NHS North Norfolk and NHS South Norfolk General Practice Forward View Operational Plan

NHS North Norfolk and NHS South Norfolk General Practice Forward View Operational Plan Ensuring high quality healthcare services for the people of North and South Norfolk 1

VERSION CONTROL Document Purpose: An opportunity for NHS North and NHS South Norfolk Clinical Commissioning Groups to develop General Practice Forward View (GPFV) Operational Plan for the period 207-19, focused on the development of long term stable and sustainable primary care, new models of care, incorporating local requirements and national guidance. Authors Cal Deane, Assistant Director of Primary Care, NHS South Norfolk CCG. Sally Ross-Benham, Head of Primary Care, NHS North Norfolk CCG. Date Version Initials Summary of Amendments 13/12/2016 1 CD Creation of initial outline draft document. 14/12/2016 2 SRB Addition of NN CCG elements 14/12/2016 3 LBW Formatting 14/12/2106 4 SRB& CD Update to layout and wording Review Date: 1 st September 2017 Review Completed: Governance and Sign Off: Meeting: Date: Approved: NHS SN Clinical Executive NHS NN Executive CCGs Primary Care Joint Commissioning Committee CCGs Governing Body s 1

CONTENTS Page 2017 2019 Plan Summary 1 Local Context 1 2 Progress to Date 2 3 Patient Benefits 3 4 NHS North Norfolk & NHS South Norfolk Operating plans 2017-19 4 5 General Practice Access 8 6 Transformational Funds 10 7 Workforce 11 8 10 High Impact Innovations 13 9 NHS England Funding Streams 15 References 18

2017-2019 Plan Summary Year 2016/17 2017/18 2018/19 onwards Working at Scale Development of a working at scale (MCP) model Formal commencement of working at scale model including understanding of Out of Hospital requirements Delivery of whole system working at scale supporting service redesign Delegated Commissioning Preparation for delegated commissioing & development of quality and performance dashboard Commence delegated commissioning Continued delegated commissioning Primary Care Development Establish 3 per head fund Support delivery of ETTF Aligned to STP & LDR Development & commencement of primary care transformation support plans Transformed and sustainable Primary Care supporting STP ambitions Workforce & Workload Baseline Assessment Engage HEE Promotion and commencment of National support programmes Working with HEE to develop and implement workforce & workload plans Continous review and application of programmes Access Review data from existing local and national patient feedback and access survey Establish local population requirements Identify service gaps Develop outcome based service spec Commence procurement Implemention of new service and review

1 LOCAL CONTEXT Both North and South Norfolk Clinical Commissioning Group (the CCGs) are clinically-led organisations, which means doctors, nurses and healthcare professionals working primarily in North and South Norfolk are shaping and supporting the delivery of integrated health and social care for the area. The CCGs continue to work with a wide range of partners to commission plan and purchase NHS care for the total population of North and South Norfolk. The CCGs receive financial allocations from NHS England and holds contracts with NHS and independent providers who deliver a range of services to patients in the area. The population covered by North Norfolk and South Norfolk CCGs, are 172,083 and 234,063 respectively and are predominantly rural areas with locations of high population density, e.g. Cromer, Sheringham, Fakenham, Thetford, Dereham, Wymondham. The CCGs are membership organisation with 24 member GP Practices in South Norfolk and 19 in North Norfolk that were formally established as a statutory bodies on 1 April 2013. The CCGs took over responsibility for most local commissioning from NHS Norfolk, as a result of the Health and Social Care Act 2012. The CCGs are led by a shared Chief Officer and Chief Finance Officer, supported by a team of finance, commissioning, contracting, quality and admin staff. In addition North East London Commissioning Support Unit (CSU) is contracted to provide a range of support services such as Medicine Management, Procurement and Continuing Healthcare Assessments. The CCGs collaborative approach to commissioning includes clinical networks for Planned Care, Unplanned Care, and Mental Health and Learning Disability. It is important to note NHS North Norfolk CCG and NHS South Norfolk CCG are statutorily independent bodies and where practical and possible, work in a collaborative approach for the delivery of integrated health and social care services. 1

