will benefit future capital schemes both in the local and wider area.

Post Project Evaluation (PPE) will set in place a framework within which the benefits realisation plan can be tested to identify which benefits have been achieved and which have not – with the reasons for these understood in a clear way.

The key stages of PPE that will be evaluated are:

• Implementation • Shortly after the new service has been brought on line • Once the service is well established.

1.7 Conclusion and Recommendation

1.7.1 Conclusion

This business case provides a compelling case for investment in a new primary care centre in Beaconsfield. This business case demonstrates that this project will deliver the following substantial benefits at an affordable cost:

• An increase in clinical capacity to provide greater access to GP services, cater for predicted population growth and provide extended hours by becoming a ‘hub’ for use by the practices and the wider PCN.

• The building will lend itself to the potential formal merger of both practices in the future with minimal physical alteration and disruption to patient care.

• The scheme brings the benefit of a pharmacy operating from a standalone unit adjacent to the building, offering its own consulting rooms and ability to work closely with practice staff.

• It offers clinical space capable of bringing more services within the community and away from a hospital setting and encouraging GPs within the practices with special interests and other qualified providers to offer clinics.

• The buildings’ design and security facilities will enable a portion of the building to be available to other users and providers outside the buildings operational hours. This could include triage facilities, out of hours or extended hours of operation. These facilities may be utilised by other agencies for example PPGs, carers' associations, dementia charities and Active Bucks both in and out of work hours. The size of some of the rooms can be altered to provide the correct ambience for small and larger meetings.

• The development site has the capacity to enable the building and the car parking to be extended in the future without the need to buy any additional land. The building design can accommodate a single or two storey extension by extending existing clinical corridors to provide between 4 and 16 additional clinical rooms to accommodate other users to provide a greater range of services.

These benefits enable sustainable transformation for the immediate area but will also have a wider impact across the locality as well as the ICS. It is an essential part of the CCG Primary Care Strategy and ICS Operational Plan.

1.7.2 Recommendation

This development supports the delivery of primary care and PCN services and is seen as an essential enabler to the successful delivery of new ways of working to patients and staff living and working in the Beaconsfield areas. In summary, our recommendation is supported by:

• The District Valuer report confirming Value for Money

• The results of the Options Appraisal exercise

• The benefits that a new building can offer, and

• the overriding economic benefit that the ETTF capital support will provide

This Full Business Case is presented with a request to NHS England to approve the funding requested under the ETTF scheme.

Gary Heneage SRO for this Project and Chief Finance Officer, NHS Buckinghamshire CCG

MEETING: Primary Care Commissioning Committee PAPER: Q


TITLE: Threeways Surgery Reconfiguration: Full Business Case Executive Summary




A full business case in support of reconfiguring the existing Threeways practice building in Stoke Poges in order to support the delivery of additional in hours and out-of-hours services has been approved by NHS England.

The Primary Care Commissioning Committee is requested to note this paper for information.

Authority to make a decision – process and/or commissioning (if relevant) This scheme has been approved by the CCG Finance Committee on 30.10.19. Conflicts of Interest: (please tick accordingly) There are no material conflicts of interest for member GPs given they are not voting members of the Primary Care Committee.

No conflict identified Conflict noted, conflicted party can participate in discussion and decision (see below) Conflict noted, conflicted party can participate in discussion but not decision (see below) Conflict noted, conflicted party can remain but not participate in discussion (see below) Conflicted party is excluded from discussion (see below) Governance assurance (see below) Strategic aims supported by this paper (please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all

Better Care for Bucks – to commission personalised, high value integrated care in the right

place at the right time Better Care for Bucks – to ensure local people and stakeholders have a greater influence on the services we commission


Leadership across Bucks – to promote equity as an employer and as clinical commissioners Governance requirements: (Please tick each box as is relevant to the paper) Governance Element Y N N/A Comments/Summary Patient & Public Involvement

The practice will be informing their patients of proposed works during December 2019.

Equality N/A Quality The Quality Team has reviewed the proposed works

and has comments on infection prevention and control matters. They will visit once the scheme is completed.



Membership Involvement Proposal involves Threeways Surgery, Stoke Poges.

