Hammersmith and Fulham s primary care strategy Developing primary care as the foundation for better population health across the borough

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1 Hammersmith and Fulham s primary care strategy Developing primary care as the foundation for better population health across the borough September 2017

2 Purpose and content This document describes how the CCG and GP Federation in Hammersmith and Fulham will work with each other and their partners to further develop the standard of primary care for residents of the borough. We will do this by creating primary care networks which will work with other care services on which our patients rely. This will provide the foundation for a more unified and co-ordinated care system for local people, which we describe as accountable care. # Chapter Page 1 Foreword an introduction from Dr Tim Spicer and Dr David Wingfield 3 2 Our vision for an integrated health and social care system 4 3 Developing primary care at scale for the benefit of local residents towards accountable care 9 4 Appendices 16 2

3 FOREWORD: Improving primary care to achieve better population health Primary care in Hammersmith and Fulham is improving, based on what local people have said about the need for more patient-centred care closer to home. What we have achieved so far: Access to doctor appointments seven day a week Access to primary care through digital technology, as local practices trial smartphone apps. Access to many more services in primary care including enhanced support for mental health, warfarin monitoring and more diabetic care and support Improved investment in buildings: Parkview Centre for Health and Wellbeing was completed in 2014 and now provides primary and community care to more than 17,000 people. What we need to do: Primary care is a key force in delivering the following areas of the Sustainability and Transformation Plan (STP): radically upgrading prevention and wellbeing eliminating unwarranted variation and improving the management of long-term conditions achieving better outcomes and experiences for older people. This is what our local residents have told us they require from primary care: I want to access care easily and in the way most convenient for me, either in person or by using technology. I want the range of people who provide my care to all work together, communicate effectively, and have clear roles that I understand. Together, they can provide me with seamless care We want to harness the energy and ideas of people who deliver and receive care in Hammersmith and Fulham to create a system that works seamlessly for everyone in the borough. Within the limited resources we have, we are aiming for steady but material improvement over coming years. This will be based on sustainable changes in how local GP Practices will work together and with other health and care services. The end result will be a local care system that uses the collected expertise and compassion of all of our local care organisations to deliver the health and wellbeing outcomes that we and our residents want. Dr Tim Spicer Chair, Hammersmith and Fulham CCG Dr David Wingfield Chair, Hammersmith and Fulham GP Federation 3

4 Our vision for care and the role of primary care in achieving it I want my GP and his/her colleagues to be linked in closely to all the other people and organisations who provide care for me and support me in other ways We are ambitious for how good local primary care can be and how it can help to build a truly integrated service for patients and rewarding careers for staff. Expectations for how primary care should develop are set out in London s Strategic Commissioning Framework (2014), the GP Forward View (2016), and the Sustainability Transformation Plan (2016), which are already resulting in change on the ground. The way forward General Practice has worked more collaboratively over the past few years through the practice networks. In order to deliver population health benefits and improved experiences of care we need to move to the next stage. In the future, we want primary care to be better integrated with social care, voluntary care and other community services (i.e. district nursing, community independence service). The way forward for Hammersmith and Fulham 4

5 Improvements will be based on understanding local residents needs Source: NWL Local Services strategy 5

6 Our journey towards an integrated system known as accountable care Practices work together effectively in local groups Multi-disciplinary team (MDT) working is established as well as the sharing of learning and best practice Low level of cross practice shared services No shared workforce Practices are working in larger established networks to provide services at scale for the local population Practices work towards reducing variation and unnecessary admissions /referrals through an agreed common set of outcomes and quality standards A shared workforce across practices is established that allows a greater range of services to be delivered in primary care Principles of joint working are well Improved access to community established through integrated and specialist care community care teams Community-facing consultants There is clarity about local need and Greater focus on driving better local resources and agreements are in health outcomes for local residents place which facilitate local flexibility with payment systems linked to this The integration of services around More services delivered closer to people is extended across health and the patient's home social care Links with local charities are established to increase the services available locally One person, one service, one team, one budget approach 6

