Interim Report July 2016

The South Yorkshire and Bassetlaw Primary Care Workforce Group Chair: Dr Ben Jackson Project Manager: Elen Williams e- mail: elen.williams1@nhs.net https://sybwg.wordpress.com Interim Report July 2016 1. Background The primary care workforce group was re- convened in autumn 2015 following the resignation of the previous chair and resulting inactivity of the SY&B Primary & Community Workforce Group (PCWG). The original group s intent was to provide a proactive forum for collaboration, providing: A shared view of risks through sharing intelligence; Opportunities to coordinate actions to drive improvement Determining priorities for taking forward joint work programmes Following the appointment of a new chair, Dr Ben Jackson (a Doncaster GP and Senior Clinical Teacher at the University of Sheffield) Health Education England (working across Yorkshire and Humber) also agreed to provide a year of funding for a full time project lead (Elen Williams) to support the groups development and delivery in supporting primary care in South Yorkshire and Bassetlaw. 2. The SYBWB Group The reformed group met for the first time in January 2016 with a proposed new title South Yorkshire & Bassetlaw Primary Care Workforce group and revised terms of reference. It was felt that in order to maintain purpose and energy the group should focus on what members of the community recognise as their primary care unit, general practice, community nursing and community pharmacy. The group set itself the task of driving the development and transformation of the primary care workforce in South Yorkshire in order to ensure it is fit to deliver high quality, modern healthcare across the whole of the region. Dr Jackson was keen to widen the membership of the group to include all the key players in the primary care workforce agenda. The first meeting therefore included representatives from frontline GPs involved in provider groups, Health Education England, Local Medical Committee, and CCG senior staff as well as from Higher Education Institutions 1 P a g e

(Sheffield Hallam and University of Sheffield). The welcome addition of Local Pharmaceutical Committee representatives completed the group. 2.1 Quick wins The first meeting generated considerable discussion about the terms of reference and purpose of the group as it became clear there was a real commitment to both achieving outcomes for the longer term but also in developing some quick- wins. It was agreed the group should look to catalyse change where possible, as the situation was critical. One of the key elements identified in ensuring the group was successful in delivering its stated objectives was the need to maintain engagement with frontline workers. It was considered essential that GPs in South Yorkshire were kept informed and involved in what the group was doing whilst gaining feedback and contributions to delivering outcomes that work for practices. Dean Eggitt kindly agreed that communications from the group could be circulated via the LMC networks across the region. The quick wins identified by the group were as follows: a) Collate and circulate potential workforce solutions in an easy to read format. b) Share and celebrate success of what is already happening in the region. c) Build on the success of our training hubs to enhance training opportunities for all. d) Understand and share the data we have on our existing workforce. e) Provide workforce workshops to allow GPs at the frontline some time to think about how they might explore possible solutions. 2.2 Reference work The previous group had functioned as a reference group for HEE and CCGs, informing and commenting on plans for primary care workforce change. The SYBWG has therefore continued to inform and influence plans for workforce transformation. In particular through working where possible with HEE, CCGs and the sustainability and transformation planning process. 3 Progress update: Since the first meeting of the reformed group in January 2016 the group has had two further meetings (quarterly) and membership of the group has developed to include representatives from other provider groups identified such as Primary Care Sheffield, and Barnsley GP Federation. 2 P age

3.1 The Website https://sybwg.wordpress.com/ In order to provide a repository of useful information and an effective communication medium for GP practices the group established a web presence (address above). The site provides a means for GPs to keep up to date with the activities of the group but most importantly provides a resource to inform practices about the workforce solutions and opportunities for new roles in primary care. The website has posted communications providing information and resources including focus on documents on pharmacists, physician associates, care navigators and HCAs and their potential roles in primary care. Each focus has included useful links to the relevant websites and information resources to support GPs in determining how new roles might support work in their practice. These focus on documents were also shared with the LMC for dissemination. In addition the website has reported on workforce events across South Yorkshire &Bassetlaw including HEE workshop events; ATP hub activity; new initiatives and most recently has provided updates on the progress of the STP in South Yorkshire and the input of Primary care in to the process. GPs are actively encouraged to sign up to the website in order to receive regular updates. Sign up to the site is steadily increasing as the activity of the group gains momentum, particularly in delivering local workforce workshops to GPs. 3.2 Workforce Workshops The group identified the need to provide GPs with protected time out from service provision, potentially in the form of workforce workshops. The aim was to provide an opportunity for thinking time around workforce solutions. CCGs representatives were approached on behalf of the group to seek funded time out for GPs to attend the proposed workshops. There was an initial positive response from four out of five CCGs in the region and the first workshops were held at a Sheffield PLI event on Tuesday 28 th June. Dr Jackson and Elen Williams delivered the workshops supported by local GPs from Sheffield CCG and the ATP Hub. The workshops involved discussions around three case studies of practices with different workforce challenges. GPs were provided with useful information on the possible new roles they might use in solving the workforce issues in each practice without any additional GPs. Feedback from the sessions was positive and highlighted a significant gap in understanding amongst GPs about what options for workforce solutions were available and how they might access them. Maddy Ruff, primary care workforce lead for the Sustainability and Transformation Plan (STP), also attended the workforce workshops. 3 P age

