Public Meeting of the South West Lincolnshire Clinical Commissioning Group (CCG) Primary Care Commissioning Committee

Transcription

1 Public Meeting of the South West Lincolnshire Clinical Commissioning Group (CCG) Primary Care Commissioning Committee To be held on Wednesday, 15 March am Glen Room, SKDC, Grantham NG31 6PZ

2 PRIMARY CARE COMMISSIONING COMMITTEE South West Lincolnshire CCG will meet on Wednesday, 15 March am Glen Room, South Kesteven District Council offices, St Peter s Hill, Grantham NG31 6PZ Chair Mr A Burton, Lay Member - Patient and Public Involvement Meeting Number 13 Standing Items A G E N D A Enclosure/ Verbal Lead 1. Welcome and introductions Verbal Mr A Burton 2. To receive apologies for absence Verbal Mr A Burton 3. To receive any declarations of pecuniary and non-pecuniary interests and conflicts of interest 4. To consider and approve the minutes of the last meeting held on 18 January 2017 Verbal Enclosure Mr A Burton Mr A Burton 5. To consider matters arising from previous minutes and Action Log Enclosure Mr A Burton Quality 6. To receive an update from the Chief Nurse, including CQC Reports. Performance and Finance Verbal Mrs P Palmer 7. To receive the monthly Finance Report Enclosure Miss J Wright Strategy and Policy 8. To receive an update from Dr Sue Marris, Lead Mentor, GP Wellbeing Scheme-Mentorship programme. Verbal Mrs P Palmer / Dr S Marris 9. To receive an update on the 2017/18 GMS Contract changes Verbal Mr A Audis 10. To receive the General Practice Forward View (GPFV) Plan Stage Two Submission 11. To receive an update on the Primary Care Commissioning Committee revised Terms of Reference 12. To receive the Draft Primary Care Commissioning Committee GP Lay Member job description Primary Care Contracting NHS England Enclosure Verbal Enclosure To Follow Mrs C Raybould Mrs J Ellis- Fenwick Mrs J Ellis- Fenwick 13. To receive an update from NHS England Verbal Mr A Audis For Information

3 14. To consider any potential risks identified during the meeting Verbal All Date, Time and Venue of the next meeting 15. The next meeting will be held on Wednesday, 17 May 2017, in The Glen Room, South Kesteven District Council offices, Grantham NG31 6PZ from am. The items on this agenda are submitted to the Primary Care Commissioning Committee for discussion, amendment and approval as appropriate. They should not be regarded, or published, as organisation policy until formally agreed. Papers are available on the NHS South West Lincolnshire website: In case of difficulty accessing the papers, please contact Jules Ellis-Fenwick, Corporate Secretary/Manager on (via at The Primary Care Commissioning Committee will be asked to consider the following resolution:- That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest. Section 1(2) Public Bodies (Admission to Meetings) Act 1960) Items in the private part of the meeting are either commercial in confidence or relate to individual staff and patients Jules Ellis-Fenwick, CCG Corporate Secretary/Manager

4 Subject to approval by the PCCC at its meeting on 15 March 2017 MINUTES OF THE SOUTH WEST LINCOLNSHIRE CLINICAL COMMISSIONING GROUP PUBLIC SESSION OF THE PRIMARY CARE COMMISSIONING COMMITTEE HELD ON WEDNESDAY, 18 JANUARY 2017 AT 10.45AM IN THE WITHAM ROOM, SOUTH KESTEVEN DISTRICT COUNCIL, ST PETER S HILL, GRANTHAM NG31 6PZ PRESENT: Dr Raghu Ramaiah Mr Andrew Burton Mr Graham Felston Mr Allan Kitt Mrs Pamela Palmer Mrs Paula Pilkington Mrs Clair Raybould IN ATTENDANCE: Mr Adrian Audis Miss Karen Bates Mrs Christine Cobham Mr Mike Hill Miss Jen Rousseau APOLOGIES: Mrs Julie Ellis-Fenwick Cllr Sue Woolley Miss Jo Wright Secondary Care Doctor, Clinical Lay Member, SWLCCG (Chair) Lay Member, Patient and Public Involvement, SWLCCG Lay Member, Governance, SWLCCG Chief Officer, SWLCCG Chief Nurse, SWLCCG Deputy Chief Finance Officer, SWLCCG Chief Commissioning Officer, SWLCCG Assistant Contract Manager, NHS England Team Secretary, SWLCCG Quality Lead, SWLCCG Healthwatch Representative Corporate Assistant and Office Manager, SWLCCG (minutes) CCG Corporate Secretary/Manager, SWLCCG Chair of the Health and Wellbeing Board, Lincolnshire County Council Deputy Chief Officer, SWLCCG 16/54 WELCOME AND INTRODUCTIONS Dr Ramaiah welcomed all those present to the meeting. All those present introduced themselves. Dr Ramaiah confirmed the meeting was quorate. 16/55 DECLARATIONS OF PECUNIARY AND NON PECUNIARY INTERESTS AND CONFLICTS OF INTEREST There were no declarations of interest received and no conflict of interests declared in relation to items on the agenda. 16/56 MINUTES OF THE PREVIOUS MEETING The minutes of the previous meeting held on 16 November 2016 were presented. Mr Felston queried if the Billinghay Surgery Care Quality Commission (CQC) visit took place, page 2 Item 16/48. Mrs Cobham confirmed that it had taken place on 29 November 2016 but as yet no report had ben received. The PCCC agreed to: Approve the minutes as a true record. 1

5 Subject to approval by the PCCC at its meeting on 15 March /57 MATTERS ARISING FROM THE PREVIOUS MINUTES AND ACTION LOG Dr Ramaiah presented the Action Log as at January There were four actions included, all of which were listed as in progress. 16/51 Mrs Raybould will send the Sleaford and Grantham plans to Mr Burton Action: Mrs Raybould 16/50 Mrs Raybould advised that Mrs Ellis-Fenwick had sourced a job description from a neighbouring CCG and that this had been discussed at a recent CCG Senior Team meeting. The sample job description did not stipulate that the role was specifically for a GP member of the Primary Care Commissioning Committee. Mrs Ellis-Fenwick would be amending the job description and an update will be provided at the March PCCC. Action: Mrs Ellis-Fenwick 16/41 Miss Rousseau to organise a convenient time for Dr Ramaiah and Mrs Ellis-Fenwick to meet to discuss virtual options for paper distribution. Action: Miss Rousseau 16/40 Mrs Pilkington advised that the Memorandum of Understanding was received in December. This had not yet been distributed to the committee. Action: Miss J Wright/Mrs Pilkington The PCCC agreed to: Note the Action Log and verbal updates. 16/58 CHIEF NURSE UPDATE Mrs Palmer provided an update on the current Status of SWLCCG GP Practices CQC visits and reports and the main points to highlight were: Billinghay Surgery had their initial CQC visit, report not yet received. Glenside Country Practice had their re-visit, report not yet received. Practice visits have taken place at Sleaford Medical Group; Belvoir Vale; Billinghay; Glenside Country Practice and New Springwells. Mrs Palmer confirmed that there were no major concerns raised at these visits any challenges are being followed up by the Quality team. The PCCC agreed to: Note the report and verbal update. 16/59 MONTHLY FINANCE REPORT Mrs Pilkington presented the month nine Finance Report and highlighted the main points: The actual spend as at month nine is 335k under budget with a forecast outturn position of 447k under budget. The 16/17 budget of 18,782k aligns to the CCGs allocation. The under spend is being used to offset other CCG expenditure pressures. Internal audit are reviewing primary care commissioning as part pf the internal audit programme. Mrs Pilkington will bring the feedback to the PCCC when this has been completed. The PCCC agreed to: Note the report and verbal update. 2

6 Subject to approval by the PCCC at its meeting on 15 March /60 PRIMARY CARE COMMISSIONING COMMITTEE TERMS OF REFERENCE Mrs Raybould advised that the PCCC Terms of Reference (ToRs) had been reviewed by the Senior Management Team and that they would be presented at the February Governing Body meeting for approval. The PCCC agreed to: Note the verbal update. Post meeting Mrs Ellis-Fenwick confirmed that the ToRs would be circulated to the PCCC once approved at the Governing Body meeting in February. 16/61 UPDATE FROM NHS ENGLAND Mr Audis advised that the National E-declaration process had been completed December 2016 and that colleagues in the NHS E team were now working through the practice submissions. The key areas of concentration would be access and opening hours. The Committee acknowledged that there had been two proposed practice mergers discussed in the Private Session of the PCCC held prior to this meeting. The outcome of those discussions were shared for noting: The PCCC had agreed to: Proposed Merger of Welby and Belvoir Vale surgeries, it was agreed to go out to public consultation for a period 45 days. Proposed Merger of Stackyard and Woolsthorpe surgeries, it was agreed to go out to public consultation for a period 45 days. 16/62 POTENTIAL RISKS IDENTIFIED DURING THE MEETING The Primary Care Commissioning Committee considered whether any new risks had been identified during the meeting, and agreed that any issues identified were covered through existing risks. 16/63 DATE, TIME AND VENUE OF THE NEXT MEETING The next meeting will be held on Wednesday, 15 March 2017 at 10.45am in the Witham Room, South Kesteven District Council offices, Grantham NG31 6PZ 3