7 What are aims are for our residents and workforce? People who have low care needs can be managed by other care professionals to give GPs more time to care for people with complex needs 7

8 New investment in primary care will support GPs to meet local needs by improving standards Primary care in Hammersmith and Fulham has been historically under-funded, in comparison with other areas of the country. This is now being rectified and over the next four years, the CCG will be receiving accelerated growth monies as shown in the table below: m 27.2m 28.8m 30.0m 31.1m + 25% This provides an important opportunity to address current inequalities in care provision and therefore to improve population health outcomes. The CCG and GP Federation will work with local people and other partners to develop a suite of primary care standards that it will expect to be met for all patients in the borough. The core standards will focus on improving: improving patients experience of care radically upgrading prevention and wellbeing eliminating unwarranted variation and improving the management of long-term conditions achieving better outcomes and experiences for older people and people with mental ill-health reducing the number of unnecessary admissions to hospital ensuring high quality services are delivered in primary care, in line with the requirements of the Care Quality Commission (CQC). 8

9 Developing Primary Care at scale for the benefit of local residents towards an accountable care partnership 9

10 The networks have made significant progress: we now need to stretch our ambitions further My practice works with other organisations to support me to maintain my physical and mental wellbeing and to support me when I am ill This primary care strategy builds on the network system to support practices to work more closely both with each other at scale and with a wide range of other services. Building on the benefits of network collaboration There are currently five networks in the borough. The formation of networks was an important step in enabling practices to provide better care that meets local people s expectations. Networks have: enabled General Practice to see beyond the boundaries of their own practices established multi-disciplinary working across practices and the sharing of learning and best practice. This directly benefits patients in terms of the quality of care We are now aiming to extend this collaborative way of working to fully develop primary care networks, which are already being tested locally and showing positive results around the country for patients, practitioners, and their wider systems. The role of the CCG and GP Federation is to lead this process so that the benefits can be delivered as quickly and uniformly as possible. Such collaboration has already been embraced by many practices. We recognise that there is both value and challenge in working in larger primary care networks a snapshot of feedback from GPs is shown opposite. We will work with GPs to ensure that the implementation of this strategy reflects both their ambitions and concerns. As a small practice, we value our independence and autonomy and we want to be able to preserve this within larger groups. Working at scale affords benefits in terms of freeing up GPs time to do clinical work by having a larger team with a greater distribution of skills (including business and management skills). Working in larger groups needs to be able to preserve the continuity of care for those patients that need it. The focus needs to be on clinical outcomes - without stipulating a single operating model, Recruitment problems and other workforce issues mean that we have no choice but to work at greater scale that is the only solution. Relationships are key to making the networks function properly so we need to make sure that they continue to be based around practices that work well together. Source: CCG Members Meeting, 27 April

11 Reinvigorating the existing GP networks with the principles of the primary care home concept to become Primary Care Networks The primary care home model was launched by the National Association of Primary Care (NAPC) and is based on improving joint working within and beyond general practice. The model which was developed over more than a decade by clinicians around the country provides GPs with the platform to drive the improvement of care right across the system. The primary care home model implements change from within general practice, rather than being overly prescriptive. Primary care homes are designed around the needs of their local population and are commonly characterised by the following four features: provision of care to a defined, registered population of between 30,000 and 50,000 an integrated workforce, with partnerships spanning primary care, secondary care, social care, and the voluntary sector The primary care home concept preserves and improves the features of general practice that many patients and GPs value most: a first point of contact for all new health needs person-centred and continuous lifetime care comprehensive care provided for all needs within a local population co-ordination and integration of care where a person requires special services or provision from secondary or tertiary care a combined focus on personalisation of care with improvements in population health outcomes aligned clinical and financial drivers through a unified, whole population budget with appropriate shared risks and rewards Initially, fifteen sites across the country were chosen to test the principles of the primary care home. There are now more than ninety. Appendix 3 provides examples of primary care homes across the country and the benefits for patients, primary care teams and the wider health and care system. Hammersmith and Fulham GP Federation is a member of the NAPC s community of practice. Drawing learning from the primary care home concept the GP Federation is developing primary at scale across groups of local GP practices. The primary care home concept also sets out principles and a series of practical ways in which the networks in Hammersmith and Fulham can work: they are developed, implemented, and led by providers initiatives are planned and implemented at a deliverable scale staff become the drivers of positive change fosters collaboration across local systems 11

