Agenda item

This special additional briefing meeting of the Adults & Health Scrutiny Panel is to discuss the transfer of holdings from AT Medics to Operose Health Ltd and the potential impact of this on GP services in Haringey.

Cllr Connor introduced the main item noting that this special additional briefing meeting of the Scrutiny Panel had been called to discuss the transfer of holdings from AT Medics to Operose Health Ltd and the potential impact of this on GP services in Haringey.

Rachel Lissauer, Director of Integration (Haringey Borough Office) at North Central London CCG, introduced the report noting that AT Medics held 34 Alternative Provider of Medical Services (APMS) contracts across London, 8 of which were in the North Central London area. Only one of these was in Haringey Borough – the St Ann’s Road surgery. The concerns that some people had expressed was on the change in control of these contracts from AT Medics to Operose Health Ltd which was a company that held a number of GP and other health service contracts across London and elsewhere in the country.

In terms of the role of the CCG, she explained that AT Medics had to ask permission from the NHS for the change in control. In December 2020, the London CCGs undertook an exercise to do due diligence and reach assurances that the company could provide high quality, safe services for local residents. The CCGs were satisfied of this as a result of the exercise. Assurances had been given that GP services would continue to be run as they are now and these services would also be covered by the CQC quality assurance processes. The commissioning rules and national guidance were applied in the same way as any other GP contract and legal advice was also taken. There was no legal or contractual basis for the CCGs to object to the transfer of control to Operose Health and to do so would have risked both legal challenge and continuity of care for patients. Patient involvement was not a requirement for a change of control unless there was a change in service provision.

Paul Sinden, Chief Operating Officer at North Central London CCG, added that the Primary Care Commissioning Committee requested regular monitoring of the quality of services provided. He said that, while the CCG had published papers in line with their terms of reference, they should have alerted people to the contentious decision that was about to be made. As a piece of learning from that, a meeting now takes place with the five Lead Members for Health and Care for each Borough ahead of each Primary Care Commissioning Committee meeting in order to go through the papers. The CCG would also look again at its procurement process, including the weighting put towards social value and integration.

Asked about the different types of contracts, Paul Sinden said that the original GP contracts with the NHS were for General Medical Services (GMS). These was contracts for life that were only end on retirement or if services were exceptionally poor. Personal Medical Services (PMS) contracts were then introduced as a top up to the GMS contracts which allowed GP practices to opt to provide additional services such as managing people with specific long-term conditions. Alternative Provider of Medical Services (APMS) contracts were then added and, unlike the GMS and PMS contracts, these are time-limited contracts making it easier to change provider if the CCG considered that performance was not meeting the requirements of the contract.

Paul Sinden then responded to questions from the Panel:

• Asked by Cllr Culverwell about the criteria for providers of APMS, Paul Sinden said the term ‘alternative’ referred to the nature of the contract rather that the provider and that there were local providers which held APMS contracts. 
• Asked by Helena Kania about the implications of Integrated Care Systems (ICS), Paul Sinden said that the CCG was working on developing ‘provider alliances’ which would ensure that the voice of General Practice would be heard within the ICS. The Primary Care Provider Alliance would have two peer-selected representatives from each borough and from those there would be two primary care representatives on the overall Provider Alliance for NCL. 
• Cllr Bull asked whether there was specific weighting of procurement criteria in favour of local knowledge and expertise. Paul Sinden said that the weightings were being considered and that he would be happy to learn from Haringey Council and others about their procurement practices to ensure that these weightings help to select the most appropriate providers.
• Asked by Cllr Connor whether local determinants of health and the development of local care providers could be included in the weighting of procurement criteria, Paul Sinden said that the CCG had committed to looking at their procurement criteria and would be open to discussion or advice from local authority procurement teams on including these specific criteria.
• Cllr da Costa asked about the relationship between AT Medics and its parent companies such as Circle Health and the referrals of patients to secondary care services which it could have connections with. Paul Sinden said that AT Medics continued to hold contracts in the NCL area and that the CCG would monitor referral patterns from primary care providers and would be alert to any change in this. The CCG would expect local providers to be the recipients of referrals apart from some specialist referrals that might go further afield. The elective recovery programme (being deployed to reduce the waiting list backlog resulting from the pandemic) was making some use of the independent sector and there was a Clinical Prioritisation Group in place to ensure that people were treated in an equitable order. Asked by Cllr Connor whether details on monitoring would be provided to the Lead Members in the pre-meetings prior to the Primary Care Commissioning Committee, Paul Sinden said that this would not necessarily happen routinely because this was not a primary care commissioning issue. However, the Members could be alerted if any changes in referral patterns emerged. Cllr Connor asked for more information to be provided in writing about how this monitoring information would be made available and which committees would be involved. (ACTION – included in recommendations below)
• Asked by Cllr Peacock about the ICS reforms, Paul Sinden said that the benefit of an integrated care system was in a collaborative approach and about making decisions in the interests of the whole system rather than that of individual organisations. Cllr Bull said that while he felt the ICS was a good idea in principle, the concern from residents about it was a perception of it providing a possible back door for privatisation. He also expressed concerns about whether a borough like Haringey without an acute trust would have parity of esteem with boroughs that did. Rachel Lissauer commented that, within the ICS frameworks that had been produced, there was a different focus on procurement than there had been in the past with recognition that health services are different from other kinds of services and a focus on social value in contracts. She had been encouraged by the potential of the ICS work so far to help with issues in Haringey, such as through the Inequality Fund.
• Cllr Connor questioned how local accountability and transparency could be ensured through the ICS, including by ensuring through representation on the ICS Board and ensuring that the information provided was clear, easily available and received at a point at which it would be useful. Paul Sinden said that there would be formal places for local authorities on the ICS Board and then a broader health and care partnership within the ICS statute that would feed in views and information from boroughs into the ICS. There should also be conversations outside of these formal structures, particularly when difficult decisions are coming up.

