report to the sutton clinical commissioning group ... board papers/4sc… · to date marguerite has...

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Report to the Sutton Clinical Commissioning Group Governing Body

Date of Meeting: 5th November 2014 Agenda No: 5.1 ATTACHMENT: 04

Title of Document: Local Enhanced Services (LES) Review Report

Purpose of Report: To approve the recommendations for each LES scheme

Report Authors: Marguerite Macfarlane, QIPP Redesign Manager,

Lead Director: Susan Roostan, Director of Commissioning and Planning

Executive Summary: This paper provides an outline of each existing LES scheme (provider, cost, activity), includes an options appraisal and makes recommendations for each service going forward. The report is brought to the governing body for approval because the Executive Committee is conflicted on making a decision concerning primary care issues. Conflicted board members will need to step away from the decision making of the governing body, to ensure good governance practices are followed.

Key sections for particular note (paragraph/page), areas of concern etc: Conclusions and recommendations for each LES scheme: from page 6 - 10

Recommendation(s): The Board is asked to note and approve the recommendations for each existing LES as outlined in the report.

Committees which have previously discussed/agreed the report: LES Review Group chaired by Sue Roostan. The Executive Committee has discussed the report but cannot approve it due to conflicts of interest.

Financial Implications: Workforce resource required to undertake work to transfer the schemes to the NHS Standard Contract and/or de-commission services (short-term); and Additional workforce capacity to undertake performance management of the newly contracted provider schemes (long-term).

Other Implications: N/A

Information Privacy Issues: n/a

Communication Plan: n/a

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Local Enhanced Services Review: Report

1. Purpose The purpose of this report is to provide the Executive Committee with an overview and options appraisal of each the Local Enhanced Services currently commissioned across Sutton with recommendations for either transferring the existing schemes to NHS Standard contracts (for individual practices, the Federation or for third party providers), reviewing schemes as part of a wider system redesign or de-commissioning schemes from the 1st April 2014.

2. Background As PCTs ceased to exist, all local enhanced services (LES) held by the PCT were distributed between Clinical Commissioning Groups (CCGs), Local Authority (LA) or the NHS Commissioning Board (NHS CB) Area Teams. LES contracts will cease to exist as a contracting mechanism on 31st March 2014; CCGs are required to review existing schemes and commence transfer to their new form. CCGs are free to determine how to use the associated funds from these services to procure community based services using the new NHS Standard contract for clinical services. Acting in the best interests of patients when making decisions, the CCG can decide when and how to use competitive procurements.

CCGs need to decide whether these services could be delivered by a number of potential providers (which may include general practice) or whether they could only be provided by general practice. CCGs will need to decide whether to undertake competitive procurements to identify a single provider (or limited group of providers) or whether to allow patients to choose from a range of qualified providers by using the AQP route. For services for which there are no other possible providers or would require the provider to have registered lists, SCCG could either commission services directly with GP practices or appoint a single award to the GP Federation on behalf of all member practices (and sub-contract to non-member practices).

General practice had been given prior notice of the changes to contracting in relation to LES schemes commissioned by NHS Sutton CCG which are likely to take effect from 1st April 2015. This review does not include any LES schemes that are currently commissioned by Public Health/Local Authority nor do they impact on any medicines management schemes that are currently in place.

3. Governance arrangements

3.1 LES Review Group

In order to take this work forward apace, the LES Review Group was formed to lead and oversee the review process and guide implementation of agreed recommendations. The Group is chaired by Sue Roostan and met for the first time on the 30th July 2014; clinical input is provided by Dr Dino Pardhanani and Dr Clare O’Sullivan with management input from commissioning, finance and performance colleagues – see attached Terms of Reference as Appendix 1. Marguerite Macfarlane

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was appointed to undertake an options appraisal for each LES, working with Carolyn Reynolds to produce a report with specific recommendations for each scheme.

3.2 Services under review

The LES schemes currently commissioned by the CCG are as follows:

Menorrhagia

End of Life care

Phlebotomy

Anti-coagulation

Insulin Initiation

Diabetes

ECG

Physiotherapy

Post-operative wound care

Intermediate care beds (GP support)

Counselling

3.3 Options The Group agreed the LES schemes would be appraised against the following options:

Do minimal (ie transfer existing LES for each provider into the new NHS Standard Contract);

Expand provision across all practices (if the LES pertains to a limited number of practices, increase investment to allow all practices to take part in the scheme);

Redesign fully integrated pathway (ie review whether the existing LES should be part of a wider system-wide review of a specific pathway – work that would be undertaken by the QIPP team);

Competitive tendering (ie contract value and/or plurality of providers could mean some schemes would be better tendered on the open market);

Serve notice of termination (if the scheme is very limited in scope, cost and activity for patients across Sutton and doesn’t fit within the ‘expand across all practices’ option, this option would apply).

3.4 Options appraisal criteria

Each option for each LES was appraised against the following criteria:

Clinical effectiveness

Strategic fit (commissioning intentions & JSNA)

Equity and access

Affordability and value for money

Sustainability and deliverability

3.5 Consultation with providers/primary care colleagues

The Group considered it important that views and opinions from current providers and primary care colleagues should be taken into consideration as part of this review. Marguerite Macfarlane therefore wrote out to all practices explain the review process and offering to visit each practice to hear their views on the future of existing schemes.

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To date Marguerite has visited twelve practices to garner their views and concerns regarding the LES schemes. A summary of their views are contained within the attached Appendix 2.

3.5 Timescale

Timescales for completion were agreed by the LES Group as follows:

Practice visits and collection of activity/data to be undertaken throughout August/early September;

The options appraisal matrix (x11 schemes) to be circulated to members by the end of September 2014;

First draft of report to be sent for comment to the Group for comment/feedback by 13th October 2014;

Report to QIPP Steering Group and Executive Committee on 22nd October 2014;

Report to the Governing Body on 5th November 2014.

4. LES schemes

4.1 Profile of each LES scheme

4.1.1 Menorrhagia Service: Management and treatment of patients with a history of heavy cyclical menstrual blood loss (oral therapy and/or coil fitting); Provider: Originally commissioned by Nelson Consortium and currently provided by seven practices (to their own patients only). Annual Budget: £20,940 Actual Payments made 2013/14: £33,380

4.1.2 End of Life Care Service: Entry of suitable patients onto CMC; hold 2 MDT meetings per quarter; completion of after death audit. Provider: 26 practices delivering these services (exception of GMS practice). Annual Budget: £52,350 Actual Payments made 2013/14: £25,338

4.1.3 Phlebotomy Service: phlebotomy service provision within local community settings and for housebound patients. Provider: All 27 practices are covered by either in-house provision, referral to StH Hubs or have sub-contract arrangements in place with Virgin Health. Annual Budget: £104,700 Actual Payments made 2013/14: £101,558

4.1.4 Anti-coagulation Service: Anticoagulation management to patients on warfarin or phenindione therapy. Provider: Offered in-house by a few practices but in the main referrals to one of three Hub practices (Green Wrythe, Robin Hood and Maldon Road). Annual Budget: £104,700

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Actual Payments made 2013/14: £164,602

4.1.5 Insulin Initiation Service: Initiation of insulin therapy for patients with Type 2 diabetes who are not achieving Hb1Ac targets and have no reason for hospital assessment. Provider: The Hub provision was decommissioned from 1.4.14; only 6 practices currently provide the service to their own patients. Annual Budget: £ Actual Payments made 2013/14: £3,520

4.1.6 Diabetes Service: Provision of team of clinicians to provide diabetic clinics to carry out a comprehensive management and treatment programme for all diabetics identified with Type 1 and Type 2 diabetes within the practice. Provider: Wrythe Green Surgery (to own patients only) Annual Budget: £25,111 Actual Payments made 2013/14: £23,191

4.1.7 ECG Service: Provision of resting ECG and 7 day event monitoring walk-in clinics (or by appointment). Provider(s): Old Court House acts as a Hub for all practices with the exception of Grove Rd and Mulgrave Rd surgeries who provide the service in-house for their own patients. Annual Budget: £105,000 Actual Payments made 2013/14: £99,720

4.1.8 Physiotherapy Service: Two senior musculoskeletal physiotherapists provide a comprehensive musculoskeletal physiotherapy service to the patients of Wrythe Green Surgery (only in-house referrals received). Provider(s): Wrythe Green Surgery Annual Budget: £32,145 Actual Payments made 2013/14: £34,862

4.1.9 Post-Operative Wound Care Service: Removing clips and sutures which did not originate within primary care and providing post-operative wound care. Provider(s): All 27 practices within Sutton CCG Annual Budget: £20,940 Actual Payments made 2013/14: £19,616

4.1.10 Intermediate Care Beds (GP support) Service: Medical Support provided by GPs for 33 intermediate care beds within three Care Homes (Crossways, Abbey Cheam & Eversfield): Provider(s): Drs Elliott, Pardhanani & Scerri Annual Budget: £35,000 Actual Payments made 2013/14: £47,658 (Adjusted investment in 4 additional prevention of admission beds)

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4.1.11 Counselling Service: Provision of an in-house counselling service for selected patients (short-term – six weekly sessions). Provider: Cheam Family Practice Annual Budget: £18,306 Actual Payments made 2013/14: £15,255 (made via NHS England)

A synopsis of the schemes is attached as Appendix 3.

4.2 Options appraisal

An options appraisal was carried out for each LES scheme to establish the best commissioning option for delivery of those services going forward or indeed whether to serve notice on the service. The schemes were then scored against each criterion (with input from Group members) and the option attracting the highest score forms the basis of the recommendations listed in section 4.4 below. See the attached options appraisal matrix Appendix 4.

