NHS Telford and Wrekin CCG The Journey towards excellence in General Practice Primary Care Delegated Commissioning Strategy This is the first Primary Care Delegated Commissioning Strategy for NHS Telford and Wrekin and is designed to be read alongside the 2 year and 5 year plans which can be found at http://www.telfordccg.nhs.uk/strategies. The strategy provides the CCGs direction in order to achieve excellence in the delivery of our Primary Care Responsibilities whilst endeavouring to meet the expectations of our stakeholders, within a challenging environment. Author: Nicky Wilde, Deputy Executive - Commissioning and Planning - Primary Care Working with our patients, Telford & Wrekin CCG aspires to have the healthiest population in England Healthier, Happier, Longer.
Contents Executive Summary - The Journey towards excellence in General Practice 2 CCG Priorities 3 Delegated Responsibilities 4 8 Areas of commitment 6 Public Health Information 8 Governance 11 Engaging with Practices 13 Hearing the Patient Voice 14 Clinical Services 16 Improving and Measuring Quality 19 Working with the GP Federation 24 Interface with NHS England, Commissioning Support Unit and Local Medical Committee 25 Finance 26 Information Management and Technology 27 Primary Care Estate 30 Contracts 31 Medicines Optimisation 32 Appendices 1 Primary Care Committee Terms of Reference 33 2 Primary Care Risk Register 40 1
Primary Care Delegated Commissioning Strategy This is the first Primary Care Delegated Commissioning Strategy for NHS Telford and Wrekin and is designed to be read alongside the CCGs 2 and 5 year plans which can be found at http://www.telfordccg.nhs.uk/strategies. The strategy provides the CCGs plans to achieve excellence in the delivery of our Primary Care Responsibilities, whilst endeavouring to meet the expectations of our stakeholders, within a challenging environment. The CCG has only taken responsibility for Primary Care Commissioning since April 2015 and therefore this paper should be read in this context and it will be updated on an annual basis. Executive Summary - The Journey towards excellence in General Practice Our strategy is about facilitating, shaping and exploring possibilities, in partnership with our stakeholders. We have a vision of a Primary Care Service, led by GPs who are sufficiently resourced to offer appropriate and prompt access to excellent quality care for our population that is robust against challenge. Our GPs will lead innovatively staffed multi-disciplinary teams, which will include many disciplines of health and social care workers as well as those historically involved such as community nursing teams. This model will be clustered around Health hubs as proposed by the Clinical Reference Group of the Future Fit Programme and Community Fit. Primary Care Services will be designed around the needs of our population, as mandated by Patient Focus Groups. This will require careful and thoughtful management of patient expectations, and a care navigator role for many of the clinicians and other health and social care professionals. Telford and Wrekin will strive to continue to be an attractive place for Primary Care Clinicians of all disciplines to work and will be evidenced by the number of applicants for every job advertised and the excellent reputation of our Primary Care regionally and even nationally. We will know when we have achieved our vision because:- patients will consistently tell us improved outcomes will have been demonstrated and we will have an empowered, diverse and self-sustained workforce We have shared the initial draft Strategy with our stakeholders and this final version includes their suggested amendments. 2
CCG key priorities The overall commitment of the CCG is to have a system that provides the right care, at the right time, in the right place and within our allocated resources. Patients will be at the centre of every decision, local citizens will be fully included in all aspects of service design and patients will be fully empowered in their own care. All decisions will be evidence based where possible. There will be an open and transparent culture, and we will listen and learn and constantly strive for improvement. The CCG key priorities: To improve the commissioning of effective, safe and sustainable services which deliver the best possible outcomes, based upon best available evidence To increase life expectancy and reduce health inequalities and prevent people from dying prematurely To encourage healthier lifestyles To support vulnerable people In meeting the objectives of the CCG functions effectively, efficiently and economically and in accordance with generally accepted principles of good governance and as an employer of choice The Values at the heart of the CCG, which underpin all the work of the CCG are outlined in our Constitution, as being: Respect, dignity and compassion; To put patients and the public at the heart of commissioning in Telford and Wrekin allowing services to be personal and responsive to local need; To deliver effective planning for health services based on a true understanding of the population and their needs based on the Telford and Wrekin Joint Strategic Needs Assessment; To maintain and improve the quality of health outcomes and the safety of services for patients; To ensure clinical engagement and the achievement of the Quality, Innovation, Productivity and Prevention; To ensure a partnership approach to health and social care e.g. through the Health and Wellbeing Board; and To work within the resources available These priorities and values remain at the forefront of the CCGs Primary Care Commissioning Strategy and our Primary Care delegated responsibilities are detailed overleaf. 3