7 South West Lincolnshire CCG Primary Care Commissioning Committee Action Log As at: March 2017 Complete In progress Outstanding PCCC Action required By whom By when Status meeting / Item Ref 16/51 Mr Raybould to send Mr Burton a copy of the Mrs C Raybould Next meeting In progress Sleaford and Grantham plan. 16/50 Mrs Ellis-Fenwick to revise the job description for the recruitment of a GP member for the PCCC and to provide an update at the next meeting. 16/41 A meeting to be arranged for Dr Ramaiah and Mrs Ellis-Fenwick to look at low cost suggestions for sharing meeting papers and for having virtual discussions for all committee members. 16/40 Miss Wright to see the revised MoU that Mrs Pilkington has received from NHSE and then distribute to the Committee. Mrs J Ellis- Fenwick 15 March 2017 In progress Miss J Rousseau 15 March 2017 In progress Miss J Wright/Mrs P Pilkington Next meeting In progress

8 SOUTH WEST LINCOLNSHIRE CCG PRIMARY CARE COMMISSIONING COMMITTEE Date of Meeting: 15 th March Public Agenda item: 7. Title of Report: Report Author and Title: Appendices: Primary Care Commissioning Committee Finance Report Month 10 Jo Wright Chief Finance Officer 1. Purpose of the Report (including link to objectives) The Finance report gives the latest information on the financial position of South West Lincolnshire CCG primary care commissioning spend to the end of January The report includes a forecast position to the end of March Recommendations The Primary Care Commissioning Committee is requested to receive the report. 3. Executive Summary 1. Background For 2016/17, Payments to primary care are transacted via CCG ledger i.e. NHSE are not transacting payment on our behalf. The current hub arrangement with NHSE will continue for 2016/17 with a timely review during the year to support 17/18 governance intentions thereby for this year NHSE continue to provide support for the analysis and to be a conduit for primary care queries. 2. Allocation The table below summarises the allocation updates during the year which are included within the monthly finance report to Governing Body. There are no changes to the allocation reported in month 9 PCCC Finance report Allocation Description 3. Summary Financial Spend against Budget Month of Adjustment Recurrence '000 Month 9 reported Allocation Recurrent 18,782 No Adjustment 0 Total Month 10 Allocation 18,782 The table below provides a summary of all transactions for primary care commissioning for the Month 10 cumulative period to date i.e. April 2016 and forecast until end March

9 The actual spend at month 10 is 353k under budget with a forecast outturn position of 423k under budget. This is minimal movement to the forecast position reported in the month 9 report. The 16/17 budget of 18,782k aligns to our allocation. The under spend is being used to offset other CCG expenditure pressures. 4. Other Updates Internal Audit have completed their review of primary care commissioning as part of the internal audit programme. The report is awaited and shall be available for the Audit Committee in March Findings and recommendations from the report shall be highlighted at the next Primary Care Commissioning Committee. 4. Management of Conflicts of Interest No anticipated conflicts of interest. 5. Finance, QIPP and Resource Implications No additional issues to report. 6. Legal/NHS Constitution Considerations This is part of the risk assessment. 7. Analysis of Risk including Assessments This paper is focussing on supporting the update to the risk register Please state if the risk is on the CCG Risk Register. No 8. Outline engagement clinical, stakeholder and public/patient These are outlined within the report. 9. Outcome of Impact Assessments This will be part of the review of risk assessment. 2

10 10. Assurance Departments/Organisations who will be affected have been consulted For information report Finance Commissioning Contracting Medicines Optimisation Clinical Leads Quality Safeguarding Other X 11. Report previously presented at: None 12. For further information or for any enquiries relating to this report, please contact Paula Pilkington, Deputy Chief Finance Officer, paula.pilkington@southwestlincolnshireccg.nhs.uk 3

11 PRIMARY CARE COMMISSIONING COMMITTEE MEETING Date of Meeting: 15 March Public Agenda item: 10. Title of Report: Report Author and Title: Appendices: General Practice Forward View (GPFV) Plan Stage Two submission. Clair Raybould, Acting Chief Operating Officer and Shona Brewster, Acting Head of Commissioning South West Lincolnshire CCG GPFV Plan v6 1. Purpose of the Report (including link to objectives) The Primary Care Commissioning Committee is receiving the General Practice Forward View (GPFV) Plan Stage Two submission for information and comment. 2. Recommendations The Primary Care Commissioning Committee is being asked to note the plan and progress to date. 3. Executive Summary CCG s that have delegated authority for Primary Care Commissioning were requested to produce a draft plan for GPFV by 23 February The GPFV has been discussed at the CCG s Members Council but has had limited input from Primary Care in producing a first draft. However, the content around the plan is in alignment with the CCG s Operational Plan and the STP and both of those plans have been signed off by the organisation. Officers have been working with elected members of the Executive Committee to form a GPFV workshop session to discuss some of the finer details of the plan before any subsequent submissions or decisions are made. The GPFV guidance is available at: 4. Management of Conflicts of Interest All Members have a Conflict of Interest for Primary Care Commissioning by the fact that they hold contracts for Primary Care. These are included on the CCG s Declaration of Interest registers. 5. Finance, QIPP and Resource Implications All financial implications have been modelled through in the Operational plan for the CCG. Allocations for future years will be part of the workshop discussions. 6. Legal/NHS Constitution Considerations None identified at this stage. 1

12 7. Analysis of Risk including Assessments No known additional risk that what are already listed in the risk register, the Primary Care Commissioning Committee involvements mitigates risk. 8. Outline engagement clinical, stakeholder and public/patient All public and patient feedback collated at engagement listening events have formed a basis for the plan. 9. Outcome of Impact Assessments Not applicable. 10. Assurance Departments/Organisations who will be affected have been consulted Insert details of the departments you have worked with or consulted during the process: Finance Commissioning Contracting Medicines Optimisation Clinical Leads Quality Safeguarding Other NHS England as cocommissioner x x x x x x 11. Report previously presented at: Item 8 GPFV update Primary Care Commissioning Committee 15 June For further information or for any enquiries relating to this report, please contact Clair Raybould clair.raybould@southwestlincolnshireccg.nhs.uk 2

13 South West Lincolnshire Clinical Commissioning Group General Practice Forward View Plan Stage Two Submission 1

14 Contents Page 1 Purpose & Context 2 Introduction 3 Vision 4 Model of Care 5 Access 6 Workforce 7 Workload 8 Infrastructure 9 Investment 10 Leadership, governance and programme arrangements Appendices 2

15 1. Purpose and Context The purpose of this document is to set out South West Lincolnshire Clinical Commissioning Groups implementation plan for the General Practice Forward View (GPFV). The sections of this document follow the format of the NHSE Planning Guidance - GP Forward View. The plan should be read alongside the full Joint Lincolnshire Operational Plan and the Sustainability and Transformation Plan. Milestones tables have been included within this document to support the submission. The GPFV, published on 21 April 2016, sets out investment and commitments to strengthen general practice in the short term and support sustainable transformation of primary care for the future. It includes specific, practical and funded investment in five areas investment, workforce, workload, practice infrastructure and care redesign. On 22 September 2016 NHSE published the NHS Operational Planning and Contracting Guidance , this included technical Annex 6 General Practice Forward View (GPFV) planning requirements. Further guidance was published by NHSE on Friday 9th December setting out that GPFV plans were required in two stages comprising of initial draft narrative plans in December followed by more detailed plans with planning trajectories in February Lincolnshire STP has four CCGs; Lincolnshire East CCG, Lincolnshire West CCG, South Lincolnshire CCG and South West Lincolnshire CCG. Our GPFV plans have been developed to include STP level alignment where appropriate but individualised by each CCG to ensure the overarching plan is adapted to each locality. Whilst our February submissions are submitted separately we are working towards having one individual plan that includes local elements where applicable 2. Introduction There are many challenges facing the healthcare system which is driving the need for change across the system. The most significant driver is the ever increasing older population and the percentage that will have multiple long term conditions, increasing demand for health and care intervention. All parts of the health and care system are under pressure and require a new way of working in partnership with patients integral to this will be self-care / management. Locally across Lincolnshire there are currently 95 GP practices, serving a total registered population of c. 725,000. Primary care across the county is under strain, more than it has ever been due to challenges in recruiting and retaining workforce and increasing demand falling from the population needs. The need to develop primary care expands further than the issues faced within primary care as is it also the keystone to delivering the Lincolnshire Sustainability and Transformation Plan. Primary care impacts all other STP clinical programmes and is expected to play a significant role in achieving projected left activity shift activity across planned and urgent care, yet it is the most underdeveloped of the STP work streams. The four CCGs will work with their member practices in a leading role to drive forward the implementation of the General Practice Forward View (GPFV), including the 10 high impact actions. This will include the development of multi-speciality community provider (MCP) and being responsible and responsive to population health. The CCGs envisage that moving towards Federated working and Primary Care at scale by GPs will be a key focus of development over the next two years. These key actions align to the Lincolnshire Sustainability and Transformation Plan and the Joint CCG Operational Plan. 3