NHS Buckinghamshire CCG Full Business Case: Executive Summary

Southern Locality

Threeways Primary Care Network Hub

“

October 2019

V0.7

VERSION CONTROL


01 19.08.19 First draft – strategic and management cases

JB HD

02 11.10.19 Second draft – economic, financial and commercial cases

JB PR

03 14.10.19 Third draft – amends to full business case

PR HD

04 16.10.19 Fourth draft – addition of Executive Summary

HD PR

05 18.10.19 Fifth draft – addition of Appendices

HD GH

06 28.10.19 Sixth draft – addition of map and managing the works

HD GH/JB

07 30.10.19 FINAL – sign off by Finance Committee

HD Committee

CONTACT DETAILS

SPONSORING NHS ORGANISATION

NHS Buckinghamshire CCG

Executive Offices

Amersham Hospital

Whielden Street

Amersham HP7 0JD

TITLE OF SCHEME Threeways Primary Care Network Hub

CONTACT DETAILS

Provide details of lead officer for the scheme and relevant NHS Director of Finance / Chief Financial Officer in the sponsoring organisation – name/title/ office & mobile phone number and email address.

SRO

Gary Heneage; Chief Finance Officer Helen Delaitre; Associate Director of Primary Care NHS Buckinghamshire Clinical Commissioning Group Executive Offices Amersham Hospital Whielden Street Amersham HP7 0JD

Tel: 01494 586773

Mobile: 07769 248733

Email: [email protected]

•


1 EXECUTIVE SUMMARY

1.1 Introduction

This FBC seeks approval to invest £500k in the reconfiguration of the existing Threeways practice building in Stoke Poges in order to support the delivery of additional in hours and out-of-hours services.

1.2 Strategic case

1.2.1 The strategic context for additional services in the South Bucks Locality

The future direction of primary care provision focuses on providing a wider range of services for patients. This service model is expected to incorporate not just general practice, but increasingly, integration of community services, out-of-hours services and other specialist-based services such as diagnostics, more case management of vulnerable patients and more working with the voluntary sector. These services will be designed to respond to local need, help people manage their own health conditions and keep them independent in their community for as long as possible. Primary care services also need to be available 24 hours per day/seven days per week, and will require some services to work together to improve urgent access at evenings and weekends.

General practice will still be at the centre of the provision of patient care and care planning. However, primary care services will be integrated and will be closely connected with the local communities they serve, and will be at the heart of their primary care network (PCN). GPs will work even more closely with nursing disciplines, other community health practitioners, and hospital specialists, mental health, the voluntary sector and social care workers – creating a wider integrated team that will wrap care around the patient.

In order to deliver this emerging service model, the 5 Year Framework for GP Reform introduces additional roles into the primary care network team that, over the next 3 years, will attract additional funding. PCNs will be expected to employ teams of staff that will work together with other health and social care providers. Increasingly, local primary care services will be delivered to communities of between 30,000 and 50,000 and practices are now beginning to see the benefits of working together.

The Integrated Care Partnership (ICP) is beginning to build a solid foundation on which primary care and PCNs will become central to strong community care integrated teams, resilient enough to face today’s and the future’s healthcare challenges.

Our practices are already struggling to keep up with the increase in population as a result of housing growth, while others are finding it difficult to recruit and retain staff, given the increase in workload in primary care today. Despite these challenges, the staff who are working within Primary Care, are as committed as ever to delivering safe, quality services but need space in which to expand and develop more services.

The investment objectives for this project are to:

• Improve resilience in primary care services to meet on the day needs of residents • Provide better support integrated care closer to home

• Adopt a whole system approach to transforming health and care to achieve better patient experience and outcomes

• Redesign our care model and make best use of clinical, estate and digital resources • Deliver better value for money for the tax payer.

These objectives are derived from listening to the membership of the Clinical Commissioning Group (CCG) who have repeatedly voiced concerns regarding the resilience within primary care, given all the challenges currently being faced. Our solution to these concerns is the development of the care model, with all partners within the ICP who have a stake in ensuring that we have a sustainable future.

Investment in estates will also underpin the delivery of a sustainable model of general practice in support of adopting new models of care and ways of working that will not only provide core services but those that are targeted to local populations.

1.2.2 The Case for Change: Health profiles and housing growth challenges for South Buckinghamshire

This area at the southern-most tip of Buckinghamshire stretches across Iver and Denham in the east, Burnham and Taplow to the west, Chalfont St Giles in the north to Stoke Poges in the south. The area shares borders with both Middlesex and Berkshire and is densely populated (compared to the north of the county). The population is predicted to increase by 9% (6,600 people) by 2026. Most of this increase will be driven by new housing developments in the area.

There are two PCNs in this area: South Bucks comprising 5 practices with a registered population of 54,000. The second PCN is called The Chalfonts and covers 3 practices with a population of nearly 31,000.

