NHS Waltham Forest Clinical Commissioning Group. Primary Care Strategy 2014/ /20

P r i m a r y C a r e S t r a t e g y P a g e 1 NHS Waltham Forest Clinical Commissioning Group Primary Care Strategy 2014/15-2019/20

P r i m a r y C a r e S t r a t e g y P a g e 2 Document revision history Date Version Revision Comment Author / Editor 18.06.14 1 Author Natalie Keefe 26.08.14 2 Update Update after discussion with Commissioning colleagues 10.09.14 2.1 Patient engagement terminology. Estates ambitions added After discussions with WF CCG Estates group and Planning & Innovation committee 27.10.14 2.2 Updated Updated following comments from Jamie Walsh, Waltham Forest Health Watch 08.12.14 2.3 Updated Updated following engagement events with stakeholders including GP members and patients 02.02.15 2.4 Updated Updated following comments from Waltham Forest Public Health department 09.02.15 2.5 Updated Final updates including additions from LPC. 12.02.15 2.6 Highlighted delivery areas linked to NHSE Transforming Primary Care Framework and updated cocommissioning information and integrated care. 27.02.15 2.7 Changes to engagement terminology Discussed at CCG Governing Body 25.02.15 Natalie Keefe Carl Edmonds Natalie Keefe Natalie Keefe Natalie Keefe Natalie Keefe Carl Edmonds Carl Edmonds Document approval Date Version Revision Role of approver Approver 24.09.14 2.1 Advice on draft CCG Governing Body 01.12.15 2.4 Advice on draft Primary Care Improvement Group 25.02.15 2.6 WF CCG Governing Body 26.03.15 2.7 Health and Wellbeing Board

P r i m a r y C a r e S t r a t e g y P a g e 3 TABLE OF CONTENTS... PAGES 1. FOREWORD. 4 2. EXECUTIVE SUMMARY. 4 3. CONTEXT.. 5 4. CHARACTERISTICS OF OUR POPULATION... 7 Ethnicity Deprivation 5. CURRENT SITUATION 8 Children & Young People Working age Adults Older People Patient Experience Quality 6. PROVIDER LANDSCAPE 11 Acute Primary Care Providers: General Practice, Networks, Pharmacy, Dental, Optometry and other providers 7. INFRASTRUCTURE 13 Premises IM&T 8. PARTNERSHIPS. 13 9. PRE STRATEGY ENGAGEMENT.. 14 10. OUR VISION & OBJECTIVES.. 15 Proactive Care Accessible, Quality Care Co-Ordinated Care 11. IMPLEMENTING THE PLAN 27 APPENDIX A : FULL LIST OF PRACTICES WITH THEIR ADDRESSES.. 33 APPENDIX B: ACTIONS FROM IT STRATEGY 36 APPENDIX C: EQUALITY ANALYSIS 37

P r i m a r y C a r e S t r a t e g y P a g e 4 1. FOREWORD As Chair of the CCG I am pleased to present NHS Waltham Forest Clinical Commissioning Group s (CCG) Primary Care Strategy for the next five years (2014/5 2019/20). Primary care is at the heart of the transformation of health and health services. Today 90 per cent of NHS activity takes place in primary care for 7.5 per cent of the cost, seeing more than 20 million patients per year. However, the model of general practice that has served us well in the past is now under unprecedented strain and there are significant challenges that must be addressed. We need to celebrate what primary care does well and retain what works, but we also need to see through significant changes to how primary care is organised, how services are delivered and how the workforce will develop. We will use the opportunities brought about by co-commissioning and work with Newham and Tower Hamlets CCGs as a group to support practices to help them achieve the specifications within the London Strategic GP Commissioning Framework, which will improve access, proactive care and coordination of care. At the heart of our proposal is the desire to make local decisions about primary care services for our population. This strategy sets out our challenges and the priority areas that have been identified to ensuring we have a primary care system that can thrive and deliver the care that patients need and deserve. Waltham Forest is a vibrant, diverse and exciting place with the potential for a very bright future; we look forward to the challenges ahead, knowing that there are also great opportunities for making positive and lasting changes to the health of local people in the borough. Dr Anwar Khan Chair, NHS Waltham Forest Clinical Commissioning Group 2. EXECUTIVE SUMMARY High quality primary care provides a holistic approach to care, from preventing illness and diagnosing problems, to treating diseases and managing long term conditions. General practice doesn t just provide care, it also helps patients to navigate the system and access the care they need in other settings. It represents a single coordinator of care for people from birth through to the end of their life. But models that have served well in the past are now under unprecedented strain. There are significant challenges that must be addressed. The Clinical Commissioning Group (CCG) will build on the excellent work currently being delivered by primary care, harness local skills and experience to create one of the best primary care services in the country. From engagement with our members, patients and partners the CCG will focus on the following objectives: 1. To improve primary care services to deliver better health outcomes for our local population 2. Improve patient access to and experience of primary care services 3. To ensure effective community engagement to help support the delivery of patient centred care 4. To maximise clinical engagement, ensuring strong leadership across all primary care services 5. Embrace technology and ensure that the primary care infrastructure is fit for purpose and supports patients to self-manage. 6. Practices working collaboratively with other agencies to support the delivery of integrated care

