Hillingdon Primary Care Strategy General Practice Services October 2017 Version 16.0

Hillingdon Primary Care Strategy General Practice Services 2017-21 October 2017 Version 16.0

Purpose of the Strategy General Practice is one of the key providers of primary care in Hillingdon that underpinning the whole system of care. This Strategy aims to describe how General Practice will be supported to achieve key objectives working in the wider context of community based services. Therefore the objectives of producing the strategy are as follows: To Bring together national, regional and local strategies relevant to general practice in one document To describe the vision for the future of general practice and primary care in general To drive progress against the Hillingdon Sustainability and Transformation Plan from a primary care perspective to improve health outcomes and the experience of care for the population of Hillingdon To maximise the opportunities generated by level 3 delegation of commissioning responsibilities for primary medical services To ensure that the system as a whole is sustainable in the future To promote integrated care moving towards accountable care While the focus of this strategy is general practice and its role in the care system, it is acknowledged that a more comprehensive strategy incorporating community based and out of hospital services may be required in future 2

Strategy at a glance Drivers Objectives Investment Enablers Priorities Demographics: Population growth in certain areas of borough Health inequalities, e.g., life expectancy Workforce: Increasing workload Lower than average number of GPs Significant population close to retirement Estates and infrastructure Limited estate and facilities in need of maintenance Digitalisation Policy: GP Forward View and STP Plan Local factors: Level three cocommissioning Managing the health of a population by working in partnership with others to prevent ill-health Delivering care to manage increasingly complex chronic disease in a community setting Support patients to access high quality services, drawing on new approaches and technologies Addressing current pressures and creating a sustainable primary care sector GP Forward view investment growth headroom through level three commissioning in 17/18 and in 18/19 Team of three primary care commissioning managers for Hillingdon CCG to support delegated commissioning activity Investment in premises and infrastructure via Estates and Technology Transformation Fund HEE and CPEN funding streams GP Confederation and locality structure Fully delegated (level three) cocommissioning Accountable care Provider and workforce development Manage and develop provider landscape Commission outcome based contracts at appropriate levels Commission proactive and co-ordinated care, especially for people with LTCs, multimorbidities and complex needs Enable better, appropriate access to to general practice Focus on recruitment, retention, and develop additional capacity and broader skill mix to meet growth in demand Commission preventative care programmes focused on local needs, integrated with partners 3

Introduction-The Strategic context Nine priorities of the North West London STP The local STP states that North West London will look to: In October 2016, Hillingdon CCG set out its plans for the next five years as part of the North West London Sustainability and Transformation Plan (STP) and the local Hillingdon chapter that accompanied it. The plan set out nine priorities to meet the three gaps articulated in the Five Year Forward View: Health and Wellbeing Care and Quality Productivity and closing the financial gap In order to achieve this aim, the STP emphasised the importance of the transformation of general practice, with consistent services to the whole population ensuring proactive, co-ordinated and accessible care, saying that we will deliver this through primary care operating at scale through networks, federations of practices or superpractices, working with partners to deliver integrated care. 1. Support people who are mainly healthy to stay mentally and physically well, enabling and empowering them to make healthy choices and look after themselves 2. Improve children s mental and physical health and well-being 3. Reduce health inequalities and disparity in outcomes for the top 3 killers: cancer, heart diseases and respiratory illness 4. Reduce social isolation 5. Reducing unwarranted variation in the management of long term conditions diabetes, cardio vascular disease and respiratory disease 6. Ensure people access the right care in the right place at the right time 7. Improve the overall quality of care for people in their last phase of life and enabling them to die in their place of choice 8. Reduce the gap in life expectancy between adults with serious and long term mental health needs and the rest of the population 9. Improve consistency in patient outcomes and experience regardless of the day of the week that services are accessed For a compendium of strategies see appendix A For the Profile of Hillingdon See appendix B STP Delivery areas DA 1 Radically upgrading prevention and wellbeing DA 2 Eliminating unwarranted variation and improving LTC management DA 3 Achieving better outcomes and experiences for older people DA 4 Improving outcomes for children ) &adults with mental health needs DA 5 Ensuring we have safe, high quality sustainable acute services 4