The age profile in this locality is very similar to other Buckinghamshire localities:

Age % of Population

>65 20.0%

>75 9.5%

>85 3.0 %

The locality is less deprived compared to Buckinghamshire as a whole but areas in Burnham Church, Burnham Lent Rise, Iver Heath, Iver Village, Richings Park, Stoke Poges, Wexham and Iver West are in the most deprived population quintile in Buckinghamshire. The locality is less ethnically diverse compared to Buckinghamshire as a whole and there is a difference of 3 years in life expectancy between males and females compared with the Buckinghamshire average.

Home visiting and looking after patients in care home settings are areas of particularly high workload for all Southern locality practices. As a result the CCG is responding by prioritising the creation of a facility in the south of this area, close to the East Berkshire border that will alleviate pressure on Frimley Health NHS Foundation Trust and primarily at Wexham Park Hospital.

More capacity created as a result of this investment , will enable the two PCNs to be at the heart of the wider system of integrated out of hospital care, working in collaboration with community teams, other service providers and the voluntary sector to offer flexible and improved access to patients. Ultimately, they will be able to deliver the new model of care.

1.2.3 Business needs: Existing Surgery Premises

South Buckinghamshire Locality

In South Buckinghamshire, the geography of the area and the presence of Frimley Health NHS Foundation Trust on the border of Buckinghamshire and Berkshire mean that the local population tends to use Wexham Park Hospital as their first choice of hospital, particularly for non-elective care. The proposal will create additional capacity to allow for services tailored to meeting the needs of local residents geared towards an increase in unplanned care to provide a realistic alternative to the hospital.

Our options appraisal has highlighted that there is little opportunity to establish a single, physical facility given the cost of acquiring land and the lack of suitable brownfield sites. We therefore asked development consultants to undertake a feasibility study on existing premises so as to develop a more pragmatic approach to our need for additional space. A number of options were considered and the choice for development is Threeways Surgery.

Threeways Surgery

The building is 650m² in size (gross internal area or GIA) and leased from Assura Medical Properties. The site is considered to be under-utilised and this is partly due to current layout and functionality of the rooms. In particular most of the first floor consulting, admin, health education and counselling rooms are not able to be utilised as clinical consulting rooms and on the ground floor the current reception/waiting area is considered over-sized for current use and poorly set out. In the current layout the practice would be unable to support the vision for PCN services or the requirements of the new PCN service specifications anticipated being in place from 1 April 2020.

The site boundary runs closely on three sides of the practice, which limits extension opportunities. Where the building returns at the front entrance, there is potential to extend in this area without compromising parking spaces. There are 16 parking spaces on site currently, which is deemed adequate given there are presently no parking restrictions on the adjoining streets or nearby retail area. The parcel of land outside adjoining the tarmacked parking area at the front corner of the site is also owned by Assura and in the future, opportunities could be explored to develop this into more parking. In the event that developing this option as parking is not viable, the opportunity to extend the first floor over the existing car park could be explored.

One of the transformational priorities within the ICS Operational Plan for 2019/20 is to manage demand for non-elective care and so this proposal seeks to create additional capacity in a location near to Wexham Park Hospital to provide a single point of access to rapid response and access to same day urgent care which reduces A&E attendances and avoids admissions. The chosen site has the benefit of free parking which, given the constraints on parking at Wexham Park, patients will find particularly beneficial and convenient out of hours.

1.3 Economic case This section of the business case documents the range of options that have been considered in response to the needs identified within the strategic case.

This project forms one element of the overarching programme for developing Primary and Community Care Centres to serve the Buckinghamshire population into the future.

The overall programme is a mixture of new build and development of existing estate to ensure that outcomes are maximised at minimal investment. The programme encompasses funding via ETTF and Wave 2 capital.

1.3.1 Critical success factors

The following guiding Critical Success Factors (CSFs) need to be met by all NHS Buckinghamshire CCG primary care developments.

• Efficient, fit for purpose environment • Sustainable for the future development of integrated services that will deliver primary and

community care services associated with general health and wellbeing • Delivering the Long Term Plan for health and social care.

The CSFs have been applied specifically alongside the investment objectives for the project to evaluate the list of possible options.

• CSF 1: Improved resilience in primary care services to meet on the day needs of residents • CSF 2: Care integrated locally to provide better support closer to home • CSF 3: Whole system approach to transforming health and care to achieve better patient

experience and outcomes • CSF 4: Redesign of care model and make best use of clinical, estate and digital resources • CSF 5: Deliver better value for money for the tax payer.