Some of the key messages from the workshops included: The need to explore further new roles in primary care eg. Physiotherapists; Orthopaedic; mental health workers The pharmacist pilot success had been mixed across practice but an agreement that more support on integration of pharmacists in to the primary care was needed for it to succeed. Practices need for organisational development support to manage significant and transformational change GPs had not heard of certain new roles e.g. care navigators but considered them a positive step. It was recognised that receptionists already carried out some of this role but would benefit enormously from supported training to broaden this and add credibility to the role. The ATP representative at the workshop picked up this message. Further workshops are planned in Doncaster and Rotherham after the summer. A similar format will be used with the addition of some information on the roles suggested by the group. Barnsley CCG has since re- configured their next PLI event and a future date has not yet been agreed. 3.4 Working to influence and inform. The group potentially has its most important function here. Primary care is a heterogeneous group and, unlike a secondary care organisation, it is difficult to provide a collective voice. The representation within the group from commissioners, providers and educational and training bodies provides the group with credibility. On 7 March 2016 the Chair wrote on behalf of the group to all CCG chairs explaining the re- configuration of the group and terms of reference, asking for support and representation (Appendix A). A positive response was received from each CCG in the region as well as the CCG working together group across the region. A response from the group to a request for priorities for workforce training opportunities was prepared for the Yorkshire and the Humber Director of Health Education England. (Appendix B) A submission was prepared for the Sustainability and Transformation Plan Executive group on the priorities and principals of a successful approach to transforming primary care services in the region. (Appendix C) Further meetings are in progress over the summer between the workforce leads for the STP and the Chair to consider how to both catalyse change but also to ensure that appropriate integration of new initiatives with current primary care workforce is achieved a key concern of the group. 4 P age

4. Summary and next steps: The group has achieved significant success in achieving the outcomes described by the group in the first meeting in January in a relatively short time and is well placed to ensure all the relevant workforce groups related to primary care are positioned to engage and influence the primary care element of the Sustainability and Transformation Plan (STP) for South Yorkshire and Bassetlaw. 4.1 Future role of the SYBWG As regional healthcare workforce structures are restructured over the coming months to create Local Workforce and Action Boards (LWABs) there are important considerations:- Where such a group best fits within these structures? What the primary function of the group should be? Should it function primarily as a reference group for the LWAB or should it continue to have a role as an agent of change within the region. The terms of reference for the group may need to change according to the answers to these questions to clearly describe the role of the group, who it represents and where its accountability lies. 4.2 Future Support The achievements of the group to date could not have been possible without project management support. The Chair currently takes time from his university role in the Academic Unit of Primary Medical Care to support the group based on the good will of the university. The funding for the project manager currently ceases in September. At a time of such rapid change in service configuration, when the NHS has recognised, through the investment described in the GP Forward View, that a successful and sustainable transformation relies on the strength of future primary care service, the SYBWG can play a critical role. 5. Recommendations It is recommended that the group should continue to function with the following roles: 1. As an agent for change within primary care across the region, through acting as a conduit for communication between the STP and frontline primary care services and developing workforce strategies in a way that maximises synergy and integration between new and current services. 5 P age

2. As a monitoring group to ensure that the investment described by the NHS GP Forward View reach General Practice in the most efficient and effective manner possible, whether through the CCG locally or the STP on a regional basis. It is clear that decisions on these matters are not in the gift of the group itself but depend on decisions made on the role the group should play in the new NHS workforce architecture by the Local Workforce and Action Board and others. It is the opinion of the group that it cannot provide more than a reference role without continued investment in some support for project work as has been provided thus far. As the group is focused clearly on supporting a strong and vibrant primary care workforce it is also proposed that any further support sits more reasonably within NHS England structures rather then primarily within Health Education England, as is currently the case. I look forward to the outcomes of discussions regarding all of the above over the next weeks and months. I also have to report that since the last meeting, Elen Williams has informed me that she is leaving her post to take up a new role elsewhere and I would like to thank her for all her work in the short time she has been with us supporting the group so far. We plan to deliver the workforce workshops as planned whatever decisions on the future of the group is made. Dr Ben Jackson MBBS, MRCP, MRCGP, FMLM Chair, South Yorkshire and Bassetlaw Primary Care Workforce Group 11 th July 2016 6 P age

