Board Paper 21.1.16 Item 16/22 To improve health and provide excellent care Title: North Denbighshire Primary Care Services Author: Bethan Jones, Area Director – Central Chris Stockport, Area Medical Director Clare Darlington , Asst Area Director Primary Care – Central Responsible Director: Morag Olsen Chief Operating Officer Summary of Key Issues: Pendyffryn Medical Group and Seabank Surgery, both in Prestatyn, have given notice that they will be terminating their contract with the Health Board on the 31 st March 2016. These practices will therefore no longer be providers of General Medical Services and primary care services. At the meeting on 10 th November the Board approved the recommendation to develop a business case to for a Health Board managed solution providing a new model of Primary Care in Prestatyn. The attached Business Case has been developed for consideration and approval by the Board. Action Required By Board: It is recommended that the Board: Note Endorse Ratify Approve Approves the recommendations set out in the Business Case Key Impacts: (Please provide a short summary against all that apply) Corporate Objective The Health Board has a duty to ensure the availability of GP and primary care services for the population. Finance There is a requirement to approve the funding of the business case on a recurring basis, with a non-recurring element as detailed. There will be a requirement to utilise a share of the additional Welsh Government funding for
Transcript
Board Paper 21.1.16 Item 16/22
To improve health and provide excellent care
Title:
North Denbighshire Primary Care Services
Author:
Bethan Jones, Area Director – Central Chris Stockport, Area Medical Director Clare Darlington , Asst Area Director Primary Care – Central
Responsible Director:
Morag Olsen Chief Operating Officer
Summary of Key Issues:
Pendyffryn Medical Group and Seabank Surgery, both in Prestatyn, have given notice that they will be terminating their contract with the Health Board on the 31st March 2016. These practices will therefore no longer be providers of General Medical Services and primary care services. At the meeting on 10th November the Board approved the recommendation to develop a business case to for a Health Board managed solution providing a new model of Primary Care in Prestatyn. The attached Business Case has been developed for consideration and approval by the Board.
Action Required By Board:
It is recommended that the Board: Note Endorse Ratify Approve � Approves the recommendations set out in
the Business Case
Key Impacts:
(Please provide a short summary against all that apply) Corporate Objective
The Health Board has a duty to ensure the availability of GP and primary care services for the population.
Finance There is a requirement to approve the funding of the business case on a recurring basis, with a non-recurring element as detailed. There will be a requirement to utilise a share of the additional Welsh Government funding for
primary care services, based on the population affected.
Quality Impact Assessment
The impact on service quality will be considered as part of the development and ongoing evaluation of the new service model.
Standards for Health Services in Wales
The delivery of sustainable Primary care Services supports various Standards for Health Services: Health Promotion, Protection and Improvement Citizen Engagement and Feedback Safe and Clinically Effective Care Care Planning and Provision Communicating Effectively Workforce Planning
Equalities, Diversity & Human Rights
An equalities impact assessment will be undertaken as part of the development and implementation of the new model.
Risk & Assurance
A risk assessment of service sustainability has been undertaken and a risk log will be maintained throughout the development of the alternative service provision.
Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board
Board Coversheet v5.0 October 2014
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BCUHB – CENTRAL AREA
Business Case for the development of a Managed Prac tice in Prestatyn
Division Central Area Development or Scheme
‘Healthy Prestatyn Iach’ – a new model of primary care
Author/s Clare Darlington, Asst Area Director Primary Care & Commissioning
Version V0.04.1 Date 13th January 2016
1. Executive Summary 1.1 Purpose
This Business Case has been developed to ensure the continued availability of primary care services to the patients currently registered with the Pendyffryn Medical Group and Seabank Surgery, both located in Prestatyn, Denbighshire. Both of these GP Practices have issued the Health Board with notice against their contracts from 1st April 2016. The Health Board has a statutory duty to ensure that the population of North Wales has access to core primary care services. There is therefore an absolute requirement that the Health Board ensures an alternative provision of service for the 21,000 patients affected in Prestatyn and delivery of this must be achieved by 1st April 2016. A ‘do nothing’ option can therefore not be considered in this Business Case. Whilst recognising the clear risk to service delivery, this is also an exciting opportunity to develop and implement a new model of care which better responds to the changing needs of the population, the challenges being faced in relation growing demands across the health and care systems and the difficulties in workforce recruitment and retention. The Business Case therefore sets out a new model of primary care services which builds upon best practice in the UK and internationally. It provides a more accessible, person-centred approach than the traditional model of care. By broadening the professional skill mix of the primary care team a wider range of care options can be delivered to include a ‘Same Day Service’ for minor ailments and injuries; an Elective Centre to facilitate multi-disciplinary case management better tailored for individual patients; increased support for the frail and elderly with a team of professionals specifically providing domiciliary care including those patients who are residents of Care Homes; a focus on training and research for professionals, as well as improvements to access to lifestyle and health promotion activities, and social prescribing for patients. The development of this new model will take several months to fully implement and longer again to deliver optimum improvements. It will continuously be evaluated and rely on patient feedback, involvement and ownership. The need to ensure the delivery of core services by the 1st April must therefore be a key focus whilst developing the
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various elements of the new model. The Project Team is working closely with staff within the practices to ensure a smooth transfer of activities and processes that will support the ongoing delivery of services from the beginning of April. As well as completing arrangements for the transfer of staff currently employed by the practices to the Health Board, the recruitment of additional staff is a priority. The required premises and facilities will also need to be secured in readiness for the transfer to a health board managed solution. The following key milestones will be delivered:
• Provision of core primary care services – 1st April 2016 • Provision of ‘Same Day Service’ and Key Teams (Elective Care) – April to
June 2016 • Development of Domiciliary and Care Home support – October 2016 • Formal launch of ‘The Academy’ – January 2017
Furthermore the successful development and delivery of this proposal links closely with the development of a Primary Care Strategy for North Wales and will inform this work going forward. There is a requirement that this Business Case is agreed at Executive and Board levels, with each member of the Executive Management Group acknowledging the key risks and responsibilities in ensuring the successful delivery of the replacement service.