12 This way of working will benefit patients and primary care teams WORKFORCE INNOVATION FINANCIAL SUSTAINABILITY Workforce enhancement - practices can address their workforce issues more comprehensively than when working alone, including recruiting for a wider range of roles and across multiple practices. This can improve retention by allowing for more collaborative ways of working such as improving clinical processes. More varied careers - GPs and nurses can specialise if they wish, because there is sufficient demand across multiple practice lists. This allows people to perform to the top of their licence which can help with recruitment and retention. New structures for collaboration provide more robust means of sharing learning and best practice. Broader multi-disciplinary teams that brings together all expertise to deliver better population health outcomes. Practices can join forces to innovate through investment in technology, as care through digital care becomes more effective over larger groups of people. Patient records can be shared across all practitioners involved in providing care. General Practice will be able to influence change as they decide how to collaborate and innovate, based on their patients needs. This may result in smoother pathways from General Practice into a wider primary care offer, as well as into social care and voluntary services. New service initiatives, based on the needs of the networks registered population. Sharing back-office functions can improve operational efficiency and financially sustainability. It can also free up GPs time to be spent with patients. Greater efficiency savings will be realised through practices operating at scale delivering centralised business and clinical functions (i.e. patient recalls) 12

13 Next steps I have a clear say in how my care is delivered and can access different services by using my personal budget As explained previously the following steps will be undertaken to further improve care for local residents: Stage 1 as described previously involves the reinvigoration of existing General Practice networks to become primary care networks Stage 2 brings primary care networks together into a unified approach to provide community based care this will be through the platform of a Multispecialty Community Provider (MCP); and Stage 3 adds acute services to the MCP for a co-ordinated, outcome- based borough-wide approach to all care this is accountable care. Accountable care is our end-point ambition for Hammersmith and Fulham. This means continuing furthering our work in bringing services together into a single, co-ordinated approach to deliver: high-quality care that is aligned to outcomes, for the whole population; good patient experience of health care; and cost-effective care, within the given budget. The North West London Collaboration of CCGs have developed a Provider Maturity Assessment tool which the CCG and GP Federation will jointly use to understand the readiness of local primary at scale organisations to take on the delivery and leadership of community-based care as part of an MCP and an Accountable Care organisation. Appendix 5 provides more detailed information on the Provider Maturity Assessment tool. The GP Federation has been working towards accountable care since January 2016, when it led the establishment of the Hammersmith and Fulham Integrated Care Programme. This is a partnership of four organisations committed to integrated healthcare: the GP Federation, Imperial Healthcare Trust, Chelsea and Westminster Foundation Trust, and West London Mental Health Trust. The partnership is also working with the council on a range of issues, including the extension of partnership working into adult social care. 13

14 Multispecialty Community Provider: As a patient with multiple health conditions, I would like to have all my health care providers to work together Hammersmith and Fulham will take learning from the MCP vanguards to understand the evidence base for different approaches. In particular, it will seek evidence about how best to extend the MCP model from health care into adult social care and public health, both of which are commissioned by the council. This is being done in a phased way in other parts of the country. An MCP s core aim is to build on the primary care networks to increase the breadth of services and depth of interventions delivered in primary care and the wider community There are a number of options for this, which range from: an alliance of relevant service providers with no new contractual arrangements (a virtual MCP) a more formal arrangement in which all relevant budgets, including core general practice, are put within a single contract. In this case, GPs are able to reactivate their core contracts at the end of the MCP contract period. Whatever decision local GPs make about their own contracts, the centrality of GPs to each primary care network means that they will be a key voice within whatever organisational form underpins the MCP. The implications and opportunities for GPs under each MCP model are described in more detail in GP participation in a multispecialty community provider (NHSE, 2016). There is a link to this document in Appendix 2. Both options will bring together providers of care delivered in the community to decide how a unified budget for the care they provide should be invested; in order to meet the outcomes set by commissioners. 14

