PAPER FOR THE LUTON CLINICAL COMMMISSIONING GROUP PUBLIC BOARD TO BE HELD ON TUESDAY AUGUST 19 TH Transforming Primary Care

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1 Agenda Item 12 PAPER FOR THE LUTON CLINICAL COMMMISSIONING GROUP PUBLIC BOARD TO BE HELD ON TUESDAY AUGUST 19 TH 2014 TITLE PRESENTED BY (Plus contact details for pre Board enquiries) LEAD CLINICIAN/MANAGER Transforming Primary Care Nicky Poulain Director of Commissioning and Integration Lead manager: Nicky Poulain - Director of Commissioning and Integration Paul Lindars - Primary Care Development Manager WHAT IS THE OBJECTIVE OF THE PAPER? This paper provides the Board with a high level overview of: - Primary care strategy which is a key element of the CCG s 5 year strategy - Progress to date regarding the transformation of primary care in Luton WHAT IS THE BOARD BEING ASKED TO DO? To consider the paper and provide feedback to the Commissioning/Primary Care team WHICH OTHER COMMITTEES HAVE REVIEWED THIS PAPER? HAS AN IIA BEEN CARRIED OUT? WHAT IS THE IMPACT? IF THE IMPACT IS NEGATIVE, HOW WILL IT BE MANAGED? WHICH CORPORATE OBJECTIVE(S) DOES THIS PAPER RELATE TO - The Executive Committee - The Primary Care Strategic Implementation Group INTEGRATED IMPACT ASSESSMENT (IIA) N/A Although an IIA is still to be carried out, it is anticipated that building capacity and capability in primary care will enable improved integration, access and address some of the structural inequalities in Luton as outlined in the paper. LINK TO CORPORATE OBJECTIVES AND RISK 2. Work with partner organisations and the Health and Wellbeing Board to ensure the delivery of objectives set out in the CCG Operational Plan including: Frail Elderly Programme Capacity and Capability of Primary Care 1

2 3. Further development of practice engagement ensuring effective distributed clinical leadership is in place across our member practices, to include the implementation of 4 Clusters WHAT ARE THE KEY RISKS? (State risk ID and risk as stated on the Risk Register) 468 GP practice engagement EXECUTIVE SUMMARY This paper provides a high level overview of Luton s strategic direction for primary care, offering an insight into some of the current and completed projects, and next steps for primary care development in Luton, including: Primary care strategy driven forward through the set-up of a primary care programme Board Increased patient engagement: CCG to support the development of practice level Patient Participation Groups (PPGs), and links to the CCG Patient Reference Group (PRG) Co-commissioning with the Area Team- sharing intelligence to improve: primary care premises, workforce, contracts, quality and performance Development of practice Clusters to reduce the variation in care and build capacity and capability across the system The development of a new model of integrated care for Luton s Frail and Elderly population The re-shaping of primary care contracts to encourage new ways of working Development of IM&T The paper also highlights challenges and potential barriers to delivery, including: - Workforce, recruitment and retention issues - Limitations of current use of Business Intelligence to inform commissioning decisions APPENDICES 1. Primary Care Transformation: Options for new GP models 2. LCCG GP practice Clusters and population size 3. Patient access survey results (Jan Sept13) 4. How the Frail and Elderly model builds on the transformation of primary care 2