1.3.2 The Options Assessed

OPTION 1 Do Nothing

2 Reconfigure and upgrade Threeways Surgery 3 Extend Burnham Health Centre 4 Extend Southmead Surgery

1.3.3 Summary of Options Appraisal

Points W’ting

OPTION 1 2 3 4 Max

Access to the facility and services 5 20 60.0 93.3 53.3 60.0 100 Choice for patients 5 20 33.3 86.7 60.0 60.0 100 Transformation in line with national and local strategies 5 20 20.0 93.3 53.3 53.3 100

Modern inspirational environment 5 10 26.7 40.0 20.0 36.7 50 Deliverability 5 15 75.0 65.0 45.0 25.0 75 Sustainability 5 15 25.0 60.0 50.0 45.0 75 TOTAL 100 240 438.3 281.7 280 500 PERCENTAGE 48.0% 87.7% 56.3% 56.0% RANKING 4 1 2 3

Table 1 Summary of Options Appraisal

1.3.4 Overall Findings: the preferred option The development at the Threeways practice site is pivotal to supporting one of the Southern Locality PCN’s and providing estate capacity to enable them to deliver the new PCN DES into the future.

The remaining term on the lease is 9 years but the practice and Assura, who are keen to support development of services on the site, have agreed to enter into a new leasing arrangement for 25 years from completion of the works.

The Market Rent value has not increased as a result of the improvement works, since the overall Net Internal Area (NIA) is not increased. Furthermore, the investment in this reconfiguration is being treated as Tenants Improvements (under the Landlord and Tenant Act 1954) and therefore (a) there will be no additional rent to pay for the works and (b) there will be no abatement of the rent.

Assura, the owners of the site, have agreed that settlement of the 2017 rent review will be the initial rent in the new 25 year lease. The next rent review will then apply in 2023 as the new lease will have 3-yearly rent reviews. They are also supporting the scheme by funding:

• Fees connected with the development of the plans • Any Stamp Duty Land Tax and all solicitor costs associated with the new lease • Development until completion of the works • A contribution of £62,800 to the development works.

The main purpose of this investment is to provide facilities that will: • Support localised services for patients, thus resulting in a reduction in the number of

inappropriate A&E attendances, this will create benefit to the CCG by way of managing demand for unplanned care.

• Provision of out of hospital services for the management of patients with long term conditions.

• Ultimately support a reduction in non-elective admissions and readmissions thus reducing excess bed days and delayed transfers of care for Buckinghamshire patients admitted to Wexham Park Hospital needing repatriation into Buckinghamshire.

As a relatively low value investment at £500k, the project delivers considerable value for money just by redesigning the existing site to provide:

• An additional 5 clinical rooms • Replacing flooring in existing carpeted rooms to offer improved hygiene compliance • Redesigning the downstairs waiting area and creating a new sub-wait area upstairs.

1.3.5 Small GEM

(NHS England Generic Economic Model for projects requiring under £5m capital investment)

For GEM purposes only Option 1 – Do Nothing and Option 2 were put through the template as Option 3 and Option 4 were rejected as part of the Qualitative Options Appraisal.

The output from the Options appraisal is applied to GEM to reflect the differential between the Options. Option 3.2 the Preferred Option is expressed as 88 points in GEM. GEM then

reflects both the financial impact of the options as well as the ability to deliver giving an overall economic reflection of the project.

SUMMARY NPV AEC Points £ per £000s £000s Point

Do Nothing 2,069 109 48 43.1 Threeways Surgery 2,486 96 88 28.2

Table 2: Outcome of GEM Process

The summary clearly reflects that by delivering the criteria, Option 2 is the best value.

Key Assumptions

• The discount factor applied to both Options is 3.5% • Rent assumed as flat per DV valuation • Both options have been assessed over 25 years as reflecting the term of the lease • Abatement does not apply as this is considered a tenant’s improvement • The Market Rent will not increase at any time throughout the life of the lease in respect

of the development changes. Inflationary or market increases will apply but as they would also apply to the option to do nothing they have been ignored for modelling of the outcomes.

• Capital investment at £ 417k (net of VAT) £500k (gross).

Optimism Bias

This Full Business case incorporates the tendered costings. On proceeding to contract the contractual amount will be fixed. The inherent uncertainty normally present in the earlier stages of the process does not apply. The build costs currently incorporate a 5% contingency for any design changes required during the build.

No Capital injection is required for Option 1. The maximum capital funding in respect of the build is fixed at £500k inclusive of VAT, with Assura bearing the risk on capital overspend.