The Delegated responsibilities for Primary Care accepted by the CCG Decisions in relation to the commissioning, procurement and management of Primary Medical Services Contracts, including but not limited to the following activities: Decisions in relation to Enhanced Services Decisions in relation to Local Incentive Schemes (including the design of such schemes Decisions in relation to the establishment of new GP practices (including branch surgeries) and closure of GP practices; Decisions about commissioning urgent care (including home visits as required) for out of area registered patients; Decisions in relation to the management of poorly performing GP practices and including, without limitation, decisions and liaison with the CQC where the CQC has reported non-compliance with standards (but excluding any decisions in relation to the performers list); Decisions about discretionary payments Responsibilities currently staying with NHS England Management of the national performers list; Administration of payments in circumstances where a performer is suspended and related performers list management activities; Section 7A Functions ( Public Health) Decisions in relation to the Prime Minister s Challenge Fund The approval of practice mergers; Planning primary medical care services in the Area, including carrying out needs assessments Undertaking reviews of primary medical care services in the Area; Management of the Delegated Funds in the Area; Premises Costs Directions Functions Co-ordinating a common approach to the commissioning of primary care services with other commissioners in the Area where appropriate; and Such other ancillary activities that are necessary in order to exercise the Delegated Functions Management of the revalidation and appraisal process; Capital Expenditure Functions; Functions in relation to complaints management; Such other ancillary activities that are necessary in order to exercise the Reserved Functions 4
Opportunities of delegated commissioning The CCG recognised that there was a need to increase its commissioning portfolio to include the delegated commissioning of Primary Care. Whilst this comes with some risks which need to be mitigated (see summary at appendix 2) there are also compelling reasons why the CCG agreed to this significant change. Demographic changes, increasing multi-morbidity and the rising needs of frail older people are piling pressure on primary care. Whilst General Practice should be central to the heart of the healthcare system to allow them to respond to these pressures, there is a need to improve the coordination of health and social care, breaking down organisational boundaries. The CCG has welcomed the opportunity to have a greater influence over a wider NHS budget. The CCG will enable investment opportunities that will lead to new models of care while ensuring that the funding follows the need of the patient. The CCG has not yet agreed the future model and this may be developed as part of the Community Fit programme of work. The CCG will continue to horizon scan for new innovations and surrounding these innovations will be a new and robust quality and accountability assurance framework. All rounded approach to commissioning Support new collaborative working, with GPs and patients truly at the heart of the healthcare system Local Determination of Change - ablity to design local schemes Reduced boundaries and fragmentation New and robust quality and accountability assurance 5
Telford and Wrekin CCG - 8 Areas of Commitment To provide a framework for the new delegated arrangements, the CCG has agreed 8 areas of commitment. These build on the wider objectives of the CCG and will specifically impact on the Primary Care outcomes, putting the patient and the local GP at the heart of a personcentred model of care. The CCG has re-designed their staffing structure to enable coordination of these outcomes and close working with the wider CCG team, local General Practices, Patients and stakeholders will jointly debate these areas of commitment with the aim to receive approved commitments during the first quarter of the 2015/16. Engagement, Empowerment and Involvement No decision about me Sustainable Multidisciplinary and seamless care pathways - Social prescribing Patient Centred high quality and safe care Care closer to home admission avoidance Improved Access for urgent and routine care Reduced bureaucracy - Time to improve outcomes Reduction in variation care and inequalities Indicative Budget The anticipated outcomes of these commitments are shown on the following page, with some of the key interventions that are being considered to bring them to fruition. Monitoring of these 8 areas of commitment will be monitored quarterly by the Primary Care Committee. 6
CCG 8 Areas of Commitment, key interventions and outcomes Engagement and Empowerment Sustainable Multidisciplinary working Patient Centred high quality and safe care Care closer to home Better Care Fund admission avoidance Improved Access for urgent / routine care Reduced bureaucracy Reduction in variation care and inequalities Patient Participation Groups in all Practices Access to information via multi-media Multi-morbidity personal care plans Team around the Practice Social Prescribing Seamless pathways of care Professional Development and support New model for the management of Long Term Conditions New improved Quality Assurance Framework Review of Enhanced Services and Quality/outcomes Framework Better Care Fund Streamlined working with health and social care Risk Stratification Improved communication with Ambulance and Out of Hours Enable flexible appointment schedules Clear understanding of demand and capacity needs Review of current reporting arrangement for GP practices Allowing more time to see patients Improved Contract requirements TRaQs will continue to drive quality and improve referral processes Improved referral pathway for 2 week waits for Cancer Practices supported to meet their specific patient needs All Patients will have the opportunity to contribute. All Patients with a long term condition will have agreed personal care plans and feel empowered to self-manage care Patients will receive care from appropriately qualified and caring team of clinicians. Patients will be signposted to voluntary and community organisation for support Patient will understand the quality of care they should receive and contribute to their management plans, putting their needs at the heart of their care Patients will receive high quality coordinated care in a safe environment close to their home whenever possible. Health and Social care will jointly support this commitment Patients will identify a new flexible approach to accessing Primary Care, which is improve productivity and be reactive to patient needs Increased use of technology and automated data collection combined with the information requests that lead to improvements in patient care Variation will be understood by practices and patients Best practice will be shared and implemented across Practices Process will be better managed and improved Quality of Referrals will be increased Most effective use of resources Public Health Information Understand how primary care decision making impacts on the utilisation of healthcare Practices will understand their patient expenditure and work with patient groups to identify areas for improvement. Improved use of financial incentives 7
