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1 North Hampshire Clinical Commissioning Group Primary Care Strategy 2016 to 2020
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North Hampshire Clinical Commissioning Group
Primary Care Strategy
2016 to 2020
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Document Version Control
Document Title : North Hampshire Clinical Commissioning Group
Primary Care Strategy
Ref: FINAL DRAFT v 3
Date: 31.10.16
Programme: Primary Care Development – Integration and Transformation
Authors: Rebecca Thornley and Dr Richard Coppin (Clinical lead for Integration and Transformation)
Programme Manager: May 2016 to September 2016 - Rebecca Thornley; Interim Head of Primary Care Strategy
from 1st October 2016 Sharon Martin, Associate Director of Primary Care
Senior Responsible Owner:
Zara Hyde-Peters - Director of Integration and Transformation
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Contents Page
Table of Contents 1 Executive Summary ...................................................................................................................................................................... 5
2 Our CCG vision for health and wellbeing in North Hampshire ....................................................................................................... 6
2.1 Introduction ............................................................................................................................................................................ 7
2.2 Primary Care Strategy ........................................................................................................................................................... 8
2.3 Who we serve - the North Hampshire Population .................................................................................................................. 9
2.4 Primary Care in North Hampshire ........................................................................................................................................ 12
3 Setting our Strategic Direction ..................................................................................................................................................... 18
3.1 GP Away Day – priorities for primary care providers ............................................................................................................ 20
3.2 Feedback from North Hampshire practice visits ................................................................................................................... 21
3.3 Stakeholder workshop feedback – 4 August 2016 ............................................................................................................... 22
4 National and regional policy drivers............................................................................................................................................. 24
4.1 Delivering ambitions against the Five Year Forward View .................................................................................................... 24
4.2 The General Practice Forward View and Joint Commissioning with NHS England .............................................................. 25
5 Establishing the primary care vision for North Hampshire ........................................................................................................... 29
6 Primary Care System Enablers ................................................................................................................................................... 39
7 Primary Care Transformation Enablers ....................................................................................................................................... 40
7.1 Key User Groups ................................................................................................................................................................. 41
7.2 People with Mental Health and Learning Disabilities ............................................................................................................ 41
7.3 Children’s Service Commissioning ....................................................................................................................................... 43
7.4 Older people’s services and frailty pathway supporting the primary care system ................................................................. 45
7.5 Examples of support being provided to deliver primary care to vulnerable groups ............................................................... 46
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8 Primary Care Services ................................................................................................................................................................ 49
8.1 Pharmacy - Medicines Management .................................................................................................................................... 49
9 What does good Primary Care look like ...................................................................................................................................... 51
10 Governance supporting the primary care strategic plan ........................................................................................................... 58
11 Appendices ............................................................................................................................................................................. 60
Glossary of Terms
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Primary Care Strategy for North Hampshire
1 Executive Summary North Hampshire CCG made a commitment in its April 2016 operational plan1 to facilitate secondary, primary, community and social
care in working actively together to deliver accessible, proactive and coordinated care. Key to this, as championed through both the
Five Year Forward View2 and the General Practice Forward View3 is to put primary care at the very forefront of service redesign and
transformation, using the innovative commissioning of services to impact positively on the wider health and social care system. This
is also a key ambition of the Hampshire and Isle of Wight STP and the Better Local Care Multi-specialty Community Provider (MCP).
The CCG Governing Body has taken time to invest in a local strategic plan for primary care which meets the specific needs of our
local population – working with our public health colleagues, service providers and patients to determine the current and future need
and to plan for the changes in population and workforce that are likely to arise.
To facilitate the process the CCG has actively engaged with key stakeholders to develop a series of strategic questions and themes
which determine our primary care priorities. Setting clear objectives and measurable outcomes against these priorities and
identifying the gaps through our work programme “Primary care in Action” we will support our GP practices to ensure that patients
continue to receive the very highest quality of service and patient experience.
Together with our partners from the wider health and social care system we will work to develop a sustainable, patient-centred care model that provides equitable access for all.
1 NHS North Hampshire CCG Operating Plan 2016-2017
2 https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
3 https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf ·
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2 Our CCG vision for health and wellbeing in North Hampshire Our mission - To make a positive difference to the health and wellbeing of our population
Our vision - To deliver an excellent patient experience and clinical outcomes and to see a better integrated health and social care system for the future
This vision will be achieved by focusing on:
Better clinical outcomes
Improving patient experience
Reducing costs
Promoting partnership working
Changing the system to make it work better
Delivering care out of hospital where possible
Our values
“We are accountable for what we do. Quality is at the heart of our work. Each patient is at the centre of their own health. Meaningful and open engagement with our population is at the core of how we work. We make decisions using evidence, good practice and innovation. We will deliver financial sustainability and value for money”
Our behaviours “As a whole health and social care system we need to:
Listen and create a learning environment
Be driven, challenging, resilient and fair
Use the strengths and support of our clinical leadership
Work together with partners to create and deliver a shared vision
Promote positive relationships to achieve the best possible health outcomes
Use co-operation and competition appropriately
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2.1 Introduction
Our Primary care strategy explained
Our strategy is made up of an evolving set of choices and principles which enacted together will achieve equity across North
Hampshire enabling patients to receive accessible, highly effective, proactive, integrated and high quality primary care while building
on the core visions and goals of the CCG.
The strategy aims to enable primary care to:
Be proactive by promoting prevention, self-management and wellbeing, targeting those in greatest need while ensuring services to patients offer good value to the public purse and are resilient and sustainable
Be more accessible – improving access while delivering convenient and high quality primary care
Be co-ordinated - ensuring co-ordination of services around the individual patient, delivering best outcomes by improving integration of service delivery by all agencies (including the third sector) while providing care as close to the patient’s home as possible
This will be underpinned by a programme of transforming primary care. The plan sets out our long term goals, service and resource gaps and priorities to ensure primary care is both resilient and fully aligned with the wider health and social care system. The strategy supports communication of purpose, enables prioritisation and provides organisational direction for primary care. The strategy also provides a template to support the Hampshire and Isle of Wight sustainability and transformation plan (STP) ambitions, provides assurance to our joint commissioners from NHS England, works alongside the Better Local Care MCP and enables the securing of future investment for primary care services. We adopted the Monitor4 approach to strategic planning to frame, diagnose, forecast, develop the strategic questions and options and prioritise the services for North Hampshire5. The delivery will be through our primary care work programme and through the Better Local Care natural communities of care programme. We have also focused on primary medical care and to a lesser extent on community pharmacy (in respect of medicines management and locally commissioned services), but the importance of integrated working with other out of hospital services is a key theme – and it is anticipated that the CCG will be commissioning more services from dentistry, eye care and community pharmacy in time. For now the responsibility of managing dental, eye care and community pharmacy contracts lies with NHS England but we will work with NHS England to ensure all planning aligns to their priorities for these services.
4 Developing strategy - Gov.uk
5 Appendix 1
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2.2 Primary Care Strategy
Accessible care
rapid access, continuity of care, online services, out of core hours primary care together with capturing patient need and experience
Co-ordinated Care
Care planning and review, reducing hospital
admissions, care coordination,
multidisciplinary working, patients
supported to manage their own conditions
Proactive Care
Co-designing services with public health,
improving health litereacy, targeting the
unregistered population and the most needy
Transformed Care
enabling practices to lead new ways of working, innovate, be sustainable and deliver high quality out of hospital care
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2.3 Who we serve - the North Hampshire Population Working with the Hampshire County Council Lead for public health we have been able to summarise our demographic population from information contained in the North Hampshire Joint Strategic Needs Assessment (JSNA)6 and work currently being delivered to shape the public health and wellbeing strategy. The North Hampshire CCG population, compared to Hampshire is relatively young, with a higher proportion of people under the age of 16 and is expected to increase by 8.2% by 2021. The greatest increase is forecast to be in the over 85 year olds which is predicted to increase by 47.5% compared to a 26% increase across the County. People in North Hampshire remain in good health for longer compared to the rest of England. However this is beginning to change,
with a fall in healthy life expectancy being seen over the last three years. This means people are living in poorer health for longer
requiring increased use of health and social care services.7 We need to ensure that primary care facilitates a change to the way we
live, changing the approach from a sickness to wellness model that supports people to eat more healthily and be more active now, to
ensure they can remain independent, confident and living at home in the future.
Children and young people
For children, our CCG has significantly higher levels of emergency admissions and unplanned hospitalisations for children aged less than 19 years than the national rate8 requiring a proactive approach to supporting children and families to manage their health. A further issue for children is the levels of obesity (6.9% of reception year children and 15.25% of year 6 children). While this is significantly better when compared to the rest of England9 it is still high and will impact on poor long term health, this requires concerted efforts to reduce. Deprivation While the CCG has a low overall level of deprivation when compared to England, small pockets of deprivation exist in communities across the CCG area, affecting a substantial number of people who are consequently likely to have poorer health. We will focus our attention on these people and populations where there is most need. Causes of premature death
6 http://www3.hants.gov.uk/factsandfigures/jsna/jsna-2013.htm
7 (source: NH CCG JSNA 2015)
8 (source: NH CCG JSNA 2015)
9 (Source: Hampshire County Council Public Health NCMP Data Pack 2015).
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For adults in North Hampshire, the main causes of premature death are cancer, heart disease and respiratory disease. A priority
area of focus is improving diabetic control. In addition, the plateauing levels of cancer mortality require a renewed focus on
improving early diagnosis, robust care planning and screening uptake.
Older people
For older people, the prevalence of dementia in North Hampshire is significantly higher than England10 and this number is predicted to increase 23% in the over 65s between 2014 and 202011. Supporting these people needs a coordinated approach with health, social care and voluntary sector partners. Health and wellbeing priorities To improve the health of the population we need to focus on:
Smoking - the estimated proportion of adults to be currently smoking is 16.7 %12. It is worth noting that the estimated figure in Basingstoke and Deane has increased bucking national trends.
Obesity - It is estimated 63.4%13 of the adult population in are classified as overweight or obese which will impact on diabetes prevalence in the future
Alcohol misuse - 19% of the population are identified as binge drinkers 14 which will impact on liver disease, cancer and emergency admissions.
Work on improving lifestyles (prevention of disease) will be most effective in primary care if a focus is given to those with long term conditions who will often create the greatest system pressure and experience more complications as a result of their condition. The focus will be on ensuring that they receive interventions to help them make positive lifestyle choices and self-manage their conditions for better health outcomes. To provide active support the CCG and public health will work together to enable all primary care professionals to be trained in healthy conversations and to actively empower people to take control of their health and to make healthy choices. Focused work is needed with different groups of people with poorer mental health to understand better the lack of access to current services, particularly primary care, and to co-design these services to improve accessibility.
10
(Source: NH CCG JSNA 2015) 11
(Source: POPPI) 12
(Source: Quit for Life) 13
(Source: Active People Survey via PHE, 2012/13) 14
(Source: Health Survey for England via PHE, 2007/08)
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People with poorer mental health are also at significant risk of social isolation. In those with serious mental illness there are higher levels of preventable mortality (under 75 years)15. Again a focus on lifestyles and health checks is vital to support behaviour change.
Children • Higher levels of emergency admissions and unplanned hospitalisation for under 19 years than the national rate.
• Require proactive approach to support children and families manage their health • High levels of obesity - 6.9% of reception year children and 15.25% of year 6 children impacting on
long term poor health
Adults • Main causes of premature death are cancer, heart disease and respiratory disease. • Key area of focus is improving diabetic control • Plateauing levels of cancer mortality requires a renewed focus on improving early diagnosis and
screening uptake.
Older People • The prevalence of dementia in North Hampshire is significantly higher for than England and the number is set to increase by 23% in the over 65s between 2015 and 2020. Preventing and supporting these people needs a co-ordinated approach with health, social care and the voluntary sector.
15
(source: NH CCG JSNA 2015)
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2.4 Primary Care in North Hampshire We cannot underestimate the value that primary care provides to our patient population. National figures tell us that in England, 90% of our health care service provision takes place in primary care for only 8% of the cost with a turnover of over 20 million patients per year16. Increasing demand on the primary care health system is putting the traditional model of general practice under increasing pressure with the need for primary care service providers to embrace change if it is to be resilient. . GP practices in North Hampshire North Hampshire CCG currently hosts 19 GP practices17 all of which are constituent members of the CCG. The practices are all independent primary care service providers who hold a mix of general medical service (GMS), personal medical service (PMS) and alternative medical service provider (APMS) contracts. These contracts are jointly commissioned by NHS England and the CCG. Our PMS practices are currently undergoing contractual reviews by NHS England and North Hampshire CCG to ensure equity of financial investment for all. The practices are also contracted to provide public health services from Hampshire County Council, local priority services for the CCG and some deliver enhanced services through the GP federation (North Hampshire Alliance). All practices belong to the North Hampshire Alliance which works to support practice resilience through delivering services at scale – aligned to the Better Local Care multi-speciality community provider (MCP) ambitions.
To support multidisciplinary team working and new models of care, the practices have been divided into four areas which are served by the four integrated care teams. These teams are made up of specialist community nursing and therapists working alingside OPMH and Adult Social Care. Each team is allocated to nominated practices to provide response support to prevent a hospital admission or to support early discharge from hospital. They facilitate a range of health and personal care interventions to be put in place quickly. Some interventions require specialist input from our acute hospital providers and community care which the ICT teams co-ordinate. The ICTs are defined as:
• Basingstoke East (located at Parklands in Basingstoke)
• Basingstoke West (again located in Parklands, Basingstoke)
• North Hampshire Rural East (located in Alton Community Hospital, Alton village)
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RCGP 2016 17
See Appendix 2 – Constituent GP Practices including list sizes as of 1.9.16 – information updated from individual practdeliverice websites 30.8.16
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• North Hampshire Rural West (Located in Tadley Village)
This model will be closely aligned to the Better Local Care MCP supporting the development of natural communities of care which will further support practice resilience and out of hospital working.
Service delivery All GP contracts require practices to deliver primary care from 8.00 am until 6.30 pm from Monday to Friday (excluding bank holidays). GP practices can also deliver additional extended hours as part of the directed enhanced services (DES) via NHS England meaning they open on Saturday mornings or evenings but this is optional. Out of area patients can be seen by the practices but the majority of GP services within North Hampshire are serving the residents of North Hampshire. GP practices are also required to provide emergency and immediately necessary treatment to anyone, whether or not they are registered with the GP practice. For the most part, patients must book an appointment to see a GP or practice nurse, although the process for managing appointments differs from practice to practice and there is no national requirement to standardise this. However in North Hampshire all practices are now on the same clinical system (EMIS) and are developing data sharing agreements to enable clinical records to be shared across the CCG area and with other service providers such as community services, facilitating new models of working. Primary care infrastructure In terms of primary care estate, there is a mix of owned and leased property which is outlined in the North Hampshire CCG Estate Strategy. There are funds to support estate development where there are growth areas and service transformation needs and local infrastructure funds for local improvement schemes. Practices are supported with their clinical systems, information and technology requirements etc through the prioritisation process outlined in the CCGs IM&T strategy. This is resources through the Estate and Technology Transformation Fund (ETTF)18 which provides investment for both estate and information and technology development working towards the aims of the NHS Digital Roadmap for one single patient record. Primary care funding As of June 2016, the Joint Primary Care Committee reported total budget for primary medical services for North Hampshire CCG of £26,613,000.00. This budget includes GMS, PMS and APMS contracts, QOF; direct enhanced services, premises, and additional contingency funding. This does not include funding invested directly by the CCG for locally commissioned services or any transformational funding.