Optimism Bias (OB) required by GEM as described above is therefore Zero at this stage:

OPTIMISM BIAS CAPITAL REVENUE Option 1 0% 0% Option 2 0% 0%

Table 3: Optimism Bias required by GEM

1.3.6 The preferred option – Threeways reconfiguration

Table 4: Preferred Option: Threeways reconfiguration

Preferred Option 0 1 2 3 4 5 6-10 11-15 16-20 21-25 TOTAL 25

£000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000sOpportunity Costs 0 0 0 0 0 0 0 0 0 0 0 0Land Transactions 0 0 0 0 0 0 0 0 0 0 0 0Capital Costs 417 0 0 0 0 0 0 0 0 0 417 0Service Costs 0 126 126 126 126 126 628 628 628 628 3,139 126Transition Costs 0 0 0 0 0 0 0 0 0 0 0 0Optimism Bias 0

Capital 0 0 0 0 0 0 0 0 0 0 0 0Service 0 0 0 0 0 0 0 0 0 0 0 0

Total Optimism Bias 0 0 0 0 0 0 0 0 0 0 0 0TOTAL 417 126 126 126 126 126 628 628 628 628 3,555 126Discounted Total 2,486Annual Equivalent Cost 96

Year

Building design

The building reconfiguration design has adopted the principles of HBN 11-01 as far as possible to make the most of the existing accommodation.

The refurbishment of the downstairs consulting rooms and reception area will improve infection control by removing the existing carpeting and changing surfaces and lighting where possible.

By bringing in a separate waiting area on the first floor this development will facilitate the practice in responding to any future pandemics. This would be supported by making use of the existing separate entrance to the first floor currently only used by staff.

The increased consulting room activity upstairs would have enough ground floor waiting room capacity but the additional waiting area on the first floor offers additional flexibility.

The internal environment will be naturally lit where possible.

The design can accommodate future building and parking extensions within the site boundary, therefore offering future-proofing to changes in demand and services.

Patient Facing Capacity

Current Future Increase Floor GF FF GF FF Clinical Consulting Rooms 5 2 6 6 5 Training Rooms 1 1 Treatment Rooms 2 2 Reception /Waiting 1 0 1 1 1

Table 5: Patient Facing Capacity

The ground floor already provides a reception and patient waiting area leading to the consulting rooms (16 m² each) and the 2 treatment rooms (20 m² each).

The first floor will also now have a small sub-wait area serving the planned Out of Hours service and additional day time services.

The development will create 5 additional Clinical Rooms by rearranging the space on the ground floor and upgrading the rooms on the first floor.

The practices back office function is split over both floors.

Utilisation of Accommodation

The Threeways site has the following issues:

• A number of rooms on the first floor which were intended as consulting rooms do not have basins or are not equipped to function as clinical space they are therefore hardly used or end up being used for storage

• There are two large meeting rooms which are under-utilised in their current format • The reception area on the ground floor accommodates admin staff working in a large

glazed enclosure, so that they have access to natural light and the patient section is excessive for the appointment flow

• There is a small room on the ground floor which is only used occasionally for taking bloods.

The new PCN needs space to accommodate the services of a Pharmacist, Physiotherapist, Talking Therapies, etc. as well as being able to consider other community services operating locally to support frail and elderly patients. The Out of Hours service is currently operating out of the Herschel Centre in Slough. This is a shared service run by East Berkshire GP Out of Hours Service under a contract held by East Berkshire CCG. It is expected that this service will be relocated to Threeways and operated by the Buckinghamshire Provider Collaborative once refurbishment works are completed. Although the service could run in the practice as is, these changes will facilitate a much improved working area and experience for patients. A plan of the new layout is attached in Appendix H but also included in the GEM.

A first draft of how utilisation might look in the future is included in GEM but this is very much work in progress and will be part of the developing conversations with the PCN and community providers.

Capital costs

The total project cost is forecast to be £562.80k including VAT, building construction costs, surveys, planning, legal and consultant fees and interest costs.

The funding of £500k including VAT is to be funded by NHS Capital Grant. Any excess over this amount will be met by Assura. Assura have agreed that no increase in rental will be expected with regard to the improvements for the life of the lease.

CAPITAL Assura NHS Capital TOTAL

£k £k £k

Project Cost 562.80

Capital Split 31.33 403.67 435.00

Contingency 21.00 21.00

VAT 10.47 80.73 91.20

Construction Funding 62.80 484.40 547.20

Additional IT 15.60 15.60

TOTAL 62.80 500.00 562.80 Table 6: Total Development Costs

1.4 Commercial Case

1.4.1 Commercial Feasibility

Consent for the proposed improvements to the premises has been obtained from the current Landlords, Assura.

This reconfiguration will not increase rent reimbursement for the CCG, as net floor areas are not increased and the new lease rental will be the Rental Value agreed for the current rent review for the existing premises.

Assura will gain from these works by virtue of an increased asset value and the surrender of the old lease (with 9 years’ term unexpired) and renewal with a longer 25 year lease. They are

therefore willing to contribute the difference between the overall project cost and the NHS capital available for the reconfiguration works.