3 Transforming Primary Care 1. Introduction Luton Clinical Commissioning Group (LCCG) is currently developing a comprehensive primary care strategy (PCS) in order to; place primary care at the centre of the development of services ensure that primary care as a whole is able to drive a decreased reliance on the hospital build capacity in primary care to allow LCCG to deliver better outcomes for patients and the local health economy Current variations with access to primary care, variations in patient activity to secondary care and health outcomes have been identified as the need to transform Primary Care. The primary care strategy is the essential building block of future success and for this reason Luton s five year system strategy includes Transforming Primary Care as one of the Big 4 improvement programmes. Working closely with NHS England Hertfordshire & South Midlands Area Team, Luton Borough Council will be essential to enable the transformation of primary care for the population of Luton. 2. Primary care programme The vision for primary care has been developed with member practices and will ensure a comprehensive, person-centred, population oriented, proactive and integrated care that is safe and of high quality. The programme structure to support the implementation will be via a primary care strategic implementation group. The recruitment process for the Clinical Director with lead clinical responsibility is scheduled to commence during August. The identified overarching work streams for the programme include: Development of practice Clusters Improving patient access to primary care and quality improvement Integration of services for the elderly and vulnerable people Utilising Primary Care contracts (local and national enhanced services) to improve quality 3. Patient engagement Many practices in Luton do not currently have an active Patient Participation Group (PPG) and therefore do not have a mechanism in place to receive constructive feedback from their patients. The CCG has committed to supporting a Big Push campaign the week commencing the 8th of September to help practices launch or re launch their PPG. As part of this initiative a toolkit will be provided that can be used by practice managers to help support them in setting up an effective group. Smaller practices will be encouraged to buddy up and have joint PPGs where appropriate. These groups help the focus to remain on patient centred care and the general principle of no decision about me, without me. PPG members are then invited to sit on the CCG wide Patient Reference Group (PRG) to allow feedback to flow into the decision making processes for the CCG. 3

4 4. Co-commissioning Luton CCG will build upon the established working partnership with the Local Area Team, thereby sharing information and ensuring that local primary care services receive targeted support. Recent successes of this partnership work include: Shared decision making with NHS England related to primary care premises Increasing practice engagement to implement Enhanced Services commissions by the AT Agreed implementation plans for local practice quality improvement visits Co-commissioning offers the opportunity for further pro-active working with the Area Team to influence commissioning decisions that affect the health and wellbeing of our population. Where appropriate, the primary care strategy will formalise joint commissioning arrangements to enable LCCG to deliver the 2 year operational plan. The immediate key areas identified as critical to enable us to transform Primary Care include joint working with the Area Team support on the following projects: Practice procurements and potential mergers o APMS flexibilities and content of local contracts o Practice mergers and size and location of premises o Innovative new providers and use of premises The CCG are keen to work with the Area Team over the next 3 months to ensure we are able to inform and influence commissioning decisions for the 4 APMS practices out to tender in 2014/15. Table1. The Area Team will be going out to tender in 2014/15 for the following 4 Luton APMS contracts: Actual list Surgery Name Code Type Post Code Leased/ size per Actual Patients NIA m2 Owned surgery per m2 (Jan 2014) SUNDON PARK HEALTH CENTRE E APMS LU3 3EP Leased AT to confirm 2,914 AT to confirm The Tow n Centre Surgery Y02463 APMS LU1 2SE Leased AT to confirm 4,934 AT to confirm Moakes Medical Centre Y02464 APMS LU3 3SR Leased AT to confirm 2,252 AT to confirm Whipperly Medical Centre Y02477 APMS LU1 5QY Leased AT to confirm 2,155 AT to confirm Primary care premises o Needs assessment-using findings of objective surgery reviews o Development and implementation of a Luton premises strategy When we look at the size of existing GP premises 20 patients per m2 is the general benchmark. When developing new premises or planning a major investment in current stock the aim is to achieve 15 patients per m2 to factor in that leases will be for circa 21 years and there will be further housing growth. The Area Team are assessing the measured areas for Luton and have shared the details for 16 practices (52%) so far, 11 of these have been assessed as sub-optimal based on the the benchmark of 20 patients per m2. In 2009 architects were commissioned to carry out a quality survey to assess Luton GP premises. Some of the key findings which still apply today include: - 4 premises not fit for purpose and should be replaced - 13 practices not enough space, of which - 5 practices have potential for extension, and a further - 3 practices are prepared to join with another practice - 5 practices require refurbishment In partnership with the Area Team and local planning authorities, we will agree a strategic plan over the next 6-9 months to enable new / redeveloped premises to meet the growing 4