One of the key indicators for identifying improvements to health is by the use of Public Health data. This section of the strategy outlines the main issues for the population of the CCG. The full Public Health Profile can be found on the CCG Website, however, for ease of reference the main areas of concern are described below. The current priorities of the Telford & Wrekin Health & Wellbeing Board are as follows: Reduce excess weight in children and adults Reduce teenage pregnancy Improve emotional health and wellbeing Support people with autism Reduce the number of people who smoke Reduce the misuse of alcohol or drugs Support people with dementia Improve adult and children carers health and wellbeing Improve life expectancy and reduce health inequalities Support people to live independently According to the Index of Multiple Deprivation 2010, Telford and Wrekin as a whole is relatively deprived, with certain areas (such as Malinslee and Woodside) ranked within the top 10% most deprived nationally. However, there are also areas at the other end of the scale, such as Newport and Priorslee. Almost a third of Telford & Wrekin s young people live in areas ranked in the 20% most deprived nationally. The JSNA was originally produced in 2009/10 and had a refresh in 2012/13. The JSNA clearly demonstrates inequalities relating to life expectancy in Telford and Wrekin, including geographical hot spots where early death rates are significantly worse than average and variations in the uptake of bowel cancer screening across GP practices. There are key interdependencies with the improving life expectancy and reducing health inequalities priority of the CCG and several of the Health and Well-being Board strategic priorities. Smoking, alcohol consumption and excess weight are well acknowledged and significant lifestyle risk factors for a wide range of cancers, including: lung cancer, bowel cancer and breast cancer. Health and Care: 2011 Census The majority of residents (80.2%) reported good health, slightly lower than the national average (81.4%), 30,995 people (18.6%) reported a long term health problem or disability which limits their daily activities. An increasing number of residents provide some level of unpaid care 17,944 people or 10.8% compared to 9.9% in 2001. More than a quarter (4,978 people) provide 50+ hours a week of unpaid care Reducing health inequalities 8
The JSNA confirms that the lifestyle implications with higher prevalence rates of CVD and cancers are a challenge and the CCG continues to work closely with primary care, public health and patient groups to focus on weight reduction, smoking cessation and more active lifestyles. Following Telford and Wrekin s poor results in the published 1 year cancer survivorship figures the CCG has been proactive in working in partnership with GP, Local Authority, NHS England, SaTH, Macmillan and patients to improve these figures. Other projects specifically around Primary Care are about improving the identification and management of patients with long term conditions and to improve the outcomes for potential years' life lost. The CCGs further work on reducing health inequalities and how we are implementing the five most cost-effective high impact interventions can be found at http://www.telfordccg.nhs.uk/strategies. The Equality Delivery System Under the EDS2 Equality performance toolkit, the CCG is required to set itself equality objectives at least every 4 years. NHS Telford and Wrekin CCG has set itself 4 objectives as part of the EDS2 process, and these are: Objective 1 Improve understanding of equality, human rights and community needs across the CCG Objective 2 To ensure the equality of opportunity in employment and training provision, with focus on improving workforce data and analysis Objective 3 To achieve greater engagement between Telford and Wrekin CCG and minority groups Objective 4 To ensure accessibility to services and information across commissioning and commissioned services In order to comply with the Equality Act 2010, the CCG provides an update on the actions it is taking to meet each of these objectives in an annual report which can be found on the CCG website: http://www.telfordccg.nhs.uk/equality-and-inclusion. We have made some significant progress across a number of different CCG functions during 2014, albeit we still consider that we are developing in terms of equality performance. We believe that the breadth of progress outlined in this report, demonstrates the CCG s continuing commitment to ensuring that our local population has equality of access to NHS services and in outcomes of treatment Long Term Conditions and potential Years life Lost : Key Messages The table on the following page provides the key messages for long term conditions and potential years life lost. 9