18
https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/05/ettf-guidance-may16.pdf
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Quality in primary care In terms of quality – the quality of primary care provision is generally very high with the average Quality and Outcomes (QOF) achievement by practices exceeding the England average and GP patient survey results higher than average for England. All practices are required to participate in a Care Quality Commission review – to date 60% of North Hampshire’s practices have been visited with the majority being good. However there have been a small number of practices who have required improvement and one that is currently in special measures due largely to practice resilience. The CCG is supporting this practice in partnership with NHS England and the Royal College of General Practitioners (RCGP) to address the challenges through a shared action plan. Practice profiling The CCG is working with NHS England, the Commissioning Support Unit (CSU) analytics team and the CCG quality team to develop a primary care profile which will support both practice development and quality assurance. This will enable us to target support as well as enable the sharing of best practice. The work builds on the NHS England dashboard which currently comprises of QOF prevalence and achievement, screening and immunisation uptake rates, A&E attendances, prescribing, non-elective admissions and national survey results but we will use soft intelligence to further strengthen the profiles – which practices can also use internally to promote and develop their individual primary care services. Urgent Care In terms of urgent care - primary care out of hours services are currently being provided by NHUC (North Hampshire Urgent Care) and NHS 111. NHUC delivers high quality out of hours provision, being staffed predominantly by local GPs and nurses – and it is this local insight which ensures that local care pathways and access to shared patient records strengthens the health outcomes being delivered. The CCG is reviewing with practices how urgent on the day primary care can be more effectively managed – ideally again at scale. Primary care working at scale National and regional policy advocates practices working collaboratively to support new models of healthcare. In North Hampshire GP practices have joined together to establish a legally binding company - the North Hampshire Alliance Ltd which developed from informal networks into one single provider network.
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This organisational form has enabled the delivery of services “at scale” across the CCG area and continues to develop. As a legal provider the NH Alliance is able to submit competitive tenders for new services as they are developed and members support each other in its delivery. Primary care workforce
One of the biggest challenges facing primary care locally is GP recruitment and retention. The Nuffield Trust reported in 2014 that over a third of GPs aged fewer than 50 is considering leaving general practice due to workload pressures19. Although our rural practices have more positive experiences of recruitment our town practices have particularly struggled. The CCG is working with Better Local Care to prioritise clinical leadership and resilience through a transformational programme of support, starting in the winter of 2016/17 with a view to widening support over the next two years. There is an increasing trend to part-time and salaried
working with 66% of GPs now working as partners compared to 79% in 200620
and these flexible working arrangements need to be supported both within practice and by the CCG. Federative and collaborative working and alignments to natural communities of care will work to address resilience challenges in partnership too with the LMC, Better Local Care MCP, Health
19
www.nuffieldtrust.org.uk/.../general_practice_in_crisis_3.pdf 20
www.bma.org.uk/.../contracts/gp-contracts...gps/focus-on-salaried-gps
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Education England and the Wessex Deanery. We have very high quality teaching practices that attract GP registrars and foundation year students both in urban and rural areas. Practice management The CCG are also working with practice managers through the practice manager shared forum with the CCG and the practice manager advisory group and we will be working with the Wessex LMC to support a regional practice management development programme in 2017. There is a practice management representative on the Joint Primary Care Commissioning Committee and practice managers attend CCG incentivised development sessions. Practice nurses are being supported through a quarterly network and we are looking to support their development through work with Primary Care Commissioning and the Queens Institute as well as Health Education England. Training and development There are several practices across North Hampshire who are registered with the Wessex Deanery to provide training and mentoring to medical students and GP registrars. They provide placements for foundation year medical students and host GP registrars. This has provided natural succession planning for many seeing trainee doctors return to North Hampshire as GP practice partners, salaried GPs, GP retainers and locum GPs. The CCG is working with GP representatives to shape a programme of clinical leadership in partnership with Better Local Care to further support the development of local GPs and practices. Practice nursing is also supported through the practice nursing forum but also formally through working with Health Education England and other partners to enable nurse mentoring, training and practice placement.
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Locally commissioned services from Primary Care In addition to the core services delivered through the nationally negotiated contract the CCG commissions additional local services from practices directly and through the North Hampshire Alliance – which include specialist service delivery out of hospital (gastrointestinal service, fexible sigmoidoscopy, urology and gynaecology) enabling care closer to people’s homes:-
Service Service Provider/Location of Service
North Hampshire
Alliance
Near Patient Testing All Practices
Phlebotomy All Practices
Anticoagulation Monitoring All Practices
RAS ENT Hampshire Hospitals Foundation Trust (HHFT)
RAS Dermatology Hampshire Hospitals Foundation Trust (HHFT)
Oakridge Nursing Home (Pilot) GP from Bramblys Grange
Tier 2
Upper Gastro Intestinal Service Tadley Medical Partnership
Flexible Sigmoidoscopy Tadley Medical Partnership
Urology Odiham Health Centre
Gynaecology Whitewater Health (Formerly Hook & Hartley Wintney)
Primary Care Services
Diabetes (Excluding Insulin Initiation) All Practices
Diabetes (Insulin Initiation) All Practices
Intra Uterine Systems (Non Contraceptive) All Practices
Extended Hours All Practices signed up to Wessex DES
Minor Injuries Wilson, Whitewater Health, Odiham, Chawton Park
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3 Setting our Strategic Direction Stakeholder Feedback – what do patients and service providers want from primary care?
Patients and their carers
What patients want to see from primary care has been shared via engagement sessions with patient participation groups, discussion
sessions at the CCG collaborative patient representative group, contribution from the Alton Patients Stakeholder Group and
information from earlier workshops and engagement sessions. In summary their priorities are:-
Effective
communication Good active
listening skills
Prompt and
appropriate
treatment
Responsive to all patients
and carers
Pro
vid
ing
cle
ar
info
rmat
ion
My Primary Care Service
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When asked about how patients want to be supported to keep healthy, manage complex and long term conditions and keep out of
hospital, the table below captures the priorities:-
Keeping Healthy
Managing complex needs
Keeping out of hospital
I can easily access the primary care services I need
I know how to access expert help from my practice without going to hospital
I am in hospital for the minimum time
I know how to care for myself and avoid being ill
I feel able to manage my complex needs in my own home
I only go to hospital when absolutely necessary
I feel supported by others to keep myself well
I know the main person in charge of my care and can go to them at any time with my questions
I can get all of my diagnostics and care interventions locally without having to go to hospital
I know how to access support from my GP practice and the wider community to access information (*Alton directory of care21)
I understand my medicines and the practice and/or pharmacy can answer my questions when I need them to
Everything I need is at home when I am discharged from hospital and my practice knows I am home
I feel supported to achieve my own individual health goals
My carer feels fully supported and fully understands my health needs
I have enough medication at home to stop me needing to go back into hospital
I feel part of my community
My records are available to any health professional and to me
There is a full care package at home so I can be discharged home safely
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Alton programme stakeholder group has produced a service directory which informs the community of the different services available including those provided by the voluntary sector – this is seen as an example of best practice and the CCG will look to work with the other ICT areas to develop a directory.
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Additional feedback from patients has been captured from the July 2016 GP patient survey results (Appendix 6) which prioritises
access, obtaining pre-bookable appointments, telephone access and opening hours as areas for review – although it should be noted
that the CCG practices score highly compared to the England average which is celebrated. We will work with the practice managers
to identify best practice and assess the stories behind some of the information checking its accuracy and providing support as
needed.
3.1 GP Away Day – priorities for primary care providers
At our GP away day on 13th April 2016, attendees from general practice including GPs, practice managers, practice nurses (see
Appendix 5) prioritised the following as reasons why transformational change is needed. These priorities were also reinforced at
subsequent practice visits, where general practice resilience was the main area of pressure needing change:
GP practice resilience – at a time when GP recruitment and retention is challenged, practices are overwhelmed with urgent on the
day primary care demand, financial investment is harder to sustain, more GPs are taking early retirement and more acute medicine is
being referred to primary care resilience support is needed. More investment in education, recruitment and communications will
further support resilience. Many reported that “headspace” is required to allow the opportunity to innovate but currently urgent on the
day demand for primary care access means there is little time for piloting new services. Robust contract management of acute and
community providers as well as GP practice will ensure that core acute and community work is not being pushed into primary care
without investing in workforce capacity to meet demand.
Stronger working relationships with the CCG – strengthening the partnership between the CCG and GP practices was also
identified as a priority – shaping the direction of primary care together – strengthening communication and reducing bureaucratic
processes were also priorities to strengthen collaboration.
Financial investment - Directing CCG allocated resources into primary care through reinvestment of QIPP savings to enable the
movement of care out of hospital into general practice was a key priority for all. The PMS review process had been challenging for
many practices in terms of financial viability and the incentive schemes need to be simple and not over demanding to achieve clear
outcomes.
Reducing unwanted variation – all agreed that the current service delivery across the CCG area is not consistent – and there are
gaps in service provision. Care needs to be targeted at the needy and vulnerable with a focus on supporting frailty at a time when
the ageing population of Basingstoke and the surrounding areas is set to increase by 46% over the next ten years.
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Supporting the prevention agenda – as outlined in the North Hampshire profile, prevention needs to be a priority in order to reduce
the health burden on the system in the coming years. Practices need more headspace and support to be able to dedicate time to
educate patients how to self-manage their care. With a 30% target over the next five years to reduce the burden on general practice
through self-management there is a lot of work to do between stakeholders to support living well.
Ensuring other providers deliver their contracting commitments to primary care – There were concerns that not all providers
are adhering to contractual obligations in terms of how they engage with primary care. There should be clear policies for onward
referrals for non-urgent related cases, discharge summaries should be provided within 24 hours and steps in care pathways
organised promptly. Operational priorities such as ensuring medication is supplied on discharge from hospital will ensure there are
fewer readmissions to hospital.
3.2 Feedback from North Hampshire practice visits
The CCG team worked closely with practice teams22 to understand what the local challenges and opportunities are for General
Practice. We were invited to attend some partnership meetings where GPs and managers were all agreed that they are no longer
able to deliver the same consistent levels of care now as they were a decade ago. Increasing demand means there is less protected
time or “headspace” to be able to deliver both urgent on the day care and focused targeted care for long term conditions
management and new services. This is also because funding in general practice has been reducing in real terms – with general
practice nationally now receiving just over 7% of the national budget compared with over 10% in 2006 while still working to deliver
the majority of NHS care.
What practices have told us they need to see:
An increase in investment – being able to see the investment pledges of national policy disseminated locally
Creation of headspace to be able to deliver innovative and new services as well as improve the quality of existing care
A focus on ensuring that acute and community care deliver against their contracts rather than pushing their work out to primary care
Increased opportunities to be able to innovate and develop new care models
A commitment to supporting recruitment and retention of new GPs and leadership development
Supportive profiling so that practices can understand clearly where improvements can be made and that this is supported
Investment in estate, technology, and workforce for all practices
Strong communication between practices and the CCG – reducing bureaucracy and strengthening leadership
22
See Appendix 4 Contributors to the Primary Care Strategy
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3.3 Stakeholder workshop feedback – 4 August 2016
Strategic themes
GP practice resilience – the first priority identified was to support practice resilience by addressing workforce stress, simplifying
administration processes, encouraging skill mixing, supporting patient education and activation, adopting the GP forward view
priorities and LMC programme for supporting resilience and developing the primary care workforce. Workforce development is key
to creating sustainable general practice and the CCG were encouraged to:
Promote a greater understanding of
generalist care and demonstrate its value
to the health service
Develop new GP-led integrated services to
deliver personalised, cost-effective care
Expand the capacity of the general practice
workforce to meet population and service
needs
Enhance the skills and flexibility of the
general practice workforce to provide
complex care
Support the organisational development of
natural communities of care which support
new care models
Introduce a North Hampshire Clinical
Leadership Programme to improve
effectiveness, knowledge, quality and
competence
Transforming GP delivery – transforming GP delivery will be achieved by improving access, including extending access over seven
days where needed by working at scale via primary care urgent care hubs. It was recognised that there are differences between
urban and rural communities and this should be assessed when redesigning services – including noting the preferences of
populations (ie Sunday afternoons may not be required out of central Basingstoke). Investment in skill mix and training is required to
support transformation. Operational priorities such as merging back office functions are a challenge that the NH Alliance is looking to
support. The CCG will need to work to ensure that clinical pathways are IT enabled and accessible to all providers as well as
primary care.
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Delivering excellent primary care – this will be achieved by focusing on patient centred health and social care outcomes,
supporting and assuring the quality of the workforce while rewarding success. A process of predicting risk and challenge rather than
being reactive will improve quality. Practice profiling and the establishment of a North Hampshire CCG dashboard will demonstrate
best practice which can be more widely adopted but also identify areas of challenge which can be supported. Patient and carer
experience should be captured and analysed to improve customer service and support service planning.
Patient focused care system – it was agreed that patients want to have a seamless service experience with named leads identified
to co-ordinate their care. Patient education including how to self-care should be actively promoted and invested together with social
prescribing – patient champions can help facilitate this process. Patient participation group engagement and identification of carers
is a priority. Service pathways and shared care protocols should be produced in language which patients can understand and
shared with them during their care journey.
CCG role in primary care – the CCG has a key role in engaging with practices and developing programmes that support clinical
leadership. Collaboration with the North Hampshire Alliance, Better Local Care MCP and North Hampshire Urgent Care will also
ensure that strategic plans and operational priorities are delivered. The CCG will be working more closely with its STP CCG partners
– in particular West Hampshire CCG addressing boundary issues and working together to deliver joint programmes such as the
Emergency Care Improvement Programme (ECIP) to support the urgent and emergency care systems.
Cultural change – It was appreciated by all that to fully engage in a cultural change programme resource needs to be developed
within the CCG to allow capacity to engage fully with primary care. This is already being done with a new team in place from 1st
October 2016 led by a substantive Associate Director of Primary Care. Stakeholders asked that we remove the current bureaucracy
and instead create more effective incentive schemes/programmes which support performance and attract new resources and skills.
We need to learn from past successes and develop a culture of leadership, learning and sharing of best practice.
Prevention agenda – Collaboration with public health will enable us to establish clear priorities and determine risk. Prevention
needs to inform pathway design applying upstream interventions for priority areas. There needs to be more focus on the vulnerable
ensuring there is equality and diversity assessments applied to primary care.
Integration of physical and mental health - Implementation of the ‘Futures in Mind’ programme for children and young people will
enable more integration together with a reduction in waiting times for Child and Adolescent Mental Health (CAMHs) services. We
need to achieve the IAPT access target from 15% of the current prevalence population to 25% by 2020/21. The delivery of the
mental health crisis care concordat will support integration and support community crisis initiatives. Maintaining and improving on the
67% diagnosis rate for dementia and improvement of post diagnostic services is a key target together with the delivery of the
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Transforming Care Programme (TCP) which aims to improve the care of people with learning disabilities The CCG will also proritise
working with providers and the CCG to improve mental health in the health service workplace.