Appendix A South Yorkshire and Bassetlaw Primary Care Workforce Group To: CCG Chairs South Yorkshire CCG Chief Officers South Yorkshire 7 March 2016 Dear Colleague I am writing as chair of the re-invigorated Health Education England South Yorkshire and Bassetlaw Primary Care Workforce Group. You may remember this group functioned for a few years with Margaret Kitching as chair until about eighteen months ago, when it was decided it needed more support if it was going to deliver significantly for the region. I am therefore pleased that the group is now supported by Elen Williams, a full time project officer who can help co-ordinate the group s activities. We held our first meeting in Rotherham last month and had representatives from CCGs, LMC, Health Education England, local universities, large primary care federations and the local pharmaceutical committee. The terms of reference (attached as an appendix) were agreed along with first priorities for the group s work streams. You will see that we are positioning the work of the group to support the wider primary care team delivering first contact care for health problems and are not at this stage widening this to include dentist, optometrists etc. We want the group to be active, with a clear focus about what and where it might make a significant contribution. South Yorkshire LMC and LPC are supporting the group and have agreed to circulate communications to their members. You will also see that the group, though supported by HEE, is asked to report to SYB CCGCOM in addition. The previous group had formal support from each CCG in the region and I am writing to ask that you adopt this position again. We would wish that there was senior input to the meeting from CCG workforce teams, to help us co-ordinate any activity for maximal impact. I very much hope this is acceptable and look forward to your response. If you wish to discuss any of the above please don t hesitate to contact me as below. Very Best Wishes Dr Ben Jackson Tel: 07710432362 GP, Conisbrough, Doncaster Senior Clinical Lecturer in Primary Care, University of Sheffield HEE LETB Board Member 7 P a g e

Appendix B South Yorkshire and Bassetlaw Primary Care Workforce Group Chair: Dr Ben Jackson Project Manager: Elen Williams e- mail: elen.williams1@nhs.net https://sybwg.wordpress.com/ 27 May 2016 Dear Mike Thank you for your letter dated the 24.3.16 regarding potential re-investment of in-year savings to support workforce changes. It is clear that between then and now the pace of change and re-organisation has been rapid. With respect to options for re-investment the following are derived from discussions within the workforce group and our recent representation to the regional STP. Much of this is about development/expansion but new areas are also described. It was considered particularly important that new training opportunities were rooted in primary care to accelerate the development of competence in that environment, and that new providers of education within practice may develop to meet needs. They are ordered in general order of priority in the short to medium term. Assistant roles - the development of Health Care assistant training opportunities were also welcomed but it was recognised that the needs of practices would differ in terms of where the most urgent need for assistant was and that training could be broadened to reflect this, supporting new assistant roles within a team (clinical administration, care navigator roles) Priorities for in-year investment commissioning new training opportunities within the Health Care Assistant model for roles that are either more clinician facing (medical assistance) or more pubic facing (care navigation) Practice nursing. - The Nurse Mentorship, Pre-ceptorship and Return to Nursing practice models were considered very positive by the group as a whole Priorities for in-year investment - marketing these projects further whilst expanding where possible pre-ceptorships and return to practice. Advanced Clinical Practice there is a growing need for flexible advanced practice roles within primary care teams, to support community medical care such as care planning, home visits, residents in nursing and residential homes. 8 P a g e

Priorities for in-year investment to support the development of these new roles through developing training opportunities or piloting opportunities within practices to allow better understanding of how these roles might develop. Leadership it is critical for new roles to have champions within the new communities of practice that those training can see are helping to establish new roles Priorities for in-year investment providing a forum for individuals and practice teams to meet, share good practice and celebrate successes in incorporating new roles into teams. Pharmacy support collaboration between practices and pharmacies is developing apace across the region with pharmacists being employed by individual or groups of practices to support medicines management Priorities for in-year investment a primary care training module for pharmacists/pharmacy technicians to that can orientate them to important aspects of prescribing practices and governance. On behalf of the group I very much hope this is helpful. Very Best Wishes Dr Ben Jackson Tel: 07710432362e-mail: Ben.Jackson@sheffield.ac.uk GP, Conisbrough, Doncaster, Senior Clinical Lecturer in Primary Care, University of Sheffield Chair, South Yorkshire & Bassetlaw Primary Care Workforce Group HEE LETB Board Member 9 P age