5 population and to support changes to service models across health and social care. This plan would take into consideration the options for new GP models: Vertical Integration, Merged Delivery, Combined Delivery and Bigger Delivery (Appendix 1). Workforce planning GP and Practice Nurse Recruitment & retention are a significant issue for Luton. Some workforce intelligence data is held by NHS England to inform: o Capacity Planning o Training requirements, R&R o Horizon scanning The CCG and Area Team are already using this information to inform individual practice visits, and will work more closely on high level analysis to inform CCG workforce planning. Improving practice quality and performance o Shared resource: data, expertise, knowledge - targeting support to outlier practices Section 8 gives an overview of the CCG and Area Teams co-commissioning approach to practice quality visits. Planning and timescales for delivery will be agreed with NHS England Hertfordshire & South Midlands Area Team through formalisation of LCCGs co-commissioning expression of interest. 5. Development of practice Clusters A key enabler to transforming primary care is the establishment of Practice Groups Clusters that are integrated within the LCCG governance structure. This initiative will support the development of local clinical leadership to address variation via peer review and to also build commissioning capacity Four Clusters covering populations of approx. 40,000 to 65,000 have been agreed. Appendix 2 provides a list of practices in each Cluster and their population size. The significant change will be the alignment of community services (initially with a lead nurse for each cluster), adult social care, and mental health and medicines optimisation services. Diagram 1 shows how Clusters have been incorporated in to the CCG governance structure: Diagram 1: Luton CCG Governance Structure - Practice Clusters CCG Board PSQC Clinical Commissioning Committee (CCC) CoI Panel F&P Cluster meeting representation General practice GP (each practice) Primary Care & other Strategic Implementation Groups (SIGs) Cluster Clinical Chairs/ CCG Management Primary Care Programme Board Practice Nurse or Manager (each practice) Clinical Chair (1 per Cluster) CCG Cluster Co-ordinator 1 Business Intelligence/ Cluster Co-ordinator 2 Finance Officer Management Social Services Community Services- Green Team Community Services- Blue Team Social Services Social Services Social Services Social Services Practice Cluster 1 Practice Cluster 2 Practice Cluster 3 Practice Cluster 4 Member Practices Member Practices Member Practices Member Practices Specialist (eg Geriatrician) Specialist (eg Geriatrician) Specialist (eg Geriatrician) Specialist (eg Geriatrician) Clinical Co-ordinators Workstream eg Frail Elderly Social Services lead Community Services District Nurse - lead Community Matron - lead Mental Health - lead Specialist dependant on workstream 5