P r i m a r y C a r e S t r a t e g y P a g e 5 To achieve the above objectives the CCG has set out a programme of work that will lead to a number of measurable outcomes. Our case for change is set out in section 5; however it addresses the following factors: Population projection and future demand on services, Variations in access and quality to primary care medical services Financial sustainability Developing a workforce that can meet the challenges of the changing NHS landscape and to support the delivery of better health comes for the local population. Our work programme will fall under three improvement areas, namely, proactive, accessible and coordinated care. These are the same areas set out in the NHSE London Primary Care Framework which sets a direction of travel for all London primary care systems. We will use our new responsibilities of managing primary care contracts from 1 st April as a lever to drive change through the system and implement our work programme. Where it is beneficial, we will do this with our East London CCG partners (Tower Hamlets and Newham) as we will share some cocommissioning responsibilities and governance. This strategy will be overseen by the Primary Care Improvement Group (name may change when cocommissioning governance is established) which is a local body made up of all relevant stakeholder groups including the local authority, primary care practitioners and health watch. 3. CONTEXT The 2012 Health and Social Care Act changed the primary care commissioning landscape. Primary Care Trusts (PCT) and Strategic Health Authorities were abolished and from April 2013 responsibility for primary care contracting was passed to NHS England and is now being managed through the regional teams. CCGs also took on a number of the functions from PCTs including planned hospital care, rehabilitative care, urgent and emergency care (including out-of-hours), most community health services and mental health and learning disability services. CCG s also have a remit to support and encourage the development of primary care services. In addition, local authorities have assumed responsibility for public health and Health and Wellbeing boards. The diagram below set out the new organisations in the health system.

P r i m a r y C a r e S t r a t e g y P a g e 6 In July 2013, NHS England published The NHS belongs to the People: A Call to Action which sets out the current challenges faced by the NHS. In addition a London case for change has also been developed to respond to the specific challenges faced by the capital. It examines the future challenges of health and social care such as an ageing society, an increase in long-term conditions, changing expectations, increasing cost of provision and constrained public resources. However, it also highlights the opportunities available to transform the NHS giving patients greater control over their health, harnessing transformational technologies, exploiting the potential of transparent data, moving away from a one-size fits all model of care and unlocking healthcare as a key source of future economic growth. Locally the Health, Adults and Older Persons Scrutiny Sub-Committee established a GP review panel. This was partly in response to the changes brought about by the 2012 Health and Social Care Act, but also in response to evidence presented to the Committee about the quality and standards of primary care across the borough. The panel gathered feedback from service users, providers and other local stakeholders. A report was presented in January 2014 and the main areas for improvement that were identified included; patient access to GP services, better stakeholder engagement, reducing the variation in the quality of primary care, training and development of the primary care workforce and patient education. In May 2014 NHS England announced an option for Clinical Commissioning Groups to co-commission primary care in partnership. This will mean that some commissioning responsibility will transfer from NHS England to CCG s and provide CCG s with levers to manage the local health economy. Waltham Forest CCG submitted it application to manage primary care contract (in collaboration with Tower Hamlets and Newham CCGs) in January 2015 and hope to assume the new responsibility from April 2015. In November 2014, NHSE London published its document, Strategic Commissioning Framework for Transforming Primary care in London. This provide a strategic direction of travel for al London economies and lists 17 specifications under three areas, proactive, access and co-ordinated care. CCGs are currently review this document and planning how they might deliver the specifications. There are a range of other national, cluster and borough wide strategies that will impact on primary care. These are outlined in the table below. Strategy National, London, What this means to primary care in Waltham Forest Regional or Local Call to Action Optometry, London Sets out the challenges for primary care in London Dental, Pharmacy and GPs. London Cancer Strategy London A London strategy to improve early diagnosis, and follow up of cancer. Strategic Commissioning Framework for Primary Care London Framework for primary care that sets out solutions to the challenges faced by general practice. Transformation in London Better Care for London London Promotes role of primary care, invest 1billion in estates, encourages practices to work in federated networks and other providers to practice where care is currently poor.