Emma Dove, Inspection Manager at the CQC London Region, was introduced and it was noted that she was the relationship owner for AT Medics. She explained that the CQC registers and regulates providers to carry out regulated activities. AT Medics had 39 contracts across London registered with the CQC.

Emma Dove then responded to questions from the Panel:

• Asked by Cllr Culverwell regarding complaints about providers, Emma Dove said that the CQC did not currently have any remit to investigate complaints. However, health and social care was changing rapidly and the Secretary of State had asked the CQC to report on systems, the findings of which had been in favour of organisations working together to provide better outcomes for patients.
• Asked by Cllr Connor about changes in primary care during the pandemic, Emma Dove, said that the CQC was conducting a significant piece of work on patient access to GP appointments which had recently changed for a number of patients. This included an increase in video appointments and also appointments being triaged with options such as referrals to pharmacies. The report on this work was expected to be published in August.
• In response to a question from Cllr Connor about inspections, Emma Dove said that information received from various sources and the examination of risk factors help to decide whether an inspection at a particular service was required. Services that had previously been rated as ‘Inadequate’ would receive follow-up inspections. Two inspections had been carried out on AT Medics-run practices in London. One was recently based on information received and that report was due to be published the following day (25^th June). Concerns had been identified and the provider had responded to these. The other inspection involved a practice in Camden registered by AT Medics in April 2020. That report had been published the previous week with Good ratings awarded in most areas. Cllr Connor asked for the Scrutiny Officer to provide these reports to the Panel Members. (ACTION) Paul Sinden added that when practices receive ‘Inadequate’ or ‘Requires Improvement’ ratings, the CCG sends a contract note to the practice to ensure that the concerns raised are addressed. In Haringey, the practices at Staunton Group Practice, Tynemouth Medical Practice, Stuart Crescent Medical Practice currently had contract notices against them.
• Asked by Helena Kania about her relationship owner role with AT Medics, Emma Dove said she met with AT Medics every 4-6 weeks. This was to maintain on ongoing conversation about their governance arrangements, discuss their plans for the future and establish how they monitor their own services. They are also updated about the CQC inspection programme. Asked whether this had involved Operose Health, she said that she had met with Operose on one occasion so far as an introductory meeting, but no further meetings had yet been considered necessary.
• Asked by Cllr Connor about meetings with the CCG, Emma Dove said that she didn’t personally meet with Haringey CCG as she worked in a different area of London, but that CQC inspection managers do meet with their local CCGs on a range of issues. Rachel Lissauer added that there was very good regular contact and information sharing in Haringey with the CQC and with primary care commissioners.

The Panel then discussed the recommendations of the Panel based on the conversation that had taken place which were summarised by Cllr Connor as follows:

1 – That there should be recognition of the importance of local accountability and transparency. This should include appropriate links between committees such as the ICS Board and representatives of local communities. There also needed to be clarity about how information on contractual issues, monitoring of referrals and about providers’ connections to other services and providers would be made available including which committee that information would be provided to.

2 – That there should be clarification about the procurement criteria and how this should be weighted, including:

• Social value
• Local determinants of health
• Development of local care providers with local knowledge (including a level playing field for smaller providers) 

3 - The Panel had heard about how the CCG and CQC share information and identify risk. The Panel requested clarification about how information, such as the information about AT Medics, is shared more widely.

4 - The Panel requested clarification about how various local authority and patient groups (such as the Health & Wellbeing Board, Borough Partnerships and healthcare partnerships) would sit within new ICS board and how the flow of information would work. It was noted that a chart illustrating this would be useful if possible.