2 PROGRESS TO DATE The CCG s General Practice Forward View Operational Plan 2017-19 (the Plan) has been developed in the context of; (i) (ii) (iii) The CCGs 2017-19 Operational Plans The CCG s financial position, national planning requirements, and The Norfolk and Waveney 5 year Sustainability and Transformation Plan (STP) In Good Health. The Plan reflects the expectations of Annex 6 (Annex 6) of the NHS Operational Planning and Contracting Planning Guidance, 2017-19, to stimulate development of at scale providers for improved access, implementation of 10 high impact innovations to free up General Practice time and secure sustainability of general practice. It is the intention of the CCGs, through primary care at scale and the development of MCP type models, to bring Primary Care, providers and commissioners together, to develop and facilitate clinically led, primary and community care service wrap around. The Plan will require detailed financial and staffing analysis of each provider, by service line, broken down to Locality and GP practice, allowing Primary Care the understanding of how, currently, services are funded and delivered and the opportunity to develop new models of care which meet the requirements of the local population, that of the local clinicians and national guidance / frameworks. It is proposed that the Plan will assist; - The system retuning to financial balance. - The sustainability and quality of general practice. - The development of a 7 day service delivery. - The delivery of the GP Forward View and NHS Operational Plan - With the reduction in referral variation. - Improvement in the implementation of Primary Care Mental health services and parity of esteem. - Integration out of hospital, social and community care delivery. - Primary Care with recruitment and retention. - Prescribing decisions and use of Electronic Prescribing. Through the adoption of the above, it is expected that commitment will be attained to work across organisational boundaries, benefiting all patients within North and South Norfolk and increase opportunities for system efficiencies. This is essentially the MCP model, but the exact boundaries are still to be developed. 2

3 PATIENT BENEFITS Through the implementation of the General Practice Forward View and Annex 6, the future benefits to patients will include; i. Increased GP access and appointment times. ii. Stabilisation of primary care practices within both CCGs. iii. Integrated care delivery and working, e.g. clinical pharmacy within primary care, integrated health and social care services, improved MDT meetings. iv. Greater clinical skill mix. v. For the individual, improved flow through their care pathway. vi. Patients perceive a better care experience. vii. Improved quality and delivery of care, within suitable GP and community premises. viii. Improved access to mental health services, via practice based mental health therapists. ix. Individuals being signed posted, at first point of contact, to the most appropriate health and social care service x. Through the Digital Roadmap, the development and use of a single care record, accessible by the patient and their care professionals. xi. Patients and their Careers feeling in control and responsible for their health care. xii. Improved Poly-pharmacy and medication compliance, resulting in better health and life outcomes for the individual. The plan is expected to meet the following NHS Outcomes Framework Domains & Indicators (DoH 2016); Domain 1 Preventing people from dying prematurely. Domain 2 Enhanced Quality of life for people with long term conditions. Domain 3 helping people to recover from episodes of ill health or following injury. Domain 4 Ensuring people have a positive experience of care. Domain 5 Treating and caring for people in a safe environment and protecting them from avoidable harm. 3

4 NHS NORTH NORFOLK & NHS SOUTH NORFOLK OPERATING PLANS 2017-19 NHS North Norfolk and NHS South Norfolk CCGs have separately applied for Delegated Commissioning with effect from 1 April 2017 and are currently working with the other Norfolk & Waveney CCGs to evaluate the scope and opportunities for having a shared Primary Care Commissioning team across the STP footprint, whilst retaining some local function and individuality Priority 3 of the 9 priorities outlines in the NHS Operational Planning and Contracting Guidance 2017-19 highlights five key areas for Primary Care: Five Key Areas The How Delivery Timeframe Investment Stabilization of Primary Care through the implementation of the GP Forward View to included plans for practice transformation support and 10 high impact changes Practice Infrastructure ETTF submissions for primary care estates and IT Workforce Engagement with local and nation training and education programmers Workload CCG investment of 3 per head (non-recurrent). Ensure local investment meets or exceeds minimum requirements GP mobile working and WIFI Practice redesign Potential new Primary Care new builds Through: 1) PGP Programme 2) GP Leadership Programme 3) Receptionist Training and document management and or online consultation systems 4) GP Resilience Programme & STP Leadership Through: 2017/18 or 2018/19 and dependent on primary care business case submission March 2017 Cohort 1 by March 2017 Cohort 2 by march 18 or March 19, dependent on allocation By March 2017 2016 onwards 2016 onwards 2016 onwards 2016 onwards 4