Long Term Conditions and potential Years life Lost : Key Messages Details of how the CCG is addressing these are illustrated by accessing http://www.telfordccg.nhs.uk/strategies Disease Area Key Message Potential Years Life Lost Coronary Heart Disease Stroke and TIA Hypertension It is estimated that 5.6% of people aged 16+ years (approximately 7,849 adults) have coronary heart disease. However, at the end of March 2011 only 3.2% of the general practice population (5,472 adults) were recorded as having a diagnosis of CHD in primary care It is estimated that 2.5% of people aged 16+ years (approximately 4,418 adults) have suffered a stroke or TIA. However, at the end of March 2011 only 1.5% of the general practice population (2,656 adults) were recorded are recorded as having a diagnosis of hypertension in primary care It is estimated that 30.9% of people aged 16+ years (approximately 39,798 adults) have hypertension. However, at the end of March 2011 only 13.5% of the general practice population (23,059 adults) were recorded as having a diagnosis of hypertension in primary care Accounting for 30% and 13% of the total PYLLs respectively Early death rates from all cardiovascular diseases have declined significantly over the past decade in both men and women. In 2011-13 the rates of preventable early death from CVD were not significantly different to the England average from men, women or persons. However, the early death rate from CVD which is considered amenable to healthcare remained worse than the England average in both men and women. Actions required are in the improvement of CVD management and treatment for patients in primary care. Diagnosis and treatment of hypertension. Referral to the NHS Health Check programme. Referral to Smoking cessation service. Atrial Fibrillation diagnosis and management. Chronic Obstructive Pulmonary Disease Cancers It is estimated that 3.4% of people aged 16+ years (approximately 4,418 adults) suffer from COPD. However, at the end of March 2011 only 1.8% of the general practice population (3,136 adults) were recorded as having a diagnosis of COPD in primary care Early death rates from all cancers have been relatively static over the past decade with trends showing little decline. The early death rates from all cancers for persons and women remain significantly worse than the England average as do the rates from cancers considered preventable (persons) and cancers which are amenable to healthcare (both rates for men and women). The top three cancers with the greatest number of early deaths which are amenable to healthcare are bowel cancers, breast cancers and bladder cancers. Accounting for 6% of the total PYLLs. Although respiratory accounts for the smallest proportion of PYLL, considerable work has already been undertaken by T&W CCG. The next stage is to work with Practices to identify the best way to expand the Community Consultant support to cover a wider range of respiratory patients. Accounting for 31% of the total PYLLs. Adherence to the Cancer survivorship plan Diabetes Dementia Prevalence and incidence of Diabetes are higher within T&W than the national average at the 6.3 rd centile; UK average is the 6 th centile. It is estimated that 1,580 people were suffering from dementia in 2010. The numbers of people expected to be suffering from dementia by 2015 is set to increase by 17% to 1,851. At the end of March 2011 only 644 adults were recorded as having dementia in primary care Not identified as a specific contributor in the Telford and Wrekin data Not identified as a specific contributor in the Telford and Wrekin data 10
Governance and Assurance Framework The CCG will comply with the assurance required from NHS England and provide a quarterly certification of compliance for delegated commissioning and out of hours. This will include governance assurance and management of conflict of interest, procurement, expiry of any responsible contracts, availability of services and outcome. This certification of compliance will be signed off by the CCG Governing Body as required. This will be part of the wider CCG Assurance which is required by NHS England. In addition to this assurance, the CCG acknowledges the requirement to produce an annual business plan, commissioning plan and annual report. The CCG has updated its governance arrangements and scheme of reservation and delegation to accommodate delegated responsibilities. We have also introduced a Primary Care Committee; terms of reference for which can be found at appendix 1. The CCG is also currently recruiting an external GP Committee member and has recruited a lay member to chair the Committee and to oversee the Primary Care Delegation. An invitation is extended to Telford and Wrekin Healthwatch and Telford Council to nominate observers to attend the meeting. The CCG has also amended its constitution to incorporate decision making on behalf of NHS England. The Primary Care Committee will be held in public. A register of conflict of interests and decisions made by the Primary Care Committee in connection with the responsibilities identified on the previous page is currently being put into place. The CCG has extended an open invitation to NHS England to attend the Primary Care Committee and will adhere to the requiremen t to provide copies of the Committee s Agenda and minutes to NHS England. Telford and Wrekin CCG has already in place an established Patient Health Roundtable that aims to be a voice promoting the health interests and concerns of the residents of Telford & Wrekin with the aim of influencing CCG commissioning to improve health outcomes and health services locally. This group will also be involved in the oversight of delegated arrangements. As described earlier in this paper, the CCG has considered potential risks associated with the acceptance of delegated functions and has put together a risk register, a summary of which is provided at appendix 2. This register will be maintained and reviewed by the Primary Care Committee. 11
The CCG Governance Structure NHS Telford and Wrekin CCG 22 GP Practices CCG GP Practice Forum CCG Governance Board NHS England Audit Committee Remuneration Committee Personal Health Budgets Risk and Scrutiny Committee Primary Care Commissioning Committee Planning, Performance and Quality Committee Health Roundtable Individual Funding Committe e Joint Commissioning Policies Advisory Committee Clinical Pathways Sub Committee Medicines Safety Committee QIPP Sub Committee 12