16 Map of South West Lincolnshire Clinical Commissioning Group showing member practices 4

17 South West Lincolnshire CCG has at its heart 19 General Practices covering a population of 132,845 (January 2017). The practices vary in size from 1200 to and are based in Grantham and Sleaford and surrounding villages. The CCG practices CQC ratings for the practices are shown in the chart following: The CCG has undertaken a supporting role in commissioning of primary care since its inception in 2013 by supporting general practice to engage in shaping the future of healthcare locally. We believe that general practice is at the heart of improvements in health, wellbeing and prevention as well as supporting patients that need onward referral to other services. The CCG have commissioned a number of services over core primary care that general practice deliver showing the commitment to providing holistic whole person care closer to home. We have a vision to support our member practices to deliver consistent, accessible and high quality primary care, using networks of healthcare and other professionals and innovative solutions to deliver services. We will support members to widen the primary care offering to our patients, to allow them to receive care in the community where appropriate and in partnership with other providers where it makes sense to do so. 5

18 3. Vision Primary care is pivotal in preventing ill health and moderating demand (particularly reducing high cost preventable causes of ill health such as CVD, cancer, respiratory disease) through focus on prevention, self-care, screening, and early intervention. The risk management skills and continuity of care afforded by general practice are vital in moderating demand. The GP list system, in theory, should enable us to do whole population health management really well. This is why the stability and success of general practice and wider primary care are so important. We have to invest in and support primary care to become effective whole population health managers and risk stratifies not just overworked and increasingly precarious gateways to accessing secondary care." General practice is highly rated by patients and is the access point for them for health needs. This success has in part led to an increased pressure in primary care. In essence, our patients simply can t get enough of us. We need to maximise the potential of this important and highly valued relationship between primary care and the population, and unlock the dataset to proactively improve population health. To do this, small practice units will work together with each other, with other teams, providers and health care professionals with different skillsets to minimise duplication, be resilient and meet the demands of both clinical and non-clinical workload including regulation. The general practice of 2021 will be part of a larger organisation, either a super-practice or federation, serving a population of 30-50,000 patients. Circa 5-7 Super- practices or federations in turn will be at the heart of a Multispecialty Community Provider. So, in effect, primary care will be at the heart of community healthcare, and critically important in providing continuity of care so beneficial to patient experience. The vision for primary care is one of consolidation and joint working with access 365 days a year provided by a network of practices working together as federations or super practices and working with community services to provide a wider range of services delivered by a new more integrated workforce. Primary care will become a resilient, reliable workforce that reduces variation and is able to offer a portfolio career to its workforce. It is hoped that the proportion of GP partners remains at the same level to strengthen the leadership capacity and capability but reduce the ration of senior GPs to allied health professionals. An increase in other professionals groups working in primary care, e.g. pharmacists, wider nursing teams, physician s associates, advanced nurse practitioners and paramedics. These roles will be embedded in practices, led by GPs as part of our Multispecialty Community Providers new models of service delivery. Access into primary care will be better managed through increased use of self-care, use of IT and access to a wider range of primary care / community providing integrated care and care co-ordination, releasing GPs to take clinical leadership roles and focus on seeing people with the most complex needs, supported by access to secondary care consultant time and greater peer review A wider range of clinical staff and associated community services (including dentistry ophthalmology, community pharmacy, social care, third sector) will work alongside General Practitioners to form integrated community teams or networks providing comprehensive care, split into: Proactive care prevention self- care, management of LTC, end of life care Urgent, same day responsive service including nurse practitioners, clinical pharmacists, Planned care Children s care 6

19 Primary care will begin to use all the data we currently hold to map, track and improve population health. The development of a wider team means GPs will work differently as workload will be distributed across team members. General Practitioners will be freed up to: Develop new roles delivering proactive care, urgent care, planned care or care for children Develop joint working with consultants drawing on capability when needed in a clinically driven timeframe, either using technology or in person. This will mean that we bring in expertise, not send the patient out to seek it. Give more face to face time to those patients with most complex need Function as clinical leaders of integrated teams The new model of care will allow for the number of patients per GP partner to rise to 1 FTE GP partner to patients. The telephone access and back office functions will be centralised, and at a scale providing a resilient service able to function continuously with a largely part time workforce. The contractual model will be the GMS contract at its core, overlaid by an MCP contract which allows either direct employment of or commissioning of the supporting team. The critical factor in the success of this team is that GP partners take up the leadership of the whole team and in return are able to direct the work of the whole team, whoever directly employs them. There will be a continuous and enhanced offer of organisational and clinical development through working at scale. This will include opportunities for portfolio careers which will be actively encouraged, and a well mapped out career pathway from GP registrar to partner over a number of years. Similarly, there will be a path for all professionals, clinical and non-clinical, so that we retain the very best in primary care. 4. Model of Primary Care 7

20 Transforming and strengthening primary care is a key foundation in the Lincolnshire Sustainability and Transformation Plan and is core to the delivery of the ambitions for the CCGs. Lincolnshire must start to capitalise on the scale of its population and begin to operate, plan and deliver services for our growing and ageing population. There will need to be a stepped change to move services closer to home with the development of Neighbourhood Teams and the significant expansion of primary care bases services across all care groups. The GPFV sets out the key areas in which CCGs need to focus to transact the vison into delivery of high quality, locally focussed and integrated services being provided to patients. This will be enabled by the development of GP-led MCP organisations. The organisational form of Lincolnshire will evolve rapidly in the next 2 years as form follows function. Lincolnshire STP Plan on a page 8

21 This GPFV plan sets out how the CCG will support our member practices to deliver consistent, accessible and high quality primary care, using networks of healthcare and other professionals and innovative solutions to deliver services. We will support members to widen the primary care offering to our patients, to allow them to receive out of hospital care in the community where appropriate and in partnership with other providers where it makes sense to do so. Primary care is pivotal in preventing ill health and moderating demand. Particularly reducing high cost preventable causes of ill health such as cardio vascular disease, cancer, respiratory disease through focus on screening, early intervention and prevention. In order to achieve our vision Lincolnshire CCGs are working with NHSE and HEE on the delivery and funding of a number of initiatives to redesign how care is provided across primary care. The following 6 initiatives are key drivers in delivering this plan. Neighbourhood Teams: the initial building block providing services to a geographically based population of between 30,000 and 50,000 people and linking a GP Federation with other primary care professionals, prevention services, community health services, community mental health services, pharmacy, therapies and social care. Community involvement will be essential. They will have lead clinicians and managers. The Neighbourhoods Team are the building blocks for the plan to move to multi-speciality community provider (MCP) and being responsible and responsive to population health over the next five years. 9

22 The diagrams below outline the operating framework and outcome framework for Neighbourhood Teams. The operating framework demonstrates how case management will be processed through the Neighbourhood Teams. The outcome framework highlights the indicators we can measure our success on. Across the CCG member practices are already part of one of three Neighbourhood Teams in the CCG, Grantham Town, Grantham Rural and Sleaford & Rural with partner organisations built around the GP and the patient. Operating Framework Outcome Framework The key areas of Neighbourhood team development which align to primary care are: Risk Stratification to work with primary care to agree and roll-out a single methodology that ensures a systematic approach to risk stratification across the county. Care and Support Planning work streams are already in place to develop care and support planning processes, particularly within Integrated Personal Commissioning. It is imperative that primary care is integrated into these developments to ensure a sensible, common approach to care planning is agreed. Care Navigators as detailed above, work is already across the Lincolnshire system to identify and train Care Navigators, initially within Neighbourhood Teams. Multispecialty Community Providers the MCP framework and principles are the vehicle for delivering its vision for integrated neighbourhood working. The exact number across Lincolnshire will be determined in partnership with local providers and communities balancing localism with the need for scale; it is expected that at a minimum scale each MCP will host 6 or 7 neighbourhood teams. There will a real shift of responsibility from CCGs to MCPs as they increasingly take on decision making around how resources are used to deliver care better. 10