1.2 Approval Process
Version Date 0.01 Project Team –
comments received 16.12.2015
0.02 Project Board – comments received
23.12.2015
0.03 Executive Management Group – comments received
06.01.2016
0.04.1 Area Director/Chair of Project Board
13.01.2016
0.04.1 Board – for consideration & approval
21.01.2016
2. The Strategic Case 2.1 Overview of the Business Case
Betsi Cadwaladr University Health Board (BCUHB) is responsible for ensuring that the population of North Wales has access to primary care services. At the end of September 2015, the Pendyffryn Medical Group (PMG) and Seabank Surgery, both in Prestatyn, gave notice that they will be terminating their contract with the Health Board on the 31st March 2016. From April 2016, these practices will no
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longer be providers of General Medical Services and primary care services, affecting around 21,000 patients. The following business case therefore provides proposals and recommendations to ensure the provision of primary care services for those patients from the PMG and Seabank Surgery from 1st April 2016. The Business Case has been developed by the established Project Team, jointly chaired by the Area Medical Director and the Asst. Area Director Primary Care & Commissioning. It has been considered in detail by the Project Board (chaired by the Area Director – Central), with comments received for a draft version to be considered by the Executive Management Group on the 6th January 2016 in readiness for the Health Board to consider in January 2016. It should be noted that the GP in Rhuddlan has given notice to the Health Board that she too will be terminating her contract on the 31st March 2016. This notification was received on the 14th December 2015. As a result various options have to be considered for the patients affected and this is referred to under section 5.3. Final recommendations regarding the patients affected by the Rhuddlan Surgery contract termination will be made in the coming weeks.
2.2 The Current Service 2.2.1 Service Provision The traditional model of primary care is predominantly provided through the GMS contractual arrangements with individual practices. The main income source for both practices is from the Health Board which commissions the services. Services are, in the main provided by core professional groups usually consisting of GP partners, practice nurses (and in some instances nurse practitioners) and an administrative team. The Pendyffryn Medical Group (PMG) has a list size of around 18,000 patients, the majority living in the Prestatyn and Rhyl area, but with around 2,500 in parts of Flintshire (see maps in Appendix 1). The PMG main surgery is in Prestatyn with branch surgeries in Ffynnongroew and Meliden. The practice population has a comparatively high elderly population, with significant numbers of patients resident in 12 care homes and further numbers in another 8 care homes out of the immediate area. The PMG provides essential services under the terms of the General Medical Services (GMS) Contract, along with additional services which include cervical cytology, contraception, immunisations, minor surgery, child health surveillance and maternity medical services. The Practice is also able to offer a wide range of enhanced services, including Near Patient Testing, Contraceptive services, Anticoagulation, COPD, smoking cessation, wound care, further minor surgery, specific services for Care Homes, Learning Disabilities and Mental Health patients. Seabank Surgery is also in Prestatyn and has a practice population of around 2,400
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patients, mainly resident in Prestatyn but also across the catchment of North Denbighshire (see Appendix1). This is a single handed GP practice again providing essential services under a GMS contract arrangement, along with additional services which include, cervical screening, contraceptive services, vaccines and immunisations, some minor surgery, child health surveillance services, maternity medical services. The Practice also offers some Enhanced Services including Near Patient Testing, Contraceptive implants, Anticoagulation and further minor surgery. The Practice operates from one building. 2.2.2 Needs of the Practice Populations The main determinants of need and demand for primary care services are deprivation and the age profile of the registered patient population.
A summary focusing on these two indicators is provided below (Source: Public Health Wales Observatory)
Deprivation
In considering Pendyffryn Medical Group and Seabank Surgery there is a significantly higher proportion of patients in the most deprived 40% of areas in Wales, and higher than the Health Board average.
Percentage of patients living in the 40% most depri ved LSOAs in Wales, North Denbighshire Cluster, Betsi Cadwaladr UHB, 2014
Pendyffryn Medical Group 49.2
Seabank Surgery 41.5
North Denbighshire Cluster 52.7 Betsi Cadwaladr UHB 30.6
The graph below highlights that the percentage of patients registered at the PMG(W91009) living in a deprived area is significantly higher than the BCUHB and all Wales average.
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Similarly the further graph below highlights that the percentage of patients registered at the Seabank Surgery (W91632) living in a deprived area is significantly higher than the BCUHB and above the all Wales average.
Age profile
The graphs below highlight that the Pendyffryn Medical Group has a high proportion of older people relative to the Welsh average, and this has significantly increased over the last decade. Whist the smaller Seabank Surgery has a smaller percentage over the age of 85, it must be recognised that this practice has a significantly fewer number of registered patients.
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Proportion of registered patients aged over 65 and 85, at PMG and Seabank Surgery compared with the all Wales average, 2014
Furthermore, as indicated below, both practices care for more people between 65 and 84 than the Health Board average, with a higher percentage of over 85s registered with the PMG.
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The Practices have 184 registered patients who are living in care homes. However, there are a relatively low proportion of people over 65 living in care homes in North Denbighshire (estimated 1.7% from the 2011 census), compared to 3.8% in Wales and 4% on average for the Health Board. This may reflect the relatively low number of care home beds available and suggest that the Practices may be managing more frail older people at home, also noting that around 32.5% of patients over the age of 65 from the two practices live alone. Other factors relating to the level of need
Healthy lifestyles Both Practices have significantly higher proportions of adults who smoke (22.3% where Wales average is 20.5%) and adults who are overweight and obese (59.3% and 60.4% where Wales average is 57.8%)
Chronic conditions Pendyffryn Medical Group has a higher rate of COPD and CHD than the Wales, the Health Board and Cluster average. There are over 700 patients with COPD (3.2% of population adjusted for age), and there are over 1100 patients with CHD (5.1% of the population adjusted for age).
Secondary care use The rate of OOH and ED attendances is average or below average compared across the cluster, for both practices: this suggests case management is currently similar to other local Practices. There is potential to take more intensive case management approaches and hospital avoidance with the advantage of a wider integrated primary care team.
