GP Forward View Operational Plan 2017-2019 Draft Narrative December 2016 Subject to final approvals
Chairman s Foreword In March 2015 we published our Primary Care Strategy, which alongside its accompanying action plan have defined our work programme over the past 18-months. Together they provide the foundations of this GP Forward View (GPFV) submission and enable delivery of our local health and care strategy and Sustainability and Transformation Plan (STP). In this, we hope you will see our vision, leadership and commitment to build vibrant, sustainable primary care at the heart of high quality, integrated health and care services for the people we serve. Dr Mark Shenton Chair, Ipswich and East Suffolk CCG 2
Contents Contents Page number Introduction 4 Foundations 6 Current Local Context 8 Future Core Programmes: 19 Care re-design 19 Access 23 Workforce 25 Infrastructure Estates and Digital 32 Investment 37 3
Introduction National and STP Context The GP Forward View, published by NHS England in April 2016, sets out the Government s investment and commitment to strengthen General Practice and support the sustainable transformation of primary care for the future. The paper identifies a number of actions required at a national and local level: Increased investment Addressing the workforce issues Dealing with workload - reducing practice burdens; helping to release time Improving infrastructure: primary care estate and technology Care redesign - changing the model of care with support to practices Since March 2016 health and care organisations in Suffolk and North East Essex have worked together to develop a vision and priorities for action for the next five years. Primary care plays a pivotal role in this shared vision. The primary care strategy, which Ipswich and east Suffolk CCG began developing in 2014 is entirely consistent with, and enables delivery of both the STP and national GP Forward View. 4
STP Context Vision and Objectives Our vision is that people across Suffolk and North East Essex live healthier, happier lives by having greater choice, control and responsibility for their health and wellbeing We will deliver this vision through three change programmes Over the next 5 years we will change the shape of health and care services within Suffolk & North East Essex. This will shift the centre of care away from hospitals into local communities as we support people to take control of their own health and wellbeing. This will not be easy to deliver, and we will need to work together in partnership with patients, members of the public, partner organisations and our regulators to ensure that we design safe and high quality services that are sustainable for the long term. 5
Foundations Clinical Leadership Ipswich and East Suffolk CCG s primary care strategy and plans have been developed with leadership from its 12 Clinical Executive Members and engagement with its wider GP member practices GP Clinical Leaders have engaged systematically with Consultant counterparts in care re-design over the past five years and increasingly in operational partnerships. This will evolve further in 2017-19 through the creation of One Clinical Community spanning primary, secondary including mental health and community services. This approach to local clinical leadership is nurtured and strengthened though a series of training and education events which are held between local GPs and consultants throughout the year. 6
Foundations Patient and Public Engagement Over the last 12-months we have developed a GP Practice Patient Participation Group (PPG) Network. The Network, chaired by our Lay Member for Patient and Public Involvement, has shared good practice and engaged on key issues including those core to the GPFV i.e. new staffing models within practice teams and practice collaboration. The Network has worked alongside our Community Engagement Partnership (CEP) and award-winning Youth Engagement and Health group (YEAH!) to help promote wellbeing, self-care and medicines management messages, which are integral to the 10 High Impact Actions. In 2017-19 we will continue and enhance this journey to ensure that primary care transformation is a collaborative endeavor that meets patients needs. 7
Current Local Context: Patients and Practices 40 practices work from 56 sites to serve 402,932 patients 26 practices hold PMS contracts and 14 hold GMS contracts Primary care currently provides higher than national average quality of service for most metrics. This is evidenced by: CQC reports (2 outstanding; 31 good; 2 require improvement; 2 awaiting reports; 4 to be inspected) QOF (96.9% compared to 95.3% England average); Patient experience (the majority of practices have scored above the England average for the six Timely Access to a Registered Health Professional indicators). All practices in Ipswich and East Suffolk are members of the Suffolk GP Federation and LMC The CCG has successfully operated a Co-Commissioning primary care model and, subject to sign off by NHS England, will move to a fully delegated model in April 2017 8
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Current Local Context Access An important element of GP access relates to GP extended access. Our position is quite strong. 31/40 practices achieved full provision of extended access (83.8%) compared to EoE average of 17.2% 10
Current Local Context Access GP+ is an extended primary care access hub based in Ipswich, funded by the second wave of Prime Minister s Challenge Fund pilots. Appointments are made via a patient s own GP practice. Referrals are also accepted from NHS 111, Out of Hours, the ambulance service and A&E. The Ipswich based service is operational each evening from 6:30 to 9:00pm and at weekends and bank holidays from 9:00am to 9:00pm. A service is also provided in Bury St Edmunds. The service is delivered by GPs and Nurses. 11
Current Local Context Workforce Number of practices within the boundaries of Ipswich and East Suffolk CCG Approximate number of patients served by the practices Number of full time equivalent GPs in the Primary Care workforce Number of patients per GP Number of full time equivalent nurses in the Primary Care workforce of which 47 are specialist or advanced nurse practitioners Number of patients per Nurse In common with many areas, the age profile of our workforce and the challenges of recruitment and retention present a major current and future issue. This is particularly acute 12 in Ipswich and therefore a priority of this plan.
