Agenda item

At its meeting on 18 August 2020 the Committee received briefings from the Kent and Medway Clinical Commissioning Group (CCG) on the concerns affecting both the dermatology and primary care contracted services run by DMC Healthcare (DMC) across Medway. Since the last briefing both the dermatology and primary care contracts with DMC have been terminated by mutual agreement and alternative service provisions put in place. In circumstance where contracts are discontinued prematurely the CCG conducts a formal review. This report details the findings of the final review for dermatology and the initial draft ones covering primary care which are still works in progress.

Discussion:

Members considered a report from the Clinical Commissioning Group (CCG) on the findings of the final review for dermatology and the initial draft ones covering primary care. This followed a briefing at the August 2020 meeting of the Committee on concerns affecting both the dermatology and primary care contracted services run by DMC Healthcare (DMC) across Medway. Since then both the dermatology and primary care contracts with DMC had been terminated by mutual agreement and alternative service provisions put in place.

The CCG reported these arrangements were working well and they would continue to be actively supported and monitored. In circumstances where contracts were discontinued prematurely the CCG conducted a formal review, in accordance with good organisational learning and development practice.

In terms of the dermatology service, the CCG reported that the interim provider had moved forward very quickly and over 12,000 patients had been seen with the backlog cleared. Targets had been met and there were waits of around 6-8 weeks for routine appointments, which was expected to be below 6 weeks by the end of January 2021.

In relation to primary care services, the CCG commented that they were trying to address long standing recruitment and retention problems in these 5 practices. There were still some remaining governance issues to resolve.

The CCG Accountable Officer acknowledged that mistakes had been made but assured Members the CCG was committed to learning from these and making improvements, as well as listening to stakeholders, so this would not happen again. The new arrangements put in place were delivering improvements in services. An assurance was given that there would be proper engagement with stakeholders when developing services in the future. The now larger CCG meant that there could be tensions between scale and local focus, but it was felt a larger organisation was better placed to respond to the problems that had been identified.

The following issues were discussed:

·       Assurances offered by the CCG – the point was made that whilst the CCG seemed to be addressing the problems it was difficult to not be wary of the assurances offered given that the CCG had made similar assurances to the Committee previously that the dermatology service was working well in spite of concerns expressed by the Committee and the public and patients. The CCG was asked if any other contracts had gone wrong where this had not been anticipated. The CCG advised that most contracts were with very large providers. Given the number of contracts it was inevitable that issues would arise, but Members could be assured by the fact that the suspension of a contract was rare.

·       DMC contract – reference was made to the CCG’s comment that 4 submissions had been received to run the dermatology service and DMC’s perception that they were the only organisation in the running and had been faced with an unrealistic time to improve the service. How the contract with DMC had never been signed was also questioned. The CCG responded that DMC had willingly accepted the contract. In future, contracts would always be signed, although in the case of dermatology the CCG clarified they were operating under an implied standard NHS contract. There were issues about data transfer to DMC from the beginning of the contract and DMC had been supported and given extra time to resolve these.

Reference was made to the difficulties faced by the new primary care providers in dealing with staff transferred from DMC. How they were being supported by the CCG in what was a short 12-month contract period was questioned as well as whether it was possible to extend the contracts. The CCG commented there had been an obligation to TUPE staff across. It was accepted that the short notice DMC gave to hand back the dermatology contract should not have been accepted. While this had been followed by public engagement on the way forward, the CCG commented this was not at the level it should have been.

It was noted that DMC had received an outstanding report from the Care Quality Commission in relation to a GP practice elsewhere in the country. Why there was such an inconsistency was queried.

·       Data and Performance monitoring – given DMC’s claim that the full extent of waiting lists was not disclosed to them, an assurance was sought that the data for the new contract holders was accurate and that there were now agreements in place about performance monitoring and what systems would be used for both service. Whether the Local Medical Committee would be part of the new performance monitoring arrangements was also queried.

It was suggested that the CCG should fine a provider where they were not delivering in accordance with a contract. The CCG responded that they were looking to work in different, more collaborative ways with providers and fines did not always provide an incentive to change, although financial penalties may be necessary on occasion. The CCG would look at all relevant information including clinical data, financial status, staff turnover and training. This would be triangulated to gain an understanding of how a provider was performing. The CCG would also work closely with the CQC and NHS England to obtain soft intelligence about performance. Feedback would be given to practices on their performance relative to neighbouring authorities. The CCG would ensure the proper polices and reporting systems were in place and also improve governance arrangements. The CCG Governing Body would receive regular updates on performance.

In terms of how the new contacts were being monitored differently, the CCG advised that the Sussex Community Dermatology service had reverted to normal contract monitoring with regular reports and data which was validated and peer reviewed. The CCG were confident the data was now robust. An important lesson learned by the CCG had been that when a service transitioned to a new provider there was a need to closely monitor and work with the new provider and not allow them any significant leeway.

·       Patient voices – it was suggested the patient voice was not very prominent in either service and this was an opportunity for the CCG to review how it encouraged practices to listen to their patients and act on feedback and actively champion this. Not all GPs had a patient participation group and the ones that existed were not always very diverse and could be insular with long standing memberships. Primary care was changing due to Covid and it was important the patient voice was heard and information triangulated to learn as much as possible. The CCG commented that primary care contractors were required to set up patient participation groups to feedback on how practices were operating. This was set out in the contract with Medway Practices Alliance.

·       Travelling outside Medway – in response to a question about waiting times and Medway residents having to travel outside the borough for dermatology face to face appointments, it was clarified that some patients may be triaged online but there would then be a face to face appointment in Medway. The CCG added that the 6 weeks wait referred to was for routine appointments with a target of 18 weeks. All cancer pathways were being met within target.

·       Harm to patients – Members were advised that all patients at the point of the termination of the DMC contract had been seen. The harm review would look at what impact on an individual’s condition had been caused by any delay in treatment. All GPs had been advised to re-refer any patients who had been referred to DMC and discharged if they were concerned about them. The harm review would include cases where a patient had died while waiting for treatment to establish if this was related to their wait to be seen by the dermatology service.

·       Impact of Covid – the significant impact of Covid on these reviews and on surgeries in terms of closures and reduced hours together with new ways of working required was referred to. The CCG was commended for its recent virtual public engagement sessions, although attendance had been disappointing.

·       Pathways – reference was made to the sometimes complex and confusing pathways facing dermatology patients and the importance of clear communications, so patients knew how to access the service.

·       GP information across Medway – a briefing paper was requested on the numbers of GPs before the pandemic compared to the optimum number felt needed and also the spread of GP practices across Medway. The CCG undertook to provide this information, commenting that workforce models in primary care were changing and the key was whether there was the right workforce and capacity to deliver services. Some of the most innovative practices were in areas of relatively low number of GPs.

Decision:

The Committee:

a)      thanked the CCG for their update.

b)      requested a briefing paper on the findings of the Primary Care Lessons Learned Review.

c)      requested a briefing paper on GP numbers across Medway, to also include the numbers of other primary care practitioners.