Finances: investment Source of funding Value New money? Practice Transformational Support i.e. 3 per head of CCG allocation investment in general practice 942K over 2 years (17/18 and 18/19) (estimated) PMS premium [to be confirmed] c. 900K No. Primary Medical budgets growth headroom available for new investment 1.2M (17/18) and TBA (18/19) but based on growth of 4.7% overall* Local Incentive Scheme (LIS) and Local Enhanced Services (LES) 2,396,000 (17/18) No Integrated Care Programme (ICP) funding 1,515,000 (transferring to ACP) No Resilience funding 139,743 (16/17); estimated 39K for 17/18 GP Extended access Fund 544,446 (based on 1 April 17 population) GPFV: Training care navigators and medical assistants for practices 53,971 (17/18) and 54,362 (18/19) Yes No Yes Yes Yes GPFV: Online general practice consultations software(working across NW London) 80,957 (17/18) and 108,725 (18/19) Yes *Projected Primary Care medical budgets in North West London (TBC) 2018/19 Allocation '000 5 2019/20 Allocation '000 2020/21 Allocation '000 2016/17 2017/18 P Care Med Alloc & Growth Allocation '000 Allocation '000 Growth Growth Growth Growth NHS Brent CCG 42,618 46,687 9.55% 48,571 4.04% 50,247 3.45% 52,386 4.26% NHS Ealing CCG 48,192 53,017 10.01% 55,261 4.23% 57,252 3.60% 59,958 4.73% NHS Hounslow CCG 35,250 37,859 7.40% 39,511 4.36% 41,184 4.23% 43,569 5.79% NHS Hammersmith and Fulham CCG 24,869 27,245 9.55% 28,812 5.75% 29,977 4.04% 31,111 3.78% NHS Harrow CCG 29,840 30,824 3.30% 31,890 3.46% 33,238 4.23% 35,128 5.69% NHS Hillingdon CCG 35,274 38,470 9.06% 40,281 4.71% 42,040 4.37% 44,548 5.97% NHS West London (K&C & QPP) CCG 36,301 36,708 1.12% 37,256 1.49% 38,050 2.13% 39,510 3.84% NHS Central London (Westminster) CCG 27,629 28,451 2.98% 29,446 3.50% 30,515 3.63% 31,857 4.40% Source: NHS England projections-dec 2016

Delegated Commissioning (level three) Opportunities To enable strategic investment in primary care that encompasses the totality of resources available To bring together sometimes disparate commissioning work streams and initiatives to plan in a more coherent way (for instance, the strategic commissioning of the GP Confederation and Hillingdon ACP) To draw on local leadership and expertise to commission primary care in a way that addresses local health needs and has the greatest scope for influencing health and system outcomes in the borough To design and commission outcome based local contracts that reduce reporting requirements and promotes service integration Risks Additional funding to primary care places other commissioned services under pressure That resources delegated (both commissioning resource and commissioning budget) is transferred at a lower level than NHSE currently deploy Insufficient capacity to manage commissioning and contracting That there is increased exposure to conflicts of interest (real or perceived) That accountability to public around the commissioning of general practice requires significant resource to ensure transparency That relationship between CCG and practices is damaged where difficult decisions have to be made Actions to achieve these Engage with a wide range of stakeholders including Healthwatch and the local authority on the content of this strategy to create a joint local vision for primary care Continue to engage wider CCG to commission in a coherent way Hold a series of workshops with the federation / CCG members to review national and local scheme Support the GP Confederation as part of the Hillingdon ACP to deliver whole-population, outcome-based contracts Develop primary care framework to provide a wrap around contract that will strengthen primary care Mitigation Apply rigour to the process for integrating the NHSE team Agree governance (including Chinese walls) to manage relationships with CCG and practices / GP Confederation Engage with the public and Healthwatch about commissioning plans for primary care (including this strategy) Continue strategic conversations with the full range of partner organisations in line with the spirit of the STP and the local ACP to help ensure that resources are shifted into the community from the hospital setting in a managed and safe way Increase capacity and training in the primary care team 6

Involving Patients and carers Patient engagement and involvement The involvement of patients is essential in the process of setting priorities, service re-design and implementation of service transformation and change in primary care, however, we run the risk of dis-engaging our patients if we do not take two fundamental approaches to participation and involvement: 1. Engagement/Participation needs to be joined up people are tired of being asked over and over again about how they feel about a service or what they want in a service. Worse yet, when they engage and never hear back from those asking the questions 2. Many people first need to benefit from a better understanding of their own health condition, or that of the person they care for, before they can fully engage and lend over their patient/carer experiences As a result, our approach to involvement and engagement has matured over the years enabling more patient and carers than ever before to input to the local NHS landscape. This strategy promises to continue with this approach. Engagement and Involvement will take many guises; it will be tailored to support the needs of core business, but in a way that offers transparency and real co-production to breathe. We will not refer to people and patients as Seldom Heard or Hard to Reach we will instead collaborate with partners and the voluntary sector and our own tried and tested outreach model to include everyone. Self-management Self-management is the term given to a range of approaches that aim to enable people living with long term conditions to manage their own health effectively. Self-management recognises individuals as experts in their own lives, having acquired the skills and knowledge to cope as best they can with their long term condition. Self-management approaches, such as peer support or self-management education, seek to build on this by supporting and enabling people to further develop their skills, knowledge and confidence. By recognising patients as experts in their own health and by providing support to develop understanding and confidence, self-management leads to improved health outcomes, improved patient experience, reductions in unplanned hospital admissions and improved adherence to treatment and medication In Hillingdon the MyHealth programme provides a range of resources and educational activities for patients with long-term conditions and we will encourage GPs to refer to them as well as inviting patients to self-refer http://www.myhealthhillingdon.nhs.uk/ Personalised care and support planning in primary care Care plans are central to the effective care of people with long term conditions including those with multi-morbidity in primary care. Personalised care and support planning uses what matters to the individual as the starting point, involving the whole practice team and focusing on creating a single process, the practice has created a more effective and efficient approach to care planning in which staff are enthusiastic and patients feel listened to and supported. Patients are then empowered to take responsibility and control over the management of their conditions. The House of Care framework provides a useful view of person-centred and collaborative care as well as the elements that need to wrap around this process of care 7