Current Local Context Workforce GP Demographics in Ipswich and east Suffolk % of GPs aged under 35 % of GPs aged 36-53 % of GPs aged over 54 GP Demographics in England % of GPs aged under 35 % of GPs aged 36-53 % of GPs aged over 54 7% 24% 21% 18% 69% 61% 13
Current Local Context Primary Care Strategy Excellence and equity in outcomes, Empowered and enabled in delivery In the last half of 2014 and early 2015, the CCG engaged with member practices and partners to develop our primary care strategy, which was approved by our Governing Body in March 2015. A link to the full document can be found here: Primary Care Strategy Our vision for primary care in Ipswich and East Suffolk can be described simply; safe, local, high quality care that is delivered by local practices and other organisations working together seamlessly to care for patients effectively and at a sufficient scale to facilitate the provision of an enhanced range of services. 14
Current Local Context Primary Care Strategy Objectives Our strategy has nine objectives: 1. To enable GPs to have time to care ; diagnose and manage risk most effectively 2. To support and enable patients to practice self care including with the increased use of technology 3. To provide continuity of care (not always continuity of professional) 4. To deliver prevention programmes effectively 5. To extend the system leadership role across the extended community team 6. To increase the pace of transition of care from a secondary to primary care setting with appropriate transfers of resources 7. To facilitate GPs to manage patients who are acutely ill and oversee the care of patients with long term conditions but with much of the care being delivered by the wider team 8. To plan that all services are provided in a primary care setting unless they must be provided in another setting for safety or other reasons 9. To facilitate practices working in groups or on a locality basis 15
Current Local Context Primary Care Strategy: Levels of Care Our strategy identifies three levels of care: 1. Personal care at a practice level 2. Provision of care that requires a larger, locality, population to be sustainable/cost effective 3. Delivery and management of care that is patch (CCG) wide for example urgent care, OOHs 16
Current Local Context Health and Care Re-design The CCG s primary care strategy is one key element of its wider Suffolk Health and Care Review Strategy, also published in 2015, which now fits within our STP. The key features of this are: An increased focus on prevention and well being Development of a hub based approach for the delivery of integrated health and care services within a local community with primary care at its heart 17
Current Local Context System links A number of admission avoidance services are accessible to primary care: The Crisis Action Team (CAT) A 24/7, multi-agency health, social care and voluntary sector admission avoidance service, which can be accessed through a dedicated 24/7 phone line; The Frailty Assessment Base (FAB) Located within the local hospital, FAB provides multidisciplinary advice and assessment for frail older people The Admission Prevention Service (APS) A community service available for medically stable patients requiring nursing interventions or functional assessment in the event of a health crisis. Interventions can include administration of IV antibiotics, subcutaneous infusions, anti-coagulant management (including the administration of oral Vitamin K), monitoring of unstable INR, first catheterisations following medical assessment, the co-ordination of integrated packages of care and referral to specialist service. APS is available 24/7 and accessed via the Care Coordination Centre. 18
Future: Care Re-design New Models of Care Primary Care at Scale The CCG is working with practices and partners to facilitate primary care at scale. At present, four groupings are developing: 1. Suffolk Primary Care - initially to be made up of 14 GP practices in Suffolk with a combined total of 112,641 registered patients 2. A Deben Health Group collaboration 3. An @Ipswich practice grouping 4. A rural network The CCG is investing its own resources to match those of practices in the development of these new collaborations. The CCG may also commission some Local Enhanced Services at a scale of 30,000+ populations to facilitate the delivery of national and local strategy 19
Future Care Re-design New models of care The NHS in Suffolk is ambitious about how it wants services to be delivered seamlessly. Primary care at scale and within localities is central to the development of Integrated Neighbourhood Teams, operating out of local hubs. The CCG is working with the local acute hospital to develop One Clinical Community. Over GPs and consultants have been attending workshops to facilitate a transition from pathway based liaison to one aligned clinical team. The CCG is currently pursuing an Alliance Contract for all community services, with mental health and social care. The local partnership will enable this integrated working. A Multi-speciality Community Provider model and contract could supplement and complement this. Suffolk GP Federation has appointed a New Models of Care Director and is in the process of appointing a Workforce Director to support the development of this work The CCG is also working to improve the coordination of 111, Out of Hours (OOHs) and urgent care services through the procurement of these services using a new service specification. 20