Appendix C South Yorkshire and & Bassetlaw Sustainable Transformation Plan - Primary Care Strategic Priorities/Principles A Sustainable Transformation Plan requires sustainable Primary Care. 1. Key Principles Systems approach rather than organizational silo The system needs to have a collective responsibility for the health and well being of the whole population spanning both primary and secondary care, health and social care, provider and commissioner, statutory and voluntary sectors and fundamentally the citizens themselves. At the heart of this system there needs to be adequately resourced, strong and consistent high quality primary medical care that has parity with the other stakeholders in terms of influence and resource and around which other health and social care services are integrated. Reaffirming the GP s role as Expert Generalists primary care consultants We should not overlook the core values of General Practice, the huge efficiency it affords the health service as the holder of continual care and its potential to address health inequalities. The huge level of experience, knowledge and skill of the profession must not go unrecognised. If GP s are to redefine their role it should be along the lines of that at which they presently excel- building trusting relationships and continuity, managing risk and uncertainty, making sense out of vague & nebulous symptoms, translating evidence base into pragmatic choices for patients that fit with their individual circumstances and managing co- morbidity, poly- pharmacy and complexity. Communication and Relationships Communication is key whether face to face or by telephone or through digital systems and intra- operability of records. Good quality efficient care is built around relationships which should be unconstrained by organizational boundaries or contracting methods such as payment by results (PBR) and tariff. Wrapping services around practices/groups of practices gives the opportunity to build these relationships, improving trust and delivering efficiency. Multi- disciplinary work force development: The existing skill mix in General Practice teams of GP s, ANP s, practice nurses and HCA s currently working together needs to expand further and involve closer working with the extended primary care team of pharmacists, physiotherapists, community nurses, IAPT and mental health teams as well as developing new roles such as physicians associates and medical assistants. The future primary and community workforce needs be developed as a system in a way that ensures it is integrated with practices, responsive to their needs and those of their patients and not working in parallel to or in replication of practice staff. 2. General Practice at Scale Collaborative general practice at the heart of an integrated system with services aligned to the needs of patients. A complete Primary Care offer 10 P age

In response to the increasing demand and drive for greater efficiency with greater integration of services along with 7 day access there needs to be a more complete offer from Primary Care. This should include a collective approach to urgent access to primary care throughout the week, a reassertion of the GP role as the senior decision maker in managing complex patients and long term conditions through a registered list, a proactive, coordinated approach to workforce development and a move towards shared administrative and management systems. Potential considerations include: Urgent Primary Care A shared approach to delivering urgent primary care access 7 days per week until 8 or 10pm, both from practices but also building on the learning through the Prime Ministers challenge/gp Access pilots using primary care at scale delivering care from satellite/hubs with practices committing to staff their share of satellite rotas under an extended primary care type contract. Whilst call handling/clinical triage 6.30pm- 8am Monday- Friday and 6.30pm Friday - 8am Monday would be by a single urgent care unit for triaged appointments and home visiting, satellites could be an extension of the Single urgent Care unit offering greater geographical spread thereby improving patient choice/experience and also better staff recruitment from nearby practices. Greater workforce diversity to manage minor ailments and illness e.g. First contact pharmacists, nurses, physiotherapists, emergency care practitioners physicians associates and IAPT workers supported by GP oversight The potential to develop a shared telephone clinical triage systems staffed by nurse practitioners to manage requests for same day appointments. This could be remote from practices with access to appointments on practice clinical systems and when compared with the non- clinical triage offered by receptionists has the potential to significantly reduce demand on GP appointments making better use of skill mix. Inter- practice same day acute appointment sharing to balance demand and capacity across groups of practices Shared Roving GP s and nurses for acute home visits and to offer rapid medical support to district nurses, case managers and community matrons, leaving Practice GP s to provide continuity of care and do more planned visits. Greater use of technology to enhance and promote patient self- care, improve access and develop interoperability of clinical systems. Prevention, Patient- Centered Planned Care and Chronic Disease Management A shared approach and collective responsibility for urgent access utilising a more diverse skill mix and blurring the boundary between in and out of hours through the use of satellites/hubs potentially frees up GP time to manage complex patients with multiple morbidity in a proactive and planned manner. GP s would have greater capacity to give medical oversight to the care planning process supporting a range of other staff integrated into the practice team. (e.g. HCA s, health trainers, CSW, community nurses) Greater shared infrastructure, integrated with community services would allow practices to share Roving Health Care Assistants and nurses to provide ongoing 11 P age