23 A more efficient way of working this will reduce transaction costs and overheads. Partnerships out of county: An acute hospital sector with links to a number of larger specialist hospitals out of county; there is acceptance that Lincolnshire can never be totally self-sufficient in terms of expertise. Working together to plan and deliver services: A more integrated strategic commissioning arrangement for health and social care with appropriate clinical support and advisory arrangements; we are on a journey to develop a single strategic commissioning body which will develop as MCPs develop in the next few years to take on increasing levels of responsibility around funding for groups of patients. An ongoing commitment to work with patients and the public to design and provide the services they need. The following excerpt from the Joint Operational Plan highlights the milestones and trajectories Priorities Key Deliverables Baseline Position 2017/18 actions/ milestones 2018/19 actions/ milestones Success measures New models of Working / Multi Specialty Community Providers (MCP) 5. Access Locally focussed integrated teams to include a wide range of primary and community services, Delivery of new care models through emerging MCPs System-wide commitment to develop and deliver MCPs incorporating fledgling GP Federations, LCHS, LPFT, some secondary care services and CCGs. STP MCP Working Group established and will lead, actively promote and develop the MCP model for Lincolnshire; driving development, working with existing partners and encouraging GP clinical leadership. To be defined MCPs fully established and delivering locally integrated services to patients. The GPFV includes a commitment to provide routine access to primary care in evenings and weekends. Funding has been provided in 2018/19 to support delivery of extended GP access to 100% of the population by March The CCG will use funds made available in 2018/19 to develop extended access this is most likely to be delivered from two primary care hubs in Sleaford and Grantham. The CCG already operates Urgent Minor Illness and Minor Injury Care 7 days a week in Sleaford but on a walk in basis as that was the public s preference. The service currently provided in Sleaford is delivered from Sleaford Medical Practice. The service is well developed having been implemented as a pilot in October 2014 funded through system resilience monies and is now contracted direct with the practice. This model of care can support the delivery of seven day access on a hub basis, offering extended hours services in the evenings and at weekends with a number of protected bookable appointments. This model can be looked at to provide the same in Grantham with both being able to have bookable appointments in 2018/19. The CCG and its partners will be seeking to achieve seven day access for same day primary care services for 100% of the registered populations as a priority. The CCG is committed to the proposed non-recurrent investment of 3 per head of population over the two year period , which will be funded from the CCG s allocation. The CCG will stimulate the development of the federation and facilitate delivery of the 10 high impact actions described within the GPFV in 11

24 addition to supporting their journey of maturity. The nationally commissioned tool, to be introduced in 2017/18 to automatically measure appointment activity by all participating practices, will be used to enable improvements in matching capacity to demand. Inequalities in access will be assessed and changes implemented to improve access and reduce inequalities for all populations across the CCG. Patient engagement and communication will be planned to ensure that new provisions meet local population needs and are effectively communicated Trajectory The number of practices within the CCG which meet the definition of offering full extended access = 4 by Q4 2017/18; 8 by Q2 2018/19 and 19 by Q4 2018/19. The CCG will explore using the existing Sleaford service to be able to accept bookable slots in 2017/18 which will enable us to deliver ahead of schedule. Table below showing the baseline of extended access as of February 2017 Practice Name Address1 Town Postcode Enhanced Service Session Minimum Hours Required Hours Provided (Plan) The Welby Practice The Woll Surgery Bottesford NG13 0AN Extended Hours Access Scheme 16/17 Thurs h15 2h20 Belvoir Vale Surgery 17A Walford Close Bottesford NG13 0AN Extended Hours Access Scheme 16/17 Mon h45 1h45 Millview Medical Centre Ruskington Medical Practice Ancaster Surgery 1 Sleaford Road Heckington NG34 9QP Extended Hours Access Scheme 16/17 Brookside Close Ruskington NG34 9GQ Extended Hours Access Scheme 16/17 12 Ermine Street Ancaster NG32 3PP Extended Hours Access Scheme 16/17 Mon h30 4h30 Mon h45 4h Mon Tue Thurs Fri Fri Tue h30 6h Sleaford Medical 47 Boston Road Sleaford NG34 7HD Extended Hours Access Tue h15 9h15 12

25 Group Scheme 16/17 Wed Thurs Glenside Country 12B High Street Castle Bytham NG33 4RZ Extended Hours Access Mon h45 2h Practice Scheme 16/17 Thurs Billinghay Medical Practice St Peters Hill Surgery St Johns Medical Centre 39 High Street Billinghay LN4 4AU Extended Hours Access Scheme 16/17 15 St Peters Hill Grantham NG31 6QA Extended Hours Access Scheme 16/17 62 London Road Grantham NG31 6HR Extended Hours Access Scheme 16/17 The Medical Centre Dring's Field Long Bennington NG23 5FR Extended Hours Access Scheme 16/17 The Surgery Main Street Woolsthorpe By Belvoir The Market Cross Surgery The Stackyard Surgery The New Springwells Practice NG32 1LX Extended Hours Access Scheme 16/17 Bourne Road Corby Glen NG33 4BB Extended Hours Access Scheme 16/17 1 The Stackyard Croxton Kerrial NG32 1QS Extended Hours Access Scheme 16/17 The Surgery Billingborough NG34 0QQ Extended Hours Access Scheme 16/17 Wed h30 2h30 Sat h 8h Tue h30 7h30 Sat Mon h 3h Thurs Sat * 4h45* 4h45* Mon h15 3h (7h alternate Sat weeks) Sat * 4h45* 4h45* Tue h15 3h30 13

26 Access milestones and trajectories Priorities Key Deliverables Baseline Position 2017/18 actions/ milestones 2018/19 actions/ milestones Success measures Access Improved 7 day and extended access to Primary Care services See table above Q1 workshop with practices to agree models for extended access Q2 Develop mobilisation and communication plan Q3 Mobilise access Q4 Evaluate services to inform 2018/19 mobilisation Q1 review mobilisation and communications plan Q2 Mobilise services Q3/4 Monitor and evaluate Increase is the coverage to 100% of full extended access of 5985 minutes additional access Patient Experience of service measured through Patient Council Release staff capacity with an increase in patient self-management Data available from patient survey, listening clinics, patient complaints, NHS Choices, Healthwatch. Q1 - Education through use of patient information screens via videos on self-management of many Long Term Conditions Lower rates of frequent attenders at GPs and A&E Q1 Signposting to NHS Choices Address inequalities in patient access Data available from patient survey, listening clinics, patient complaints, NHS Choices, Healthwatch. Develop clear plans to address variation in access, target areas of need, including linked to Extended Access. Patient Feedback from listening events, Health watch, complaints, NHS Choices Patient Council report 6. Workforce Workforce Challenges Due to the workforce challenges across the county it is becoming increasingly challenging to meet population needs. Lincolnshire GP practices are understaffed with doctors relative to the peer average. In Lincolnshire the average number of GPs and nurses per 1,000 population is 0.66 (2016). 14

27 The CCG breakdown is as follows: CCG GPs & Nurses per 1,000 Lincolnshire East CCG 0.59 Lincolnshire West CCG 0.65 South Lincolnshire CCG 0.67 South West Lincolnshire East CCG 0.71 Along with this Lincolnshire have the greatest percentage of GPs aged 55 and above. The combination of the ageing workforce population and the ratio of patients per GP shown above highlight the potential pressures on aging GPs within this footprint. Workforce baseline (HSCIC GP 2017 publication, all other workforce 2016 publication) Staff Group Headcount FTE GPs (excluding Retainers, Registrars and Locums) Nurses of which Advanced, Specialist and Extended Nurse Roles of which District Nurses 0 0 Total Direct Patient Care (DPC) of which Therapists (DPC) 1 1 of which Pharmacists (DPC) 0 0 of which Physician Associates (DPC) 0 0 Admin/Non-Clinical Workforce Vision Lincolnshire s vision is to develop a sustainable workforce supported by Organisational Development (OD). In the FYFV, NHS England clearly set out that the definition of quality in health care is based on three key aspects: patient safety, clinical effectiveness and patient experience. It goes on to state, achieving all three ultimately happens when a caring culture, professional commitment and strong leadership are combined to serve patients. Within Lincolnshire, we want it to be a great place to work and a place where staff feel valued and empowered to carry out their roles. Our staff, across all levels, professional groups and services, will have a clear understanding of their own role and skills and where these fit in with others across the health and social care setting. 15