Future Implementing the 10 High Impact Actions: Summary Action Summary 1 Active signposting The CCG has invested in Map of Medicine to provide access for the whole clinical team to care pathways including pre-referral guidance, patient information and resource packs for LTC management as well as Wellbeing and Prevention services. A growing number of practices are pursuing supported triage systems directly to pharmacists, physiotherapists and mental health workers. Live web-based advice and guidance tools, e.g. VirtTuri and GP advice text message tools are also being piloted. 2 New consultation types Most practices are already providing telephone consultations as an alternative to face to face. This is being further developed and supported. 3 Reduce DNAs This is a focus of work in 2017 following preliminary discussions with both a sample of practices and our PPG Network. 4 Develop the team Our full set of actions is detailed in the Future Workforce Section 5 Productive workflows Individual practices currently undertake workflow analysis to match demand and capacity. This will be further evolved through the emerging local practice hub and collaboration models. The DHG locality is developing a centralised telephone system, supported by EETF. 21
Implementing the 10 High Impact Actions: Summary Action Summary 6 Personal productivity Our action is further detailed in the Workforce Section 7 Partnership working Our action is detailed in the New Models of Care section 8 Social prescribing The CCG and practices work with a diverse network of voluntary sector organisations to provide access to supplementary services. The CCG is working with Waveney and Suffolk Coastal District Council and Leiston GP Practice to develop a major social prescribing initiative and funding bid to DCLG. This will be fully evaluated and other initiatives will be developed. 9 Support self care This is a major STP and local CCG priority. The CCG will build on its award winning patient and public communication and engagement campaigns and partnerships with County Council and provider partners over the next 12-months. 10 Develop Quality Improvement expertise This is a focus of the CCG s training and education programme, engaging primary and secondary care. The CCG is also working with EASHN on a range of quality improvement programmes to support delivery of STP and local transformation objectives. 22
Future: Improving Access GP Access Fund In 2017, in addition to the current hubs in Ipswich and Bury St Edmunds, further hubs will be opened in Felixstowe, Stowmarket and Saxmundham (co-located with Out Of Hours bases) (see map). The bases outside of Ipswich will have a presence each evening and weekend. 50% of the appointments will be available at the Ipswich base. From November 2016, GP+ will provide an additional 30 minutes per 1,000 population, which equates to an extra 201 hours per week. This will rise to 45minutes per 1,000 population from 1 January 2017, equating to an extra 302 hours per week. This additional activity will be delivered utilising the recurrent 6 per head to be provided to the CCG from April 2017. This meets the national requirements set out by NHS England. It will provide 100% access to all of our population. It is planned to review other access needs, for example in hours provision, in 2017. This will inform future planning. On the day hubs are being explored as a potential answer to the inhours demand. The utilisation of national measurement tool will be implemented from April 2017. The service will be continued with the existing provider in 2017/18. The trajectories relating to this service will be provided in the return that will accompany the final draft of this plan in February 2017. 23
24 Future Improving Access: new GP+ Hubs
Future Workforce: GPs The retention of existing staff and the recruitment of new staff is one of the most significant challenges facing primary care nationally as well as within Suffolk. We will work with partners across the health and care sectors including Health Education East, our national and local statutory and provider partners, professional and academic bodies and practices to retain and develop existing excellent talent and to facilitate recruitment to new roles and career opportunities. Our recent workforce submission can be found HERE For GPs, plans will build on current action and include: Continuous improvement in the training programme and promotion of Ipswich and East Suffolk s opportunities Retention programmes for GPs aged 55plus Return to practice schemes Fellowship and Leadership programmes Portfolio career opportunities The schemes operated currently operated by Suffolk GP Federation including: Suffolk GP Portfolio; Recently Qualified Dr programme; GP Fellowship Programme; Younger GP Development Programme; and Pre-retirement Support Programme, can be found here: http://suffolkfed.org.uk/vacancies-2/careerdevelopment/ 25