For all the above reasons, the Practices are already coping with greater challenges than the average. There is great potential to develop a new model to allow flexible
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evidence-based approaches to improve health, and improve health outcomes. Whilst patients can currently access a range of services there is potential to improve integration across primary, community and social care services, as well as those provided by the voluntary sector. This would include a more coordinated approach to support services such as phlebotomy as well as an increase in ‘social prescribing’ to holistically care for patients general health and well-being.
2.3 The Case for Change
The challenges facing GP practices in North Wales and across many parts of Wales and the UK are evident. For a number of practices GP recruitment is extremely difficult and workload is reported as high. The sustainability of these practices is therefore a significant risk, along with the potential for the number of practices affected to increase. The Central Area Team & Primary Care Support Unit for BCUHB recognised particular growing concerns in relation to practice and service sustainability in the North Denbighshire Cluster. In summary: • There are 8 GP practices in the Cluster (4 of which are single contractors) • The average list size in the cluster of 2,401 patients per GP, compared with an
average in North Wales of 1,873. • Around 60% of the GPs are 50years or over • The ratio of practice list size per session is the highest of all the North Wales
clusters at just under 300 • The cluster has some of the highest levels of deprivation in North Wales As a result, at the beginning of July 2015, a cluster level risk assessment to GMS sustainability was undertaken by the North Denbighshire Cluster; risks were identified, scored in terms of probability and impact, and mitigating actions agreed. These have been included in the annual plan developed by the cluster and will be implemented over the coming months. A similar exercise has been undertaken with the Conwy West and Conwy East Clusters and will be progressed with the Central/South Denbighshire Cluster in January 2016. On the 24th September a letter was received from the Pendyffryn Medical Group (PMG), Prestatyn, giving notice that they will be terminating their contract with the Health Board on the 31st March 2016. This is due to a number of retirements, workload pressures and their inability to recruit GPs. Subsequently on the 30th September, Dr Bradshaw, of Seabank Surgery also issued 6 months notice to terminate his contract, due to challenges of sustaining his practice as a single handed GP. The Health Board must therefore respond robustly and effectively to ensure that Primary Care Services continue to be provided to those 21,000 patients affected. In addition the case for a new model of care, rather than replacing ‘like-for-like’ is strengthened by seeking greater opportunities for:
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• long term sustainability; • increasing patient/ customer participation and ownership; • developing new models and roles; • flexibility to better meet the needs of the population; • bringing more services into the community with improved integration with social
care and third sector; • prevention and well being approaches; • demonstrating prudent health care.
2.4 Strategic Co ntext In 2015, Welsh Government published the document ‘Our Plan for a Primary Care Service for Wales up to 2018’ .
This highlighted the current and prospective challenges for the NHS in Wales. In particular:
• The challenges of the economic environment in which the NHS is operating; • The pressures of increased demand in Primary Care. More people are being
diagnosed with one or more long term conditions like diabetes and dementia and frail older people increasingly have more complex needs;
• Rising public expectations; • The challenges of a reducing GP workforce where significant numbers of GPs
are coming close to retirement age at the same time as parts of Wales are experiencing difficulties in recruiting GPs;
• The need to provide more care locally in out of hospital settings. To address these challenges, the plan identified five priority areas for action:
• Planning Care Locally • Improving access and quality • Equitable access • A skilled local workforce • Strong leadership
Underpinning this plan, the overall principles were defined as:
• Prevention, early intervention and improving health, not just treatment; • Co-ordinated Care where generalists work closely with specialists and the
wider support in the community to prevent ill health, reduce dependency and effectively treat illness;
• Active involvement of the public, patients and their carers in decisions about their care and well-being;
• Planning services at a community level of 25,000-100,000 people which the King’s Fund has determined as the optimum size for planning and provision of Primary Care;
• Prudent Healthcare.
In addition, Welsh Government have recognised the need to deliver a more social
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model of care, which is addressed in new legislation to support better health and well- being, including the Social Services and Wellbeing (Wales) Act 2014, the Wellbeing of Future Generations Act and the Public Health Bill .
In North Wales the Health Board have been undertaking a listening and engagement exercise, “Living Healthier, Staying Well”. The key themes relevant to the development of this business case include; improved access, better communication, listening to patients and carers and good staffing levels and expertise. Locally, the Central Area Senior Leadership Team have been developing their three year plan. In November 2015 a ‘Visioning Day’ was held with a wide range of stakeholders including the Health Board, Primary Care contractors, Local Authorities, Housing Associations, Public Health Wales, Grŵp Llandrillo Menai, North Wales Police and various voluntary sector organisations. To ensure that the workshop had a practical, realistic approach, ‘Stryd Ni’ was introduced. Stryd Ni’ is a street, the residents of which have a high range of health, social care and other needs. It has been created to bring to life the situations that people find themselves. This work reiterated the fact that one agency alone cannot impact on the health and well being status of the population. As a result the Area Team will be developing their plans further to ensure that we:
• Shift our focus towards Prevention and Health Improvement and ensuring that we progressively realign services in this way
• Strengthen Primary and Community Care – with particular emphasis upon new models of care outside hospitals that move care and intervention close to people’s homes
• Work with others to provide more integrated care, developing stronger partnerships with Local Government, the third sector and Carers
• Deliver hospital based services that provide the best possible outcomes for people and are sustainable for the future.
2.5 Proposed Service Development As outlined in section 2.3, it is well recognised that the traditional model of General Practice is experiencing unprecedented challenges and there is therefore significant concern by the patients, staff, neighbouring GP practices and local stakeholders about the decision made by the two practices in Prestatyn to terminate their GMS contract. In responding to this and by working with all stakeholders, the Central Area Team and Project Board see this as a clear opportunity to develop a sustainable Primary Care model of services to better meet the changing needs of the population, as well as ensure service sustainability.