4.3 Emerging themes Some of the generalised themes emerging from the practice visits and discussions with commissioners were captured and summarised on the attached Appendix 5. Areas of particular concern and/or interest include the following:

4.3.1 Contracting issues;

4.3.2 Federation readiness (of significant concern); 4.3.3 Information governance (predominantly around patient sharing information);

4.3.4 New models of service and community services (concerns about redesigning or introducing new primary care models of care that may have an unintended impact on existing community services – and concerns that planning dovetails with plans for the re-procurement of community services);

4.3.5 MDTs (potential overlap with MDT requirements for other schemes);

4.3.6 Performance management (capacity issues);

4.3.7 Implementation timelines (are realistic and subject to thorough planning and execution)

4.4 Recommendations

4.4.1 Menorrhagia Conclusions:

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There is no doubt that clinicians and managers alike believe this is an essential scheme that should be rolled out and offered to all practices so patients can benefit from in-house expertise and treatment. However, while reviewing the value of this service, practices have also expressed concern and regret that the Gynaecology Community Service (commissioned by Sutton & Merton) has been de-commissioned. It therefore seems like an opportune moment to review all gynae services/pathways, to consider widening the scope of the scheme by re-commissioning a new model Gynaecology Community Service preferably involving all our local health partners in delivery of the scheme. Recommended option: Option 3 In the short term to continue to commission the 7 practices to continue with the Menorrhagia scheme (agreement via Heads of Terms – subject to legal advice) while commissioners and clinicians work together to design and implement a new community gynaecology service. If local health partners are resistant to working together to deliver a proposed scheme, the CCG should progress to Option 4 – procurement via open tender.

4.4.2 End of Life Care Conclusions: EoL is a key priority for the CCG and encouraging practices to take part in this scheme has proved beneficial in meeting the CMC targets and feedback regarding the benefits of holding regular MDTs in the practice is (in the main) positive. However, in re-writing the specifications for this scheme, clinicians believe the requirements could be tweaked to achieve more effective outcomes – the EoL Clinical Lead is in agreement and is willing to refresh the scheme for next year. However, rather than have 27 contracts to manage, it would be less resource intensive if a Lead Provider (possibly Sutton Federation) model representing all practices, could be adopted going forward. Recommended option: Option 2 To contract with all practices to deliver a slightly modified EoL scheme with defined outcomes preferably via Lead Provider (to minimise contract management resource).

4.4.3 Phlebotomy Conclusions: It is essential that this service remains available to all patients within primary care; the current provision is acceptable (although tariffs vary across providers) and contracts could be drawn up with each practice incorporating clear cut service specifications with clear outcomes and performance measures. However, there could be alternative ways of delivering this service and contracting with a Lead Provider could lead to proposals for new and innovative ways of delivering the service which meets the outcomes but also improves patient experience by eradicating variation in provision. If new models of delivery are approved, this may mean terminating some existing contracting arrangements eg Virgin and St Helier’s.

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Recommended option: Option 2 To amend specifications with defined outcomes and strengthened performance monitoring arrangements, agree tariffs (clinic and domiciliary) and contract with all practices to deliver phlebotomy services within each practice/locality preferably with a Lead Provider (eg Sutton Federation).

4.4.4 Anti-coagulation Conclusions: Repatriating patients from secondary care back to primary care for anti-coagulation services is a key priority for the CCG and this scheme will continue to be rolled out across Sutton. Service specifications will need to be revised to include domiciliary services with strengthened contract and performance requirements. The scheme could be delivered by contracting with the current providers (some acting as hubs), or, alternatively Sutton Federation could be commissioned as the Lead Provider to deliver the scheme within existing arrangements or propose new models of delivery. Having a single contract to manage will reduce management overheads for both practices and the CCG. Recommended option: Option 2 To revise specifications with defined outcomes and strengthened performance monitoring arrangements, agree tariffs (clinic and domiciliary) and contract with all practices to deliver anti-coagulation services within each practice/locality preferably with a Lead Provider (eg Sutton Federation).

4.4.5 Insulin Initiation Conclusions: Only six practices currently provide this service, others refer to Tier 3 or Tier 4, and a few undertake the work in-house without funding. As diabetes is such a key priority for the CCG, retaining expertise within general practice and/or encouraging peer review can only benefit GPs and patients alike. It would therefore make sense to continue with this scheme but to scale up by rolling the scheme out to all practices. It is unlikely that all practices will want to enrol as they won’t all have the in-house skills/resources but Commissioners consider it would be better to bring those currently undertaking the work ‘unfunded’ into the scheme. This option will require additional funding to roll out the scheme across all practices. Recommended option: Option 2 Establish affordability of rolling out the scheme across all practices, and, if affordable, contract with Sutton Federation to deliver the service within all participating practices. Patients from non-participating practices will continue to be seen by Tier 3 or Tier 4 services.

4.4.6 Diabetes Conclusions: This service, whilst acknowledged as providing a gold standard service, is neither equitable nor accessible to patients outside the practice. Introducing the 4 Tier model has been a priority for the CCG so rolling this scheme/model of service out across Sutton would not be consistent with CCG commissioning

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intentions and would require considerable investment. De-commissioning the service is the most obvious option, but there may be TUPE issues to consider. Recommended option: Option 5 Wrythe Green Surgery should be served notice of termination as soon as possible as they will need to consult with their staff around TUPE. If funding is transferred into the roll out of the Insulin Initiation scheme across all practices, consideration will need to be given to ascertain whether TUPE would apply. The CCG will need to work with the practice to agree de-commissioning timescales and should make every attempt to limit the negative impact on the practice, practice staff, finances and expectations.

4.4.7 ECG Conclusions: This service is provided in the main by Old Court House surgery to all practices other than Mulgrave Road and Grove Road (who provide it for their own patients). The model of service provided by Old Court House has consultant input and is well-liked by GPs for both quality of reporting and accessibility. Commissioning Old Court House (as the Lead Provider) to continue to provide ECG services across Sutton would be the short-term solution, whilst work consideration is given to design and potentially commission Direct Access Diagnostics which may or may not include ECGs. Recommended option: Option 2 Refresh the current specification to include defined outcomes and strengthened performance monitoring arrangements. Draw up a contract with Sutton Federation to deliver the services – probably by contracting with Old Court House, Grove Road and Mulgrave Road if they meet the requirements of the revised specification.

4.4.8 Physiotherapy Conclusions: This service is only provided by Wrythe Green Surgery for their own patients offering excellent valued in-house provision. However it isn’t equitable across all practices and isn’t accessible to patients outside the practice. All other practices have to refer into the community physiotherapy service. The feedback from practices regarding the community physiotherapy service has been negative due to waiting times although the service has improved against this measure. Since additional funding has been invested in the community service by Merton CCG real improvements are being seen in KPI performance reporting (including a reduction in waiting times). The community physiotherapy service is also part of the re-procurement of community services with a proposed service commencement date of April 2016. In coming to a recommendation, the CCG will need to take account of the views of member practices, to consider whether the recent improvement in community services is adequate or whether the service should in fact be withdrawn from the re-procurement exercise and alternative provision considered. The options could be to:

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a) Retain the scheme at Wrythe Green Surgery, but only if they agree to extend the service out to all practices/patients while the re-procurement is undertaken;

b) De-commission the Wrythe Green scheme and re-invest the funding into the community service to increase capacity and improve standards; or

c) De-commission the Wrythe Green scheme, review whether the physiotherapy service should be withdrawn from the Community Service tender and procure a new physiotherapy service across Sutton.

NB Due consideration will need to be given to any TUPE issues that apply and the CCG will need to work sensitively with practices to limit any negative impact caused by the withdrawal of services from Wrythe Green Surgery. Recommended option: The Executive Committee advised that any decision regarding the future of this scheme would need to be considered in conjunction with discussions around the re-procurement of community physiotherapy services. As feedback from practices on the existing physiotherapy community service has been quite negative so their preference for commissioners to procure alternative provision (to the community service) should be given due consideration before any recommendation can be made for the future of the Wrythe Green Surgery scheme.

4.4.9 Post-Operative Wound Care

Conclusions: All practices provide this service and as demand is increasing (with an ageing population) so is the activity – payment is currently made on a capitation basis. Practices have asked that the scope of this scheme is expanded to include complex wound dressings undertaken by practice nurses which are currently unfunded. The CCG may wish to consider working up a QIPP case for change to fund practices to undertake complex wound dressings – however this work would sit outside the remit of this LES review. Commissioners are advised to contract with a Lead Provider to deliver the POWC scheme in line with a revised service specification which includes clearly defined service outcomes and strengthened performance monitoring arrangements. Recommended option: Option 2 To refresh the specification adding clearly defined outcomes and strengthened performance monitoring arrangements and contract with all practices to deliver POWC services within each practice/locality preferably with a Lead Provider (Sutton Federation).

4.4.10 Intermediate Care beds (GP support) Conclusions: Sutton currently has 33 intermediate care beds that require primary medical cover in three Care Homes (Crossways, Abbey Cheam and Eversfield). This is clearly and essential service provided by three GPs and Commissioners would wish to see these arrangements continue into the future. Transferring these

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LES schemes directly into three NHS Standard Contracts for each of the three providers would be the preferred option. Recommended option: Option 1

4.4.11 Counselling Conclusions: Cheam Family Practice has had an in-house salaried counsellor providing services to practice patients for over 20 years. NHSE is currently funding this scheme, so it may not be within the remit of the CCG to decide on future investment for this service. Carolyn Reynolds will try to find out what plans NHSE have for this scheme going forward. However, if NHSE do expect to transfer responsibility to the CCG, continuing to commission this scheme would fly in the face of CCG tendering plans to provide a Sutton-wide primary and community care model for all patients. The new model has been fully costed and individual funding streams for counselling services within general practice do not feature in this model so there would be no intent to re-commission this service in future. The service will therefore need to be de-commissioned as soon as possible to allow the practice to consult with their staff. TUPE may apply and the mental health leads have incorporated this (potential) requirement within the tender documentation. Recommended option: If we receive confirmation that commissioning responsibility for the scheme is passed from NHSE to the CCG for future funding, the recommendation would be to de-commission the service and serve notice on Cheam Family Practice – Option 5.