These costs include:

• SDLT, • Legal costs; both their own as well as the Practice’s reasonable legal costs to

complete a new lease, • Professional fees for the design and administration of the works.

As a purely internal reconfiguration and upgrade, the works do not require planning consent.

1.4.2 Appointment of Developer

Assura as Landlords will act as developer (see above). Assura are long-lessees of Threeways Surgery, and pay a ground rent to the District Council who is the ultimate Freeholder of the site.

Assura are well-placed to project manage the proposed works, being a specialist investor/developer within the healthcare sector and Landlord of many modern purpose–built GP surgeries in the UK.

Assura has many retained consultants who advise them on architectural, cost and construction issues and have called on such expertise as is necessary to meet the time constraints demanded of this project

1.4.3 Procurement Strategy

Assura as the developer will procure the contractor for the new building under their formal tender processes for a build of this scale.

The CCG needs the facilities in place to support the new PCN contract and ideally by 1 April 2020. This will put a time pressure on the delivery of this project. Assura have therefore advocated a negotiated route with one of their ‘framework’ contractors. This has a number of benefits but specifically ensures the contractor is familiar with the technical standards required from healthcare projects and the risks etc. associated with working to maintain the delivery of clinical services throughout the duration of the project.

Value for money is ensured via

• Benchmarking of contractor rates against other competitively tendered schemes by both the contractor and Assura’s wider cost database, collated from live and recently completed schemes.

• The M&E elements of the scheme have been priced by two sub-contractors and the lowest contractor selected.

• A tender evaluation has been carried out by Assura’s Cost Consultant.

• Assura have taken full responsibility for the entire development process including costs and managing the programme together with the associated cost risks.

The recommendation for award of contract has been shared with the CCG and has been subject to scrutiny of both the CCG and Assura’s Investment Committee.

The Practice, the CCG and Assura have agreed the design and Assura will be responsible for overseeing the construction work to reconfigure Threeways Surgery in Stoke Poges.

1.4.4 Statutory Approvals/Compliance

Following approval of the FBC, Assura will appoint a Building Regulations Consultant for the project. A formal public consultation event will not be necessary. However, the practice will be engaging with patients as soon as approval is given to ensure they are kept informed.

The building changes being made will offer future internal flexibility and physical capacity to enable the building to be better utilised to provide additional clinical capacity. The new spaces will comply with NHS design and specification standards, infection control standards, BREEAM principles and where possible, without major building work, will improve the existing rooms. In this regard we are aware of one consulting room created by the reconfiguration which is marginally under the recommended HBNs at 15m2.

The building specifications will include the IT and telephone cabling infrastructure. However, in accordance with the GMS contract, the practice will be responsible for their telephone systems and the CCG responsible for any upgrading of IT equipment required. This is considered to be minimal and provision for this has been made in the budget.

1.4.5 Contractual Considerations

Construction will be procured through the JCT Management Form of Contract with Amendments, administered and project managed wholly by Assura. This arrangement provides greater control over the Main Contractor and ensures involvement with every element of letting the works. As noted above the works will be contracted with a design package that ensures full compliance and the risk for this will sit with Assura and the Contractor.

Assura, as client under the JCT contract, will cash flow the works and invoice the practice, with a full breakdown of works carried out and supporting invoices on completion.

A project programme has been prepared and is attached at Appendix K.

1.4.6 Risk

The Risk Register will continue to be a live document throughout the life of the project and will be used to identify, track, and manage risk items down. Monthly meetings will provide the platform to ensure these items are proactively addressed both in the practice and in addition with the wider stakeholders.

1.4.7 Project Management

The project will be managed by a project management board comprising partners of the practices, Assura, and the CCG.

The CCG’s Estates and Development Manager will make regular inspections of the work during its progression and will advise on any risks if or when they develop.

1.4.8 Key Milestones The proposed development programme includes the following milestone events, leading to completion of the project by March 2020. The Development Programme can be found in Appendix K.

Milestone Date Confirmation of Funding route October 2019 Submission of Business case and Supporting Documents 6 November 2019

Approval of Funding 14 November 2019 Legal close on Lease Agreements 21 November 2019 Construction Commenced December 2019 Construction completed 13 March 2020

Table 7 Key Milestones

1.4.9 Operating Strategy for the practice whilst the works are in progress

Full CDM compliant Risk Assessments will be carried out by the Contractor as part of the Tender process. Although work will, wherever possible, be undertaken during the working week, works will be phased and planned in advance so as to minimise disruption to staff and patients and as a result will require some evening and weekend working.

