Luton CCG General Practice Forward View Plan. Second Submission February 2017 Final Version

Transcription

1 Luton CCG General Practice Forward View Plan Second Submission February 2017 Final Version 1

2 General Practice Forward View Stage 2 Plan Luton CCG Contents Contents... 2 Foreword Introduction to the Plan across BLMK STP Our Populations BLMK Health Needs/Inequalities Current Primary Care Infrastructure The Luton Population and their Health and Care needs Child Wellbeing (0-19 years) Adult Wellbeing Ageing Well in Luton (>65 years) Delegated Commissioning Context - Primary Care in Luton IM&T Estates Quality Luton Place Based Model How this Plan Supports Delivery of the Nine Must-do s Summary of Deliverables Model of Care STP STP Model of Care Practice Infrastructure Technology Enabled Transformation Expected Benefits of Service Offer Interdependencies with other Transformation: Engagement Programme Delivery The Plan for Luton Community Integrated Health and Social Care Teams Intensive Case Management Rapid Response NAPC Primary Care Home Pilot Specialist Support in the Community Care Homes Self-care

3 2.9 Mental Health and Wellbeing Service Access STP Narrative The Plan for Luton Access to Urgent Primary Care Services CMSK Physiotherapists Improving access for patients and increasing practice efficiency Workforce STP Workforce Current workforce Key risks and issues Workforce Planning Community Education Provider Networks New Models of Care: Workforce Implications New Ways of Working in Primary Care The GP Session The Duty Role Staff Skill Mix Joint Community and Primary Care Initiatives The Plan for Luton Clinical Pharmacists Mental Health Therapists Recruitment and Retention GP Future Leaders programme GP Induction and Refresher and GP Retainer Scheme Overseas Recruitment Practice Nurse Development and Support Workload STP The Plan for Luton GP Resilience Programme (GPRP) and Vulnerable Practice Scheme LMC Support Package to Practices Access Improvement Initiative Intensive Coaching for Practices Support for Practice Managers Infrastructure STP Estates IM&T The Plan for Luton IM&T Estates ETTF - Farley Hill Project Investment STP The Plan for Luton

4 7.3 Practice Transformational Funding Training Care Navigators and Medical Assistants Online GP Consultation Software Access to General Practice Infrastructure Funding Governance STP Governance Local Governance Clinical Leadership Risk Management Risks to the delivery of the plan Board Assurance Framework

5 Foreword This document sets out the BLMK STP vision for Primary Care, and appends the local delivery plans, framed at the CCG level, by which we want to realise this vision. It describes how BLMK CCGs will commission services and work with providers to promote illness prevention and to deliver, safe, high quality and sustainable care in the context of the General Practice Forward View (GPFV) 1. These delivery plans set out how we will implement specific GPFV requirements during and beyond, ensuring sustainability of and providing support to general practice. The plans are aligned with our wider ambition to help our residents to stay well for longer, to direct them to effective sources of support sitting outside the statutory sector and to offer a joined-up service when they receive care from us in community and home settings. Key elements of the plans have also been developed with Local Medical Committee colleagues and have benefitted from insights and advice from BLMK s RCGP representative. Our vision sets out how we will work with and support GPs to address the challenges facing primary and Out of Hospital Care. This will ensure we co-design a resilient, multi-disciplinary and high quality primary care platform to be front and centre in our local communities across BLMK GPs will be at the centre of patient care, supporting and directing the provision and co-ordination of high quality medical care and treatment for those that are ill, but also in bringing about improved health and well-being for our population as a whole. Our local plans underpin broader BLMK STP goals. These goals see local partners commissioning and providing more care in community and home settings, along streamlined care pathways, by making better use of the resources available to us. We know that this will happen only if we do more with what we already have. As a result, we want to direct our GPFV transformation investment to: Free up time for our senior primary and community clinicians to provide clinical leadership for delivery of delegated care across community settings, ensuring they can focus their scarce clinical capacity on people with the most complex needs Maximise the contributions that the wider primary and community services workforce can make to deliver safe and effective care in community settings Harness technology that enables primary care to in-reach into people s homes and gives a peripatetic workforce the digital tools it needs to work effectively and efficiently Support those individuals (and their family carers) who have the appetite and capacity to take more control of their own care. Our Vision for BLMK Primary Care Responsive, proactive and accessible primary care needs to be led and orchestrated by general practice. It must be delivered though, by a wide range of professionals. In BLMK, 1 NHS England: GP 5 Year Forward View, April

6 we see this being achieved through an enhanced delivery model which, in design and operating model, draws inspiration from the Primary Care Home (PCH) model. The integration of community health, mental health and social care services with primary care clinicians is crucial. However, this integration will be effective and sustainable only if services are co-designed with GPs to be wrapped around a strengthened and scaled primary care delivery model. We believe that, scaled at the 30-50,000 population level, community, mental health and appropriate secondary care services can be effectively and efficiently integrated with primary care. In addition, we can align ourselves closely with Council services, where there is direct interplay with health services, such as social care, and those, such as housing, that make such a significant contribution in determining the health and well-being of our residents. Context BLMK s combined population is circa 985,000 and in the next 15 years, is expected to increase by 160,000 people (17%), which is almost double the national average. Across the region, the 85+ age group is predicted to grow faster than the rest of the population. In addition, the numbers of children in Luton and Bedfordshire are also expected to increase much faster than in England as a whole. There are also significant differences in demographics, ethnic diversity and deprivation within the footprint which our plans need to be alive to. For example, healthy life expectancy, an estimate of the average number of years lived in good health, varies from 59.3 years for men in Luton to 67.2 years for women in Bedford Borough. There are 109 GP practices within the BLMK footprint, employing 411 GPs. At 2,349, the average list size per GP compares unfavourably with England as a whole (with Luton a particular outlier at 2,804 patients per GP). Our ageing GP workforce is a major issue, and recruitment challenges for new GPs and practice-attached nurses remain stubbornly difficult to resolve. The legacy infrastructure with which general practice in BLMK is wrestling dictates the need for radical transformation, designed to develop capabilities, to re-purpose existing capacity and to deepen the multi-disciplinary resource base that can be drawn upon. All 16 partner organisations comprise the BLMK STP recognise this and all are committed to supporting new models of working with and alongside general practice. Next Steps We intend to use the PCH model as the common design template across BLMK by which our vision for primary care will be achieved. The PCH solution will, of course, manifest itself in different ways in different parts of the footprint. However, we do expect some elements of the PCH solution to be common. For example, general practices will be supported to create coherent and cohesive collaboratives, to manage the health and well-being, and deliver out of hospital care, to their localities numbering between 30-50,000 people. 6

7 Through the local programmed activities relating to the 10 high impact changes, collaborative working between practices, facilitated by the three CCGs, the STP and the respective LMCs, is expected to lead to better access, a more fit-for-purpose primary care workforce and more manageable workload in primary care. We have put in place an effective blend of STP-wide and locally sensitive governance mechanisms which will draw in relevant stakeholders at the right time. The attaching local delivery plans set out, in some detail, the actions we expect to take, when we expect to take them and the results we expect to achieve. Key performance indicators are under development to provide assurance on the successful delivery of proposed changes and the impact on patient flows, on services and on health and well-being outcomes. The CEOs of the 16 partner organisations, supported by the three CCG Clinical Chairs and the LMCs, will review progress on these actions monthly at BLMK s Accountable Care System Activation Board. Request The development of primary care, more broadly, and general practice, in particular, is mission critical to the delivery of BLMK s STP goals. Based on consensus and clarity of purpose across commissioners and providers, our clearly planned programme of work and our commitment to delivery, we look forward to receiving NHS England s support to the scope, the activities and the timeline we have set out in our local delivery plans. Pauline Phillip Dr Alvin Low Dr Nina Pearson Dr Nicola Smith STP SRO Clinical Chair Clinical Chair Clinical Chair Chief Executive Officer Bedfordshire CCG Luton CCG Milton Keynes CCG Luton and Dunstable University Hospital 7

8 1 Introduction to the Plan across BLMK STP Figure 1: Five STP Priorities BLMK have identified a total of five STP priorities to deliver the future vision for health and social care. The five priorities all overlap, and the benefits expected will only be fully realised if all five proceed in parallel. No one priority is therefore, seen as more important than any other. The development and transformation of primary care is addressed under Priority 2 with the aim to deliver high quality, scaled and resilient primary care, community and social care services across BLMK. 8

9 Figure 2: Five STP Priorities Within the STP footprint there are pockets of transformation, with more care than ever before now being delivered in the community, closer to and within people s homes. However, the resources made available to primary and community care have remained static. The GP Five Year Forward View forms an inherently important opportunity to achieve the ambitions of Priority 2 as set out within the STP, namely to:- Strengthen primary care services to ensure sustainability and enable transformation Increase the health of the population by maximising prevention and self-care Shift activity away from acute services to community settings, closer to home Ensure that people are able to access appropriate urgent care services, reducing reliance on A&E and reducing avoidable unplanned admissions Close integration of health and social care services Supports the transformation of services for people with Learning Disabilities 9

10 Helps to integrate physical and mental health services and achieve parity of esteem BLMK system leaders have supported the governance structure of four placed based delivery boards and are working together to achieve the transformation goals associated with this priority. The outcomes include: 1. Improved population health and wellbeing Improved demand management through patient activation and self-care Improved stratification and analysis of population health needs - more prevention, early detection and screening (addressing inequalities) 2. Improved quality of care for patients in local communities Greater accessibility to primary care Improved service availability - patients receive the right care in the right place More finished episodes of care and extended continuity through proactive and integrated community therapy 3. Improved utilisation & sustainability of local health & social care resources Improved deployment of NHS and social care resources with improved patient experience and empowerment. (skill mix - clinicians working to the top of their license & less duplication and bureaucracy of services ) Better cross-organisational working to develop care management packages for identified high risk people with complex needs to improve their wellbeing, outcomes & reduce avoidable A&E visits/admissions/lengths of stay/expensive long-term care packages In conducting the design and development work required for the Priority 2 initiatives, the STP programme will need to rely on the full co-operation and enthusiastic participation of our GPs, of our local Councils and of our community health and our mental health service providers. To support this work Priority 2 has been sub-divided into 6 separate, complementary work streams. 10

11 Figure 3: STP Priority 2 Work Streams The objectives of the streams are interlinked and teams will work together across the STP footprint to reduce duplication and ensure alignment of plans to successfully deliver improved, sustainable and high quality services to our residents within available finances. Key projects across the footprint, for which funding is being made available include improved access, enabling on-line consultations, training of care navigators and medical assistants, and improving primary care infrastructure. The table below sets out the funding available. Detailed information on the projects and timeframes for implementation are set out in the relevant sections of this plan. 11

12 Table 1: Funding Bedfordshire Luton Milton Keynes 17/18 18/19 17/18 18/19 17/18 18/19 Access 0 1,511, ,397 1,590,653 1,611,475 On-Line Consultations Training Care Navigators & Medical Assistants Practice Transformational Funding Primary Care Infrastructure Estates (ETTF) Primary Care Infrastructure Digitalisation (ETTF) 122, ,664 59,953 80,292 74, ,438 81,481 81,832 39,969 40,146 49,928 50, , , , , , , ,000 1,607,400 80,000 1,021,700 1,627, /18 1,200, /19 300,000 Further funding is being provided within specific schemes: Support to 28 prioritised practices across BLMK, via NHS England under the General Practice Resilience Programme Practice involvement in Wave 1, and expected in Wave 2 of the Clinical Pharmacist pilot Expected funding towards practice-based mental therapists. The GPFV plan is a key delivery enabler for establishing the crucial groundwork for this scale of change. The following sections describe how transformation across the STP footprint and individually within BLMK CCGs will be achieved. Section 2 provides a description of the model of care for Primary Care Services across the STP footprint and detailed descriptions of work being undertaken in Bedfordshire to deliver improvements to Primary Care in line with this model. 12

13 1.1 Our Populations The total resident population in BLMK is circa 985,000 and, in the next 15 years, is expected to increase by 160,000 people (17%), which is almost double the national average. This means we will see some 1.1 million people living in BLMK by The local population is served by three CCGs and four local Councils. At 467,000 Bedfordshire is the largest of the three CCGs, being a little over twice the size of Luton (230,000), and over one and half times as large as Milton Keynes (287,000) (see map below for geographical span of BLMK footprint). Figure 4: BLMK Footprint There are significant differences in demographics, ethnic diversity and deprivation within the footprint. For example, the population of Luton is younger, more ethnically diverse and more deprived. Central Bedfordshire is the least diverse and least deprived, while Bedford Borough has a significantly older population. Milton Keynes population continues to grow more rapidly than other parts of BLMK but, having experienced rapid population inflows of people of working age for some decades now, is also now ageing faster. 13

14 Figure 5: Population Size across STP Footprint 1.2 BLMK Health Needs/Inequalities Life expectancy is better than the national average in Bedford Borough and Central Bedfordshire and worse in Luton and Milton Keynes. Healthy life expectancy, an estimate of the average number of years lived in good health, varies from 59.3 years for men in Luton to 67.2 years for women in Bedford Borough. There are significant health inequalities within our communities. For example, we see a 10- year life-expectancy gap between women from the most and least deprived areas of Bedford Borough, and a 12-year gap for men from the most and least deprived areas in Luton. In light of an aging population, and one that, as it ages, is increasingly presenting with multiple morbidities, improving healthy life expectancy, and compressing the number of years lived in poor health, is key to containing pressures on the health and social care system. Key health needs across BLMK include: The four big killers driving premature mortality and health inequality in BLMK are diabetes, cardiovascular disease (heart disease and stroke), cancer and chronic obstructive pulmonary disease (COPD) Smoking remains the single greatest preventable cause of ill health and premature mortality Alcohol-related hospital admissions are rising across BLMK Less than two-thirds of people with a long term condition feel adequately supported by the GP to manage their condition Screening performance across BLMK is patchy Recorded prevalence of depression is rising Prevalence of recorded severe mental illness is rising, and ranges from 0.68% in MK to 0.95% in Luton, which is higher than the England average (0.88%) 14

15 One in five children is overweight or very overweight by the age of five, rising to one in three by the age of 11. The proportion overweight or very overweight by age 11 is rising in three out of the four local authority areas Effective primary care and self-management of asthma can prevent exacerbations and unplanned hospital admissions, yet asthma admissions in the under 19s are high and rising in three out of four local authority areas. 1.3 Current Primary Care Infrastructure There are 108 GP practices within the BLMK footprint, employing just over 400 GPs. At 2,349, the average list size per GP in BLMK compares unfavourably with England as a whole (see below). Luton is a particular outlier at 2,804 patients per GP. An estimated 5 million encounters with GPs take place each year 4, governed by a mix of GMS and APMS arrangements, via which 127m is spent each year. Table 2: Primary Care Infrastructure No of GP Practices Bedfordshire Luton 15 Milton Keynes BLMK No of GPs No of Practice nurses Regional Average England Average Patients per GP n/a 1650 Patients per Practice Nurse Patients per GP practice GPs per 000 patients GP Practice nurses per 000 patients n/a n/a % of GPs age >55 24% 23% 25% 24% n/a 20% % GP practice nurses >55 GP Clusters 28% 25% 27% 27% n/a n/a Bedford 25 practices (24 from July 2017) Ivel Valley 9 Practices Chiltern Vale 10 Practices West Mid Beds 6 Practices Medics United 5 practices Larkside 8 practices South East Luton 7 practices Kingsway 8 practices North 7 practices East 7 practices Southern 7 practices West 6 practices

