NHS Waltham Forest Clinical Commissioning Group. Primary Care Strategy 2014/ /2020. Version /17

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1 P r i m a r y C a r e S t r a t e g y P a g e 1 NHS Waltham Forest Clinical Commissioning Group Primary Care Strategy 2014/ /2020 Version /17

2 P r i m a r y C a r e S t r a t e g y P a g e 2 Document revision history Date Version Revision Comment Author / Editor Author Natalie Keefe Update Update after discussion with Commissioning colleagues Patient engagement terminology. Estates ambitions added After discussions with WF CCG Estates group and Planning & Innovation committee Updated Updated following comments from Jamie Walsh, Waltham Forest Health Watch Updated Updated following engagement events with stakeholders including GP members and patients Updated Updated following comments from Waltham Forest Public Health department Updated Final updates including additions from LPC Highlighted delivery areas linked to NHSE Transforming Primary Care Framework and updated cocommissioning information and integrated care Changes to engagement terminology Discussed at CCG Governing Body Natalie Keefe Carl Edmonds Natalie Keefe Natalie Keefe Natalie Keefe Natalie Keefe Carl Edmonds Carl Edmonds Annual Revision 2016/17 Aysha Patel Document approval Date Version Revision Role of approver Approver Advice on draft CCG Governing Body Advice on draft Primary Care Improvement Group WF CCG Governing Body Health and Wellbeing Board Advice on refresh Primary Care Development Committee Advice on refresh Primary Care Commissioning Committee

3 P r i m a r y C a r e S t r a t e g y P a g e 3 TABLE OF CONTENTS... PAGES 1. FOREWORD EXECUTIVE SUMMARY CCG VISION CONTEXT CHARACTERISTICS OF OUR POPULATION... 9 Ethnicity Deprivation 6. CURRENT SITUATION 11 Children & Young People Working age Adults Older People Patient Experience Quality 7. PROVIDER LANDSCAPE 13 Acute Primary Care Providers: General Practice, Networks, Pharmacy, Dental, Optometry and other providers 8. ENABLERS.. 15 Premises IM&T 9. PARTNERSHIPS ACTIVITIES TO IMPROVE PRIMARY CARE.. 19 Proactive Care Accessible, Quality Care Co-Ordinated Care 11. IMPLEMENTING THE PLAN 31 APPENDIX A:PRE STRATEGY ENGAGEMENT. 35 APPENDIX B: RISKS AND MITIGATING CIRCUMSTANCES 35 APPENDIX C: FULL LIST OF PRACTICE ADDRESSES AND MAP 37 APPENDIX D: WFCCG TRANSFORMATION PROGRAMME 2016/ APPENDIX E:EQUALITY ANALYSIS.. 42

4 P r i m a r y C a r e S t r a t e g y P a g e 4 1. FOREWORD As Chair of the CCG, I am pleased to present NHS Waltham Forest Clinical Commissioning Group s (CCG) refreshed Primary Care Strategy. Primary Care Strategy Refresh- 2016/17 We are now two years on from when the strategy was first developed and there have been significant changes which need to be reflected within the strategy. This includes the fact that from April 2015 we were awarded the responsibility of becoming a fully delegated CCG for primary care commissioning, meaning we now have a lead role in commissioning and managing GP services. We have also strengthened our governance structures, and are well on track to achieving the majority of the actions set out within the original primary care strategy implementation plan. We would like to continue to focus and work hard to deliver our ambitions, and therefore have revised the implementation plan and committed to annually refreshing the strategy. Primary care is at the heart of the transformation of health and health services. Today 90 per cent of NHS activity takes place in primary care for 7.5 per cent of the cost, seeing more than 20 million patients per year. However, the model of general practice that has served us well in the past is now under unprecedented strain and there are significant challenges that must be addressed. We need to celebrate what primary care does well and retain what works, but we also need to see through significant changes to how primary care is organised, how services are delivered and how the workforce will develop. We will use the opportunities brought about by co-commissioning and work with Newham and Tower Hamlets CCGs as a group to support practices to help them achieve the specifications within the London Strategic GP Commissioning Framework, which will improve access, proactive care and coordination of care. At the heart of our proposal is the desire to make local decisions about primary care services for our population. This strategy sets out our challenges and the priority areas that have been identified to ensuring we have a primary care system that can thrive and deliver the care that patients need and deserve. Waltham Forest is a vibrant, diverse and exciting place with the potential for a very bright future; we look forward to the challenges ahead, knowing that there are also great opportunities for making positive and lasting changes to the health of local people in the borough. Dr Anwar Khan Chair, NHS Waltham Forest Clinical Commissioning Group 2. EXECUTIVE SUMMARY High quality primary care provides a holistic approach to care, from preventing illness and diagnosing problems, to treating diseases and managing long term conditions. General practice doesn t just provide care, it also helps patients to navigate the system and access the care they need in other settings. It represents a single coordinator of care for people from birth through to the end of their life. But models that have served well in the past are now under unprecedented strain. There are significant challenges that must be addressed. The Clinical Commissioning Group (CCG) will build on the excellent work currently being delivered by primary care, harness local skills and experience to create one of the best primary care services in the country. From engagement with our members, patients and partners the CCG will focus on the following objectives: 1. To improve primary care services to deliver better health outcomes for our local population

5 P r i m a r y C a r e S t r a t e g y P a g e 5 2. Improve patient access to and experience of primary care services 3. To ensure effective community engagement to help support the delivery of patient centred care 4. To maximise clinical engagement, ensuring strong leadership across all primary care services 5. Embrace technology and ensure that the primary care infrastructure is fit for purpose and supports patients to self-manage. 6. Practices working collaboratively with other agencies to support the delivery of integrated care To achieve the above objectives the CCG has set out a programme of work that will lead to a number of measurable outcomes. Our changing demography is set out in section 5; the primary care strategy needs to addresses the following factors: Population projection and future demand on services, Variations in access and quality to primary care medical services Financial sustainability Developing a workforce that can meet the challenges of the changing NHS landscape and to support the delivery of better health outcomes for the local population. Our work programme will fall under three improvement areas, namely, proactive, accessible and coordinated care. These are the same areas set out in the NHSE London Primary Care Framework which sets a direction of travel for all London primary care systems. We are using our responsibilities of managing primary care contracts from 1 st April 2015 as a lever to drive change through the system and implement our work programme. We aim to help secure high quality services and reduce variation in quality and outcomes focusing on quality reporting, patient engagement and ensuring that the necessary IT, workforce and estate infrastructure is in place to enable transformation. Where it is beneficial, we will do this with our East London CCG partners (Tower Hamlets and Newham) as we will share some co-commissioning responsibilities and governance. Transforming Services Together (TST) The three CCGs in WEL (Waltham Forest, Newham and Tower Hamlets) are collaborating on a whole system strategic programme in partnership with local providers. The programme has been developed to achieve a financially and clinically sustainable health economy. There are 13 work streams in TST, of which primary care is one and forms the basis of the WEL primary care strategic approach. This approach includes the commitment to delivery of the London Primary Care Strategic Commissioning Framework and is based on the development of GP federations in each borough to support delivery of the shift of care and improvement in the quality of primary care. This strategy will be overseen by the Primary Care Advisory Committee (PCAC) which reports to the Primary Care Commissioning Committee (PCCC). The committees are made up of relevant stakeholder groups including the local authority, primary care practitioners and health watch,both Committees meet monthly and the PCDC has the decision making function for local services. 3. THE CCG VISION Waltham Forest CCG Vision To put patients at the centre of everything that we do by using their experience to shape care pathways, improve service delivery and ensure value for money Having high quality and equitable primary care is key to achieving this vision; if the CCG is going to achieve the objectives that patients, members and partners have said are important we need to recognise the key