Engaging with our Practices The CCG has a proven record of working with the 22 Practices within their areas of responsibility. The CCG is currently negotiating with Practices to agree how the working relationship will work in connection with Delegated Commissioning arrangements. A workshop has taken place which identified the strengths; weakness, opportunities and threats from a GP Practice point of view. These very important discussions will inform the future working relationship with Practices. The analysis summary is provided below:- Strengths Weaknesses Not afraid to challenge authority Similar practices / patients Good at expressing opinions Adapt to change well Fantastic workforce Shared vision Innovative Good Practice Managers group Good GP leaders (and support team) Care for patient s Cooperation between practices Conflict of interest as GPs Finance conflict Lack of expertise Consensus of opinion Don t understand jargon Decision making at forum / meetings needs strengthening Lack of stability Need to increase the safety culture e.g. Datix reporting Proper terms of reference needed Lack of knowledge who to contact causes problems Time is needed to make the right decisions Missing members when decisions are made causes issues Opportunities Threats Aim for stability Support for CQC visits Better technology Coordinated efforts for urgent care Wider and more diverse workforce Improved transparency Explore funding models Equal use of resources Listen to the GPs and let them take ownership of decisions Reduce burden without increasing workforce Increasing population with decreasing GP workforce National Recruitment issues GP + admin/paperwork etc Secondary care discharges Lack of income for services Loss of local knowledge with people leaving Improved quality at the risk of an exhausted workforce Threat of losing GMS/PMS contracts Lack of properly costed work being transferred into GP Practices 13
This analysis will provide a background for future discussions with Practices and an agreement was made for another session to take place in May to work through some further issues and agree how the CCG will interact with Practices in the longer term. The options being considered are alternating the current commissioning Forum which is held monthly with a Primary Care Forum; setting up a duplicate arrangement as is in place for Commissioning and to hold a monthly Primary Care Forum as well as a monthly commissioning forum; however this option is considered to be time intensive for all parties. Other options may arise during discussions. Some of the key areas which the CCG will be working with GP Practices are:- The delivery of the 8 CCG commitments as identified on page 2 Workforce development and sustainable Primary Care Multidisciplinary working e.g. Pharmacists, Emergency Care Practitioners Decision making processes Succession Planning Continuous improvements and transformation Consideration to a Memorandum of understanding between the CCG and Practices. Hearing the Patient Voice In July 2013 our CCG and Shropshire CCG began a joint local consultation process known as Future Fit mirroring the national Call to Action initiative. Patients have been consulted widely on the future shape of the NHS and what is important to them. Improving access to GP services has been identified as an important issue for patients with seven day access to primary care and GP s being able to spend more time with patients and less on administrative duties is a key concern. Community Fit has now been established as a separate work stream of the broader Future Fit project looking specifically at the future shape of community services including Primary Care. 14
In everything the CCG aspires to, hearing the patient voice and working towards patient centre care is at the forefront. The assurance processes identified earlier, has introduced the Patient Health Roundtable and how the CCG engages and involves patients in decision making and Governance. In addition one of the key areas which have been highlighted by patients is the need to provide improved signposting to services and improved information to enable and empower patients to selfmanage their conditions. The CCG is also aware that enabling GPs to socially prescribe to the voluntary sector and community groups is a key enabler to a healthy society. Whilst the CCG has commenced this process, it needs to be more formal and the good initial progress built upon. The CCG has made progress towards Citizen inclusion and patient empowerment and this work is becoming embedded as business as usual. The CCG Health Roundtable is a sub-group of the CCG Board and the Chair of the Roundtable attends each Board meeting to ensure the voice of the patient is heard at every level in the CCG. The CCG has a patient engagement strategy and also a Communication Plan, which has patients at the helm of this process. We have been able to identify what is important to patients and ensure they are involved in the difficult decisions that we face. Patient members produced their flower of engagement and assurance which identifies their areas of importance. The CCG has in place a GP lead for primary care which includes quality and experience. This is also within the remit of the Executive Nurse. The Quality Leads along with the Primary Care Committee and Health Roundtable focus on the experiences of patients as a key driver for change and improvement. Not all GP Practices have formed Patient Participation Groups and therefore are not receiving the direct patient voice in delivering improvements. As part of the development work with Practices the Patient Roundtable will work with the CCG to ensure that all patients have the opportunity to become part of a Practice based patient participation group. One of the pieces of work that the CCG is taking forward with Patients is to reduce waste in the health system especially in GP Practices around DNAs. Patients also identified improving access to Primary Care as a priority. Both these areas will be taken forward together with the Friends and Family Test. 15