28 To support the delivery of this vision, over the next two years the Lincolnshire Workforce Advisory Board will develop 4 key products, these are: A comprehensive baseline of the NHS and care workforce within the STP footprint and an overarching assessment of the key issues that the relevant labour market(s) present. This will describe the workforce case for change. A scenario based, high level workforce strategy that sets out the workforce implications of the STP s ambitions in terms of workforce type, numbers and skills, including leadership development. A workforce transformation plan focused on what is needed to deliver the service ambitions set out in the STP. An action plan that proposes the necessary investment in the workforce required to support STP delivery, identifying sources of funds to enable its implementation. Expanding Workforce Capacity There are a number of initiatives already underway to support the delivery of the GPFV workforce development and to facilitate recruitment and retention of staff. The implementation plans for these initiatives are detailed within the Joint Operational Plan. One of the key themes of the primary care workforce reviews is to seek opportunities to expand the roles of all professional groups; upskilling existing groups, introduction of new workforce roles into the primary care workforce and overall developing a new way of working within primary care. For example, Lakeside Healthcare is already seeking to develop an increased focus on advanced nursing skills. International Recruitment of GPs The Lincolnshire LMC is mid-way through an international recruitment programme, supported by NHSE as a national scoping pilot. The pilot commenced in August 2016, with an initial plan for recruitment of 12 GPs in phase one by April As of December 2016, 12 GPs have been appointed to the programme and are due to commence a training campus in January Phase two of the programme is due to commence early in 2017, with completion mid-summer. GP Mentorship Programme A second LMC-led programme to support the recruitment, development and retention of high quality GPs to the area. The service initially launched in November 2016 and lead mentors have now been appointed. Access to the programme is via self-referral, appraisers and partnerships. Care Navigators and Medical Assistants (Reception and Clerical) Receptionists, where appropriately trained, can act as effective care navigators, ensuring patients are directed to the right service or person, first time. Supporting effective delivery will improve access to appropriate services, reduce unnecessary demand on limited resources (e.g. face-to-face GP consultations) and will improve patient experience. Work streams are already in place across Lincolnshire to look at the role of care navigators in supporting the future healthcare system. The CCG will work with Lakeside Healthcare and AHSL to support training provision and access to a directory of information regarding available local services. Given additional training and carefully developed protocols, clerical staff can provide additional support to GPs in clinical administration. This is particularly pertinent for individuals with extensive skill sets and experience in providing healthcare administration and supports development of an often under-utilised 16

29 resource. Mental Health Therapists The General Practice Forward View includes a commitment to 3000 additional therapists working in primary care. This links to the Mental Health Forward View commitment to expand IAPT services by two thirds: so that 1.5m people with common mental health problems enter treatment each year. The majority of this expansion will be new integrated services, focused on people with co-morbid long term physical health conditions and/or medically unexplained symptoms. There are 4,500 extra mental health therapists planned under the IAPT programme by 2020/ of these mental health therapists will provide psychological therapies integrated into physical health pathways. These therapists will be employed by existing IAPT providers but in support of the overall shift to more community/primary care based interventions it is anticipated that these additional therapists will be based in general practices, or within primary care based teams depending on what makes sense for patients and services in that area. A collaborative bid for transformation funds has been submitted to NHS England, thorough the Lincolnshire Sustainable Transformation Plan Programme Board. The intention for Lincolnshire is to deliver integrated psychological therapies, at scale to our prevalent population and to meet the required target growth; co-located with neighbourhood teams. Expansion of these services is envisaged to have a cross-system impact on finance, quality and patient experience. Whilst our proposal is still being considered by NHS England, CCGs are working collaboratively within relevant governance structures to agree a methodology of recurrent funding, and to oversee the associated monitoring and assurance systems, inclusive of wider healthcare system financial impact. Clinical Pharmacists The federation that covers the CCG practices has bid for clinical pharmacists and the CCG will support the development of this role. 17

30 Workforce milestones and trajectories Priorities Key Deliverables Baseline Position 2017/18 actions/ milestones Workforce Development International Recruitment of 25 GPs across Lincolnshire Lincolnshire LMC Pilot approved and supported by NHSE as national scoping pilot for the GPFV Commenced August 2016 with plan for initial recruitment and appointment of 12 GPs for first phase completion by April 2017 As at 8 December 2016, 12 GP s appointed to Lincolnshire practices and ready to commence training campus in Warsaw on 16 th January SWLCCG no GPs in phase 1 Recruitment of 2 nd phase of 12 GPs to commence in January 2017 to be completed by August SWLCCG 3 practices have confirmed for phase /19 actions/ milestones Project completed and practices able to also avail themselves of opportunities for recruitment through the national offer via GPFV Success measures An additional 25 GPs employed from within Europe in Lincolnshire General Practice Implementation of GP Mentorship Programme Lincolnshire LMC project; 1 st Nov16 service for GPs launched. GP-S Lead mentors appointed access through self-referral, appraiser, and partnership. Direct access through website Mentorship programme embedded within the culture of GP profession. Increase numbers of trained mentors as required Additional resources through the GPFV to support the programme Retention of GPs within the workforce Workforce Data Software Lincs LMC Pilot to be delivered by March 2017 to support real-time recording of workforce data in general practice Practices and workforce planners able to consider succession planning and skill capacity within primary care On-going support and development of the tool by HEE Real time workforce data available for planning Marketing Lincolnshire project LMC project completed - marketing Lincolnshire as a place to work, live and train. On-going: full branded marketing exposure through BMJ, website and video. National Recruitment fairs Now embedded within the Lincolnshire Healthcare Attraction Strategy Successful recruitment of GPs through the project, access for practices to greater exposure of Lincolnshire and what it has to offer Support expansion of clinical pharmacists in general practice Clinical lead for Lincs Training Hubs worked with Lincoln University to enable introduction Expand number of undergraduate pharmacy placements in general Clinical Pharmacists as a member of the general practice team and first 18

31 of undergraduate pharmacists into the GP workforce. First tranche of placements from Lincoln University to take place from February 2017 practice across Lincolnshire from University of Lincoln Develop programme to support existing pharmacist working in general practice Development of programme for GPFV clinical pharmacists in general practice point of contact as appropriate Training for care navigators and medical assistants for all practices Baseline assessment not fully known Q1 Conduct a baseline assessment/raining needs analysis and develop plan Q2 Implement training plan Ongoing training as per needs assessment Reduction in GP/NP workload Better education for patients Patient feedback 7. Workload The CCG is working across the Lincolnshire Footprint to implement a range of technological advances that will support with workload. The Care Portal provides health and care professionals with a single integrated view of a patient s record which will reduce the need for clinicians to search for information to assist with patient care. This will include development of remote consultation technologies to allow clinician to clinician interaction in virtual environments, with all parties able to see the same view of the patient through the Care Portal. This will contribute to a reduced workload for primary care. This along with working with our standard contract holders to ensure appropriate communications with GPs reduces the interface burden between GP and hospitals. This will be taken further during 2018/19 to support proactive models of care using smart programmes of patients automatically identified by our care portal technology based on clinically configured triggers. It will use smart algorithms to monitor patient indicators, automate alerts and make appointments based on predetermined indicators or combination of indicators. Supporting General Practice Lincolnshire are working with practices to support them under two different programmes: Vulnerable Practice Scheme: Lincolnshire CCGs have worked with NHSE to prioritise those practices that have been identified through CQC inspections as being of most concern (rated inadequate or requires improvement) along with local intelligence to support practices on a number of improvements. Across CM the NHSE team have developed a diagnostic tool to help practices work out where the key issues are and along with the CCG support the production of an action plan to make improvements GP Resilience Programme: This programme holds invest of 40million across the country to allow CCGs to support practices to become more resilient and sustainable. Again the CCGs worked with NHSE to prioritise a list of practices throughout Lincolnshire that are in need of various support. 19