6 P r i m a r y C a r e S t r a t e g y P a g e 6 enablers and link this strategy with other work that is going on in the CCG including the community nursing, mental health and IM&T strategies and urgent care. The Commissioning Strategic Plan outlines the CCGs Priorities and Clinical priorities. These are: Integrated Care and Care Management Integrated Commissioning Community Health Services. Urgent Care and Ambulatory Care The Development of GP Provider Networks. Our clinical priorities are supported by the Waltham Forest Health and Wellbeing Board. Care for Older People Mental health Diabetes as part of long term condition management Child and Maternity Care Cancer The primary care strategy focuses on 3 main improvement areas, Proactive Care, Accessible Quality Care and Co-ordinated Care; we believe that by focusing our efforts on these areas will help us achieve the CCG vision and priorities. 4. CONTEXT The 2012 Health and Social Care Act changed the primary care commissioning landscape. Primary Care Trusts (PCT) and Strategic Health Authorities were abolished and from April 2013 responsibility for primary care contracting was passed to NHS England and is now being managed through the regional teams, with the CCG taking a lead role in decision making as fully delegated commissioners. CCGs also took on a number of the functions from PCTs including planned hospital care, rehabilitative care, urgent and emergency care (including out-of-hours), most community health services and mental health and learning disability services. CCG s also have a remit to support and encourage the development of primary care services. In addition, local authorities have assumed responsibility for public health and Health and Wellbeing boards. The diagram below set out the new organisations in the health system.

7 P r i m a r y C a r e S t r a t e g y P a g e 7 In July 2013, NHS England published The NHS belongs to the People: A Call to Action which set out the challenges faced by the NHS. In addition a London case for change was also developed to respond to the specific challenges faced by the capital. It examines the future challenges of health and social care such as an ageing society, an increase in long-term conditions, changing expectations, increasing cost of provision and constrained public resources. However, it also highlights the opportunities available to transform the NHS giving patients greater control over their health, harnessing transformational technologies, exploiting the potential of transparent data, moving away from a one-size fits all model of care and unlocking healthcare as a key source of future economic growth. Since the publication of this report clinicians, patients and commissioners from across the capital have been developing an ambitious strategy for service improvement in three key areas of general practice proactive care, accessible care, and coordinated care. Transforming Primary Care in London: A Strategic Commissioning Framework has been developed which aims to capture some of the core aims of primary care transformation, and the fundamental tenets of what would need to be done to deliver this across the capital. Locally the Health, Adults and Older Persons Scrutiny Sub-Committee established a GP review panel. This was partly in response to the changes brought about by the 2012 Health and Social Care Act, but also in response to evidence presented to the Committee about the quality and standards of primary care across the borough. The panel gathered feedback from service users, providers and other local stakeholders. A report was presented in January 2014 and the main areas for improvement that were identified included; patient access to GP services, better stakeholder engagement, reducing the variation in the quality of primary care, training and development of the primary care workforce and patient education. Delegated Commissioning In May 2014 NHS England announced an option for Clinical Commissioning Groups to co-commission primary care in partnership with NHS England. In January 2015 Waltham Forest CCG submitted its application to manage primary care contracts (in collaboration with Tower Hamlets and Newham CCGs) and assumed the responsibility from April This means that the decision making function for commissioning GP services has transferred from NHS England to the CCG, providing us with greater influence to manage the local health economy and achieve greater integration of health and care services in the borough. The WEL CCGs (Waltham Forest, Tower Hamlets and Newham) have a strong and proven track record of collaborative commissioning, and are using this opportunity as a key enabler to helping us deliver our respective CCG and Health and Well Being Board priorities and our joint Five Year Plan. There are several benefits which we hope to achieve via co-commissioning, these include: Improved access to primary care and wider out-of-hospital services, with more services available closer to home High quality out-of-hospital care improved health outcomes, equity of access and reduced inequalities A better patient experience through more joined up services. In November 2014, NHS England published its document, Strategic Commissioning Framework for Transforming Primary care in London. This provides a strategic direction of travel for al London economies and lists 17 specifications under three areas, proactive, access and co-ordinated care. This

8 P r i m a r y C a r e S t r a t e g y P a g e 8 document is used by the CCG to develop quality improvement programmes and align strategic direction. There are a range of other national, cluster and borough wide strategies that will impact on primary care. These are outlined in the table below. Strategy National, London, What this means to primary care in Waltham Forest Regional or Local Call to Action Optometry, London Sets out the challenges for primary care in London Dental, Pharmacy and GPs. London Cancer Strategy London A London strategy to improve early diagnosis, and follow up of cancer. Strategic Commissioning Framework for Primary Care London Framework for primary care that sets out solutions to the challenges faced by general practice. Transformation in London Better Care for London London Promotes role of primary care, invest 1billion in estates, encourages practices to work in federated networks and other providers to practice where WEL Five year strategic plan - Transforming Services Together Transforming Services Together (TST) Strategy and Investment case Regional (WEL) care is currently poor. Brings together the aspirations of the 3 CCGS, NHS England, primary care and specialised commissioning. Regional (WEL) Aims to improve local health and social care in Newham, Tower Hamlets and Waltham Forest aligned with the challenges of the NHS Five Year Forward Co-Commissioning Regional (WEL) Gives CCG s greater role in commissioning WELC Primary Care Development Plan Joint Dementia Strategy Better Mental Health; Waltham Forest Mental Health Strategy for Adults of Working Age Regional (WEL) Borough (but linked to national strategy) Borough (but linked to national strategy) primary care services. A shared strategy for Waltham Forest CCG and our neighbouring CCGs as primary care commissioning is transferred to CCG s. Increasing diagnosis and care coordination within primary care More emphasis on managing patients effectively in primary care; closer link between physical and mental health Better Start in Life Borough A joint plan between Waltham Forest Local Authority, the CCG that outlines the developmental and commissioning activities to ensure the best outcomes for children and young people. Community Nursing Strategy Borough Outlines how we aim to give residents of Waltham Forest affordable and sustainable community nursing to improve local health outcomes. IT Strategy Borough A borough strategy that s sets out the technological foundation to achieve many of the CCGs objectives. Urgent Care Strategy Borough A strategy for greater use of primary care services to help prevent avoidable use of A&E. Health and Wellbeing Strategy Borough Outlines the vision and priorities for the Health and Wellbeing Board, which primary care will support in the delivery of. Working for Health Equity: The Role for Health Professionals National Outlines that CCGs and GPs have an important and often under-utilised role in reducing health inequalities through taking action on the social determinants of health. Five year forward view National The Forward View sets out how the health service needs to change to accommodate people living

