Integrating Primary and Community Care: A Briefing on the Oxfordshire Joint Enterprise

MEMBERSHIP BRIEFING PAPER Integrating Primary and Community Care: A Briefing on the Oxfordshire Joint Enterprise Background As Practices will be aware from previous discussions, the four GP federations (Principal Medical, OxFed, South East Oxford Federation and Abingdon Healthcare) and the main NHS community healthcare provider (Oxford Health NHS Foundation Trust) have been exploring opportunities to work together, developing proposals to form a joint enterprise to address the following three main objectives: Improve and support the sustainability of practices and primary care Drive locally-led integration and GP leadership of primary and community services through the establishment of effective neighbourhood teams built around clusters of local practices Develop new models of integrated care in primary and community settings to enable the shift of resources required to support more patients at or close to home It is recognised that achieving more care closer to home is not feasible unless the immediate challenge to improve primary care sustainability is addressed as a priority. The solutions to enable this will need to be tailored for the different localities in Oxfordshire. This paper is intended to generate local clinical and practice discussions. The aim is to develop a consensus on a broad framework of aims and supporting resources that can be adopted locally across Oxfordshire s 18 Neighbourhoods, in order to encourage and enable clinical innovation at a local level. The proposals in this paper should be viewed as the starting point for more formalised integrated working between OHFT community services and GP Federations. The aim is to build a local clinical consensus. 1

The Proposed Clinical Model The GP Federations and Oxford Health have considered what is within our gift to change quickly and what requires public consultation or wider system partnerships to deliver. Our approach will be to enable local, clinically-led ownership and redesign of the available clinical resources that will: Offer tangible options to support the sustainability of local General Practice and primary care Create effective Neighbourhood teams with joint GP and Nurse leadership to maximise the clinical capacity for patients with the highest frailty / complex comorbidity, with particular focus on those patients who most benefit from home visits Develop effective team working across localities to maximise clinical capacity. How will the Joint Enterprise improve everyday working for Practice and District Nursing Teams? GPs, practice nurses, community nurses and other practitioners will work together again as one neighbourhood team developing care pathways from their front-line experience Time will be spent together regularly as a team, focused on local cohorts of patients, building a common identity and purpose Increased back office support will be provided to reduce everyday admin Simplified clinical arrangements, IT/record-keeping, contracts and corporate governance will be put in place A wider range of practitioners will be trained with an increased range of skills, reducing vacancies and improving job satisfaction There will be flexibility for both locally tailored and county-wide approaches, depending on what is most sensible The Proposed Organisational Structure To organise this new way of working across the county, it is proposed to set up a formal joint enterprise organisation. Detailed legal and financial advice is being sought on the best legal options for this new organisation. The federations will continue to operate independently on their own activities but will work together with Oxford Health to provide integrated services. The federations will carry 2/3 rds of the votes in the Joint Enterprise Board, ensuring it is a primary care led organisation. 2

The Joint Enterprise will operate through three integrated local delivery boards responsible for roughly equal population sizes of 215K-250K people one for the north of the county, one for the south and one for the city. Together, each Local Delivery Board and its constituent Neighbourhood teams (each covering 30K-50K patients) and their local practices will form an integrated network for delivering integrated care. This integrated network will: Provide both proactive and reactive care to patients with long term conditions and frailty who require care in their home or in community settings Develop services to support this, such as urgent home visiting services and a virtual ward system for patients at risk of or experiencing a deterioration Offer opportunities to bring together unscheduled minor injuries and acute illness service provision seamlessly at a local level for example, through the development of urgent treatment centres as defined by NHS England Develop clinical networks (including acute / EMU / RACU input) to provide urgent care in community settings for patients with complex frailty, as an alternative to acute admission, where clinically appropriate Bring together existing clinical resources to provide MDT joined up proactive / unscheduled care intervention to local care homes and nursing homes Create joint clinical pathways with local end-of-life care / hospice providers to support more people to die at home if they wish, with particular focus on developing seamless care across in- and out-of-hours All of these initiatives will help to manage the increasing demand in acute hospital settings; firstly assisting to bring the Oxfordshire NHS into financial balance (and so reversing the pull on NHS resources towards the hospital) and also creating delivery models for care closer to home, where additional investment in primary and community provision will accelerate reduced acute spend. The ambition behind these proposals is not new to Oxfordshire or elsewhere; all appear as part of the Oxfordshire Transformation Plan and the NHS Five Year Forward View. This framework sets out the practical application of these aims. Critically, it offers a low risk approach for local GPs and other clinicians to redesign their extended primary care team (i.e. Neighbourhood team) so it better supports local primary care, as a first step towards delivery of the Oxfordshire Transformational Plan. What also sets this approach apart from historical proposals is that it addresses directly how primary care and community services and organisations will need to change their ways of working to ensure sustainability. It also proposes a model of care and integrated care delivery structure that will directly enable additional out-of-hospital investment to translate into reduced acute activity. 3

