Agenda item

The Scrutiny Panel will receive information on the reasons for the closure and details of how patients will be allocated to alternative general practices to ensure they can continue to access primary medical services.

SUSPENSION OF COUNCIL PROCEDURE RULE NO 5 - ORDER OF BUSINESS

 

ORDERED that, in accordance with Council Procedure Rule No 5, the scrutiny panel agreed to vary the order of business.

 

The scrutiny panel received:

·        information on the reasons Foundations (Acklam Road) had served notice on its contract;

·        details of how patients would be allocated to alternative general practices to ensure they could continue to access primary medical services; and

·        information on the new specialist clinical/prescribing service for substance misuse.

 

The Commissioning Lead for Primary Care from North East and North Cumbria Integrated Care Board (ICB), the Programme Manager from Public Health South Tees and the Partners from Foundations were in attendance to present information.

 

The Commissioning Lead for Primary Care advised that the Foundations GP practice (previously known as Fulcrum) delivered essential, additional, and enhanced primary medical care services. It was explained that, as per the terms and conditions of the Primary Medical Services (PMS) Agreement, notice could have been served at any time with a standard six months’ notice. The practice had initially served notice on 29 September 2022, with a longer notice period for Acklam Road and a closure planned for 31 March 2024 - that could not be maintained. Subsequently, the practice had re-served notice on 31 March 2023, providing the standard 6 months’ notice, with closure planned for 30 September 2023. The decision to proceed with the closure had been taken by the ICB.

 

To provide some context, Members were advised that the average list size for a practice was approximately 8,600 (NHS Digital). Foundations list size, at the time the original notice was served, was approximately 734. The list size had increased since then to 748 patients being registered on 1 June 2023 (NHS Digital). Of those 748 patients, 29 were registered on the Special Allocation Scheme (SAS). The Special Allocation Scheme (previously known as the violent patient scheme) had been commissioned via an NHS England Directed Enhanced Service (DES) for patients who had been removed from a General Practice registered list due to violent or threatening behaviour.

 

The scrutiny panel was advised that Foundations provided a specialist prescribing service, relating to drug and alcohol treatment, which had been commissioned by Middlesbrough Council. Members heard that it was important to note that not all of the 748 patients registered with the GP practice accessed opioid substitution therapy. There were a significant number of patients who accessed Foundations for the opioid substitution therapy who were registered at GP practices elsewhere in Middlesbrough. It was highlighted that the ICB was only responsible for the management of the PMS Agreement termination, which related to the 748 patients registered for primary care services.

 

Members heard that to ensure continued access to primary medical care services, all patients registered for GP services would be allocated to an alternative practice close to where they lived by 30 September 2023. Patients had been sent an initial letter informing them of the planned closure and a further letter would be issued in August informing patients of the new practice they would be allocated to and registered with in September. The scrutiny panel was advised that the SAS patients would not be included in the main allocation to alternative practices as their care needed to be met by SAS provision. Patients on the SAS register would be allocated to another SAS GP practice by 30 September 2023. It was commented that, until the allocation in September, all patients would continue to access GP services at Foundations.

 

It was explained that allocation meant patients would be automatically registered and were not, therefore, required find a practice and complete application forms. However, Members heard that all patients did have the right to exercise choice and register themselves with another practice at any time.

 

The scrutiny panel was informed that the process of allocation differed to a general dispersal, where it would be the responsibility of the patient to find an alternative GP practice. Due to the vulnerability of some of the patients and the potential risk of them not accessing health care, allocation had been used to safety net and ensure registration was not a barrier to access. The ICB had been working with NHS England, the Cleveland Local Medical Committee, Foundations and other GP practices in Middlesbrough to determine the patient allocations.

 

Members heard that the ICB was supporting practices and providing guidance to enable them to prepare to register the patients and to ensure a smooth transition for patients and effective ongoing management of their health care needs. The ICB continued to work closely with Foundations and Local Authority colleagues in Public Health to ensure communications to patients and stakeholders were clear, due to the different services currently commissioned from the practice by different organisations. It was advised that operational aspects of a practice closure e.g. assets, clinical system access etc were being managed by a project group and followed a standard operating procedure and action plan developed by NHS England.