32 Lincolnshire in total prioritised 20 practices (practice groups) for support across the 2 schemes in 2016/17. It is thought this support will continue into 17/18 for a proportion of these practices. South West Lincolnshire CCG has support identified for 3 practices. Time for Care Progress against the 10 high Impact Actions Ten areas have been identified that enable the release of capacity within GP practices if actions are taken to do so, demonstrated on the diagram below. 1. Active signposting: Provides patients with a first point of contact which directs them to the most appropriate source of help. Web and app-based portals can provide self-help and self-management resources as well as signposting to the most appropriate professional. Active signposting is evidenced to free up GP time, releasing about 5% of demand for GP consultations in most practices 2. New consultation types: Introduce new communication methods for some consultations, such as phone and , improving continuity and convenience for the patient, and reducing clinical contact time 3. Reduce Did Not Attend (DNAs): Maximise the use of appointment slots and improve continuity by reducing DNAs. Changes may include redesigning the appointment system, encouraging patients to write appointment cards themselves, issuing appointment reminders by text message, and making it quick for patients to cancel or rearrange an appointment. 4. Develop the team: Broaden the workforce in order to reduce demand for GP time and connect the patient directly with the most appropriate professional. 5. Productive work flows: Introduce new ways of working which enable staff to work smarter, not harder. 6. Personal productivity: Support staff to develop their personal resilience and learn specific skills that enable them to work in the most efficient way possible. 7. Partnership working: Create partnerships and collaborations with other practices and providers in the local health and social care system. 8. Social prescribing: Use referral and signposting to non-medical services in the community that increase wellbeing and independence. 9. Support self-care: Take every opportunity to support people to play a greater role in their own health and care with methods of signposting patients to sources of information, advice and support in the community. 10. Develop QI expertise: Develop a specialist team of facilitators to support Each CCG will work with LMCs, Federations and practices to explore expression of interest for the Time to Care programme. Supporting practices to release capacity and work together at scale, enable self-care, introduce new technologies, and make best use of the wider workforce, so freeing up GP time and improving access to services. National resources and expertise will help groups of practices plan their own Time for Care programme. This will help use proven innovations from the 10 High Impact Actions quickly, safely and sustainably. Your programme can be tailored to meet local interests and plans. 20

33 The following table shows the progress so far for South West Lincolnshire CCG against the 10 high impact actions. High Impact Action SWLCCG Baseline Many GP Practices reception staff already carries out the role of navigation informally. Online portal many practices offer online services via their website or a secure portal. Many practices offer text message reminders and online booking of appointments and many use telephone triage. Practices have been looking at DNA s and working with Healthwatch to promote the impact of DNA s in general practice. Many practices offer easy access to cancel appointments and raise awareness of the number of missed appointments. Many of our practices use nurse practitioners and one practice uses paramedics. A number of practices have in house therapists who provide the AQP MSK Pain Assessment and Treatment Service, and therefore are able to offer advice to practice clinicians. During 2016/17 the CCG has implemented pharmacists working directly within practices to deliver QIPP, however this has promoted the potential of pharmacists within practices more widely. Many practices use clerical staff to carry out tasks that would have historically have been done by clinical staff. A couple of practices have undertaken the Productive General Practice Programme. 21

34 Many practices will already employ staff that who are proficient in touch typing and with a high level of computer confidence. All practices are part of a GP Federation and all Practices are members of one of three Neighbourhood Teams working in partnership with community providers. Practices already signpost to the Wellbeing service and third sector organisations to support patients and carers. Through our Neighbourhood Teams and Public Health Prevention we support individuals to stay well in their own homes. All practices are committed to supporting the National Diabetes Prevention Programme and have referred to date the full year planned number of referrals. Practices participate in Peer Review through attendance at a number of forums i.e. Prescribing, Clinical Governance During 2017/18 the CCG will hold a workshop with member practices on the GPFV where we will agree which areas of the 10 High Impact Changes we will progress further and the actions required to do that. See table following for baseline position on Patient Online Management Information (POMI) Indicators 22

35 23

36 The development of the federation will be a critical step in this being successful for SWLCCG. The CCG will be supporting the development of our member practices Federation to enable delivery of care across wider population footprints where it makes sense to do so. K2 Healthcare Limited is our local GP federation representing 17 local member practices K2 Healthcare is well placed to enhance the sustainability and viability of local General Practice, by working with and influencing commissioners and other providers to ensure high quality and consistent healthcare for our population. K2 Healthcare will achieve this by; supporting properly resourced member practices to work collaboratively in providing healthcare to our population; partnering with other providers and collaborating with commissioners to ensure services are retained locally; taking a unified approach to supporting member practices to better manage workload. By doing this and by valuing the population K2 Healthcare will become an organisation of outstanding reputation for care and integrity as both a provider of healthcare and as an employer. The federation will continue to develop over the next two years and will work closely with the CCG. Discussions have taken place between the CCG and K2 on how a service can be provided to support with referral management in 2017/18. This links to service improvement within Planned Care and the CCGs Quality, Innovation, Productivity and Prevention (QIPP) Programme to ensure cost efficiencies and improved outcomes. The developments at Primary care level are inextricably linked to Proactive Care and Neighbourhood Teams. The CCG is also investing 147K in development of the emerging GP Federation that covers the CCG footprint. This will enable working at scale for service delivery and will be better delivered in an MCP to support work streams such as extended access. The federation could also have practice benefits by sharing resources, purchasing power and releasing capacity. This investment will enable the CCG to work through in partnership with General Practice to review the opportunities in the 10 high impact changes. New Legal Requirements for NHS Standard Contract Making Time in General Practice (2015) acknowledged the existing bureaucracy in current communication structures between primary and secondary care and called for the whole system to work together to streamline the existing process. This included a need to reduce avoidable GP consultations and the existing workload of processing unnecessary information within internal practice systems. In July 2016, six new requirements for hospitals were introduced into the 2016/17 NHS Standard Contract as a response to these documents. The ambition of these new contractual requirements is to expand and strengthen GP services and primary care across England by helping to clarify the expectations in workload across the hospital and general practice interface. Next Steps In terms of next steps, contractual discussions are now ongoing with all local provider trusts to build all of these 6 nationally mandated requirements into all local hospital contracts through the Transfer of Care Policy for 2017/18. This will include: Priorities Key Deliverables Baseline Position 2017/18 actions/ milestones Sustainability of General Practice / Implement GP5YFV 10 high impact actions Patient Online Management Information (POMI) data shows low uptake of online 1. Support utilisation of online consultation systems and patient /19 actions/ milestones 1. Utilisation of Care Navigators. 2. Pilot medical assistant Success measures Increased numbers of appointments booked on line

37 booking for GP appointments. Care navigators not in use. online services 2. Development and training of medical assistants / care navigators 3. Promote training for Practice Managers, clerical and reception staff. 4. Review current processes to reduce bureaucracy i.e. community services contract review and CQRS support. 5. Support new consultation types utilise technology. roles. 3. Promotion of Self-care to include community pharmacy - minor ailments scheme. 4. Support development of practice teams i.e. medical assistants, pharmacists etc. 5. Review of skill mix to ensure stability of practices and meet patient need. Care Navigators (or similar) employed within primary care Training / Develop the Primary Care Element of Community Hubs Expansion of clinical placements in Training Hubs GPwSI Mentorship Programme 3 training hubs across the county In development Pharmacy training placements Clinical pharmacist placements set up A number of hubs set up Increased numbers of GPs accessing programme Pilot Physiotherapists as first point of contact In development % of MSK conditions seen as first contact by MSK Physiotherapist in primary care Employment Mentorship and supervision of existing pharmacists to work in general practice In development Numbers of pharmacists provided to Practices / Federations on a sessional basis Improving Access to Psychological Services (IAPT) For people with a long term condition Upskill Physical Healthcare staff Clarify pathways 25

38 8. Infrastructure Estates and Technology Transformation Fund (ETTF) is a work stream within GPFV focused on improving access, services, patient experience and workforce through investing in estates and technology within primary care. M&E have been allocated 128million over the next 3 years. Lincolnshire, as part of the Central Midlands have been involved in the robust process for the bidding, reviewing and allocation of funding across the STP. Lincolnshire CCGs have worked closely with practices in the past two years in the development of submissions to ETTF, to facilitate the delivery of estates which can be enablers for working at-scale in the future. The CCG will support successful practices in the development of their sites to ensure that all healthcare locations are fit for provision of appropriate services in the future. In addition, Lincolnshire s STP Estates and Operational Implementation groups have jointly assessed opportunities for estates reconfiguration to reduce underutilised estate and to maximise opportunities to facilitate delivery of accessible, local services at scale, including primary and urgent care. The key aims of the ETTF are to go beyond improvement/extension to existing facilities and to fund local GP/CCG/STP projects that achieve the following: Enhanced patient care/experience; Increase the flexibility of facilities to enable new models of care; Increase the use of technology; and/or Increase access to care to enable primary care at scale or a wider range of services All bids were reviewed for strategic fit, affordability and deliverability of the bids. The successful bids were then placed into 3 cohorts: Cohort 1: deliverable in 2016/17 Cohort 2: deliverable between Cohort 3: those deliverable beyond 2019 Lincolnshire have a number of STP led pieces of work along with local initiatives within each CCG STP Initiatives Care Portal integrated shared record One of the primary issues that prohibit a number of STP priorities in Lincolnshire including community care, proactive care, preventative care and self-care is our current inability to have a full comprehensive view of the patient journey. As a result, a care portal has been procured that will enable health and care organisations (including social care) to share on a read only basis their clinical records for Lincolnshire patients. From a primary care perspective this will enable other organisations involved in a patient s care to be able to make early interventions. This may include avoiding unnecessary GP appointments by alerting GPs to view electronic discharge summaries from outpatient appointments and surfacing hospital test results. The care portal will provide a full view of clinical records for out of hour s services. 26