Timescales Before these proposals can go ahead, practices will need to approve their federations to progress the work, through their governance systems. In PML s case, this will involve an initial shareholder vote on our further engagement in the process at our AGM in September, with the likelihood of a further ratifying vote at an EGM in November. If Federation members decide to support the plans, the implementation of this framework will be phased as described below: 1. Phase one quick impact (felt within 6-12 months) and delivered within current resources or with minimal investment for pump-priming. This phase is focused on boosting primary care sustainability and developing extended primary care through joint GP- and Nurse-led Neighbourhood teams. 2. Phase two delivered within 2 years. This involves a major redesign of current community provision (Oxford Health, GP Federation provision, palliative care contracts) into the new integrated structures. This incorporates the delivery of the Oxfordshire Transformation Plan for the community (following public consultation), to create: A local frailty network providing ambulatory care / home care for patients across the county with acute contribution clearly defined for each locality. Incorporates EMU-type care, urgent home visiting, access to clinicians with expertise in gerontology (GP or acute), MDT and home care, plus easy access to diagnostics / specialist opinion Comprehensive care home and nursing home support this will operate 24/7, incorporating redesign of 111 / 999, response to care homes through engagement and the contribution in the required 111 clinical co-ordination centre Urgent treatment centres as per NHSE requirements these will be configured to the agreed local profile and other local provision (e.g. GP streaming in ED and GPAF services) Delivery of new clinical pathways for people with long-term conditions these will provide seamless, integrated, personalised care for people with long-term conditions (e.g. diabetes) and support for their carers Phase two proposals will require: Partnership working with acute care providers Redesign of existing community provision currently within Oxford Health for example community hospitals as part of the Oxfordshire Transformation Programme and CCG-led public consultation Agreed shift of resources from acute services (together with associated patient activity); through acute clinicians working as part of local clinical networks and/or 4

through primary and community services extending into the current acute pathway A joint primary care and community services workforce plan medical, nursing, AHP and support staff to deliver ongoing sustainability and transformation plans Phase three will be delivered within 1-4 years. These changes will be focused on changes in the contracting infrastructure to drive longer term transformation and sustainability, and could include contracting for local palliative care community pathways, embedding relevant acute specialisms into a primary care clinical network (e.g. building on the developing diabetes model) and developing co-commissioning and MCP-type contracting models to offer GP practices a range of options to develop their GMS provision based on local needs. Increasing workforce capacity and skill-mix in GP practices Practices will be aware that PML has been exploring a range of options for contracting clinicians and other staff to work in primary care. Examples of requests have included the following types of clinicians: Doctors Clinical pharmacists Emergency care practitioners / advanced nurse practitioners Physiotherapists Community psychiatric nurses Managers and admin staff Such requests reflect the challenges in sustaining sufficient GP capacity in some practices, including the prohibitive costs of locum cover for GP vacancies. However, these requests also reflect a willingness to expand the diversity of the multi-disciplinary skill mix within Practice provision. A joint employment / contracting approach between Practices, Federations and Oxford Health through the Joint Enterprise will have a number of benefits for GP practices: Contracting with Oxford Health / Federation partnership reduces the employment risks and liabilities for Practices, which can be unaffordable for smaller GP partnerships Under certain arrangements, it may be possible for the Joint Enterprise to access the clinical indemnity cover available within the NHS Trust s own arrangements (so individual GP practices would not liable for the additional cost of indemnity for these professionals) Oxford Health / Federation partnerships can provide necessary clinical / professional supervision and training to practitioners to maintain registration with the appropriate professional regulatory body 5