4 National and regional policy drivers
4.1 Delivering ambitions against the Five Year Forward View
There have been significant policy drivers introduced in 2015/16 which have influenced the prioritisation process for primary care
commissioning and make the case for change. The October 2014 “Five Year Forward View” launched a “new deal for general
practice” which set central importance of the registered list and the importance of every person having access to a local family
doctor. It set out the investment plans that would be needed to support the growing demands on general practice and put the
emphasis of care out of hospital at the centre of the policy direction.
Key pledges in the “new deal for general practice”
Stabilise core funding for general practice over the next two years while reviewing fairer funding
Give CCGs more influence over the wider NHS budget – shifting care from acute to primary and community settings
Provide new funding to support access and new ways of working
Expand as fast as possible the number of GPs, community nurses and other primary care staff with returning and retention
schemes
Expand funding to upgrade infrastructure
Work with CCGs to design new incentives to encourage care in under-doctored areas and tackle health inequalities
Build public awareness around self-care and A&E avoidance
In addition to the development of GP federative working, strengthening provider networks and super partnerships the document
signposted to four new models of care (see Appendix ?)
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4.2 The General Practice Forward View and Joint Commissioning with NHS England
The General Practice Forward View was released in April 2016 and is clear recognition of the value of general practice for patients and the NHS. This sets down the following priority areas for review and investment which the CCG and primary care providers need to focus on to improve outcomes for all. These areas all align to the CCG’s vision for primary care:-
How the CCG, NHS England and our primary care providers have responded to this challenge can be seen in Appendix 8. A summary of our GP Forward View work programme in collaboration with NHS England aims to support excellence and sustainability in primary care. Joint Commissioning with NHS England Further collaboration with NHS England has been strengthened by the CCG Board’s decision to apply for Joint Commissioning of primary care which we have been delivering together since March 2016. This means that as commissioners we are not only responsible for commissioning secondary, community, mental health, children’s services, locally commissioned primary care and urgent care services but also nationally agreed services directly from general practice.
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This collaborative approach will serve as an enabler to strengthen existing quality standards, reduce variation, promote consistency of delivery and facilitate investment opportunities in primary care.
The CCG and NHS England will continue to work closely with Wessex LMC to ensure that we agree the most effective method of delivery, whether it be through GMS contracting approaches with individual practices, through commissioning directly with our evolving GP federation or through the development of new models of care which sees primary, acute and community services collaborating to deliver care as close to home as possible.
Joint Commissioning also means that North Hampshire CCG has more control of the wider NHS budget, enabling a shift of investments from acute to primary and community services. By aligning primary and secondary care commissioning, it also offers the opportunity to develop more affordable services through the financial efficiencies gained.
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Delivering the ambitions of the Sustainability and Transformation Plan (STP) In December 2015, the NHS Shared Planning Guidance 2016/2017 to 2020/2021 outlined a new approach to help ensure that health and care services are built around the needs of local populations. To do this, every health and care system in England will produce a multi-year Sustainability and Transformation Plan (STP), showing how local services will evolve and become sustainable over the next five years. This will enable delivery of the Five Year Forward View vision of better health, better patient care and improved NHS efficiency. The five CCGs delivering the STP for Hampshire and the Isle of Wight have put primary care as a central part of system delivery and again their priorities have been embedded into our local plans. These can be summarised as:-
Integrated systems of care based around New models of care
Delivering care around the person, as close to home as possible, including
shifting 30% of activity out of general practice to allow GPs to focus on high
impact activity
Delayering services
Reducing the non-beneficial steps that people go through in acute and
community settings
Radically upgrade prevention and intervention
Promoting self-management by developing the tech and workforce to support people to stay well for
longer
Primary Care at Scale By 2020/21 all GP practices across HIOW will be part of a NMC with
extended primary care teams.
Creating primary care capacity Working to shift 30% of activity
away from the GP via digital solutions to drive self-management, alternative professions and stopping
things that do not add value.
Support to vulnerable patients new models of care will ensure that all citizens with a mental
illness or learning disability have timely physical health checks to improve their overall health and
wellbeing
Targeted, integrated case management of long term conditions
Delivered via multidisciplinary team
input and provide crisis intervention for exacerbations and complex care needs,
providing alternative treatment locations in the community.
Personalised and detailed care programmes
Delivery of personalised care plans
for our patients with the most complex needs with a senior clinician providing overarching navigation on behalf of, and decision making with,
the patient
Delayed Transfers of Care
“Pulling” patients out of hospitals and support them in their own
homes, which in turn will reduce delayed transfers of care as part of
strong community based teams
Remote Consultation Infrastructure which supports remote
consultation; which will include people requiring long term follow up who will
be managed through digital patient triggered follow up programmes with
primary, community and acute clinicians all have a shared role.
Diagnostics
There will be an increase in direct access to protocol driven diagnostics.
Medicines Optimisation
New models of care will pursue evidence based medicines
optimisation to allow for more efficient and effective prescribing of medication utilising community
pharmacists.
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Creating natural communities of care through the Better Local Care Multi-specialist Community Provider (MCP) The Five Year Forward view introduced new models of care, part of which was the vision to see the establishment of multi-specialist community providers, or MCPs23. In North Hampshire the development of the MCP model is being championed through the Better Local Care MCP which will work in partnership with the CCG, NHS England, primary care providers and the wider health system to establish natural communities of care. For our area this is collaboration with Hampshire Hospitals Trust, Southern Health, North Hampshire Alliance and North Hampshire Urgent Care. What the evolving MCP hopes to achieve for the primary care system is summarised below:-
Joint partnership working NHS and care organisations primary
care, patients, third sector
Improving access to care – same day or urgent appointments at the
surgery
Patients with complex health problems getting more time with the GP
Joining up the professionals who support the same
people
Bringing specialist care nearer to the patient
Focus on prevention for health and wellbeing
Moving care out of hospital into the community
Patient engagement in designing local services
The CCG will be working with the regional MCP and the NH Alliance to introduce the Better Local Care model to all practices across North Hampshire providing awareness and engagement support through facilitated training sessions and through discussion with practices.
23
See Appendix 7 – Definitions of New Models of Care
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5 Establishing the primary care vision for North Hampshire
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• Self management programme
•social prescribing
•community health and wellbeing champions
•Public Health Strategy
•Communications portals in practice promoting health and
wellbeing
•Clinical leadership programme supporting change
•Incentivised service redesign
•Address quality and equity together
•Ensure sustainable general practice
•Better Local Care MCP - natural communities of care
- reducing admissions
•Integrated Care Team engagement
•Single patient record
•Frailty Pathway
•Addressing the needs of vulnerable patients
•Children's commissioning strategy
• Medicnes manageement plan
•Mental Health strategy
•IG sharing agreements
•GP practice resilience
•MDT working and Better Local Care MCP
•Access to GP appointments and 7 day working at scale
•IM&T development
•Estate investment
•Patient engagement with service design
•Practice Profile
•Effective Communication
Accessible care
rapid access, continuity of care, online services, out of core hours primary care together with capturing patient need and experience
Co-ordinated Care
Care planning and review, reducing hospital admissions, care
coordination, multidisciplinary working,
patients supported to manage their own
conditions
Proactive Care
Co-designing services with public health, improving
health litereacy, targeting the unregistered
population and most needy
Transforming Care
enabling practices to lead new ways of working, innovate, be sustainable and deliver high quality out of hospital care
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Accessible Care
Where we are now
Where do we want to get to
How do we get there
General Practice Resilience – GP Away Day, practice visits, practice management feedback and CQC and other outcomes demonstrate that several practices are challenged with increased demand, urgent in hours workload, recruitment challenges and income reduction (eg PMS review outcomes). Acute and Community are also directing more inappropriate work to primary care The expansion of Basingstoke is putting pressure on capacity in the Town with developments planned for rural areas in the borough council local plans.
Strong, sustainable practices that can successfully recruit to clinical vacancies and can meet increasing demand through planned and targeted investment. Practices will be able to manage services being moved out of hospital working seamlessly with other health and social care providers to enable early discharge and avoid repeat admission. Practices will be supported to expand where new communities are developing.
Work with NHS England, RCGP and the LMC and CQC to support the GP resilience programme. Develop primary care profiling to ensure workforce pressures are known and supported with targeted investment . Use resilience models (eg Tower Hamlets) to measure capacity and demand. Ensure through robust contract management that other providers are not passing inappropriate work to primary care. Use the estates strategy and investment fund to target areas of expansion to develop practice infrastructure to meet demand.
Multidisciplinary team working – patients and clinicians shared the need for more effective joined up working with one central record and plans in place to support care out of hospital.
Seamless patient health and social care involving clinicians and therapists from within the practice and linked services including acute specialists, social services, community nurses, mental health specialists, housing and finance advisors according to changing needs.
Regular multidisciplinary reviews that are incentivised together with the completion of shared care plans. Strengthening of current co-ordinated care registers. Development of shared care records across all disciplines as part of IM&T strategy.
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Access to GP appointments (i) Routine appointments
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Patients tell us from engagement and the GP survey that not all are able to access routine pre-bookable appointments when they need them (ii) Extended opening Hours Not all patients in North Hampshire can access appointments in the evening and at weekends (mainly Saturdays although there is some demand for Sundays (iii)Urgent on the day appointments Most practices are overwhelmed with demand for urgent on the day appointments and patients have fed back that they cannot always get them and therefore go to A&E or Out of Hours
Patients are able to pre-book appointments with their local practices between 8.30 am and 6.30 pm Monday to Friday and from 8.00 am until 12 noon on Saturdays All patients being able to access evening and weekend appointments in an area close to them See urgent care on the day appointments offered to all who need them while protecting practice resilience and releasing GPs and clinical leads to focus on more complex and specialist care
Work with practice managers to measure demand and capacity to address any gaps in provision and to work with the Alliance/OOH provider to identify ways in which pre-bookable Saturday appointments could be achieved at scale. Working with the NH Alliance, Out of Hours Provider and multidisciplinary community providers to assess demand and develop options around primary care hubs (virtual or physical) to offer extended access Working with a task and finish group and practices to address on the day urgent primary care, looking at “at scale” options which will address demand and create capacity for new models of working
Information and Technology Development - clear plans for primary care IM&T development including the delivery of the single patient record and improved infrastructure are all captured in the CCG IM&T strategy as part of the national digital roadmap programme.
Please see North Hampshire CCG IM&T strategy
Clear plan of delivery outlined in the CCG IM&T strategy
Primary Care Estate Investment – Practice and patient feedback prioritises investment in primary care estate to enable new models of care, meet increasing demand and improve quality
Please see CCG Estate Strategy
Estates and Technology Transformation bid highlights a Basingstoke Feasibility study to address needs for the expanding town and development to address rural expansion in Hook, Hartley Wintney.
Patient engagement with service design – Patient representatives feel disengaged with planning and shaping existing and new services.
Patient representatives actively engaged in contributing to service planning with patient champions leading on specific areas of service.
CCGs area patient participation group to actively support local PPGs to input into service redesign.
24
See Appendix 6 – Report from the GP Patient Survey July 2016
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Not all patient participation Groups (PPGs) input directly into primary care service redesign. Minority groups do not feel actively involved in shaping new and existing services to meet their needs.
Patient Participation Groups being actively involved in shaping local primary care services to meet unique local needs. Equality impact assessments completed for all service pathways.
Patient champions to be encouraged to actively work with clinical leads and managers to shape services. CCG managers to ensure that representatives from minority groups contribute to equality impact assessments for new service proposals.
Practice Profile – current profiles are limited to their content based on the NHS Dashboard and CQC outcomes – more valuable information exists which can be triangulated to create more robust profiles.
Full practice profile with accurate and timely data which the practices and CCG review together to identify opportunities for development but also champion best practice
Work with the quality team, NHS England, CQC reports, CSU and practice managers to produce accurate profiles for each practice. Agree with practices how these profiles will be used positively to support improvement and demonstrate quality.
Effective Communication – practices do not feel that the CCG communication is as effective as it could be. Patients feel that communication with practices can be improved. There is limited health and wellbeing information being shared with practices.
Clear communication between the CCG and practices through active engagement and listening with a clear communications plan. Clear systems of communication between practices and patients including health promotion and directory of services
CCG communications plan being developed both internally between the CCG and practices and externally with practices and service users. Electronic system of communication to promote health promotion Developing the Alton service directory and replicating this across the other ICT areas.
Co-ordinated Care
Where we are now
Where do we want to get to
How do we get there
Better Local Care MCP - natural communities of care Local Better Local Care programme expanded to North Hampshire with local programme lead. Working with NH Alliance, Southern Health and HHFT to actively promote the MCP model and its contribution to primary care.
Fully functioning multispecialty community provider designing and delivering new models of care effectively across all integrated care team areas.
Stakeholder awareness sessions being implemented to establish priorities. Areas of transformation being identified to submit for funding. Collaboration with other MCP areas to enable sharing of best practice
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Reducing hospital admissions – admission rates continue to rise with variation across practices in terms of activity and demand. Delayed transfers of care (DTOC) account for a large amount of excess bed days which need to be significantly reduced with Reablement a priority to move patients into a community setting.
A significant reduction in hospital admissions across all practices – with DTOC cases reduced significantly so patients are not spending unnecessary time in hospital .
Currently delivering several initiatives to reduce hospital admission. Heat mapping will help assess activity in more detail and enable support where needed. The early bird GP in a car scheme, GP in care homes and ICT working will have a further impact on reducing admissions and supporting earlier discharge.
Integrated Care Team engagement Integrated care teams across all four areas but with differing levels of primary care engagement and some gaps in staff/service provision. Challenged communication in some areas and lack of clarity around roles and responsibilities. In some areas only rudimentary integration.
Effective integrated care that is equitable across all four ICT areas with sustainable teams and a clear understanding of the roles and responsibilities of each team member. Seamless service experience for patients. Shared care records and care plans.
Regular ICT programme review with NH Alliance including sustainability plan. Improved communication and review of feedback from service users Agreed information governance to enable shared care record Incentivised care planning.
Single patient record – Hampshire Health Record in place – enhanced model being developed as part of the IM&T strategy. Information Governance agreements required to enable safe transfer of information.
One single record for each patient which is transferable between service providers and information available to the patient
Please see CCG IM&T strategy
Frailty Pathway –The elderly population in Basingstoke and the surrounding area is set to increase by 47% over the next 10 years. As a response, the CCG are developing an innovative frailty pathway to enable effective commissioning of services for our elderly population including primary care.
A complete frailty pathway that is fully adopted by all parts of the health and social care system – ensuring patients receive care closer to their homes and are supported by multidisciplinary frailty hubs seven days a week.
Please see frailty section on page 48.
Addressing the needs of vulnerable patients – Identification of vulnerable patients, whether suffering from complex health needs,
A system whereby all vulnerable patients are known to the system, risks assessed and systems put in place to address their needs.
Vulnerable patient work streams are being developed for children’s services, mental health, frailty, BME groups and those patients
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ethnicity and diversity challenges, mental health, etc needs to be improved and programmes introduced that meet their needs – work is in place to address priority issues.
In primary care the development of vulnerable patient registers, care plans and targeted services will be shaped according to patient need
needing complex medicines as can be seen from page 52 to 54
Children's commissioning strategy - From April 2013, the Children Collaborative Clinical Commissioning Group (CCG) took responsibility for commissioning children’s health services which includes primary, acute and community paediatric services. The collaborative is also responsible for commissioning child and adolescent mental health services (CAMHs), children’s continuing care and other non-NHS specialist placements, maternity services, and looked after children services.
