Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group General Practice 5 Year Forward View Operational Plan 2017-19 Leicester, Leicestershire and Rutland (LLR) STP 1
Contents This plan sets out the initial ideas for how the Leicester, Leicestershire and Rutland (LLR) STP footprint intends to design, implement and deliver locally the elements of the General Practice Five Year Forward view set out in the NHS Operational Planning and Contracting Guidance 2017-2019. In LLR there is a specific work stream of the STP for the delivery of an improved and resilient General Practice. This work is being progressed together as three CCGs working together with a common purpose and vision. This is reflected in the joint nature of this document for the key models and enablers. There are two sections on Access and Finance that are specific to each individual CCG to reflect the differing positions and progress made. Priority Work stream CCG Page Number 1 Care Redesign LLR 3 2 Workforce LLR 5 3 Workload LLR 8 4 IM&T / Estates LLR 11 5 Access ELR 6 Finance ELR 2
Priority 1: LLR General Practice 5 Year Guidance Ref: Forward View- Care Redesign Annex 6) 1.3 Key Deliverables The practice and primary healthcare team will remain the basic unit of care, with the individual practice patient list retained as the foundation of care. Significant proportion of care will be provided by practices coming together to collaborate, using their expertise, sharing premises, staff and resources to deliver care for and behalf of each other Model based on the GP as expert clinical generalist working in the community, with general practice being the locus of control, ensuring the effective coordination of care. The GP has a pivotal role in tackling co-morbidity and health inequalities but increasingly they will work with specialist co-located in primary and community settings, supported by community providers and social care to create integrated out of hospital care. Key to supporting patients is the ability to provide a differential service according to need.. A cohort of patients, especially those with multiple comorbidities who are at risk of admission for their complex condition require a more pro-active offer that could involve a multi-disciplinary team including social care, community nursing and specialist care Person-centred care recognises that an individual is best placed to make decision about their own health, lifestyle and the level and location of treatment. Successful integrated person-centred care will tend to keep a person in their own home for as long as possible. All practices providing a level of urgent primary care access as well as planned services and should support patients in self-care management Patients with complex needs require a coordinated package of care that will require care planning, regular proactive interventions and support. This continuous care is best provided by a multi-disciplinary team with the GP at the heart of that care. This level of service utilises a GPs skills to best effect and patients will be streamed accordingly. All other patients will have access with another appropriate health professional, when needed, supported by a GP Relationship to other plans: LLR Integrated Teams / Planned Care / Long Term Conditions / Urgent & Emergency Care Outcomes (Impact) Core prevention agenda, whereby the population are empowered to make the right lifestyle choices to maintain their health. Reducing the need for a visit to a GP surgery Improve access and an extended range of services to our patients at scale. This access will not necessarily be from a GP, but a nurse, pharmacist, or other health professional according to need. Active planning to prevent emergency admissions for complex or frail patients, and expedite discharge whenever a hospital stay cannot be avoided. Impact will be fewer unplanned admissions, due to proactive management greater on the day access and higher proportion of patients accessing self-care. 3
KPIs/ Trajectory General Practice with registered lists will remain at the heart of the model offering a comprehensive service to patients based on differential need according to condition and complexity. We will actively encourage practices to work together in networks or merge and provide services on multiple sites offering planned and unplanned services to meet patient s needs. This will reduce bureaucracy and enable economies of scale to enable greater clinical workforce focus. CCGs in LLR have already invested significantly into the development of formal legal GP Federations who do and will work as collective providers of services for patients such as enhanced services. Place based care provided around geographically defined populations. This will support the adaptation of services for patients, which will act as a catalyst to new models of GP collaboration for core services Milestones (Detail key milestones in chorological order, shade in green) Key Actions Workforce and Demand/Activity/Capacity Planning baseline Modelling of new models of complex / non-complex pathways Pilot Sites for new models and evaluation Integration of Locality/ Hub based working with Local Authority and Integrated teams Develop new ways of joint working / contracting to deliver sustainable models 4