P r i m a r y C a r e S t r a t e g y P a g e 7 WEL Five year strategic plan - Transforming Services Together Regional (WEL) Brings together the aspirations of the 3 CCGS, NHS England, primary care and specialised commissioning. Co-Commissioning Regional (WEL) Gives CCG s greater role in commissioning WELC Primary Care Development Plan Joint Dementia Strategy Better Mental Health; Waltham Forest Mental Health Strategy for Adults of Working Age Regional (WEL) Borough (but linked to national strategy) Borough (but linked to national strategy) primary care services. A shared strategy for Waltham Forest CCG and our neighbouring CCGs as primary care commissioning is transferred to CCG s. Increasing diagnosis and care coordination within primary care More emphasis on managing patients effectively in primary care; closer link between physical and mental health Better Start in Life Borough A joint plan between Waltham Forest Local Authority, the CCG that outlines the developmental and commissioning activities to ensure the best outcomes for children and young people. Community Nursing Strategy Borough Outlines how we aim to give residents of Waltham Forest affordable and sustainable community nursing to improve local health outcomes. IT Strategy Borough A borough strategy that s sets out the technological foundation to achieve many of the CCGs objectives. Urgent Care Strategy Borough A strategy for greater use of primary care services to help prevent avoidable use of A&E. Health and Wellbeing Strategy Borough Outlines the vision and priorities for the Health and Wellbeing Board, which primary care will support in the delivery of. Working for Health Equity: The Role for Health Professionals National Outlines that CCGs and GPs have an important and often under-utilised role in reducing health inequalities through taking action on the social determinants of health. Five year forward view National The Forward View sets out how the health service needs to change to accommodate people living longer with more complex issues. 4. CHARACTERISTICS OF OUR POPULATION According to the latest Census in March 2011 there were 258,200 people living in Waltham Forest. However, the most recent population estimates from Office for National Statistics show that the population of Waltham Forest has further increased since the Census to a total of 262,600 residents as at 30 June 2012. Age Waltham Forest (Total) Waltham Forest (%) London (%) Aged 0-15 56,600 22% 20% 19% Aged 16-24 31,800 12% 12% 12% Aged 25-49 111,300 42% 42% 34% Aged 50-64 36,400 14% 14% 18% Aged 65+ 26,400 10% 11% 17% Total 262,600 100% 100% 100% United Kingdom (%)

P r i m a r y C a r e S t r a t e g y P a g e 8 The borough s population is projected to continue to rise over the next three decades to between 70,000 and 91,400 people and the number of children and older people is expected to increase significantly in the next few years. Just over half of Waltham Forest s population is female (51%) and the age structure of the borough is relatively young, with almost 1 in 5 people in the borough under the age of 20. The most significant element of migration for Waltham Forest is from and to other London boroughs. Neighbouring boroughs prove to be the largest source of in-flows with 4650 patients coming to the borough. A similar picture is seen with population out-flow pattern with 4630 patients from Waltham Forest moving out to neighbouring boroughs1. Ethnicity & Nationality 47% of the boroughs population is from minority ethnic groups. Since the 2001 Census the proportion of white British residents has fallen from 58% to 38% in Waltham Forest, while white other has increased from 6% to 15% The 2011 Mayhew Harper Population count estimated that, of more recent arrivals to the borough just fewer than 9,000 were Eastern Europeans. Other ethnic minorities in the GLA data include almost 5,000 Turkish, almost 4,000 Somali and over 2,500 each of Ghanaians and Nigerians. The borough s population becomes more ethnically diverse going from north to south. There is a greater proportion of White British and Irish residents in wards in the north and middle of the borough and conversely BAME residents are proportionally more likely to be found in the middle and southern wards of the borough. The chart shows the country of birth as recorded in the Census 2011. Deprivation Waltham Forest continues to be one of the most deprived boroughs in England. In terms of the overall measure of multiple deprivation (IMD 2010) Waltham Forest ranks 15th most deprived among the 326 local authorities in England. Its position has declined from 25th in 2007. Out of 33 London boroughs, Waltham Forest is the 6th most deprived after Hackney, Newham, Tower Hamlets, Haringey and Islington. More information about the health needs of Waltham Forest can be found in the latest Joint Strategic Needs Assessment (JSNA) http://www.walthamforest.gov.uk/jsna 1 ONS Migration Statistics Unit (Moves registered during the year ending June 2011).

P r i m a r y C a r e S t r a t e g y P a g e 9 5. CURRENT SITUATION Children and Young people Working Age Adults Older People Around 29% of the population of Waltham Forest is under the age of 20, an estimated 67,200 children and young people. Births increased in Whipps Cross by 27% between 2006/07 to 2010/11. However between 2010/11 to 2011/12 births decreased by 8.2%. Diabetes and emergency hospital admissions for <18 year olds lower than London and the Outer North East London boroughs. Accident and Emergency attendances for <5 year olds lower than London and England. Infant mortality higher than London and England rate. Still births, perinatal mortality, low birth weight higher than London and England. Large drop in prevalence of Breastfeeding from initiation to 6-8 weeks. Childhood immunisations coverage below local targets and World Health Organisation (WHO) target of 95%. Asthma and Epilepsy emergency hospital admissions for <18 year olds higher than London and England. Mortality rates for all causes, all ages in Waltham Forest are significantly higher than the national and London average for both males and females Growing prevalence of long term conditions particularly diabetes where prevalence is expected to continue to rise. The rates of obesity continue to rise. Cancer is the second most common cause of death and accounts for nearly 25% of all deaths in the borough. There is variation in the quality of primary care for Long term conditions including the exception reporting rate. Waltham Forest has a relatively high prevalence of mental health disorders, as well as high rates of hospital admission for problems related to mental health and alcohol. Tuberculosis (TB) is the communicable disease of greatest concern, and numbers of confirmed cases of in the borough have increased. The 2011 census population data reported that there are 25,528 (9.91%) people in Waltham Forest aged 65 and over. The number of older people is projected to increase from 25,770 to 28,386 by 2021. Chingford has the highest proportion of older people out of the three GP Consortia. In 2011 there were approximately 11,830 older people living with a limiting long term illnesses (LLTI) and by 2030 this is expected to increase by 26% Cardiovascular disease is the largest single cause of long-term ill-