9 P r i m a r y C a r e S t r a t e g y P a g e 9 longer with more complex issues. General Practice Forward View National Highlights how General practice resource allocation and requirements will change in light of the Five year Forward view. Digital Health Strategy Borough Sets out IT and interoperability solutions for health care provision Estates Strategy Borough Highlights the Estates challenges faced by Primary care providers and outlines strategic direction for Primary Care Estate within the next 10 years. 5. CHARACTERISTICS OF OUR POPULATION According to the latest Census in March 2011 there were 258,200 people living in Waltham Forest. However, the most recent population estimates from Office for National Statistics show that the population of Waltham Forest has further increased since the Census to a total of 262,600 residents as at 30 June Age Waltham Forest (Total) Waltham Forest (%) London (%) Aged ,600 22% 20% 19% Aged ,800 12% 12% 12% Aged ,300 42% 42% 34% Aged ,400 14% 14% 18% Aged ,400 10% 11% 17% Total 262, % 100% 100% United Kingdom (%) The borough s population is projected to continue to rise over the next three decades to between 70,000 and 91,400 people and the number of children and older people is expected to increase significantly in the next few years. Just over half of Waltham Forest s population is female (51%) and the age structure of the borough is relatively young, with almost 1 in 5 people in the borough under the age of 20. The most significant element of migration for Waltham Forest is from and to other London boroughs. Neighbouring boroughs prove to be the largest source of in-flows with 4650 patients coming to the borough. A similar picture is seen with population out-flow pattern with 4630 patients from Waltham Forest moving out to neighbouring boroughs 1. Ethnicity & Nationality 47% of the boroughs population is from minority ethnic groups. Since the 2001 Census the proportion of white British residents has fallen from 58% to 38% in Waltham Forest, while white other has increased from 6% to 15% The 2011 Mayhew Harper Population count estimated that, of more recent arrivals to the borough just fewer than 9,000 were Eastern Europeans. Other ethnic minorities in the GLA data include almost 5,000 Turkish, almost 4,000 Somali and over 2,500 each of Ghanaians and Nigerians. The borough s population becomes more ethnically diverse going from north to south. There is a greater proportion of White British and Irish residents in wards in the north and middle of the borough and 1 ONS Migration Statistics Unit (Moves registered during the year ending June 2011).

10 P r i m a r y C a r e S t r a t e g y P a g e 10 conversely BAME residents are proportionally more likely to be found in the middle and southern wards of the borough. The chart shows the country of birth as recorded in the Census Deprivation Waltham Forest continues to be one of the most deprived boroughs in England. There are significant health inequalities and a high number of people with long term conditions and comorbidity. In terms of the overall measure of multiple deprivation (IMD 2010) Waltham Forest ranks 15th most deprived among the 326 local authorities in England. Its position has declined from 25th in Out of 33 London boroughs, Waltham Forest is the 6th most deprived after Hackney, Newham, Tower Hamlets, Haringey and Islington. More information about the health needs of Waltham Forest can be found in the latest Joint Strategic Needs Assessment (JSNA) We face a shared financial challenge in east London, due to growing demand and an expanding and aging population. The TST strategy states that if we do nothing different, we ll need an extra 550 inpatient beds by 2025 (costing about 450 million to build and 250 million a year to run) and overall our organisations will be in deficit by almost 400 million by 2021/22

11 P r i m a r y C a r e S t r a t e g y P a g e CURRENT SITUATION Children and Young people Working Age Adults Older People Around 29% of the population of Waltham Forest is under the age of 20, an estimated 67,200 children and young people. Births increased in Whipps Cross by 27% between 2006/07 to 2010/11. However between 2010/11 to 2011/12 births decreased by 8.2%. Diabetes and emergency hospital admissions for <18 year olds lower than London and the Outer North East London boroughs. Accident and Emergency attendances for <5 year olds lower than London and England. Infant mortality higher than London and England rate. Still births, perinatal mortality, low birth weight higher than London and England. Large drop in prevalence of Breastfeeding from initiation to 6-8 weeks. Childhood immunisations coverage below local targets and World Health Organisation (WHO) target of 95%. Asthma and Epilepsy emergency hospital admissions for <18 year olds higher than London and England. Mortality rates for all causes, all ages in Waltham Forest are significantly higher than the national and London average for both males and females Growing prevalence of long term conditions particularly diabetes where prevalence is expected to continue to rise. The rates of obesity continue to rise. Cancer is the second most common cause of death and accounts for nearly 25% of all deaths in the borough. There is variation in the quality of primary care for Long term conditions including the exception reporting rate. Waltham Forest has a relatively high prevalence of mental health disorders, as well as high rates of hospital admission for problems related to mental health and alcohol. Tuberculosis (TB) is the communicable disease of greatest concern, and numbers of confirmed cases of in the borough have increased. The 2011 census population data reported that there are 25,528 (9.91%) people in Waltham Forest aged 65 and over. The number of older people is projected to increase from 25,770 to 28,386 by Chingford has the highest proportion of older people out of the three GP localities. In 2011 there were approximately 11,830 older people living with a limiting long term illnesses (LLTI) and by 2030 this is expected to increase by 26% Cardiovascular disease is the largest single cause of long-term ill-

12 P r i m a r y C a r e S t r a t e g y P a g e 12 health and disability, among older people. Life expectancy for men and women in England and for those living in Waltham Forest continues to rise. However there is significant variation in life expectancy in the borough with a difference of 7.1 years for men between the wealthiest and poorest parts of the borough and 5.5 years for women. Hospital admissions for falls and falls injuries in Waltham Forest in 2010/11 was significantly higher than London and England. Summary Waltham Forest is an ethnically diverse borough with some communities more prevalent in parts of the borough than others. Each community brings its own health and social care challenges including deprivation, long term conditions, cultural and communication factors. Patient experience Annually the Department of Health commission Ipsos MORI to carry out a GP Patient Survey. The survey includes items such as physical access to surgeries, overall satisfaction with practice and out of hour s services. The results by practice are available at Data shows that satisfaction in Waltham Forest is lower than the London and national average in the following areas: Ease of getting through to someone on the phone at the GP surgery Able to get an appointment to see or speak to someone Satisfaction with opening hours Overall Experience of GP surgery Locally, Healthwatch Waltham Forest has published a number of reports based on service user s experiences. They range from general reports about GP access and treatment to reports particularly focusing on vulnerable 2 groups, like carers, deaf and hard of hearing patients. In each of the reports there are a number of commonalities that service users are recommending including improvements to appointment and telephone systems and improvements to waiting times and greater use of modern technology. Quality NHS England has created a national Primary Care Web Tool which is an information portal that gathers data in regard to performance, quality and experience of GP services; it incorporates GP Outcome Standards (GPOS) and the GP High Level Indicators (GPHLI). The GPHLI data identifies practices as outliers if they are an outlier against 5 or more of the indicators. As of April 2016 Waltham Forest has 6 practices that have been highlighted as outliers on 5 or more of the GPHLI indicators. The GPOS data groups practices into four categories based on an overall assessment of performance drawing on a wide range of indicators. The categories are: Higher Achieving, Achieving, Approaching review and Review identified. Waltham Forest has 1 high achieving practice, 4 achieving practices, 17 practice approaching review and 23 practices with a review identified 2 For the purpose of the strategy the following groups of people are defined as vulnerable; Elderly/frail, people with hearing impairment, visual impairment, mental Health, learning disabilities, substance misuse, carers, limited spoken/written English and from deprived communities