Future Workforce: New Roles In 2015, the CCG in partnership with Suffolk GP Federation submitted a bid to Health Education East of England (HEE) to become a pilot site for a Community Education Provider Network (CEPN). The CEPN project is bringing primary and community care services and education providers together to focus on education and workforce planning to support primary care. The key deliverables are: to pilot the hub and spoke model for student placements within Suffolk; to increase mentorship capacity to increase pre-registered nursing placements in Primary Care; to upskill the existing primary care workforce to explore ways to introduce the roles of clinical/pharmacists and paramedics in Primary Care; to raise awareness of careers in Primary Care. 26
Future Workforce key CEPN initiatives Pre-registration student nurse placements: Hub and spoke placements will take place from January 2017 in Ipswich and East Suffolk. Upskilling Existing Workforce: Working with University of Suffolk the CEPN will create a Training Needs Analysis for Primary Care in Suffolk to enable workforce planning and us to be more strategic about the workshops we deliver for staff including; Mental Health Awareness Training, Phlebotomy Training and Senior Receptionist Training; Clinical Administrator development. Introducing the roles of clinical/pharmacists and paramedics in Primary Care: Case Study Pharmacists working in practices In an Ipswich GP practice, the practice pharmacist assists with medication-related patient queries and to hold face-toface clinics. The pharmacist reviews the practice case load and select the patients who they are able to help. They contact the patient and help resolve their query. This supports safe and appropriate medication use by the patient, promotes self-care of minor ailments and frees up GP time to deal with other patients. Raising Awareness of Primary Care Careers: Step into the NHS careers events and work experience opportunities will be further progressed. Health Ambassadors will be supporting us to raise awareness of careers in Primary Care. 27
Future Workforce key CEPN initiatives Communication and Engagement with practices is being further developed with a webpage for CEPN on both CCG websites; quarterly e-newsletter for practices; the work of the CEPN will continue to be promoted through Practice Managers forums and newsletters as well as through our representatives from Primary Care who are on the steering group. UCS Centre for Integrated Primary Care: University Campus Suffolk (UCS) is developing a Centre for Integrated Primary Care that will link into a number of the Community Education Provider Network workstreams. Apprenticeships: The CCG continues to use Apprenticeships to upskill the nonregistered workforce in primary care and the wider health and social care system. The Apprenticeship Coordinator works closely with practices to support them in recruiting apprentices and to upskill existing staff using a number of apprenticeship frameworks including; Business Administration, Business Administration (Medical Administration pathway), Clinical Healthcare Support, ILM Level 4 and 5 Management, Pharmacy services. The Apprenticeship Coordinator works with a number of health and social care organisations across Suffolk to deliver a rotational apprenticeship programme. A cohort of apprentices will complete their placements in Autumn 2017. 28
Future Workforce Training for care navigators and medical assistants The CCG will be working with the Suffolk GP Federation through the Ipswich and East Suffolk Community Education Provider Network to expand their existing Medical Assistants pilot. Suffolk GP Federation have developed their own training scheme to introduce this role into primary care. The CEPN will be working collaboratively with the Federation to roll out the pilot across the 4 localities. The Medical Assistants pilot will highlight a reduction in GP workload thus increasing practice buy in, allowing this work to be expanded further across the localities and STP footprint. The expected outcomes include: Active signposting reduces the number of non urgent appointments in practices. Increase in staff morale Reduction in recruitment and retention challenges Proven increase in patient satisfaction through family and friends test. Ipswich and East Suffolk CEPN has already delivered workshops for receptionist staff to support them to signpost patients to relevant services as well as supporting the development of their resilience and communication skills. Ipswich and East Suffolk CEPN will continue and evolve this training for care navigators in 2017. 29