5 Approval & Next Steps The Governing Body is asked to note and approve the recommendations which have been previously reviewed and amended by the LES Review Group and the Executive Committee. (The Executive Committee approved change in the recommendation on 4.4.8 (physiotherapy) at the request of the Chief Operating Officer). If the recommendations are approved, then implementation timelines for each of the LES schemes will need to be drawn up and submitted to the Executive Team for approval in November 2014.

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Note: A number of the recommendations (for Option 2) proposed are made on the basis that Sutton Federation will not only be incorporated by March 2014, but will be in a position to respond to single award tender action (STA) requirements and be able to provide assurances to the commissioners that they comply with all the necessary statutory requirements eg CQC registration, IG Toolkit compliance, safeguarding etc. If the state of readiness isn’t satisfactory, then the recommendation will default to supporting Option 1 (for one year).

LES Review Group (Appendix 1) Executive Lead Sue Roostan

Purpose The purpose of the Review Group is to oversee a review of existing Local Enhanced Services currently commissioned by NHS Sutton CCG. From April 2015 CCGs can no longer commission services via the LES contracting mechanism, existing contracts will therefore need to be assessed a suitable for transfer into the Standard National NHS contract via contract variation, procurement or termination. The services under review include the following: • Anticoagulation ● Insulin Initiation • ECG Monitoring ● End of Life Care • Menorrhagia ● Phlebotomy • Post-Operative Wound Care ● Physiotherapy The Review Group will consider the methodology for generating and shortlisting options, agree weighting criteria and propose parameters within which the reviewer will undertake this piece of work and sign off the Options Appraisal Report to the Executive Team and the Board. Practices will be informed about the review and invited to give their views and feedback on the future of the LES schemes going forward.

Objectives • To review existing LES and provide an Options Appraisal report to the Executive Team (and/or the Board); • To review action plans for each LES and oversee implementation for each service change; • To address any clinical service issues that arise pre and post implementation; • To ensure patient safety and service quality remain at the forefront of all discussions and any changes to service provision will

ensure these core elements remain at the heart of the review; • To identify risks , issues and any other dependencies and to manage mitigating actions; escalate major risks/issues to the

Executive team; • Report progress to the Executive Team in line with reporting requirements;

Membership Reporting Structure Key Deliverables:

• Director of Commissioning & Planning (Chair); • System Director Commissioning Children & Community

Services; • QIPP Programme Director; • Service Redesign Manager(s); • Clinical/Managerial Lead(s) for service area • Management Leads from SWL CSU (contracts, IG etc as

required) Quorate when at least 50% of the Group are present; administration undertaken by the Service Redesign Manager.

• LES Review Group – reporting into Executive Team;

• Options Appraisal Report to be reviewed/approved by:

- LES Review Group; - Executive Team; - CCG Board.

• Review Brief;

• Mini profiles for each service;

• Options template;

• Options Appraisal Report

• Up to date risk & issue logs;

• Completed QIA, EqIA and PIA ;

• Action plan (implementation for each LES)

Draft v1

Appendix 2

LES Summary of feedback from 12 practice visits:

Well Court, GP Centre, Shotfield, Cheam, Wrythe Green, Old Court House (OCH), Grove Road, Benhill & Belmont, Wallington Family Practice, Mulgrave Road, Wallington Medical Practice, Beeches Surgery

Options (1-5)

Menorrhagia

The general view is that the LES has a very narrow criteria which ideally should be broadened to include a wider range of gynae services;

De-commissioning the gynae service is likely to have seen an increase in gynae referrals (Post visit note – the referral data has been analysed and this assertion hasn’t been borne out by the statistics to date);

Wrythe Green/Shotfield believe they provide gold standard out of hospital gynae care – suggest a similar model of provision is designed and offered across all practices; this generated much discussion around community based provision and transferring ‘appropriate’ secondary care activity into the community (eg one stop shop approach) preferably locality based; fair amount of enthusiasm to get involved in exploratory discussions around designing the new model.

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End of Life Care

Feedback regarding the requirement for MDTs was mixed – a synopsis of views below:

Inappropriate for this cohort of patients whose circumstances are constantly changing and who need much more regular/frequent review;

Very effective as it brings all clinicians into the frame – they are brought up to speed with the circumstances for each of these patients which they find invaluable;

Very work/effort intensive for clinicians with minimal clinical benefit;

Doesn’t provide value for money;

Guaranteed overlap with other MDT requirements – potential for double payment for same patient/MDT; some practices say there is no overlap at all and others say they run searches to make sure they are not duplicating MDTs for the same patients;

Difficulty getting the DNs to attend and issues around capacity for palliative care teams to attend too;

MDT representation is varied – some involve the respite service, some DNs, some just run the MDT with practice staff alone

Practices are aware that this element of the service could be up for review/change.

Many felt the MDTs should continue as they provided valuable fixed opportunities for updates for all clinicians and access to colleagues from respite services on a monthly basis – this seems to be particularly related to the larger practices.

CMC database – comes in for a huge amount of abuse! It doesn’t self-populate; has too many mandatory fields, is so time consuming that it acts as a deterrent to complete; commissioners need to influence the CMC to improve the register or fund it better to encourage uptake!

ADA form is acceptable – but many don’t know why they complete it; others think it could be better designed to incorporate more pertinent information, and others would like to know what are the clinical benefits of completing them – has any evaluation been carried out?

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Appendix 2

Phlebotomy

Mixed provision – in the main, happy with the services they have chosen to either provide or outsource; contractual arrangements are very varied and if the service is put out to procurement then there may be some workforce issues to consider (eg TUPE); some would prefer to carry phlebotomy in-house but haven’t the physical capacity (eg GP Centre) others consider payments to be minimal and a disincentive to providing the service in-house; others have offered and would like to carry out the service in-house but have been refused in the past.

Only real negative was in relation to the clinic at Priory Crescent – long queues particularly at the start of the day – why is it not run at least 3 times a week or more to more adequately match capacity/demand?

The Virgin tariffs are greater than in-house tariffs - thus creating an unnecessary and perverse disincentive to provide in-house services.

The contract value for phlebotomy is significant enough to require re-procurement considerations.

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Anticoagulation

Mixed provision; generally works well but ongoing unresolved issues around governance/clinical safety as the platform for sharing patient information (electronically) doesn’t exist; nurses undertaking the service don’t have access to the most recent readings – they therefore rely on the ‘yellow book’ details carried by the patients; dom visits need to be agreed/reviewed – little interest in carrying this out for any but own patients due to the cost/time and governance issues; ongoing issues with patient repatriation – patients are NOT being advised to return to primary care for their procedures.

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Insulin Initiation

Those who deliver it believe patients get value and commissioners save on referrals; those who don’t deliver it say the LES targets a very narrow clinical ‘episode’ and could include so much more ie pre-insulin and post-insulin issues should be included; is there any vfm in continuing this service – are there significantly fewer referrals from practicing practices (Vladimir to check); some feel that basic diabetes care is so time consuming/intensive in primary care, this LES should be scrapped and a more revolutionary primary care ‘diabetes’ LES introduced.

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Diabetes

This ‘gold standard’ LES is delivered by Wrythe Green Surgery alone – they believe they deliver the ideal primary care model which relies very little on Tier 3 and minimal intervention from Tier 4; others do feel there is potential to revise the models for both primary care (Tier 2) and/or the community service (Tier 3).

Significant concerns expressed by many that patients referred to either Tier 3 but more particularly Tier 4 services are put through the exact same treatments/procedures already tried by GPs in primary care and then the patients stay in those services ‘forever’ being recalled time and time again rather than being treated and discharged with appropriate onward treatment/care planning.

There is some appetite to be involved in exploring revisions of the diabetes Tier models. Need to improve diabetes education within primary care – incorporate the requirements within the service models.

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ECG

Apart from 2 practices, this is undertaken by Old Court House and has very good reviews; some frustration that even the new forms don’t self-populate; one practice has issues with the reports (nb practices need to access the reports separate to the ECG itself so there may just be a communication issue with this practice).

There is some interest however in reviewing all the cardiology services including diagnostics, eCardiology, heart failure services (which has limited capacity) with a view to creating perhaps a consultant-led community service (with outpatient clinics).

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Appendix 2

Physiotherapy

Almost universal condemnation of this service – on quality, waiting times, paperwork, feedback, interaction with primary care etc. Lots of references to ‘the excellent service provided by the private provider previously’.

Seems like an obvious service for review within the new community service procurement or for open tender outside the community contract. Negative feedback regarding the MSK service – but didn’t pursue the detail on this except to confirm the poor waiting times and it may be appropriate to review/revise the specs for this and the physio service at the same time.

4/5

Post-Operative Wound Care

All practices provide this service and payment is made for suture/clip removal, but universal grievance that the LES doesn’t recognise the resource time/effort that is taken up for dressings. Stories of dressings done daily on some patients and taking over an hour to treat – no related payment. This is seen as unfair and in urgent need of review. Suggestions that if a contract is drawn up that appropriately remunerates practices for a reasonably long (ie 3 years +) term, this would be welcomed, dedicated resource can be recruited allowing practice nurses time to concentrate greater efforts on their patients with LTC and chronic conditions. Opportunity for tissue viability nurses to oversee leg ulcer clinics, dopplers etc. Specification would need major overhaul.

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Intermediate Care beds (GP Support)

So far, only feedback is from Cheam who provide GP support to Abbey Cheam – the contract is up for renewal at the end of November 2014 (£1,500/month). Expectation that the contract will need to be transferred into the new format but will continue as before with new payment arrangements.