15 An accountable care system brings together all local providers of care, with primary care networks at its heart More of my care needs can be delivered within primary care, without the need to visit the hospital Primary care networks are the building blocks to establishing an MCP and then an accountable care system in Hammersmith and Fulham. Accountable care will bring together the MCP with the acute and mental health trusts into a single budget for all care commissioned by the CCG (and, potentially, from the local council as well).the importance of a single approach towards shared goals is understood by all parties. The CCG, the GP Federation, and the other Integrated Care Programme partners began developing this single approach over the period of May to July 2017, to confirm: shared goals, objectives and milestones (including developmental stages) for accountable care development the necessary workstreams to deliver the work the resources needs and timelines - Appendix 7 provides a high level delivery plan for the implementation of the strategy The approach agreed will provide the development framework for accountable care, based on the stages shown below. Vision and model Scope and impact Contractual analysis Financial analysis Contractual approach Review Monitoring Contract April 2019 Financial framework Specification NHS England has recently published contractual guidance on Accountable Care Partnerships, a link to this publication can be found in Appendix 2. The CCG will work with NHS England to incorporate this guidance into the development of its contracting approach for accountable care. This will be done to ensure that local integration agreements reflect the national view; in terms of the level of integration required between primary care and other services in order to deliver integrated care. 15

16 o Appendix 1 - Glossary acronym and abbreviations o Appendix 2 - Links to documents referenced in this strategy APPENDICES o Appendix 3 - Key benefits and results from the primary care home test sites o Appendix 4 - Examples of the difference that the strategy will make to patients experience of care o Appendix 5 - Introduction to North West London Collaboration of CCGs Maturity assessment tool o Appendix 6 - Developing the optimum network configuration for primary at scale o Appendix 7 - High level delivery plan for the implementation of the strategy o Appendix 8 - Local Engagement undertaken for the development of the strategy o Appendix 9 - List of Hammersmith and Fulham GP Practices 16

17 Appendix 1 acronyms and abbreviations glossary Appendix 2 links to documents referenced in this strategy 1 CCG GP MCP MDT NAPC NHS PCH STP Clinical Commissioning Group General Practice / General Practitioner Multispecialty Community Provider Multi-Disciplinary Team National Association of Primary Care National Health Service Primary Care Home Sustainability and Transformation Plan 2 Five Year Forward View (2014) Transforming Primary Care in London: A Strategic Commissioning Framework (2015) NHS England s publications on Accountable Care Models The GP Forward View (2016) NWL Sustainability and Transformation Plan (2016) GP participation in a multispecialty community provider (2016) Next Steps on the Five Year Forward View (2017) Does the Primary Care Home make a difference? Understanding its impact (2017) er_submission_v01pub.pdf YEAR-FORWARD-VIEW.pdf e_make_a_difference_march_2017.pdf 17

18 Appendix 3: Key benefits and results from the primary care home test sites Evaluating the impact of the first primary care homes The National Association of Primary Care (NAPC) has recently evaluated the early impact of three of the primary care home test sites. In line with the approach of fostering provider-led innovation designed to meet the specific local needs, the sites have introduced a range of initiatives. The sites analysed are shown opposite. The evaluation covered three perspectives relevant to Hammersmith and Fulham: Larwood and Bawtry practices in South Yorkshire two practices covering 30,450 people 1. the patient perspective new services and better experience 2. the practitioner perspective satisfaction, recruitment, retention 3. the system perspective impact on demand for other services The Beacon Medical Group in Plymouth four practices covering 32,500 people Thanet Health Community Interest Company eighteen practices covering 47,550 people 18