Clear measurable outcomes available from the Children’s collaborative programme which show improvements for child health, maternity care, looked after children and children with special needs
Please see page 46 which outlines the commissioning priorities, the process for delivery and what the future services will look like.
Medicines management programme - 175 million will be invested in net ingredient cost of drugs in North Hampshire system between 2015-2020 – savings need to be made together with the provision of support for practices to deliver value for money, quality prescribing and patient education.
Implementing medicines optimisation within front line services in order to optimise the use of medicines across primary care and the wider health system – ensuring that the right patient receives the right choice of medicine at the right time
Please see page 50 to 52 outlining the work currently being undertaken in partnership with GP practices and the medicines management team. This summary includes the agreed work programme and deliverables.
Mental health strategy – Mental health and learning disabilities are key priority areas for integration and transformation for the CCG – with a clear operating plan commitment to deliver parity of esteem; valuing mental health equally with physical health.
Delivery of improved support and services for people with mental health needs and learning disabilities; improving crisis care, access to treatment and recovery with a focus on parity of esteem.
Please see information page 44 to 48 which outlines the mental health programme for the CCG, key deliverables and timescales
Information governance (IG) agreements – although information sharing is progressing, there is still a requirement for formal IG agreements between practices and other
Achieving a position whereby all information governance is in place to enable movement towards the single patient record – supporting urgent in hours collaborative working,
IM&T strategy working group have information governance as a standing item enabling data sharing and joint care planning as part of new models of care.
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providers to enable in hours notes and data sharing. This area is a priority for the IM&T working group
delivering expert clinics in primary care for other practice patients and supporting informed care planning between providers.
Proactive Care
Where we are now
Where do we want to get to
How do we get there
Self-management programme – Although a great deal of work has already been done, not all patients are feeling empowered to manage their own health conditions. We have a target in the STP to deliver self-management reducing GP interventions by 30% - this is therefore a significant priority for the CCG
The development and delivery of a programme which outlines s the importance of empowering patients, supporting people to self-manage their health condition and increasing the direct control patients have over the care that is provided for them.
SCAS High Intensity users Patient Activation Management (PAM) Self Management in diabetes Pocket Medic – films on prescription A range of GP-supported approaches including:
• Social Prescribing • Health Coaching • Peer Support • Community-centred approaches • Personal health budgets
Social prescribing – currently GP practices are not systematically linking patients up to activities that support them in the community that may benefit them and are unaware of the many voluntary sector schemes that can support social prescriptions.
Have a system whereby GPs and other MDT leads are actively linking patients to community projects and initiatives that can support their health and wellbeing. The service will be linked to the voluntary sector delivering activities and groups that make up the social prescriptions.
Developing a social prescribing approach which links to self-management and engages with the voluntary sector. This will be evaluated and measured against STP targets to reduce GP interventions and support self-management.
Community health and wellbeing champions – more can be done in the CCG to actively promote health champions, especially in the areas frailty and long term conditions such as diabetes and respiratory disease, mental health etc
Having health and wellbeing champions representing the main long term condition areas, mental health and frailty in place to champion best practice and challenge areas in the system where improvement is needed
Working in partnership with national and local approaches (eg Altogether Better programme). Developing a directory of health champions. Using patient experts in the planning of new services.
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Public Health Prevention Strategy – prevention strategy needs to be updated to inform primary care of priority areas and actions needed including the future commissioning of public health services through primary care
Publication and adoption of the prevention strategy which informs service design and enables active participation in prioritisation from practices
Hampshire County Council are in the process of updating the public health prevention strategy and promoting this in collaboration with the CCG to practices, patients and other providers.
Communications portals in practice promoting health and wellbeing – currently there is little effective communication methods in practice apart from leaflets and limited promotion through practice screens and websites to support health and wellbeing
A system where patients get timely information both via TV screens in the practice, via the practice website and through newsletters/patient participation updates
The CCG communications team are working with practices to develop a central information system which runs through existing practice screens, websites and bulletins which is populated with health prevention material from public health, the CCG and other sources.
Transformed Care
Where we are now
Where do we want to get to
How do we get there
Clinical leadership programme supporting change – clinical leadership needs re-energising across the area with a programme that not only supports clinicians in commissioning but also supports sustainable primary care provision.
A cohort of strong clinical leaders from all areas in North Hampshire that feel empowered and supported to direct real change both as commissioning leads for the CCG and as clinical leaders within their practices and overseeing multidisciplinary teams
By introducing a North Hampshire CCG clinical leadership transformation programme in partnership with academic leaders, change management facilitators and NHS England.
Incentivised service planning – incentive schemes for primary care are currently labour intensive and feel bureaucratic and are not stimulating innovation.
An incentive scheme that delivers measurable health outcomes for patients, supports innovation in practice and rewards success.
The CCG primary care team will be reviewing the current incentive scheme with the aim of redesigning this to a more manageable transformation programme that is well resourced and communicated in a simplified and timely way
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Address quality and equity together – currently quality and equity of service provision is not fully evaluated and shared with practices to address imbalances
Having a primary care system that can demonstrate equal delivery of quality and equity of service across all areas of North Hampshire
The primary care team are working with practices and the quality team to demonstrate quality and equity of services through dashboard development, systems resilience profiling, in partnership with practice managers and clinical leads.
Ensure sustainable general practice – as outlined sustainable general practice is under threat through a number of factors including increasing demand, reduced financial investment and workforce recruitment challenges.
Strong, sustainable and well-resourced general practice that is able to meet demand and deliver new services without impacting core services
Work with NHS England, the LMC and RCGP to support vulnerable practices, work with the CQC to address any challenges and plan to move more investment into primary care out of hospital to support out of hospital care.
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6 Primary Care System Enablers The key delivery areas which support the CCG priorities outlined above are supported by three main enablers, estate, information
technology and workforce development. Work in these areas will enable us to overcome the challenges facing health and social care
in North Hampshire. This table highlights the key priorities for the CCG in these areas with more detail captured in the CCG Estates
and IM&T strategies and evolving workforce plan.
Stakeholder Strategic Themes
By 2020 system enablers will change the landscape for primary care in North Hampshire
Estates will… Information Technology will… Workforce will …
Promote prevention, self-management and wellbeing
Deliver a clear strategy and shared vision to maximise use of current and future primary care estate
Further develop the shared care record across primary care to improve care, reduce risk and support care out of hospital
Target recruitment and retention of GPs and practice/MDT teams collaborating with NHS England, Wessex Deanery and HEE
Improve access – delivering high quality primary care
Increase the use of technology to reduce the reliance on physical estate
Provide patients with the technical tools to self-manage their care
Address primary care workforce shortages through the NHSE practice resilience plan, RCGP programme and work with key stakeholders eg GP Alliance
Target care for those most at need
Deliver improvements to the sustainability and condition of primary care estate through the ETTF fund and minor local improvement grants
Develop a robust strategy for information governance so that information can be safely shared between primary care and other key stakeholders with patient consent
Move to multidisciplinary team ways of working supporting the right professional to deliver the right care at the right time to patients
Provide care close to the patients home where possible
Deliver a feasibility study for primary care estate to support the increasing expansion of Basingstoke
Extend patient records to patients and carers to actively promote involvement in their own care
Deliver effective local targeted education which adapts to changing local needs (eg Frail elderly training, self-management)
Improve integration of services around the individual patient
Work with acute and community colleagues to improve their estate to bridge the gap between providers
Automate clinical workflows and care plans which support transfers of care removing the need for paper and improving quality
Establish a CCG Clinical Leadership programme through transformation funding with a focus on sharing the knowledge and working alongside BLC
Ensure services to patients offer VFM, being resilient and sustainable
Work to deliver primary care hubs to deliver more services at scale eg urgent on the day demand with multidisciplinary teams
Use dynamic data analytics to inform care decisions, focus interventions and support integrated health and social care systems
Develop a robust workforce directory which identifies gaps and opportunities for sharing expertise across primary care
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7 Primary Care Transformation Enablers Other enablers include Joint Commissioning, which facilitates collaboration between NHS England and the CCG to jointly shape the
future of general practice, practice profiling to demonstrate measurable outcomes as well as showcase best practice and identify
areas of support and practice development where the CCG will focus support on ensuring GP practices are well equipped and able
to manage the change that need to happen to support the future health and social care system.
Stakeholder Strategic Themes
By 2020 trabsformation enablers will change the landscape for primary care in North Hampshire
Joint commissioning will… Practice Profiling will… GP practice development will…
Promote prevention, self-management and wellbeing
Strengthen existing quality standards through shared performance management
Support practice resilience – highlighting areas of challenges and enable where targeted support can be aligned
Create headspace for clinical leaders to design new ways of working/new service offers.
Improve access – delivering high quality primary care
Work together to support practice resilience with investment and targeted support
Demonstrate quality and health outcome measures that will support system change and identify areas for investment.
Support practice resilience especially in the areas of recruitment and retention and financial sustainability
Target care for those most at need
Promote consistency of delivery to ensure equitable access to all primary care services
Support patient awareness and choice – by showcasing what each practice is able to deliver
Enable a stronger focus on quality improvement and equitable access to services
Provide care close to the patients home where possible
Facilitate investment opportunities in primary care whilst ensuring equity (eg joint review of PMS contracts)
To clearly identify primary care champions and exemplar practice that can be shared across the local health economy
Support engagement other key partners across the full range of health and social care organisations
Improve integration of services around the individual patient
Assure governance processes for decision making are fair and transparent avoiding conflict of interest
Support natural communities of care by detailing local needs and prioritising areas for transformation
Build practice teams that are multidisciplinary to enable GPs to focus on more complex out of hospital care
Ensure services to patients offer VFM, being resilient and sustainable
Utilise local commissioning opportunities to deliver strategic outcomes
Enable focus for PRISM programme with the aim of using accurate data to identify areas of opportunity for improvement to reduce secondary care activity as needed
Create the environment to support more effective care planning and case management
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7.1 Key User Groups
7.2 People with Mental Health and Learning Disabilities Mental health and learning disabilities are again key priority areas for integration and transformation for the CCG – with a clear
operating plan commitment to deliver parity of esteem; valuing mental health equally with physical health.
The vision is to improve support and services for people with mental health needs and learning disabilities; improving crisis care,
access to treatment and recovery with a focus on parity of esteem. It is reported that one in four people will experience a mental
health problem at some point in their lives and one in six adults has a mental health problem at any one time.
Good mental health and resilience is fundamental to enable improved physical health, relationships, employment and achieving
potential; furthermore improving mental health and wellbeing has wider social and economic benefits.
Children and Adolescent Mental Health (CAMHs)
Indications are that mental health needs in children are increasing and will continue to do so. In the absence of up to date
epidemiological data it is not clear whether this is because we are getting better at recognising the need or whether the profile of
needs is changing. It is estimated that in North Hampshire CCG (mid population data -2012) there are approximately 2930 children
aged 5-16 with a mental health disorder.
Adult mental health
It is expected that over 17’000 adults within the NHCCG have a common mental health problem, predominantly suffering from mild to
moderate depression and anxiety. National estimates on severe mental illness (SMI) suggest that 1 in 100 will suffer from a
condition such as bi-polar and Schizophrenia. Southern Health NHS Foundation Trust; secondary care provider, reports an
increased in acuity of patients and number of referrals for complex cases. Hampshire Hospitals NHS Foundation Trust has had an
increase of 22% since 14/15 of Emergency Department Admissions relating to mental health.
According to the Hampshire’s Older Person Joint Mental Health Strategy 2013 it is expected that depression, severe enough to
warrant intervention, affects one in four older people living in the community, yet only one in three of these will discuss their condition
with their GP and only half of those are diagnosed and treated.
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We also know that there is an increasing prevalence in Dementia. Older People with a mental health need account for a significant
proportion of those who use health and social care services. A conservative estimate is that around:
40% of people attending their GP
50% of all general hospital inpatients and
60% of care home residents have a mental health problem.
Learning Disabilities
General Practices are incentivised to undertake health checks for patients with learning disabilities. In doing so they are currently
building registers that will demonstrate the numbers of children and adults within the area with learning disabilities so that their care
can be more focused and equitable. This is because people with learning disabilities have a much greater chance to develop health
problems and is at least 2.5 times more likely to have physical and/or mental health problems, as compared with the general
population. In addition, they are likely to find it more difficult than others to describe their symptoms. As a result it is more difficult for
health-care workers to identify health needs among people with learning disabilities, therefore leaving some problems left
unrecognised. It has also been found that people also have reduced access to generic preventative screening and health promotion
procedures, such as breast or cervical screening.
People with learning disabilities have an increased risk of early death compared to the general population although the life
expectancy of this population is increasing over time and, for people with mild learning disabilities, approaching that of the general
population.
The CCG priority is therefore to further promote the active delivery of care plans for patients with learning disabilities by supporting
practices with the development of their registers and increasing the uptake of health checks across all ICT areas.
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7.3 Children’s Service Commissioning From April 2013, The Children Collaborative Clinical Commissioning Group (CCG) took responsibility for commissioning children’s
health services which includes primary, acute and community paediatric services. They collaborative is also responsible for
commissioning child and adolescent mental health services (CAMHs), children’s continuing care and other non-NHS specialist
placements, maternity services, and looked after children services.
As well as commissioning responsibilities, the CCG is also collaborating with Hampshire County Council children’s services and
other external stakeholders to ensure where appropriate there are joint initiatives, strategic forums and joint commissioning
arrangements in place to ensure a whole system approach to the delivery of children’s service across North Hampshire.
The Five Year forward View; Facing the Future Together for Better Child Health; Future in Mind; and Better Births; are key drivers of
change. In North Hampshire we recognise the importance of children, young people and families being at the heart of decision-
making as we re-design services so that they are fit for the future and in particular how this relates to primary care.
Services, from pregnancy through to adolescence and beyond, will be high quality, evidence based and safe, delivered at the right
time, in the right place, by a properly planned, educated and trained workforce. Good mental and physical health and early
interventions, including for children and young people with long term conditions, will be of equal importance to caring for those who
become acutely unwell.
Coordinating care around the individual
Services will be integrated and care will be coordinated around the individual child. The CCG aims for an optimal experience of
transition to adult services for those young people who require ongoing health and care in adult life, based on an assessment of their
need.
Every child should have timely access to high-quality urgent, on the day care services that are safe, effective and caring, that
promote good health and wellbeing and that reduce the impact of illness on the child and their parents and carers. Where possible,
care should be provided outside the hospital in their locality and close to home, the right care at the right time in the right place.
Looked After Children
It is widely known that this group of children is not as well served by mainstream NHS Services because they are often transient.
Our Children’s commissioning team is committed to ensuring that health need for this potential patient group is prioritised working
44
with primary care to ensure that they are safeguarded with seamless transfer of patient notes between practices and services, that a
template captures their statutory annual health review and that practices develop their looked after children registers.
Maternity & Children
Maternity
We will
respond to the national maternity
review recommendations
and ensure all women have access
to personalised health care, choice and good quality
antenatal and postnatal support.
Children and Young People with Additional
Health Needs
We will
improve access to services specifically supporting the roll
out of personal health budgets and integrated working models, ensuring services are co-produced with
children and families at the heart of the
design.
Emotional Wellbeing and Mental Health
We will
deliver the priorities of the ‘Make it Worthwhile’
emotional wellbeing and mental health strategy. Improve timely access to services through
earlier intervention and prevention.