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Counselling Cheam is the only practice that employs a salaried counsellor for which they have received reimbursement up until this year; if there are any changes to the service (as a result of the LES Review or Procurement of mental health services) that result in termination of payments – TUPE could apply.

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GP Chair: Dr B Hudson

V6

MINI-PROFILE OF CURRENT LOCAL ENHANCED SERVICES

January 2014 (Revised July 2014) Existing services

LES (under review)

Used by these

Practices Cost

Service Provision Notes

Options (1-5) Provider User

Menorrhagia 7

£20,940

Wrythe Green Benhill & Belmont

Cheam Family The GP Centre (3)

Well Court

Providers’ own patients

Commissioned by Nelson Consortium; may need to review gynaecology provision following the decommissioning of the LES

3

End of Life Care 26 £52,350 Excludes

Wandle Valley Own Patients 2

Phlebotomy

27 £104,700 All practices

Own Patients Or Hub

Practices either carry out phlebotomy in house, refer to a hub/St. Helier or sub contract to Assura

2

Anticoagulation

27 £104,700 All practices

Own Patients Or Hub

Practices carry out this service in house or refer to a hub (repatriation from secondary care); will need to consider introducing a domiciliary tariff

2

Insulin Initiation** 6

£3,520

GP Centre (3) Shotfield

Wallington Family Old Court House

Own patients Hub provision decommissioned from 1.4.14; practices provide service for own patients only

2

Diabetes 1 £25,111 Wrythe Green Surgery Own patients Commissioned by Nelson Consortium 5

ECG 27 £105,000

Old Court House All practices

2 Grove Rd Own patients

Mulgrave Road Own patients

Physiotherapy 1 £32,145 Wrythe Green Surgery Own patients 5

Post-Operative Wound Care

27 £20,940 All practices Own patients Paid at a rate of £0.02626 per head of capitation on a quarterly basis

2

GP Chair: Dr B Hudson

V6

Methotrexate Injections

1 NA NA Sutton Horizon

from Jubilee Shared care agreement

Not part of LES review

Intermediate Care beds (GP support)

£35,000 Mulgrave

Benhill & Belmont

Grove Rd Paid a sessional rate for carrying out MDT 1

Counselling 1 £18,306 Cheam Family Set up 20-25 years ago. No service specification and no history of when/why the service was set up – funded by NHSE?

Need clarification

whether should be part of the

LES Review

Others

Decommissioned services

Diabetes

Decommissioned

Gynaecology

Decommissioned

Ultrasound

Decommissioned

Option 1: Option 2: Option 3: Option 4: Option 5:

Do Minimal - transfer to NHS Contract Expand provision across all practices (Lead Provider model)

Redesign fully integrated pathway Competitive tendering Serve notice of termination

Clinical Effectiveness

Coil fittings for contraception are undertaken by public health and family planning - this LES provides funding for women who fall outside this criteria; Clinicians report it would be more effective if the service provision is extended beyond treatment of menorrhagia; Participating practices believe having this in-house service is clinically effective, they can offer ongoing care and coil removal too;Non-participating practices - some say they are disadvantaged as they provide the service inhouse but don't get funded for it, others refer to secondary care.

As for Option 1 but will be much more effective if the service could be rolled out and available across all practices - the issue will be whether practices all have the skills/accommodation to provide the service inhouse - the roll-out would need to be accompanied by extensive education/training programmes to support this option;

Alternatively if the CCG were to commission a Lead Provider to deliver this scheme across all practices, there may be a way of designing services more creatively to deliver local services with real economies of scale eg the Lead Provider could engage a GPwSI to run menorrhagia clinics (rotating between practices or local clinics).

General consensus is that de-commissioning the gynaecology service has removed a valuable community service and it would be more clinically effective if the scope of the LES were to be expanded to incorporate more gynae interventions accessible to patients across Sutton;Participating practices would argue that there is more clinical benefit for patients if the service is delivered essentially by primary care with input from consultants into any proposed service. They suggest the Federation is best placed to deliver this

If the LES is to include a wider range of gynae interventions with a significant contract value, then a competitve tendering 'Lead Provider' model may be required (to meet OJEU regulations) which could be both clinically effective and provide greater vfm.

If in the first instance, local providers are encouraged to deliver the model and negotiations fail, then this option would be the default option; the service would then be

Not an option worth considering as clinical practice will be negatively impacted for those already delivering the service and gaps in service will remain unfilled.

Score 2 3 5 4 0

Strategic fit (& JSNA)

Menorrhagia is not a key priority area for the CCG but retaining the service will maintain the status quo for participating practices and will ensure that referrals into secondary care remain at existing levels.

Whilst not a key priority for the CCG, expanding provision across Sutton would align with the Sutton CCG Plan (2014-16) for Out of Hospital Care: Reduced growth in hospital attendances through GP locality working and access to telephone / e-mail consultant advice.

Whilst not a key priority for the CCG, commissioning a 'gynae community service' across Sutton would most closely align with the Sutton CCG Plan (2014-16) - Out of Hospital Care: Reduced growth in hospital attendances through GP locality working and access to telephone / e-mail consultant advice.

Whilst not a key priority for the CCG, commissioning a 'gynae community service' across Sutton would not only align with the Sutton CCG Plan (2014-16) - Out of Hospital Care (as for option 2 & 3) but could also meet the CCG mission of:'Working together to build the best affordable h lth f S tt '

Not applicable

Score 3 3 3 3 0

Equity & Access

Whilst this service is valued by participating practices and their patients who benefit from in-house services, funding has not been offered across all practices resulting in inequity and inaccessibility for most of the practices and their patients who are not currently enrolled in this scheme.

Rolling the scheme out across all practices (27 contracts) will resolve the equity/access issue but the assumption that all practices will be willing and/or able (skills/resources) to undertake this service is unrealistic.

Re-designing the pathway and widening the scope of this scheme and rolling the service out across all practices will meet the equity and access issues; working with practices/Federation to deliver the service within primary care would provide the best

Development of a bespoke 'gynae community service' tendered and commissioned for all patients across Sutton will ensure equity and access for all patients; however those patients previously managed inhouse will be marginally

Removing this service will disadvantage those patients and practices currently delivering the service and be a set back to providing care services closer to

Score 1 2 5 4 0

Affordability & vfm

7 practices currently provide the service to their own patients at a cost of £20,940: the volume of activity is so small, that it is difficult to come to any conclusions whether referrals for those participating practices are fewer than non-participating practices

Rolling this scheme out to all practices for patients across Sutton will require increased investment with a full business case outlining potential savings (reduced FOP & FUP attendances); Start-up costs will need to be included but if directly contracting with practices, a tender process will not be required;This option has potential to provide more vfm in the long term and there may be more cost efficiencies realised by contracting with a Lead Provider with the potential to deliver more flexible models of care.

The CCG will need to consider the additional investment required to start-up and run a 'Gynae Community Service' which incorporates the menorraghia service and other gynae treatments;A full business case outlining potential savings (FOP & FUP attendances) will need to outline the vfm case for change;Commissioning primary care directly (or the Federation via single tender) will not incur tendering costs

As with option 3;

The CCG will incurr tendering costs but there is the opportunity for reaslising increased vfm through a competitive tendering process.

If the service were to cease, one would assume the knock on effect would see an increase in secondary care referrals;

However the CCG would 'save' £20,940 per annum from decommissioning the service altogether.

Score 2 3 5 4 1

Sustainability & deliverability

Transferring to the Standard NHS Contract will require both commissioners and providers to be more robust in the delivery and reporting against service requirements. Service specifications will be amended and providers will need to provide assurance of delivering/sustaining the contract over any proposed contract term. Performance management arrangements will need to be stregthened. Participating practices believe they will be able to fulfil all the proposed requirements.

Extending the scheme across all practices will significantly increase the burden of contract performance management by the CCG; the business case will need to identify whether this level of input is achievable/sustainable for the CCG and acceptable/sustainable for practices. There is a low expectation that all practices will have the inhouse skills/resources/commitment to deliver this service. Also concerns that when the 'gynae' clinician isn't available or leaves there will be gaps in service.

If the CCG were to consider investing in a 'Gynae Community Service' once the case for change has been agreed, then a decision will need to be made around the model of service - should it be a 'Lead Provider model' with primary care as the lead provider (in the form of the Federation perhaps) or should secondary care be the lead provider?Whichever option is chosen, the lead provider will then have to provide plans and assurances around

If the CCG choosed to go to open market tender, then the contract term should be set at a realistic level (3 + 1+1 perhaps) to ensure the service has time to bed down and realise expectations/savings; working closely with the provider service, having clear service specifications and appropriate performance management arrangements will minise any risk of deliverability.

Not applicable

Score 3 1 4 4 0

Total 11 12 22 19 0

Quality/service performance Current services provide no quality or performance reports, so unable to assess the quality of service being delivered. NB Requirement for audit within the specification but none rececived.

3

4

5

Criteria

Options Appraisal Matrix: Menorrhagia LES

Number

1

2





26 practices currently delilvering the following:- MDTs- CMC register- Adult Death AuditPractices have in varying degrees queried the effectiveness of undertaking/being paid for the ADA, they cannot see much benefit from using the register and there are conflicting views on the effectiveness/frequency of running MDTsThe new contracts should include amendments to the three payment elements to ensure greater take-up, to provide greater clinical effectiveness and improved vfm.

The three requirements of the current LES need to be re-visited to get a greater degree of buy in from clinicians. The MDTs are clinically effective and valued but the frequency requirement is queried. The benefits and clinical effectiveness of the audit are questionable - perhaps facilitation with the audit would make it more useful? The CMC register database is universally condemned and the clinical effectiveness challenged by some. Suggest the service specification is reviewed and amended.

An EoL Network made up of commissioners, providers and local authority staff exists (across Sutton/Merton) to review EoL services and design changes to contracts and service delivery where needed. There is therefore no defined need for a review of the EoL pathway as this is an ongoing function of the Network.