P r i m a r y C a r e S t r a t e g y P a g e 10 health and disability, among older people. Life expectancy for men and women in England and for those living in Waltham Forest continues to rise. However there is significant variation in life expectancy in the borough with a difference of 7.1 years for men between the wealthiest and poorest parts of the borough and 5.5 years for women. Hospital admissions for falls and falls injuries in Waltham Forest in 2010/11 was significantly higher than London and England. Summary Waltham Forest is an ethnically diverse borough with some communities more prevalent in parts of the borough than others. Each community brings its own health and social care challenges including deprivation, long term conditions, cultural and communication factors. Patient experience Annually the Department of Health commission Ipsos MORI to carry out a GP Patient Survey. The survey includes items such as physical access to surgeries, overall satisfaction with practice and out of hour s services. The results by practice are available at http://www.gp-patient.co.uk Recent data shows that satisfaction in Waltham Forest is lower than the London and national average in the following areas: Ease of getting through to someone on the phone at the GP surgery Able to get an appointment to see or speak to someone Satisfaction with opening hours Overall Experience of GP surgery Would recommend the GP surgery Overall Experience of out of hours service In January-September 2014 satisfaction with the quality of consultation was 403.8 compared to London which was 416.4 and England 437.3 2 For the same period satisfaction with the overall care received at the surgery was 77% in Waltham Forest compared to 81% in London and 85.2% in England. Satisfaction with accessing primary care was 67.7& compared to 69.8 in London and 73.8 in England. Locally, Healthwatch Waltham Forest has published a number of reports based on service user s experiences. They range from general reports about GP access and treatment to reports particularly focusing on vulnerable 3 groups, like carers, deaf and hard of hearing patients. In each of the reports there are a number of commonalities that service users are recommending including improvements to appointment and telephone systems and improvements to waiting times and greater use of modern technology. Quality NHS England has created a national Primary Care Web Tool https://www.primarycare.nhs.uk which is an information portal that gathers data in regard to performance, quality and experience of GP services; it incorporates GP Outcome Standards (GPOS) and the GP High Level Indicators (GPHLI). The GPHLI data identifies practices as outliers if they are an outlier against 5 or more of the indicators. Waltham Forest has 10 practices that have been highlighted as outliers this is the most outliers in any of the North East London CCGs. 2 This indicator looks at 5 questions in the patient survey question numbers 21 A-E. 3 For the purpose of the strategy the following groups of people are defined as vulnerable; Elderly/frail, people with hearing impairment, visual impairment, mental Health, learning disabilities, substance misuse, carers, limited spoken/written English and from deprived communities

P r i m a r y C a r e S t r a t e g y P a g e 11 The GPOS data groups practices into four categories based on an overall assessment of performance drawing on a wide range of indicators. The categories are: Higher Achieving, Achieving, Approaching review and Review identified. Waltham Forest has no high achieving practices, nine achieving practices, 13 approaching review and 23 where a review is identified. Quality and Outcomes Framework (QOF) is a voluntary incentive scheme for GP practices rewarding them for how well they care for patients. The QOF contains groups of indicators, against which practices score points according to their level of achievement. There are clinical, quality and public health domains. The number of points achieved in QOF varies across the borough with the lowest achievement being 925.40 and the highest achieving practice achieving 1000. Prevalence rates of certain diseases also vary between practices. This can be an indication of unmet health need in the population, varying effectiveness of diagnosis practices, as well as a product of the differences in ethnic, social and age profiles of GP practice lists across the borough. It should be noted with all of the above that each individual and every population is unique and therefore some clinical variation is not only inevitable but also necessary in both clinical practice and commissioning. To understand the variation and outliers more detailed analysis of QOF results needs to be undertaken to understand what the information is telling us; including work looking at how diagnosed prevalence of disease differs from modelled estimates. 6. PROVIDER LANDSCAPE The North and East London provider landscape is characterised by a wide mix of organisational types, ranging from very large specialist teaching hospitals, specialist hospitals and integrated care organisations through to smaller acute units and individual primary care providers like general practice and Pharmacists Acute Information below shows the acute hospitals in north and east London. The area is served by three acute hospitals, each with an A&E department and a range of local acute services, managed by Barts Health Trust: The Royal London Hospital (Tower Hamlets) Newham Hospital Whipps Cross Hospital (Waltham Forest) Barts Health Trust also operates from: Mile End Hospital (a community hospital serving Tower Hamlets) St Bartholomew s Hospital (a specialist unit providing cancer, cardiac and other services in the City of London) The London Chest Hospital(a specialist cardiac unit in Tower Hamlets) Primary Care Providers Changes to NHS organisations over the last year have resulted in important differences for the primary care landscape. Primary Care Contracting is now led by NHS England through the regional teams. However, primary care development and improvement remains a core duty of the CCG, therefore requiring a partnership approach across the organisation.