Work in partnership with the third sector
organisations.
Participation and Life Choices
We will
develop and implement a youth
engagement strategy. Encourage healthy
life choices to reduce obesity and support the development of seamless services
between childhood and adults or end of
life care
Avoidable Hospital Admissions and
Attendances
We will
implement the ‘Facing the Future’
recommendations to help avoid admissions and/or attendances at
hospital. We will promote accident
avoidance and support parents to manage illnesses at home through improved
pathways of care in the community.
45
Children and Young People with Special Education Needs and Disability
The CCG is committed to ensuring that disabled children and young people have the same life chances as those children without
disability. The CCG is committed through the work the collaborative programme to ensure that this group of children has a clear care
plan with a focus for young people on the transition to adult services when the role of primarycare is likely to increase significantly.
The more detailed Hampshire Maternity and Children Health Collaborative Operating Plan for 2016 to 2019 – outlining how the
targets will be achieved with proposed timelines for delivery can be accessed via the North Hampshire CCG website25.
7.4 Older people’s services and frailty pathway supporting the primary care system Colleagues from across the health and care system have engaged with the development of a frailty pathway project which has
included the delivery of engagement workshops and individual meetings with key stakeholders, including primary care. This is
urgently required due to the ageing population of our demographic area with a predicted increase of 47.5% in the over 85 year olds in
the next ten years and the currently demand on the system from the over 75s now. This pathway will focus on:-
Illness prevention to reduce escalation of care needs and builds on best practice and expert advice.
the interface between maintaining independence/illness prevention and acute treatment.
The establishment of an urgent and acute frailty assessment unit which will be the control point for seeking early alternatives
to hospitalisation when the older persons’ health state appears to be deteriorating.
Leading urgent and acute care planning including the allocation of resources via enhanced recovery community support.
Case identification, multi-disciplinary assessment, case management and care planning will be core to enabling the pathway of care,
with access to a rapid assessment process by a multidisciplinary team, effective review process and enhanced care at home and in
the community
Three key areas of additional support will further enhance the care of elderly people with the aim of providing care out of hospital:-
Locality hubs are being developed in collaboration with Hampshire County Council as part of a nationally supported locality
transformation. Linked to this the new model of care proposes to introduce community hub and spoke centres, a chain of ‘Wellbeing
25
http://www.northhampshireccg.com
46
Cafés, led by the voluntary sector and potentially situated in community and primary care venues. The preventative and self-
management focus will be supported through offering sign-posting, advice and information, exercise classes, social engagement and
a show case for assistive technology, tele-medicine & tele care.
Integrated Care Teams will drive complex long term case management in partnership with GPs and their primary care teams, adult
social care and mental health services. The Integrated Care Teams (ICTs) will be enhanced for frailty via training and skill mix with
new roles and inter-organisational recruitment and rotation of staff, integrated care planning and delivery. GP’s and primary care
teams, adult social care and wider health and care network will identify frail older people and associated level of needs creating a
frailty register that will feed into risk stratification and case management meetings.
The urgent and acute frailty assessment unit – A multidisciplinary team (MDT) will focus on assessment and case management
with the ability to meet immediate care needs via an integrated care arm. This team will bring together practitioners from multiple
organisations and work across the community and acute services. Led by a dedicated consultant geriatrician and frailty consultant
nurse, the MDT will carry out the implementation of acute frailty assessment and the proactive management of deemed short stay
patients (i.e. anticipated admission less than 72 hours) or those with low medical need to facilitate admission avoidance and enhance
early discharge when clinically suitable.
The aim is to develop a locality focused geriatrician model of care for the inpatient bed base, linking the community caseload with
acute admission, supported by a daily MDT meeting with call-ins from the community and primary care. This meeting will enable the
consultant led team to set the tempo of reviewing and discharging patients at the start of each working day, seven days a week. It will
coordinate the allocation of services, matching the capacity to demand in intermediate community services e.g. D2A beds and
enhanced recovery community support. This will facilitate enhanced working arrangements across the locality, better understanding
of the services available across the locality and more rapid turnaround in the case of complex discharges.
This programme will also be shaped collaboratively with West Hampshire CCG to support collaborative STP working with each
element supporting the vision for a patient focused care system
7.5 Examples of support being provided to deliver primary care to vulnerable groups
Basingstoke Nepalese Community
47
Key members of the CCG patient participation group are representatives from the Basingstoke Nepalese community. This is a fairly
new ethnic minority group with settlement growing rapidly since 2006 with now nearly 200 people from Nepal living in the town. The
Nepalese residents are supported by the Basingstoke Nepalese Community (BNC) Forum26 who are working with health and social
care to ensure that the needs of their members are addressed. For primary care this means a focus on understanding the unique
cultural beliefs, enabling translation services and ensuring that their health needs are met. The CCG is working with the
representatives to ensure that preventative as well as coordinated care is available for them and access needs identified and
addressed through their registered practices.
Chrysalis – working in partnership with the CCG to support the transgender community
The Link Engagement and Participation (LEAP) Committee of the CCG is an active partner with Chrysalis who are working with the
transgender community to provide support through their meeting centres counselling services and to champion the health and social
care rights of each of their members. One key area of work is their training and development programmes which they are keen to
share with primary care – supporting health professionals and practice teams to understand how to support patients through
transitioning and how to strengthen communication and engagement. The CCG are actively promoting this service and working to
include training for primary care teams as part of the primary care development programme.
Basingstoke District Borough Council – collaboration in supporting the single homeless and rough sleepers
Basingstoke District Borough Council has recently undertaken a health audit of its single homeless clients and rough sleepers with
the aim of informing strategic planning to improve health outcomes and reduce health inequalities by providing an evidence base for
their health needs. Working in collaboration with the CCG and the voluntary sector we will look to improve service access and
delivery. It is well known that homeless people experience poor health, accessing acute health services four times more and
inpatient services eight times more than members of the general population with an estimated cost of 85 million nationally every year.
Making Every Adult Matter27 estimates that an average a rough sleeper will cost between £30-35k more to the health, housing,
criminal justice and drug and alcohol services per annum. Current financial pressures make addressing health needs appropriately
and avoiding wider impacts of poor health even more important.
26
http://basingstokenepalesecommunity.com/ 27
http://meam.org.uk/
48
Currently in Basingstoke there is a direct access homeless hostel which provides 20 bed spaces and 45 spaces in the housing and
support service. The Council provides a day centre on Tuesdays and Thursdays for rough sleepers, seeing up to 35 people a day by
the in house and outreach teams. The rough sleeper outreach team is currently working with 15 to 25 rough sleepers at any one
time. The community based homelessness prevention service sees up to 400 people a year. All clients seen require primary
healthcare support and are high users of urgent care and A&E services.
The audit conducted was self-reporting and voluntary with a cross section of the homeless community and their key workers.
Some of the information shared (especially in relation to mental health, drug and alcohol use) was moderated with the tool allowing
people to talk about their conditions as diagnosed by their GP.
46 interviews were undertaken with the majority of returns from rough sleepers/sofa surfers and people from the direct access hostel
giving good representation of people living close to or on the streets. The average age was 39 (minimum age 18 and maximum 63).
22% of clients stated that mental or physical health problems had caused them to become homeless.
72% of clients stated they had a long-standing illness, disability or infirmity.
11% of people reported having dental problems in the last 12 months
20% of people reported joint aches/problems with bones and muscles in last 12 months
22% of people stated there was a time that they needed medical treatment but did not receive it. Most common reason why is
length of waiting list, but reasons also included being banned from services and being refused treatment
The full report is due to be published on the Basingstoke Council website shortly but the CCG are working with the Council’s Social
Inclusion Manager to address the findings in respect of primary care access and identify where enhanced service models can
address the specific needs of the homeless community. This will either be addressed individually with local practices or via the
Better Local Care programme MCP/NH Alliance to deliver support to the homeless at scale. The focus will be to support improved
health outcomes, improve primary care access and avoid unplanned hospital admission.
49
8 Primary Care Services
8.1 Pharmacy - Medicines Management
The Five Year Forward View challenges CCGs to ensure that they deliver value for money and develop the workforce to support this
goal. Key to this is the successful delivery of medicines management objectives and the North Hampshire medicines management
team have developed a strategic plan to realise health improvement and financial savings in collaboration with our GP practices.
Between 2016-2020 by working with primary care, community services and acute trusts the CCG will work to achieve the following:-
Each integrated care team (ICT) should have access to a clinical pharmacist, medicine management team and links to local
community pharmacies through the natural communities of care initiative supported by the Better Local Care vanguard by
2018
General Practice will have increased access to clinical pharmacist and technicians facilitated through a service level
agreement or memorandum of understanding between the CCG medicines management team and practice by 2017
Nursing Homes will have input from dedicated nursing home pharmacist
Community Pharmacy will work with the Better Local Care (BLC) MCP and key pharmacy teams to provide continued
pharmaceutical support to patients in the community.
Medicine Management Team to support and co-ordinate national and local work programmes to embed medicine
management programmes.
Local acute trust pharmacy teams will work with the BLC MCP to develop the workforce – this will be six monthly rotations of
Band 7 clinical pharmacists in general practice and the CCG medicines management team.
Commission services via the community such as direct access to urgent repeat medicines during out of hours
This is being undertaken because £175 million will be invested in net ingredient cost of drugs in North Hampshire system between
2015-2020. Overall responsibility for the appropriate spend and use of these medicines lies with the commissioners within
constitutional duties.
Enablers such as the use of contractual levers, primary care incentives and enhanced commissioning has proven to be successful in
implementing medicine management services in primary care. However gaps remain and it is this investment programme that will
address these.
50
The CCGs vision is to implement medicine optimisation within front line services in order to optimise the use of medicines across
primary care and the wider health system – ensuring that the right patient receives the right choice of medicine at the right time.
The key outcomes of investing in the workforce through skill mix in primary care will ensure that patients:-
Improve their outcomes.
Have access to innovation such as NICE approved medicines and supporting NICE guidance implementation.
Take their medicines correctly and maximise the therapeutic benefits
Avoid taking unnecessary medicines and reduce harm.
Reduce wastage of medicines
Improve medicines safety
Improve value for money and efficiency in the system
Finally the medicines management team will focus on undertaking clinical medication review of high risk patients for example frailty,
patients with multiple long term conditions, care home residents and patients at high risk of admission to hospital. These
assessments will occur either within the practices or within the patient’s home setting as appropriate to each patient’s needs.
Clinical medication reviews of high risks patients will address:-
The recruitment and retention crisis within primary care and capacity issues.
The integration of pharmacy services within community/primary care. Increased efficiency and reduced duplication and hand-
offs.
Integrated medication reviews during admission/discharge.
Pharmacy Teams are capable of providing minor illness advice (1 in 5 General Practitioner consultations are for minor
illnesses), and are able to independently prescribe with the appropriate competencies and governance.
There is presently a desire amongst a cohort of pharmacists in the system to enhance their clinical roles, but little potential for
them to develop their roles to become independent prescribers. The service will therefore offer career development
opportunities and be attractive to the workforce, supporting recruitment and retention.
A sustainable model which delivers improved patient outcomes through high quality, safe and clinically effective care,
together with financial savings.
51
Investment in the programme will come through optimisation QIPP schemes, local practice joint investment in a practice pharmacist
(practices have already expressed an interest in exploring this scheme) extending funding from transformation funding (new models
of care MCP). Work is already commencing with GP practices, the NH Alliance and the Better Local Care MCP to shape these
proposals and deliver new innovative models of medicines management and evaluate their outcomes.
9 What does good Primary Care look like
52
From our engagement work with stakeholders, from the series of “must do’s” determined by national and local policy and from
discussion and involvement from the North Hampshire CCG GP practices alomngside our gap analysis – we have our list of
strategic themes that through delivery will take us toward the visions and goals we have set. These themes will direct our primary
care work programme for the next four years:-
Implementation and delivery of the work will be managed by the Joint Primary Care Commissioning Committee and primary care
working group. The work programme will also link with other CCG work streams and strategic plans. This work begins with a gap
analysis to identify priority areas for investment, resource, project work and development.
Future patient and public engagement around the primary care priorities will be undertaken as part of the wider communications and
engagement strategy. As already outlined outcomes from the work programme will also be aligned to the Hampshire and Isle of
Wight Sustainability and Transformation Plan, Operations Plan, Urgent Care Strategy, workforce development programme and to key
enabler work streams such as the IM&T strategy, Estates Strategy, Health and Wellbeing strategy and work programme for self-care.
53
A gap analysis has been supported by a survey of practices to set poriorities for 2017-18
Key Themes Outcomes Enablers Gaps in provision – opportunities
Promoting prevention, self-management and wellbeing
Promoting self-care using technology and workforce
IT strategy Patient Activation Measure (PAM) training Primary Care Contracted Services
Gillies and Bermuda Marlowe - EMIS system (compliant by 1.4.17); Web GP and Pocket Medic; All-inclusive system for E-referral. ACG (or similar) tool adoption to support remote extraction and profiling.
Encourage measures for disease prevention and public health
CCG Prevention Strategy / Public Health Strategy Public Health Local Enhanced Service (LES) schemes
Shared PH strategy with primary care. Public health lead for the CCG to work with council colleagues. Practice profiles to include public health.
Promote and encourage wellbeing
Health and wellbeing strategy in collaboration with social care and integrated care teams
Collaborative health and wellbeing task and finish group with CCG/public health
Working as part of wider health team to prevent ill health
Developing voluntary sector partnerships, Out of Hours Provider, GP Federation, MCP
Engagement with all Voluntary Sector Organisation (VSO) representatives. Map of current VSO provision; Forum for VSO/primary care engagement VSO engagement lead within the primary care team Inputting prevention agenda into Out of Hours and wider service pathway delivery.
Improve access, convenience, and quality of primary care services
Improve GP capacity and working at scale, access and extended hours
Networks – LMC, Wessex LAT Vanguards (Better Local Care)
Need a GP lead for CCG primary care. Task and finish group for clinical leadership programme (NHSE funded) linked to Better Local Care transformation funding; knowledge of future leaders from within primary care. Support leadership for practice nursing. Programme to explore urgent care hubs to support practice resilience. Task and finish group and agreed plan for seven day working.
54
Utilise different skill mixes and multi-disciplinary working, IT and new models of care
Leadership (see later) Clinical Discussion Forum Better Local Care One Team
Practice management training programme (being developed by Wessex LMC); practice nursing training programme aligned to Queens Institute programme and Health Education England; Practice Nursing mentors. CCG directory of GP trainers. Best practice sharing opportunities
Shift 30% activity away from GP to enable GPs to focus on high impact activity
Workforce training capacity STP Self-care work programme
Clear vision for working at scale in each of the ICT areas. Task and finish group to deliver "at scale" working. Financial resources (e.g. NHS England transformation funding/Vanguard).
De-layer services to remove non-beneficial steps; stop activities of no value
Project plan to work at scale IM&T Strategy
More clinical leads to design pathways. Service specifications to deliver redesign. Evidence of exemplars from other Right Care ONS (Office of National Statistics) cluster CCGs and Wessex CCGs. Use of system tools (e.g. DXS) to link with EMIS Web to enable easier referral guidance.