Future Infrastructure Estates The CCG has a well-developed Strategic Estates Plan with the objective to ensure that the estate is planned to meet future needs, both in terms of population growth and also the additional services that can be moved from a secondary care setting as set out in our STP. Some estate must also be modernised to ensure delivery of safe, high quality patient services. The CCG is utilising ETTF funding and other innovative approaches to the provision of new estate to enable the development of primary care at scale and the development of hubs. Services will be wrapped around these hubs through our Integrated Neighbourhood Teams, with the local hub practice/s acting as the cornerstone of the Team. The purpose of the hubs is to transform the way health is provided in Ipswich and rural Suffolk. The hubs would not only provide the core GP practice services in an efficient way but would allow for the increase in services offered including diagnostics, outpatients and community services which would facilitate the transfer of some patient activity from hospitals to a more local setting. This approach would be complemented by wrapping services around the practices, for example social care, community services and increased engagement with the voluntary sector. 30
Future Ipswich Hubs Map The CCG with the Ipswich practices have identified 5 potential hubs where practices will be co-located. This will create efficiencies, support collaborate working at scale and creates a level of practice resilience. Current GP Practice surgery sites 31
Future Infrastructure - Estates The CCG has been working closely with Ipswich Borough Council (IBC) to develop these plans further. IBC has offered, as landowners and the local planning authority, to be property developer and landlord for the Ipswich developments. This is further supported by funding from the Estates and Transformation Fund The CCG is also working with non-ipswich practices; practices have identified potential rural hub locations but the progression of these plans is proving more challenging given their geography and location relative to each other. The CCG is working with NHS England and NHS Property Services to fully understand the revenue impact of the estates plan. It is anticipated that there will be additional revenue consequences as a result of the hubs but reduced system costs overall including a reduction in acute unplanned and planned admissions, and a transfer of out-patient and diagnostic activity from the hospital setting 32
Future Infrastructure Digital Road Map The CCG s Digital Road Map will be published in January 2017. In line with our Digital Roadmap and GP IT Programme, as opportunities present to rapidly deploy technologies that meet our strategy, these will be factored into the on-going plans. All GP IT initiatives are coordinated alongside the rest of the STP footprint under the guidance of the Digital Roadmap, associated governance, and wider connections beyond our footprint. A summary of the key elements are provided on the next 2 slides link goes here 33
Future Infrastructure Digital Road Map 34
Future Infrastructure Digital Road Map Our STP Digital Roadmap includes: 1. A detailed plan so that we have the mechanisms in place to share high-risk and critical information for people when they need it most, and with their consent 2. A strategic plan to shift the way the NHS and social care operate. It will mean we can implement new ways of working so that people get access to care differently. Staff will need the technology and skills to use them so they can focus on quality of care. 3. Ways to connect health and social care workers with the wider public sector, e.g. police, housing and beyond Our Digital Roadmap Outcomes are: Digital Inclusion Enabling and empowering patients and citizens to interact with health and care services digitally Digital Workforce Enabling and empowering our workforce to bring digital capability into the heart of transformation and services Information Sharing Delivering shared care records and enabling paper free services iphwbi3 Ensuring that anonymised information is available where required to inform decisions and improve care outcomes Infrastructure Ensuring that our infrastructure is fit for purpose, achieves value for money and effectively underpins our digital strategy Investment Coordination of all associated portfolio activity around resources, investment and benefits Governance Coordination of the pan-footprint governance required to deliver our Digital Roadmap 35