16 Leighton Buzzard 4 practices At an STP level, the quality of outcome and patient confidence in primary care is reasonably good, although there are some unwarranted practice-level variations that need to be addressed, both in identifying disease early enough, and in managing disease once diagnosed. Only one practice across BLMK is in CQC special measures. This performance is being achieved despite BLMK s primary care infrastructure being fragmented and lacking resilience. The figure below underlines the fact that the ageing GP workforce is a particular issue, and recruitment challenges for new GPs (for example, in February 2016, there were 19 GP vacancies in Bedfordshire alone) and practice-attached nurses in BLMK remain stubbornly difficult to resolve, even when incentive schemes are on offer. Figure 6: Age Profile of GP Workforce The capacity, scale and resilience of the prevailing operational and business model in primary care across BLMK is acknowledged as unfit to respond effectively to future challenges. Each CCG has GP cluster architecture in place. However, the supporting apparatus for cross-cluster leadership and administration remains at an early stage. Although there are starting to be some encouraging signs, the development of GP federations across BLMK has not proceeded at the pace of other areas. BLMK is therefore lacking a developed organisational springboard in primary care, from which new models, aimed at scaling and strengthening primary care, might be launched. BLMK has not featured prominently in NHS England s New Models of Care (NMOC) programme, despite having pockets of very modern practice (for example, GP telephone triage, nurse practitioners and 16

17 in-practice community pharmacy). Luton CCG is one of the fifteen Rapid Test Sites for the National Association of Primary Care Home Model, the agreed model of care for the STP and the Newport Pagnell Medical Centre model is a further test site for the Primary Care Home model within Milton Keynes CCG. There is considerable interest amongst BLMK CCGs and local GPs to examine the benefits that may arise from introducing NMOCs and realising the benefits of scale. For example, Milton Keynes CCG held a number of local engagement workshops on developing a Multispecialty Community Provider (MCP) models and has indicated its willingness to host an STP pilot site. These workshops secured broad sign-up from the CCG and acute, community, social and primary care providers in Milton Keynes, to work towards a MCP (+/-) model that would align to the overall STP ambition of an Accountable Care system. In addition, Bedfordshire CCG has established a Models of Care Working Group which includes representatives from health and social care, as part of its community services work on commissioning integrated community health and social care services. Procurement of a new Community Services provider is currently underway using the competitive dialogue process. 1.4 The Luton Population and their Health and Care needs Around 210,000 people live in Luton. Each and every one of them has their own health and wellbeing needs and assets they can offer. Meeting those needs and enabling communities to support each other is a complex task. It means everybody the council, health, social care, voluntary community sector and community leaders need to work together to succeed in supporting people to resolve these issues in an effective and efficient manner. Over the next 20 years the estimated increase in the population size is 30,000 people including large growth in children and those above retirement age. Luton has a high population density; 4736 persons per square kilometre compared to 408 in England plus significant inward and outward migration. Between the 2001 and 2011 Census around 70% of the population changed. Luton is ethnically diverse population with around 55% of the population from black and minority ethnic groups and 75% of school pupils from black and minority ethnic groups. Half of our children do not speak English as their first language. Cultural participation is low, with the engagement in arts, sport and physical activity low. One in three of our adults is inactive. Luton has high levels of deprivation and low levels of life expectancy (compared to England) and there is a large gap between least and most deprived areas within Luton (7.1 years for males and 5.3 years for females). The most common causes of premature deaths are due to circulatory disease, cancer, respiratory disease, and physical conditions in people with mental illness. The CCG is making full use of the recently refreshed Joint Strategic Needs Assessment (JSNA) developing our strategic and operational plans. This Five Year Forward View is the bedrock for our Operational Plan. Working in collaboration with system partners we will 17

18 continue to commission services that specifically address the health and care needs of the people of Luton. The most recent Commissioning for Value pack has identified 11 areas where Luton has an opportunity to improve the cost-effectiveness of locally commissioned services: Cancer and Tumours Circulation Problems Endocrine Gastrointestinal Genitourinary Maternity and Reproductive Health Mental Health Problems Musculoskeletal Problems Neurological System Problems Respiratory System Problems Trauma and Injuries Under the Right Care programme LCCG has prioritised six of these to undertake a change programme. 40% of the opportunities identified will be looked at in the first year of the plan with the further 60% in the second year. The aim of this approach is to ensure that commissioning plans are focused on the opportunities that have the potential to provide the biggest improvements in health outcomes, resource allocation and reducing inequalities. Table 3: Six Prioritised Programmes of Care Programme of Care Intervention 1 Problems of the respiratory system Intervention 2 Problems of the gastro intestinal system Intervention 3 Problems of circulation Intervention 4 Problems of the genito urinary system Intervention 5 Endocrine, Nutritional and Metabolic Disorders Intervention 6 Problems of the Musculo skeletal system 18

19 Three Strategic Priorities Child Wellbeing (0-19 years) The CCG has established an integrated Children s Commissioning Team via a Section 75 agreement with Luton Borough Council (LBC) to ensure all children and families are supported to realise their full potential through the coordination of early years support. Table 4: Child Wellbeing Objectives Strategic Objectives Give Luton s children a Flying Start and reduce infant deaths and neglect by improving the coordination of early years provision including midwifery, Family Nurse Partnership, health visiting, school nursing, children's centres, childcare provision and primary care and ensure a consistent evidenced-based core offer Safeguard children and young people from the risks of radicalisation, child sexual exploitation and gangs through a child-centred coordinated agency approach Reduce dental cavities by reviewing and increasing the provision of oral health services Improve adolescent emotional resilience to improve long-term adult mental wellbeing through investing in prevention services Reduce childhood obesity by developing multi-agency/department approach to reduce obesity, and develop a specific offer for schools Reduce tobacco usage in expectant mothers and young people, including focusing on illegal tobacco availability Adult Wellbeing Improving physical and mental wellbeing is a joint health and social care aim informed by the JSNA, by supporting adults to have a greater ability to manage their own lives, have stronger social relationships and improved care when they need it. Table 5: Adult Wellbeing Objectives Strategic Objectives Increase the physical health for those with diagnosed with a mental health problem, a disability and at risk black minority ethnic communities Increase access and provision of IAPT (Improving Access to Physiological Therapies) and social prescribing to improve mental wellbeing and reduce social isolation Reduce adult obesity by developing a multi-agency/department approach to reduce obesity, and increase the take up of physical activity (leisure and sporting) opportunities Improve access and facilitate better system working to support completion of drug and alcohol treatment led by Public Health and to promote a recovery model to reduce substance misuse Improve sexual health (especially HIV late and chlamydia diagnosis) by reviewing the model with Public Health to improve outcomes Increase and improve primary care access and outcomes by up skilling and developing the workforce and by tackling the variation of care, with an initial focus on cardiovascular disease and stroke prevention,, diabetes, respiratory disease and earlier detection of cancer 19

20 Ageing Well in Luton (>65 years) The CCG is working in partnership and establishing integrated commissioning teams with LBC to ensure person centred and integrated commissioned services are developed for older people and those with debilitating long term conditions. Collaboratively we want to support older people to age well and continue to live independently by enabling them to have the information, opportunities and resilience to make choices about their lives. Table 6: Aging Well in Luton Objectives Strategic Objectives Increase independence through a focus on prevention, early intervention and safeguarding Increase independence and re-enablement by a comprehensive falls prevention plan Improve support to carers to enable them to support and feel confident in supporting the people they care for Improve our responsiveness so that people can access the information and services they need in a timely manner to make informed decisions Reduce seasonal excess deaths by implementing a systematic approach to vulnerable older people Reduce social isolation and its consequences by bringing together different support initiatives across the Borough The Health and Wellbeing Board offers the overarching governance on the implementation of the strategic objectives (including equality dimensions) and evaluation of the implementation of plans. These will in turn inform the agreement of future priorities. 1.5 Delegated Commissioning Luton CCG formally moved into a joint commissioning arrangement with NHS England in October 2016 and the co-commissioning arrangements have enabled the CCG to take a more responsibility in supporting the development of primary care. A Primary Medical Care Information Sharing sub group of the co-commissioning board has enabled targeted work to support practices who are struggling and in turn this has enabling us to work with local clinicians to develop a strategic plan to increase the resilience within the 28 practices. The CCG is working within the STP foot print and planning on taking on full delegated responsibility for primary care commissioning in The benefit of working at a STP level is the economy of scale with building and developing teams with the operational primary care contracting functions and avoiding the fragility of small contracting teams. The primary medical services and their related contracts are essential for greater coordination of planning and commissioning of services across the spectrum of primary, secondary and community and social care. In our joint commissioning role, LCCG has provided local leadership to NHS England with the re-procurement of a four Alternative Provider Medical Services and has successfully developed more sustainable primary care services. 20

21 1.6 Context - Primary Care in Luton Strengthening the role of GPs as providers has required a new approach to commissioning and consideration of a population based funding system, further utilising collaborative working and joint developments adopting the learning from the Primary Care Home pilots. The CCG is committed to ensuring a population based and outcome-focused model which will be encouraged through gain share and risk sharing agreements. In order to make this a possibility, Luton CCG will work across the BLMK STP to develop an environment that breaks down barriers between funding streams and services and encourages GPs and managers to make professional integration in the community a reality. Co-commissioning and pooling of budgets are opportunities to focus on what providers are expected to deliver rather than how they should do so. LCCG comprises of 28 practices aligned to four commissioning clusters that were selfselected by GP Members: Larkside, Kingsway, Medics United and South East Luton. Luton is co-terminus with Luton Borough Council. Figure 7: Luton GP Cluster, Care Home, Children s and Sport Centre Map Although member practices within each of Luton s Cluster work together and have expressed a wish to retain the cluster arrangement for provider development, none have federated into provider groups e.g. Limited Liability Partnerships (LLPs) or Community Interest Companies (CiCs). It is recognised locally that small practices working in relative isolation are unlikely to be supported by the transformational funds for Luton as such practices in isolation cannot offer sufficient resilient primary care services. Locally the LMC has highlighted to practices that delivering services at scale may become vital in maintaining 21

22 the viability of some of Luton s general practices. The CCG are working with the LMC to support practices to consider new models of care that will support better patient outcomes in line with the models described within Section 2 of this document. With the development of population based care via Cluster Groups and their alignment with community and social care staff (see Appendix 1), the CCG Commissioning priority has been driven by Clusters and clinical ownership has been achieved in a relatively short space of time, utilising finite resources to a cluster population. It is increasingly evident that Cluster working is starting to have a positive impact on working practices within primary care; improving quality, reducing variation, and reducing inappropriate commissioning expenditure. Clusters were set up with commissioner focus and these structures are now considering how they can develop as practice provider groups. Although the four Clusters are not aligned geographically this has been debated and not considered as a problem; Luton CCG covers a relatively small geographic area hence 'federations' of like-minded practices with a range of capabilities that choose to work together irrespective of geography will be encouraged through the development of new models of care. Dialogue from many practice staff including the Practice Modernisation, Finance and Information Group (PMFI) show low enthusiasm with many either not accepting the case for change or stating their reluctance using reasons of time constraints and competing pressures. Following Luton s successful bid to be one of the 15 NAPC Primary Care Home Rapid Test Sites clusters have been re-energised with two Clusters now embracing the concept and working closely with the local community and social care providers to develop a joint approach to provide comprehensive services across primary and community care to benefit the population. The GPS on the Governing Body and Cluster Chairs are supporting the work raising awareness of the need for change with their GP peers at every opportunity. Sharing the results from the GP patient survey to clusters clearly demonstrates that there is a wide variation in patient s perception of access to primary care compared to surrounding CCGs. Luton CCG has practices with the poorest results and practices with the very best results in each of the 4 questions measured that relate to GP access. Luton CCG practices on average still rank low nationally when benchmarked with other CCGs. There is, alongside other factors, a correlation between how satisfied patients are with access to their GP services and how they utilise urgent care. Those practices where patients perceive access to be poor tend to have higher A&E, WiC and Urgent GP Clinic activity. The analysis of this data supported the CCGs urgent care strategy and the recent opportunities utilised described below to improve access to bookable urgent GP appointments, where appropriate, through Cluster arrangements. The additional funding to support improved primary care access that the CCG will receive in 2018/19 is incorporated into the plan and required to enable a more collaborative, scaled up, approach to offering appointments in extended hours ensuring better access to pre-bookable and same day appointments. 22

23 1.6.1 IM&T Of the 28 practices, 21 practices use SystmOne, 4 practices use EMIS Web and 3 practices use Vision (INPS) as their medical records system. Work is underway within the STP footprint through the implementation of the Local Digital Roadmap to ensure that primary care records will be viewable across the system, including community service providers and acute Trusts. More detail is provided in the Infrastructure section of this document below. Practices in our area are supported by Hertfordshire, Bedfordshire and Luton ICT who have undertaken a thorough review and upgrade of ICT in all practices in line with the IT operating framework to ensure the primary care infrastructure is sustainable and able to support transformation. The CCG 2016/17 e-referrals baseline is 31%. By November 2016 member practices had increased to 43% meaning we are on track to meet the local target of 51% by March Estates Luton practices work across has 37 primary care sites (28 GP practices). 14 of these are owned by a 3 rd Party Landlord, 17 are owned by GPs and 6 are owned by NHS property services. There is a considerable range of building types, sizes of premises, and of working conditions within them. Most require improvement to meet current standards or to provide for the required expansion of services needed. To transform the large number of outdated GP premises into modern primary care premises fit for the future is a significant challenge that is being addressed via a Luton system estates forum called Luton One Public Estate. A number of options are being considered and will run in parallel: Developing projects which bring together several practices who would like to work together for radical change will not only address short term issues but will develop longer term opportunities. The practices, which are often working in difficult conditions, accept these constraints, responding to them by maximising the use of all available space, and being flexible in their allocation of activities to rooms. The infrastructure section below provides further detail on the local STP and One Public Estate initiatives Quality 28 practice visits have been completed by a CQC inspector and 23 practices have subsequently had their report published on the CQC website. These reports describes CQC judgement of the quality of care provided and is based on a combination of what they found when they inspected, information from ongoing monitoring of data about services and information given to them from the provider, patients, and the public and other organisations. 20 practices have been given an overall rating of good (one now disbanded) 3 practices have been given an overall rating of requires improvement 23