Engagement with local and nation training and education programmers Care Redesign Improved GP Access through the 3.34 available from NHS England in 2018/19 1) Working with Localities to develop and implement MCP type models 2) Training care navigators and assistants for all practices 3) Clinical pharmacy in general practice Through: During the spring of 2017, commence work with Primary Care develop an improved access model to include greater timing of appointments, including extended access and increased capacity and use of IT Model to be developed by December 2017. Model procurement to commence early 2018. Model go live late 2018. NHS South Norfolk CCG 2016/17 has seen the four South Norfolk Localities operate in virtual MCP-type models. The remainder of 2016 and start of 2017 will see Localities move from a Virtual to Partial MCP-type model. The CCG will bring Primary Care, health and social care, voluntary providers and commissioners together to develop and facilitate seven day clinically lead, integrated (health and social care) primary and community care service wrap around transformational hubs. These hubs will (i) be stable and sustainable, (ii) be patient focused, (iii) be quality driven, (iv) deliver care at the right place at the right time and (v) see more individuals and their carers cared for, holistically, in the community. Through continued development of the MCP-type model commitment is expected for working across all organisational boundaries and structures, benefiting all people within South Norfolk and increasing opportunities for system efficiencies. The next two years will see: By March 2019, improved access to primary care services for patients through procuring and funding of extra capacity Improved clinical outcomes for people living with long term conditions, and ensure they and their carers feel supported. Specifically, the CCG will aim to: - Reduce premature mortality due to cardiovascular conditions by improving detection and treatment of hypertension and other risk factors 5

- Reduce poor outcomes for diabetics such as leg amputations by helping patients improve their control of blood glucose, blood pressure and cholesterol - Reduce hospital admissions in asthmatics By June 2017, implement integrated and holistic primary and community health care for Locality populations During 2017 see a reduction in variation as to the quality of care, and prevent avoidable referrals and admissions to hospital By March 2019, support the sustainability of the wider health and care system through the delivery of more care closer to home and greater focus on prevention By May 2017 the CCG will have developed and commence trialling a Primary Care Quality & Performance dashboard, for the intention of establishing minimum thresholds all primary care providers will be expected to achieve. NHS North Norfolk CCG North Norfolk Practices are working together to develop a single partially integrated MCP model. The CCG is supporting primary care to deliver a model that harnesses the benefits of larger scale while preserving the localism and expert generalism of North Norfolk Practices. It will be essential for this new organisation to develop a structure and way of operating that will offer solutions through multiple providers or by contracting a sufficient variety of staff or services to enable whole pathways to be delivered across the entire patient population of North Norfolk. By being part of an MCP type organisation GP practices will be able to realise benefits such as: More easily meet the requirements of improved access to services 7 days a week More flexible workload management More effective utilisation of specialist knowledge and staff Economies of scale for procurement and backroom functions Shared governance resource Development of locum solutions such as shift availability apps and a locum chamber Be able to offer additional services as they shift out of secondary care. Through the MCP practices will be at the center of integrated teams which will have a comprehensive, pre-authorised range of interventions. These will include: 6

Community staff interventions Domiciliary care support Integrated rapid response care in the home comprising nursing, therapy and reablement workers Deployment of volunteer support to people with limited or no other social support Integrated post discharge/reablement support in the home A range of housing options including home adaptions through to placement in housing with care and other supported living options On-going medical/nursing/therapy support to people in their homes for people with Long Term Conditions, and at the end of life Readily accessible support for careers Digital technologies to improve access to diagnostic results and specialist opinion from secondary care 7

5 GENERAL PRACTICE ACCESS How access to general practice will be improved? Additional Access 2018/19 will see NHS England make recurrent funding of 3.34 per head of population available, increasing to 6, recurrent funding, per head of population in 2019/20, to CCGs, for the commissioning of extra primary care capacity, with the aim of: i. Increasing access to GP services ii. Improving access to pre-bookable and same day appointments after 18:30hrs iii. Provision of 1.5 additional hours of appointments per day (Monday to Friday) iv. Provide access to pre-bookable and same day appointments on Saturdays and Sundays, dependent on local needs CCGs will be required to follow an appropriate procurement process. South Norfolk CCG will seek to work in collaboration and partnership with other Norfolk CCGs and stakeholders for outcome based service specification development, procurement and service implementation with a commencement date of March 2018. Date April 2017 March 2017 June 2017 July to December 2017 January 2018 March 2018 Procurement Timeframe Action Base line data collection and stakeholder engagement. Outcome based service specification development. Stakeholder engagement continuation. Release of PIN. Procurement exercise and contract award. Mobilization phase.. Commencement of service. Community Education Provider Networks (CEPNs) The Central Norfolk CCGs have developed and will submit a CEPN bid, by 30 th December 2016, for a CEPN within each of the Central Norfolk CCG s. It is the intention that this post will be operational from 1 st March 2017. 8