19 Appendix 3: The first primary care homes - exciting results for patients, GPs and other practitioners The patient perspective new services and better experience The three primary care homes on the previous page have introduced a range of new services to meet the needs of their combined practice populations. Examples include: enhanced care home services, including ward rounds, medication changes, and review of discharge summaries a new acute response team to safely manage unwell people outside of hospital the reconfiguration of virtual wards to involve community health and the voluntary sector new roles for pharmacists within and beyond practices a collaborative flu campaign additional GP input into the redesign of care pathways, including for dermatology and musculoskeletal conditions Other initiatives in the pipeline include: hosting Citizens Advice clinics in practices, run by local volunteers providing social care clinics to reduce assessment waiting times; reviewing clinical and non-clinical processes to identify opportunities for improving productivity Initiatives have been funded in a variety of ways from existing CCG budgets, by practices, and a combination of the two. In some cases, no additional funding was required. The initial combined impact of these initiatives for the patient experience looks promising, in terms of: shorter GP waiting times lower A&E attendances lower A&E admissions more appropriate medication regimes slower growth in referrals, demonstrating that more of people s total care needs are being accommodated within primary care The information on this page is taken from Does the Primary Care Home make a difference? Understanding its impact (NAPC, 2017) 19

20 Appendix 3: The first primary care homes - exciting results The practitioner perspective - satisfaction, recruitment, retention As part of the evaluation, GPs and their colleagues in the primary care homes were surveyed about the difference that the new ways of working have made to their professional lives. Some of the main results were: Beacon Medical Group: 87% of staff enjoy their job, compared to 61% in % of staff speak positively of the practice when speaking to patients or external colleagues, compared to 69% in 2015 Thanet Health Community Interest Company: vacancies for community nurses have fallen from 24 to 0 over the PCH pilot Larwood and Bawtry: 87% of staff feel that the primary care home way of working has improved their job satisfaction 78% of staff over the three sites feel that the PCH model has decreased or not added to their workload Overall, the pilot sites reported that the PCH way of working had activated staff GPs and others to become the drivers of positive change. The information on this page is taken from Does the Primary Care Home make a difference? Understanding its impact (NAPC, 2017) The system The system perspective perspective impact impact on demand on demand for other for services. other services The PCH initiatives have not yet been underway for long enough to establish a definitive causal link between new ways of working and a range of system metrics. However, the early results suggest some exciting results are already being achieved. Across the three primary care homes, these include: reduced A&E attendances and admissions reduced lengths of stay in hospital following care home admissions a slow-down in the growth rate of GP referrals waiting times for GP appointments prescribing savings The report also quantifies the savings realised. In Thanet these were: c. 295,000 annual savings from a reduction of 14 A&E admissions a week following the roll out of the Acute Response Team 27,000 expected annual savings from reduced A&E attendances by cross-practice working to provide extended primary care access on bank holidays, supported by the shared patient care record 165 per care home medication review from a pilot extended across the local care home population, this would equate to a system saving of 216,000 These impacts on the patient experience, practitioner experience, and system metrics are key means of delivering the triple aim ambitions set out in the test sites local STPs and the same is true locally. 20