 

The Programme Manager advised that Middlesbrough Council had commissioned Foundations to deliver a specialist clinical and prescribing substance misuse model. The delivery of the service, by the practice, had been a long standing arrangement.

 

Members heard that in 2020, following the publication of new guidance from NHS England in relation to the commissioning and procurement of services, the safest way to protect the interests of the Local Authority was for the contract to be tested in the open market. The scrutiny panel was advised that a review of the service had been undertaken by an Independent Clinical Lead, a specification was then developed and the tender went out to the market in order to ensure the longest and safest mobilisation period.

 

Work had been undertaken to secure an additional year’s extension to the contract, which would have ensured delivery until 31 March 2024.  However, it was explained that, on 31 March 2023, Foundations had served notice on its contract with a planned closure for 30 September 2023.

 

Due to Foundations ending their provision on 30 September 2023, a new service specification for the Council’s contract had been put out to tender in early 2023, as a standalone specialist clinical/prescribing service for substance misuse, with delivery to commence 1 October 2023. It was confirmed that the tender submission closing date had been May 2023 and no organisations had submitted proposals. The Council’s Executive had therefore granted approval for the specialist clinical/prescribing service for substance misuse to be brought into Middlesbrough Council, to be delivered by the in-house Recovery Co-ordination Service. That decision had been taken due to the risks associated with having any break in service provision for extremely vulnerable people. Following the Executive’s approval, patients had been contacted and informed of the Council’s decision to bring the service in-house and work was being undertaken by the project board and its sub-groups in respect of transfer management, clinical governance, ICT and information governance, workforce and communications.

 

The scrutiny panel was informed that the Council and the ICB would ensure that service users and stakeholders within the local system were appropriately informed and assurance was given regarding high-quality service continuity and support.

 

A Partner advised that Foundations had been in operation for 23 years and had been established initially due to an epidemic of heroin use in the town. The practice had always operated with a harm reduction, health-focused approach. With funding, the practice had been able to deliver specialist clinical care and a GP specialist addiction service. Members heard that the practice offered interventions such as heroin assisted treatment and patients were able to access treatment quicker than elsewhere in the UK. It was explained that Foundations had been recognised both regionally, nationally, and internationally as a beacon of best practice for supporting those with problematic substance misuse and health inequalities. Members heard that the practice felt extremely proud of the work it had undertaken to improve the lives of those who had drug or alcohol issues. It was commented that Foundations was thankful to the Council and the ICB for the support, guidance and funding that had been provided throughout the years, which had enabled the practice to deliver specialist clinical care, primary care and prescribing services for those in the community that required support. It was conveyed that it was deeply saddening that due to the changes in landscape, the practice was no longer able to provide those services.

 

A Member raised a query regarding the allocation of SAS patients. In response, the Commissioning Lead for Primary Care advised that it was likely that those patients would be allocated a practice out of the area. With the SAS being commissioned via an NHS England Directed Enhanced Service (DES), those patients registered on the SAS needed to be allocated to an alternative SAS provision. It was explained that all of the GP practices in Middlesbrough had been contacted to enquire whether those practices would be interested in providing general primary care services to patients who have been excluded from their mainstream GP list through the Special Allocation Service (SAS). No expressions of interest had been received. It was added that, although it was anticipated that SAS patients would be allocated to an out of area practice, in the Tees Valley, a good level of remote care could still be provided via enhanced technologies and online appointment and consultation systems, such as Econsult.

 

A Member raised a query regarding access to substance misuse support groups. In response, a Partner advised that the holistic approach taken in respect of substance misuse and access to support groups would continue via the new substance misuse clinical prescribing service, Middlesbrough Alcohol Centre of Excellence (MACE) and Voluntary Community Sector (VCS) organisations.

 

A Member raised a query in respect of the cohort of patients and the impact on GP practices. In response, the Commissioning Lead for Primary Care advised that not all of the 748 patients registered with the GP practice accessed opioid substitution therapy. It was added that there were a significant number of patients who accessed Foundations for the opioid substitution therapy but who were registered at GP practices elsewhere in Middlesbrough. A Partner commented that most of the patients accessing Foundations did have some level of alcohol or drug dependency. It was explained that the children of those patients also seemed to remain registered with the practice well into adulthood. Members heard that SAS patients presented their own challenges, were often quite vulnerable and suffered from a range of health conditions. It was confirmed that the vast majority of patients had ongoing needs and were vulnerable.