P r i m a r y C a r e S t r a t e g y P a g e 12 General Practice There are currently 45 practices in Waltham Forest, 23 with a Personal Medical Services contract, 21 with a General Medical services contract and 1 practice with an Alternative Provider Medical Services contract, with list sizes varying from 2,030 to 15,163 (For a full list see appendix a) The structure of general practice in Waltham Forest includes a high number of single handed contract holders with GPs working outside the traditional model with more sessional and locum GPs. Waltham Forest has an aging workforce with 38% of GPs over the age of 60. Over the next 5-10 years this could potentially cause workforce planning issues. Practices are also seeing capacity issues in relation to workforce planning for practice Nurses. General Practice Networks GP providers have already commenced an ambitious programme of primary care transformation based upon the development of GP networks across the borough. GPs in Waltham Forest have now agreed to become one legal entity as a social enterprise under the name of Waltham Forest Collaborative. Within the Network there are 3 geographical sub-groups: Chingford - 8 practices with a total population of 64,052 Leyton/Leytonstone 17 practices with a total population of 120,362 Walthamstow - 20 practices with a total population of 110, 490 Pharmacy The Local Authority has recently developed a Pharmaceutical Needs Assessment (PNA) this sets out the services currently provided to patients in the borough. Waltham Forest currently has 60 pharmacies, all providing Essential services to patients (essential services include dispensing, repeat dispensing, receipt of unwanted medicines for safe disposal, support for selfcare, health promotion, signposting to other service provision and clinical governance.) 3 pharmacists are contracted to open for 100 hours a week, and one dispensing appliance contractor. The PNA sets out that as well as Essential Services many pharmacies also provide additional services including medicines use reviews, new medicine service, minor aliments service and Influenza vaccinations, sexual health services and access to smoking cessation. Dental & Optometry NHS England took over responsibility for commissioning General Ophthalmic Services (GOS) and General Dental Services (GDS) from 1 April 2013. There are 34 NHS dental practices in Waltham Forest and 1 specialist practice offering Orthodontic surgery only. This equates to 1 practice per 7594 patients. Optometrists (such as those based in high street Optical practices) play a vital role in the maintenance of eye health. Therefore, it is important that members of the community are able to access an optometrist in their local area. There are 34 optical practices in Waltham Forest, this equates to one optician per 7594 people. They are relatively evenly spread across the borough; however, there is a notable lack of optical practices in Leyton and Leytonstone. Although the core contracts are currently managed by NHS England the CCG has the scope to commission local enhanced services that meet the needs of the population. Other Providers Out of hour s provision is provided by Partnership of East London Cooperative (PELC) between the hours of 6.30pm - 8.00am Monday to Friday and all day Saturdays and Sundays and Bank Holidays. Some practices do close during the day when they are still responsible for their patients, and these practices commission PELC to provide cover during in-hours when closed.

P r i m a r y C a r e S t r a t e g y P a g e 13 Walk in centres (commissioned by CCGs) throughout Outer North East London provide some support to primary care access needs. NHS England is responsible for the registered list element of these services and the CCG is responsible for the unregistered walk-in element. During 2014/15 the CCG will redesign the urgent care pathway, and will be reviewing this contract as part of that pathway. 7. INFRASTRUCTURE Premises A number of practices in Waltham Forest are in premises that have been developed from residential houses and the condition varies considerably. In 2010, Waltham Forest PCT commissioned a six-facet and minimum standards survey that reviewed all GP practice premises, it found a number of premises needed considerable work to meet the required standards. However, since the survey was undertaken the introduction of CQC has meant that a number of practices have made improvements. A McKinsey piece of work in 2012 suggested that it would be expedient to reduce the number of surgeries to as low as 30 but improve the standard and range of service available. To understand the current situation the CCG will work with NHS Property Services, the local authority, NHS England and local patients to develop an Estates Strategy to ensure patients are treated in premises that fit for purpose. Primary Care Information Management and Technology (IM&T) IM&T is a key enabler to this primary care strategy. The ideal end state will be to have all health care providers able to share patient records and to communicate electronically with each other. The CCG has an IT committee which has developed an IT strategy, which outlines the work that will be undertaken over the 5 years. The overall objectives of the strategy are to ensure the following: Modern IT systems for individual GP Practices Connectedness across the local health economy An IT foundation for GP Networks A vehicle to analyse, benchmark and report on activity and outcomes A confident user community The purpose of the committee is to ensure a co-ordinated approach is taken across the CCG with regards to IM&T and that in conjunction with relevant provider organisations patient care is enhanced by integrated IT systems. The committee will also ensure that the CCG embraces and exploits technology to ensure that patients are able to use digital tools to self-help and engagement in their own health. It also mean that clinicians will be given the digital tools to be able to respond to changing demands and focus on efficient, effective and safe health care. 8. PARTNERSHIP NHS England In May this year Simon Stevens the new Chief Executive of NHS England announced an option for local Clinical Commissioning Groups to co-commission primary care in partnership with NHS England. The CCG sees this as a good opportunity to achieve greater integration of health and care services in the borough, so along with Tower Hamlets and Newham CCG s have submitted a joint application to co-commission some primary care services. The WEL CCGs (Waltham Forest, Tower Hamlets and Newham) have a strong and proven track record of collaborative commissioning and we see this opportunity as a key enabler to helping us deliver our respective CCG and Health and Well Being Board priorities and our joint Five Year Plan.