24 One practice had been given an overall rating of inadequate, and has subsequently been re-inspected with a report published in January 2017 giving them a rating of good. The CQC informs NHSE and the CCG when inspection dates are due to occur prior to the visit. Post inspection the CQC will provide NHSE (Central Midlands) with an update. The Central Midlands Team will consider the outcome of each inspection and will share information with the CCG via the Primary Medical Care Information Sharing Group (a subgroup of the PCJCC). This group has been established to: Share intelligence between partners (NHS England, CQC, CCG and Healthwatch) in relation to any identified moderate risk which could impact on the quality and/or safety of care being provided within Primary Medical Services Ensure effective communication and dialog between partner organisations to ensure consistency of approach and to eliminate duplication of effort To agree responsibilities and actions to be taken to mitigate any identified risk To ensure continued focus until any issues of concern are resolved A Risk Log has been developed by the PMCISG with appropriate data populated by each of the member organisations. This log is an iterative document, with agreed actions reported back to the group by the responsible organisation. 1.7 Luton Place Based Model The General Practice Forward View has highlighted to the local system that a significant change in the level of investment and support being offered for general practice is required. The aim of the plans is to help and support struggling practices, reduce GP workload, support the expansion of a wider workforce, invest in technology and estates and a deliver a national development programme to accelerate the transformation of services. NHS England is committing to an increase in investment to support general practice over the next five years supplemented by the CCG to transform local care systems. The GP Forward View is a key work stream under Priority 2 of BLMK STP and all partners have agreed to prioritise the development of integrated locality systems. The Luton model is community health and mental health working in an integrated way wrapped around GP practice populations of approximately 50,000. The CCG Board is focused on the development of primary care, and in particular to develop our clinical leaders who in turn can secure the engagement of all practices in clinical commissioning and the consequent management of financial resources. Our ambitions are to ensure: Sufficient practice workforce capacity and capability to ensure resilient and future proof integrated health and social care services delivered at scale for the population of Luton. Work within the STP Priority 2 Luton placed based delivery is informing the workforce model. 24

25 Extended Primary Health Care Teams centered around the practice or practice clusters, with the aim to reduce GP workload Right technology and infrastructure including the right connections and communications across services to support self-care and signposting for patients. Flexibility to innovate locally, utilising existing skills and experiences With a focus on effective demand management and the critical role of primary care to help steer teams to provide population oriented, personalised, accessible, coordinated, safe and high quality services. Luton practices are facilitated by the clinical leadership to put an increasing emphasis on review of clinical practice and new ways of working such as increased self-care, prevention, early intervention, detailed multi-disciplinary team (MDT) care planning for high risk and complex patients and to support rapid response care pathways where urgent primary/community care is required. Each of the 4 Luton Clusters has now adopted an enhanced MDT approach utilising MDT coordinators who liaise with GPs, community and mental health clinicians and social workers to ensure patients who need a range of support receive the best quality and truly integrated care. This model has been developed over 2 years and is called At Home First and is the building block for Primary Care Home. In future other clinical roles including clinical pharmacists will increase clinical capacity in this model. We are exploring how best to utilise the Clinical Pharmacist s skills, for example undertaking clinical medication reviews for at risk patients. 1.8 How this Plan Supports Delivery of the Nine Must-do s Table 7: Delivery of Nine Must-do s 1. STPs Delivery of the Multispecialty Community Provider (MCP) New Model Of Care Primary Care Home This plan will support the establishment of GP clusters and community and social care teams throughout Luton, as the foundation for the local Primary Care Home model. Related schemes: 2. Finance 3. Primary Care PMS redistribution (improving quality and reducing variation in general practice) Medicines Optimisation Demand management including GP peer review and access to consultant advice and guidance Practice Visits Introduction of strengthened POLCE Right Care Programmes Procurement of comprehensive 111/OOH and integrated urgent primary care services Provision of 3 per head Practice Transformational Funding across 2017/18 and 2018/19 to support Development of Luton s GP Clusters including shared delivery of functions between 25

26 4. Urgent and Emergency Care 5. Referral to treatment times and elective care 6. Cancer 7. Mental Health 8. People with Learning Disabilities 9. Improving Quality in Organisations practices towards primary care at scale, and implementation of 10 high impact actions. Delivery of the General Practice Development programme to help reduce GP workload freeing up time for care Comprehensive workforce development programme Implementation of e-consultations from 2017/18 Achievement of 100% extended access by March 2019 Care navigation and signposting training GP Resilience Programme Implementation of e-consultations from 2017/18 Clinical Pharmacists in General Practice Further development of the mental health link-workers in general practice Care navigation and signposting training Programme to improve the health and wellbeing of people in care homes through providing more joined-up health and social care services Access to Urgent Primary Care Services development Urgent same day Primary Care appointments Agreed solution to allow access to Urgent Primary Care services via 111. Luton RightCare Programme: Diabetes (Endocrine), Gastro- Intestinal, Respiratory, Circulation, Genito-urinary and Neurology (MSK pain). Advice & Guidance Service provision of rapid primary care access to specialist opinion in two different ways; one for urgent advice, via phone, for patients who would otherwise be sent by a GP to A&E and the other via a platform (Medefer) which will provide GPs with prompt but non-urgent Advice and Guidance when they would otherwise refer a patient into Secondary Care. Increase e-referral uptake Support patients with early detection Increase uptake of screening for Bowel, Breast and Cervical cancer Additional psychological therapies for people with anxiety and depression. To be integrated with physical care. IAPT improved access target 2017/18. Introduction of the integrated Health and Wellbeing service building on the number of Mental Health link works aligned with GP Clusters Encourage GP practices to engage with NHS England (DES) to increase number of health checks/ annual reviews carried out by GPs for patients with learning disabilities Primary Medical Care Information Sharing Group (sub group of the PCJCC). Triangulation of data from NHS England, CCG and CQC from a variety of sources to inform the practice level risk log and subsequent actions to ensure quality improvement Members (hospital activity) pack issued to all practices, CCG key staff and wider stakeholders - to support the reduction in variation between member practices 26

27 CCG Patient Safety and Quality Committee forum quarterly Quality in Primary Care review. Continuation of Practice Visits to all general practices 1.9 Summary of Deliverables Table 8: Summary of Deliverable including Trajectories Deliverable Trajectory Primary care extended access 100% by end of Q Awaiting NHS England specification and expected deliverables. Indicative trajectory below: E-consultations E-consultations offered to 50% of patients by end of Q1, 2018/19 Increased e-referral utilisation 51% utilisation by March % utilisation by April Model of Care 2.1 STP Section 1 Introduction, describes the STP Footprint, population health and growth and wider plans for achieving our ambition for Primary, Community and Social Care services. It is signed by the three CCG Chairs and STP Lead. This section provides a description of the model of care for Primary Care Services across the STP footprint and detailed descriptions of work being undertaken in Bedfordshire to deliver improvements to Primary Care in line with this model. 2.2 STP Model of Care Within the STP foot print there are pockets of transformation, with more care than ever before now being delivered in the community, closer to and within people s homes, however, the resource to primary and community care has remained static. The GP Five Year Forward View forms an inherently important opportunity to achieve our ambitions to:- Strengthen primary care services to ensure sustainability and enable transformation Increase the health of the population by maximising prevention and self-care Shift activity away from acute services to community settings, closer to home supported by physical integrated Health and Care hubs as appropriate Ensure that people are able to access appropriate urgent care services, reducing reliance on A&E and reducing avoidable unplanned admissions 27

28 Close integration of health and social care services including community and mental health services wrapped around Primary Care at scale across clusters serving 30-50,000 populations Supports the transformation of services for people with Learning Disabilities Helps to integrate physical and mental health services and achieve parity of esteem Individual CCGs will work with their local GP members and partners to co-design the future model as relevant for each local area, based on the principles described and depending on the learning from the test sites. BLMK understands and looks to build on the uniqueness of Primary Care and the registered practice list, this should remain at the centre of care at, or close to, home offering systemwide clinical leadership and retaining responsibility for coordinating the care that individual patients receive. The STP have utilised the Optum model identifying the top 2% of the population with complex care needs, the next 18% with high health care needs and the remaining 80% generally healthy. Commissioners across the BLMK STP have agreed a joint approach to primary care modelling based on the following ambitions. These ambitions are:- Provision of care to a defined, registered population of between 30,000 and 60,000; A combined focus on personalisation of care with improvements in population health outcomes; An integrated workforce, with a strong focus on partnerships spanning primary, secondary and social care. These objectives are in line with the National Association of Primary Care (NAPC) model Primary Care Home (PCH) model formed to deliver the Five Year Forward View ambitions. Although PCH is not part of the Vanguard programme it is consistent with the ambitions of the Five Year Forward View and supported by the New Care Models Team. Luton CCG is one of 15 Rapid Test Sites (RTS) for the NAPC PCH model and will have access to, and be able to learn from, a RTS learning network called The Community of Practice. This network will be testing the delivery of the wide-ranging components of a PCH. BLMK CCGs are developing plans to move all services to a similar baseline model. The focus of this work is to create a level of standardisation and learn from experiences in Luton, and other areas to enhance rather than replace the local development work already undertaken. Luton CCG is one of 15 Rapid Test Sites for the NAPC Primary Care Home model and BLMK CCGs are developing plans to move all services to a similar baseline model. The Milton Keynes Newport Pagnell Medical Centre is also a test site for the Primary Care Home model to a population of 30-50,000. The focus of this work is to create a level of standardisation and learn from experiences in Luton and Milton Keynes, rather than replace the local development work already undertaken. 28

29 This innovative approach will enable us to strengthen and redesign our primary care, services, ensuring they are centered on the needs of local communities, and utilise the expertise of a wide array of health professionals within the health economy. Through it we will demonstrate that health professionals across primary care are committed to change and working in partnership. This will be another step towards greater integration between primary, community, secondary and social care services providing personal populationorientated primary care where physical, mental and social care is integrated around the needs of communities, particularly older frail people with long term conditions. This model will be integrated as part of the planned development of community and other commissioned services across BLMK STP and will be co-designed by commissioners and providers to wrap services around patient populations of 30-50,000 with the GP at the centre of our patient s care. Figure 8: Primary Care Home Model The new model of care a complete care community as depicted above is built around patients and for patients, ensuring they receive the Right Care in the Right Place at the Right Time. This will ensure: Integrated working across the wider health, social care and voluntary community ensuring that our residents and patients receive care from the appropriate service or professional Patients are provided with personalised, coordinated and responsive care nearer to their home 29

30 The GP remains central to patient care and care planning, supported by the multidisciplinary team to coordinate care across all elements of the r health and social care system GP shared decision making and involvement during transitions between sites of care, e.g. when patients are being discharged from the hospital; Clear and timely communication and information flows between health and social care professionals, patients and their families. The needs of the registered population are better analysis to inform, workforce development, early detection, prevention and improved health screening. BLMK STP has considered the four big killers: diabetes, cardiovascular disease (heart disease and stroke), cancer and chronic obstructive pulmonary disease (COPD), and has agreed that respiratory will be the first specialist area to come out in to the community. It is envisaged that specialists from the local acute trust will align with practice Clusters to support the PCH agenda, 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 the STP footprint. Patients will benefit by being able to access services quickly and will be helped to be more independent and manage their own health needs, understanding when and who to call for assistance if their condition exacerbates Practice Infrastructure Technology Enabled Transformation By working with the focus, scale and expertise available at the STP footprint level, funds already received by the Estates & Technology Transformation Fund (ETTF) will be used in the key area of technology enabled transformation. Our responsive, proactive and multi-disciplinary approach to the delivery of primary care will be best enabled via effective use of the digital tools which are in place and are being used daily in some parts of the STP footprint. For example, effective triage and care coordination are already successfully being delivered in some areas. Focus needs to be widened to support the change management and service redesign skills that will embed these new models of care. Increasing use of non-face to face and asynchronous consultation are fundamental to delivering the capacity required for general practice to engage with transformation. Some successful models already exist in BLMK, which can act as demonstrator sites for others enthusiastic about transformation. These GPFV Plans will provide a mechanism for creating a more holistic programme of care pathway redesign. Technology is only a minor part of this. The main investment required is in the time and expertise to develop capabilities within individual practices and multi-disciplinary teams. Technology will enable the safe transition for GPs to increasingly lead the care of patients using the resources of the wider team in primary care. This links closely with the STP s Priority 4 work, which focuses on Digitisation, and through which we are coordinating BLMK s approach to ETTF primary care technology funding deployment. 30

31 The Local Digital Roadmap (LDR) is a key enabler for new models of care and will help to ensure patients have access to their care record. BLMK s LDR priorities are set out below. As well as focusing on improved communication for general practice, key priorities are around patient activation and self-care via access to their own records. This builds out from the already considerable progress made by some practices with regard to patient utilisation of record access options. An example of where our LDR is focusing on innovation is in looking at the integration of new evolving pre-primary care solutions such as those delivered by patient-focusing apps. The use of these new tools within pathways to empower patients to take control of their condition is our aspiration. The role of prescribed app s to support self-care is one which the STP is seeking to embrace Expected Benefits of Service Offer The new model of care is built around patients and for patients, ensuring they receive the Right Care in the Right Place at the Right Time. By working together across the wider health, social care and voluntary community we will ensure that our residents and patients receive care from an appropriate service or professional. This will be achieved through changing the structure of our workforce and increasing the use of voluntary organisations to deliver services. Patients will benefit by being able to access services quickly and will be helped to be more independent and manage their own health needs, understanding when and who to call for assistance if their condition exacerbates. We will do this through a variety of methods including use of apps, web based solutions such as The Sound Doctor through these actions we will deliver: Table 9: New Model of Care Improved patient health and wellbeing Improved demand management through patient activation and self-care Improved stratification and analysis of population health needs, more prevention, early detection and screening. Greater accessibility to primary care reducing demand on A&E Improved service availability - patients receive the right care in the right place Improved quality of care for patients in local communities Improved utilisation and sustainability of local health and social care resources More finished episodes of care Extended continuity through perceptive and integrated community therapy Improved access and lower waiting times Improved deployment of NHS and social care resources with improved patient experience and empowerment 31

32 2.2.3 Interdependencies with other Transformation: As highlighted in the introduction, our plans for the GP Forward View form an intrinsic part of the BLMK Priority 2 work stream and has interdependencies with:- STP Workforce workstream - details of this linkage are contained within the workforce section of this document STP P3 Acute Care will link with our work to reduce demand on A&E, avoiding unnecessary hospital admissions and reducing length of stay by supporting early discharge. STP Priority 4 Work stream which is delivering the Local Digital Roadmap. This is a key enabler for new models of care and will help to ensure patients have access to their care record. The Local Digital Roadmap priorities are set out below. Figure 9: Local Digital Roadmap Priorities In developing our models of care, CCGs will ensure that they maximise the benefits of remote monitoring and self-care, supporting our residents and patients to manage their own health and enabling them to remain as independent as possible for as long as possible Engagement A full programme of engagement has been developed across the STP and within individual CCGs, each complimenting the other to avoid duplication while ensuring comprehensive engagement. We will continue to build on this through our work to define our Out of Hospital Strategy and as part of the Bedfordshire and Milton Keynes Healthcare Review. The Priority 2 Delivery Board will identify any key changes which will require public consultation and this will add further value to current engagement plans. 32