13 P r i m a r y C a r e S t r a t e g y P a g e 13 Quality and Outcomes Framework (QOF) is a voluntary incentive scheme for GP practices rewarding them for how well they care for patients. The QOF contains groups of indicators, against which practices score points according to their level of achievement. There are clinical, quality and public health domains. The maximum number of QOF points available in 2014/15 was 559. The number of points achieved in QOF varies across the borough with the lowest achievement being points and highest being Prevalence rates of certain diseases also vary between practices. This can be an indication of unmet health need in the population, varying effectiveness of diagnosis practices, as well as a product of the differences in ethnic, social and age profiles of GP practice lists across the borough. Primary Care Dashboard A Primary Care Dashboard has been developed in line with the London Primary Care Strategic Commissioning Framework and the CCG Primary Care Strategy. The purpose of the dashboard is: To promote primary care quality and improvement in Waltham Forest; To provide a local picture and summary to better understand primary care quality including any variation in services and care; Identify areas for improvement to support practices and prioritise appropriate implementation of interventions which have the most beneficial impact on health outcomes and patient experience; Support the CCG aim of using data, and sharing information across practices and localities in regard to primary care to raise awareness and identify good practice. Thereby supporting an open culture of peer review, constructive challenge and shared learning. It should be noted with all of the above that each individual and every population is unique and therefore some clinical variation is not only inevitable but also necessary in both clinical practice and commissioning. To understand the variation and outliers, more detailed analysis of quality results needs to be undertaken to understand what the information is telling us; including work looking at how diagnosed prevalence of disease differs from modelled estimates. 7. PROVIDER LANDSCAPE The North and East London provider landscape is characterised by a wide mix of organisational types, ranging from very large specialist teaching hospitals, specialist hospitals and integrated care organisations through to smaller acute units and individual primary care providers like general practice and Pharmacists Acute Information below shows the acute hospitals in north and east London. The area is served by three acute hospitals, each with an A&E department and a range of local acute services, managed by Barts Health Trust: The Royal London Hospital (Tower Hamlets) Newham Hospital Whipps Cross Hospital (Waltham Forest) Barts Health Trust also operates from: Mile End Hospital (a community hospital serving Tower Hamlets) St Bartholomew s Hospital (a specialist unit providing cancer, cardiac and other services in the City of London) The London Chest Hospital(a specialist cardiac unit in Tower Hamlets)

14 P r i m a r y C a r e S t r a t e g y P a g e 14 Primary Care Providers Changes to NHS organisations over the last few years have resulted in important differences for the primary care landscape. The Business as Usual functions of Primary Care Contracting is now managed by NHS England through the regional teams, however as a fully delegated CCG the decision making takes place at the CCG, with Primary care development and improvement remaining as a core duty of the CCG and NHS England, therefore requiring a partnership approach. General Practice There are currently 44 practices in Waltham Forest, 20 with a General Medical services (GMS) contract, which is the national standard contract for GP Practices, 23 with a Personal Medical Services contract (PMS), which is the standard contract with additional local indicators and 1 practice with an Alternative Provider Medical Services (APMS) contract, which is a local contract with a limited lifespan. Within Waltham Forest list sizes vary from 1919 to (For a full list of practice see appendix A) The structure of general practice in Waltham Forest includes a high number of single handed contract holders with GPs working outside the traditional model with more sessional and locum GPs. Waltham Forest has an aging workforce with 38% of GPs over the age of 60 and 15 % of GPs stating that they plan to leave within the next five years. Practices are also seeing capacity issues in relation to workforce planning for practice Nurses, with 13% of Nurses stating they wish to leave within the next five years coupled with the fact that less than half of the practices have Health Care Assistants in place. Over the next 5-10 years this could potentially cause workforce shortages which need to be addressed now. GMS and PMS Contract Review A review of GP contracts has been mandated by NHS England, the review supports fairer distribution of funding at practice level to ensure that patients have access to the same range of services regardless of what type of contract is held by the practice they are registered with. This review aims to help reduce health inequalities by ensuring consistency of services across all practices. Our aim is to ensure that GMS and PMS practices are remunerated equally. We recognise that there needs to be a transition process for PMS practices who are most affected by the changes to their contracts and this is being factored into the review. General Practice Networks GP providers have already commenced an ambitious programme of primary care transformation based upon the development of one single federated network across the borough. GPs in Waltham Forest have become one legal entity social enterprise organisation under the name of FedNet. Within the Network there are 3 geographical sub-groups: - Chingford - 8 practices with a total population of 64,052 - Leyton/Leytonstone 17 practices with a total population of 120,362 - Walthamstow - 19 practices with a total population of 110, 490 Pharmacy The Local Authority has developed a Pharmaceutical Needs Assessment (PNA) this sets out the services currently provided to patients in the borough. Waltham Forest currently has 60 pharmacies, all providing Essential services to patients (essential services include dispensing, repeat dispensing, receipt of unwanted medicines for safe disposal, support for selfcare, health promotion, signposting to other service provision and clinical governance.) 3 pharmacists are contracted to open for 100 hours a week, and one dispensing appliance contractor. The PNA sets out that as well as Essential Services many pharmacies also provide additional services including medicines use reviews, new medicine service, minor aliments service and Influenza vaccinations, sexual health services and access to smoking cessation.

15 P r i m a r y C a r e S t r a t e g y P a g e 15 Dental & Optometry NHS England took over responsibility for commissioning General Ophthalmic Services (GOS) and General Dental Services (GDS) from 1 April There are 34 NHS dental practices in Waltham Forest and 1 specialist practice offering Orthodontic surgery only. This equates to 1 practice per 7594 patients. Optometrists (such as those based in high street Optical practices) play a vital role in the maintenance of eye health. Therefore, it is important that members of the community are able to access an optometrist in their local area. There are 34 optical practices in Waltham Forest, this equates to one optician per 7594 people. They are relatively evenly spread across the borough; however, there is a notable lack of optical practices in Leyton and Leytonstone. Although the core contracts are currently managed by NHS England the CCG has the scope to commission local enhanced services that meet the needs of the population. Other Providers Out of hour s provision is provided between the hours of 6.30pm am Monday to Friday and all day Saturdays and Sundays and Bank Holidays. Some practices do close during the day when they are still responsible for their patients, and these practices commission SEPT to provide cover during in-hours when closed. Walk in centres (commissioned by CCGs) throughout Outer North East London provide some support to primary care access needs. NHS England manages the registered list element of these services and the CCG is responsible for the unregistered walk-in element. In 2015/16 WFCCG undertook a consultation regarding the walk in service at Oliver Road and took the decision to decommission this service by the end of August The consultation showed that patients are attending the walk in service for primary care reasons that would be better managed by their own GP or by an appointment at a GP Hub. Patients that required further investigation for minor injuries would be better managed at the Urgent Care Centre at Whipps Cross Hospital. All of the information gathered from the consultation is being used to redesign the services offered to patients. 8. ENABLERS Premises Local primary care practices operate from a mixture of privately owned buildings and leased health centres. A high percentage of practices in Waltham Forest are in premises that have been developed from residential houses and the condition varies considerably. In 2015 Waltham Forest CCG commissioned a six-facet and minimum standards survey that reviewed all GP practice premises; it found a number of premises (34%) needed considerable work to meet the required building standards. To understand the current situation the CCG has worked with NHS Property Services, the local authority, NHS England and local patients to develop an Estates Strategy, which aims to ensure patients are treated in premises that are fit for purpose and improvements are made to our estate so that we can deliver better and more convenient care. The estates strategy outlines how the CCG intends to maximise the use of facilities to ensure equality of access for primary care and other community based services across the borough. This includes working closely with the Transforming Services Together and One Public Estates programmes to deliver, where possible, care hubs in each locality which improve access for patients. Primary Care Information Management and Technology (IM&T) IM&T is a key enabler to this primary care strategy. The ideal end state will be to have all health care providers able to share patient records and to communicate electronically with each other.