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Led by the Area Medical Director, the established Project Team agreed that there were four main options worthy of consideration for ensuring the continued delivery of primary care services in Prestatyn, with the ability to ‘do nothing’ not being an option. These were: 1. To re-contract a provider to provide General Medical Services 2. To appoint an Alternative Provider Medical Services (APMS) contract provider 3. To introduce a long-term Health Board managed service 4. To disperse the list across the other local GP practices Recognising the current challenges key features needed to be reflected upon in reviewing the options, which included: ‐ A strong focus on the psychosocial determinants of ill health - Greater emphasis on preventative care - A prudent approach to care and treatment - The use of a wider range of professional to deliver core services - An approach which is seen as innovative and enticing by professionals within and outside of North Wales - A permissive governance framework which appropriately empowers professionals - A breakdown of traditional barriers with care being person-centred rather than system-centred The Project Team, Central Area Team and Project Board considered the options presented alongside the feedback, comments and ideas gathered through engagement with key stakeholders. There was also a strong willingness to use this as an opportunity to develop a new model of care and overwhelmingly positive feedback has been received from the majority of stakeholders with whom this has been discussed. Stakeholders also, in the main, accepted the limitations and difficulties of being able to deliver this utilising the current GMS contract. On the 10th November 2015, the Health Board approved the recommendations of the Project Board that the APMS and Dispersal options should be dismissed and that there should be a focused effort on developing a Health Board Managed Solution to deliver the more contemporary model of care. In developing this detail it should be benchmarked again the current GMS contracted services. An alternative model of has therefore been developed to be delivered as Health Board managed services.
2.5.1 Proposed Model of Care The Primary Care model being developed for Prestatyn is based upon learning from leading centres from across the UK and other developed countries and promises great potential for offering more accessible, and more person-centred care. In developing this new model of care, consideration has been given to the opportunity to better respond to the changing needs of the population, growing demands and patient
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satisfaction. The model of care is divided into four reasonably distinct elements. Although each element requires a different cross-section of professionals, in reality professionals are likely to work across a number of elements and far more collaboratively than before. The four elements are as follows:
1 2 3 4
‘Same Day Service’ Elective Centre – ‘Planned Care’
Domiciliary and Care Home Support
The ‘Academy’
For unplanned ‘urgent’ care
For all minor illness and minor injury.
No appointment needed.
GP supported, but care mainly delivered by other professionals such as nurse practitioners, extended scope pharmacists and extended scope physiotherapists.
Estimated to account for approximately 20% of total encounters.
Very important function to take unnecessary demand on the rest of the system and service providers, such as ED and out of hours services.
Main delivery arm for planned care including chronic conditions management and proactive case management with risk stratification techniques.
Calmer environment by removing the demand for ‘urgent’ treatment of minor illness and injury.
Appointment based, using wider multidisciplinary ‘key’ team supported by a wide range of professionals.
Continuity of care important.
Appointments with patient’s key-worker team where possible.
Wide array of innovative approaches to consultation delivery.
Support team providing proactive care, and acute care for patients in their own homes and care homes.
Delivery of enhanced care and supported by other services such as intermediate care and palliative care.
‘Pull-out’ from secondary care.
Delivering training for professionals and patients. Locality/Cluster Professionals: - comms skills - clinical skills - updates on available community assets - training re ethos/values Patients: - lifestyle & health promotion sessions - co-production of services - social prescribing Other: - Education of professionals from outside of the Cluster - Research of transformation of PC - Dissemination of learning from transformation - Promotion of a new model of Primary Care to improve future recruitment
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The Elective Care Centre for planned care, builds upon a service model in Alaska, called NUKA, which has been studied internationally and in the UK, and promoted as an effective model of care. The Centre will operate in line with the following key principles:
• All patients registered with the practice will be able to access these services; • The service will be built around ‘key teams’; • There will be a pre-bookable appointment system, with direct access
appointments with the whole team; • Each team will have a lead administrative coordinator; • They have small teams of 4 or 5 professionals who meet the main care needs of
a group of around 5000 patients (see diagram below); • Supporting the core key teams will be a wider range of more specialist
professionals who support them and are constantly available to the service, such as chronic conditions specialist nurses, palliative care nurses, CPNs and extended scope pharmacists and physiotherapists.
This whole model of care will support improvements to the way services are provided and also respond more holistically to patients’ needs by moving away from a traditional predominantly medical model of care. It would also provide an alternative career option for health professionals and allow GPs a choice of employment with the Health Board or partnership with a continuing ‘GMS’ practice.
2.5.2 Performance, Activity and Contracting The population to be served will be those patients registered with the Pendyffryn Medical Group and Seabank Surgery on the 1st April 2016.
Through the work undertaken to produce the Workforce Plan it is anticipated that the likely appointment demand (to meet GMS workload) will be for 110,000 appointments
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Based wherever possible upon existing data, and then fine-tuned and with gaps filled using professional experience and judgment, the Project Team anticipate that the appointment type will broadly break down into these proportions:
It is recognised that the service will need to respond to variation in demand as a whole and across the main elements. The workforce plan has been developed to do this, for examples members of the key teams will be able to provide support to the Same Day Service. In addition an allowance has been made to allow cover of annual leave, training and sickness. As with other primary care services activity levels will continue to be recorded and reviewed for additional and enhanced services. The quality of services provided will be monitored using the GMS Quality Outcomes Framework (QOF). This will also allow the services to be benchmarked with other provision across the Cluster, Area and Region.
The service split above results in the following workloads:
Annual appts
Average Daily appts
Same Day Service (20%) 22,000 88
Domiciliary / Care Home (5%) 5,500 22
Treatment Room nursing (20%) 22,000 88
KeyTeam/Elective Care (55%) 60,500 242
TOTAL 110,000 440
Patient enquiry
Same Day Service
Domiciliary / Care Home
Treatment Room nursing
Key Team/Elective Care & booked appointments
20%
5%
20%
55%
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In addition the Clinical Governance Practice Self Assessment Toolkit will be utilised. This is a voluntary self report toolkit which all practices in North Wales currently utilise. It has 47 matrices covering a wide area of Clinical Governance and forms part of the QOF. There will also be an emphasis on user feedback which fully reflects user experience as well as clinical outcomes. This will be shred publicly and be used to refine and improve services. The new practice will be a member of the North Denbighshire Cluster and contribute to the cluster meetings, planning and activities alongside other local practices. Other measures, linked to the benefits of the new model (detailed in section 3.2) will be monitored such as prescribing measures and utilisation of out of hours services and Emergency Departments.