6 The Practice Cluster Chairs Group will consist of 4 GP Chairs (one from each Cluster) and this group will be responsible for co-ordinating and reviewing recommendations and issues raised by the Practice Clusters. The established Strategic Implementation Groups (SIGs) will work collaboratively with the Practice Clusters in making formal submissions to the CCG Governing Body to improve the delivery of health services for Luton s population. The Practice Clusters will be pivotal in the successful implementation of any decisions made. Effective working relationships between practice members and their Cluster Groups is critical to ensure that all practice staff are supportive and committed to the CCG strategies and priorities. The Cluster Chairs will report directly to the Clinical Commissioning Committee (CCC). It is proposed that the 4 Cluster Chairs rotate a seat on the CCC and each Cluster will provide a monthly written reports. The establishment of Clusters is providing an opportunity for practices to meet together to gain a better understanding of their role as commissioners and through a management support structure to consider how best to improve health and social care systems. The benefits for practices and patients include: Sharing of good practice and clinical expertise Forum for sharing CCG: strategy, priorities, activity and KPI reporting and decisions Practices considering system- wide efficiencies, e.g. sharing practice guidelines/procedures, training opportunities, shared back office functions, using existing premises in different ways, better IT and workforce to allow Increased workforce development opportunities LCCGs vision is that current practices develop collaborative working or group together to provide primary care services at scale, resulting in: Improved access, and equity of access, to services for Luton s population Efficient streamlined integrated services utilising latest technology to improve the patient experience A well-developed motivated workforce offering safe quality services in convenient out of hospital locations New or improved services focusing on: health & wellbeing (prevention), collaborative care teams, urgent care To date the following has been achieved: Three Cluster Chairs appointed, expression of interest received for the remaining Cluster. Clusters have met and agreed governance arrangements e.g. ToR, Clusters have tabled a range of agenda items Larkside Cluster progressing the phase1 Frail and Elderly (MDT) model Interim Cluster Co-ordinator appointed after failed substantive recruitment The clusters are being used to promote the 2014/15 Primary Care Investment Scheme (PCIS) which predominantly focuses on enabling and embedding practice Cluster working. The scheme offers the CCG a mechanism to encourage practice engagement through backfill of GP, PM and PN time. In order to inform effective commissioning the CCG and Public Health (LBC) have joint commissioned Data Quality Assessments (DQA) for all GP practices in Luton. The intention is to improve diagnosis and coding to maximise patient identification for disease registers in the key clinical domains. This work covers all of the clinical Quality and Outcomes Framework domains with specific priority given to key areas: CVD, respiratory, cancer and learning disabilities. 6

7 Next steps: In order to overcome the substantial variation at practice level it will be crucial to establish indicative practice level budgets; reporting activity and finance at Cluster level with member practices taking responsibility for the Clusters financial position. Effective commissioning support for cluster development including business intelligence, finance and contracts management will need additional capacity to the services currently provided by CSU. There is also a need to resign the CCG s management support to ensure there is sufficient capacity and capability for Cluster working to be effective. The immediate areas of that require priority are: Substantive Cluster managers with robust business intelligence (BI)and finance support. MDT co-ordinators utilising the 5 per head CCG fund (Everyone Counts) There has been a GP access working group in place for the last 18 months meeting approximately 3 times annually. Although Luton is still ranked low (190/211) compared to national results in the Jan September 2013 GP patient survey, it is worth noting that Luton is the only CCG across the AT that improved its average for the 4 GP access indicators (Appendix 3). This group have agreed to explore the ideas that have come out of Luton s unsuccessful Challenge Fund bid working closely with Clusters to improve patient access, engagement and education through: o Use of new technologies for health advice and signposting o Text/SMS for communicating with patients o Innovative access to appointments for consultations telephone, Skype, o Triage by GP (e.g. Doctor First ) 6. Proposed new model of care (Frail and Elderly) to support integration. Integration is driven through the Better Together programme aligning health, local authority, voluntary and community sector. The first key work-stream included in the Better Together programme has been the design a new integrated model of care for the frail and elderly population of Luton. This is intrinsically linked with our vision to transform primary care services and the two go hand in hand. Appendix 4 shows how the Frail and Elderly new model of care overlaps and builds on the work practices are already completing for over 75s (core GMS) and the avoiding unplanned admissions enhanced service. Larkside GP cluster is leading the design principles for patients identified as frail and elderly. Phase 1 work to date includes: Design and formation of multidisciplinary team model A standard approach to implementing health and social care plans Re-configuring hospital ward management to ensure patients are aligned with the Clusters allocated geriatrician Risk stratification to identify a cohort of patients at risk of a hospital admission A Single Point Of Contact (SPOC) for patients identified for case management Development of an acute trust community geriatrician offer 7. Extended primary care and community contracts (building capacity and capability primary care at scale) The CCG is committed to ensuring the appropriate mechanisms such as population based and outcome-focused contracts, incentives and risk sharing agreements are developed and in place to allow the commissioning of innovative new models of care. 7