16 P r i m a r y C a r e S t r a t e g y P a g e 16 The CCG has an IT committee which has developed an IT & Digital strategy, which outlines the work that will be undertaken over the 5 years. The Digital Strategy will focus on patient and public services, while the IT Strategy will address paperless processing. The overall objectives of the strategies are to ensure the following: Modern IT systems for individual GP Practices Relevant, have reach and responsive Connectedness across the local health economy An IT foundation for GP Networks A vehicle to analyse, benchmark and report on activity and outcomes To provide digital tools to increase self-care and self-management and thus support a preventative approach to health care. A confident user community The purpose of the committee is to ensure a co-ordinated approach is taken across the CCG with regards to IM&T and that in conjunction with relevant provider organisations patient care is enhanced by integrated IT systems. The committee will also ensure that the CCG embraces and exploits technology to ensure that patients are able to use digital tools to self-help and engagement in their own health. It also mean that clinicians will be given the digital tools to be able to respond to changing demands and focus on efficient, effective and safe health care. Medicines Optimisation The medicines optimisation team work with all stakeholders to support prescribing in accordance with the principles and values of the NHS constitution. They use good clinical evidence to ensure that the most cost effective medicines are available for patients, that will improve their outcomes and ensure value for money to the NHS. Prescribing issues are considered in all clinical pathways that are developed by the CCG or local hospitals. Key Objectives include: Provide a medication review service for patients, resident in care homes that will optimise the medication that is prescribed. Development of an Outpatient Parenteral Antibiotic Therapy (OPAT) service. This will allow the administration of some injectable antibiotics in primary care and avoid the need for patients to be admitted to hospital. Produce prescribing guidance and monitor the prescribing of antibiotics to support the national agenda for reducing inappropriate prescribing of antibiotics and the resistance to antibiotics that are currently available. Development of shared care guidelines with our local acute trust that supports the safe prescribing of some drugs in primary care and avoiding the need for the patient to attend hospital, ultimately improving patient experience Development of prescribing guidance for the management of Long Term Conditions such as asthma, COPD, diabetes and cardiovascular diseases. 9. PARTNERSHIP NHS England NHS England leads the National Health Service (NHS) in England and provides priorities and direction for the NHS to inform the national debate to improve health and care.

17 P r i m a r y C a r e S t r a t e g y P a g e 17 As Waltham, Forest CCG is a fully delegated CCG, NHS England support the management of GP contracts by delivering the contracting functions on a day to day basis. NHSE are fully responsible for commissioning the contracts for, Pharmacists, Optometrists and Dentists. Health and Well-being Board The CCG is a member of the Waltham Forest Health and Well-being Board (HWBB) and is fully committed to the Health and Well-being Strategy (HWBS). This strategy is one of the ways the CCG will implement the health service elements of the HWBS. Local Authority We are working with the Local Authority through the Better Care Together Programme to deliver integrated health and social care. The Better Care Together Programme was announced by the Government in June 2013, to enable a transformation in integrated health and social care. The Better Care Fund (BCF) is one of the most ambitious ever programmes across the NHS and Local Government. It creates a local single pooled budget to incentivise the NHS and local government to work more closely together around people, placing their well-being as the focus of health and care services. The vision in Waltham Forest is to create a simplified and easy to access care system for residents where services are personalised to fit their individual needs and provide value for money. The underpinning principles are: Acknowledge and address ease of access to care services including sign posting and packages of care Pro-active care planning, incorporating later life planning, mental health needs and loneliness, and high quality specialist care services at the right time Care co-ordination/ navigation is a key component to an integrated service, with GPs playing central role as part of a multi-disciplinary team Services need to be planned with the client/patient at the centre of decision-making, both to respond to vulnerability and safeguarding needs and to empower self-care and self-management for people to live their lives Care plans and care budgets need to be personalised and tailored to individuals needs, their carers and families Rapid Response and re-ablement to prevent unplanned and crisis response which respond to the social, physical and mental health needs in a whole-person approach Hospitals to care only for people with genuinely unavoidable admissions Active voluntary sector involvement in design and capacity building Strategic approach to housing and welfare needs to enhance wellbeing NEL Sustainability and Transformation Plan There is a five year Strategy and Plan for the transformation of primary care in North East London (NEL), which covers Waltham Forest, Newham, Tower Hamlets, City & Hackney, and Barking, Redbridge and Havering (BHR). This plan sets out how the NHS can remain sustainable and deliver high quality services and improved outcomes for local patients. NEL are working together to deliver integrated service models in which high quality as scale primary care plays a leading role. Primary Care across NEL will be provided through a common approach enabled by population- based contracts to deliver health outcomes for the local population. This work is on-going and local delivery models will be developed and mobilised across the next year.

18 STRATEGY OBJECTIVES OVER THE NEXT 5 YEARS HOW WILL WE ACHIEVE THE OUTCOMES Improvement Areas Work Areas Overarching actions.we will (for more detailed plans see section 11 Outcomes P r i m a r y C a r e S t r a t e g y P a g e 18 Proactive Care Self-management Utilising modern technology/im&t Strategy Patient involvement Increase the use of technology to enable patients to be better equipped to manage their own conditions, including getting help, support and advice on-line. Work with our members and providers to look at how technology can support demand management. Areas we will explore further include managing appointments online, online repeat prescriptions, telephone or video consultations and or text reminders. Encourage and promote patient and public involvement in service development to support the delivery of patient centred care. Improved primary care services that involves patients and builds capacity. Empowered patients to self-care and stay healthy. This will in turn deliver better health outcomes for the local population. Accessible, Quality Care Improved Access Fully utilised Estates Improving the quality of primary care Work with members and providers to pilot a range of new initiatives that will deliver new and innovative approaches to primary care access to address demand. Work with partner organisations to ensure the premises that are being used for primary care services have the capability and capacity to provide the best care possible in a modern environment. Harness the skills of other independent contractors and allied health professionals to support and complement those of General Practice in order to make best use of the varied workforce to deliver high quality care. A responsive, quality and accessible service that responds to different patient needs and preferences. Workforce development Coordinated Care Co-commissioning Integrated care Development of Primary Care Provider We will provide opportunities for primary care services to work in a collaborative way to increasingly offer services in the community. One example of this is the development of GP provider networks. The CCG will continue to work with partners across East London to build on the current a model of integrated care that looks at the whole person their physical health, mental health and social care needs. We will work with the neighbouring 3 CCG s partners to co-commission with NHS England a range of additional primary care services. We believe this will benefit patients and ensure services are not fragmented. Providing patientcentred, coordinated care.

19 P r i m a r y C a r e S t r a t e g y P a g e ACTIVITIES TO IMPROVE PRIMARY CARE The CCG is committed to developing a proactive and personalised programme of care tailored to support the health and wellness of patients in the borough. PC Delivery plan Action plan To ensure we are delivering Proactive Care there are 3 key enablers 1) Self-care 2) Utilising technology 3) Patient involvement 1) Self-Care Improved knowledge about condition and treatment Increasing confidence in self-care Increased motivation to change behaviour Empowered patients Our vision for self-care is an empowered population equipped with the knowledge and motivation to self-care. A population with greater confidence to look after themselves, knowing when it s safe to self-care and when professional help is needed. We will aim to have services that support self-care, both enabling people to keep well, and to effectively manage their own health and wellbeing. This will be achieved by the following actions: The CCG will work with NHS England to support the development of a pan London approach to working with community pharmacy to review the current use of the minor aliments scheme, to see how this service benefits patients or can be used differently to empower patients to self-care. We will also look at different ways of bring together primary care providers, general practice, community health services, pharmacy, dentistry, optometry, voluntary organisations and social care to improving health and wellbeing rather than working apart. The CCG will work jointly with public health to strengthen the links between healthcare providers, community and voluntary services to implement non-medical interventions often referred to as social prescribing We will work with partner organisations to develop a communications programme designed to inform the public about primary care services available to the population and how to access them as easily as possible. This will be combined with self-care and healthy living advice and support on the social determinants of heath. We will use the information gathered as part of the strategy consultation to ensure that all new initiatives are developed with vulnerable patients in mind. This will ensure that those that are more vulnerable in society including those that are deaf, hard of hearing, the elderly, those with learning disabilities and carers looking after a vulnerable person will benefit from new initiatives and not be disadvantaged in any way.