Enable remote consultations and patient triggered digital follow-up shared between 1ry/2ry clinicians
Clinical pathway redesign,
Regular GP federation forums. Engagement with all practices. Federative model for seven day working. Quality profile of GP practice members. Quality outcome portfolio for services delivered by the Alliance.
Increase direct access to protocol driven diagnostics
Mature GP federation . Task and finish group and collaboration with West to showcase best practice
Reduce variation in quality of primary care
Performance monitoring
IT solution and IG agreements to enable shared records for seven day working and improved access at scale. Development of PC dashboard and practice profiles with CSU and quality team
Targeting care on the most needy
Support vulnerable patients with New Models of Care and timely physical checks for mental illness and learning disability
Better Local Care LD health checks Health and wellbeing strategy
Better Local Care project board to develop new models
55
Targeted integrated management of long term conditions with MDT input and crisis intervention
New models of care Profile of vulnerable groups (e.g. Nepalese/entrenched and transient homeless) both urban and rural. Profile of new entrants - Basingstoke expansion required - Estates and Technology Transformation Fund(ETTF) bid for Basingstoke feasibility study to support this.
Provide alternative treatment locations in the community
MCP/Estates Strategy GP list profiling
Mobilisation of patient groups - LEAP/CCG PPG/ local PPGs to confirm service user need – List profiles to determine demographic priorities. Alignment to estates strategy to enable co-location.
Personalised detailed care programmes with senior clinicians providing care for the most complex
MCP Better Local Care Patient activation Developing voluntary sector partnerships
Capacity to engage with VSOs. Commissioning lead and clinical lead for VSO engagement. VSO engagement strategy.
Develop New Models of Care delivering evidence based optimisation using community pharmacists
GP forward view – community pharmacists Medicines Management incentive Scheme. Better Local Care Support for greater multidisciplinary working (professional standards)
List of professional standards. Agreed Memorandum of Understanding between MDT teams. Alignment with medicines management priorities to primary care strategy
Providing care close to home where possible
Ensure care is provided close to home where possible
Better Local Care MCP
Engagement strategy for promoting benefits of care close to home. Education information. Interactive communication with service users. Communications plan. Alignment to Better Local Care. Establishment of natural communities of care.
Support patients in their own homes with strong community based teams
Patient activation measure (PAM) Better Local Care MCP
Training in Patient Activation Measures. Communications strategies for care close to home. Examples of exemplar working from other CCGs.
Pull patients out of hospital when
Effective communications with
ICT task and finish group via Better Local Care. Agreement of ICT demographics between providers.
56
appropriate patients and other stakeholders
Workforce capacity.
Improving transport for patients to access care
ICT development Transport policy
Engagement from primary care for the pathway.
Key Themes Outcomes Enablers Gaps in provision – opportunities
Improve patient experience and outcomes by ensuring that care services are joined up and aligned to patient need
Frailty Pathway / developing Out of Hospital strategy Better Local Care MCP
Seamless transfer of care required with close collaboration with all stakeholders including social care and the voluntary sector.
Ensure joined-up services around the individual patient
Improve effectiveness and value of service delivery by ensuring greater integration of service delivery by all agencies including third sector
Integrated Care Programme Working group for Integrated Care Programme required. Clinical lead for integrated care. clear signposting to main IT strategy in place.
Vision, values / priorities, organisational coherence
IT strategy Patient engagement plan around patient activation and programme development.
Engagement / relationships / partnerships
Better Local Care Patient activation and co-production
As above
Ensure services to patients are resilient and sustainable and offer good value
Public engagement / awareness / support
Primary Care Contracts QIPP Primary Care Dashboard
Review of all current primary care contracts and the aligned outcomes required to measure effectiveness. Reinvestment plans required as services are moved out of hospital as part of QIPP into primary care.
Developing organisations and individuals
Effective contracting (including personalised health budgets) Primary Care Dashboard CCG Leadership Programme
Systems resilience plan. CQC reports for all practices. Resilience profile for each practice. Task and finish group for clinical leadership programme.
57
System resilience planning Financial evaluation of best value in primary care. Clear primary care investment profiles (e.g. equity of investment for each provider) Representative for primary care on SRG board.
Provider alliances Effective outcome measure reporting from Federation including portfolio of achievement for further contract tenders
Mature GP federation Local federation strategy for supporting practice resilience aligned to RCGP programme.
Enabling and supporting change
Creating a change culture CCG Clinical Leadership Programme with Better Local Care
Primary care clinical lead with representation on Quality, SRG and performance committee. Updated conflicts of interest policy enabling new models. Equality and Diversity impact assessment for primary care
Ensuring capacity can support core business and foster continuous improvement
Good governance Change management programme for membership practices with CCG Leadership Programme aligned to Better Local Care
Pipeline of future leaders established
Leadership Primary care transformation working group.
Championing transformation
Detailed feedback from allied providers re primary care. Active listening to the patient voice. CCG engagement with all membership practices to facilitate change.
Provider alliances Mature GP Federation
Vision from NH Alliance to support change. Vision and engagement with the federation for leading and enabling change.
These objectives will be reviewed and updated regularly and the strategy itself reviewed six monthly by the working group and Joint
Primary Care Commissioning Committee to ensure it achieves against objectives set.
58
10 Governance supporting the primary care strategic plan
Addressing conflicts of interest and assurance
As a CCG we must be able to demonstrate strong governance in the area of primary care commissioning due to potential conflicts of interest. GP providers are not only independent businesses but constituent members of the CCG with commissioning responsibilities and have additional provider interest as registered members of the NHS Alliance.
Operational governance and strategic planning
Clinical redesign Financial and investment assurance
Quality Assurance Corporate governance
Joint Primary Care Commissioning Committee
Clinical Executive Committee Finance and Performance Committee
Quality and Assurance Committee and CQC
CCG Governing Body
The Joint Primary Care Commissioning Committee (JPCCC) provides scrutiny in terms of operational governance working in collaboration with NHS England. Strategic oversight and corporate governance continues to lie with the Governing Body with scrutiny provided by the CCG executive and lay membership. Service redesign is supported by the Clinical Executive Committee (CEC) and quality assurance with the Quality Assurance Committee internally and the Care Quality Commission (CQC) externally. Financial assurance and governance is provided by the Finance and Performance Committee supported by internal and external audit.
Clinicians remain accountable to their professional regulatory bodies for professional practice and GP practices and other primary care providers are protected by professional indemnity.
Externally North Hampshire’s Borough Councils’ Health and Wellbeing Committees and Hampshire County Council’s Overview and Scrutiny Committee will further assure the governance process on behalf of the local population with formal public consultation undertaken for any major service change. Members of the CCG Patient Participation Group and the CCG Link Engagement and Participation (LEAP) Committee provide additional assurance.
Equality impact assessment
We are required under the Health and Social Care Act of 2012 and requirements relating to people with protected characteristics in
the Equality Act 2010 (age, disability, ethnicity, gender reassignment, marriage and civil partnership, religion, pregnancy and
maternity, sex (gender) and sexual orientation to undertake an Equalities Impact Assessment (EIA).
59
The EIA is being developed to support this strategy and is available as a separate supplement. This assessment will determine
whether the strategy provides a structure within which a consistent primary care offer will be made to the whole population of North
Hampshire CCG.
The CCG will work to ensure that the strategic priorities address health inequalities of all with particular attention focused on the care
of vulnerable groups such as the homeless, looked after children, adults and children with learning disabilities, transgender patients,
ethnic communities etc.
60
11 Appendices
Appendix 1 – The strategic approach to shaping the strategy
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Appendix 2 - Constituent GP Practice Members – North Hampshire CCG (Source: GP Practice Websites 30 August 2016) Practice and Address
Practice Partners and Practice Manager Registered List Size
Beggarwood Surgery Broadmere Road Basingstoke Hampshire RG22 4AQ Telephone: 01256-396500
Dr Louise Benyon Dr Jonathon Church Dr Radha Venkatraman Dr Asil Ishmail Dr Katherine O’Sullivan Dr Fiona Thornton Practice Manager: Davina Mason Operational Manager: Pat Bray
5,435
Bentley Village Surgery Hole Lane Bentley Farnham GU10 5LP Tel: 01420 22106
Dr Abigail Evers Dr Iona Moore Dr Jonathan Moore Dr Melanie Way Practice Manager – Donna Mant
3,561
Bermuda and Marlowe Practice Shakespeare Road Basingstoke Hampshire RG24 9DT Branch Surgery Fort Hill Surgery, Winklebury RG23 8BU Telephone: 01256 464151
Dr Paul Conley Dr Jeffrey Stoker Dr Fransiscus Berkelaar Dr Ayesha Chaudhry Dr Naureen Akhtar Practice Manager: Wendy Lock
13,181
Boundaries Surgery 17 Winchester Road, Four Marks Alton, Hampshire GU34 5HG
Dr Philip West Dr Heather Scott Dr Liz Hughes Practice Manager: Kevin Evans
3,818
62
Tel: 01420-562153
Bramblys Grange Dickson House, Alencon Link, Basingstoke RG21 7AP Tel: 01256-467778
Dr Andrew Bill Dr Joanna Foley Dr Amanda Murn Dr Ranjeet Rai Dr Sunil Rathod Dr Marina Bartlett Dr Tania Phillips Practice Manager: Andrew Smythe
11,651
Camrose Medical Partnership St Andrews Centre Western Way Basingstoke RG22 6ER Tel: 01256-324666
Dr Richard Parker Dr Michael Partridge Dr Catherine Bayliss Dr Ruth Dyson Dr Anna Reed Dr Swati Patel Dr Nicholas Western Dr Rosamonde Jones Dr Lucy Wilson Practice Manager: Claire Shelbourn
11,088
Chawton Park Surgery Chawton Park Road Alton GU34 1RJ Telephone: 01420-542542
Dr Nichola White Dr Jacqueline Over Dr Matthew de Quincey Dr Emma Bowen-Simpkins Dr Julian Barber Dr Sarah Loch Dr Victoria Collins Practice Manager: Nicky Maule
8,954
Chineham Medical Practice Reading Road Chineham Basingstoke RG24 8ND Tel: 01256-479244
Dr Deborah Abbott Dr Keith Ollerhead Dr Helen Bruce Dr Catherine De Mars Dr Shehla Jamil Dr Rachel Yarnton Dr Chiranthi Marston Dr Vith Rahunathan Dr Zoe Thomas Dr Teresa Harper
9,860
63
Practice Manager: Emma Trimnell
Clift Surgery Minchens Lane Bramley Tadley Hampshire RG26 5BH Tel: 01256 881228
Dr Diana Kenshole Dr Nigel Fisher Dr Roisin Ward Dr Claire Walton Dr Rachel Quew Practice Manager: Sarah Roberts
6,110
Crown Heights Medical Practice 2 Dickson House Alencon Link Basingstoke Hampshire RG21 7AN Tel: 01256 329021
Dr David Knight Dr Cedric Cochrane Dr Andrew Cole Dr Matthew Nisbet Dr Richard Trueman Dr Graham Hullah Dr Dawn Coxhead Dr Vital Sijbers Dr Masum Meah Dr Felicity Groom Dr Victoria Boyd Dr Euphan Hunter Dr Usha Thankam Dr Ros Meacher Dr Sam Wild Practice Manager: Paul Butterworth
24,655
Gillies Health Centre Sullivan Road Brighton Hill Basingstoke Hampshire RG22 4EH Telephone: 01256 479747
Dr P M Knowles Dr A Carnegy Dr C S Huyton Dr E A Williams Dr R E Walker Dr M J Browning Dr J E Dixon Dr N Rose Dr S L Longley Dr V Turner Dr N Lizinde Practice Manager: Alex Woodroffe
18,166
64
Hackwood Partnership Essex House Essex Road Basingstoke RG21 8SU Tel: 01256 637210
Dr Amanda Britton Dr Susan Bowen Dr Andrew Cameron Dr Lynne Heathorn Dr Clair Botting Dr Caroline Sykes Dr Caroline O’Keeffe Dr Roopa Radhakrishnan Dr Sarah Care Dr Louise Carney Dr Steve Pratt Practice Manager: Vacant
13,502
Kingsclere Medical Practice Kingsclere Health Centre North Street Kingsclere Newbury Berkshire RG20 5QX Tel: 01635 296000
Dr Sarah Bond Dr Sarah Still Dr Alison Steare Dr Tom Jacobs Practice Manager: Win Harfield
5,551
Oakley & Overton Partnership The Surgery Station Road Overton Basingstoke Hampshire RG25 3DU Tel: 01256 770212
Dr Nicola Decker Dr Judith Lindsay Dr David Bartlett Dr Julia Hopkins Dr Christian Chilcott Dr Kirsty Pollard Dr Jonathan Rial Dr Manon Phillips Practice Manager: Moira Clark
12,151
Odiham Health Centre Deer Park View Odiham Hampshire RG29 1JY Telephone: 01256 702371
Dr Anthony Weaver Dr Claudia Shand Dr Raffi Assadourian Dr David Andrews Dr Helena Heywood Dr Jessica Pizzotti Dr Victoria Bates Dr Oliver Sweeney
11,324
65
Dr Juliette Williams Dr Faye Sufi Dr Katharine Edmonds Dr Nkolika Ezeh Practice Manager: Sue East
Rooksdown Practice Mill Road Rooksdown Basingstoke Hampshire RG24 9SP Telephone: 01256 320303
Dr Rachel Quew Dr Radha Venkatraman (f) Dr Kikelomo Amira (f) Practice Manager: TBC
6,197
Tadley Medical Partnership Holmwood Health Centre Franklin Avenue Tadley Hampshire RG26 4ER Telephone: 0118 981 4166
Dr Christine Caren Dr Vivienne Adler Dr Sunil Bhanot Dr David Newman Dr Anne Hogan Dr Harriet Walford Dr Rohit Chander Dr Bilal Amin Dr Kat Moir Dr Helen Prince Dr Rebecca Maynard Dr Heather Lambert Practice Manager: Alison Jenner
18,490
Whitewater Health (previously Hook Hartley Wintney Surgery) The Surgery Reading Road Hook Hampshire RG27 9EP Tel: 01256 762125
Dr Sarah F Longstaff Dr Andrew M Fernando Dr Andrea E Clay Dr Charlotte A Hutchings Dr Jeni Rees Dr Hugh Riveros Dr Kate McKenna Dr Fabian Trevelyan Dr Rachel Freer Dr Nuala Lynch Dr Gemma Fornai Practice Manager: Beccie Van Oostrum
16,902
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The Wilson Practice Alton Health Centre Anstey Road Alton Hampshire GU34 2QX Tel: 01420 84676
Dr Andrew Fellows Dr Jane Peckham Dr Alison Rickard Dr Sally Louden Dr Oliver Kemp Dr Mark Longley Dr Avril Rush Dr Katy May Practice Business Director: Rosie Lewis Practice Manager: Sharon Cox
14,006
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Appendix 3 – National and regional strategies influencing primary care
Strategy National/Regional/Local Implications for primary care in North Hampshire Five Year Forward View https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
National NHS England – October 2014
National road map for delivering effective, sustainable accessible and high quality healthcare in England – with a focus on avoiding variation and enabling new models of care. This was developed in partnership with Care Quality Commission, Public Health England and NHS Improvement.