2.5.3 Workforce Workforce Plan
The Project Team has developed a Workforce Plan which maps the likely time requirements for the different professional groups involved to deliver the activity levels above, and from there the number of staff required. It takes into consideration:
1. a service model which identifies which professional group can undertake which tasks;
2. a knowledge of the number of consultation requests and enquiries likely to be made;
3. a knowledge of how these requests and enquiries break down in terms of the nature of the problems being presented, because this informs
� how many contacts could be dealt with by non-GP professional groups, post-transition, and
� how many contacts could be dealt with in more efficient ways than face-to-face appointments.
The Workforce Plan has been approved by the Project Board and an overview of staffing requirements is provided as part of the Financial Case in Section 4, with further detail in Appendix 2. Workforce Recruitment All staff currently employed by the GP partners of both practices are protected under Transfer of Undertakings (Protection of Employment) Regulations (2006) as amended (2014), referred to as ‘TUPE’. When a business or undertaking is transferred to another employer, TUPE is safeguards the interests of current employees by preserving their continuity of employment and
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terms and conditions. Therefore all staff employed by the GP partners on 31st March 2016 will be transferred to be employees of the Health Board on the 1st April 2016. The current workforce within the two practices does not fully match the requirements outlined in the workforce plan required for the new model of care. With the support of both practices, the Project Team has identified some additional posts that are required and has commenced recruitment processes to ensure that these are filled by 1st April. This includes the need to recruit 6wte salaried GPs. Similarly there are some posts in the current workforce that do not readily align with the workforce plan. Account of these are made in the transitional requirements, recognising that the cost can be absorbed into the affordability of the new model and only equates to 2% of the total costs. During the transition period staff changes and ‘natural wastage will also support the management of these differences. Given the innovative nature of this project it is well recognised that workforce requirements across all the professional groups will be constantly reviewed and evaluated as the model of care matures and becomes embedded.
2.5.4 Premises
The current providers Pendyffryn Medical Group have a main surgery and two branch surgeries, and Seabank Surgery have one main surgery and no branch premises. The Health Board reimburses the Practices for the cost of rent or a notional value based on a valuation if the Premises are owned by the Partners.
A rapid desktop review of the current Primary Care premises, suggests that Pendyffryn Main Surgery is the largest and best placed of the four sites and as such would be the Main Building offering the Same Day and Planned Care Services. However there are significant limitations to the building in terms of expansion and ability to support the delivery of the new service model. Car parking is also a concern.
Further more evidence demonstrates that delivering the new model of care to it’s full potential requires the whole team to be co-located and the premises are not big enough to accommodate the full staffing requirements and aspirations of the new model.
The Project Team has therefore reviewed other potential properties in Prestatyn that may be suitable.
As a result, a formal expression of interest subject to contract and without prejudice has been sent to Denbighshire LA for potentially leasing the ‘Ty Nant’ building in Prestatyn.
This is a modern building in a central location which would be able to accommodate the core services in the new model, the key teams and community based staff. Enabling works would need to be undertaken and estates colleagues are currently developing the detail of this, with initial estimates being no more than £500K, depending on the final agreed requirements.
It is recognised that for the initial 9-12months the current main surgery would need to be leased.
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In relation to other premises, the Project Team is reviewing the use of the community clinic in Prestatyn with the view of moving those services into the main building. This building would then either be used to house ‘The Academy’ or revenue release to identify an alternative building. Subject to necessary agreements the Project Team is also pursuing leases on the two branch surgeries and Seabank surgery. The use of these buildings will be reviewed on an ongoing basis as part of the project evaluation process of introducing the new model of care in Prestatyn. In summary the Board is asked to approve the progression of following lease arrangements:
• Seabank Surgery • Meliden Surgery (Branch) • Ffynongroew Surgery (Branch) • Prestatyn (Central) Surgery (prior to relocating to new premises if secured) • Ty Nant (proposed new facility)
It is recognised that not all of these arrangements are ideal however given the constraints imposed by the notice period to the current contracts and subsequent project timescales, they are recommended as the most appropriate way forward to support the delivery of the new model of care as well as respond to the access needs of the practice populations.
2.5.5 Management
As a managed practice, the management requirements to support primary care services in Prestatyn will be embedded in the Central Area structure. The development of a robust management structure to support the day-to-day operational delivery of services in Prestatyn as well as the ongoing implementation of the new model of care is critical. The Project Team has drafted a management proposal which ensures both. The draft structure is outlined below and links to the Area Leadership Team. The Business Manager will be responsible for the running of the Practice across four sites. The Head of Clinical Services (identified from one of the appointed clinical professionals) will be responsible for overseeing the clinical care within service, ensuring it is of a high quality, and will provide first-line clinical leadership support to the Clinical Governance Manager, Service Redesign Lead, the Key Team Leaders, and the Same Day Service & Nursing Lead. Work is progressing to develop this management structure, to ensure lines of accountability which are clear and transparent.
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2.6 Areas Affected by the Proposal, Inter -dependencies
The successful development and delivery of this proposal links very closely with the development of a Primary Care Strategy for North Wales and will inform this work going forward. There is also a clear link and inter-dependency to key priorities within the needs assessment work undertaken to support the development of the Health Boards’ Integrated Medium Term Plan. These include, reducing health inequalities by ensuring the best start in life, heart disease, cancers, respiratory disease, smoking, obesity, alcohol, vaccination and immunisation, mental health & wellbeing and frailty. In relation to service delivery, the model is very much focused upon a multidisciplinary approach, as well as developing more service provision out of hospital settings. This will require close working with community nursing services as well as professionals already working within the Health Board, such chronic disease nurses, CPNs and palliative care nurses, and will demonstrate a strategic shift of resources into a community setting.