20 P r i m a r y C a r e S t r a t e g y P a g e 20 Commissioning self-management/self-care from our Community Health Services and Pharmacy providers We have implemented a project around carers. The project aims to support and involve carers in their own health and the health of the people they care for, this project will be evaluated to ensure that effective provision for carers is commissioned in the future. Waltham Forest implemented a pilot programme of clinical health coaching, which has proved to be successful in the East Midlands. It helps patients to gain knowledge of their condition and provide them with confidence to manage their own condition by becoming an active participant in their care. The coaching is provided by telephone (tele coaching) by qualified registered nurses who have received programme specific training. Patients are called by the nurses and receive advice on following their care plan, taking their medication and adopting a healthy lifestyle. The Expert Patient Programme (EPP) is a peer led self-management programme, which builds support networks for patients. It allows patients to participate in a fixed six-week programme suitable for any long-term health condition and covers topics including healthy eating, exercise, pain management, relaxation, action planning and problem solving. The objectives of both Health Coaching and the Expert Patient Programme is to provide patients with the skills and knowledge to maintain their well-being effectively and provide them with practical solutions for the day-to-day problems of living with an LTC. It also looks to provide patients with skills to enable them to work with health professionals as an equal partner. The CCG has reviewed the outcomes of the expert patient programme and the health coaching pilots and has now developed an outcomes based commissioning Pilot, which aims to offer diabetes patient education that meets the needs of the local population. The Health coaching pilot did not demonstrate the desired outcomes, however the expert patient programme is being developed using innovative models to support patients, whilst taking into account that patients cannot always attend multiple sessions. 2) Utilising technology New technology has enormous potential to improve systems and communications. If technology can be effectively utilised, it is expected that patient contacts conducted through a digital health environment will eventually exceed face-to-face contacts in the future. Nationally the GP contract changes that came into effect from April 2014 required practices to promote and offer patients the opportunity to book, view, amend and cancel appointments online; order repeat prescriptions and view a list of their repeat medicines or appliances. The changes also require practices to ensure that by the 31 st March 2015 all patients can gain access to their medical records online. All practices now have the functionality to enable patients to access the above. A key objective of this strategy is to ensure that all practices have the technology that enables them to meet the contract requirements and that practice staff are adequately trained to manage the system, and this is something that has been achieved in The CCG IT committee has developed a five year IT Strategy which focuses on 5 objectives:

21 P r i m a r y C a r e S t r a t e g y P a g e Modern IT systems for individual GP Practices, enabling them to be efficient and effective local healthcare providers 2. Connectedness across the local health economy to enable the integration of care, such that: a. patients get safer, more effective and more personalised care b. the right care can be provided in the right place at the right time because clinicians are able to view/update patient records as needed across organisational boundaries for the role they are there to fulfil c. GPs are able to have oversight and control of all care provided for their patients, because their IT allows them to view details of acute, community and mental healthcare provided beyond the practice and to plan and monitor managed care proactively 3. An IT foundation for GP Networks, enabling them to consistently and efficiently plan, deliver and account for care provided across multiple GP practices 4. A vehicle to analyse, benchmark and report on activity and outcomes across GP practices as a means for clinicians to improve quality in primary care, capturing the data needed with the lowest possible overhead 5. A confident user community (clinicians, managers, support staff), able to make best use of the IT they have to do a better job and thereby get better value from the CCG s continuing IT investment and patients that are confident to utilise the IT solution that are available to them to help manage their health and wellbeing. To ensure that the objectives of the strategy are met an IT implementation group has been set up. The role of the implementation group is to identify, take ownership of and carry out the actions. A list of actions and timeframes that have been identified as part of the IT strategy, along with these actions the CCG is also committed to working with our neighbouring CCG s and has developed some additional objectives; Support practices with registrations, repeat prescriptions and appointment booking online or through an app. Support and incentivise practices and networks to offer flexible consultations, online care and advice and telephone/video consultations. Ensure harmonisation of GP systems to enable collaborative working and improve urgent care and access out-of-hours. Help practices use new technology to offer bespoke care for patients particularly those with long term conditions. We will embrace digital technology to ensure patients are able to gain information as easily as possible about their health. The details of this have been worked up as part of the digitalisation strategy that has been developed. The aim is that patients will be able use a range of technology including mobile phones to access and share information. When carrying out all of the above initiatives we will ensure that information governance is paramount. We will ensure there are clear agreements between NHS providers that are sharing information. We will ensure that patients are also clear about what information we are sharing about them and how and why we are doing this. 3) Patient Involvement Waltham Forest CCG recognises how important patient engagement and communications is to improve local health services.

22 P r i m a r y C a r e S t r a t e g y P a g e 22 The CCGs vision is to put patients at the centre of everything that we do by using their experience to shape care pathways, improve service delivery and ensure value for money. The CCG has developed a Community Participation Strategy; and we fully utilise our patient engagement structures including a Patient Reference Group and a Rapid group. Through these structures we have already involved a number of patients in developing our commissioning intentions and redesigning local services. The key objectives around patient involvement are: Embed the Community Participation strategy, including an ongoing review of what engagement is currently taking place and Patient Participation Groups (PPGs). Implement a pilot of having patient experience machines in 10 practices. The machines will ask patients the Friends and Family test question, as well as some follow up questions on experience. Encourage optimal uptake of the friends and family test (FFT) in GP practices to ensure all patients views are heard. Ensure the outcomes of the FFT is reported to all PPG s Ensure that PPG reports reference the outcomes of the FFT and practice actions. Ensuring the health system gets the best out of PPG s Propose targets to raise patient experience (using the bi-annual GP survey) The CCG is committed to providing a responsive, timely and accessible service that responds to the boroughs different patient preferences and access needs To ensure we are delivering Accessible Quality Care there are 4 key enablers 1) Improved Access 2) Fully utilised Estates 3) Improved quality of primary care 4) Workforce development 1) Improved access Strengthening primary care is key to the delivery of integrated care and has the potential to limit unscheduled admissions as well as reduce reliance upon accident and emergency, urgent care and out of hours services. We also know that GP practices are under increasing strain, with rising demand and poor workforce morale and in order to ensure general practice of the future is viewed as a positive career choice attracting high quality clinicians and staff, the way we work has to change. But most importantly we want to improve patient experience. The CCG recognises that the current model of 7 day primary care access delivered through a walk in service is unsustainable and does not meet the needs of much of our population. We will pilot, and evaluate alternative methods of 7 day access across the borough establishing three network based hubs to provide a consistent effective and accessible seven day primary care offer to all patients in Waltham Forest. The objectives from this work will be: The availability of seven day access to GP services within each of the three localities