8 The aim in the medium to long-term would be for Luton practices to form well governed provider organisations to manage and or deliver community/ primary care extended contracts at scale. These provider organisations might include Limited Liability Companies, CICs or super-partnerships and could take 'make or buy' decisions taking a prime contractor role- sub contracting where appropriate. As part of the transition from Local Enhanced Services (LESs) to NHS standard contract Luton CCG have already placed an emphasis on practices being in a position to offer a phlebotomy service for patients who are registered with a practice who are not able or willing to provide this service. Once Luton s community and mental health procurement is complete the next step is to consider development of outcome focused extended primary/ community contracts that encourage vertical integration, including: General practice working with non GP providers (acute, local authority) More collaborative working across primary, secondary, community and voluntary sector Extended services (up to 7 days a week) These new services would complement services commissioned from acute, community and mental health providers. 8. Improving Quality through improvement visits LCCG are committed to work with the AT via constructive collaborative working with practices (and the support of the LMC) to drive up the quality of primary care services. A schedule of quality visits will facilitate quality improvement with a strong focus on patient experience focusing specifically on areas where experience is below average, subsequent improvement should lead to a more positive patient experience. The sharing of local and national high quality data and information are at the heart of this work. The programme of visits will be undertaken following analysis of the national NHS England Primary Care Web Tool; the currently under development Primary Care Web Plus tool will soon be available providing more up to date qualitative and quantitative information about challenged practices. There is a variation in quality in GP services across Luton. The Primary Care Web Tool has identified 13 practices (4%) across the Hertfordshire and South Midlands AT that require quality assurance visits i.e. those practices that have 5 or more outlying indicators. 7 of these are Luton practices. Table 2: LCCG practices identified by the primary care web tool as having 5 or more outlying indicators Practice with 5 or more outlying areas Cluster Outlying Data Points Supporting information Visit schedule Practice Under new management. New process/ policies/ procedures being introduced. CCG/ AT planning meeting scheduled for 29 th July Practice Practice has not received a visit from GP Clinical Director/ CCG management for >12 Visit confirmed - months. 21 st July 2014 Practice Practice rec d a Primary Care visit from Clinical Director/ Primary Care Development manager (October 2013) Practice Numerous Meds Optimisation visits (action plans and training sessions) over the last 12 months. Practice Primary Care visit from Clinical Director/ Primary Care Development manager (July 2013) Practice Practice has not received a visit from GP Clinical Director/ CCG management for >12 months. CCG/ AT planning meeting scheduled for 29th July CCG/ AT planning meeting scheduled for 29th July CCG/ AT planning meeting scheduled for 29th July Practice Under new management. New process/ policies/ procedures being introduced. CCG/ AT planning meeting scheduled for 29th July Practice Practice Primary Care visit from Clinical Director/ Primary Care Development manager (December 2013) CCG/ AT planning meeting scheduled for 29th July 8