The service for EoL patients needs to be delivered in-house by by primary care clinicians - it would be inappropriate to invite any third party provider to deliver these particular services for patients.

Not applicable

Score 3 3 0 0 0


End of Life care is one of the key priorities for the CCG and aligns with the Sutton CCG Plan (2014-16) for Long Term Conditions & EoL Care: Active case management model implemented, helping to integrate local health and social care professionals.Funding MDTs helps achive a key LTC objective to:Embed care planning and a person-centred approach delivered by a team of key professionals who are connected with GPs and specialists.'

As Option 1 Not applicable Not appropriate Not applicable

Score 5 5

Equity & Access

Only one practice is not signed up to the LES - this is a historical result of not being able to offer any LES scheme funding to the one GMS practice. If, following investigation, GMS practices are able to sign up to NHS contracts for additional services, then the one practice could be approached to enrol onto the scheme.

If the one practice outside the scheme is allowed and willing to enrol on the scheme there would be no further equity or access issues to resolve.

Not applicable Not appropriate Not applicable

Score 4 5

Affordability & vfm

26 practices currently provide EoL services to their own patients at a total cost of £52,350 per annum;MDTs - concensus they provide vfm (query frequency);CMC payments - Sutton has highest registered list in London so funding needs to continue;ADA - review needs to be undertaken to establish whether this element provides vfm - seen to be a paper/payment exercise by most!The new contracts should include amendments to the three payment elements to ensure greater take-up, to provide greater clinical effectiveness and improved vfm.

As option 1 - however the new contracts will include minor changes to the three payment elements to ensure greater take-up, to provide greater clinical effectiveness and improved vfmeg mandatory requirement to share the outcome of death audits within the EoL MDTs.Management overheads in terms of managing a single contract (Lead Provider) will be more cost effective and provide better vfm.


Score 3 4


This LES could be transferred into 26 NHS contracts with more robust service specifications, quality and performance schedules. This is likely to be more time consuming for both commissioners/providers than in the past when practices simply submitted activty reports which formed the basis for payment.Only practices can deliver this scheme - it would not be appropriate to tender this out to any third party provider.

For the CCG, managing 27 contracts for EoL would be time-consuming so this could be an option for delivery via a Lead Provider. As EoL care must be delivered within general practice, the Federation would perhaps be the ideal contracting vehicle to manage this contract across all member practices (sub-contracting for non-member practices).This service will need to remain under constant review as changes to other services (eg St Raphael's, community servies, BCF) could impact on delivery; flexibility will be key to sustainability.


Score 3 4

Total 18 21 0 0 0

Quality/service performance

MDTs - activity/payments logged - but no quality reports available;CMC regsiter - activity/payments logged - activity also monitored and recorded monthly across London;ADA - carried out and payments claimed but no learning shared or quality reports produced.More detailed service specifications and more robust performance management arrangements will need to be included in any new contract.

3

4

5

Options Appraisal Matrix: End of Life

Number Criteria

1

2





Current provision of phlebotomy services is as follows:- carried out in-house;- referred to StH hub;- carried out by Virgin in practices (sub-contract arrangements in place)Practices believe this service is an absolute necessity, is clinically effective and continuity of care is paramount. It is an essential service within primary care and should transfer to the NHS standard contract with revised service specs and stregthened contractual arrangements.

Service is currently available to all patients (but in different locations);Clinicians believe this service is most clinically effective if delivered within primary care - an opportunity to contract with the Federation perhaps on behalf of all member practices (or sub-contracted practices); commissioners would need to be clear in writing the service specification that they wish phelebotomy to be delivered within practices to registered patients (single award).

Not applicable - no plans to redesign the pathway

Clinicians are keen to retain this service in-house; they retain greater control and follow-up which they believe would not be as effective if any third party provider were commissioned to deliver the service;However, as Virgin are currently contracted to provide phelebotomy to some practices, their services would need to be terminated and they could potientially challenge the 'single award' - value over £100K.

Not under consideration.

Score 4 4 0 3 0


This service does wholly meet the expectations of one of the 'Planned Care' objectives highlighted in the Joint Srategy for Health & Social Care for Sutton of:'Providing services in convenient services, closer to where people live'.It is also loosely aligned with the Out of Hospital Care aim for:Reduced growth in hospital attendances through GP locality working and access to telephone / e-mail consultant advice

As Option 1 Not applicable As Option 1 Not applicable

Score 3 3 0 3

Equity & Access

Majority of patients are able to have their bloods taken in the practice (or within the same building); however a few practices refer patients to the hub which may (in some instances) be located some distance from the practice (without booked appointments) - they are more disadvantaged as a result; domiciliary care is undertaken by StH.

If the Federation is able to deliver phlebotomy into each practice (or within a reasonable radius) with booked appointments, then the service will be providing both equity to all patients in Sutton and easy access; it would also be possible to provide domiciliary services by a single provider realising economies of scale

Not applicable If a third party provider is asked to deliver phlebotomy into each practice (or within a reasonable radius) with booked appointments, then the service will be providing both equity to all patients in Sutton and easy access but it will require agreement from each practice ; it would also be possible to provide domiciliary services by a single provider realising economies of scale.

Not applicable

Score 3 4 0 4

Affordability & vfm

Current arrangments include variable tariffs for different providers - if contracts are to be re-negotiated, a single agreed tariff should be agreed and this could provide improved vfm;

Query - whether StH phlebotomy is part of the block?

As for option 1 but a community tariff should be negotiated for domiciliary visits to be undertaken as part of the service - thus providing improved vfm.

Management overheads in terms of managing a single contract (Lead Provider) will be more cost effective and provide better vfm.

Not applicable As for option 1 but a community tariff could be tendered out inviting more competitve bids; domiciliary visits to be incorporated within the service specification too.

Not applicable

Score 4 4 0 3 0


The CCG will need to establish more robust contractual arrangments with each provider with strengthened performance monitoring arrangements in place.Providers will need to consider whether they have the resources to comply with the strengthened contracting requirements.

Single provider model - Federation is more likely to get buy-in from practices (than any other third party provider) in both the short and long-term.CCG would only have to manage the Lead Provider who would be responsible for delivery and sustainability across all the practices. This would ease the burden of performance management capacity for both practices and the CG.

Not applicable Single provider model - third party provider would be likely to meet with resistance from practices which could impact on deliverability;The track record for any third party provider may be unknown.

Not applicable

Score 3 4 0 3 0

Total 17 19 0 16 0


No quality/service reports available;

Practice visit feedback is fairly positive about existing services with a couple of exceptions; - long waits at the Priory Crescent Clinic (run by StH) are unacceptable - would prefer the clinic is open more frequently across the week;- one practice feedback negative experience with Virgin carrying out their service (SUI);

This single provider model (ie Federation as lead provider) would need to provide assurance of quality and service performance - requirements would need to be clearly stated and performance monitoring arrangements established with escalation procedures in place should providers fail to comply with those requirements.Query - will the Federation be in place in time and will they be in a position to offer the IM&T infrastructure to support sharing of patient identifiable information?

4

5

6

Options Appraisal Matrix: Phlebotomy

Number Criteria

1

3





Two delivery options currently in place across Sutton:- patients are seen within their own practice; or- patients are referred to Hubs in each locality;This LES has been successful in repatriating activity back into primary care. The feedback overall is positive from those undertaking the service;Activity is increasing month on month as patients are re-patriated and the scheme is seen to be both clinically effective and provides improved patient experience;Clinicians report some confusion regarding referrals for domicilliary anti-coag - will this be an issue that requires clarity and inclusion in any proposed new contract?

As Option 1;However some clinicians believe this service is more effective if delivered within primary care (rather than the mixed provision that is delivered currently). The CCG could commission a Lead Provider to deliver this scheme across all practices - they could design services new models of delivery eg engage clinicians to provide a hub and spoke model across Sutton, or to rotate visits across all practices each week etc. This could provide an opportunity to contract with the Federation on behalf of all member practices (or sub-contracted practices); The contract will need to be reviewed to include dom visits/tariffs and the Federation could define how this would be undertaken across Sutton.

The redesign process has already been recently undertaken and implemented by the QIPP team, so there is no need for further review.

This service is best provided by primary care so a single award to the Federation is perhaps the only model worth considering, not tendering to other third party providers.

This essential service meets the wider CCG aspirations of delivering care closer to home - this option will not be considered.

Score 5 5 0 0 0


Anti-coagulation re-provision is a key priority for the CCG, aligned with the Sutton CCG Plan (2014-16) for Hospital Care to: 'Decommission more anti-coagulation services and reprovide in the Community .'

Additionally it meets a key 'Planned Care' objective of the Joint Srategy for Health & Social Care for Sutton of:'Providing services in convenient services, closer to where people live'.

As Option 1 Not applicable Not applicable Not applicable

Score 5 5 0 0 0

Equity & Access

All patients have access to anti-coagulation services either within their practices or from the Hub practices within their localities.

Doms are currently provided by some Hubs but the majority are undertaken by StH - this may change with the transfer to the NHS standard contract but should not impact on equity or access as these patients will be seen at home regardless of the choice of provider.

As Option 1

However the Lead Provider could define a new model of service that is more convenient for patients with easier access.

Not applicable Not applicable Not applicable

Score 4 5 0 0 0

Affordability & vfm

The annual budget for the re-patriation of anti-coagulation services was £104,700; the level of activity for the year has been exceeded by M8; the budget has consequently been increased to £ £254,700 to meet the underspend from last year and increased activity costs to year end.

On target for meeting the QIPP savings for 2014/15 and anticipate ongoing savings will accrue throughout 2015/16.

As Option 1



Score 4 5


This scheme will definitely need to be transferred to NHS contracts but revised to include domiciliary visits and service specifications will need to be strengthened incorporating robust performance monitoring arrangements.