Detailed Objectives Relevant SCF domains Primary Care Ambitions Primary care commissioning objectives 1. Delivering care to manage increasingly complex chronic disease in a community setting 2. Managing the health of a population by working in partnership with others to prevent ill-health 3. Support patients with urgent need to access high quality services, including self care, drawing on new approaches and technologies 4. Addressing current pressures and creating a sustainable primary care sector Coordinated Proactive Accessible Encourage and support general practices to work in localities Develop the GP Confederation to drive up standards as a whole and tackle unwarranted variation Ensure that all of the Hillingdon population has access to the full range of GP services Commission wholepopulation care through the Accountable Care Partnership Draw on local initiatives such as My Health to support patients to better manage their long term conditions Commission new or improved services in areas of persistent poor provision or anticipated future need Strengthen links with the local authority to improve the integration of primary care and social care, including care homes and home care Support the voluntary sector to continue to work in an integrated way, e.g. through Hillingdon 4 All Implement or support a wide range of public health initiatives to support people of all ages to stay healthy Work with health, education and social care to commission integrated prevention services Support increase in clinical capacity via the introduction of new roles and functions and systems Develop extended access hubs and other hub services Support sign-posting, care navigation and re-design the role of reception as a way to engage with patients Implement technological solutions to provide patients with information they need Enable patient digital access Implement the Patient Activation Measure (PAM) as a way of supporting people in a patient-centred way, Commission enhanced services from high street pharmacies Increase the proportion of NHS spending on primary care services from 7% in 16/17 to 11% in 20/21 Develop GP premises Increase the primary care workforce in Hillingdon focusing on the broader skills mix of the team and working closely with Health Education England by: GPs: 40 FTEs Nurses: 55 placements Substantial increase in other clinical roles Reduce the number of GP practices that require improvement or inadequate from 16.7% (March, 17) to 5% in 20/21 For more information see appendix C 8

Primary Care framework Services Definition: Vehicle to implement new models of care. It includes general practice and services that need to be wrapped around general practice, e.g. aligned community services, out of hospital services, voluntary services etc. These non-core services will attract investment from primary care growth headroom as well as core CCG funding Key priorities Supporting vulnerable patients (e.g. Care homes, mental health Long-term Conditions and Multimorbidities Improving access (including extended hours and core hours access Bringing services out of hospital Key Drivers GP Confederation/Local networks Primary care hubs Integrated EMIS hubs enabling record sharing Rigorous coding Primary Care Contracts Unified, outcomes based wrapped around contract Contracting models for services depending on scale including transition away from counting activity to outcome based contracts (less bureaucracy) Examples of services within the framework: 2017-18 GP Practice Primary Care Contract Diabetes End of Life Luteinising hormone releasing Post-operative wound DMARDS Commissioning Contract Latent TB To be mobilised in 17/18 Extended Access hubs 24 hours bood pressure monitoring Atrial Fillibration audit Prostrate cancer monitoring Increasing clinical capacity/access contract New commissioning intentions for 18/19 and beyond Multimorbidities clinics (pilots in 17/18) Mental health GP care homes visiting service (piloted in 17/18) Asthma and COPD detection Paediatric Integrated Clinics (piloted in 17/18) Anticoagulation clinics Clinical pharmacists (Pilot 17/18) 9

Increasing capacity to meet future Other service improvements include: The population of Uxbridge North is expected to increase by nearly 40% over the next 10 years. This is largely due to significant building developments such as St Andrews which is expected to put significant pressure on current services. The CCG aims to commission additional primary care capacity through the new primary care hub to meet the anticipated increase in demand, through the final site is still to be confirmed. Reprocurement of Hesa Centre (APMS) Heathrow Medical Centre is building three additional consulting rooms Significant increase in capacity at Otterfield Health Centre Options being reviewed for Kirk House as replacement from 2019 of current Yiewsley site which is too small to support future service demand Significant development is also happening in Yiewsley / West Drayton, for instance the West Drayton Garden Village. The CCG aims to build additional capacity in this area The population around Harlington is expected to increase by 12% over the next 10 years. The CCG will look to ensure this area has sufficient capacity, which could include an additional practice site in this area for instance to improve access and reduce health inequalities. 10