The CEPN will provide: i. A focus for multi-professional communities of educational practice in local geographies and local leadership in the development of high quality, locally-tailored education and training for staff in primary and community care. ii. iii. iv. A multi-professional East of England School of Primary and Community Care to provide strategic leadership and to commission education and training programmes from CEPNs in line with local priorities. Workforce Planning: Developing robust local workforce planning data to inform decisions over how education and training funding should best be invested. Education Programme Quality and Coordination: Local coordination of education programmes to ensure economies of scale, reduced administration costs and improved educational governance. Supporting improvements in the quality of education programmes delivered in primary and community care, for example, through peer review. v. Faculty Development: Developing local educational capacity and capability (for example, an ability to accommodate greater numbers of nursing placements or the development of multiprofessional educators in community settings). vi. vii. viii. ix. Sharing resources: For example educational faculty such as nurse mentors or physical capacity within the locality Responding to Local Workforce Needs: Collaborating to meet local workforce requirements (such as specific skills shortages), including the development of new bespoke programmes to meet specific local needs. Workforce Development: Developing, commissioning and delivering continuing professional development for all staff groups. Ensuring education at scale to support wider primary care at scale and the use of current nontraining practices as appropriate. x. To encourage innovation in primary care education, including the introduction of new roles and the support of new service pathways. In addition, Norfolk CCGs continue to work with NHS Health Education England (HEE) in developing its primary care educational capacity to support workforce development and the infrastructure necessary to support CEPNs. 9

6 TRANSFORMATIONAL FUNDS How Transformational Funds for practice transformation support will be created and developed to support general practice? Separately, NHS North Norfolk CCG and NHS South Norfolk CCGs have identified, from their baseline allocations and have included within respective provisional accounts, non-recurrent funding of 3 per head of population for the period 2017-19. With investment commencing in 2017/18 and will take place over two years. i.e. 3 per head in 2017/18 or 2018/19 or split over two years. The investment will be used to stimulate development of at scale providers for improved access, support implementation of the 10 high impact actions to free up GP time, and secure sustainability of general practice.. 3 per Head of Population Funding CCG Period Total Identified Funding North Norfolk CCG 2017-19 516,000 South Norfolk CCG 2017-19 710,000 NHS South Norfolk CCG On the 24 th November 2016, NHS South Norfolk CCG wrote to South Norfolk Practices welcoming applications, either at a South Norfolk wide or Locality level, as to how the above funding can be best utilised to support developing MCP type models and 10 high impact innovations, ensuring funding is not used twice. To support Localities with business plan development, the South Norfolk CCG has provided a business case template, including a milestone tracker and financial template. Dialogue as to business plan development continues via the South Norfolk Locality meetings. NHS North Norfolk CCG North Norfolk CCG and the locally developing MCP are working together on a two year plan for ultilisation of the transformational monies that will deliver the aims of the GPFV and facilitate the new ways of working outlined in North Norfolk s primary care strategy. Our clear joint ambition is to improve sustainability and access to primary care whilst delivering whole system change that will tackle key issues such as demand management, ensuring patients continue to receive high quality care. North Norfolk CCG have provided some funding for backfill for nominated GPs and managers to move this forward along with project management support. 10

7 WORKFORCE How ring-fenced funding being devolved to CCGs to support the training of care navigators and medical assistants and stimulate the use of online consultations will be deployed? NHS South Norfolk CCG NHS England has allocated 20,000, for 2016/17, to the CCG for reception and clerical staff training and online consultation systems. This funding is to contribute towards the costs of practices training reception and clerical staff to undertake enhanced roles in active signposting and management of clinical correspondence. South Norfolk practices wish to use the initial tranche of funding (2016/17) to support and develop their Reception Teams in active signposting. Practices have reviewed and evaluated a number of training providers and are working with a preferred provider to develop and implement a training programme which meets specific local needs and requirements. Active signposting frees up GP time, releasing about 5% of demand for GP consultations in most practices. It makes more appropriate use of each team member s skills and increases job satisfaction for receptionists. Over the remaining four year (2017-2021) of this funding stream South Norfolk practices will continue to develop the signposting training and examine the opportunities associated with the management of clinical correspondence. It is estimated through the use of clerical staff to manage clinical correspondence, 80-90% of letters can be processed without the involvement of a GP, freeing up approximately 40 minutes per day per GP. For the clerical team, job satisfaction is often increased as well. NHS North Norfolk CCG NHS England has allocated 15,000, for 2016/17, to the CCG for reception and clerical staff training and online consultation systems. In North Norfolk two teams of three have successfully applied for the HEE funded Primary Care Leadership Collaborative and one of the groups has chosen signposting training as the key focus of their project. Many of the NNCCG practices are already providing signposting to their patients and at the November practice managers meeting the group agreed that it would like to arrange a workshop for reception staff across the whole of the CCG to share best practice. It was felt that initially sharing best practice would be more beneficial than purchasing national training, although it was likely that this 11