This option will require management of a minimum of 7 contracts which is sustainable but will require ongoing contract management input from the CCG.

This service is currently delivered to a number of primary care providers (hub and spoke model) - a single Lead Provider model would be less onerous in terms of contract management for both the CCG and providers.


Score 4 5

Total 22 25 0 0 0

Options Appraisal Matrix: Anti-coagulation services

Number Criteria

1

2

Annual audits are submitted by all practices delivering the service to own or neighbouring practices; the CCG has been assured (through audits) that performance is 'good'.

One issue raised during the practice visits was concern from a Hub nurse around information sharing and governance. Results from previous bloods are not availbe electronically so there is a reliance purely on the 'yellow book' being kept up to date/accurate readings. This issue will need to be addressed whether the model of service remains the same or whether the Federation takes over as the Lead Provider.

Domicilliary visits - need greater clarity regarding future commissioning intentions and related payments (ie will the tariff be variable depending on the distance for each visit?)


3

4

5





This LES scheme is only provided by 6 practices for their own patients, other practices refer patients to the Tier 3 or Tier 4 services.Feedback from participating practices is positive as they are able to better manage their diabetic patients in-house, however the scope of the scheme is limited and clinical effectiveness could be enhanced by adding in pre and post insulin intitiation treatments.Some non-participating practices do undertake this service as they believe they are offering the best care for their patients - but are not funded to do so currently.

As for option 1;GPs have expressed interest in being offered the opportunity to enrol onto this scheme to deliver insulin initiation in-house. However, not all practices will have the staff/skills to undertake this service which would limit roll out of this scheme more widely.

The CCG could commission a Lead Provider to deliver this scheme across all practices - they could design services more creatively to deliver quality services with real economies of scale eg the Lead Provider could engage a GP/Nurse specialist to rotate between practices to deliver insulin initiation for all participating practices.

The 4 tier system introduced quite recently hasn't had enough time to bed down so the clinical effectiveness has yet to be evaluated. Feedback from practices is varied, there is a great deal of confusion about who/when to refer to each Tier. Some would like to see whether benefits identified have been realised, others would like to see a community model of service such as a 'one-stop-shop' for diabetes similar to that delivered by Wrythe Green Surgery. There is unlikely to be any appetite within the CCG to overturn the recently implemented 4 Tier model - an evaluation at the end of Year 1 would be useful.

This option would only be viable if the scope of the Insulin Initiation were to widen considerably and a community model developed - if the activity and contract value were of sufficient size to attract third party providers, then it would be worthwhile tendering the service.

However, given that the 4 Tier model has been implemented and adopted in Sutton, this option will not apply.

This scheme could be terminated and all activity undertaken by Tier 3 services, however could potentially result in de-skilling of primary care clinicians and poorer patient experience. Having diabetic 'specialist' GPs in practice is a desirable goal as the overall management of diabetic patients in the practice is enhanced, referrals are minimised and colleagues benefit from peer review. So this option will not apply.

Score 4 5 0 0 0


Diabetes is a key priority for the CCG, and this scheme (Tier 2) is clearly aligned with the Sutton CCG Plan (2014-16) for Long Term Conditions & EoL Care to: 'Deliver the ‘4 Tier model’ for diabetes'; The scheme also meets the expectations of one of the 'Planned Care' objectives highlighted in the Joint Srategy for Health & Social Care for Sutton of:'Providing services in convenient services, closer to where people live'.

As Option 1 Not applicable Not applicable Not applicable

Score 5 5 0 0 0

Equity & Access

Whilst this service is valued by participating practices and their patients who benefit from in-house services, funding has not been offered across all practices resulting in inequity and inaccessibility for most of the practices and their patients who are not currently enrolled in this scheme - they are referred to the community Tier 3 service (increased travel time and longer wait times for appointments)

Rolling the scheme out across all practices (27 contracts) will resolve the equity/access issue but the assumption that all practices will be willing and/or able (skills/resources) to undertake this service is unrealistic. This option would be feasible if the Federation were contracted to offer this service to each practice across Sutton (ie travelling clinical team for those practices without the in-house capabilities).


Score 3 4 0 0 0

Affordability & vfm

6 practices currently provide the service to their own patients at a cost of £2,240: the volume of activity is so small, that it is difficult to come to any conclusions whether referrals for those participating practices are fewer than non-participating practices; however participating practices believe developing in-house specialists inevitably results in fewer referrals to secondary care and is therefore providing vfm.

Rolling this scheme out to all practices for patients across Sutton will require increased investment with a full business case outlining potential savings (reduced FOP & FUP attendances); Start-up costs will need to be included but if directly contracting with practices (or awarding the contract to the Federation), tendering costs will not accrue.Management overheads in terms of managing a single contract (Lead Provider) will be more cost effective and provide better vfm.


Score 0


Participating practices are very keen to retain funding for this service in-house - the work usually undertaken by the diabetic 'specialist' GP;Individual contracts will need to be developed for participating practices(6)and managed by the CCG.

For the CCG, managing 27 contracts for this low value contract would be time-consuming so this could be an option for delivery via a Lead Provider. Possibly contracting with the Federation on behalf of all member practices and sub-contracting for non-member practices.


Score 3 4

Total 12 18 0 0 0


For participating practices, patients receive appropriate in-house services, for those not participating, Tier 3 services provide an alternative. There are concerns regarding the entry/exit points for Tier 3 patients and more generally what and where patients should be managed withint he 4 Tier model.Use of Tier 3 services is patchy, GPs say there is little added value provided and patients are seen too often and not repatriated back to primary care appropriately.

Revised service specifications would need to be very clear about the staffing/skills requirements for delivery of this service with related KPIs.There would need to be extensive education/training programmes put in place to support this option.It is unlikely that every practice will have in-house skilled clinicians able to undertake this service.

3

4

5

Options Appraisal Matrix: Insulin Initiation

Number Criteria

1

2





Wrythe Green Surgery delivers an in-house diabetes clinic; they believe this provides the best quality of service, reducing referrals to both Tier 3 and Tier 4 whilst giving patients the best expereince from the one-stop-shop;Non-participating practices use Tier 3 and Tier 4 services - the 4 Tier model launched by the CCG last year. Clinicians don't believe it is working as effectively as it should, patients are not transferred appropriately between Tiers and there is a great deal of confusion about where/when referrals should be made.

With only one practice undertaking this LES, it is unrealistic to expect this model to be rolled out in each practice - both in terms of expertise, resource and budget, so this option is not one for consideration.

The one-stop model undertaken by Wrythe Green surgery is acknowledge to be of high quality, but the preferred model adopted (4 Tier service) across the CCG is still in the early stages of implementation. The one stop model isn't a natural fit with this service and any further redesign is unlikely. In time, it would be worthwhile to carry out an evaluation of the clinical effectiveness of introducing the 4 Tier service, find out what is working well and what needs further facilitation and development.

Not applicable The CCG has committed to introducing and embedding the 4 Tier model of care for diabetes for all patients in Sutton. Encouraging integration between healthcare providers is deemed to be clinically effective in supporting patients with this condition. Whilst the Wrythe Green model of service may be providing patients with a gold standard of primary model of diabetes care, it isn't closely aligned with the CCG 4 Tier model and is therefore unlikely to be continue to be funded.

Score 5 0 0 0 4


Diabetes is one of the key priorities for the CCG and aligns with the Sutton CCG Plan (2014-16) for Long Term Conditions & EoL Care: however the aim is to: Deliver the ‘4 Tier model’ for diabetes

As this scheme is not consistent with the 4 Tier model adopted by Sutton CCG there is no realistic expectation of adopting this model in future.

Not applicable Not applicable Not applicable As Option 1

Score 1 0 0 0 1

Equity & Access

With only one practice currently funded to deliver this model which is only accessible to their own patients, re-commissioning this scheme would be inequitable across Sutton.

Not applicable Not applicable Not applicable With only one practice currently funded to deliver this model which is only accessible to their own patients, re-commissioning this scheme would be inequitable across Sutton.Terminating this service and investing additional resource into the Tier 3 service (or finance the roll out of this service across all practices) making it more equitable.

Score 1 0 1

Affordability & vfm

Wrythe Green Surgery provides an in-house diabetic clinic service at a cost of £25,111 per annum. The margins for reduction in diabetic referrals are so minimal, the evidence base for establlishing vfm is negligible. If notice is served on this LES, staff could potentially be subject to TUPE with related costs.

Not applicable Not applicable Not applicable If this service were to cease to be commissioned, the budget could be re-directed to roll out Tier 2 (insulin initiation) services (currently provided by only 6 practices) across all practices in the CCG.

Staff within the existing scheme may be subject to TUPE if it applies.

Score 2 4


Whilst it would be possible to transfer this LES across into an NHS contract, by introducing the 4 Tier model across Sutton, re-commissioning this scheme would not be consistent with the direction of travel for the CCG so the sustainability of the service into the future would be questionable.

Not applicable Not applicable Not applicable If the contract were to be terminated and the budget transferredinto Tier 2 services, it would mean one less contract to manage.

Score 1 4

Total 10 14

Options Appraisal Matrix: Diabetes

Number Criteria

1

3

Positive feedback from Wrythe Green Surgery - gold standard diabetic model of care delivered in-house with high level of patient satisfaction attained;Some negative feedback from practices in relation to the Tier 3 service - for non-controlled diabetics, they provide little added value and frequently repeat what has already been undertaken in primary care and they retain patients longer than necessary;Some negative feedback from Tier 4 too - they retain patients who should be passed down through the tiers more quickly - relationships are strained between provider organisations which makes this model more challenging to deliver.Quality/service performance

4

5

6





This LES scheme is only provided by 3 practices (Old Court House, Mulgrave Rd and Grove Rd) however Mulgrave and Grove provide the service for their own patients and all other practices refer into Old Court House for their ECGs and 7 day event monitoring. Feedback is very positive; reports are well received and the quality of service is receives high praise from clinicians. This community based service encourages continuity of care and limits the number of visit to the Trusts for diagnosis and treatment . The CCG would recommend continuing with this service in the community, but would need to decide whether it commissions all three providers or just one provider to deliver across Sutton.