Delivering care at scale through hubs Primary care hubs Plans relating to primary care hubs to date have been set out in the Strategic Service Delivery Plan (SSDP) The SSDP identifies a need to fully utilise the existing estate and effectively target strategic investment in new estate to meet forecast demand for OoH, with estate transformation priorities as follows: Finding a home for additional out of hospital activity and integrating services where possible Moving GPs providing high quality services into high quality premises Managing the impact of moving or dispersing patient lists belonging to GP practices currently delivering poor quality service Demonstrating the benefits of co-location to whole-systems integrated care The planning assumptions used suggest a total floor area of between 2,700 and 3,600 m2 is required as illustrated by locality to (figure on right), with a pipeline for investment and service identified for 60 treatment rooms across the borough Three hubs are being planned in Hillingdon, one for each locality in the borough It is expected that primary care hubs will be co-located with extended hours hubs to ensure that capacity, demand and economies of scale are closely matched Co-location of services, including with social care and voluntary sector services, will be promoted as much as possible Enhanced diagnostic facilities will facilitate better diagnosis in the community A superhub will connect patient into the primary care hubs or their own practices directly from the 111 service Some services may be provided virtually from the hub, for instance telephone triage, remote consultations or back office functions Distribution of hubs will be reviewed, particularly in light of NHSE guidance suggested that hubs have a population catchment of around 30-50k population, which would broadly translate to two hubs per locality rather than one Source: Hillingdon CCG SSDP 11

NHS NW London Local Digital Roadmap Hillingdon CCG - Digital Strategy Primary Care - GP systems: 100% adoption of EMIS Web and DocMan across all HCCG practices, integrated with ICE for diagnostics HCCG/NHSE invested in IT for mobile GP working (e.g. in care homes and visiting service) Not clear whether DocMan can support federated document sharing across practices HCCG to investigate technical options Key is standardisation: HCCG driving standard clinical coding and templates. Opportunity for innovation using technology, e.g. replace N3 tokens for mobile EMIS will migrate EMIS Web from Read to SNOMED CT codes (under GPSoC) HCCG awaiting details from EMIS Plan HCCG project when known Pathway decision support: under review, but cost of decision support systems probably not justified by the reduction in unnecessary referrals Care Planning: currently use EMIS doc templates, new EMIS module awaited -Evaluate module when available Main issue: current model for functional support/training of practices HCCG/PMs to review options, e.g. NWL s EMIS GP support team Primary Care IT infrastructure & support: Current in-house support by HCCG team viewed as high quality and good value N3 network bandwidth under pressure; NHSE cost model for its replacement (HSCN) will introduce new pressures Analyse impact HCCG has invested in cyber security - held up well during recent virus attacks but constant challenges, and security investment must be ongoing Cost pressures on GP IT Support budget; HCCG s capital funding from NHSE historically high but currently low; e.g. NHSE wi-fi funding GP Confederation may require new infrastructure e.g. integrated telephony across practices and Hub, linked to EMIS Web-consider funding implications Primary Care Strategy: GP Confederation: extended services for OOH, paeds, RBP, etc. ISA in place; EMIS sharing (Remote Consultation module) works, but implementation by Confederation not yet complete and does not link to DocMan, ICE, e-rs; Virtual practice sharing model can be used for many shared services, e.g. GP visiting/care homes, end of life care Federation approach requires standardisation of EMIS Web use across practices and administrator resource Online Patient Access: 19% of HCCG patients registered (appts/scripts), national average 20% - but variable usage (very few practices sharing detailed records) Virtual e-consultations: to be piloted with Babylon in NWL, with one pilot HCCG practice in 2017-18 Patient Activation: PAM reporting tool to be implemented by NWL as part of STP DA2 (variation in LTCs) in 2017-18 Business Intelligence (e.g. EMIS QAdmissions, WSIC, WHYSE, MSDi required for STP DA1 (case finding), DA2 and 3 (variation). Tools are adequate, but poorly exploited by practices/ccg; needs of ACP still being defined; HCCG to consider need for QOF Masters/Data Quality reporting Main issue: lack of project resources in GP Confederation and ACP to implement enabling IT and IG for integrated care Primary Care - national systems: EPS2, GP2GP, SCR, e-rs, EPaCCS (CMC) good usage, exploit further Child Health - CHIS and CP-IS: follow national trajectories 12