P r i m a r y C a r e S t r a t e g y P a g e 14 Health and Well-being Board The CCG is a member of the Waltham Forest Health and Well-being Board (HWBB) and is fully committed to the Health and Well-being Strategy (HWBS). This strategy is one of the ways the CCG will implement the health service elements of the HWBS. Local Authority We are working with the Local Authority through the Better Care Fund to deliver integrated health and social care. The Better Care Fund (formerly the Integration Transformation Fund) was announced by the Government in June 2013, to enable a transformation in integrated health and social care. The Better Care Fund (BCF) is one of the most ambitious ever programmes across the NHS and Local Government. It creates a local single pooled budget to incentivise the NHS and local government to work more closely together around people, placing their well-being as the focus of health and care services. The vision in Waltham Forest is to create a simplified and easy to access care system for residents where services are personalised to fit their individual needs and provide value for money. The underpinning principles are: Acknowledge and address ease of access to care services including sign posting and packages of care Pro-active care planning, incorporating later life planning, mental health needs and loneliness, and high quality specialist care services at the right time Care co-ordination/ navigation is a key component to an integrated service, with GPs playing central role as part of a multi-disciplinary team Services need to be planned with the client/patient at the centre of decision-making, both to respond to vulnerability and safeguarding needs and to empower self-care and self-management for people to live their lives Care plans and care budgets need to be personalised and tailored to individuals needs, their carers and families Rapid Response and re-ablement to prevent unplanned and crisis response which respond to the social, physical and mental health needs in a whole-person approach Hospitals to care only for people with genuinely unavoidable admissions Active voluntary sector involvement in design and capacity building Strategic approach to housing and welfare needs to enhance wellbeing 9. PRE STRATEGY ENGAGEMENT In preparation for the strategy, the CCG held a number of engagement briefings and events with stakeholders, including, GP member practices, patients, local voluntary sector organisations and the local authority with the aim of understanding what s important to the local community. This feedback is reflected in the current document and has served as important guidance about what the priority areas are. Below is the brief summary of the feedback we received. The strategy should focus on utilising technology, for example patients being able to book on-line appointments, video conference and email consultations; Enable patients to self-manage their health and long term conditions; Don t increase capacity of services, work with the current services we have to improve quality and access; Develop the workforce so patients have more choice and GP practices have strong, adequately resourced workforce; More responsive, timely and accessible service that responds to individual patient s needs. Including those with the most complex problems. Develop a patient/practitioner partnership agreement that sets out what can be expected from both parties. Specify how the strategy will support vulnerable patients.

P r i m a r y C a r e S t r a t e g y P a g e 15 Put more emphasis on wellness clinics and education and support. Service should focus on being proactive rather than reactive. 10. THE CCG VISION Waltham Forest CCG Vision To put patients at the centre of everything that we do by using their experience to shape care pathways, improve service delivery and ensure value for money Having high quality and equitable primary care is key to achieving this vision; if the CCG is going to achieve the objectives that patients, members and partners have said are important we need to recognise the key enablers and link this strategy with other work that is going on in the CCG including the community nursing, mental health and IM&T strategies and the urgent care. The Commissioning Strategic Plan outlines the CCGs Priorities and Clinical priorities. These are: Integrated Care and Care Management Integrated Commissioning Community Health Services. Urgent Care and Ambulatory Care The Development of GP Provider Networks. Our clinical priorities are supported by the Waltham Forest Health and Wellbeing Board. Care for Older People Mental health Diabetes as part of long term condition management Child and Maternity Care Cancer The primary care strategy focuses on 3 main improvement areas, Proactive Care, Accessible Quality Care and Co-ordinated Care, we believe that by focusing our efforts on these areas will help us achieve the CCG vision and priorities.