23 P r i m a r y C a r e S t r a t e g y P a g e 23 The development and agreement an overarching model of primary care that sets out the offer for patients which includes: Longer appointments where necessary Continuity of clinician where this is preferred A range of options for accessing advice and care at a time that is convenient and supports a busy lifestyle Ability to access a same day appointment with a GP when necessary and the ability to book in advance. Not having to wait on the telephone on hold for more than reasonably expected Ensuring vulnerable groups of patients have access to primary care services is key to reducing health inequalities within Waltham Forest. Often patient groups including the deaf, hard of hearing, the elderly, those with learning disabilities, homeless people, refugees, exoffenders and carers looking after a vulnerable person or those with similar needs find it difficult to access health services and their health suffers as result. We are working closely with key partners who include NHS England, public health and the local authority to address the needs of these patients. There is currently a review being undertaken across London for homeless provision, and we are working closely with key stakeholders to ensure vulnerable patients needs are met. This work will help us to develop accessible and integrated services which meet the needs of all patients. 2) Fully utilised estates Responsibility for primary care estates currently sits with NHS Property Services (NHSPS) and capital developments sit with NHS England. In January 2015 NHS England announced that over the next four years ( ) there will be funding available across London to support primary care infrastructure and transformation projects for both estates and technology. The CCG submitted a draft estates strategy to NHSE in December 2015, and has to update and confirm the strategic direction by the end of June The estates strategy is a jointly written document with local partners, such as the Local Authority, and is written in response to the NHSE Five Year Forward View as well as aligning to key stakeholder strategic plans. The CCG strategy aims to develop a series of local GP hubs where general practice services will be delivered locally. In addition the CCG aims to develop services in locations where GPs and out of hospital services can be co-located. This may include Local Authority commissioned services as opportunities present themselves. The strategy also highlights areas where population growth and new housing developments may offer opportunities to provide primary care services in more modern, purpose built, facilities, as well as funding streams and financial impacts of changes to estate usage over the coming years. Although Waltham Forest generally scores well for statutory compliance issues, there are still significant inconsistencies to condition, statutory compliance, space utilisation, quality and accessibility across primary care estate in Waltham Forest and there are other NHS and borough estate that is not fully utilised or needs to be rationalised. The strategic direction involves supporting GP practices to work more closely to deliver new models of care in the community, provided improved access to services, and where possible moving non-acute activities to community locations. In order to do this the CCG is adhering to recommendations from NHSE that practises should have a minimum list size of 10,000 patients and that access to care should be on a 7 day basis. The impacts on estates have been mapped over ten years as the borough does not have funding to build new purpose built health centres, and the outcomes from the Transforming Services Together programme are in development in 2016.

24 P r i m a r y C a r e S t r a t e g y P a g e 24 3) Improving quality of primary care Primary care has provided a range of services over a long period of time, and the quality is not always consistent. A patient with the same condition may undergo a different programme of treatment if they go to one provider rather than another. We aim to ensure that all patients are treated via consistently high quality standards, and we are developing a quality improvement programme which uses various sources of data and soft intelligence to assess where additional support is required to drive improvement. The CCG has a Primary Care Commissioning Committee that brings together key stakeholders and partner organisations with the aim of ensuring the delivery of high quality primary care services to the local population. Some of the key work the group is leading on includes: Oversee programmes of work including key public health areas like Influenza vaccinations, screening programmes, childhood Immunisations, NHS health checks, smoking cessation and sexual health. To maximise the opportunities around co-commissioning and work with our members to develop and implement a primary care improvement plan. Other high priority areas for Waltham Forest include the following clinical areas where detection and or treatment need to be improved. These are: 1. Cancer diagnosis in primary care - we know timely primary care interventions can improve the proportion of cancer patients still alive one year on from their first diagnosis. Currently Waltham Forest has poor outcomes and higher than national death rates in under 75 year olds for cancer. Cancer is also one of the main causes of death in people in Waltham Forest. We are committed to improving cancer care and are signed up to the National Cancer Early Diagnosis Primary Care Engagement Pilot to help support primary care to drive up quality and improving outcomes. Plans that will be delivered as part of the pilot include: A dedicated facilitator for Waltham Forest practices who will act as a single point of contact for early diagnosis issues Joining up of local cancer activities to ensure that there is consistency and a stream lined approach to primary care engagement on early diagnosis Support to nurses and non-clinical staff to engage with early diagnosis and ensuring there are appropriate safety netting procedures in place Driving up quality through an overall reduction in the variation of GP two week wait referrals to secondary care and conversion to cancer ratios across the CCG Contribution to reducing emergency admissions Improving patient experience and clinical outcomes. The CCG will also be working more closely with practices to improve the uptake of cancer screening programmes, particularly focused on cervical screening rates. Actions to be taken will include targeted engagement at locality and individual practice level, led by local clinical leads, and engagement with Waltham Forest FedNet to agree how they can support improved screening performance. 2. Mental Health Services - Waltham Forest CCG has actively worked with Local Authority, NELFT, primary care and third sector providers to meet the standards and requirements set in NHS Five Year Forward View plan.

25 P r i m a r y C a r e S t r a t e g y P a g e 25 After extensive consultation and development of the Better Mental Health Strategy the CCG and the Local Authority along with other partners have been implementing the priorities set out in the strategy. The following areas have been prioritised: Delivering the Mental Health wellness Service pilot and effectively evaluating it. New pathways for early intervention in Psychosis to be established and implemented. Joint work with Local authority, public health for early intervention, support in community and primary care model of service. Developing MH integrated care commissioning model with Local Authority. Developing a 5 Year WELC Mental Health Strategy. Analyse existing pathways and the implementation plans of existing initiatives (including all access and waiting times standards) and establish options for 5 year models of care to improve delivery and outcomes. Implementation of CAMHS transformation Plan. Development of Paediatric Care and Vulnerable care pathway for crisis care. Expansion of Psychiatric liaison to target the reduction in alcohol related admissions and A&E presentation at Whipps Cross Reduction in admission of self-harm patients and personality disorder cases. Launch of Digital Mental Wellbeing service. Implementation of the perinatal mental health commissioning guidance IAPTs (talking therapies) This is not currently part of the WEL integrated care programme but the CCG recognises the importance of managing depression and anxiety within primary care. IAPTs is essentially an integrated care model as the importance of psychological medicine in treating COPD, Diabetes, Medically Unexplained Symptoms (MUS) and other physical long term conditions is nationally recognised. The CCG intends over the next 2 years to develop a primary care based IAPT model of care which links to GP practices and within the 3 localities across the primary care network. Key targets include delivering a minimum 50% recovery rate, access within 28 days and more than 15% of those in need of treatment accessing the service. 4) Workforce Development The primary care workforce is an essential enabler to the delivery of several CCG strategies including the IM&T, Urgent Care, Community Nursing and Integrated Care Strategies. Ultimately the development of the workforce is the responsibility of each provider but the CCG believes that in collaboration with Local Education and Training Boards (LETBs) & their local initiatives like Community Education Collaboration Networks (CEPNs) and Public Health England, that we have a significant role to play in the on-going professional development and professional support for of all employees from admin to practice managers, HCAs to nurses, allied health professionals to GPs, Dentists and Opticians through to Pharmacists. At the present time we continue to not making the best use of other primary care professionals. For example, pharmacists are the third largest health profession after medicine and nursing. They are highly trained professionals, yet their skills are not always fully utilised. The role of the community pharmacist could be developed to provide a greater input into patient care particularly with patient with long term conditions or with greatest need.