33 2.2.5 Programme Delivery Focussed programme delivery will be required to ensure we achieve the scale of transformation to which we aspire. Our approach includes effective governance of the GP5YFV and Primary Care Home projects through a combined programme of Primary Care Transformation. The two critical constituents of our approach are (i) active co-design and organisational development support with Local Medical Committees and (ii) Engagement of practice management to provide personal and leadership development. Priority 2 of the STP is focussed on providing capacity and capability to demonstrate, seed and nurture innovative solutions in General Practice. Our initial focus will be with practices that have expressed an interest in transformational change, using what is already proven within BLMK. The programme will be expanded to new practices as successful projects are delivered. 2.3 The Plan for Luton The CCG will utilise the established four Clusters and use these forums to facilitate enthusiastic like-minded practices with the will and vision to collaborate and formalise the Primary Care Home model of care which can be described as: Provision of care to a defined, registered population of approximately 50,000. An integrated workforce, with a strong focus on partnerships spanning primary, secondary and social care A combined focus on personalisation of care with improvements in population health outcomes-(shared decision making and supported self-care) Aligned clinical and financial drivers through a unified, capitated budget with appropriate shared risks and rewards Currently two of the four clusters are part of the NAPC pilot scheme and it is envisaged that, over time, other practices will see the benefits and gravitate towards this model. The approach of innovative practices demonstrating the benefits to others offers the CCG the best opportunity to achieve higher levels of resilience through scale. Participating in the Primary Care Home pilot will encourage practices to forge partnership working with organisations that have the skills not traditionally found in general practice to be able to manage at scale contracts and budgets successfully and learn from these. In order to support delivery plan of the Luton Primary, Community and Social Care deliver board, we are working with GP practices to raise awareness that they will need to operate at greater scale (in order to increase their scope and organisational capacity) and in greater collaboration with other providers and professionals and with patients, carers and local communities. This will enable the provision of a more comprehensive range of services, which are coordinated and community-based. At the same time, general practice will need to preserve and build on its traditional strengths of providing personal continuity of care and its strong links with local communities that comes from individual practice units. 33

34 Cambridgeshire Community Services NHS Trust (lead provider) working jointly with Primary care is a rapid test site for the Primary Care Home model in Luton. We will continue to develop the PCH model to enable primary care, community health and social care professionals to work in partnership, dismantling historical organisational boundaries and working collectively to improve patient-centred care. To make these changes sustainable for Luton and across the BLMK STP, the model will be underpinned by changes to the contracting, payments and investment schemes to ensure that the care at, and close to home sector is sustainably funded. This new framework will be based on the Multi-Speciality Community Provider (MCP) model as described in the 5YFV: The PCH model will deliver improved health and well-being through better prevention, with an initial focus on adults with long term conditions and co-morbidities, closer working across traditional organisational boundaries and joint incentives. This work has already started and central to our approach is improved responsiveness to changing needs. 2.4 Community Integrated Health and Social Care Teams Wrapped around enhanced, strengthened Primary Care and jointly providing coordinated, joined -up care, community integrated health (including mental health) and social care multidisciplinary teams will provide intensive case management and rapid response services Intensive Case Management By working with GPs and using a pro-active risk stratification tool the physical & mental health and social care management of people that are identified as high risk of emergency hospital admission will be improved. Over a 30 to 90 day period, Community Matrons provide intensive support with case management provided by MDT Coordinators. Both work closely with the patient s GP. This approach builds a holistic Anticipatory Care Plan that enables the patient and carers to access appropriate support services and information and to escalate if their health needs urgent assessment and treatment in order to remain at home. Figure 10: Intensive Case Management Model 34

35 2.4.2 Rapid Response The Integrated Rapid Response service has the overarching aim to stabilise and support the patient to remain in their own home thus avoiding, if appropriate, a hospital admission. It unifies and coordinates the efforts of other community health and social care teams such as: Rapid Response Nursing Social Care Re-ablement Therapies Figure 11: Rapid Response Model These services are supported by a single point of access for all professionals, including Primary Care Staff, which provides multidisciplinary clinical triage and a response from the appropriate teams/service within 60 minutes. 2.5 NAPC Primary Care Home Pilot The Medics United Cluster within Luton is focusing on poly-pharmacy for the Primary Care Home pilot. Tackling issues through a systematic, standardised and integrated approach, sharing primary and community care resources with the aim of providing a seamless service to reduce hospital admissions, improve patient outcomes and optimise use of medications, all of which will be measured based on outcomes. The prevalence of diabetes in Luton, particularly among the South Asian population, means that it is not uncommon for several members of a family to either have or be at risk of developing diabetes, therefore, the Kingsway Cluster is applying the PCH model sharing resource across the system focussing on improving diabetes care, targeting patients diagnosed in the last 5 years, who are finding it difficult to self-manage their condition. 35

36 For the system, success will add collateral and momentum to the STP and the intent to anchor future care in the PCH and MCP models. These initiatives will lay the groundwork for a long-term collaboration at scale between primary and community care in Luton. 2.6 Specialist Support in the Community The STP and Luton plan is to develop a greater range and complexity of services in the community taking a population health-based approach in designing the service. This means that commissioned services in acute settings will be transformed and patients will receive more of their required care within the community. Following analysis of our data sources, and focused work speciality with clinical teams, the best clinical and resource opportunities are within the speciality of respiratory care. It is therefore proposed that respiratory is first service to have a total whole system review with the aim to commission all except critical and emergency respiratory services be within the community setting. Specialist consultant, hospital staff, GPs and community staff will all require significant organisational development programmes to implement the transformational change; helping transition staff from traditional models and styles of working. This model of care emphasis facilitation of self-management with specialists working with community teams with alignment to practice Clusters. In addition to STP redesign, some small scale step changes have been implemented, for example, a geriatrician working a session in a cluster and a joint plan includes consultants working in care homes to manage urgent care needs, but the opinion is that a large scale transformation is needed at an STP level. Specialists working in the community will ensure: Well-designed services are co-produced to help the patients to manage their chronic condition that will improve patient experience There is more capacity in primary care with better coordination and reduced waiting times Better alignment with health promotion, e.g.: smoking cessation services targeted to people with greatest need (reducing inequalities in access) 2.7 Care Homes In Luton there are approximately 1120 nursing & residential beds across 22 care homes, of which 6 are nursing homes. Residents are the frailest members of our population and are highly likely to be within the top 2% at risk cohort. Although there are already multiple services available to residents of care homes, these services on the whole are uncoordinated and variable, and they are divided between different statutory and voluntary providers. Local gap analysis against the recently published NHS England framework for enhanced health in care homes (ENCH) has supported development of a case for investment in Luton to support improving the health and wellbeing of people in care homes through providing 36

37 more joined-up health and social care services for those residents who need them and improving the quality of care they receive. Our plan is to implement proven changes from the care home vanguards, in a systematic and consistent manner across Luton. A placed based model of care has been developed which focuses on delivering the following objectives: To improve overall care for patients in care homes, both residential and nursing homes. To make it easier for GPs to care for this cohort by encouraging more proactive care and reducing unscheduled visits. To reduce the unnecessary utilisation of ambulance and secondary care services and therefore cost. To increase medication reviews in care homes and reduce polypharmacy, waste and associated costs; improving safety by ensuring regular review of patient s medication and encouraging de-prescribing. To facilitate improved quality and co-ordination of care in the community setting. To reduce the risk that safeguarding incidences may be missed. To improve end of life care so that more patients are able to die in their place of choice. We are adopting a whole-system approach which is closely aligned to the priorities of BLMK STP. Figure 12: STP Priorities Whole System Approach Our focus will be on early implementation of the enhanced primary care element of NHSE EHCH Framework during 2017/18 and a local multi-stakeholder Enhanced Health in Care Home Delivery Group has been established to oversee implementation. 37

38 2.8 Self-Care Evidence tells us that supporting patients to be actively involved in their own care, treatment and support can improve outcomes and experience for patients, and potentially yield efficiency savings for the system through more personalised commissioning and supporting people to stay well and manage their own conditions better. The CCG are committed to improve patients and carers involvement to equip them to manage their own health and make informed decisions about their care and treatment. There is local agreement on system-wide definitions of self-care, self-management and enhanced recovery for Luton, which will enhance our ability to work together towards a future state in which patients are empowered to self-care, taking responsibility for their own health and wellbeing, and where health and social care professionals are equipped with the tools, techniques and resources to support patients on this journey. Our main areas of focus are: Developing a delivery framework for Self-Care, Self-Management & Enhanced Recovery Developing a Communication & Engagement Plan Self-Care/ Patient Activation Tools: Testing & Implementation Enhanced Recovery Tools: Testing & Implementation Priorities for 2017/18 include: Improving self-care and supported self-management for the population by improving awareness of community activities and the commissioned wellbeing and wellness services. Testing utilisation of the Patient Activation Measure (PAM) as a tool to tailor care and support to people with the most appropriate intervention. Developing and implementing an 'Enhanced Recovery Programme' for all surgical referrals, to ensure patients have optimised their health for recovery from surgical procedures. Agreeing minimum standards for shared decision making in primary care, review relevant tools and agree what good looks like, and describe tips for primary care to implement. Co-producing minimum standards for primary care signposting, utilising tools and resources provided by National Self-Care Forum. 2.9 Mental Health and Wellbeing Service The table below outlines the size of the challenge for a Luton cluster to ensure patients are supported with their mental health and wellbeing. 38

39 Table 10: Mental Health in Primary Care No of People per Cluster Mental Health in Primary Care in Luton 10,560 People with a Common Mental Health Problem 240 Est no: of people with Psychosis 5,280 Est no: of people with a Personality Disorder 3,750 Est no: of people with a Long Term Condition with a Co-Morbid Mental Illness 3,000 Est no: of people with MUS (Medically Unexplained Symptoms) 22,830 Total Baseline: average cluster size 55,249 registered patients; calculation based on a population of 240,000 The Luton Primary Care Home model provides the opportunity to develop a holistic approach to a mental wellbeing service in the community. The CCG is working collaboratively with the local authority to develop a new model for a primary care-based mental health and wellbeing, integrated within Primary Care Home. This approach will reduce the GP workload and transform how people with a mental wellbeing need access support at a locality level. The collaborative commissioning approach between the CCG and Luton Borough Council includes two phases; IAPT, social prescribing, primary care liaison workers and healthy lifestyle services will be in phase one, with phase two to include a single-point-of-access for GP referrals, community teams, dementia care, early intervention in psychosis and other support moving into the integrated service. The new model will: Signal a move from the current model (often reactive, organisation- driven, inflexible, uncoordinated) to pro-active population health management that puts the needs of the person at the centre and is fully integrated into physical health care pathways Provide a first point of referral for GPs and other primary, community and social care professionals to a range of integrated care and support, reducing the need for GPs to refer to separate services Be integrated into long-term conditions pathways and fully integrated as part of the offer for LTCs The healthy lifestyles element of the service will enable people to access weight management, exercise, social prescriptions and a range of prevention advice and support 39

40 Figure 13: PCH Phased Transformation Process The clinical model was endorsed by the GP Members Forum in February. Members stated that better integration within Primary, Community and Social Care services at a cluster level was needed to reduce the workload and pressure on local GPs. An important aspect of the mental health and wellbeing service will be close alignment to long term conditions services, integrated personalised commissioning (IPC). An emphasis on self-care and building personal resilience is expected to have a significant effect reducing demand for health and social care services. 3 Access 3.1 STP Narrative There is a greater expectation for services to be available over 7 days with evidence that poorer outcomes are associated with reduced NHS services at weekends. Access to GP services is continually an area which receives high levels of interest and scrutiny from patients, the media, government and other stakeholder groups. Timely access to healthcare professionals is essential for patients and central to the development of the BLMK STP new model of care. There are benefits to patients, GP practices and the wider health economy of delivering good access. Evidence also exists that suggests a correlation between GP access and A&E attendance. For example, research has been undertaken to determine a lower use of A&E services (20%) relating to ease of access to a GP by telephone. 40

41 Best practice suggests that good access to GP services should include the ability of patients to: Book an appointment quickly, with a reasonable timeframe, and pre-book an appointment if they wish See a preferred clinician if they wish to wait longer for an appointment Access to reliable information about the practice, so they can make their own decisions about the access they require Being able to book an appointment on the telephone but also by other means, such as through the internet, , TV or by text message Contribute to feedback through Patient Participation Groups and other forums Patients being able to telephone the practice throughout the day NHS England has informed CCGs of the additional funding available, on top of existing primary medical care allocations, and when this funding will be received to commission extra capacity to ensure that everyone has access to GP services, including sufficient routine and same day appointments at evenings and weekends to meet locally determined demand, alongside effective access to other primary care and general practice services such as urgent care services. The recurrent funding to commission additional capacity and improve patient access will increase over time. In order to be eligible for additional recurrent funding, CCGs will need to commission and demonstrate the following: commission weekday provision of access to pre-bookable and same day appointments to general practice services in evenings (after 6:30pm) to provide an additional 1.5 hours a day; commission weekend provision of access to pre-bookable and same day appointments on both Saturdays and Sundays to meet local population needs; provide robust evidence, based on utilisation rates, for the proposed disposition of services throughout the week; and appointments can be provided on a hub basis with practices working at scale. CCGs within BLMK will commission a minimum additional 30 minutes consultation capacity per 1000 population, rising to 45 minutes per 1000 population (per week). CCGs across BLM STP will these secure services following appropriate procurement processes. Appointment activity by all participating practices, both in-hours and in extended hours, will be monitored using a nationally commissioned new tool to be introduced during 2017/18. This will enable improvements in matching capacity to times of high demand. BLMK STP will ensure services are advertised to patients, including notification on practice websites, notices in local urgent care services and publicity into the community, so that it is clear to patients how they can access these appointments and the associated service. 41

42 The CCGs within BLMK will ensure 100% coverage of extended access (evening and weekend appointments) is achieved from April 2019, when funding will reach at least 6 per head of population in 2019/20. Currently there is wide variation across the STP for patient access in primary care; the vision is to deliver a consistent offer and access to the BLMK STP registered population, ensuring alignment with seven day services delivering increased numbers of pre-bookable appointments in the evenings and at weekends. We will commission services that align with best practice (as detailed above). It is recognised that there are currently significant inequalities in different groups experience of access across BLMK STP. Whilst making changes designed to improve access, we will ensure that new initiatives work to reduce inequalities as well as improve overall access. The BLMK STP will scope local need and benchmark access across its practices, sharing best practice both locally and nationally. A key priority will be commissioning services which maximise continuity of care for patients and learning from the GP Access Fund currently being delivered across Milton Keynes. 3.2 The Plan for Luton Improving access to Primary Care for the total population of Luton is a CCG Board priority as work with Luton HealthWatch, Care Homes and the access indicators from the National GP patient survey shows that Luton patients perceive access to GP services as difficult. Supporting GP practices to manage the increasing demand from a diverse population has required collaborative working between practices, especially patients within the top 2% of complex needs, for example bespoke teams to work with practices and care homes. Luton CCG has planned to utilise new recurrent funding devolved from NHS England to commission additional capacity and improve access to primary care pre-bookable appointments utilising the established four clusters of GP practices. The NHS England funding available for Luton is outlined below: 2018/ per head of population ( 780K) 2019/20- at least 6 per head recurrent ( 1.402M) As it is now a mandatory contractual obligation for all practices to submit their survey return through the Primary Care Web Tool (PCWT), the CCG can monitor practice/ cluster compliance (e.g. fully, partially or non-compliant) with the extended access criteria. Practices provide feedback on the availability of: Pre-bookable appointments (before 8.00am or after 6:30pm) during the week Pre-bookable appointments on Saturday Pre-bookable appointments on Sunday A practice is only deemed fully compliant if they (in isolation or as part of a group of practices) have made appointments available for all three of the categories listed above. Currently, 18 Luton member practices are partially compliant- with 18 of 28 practices offering 42