Workforce and resilience As we established on page six, primary care is under significant pressure, and this is unlikely to be relieved through the recruitment of new GPs alone. We plan to develop the primary care workforce in line with the GP Forward View, to recruit and retain people with a more diverse range of skills and to do things more efficiently to improve patient care as well as the working lives of primary care staff. Recruitment GPs We will aim to recruit 10 new GPs into Hillingdon per year (including retaining ST3s), totalling a net 40 new GPs by 20/21 We will work with General Practices to ensure that employment conditions, job descriptions and expectations are attractive to ensure GPs seem Hillingdon as an attractive place to work. Nurses We will expand nurse placements from 38 to 55 by 20/21 We will increase the number of nurse mentors within the borough from 18 to 28 by 20/ 21 to address the future anticipated shortage in this area We aim to have three sign off mentors by 20/21 to support more nurses to stay in Hillingdon Other We will increase apprenticeships for receptionists, admin staff, HCAs and nursing associates to 30 by 20/21 Efficiency and releasing time to practice We will upskill receptionists and administrative staff in clinical correspondence and signposting work to release clinical time We will up-skill practice pharmacists to undertake patient consultations We will draw on our relationships with Brent and Harrow CCGs to share the cost of external training, where appropriate (e.g. HCA training) and to try to achieve maximum workshop attendance We will continue to provide masterclass training environments for nurses, HCAs and receptionists, which will be delivered in practices so teams learn together embed new skills in everyday practice GPs Retention We will continue to provide leadership development for GPs and practice managers We will continue to support the Young Practitioner Group We will ensure we support increasing skill sets Other We will continue to provide supervision and coaching skills for practice managers and practice nurses We will ensure that all clinical staff undergoing formal training to expand their skills have the opportunity to apply learning in their practice Building a broader skill mix We will support practices to adopt a broader skill mix where this provide additional skills and capacity, including: Wellbeing officers Physicians associates Care coordinators Healthcare assistants (HCA) Advanced nurse practitioners Nurse associates Clinical and senior clinical pharmacists We will continue to develop competency frameworks for new roles (including the HCA care certificate, care navigator competency framework and receptionist competency framework) 13

By end of 17/18 By end of 18/19 By end of 20/21 Roadmap for the GP Confederation Hillingdon Primary Care Confederation The Confederation established as a legal entity and will be holding contracts Single wraparound contract for primary care will be implemented to replace old LIS / LES arrangements Practices supported to provide population access to services The Confederation will provide general practice with a unified voice, representative of general practice in Hillingdon The Confederation will negotiate (e.g., with the ACP) on behalf of all practices in Hillingdon The Confederation will provide up scale services on behalf of member practices The Confederation will support addressing unwarranted variation, e.g., in LTC management and health inequalities Confederation will lead on workforce development Practices with resilience or performance issues (e.g., poor CQC ratings) will be supported to improve The Confederation will support practices to become more efficient, e.g., 10 high impact actions The Confederation works closely with the local authority to improve integration of heath and social care The Confederation helps to shape the development of contracts and incentive schemes The Confederation will be used as a vehicle for driving innovation in primary care locally The Confederation operates as a central component of the ACP, driving forward the shift of care into the community The Confederation will deliver economies of scale for general practice so that services and functions are delivered at the right scale, whether that is Federation, locality or practice level The Confederation will play a facilitative role with regards to changes to delivery models as these are required and agreed Practices will be supported to develop teams with a broader skill mix to improve efficiency and reduce pressure in primary care Strategic estates discussions take place including the Confederation as a strategic partner 14

In 17/18 and 18/19 we will have... Level 3 delegated co-commissioning infrastructure in place, and the CCG will be making commissioning decisions targeted at driving improvements in outcomes and ensuring that the primary care and the system as a whole is resilient and sustainable. 3 Primary Care Managers will join the CCG to support cocommissioning objectives 1 Hillingdon GP Confederation established as a legal entity and holding contracts and delivering services 100% Care home beds supported by enhanced GP visiting service 1 Unified primary care contract for long term conditions and management of multi-morbidity based on current LIS / LES contracts 9 Additional mental health therapists in primary care 46 Practices to offer online access to booking appointments and repeat prescriptions 15 Care connection teams rolled out across the borough 15 Guided care nurses recruited for care connection teams 15 Care coordinators recruited for care connection teams 1 Accountable Care Partnership with GP Confederation at its centre delivering care for people aged 65 and over 10 Additional practice based pharmacistsone senior clinical pharmacist for each locality and seven clinical pharmacists all practices 46 Practices will have recorded PAM scores for their patients to enable them to better support people to manage their own health 3 Paediatric hubs providing integrated community clinics with specialist support- delivering care closer to home and upskilling primary care and creating a network of services 3 Extended access hubs will be in place and piloted, with evaluation underway to determine their impact and future Hillingdon 4 will have continued in its pilot phase and the service will have All been evaluated 46 Practices signed up to the Information Sharing Agreement 8 Practices receiving targeted GP resilience funding (46 practices receiving some funding) 111 service with integrated CATS function in place 1 Superhub in place connecting patients to primary care via the 111 service 1 Integrated urgent care system that works proactively to ensure people access care in the right setting 1 Pool of health connectors working from the urgent care centre to facilitate patients access to primary care See summary of Delivery plan in appendix D 15

Looking five years forward In five years time we expect the care delivered in general practice and the wider community setting to look very different. Patients will say: The care I receive is high quality and centred on my specific needs and circumstances I am empowered to care for myself, provided with all of the support and information I need I am seen in the most appropriate setting for me; as much as possible this means in my own community I received the same GP services, to the same standard, no matter which practice I belong to (practices are effectively networked to facilitate this) I can access services that are appropriate to my needs- online, at short notice when urgent and outside of office hours when convenient I don t always see a GP when I go into my practice, but I always see the right person for my needs The care I receive for my long term condition is effective and I understand it a lot better than I used to My care is integrated so that all of my health and wellbeing needs are addressed together, including physical health, mental health and social care GPs will say: I am supported to manage my workload effectively I am able to provide my patients with the best possible care I understand how services locally fit together and am reassured they will support my patients in the community The diverse range of staff in my practice collaborate as an effective team I work collaboratively with practices in my area and across Hillingdon to ensure services are delivered at scale Communication with other organisations, such as social care and the hospital, is excellent 16