STRATEGY OBJECTIVES OVER THE NEXT 5 YEARS HOW WILL WE ACHIEVE THE OUTCOMES Improvement Areas Work Areas Overarching actions.we will (for more detailed plans see section 12 Outcomes P r i m a r y C a r e S t r a t e g y P a g e 16 Proactive Care Self-management Utilising modern technology/im&t Strategy Patient involvement Increase the use of technology to enable patients to be better equipped to manage their own conditions, including getting help, support and advice on-line. Work with our members and providers to look at how technology can support demand management. Areas we will explore further include managing appointments online, online repeat prescriptions, telephone or video consultations and email or text reminders. Encourage and promote patient and public involvement in service development to support the delivery of patient centred care. Improved primary care services that involves patients and builds capacity. Empowered patients to self-care and stay healthy. This will in turn deliver better health outcomes for the local population. Accessible, Quality Care Improved Access Fully utilised Estates Improving the quality of primary care Work with members and providers to pilot a range of new initiatives that will deliver new and innovative approaches to primary care access to address demand. Work with partner organisations to ensure the premises that are being used for primary care services have the capability and capacity to provide the best care possible in a modern environment. Harness the skills of other independent contractors and allied health professionals to support and complement those of General Practice in order to make best use of the varied workforce to deliver high quality care. A responsive, quality and accessible service that responds to different patient needs and preferences. Workforce development Coordinated Care Co-commissioning Integrated care Development of Primary Care Provider We will provide opportunities for primary care services to work in a collaborative way to increasingly offer services in the community. One example of this is the development of GP provider networks. The CCG will continue to work with partners across East London to build on the current a model of integrated care that looks at the whole person their physical health, mental health and social care needs. We will work with the neighbouring 3 CCG s partners to co-commission with NHS England a range of additional primary care services. We believe this will benefit patients and ensure services are not fragmented. Providing patientcentred, coordinated care.

P r i m a r y C a r e S t r a t e g y P a g e 17 11. ACTIVITIES TO IMPROVE PRIMARY CARE The CCG is committed to developing a proactive and personalised programme of care tailored to support the health and wellness of patients in the borough. To ensure we are delivering Proactive Care there are 3 key enablers 1) Self-care 2) Utilising technology 3) Patient involvement 1) Self-Care Improved knowledge about condition and treatment Increasing confidence in self-care Increased motivation to change behaviour Empowered patients Our vision for self-care is an empowered population equipped with the knowledge and motivation to self-care. A population with greater confidence to look after themselves, knowing when it s safe to self-care and when professional help is needed. We will aim to have services that support self-care, both enabling people to keep well, and to effectively manage their own health and wellbeing. This will be achieved by the following actions: The CCG will use opportunities around co-commissioning to work with community pharmacy and review the current use of the minor aliments scheme, to see how this service benefits patients or can be used differently to empower patients to self-care. We will work with our members and patient groups to develop new patient communication. This may be in the form of a leaflet, DVD or YouTube video. The purpose of this would be to ensure new patients coming in to the country are clear about what services are available and what they can expect from the service. We will also look at different ways of bring together primary care providers, general practice, community health services, pharmacy, dentistry, optometry, voluntary organisations and social care to improving health and wellbeing rather than working apart. The CCG will work jointly with public health to strengthen the links between healthcare providers, community and voluntary services to implement non-medical interventions often referred to as social prescribing We will identify a clinical lead for self-care who will work with the CCG to identify initiatives that will support patients to self-care. We will work with partner organisations to develop a communications programme designed to inform the public about primary care services available to the population and how to access them as easily as possible. This will be combined with self-care and healthy living advice and support on the social determinants of heath.

P r i m a r y C a r e S t r a t e g y P a g e 18 We will use the information gathered as part of the strategy consultation to ensure that all new initiatives are developed with vulnerable patients in mind. This will ensure that those that are more vulnerable in society including those that are deaf, hard of hearing, the elderly, those with learning disabilities and carers looking after a vulnerable person will benefit from new initiatives and not be disadvantaged in any way. We will implement a project around careers. The project aims to support and involve carers in their own health and the health of the people they care for. Waltham Forest has implemented a pilot programme of clinical health coaching, which has proved to be successful in the East Midlands. It helps patients to gain knowledge of their condition and provide them with confidence to manage their own condition by becoming an active participant in their care. The coaching is provided by telephone (telecoaching) by qualified registered nurses who have received programme specific training. Patients are called by the nurses and receive advice on following their care plan, taking their medication and adopting a healthy lifestyle. The Expert Patient Programme (EPP) is a peer led self-management programme, which builds support networks for patients. It allows patients to participate in a fixed six-week programme suitable for any long-term health condition and covers topics including healthy eating, exercise, pain management, relaxation, action planning and problem solving. The objectives of both Health Coaching and the Expert Patient Programme is to provide patients with the skills and knowledge to maintain their well-being effectively and provide them with practical solutions for the day-to-day problems of living with an LTC. It also looks to provide patients with skills to enable them to work with health professionals as an equal partner. The CCG will review the outcomes of the diabetes structured education and health coaching pilots and evaluate whether to continue or extend the programme. 2) Utilising technology New technology has enormous potential to improve systems and communications. If technology can be effectively utilised, it is expected that patient contacts conducted through a digital health environment will eventually exceed face-to-face contacts in the future. Nationally the GP contract changes that came into effect from April 2014 required practices to promote and offer patients the opportunity to book, view, amend and cancel appointments online; order repeat prescriptions and view a list of their repeat medicines or appliances. The changes also required practices to put plans in place by the end of September to ensure that by the 31 st March 2015 all patients can gain access to their medical records online. At the present time only a small proportion of practices are currently using technologies which enable patients to access the above. A key objective of this strategy is to ensure that all practices have the technology that enables them to meet the contract requirements and that practice staff are adequately trained to manage the system. Locally the CCG IT committee has recently developed a five year IT Strategy. The strategy focuses 5 objectives: 1. Modern IT systems for individual GP Practices, enabling them to be efficient and effective local healthcare providers