43 extended hours under the terms of Extended Access DES or via their current APMS contract. 9 out of 28 practices currently have access on Saturdays. No practices currently offer access on Sundays. The CCG are now pro-actively engaging with member practices and GP Clusters to agree the best approach to utilise funding in 2018/19 to commission the extended access core requirements, with the aim to be 100% compliant by the end of March The CCG will adopt the nationally commissioned tool due to be available in 2017/18. This tool will monitor appointment activity and will be used to inform the commissioned requirements thereby matching capacity with demand throughout the day. Utilising shared learning across the STP especially from the MK vanguard in order to act as a catalyst for change to increase pace and scale of primary care access in Luton. Motivating and facilitating clinical educational events through CCG PLT sessions, the practice managers forum, and within Clusters will also be arranged with the aim to explore different approaches to managing patient access. The access work will overlap with workforce developments and other transformation plans e.g. 8 of Luton s member practices have committed to working together to improve access and have submitted an expression of Interest (EoI) to utilise General Practice Resilience Programme funding to obtain expert facilitation and their release time to consider collaborative working. This project will also link closely with the work streams to offer new forms of consultation to patients, including structured telephone and online consultations. Next steps include: Understand local variation and identify and share effective local practice. Scoping local need during Quarters 1 and 2 of 2017/18 Discussion at CCG members forum, Protected Learning Time (PLT) sessions and Cluster meetings to present models which are already operating successfully in other areas of the country, these sessions to be informed/ supported by MKCCG Identify high risk patient groups including those living in care homes to design collaborative working between GPs Support cluster development by offering Practice Transformational Funding to bring in external expertise to facilitate collaboration Work with practices to identify the locations to offer extended access e.g. within each cluster Work with the CCG communications team and Patient Reference Group to ensure engagement to support development of the model Develop the Information Governance policies and technical solutions for sharing information and functionality between practice systems via the STP-wide Primary Care IM&T transformation programme Scoping the procurement options for commissioning these services, and making key decisions around the procurement route. 43

44 This Improving Access initiative will need to be aligned with the integrated urgent care service described below to ensure both pre-bookable (extended access) and urgent primary care appointments are easily accessible where appropriate for the Luton population Access to Urgent Primary Care Services Practices in Luton have co-produced the clinical model for Urgent same day Primary Care, appointments with the aim to make access to GP services easier to the patient. If the patient is unable to access an appointment with their own GP, there will be a single point of contact available 24 hours a day for all Urgent Primary care needs via the (111) phone number. Figure 14: Access to Urgent Primary Care Services - Current Model The current Primary Care access model in Luton provides over 83,000 patient appointments per annum. This activity is often driven by demand rather than need and the future model commencing in 2017 will ensure demand is addressed promptly, providing the right care at the right time in the right place which will include advice, guidance and support without the need for a face to face appointment. Having engaged with the local population and stakeholders, it is clear there is a need for a clear and simple single point of contact that allows a patient to be directed to the appropriate service in Luton. The locally agreed solution is to allow access to Urgent Primary Care services via

45 Figure 15: Access to Urgent Primary Care Services - Future Model The Integrated Urgent Care service will work collaboratively with GP practices and clusters during the in hours period to offer directly bookable urgent appointments for patients who are assessed to require face to face urgent care. The seamless collaboration with Out of Hours services means urgent appointments will be available 24/7, where clinically indicated. This service will support Luton CCGs member practices by adopting and promoting the use of self-care, alternative services and different appointment methods such as telephone and e- consultation. The integrated urgent care service and GP practices will have access to shared care records, thereby facilitating continuity of care. The CCG is currently identifying member practices (early implementers), to assess the approach of allowing the Integrated Urgent Care service to directly book an appointment with the patients registered GP practice. The CCG will work with these early implementers, secondary care, ambulance service and community care specialists to develop innovative solutions to support patients to receive urgent care away from the hospital CMSK Physiotherapists The newly commissioned Community Musculoskeletal (CMSK) Service was developed with significant practice input during 2016 and is the primary referral route for all (MSK) related presentations to ensure early intervention and supported self-management. The service is intended to support GP practice workload and offers: A multi-disciplinary approach with patients seen by the most appropriate healthcare professional best placed to meet their needs and all patients accessing the service have a personalised care plan and are innovatively supported to achieve their jointly agreed care plan goals with a focus on self-management Holistic care with signposting to services for lifestyle intervention, weight management, increasing physical activity, smoking cessation. Support with psychological aspects of chronic illness and pain signposting to locally-available psychological services. 45

46 Orthopaedic specialist consultations in the community setting with direct listing for surgery if surgical intervention is deemed necessary (and POLCE and Enhanced Recovery Programme criteria are satisfied) Pain management services Packages of care that move patients efficiently along an evidenced-based pathway (with stepped approach and one-stop services where possible or appropriate) Reduced reliance on secondary care services The service is led primarily by Extended Scope Practitioner physiotherapists (ESPs) supported by orthopaedic, rheumatology and pain consultants and is a point of contact for practices. Within BLMK STP there is evidence that access to physiotherapy services within GP practices is beneficial in that Milton Keynes access scheme found that 30% of patient appointments relate to MSK. In 2017/18 LCCG and member practices will work with the CMSK provider to bring physiotherapists out in to GP practices as part of a multidisciplinary team, with a view to supporting GPs to reduce demand on their current services Improving access for patients and increasing practice efficiency We will support practices to manage demand for services, and improve patient experience, through making more GP practice services available online via practice websites, and empowering patients to self-care and self-manage their conditions with digital support. This will include development of more online tools and smart apps to provide tailored advice and support. In addition, using learning and experience from trials in other parts of the country we plan to work with GPs to expand the type and range of consultation experience to fit the needs of our patients including: structured telephone appointments online consultations/e-consultations group consultations for patients with long-term conditions/multi-morbidities. Details around the delivery plan for e-consultations, and patient-facing technology, is provided in the Infrastructure section of this Plan. Alongside this programme, primary care access to specialist opinion is formally available to GPs for urgent advice, via phone, for patients who would otherwise be sent by a GP to A&E. The CCG is also looking to introduce another platform which will provide GPs with prompt but non-urgent Advice and Guidance when they would otherwise refer a patient into Secondary Care. This will be introduced in two phases. The plan is to commence with phase 1 in March 2017, to include access to Advice and Guidance for the following specialities: Urology Cardiology 46

47 Respiratory Gastroenterology (inc. Hepatology) Haematology Nephrology Rheumatology Neurology GPs will be able to ask for advice and guidance direct from their clinical system with the response ed back within 48 hours for the following: advice on a treatment plan or ongoing management of a patient within Primary Care clarification or advice regarding patient s test results advice on the appropriateness of a referral for a patient Identifying alternative clinically appropriate services to refer patients to Currently GPs access consultant advice in an ad hoc manner. It is hoped that introducing this platform will enable all GPs to access advice in a quick and easy way to support their decision making, allowing quick educational feedback to support their continued professional development. 4 Workforce 4.1 STP Workforce Ensuring the sustainability of primary care services and the delivery of future models of care is reliant on the recruitment, retention and development of a motivated, resilient workforce coupled with the introduction of new roles, enhanced skill mix and new ways of working. The GPFV outlines the Government's commitment to expand the workforce capacity in General Practice. The aim is to double the rate of growth in medical workforce over the next five years, creating an additional 5,000 doctors working in primary care. This expansion will be supported by growth in the non-medical workforce - an extra 5,000 staff consisting of clinical pharmacists, mental health workers, nurses, physician associates and others. The future model for primary, community and social care across BLMK is predicated on a strengthened, primary care led integrated out of hospital care service, a standardised approach to care co-ordination and an invigorated approach to self-care, self-management and the use of social networks and prescribing Current workforce Key risks and issues Significant workforce challenges face primary care across the Bedfordshire, Luton and Milton Keynes STP footprint. Workforce data shows a high percentage of staff reaching retirement age, and we have challenges recruiting health professionals in primary, community and social care. Compared to the East of England we have the second highest proportion of GPs due to retire in the next 5 10 years, 4% above the national average. There are more 209 more patients per GP compared to the national average. At 2,349, the average list size per GP in BLMK compares unfavourably with England as a whole there is a growing aging population with increasingly more multi-morbidities. 47

48 In contrast, the ratio of patients per nurse is between the regional and national averages at 3780 patients per nurse compared to 3804 nationally and 3671 regionally. However, 27% of practice nurses are over 55. The percentage of advanced or specialist nurses ranks second in the region ranging from 34% in Bedfordshire to 24% in Milton Keynes. Proportionally, Bedfordshire CCG has the fewest health care assistants, whereas across Luton Health Care Assistants make up 85% of the direct patient care staff. The vacancy rate for Mental Health Nurses is 19% with 15% over 55, Learning Disability Nursing has 17% vacancies with Social Care posts sitting at 12% vacancy rate and 27% turnover. The workforce challenge in community health services is significant and pressing. High turnover and high vacancy rates feature prominently across BLMK. The community workforce is ageing, particularly in the large peripatetic staff groups, such as district nursing and health visiting. Impending GP and Practice Nurse retirement, GP emigration and wide variation in the ability to recruit to vacancies and attract trainees, resulting in posts remaining unfilled or practices relying on long term locum support continues to put pressure on the existing workforce. Historically, a lack of comprehensive primary care workforce data has hindered the ability for effective workforce planning, impacted by a lack of focus on workforce development, career pathways and succession planning. In addition, practices resilience issues are affecting their capacity to support increased training in primary and community care settings or provide the appropriate level of support and supervision to new roles such as Clinical Pharmacists or Physicians Associates Workforce Planning Across the STP footprint workforce planning is approached through the Local Workforce Advisory Board (LWAB), which has comprehensive and coordinated oversight of the interrelated workforce challenges and assures collective action. The LWAB includes representation from each of the three CCGs, STP partner organisations, Health Education England, education providers, Community Education Provider Network (CEPN) leads and the Local Medical Committee. The LWAB is responsible for the workforce strategy and transformation plan and reports directly into the STP steering group. The modelling provided in Appendix 4 of the GP Forward View Guidance indicates a demand-supply gap (high end threshold) of 1 extra doctor working in primary care and 8 other primary care clinicians. Further analysis of the figures relating to other primary care clinicians is required particularly in relation to overseas recruitment and the number of mental health therapists working in primary care, as they do not resonate with our local intelligence Community Education Provider Networks Bedfordshire s Community Education Provider Network was established in April 2016 and draws together key system partners including GP educationalists, practice nurse and practice manager representatives. The network collectively plan local primary care 48

49 recruitment and retention initiatives, strategies for increasing pre and post registration training placements and mentors and the development of wider multi-professional education and training. Luton CCG was successful in their application for wave 3 CEPN status in January The three CCGs will work increasingly more closely to share learning, best practice and maximise opportunities to work collaboratively and at scale, on workforce initiatives across the STP footprint with the aim of; increasing resilience through new ways of working providing education and development to create an energised and sustainable workforce motivating, valuing and engaging existing teams creating vibrant organisations, interesting roles, career structures and supported development opportunities attracting more people to want a career in BLMK through targeted marketing campaigns developing a flexible workforce made up of skill mixed teams and extended teams that reflect the needs of the population supporting the implementation of new approaches to the delivery and organisation of care such as integration, extended roles in risk stratification, care planning and case management New Models of Care: Workforce Implications Underpinning the Primary, Community and Social care model within BLMK are the primary care home principles of a single integrated and multidisciplinary team, working to provide comprehensive and personalised care to individuals. Figure 16: New Models of Care (Primary, Community and Social Care) This will be delivered through new ways of working within general practice and primary care, providing strengthened, enhanced GP services and also supported through a wider health and social care workforce, wrapped around GP services, to offer coordinated, joined up, placebased care The workforce implications of this future model of care will be; 49

50 New ways of working to enable ready access to stronger multi-disciplinary clinical skills Staff trained to enable ready access to high quality decision support systems & technology Professionals able to operate at the top of license, Development of specialist skills with focus of scarce skills on patients with complex or chronic needs Capacity created to undertake anticipatory care and to in-reach into care hot-spots, such as care homes Closer co-ordination between GPs and hospital clinicians across care pathways Closer connectivity between GPs and hospitals facilitating a smooth transition for patients between care settings, either into or out of hospital Hospital clinicians supporting the development of specialist clinical expertise in the community New ways to engage with and incentivise GPs and other Primary Care clinicians to support vulnerable practices or to solve hard to recruit into areas/practices The opportunity to enhance skill mix, freeing up GPs and other primary care clinicians to focus on care management and delivery and reduce administrative burden The opportunity to develop rotational placements, embed career pathways and create generic roles New Ways of Working in Primary Care Luton CCG s Primary Care Home initiative provides a test bed for new ways of working in General Practice that will be rolled out across BLMK to develop strengthened, enhanced GP services. Figure 17: New Ways of Working in Primary Care GP Session Duty Roles Staff skill mix Since May 2016 Lea Vale Medical Group in Luton have revolutionised the general practice team, introducing new ways of working and new roles with significant results: GP capacity increase by 44% DNA rate reduced from 8% to 2% Pharmacist Access clinical Admin Patients seen by most appropriate clinician = 16% of GP work moved down to nursing team, ECP and practice pharmacist ECP Training LTC Management Team based working = reduced stress of whole team 50

51 Following a six month planning period, including engagement with the patient participation group and a comprehensive staff training programme, new ways of working have improved patient access and staff workload: The GP Session Table 11: New Ways of Working GP Sessions Traditional Practice New Way of Working Impact Outcomes 1 GP Session - 18 pre-booked patient requested Appointments - Booked up to 6 weeks in advance - High numbers of clinically unnecessary appointments with GPs GP Telephone Triage - For all pre-booked appointments - For all call slot appointments 1 GP Session - 5 pre-booked 10 min appointments - 16 telephone triage 5 min appointments - 5 same day call in 10 min appointments - 8 additional patient contacts per GP session - 1 WTE GP = 3,240 extra patient contacts per year - Patient contact clinically appropriate - Patient choice on appointment time - All time slot used The Duty Role Table 12: New Ways of Working Duty Doctor Traditional Practice New Way of Working Impact Outcomes Duty GP for patients unable to see own GP that day Duty GP supported by: - Duty Nurse; telephone triage or face to face appointments - Duty HCA; same day ECG, dressings etc. - Duty Admin; all nonclinical queries and liaises with other services - Improved coordination and information sharing with other services e.g. District Nurse, Ambulance, Care Home - Telephone or face to face access for patients - Option for same day or later appointment Duty Team approach consisting of GP, Nurse, HCA and Administrator offers more effective and efficient service 51