21 Appendix 4: PATIENT EXAMPLE 1 Highlighting the benefits of accountable care for patients with mental heath needs ROD SMITH: Age 53. Diagnosed with Schizophrenia aged 24. Lives with sister, but often sleeps rough especially when drinking. Prescribed small dose of regular tranquiliser. Currently: Has been discharged from follow up by psychiatrist Under care of Community Psychiatric Nurse (CPN) but frequently fails to attend Rod feels he is a nuisance to his sister who works from home. He tries to get out from under her feet and spends a lot of time wandering the area, smoking, and sometimes sleeps rough for days or weeks at a time Rod sometimes forgets to take his medication. Over the years there have been a couple of crises that have required urgent visits by a psychiatrist Rod doesn't like his current medication. His GP would like specialist advice on an alternative but Rod is reluctant to visit the psychiatrist Rod seems to develop chronic bronchitis rather suddenly. The GP recommends an urgent hospital investigation but knows that Rod is unlikely to attend for all the necessary appointments Anticipated benefits of Accountable Care: CPN is available to see patients locally in one of the GP practices that forms part of a small, local health and social care network, and can visit patients at home when necessary The Primary Care Collaboration includes various local community organisations. The CPN has referred Rod to a health and social care coordinator. After a discussion Rod has joined a local allotment group and finds he enjoys gardening. He has also joined an art group and smokes and drinks much less The Primary Care Collaboration employs pharmacists who routinely monitor repeat prescribing systems including Rod s usage of medication. They can use the shared computer system to leave messages for GP colleagues, the CPN and to ensure that someone contacts Rod to check on his wellbeing The GP and consultant can both access Rod s medical record and hold a virtual clinic where they discuss the case by video link while both viewing the record at the same time. They agree on a plan of action including a trial of a modern medicine with fewer side-effects There is a multidisciplinary diagnostic service in the local hospital where the staff includes GPs from Rod s local GP network. A care navigator keeps him informed as the day progresses with various investigations The chest specialist and GP compare notes and exclude a diagnosis of cancer. They make a record in Rod s clinical notes and agree with Rod that he will attend for follow up with his GP rather than the hospital 21

22 Appendix 4: PATIENT EXAMPLE 2: Highlighting the benefits of accountable care for patients with multiple long term conditions DANUTA KOWALSKI: Age 79. Widow. Lives alone. Suffers from diabetes, chronic kidney disease, high blood pressure and mild heart failure. She has been admitted to hospital recently following some falls. She tries to help her struggling daughter with cash, leaving her with little money of her own to feed herself properly. Currently: A heart failure nurse visits Danuta at home, but sometimes Danuta needs to attend the hospital for tests. She tries to combine visits to her GP for diabetes or blood pressure review with days when her daughter is available. She can also usually co-ordinate her hospital visits to the kidney specialist every three months to suit her daughter. She sometimes misses her appointments Danuta frequently needs hospital admissions, for heart failure or worsening of her kidney condition Currently, communication between health care professionals and social care is typically in the form of letters There are frequent mix-ups over medication, when for example one of the specialists recommends a change, but the letter arrives late at the GP surgery Danuta s daughter is re-housed to another borough following the birth of her child, and Danuta becomes increasingly isolated. A neighbour suggests she discuss the issue with social services. She is offered a weekly visit to a day care centre but feels that would not suit her Danuta s daughter is increasingly pre-occupied and it becomes more difficult for Danuta to access help or get equipment. Danuta sees a GP she has not seen before who is a little concerned to hear about Danuta's financial support for the daughter. The GP is reluctant to trigger formal safeguarding proceedings and takes no action. Anticipated benefits of Accountable Care: Local GPs and social services are combined in an integrated care service. The team is based in one of the GP practices. The combined team ensures that the same, suitably trained nurse can provide home visiting for all the various specialist needs in a single, regular visit. The nurse can discuss Danuta s case regularly with each of the specialists in virtual clinics where both have access to the same, shared record system. Hospital visits become less frequent An integrated team as well as shared records allows for better planning and anticipation of crises, especially by making use of pharmacists who keep track of medication usage. When crises do occur, they can usually be managed by a community support team that visits Danuta several times daily including the use of mobile diagnostic equipment With health and social care combined in a single, local organisation, communication is much easier using a shared record and regular meetings All the specialists involved have access to the GP record, and changes to medication are more immediate. Also each integrated local care network will include pharmacists who can regularly review prescribing and raise issues with the doctors or nurses involved. Integrated health and social care makes it easier for the nurse and social care to share information. With more emphasis on prevention and with better communication, this situation is anticipated much earlier, and a local housing solution is found which allows Danuta s daughter to continue providing some support Whenever help is required, it is accessed by a single phone call to the same number each time. Danuta knows her care navigator very well, and since payments for equipment come directly from a single, unified budget, personalised help and equipment can be accessed much quicker The care navigator is able to connect Danuta to a local visiting service. One of their volunteers is Polish and subsequently visits Danuta regularly to chat in her native language The GP is very familiar with their social care colleagues who now work in the same team. They are able to have an informal discussion and the nurse who visits feels able to raise the issue with Danuta and her daughter and finds a solution that everyone is happy with 22