Priority 2: LLR General Practice 5 Year Guidance Ref: Forward View- Workforce Annex 6) 1.2.1c/1.3/1.3.1/1.3.3/1.4 Key Deliverables Engage with constituent member practices on the workforce issues facing primary medical care and work together to develop solutions Target the existing primary care workforce to improve recruitment and retention but equally important to identify new capabilities, competencies, skills and behaviours required to make an enhanced primary care offer. Identify new roles and capabilities in new staff groups. There is an urgent need to focus on alternative professional roles that support integration, increase capacity and reduce admissions by freeing up GPs time to manage increasing complexity. Such roles include primary care physicians assistants. Identify roles and competencies currently that sit outside of primary care that will be required to support the demand. Such roles include primary care paramedical staff, community pharmacists, emergency care practitioners, and specialist roles such as geriatricians. Actively support undergraduate medical, nursing and pharmacy training and GP training at a federated level to promote our practices as positive places to work to aid recruitment and retention. To this end we will work with our federated localities, our neighbouring CCGs, local universities and Health Education East Midlands (HEEM) to identify current skills and extended skills that could benefit patients and practices Deliver Strategy for New Models of Care: Linking directly with the three clinical work streams for Complex, non-complex and Planned care within the STP GP Programme Board to asses, analyse and model the following Skill mix / Competency / Numbers needed Capacity / staffing numbers necessary Training needs formal and informal Organisational Development capabilities Financial Impact Relationship to other plans: LLR Workforce Strategy/Local Workforce Action Board Outcomes (Impact) Ensure that education and training needs are identified for primary medical care staff and reflected in the LLR-wide workforce development plans provided to Health Education England Support the workforce objectives of BCT and now the STP, including new models of care. Produce a comprehensive baseline of current workforce numbers and skills in General Practice. Map the existing programmes of training, education and development for all staff groups within General Practice in LLR and understand Gaps and risks. Map the future workforce needs in line with the proposed new models of care in General Practice Design a strategy for how we meet these needs for GPs, Nurses, Other Health Professionals, Practice Managers and Administrative staff. Create an implementation plan that will link this to the General Practice and Integrated Team STP work streams and help deliver both sustainable solutions in General Practice and the GP5 year forward view. Success to Date: The primary care workforce agenda is driven through an LLR-wide delivery group consisting of stakeholders including HEE, LMC, LPC and clinicians. This has resulted in new delivery models and extended roles including Clinical Pharmacists and Emergency Care Practitioners. Some examples of success Training Care Navigators and Medical Assistants Manage demand on GP Appointments. Patients will be signposted to the most appropriate service first time, including Pharmacy, community support services, emergency dentists etc. Enact a change in patient perception of the GP being the first point of call for all health queries. Reduce unnecessary appointment, which will result in GPs able to concentrate on the most complex patients. Upskill front of house staff/receptionists to feel confident to signpost and navigate patients to the most appropriate service and support 5
1. Training Care Navigators and Medical Assistants. Five year 45m fund has been created to contribute towards the costs for practices of training reception and clerical staff to undertake enhanced roles in active signposting and management of clinical correspondence. The task of active signposting for patients. This is an enhancement to normal good customer service. It requires the receptionist to be skilled and confident in sensitively ascertaining the nature of the patient s need and exploring with them safe and appropriate options. Training will be provided in local cohorts across the STP footprint and the planning has already been in association with member practices. 