Looking five years forward In five years time we expect primary care to deliver services at different scales, delivering targeted services appropriate for local need whilst also securing the benefits of working at scale wherever possible We also expect primary care to be a leading partner in the accountable care partnership GP Confederation By 2021, we expect the GP Confederation to provide the leadership and coordination for general practice in Hillingdon to deliver effective, population based-services to drive up patient outcomes and shift care into the community to be delivered at scale. Localities Localities Localities By 2021, we expect care to be organised locally across the three Hillingdon localities, so that local communities are able to access population-based services free from unwarranted variation either from their own practice or from another practice in their locality. We also expect localities to act as the local voice of primary care for commissioning purposes GP practices By 2021, we expect the GP practices to work collaboratively and innovatively to deliver high quality care in a networked way. We expect teams to be multidisciplinary, with each role working at the top of their license 17

Appendices 18 18

Appendix A Compendium of strategies This strategy draws on national, regional and local strategies: And builds upon previous local strategies: As well as: Health and Wellbeing Strategy 2018-2021 (Currently in draft) The Older People s Strategy Children s strategy 19

Appendix B Hillingdon Primary Care Profile 20

Hillingdon Population profile Analysis commissioned in August 2016 sought to to better understand the current and future trends with regards to health needs and general practice. This analysis identified a number of key themes. Hillingdon s demographic profile is changing; whilst historic differences between the north and south of the borough are set to continue, growth is likely to be concentrated in specific areas of new development. Growth forecast The latest ward level projections estimate that the resident Hillingdon population will grow by 2.6% within five years and 5% within 10 years. Some areas will see more growth than others: the population of Uxbridge North is forecast to grow by nearly 40% within 10 years and Heathrow Villages is forecast to grow by 12% within 10 years 10 year growth 2015-2025 2 1 3 Other growth Demographics In addition to the above growth modelled using GLA data, there are a number of other factors that are likely to increase the projections further: Cross rail corridor is expected to significantly increase 1 housing demand around Hayes and West Drayton ( ) We are expecting a 10% population increase in the south of the borough above projections, in part due to additional housing for employees working at Heathrow as the airport expands ( ) as well as Hayes being designated a housing zone Plans for new high dependency care homes could also change the health needs of the borough 3 2 The wards in the North of the borough have a higher proportion of older people which may be an indicator of future need The areas in the South of the borough have higher levels of deprivation than those in the North Deprivation appears to be a major factor in the use of acute healthcare services There is considerable variation in life expectancy at birth. Wards in the North East of the borough have higher life expectancy than those in the South West From the age of 65, females across Hillingdon are expected to live to close to 87 years, whereas males are expected to live to 84 years 21

Hillingdon health Profile Hillingdon good news Generally People living in Hillingdon live longer and healthier lives compared to the average for England. Some Hillingdon outcomes are positive Good levels of breastfeeding, which provides the best start in life for babies and leads to a healthier life, are higher in Hillingdon than the national average. A lower proportion of pregnant women in Hillingdon smoke, compared to the rest of England. Fewer people are admitted to hospitals in Hillingdon with an alcohol-related condition than the England average. Early death rates (under age 75) from respiratory diseases are lower than the England average..however: Some of our health outcomes are also worse than the national average: Rates of social isolation among social care users and their carers are still too high. Accommodation and employment needs of adults with learning disabilities are not being adequately met. A higher proportion of children aged 10-11 are overweight / obese as compared to the national average. The proportion of children with dental decay is significantly worse than the national average. Rates of childhood vaccination are lower than the national average. Proportion of adults who are physically active is lower than the national average. Deaths rates for men aged 75 or under from cardiovascular diseases is significantly higher than the England average. Cancer screening rates are low and the percentage of population being offered an NHS health check is low. Hillingdon JSNA The Local Government and Public Involvement in Health Act 2007 requires Local Authorities and Clinical Commissioning Groups to produced a Joint Strategic Needs Assessment (JSNA) of the health and wellbeing of their local communities The main themes of the JSNA are: promoting healthier lifestyles improved co-ordination of joint health and social care working safeguarding, prevention and protection community-based, resident-focussed services promoting economic resilience preserving and protecting the environment reducing disparities in health outcomes Health inequalities Health status is not the same in all parts of Hillingdon, There are health inequalities and differences in life expectancy depending on where people are living in the borough. This tends to correlate with levels of deprivation, high concentrations of BME residents and accessibility to services. As a result that there is a difference of around 8 years in the life expectancy of people living in Botwell ward situated in the more deprived South of the Borough compared to people living in Eastcote and East Ruislip ward. 22 22