26 P r i m a r y C a r e S t r a t e g y P a g e 26 To enable effective workforce planning, the CCG in its role of supporting primary care development needs to have continuous accurate and up to date information about the local workforce. To address this, a key objective is to: Work to scale to begin to deliver a workforce that supports whole systems working across North & East London Yearly data capture baseline survey of all primary care staff including numbers, WTE, age, profession type and plans for retirement and match this with projected list size growth. Explore how WELC workforce strategy through Strategic partnership at Transforming Services Together level & Sustainability and Transformation Plan (STP) fits into wider Primary Care planning long-term Work Collaboratively with Waltham Forest to develop and build up the Multidisciplinary Multi-development Collaborative Learning environment for the workforce To explore options around Social Care & Community Care as part of Primary Care workforce family The CCG has also been piloting a Community Education Provider Networks (CPEN) which is a network which brings together primary and community care stakeholders to collaborate in regard to strengthening workforce, education and training in the borough. Some of the key objectives of this group are: Increase nursing in general practice through placement & rotation programmes through Training Super-Hub partnership with NEFLT, Barts & BHR Increase HCAs in general practice Increase hybrid Apprentices that work between general practice & social care Increase hybrid coordinator roles and/or skills that work between general practice & social care Increase Care Certificate in Health & Social Care/ for Hybrid Apprentices Up-skills current workforce to have multi-disciplinary & multi-development skills Deliver or Coordinate CPPD Education & Training for primary care staff using a skills Matrix scheme Analyse the current health and social care workforce within Waltham Forest (identifying skills mix any skills shortages ) Promotion of Continuing professional development (CPD) for frontline workforce in the locality (receptionists, admin staff) Promotion of North East London as a place to work & clear recruitment & retention strategy for new & current workforce in the system Improving education and training around long term conditions using multi-disciplinary multi-professional whole systems method Improving education and training within the community particularly around Pharmacy and Optometry Developing Networks between Community, Primary & Secondary Care settings Supporting the strategic planning towards the move to Accountable Care Organizations (ACOs)

27 P r i m a r y C a r e S t r a t e g y P a g e 27 Finally the CCG will work with it members and networks will bid for available funding from Health Education North Central and East London, Estates and Technology Transformation Fund (Primary Care), Vanguard Funding, other Health & Social Care funding to ensure there is funding available to provide education and training opportunities for Waltham Forest. This will help us support current workforce as well as those new into community / primary care. The CCG is committed to providing care and support that is integrated across health and social care and is focussed and centred on patients needs. To ensure we are delivering co-ordinated care there are 3 key enablers: 1) Co-Commissioning 2) Integrated Care 3) Development of Provider Networks 1) Co-commissioning In May 2014, NHS England published a paper entitled, Making Change Happen A CCG manifesto for a high-quality, sustainable NHS. The document highlighted the urgency to build upon the unique relationships that clinicians have with their patients and their clinical insights in order to commission a truly transformational NHS with communities at the heart. Co-commissioning is one of a series of changes set out in the NHS Five Year Forward View. The Forward View sets out the need to break down traditional barriers in how care is provided. It calls for out-of-hospital care to become a much larger part of what the NHS does, and for services to be better integrated around the patient. Co-commissioning is a key driver of this by enabling greater collaboration between commissioners across local health economies and wider geographical and organisational footprints. New models of care are much easier to deliver by having commissioning responsibilities for primary and secondary care in the same place. Furthermore, co-commissioning provides GPs with a greater say over the development of new services and models of care for their local communities. Waltham Forest CCG along with Tower Hamlets, Newham CCGs submitted a joint application for delegated commissioning powers which was approved by NHS England, and from April 2015 we adopted responsibility from NHS England for a range of primary care commissioning activities that support the CCGs and WEL s Five Year Strategic Plan and the primary care transformation agenda. The objectives of our WELC co-commissioning plan are: Improve the quality and outcomes of primary medical services Provide strategic leadership to the development of primary care Work in partnership with other NHS organisations to improve and modernise the primary care infrastructure. A greater role in commissioning of primary care services would include:

28 P r i m a r y C a r e S t r a t e g y P a g e 28 Working with patients the public, the voluntary sector and with Health and Wellbeing Boards to assess needs and decide strategic priorities designing and negotiating local contracts (e.g. PMS, APMS, any enhanced services commissioned by NHS England); approving discretionary payments, e.g. for premises reimbursement; managing financial resources and ensuring that expenditure does not exceed the resources available; monitoring contractual performance; applying any contractual sanctions; Deciding in what circumstances to bring in new providers and managing associated procurements and making decisions on practice mergers. We see co-commissioning as a real opportunity for the CCG to have greater influence over the way NHS funding is invested locally. 2) Integrated Care Waltham Forest introduced Integrated Care Management as a key transformational programme in 2011 and is part of a national Pioneer Programme; integrating care and improving patient experience is key to delivery of the CCG Strategic Objectives. I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me. Ref National Voices Too many people (Ref UM Points of Care review; 42%) are in a hospital bed when they could be more comfortably and effectively supported in a community bed or their own home We won t be able to recruit the workforce to staff these beds, and we know that hospital is not the right place for many people.. Initially the Integrated Care Management Programme focussed on the elderly, vulnerable patients, those with long term conditions or complex physical or mental health needs, who are at high risk of hospital admission or readmission. (Top 5% of borough population). Since the Programme commenced, it has been gradually scaling up to reach around the top 20% of the population of Waltham Forest who are most at risk of an unplanned admission. A range of primary care and community interventions have been commissioned to enable people to stay well at home and to help prevent unplanned hospital admissions which include: Acute unplanned avoidance direct enhanced scheme (AUA DES); a national scheme to enable practices to identify and support people most in need in the top 2% of their practice population Integrated Care Management Local improvement scheme (ICM LIS); a local scheme which further supports practices to case find and case manage the top 5% of the borough population as part of a multidisciplinary team with community services Community health and mental health services including: Case management by a team of health and social care professionals including a nominated Community Matron and integrated Care Liaison Officer supported by nursing, therapy staff and Social Workers. Their main aim is to enable adults to stay remain in their own homes, maximise their independence and improve health and social care outcomes and quality of life

29 P r i m a r y C a r e S t r a t e g y P a g e 29 Rapid Response, proving an alternative to unnecessary acute admissions by responding to patient s needs in situations of crisis and ensuring that the relevant providers are able to put in care packages quickly to support the patient at home Mental Health Psychiatric Liaison; over 40% of all inpatient cases are related to dementia and delirium and 28% of all admissions for acute care have a mental health condition. 5% of all A&E related attendances are related to mental health conditions such as substance misuse and service users in crisis. The psychiatric liaison function is based on national evidence that if you put psychiatric support teams within acute services the resulting integration results in better outcomes and reduced costs. It also interface with primary care ensuring improved management for people with comorbidities IAPTs (talking therapies) ; IAPTs is an important component supporting practices with the management of psychological medicine in treating COPD, Diabetes, Medically Unexplained Symptoms (MUS) and other physical long term conditions Specialist Falls service support to help prevent people for falling at home 3rd sector support to enable people to be supported home from hospital and also importantly to help people stay well at home and avoid unplanned hospital admission. In 16/17 we have additionally commissioned: Enhanced primary care for people in care homes Self-management/self-care from our Community Health Services and Pharmacy providers Social prescribing to enable primary care services to refer patients with social, emotional, or practical needs to a range of local, non-clinical. services, provided by the 3 rd sector With the Local Authority we are moving towards commissioning a Local Area Coordination approach to support people with disabilities, mental health needs, older people and their families/carers and hard to reach groups to manage their health and social care needs and help prevent people falling into crisis. This combined Integrated Care offer (Figure 1) delivers a whole system, population based approach to care delivery for the adult population of Waltham Forest, enabling people to manage their own health conditions better and ensure people most at risk of unplanned admission are well supported by primary and community services in their homes. Figure 1 Integrated Care System

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