52 4.1.8 Staff Skill Mix Table 13: New Ways of Working Staff Skill Mix Traditional Practice New Way of Working Impact Outcomes GP, Practice Nurse, HCA, Practice Manager Admin & Reception Staff Introducing new skill mix and roles: - Emergency Care Practitioner - Clinical Pharmacists - Advanced Nursing Roles - Physicians Associates - Clinical Administrator - Long term locums - Physiotherapist - Variety of prescribing professionals (either independent or protocol) - Nurse Led LTC Clinics - Greater support to paediatric care (ECP) - Protocol driven review of clinical info (Admin) - Home Visit support - Medicines optimisation - Release GP time for clinically appropriate appointments - 70% reduction in GP paperwork - Multi-professional learning and support Joint Community and Primary Care Initiatives Across Luton CCG Joint workforce transformation initiatives are being developed that can be shared across the BLMK footprint. These include: Baseline workforce assessment profiles that include community services to identify opportunities for joint solutions Development of collaborative approach for post registration nurse pathways in community health and practice nurse roles Cross sector planning for developing roles (e.g. support worker roles) and implementing new roles (e.g. Physicians Associates) at scale Developing rotational opportunities for staff e.g. ECPs in Primary Care which the local place-based system also support to ensure services are not depleted of staff e.g. Emergency Nurse Practitioners rotate into ambulance service also. Roll out of Primary Care Mental Health Link Worker Development of multi-professional, collaborative team leadership training opportunities. 4.2 The Plan for Luton The model of health and social care multidisciplinary teams working collaboratively with GPs and practice staff will provide patients with timely access to the right professional within the community setting. This will enable: The development of a wider, virtual practice team, working with aligned MDT Coordinators (clinical navigator roles), clinical pharmacist and mental health workers (Primary Care Mental Health Link Workers) and developing the role of the nurse. 52

53 Access to timely and efficient pathways of care which ensure patients see the right professional in the right setting; this is especially relevant for patients with long term conditions. Support to work in proactive, anticipatory care approaches for patients with complex needs Increased use of telephone or skype consultations with a reduction in clinically preventable face to face GP appointments Coordinated working across differing sectors, organisations and professionals As a result GPs and wider practice staff will continue to build rewarding roles that support recruitment and retention of staff and offer a wider diversity of opportunities to work in a portfolio career and develop enhanced skills. This development programme will be supported by and benefit from the work derived through Luton s wave 3 CEPN status with shared learning of best practice to maximise opportunities Clinical Pharmacists Luton CCG welcomed the announcement that the General Practice Forward View had committed to over 100m of investment to support an extra 1,500 Clinical Pharmacists to work in General Practice by 2020/21. There are currently 0.83 full-time equivalent GPs, nurses and direct patient care staff working in Luton per 1,000 patients - a lower rate than the England average. Research suggests that many requests for appointments are for minor illnesses or long term conditions which could be managed by a community pharmacist. Clinical Pharmacists have been recognised at both STP and local level as being critical to the success of delivering the STP Priority 2 achieving high quality, scaled and resilient primary, and community & social care services. The Clinical Pharmacists offer clinical experience and seniority to fully maximise their contribution to improving the health of the population. They will work within an advanced level framework and will have a range of specialist clinical interests such as diabetes, respiratory or cardiology. Key responsibilities of Clinical Pharmacists in general practice include: Long Term Condition Management medication reviews, patient-centred outcomes Medication Safety risk stratification tools Interface supporting patient discharge from secondary care and tertiary care. And care within nursing homes Medication Queries prescribing support for both patients and wider members of the practice team Clinical Pharmacists may also be able to provide additional support and expert advice and guidance on: 53

54 Medication safety yellow card reports and NRLS reporting of patient safety incidents involving medication, including sharing learning from significant events. Clinical audit to inform commissioning priorities and improve patient outcomes. Over fifty percent of GP practices have expressed agreement to employ clinical pharmacists to enable them to manage current GP workload. The introduction of the role has also facilitated clinicians to review individual roles and to ensure each clinician is working to the top of their professional license. Luton CCG has therefore submitted an Expression of Interest as part of the GP Forward view in line with the national framework requirements requesting funds over three years to recruit five clinical pharmacists and one senior pharmacist to work across 16 practices in order to support general practice and alleviate workforce concerns. The CCG have a team of 5 senior pharmacists and 2 senior management pharmacists in the medicines optimisation (MO) team. The clinical pharmacist recruited will receive induction training with the MO pharmacists. The induction will include an introduction to primary care, QIPP and work streams, and quality and safety in prescribing. All practices currently have a nominated MO pharmacist and they will provide additional support/training to the clinical pharmacist. The clinical pharmacists also have an open invitation to attend the monthly MO team meetings. All pharmacists will have access to an assigned GP clinical supervisor for support and development. The CPPE programme also offers an opportunity for networking across an area. Local pharmacists have informal groups which provide a forum for sharing and learning. Luton has a high prevalence of type 2 diabetes, respiratory and circulatory conditions as well as paediatric asthma and clinical pharmacists will add clinical capacity to support patients to receive NICE compliant treatment. Sharing experience from practices who employ pharmacists from within the STP and Luton have shown that the pharmacists role has taken work from the GP role and generated practice income. Furthermore there are improvements in repeat prescription management, improved QoF performance, identifying undiagnosed conditions leading to improved prevalence and effective management of long term conditions. Furthermore there is the opportunity for improved income from extra services supplied and better use of current resources. Pharmacists can support a reduction in polypharmacy and pharmacy waste, again releasing savings into the health economy Mental Health Therapists The CCG await further details about the 3,000 ne fully funded practice based mental health therapists and we propose to incorporate this resource to the mental health and wellbeing section. Luton s approach to aligning mental health link workers to the four GP Clusters as part of phased introduction of its mental Health and Wellbeing service is covered in section with key milestones and deliverables described within the attached delivery plan. 54

55 4.2.3 Recruitment and Retention The Community Education Provider Network (CEPN) will continue to work collaboratively to implement our workforce development plan and focus efforts on; Addressing the shortfall in Primary Care workforce provision Enhancing the development and availability of innovative primary care roles Improving educational quality through better integration and communication across educational partnerships Expanding multi-professional capacity, skills and educational opportunities Continuing to provide evidence-based and practical support for practices around workforce development and new models of service delivery GP Future Leaders programme Areas of high deprivation are commonly hardest hit during a shortfall of primary care doctors and nurses. As one such area of high deprivation, there is a great deal of anecdotal evidence that practices in Luton are starting to find it very difficult to recruit. The GP Future leaders programme (a partnership between the Deanery and the local University) was locally funded and launched in 2103 as a development programme designed to develop our clinical leaders of the future, encouraging outside GPs to come and work in Luton. A portfolio career option, the posts comprise of clinical sessions, a commissioning placement with comprehensive induction and training programme and a funded MBA. This opportunity gives them leadership skills to act as change managers offering flexibility within GP practices to work in new ways - these GPs have become role models where previously there has been reluctance from general practice to change their way of doing things. Through two recruitment rounds, this initiative has successfully attracted four out of area GPs to a three year programme. Unsuccessful applications have however, been supported to remain in Luton with development opportunities. Although further evaluation of the initiative is planned, it is clear all recruited GPs have been critical to enabling their chosen practices to keep functioning, and have implemented change management practices within their chosen GP practice GP Induction and Refresher and GP Retainer Scheme We will continue to promote both schemes to our practices through our GP Clusters Overseas Recruitment This has been promoted locally however further to initial interest, there was no practice committed as this was deemed expensive and unlikely to address local need Practice Nurse Development and Support We will continue to facilitate the Practice Nurse and HCA PLT sessions, to encourage sharing of good practice and peer networking with the view to support retention and promote development and training. The CCG recently promoted and funded a spirometry training 55

56 session for practice clinicians as part of a wider respiratory improvement programme. We are working in partnership with Bedfordshire CCG, the acute trusts and local universities to maximise the funded training opportunities available to our workforce to ensure patients receive a quality nurse led service (minor ailments, prescribing for LTCs, Wound Care), freeing up GP clinical time to ensure they are working at the top of their license focusing on MDT facilitation to manage the complex 2%/ 18% of the population to keep them well and out of hospital. 5 Workload 5.1 STP Across the STP footprint we recognise our practices workload has increased significantly due to unprecedented levels of demand, increased bureaucracy and workforce pressures including high levels of vacant posts. While some of this workload pressure can be addressed by increasing the workforce, ensuring appropriate skill mix and more integration with the wider health and care system, practices need support to help moderate demand, divert unnecessary work and to be able to reform to support and organise services. In consultation with NHS England, over half of the practices across the three CCGs were identified for support under the GP Resilience Programme, 26% were shortlisted to receive support during Across Bedfordshire and Luton CCGs this support will be provided by the Local Medical Committee and will take the form of a diagnostic assessment followed by support to create an appropriate business development plan. The development plans will enable practices to understand the steps needed to increase their resilience and to be in a stronger and more sustainable position to be able to progress opportunities of working together in different ways. Within Luton CCG four practices have also been identified to receive intensive team coaching and within Milton Keynes CCG two practices have been identified to receive rapid intervention. Across Milton Keynes and Bedfordshire CCGs both individual and clusters of practices have submitted expressions of interest for the Time for Care Programme. The practices, supported by their locality teams, are working in partnership with the Sustainable Improvement Team to organise facilitated workshops planning for the implementation of the 10 High Impact Actions. We will work across the STP to share local learning, best practice and encourage further expressions of interest. We will share national case studies and work in partnership to ensure there is widespread awareness of the further opportunities available to practices through the General Practice Development Programme, including the support available to; Build Capacity for Improvement Create a Productive General Practice Training for Reception and Clerical Staff Practice Manager Development Online Consultations 56

57 5.2 The Plan for Luton Luton CCG will utilise existing GP and Practice Managers networks to ensure member practices are aware of the range of support and funding opportunities available via the General Practice Development Programme. The CCG also work with the LMC to try and communicate the message. We will utilise GP Cluster forums and the clinical leaders to develop plans to deliver the 10 High Impact Actions which will build on existing local strategies to increase capacity and reduce workload within general practice to enable: Further development of Practice Managers via network to create greater peer support, shared learning and access to leadership courses Training reception and clerical staff to undertake enhanced roles in active signposting and management of clinical correspondence Training and networking opportunities for Medical Secretaries to undertake enhanced roles in demand management - including establishing a Medical Secretaries Network Forum Training and development opportunities for practice nurses and health care assistants to support the change management in introducing new models of care Introduction of Clinical Pharmacists to allow clinicians to work to the top of their professional license Greater collaborative working between practices to deliver more sustainable primary care Stronger partnerships between health and social care, through the ongoing development of multi-disciplinary teams to release GP time and improve patient outcome Expansion of Social Prescription to additional practices across Luton to enable GPs and nursing staff to refer patients to a range of non-clinical services Creation of single GP Practice/Care Home relationships to address inefficient use of clinical time and poor communication with Care Homes We have mapped all the relevant general practice development programme work streams below and will engage with practices ensuring clinical and CCG management alignment for each of these: 57

58 Table 14: Local Progress against General Practice Development Programme General Practice Development Programme Area Key Elements Overview & Next Steps Starting Releasing Time for Care Programme Overview: Programme provides knowledge exchange with other practices nationally, expert facilitation in service redesign, peer sharing and support to implement change. Every practice in the country to have opportunity to join a local Time for Care programme over the next 3 years. Next Steps: Discuss at PCJCC and raise awareness with Practices via GP Clusters, Member s Forum and Practice Managers Group to determine local interest. Practice to submit EoI - advisor to make contact within 4 weeks to begin designing programme Funding/Cost & Timeframes FOC EoI anytime until Aug 18 Releasing Time for Care Showcase Events Overview: Showcase events offered to groups of practices at CCG or LMC footprint. Expression of Interest form to notify NHSE about holding a Ten High Impact Actions showcase within local area Next Steps: raise awareness to Practice Managers Group to determine level of local interest FOC From July 16 Time for Care Champions Overview: NHSE to build broad community of Champions, including clinicians, managers, patients and others Next Steps: Discuss with Practices via GP Clusters & Practice Managers forum to identify local Champions FOC 10 High Impact Actions Overview: Practices to use Actions to release capacity. NHSE to gather and share examples of good practice. Next Steps: Develop plans with GP Cluster Leads for consideration by Practices FOC Building Capability for Improvement General Practice Improvement Leader Programme Overview: Programme for GPs, PM, nurses and Project Managers /Facilitators actively working with practices to support GPFV: - Module and webinar dates for April What is Quality Improvement? half-day learning session Next Steps: Circulate details to practices and relevant CCG staff for consideration FOC (overnight accommodation & meal included) travel costs not covered 9 month PDP (up to 6 days) ½ day QI session Training for Reception and Clerical Staff Active signposting by reception staff Correspondence management by clerical staff Overview: Staff training and access to local service information to help direct patients to most appropriate source of help/advice. Training delivered via Clarimed during Next Steps: Determine practice demand for additional training during Overview: Clerical staff given additional training and relevant protocols to support GP in clinical administration tasks. Next Steps: Insight Solutions commissioned to provide bespoke support to individual practices Feb 17 5 year funding from year funding from

59 Practice Manager Development Regional Workshops Local Networks Overview: Sessions to support and develop Practice Managers available Next Steps: Workshops delivered in Dec no further action Overview: NHSE to support growth of local networks of PM to promote sharing of good ideas, action learning and peer support Next Steps: Determine level of NHSE support to further develop existing local PM network FOC Dec 16 3 year funding from Overview: Support for practices to purchase online consultation systems (mobile app or online portal) Online Consultation Systems Purchase of Online Systems Next Steps: Work closely with ETTF Group across STP to consider available solutions and procure best option at scale. Liaise with GP IT Group (consisting of LCCG, HBLICT, GPs, Practices Managers and LMC) to determine local needs 3 year funding from GP Resilience Programme (GPRP) and Vulnerable Practice Scheme In addition to the longer-term primary care development work to support the establishment of more sustainable business and delivery models, we will continue to deliver short-term support to struggling practices in partnership with NHS England. This support will help practices to address their immediate challenges, whilst enabling movement towards more collaborative longer-term solutions where possible. The sustainability of local practices will continue to be closely monitored by the CCG Executive and the Joint Co-Commissioning Committee with NHS England. NHS England have confirmed that the vulnerable practice funding to be utilised for practice diagnostic assessment has been aligned to, and will be deployed as part of, the GPRP. The aims of the GPRP are as follows: to offer a menu of support to ensure practices are more sustainable and resilient, and equipped to tackle the challenges they face now and in the future securing high quality care for patients. 12 practices in Luton have been successfully prioritised to receive support from the national funding made available through Supporting Vulnerable Practices and GP Resilience Programme. The diagnostic phase of the programme is to be led by the LMC and has now been launched with support from NHS England, this will continue into 2017/ LMC Support Package to Practices The Local Medical Committee (LMC) has developed a support package to offer to practices across Bedfordshire and Hertfordshire, for which funding has been approved in principle by NHS England. The package will include a practice health-check diagnostic tool to support practices gauge where they are on the spectrum from struggling to succeeding, and coaching and facilitation to support practices with developing forward plan solutions aimed at achieving maximum stability for practices and localities. LCCG will continue to work closely with the LMC and NHS England to support implementation of this support package. 59