39 Care Portal Personal Community We acknowledge that in order to achieve our commitments set out in our STP we must invest in prevention, promoting health and wellbeing within the Lincolnshire population. This can only be achieved by new models of care that are supported by enabling technology that give our patients the ability to interact with health and social care workers involved in their care. This module of the care portal technology enables patient access to records. From a primary care perspective, GP s will be able to review patient conditions including input to their record (specialist devices). GP s will be able to communicate via secure messaging, forms and questionnaires as well as develop an interactive care plan with the patient. It is our view that this interactive approach will be particularly beneficial providing better outcomes for patients with long term conditions such as diabetes or asthma. Care Portal Health Insight Only through quality joined up health and social care data can we appropriately respond to our patients feedback to providing, safe and good quality care for all. This analytics module of the care portal supports our ambition to makes services more efficient with a view of reinvestment, to provide continuous improvement for sustainable services in Lincolnshire. Care Portal Care Community Supporting patients and carers to play an active part in their care and enabling health and care workers from multiple organisations to contribute to care plans will support the provision of integrated care for patients. The Care Planning module of the Care Portal supports the production and sharing of care plans across the health and care community. Alongside electronic end of life care plans that are being rolled out across the county as part of the EPaCCS project, this module will support improved multi-agency patient management. Lincolnshire has successfully bid for funding through the Primary Care Transformation Fund and ETTF for each of the Care Portal modules. Procurement is complete and implementation planned over the next 3 years, up to GPIT funding wireless We are in the process of deploying Wi-Fi to our 95 GP practices in the county. This will enable all Lincolnshire health and social care organisations to access clinical records from GP practices. Patients will also be able to access guest Wi-Fi from GP practices to access records and manage their own care. This is an enabler to linking primary and community care for the benefit of patients, supporting integrated care teams across the county. Virtual and Tele-health We have reviewed a number of case studies where remote virtual consultant consultations and GP appointments can deliver significant benefits to maximise GP time, avoid unnecessary referrals and support GP decision making. To ensure that we are making the correct investment choices we are looking at trialling a number of virtual and Telehealth scenarios. These trials include SKYPE consultations between GP s and Patients, SKYPE between GP s and Diabetes specialities, and E-consultations between GPs and care homes. Patient online We are actively promoting the national strategy in terms of patient access to detailed SCR, we have almost hit the target of 10% of all patients regularly using online services. We only have 5 practices which we need to focus on. On average we have 35% of all repeat prescriptions booked online, with 10% average of appointments booked online. This is reducing the burden on GP admin staff and freeing up GP time. HSCN GP sites previously have prioritised bandwidth for clinical systems and have struggled as a result to use new technologies to deliver better and new approaches to care. We are currently in the process of re-procuring our collaborative network in Lincolnshire. With central GP Network funding now being devolved down to CCG s this gives us the opportunity to standardise the network performance in Lincolnshire, to enable the same capabilities from all GP sites. Collaboration and enablement in compiling our digital maturity submission and review of the outputs, it particularly highlighted that health and social care organisations are at vastly different levels in terms of their ability to exploit technology. Therefore, we need to invest in and standardise the capabilities of our health and care community to provide joined up services. This will provide benefits such as faster appointment times, turnaround of test results, and easier access to clinicians, but also ease the pressure on services. 27

40 Community Directory of Services Feedback from our patients highlighted that they were confused by the many avenues to access care within Lincolnshire. With that in mind we are working with Lincs2Advice to provide a community Directory of Service. This we see as a further enabler to reduce the current stress on services, enabling more GP time with patients while also promoting self-care. Electronic referrals currently is utilised on all GP practices in Lincolnshire however we acknowledge that more must be done. With that in mind the acute trust is increasing capacity to drive electronic referrals within existing systems and strive to ensure that 80% of first outpatient appointments can be sent electronically. The mental health trust is developing apps that will enable GP s to refer electronically; this is currently in the trial stage. End of life GP and community providers now use a standard end of life template that feeds the Electronic Palliative Care Coordination System (EPaCCS). We are expanding the cloud based My Right care MRC system so that end of life care plans can be shared with consent. Deployment of this system is ongoing with health and social care providers across the county. Electronic prescribing EPSr2 is currently deployed in 44% of GP practices in Lincolnshire and at these sites just over 50% of all repeat prescriptions are sent electronically. It is our aim to increase that figure to 10-15% of all repeats sent electronically by the end of the 2016/17 financial year. Locally Led Initiatives All practices have digital screens that are in patient facing areas; these display key messages, videos and other information that is used to promote self-care, service availability, urgent health messages, awareness campaigns and signposting. Teledermatology 14 of the 19 practices use technology in primary care specialists triage and diagnose dermatology conditions via photographic images, allowing these patients to be managed in the community or referred into secondary care where appropriate. The patient pathway is improved by providing rapid access to specialist advice and treatment locally and GP's experience educational benefits from specialist feedback which over time can further reduce the need for secondary care referrals. Diabetes - a project has been implemented in conjunction with the funding from a bid made to the Health and Wellbeing Fund to ensure people with diabetes in the locality are supported. The project links with Diabetes UK to deliver Living with Diabetes Days, production of patient information packs and the development of Peer Support Groups. Practices are a key part of this project and patient information packs have been circulated to all Practices for provision to people with diabetes. The project will support the planned improvements to the delivery of diabetes services for patients across Lincolnshire, linking to the theme of delivering high quality systematic care for major causes of ill health and disability. By encouraging and educating patients to self-manage their condition we aim to reduce or delay the potential complications of diabetes, including, but not exclusively, amputations, strokes and coronary heart disease. By encouraging and supporting patients to effectively self-care / manage their diabetes as a long term condition not only will enhance their quality of live but will support practices to release time. Resources will be provided to patients that will include mobile applications engaging those who use technology on a daily basis and allowing user to have easy access to resources in social situations, supporting them to make health food choices. The CCG will support Improvement of GP premises through the delivery of the CCG Estates Strategy ensuring maximum use of section 106 funding and ETTF opportunities. The STP includes the establishment of primary care hubs across the county with two in the CCG area, Sleaford and Grantham. 28

41 Priorities Key Objectives Baseline Position 2017/18 actions/ milestones Maximise Utilisation of 9-12 months from date Estate of Approval Development of Outline Business Case for Primary Care Hubs, Lincoln, Grantham, Gainsborough, Sleaford Awaiting decision on funding for resource to project manage Exploring options for capital 2018/19 actions/ milestones 2018/19 actions and milestones will be dependent on outcomes of the Outline Business Case Success measures Primary Care Hubs Business Case developed 9. Investment Investment Breakdown CCGs must plan to increase general practice funding by at least the % increase in core CCG allocations, to fund core contract changes 3 per head non-recurrent transformation support funded from CCG allocations starting in 2017/18 and can be split over 2017/18 and 2018/19 to be used to stimulate development of at scale providers, implementation of 10 high impact actions and secure sustainability; 15m devolved to CCGs in 2017/18 and 20m in 2018/19 to fund online GP consultation software in line with national specification (specification to follow in New Year); 10m devolved to NHS England local teams or delegated CCGs in each 2017/18 and 2018/19 to fund training for care navigators and medical assistants for all practices in line with national specification; 8m funding in each 2017/18 and 2018/19 to support practice resilience (NHS England) 6 per weighted patient for GPAF site CCGs in both 2017/18 and 2018/19, and 3.34 per head for all remaining CCGs in 2018/19 Year Description Allocation ' /18 Practice Transformation Support /18 (equates to 3 per head non recurrent allocation) /18 Development of Federations /18 Online Consultations /18 Training Care Navigators & Medical Assistants /19 Online Consultations /19 Training Care Navigators & Medical Assistants /19 Access Funding (equates to 3.34 per head)