9 A co-commissioning approach is imperative if this improvement work is to have the legitimacy needed to bring about fundamental sustainable quality improvements. This joint work has already resulted in development of a standardised approach, bringing strong commitment to the visits from the CCG and the AT. The first visit was completed on the 21 st July, with positive feedback initially received from the visiting team and visited practice. The Area Team and CCG primary care development manager reviewed the process on 29 th July and further visits are being scheduled. 9. IM&T The CCG is committed to working with the IM&T team, LMC and NHS England Hertfordshire & South Midlands Area Team to support practice compliance with the GMS IM&T contract obligations. These include: Appointments online - offering the facility for patients to book, view, amend and cancel appointments e-referral to provide better and more targeted information to patients and carers to facilitate choice of service or clinician Repeat prescriptions the ability to order, view and print a list of repeat medications Summary Care Record automated practice clinical system upload allowing patients to view online, export or print their summary GP2GP - facility for transfer of all patient records between practices, when a patient registers with another practice The following initiatives are also in progress: Electronic Prescription Service EPS2. Phased rollout across Luton The purchase of an integrated portal to improve interoperability and support the implementation of a shared Health and Social Care Plan Another aspiration is to modernise clinician to clinician consultation and to support practices to address variation is through establishing online collaborative workspaces to enable groups of clinicians to discuss patients. In effect this would be a multidisciplinary healthcare professional social network to facilitate clinical collaboration. 10. Workforce development a. Clinical leadership There is a critical need to build local leadership and organisational capabilities to support and drive the changes highlighted above with GPs leading service planning and quality improvement. Succession planning and developing future GP leaders is crucial for Luton. The CCG, in collaboration with the University of Bedfordshire and Health Education East of England, is implementing an innovative scheme to recruit high-calibre GPs with leadership potential. The recruits (2 per year) will receive mentoring and higher professional learning (MBA or MEd) over their 3-year contract, while gaining paid experience in commissioning or medical education to equip them for future leadership and also undertaking 2 ½ days per week clinical work in a local practice. A strong shortlisted field of high calibre candidates were interviewed, and two GPs have subsequently been recruited. b. Professional development Multi-speciality medical practice providing new models of care closer to home will require the support of specialists. As part of the new frail and elderly model of care, geriatricians from the 9

10 local acute trust will align with practice Clusters offering clinical advice for complex patients within a multidisciplinary environment. This process will enable the continued professional development of community and practice based clinicians across Luton. 11. Other improvement initiatives Healthwatch recommendations the results of a recent healthwatch review of general practice across Luton provide a unique set of results and recommendations for each surgery. The CCG and NHS England will discuss these recommendations, supporting practices to action recommendations where appropriate as part of the programme of quality visits. 12. Key enablers Two urgent issues that risk Transformation of Primary Care in Luton include: Staffing, recruitment and retention o GP practices are struggling to recruit and retain clinicians o Limited pool of willing clinical leaders within Luton o The CCG finding it difficult to recruit to management vacancies leading to a lack of delivery o Business intelligence, IM&T and contracts teams have limited capacity to support: practice reporting, infrastructure and development of new contracts Business Intelligence (Medeanalytics) o Short-term contract with current system provider makes it difficult to develop a long term activity performance reporting mechanism o Current software requires intensive BI staff support, and o has limitations regarding data source (SUS only) 10

11 Appendix 1 Primary Care Transformation: Options for new GP models Vertical Integration GP practice working with non GP provider e.g acute, local authority - More collaborative working across primary, secondary, community and vol sector -Platform for outcome based pathways across providers - Strong foundations for co-commissioning Merged Delivery GP practices merging to form a larger practice - Efficiency of working at scale - GP skill sets can be shared - Sustainability of general practice Patient Combined Delivery GP practices not merging but working more closely together e.g. federation - Allows practices to work in collaboration without merging - Efficiency of working at scale - Risk sharing without merging - GP skills set can be shared. Bigger Delivery Already existing super partnerships expanding further to take over smaller practices - Practice able to recruit team with large skill set. - Sustainable general practice - Efficiency of working at scale 11