2. Clinical Pharmacists in General Practice - ELR CCG have funded 2 per patient in wave one for employment of pharmacists to improve quality, workload and cost effectiveness, following a successful pilot phase in 2015/16. City CCG were successful in bidding for the national programme for pharmacists 3. AVS/ CRT Urgent Home Visiting The clinical response team take referrals directly from GPs and/or Care homes for patients that require a same day home visit in order to potentially avoid an emergency admission to hospital. The service is moving towards e-referral from GPs in city and is provided 7 days per week. In West Leicestershire the service has been running for 2 years with similar results and has been rolled out in ELR in 2016. This adds clinical workforce capacity and supports workload. Clinical Pharmacy: Aim to have a clinical pharmacist in every practice as a member of the practice team building on the experience and outcomes of the first wave pilotsutilise the skills of specialist clinical pharmacists in primary care e.g. Respiratory and diabetes clinical pharmacist specialist, care homes and linking with community pharmacy. AVS/ CRT Urgent Home Visiting Reduce avoidable emergency attendances and admissions. Supports Residential and Nursing homes in executing agreed care plans. Supports primary care in managing the volume of housebound and care home requests, freeing up capacity to meet growing demand Golden Hello The scheme provides a golden hello payment of up to 10,000 per year, for two years, to eligible clinicians to join the most deprived areas in Leicester City. Builds on the existing LC CCG General Practice recruitment scheme to ensure practice sustainability. Investment in practice staff Target effective recruitment to maintain local primary medical services and the 5YGPFV 6
KPIs/ Trajectory Appendix 1 Clear baseline and analysis of current skills, roles and capacity for General Practice Gaps, risks and sustainability analysis Clear understanding of staffing numbers, training needs for new model- matched with plan for how to deliver / commission training Clear plan for 5 year implementation of staffing needs for New models of care Joint local plan for the training and recruitment of staffing Delivery of the 1% increase in GPs and 3% increase in other clinical staffing to support new models of working By 2020 LLR share of new 5000 doctors is 100- LLR propose a 1% only increase due to significant expected retirement. Any additional GPs from the 5000 will support long term GP resilience. 3% increase in other clinical staff includes existing and planned funding for Pharmacists and local academies/ clinical hubs supporting training and education of students and return to work nurses/ GPs Planned number of increased staffing GP (WTE) GP Support staff (WTE) Current 2020/21 Current 2020/21 593 617 1,678 1,888 Milestones (Detail key milestones in chorological order, shade in green) Key Actions Baseline analysis of Numbers / Roles / skills/ Education Programmes Gaps and Risks of Current Model/Recruitment / Retention and Training Needs Map New Models of Care/ Skill Mix/staff Numbers/ Training needs for patient groups Design and Develop Toolkit for practices to manage DAC planning and skill mix Design staff needs analysis to deliver STP GP Programme Board Models of Care With HEEM, Medical/ Pharmacy / Nursing School joint strategy for placement needs Implementation for staffing to deliver pilot phases of new models of care Training Care Navigators and Medical Assistants. Clinical Pharmacists in General Practice 7
Priority 3: LLR General Practice 5 Year Guidance Ref: Forward View- Workload Annex 6) All Key Deliverables This project summary sets out our approach to reduce pressure on general practice and release time for care. The plan seeks to maximise and implement the initiatives developed to date as part of the GPFV and Operational Planning and Contracting Guidance. General Practice Development Programme Working on the STP footprint CCGs applied for and secured support for a collaborative bid to rollout elements of the GP Development Programme. Key components of this programme include: Productive General Practice (PGP) General Practice Improvement Leaders Programme Ten high impact actions. As part of our collaborative approach, to date 28 practices are part of PGP in 20. Our plan is to build on this positive start and support a wider number of practices to benefit. To support delivery of this programme and recruit groups of practise to participate in the ten high impact actions a series of launch events are planned during Q1 20. Transferring Care Safely The un-managed and inappropriate left shift of activity from secondary care to primary care puts significant unnecessary pressure on GP workload. A pan LLR Transferring Care Safely Interface Group has been established to identify and influence how we can transfer care across the whole LLR system in the most effective ways, to improve the patient journey and ensure work is done in the right place at the right time. The group will recommend workforce solutions identifying and taking into account of skills, capacity and communication needed, promote integrated team approaches and develop systems to monitor, learn, refine and improve the service. Relationship to other plans: All Outcomes (Impact) General Practice