Clinical Services Working in partnership with GP Practices The CCG has a good working relationship with its constituent practices. All practices take part in service redesign projects with the CCG. This successful relationship is continuing into 2015/16 with the clinical areas being agreed jointly between the local GPs, local providers and the CCG. This works results in many new pathways being agreed and together with the Telford Referral and Quality Service (TRaQs) has resulted in the improved quality of referrals into secondary care whilst offering patient choice. 2 week wait referrals are also to be referred through TRaQS to ensure a consistency in quality and adherence to agreed pathways. This is a demonstration of our commitment to joint working with our Practices and is also delivering improved care for our patients. The CCG continues to work with Practices to look at patient feedback, activity, finance and benchmarking information. Risk stratification data has been used by Practices to identify patients with the most need and to introduce personalised care plans, early intervention and treatment which lead to admissions avoidance where appropriate. Whilst work via the risk stratification tool has been introduced, there are still improvements which can be made and further work is required to ensure that there is full connectivity with all stakeholders to improve patient centred coordinated care. The Joint Strategic Needs Assessment continues to show that there is a growing prevalence of patients with Long Term Conditions and this is leading to the potential years life lost as identified earlier in this strategy. The CCG will work with practices to identify a new model of care for the management of Long Term Condition, potentially building on the House of Care model which includes strengthening self-care, prevention, early intervention and wellbeing in a co-ordinated manner. The CCG will continue to offer some extended services to GP Practices (traditionally known as Enhanced Services) and will discuss the opportunity to look at a more local solution to Enhanced Services to improve overarching outcomes, reduce variation and decrease bureaucracy and excessive reporting. The CCG will also consider options around the future of the Quality and Outcomes Framework with practices. This piece of work will look at possible redesign to achieve the most effective and efficient use of resources to support Practices in delivering the overarching strategic objectives of the CCG and improving the quality of care provided to patients. Risk Stratification Long Term Conditions Extended (Enhanced) Services Quality and Outcomes Framework 16
Better Care Fund and Team around the Practice An enhanced Enablement Team will be providing integrated health and social care for our patients through the Better Care Fund. This project will provide alternatives to admission and community based rehabilitation, enablement and end of life care. The diagram shows our model for Enhanced Integration. Details of the work of the Better Care Fund can be found on the CCG website www.telfordccg.nhs.uk. The output from the Enhanced Care model will be delivered via a new workforce strategy which will have built up skills across disciplines to ensure people receive a holistic service without fragmentation. 17
To further strengthen integrated Primary Care and effectively case manage patients in out-of-hospital settings, the CCG commenced a pilot which was to look at enabling practices to work together with dedicated community teams. This has been slow to progress and there is currently 1 practice level pilot underway. This will be a priority area to develop in 2015/16. Whilst the Better Care Fund Project concentrates on the step up and step down care based in the community, the Practices will concentrate on supporting their practice populations highest needs, supporting the frail and elderly, children and high risk patients. This will only be successful by co-ordinating the community nurses directly from the GP Practice Clusters and will be the major move towards delivering Primary Care at scale. Whatever the highest need within the Cluster (depending on their demographics) will dictate the type of community professionals attached to each Cluster. These extended multidisciplinary teams will also be able to support the continual development of personalised care plans to ensure that patients are supported with the Primary Care Setting as far as possible. The Total extent of the projects will be agreed with the Practices as a priority. To enable change, we have already commenced strengthening our infrastructure for the voluntary sector, carers and neighbourhood development schemes with a new grant framework which was implemented in 14/15. With delegated arrangements in place, we will ensure that Primary Care is more accessible, with less variation, and strengthened through a 'Team around the Practice' model of care designed with key community services Social Care and the Voluntary sector. Teams around Practices will be proactively case managing the most vulnerable patients to prevent exacerbations of Long Term Conditions/Mental Health problems. Practices will be collaborating in groups to ensure the principles of 7 day working can be developed. This is being piloted as part of the GP Federation, Prime Ministers Challenge Fund to ascertain the level of need in Telford and Wrekin. This pilot will inform the future decision making of extended the access to Primary Care in the future. As previously stated, we are cognisant of the fact that as more services migrate to community environments, we must discuss estates options. However, we have already thought ahead regarding this matter and have begun to consider the use of video conferencing and other electronic means of communication. Increasing the use of assistive technology to increase mobile working, conducting appointments via Skype or equivalent media are early considerations. This will enable care closer to place of residence e.g. by installing Skype options in care and nursing homes, again reducing unnecessary travel. 18
Operational resilience The CCG is mindful that operational resilience needs to be assured to provide sustainable services in times of increased pressure. This needs to be assured throughout the year and not purely in the traditional times winter pressures. The CCG will support the mergers of practices to ensure that there is reduced back office functions required, releasing time to dedicate to clinical care. During 2014/15 several projects were introduced to increase capacity during times of increased pressure. These schemes will be reviewed as part of the implementation of this strategy and formal arrangements put into place for 2015/16. The schemes will concentrate on areas such as no attendance at A&E as a result of lack of appointments in Primary Care (in and out of hours) and improved liaison with ambulance staff to avoid unnecessary transfers to hospital. In addition a needs assessment will need to be undertaken to identify future Primary Care requirements. Improving and Measuring Quality The CCG has an overarching vision for quality Every patient has the best possible experience and Care that we can commission. As previously indicated the CCG is currently reviewing the quality assurance framework for the CCG and this will include areas of Primary Care. It will concentrate on 3 key areas of Patient experience, Patient safety and Clinical effectiveness and set in the context of the 6Cs. 19