P r i m a r y C a r e S t r a t e g y P a g e 19 2. Connectedness across the local health economy to enable the integration of care, such that: a. patients get safer, more effective and more personalised care b. the right care can be provided in the right place at the right time because clinicians are able to view/update patient records as needed across organisational boundaries for the role they are there to fulfil c. GPs are able to have oversight and control of all care provided for their patients, because their IT allows them to view details of acute, community and mental healthcare provided beyond the practice and to plan and monitor managed care proactively 3. An IT foundation for GP Networks, enabling them to consistently and efficiently plan, deliver and account for care provided across multiple GP practices 4. A vehicle to analyse, benchmark and report on activity and outcomes across GP practices as a means for clinicians to improve quality in primary care, capturing the data needed with the lowest possible overhead 5. A confident user community (clinicians, managers, support staff), able to make best use of the IT they have to do a better job and thereby get better value from the CCG s continuing IT investment and patients that are confident to utilise the IT solution that are available to them to help manage their health and wellbeing. To ensure that the objectives of the strategy are met an IT implementation group has been set up. The role of the implementation group is to identify, take ownership of and carry out the actions. A list of action and timeframes that have been identified as part of the IT strategy can be found in appendix b. Along with these actions that CCG is also committed to working with our neighbouring CCG s and has developed some additional objectives; Support practices in registrations, repeat prescriptions and appointment booking online or through an app. Support and incentivise practices and networks to offer flexible consultations, online care and advice and telephone/video consultations. Ensure harmonisation of GP systems to enable collaborative working and improve urgent case and access out-of-hours. Help practices use new technology to offer bespoke care for patients particularly those with long term conditions. We will embrace digital technology to ensure patients are able to gain information as easily as possible about their health. The exact details of this will be worked up as part of the digitalisation strategy that is currently being developed. However it is anticipated that patients will be able use a range of technology including mobile phones to access and share information. When carrying out all of the above initiatives we will ensure that information governance is paramount. We will ensure there are clear agreements between NHS providers that are sharing information. We will ensure that patients are also clear about what information we are sharing about them and how and why we are doing this. 3) Patient Involvement Waltham Forest CCG recognises how important patient engagement and communications is to improve local health services. The CCGs vision is to put patients at the centre of everything that we do by using their experience to shape care pathways, improve service delivery and ensure value for money.

P r i m a r y C a r e S t r a t e g y P a g e 20 The CCG will be developing a primary care involvement strategy in 2014/2015; and fully utilise our patient engagement structures including a Patient Reference Group and a Rapid email group. Through these structures we have already involved a number of patients in developing our commissioning intentions and redesigning local services. The key objectives around patient involvement are: Develop a primary care involvement strategy, including a review of what engagement is currently taking place and Patient Participation Groups (PPGs). Implement a pilot of having patient experience machines in 10 practices. The machines will ask patients the Friends and Family test question, as well as some follow up questions on experience. Encourage optimal uptake of the friends and family test (FFT) in GP practices to ensure all patients views are heard. Ensure the outcomes of the FFT is reported to all PPG Ensure that PPG reports reference the outcomes of the FFT and practice actions. Ensuring the health system gets the best out of PPG s Propose targets to raise patient experience (using the bi-annual GP survey) The CCG is committed to providing a responsive, timely and accessible service that responds to the boroughs different patient preferences and access needs To ensure we are delivering Accessible Quality Care there are 4 key enablers 1) Improved Access 2) Fully utilised Estates 3) Improved quality of primary care 4) Workforce development 1) Improved access Strengthening primary care is key to the delivery of integrated care and has the potential to limit unscheduled admissions as well as reduce reliance upon accident and emergency, urgent care and out of hours services. We also know that GP practices are under increasing strain, with rising demand and poor workforce morale and in order to ensure general practice of the future is viewed as a positive career choice attracting high quality clinicians and staff, the way we work has to change. But most importantly we want to improve patient experience. The CCG recognises that the current model of 7 day primary care access delivered through a walk in service is unsustainable and does not meet the needs of much of our population. We will pilot, and evaluate alternative methods of 7 day access across the borough establishing three network based hubs to provide a consistent effective and accessible seven day primary care offer to all patients in Waltham Forest. The objectives from this work will be: The availability of seven day access to GP services within each of the three localities The development and agreement an overarching model of primary care that sets out the offer for patients which includes: Longer appointments where necessary Continuity of clinician where this is preferred