Development Programme General Practice engaged and leading initiatives to work differently and free up time to care. Increased knowledge and skills to support working differently Increased capacity to focus on GP resilience Transferring Care Safely Improve clinician and patient experience Improve patient safety in regard to prescribing and medicine usage Reduce un-necessary hand overs Reduce un-necessary follow up appointments (primary and secondary care) Reduce un-necessary or duplicate out-patient/consultant lead care referrals Release primary care capacity General Practice Resilience Programme - STPs and CCGs in partnership with local NHSE teams to ensure funding is used to target support at areas of greatest need and work to deliver upstream support for practices. LC CCG 32 Applications, 4 Supported, 10 on Reserve List and 18 not supported ELR CCG 7 applications, 1 supported, 2 on reserve list and 4 not supported WL CCG 13 applications, 5 supported, 4 on reserve list and 4 not supported Support more practices and offer support on a timely basis. Proactive Care Planning Builds on the Avoiding Unplanned Admissions DES by further reducing emergency admissions and attendances, strengthening the capacity of primary care, and better integrating health and social care for those with complex needs. Actions to date include:- Left Shift primary care impact survey across WLCCG practices identified 8
themes, main impact areas and to some extend quantity (similar impact assessment proposed for other partner providers) Interface Group established with TOR and meeting regularly General Practice Resilience Programme (GPRP) Deliver a menu of support to help practices become more sustainable and resilient. Encourage and support practices to apply for the GPRP LCCCG implemented local GP Resilience Programme to enhance and expedite national programme, ELR programme for practices in need of support. Proactive Care Planning The main principle embodied in this is to link all Health organisations involved with a patients care e.g. 111, EMAS, OOH to ensure that a patient is managed in their place of choice. This proactive management prior to crisis is beneficial to the patient and health system. All three CCGs have care plans for at least 2% of their patients and the majority of patients in Care Homes or at the end of their life. In Leicester City,to help practices to deliver more person centred care the CCG has recruited four case coordinators who work with the top 800 patients as identified using ACG Risk Stratification. 9
KPIs/ Trajectory Appendix 1 General Practice Development Programme 20 25% of LLR practices to be participating in one of the 3 programmes. 20 50% of LLR practices to be participating in one of the 3 programmes. 20 75% of LLR practices to be participating in one of the 3 programmes. General Practice Resilience Programme Supporting more practices who require direct input from NHSE or funding Proactive Care Planning Develop new models of care that support patients and General Practice to manage this patient group Milestones (Detail key milestones in chorological order, shade in green) Key Actions General Practice Development Programme Productive General Practice (PGP)rollout cohort 1,2,3 Recruitment of practices for future cohorts General Practice Improvement Leaders Programme recruitment Ten high impact actions launch event and rollout of supported cohorts Transferring Care Safely Left Shift survey WLCCG Interface Group established TCS Guide v1 produced General Practice Resilience Programme GPRP Supported Practices informed of approval and next steps GPRP Confirm funding and support with practices and agree action plans GPRP six month review 10
Priority 4: LLR General Practice 5 Year Guidance Ref: Forward View- IM&T / Estates Annex 6)1.2.1b/ 1.2.3/1.3.3/1.6 Key Deliverables IM&T Interoperability between all primary, community and Urgent Care/ Extended access systems All LLR practices enabled to offer patient-facing digital services to allow patients to book appointments, order prescriptions and gain access to their detailed coded record and robust implementation of nationally mandated systems such as EPSr2. Technology giving the ability for clinicians in out of hours and urgent care settings to view key elements of a patient s clinical record at the point of care in real time using the Medical Interoperability Gateway (MIG) GPFV Investment Online General Practice Consultation Software Systems. CCGs and practices in LLR will utilise the funding to support the development of online consultation systems with a view to improving access and making the best use of clinical time. Building on the early adopter sites, our plan to is to pilot online General Practice Consultation Systems in 3 areas during 20 as part of a range of initiatives to improve access and make best use of clinical time. Estates and Technology Transformation Funding (ETTF) As part of the ETTF (technology) programme two schemes were funded in 20: System Integration and Joint Working Hubs: This