Rolling this service out to all practiceswould perhaps be clinically effective, but would need to be supported by high equipment costs, educational and mentoring costs.

As the service from Old Court House is so popular and effective, the CCG could contract with a single provider directly (or via the Federation) whilst establishing more robust performance and reporting arrangements.

The CCG has proposals that are being worked up to commission direct access diagnostics in the community. Commissioning ECGs and 7 day event monitoring could be part of that QIPP scheme. Whilst the scheme is being worked up, Old Court House could be commissioned (with a new short-term contract) to provide the service until the direct access diagnostics model is fully developed, procured and rolled out. Clinicians would welcome this and there would be some consistency and familiarity in using the single provider with consistent paperwork.

Whilst it would be possible to put this service out to tender, the contract value would be too minimal to attract an open market. If however, the CCG develops the proposal for direct access diagnostics with a wider scope and increase contract values, then this would be the most effective way of establishing the best quality service for the best price. However, the CCG will need to weigh up the benefits of attracting new entrants into the marketplace against maintaining continuity of provision from current providers.

Not applicable

Score 4 4 5 4 0


No direct alignment with CCG Operating Plan or JSNA but is more generally aligned to bringing services and care closer to home.

As option 1 As option 1 As option 1 Not applicable

Score 2 2 2 2 0

Equity & Access

All patients can access the service at Old Court House; patients at Mulgrave and Grove benefit more advantageously from having an in-house service with much easier access.However, all patients benefit from minimising the number of visits to secondary care from this community service that providies both equity and access to all patients.

Contracting a Lead Provider to deliver services across Sutton will provide both equity and access to all patients.

Setting up a short-term contract with Old Court House whilst the direct access diagnostics proposal is drawn up and services activated will not disadvantage patients in terms of access or equity.

Competitive tendering will provide an even playing field for all practices - referalls can be made to the one preferred bidder for all patients across Sutton. The proposal could improve access by stipulating that services are provided in each locality (if necessary).

Not applicable

Score 4 5 4 5 0

Affordability & vfm

The budget for this service across the three practices is £109,935; Delivered in primary care providing value for money.


If incorporated within the Direct Access Diagnostics scheme - there could be potential savings on revised tariffs.

Competeitive tendering - could result in reduced tariffs but unless the scope is widened, the value of the contract is unlikely to attract interest from the wider market (for the level of investment in equipment, premises, staff etc required).

Not applicable

Score 4 5 4 3 0


Old Court House has the premises, staff and facilities to continue to deliver this service either in the short or long-term - need legal advice whether the CCG can contract with Old Court House directly as a single award or whether the CCG should take the approach that the Lead Provider should be the Federation alone.

This would be an alternativel Lead Provider contractual arrangement for delivery by Sutton Federation who would in turn contract with Old Court House (and possibly Grove Rd and Mulgrave) working to the revised specification.

Not applicable

Score 4 5 3 2 0

Total 18 21 18 16 0


3

4

5

Options Appraisal Matrix: ECG

Number Criteria

1

2





Wrythe Green Surgery is the only practice currently funded to deliver in-house physiotherapy services. The practice believes their patients benefit from easy access to physio with short wait times and easy access.

Non-participating practices have access to community physiotherapy services - their feedback is that it would be far more clinically effective (in terms of quality, access, waiting times etc) to procure an alternative physio service and believe the re-procurement of community services provides the ideal opportunity to terminate the current service in favour of a new provider.

There is very little likelihood of the CCG considering rolling out the physio model currently delivered by Wrythe Green Surgery to all other practices; it would duplicate services commissioned from the community and would be unaffordable so this option will not apply.

If the CCG considers there is an appetite to improve the provision of physio across Sutton, it has a number of options to consider:- serve notice on the current LES scheme and transfer funds into the community service to raise standards;- serve notice on the current LES scheme and carry out a review physiotherapy provision/specifications as part of the re-procurement of community services;;- serve notice on the current LES scheme and invest in additional capacity for a year leading up to the re-procurement of community services.If the last option is favoured, then additional short-term investment could be made into the existing physiotherapy community service to help clear the background. NB Merton has recently increased funding into the service which should result in increased capacity and improved standards).

Not applicable as the CCG is already involved in the re-procurement of physiotherapy services (via the Community Service tender).

It hasn't been possible to analyse the clinical effectiveness of the service at Wrythe Green Surgery in terms of reduction in referrals, quality or patient experience - no quality reports. The practice believes it provides patients with a gold standard service but continuing to commission or extend this model across Sutton isn't aligned with any CCG plans. By decommissioning this service, funding/staff could transfer into the Community service to help address some of the quality and capacity (ie waiting times) issues which would benefit patients right across Sutton rather than just patients from one practice.

Score 5 0 tba 0 4


Physiotherapy services are not specifically identified as a key priority development area within the Sutton CCG Plan (2014-16), however a review of the community physio service is detailed as an Out of Hospital Care aim to provide:'Clarity on the metrics and specification for re-procuring community services '; and loosely aligned to the Hospital Care aim to:Review Musculoskeletal service to develop more effective triage and diagnostic pathway'.As this scheme is not consistent with CCG plans, there is no realistic expectation of adopting this model in future.

Not applicable As Option 1 however, reviewing and strengthening the service specification as part of the re-procurement of Community Services is closely aligned to CCG strategic aims.

Not applicable As Option 3

Score 1 0 tba 0 3

Equity & Access

This LES is only available to patients in one practice - it is neither equitable nor accessible to patients in other practices across Sutton.

Not applicable The CCG has no plans to redesign the physio pathway, however decommissioning this service, transferring staff into the community service and investing additional funding into the service could increase capacity thus improving access and reducing wait times.

Not applicable As Option 3

Score 1 0 tba 0 4

Affordability & vfm

Wrythe Green Surgery provides an in-house physiotherapy clinic service at a cost of £33,656 per annum.

The margins for reduction in physio referrals are so minimal, the evidence base for establlishing vfm is negligible. If notice is served on this LES, the budget and staff could be transferred into the community service; they would most likely be subject to TUPE.

Not applicable - as the CCG could not afford to roll out this model of service across all practices nor is it within their intention to decommission the existing community service.

In line with agreed commissioning intentions for 2014-16, the CCG Board has made a commitment to review the existing service specifications within the community services contract and will therefore not seek to terminate this provision when re-procuring physio services;An MSK pilot is being run in Sutton which contains a physio element - successful completion of this pilot may lead to a case for change eing developed for both MSK/physio pathways across Sutton in 2015/16.

Not applicable If this service were to cease to be commissioned, the budget could be transferred into the Community Service to increase capacity and reduce waiting times

Staff within the existing scheme may be subject to TUPE (with related costs).

Score 2 0 tba 0 4


Whilst it would be possible to transfer and manage this LES scheme as an NHS contract, continuing to commission this model of service is not consistent with the direction of travel for the CCG so the sustainability of the service into the future would be questionable.

Not applicable Not applicable Not applicable If the contract were to be terminated and the budget transferred into Community services, it would mean one less contract to manage and in line with the CCG direction of travel, would be sustainable into the future.

Score 2 0 0 5

Total 11 0 tba 0 20


1) Clinicians at Wrythe Green Surgery believe they provide a gold standard service to patients - however no performance data has been shared with the CCG on which to evidence this assertion eg low referral rates intosecondary care; low wait times; patient satisfaction etc.2) Feedback from practices regarding the community physio service is negative;GPs say the quality of what is delivered is negligable with unacceptably long waiting times, when patients are finally assessed, they may be offered just one or two sessions before being discharged with leaflets;GPs increasingly avoid referring to the service and issue leaflets themselves or refer to secondary care.

3

4

5

Options Appraisal Matrix: Physiotherapy

Number Criteria

1

2





POWC (clip/suture removal) is provided by practice nurses in all practices; some activity is undertaken by DNs and/or the TVN if appropriate;Practices believe this service is an essential, clinically effective scheme which is preferably provided in primary care - patients benefit from continuity of care and ease of access.

Practices have asked that the scope of the scheme is broadened to include post operative wound dressings as this activity is time consuming and increasing in volume (particularly from an ageing population). This is currently unfunded and commissioners may wish to consider whether it would be worthwhile funding this additional element when drafting the revised service spec/contract.

As for Option 1;

If the CCG were to commission a Lead Provider to deliver this scheme across all practices, there may be a way of designing services more creatively to deliver local services with real economies of scale eg the Lead Provider could engage a 'dressings' nurse(s) to rotate between practices or local clinics to deliver the service.

The revised service specification could include additional provision of services during weekends/bank holidays.

One of the priorities for the Long Term Conditions and EoL programmes is to review the wound dressings service. The scope of this review could be widened to incorporate discussions about the more complex post operative wound dressings undertaken in general practice as additional costed work - a case for change will need to be worked up and if agreed, requirements could then be added into the revised specification for POWC. It could include cover over weekends and bank holidsy.

The contract value is minimal so will not be subject to OJEU thresholds. As this scheme is deemed appropriate for delivery by primary care clinicians within primary care settings, this option will not apply.

Not applicable

Score 4 5 0 0 0


PoWC does wholly meet the expectations of one of the 'Planned Care' objectives highlighted in the Joint Srategy for Health & Social Care for Sutton of:'Providing services in convenient services, closer to where people live'.