 

A Member raised a query about whether other GP practices would be sufficiently prepared to support patients with such challenges and vulnerabilities. In addition, concerns were expressed that with the closure of the practice, those intergenerational links and the trusting relationships that had been developed between Foundations and its patients would be lost. In response, the Commissioning Lead for Primary Care reassured the scrutiny panel that those practices taking on additional patients would already have patients with similar vulnerabilities and there would be a vulnerable cohort at those practices that were already accessing support for drug and alcohol dependency. It was highlighted that 650 patients who were registered at other GP practices in Middlesbrough were accessing opioid substitution therapy at Foundations and practices should be familiar with the support available. The scrutiny panel was advised that support would be provided by the ICB to enable practices to manage demand and the increase in patients. It was also added that Public Health had been working with the ICB to implement a communications strategy to ensure that there would be no break in service provision for patients. A phased transition period was planned to ensure there would be some form of clinical dialogue between Foundations, and each patient’s new practice, before the transfer took place. By facilitating a phased transition period, specialist support and advice could be provided by Foundations to ensure a smooth transition for patients.

 

A Member expressed concern that, due to the closure of the practice, patients may not access the support that they required. In response, the Commissioning Lead for Primary Care advised that, given the vulnerabilities of patients, the process of allocation had been taken rather than general dispersal. It was commented that allocation was used to safety net to mitigate the risk of registration being a barrier to access. Although there was a risk that patients could choose not to access the allocated practices, patients would be registered with a practice meaning they had access to ongoing medical care if it was required.

 

A Partner at Foundations advised that, given the levels of deprivation in the town, there were a number of GP practices that cared for vulnerable patient cohorts. The importance of promoting access to care and providing opportunistic care was highlighted. It was added that other practices were experienced in caring for patients with vulnerabilities, including issues with drug and alcohol dependency.

 

A Member queried whether practices were able refuse new registrations. In response, the Commissioning Lead for Primary Care advised that the ICB was able to allocate patients to all practices, including those practices that had closed patient lists. 

 

A Member raised a query regarding procurement of the specialist clinical/prescribing service. In response, the Programme Manager advised that the procurement rules applied to Public Health contracts were not the same for primary care. There had been a risk of challenge from the market, as the Local Authority was required to be open and transparent in terms of its contracting. Previously, there had been an area of contract law that had enabled the contract with Foundations to be extended on the back of the primary care contract. It was explained that, as that was no longer possible, the Local Authority had a responsibility to advertise the opportunity to the local market and go out to tender.

 

A Member raised a query regarding access. In response, the Commissioning Lead for Primary Care advised that support would be provided to practices to ensure new registrations were processed efficiently and patients would be invited to attend a new patient registration appointment. It was explained that all practices in the local area had access to interpreting services.

 

A Member queried whether those agencies involved with patients would be notified of their change of practice. In response, a Partner advised that a case-by-case safeguarding handover was planned with the receiving GPs to ensure a smooth transition for patients.

 

A Member queried the reasons for the closure of Foundations. In response, the Director of the ICB advised that the ICB was required to purchase general medical services for the local population and would have continued to fund Foundations to deliver such services. However, due to the changes of the other services provided by Foundations, that option was no longer available. A Partner advised that the commissioning landscape was complex and had changed significantly over recent years. It was commented that the general medical services contract was, unfortunately, not Foundations main income stream because it was based on low patient numbers.  Members heard that Foundations had served notice on its public health substance misuse clinical contract and its primary care elements of service due to financial risks of continuing without all components being in place and funded.

 

The Director of Public Health advised that Public Health’s funding for the specialist clinical/prescribing service and various primary care contracts, had historically made Foundations financially viable. However, due to changes in commissioning arrangements, a review of the current specialist clinical/prescribing contract had been required, the outcome of which had resulted in a new specification and associated changes to the overall operating model. Those changes had meant that Foundations was no longer able to sustain delivery of the specialist clinical/prescribing service. The Programme Manager advised that a substantial amount of work had been undertaken to mitigate the risks associated with the change in service delivery and ensure any breaks in service and disruption was avoided.

 

AGREED

 

That the information presented to the scrutiny panel be noted.