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In addition, several primary care developments are currently being implemented across the Area and Health Board funded by Welsh Government as part of their investment in primary care. These include support for Practice Nurse development, extended scope physiotherapists, pharmacists and audiologists and further expansion of telehealth. As part of the North Denbighshire Cluster, it has therefore been assumed that a proportion of these new services and staff will be supporting patients in Prestatyn.
2.7 Milestones Key milestones to ensure the delivery of a primary care service in Prestatyn on 1st April are as follows:
• Approval of Business Case – January 2016 • Securing appropriate premises – January 2016 • Recruitment of staff – March 2016 • Transfer of current practice staff – 1st April 2016 • Transfer of assets – 1st April 2016 • Provision of core primary care services – 1st April 2016 • Provision of ‘Same Day Service’ and Key Teams (Elective Care) – April to June
2016 • Delivery of operational adjustments and processes – January to April 2016
Further estimated milestones for the continued development of the model after 1st April:
• Transfer of IT systems – October 2016 • Development of Domiciliary and Care Home support – October 2016 • Relocation to new premises (if secured) – January 2017 • Formal launch of ‘The Academy’ – January 2017
3. Formulation and Short -listing of Options 3.1 Overview of Option
As described above the preferred option is that of a Health Board Managed solution to provide a contemporary model of primary care – ‘ Healthy Prestatyn Iach’.
3.2 Benefits of the Option The overarching benefit of this option is that as a managed solution it provides the opportunity to develop a model of care that is adaptable and innovative, and is not constrained by a national contracting framework. The model will provide local evidence and learning that will be vital in strategic delivery of primary care to ensure it is sustainable and best meets the changing needs of the population. The Welsh Government gives three priorities in providing additional investment for primary care:
• Achieving service sustainability;
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• Improving access; • Moving services out of hospitals into community settings.
These priorities are addressed by this proposal. This model is also designed to benefit patients, the public and staff:
• by best meeting the primary health care needs of the identified community; • by contributing to the sustainability of primary care services for the population
and visitors of North Wales, ensuring equity of provision to those in greatest need;
• establishing a primary care provider model as an alternative to the traditional GMS model which could be mobilised and implemented;
• to provide an immediate and longer term alternative to directly managing Practices where one or more Practices collapse, putting overwhelming pressure on neighbouring Practices;
• to make access to services easier, faster and more efficient for patients; • to enable closer working and/or integration with other members of the primary
care team such as district nurses, community pharmacists and Allied Health Professionals;
• to increase integration with social care and community wellness services; • to facilitate the development of new roles, such as navigators and behavioural
health therapists As a result, the following measurable benefits have therefore been identified: 1. The service model is agreed by key stakeholders; 2. Availability of core services at least equivalent to previous GMS services; 3. Maintenance or improvement in quality measures (using QoF, Clinical Governance
Practice Self Assessment and eventually the national Primary Care measures 2016/17 and indicators developed by the national Pacesetter evaluation);
4. Improvements in recruitment/ retention and diversification across all staff groups; 5. Evidence of further integration with social care (qualitative and quantitative
indicators); 6. Evidence of further integration with wellness services (social prescribing use and
uptake, number of contacts with services, patient and staff knowledge); 7. Improvements to patient outcomes ( e.g. adverse events, cancer stage of diagnosis,
self management of long term conditions, health behaviour change, breastfeeding rates);
8. Improvements in medicines management (e.g. antimicrobial and antidepressant prescribing);
9. Evidence of increased patient and public participation in self care and co-production; 10. Patient and staff satisfaction, with the development of innovative, proactive ways of
gathering feedback, as well as reviewing concerns and compliments, surveys, measures of shared decision-making;
11. Improvements or maintenance in performance of Welsh Government Tier 1 targets of relevance (e.g. vaccination programs, readmission of patients with chronic
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conditions, unscheduled care attendance/admissions at Emergency Departments and GP out of hours services);
12. Team development and workforce measures which are qualitative and quantitative: mandatory and other training, staff competencies, sickness absence;
13. Dissemination of learning supported by quantitative and qualitative measures (eg number of events, interactions, publications, feedback).
3.3 Options Appraisa l 3.3.1 Criteria for Assessing the Option
High level option appraisal criteria linked to the seven Strategic Goals of the Health Board (see Appendix 2) were developed to review the initial four options outlined in section 2.5, again noting that a ‘Do Nothing’ option was not available as the current providers had served notice on the contract to deliver services and an alternative has to be identified. In considering the options against these and reviewing all stakeholder comments, concerns and ideas to date, the following conclusions were reached:
Option Comments/Conclusions 1 To re-commission a service
using the GMS Contract by advertising for a new partnership of GPs to take over the resigning contracts.
Both practices have had difficulty in recruiting new GPs which has contributed to their decisions to serve notice. It is unlikely that the Health Board would be able to secure a new GMS contract holder/GP partnership by the 1st April 2016 and as such both practices would need to revert to being managed by the Health Board on the 1st April 2016. This would require ongoing management (“caretaking”) of the Practices until a new contract holder could be secured. Whilst the GMS contract is able to ensure the delivery of safe services, and is well embedded in the delivery of care in the Cluster, it does present a level of inflexibility to adapt to changing needs and develop different approaches to meeting those needs.
2 To appoint an Alternative Provider of Medical Services (APMS) contract
This is an option that is utilised in England but no such contracts are currently awarded in Wales. It is felt that pursuing this as an option would therefore be extremely challenging and present a significant risk in terms of achieving a feasible solution by the end of March 2016.
3 To implement a long -term Health Board managed service
The Health Board has some experience of managing Practices. There are currently 3 such practices in North Wales. This option would allow the development of a service model which could be better adapted to meet the needs and concerns of the local population. It has the
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flexibility to extend opening times and support to the out of hours service and Emergency Departments to reduce unnecessary demand. It would also provide an option for GPs to be employed by the Health Board rather than working within a partnership of independent providers. This option does not preclude the Health Board from transferring the practice(s) to a GMS or APMS status at a later date. Nevertheless adoption of a Health Board managed service must be planned as being long term in order to bring about, capitalise upon, and then ‘normalise’ a change in approach.