General Practice Forward View https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf
National NHS England – April 2016
NHS England publication setting out the support package for Primary Care over the next five years
The Future of Primary Care – creating teams for tomorrow https://hee.nhs.uk/sites/default/files/documents/The%20Future%20of%20Primary%20Care%20report.pdf
National Nuffield Trust in collaboration with the Primary Care Workforce Commission
Focus on the workforce issues facing primary care and how these can be effectively managed locally
North Hampshire Health and Wellbeing Strategy http://documents.hants.gov.uk/health-and-wellbeing-board/health-and-welllbeing-strategy.pdf
North Hampshire (County)
Defines the health and social care priorities for North Hampshire and the local route map for collaboration between health and social care services with a focus on public engagement
North Hampshire Joint Strategic Needs Assessment http://documents.hants.gov.uk/public-health/jsna-2013/NorthHampshireClinicalCommissioningGroupJSNA2013.pdf
North Hampshire (County)
Provides public health intelligence and expert information on the demographic population of North Hampshire and the health and social care needs this presents.
North Hampshire CCG – IM&T Strategy
North Hampshire (Internal)
CCG strategy setting out the IM&T priorities for North Hampshire as we seek to adopt the key elements of the digital road map and movement to a single patient health record.
North Hampshire CCG – Estates Strategy North Hampshire CCG (Internal) CCG strategy aligned to the wider NCL estates vision – highlighting estate investment priorities for North Hampshire to
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enable primary care transformation.
North Hampshire CCG Quality Strategy http://www.North Hampshireccg.nhs.uk/Downloads/Publications/Strategies/NHS-North Hampshire-CCG-Quality-Strategy-2015-18-final.pdf
North Hampshire CCG (Internal)
Strategy outlining the key quality priorities for the CCG and its service providers – linking to primary care and ensuring quality standards are maintained across the whole of the health and social care system.
Council Plan 2016 - 2020 Basingstoke Area Strategic Partnership - http://basp.basingstoke.gov.uk Manydown expansion http://manydownbasingstoke.co.uk Current community plans - http://www.basingstoke.gov.uk/communityplans n Neighbourhood renewal strategy - http://www.basingstoke.gov.uk/rte.aspx?id=351
Basingstoke and Deane Borough Council
Plans that outline the expansion plans for Basingstoke – these ambitions will align to the CCG Estates Strategy and primary care strategy vision for expansion of primary care to meet the projected need.
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Appendix 4 - Contributors to the Primary Care Strategy
CCG Contributors
Name Title and Role in the CCG
Zara Hyde Peters Director of Integration and Transformation, NHCCG
Dr Richard Coppin Clinical Lead – Integration and Transformation, NHCCG
Paul Sly CCG Accountable Officer, NHCCG
Dr Nicola Decker Clinical Chair, NHCCG
Pam Hobbs Chief Finance Officer, NHCCG
Jan Grant Director of Quality, NHCCG
Rebecca Thornley Primary Care Strategy Lead, NHCCG
Dr Charlotte Hutchings CCG GP Lead for Cancer and CEC representative, NHCCG and GP Whitewater Health
Dr Tania Phillips CCG GP Clinical lead and CEC Representative, NHCCG and Locum GP, Basingstoke
Paul Davey Head of Communications, , NHCCG
Sharon Martin Associate Director Primary Care, NHCCG
Simon Wilkinson Primary Care Commissioning Manager, NHCCG
Alma Kilgarriff Head of Medicines Management and Quality, NHCCG
Melanie Commissioning Manager – Planned Care, NHCCG
Ewen McGregor Commissioning Manager – Integrated Care, NHCCG
Sally Pastellas Senior Commissioning Manager ,Children and Maternity, NHCCG
Jessica Slater Senior Commissioning Manager – Frailty, NHCCG
Andrew Moody Senior Commissioning Manager – Unplanned Care, NHCCG
Jessica Berry Senior Commissioning Manager, Mental Health/ Self-Care, NHCCG
Pablo Alvarez Commissioning Manager – Primary Care, NHCCG
Jane Talbot Medicines Management Pharmacist, NHCCG
Becky Rogers Commissioning Manager – Urgent Care and Long Term Conditions Management, NHCCG
Lyndsay Evans Commissioning Manager – Community, Integrated and Unplanned Care
Richard Haynes Interim Head of Communications, NHCCG
All Members of the CCG Clinical Executive Committee
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Contributors from the GP Primary Care Strategy Development Away Day
Beggarwood Practice Davina Mason, Harbans Mann, Alison Hullah
Bentley Village Surgery Dr Jonathan Moore
Bermuda and Marlowe Practice Dr Ayesha Chaudhry, Dr Jeffrey Stoker, Dr Tom Jacobs
Boundaries Surgery Kevin Evans
Bramblys Grange Medical Practice Andy Smythe, Dr Ranjeet Rai, Dr Sunil Rathod, Dr Tania Phillips
Camrose Medical Partnership Dr Michael Partridge, Dr Richard Parker, Dr Swati Patel, Dr Sonia Barros D’Sa
Chawton Park Surgery Dr Nicola Wright
Chineham Practice Dr Keith Ollerhead
Clift Surgery Sarah Roberts, Margie Woods
Crown Heights Medical Practice Dr Sam Hullah, Paul Butterworth
Gillies and Overbridge Health Centre Alex Woodruffe, Dr James Dixon, Dr Robert Walker
Hackwood Partnership Dr Steve Pratt, Dr Amanda Britton
Kingsclere Medical Practice Dr Alison Steare, Dr Sarah Bond
Oakley and Overton Partnership Dr Christian Chilcott, Dr David Bartlett, Dr Judith Lindsay, Dr Nicola Decker, Faye Collins Sally Bown
Odiham Health Centre Dr Anthony Weaver
Rooksdown Practice Dr Rachel Quew, Dr Radha Venkatraman, Jodie Blanchard
Tadley Medical Partnership Dr Kat Moir
Whitewater Health Beccie Van Oostrum, Dr Andrew Fernando, Dr Charlotte Hutchings, Dr Hugo Raveros, Terry Crame
Wilson Practice Dr Alison Rikard, Dr Andrew Fellows, Sharon Cox, Rosie Lewis, Claire Muir
Also in attendance Joanne Johnstone, Sally Beeko, Anna Davies, Elaine Campbell
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Contributors via the Practice Manager Forum, Practice Manager Commissioning Advisory Group (CAG)
Beggarwood Practice Davina Mason
Bentley Village Surgery Donna Mant
Bermuda and Marlowe Practice Wendy Lock
Boundaries Surgery Kevin Evans
Bramblys Grange Medical Practice Andrew Smythe and Jodie Blanchard
Camrose Medical Partnership Claire Shelbourn
Chawton Park Sirgeru Nicky Maule and Anthony Williams
Chineham Practice Emma Trimnell
Clift Surgery Sarah Roberts
Crown Heights Medical Practice Paul Butterworth
Gillies and Overbridge Health Centre Alex Woodruffe
Hackwood Partnership Amy Taplin
Kingsclere Medical Practice Win Harfield
Oakley and Overton Partnership Moira Clark
Odiham Health Centre Sue East
Rooksdown Practice PM vacancy
Tadley Medical Partnership Alison Jenner
Whitewater Health Beccie Van Oostrum
Wilson Practice Sharon Cox, Rosie Lewis
Contributors from NHS England (Wessex)
Julia Bagshaw Associate Director of Commissioning, NHS England (Wessex)
Olivia Falgayrac-Jones Head of Primary Care, NHS England (Wessex)
Melanie Smoker Primary Care Contracting Manager, NHS England (Wessex)
Other key stakeholder contributions
NH Alliance Dr Amanda Britton -NH Alliance Chief Clinical Executive, Dr Andy Cole – NHA Chairman Keith Crate and NHA Board Members
Public Health (Hampshire CC) Simon Bryant, Associate Director of Public Health
North Hampshire Urgent Care Dr Andrew Fernando, Felicity Green and Simon
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Better Local Care MCP James Lawrence Parr
Council Representatives
Basingstoke and Deane Borough Council
Councillor Clive Saunders - Leader of Basingstoke and Deane Borough Council – Keynote Speaker Primary Care Strategy Away Day Chas Bradfied, Head of Borough Development and Implementation Marion Short, Wellbeing and Community Manager, Basingstoke and Deane Borough Council Karina Hutfield-Christiansen, Social Inclusion Manager, Basingstoke and Deane Borough Council
Hart District Council Liz Glenn - Health and Policy Project Officer, Hart District Council, Hart District Council
Health and Wellbeing Board Committee Members
North Hampshire CCG Patient Participation Group Members
Siobhan Genovese Beggarwood and Rooksdown PPG
Derek Gurney and Sally Stoodley
Wilson Practice PPG
Sue Davis Bramblys Grange PPG Elizabeth Brock Chawton Park PPG
Naj Qadri Hackwood PPG Gillian Tomlins and Paul Woodgate (Chair)
Tadley PPG
Dennis Thomas Boundaries PPG Ian Cameron Kingsclare PPG
Brian Simmonds Camrose PPG Josephine Childs Chineham PPG
A Forward and Ian Cameron Kingsclere PPG Moira Whittaker Crown Heights PPG
David Woodward Odiham PPG Ann-Marie Fawson and Barbara Herneman
Whitewater PPG
Jon Darker and Bryan Jenkins Clift Surgery PPG Basingstoke Nepalese Community representatives
Chrysalis
Alton Programme Stakeholder Group
Anstey Brierley, Claire Hughes, Deborah McCallum, Derek Gurney, Elizabeth Brock, Emma Potter, John Bird, Libby Thomas, Lisa Martin, Lottie Fellows, Nicky Maule, Olwen Long, Pauline Folkes, Peter Kelly, Rosie Lewis, Sally Stoodley, Tim Houghton, Wendy Shone
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Meetings/sessions where contribution to the content of the strategy has been sourced
3 March 2016 Joint Primary Care Committee
22 March 2016 Alton Review Programme Team
7 April 2016 Alton Review Model Workshop (Part 1)
8 April 2016 Primary Care Strategy Review with NHS England (Wessex)
12 April 2016 Alton and District Residents Association (ADRA)
13 April 2016 General Practice Away Day – The Ark
13 April 2016 NH CG Patient Participation Group – Primary Care Strategy Session
14 April 2016 CCG Clinical Executive – PC Strategy Focus
21 April 2016 Alton Review Model Workshop (Part 2)
28 April 2016 Hampshire County Council Public Health – JSNA and Primary Care
3 May 2016 Practice Managers Commissioning Advisory Group
4 May 2016 Basingstoke and Deane Borough Council
6 May 2016 Alton Programme Review Board
11 May 2016 Digital Transformation Event – NHS England
12 May 2016 North Hampshire Alliance Away Day
16 May 2016 Whitewater Health, Hook
18 May 2016 Bramblys Grange Medical Centre, Basingstoke
19 May 2016 Joint Primary Care Commissioning Committee
23 May 2016 Hook Hartney and Wintney Partnership Meeting
26 May 2016 Practice Manager Event (LMC), Centre Parcs
3 June 2016 Practice Manager and NH CCG Joint Forum
8 June 2016 NH CCG PPG Group - Update
14 June 2016 Crown Heights Partnership Meeting
21 June 2016 NH CCG LEAP Meeting
23 June 2016 The Wilson Practice Partnership Meeting
28 June 2016 NHS England Wessex Primary Care Transformation Group
30 June 2016 Basingstoke Area Strategic Partnership Visioning Workshop
5 July 2016 South Central Commissioning Support Unit Workshop – IPA
11 July 2016 Alton Practice Patient Participation Groups – PC Strategy Update
14 July 2016 Hart Council Health and Wellbeing Board
19 July 2016 NHS England Wessex Primary Care Commissioning Forum
25 July 2016 Chineham Medical Practice Partnership Meeting
28 July 2016 Health Education England Strategy Meeting
3 August 2016 Basingstoke and Deane Borough Council
4 August 2016 Provider Stakeholder Workshop – Primary Care Strategy Development
4 August 2016 NH CCG Management Team Workshop – Primary Care Strategy Development
4 August 2016 Joint Primary Care Commissioning Committee
24 August 2016 Bermuda and Marlowe Practice Partnership
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Appendix 5 - CCG Report – July 2016 GP Patient Survey
Background
One of the key aims of the primary care strategy is to realise accessible, high quality and equitable primary care services for all of our
patients across the North Hampshire CCG area. The GP patient survey continues to be one of the key sources for capturing real
time feedback outlining what patients experience when they visit their local practices and what they need from their local primary
care providers.
Compared to nationally, our practices need to be congratulated on achieving steady improvement and in most areas high levels of
achievement. Several 201628 figures show improvement from 2015 but there are still a few areas which require further work. The
results provide the CCG and our constituent member practices with a picture of where further improvements can be made to reduce
the gaps to support equity. We will work with the exemplar practices and those who have experienced a few challenges this year to
address variation and share best practice.
This summary below works to capture the key themes and highlights coming out of this year’s patient survey. We will work with the
practices to understand the story behind these results – especially where there may be workforce issues, challenges with patient
expectation and capacity pressures around appointments, telephone access and providing on line services in particular. This report
will be discussed with representatives from the practice management forum and the CCG clinical executive.
Introduction
In NHS North Hampshire 4,808 questionnaires were sent out, and 2,254 were returned completed. This represents a response rate
of 47%. It is important to note the overall high level of performance demonstrated by North Hampshire Practices – just a fraction off
the upper performance band. In view of the current challenges and increasing levels of demand on general practice this should be
celebrated!
28
https://gp-patient.co.uk/slidepacks/July2016
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The survey measures patient experience with a focus on making appointments, waiting times, perceptions of care at their
appointments, opening hours and their experience of out of hours. NHS England advises triangulating the results with other sources
of feedback (patient participation group experience, friends and family test results and local surveys to give a clearer picture of the
patient journeys.
The summary report and wider slide back results will be used to look at:-
The comparison of our CCG results against the national average
Analysing trends in a CCGs results over time
Considering questions where there is a larger range in responses - both practices and CCGs
Comparison of practice results within the CCG – with the aim of working with those practices to identify both best practice and areas for improved performance.
There are 51 slides in the CCG Survey pack for 2016. We have opted to review the significant outlying areas for the CCG – looking
at seven of the areas identified for further improvement, support and investment.
These areas of focus include:-
Overall experience of the GP surgery
Ease of getting through to a GP surgery on the telephone
Awareness of on-line services
Success in getting an appointment
What patients do when they are unable to get appointment or are offered an inconvenient appointment
Satisfaction with opening hours
Overall experience of out of hours services
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Overall experience of the GP surgery
This result shows that although the CCG is above the national average at 88% and a slightly lower national figure for poor
experience at 4% there are still a 27% gap between the highest achieving practice and the lowest. In respect of other CCGs our
percentage of lower achievement is 71% compared with 81% nationally.
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The supporting heat map to Q28 above shows the differences in variation of the services patients are experiencing – with a
significant majority reporting 86% or higher for “good” but between 70% and 84% demonstrating room for improvement.
The CCG will work with the highest performing practices to identify what lessons can be learned from best practice and with those
within the lower percentage threshold to see what improvements can be made and what support should be provided. The heat map
below identifies individual practices and will be used to prioritise discussions.