under 35 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65+ under 35 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65+ Hillingdon primary care profile (cont.) The borough has a higher than average number of GPs and nurses over the age of 55 which combined with current shortfall in the number of GPs represents a significant risk to delivering sustainable primary care services in the future. Workforce Despite growing demand for Primary Care, between 2014 and 2015 the number of FTE GPs in England fell by 6% from 36,920 to 34,592 Across England, there are 60 FTE GPs per 100,000 people. Across London this rate increases to 66 FTE. Across Hillingdon the figure is only 47 FTE indicating a supply shortfall Although exact figures vary, analyses of need indicates that Hillingdon needs a significant increase in the number of GPs At borough level it is estimated that the population of Hillingdon currently needs 169 GPs FTE, which is 34 more than present However, the figures above (for both GPs and nurses) do not account for anticipated growth due to cross rail, new care homes and new developments (so the true numbers may be higher) Across Primary Care, Administrative and Managerial staff form the largest staff group, with GPs accounting for around 30% of staff A sizeable proportion of GPs are aged over 55, which may add further pressure on supply in the next 5-10 years due to the impact of retirement A sizeable proportion of Nurses are aged over 55, which may add further pressure on supply in the next 5-10 years due to the impact of retirement Age profile of GP (FTE) workforce (2015) 20% 15% 10% 5% 0% Age profile of Nurse (FTE) workforce (2015) 40% 35% 30% 25% 20% 15% 10% 5% 0% GP's aged 55+ Headcount % female % male England 21% 54% 46% London 25% 60% 40% NW London 27% 58% 42% Hillingdon 28% 61% 39% At more than 50%, the proportion of nurses in Hillingdon aged over 55 poses a significant risk to supply over the coming 5-10 years. Nurses aged 55+ England 29% London 37% NW London 40% Hillingdon 51% 23

Hillingdon primary care profile (cont.) Hillingdon has achieved a number of successes in the past with regards to primary care which laid strong foundations for innovation and improvement. About Hillingdon Hillingdon currently has a population of 304,000 people (2016 estimate, ONS) Hillingdon has 46 GP practices There are three localities: North Hillingdon Uxbridge and West Drayton Hayes and Harlington As of April 2017, 44 practices are signed up to a single GP confederation, established as a legal entity able to hold contracts The majority of practices have GMS contracts in place (35) but 9 have PMS and two have APMS contracts There are two acute hospital sites in the borough, both run by the same hospital trust: The Hillingdon Hospitals NHS Foundation Trust Every practice in Hillingdon is on the same clinical IT system: EMIS, which supports the implementation of borough wide initiatives and more integrated working at scale via a data sharing agreement between practices As of 2017, local services are commissioned from practices through a single primary care framework contract evolving towards an outcome based contract As of April 2017, Hillingdon has level three commissioning responsibilities for primary medical services, delegated from NHS England Hillingdon works collaboratively with partner CCGs across BHH (Brent, Hillingdon and Harrow) as well as the wider STP area (the eight CCGs of North West London) to drive improvements at scale. For instance, this has included meeting the requirements of the Strategic Commissioning Framework and driving integration through the NWL Pioneer Programme: Whole Systems Integrated Care 24

25 Appendix C Strategic Commissioning framework for London

Accessible care Appropriate urgent access We aim to commission an Integrated Urgent Care system that includes: An integrated 111 and CATS services commissioned through the NWL wide re-procurement A superhub that helps triage patients and supports access to primary care hubs and individual general practices Urgent Care Centre with health connector role to facilitate patients access into primary care services Out of Hours services delivered at scale by the GP Confederation where practices have opted in (procured where they have opted out ) We intend for the MIU at Mount Vernon to become a UCC by 2018 Extended access Three extended access hubs will be in place by April 2018 providing 8am- 8pm access to primary care, seven days per week. Evaluation will be ongoing to ensure that the model is delivering best value for money for the Hillingdon population The extended hours LES will continue and practices will be encouraged to take up Embracing technology We will embrace new apps and digital technology where these will add value to patients. We will proactively seek out, trial and evaluate such approaches to learn quickly and gain benefits as early as possible We will engage with national and regional programmes to facilitate this, so that we can benefit from economies of scale and additional resources We will expedite technological solutions to sharing patients information so that care can be delivered at population level, and support patient access to information and their own care records (e.g., Care Information Exchange) We will continue to explore the role of telehealth and remote consultation in the borough, including using models such as telephone triage to more effectively manage demand in primary care and ensure that patients receive the right type of care to meet their specific needs High quality routine access All practices in Hillingdon will be open during routine hours (8.00-6.30) where the building is unlocked, practice receptionists are in place (without answering phones) and appointments are taking place Community services delivered in other primary care settings: pharmacy, dental and optometry will be commissioned and drawn on as much as possible, where these represent good value to patients and the CCG Practices in Hillingdon are currently providing care outside core hours. We expect this to rise via the extended hubs and the extended access DES Every practice will have a hearing loop in use by [Sept 2018] Every practice will have access to a British Sign Language interpreter by [April 2018] Additional routine services will be provided in areas of growth or increasing pressure (see pages 5 and 18 for details) such as around Hayes, Harlington and Uxbridge North Every practice will give patients the option to book appointments three to four weeks in advance with flexible appointment lengths (according to need) We will work with practices to improve the ease by which patients can get through on the phone We will encourage key access principles for instance patients not be asked to call back the next day for an appointment when an appointment could be booked there and then 26