4 To disperse the patient list of the two practices across other local GP practices
It is highly likely that dispersal of over 20,000 patients would compromise the ability of other GP practices within the cluster to cope, and would most certainly result in sustainability difficulties for the remaining GMS practices in the local area. A request has been made by some local GPs for the Health Board to consider a partial dispersal, whereby up to a fifth of the lists is dispersed, with the remnant being managed as a Health Board practice. The practicalities of this to administer with regard to identifying who should be dispersed, the potential need for consultation on such an exercise and acceptability to patients is of some concern. It has also been advised that there would be additional TUPE implications.
3.3.2 Selection of Preferred Option
Given the information provided, the Health Board approved the recommendation that a long-term Health Board Managed Service should be pursued at their meeting held on 10th November. This option was felt to be the most deliverable in the timescale as well as provide the most flexibility in developing a new model of care.
3.4 Cost & Resource information for the Option 3.4.1 Recurring Costs
The full recurring costs of the preferred option for a new model of care in Prestatyn are detailed below, with staffing costs shown at top incremental point and mid incremental point: Costs (with staffing at
top increment) £ Costs (with staffing at mid increment) £
Notes: 1) Staffing costs also include a level of cover for annual leave and sickness 2) The staffing levels will be reviewed on a rolling basis to ensure that they are fit for purpose as the new model matures and becomes embedded. 3) Premises costs, including service costs, are estimated until lease agreements are confirmed
3.4.2 Transition Costs As will all service changes, and particularly one of this nature, there are inevitably set-up costs and transition costs to establishing the preferred option. These are summarised as follows: £ Notes Staffing Variance 61,655 Managed through ‘natural
wastage’ and affordability (noting top increment assumptions made in costing)
Asset transfer 10,000 Current estimate based on other managed practices. Cost could be managed in 2015/16.
Potential lease of surplus premises to allow for adaptation works and associated legal, surveyors and valuers fees in connection with the leases
65,000 Current estimate at full year cost – to allow enabling works to new premises.
Total revenue transitional costs
136,655 Affordable noting top increment assumption of staff would not be required in year one.
Premises adaptations etc (capital) No more than 500K
Initial estimate, to be confirmed, depending on final requirements
Total capital costs
No more than 500K
Initial estimate (see assumptions in section 3.5 & 6)
3.5 Key Assumptions and Dependencies of the Option The following assumptions have been made at this stage, noting that over the coming weeks these will become known:
• the ability to secure appropriate premises, including the associated costs; • the ability to recruit to all staffing groups; • the terms and conditions of salaried GPs can be agreed; • robust project management capacity.
The proposal is dependent on Board approval.
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4. The Financial Case 4.1 Financial affordability test
The income and current budgets available to deliver the preferred option total £2,886,921. This includes a share of the new monies made available by Welsh Government to support primary care services (£143,008). This has been calculated in relation to the size of the population being served; primary care services across the Area will be therefore also be supported with this new investment. As this will be common across primary care practices in the Area, is outside the services provided by the GMS contract and not yet fully implemented this has been excluded in the financial information below to ensure consistency.
4.2 Value for money test The full costs for the new model are estimated to be £84k higher than the current amount spent. However, as noted, the staffing requirements have been costed at top increment and it is known that the proposed staffing structure is higher than most current staff and this will be reviewed over time. The current average cost per patient in North Wales for a non dispensing practice funded from GMS is £123. The current combined cost for Pendyffryn and Seabank is £127 per patient. In North Wales, other managed practices which have provided a more traditional model of service provision are currently costing between £151 to £162 per patient. This higher cost mainly relates to the need to utilise locum doctors. The new model equates to £128 per patient for core service provision (at mid incremental point). It is planned that over a period of three years through constantly monitoring the workforce plan as the service model is embedded, and also the opportunities for improvements to be made in prescribing efficiencies and effectiveness, there is confidence that the cost per patient will be reduced down to the average for GMS practices. Recruitment and retention of medical staff within the existing practices has proven challenging and has made it difficult for the Pharmacy & Medicines Management team and the prescribers to manage the cost of prescribing at an optimum level. This is evident when benchmarking the cost of prescribing per adjusted patient number “£/Astro pu” of Pendyffryn Medical Group against another large practice with in the cluster. This difference is less marked for the Seabank Surgery. Benchmarking shows that if the prescribing costs associated with PMG were to be reduced to this level there is potential to release £150k in prescribing budget. This would take up to 12 months to realise as the medication processes and reviews are undertaken. There is potential to release further prescribing savings as social prescribing is embedded as part of the new model of care, reducing dependence on medications in the management of both acute and long term conditions. In conclusion it is recognised that bringing together the two practices and developing an
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innovative, new model of care requires, in the short term additional costs which can be reduced over the medium term. Recurring funding of £2.53m, based upon the average cost per patient in North Wales for a non dispensing practice of £123 is required. There will also be a requirement to provide non recurrent support of £109,639 per annum for 3 years to address the short term additional costs. The financial benefits in other parts of the NHS system in North Wales will also be monitored in relation to the quality benefits outlined in section 3.2.
4.3 Financial risk assessment and sensitivity analysi s The majority of the recurring costs are associated with staff. When costed at top increment, the total recurring revenue costs are slightly higher than current costs, with a difference of £84,110. This can be managed to a balanced position due to variation in incremental payments, as staff transferring would not all be paid at top increment. Given the terms and conditions of the current practice staff it is felt that a more realistic position for the initial recurring costs would be at mid-point increment. This would provide a notional surplus of £100,966 which would support the transition costs incurred in 2016/17. In addition it provides an allowance for revisiting staffing establishments and skill mix if activity and demand estimates are under-estimated. It should be noted that costs relating to premises (both revenue and capital) are currently based on estimates.
5. Project Management 5.1 Governance
Robust project management arrangements have been put in place to develop and deliver this proposal. A Project Initiation Document has been produced which outlines the aims of project, and includes Terms of Reference for both the Project Board and Project Team. The Project Board is chaired by the Central Area Director and now meets fortnightly, alternating with the Project Team, chaired by the Central Assistant Area Director Primary Care. The Clinical Lead is the Area Medical Director. A project office has been established in Rhyl and additional project capacity is being secured. In addition support is required from corporate departments, including Estates & Facilities, Finance, Communications and Workforce. The Project Board is accountable to the Chief Operating Officer, reporting to the Executive Management Group.