Future: Improving Access Digital approaches Of greatest priority has been the need for practices to have fit for purpose infrastructure and IT Services to enable the necessary Transformational change. Core IT Services are being transitioned to a new provider, with appropriate levels of service and resilience. Investments into addressing poor connectivity across the CCG continue, in line with the emerging Health and Social Care Network Programme. IT Service transition will be completed in 2017/18. In addition, the CCG has secured ETTF funds to evaluate multiple technologies and their application across the CCG to improve access. The findings of these evaluations will factor into the wide scale deployment from 2017 onwards. The CCG, working with its member practices, has selected two products to evaluate; both are designed to reduce the non-value added activity currently undertaken by a GP (therefore releasing time to care). We are evaluating each products fit into the environment (urban vs rural for example). The technologies to be evaluated include: AskMyGp, which enables a patient to submit requests 24/7 and history econsult, which provides decision support to a patient, and signposts them to appropriate services 24/7 From 2017-19 progress will be made around enabling Wi-Fi and alternate media for consultations. 36
Future Investment National requirement Increase general practice funding by at least the % increase in core CCG allocation, to fund core contract changes 3 per head non-recurrent transformation to stimulate development of at scale providers, implementation of ten high impact actions and secure sustainability Local action and target outcomes over two year period The CCG has sought clarity from NHS England on the source of this funding and will detail local action, pending a response. The indicative purposes for which this funding will be invested are as follows (but subject, at this point, to wider discussions within the CCG and approval by the Commissioning Governance Committee): 200,000 to support practices to work at scale 600,000 to support the roll-out of the 10 high impact changes 400,000 to assist practices that need additional support. Local investment sum Assuming the primary care funding allocation is 53,813,000, a 1.7% uplift would equate to 914,821. 0.4m in 2017/18 0.8m in 2018/19 1.2m total over 2 years based on a population of 400,000 37
38 Future Investment National requirement Invest in on-line GP consultation software as per national specification Fund training for care navigators and medical assistants for all practices in line with national specification NHSE to invest and manage Practice Resilience Fund ( 8million national pot) Local action and target outcomes over two year period TBC awaiting national guidance TBC The CCG recognises that some local practices are encountering significant service and operational pressures due to increased demand and reduced clinical capacity as a result of staffing (particular GPs) and other pressures. The CCG will continue to support practices to access the Practice Resilience Programme. The CCG, working with local practices was successful in a bid to the Vulnerable Practices Fund for an Ipswich wide set of solutions to the issues facing primary care in Ipswich. The amount of funding was 249,000. The CCG has adopted a very proactive approach to identifying and addressing practice resilience issues, working closely with colleagues from NHS England Local investment sum TBC awaiting national guidance TBC NHS England on a case by case basis
Future Investment National requirement Commission additional access at 6per weighted patient NHSE to invest, and CCG to support implementation of Estates and Technology Transformation Fund Local action and target outcomes over two year period Local investment sum As detailed above 2.4m 2017/18 The CCG has put in place a project management arrangements to enable these projects to proceed, working with the practices concerned. The CCGs are leading the more complex schemes. The business case for each estates bid will be presented to the Governing Body for approval of the revenue consequences. In some cases these revenue consequences are being mitigated through a novel partnership with Ipswich Borough Council. 39
Future Other Investment National requirement Local action and target outcomes Local investment sum General practice resilience programme Estates and Technology Transformation Fund GPIT See slides above See slides above The increase in GP IT funding has been aligned to the increase in services required by GP IT as set out in the Operating Model See slides above See slides above Public health services (section 7A) TBC with Suffolk County Council Mental health therapists Bids against national funding being prepared for submission in January 2017 To be determined through bid preparation process. 40
Conclusion General practice in Ipswich and East Suffolk is well placed to continue to develop and take advantage of the opportunities available through the GP FV. The local developments of primary care at scale, taken with the alliance contract and the potential of a local MCP and Vanguard bid will mean that local GPs and partner organisations can continue to deliver high quality care and continue to innovate and respond to the needs of local people. 41