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The map demonstrates that the significant challenges are being faced predominantly in Basingstoke town – with several exemplars
working from smaller, rural practices – we will need to do more comparisons within ICT areas to understand stories behind the
statistics and how outcomes relate to other pressures such as accessibility, on the day appointment availability, workforce pressures
and patient education
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Ease of getting through to the GP surgery on the telephone
This map clearly demonstrates the differences between the practices in terms of reported outcomes for telephone access. There are
six practices below the CCG average and five below the national average – the majority of which are major town practices where
capacity pressures and demand is already producing real challenges – and where the primary care strategy is focusing resilience
support – but also pressure being felt in towns such as Alton – where pockets of deprivation and ageing populations as well as new
housing developments continue to put additional pressure on the system. We will be discussing best practice with the exemplar
practices and looking at continued ways of supporting our pressurised practices – which includes patient education and
communication support as well as resilience support.
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Awareness of online services
The CCG is committed to developing digital technology – and our IM&T strategy includes current and future plans for supporting
online services. The above chart shows that although the percentage of online services available across North Hampshire is, in all
but one domain, higher than the national average – there is still some work to do to give patients confidence about what is available.
Under the GMS contract all practices should now be offering online booking facilities but some practices found that introducing SMS
text messaging alongside online booking reduces this significantly, Again we will work with the practices to share best practice and
address challenges. Patient awareness of what is on offer needs to be raised – reducing the “don’t know” percentage for the next
survey round being one area where the CCG/practices can focus.
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Online service use
Building on the previous slide, this demonstrates that there is a significantly lower percentage of awareness for North Hampshire
patients of using on line services (6% lower than the national average reporting they do not use the services). As on line booking is
now a contractual requirement this should now continue to get higher, although using ordering ln line to request prescriptions is very
much higher than the national average. Accessing medical records is still low and needs further work – the introduction of EMIS web
for all practices will work to facilitate this improvement.
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Success in getting an appointment
Since 2013 there has been a 4% drop across the CCG area in the patients being able to see or speak to a GP or nurse in the
surgery – ie were they able to get an appointment or speak to a member of the practice team. This supports the direct feedback we
are getting from practices about the significant increased demand and the national statistics which say that patient demand is up by
10% since 2014. However the figures are very similar to the national figure but slightly less than the 90% recorded across Wessex.
Understanding what is making access to appointments more challenging needs to be assessed and ideas gained from the exemplar
practices again to inform best practice.
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There are nine practices below the CCG and the national average for securing appointments and again these are predominantly
Basingstoke town practices – reinforcing the need for more capacity to address the growing population. We will look for best practice
from the top three practices but equally work with the nine practices to see what support is needed to enable patients to make
appointments more easily – we also need to triangulate the data with other intelligence from the friends and family test, PPGs and
local intelligence from the practices themselves.
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What patients do when they are unable to get an appointment or one that is convenient
This graph is helpful because it shows us what patients tend to do when they cant get an appointment – just over half either took the
appointment offered or waited for another with a further 17% making use of telephone consultations. We can clearly see the under-
utilisation of seeking non urgent help from a pharmacist – this needs to be a service that is developed to work seamlessly with
general practice and be a first port of call for minor ailments and injuries where this service is commissioned.
The two areas that are of real concern are the 13% who did nothing which may leave untreated conditions which can lead to
undiagnosed problems which present later much more acutely and the 2% A&E which contribute to the increasing number of A&E
attendances across the area. The CCG are already prioritising assessing A&E attendance with front door primary care being
available for those patients, but equally we need to see improvements for the outlying practices where getting an appointment
continues to be challenging for their patients.
Satisfaction with opening hours
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The CCG’s practice statistics for opening hours mirrors the national statistics but does show a significant 7% deterioration since June 2013. This could be a reflection that not all practices are offering extended access – a priority for the CCG for the next 12 months, for NHS England and for patient groups. We also need to understand why patient perception has changed by such a significant margin over the past three years and learn from the exemplar practices – again supporting those practices who struggle with capacity to remain open at times when patients say then need their services.
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Overall experience of out of hours services
In this area the CCG statistics are virtually the same as the national figures showing satisfaction with OOH service provided for
patients although there is significant room for improvement. 9% have reported the experience as “poor” and we will work with our
OOH provider to assess and work to improve these figures
As part of the development of both the primary care and urgent care strategies, As a previous local GP co-op and supported by
many of the clinical leaders from the area the service does deliver coordinated and higher quality care but there is clearly
improvements to be made – particularly by communicating with the patients and the public about the service offered – to ensure it is
fully utilized and keeps patients away from the A&E front door. This information will be shared with our OOH provider and work done
to identify how patient and public awareness of the service and collaboration with practices can be further supported.
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Appendix 7 – Definitions: New Models of Care
One of the key challenges to primary care in the Five Year Forward View was for local health economies to establish a vision for delivering new models of care for patients, especially those with long term conditions – seeing the division between secondary care, community services, mental health services and primary care reducing – actively encouraging collaboration between service providers in an attempt to deliver personal, coordinated and seamless care. But this vision presents us with challenges, not least the requirement to invest in prevention, facilitate collaboration and invest where needed whilst avoiding conflicts of interest.
The Five Year Forward View acknowledges that new models of care will only happen through active engagement with primary care. To support sustainability, new models of care will add capacity and enable working at scale to remove the pressure from traditional ways of working. Below is a summary of what these new models can look like:-
Multi-speciality Community Providers (MCPs)
What they are How they could work
Greater scale and scope of services that dissolve traditional boundaries between primary and secondary care
Targeted services for registered patients with complex ongoing needs (e.g. the frail elderly or those with chronic conditions)
Expanded primary care leadership and new ways of offering care
Making the most of digital technologies, new skills and roles
Greater convenience for patients
Larger GP practices could bring in a wider range of skills – including hospital consultants, nurses and therapists, employed or as partners
Shifting outpatient consultations and ambulatory care out of hospital
Potential to own or run local community hospitals
Delegated capitated budgets – including for health and social care
By addressing the barriers to change, enabling access to funding and maximising use of technology
North Hampshire CCG are already working with the Better Local Care MCP and the North Hampshire Alliance to explore innovative ways of supporting the development the MCP model locally. In other areas MCPs are already:-
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Employing nurse practitioners and other specialist nurses, medical consultants, geriatricians, psychiatrists, and other senior secondary care specialists to work alongside groups of community nurses, physiotherapists, IAPT specialists, pharmacists etc to redesign and deliver out of hospital care pathways
Managing the majority of outpatient consultations and ambulatory care out of hospital
Taking e over the management and provision of community hospitals
Taking on delegated responsibility for their associated health care budget for their registered patients collaborating with the local council to combine health and social care investment.
Actively working with the third sector, carers and patient user groups and patient champions to adopt new ways of working.
Primary and Acute Care Systems (PACS) Other new models of care include integrated primary and acute systems – (PACS) joining up general practice, hospital, community and mental health services which are already being delivered in more than 12 areas across the country where GP federations have been established and are collaborating with other healthcare providers – additional funding being provided by NHS England to establish vanguard sites to pilot these new models. The PAC model can be summarised as
A new way of vertically integrating services
Increased flexibility for foundation trusts to use investment and surplus funding to kick start the expansion of primary care]Use contractual changes to enable hospitals to provide primary care services in some cases
PACS could take accountability for all health need for a registered list Enhanced health in care homes
Developing in reach support and services through a partnership model which sees social care and health working directly with care homes. Emergency and Urgent Care Networks
Exploring the development of seven day GP services and in hours urgent care is a priority. The re-procurement of NHS 111 and out of hours will include a focus on strengthening emergency and urgent care networks across our patch - providing more appropriate use of and referrals to A&E services, community mental health outreach teams, the local Ambulance Service and in hours urgent care access to primary care.
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Appendix 8 - General Practice Forward View- Key themes and current delivery
GPFV Theme Policy Commitments National Actions NHS England Local Delivery CCG Delivery
Investment Additional allocation Review of Carr Hill formula
Increased indemnity costs
Contract sums recalculated to reflect increased investment
Impact on PMS review calculated
PMS reinvestment plan
Indemnity being explored for additional OOH commitments with NHUC/NH Alliance
Primary Care Investment aligned against QIPP schemes that move care closer to home
Sustainability and Transformation Package
Practice Resilience programme
Workforce growth
CCG investment
BCF investment in general practice?
STP to include plans for general practice
Vulnerable practice scheme development of diagnostic tool
Transformation bid made for clinical leadership
Transformation opportunities identified for 2017 commissioning intentions
Transformation schemes open to individual practices
Workforce
Double rate of growth of medical workforce by 2020
Increase GP training recruitment
National ambassadors and advocates for general practice
Bursaries for hardest to recruit training place areas
250CCT fellowships in areas of poorest recruitment
Incentives for IOW training places 16.17
Local Wessex fellowship scheme already in place, unlikely to attract national CCT.
Returner scheme builds on local pilot from 14-16
Incentives to return for areas of greatest need – 12 incentives available across south
Practices not able to offer returner scheme places currently
Working with HEE South to identify priorities for NH.
Working with Queens Institute to support PNs and develop mentors
Support given to teaching practices for
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Increase funding for retainer placements
Attract and retain 500 GPs
Flexible working arrangements
Indicative Locum rates
Training hub in Dorset estate investment
Clinical leadership programme to address sustainability in the workforce
Minimum 5k other staff in general practice by 20/21
3000 mental health therapists
Expansion of clinical pharmacist in practice scheme
Pharmacy integration fund
General practice nurse development
Training for reception staff to care navigate
HEE to train 1000 physician associates
Pilots of medical assistant roles
Practice manager development
Southampton GP access scheme piloting an approach to mental health workers
3 clinical pharmacy pilot schemes in wave one in Wessex
care navigator pilots in Gosport
joint local oversight with HEE
GP in care home scheme being developed
JET teams being developed alongside ICTs to strengthen out of hospital workforce
Community pharmacists in general practice scheme
Practice management scheme to be promoted via Wessex LMC
Health and well being Additional investment in specialist mental health service to support GPs
Working with local MCP to explore hosting of pilot MH workers in General practice
Workload Management of demand, diversion of unnecessary work. Reduced bureaucracy
Releasing time for patients development programme
Measures in standard NHS contract re interface issues
5 yearly CQC inspections for most practices
Streamlining payment
CCG commissioning of local pathways in community pharmacy eg minor ailments.
Increase use of electronic prescription services
Vulnerable practice scheme, use of reflection and 360 tool once tested can be expanded
Developing Community Pharmacy in Care Homes and GPs in care homes to support capacity.
Working with NHS England to support vulnerable practices
Capacity review of
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processes
National review of QOF
LMC proposal to support resilience may chime with ‘resilience team’ approach
Close working with CQC to assure quality
commissioned community nursing ensuring ICT development supports workload pressures
Working with the NH Alliance and other providers to realise new models of care and working at scale within primary care
Increased integration in health and care system
Better communication between consultants and GPs
Testing ways to manage outpatient demand, consultant advice etc
Improved functionality of ‘choose and advice’
Accelerate paper free at point of care
Work with voluntary sector
Social prescribing
Digital roadmaps opportunity to flag local direction
Interoperability acceleration
GP access fund sites testing appointment ‘measuring’
Gosport volunteer navigators
IM&T and estates strategy developed to support integration including single patient record, single clinical system and ICT development
Development of social prescribing locally
Development of seamless integrated frailty pathway
Practice Infrastructure Estate Continued investment of capital in estate priorities
Changes to premises costs restrictions
Support for NHSPS tenants
Support for facilities costs for NHSPS and CHP tenants
Local development of SEP and prioritisation of primary care estate improvement
South region PMO in place to support implementation
Encourage health centre tenants to sign lease arrangements
Work with CCGs to ensure consistent approaches to application of flexibilities in reimbursements
Bids submitted to the ETTF for local infrastructure fund, Basingstoke feasibility programme and expansion of estate in Hook, Hart and Wintney
Successful outcome of infrastructure bids for Chineham and Gilles
Technology Increased allocations to CCGs for GPIT
CCG plans for ‘web GP’ systems
Bids submitted for GP system investment
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Investment in on line consultation systems
New core requirements for GPIT
Increase usage of online booking, repeat prescribing etc
17-18 Wi-Fi and further GPIT support including shared telephony
Interoperability strategy
Op plan commitments to practice based remote access to records
Outbound SMS messaging supported by CCGs
Improve oversight of utilisation by CCGs
Learn from practices who already offer Wi-Fi
Evaluate impact of VPN in NF GP access scheme
Transforming delivery at practice level to benefit from IT developments including telephony
via the ETTF to support single patient record delivery, Web GP and integrated care records and improved access
All practices now moved/moving to EMIS web.
Care Redesign Strengthen and redesign general practice
Extended access evenings and weekends- primary care hubs
CCGs investment to support transformation
New MCP contract
2 x GP access schemes early adopters
Potential sites built around vanguards ?early adopters from MCP contract
Support for collaborative approaches to change to strengthen collective working
Alignment to Better Local Care and MCP development
Extended access pilot to be developed with DES underspend and transformation funding
ICT and JET programmes to support integration
Releasing time for patients programme
Innovation spread
Service redesign
Capability building
HEE/AHSN primary care project link?
CCG support for protected learning eg TARGET
Local support for federation development
STP to include approach to provider development
Part of MCP/Better local care working to improve patient outcomes
Transformation of local pathways including diabetes, MSK, dermatology, leg ulcers
Primary Care Incentive Scheme including protected learning time and clinical forums
Support for provider
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development locally
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Glossary of Terms
A&E Accident and Emergency LES Local Enhanced Service
ACS Ambulatory Care sensitive LETB Local Education and Training
AF Atrial Fibrillation LIFT Local Improvement Finance
APMS Alternative Provider Medical Services LTC Long Term Conditions AQP Any Qualified Provider MCP Multispecialty Community Provider
BLC Better Local Care MCP MEAM Making Every Adult Matter
BME Black and Ethnic Minority MH Mental Health
BNC Basingstoke Nepalese Community MSK Musculo-Skeletal
CAMHs Child and Adolescent Mental Health NHS National Health Service
CBT Cognitive Behavioural Therapy NHSE National Health Service England
CCG Clinical Commissioning Group NHSPS National Health Service Property Services
CEC Clinical Executive Committee NICE National Institute for Clinical Excellence
COPD Chronic obstructive pulmonary disease OBC Outlying Business Case
CQUIN Commissioning for Quality and Innovation ONS Office for National Statistics
CSU Commissioning Support Unit OOH Out of Hours
CVD Cardiovascular Disease OPD Out Patient Department
DES Directed Enhanced Service PACS Primary and Acute Care System
ECIP Emergency Care Improvement Programme PMS Personal Medical Services
EMIS Egton Medical Information System PRISM Predicted Risk Stratification Model
EOLC End of Life Care PROMS Patient Reported Outcome Measures
FTE Full Time Equivalent QIPP Quality Innovation Productivity and Prevention
GMS General Medical Services QOF Quality Outcomes Framework
GP General Practitioner RAG Red, Amber, Green
GPwSI General Practitioner with a Special Interest SCAS South Central Ambulance Service
HbA1C Glycerated Haemoglobin SLA Service Level Agreement
HCA Health Care Assistant SMI Severe Mental Illness
HHFT Hampshire Hospitals Foundation Trust TBC To be confirmed
IM&T Information Management and Technology TOR Terms of Reference
JSNA Joint Strategic Needs Assessment UCC Urgent Care Centre
KPI Key Performance Indicator VTS Vocational Training Scheme
LAT Local Area Team
LEAP Link Engagement and Participation Committee