60 5.2.3 Access Improvement Initiative Eight practices submitted an expression of interest to NHS England as part of the GPRP requesting funding to bring in external expertise and to fund backfill of time to allow them to consider how they can work collaboratively to offer patients access to primary care services utilising new ways of working and sharing resource to reduce significant work pressures and to manage patient demand. NHS England have agree funding in principle pending a meeting with the CCG and the lead practice to ensure due diligence Intensive Coaching for Practices NHS England have agree GPRP funding (in principle) to allow roll out of 6 month intensive coaching support for 4 identified practice within Luton. Pending final agreement, NHS England (supported by the CCG) will put in place a MoU with each practice to ensure funding is utilised to achieve the desired outcomes. The expected outcomes of the intensive coaching are as follows: Understand more fully where they are heading as a practice in 5 years time. Identify what sort of practice and team they would like to be. Have a strategy for addressing the change that is needed. Understand their purpose, common tasks and vision. Have improved interpersonal relationships. Identify new, more productive ways of working together. Create long and short-term goals for the practice. Understand where the practice is heading and how they might get there. Have increased staff engagement and team working Support for Practice Managers Traditionally Local Medical Committee s (LMCs ) have had a key role in providing pastoral care for General Practitioners and Bedfordshire & Hertfordshire Local Medical Committee (LMC) now has a dedicated team of local volunteer GPs who are trained to identify GPs who are suffering from significant stress, mental health or addiction problems. The CCG and LMC are working with local practice managers via the PMFI group to consider making available a similar pastoral care solution for local practice managers. The CCG are also in conversation with the LMC and external training providers to consider practice manager development and how, in line with the GPFV, our local managers are encouraged to engage with the new national development programme. 6 Infrastructure 6.1 STP Estates All four Local Authorities within the BLMK STP are areas of significant housing growth. This is set against the current position where many of the facilities used to deliver primary care 60

61 services are already too small for their existing patient lists, and many are not ideal for the delivery of modern and integrated primary care services. The future vision for primary, community and social care in BLMK is centred around integrated multi-disciplinary teams delivering an expanded range of out of hospital services, so ensuring an adequate community-based estate to deliver and enable these models of working is essential. The estates strategies for each of the CCGs, and the STP Estates work programme, all focus on maximising the use of existing assets, delivering projects to increase the capacity of general practice services for this growing population, and increasingly working towards developing facilities which can be used flexibility by a range of providers to support a more integrated model of care. The CCGs local estates plans are directly aligned with the BLMK STP estates work plan where the identified priority areas include: The need for joint working across primary, community and social care to optimise the use of existing estate across the footprint Rationalisation of estate and development of flexible facilities to deliver long-term value Opportunities to release capital proceeds where sites are declared surplus to requirement Consideration of back office services and functions provided within secondary care estates to drive consolidation in community settings Opportunity to consolidate estate management services and Facilities Management provision All three CCGs are working increasingly closely with Local Authority partners to maximise opportunities around partnership working to deliver priority estates projects, including maximising section 106/CIL contributions to developments, and Council-led delivery of primary care capital projects. There is a well-established One Public Estate programme in Bedfordshire, which has provided funding to support the local hub development programme, and a One Public Estate programme has recently been established in Luton. These provide key forums for bringing partners together to develop joint estates solutions IM&T The three CCGs in the STP footprint submitted a joint application to the ETTF (Estates & Technology Transformation Fund), and were successful in being awarded funding to support implementation of priority elements of the Local Digital Roadmap. The 1.7million funding awarded across Bedfordshire, Luton and Milton Keynes, will enable development of the technologies required to support primary care at scale, the sharing of patient information across GP practices, with the out-of-hours/111 provider, and with members of the multi-disciplinary care team. With help from additional funding from NHS England for implementing e-consultations, this programme will also help to improve the technical infrastructure needed to support new forms of patient consultations, e.g. online consultations, Skype, etc, and technologies to better empower patients to self-care and selfmanage their conditions. 61

62 By the end of the first year of delivery of the programme (2016/17) the programme will have: Achieved technical interoperability between GP practices and 111 / Out of Hours service in time for go-live of new urgent care services across Bedfordshire and Luton by April 2017 Begun to enable technical interoperability across multiple providers to support STP ambitions in relation to development of multi-disciplinary working. The programme will build on this and other existing work in 2017/18 by developing and implementing the following schemes of work: Develop the use of the existing core Primary Care clinical system (SystmOne/ Emis Web/ Vision) as a basis for information sharing and clinical collaboration, including: Technical access & configuration arrangements to enable record sharing Templates Information Governance, RBAC and consent model Develop information sharing and enhanced technology pilot with the BLMK STP work stream, Innovation and Technology in Care homes Develop Child Protection Information Sharing (CP-IS) in unplanned primary care settings to ensure compliance, and work towards improving child protection information across all settings. Develop information sharing for provider services to access key primary care clinical information via the most appropriate solution, including: GPs able to access clinical records across the locality / hub Authorised members of the MDT in the locality hub able to access agreed data sets within the record Access to GP record from provider settings (Acute, Community, MH, OOH) Improved information flows for End of Life (EOL) patients. Identify and implement remote triage and care services through phased pilots, including: E- consultations suite of technical solutions to be offered to practices/clusters during Q2 of 2017/18 following options appraisal Remote monitoring Palliative / EOL care Online tools & smart apps to provide tailored advice and support Scope and develop interoperability between GP practices appointment booking systems and community/111 and out of hours providers Undertake a strategic options appraisal to identify the best approach to patient access and personalised health records to support self-care, shared care planning with professionals and patient ability to add and view data. The programme will work towards the following outcomes: 62

63 Professionals across care settings can access GP-held information on GP-prescribed medications, patient allergies and adverse reactions Information accessed for every patient presenting in an A&E, Out of Hours or 111 setting where this information may inform clinical decisions (including for out-of-area patients) Information accessed in community pharmacy and acute pharmacy where it could inform clinical decisions Clinicians in urgent and emergency care settings can access key GP-held information for those patients previously identified by GPs as most likely to present (in U&EC) subject to patient consent, encompassing reason for medication, significant medical history, anticipatory care information and immunisation Development of digital operating models to enable Primary Care at scale/ primary care hubs, enabling shared access Interoperable appointment-booking systems enabling integrated working and GP extended access Patient and Citizen access to their own care record, combined with high quality information about effective care planning Enabling earlier more effective self-care preventing disease development and exacerbation. A programme to take this work plan forward has been established, interlinked to the STP Digitalisation work stream. Table 15: STP Digitalisation Key Deliverables Key Deliverables Resource to deliver project (i.e. business analysts, change managers, functionality experts) IG Sharing matrix Baseline of current capabilities and gap analysis Information sharing agreement E-consultation suite of options for practices Specification Action/ Milestone Plan and recruit resource Produce IG sharing matrix for BLMK Determine current interoperability across whole system Develop information sharing (IG) across system Options appraisal for e-consultations produced and procurement undertaken Establish information sharing requirements across each care setting Milestone Delivery Date Q4 16/17-Q1 17/18 Q4 16/17-Q1 17/18 Q1 17/18 Q1 17/18- Ongoing Q4 16/17, Q1 & Q2 17/18 Q1 2, 17/18 63

64 Primary care/out of hours booking interoperability Options appraisal for technology solution/s Utilisation of appointment booking between practices and out of hours/111 services Develop options appraisal for approach to sharing GP-held patient record across all relevant care settings Q1 2, 17/18 Q3 17/18 BLMK health and social care shared record (with patient and citizen access) options appraisal To be commissioned and developed Q2-Q4 17/18 Deployment plan Primary care record sharing Planning for implementation of primary care record-sharing solution implementation Implementation and roll-out of sharing solution Q3-4 17/18 Q4 17/18, Q1-2 18/ The Plan for Luton IM&T Operating Paper-free at the Point of Care is about ensuring health and care professionals have access to digital information that is more comprehensive, more timely and better quality, both within and across care settings. The scope of this ambition is defined by the seven capability groups, as outlined previously. Luton CCG has put in place a 2017/18 digital capabilities delivery plan which outlines high level objectives and deliverables and aligns everything we do between now and 2020 back into the 5YFV ambition of paper free at the point of care by The objectives of the delivery plan are stated below: Ensure high quality core and mandated GP IT services are available to all practices Ensure that existing primary care systems are fully optimised and national strategic systems are deployed and utilised to achieve the full benefit Support commissioners to deliver Local Digital Roadmaps (LDRs) Work with commissioners to facilitate the development and implementation of digital technology capable of supporting and enabling new models of care Ensure local digital primary care services can respond to service and organisational change and can enable innovation. In addition, the 2016 operating model aims to set out how we will achieve world class digital primary care systems that provide flexible, responsive and integrated services for patients, giving them greater control over their health and care. This model describes the financial operating arrangements, assurance process and leadership required to support the effective delivery of GP IT services. Core and mandated GP IT services will be the first call on GP IT revenue funding that will be provided as part of annual CCG baseline allocations. Enhanced primary care IT services are discretionary services that are developed and agreed locally to support local strategic priorities and commissioning strategies to improve service delivery. This then links back to the LDR by reviewing ICT activity and plans against Local Digital Roadmap Guidance. 64

65 Current Status of Universal Capabilities Development Luton CCG has established a local Primary Care GP IT Group. The purpose of this group is to provide a forum via which practices/clusters can raise IT related matters with the aim of improving patient care and increasing efficiency. The Group addresses issues and concerns and makes recommendations for improving utilisation and ensuring solutions are used to their full potential. This group reports to the Clusters and the CCG Director of Finance via prior approval process, and is accountable to the CCG via its IM&T Clinical Lead/Chair of the group. This group overseas the progress and delivery of Universal Capabilities Development, providing a steer for practices and clusters to ensure continued practice engagement and improvement. Key areas and the current status for each of these are listed below: Patient Online Services Programme CCG Target Target Date Status - November 2016 RAG Patient Online Luton 2016/17 GMS Target: 10% of registered patients using one or more online service by 31 March Mar-17 "66.7% of practices at or over 10% registrations for online services" *November Practices on target 10 Practices still to achieve target a Electronic Prescription Service Programme CCG Target Target Date Status - November 2016 RAG EPS Luton 2016/17 GMS Target: 80% of repeat prescriptions transmitted electronically by 31 March Mar % of practices live with EPS g NHS e-referral Service Programme CCG Target Target Date Status - November 2016 RAG e-referral Luton 2016/17 Quality Premium: payment of 1 per head of population if the proportion of GP referrals made via NHS e-referral Service increases to either 80% by March 2017 or a 20% increase on the March 2016 performance 31-Mar-17 Baseline: 31% November % Increase required to achieve target 8% a The promotion, deployment and support of national digital systems, including Summary Care Record, EPS2, e-rs, Patient Online and GP2GP is key to delivering the CCGs overall LDR goals and ambitions. The GP IT group provides the ideal platform to ensure all of these solutions are activated in all 28 member practices. The e-referral Service will be undergoing a number of system enhancements to make it easier, quicker and more convenient to use. The Advice and Guidance functionality will enable providers to set up and operate Advice and Guidance services for non-urgent GP referrals, allowing GPs to access consultant advice prior to referring patients into secondary care. Deliverables in the NHS e-referral Service roadmap will help providers meet the targets set out in the Advice and Guidance CQUIN. LCCG will be working with GP practices and providers to implement and fully utilise the potential of this service. To achieve the national measure of increasing the proportion of GP referrals made via NHS e-referrals by 20% (as identified within the Quality Premium), the CCG recognised the importance of engaging with Medical Secretaries. Whilst a range of forums are available to GPs, nurses and Practice Managers, similar opportunities for Medical Secretaries were 65

66 somewhat limited. Therefore the CCG hosted the first Medical Secretaries meeting in November 2016 to primarily support the increase in e-referrals usage. Over 30 staff from 26 practices were in attendance. The success of this initial forum has resulted in requests for the meetings to continue to allow Medical Secretaries to receive training, contribute towards wider CCG initiatives and to create an environment for staff to network. The CCG is optimistic that with the continued support of Medical Secretaries and wider practice staff, Luton will achieve the 51% target set for March To boost the usage of the Electronic Prescription Service (EPS), refresher training is available to practices. The in house training team provides refresher training on an ongoing basis. Practices will be encouraged to take this up. Outbound Electronic Messaging Practices have experienced problems with patients not attending booked appointments (DNAs). The CCG now funds the utilisation of SMS messages to remind patients of upcoming appointments. The SMS service means messages can also be sent to patients to remind them to come in for vaccinations, health checks, medicine reviews and screenings. WiFi The NHS WiFi programme is rolling out WiFi access for staff and patients across NHS providers. GP practices outside of the Early Adopter areas will start to receive their new WiFi services from April 2017 onwards, with hospitals and secondary care following in This initiative aligns with the commitment set out in the General Practice Forward View commitment (NHS England, 2016). WiFi will allow patients, visitors, and staff to connect to the internet using their digital devices, including computers, tablets, and smart phones. LCCG received capital funding for the provision of staff side N3 WiFi. The funding was confirmed in 2016/17 financial year and rollout has now been completed across all member practices. Funding to Clinical Commissioning Groups from the NHS WiFi programme will be provided, we will use this funding to provide patient facing WiFi in all practices. The funding is based on a calculation of GP surgery size, and will be allocated to CCGs as an 'in year revenue transfer' which covers: the implementation costs in 2016/17 and 2017/18 only funding for quarterly services charges in 2016/17, 2017/18 and 2018/19 financial years (for a maximum of eight quarters from the implementation date) HSCN / N3 The Health and Social Care Network (HSCN) will replace the current N3 provision and provide a reliable, efficient and flexible way for health and care organisations to access and exchange electronic information. HSCN offers a standards-based network that will enable multiple suppliers to provide interoperable network services to health and social care organisations. 66

67 The HSCN offers a number of benefits over the existing N3 private network, such as: a competitive marketplace that encourages innovation, driving down cost and increasing quality offering a choice of suppliers and procurement options to suit your needs enabling easier connectivity through a simpler 'Connection Agreement' Within the BLMK STP area, an N3 replacement project is starting up under the Priority 4 Shared Infrastructure work steam. All five main IT service providers are engaged with the project and will meet regularly to plan and agree the approach. GPIT Operating Framework In line with the requirements of the GPIT Operating Model , a specific focus will be given to training and system optimisation activities. LCCG is aiming to deliver a training service that supports the safe and effective use of core clinical systems and their optimisation. A key work stream will the design and delivery of Clinical Systems Health Checks. The CCG is also considering ways to provide Data quality training, advice and guidance, including support for: National data audits / extracts / reporting e.g. National Diabetes Audit General reporting Template development / QA Spreading best practice Clinical / medical terminology The CCG has identified additional GP IT funding to progress the following work: Purchase and rollout of mobile devices to GP practices. The funding model and delivery plan has been agreed with the GP IT Group and is on track to ensure all member practices will have access to 1 remote device per 5,000 registered population Rollout of Patient Information Screens. All but 1 member practice have had their screens installed. A plan is in place to ensure the infrastructure is in place for the last practice. Public Engagement Services such as patient online and enhanced summary care records have been promoted on the GP patient information display screens within GP practices Information slides presented on GP patient information display screens raise awareness and benefits of new services available to patients Practices have been furnished with information leaflets for patients to support uptake of patient online services, the SCR and EPS. The CCG has also encouraged promotion on practice websites 67