5.2 Project Plan – Implementatio n Timeline A web based project management system is being utilised with a detailed Gantt Chart, along with a risk log; both are reviewed at every project board meeting. As detailed above the Health Board must ensure service provision continues after the
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1st April 2016. The development of the new service model is exciting but challenging and it is recognised that not all elements will be in place from the first day. It is proposed that as a minimum the ‘Same Day Service’ and Key Teams for planned care will be established with the Domiciliary and Care Home Support Service and ‘The Academy’ developing later in the year.
5.3 Review of implications of Rhuddlan Surgery Resignation Since undertaking the detailed work to develop this business case, the GP in Rhuddlan has given notice to the Health Board that she too will be terminating her contract on the 31st March 2016. This notification was received on the 14th December 2015. Rhuddlan Surgery is a single-handed GMS practice with a practice population of just under 2000. Consideration as to how best meet the needs of her practice population is being undertaken, again with various options available. During January the Area Team will work closely with the neighbouring practices and other stakeholders to determine the possible option. One of the options which will be considered will be to bring the service re-provision into the ‘Healthy Prestatyn Iach’ proposal. If this was to be the case the workforce plan would be adjusted to reflect the increased demand along with the detail within this business case.
6. Critical Assumptions, Risk and Issues In developing this business case the following assumptions have been made: • Ability to secure suitable premises to deliver the new model of care • Ability to recruit to key professional groups without a requirement for locum/bank
cover • Initial estimated costs for enabling works to new premises
In addition a risk log has been developed which is reviewed by the Project Team and Project Board at every meeting. The more significant risks align with the assumptions above in relation to workforce capacity and recruitment and securing appropriate premises. These risks are being actively managed with a range of mitigating actions identified. The current high risks are as follows:
• Lack of project management capacity to ensure the implementation of the proposal
is successful • Inability to recruit staff within the required timescales • Inability to confirm terms and conditions of salaried GPs • Inability to secure suitable premises
These risks are actively being managed by the Project Board and will continue to be highlighted to the Executive Management Group to ongoing mitigating actions as required. The provision of primary care services in Prestatyn is included on the Central Area Risk Register and a submission is to be made for inclusion on the corporate risk register.
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7. Conclusions and Recommendations This is an ambitious and exciting proposal. Whilst it provides reassurances about the deliverability of primary care services in Prestatyn from the 1st April, it will also provide wider learning to support the future provision of a sustainable primary care service. The Project Board recommend:
• ‘Healthy Prestatyn Iach’ is implemented in line with the milestones outlined in this business case;
• A recurring budget of £2.64m is provided from April 2016 which will be subject to efficiency reviews as the model is embedded and reduces to £2.53m (equating to the North Wales average cost per patient by April 2019);
• Premises are secured, with leases appropriately negotiated as outlined in section 2.5.4;
• Project management arrangements continue for a further two years to ensure full delivery of the model and robust evaluation, as well as shared learning across the three Area Teams and Health Boards across Wales.
8. Project Evaluation 8.1 Monitoring of Project Progress
Project management arrangements will continue for an estimated 2 year period to develop and embed the new model of care.
8.2 Post Project Evaluation
Project evaluation will be continuous during this period, monitoring progress with implementation and user feedback, as well as agreeing changes to continually improve. The proposed benefits will also be monitored, with the development of outcome measures. Academic support to undertake the evaluation will be sort. The budget for the services will be monitored and reviewed regularly to ensure appropriate financial controls and also demonstrate value for money.
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APPENDIX 1 – Patients registered with PMG
APPENDIX 1 – Patients registered with Seabank Surge ry
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APPENDIX 1 – Location of GP Practices & Branch Surg eries in North Denbighshire
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APPENDIX 2 – SUMMARY OF CLINICAL WORKFORCE GROUPS
Professional group Role Current wte Revised wte Nursing ANPs
Therapy Services Extended Scope Physiotherapists Occupational Therapists Allied Healthcare Professional for home care
0.00 0.00 0.00
1.00 4.00 1.00
It should be noted that there will also be access to other healthcare professionals already employed by the Health Board to provide specialist input and support.
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APPENDIX 3 – Appraisal Criteria
STRATEGIC GOAL
APPRAISAL CRITERIA
We will improve the health of our population, with particular focus upon the most vulnerable in our so ciety
• Strategic Goal 1: Improve health and wellbeing for all and reduce health inequalities
• Promotes and supports preventative health care
We will do this by developing an integrated health service which provides excellent care delivered in partnerships with the public and
other statutory and third sector organisations
• Strategic Goal 2: Work in partnership to deliver more care closer to home
• Improves access to unscheduled care
• Strategic Goal 3: Improve the safety and outcomes of care to match the NHS’ best
• Supports the development of non-medicalised care • Be safe and of acceptable quality • Reduce the risk to primary care sustainability in the Cluster
• Strategic Goal 4: Respect individuals and maintain dignity in care
• Better addresses the needs of a high population of elderly patients
• Strategic Goal 5: Listen to and learn from the experiences of individuals
• Promotes and progresses cluster working • Acceptable to the public • Acceptable to staff • Acceptable to the Cluster • Improve public confidence in healthcare delivery in North Wales
• Strategic Goal 6: Use resources wisely, transforming services through innovation
and research
• Demonstrates and delivers prudent healthcare • Supports the development of non-medicalised care • Demonstrates innovation and transferrable learning • Delivers an economically sound solution
We will develop our workforce so that it has the ri ght skills and operates in a research-rich learning culture
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• Strategic Goal 7: Support, train and develop our staff to excel
• Supports skill-mix modernisation • Revitalises recruitment in primary care • Provides support and training of individuals
Establishment of new service provider(s)
• Be deliverable by 1st April 2016 • Be scalable for the next 10years