23 Appendix 5 Introduction to North West London Maturity Assessment Tool North West London Collaboration of CCGs are introducing a provider maturity assessment to evaluate the willingness and capability of at scale primary care providers to deliver future population and outcomes based contracts. 23

24 Appendix 6: Our delivery plans set out a demanding programme of work 2017/ / / /21 GPFV implementation GPFV implementation SCF implementation Network plan implementation Borough-wide primary care homes: formation, mobilisation, innovation Borough-wide primary care homes: scaling and maturity MCP Accountable care Development and extension of accountable care Primary care standards: development Primary care standards: implementation Accountable care: launch planning Accountable care: development and extension planning Key Implementation is under way Plans to be developed Plans included within the primary care strategy Implementation state 24

25 Appendix 7: Developing the optimum network configuration for primary at scale The CCG and GP Federation are working with practices to develop the current network system into the best configuration for working at scale. This will be completed by October 2017 and will be based on a series of considerations, including existing collaborative relationships, common challenges, and an appropriate mix of practice readiness to lead the transformation process. The map on the right shows the current Network configuration. The practice names for each number can be found in Appendix 9. 25

26 Appendix 8 Local engagement for strategy development Hammersmith and Fulham CCG and GP Federation have undertaken clinical and public consultation into the development of the primary care strategy. A series of engagement events were undertaken (including two patient focus groups) in which discussions were held with GP members, local residents and other stakeholders to gain an understanding of the improvements they want to see in General Practice and the wider health and care system in future. The table below provides a list of local engagement events that were carried out. The outputs from local engagement were useful and have informed the final iteration of the strategy. For example, a request to see greater emphasis on mental health needs alongside physical health needs has been incorporated into the strategy. Stakeholders / Forum Dates Hammersmith and Fulham GP Members Meeting 27 th April 2017 Hammersmith and Fulham GP Members Meeting 7 th June 2017 Patient Reference Group (which included representation from Healthwatch, the London Borough of Hammersmith and Fulham (LBHF) as well as Community and Voluntary sector organisations) 15 th June 2017 Practice Managers Forum 5 th July 2017 Primary Care Strategy Patient Focus Group 10 th July 2017 Hammersmith and Fulham GP Members Meeting 20 th July 2017 Primary Care Strategy Patient Focus Group 27 th July

27 Appendix 9 practice list 3 1 Canberra Old Oak Surgery 2 Ashville Surgery 3 Shepherd s Bush Medical Practice 4 82 Lillie Road Surgery 5 Parkview Practice, Dr Canisius & Dr Hasan 6 South Fulham Health Clinic 7 Westway Surgery 8 Cassidy Road Medical Centre 9 Sterndale Surgery 10 Lillyville Surgery 11 Hammersmith Surgery 12 Fulham Cross Medical Centre 13 Dr Jefferies, 139 Lillie Road 14 Dr Jefferies, 292 Munster Road 15 Richford Gate Medical Centre 16 The Medical Centre (Dr Kukar) 17 Sands End Clinic 18 Palace Surgery 19 Fulham Medical Centre 21 Dr Kukar, Parkview 22 Salisbury Surgery 23 Park Medical Centre 24 The Bush Doctors 25 Brooks Green Surgery 26 Dr Uppal and Partners, Parkview 27 North End Medical Centre 28 Ashchurch Surgery 29 Brook Green Medical Centre 30 Hammersmith & Fulham Centres for Health (two sites) 20 The New Surgery 27