chronic disease management, phlebotomy and care planning of housebound patients. Greater integration with local authority and public health through strategy offers potential to enhance Primary Care s existing preventative and health promotion role targeting evidence- based interventions to improve outcomes. Neighbourhoods (groupings of geographically confluent practices covering 30-50000patients) have potential become the infrastructure around which primary care at scale is built. Demonstrating sustainability is key and is most likely to be centred on keeping people out of hospital. Neighbourhoods should be the foci of resources to manage frail elderly and at risk patients. If more generic teams (CSW, health trainers, community nurses, mental health workers, dietician, PT/OT, wellbeing officers) are wrapped around practices or groups of practices, then neighbourhoods could potentially coordinate these services across a locality. In addition they could develop more specialist services e.g. Community Geriatric appointments, Disease specific GP champions/consultant/nurse specialist advice & guidance or clinics and Complex health/social case management. Enhanced elective management of patients There is a wealth of knowledge, experience and skill in General Practice however an inability to unlock this from within individual practices to be shared more widely along with lack of timely access to specialist advice and guidance is a real barrier to GP s maximising their potential to offer consistent care for their patients and ensure that primary care is delivered in the community (and not in hospital clinics). In addition there is no financial incentive to manage patients beyond the level expected under core GMS/PMS even if advanced skills exist. If anything the additional time and resources required to go the extra mile are at a cost to the practice. Creating an infrastructure that facilitates the sharing of knowledge and skill and supports GP s to manage their patients and access more specialist help, investigation and treatments when required and in a timely way should be integral to the development of Primary Care. This could redefine the relationship between Generalist and Specialist and break down the artificial barriers between primary and secondary care created by PBR and Tariff. This could include: Peer review of referrals with feedback and education and the development of locality/neighbourhood GP clinical champions for specific disease areas. Email and telephone advice Facilitation of Inter- practice referral for enhanced services and potentially the employment of staff to maximise delivery of enhanced services e.g. joint/soft tissue injections, Endometrial Sampling, IUCD s, minor surgery, insulin initiation to list a few, thus maintaining consistency of provision of care for all patients regardless of their individual registered practice. A mixture of GP champions and specialist nurses supported by consultant specialists mentors delivering services from community hubs/satellites. A shared strategy to facilitate the training and development of GP s and nurses with an interest in specific disease areas with the potential to attract young doctors out of hospital with the option of retaining specialist interests and developing portfolio careers. 12 P age

3. Workforce Challenges The success of any health service transformation for the region will be dependent on strong and sustainable primary care workforce, led by General Practitioners. The foundations of this should be built on three core areas: meeting public need across all communities, a coherent skills strategy and economic sustainability. Meeting the needs of the public efficiently Planning for increased delivery of health care within our communities needs to be considered against current provision (or potential provision) from established primary care providers before new services are developed. Without this integration, service developments created in isolation will lead to duplication and inefficiency adding additional stress to the system and creating confusing and complex pathways for the public to navigate. The potential of co- ordinated primary care to address health inequities should be recognised and action taken to support practitioners working in deprived areas where need and demand is greatest. A coherent skills strategy The sustainable delivery of primary care will depend on the availability of medical, pharmacy, nursing, allied and support personnel with the right skills. As the number of GPs is not guaranteed over the next 10 years there will therefore need to be a shift in the skill mix within primary care as outlined below Many current health care workers (at whatever level) will want and be able to adopt new skills and roles but the current workforce is finite and new people will be required. Arrangements for the recruitment and training of the new personnel required to deliver increased care in the community care will need to be secured urgently. The adoption of new clinical (e.g. physician s associates) and non- clinical roles (e.g. care navigators) into the workforce will also be required along with increased opportunities for third sector involvement i.e. through social prescribing projects. The system needs to ensure these roles are attractive enough to draw these new workers into the health care service from other territories. As clinical competence is contextual, the skills required by new nurses, allied and support workers to work in the community need to be learned and developed primarily in community settings. An efficient and sustainable service. General Practice in the United Kingdom is recognised as one of the most efficient models for providing comprehensive universal health care in the world. This is founded on the experience of GPs and their allied staff as trained experts in community practice. Though primary care providers will need to alter their form in size and skill mix the essence of what makes General Practice efficient 13 P age

will need sustaining and require leadership by GPs and other experienced community practitioners. Support to develop this leadership must be provided, including mechanisms for system leadership, workforce development, and training within the primary care landscape. The efficiency of non- hospital medical and health services will ultimately depend on leadership from experts in community practice. Dr Andy Hilton Primary Care Representative, South Yorkshire and Bassetlaw STP exec. Dr Ben Jackson MRCP MRCGP FHLM Chair, South Yorkshire and Bassetlaw Primary Care Workforce Group MAY 12 th 2016 14 P age