To assist the CCG is gaining a level of assurance there is a need for a culture of sharing and openness to aid learning when incidents or near misses occur amongst practices. Processes are place to continue to develop a culture that promotes great patient engagement and learning, however the information we have at present is limited to what practices us therefore reactive in nature. The CCG has refreshed the DATIX system across all practices to be used as a way for practices to raise concerns or issues with CCG officers when care hasn t gone according to plan or a risk has been identified for investigation The CCG has taken on responsibility for the management of poorly performing GP Practices and a new assurance framework will be developed by June 2015 for implementation during the following months. An outline of what the framework will include is:- Patient Safety Workforce Medicines Management Infection, prevention and condtol TRqQs PATIENT SAFETY Safeguarrding Practice visits CQC Incident reporting 20
Patient experience Local Surveys National Surveys Patient Groups TRaQs PATIENT EXPERIENCE Complaints NHS Choices Social Media Soft Intelligence PALS Roundtable Healthwatch Compliments 21
Clinical effectiveness TRaQS pathways Medicine Reviews QoF Clinical Effective-ness GP Forum NICE Protected Leaning Sessions Reporting and escalation processes will be addressed as part of the new Assurance framework. The CCG will also give some consideration to the use of Commissioning for Quality and Innovation (CQUIN) incentives for practices. The CCG will provide positive support to practices in order to continue to improve outcomes and will share best practice across the CCG. 22
Education and Development The 3 strands of GP Education, Mentoring and Clinical Leadership Development were inherited by the CCG from the PCT as established services and have continued to develop in a positive direction. As part of the Primary Care Strategy the CCG will continue this excellent work. We have 2 GP Tutors who have a role to facilitate Post-graduate Education in the CCG. We deliver Protected Learning Events in two forms, in-house events which occur once every academic term for practices to organise their own training and external events are organised according to CCG priorities. We start planning for each event 2 months ahead, with regular steering group meetings, and feedback meetings after the event. The normal format involves usually 2 key speakers, followed by workshops. Events have already been planned for 2015. NHS England currently offers the service of the Practice Support Team for practices who feel that require additional support. The CCG will need to clarify the future of this service with NHS England. Mentoring There are 2 mentoring leads within the CCG. The benefit and help it offers to colleagues in terms of challenge, transition and professional development is found to be appreciated and many who have used it would use it again or recommend it to others. It is intended to try and extend this service in the future. The CCG hosts a Paean website which is a shared vehicle for leadership, education and mentoring in T&W. We are optimistic that Paean, well promoted and quietly effective, will reach out to the professionalism of time-poor GPs. Paean Mentoring lacks the immediate perception of benefits of GP education, so has to continue to sell itself as a product. Given that the Paean website itself only launched a few months ago and in its infancy, the mentoring leads and team are working hard on ideas to promote mentoring. Clinical Leadership Programme The CCG runs an annual Leadership Development Programme, delivered in partnership with Alastair Olby of Leading Beyond. The programme has an increasingly positive reputation locally and now regionally and is almost completely funded by places supported by SSSFT and Shropshire CCG for their doctors (and now Practice Managers). The programme aims to contribute to succession planning for the CCG, and 4 of the 5 current GP Board members were participants in previous cohorts. This programme has been awarded a Gold Quality Award by Health Education West Midlands, who have funded a regional cohort of the programme. This started in February 2015, and has a multi-disciplinary group of delegates, including a Telford & Wrekin GP who was unable to attend the local programme. Future Development We should like to see this activity embedded in the work around our delegated responsibilities for Primary Care. We are in the process of finding out the level of understanding of mentoring among GPs in Telford using a questionnaire, and will use this to shape the future marketing of the service in order to support our member GPs to the full extent possible. Consideration will also be given to nurse training and education. 23
Working with the GP Federation The local GP Federation (STW Provider Services Ltd), together with Shropdoc and GP First, the federation covering Stafford and the surrounding area, has been successful in a 4.2million bid for funds from the Prime Minister s Challenge Fund. This is an agreement between NHS England and the Federation; however the CCG is heavily involved in the implementation and monitoring of outcomes. The funds will support a wide range of developments in the region s primary care workforce development and technology including working towards seven day a week access to GPs, patient accessible apps and Skype consultations. The money will also be used to work with universities and deaneries to encourage new GPs and other health professionals to continue to be attracted to work in Telford and Wrekin. This will support sustainability of the workforce, as well as enhancing Community Fit, the primary care aspect of Future Fit, to develop the infrastructure and workforce to manage the increase in services being delivered outside hospital. The projects the Federation are specifically delivering are improved access to Physiotherapy, improving pathways for Dementia and frail and elderly patients, an acute visiting service, extending access to Primary Care and recruiting to new posts such as increasing the use of Advanced Nurse Practitioners and introducing urgent care practitioners. The CCG will need to ensure that the use of this funding aligns with the wider plans of the Primary Care Strategy and the CCG. We must also be sure to identify any long term impacts of the projects and the potential future funding requirements that the Federation may request or expect to continue these projects. The other issue for the CCG to clarify is how the member practices wish the CCG to interact with the Federation and how they represent the GP Practices regarding future aspects of Primary Care Commissioning. 24