Whilst PoWC does not feature as a priority in the Sutton CCG Plan (2014-16) , should consideration be given to include wound dressing within this scheme, this does link with one of the Long Term Conditions & EoL Care aims to: Review community equipment, wound dressings services and home oxygen service

As Option 1 As Option 1 Not applicable Not applicable

Score 4 4 0 0 0

Equity & Access

Services are currently available to all patients in all practices - thereby meeting the contractual requirements for providing equitable and accessible care to all.

As for Option 1 As Option 1 Not applicable Not applicable

Score 5 5 0 0 0

Affordability & vfm

27 practices currently provide PoWC services to their own patients at a total cost of nearly £20k per annum;If the scheme is expanded to include post operative wound dressings, a case will need to be made for increased investment with agreed tariffs.

Undertaking this work in primary care is more cost effective providing vfm.

As Option 1;


As Option 2;

If consideration is given to include funding for post operative wound dressings, the Lead Provider could design a delivery model that would realise some economies of scale that could potentially provide greater vfm to Commissioners.

Not applicable Not applicable

Score 4 5 0 0 0


The CCG will need to contract with each practice with the new NHS standard contract; incorporating more robust contractual arrangments with strengthened performance monitoring arrangements in place.

Providers will need to consider whether they have the resources to comply with the strengthened contracting requirements ie meeting KPIs, reporting requirements etc.

This scheme is currently delivered across all practices; appointing a Lead Provider would enable the CCG to contract via a single NHS standard contract which would be far less onerous than monitoring and performance managing 27 contracts.

This could potentially be a scheme offered via single tender award to the Federation as the Lead Provider.

As Option 2 Not applicable Not applicable

Score 4 5 0

Total 21 24 0 0 0


3

4

5

Options Appraisal Matrix: Post-Operative Wound Care

Number Criteria

1

2





GPs in three practices (Cheam, Mulgrave and Benhill & Belmont) currently provide medical cover for 33 Intermediate Care beds across 3 Care Homes - Crossways, Abbey Cheam, Eversfield.

The LES provides a means by which payment can be made to each practice for providing essential medical primary care cover for patients in these intermediate care beds.

As an essential service, this scheme and related payments could easily transfer to the NHS standard contract with revised service specs and stregthened contractual arrangements.

Not appropriate Not applicable Not applicable Not applicable

Score 5 0 0 0 0


Aligned with the CCG principles of delivering Out of Hospital Care to all patients including those in Care Homes and:Supporting delivery of advanced competencies in care homes to helpf provide the required interventions that will keep people at home.


Score 4 0 0 0 0

Equity & Access

Medical cover for all patients in all the intermediate care beds are covered thus meeting both equity and access requirements for the contract.


Score 5 0 0 0 0

Affordability & vfm

The following GPs are paid monthly to a total annnual value of:Dr Elliott - £12k;Dr Pardhanani - £12,204; andDr Scerri - £18k.


Score 0 0 0 0


The existing providers will need to be approached to ascertain their willingness to provide this service going forward for one or more years so the CCG can be assured of deliverability of the service.

This option will require management of a minimum of three NHS Standard Contracts which is sustainable and not too onerous in terms of contract management.


Score 5 0 0 0 0

Total 24


3

4

5

Options Appraisal Matrix: Intermediate Care Beds

Number Criteria

1

2





Cheam Family Practice provide an in-house counselling service - salaried counsellor. Whilst this service is clearly valuable to clinicians and patients within the practice, the CCG is currently undertaking a tendering exercise for mental health primary and community services which will provide the preferred commissioning model for all patients across Sutton.

See Quality/service performance row below.

The CCG has been involved in designing a new model of care across mental health community services (including IAPT, bereavement counselling etc) which is currently being procured.

Rolling out this scheme across all practices would fly in the face of CCG plans, so this is not a feasible option.

The CCG has been involved in designing a new model of care across mental health primary and community services (including IAPT, bereavement counselling etc) which is currently being procured.

No further review will be undertaken.

Not applicable The CCG has committed to introducing the new mental health primary and community model of service into Sutton from 2015. Contracts will have appropriate safeguards, regulations, performance and reporting requirements that meet national standards. Clinical efficacy of this LES scheme is hard to capture, but given the roll-out of the new model of care, notice of termination is proposed.

Score 3 1 0 0 5


One of the key priorities for the CCG represented in the Sutton CCG Plan (2014-16) for Mental Health is to : 'Define a joint primary and community care model and consider which components of service need re-procuring to achieve this' .Retaining the counselling service within this practice does not fit with the agreed model for primary and community care.

As Option 1 As Option 1 Not applicable As Option 1

Score 1 1 1 0 1

Equity & Access

With only one practice currently funded to deliver this model which is only accessible to their own patients, re-commissioning this scheme would be inequitable across Sutton.

As Option 1 As Option 1 Not applicable As Option 1

Score 1 1 1 0 1

Affordability & vfm

This is not a scheme historically funded by the CCG - the funding stream is currently unknown but is being clarified with NHSE.

If notice is served on this LES, staff could be subject to TUPE - the most likely scenario would be to TUPE them into the new service and the funding transferred too.

As Option 1;

Rolling out this scheme across all practices would fly in the face of CCG tendering plans for a Sutton wide primary and community care model so would be neither desirable nor affordable.

As Option 1;

The redesign process has been undertaken recently; the new model has been costed and will be funded for all patients across Sutton. Individual funding streams for counselling services within general practice does not feature as a requirement so this is not a viable option.

Not applicable Serving notice on this contract will resolve the ambiguity around funding streams but will also resolve the anomaly of having only one practice receving a dispraportionate level of funding for counselling services. The new model being rolled out in 2015 will ensure funding is equitable across all practices and patients in Sutton so the option to terminate this contract provides the most realistic solution.

Score 3 1 0 0 5


Whilst it would be possible to transfer this LES across into an NHS standard contract, by introducing the proposed new primary and community care model across Sutton, the potential to re-commission this single contract is neither sustainable nor justifiable.

As Option 1 As Option 1 Not applicable If the contract were to be terminated, there will be no requirement to allocate management resource to manage this individual contract.

Score 1 1 1 0 5

Total 9 5 3 0 17

Quality/service performanceWhilst this service is clearly well liked within the practice and the resident Counsellor has been in post for a number of years (in excess of 20 years), the practice has not carried out an evaluation of the effectiveness of the service and doesn't routinely submit any quality information to the CCG so it is difficult to state whether service outcomes have been met. The practice is aware of the fact that the service is inequitable and may be terminated but is concerned that their member of staff is handled gently and offered TUPE provision (if appropriate) as an alternative to resignation.

4

5

6

Options Appraisal Matrix: Counselling (only to be considered if commissioning responsibility transfers to the CCG)

Number Criteria

1

3

Appendix 5

Sutton CCG LES Review: 2014/15

Theme Emerging Themes to date

(30.09.14) Lead

Contracting & performance management arrangements

If the schemes are moved directly across into the standard NHS Contract format, it will mean that each practice will need a

contract (incorporating one or more schemes) – this could prove onerous for both the CCG and the practice (in terms of

manpower) as the performance schedule will be more robust with KPIs and reporting requirements for each scheme and

these will need to be collected/reported/monitored and performance managed;

One option could be to award the Federation one or more of the schemes (on the basis that they need to be undertaken in

general practice from a registered list), then the Lead Provider model can be adopted thus reducing management time;

Can the CCG award contracts to the Federation if all practices are not included in their membership?

Can contracts be awarded to the GMS practice (unable to include GMS practices in LES schemes in the past);

Introducing the standard NHS Contract will require capacity to review/re-write of all service specifications;

Capacity to revise/agree quality and reporting schedules for each scheme;

Review and agree payments and payment mechanisms for each scheme;

Need to establish more streamlined reporting and payment processes for the new contracts.

If the contract value is over £170k – the CCG will have to tender the service to avoid challenge under OJEU;

If contract terms are over a year, the whole contract value will need to be considered – this could tip the service over the

£170k threshold and into formal procurement.

SR/MMc

Federation readiness

Concerns that the Federation will not be fully formed and ready to provide services by the 1st April 2014;

Will the Federation be representative of all 27 practices? If not, will they have sub-contracting agreements in place with

non-participating practices?

Concerns that the Federation will not be able to mobilise (contracting, workforce, IT etc) adequately enough to give

assurance to the CCG of their ability to deliver any post-LES schemes;

Similar concerns around Information Governance (see section below).

CR

Information governance arrangements

Existing Hub arrangements – lack of supporting IT infrastructure;

Shared paperwork; inconsistent format; require self-populating templates; need to streamline processes

Shared protocols – do they exist?

ISA or Data sharing Deeds

MH

Appendix 5

Sutton CCG LES Review: 2014/15

Community Services

During meetings with GPs, LES discussions have led to some negative feedback on some of the community services; this may be

an opportune moment to align with the work being undertaken to review of the community service specifications prior to re-

procurement. The services affected include the following:

DNs

Physiotherapy

Dressings

CL

New or revised models of service

Gynaecology community service

Diabetes (Tier 2 model + education)

Cardiology community service

Respiratory (PR?)

QIPP

MDTs

Concerns expressed that there may be some overlap/duplication in identifying patients (and related payments) for schemes below:

EoL care

Enhanced service

Better Care Fund

CH/SG

Implementation timelines

Any LES services agreed going forward will need to be transferred to the NHS Standard Contract by 1.4.15; so the following

queries were raised:

If new models of care are being proposed, how will the CCG contract with practices in the interim (short-term)?

If new models of care are being proposed, that sufficient time and planning is given to design robust, effective and

appropriate models of care for patients in Sutton;

If the Federation is proposed as the ‘Lead Provider’ but they are not ready by the 1.4.15, what back-up plans can be put in

place to cover the interim period?

If any staff issues (eg TUPE) apply to services being de-commissioned, that sufficient time is allocated to allow for

consultation and closure

CR/MMc

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