12 Appendix 2 LARKSIDE CLUSTER GP PRACTICE GP Name Cluster Chair Practice Rep Actual LIST (01/07/ 14) BISCOT GROUP PRACTICE LISTER HOUSE SURGERY BUTE HOUSE MEDICAL CENTRE LEAGRAVE SURGERY LARKSIDE PRACTICE SUNDON MEDICAL CENTRE THE OAKLEY SURGERY DRS MIRZA SUKHANI & PARTNERS KINGSWAY CLUSTER DR I SALEH'S PRACTICE (WENLOCK SURGERY) DR DV SHAH'S PRACTICE (PASTURES WAY SURGERY) KINGSWAY HEALTH CENTRE BRAMINGHAM PARK MEDICAL CENTRE Dr. Raj Khanchandani, Dr. Abdul Ebrahim, Dr. Sahadev Swain, Dr. Tahir Mehmood Dr. Charles Acellam - Odong, Dr. Andrew Ihonor, Dr. Ratha Sivasoruban Dr. Shiwalini Karale Dr. Nasrin Razzaq, Dr Kunal Kothari, Dr Kaushalya Dissanayake, Dr. Hannah Hill, Dr. Naran Satchi Dr. Wassim Matta, Dr. Paul Deeley, Dr.Ian Ralph. Dr. Tanveer Haider, Dr. Jo Price Dr. Martin Kunzemann, Dr. Mazhar Hussain, Dr Sudha Maroju Dr. Richard Yip, Dr. Haydn Williams, Dr. Khalid Mahmood, Dr Edwina Kruszewska Dr. J Carey, Dr. Reza Chowdhury Dr. I A Mirza, Dr. G Sukhani, Dr N A Mirza, Dr. R Akhter Dr Haydn William Dr Tahir Mehmood, Dr Sahadev Swain Dr Nasrin Razzaq Dr.Ian Ralph Dr M Hussain 6757 Dr Haydn Williams Dr. I Saleh Dr. I Saleh 3142 Dr. D V Shah, Dr B S Virik, Dr S Dadabhoy Dr. Adil Ali- Khan, Dr Ednan Hashmi Dr. Ali Al-Badry, Dr Kirti Singh, Dr Monica Alabi Not appointed chair- expression of interest from Dr Anitha Bolanthur Dr. D V Shah 4321 Dr Adil Ali Khan 8461 Dr D Pirisola 5751 DR MQ HODA'S PRACTICE Dr. M.Q Hoda

13 CONWAY MEDICAL PRACTICE Dr. A Thiruchelvam, Dr K Sanjay, Dr C Mangoro, Dr M R Alam, Dr Anveeta Sinha Dr Anitha Bolanthur Dr Anveeta Sinha, Dr A Thiruchelvam 8024 DR SA SUBRAMONY'S PRACTICE (MEDINA SURGERY) Dr. R S Subramony, Dr. R.S. Subramony 5957 NEVILLE ROAD SURGERY Dr. Sajid Mehmood 2766 SUNDON PARK HEALTH CENTRE Dr. Akhtar Injeeli MEDICS UNITED CLUSTER GP PRACTICE Practice Cluster Chair Practice Rep /Lead GP ACTUAL LIST (01/07/14) GARDENIA & MARSH FARM PRACTICE BARTON HILLS MEDICAL GROUP Dr. James A Seery, Dr. Z Ahman, Dr. A Shakoor, Dr. Riaz Sadik Dr. Maria Stratford, Dr Aasim Siddique, Dr Dayan Perera Dr. M Barhey, Dr. A Shakoor BELL HOUSE MEDICAL CENTRE Dr. S K Paul Choudhury, Dr Talib AbuBacker, Dr Una Duffy, Dr Kuldip Sule, Dr. Joanne Campbell, Dr. Vinod Varghese Dr. S K Paul Choudhury 9628 MOAKES MEDICAL CENTRE THE MEDICI MEDICAL PRACTICE WOODLAND AVENUE WHIPPERLEY MEDICAL CENTRE Dr. Anthea Robinson, Dr Chandu Prasannan Dr. Ashok Sahdev, Dr. Jackie Ratne, Dr. S Conway, Dr. P. Tsagkaraski, Dr. A Quershi Dr.J Marsden, Dr. M Barhey, Dr. C Harris, Dr. S Rahman, Dr. V Ravichandran, Dr. M Mownah Dr. Fiona Sim, Dr. Kasmin Butt, Dr. Anthea Robinson, Dr. Tahir Mehmood -(Regular locum) Dr Chandu Prasannan Dr D Ratneswaran Dr. M Barhey Dr Kasim Butt