Interface with NHS England, Commissioning Support Unit and Local Medical Committee Clarity is required around the interface arrangements with NHS England (including Public Health) and the Commissioning Support Unit. This will be sought as part of the implementation arrangements. A key issue which must be resolved by September 2015 are the staffing arrangements for staff currently working in the local Area Team. The decision is whether to assign, second or employment these staff. In the first instance, personnel working in NHS England are aligned to the CCG and discussions need to continue to agree future arrangements. Another key committee for the CCG to liaise with is the Local Medical Committee. The LMC is a committee set up by law to represent general practitioners and advise NHS England Area Teams and other NHS Bodies on matters relating to GPs and general practice. 25
Finance Primary Care budgets have been set by NHS England (NHSE) for delegation to each CCG. The budgets delegated to CCGs from NHSE remain ring-fenced for primary care services during 2015/16. It has not yet been confirmed whether underspends (or overspends) on these budgets will be reported within the CCG s overall financial position or as part of NHSE s consolidated accounts. NHSE will retain commissioning responsibility for section 7a payments (public health related services) and at the time of writing we are awaiting confirmation on who will have responsibility for premises costs. In addition to the delegated budget from NHSE, the CCG already commissions a number of primary care services from within its existing financial envelope. These budget lines will also be reported to the Primary Care Committee and relate to local enhanced services. Commissioning responsibility for GP IT revenue in 2015/16 remains with NHSE. As in 2014/15, the CCG will receive a non- recurrent allocation for 2015/16. The current arrangement to manage primary care IT is via a service level agreement with the Commissioning Support Unit. (CSU) As in 2014/15, NHSE retains responsibility for GP IT Capital budgets. Ownership of capitalised GP IT assets and associated depreciation budgets also remain with NHSE. Any proposals for new in year expenditure on GP related contracts will be considered and approved by the Primary Care Committee. Decisions on these will be reported to the CCG Board through the minutes of the meeting. Summaries of in-year expenditure against budget will be presented to the Primary Care Committee on a monthly basis. Responsibility for overview and scrutiny of these budgets remains with the committee. Due to the changes required to systems and the complications in terms of cash allocations, a temporary solution has been suggested nationally. Therefore during 2015/16 all financial transactions in respect of delegated budgets will continue to be processed by the NHS England regional finance team. Journals will be posted within the CCG accounts to reflect income/expenditure at a summary level but detailed transaction data will not be held locally. 26
Information Management and Technology The CCG are committed to having a system that helps to provide the right care, at the right time in the right place and has an Information Management and Technology Strategy which is the key document in helping to deliver this. The key to a successful IT system is for it to be in the background, supporting the needs of users to access information and data safely and efficiently. Any clinical IT project needs to be benchmarked against 3 key criteria: Does it benefit patient care? Is it user friendly, efficient and does it fit in the workflow of busy clinicians? Is it safe? Our projects are measured against these criteria, and need to stand up to close scrutiny. Through the use of new ways to communicate and share information, we seek to improve the quality of the patient experience: The referral hub TRAQS is key in making the referral process more transparent and allows patients to have a central point of contact to get information and advice regarding their referrals. The hub also enables Primary Care to have an insight as to where their patients are within the referral pathway. Patient online access to book appointments, order repeat prescriptions and tele-health projects like FLO help to allow patients to manage their health and interact with clinicians. Access to medical records on home visits and in nursing homes The CCG are currently looking into tablet working for GP s and are in the process of arranging a demonstration provided by our GP clinical system supplier EMIS (used by all our GP Practices) on the systems capabilities outside of the practice. It is then planned to then offer this solution to each of our practices. Each year the CCG assesses practice hardware and funding is provided to update any hardware that may be out of spec or warranty where possible. To be able to deliver a truly integrated care model and have excellent outcomes for patients we will need to have effective IT systems for clinicians so that the patient journey through the whole health system flows uninterrupted and gives the patient confidence in the quality of care received. The implementation of this strategy should improve the quality of care that patients receive and improve the working partnerships within our local health economy. 27