Proactive care Variation in LTC management Focus will be on early identification and prevention, anticipating needs through population segmentation and risk stratification Tools such as QAdmissions, QCancer and the MSDI tool will be deployed by practices to support risk stratification using disease registers Practices will use this information to provide tailored packages of support to individuals who may otherwise access services in a frequent or unplanned way Practices will be supported to with education and training to deliver multi-morbidity clinics Collaborative care and support planning model (year of care approach) will be implemented, including a train the trainer accreditation model The success in providing peer review and support seen for diabetes will be replicated across further disease pathways, for instance developing and drawing on heat maps to identify performance outliers Virtual clinics such as those rolled out for respiratory will be used to proactively identify patients whose treatment could be improved, such as by reducing inappropriate and expensive medication Develop a LES for visiting appropriate patients within 48 hours of discharge Clinical systems such as EMIS will be improved, for instance through standardising disease-specific templates to further reduce variation in long term condition management Patients not accessing services We plan to find new ways of delivering care for seldom seen, seldom heard groups including people with drug and alcohol addiction, people with mental health needs and homeless people, particularly in the south of the borough where this need is greatest. We will work with partners such as the local authority to better coordinate services for these groups, for instance where individuals have a dual diagnosis (e.g., substance misuse and mental health problems). Prevention and wellbeing We plan to forge ever stronger relationships with both the local authority, housing and the voluntary sector to enable access to a wider range of coordinated services to support people to stay healthy with a high quality of life Hillingdon 4 All is one important way in which health and wellbeing services are being coordinated through primary care, using new wellbeing officers and patients activation tools Additionally, a targeted self-management support initiative shall be scoped and delivered in each locality and we will strengthen broader links between practices and the voluntary sector We will develop ways of preventing childhood obesity through their interaction with primary care, coordinating with current LA commissioned services such as MEND We will work with closely with schools to improve the overall health and wellbeing of school age children Community Health and Wellbeing Champions will be trained and in place in each locality We will actively support screening programmes by contacting patients who have not responded to bowel, breast or cervical screening invitations We will consider a social prescribing project across Hillingdon that reflects different localities health and wellbeing priorities, building on the current referrals for exercise model We will encourage practices patient participation groups (PPGs) to play a greater role in supporting the health and wellbeing agenda We will develop and promote a map of all health and care available within the borough We will work with the Local Authority to commission a consistent extended service offering for all patients, e.g. health checks, sexual health, smoking cessation and substance misuse 27

Coordinated Care Self-care Hillingdon currently has over 1,000 PAM licenses granted by NHS England. We plan to use these, in combination with a menu of self-care services to increase patient activation so people feel more empowered to self-care We will work closely with the local authority and voluntary sector to integrate services and signpost service users We will focus on providing people that have recently diagnosed with a long term condition with the information and support they need to effectively manage their condition Care planning / coordination We will ensure that integrated care plans and case management is in place for those at risk of an acute exacerbation This will be supported by the stratification of practice lists according to frailty We will support care to plans to be used in a proactive way that drives better patient care rather than fulfilling a tick box purpose We will support practices with training for collaborative care planning A single point of access will be established for people at the end of their lives to improve the level of coordination and ensure that palliative care is planned as much as possible Expanding ACP scope The Accountable Care Partnership is an important vehicle for integrating care to become more proactive and coordinated Whilst the current focus is a set of specific services within the 65 and over population group, this is set to expand to include all 65 and over spend (e.g., including continuing health care and prescribing) Other population groups are expected to be included in the planned capitated budget such as adults with long term conditions by April 2019 We also plan to further integrated these services with social care services Care Connection Teams Care connection teams constitute a critical part of the integrated model of care for people aged 65 and over in Hillingdon 15 care connection teams are expected to be implemented across Hillingdon by September 2017 Two new roles will be key to these teams: The care coordinator and the guided care matron We will continue to support the ACP to improve the MDT design so that social care aligns better to practices and support MDTs virtually especially for patients frequently being admitted to hospital, involving acute consultants, community geriatrician, community services, social care, and relevant GPs We will ensure that a comprehensive system and process is in place for practices to draw on community Care of the Elderly resource to assess the most complex frail elderly We will continue to support the care connection teams with tools that they need to care for complex patients effectively, including through access to integrated care dashboards and data sets We will support the development of the care connection teams in relation to the care of people outside of the 65 and over population segment as the ACP takes on increase responsibility for population based care Pathway specific MDTs We plan to continue to develop consultant-led community based MDT teams for the effective treatment of specific diseases, building on the successes of the diabetes and respiratory pathways 28