1.4.10 Impact on Staffing

This development will not result in any loss of jobs or need to transfer the existing staff in the practice anywhere.

1.5 Financial case

1.5.1 Capital Requirement

The table below sets out the total capital requirement of the Threeways Reconfiguration project. It identifies the NHS capital contribution required for the overall scheme:

CAPITAL Assura NHS Capital TOTAL

£k £k £k

Project Cost 562.80

Capital Split 31.33 403.67 435.00

Contingency 21.00 21.00

VAT 10.47 80.73 91.20

Construction Funding 62.80 484.40 547.20

Additional IT 15.60 15.60

TOTAL 62.80 500.00 562.80 Table 8: Capital Requirement

1.5.22Financial Assumptions The key financial assumptions have been agreed between Assura and the Practices and are incorporated in the draft lease agreement document enclosed in Appendix J.

• The route to transfer of funds to the Developer has been agreed between the parties under advice from NHS England.

• The practice will enter into a new 25 year term lease for the property. • VAT Treatment:

o The developer is opting to tax and is therefore able to reclaim VAT on its building costs but will charge the practices for the development work which will attract VAT.

o The current rental is already subject to VAT. • Rent will stay the same in the new lease and therefore doesn’t increase. • Abatement is not applicable. The works are classified as a Tenants Improvement and

does not result in any rent increase under the new lease. • Capital investment at £500k. • This has been confirmed as Value for Money by the District Valuer.

1.5.3 Capital Contribution

The development costs will be funded initially by the developer, Assura. The speculative costs to develop the project have been and will continue to be funded by the developer.

The CCG has no further capital funding requirement with the transaction costs being funded by Assura. The funding figure that has been applied to the project is £500k and will be awarded at Practical Completion of the works i.e. March 2020 or, as the programme is in four distinct phases, on a phased approach subject to sign off of completion by the CCG.

Assura will be responsible for the SDLT obligations and any legal fees of both themselves and the practice.

1.5.4 Revenue Impact The current annual revenue commitment to the practice in respect of rental amounts to £125,500 exclusive of VAT. The impact of the project works will be excluded from rental assessments for the life of the lease. The total incremental revenue investment over 25 years is therefore zero.

1.6 Management case

1.6.1 Project management arrangements A Project Group comprising the following stakeholders have been meeting since April 2019:

• NHS Buckinghamshire CCG • The Developer and Site Owner, Assura • Threeways Practice

The Group is responsible for:

• agreeing with the Developer how best to implement plans to deliver the required works • ensuring that NHS policies and building guidance have been taken into account in the

design of the building • mitigation of risk associated with the project.

The Project Group reports into the CCG’s Premises Sub Group, which is a sub group of the statutory CCG Primary Care Commissioning Committee (PCCC). Throughout the construction period, monthly meetings will be held with the Practice and the Project Group to report on progress and any matters arising.

1.6.2 Benefits Realisation The benefits identified from the delivery of this project are detailed below and align with both national and local strategic drivers as well as the critical success factors that will be used to assess all primary care developments in the future.

Investment objectives Main benefits criteria by stakeholder group Improved resilience in primary care services to meet on the day needs of residents

Working at scale supports continued delivery of primary care services in the community. Greater resilience reduces workload pressure on individuals thus more staff retained in the primary care setting.

Care integrated locally to provide better support closer to home

Supporting people to remain as independent as possible for longer. Care delivered closer to home.

Whole system approach to transforming health and care to achieve better patient experience and outcomes

Avoids duplication of services and makes patient care more seamless. Supports right care, right time, right place.

Redesign care model and make best use of clinical, estate and digital resources

Makes better use of existing resources and harnesses new technology to support the delivery of services.

Deliver better value for money for the tax payer. Getting better value from estates development, means more investment available for direct patient care.

Table 9: Benefits Realisation

1.6.3 Risks and Risk Mitigation The Project Group will oversee risk and risk mitigation. Risks will be escalated as appropriate to relevant bodies by the Project Group as and when necessary.

Area Project Risk Mitigation

Planning Permission Refusal of Planning Consent Planning Consent is not required for this development as this is an internal reconfiguration

ETTF Capital Funding Delay in funding approval In the event of any slippage, the programme will be assessed to establish how to absorb the delay by potentially considering undertaking tasks in parallel to gain the lost time.

Project Delays The risk of construction delays or other delays such as Building Regulations consent

The overall programme of work is the responsibility of the developer. The programme will be actively managed to ensure key milestone events are achieved on programme.

Impact on Day to Day Operations

Construction interfering with day to day access of current services

The programme of works will be managed to ensure that the impact is minimised and works carried out in non-working hours where possible.