42 Priorities for investment The CCG plans to prioritise investments to develop at scale working to sustain and transform primary care services. CCG practices are currently part of a neighbourhood team collaborating with other agencies such as social care, community and mental health trust colleagues and the voluntary sector for the benefit of our population. It is expected that these smaller hubs will become the building block for the MCP. To support the development of general practice the CCG is investing the 3 per head investment in 2017/18 to ensure each practice has a practice care coordinator. This is a clinical role that wraps around high risk and vulnerable patients through care planning, self-care and access to support. This role is crucial in linking primary care to the wider neighbourhood team and supports many elements of the ten high impact changes. CCG Clinical Care Co-ordinators The Practice Care Co-ordinator is employed by each participating practice, with outcomes reported to the CCG each quarter. The service works to a defined specification and is based within the GP practice. Working on the ethos of a whole system relationship with a wide range of stakeholders. Practice Care Coordinators are part of a wider network of care responding to patients and carers needs, as part of the Neighbourhood Team. A fluid system where the patients can be within several aspects of care pathways at the same time. The Practice Care Co-ordinators will work closely with the rest of the primary care team, secondary, intermediate and third sector care providers including diagnostic services, specialist and non-specialist community teams, social care, hospital discharge and hospital at home schemes, palliative care/acute care service providers. All other services that are involved in the care of the person and their carer. Communication, integrated working, appropriate access and response from the services will be crucial in achieving the required patient outcomes. Core Elements of service delivery are: Proactive Care - Identification and prioritisation of patients identified as vulnerable and at risk Reactive Care - Patient review following presentation Case Management - Assessment, Co-ordination and Review The key performance indicators are in the table below highlighting expected outcomes. Key Performance Indicators Requirement of Information Method of Measurement / Achievement 1. Increase the number of people who have been 1. Evidence of risk stratification of prioritised according to their level of need and population identified for Neighbourhood Team support. Development and maintenance of the Neighbourhood Team Register. Additional patients supported under service Inform future commissioning vulnerable patient group Inform future commissioning - cost per patient The number of patients on register increased from baseline April 2017 Frequency / Reporting period Six monthly collection (Provider reported information) Quarterly Collection (SystmOne / EMIS Report, provided by the Provider)

43 2. Increase the number of patients identified as being eligible for Neighbourhood Team support who are provided with an assessment of their needs and as a minimum assessment of the following key areas: i) Severity ii) Medication Review iii) Mobility(including falls) iv) Carer support v) End of life status (discussion as appropriate) Standardised quality assessment as per specification Inform future commissioning - cost per patient for case management 1. The number of patients on the Neighbourhood Team Register who receive an initial assessment 2. 80% of patients who have had initial assessment have had 5 key areas assessed Quarterly Collection (SystmOne / EMIS Report, provided by the Provider) 3. Increase the number of patients identified as eligible for Neighbourhood Team support who have been provided with a personalised care plan including as a minimum: i) A health and social care ii) The named individual iii) An optimisation and/or maintenance plan iv) An escalation plan v) An urgent care plan Standardised personal care planning that supports patient/carer to manage condition as per specification. 1. The number of patients on the Neighbourhood Team Register who have received a personalised care plan % of patients who have had initial assessment have received a personalised care plan. Quarterly Collection (SystmOne / EMIS Report, provided by the Provider) 3. The number of patients giving consent for a Neighbourhood Team approach to their care 4. Increase the number of patients identified as eligible for Neighbourhood Team support who are supported to manage their condition out of hospital The Provider will be required to provide practice level audit/case studies 1. Provision of 3 case studies per GP Practice that demonstrates review of these indicators evidencing the patient s journey, breakdowns in service provision, areas of service improvement and good areas of care provision (responsive, effective, safe, and caring provision of care) Year-end collection - March 2018 To support the development of out of hospital provision of care and the achievement of the following reductions in secondary care activity from 2016/17 2. Monitoring of Secondary Care activity to include: A&E Attendances Emergency Admissions Emergency Re-admissions Secondary Care Activity will be monitored on a monthly basis Data Source Business 31

44 baseline: 3% - A&E Attendances 3% - Emergency Admissions (includes readmissions) Information Reports. The Care Co-ordinator role is highly valued member of the team by the member practices to support them in delivery of care and reducing GP workload. It also is a great example of skill mix, signposting and partnership working which are key elements of the ten high impact changes. CCG Federation The CCG is also investing 147K in development of the emerging GP Federation that covers the CCG footprint. This will enable working at scale for service delivery and will be better delivered in an MCP to support work streams such as extended access. The federation could also have practice benefits by sharing resources, purchasing power and releasing capacity. This investment will enable the CCG to work through in partnership with General Practice to review the opportunities in the 10 high impact changes as well as supporting the shift from acute to community provision. Online Consultation Lincolnshire STP footprint is implementing a Care Portal that was procured during 2016/17, providing health and care professionals with a single integrated view of a patient s record. This will include development of remote consultation technologies to allow clinician to clinician interaction in virtual environments, with all parties able to see the same view of the patient through the Care Portal. This will contribute to a reduced workload for primary care and/or produce transformational benefits. This along with working with our standard contract holders will ensure that the benefits of reducing the interface burden between GP and hospitals are delivered. A Patient Portal will be rolled out in 2017/18 will enable patients to participate in their care and to view their assembled health records in one place, this will further develop to include self-care apps which should support self-management, access and reduce workload. This will be taken further during 2018/19 to support proactive models of care using smart programmes of patients automatically identified by our care portal technology based on clinically configured triggers. It will use smart algorithms to monitor patient indicators, automate alerts and make appointments based on predetermined indicators or combination of indicators. The CCG will work with partners across the STP footprint to procure online consultation software that meets with the national specification when released. This will be enable video conferencing for consultations and clinical advice. Training for care navigators and medical assistants Work is already in train to identify and train 69 FTE Care Navigators across the system, initially within each of the Neighbourhood Care Teams, with the role and training being developed via the Local Workforce Advisory Board. This work will supplement the GPFV expectation that each Practice will have a Navigator Role to ensure consistency and to develop an effective network of navigation across the system. Many GP practices already offer navigation as part 32

45 of the reception workforce. The CCG will work with practices to establish the baseline position for the opportunities that exist and engage with practice care coordinators to offer training for staff to deliver care navigation by non-clinical staff. The intention is that we will utilise the annual funding allocation to establish a rolling programme of training for staff within our member practices with the objective of: ensuring continuous development of the care navigator and medical assistant roles; facilitating effective use of alternative practitioner time and skills; developing new approaches to using administrative resource to support clinical capacity. The intention is that the training will be available to support reception, clerical staff or healthcare assistants to play a greater role in actively signposting patients to appropriate provision, (including practitioners offering an alternative to GP consultation, advanced nurse practitioners, clinical pharmacists, physician assistants and third sector providers) and handling clinical paperwork to free up GP time. GP Champions to be identified in each of the practices and will provide in-house support and mentorship for the developing clerical staff. Training staff in active signposting for patients: Inclusion of a focus on recognising red flag symptoms which require urgent medical attention. Skills development to ensure staff is confident in communicating available options. Support for the practice to develop its own directory of services, including the opportunity to learn from other practices examples. Training staff in document management Support for the practice to develop its own internal systems including a safe and appropriate protocol to guide staff, a system of supervision (especially for the early stages of implementation) and regular audits of safety and effectiveness. This should include the opportunity to learn from other practices examples. Opportunities for practice managers, GPs and staff to hear from others who are already working in this way ETTF Investment The table below shows the most recent allocations across Lincolnshire for ETTF funding. Cohort 1 Allocation 2016/17 Cohort 2 Allocation 2017/ /19 Cohort 3 Allocation 2019/ /21 866,760 5,099,963 55,503,872 33

46 GP Resilience Programme The CCG will support practices action plans for improvement particularly where CQC have concerns through the supporting vulnerable practice scheme (SVP) and GP resilience programme (GPRP). 2016/17 allocations have been made and the CCGs are working with NHSE to support the most vulnerable practices across the patch. Across Lincolnshire there are currently 20 practices (practice groups) that are being supported through the SVP and GPRP with funding of c. 275,000 in 16/17. Priorities Key Deliverables Baseline Position 2017/18 actions/ milestones 2018/19 actions/ milestones Sustainability of General Practice / Implement GP5YFV Transformational support 1. Development at scale of providers / federations. 2. Review development of MCP model with community health services providers. 3. Engage with Supporting Vulnerable Practices Programme and Practice Resilience Programme to support sustainability. 4. CCGs to engage with General Practice Improvement Leader programme to support delivery of change. 1. Build on development of at scale working. 2. Support development of MCP providers. Success measures Positive contractor engagement. Establishment of collaborative working arrangements to support at scale working. Extended access available to population. Clear governance and leadership of developing models of care. Monitoring of patient outcomes as result of changes. Digital Primary Care Pathways Support wider access to primary Care through digital development 5. Using devolved NHSE funding for practice on-line software develop digital processes further to include self-help advice, e- consultations, on line bookings etc. when and by whom 3. 95% of primary care patients offered e- consultation and other digital services Improved access to advice and care support for patients to selfcare 34

47 10. Leadership, governance and programme arrangements STP Governance The STP has a new governance structure to maximise the benefit of the collective vision and to allow the system delivery of the identified changes. Within the STP Primary Care features as a Clinical Redesign Programme which has a focus on a number of elements of the GPFV programme. Acute Care Primary Care Integrated Care 35