68 A message promoting the EPS service have been added to prescriptions Practices have added opt-in details to the registration documentation to increase patient uptake for patient online services SMS messages are used to remind patients of upcoming appointments/vaccinations, as well as urgent practice messages and more recently to encourage engagement in patient participation groups Estates NHS England currently has responsibility for supporting the development of premises in General Practice and it is a key priority for primary care co-commissioning moving forward. Premises plans need to be forward looking and demonstrate how the asset base will be developed to be a key enabler for service transformation. The CCG is working jointly with NHS England to support the prioritisation of premises developments and ensure effective and efficient use of limited available resource. The CCG primary care estates and premises group (sub-group of the Primary Care Joint Commissioning Committee) is closely aligned to the BLMK STP estates work plan where the identified priority areas include: The need for joint working across primary, community and social care to optimise the use existing estate across the footprint Rationalisation of estate and development of flexible facilities to deliver long-term value Opportunities to release capital proceeds where sites are declared surplus to requirement Consideration of back office services and functions provided within secondary care estates to drive consolidation in community settings Opportunity to consolidate estate management services and Facilities Management provision The CCG is an identified partner within the One Public Estate programme designed to facilitate and enable local authority partnerships to work successfully with Central Government and local agencies on public property and land. The local partnership has been successful in gaining funding for the development of a Services and Asset Delivery Plan. One of the key aims of the programme is to deliver more integrated and customer-focused services by encouraging publically funded services to co-locate, to demonstrate service efficiencies, and to work towards a more customer-focused service delivery. In partnership with the Local Authority and other stakeholders the CCG will consider the system-wide opportunities to enable the BLMK STP strategy. As we move forwards with co-commissioning arrangements, we recognise the need to work towards developing a joint NHS England/LCCG response regarding residential developments and the potential for Section 106. Having made links with LBC Town Planners it has been made clear there are currently no section 106 opportunities for Luton. The town planners have however provided planning details to ensure there is clear understanding of 68

69 the planned population growth figures so we can attribute these to practices/clusters allowing population growth factors to be considered. Through the Estates and Technology Transformation Fund the CCG identified a number of opportunities to work collaboratively and develop primary care infrastructure in partnership with Luton Borough Council. NHS England has announced that one of these schemes, the Farley Hill project will be supported with capital investment and this will progress, pending due diligence, as part of a proposed Local Authority housing development ETTF - Farley Hill Project This scheme will provide a new build to accommodate patients from the branch practice of the Lea Vale Medical Group and the patients of a recently disbanded APMS practice offering services for the entire population of Farley Hill and the surrounding area. The proposed site has been identified by the practice in partnership with Luton CCG and the Local Authority This scheme has been included as a priority in the CCG Strategic Estates Plan sent to NHS England and has been discussed and agreed as a priority by the Primary Care Premises and Estates Group (a sub group of the Primary Care Joint Commissioning Committee). It is deliverable within the ETTF timelines and also meets the main criteria, i.e. it is transformational in the sense that it would provide primary care at scale and bring wide variety of services all under one roof. Plans are significantly developed by the Local Authority and the practice concerned. This is a one off opportunity that would present great value for money in the long run and would enable the development of co-design and integrated working between the CCG and Local Authority. Aims and objectives: To ensure sustainable primary care services are available for the population of Farley Hill and the surrounding areas, and that these are provided from a building that is fit for purpose now and in the future. To encourage the delivery of primary care at scale, collaborative working across Health and Social Care and access to services out of hospital. To capitalise on the opportunity to further build and develop the Lea Vale Medical Group as a training provider. The full CMR for reimbursement purposes will be approximately 127,000 per annum. The overall cost for the build is likely to be approximately 2.1m plus VAT. If ETTF capital funds are granted by NHS England (pending due diligence) a lower rent/ rebate would bring the revenue down. These figures are indicative at this stage. The PCJCC has agreed the ongoing rent will be affordable within the current primary care budget allocation even if ETTF capital funds are not released by NHSE to bring the revenue consequences down. The key milestones and KPIs for this scheme are captured in the attached delivery plan. 69

70 7 Investment 7.1 STP The various forms of investment towards delivery of the GPFV will provide an essential lever for enabling the transformation required across primary care within BLMK, and for improving its ongoing sustainability. Transformation and practice resilience funding will be deployed to maximise progress towards place-based solutions, whilst addressing some of the shorter term sustainability issues within each area. We will work across the STP to share the learning from the MK expanding vanguard for extended access, to support the planning for taking forward appropriate models within Bedfordshire and Luton from 2018/19, and maximising the benefit from the available funding. 1.7m ETTF funding has been secured across the three CCGs for an STP-wide primary care IM&T transformation programme to enable development of the technologies required to support primary care at scale, the sharing of patient information across GP practices, with the out-of-hours/111 provider, and with members of the multi-disciplinary care team. This funding will also include the project resource for conducting an options appraisal for the best technology solutions to support e-consultations. The solutions will be commissioned within each CCG using the dedicated online consultations funding in line with the outcome of this options appraisal. 7.2 The Plan for Luton The table below provides a summary of the relevant funding streams to be deployed within Luton to support delivery of this plan. Table 16: Funding Steams Funding Source Amount Description % increase in core primary care allocation Practice Transformational Funding Online GP Consultation Software Training for care navigators and medical assistants General Practice Resilience Programme funding Extended access funding NHSE to advise ( Luton is currently only Joint Commissioning status) 2017/18: 350K 2018/19: 350K ( 3 per head) 2017/18: 59, /19: 80, /18: 39, /19: 40,146 NHSE to advise 2018/19: 780,397 ( 3.34 per head) Increase to NHSE primary care budget for Luton, to fund contract changes. See section below for description Procurement of e-consultation software following options appraisal (to be carried out under STP-wide primary care IM&T programme) See description below - deliverables are captured in the attached delivery plan To commission 100% coverage of extended access services by Q4, 2018/19 70

71 Estates & Technology Transformation Fund (Estates Projects) Estates & Technology Transformation Fund (IM&T) 1,141,700 (total) this includes funding for BC development: 2016/17: 40K 2017/18: 80K 2017/18: 1.2m 2018/19: 300,000 Funding to support planning and business case development and capital investment for Farley Hill Project. Funding to deliver STP-wide IM&T programme to support implementation of the primary care facing elements of the Local Digital Roadmap One Public Estate funding To support scoping work for within Luton to support integrated working. Bid has applied for the following: Farley Hill Medical Centre & Housing Development 112.5k Luton One Public Sector Office & Skills Hub 105k 7.3 Practice Transformational Funding In line with the national GPFV guidance Luton CCG have planned to spend a total of 3 per head, as a one off non-recurrent investment commencing 2017/18 for GP practice transformational support. Discussions have commenced with the STP Primary, Community and Social Care Delivery Board, Primary Care Joint Commissioning Committee (PCJCC), the practice managers group (PMFI), with the purpose to stimulate ideas and enthuse providers for how to utilise investment at scale for improved access and implementation of the 10 high impact areas. Budget allocation is 350k in 17/18 and 350k in 18/19. Investment to commence in 2017/18 split 50% in year 1 and a further 50% in year 2 As stated in the operating plan the CCG has committed 50% of the above funds through the 1% non-recurrent transformation fund of which 0.5% can be committed, the remaining 50% is to be funded non-recurrently through the CCG s increased allocation. The CCG are working closely with the LMC to utilise consultancy and capability-building partners from a wide range of regional and local bodies to secure ready access to credible, relevant and high quality support for the full range of practice/ provider collaborative development needs; thus providing project and change management support, potentially via GP clusters, to help reduce GP workload and increase system wide productivity. Agreement and allocation of Practice Transformational Funding will be dependent on schemes across groups of practices or a cluster covering a minimum of 50,000 population. It is not anticipated that funding will be made available to individual practices. The criteria for use include: Schemes/projects assessed as having an impact on sustainability of primary care, e.g. shared delivery of functions between practices in a cluster, supporting primary care to work at scale, 71

72 Schemes that deliver targeted workforce diagnostic assessment and facilitated change management across groups of practices Schemes implementing greater use of technology to reduce practice work load, e.g. implementation of e-consultations, patient supported IT Increasing clinical leadership capacity to support new models of integrated multidisciplinary working with community services and social care including pump-priming new workforce models Schemes assessed as supporting practices to implement the ten high impact changes Schemes providing additional project capacity to support the Time for Care programme and to support the review of primary care estates. 7.4 Training Care Navigators and Medical Assistants This funding is allocated solely for the purpose of supporting the training of reception and clerical staff in GP practices to undertake active signposting and document management. The funds may be used for any of the following: The cost of purchasing training Backfill costs for practices to cover staff time spent undertaking training Support in kind for practices for planning this change or undertaking training Sign-Posting In November 2016 the CCG facilitated 4 sessions on signposting for Receptionist/Clerical staff within Luton GP practices. Training provision was made for both afternoon and morning sessions to enable practices to release staff at times convenient to both practice demand and staff working hours. Sessions were delivered by Clarimed Training Limited, an organisation recommended and used by the Local Medical Committee (LMC) to deliver administrative training courses to general practice. Focus of the training was to share best practice as recommended by the RCGP using a signposting process flow that has been developed. Whilst recognising that this model may not work for all practices (depending on size and structure) it provided useful information for staff to take back to the practice and discuss further; for example ensuring there are clear pathways within the practice, that all receptionist staff have access to, in order to effectively signpost patients to the right healthcare professional, as this will avoid inappropriate use of GP appointment times. Using local information from the CCG, Clarimed shared with the delegates details of general ailments that can be treated at home without the need for GP Intervention. Information was also provided on the conditions that can be addressed by a local pharmacist, sexual health service, and how to contact the Out Of Hours and 111 service in an emergency. Signposting also included Is A&E for me promotional material previously designed by Luton CCG. 72

73 It is envisaged that by continually reviewing signposting processes and providing patient information within the practice and on the practice website that the population of Luton will become more familiar with the healthcare options available to them within the primary care setting alongside the GP Surgery. Clinical Correspondence Management In January 2017, the Luton Primary Care development team researched a number of providers with a view to delivering bespoke training for practices, in relation to clinical correspondence management. The outcome is to create a standard operating procedure that details the process to be followed for the management of all clinical correspondence thus reducing the administrative burden of the GP, thus allowing better use of the clinical professional s time. With a protocol in place it will empower staff to act on the instruction of the GP (whilst the GP remains clinically responsible). Insight Solutions IT Services Limited have been contracted to deliver 28 one to one sessions in Luton between 1 st March 2017 and 30 th June The program as outlined in the attached delivery plan will allow 14 practices to have the opportunity to work on an individual basis with Insight Solutions to design the protocols that will work best for their practice in managing clinical correspondence. The bespoke training will involve the receptionist staff, practice manager and clinical leads/partners who will assist in agreeing what the clinical framework should look like for their practice. The outcomes will be measured as specified in Appendix 3 and as per the criteria below when all 14 practices have completed both sessions. CCGs across BLMK will then review the impact that this, and other CCG commissioned training, has had with a view to identifying a provider to complete a second phase potentially rolled out across the whole of the STP. Phase 1: Each practice with support will be able 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. Staff will be able to recognising red flag symptoms which require urgent medical attention. Skills development to ensure that staff can confidently signpost and communicate effectively the available options. Each practice has the ability to develop and maintain its own directory of services Opportunities for practice managers, GPs and staff to hear from others who are already working in this way. 7.5 Online GP Consultation Software Under the STP-wide primary care IM&T programme (funded via the ETTF), an options appraisal will be conducted regarding the various technology solutions available to support the delivery of e-consultations. The ring-fenced online consultation funding will be utilised to purchase software following the completion of the options appraisal. As described in the IM&T section above the local GP IT group will ensure local ownership and enthusiasm for this development. 73

74 7.6 Access to General Practice We will deploy funding from NHS England ( 3.34 per head of population in 2018/19) to make progress towards commissioning 100% coverage of extended access by Quarter 4 of 2018/19, to build upon the elements of extended access already provided by 38 of our practices under the NHS England-commissioned DES. Further information around our approach to implementing extended access is provided in the Access section of this plan. 7.7 Infrastructure Funding Further information regarding the ETTF funding is provided in the Infrastructure section of this plan. 8 Governance 8.1 STP Governance The Chief Officers across BLMK have formed a Joint Commissioning Executive Committee to make recommendations to the different CCG Boards on key pan-ccg issues. This includes formal decision making where appropriate. The Joint Commissioning Executive has no formal delegated powers and individual CCG s remain accountable for meeting their own statutory duties. The STP programme is currently overseen and driven by a Steering Group. This includes the 16 key partners across the three systems, all of whom act as equal partners in the STP programme. The four local councils operating across the BLMK footprint all play a full and active role in the STP programme. The CEO of Central Bedfordshire Council is acting deputy to the nominated STP lead; Pauline Philips. Representation on the STP steering group is at CEO and/or Director Level. Involvement in the STP programme has been exemplary. 8.2 Local Governance The ultimate responsibility for the governance of the GPFV is the CCG Governing Body (the Board), utilising the sub-committees and steering groups within the CCG to assist with carrying out its functions. The Board sub-committees are composed of Board members and individuals from within and outside the CCG with a broad range of skills and experience. The committees are governed by the Standing Orders, prime Financial Policies and the Terms of Reference for the committee. The sub-committees with the lead roles in the delivery of the GPFV are: Clinical Commissioning Committee Primary Care Joint Commissioning Committee In addition to the committees of the Board, Luton CCG has also established a Primary, Social and Community Delivery Board to support the transformation of care practices outside the hospital and the delivery of the STP priorities. The delivery board is chaired by the CCG s Clinical Chair and provides assurance to the Board through reporting to the Clinical 74

75 Commissioning Committee. This further links to the wider STP through the Priority 2 Governance Structure (see figure 15) Figure 18: STP Priority 2 Governance Structure 8.3 Clinical Leadership The 28 member practices serving the population of Luton form a key element of the Governance structure for the CCG. The member practices are collectively known as the Member s Forum and each practice has a nominated member representative and is entitled to attend and vote at Forum meetings. Chaired by a member representative, the Forum brings together the collective shared knowledge, experience and expertise to ensure that the delivery of the STP priorities and the GPFV is safe and effective and based on the best clinical evidence. The support of Practices through the four clusters within Luton is essential to the delivery of the key programmes with a particular focus on operational, structural and cultural developments to enable an integrated primary, social and community care system across BLMK. Clinical Leadership and Engagement is a high priority for this work stream and the wider STP. The Clinical Chair of the CCG is the clinical lead for the BLMK STP Priority 2 and works with the wider STP Programme Management Office on all forms of engagement. This includes: 75