Table 10: Risk and Mitigation Measures

1.6.4 Post project evaluation arrangements The CCG is committed to ensuring that a thorough and robust post project evaluation is undertaken at key milestones and also once work is completed to ensure that positive lessons can be learnt and carried forward to future projects of this nature.

1.7 Recommendation

This development is crucial to the delivery of primary care and PCN services and is seen as an essential enabler to the successful delivery of new ways of working to patients and staff living and working in the South Bucks locality. In summary, our recommendation is supported by:

• The District Valuer’s report confirming Value for Money

• The results of the Options Appraisal exercise

• The benefits that the upgrade to the building will offer, and

• the overriding benefit to services that this capital support will provide.

We have no hesitation in commending the business case for the reconfiguration of the Threeways Surgery, Stoke Poges to NHS England for approval.

Signed:

Gary Heneage, Chief Finance Officer and SRO for this Project Buckinghamshire CCG 31st October 2019

MEETING: Primary Care Commissioning Committee PAPER: R

DATE: Thursday 5 December 2019

TITLE: Contract Variations (for information)


LEAD DIRECTOR: Nicola Lester, Director of Transformation

Reason for presenting this paper: For Action For Approval For Decision For Assurance For Information Summary of Purpose and Scope of Report: Report highlighting approved contract variations. Conflicts of Interest: None – paper is for information. Strategic aims supported by this paper:(please tick) Better Health in Bucks – to commission high quality services that are safe, accessible to all and achieve good patient outcomes for all






Equality/Equity Quality Financial Risks Statutory/Legal Practices must inform the CCG of any changes to

the terms of their contract.


Membership Involvement Supporting Papers: Contract Variation Log.

Contract Variations– Report Dated 25 November 2019 Dr Kate Grint 6135457

Partner GP ? 01/05/2019 K82046 The Simpson Centre GMS

Dr Dimitris Zachariades 6164496

Partner GP Locum GP 26/10/2018 K82006 Iver Medical Centre GMS

Dr Sutapa De 4069373 Partner GP Locum GP 10/07/2019 K82044 Carrington House Surgery GMS

Dr Lee Mitchell 7280891 Salaried GP

Partner GP 31/07/2019 K82079 Edlesborough Surgery GMS

Dr Ashish Patel 7410258 Salaried GP

Partner GP 09/08/2019 K82073 Poplar Grove Practice GMS

Dr Rajeev Vaikunthanathan 4559371

Partner GP ? 09/11/2018 K82066 Bourne End & Wooburn Green Medical Centre GMS

Dr Lynette Hykin 3545324 Partner GP ? 01/01/2020 K82049 Hughenden Surgery GMS

Dr Stella McGarry 6120597 Partner GP

Salaried GP 01/08/2019 K82073 Westongrove Partnership PMS

Dr Amanda Bartlett 6116946 Salaried GP

Partner GP 01/12/2017 K82053 Priory Avenue Surgery GMS

Dr Thomas Broughton 7135557 Salaried GP

Partner GP 20/05/2019 K82047 Unity Health GMS

Dr John Bell 2374619 GP Partner Retirement 31/07/2019 K82079 Edlesborough Surgery GMS

Dr Wendy Sharon Payne 3486186

Locum GP

Partner GP 06/01/2020 K82035 John Hampden Surgery GMS

Dr J-Ai Foley 7016701 Salaried GP

Partner GP 01/01/2019 K82036 Riverside Surgery GMS

Dr Elizabeth Hilary Muir 2649966

Partner GP Retirement 30/09/2016 K82038 Poplar Grove Practice GMS

Dr Ayaz Aleem 6129690 ? Partner GP 01/11/2018 K82051 The Misbourne Practice GMS

Paper S Primary Care Commissioning Committee and Primary Care Operational Group Forward Plan October 2019 to March 2020

3 Oct 2019 PCOG

7 Nov 2019 PCOG

5 Dec 2019 PCCC

9 Jan 2020 PCOG

6 Feb 2020 PCOG

5 Mar 2020 PCCC

Finance Report Quality Report Head of Primary Care Report Risk Register

Digital Transformation Locally Commissioned Services

Primary Care Networks ICS Primary Care Strategy

ICS Primary Care Estates Strategy Practice Updates and Topic Specific Updates

General Practice Forward View Review of Committee Terms of Reference

Review of Terms of Reference for Sub Groups

Primary Care Commissioning Annual Report (June)

Review of Conflicts of Interest Register

Primary Care Commissioning Committee

Documents

Transcript of Primary Care Commissioning Committee