14 SOUTH EAST LUTON CLUSTER ASHCROFT PRACTICE STOPSLEY VILLAGE PRACTICE TOWN CENTRE GP SURGERY Dr. P S Bath, Dr H Bodhani Dr. Piers Tonlimson, Dr. Irshad Shaikh, Dr. Chris Ellis, Dr. Shazia Tahseen, Dr Nighat Azhar Dr. Emilie Haworth, Dr Ram Suganth, Dr. Raza Alam, Dr. Nizar Al Musawi Dr. Abbas Zaidi Dr. P.S. Bath 5094 Dr. Nizar Al Musawi KINGFISHER PRACTICE LEA VALE MEDICAL PRACTICE (LIVERPOOL RD HEALTH CENTRE) MALZEARD ROAD CASTLE STREET SURGERY Dr. G Johnson, Dr. I Hill-Smith, Dr. S Burcombe, Dr. Manju Kappen Dr. Peter Ward Dr.Paul Singer, Dr. Audrey H Dorman, Dr. Martin Calow, Dr. Steve Gillam, Dr. Nina Pearson, Dr. Kerli Elliott, Dr. Oludolapo Alalade, Dr. Maria Charbonne Dr. Zaman, Dr. Anitha Bolanthor Dr. Helen McGill, Dr. Dorcas Owusu-Yianoma, Dr. Abbas Zaidi, Dr. Ruchira Karunadasa Dr. I Hill- Smith Dr A Zaman 2858 Dr A Zaidi

15 Appendix 3 Results of GP Patient Survey Jan13 - Sept13 - by CCG within Herts & South Midlands AT England average 79% 80% 89% 81% 82% -0.6% PCT name Ease of getting through on the phone Overall experience of making an appointment Overall experience of GP surgery Recommend GP surgery to someone who has just moved to the local area Average of 4 indicators 6 Mth Change in % (vs July12- Mar13) National Rank (211) NHS BEDFORDSHIRE CCG 83% 84% 91% 83% 85% -0.6% 49 NHS HERTS VALLEYS CCG 79% 81% 90% 83% 83% -0.7% 96 NHS CORBY CCG 81% 78% 88% 80% 82% -2.3% 120 NHS NENE CCG 76% 78% 87% 79% 80% -0.7% 151 NHS EAST AND NORTH HERTFORDSHIRE CCG 71% 74% 87% 80% 78% -1.2% 180 NHS LUTON CCG 73% 74% 85% 75% 77% 0.5% 190 NHS MILTON KEYNES CCG 62% 67% 81% 73% 71% -1.8%

16 Appendix 4 How the Frail & Elderly Workstream builds on the NHS England Transforming Primary Care Agenda (1) Named GP- 75 (GP Contract 2014/15) ~12,000 population in Luton Likely to mean the majority of frail elderly will have: A named accountable GP who will work with health & social care to deliver a multidisciplinary package Access to health check (2) Avoiding unplanned admissions (DES) ~3,500 population in Luton (2% adult list) Likely to mean the majority of frail elderly will be included on the practice case management register & have: A named accountable GP A named care co-ordinator Personalised, proactive care & support plan informed by multi-disciplinary teams Regular review of care plan (at least 3 monthly) Patient (& professional) hotline to practice clinician Timely follow up after discharge Retrospective audit of those with an unplanned admission/ A&E attendance leading to proactive change (3)Frail elderly (1) 75s and over (2) Case management register (DES) (3) Frail elderly workstream? population Identification of frail elderly (likely to be on practice case management register) Clinical frailty scale 5-9? Comprehensive (multidisciplinary) geriatric assessment/ MDT Geriatrician GP, Practice Nurse/ HCA CM, DN, Macmillan Mental health professional Pharmacist/ technician Dietician Social worker Voluntary sector (eg age concern) Wrapped around practice cluster Focus on diabetes/ respiratory/ H&F? Personalised, proactive care & support plan informed by multidisciplinary teams Care plan shared with all agencies involved (electronic) Named care co-ordinatoraround practice clusters Falls prevention Telecare/health 16