project enables practices to migrate to System one, the scheme will allow us to enable practices to work at scale and ensure there is one medical record for every patient as both the community an acute sectors utilise this platform. This allow Primary Care to work at scale and will align with the integrated teams. Interoperability and Record Sharing to support care Planning: This programme will concentrate on three information sharing technologies, SCR, MIG and S1 sharing. This programme will support and act as an enabler for enabling the new care models and allow us to transform care. Relationship to other plans: LLR Digital Road Map /STP Estates Strategy Outcomes (Impact) IM&T Plan our investments wisely over the coming years in GP technology and estates to support developments in order to: Enable self-care and self-management Reduce practice workload and pressures Help practices to work at scale Support whole systems efficiency Online General Practice Consultation Software Systems Increased efficiency and productivity Potential reduction in face to face consultations Increased use of technology to support improved access ETTF IM&T The schemes align with the Local digital roadmap Enable practices to work at scale in hub formats which align the proposed integrated care teams Support the aims and ambitions as detailed within the GP5YFV Allows the wider clinical team in integrate in the patients primary health care plan. 11
Estates The CCGs are committed to carrying out a review of all practice premises to gain an up to date understanding which will support the federated localities in the development of their local improvement plans. The following estates principles are designed to support the STP Programme and delivery of organisations clinical strategies: Services should be delivered from estate which meets clinical need; is accessible; offers value for money; is of acceptable quality; and meets safety and legislative compliance. Wherever possible, buildings will be designed to be flexible to adapt to changing needs over time We will maximise the use of physical assets wherever possible. We will have a mixed tenure of estate that can adapt quickly and effectively to changes in service need. The use of technology will be maximised to support efficient and agile working practices and to reduce dependence on fixed office accommodation. Estates and Technology Transformation Funding (ETTF) Funding to deliver general practice premises development schemes within ELRCCG, LCCCG and WLCCG to deliver: Improved access to effective care, with practices able to accommodate an increase in clinical workforce to support an increase in primary medical care capacity; Increased capacity for primary care services out of hospital, with practices able to implement a more diverse clinical skill mix. Commitment to a wider range of services as set out in the CCG s commissioning intentions to reduce unplanned admissions to hospital, with practices able to accommodate members of the wider multi-disciplinary team and members of the community team to provide a more seamless and holistic approach to caring for patients Increased training capacity, whereby practices are able to accommodate medical students and host upskilling events to support the delivery. ETTF Estates Expansion and strengthening of primary medical care services across WLCCG, including a measurable increase in appointment availability with a primary care clinician Greater range of services available to patients in a primary care setting, including specialist diabetic, COPD, Heart Failure services for patients who would otherwise be required to access secondary care Successful alignment of a greater number of primary medical care providers with the Time to Care programme and associated 10 High Impact Actions Increased patient satisfaction A measurable reduction in avoidable unplanned admissions to secondary care 12
KPIs / Trajectory All LLR Practices to either be on the same IT System or able to share patient records to support clinical pathways and locations All LLR practices to be able to share records with community service providers / UCC / ED / Other health services to support patient pathway. Greater link between Health and Social Care services. All systems to be able to share special patient records and care plans Systems in place to enable online consultations across LLR Maximise opportunity for Estates investment in line with national ETTF programme Further develop estates strategy ensuring fit for purpose premises and ability to deliver new models of care Milestones (Detail key milestones in chorological order, shade in green) Key Actions Interoperable IT systems across Primary Care Interoperable systems between Primary care and Urgent Care All systems to be able to share special patient records and care plans Online General Practice Consultation Software Systems Estates investment in line with national ETTF programme Estates strategy ensuring fit for purpose premises and ability to deliver new models 13