Oxford Health, PML and the other GP Federations will work together to develop a contractual and governance framework for provision of registered clinicians to work in primary care settings, which practices can choose to take up if they wish. Developing the Neighbourhood Teams An early activity of the Joint Enterprise will be to move to District Nursing (DN) teams that operate at a Neighbourhood level, with a shared lead nurse and GP oversight (this does not require changes in existing accommodation arrangements, unless locally determined). The priority actions will be to: Appoint a named Lead GP for each Neighbourhood with protected, funded time to lead the development of the neighbourhood team. Develop systems that provide improved oversight of the complex unscheduled GP and DN caseload offering clinical continuity and supported decision-making to the integrated team. By rationalising this caseload, capacity will be targeted more effectively towards patients who most need it. Reduce bureaucracy between GP and DN teams, with the aim of freeing clinical capacity for both professionals Initially, the Neighbourhood will not replace the existing working arrangements between named (Band 6) district nurses and individual GP practices; rather it will improve and build on these relationships and reduce the duplication of effort between practices and DNs. The Neighbourhood team will be developed to provide the bulk of care for patients who require regular home visiting, especially those who are house bound or who have high frailty / complex LTCs. It is also intended to allow the locally-determined clinical prioritisation of how DN capacity is best utilised, within professional and contractual requirements. Another central aim of establishing the Neighbourhood team is to improve clinical capacity within existing resources by improving communication, caseload management and home visiting. There are a number of practical options that Neighbourhood teams are likely to collectively or individually pursue: A Virtual Ward approach for existing DN patients with immediate and intensive needs; this will provide ongoing monitoring of at-risk patients and reduce Practice time required to co-ordinate care / undertake home visits Mentoring DNs, Practice Nurses (PNs) and Clinical Pharmacists (CPs) through prescribing training; this will reduce prescription requests from DNs to GP practices, assist workforce retention, assist in palliative care and expand capacity Locally-determined reallocation of some tasks between DNs, CPs and PNs; this will maximise clinical capacity, promote professional development and assist staff retention, and encourage a team-based approach to care 6

It is proposed that Neighbourhood teams be given autonomy to determine their own local priorities and implement these accordingly, acting within an agreed county-wide framework. This will support local leadership within the parameters of professional and clinical standards and CCG/contractual requirements. It will encourage local clinical innovation and jointworking between Practices and DNs to redesign care at home to meet local needs and geography. Required resources and commitment In order to make this happen: Each Neighbourhood will need to appoint a Lead GP and a Lead District Nurse with responsibility for liaising with the member practice teams and the DN/community therapy team and taking forward agreed changes on behalf of the Neighbourhood the Lead GP will have protected time (funded) and the Lead Nurse will be resourced from the existing DN team. The Lead GP role will initially be funded at one session per week Each Neighbourhood will be allocated a small budget to support practice administration and the change process Project admin and management support will also be provided by the Federations and OHFT Each Practice will need to nominate a named GP / senior clinician to act as the practice s voice in the local configuration of the Neighbourhood teams Commitment will be given by OH and Federation clinical and operational staff to participate in planning activities and to agree and implement changes Questions for discussion Do Federation practices support the direction of travel and proposals set out in this paper? What are your own practice s priorities for the Joint Enterprise or Neighbourhood team? What are the risks / what worries you about this initiative? Do you have any experience in this area we could learn from? What are the potential barriers to success? Who would like to be involved in more detailed design and planning? Federation representatives will be attending local Federation / Locality meetings in the coming few weeks to discuss the proposed development of a Joint Enterprise and to answer any questions you may have. Alternatively, if you have a specific question, concern about what is being proposed or would like to contribute, then please contact info@principal-medical.co.uk 7