workshop may produce a desire for training. It was hoped that this meeting may be the start of a support network for reception staff as the CCG already has a successful dispensary group and the medical secretaries of 5 practices meet quarterly which they have found extremely successful. This vision was presented at the first PCLC impact day and received an extremely positive response. It was felt that this could be a ground up, rather than top down, approach to collaborative working. Although this project may seems a small step if there are benefits to reception staff, clinicians and patients this could be the driving force for large scale change, via a soft approach, across the 19 practices in the North Norfolk CCG area. NHS Improving Quality have published a plan for implementing large scale change and this project has been defined using these terms. 12

8 10 HIGH IMPACT INNOVATIONS The GP Forward View has identified the primary care 10 high impact innovations as: 10 High Impact Innovations Innovation Descriptor Current Support Further Support Active Signposting Patients directed, at initial contact, to the most appropriate service NHS England have developed part year 1 funding (2016/17) to CCGs to support 2017-2020 funding to be allocated by NHS England New Consultation Types Reduce Did Not Attend Team Development Productive Work Flows New communication methods Maximum utilization of appointment Increased team education and training Identify and introduce new ways of working Agreement as to use of email, telephone support etc. for consultations. GP Development Programme GP Leadership Programme Practice Manager Development Clinical Pharmacy Sign posting training NHS England funding to support signposting, clinical skill mix, document management Personal productivity Staff development Various NHS England training support programmers, e.g. Time for Care, PGP, etc. Partnership working Partnership and 3 per head Social prescribing Collaborative working Referral and signposting to nonmedical services transformational funds. Sign posting training Alignment with LDR Identification of best practice within primary care and sharing with others Continued promotion of course to practices. Clarification required form NHS England as to some support elements CCG facilitation 13

Support self care Develop QI expertise STP Prevention Programme Service redesign and quality improvement 3 per head transformational funds CCG facilitation CCG facilitation 14

9 NHS ENGLAND FUNDING STREAMS Fund Amount Timeframe Availability NHS South Norfolk CCG NHS North Norfolk CCG 40m ( 16m 4 yrs. from 2 practices have self referred. in 16/17. 8m 16/17 pa for 3 yrs. GP Resilience Fund National programme. NHS England local teams to decide allocations. 3 practices have self referred. The CCG continues to work with NHS E to promote the scheme SN Practices. The CCG continues to work with NHS E to promote the scheme NN Practices. Retained Dr. Scheme GP Development Programme GP Improvement Leadership Programme 76.92 per session per week 3 years 1 July 2016 30 June 2019 30 million Expressions of interest cut off August 2018 Free to attend No additional decision making process. Retained GP and practice must meet criteria to be eligible. Expressions of interest submitted to NHS England 3 years Applications to NHS England. 300 places per year for the next 3 years. The CCG continues to promote the schemes with SN Practices. All SN practices applied for the programme, with 7 practices commencing the programme and selecting modules to work on. Discussion, facilitated by the CCG, remain on-going between SN Practices and the The CCG continues to promote the schemes with NN Practices. All NN practices applied for the programme. The first facilitated meeting has taken place and the practices are undertaking an audit to establish which module to start with. Discussion, facilitated by the CCG, remain on-going between NN Practices and the 15

Training for Reception & Clerical Staff Practice Manager Development Online Consultation Systems New Models of Care Funding Vulnerable Practice Fund Clinical Pharmacists in GP NHS GP Health Service 45 million ( 5 million in year 1 and 10 million per year over the next 4 years) unknown 45 million ( 15m year 1, 20 million year 2, 10 million year 3) 5 years 2016/17 2020/21 3 years From 2016/17 3 years From 2017/18 Central funding will be allocated to CCGs on per-head-ofpopulation basis. No information published Funding allocated to CCGs. CCGs to be disseminated in the most appropriate way. unknown 2017/18 Bids from practices with partners to NHS England and NHS Improvement 10 million 2016/17 NHS England to decide in consultation with CCGs 112 million unknown NHS England to decide regional allocations 19.5 million 5 years From 2017 National scheme open to all GPs NHS Sustainable Improvement Team Development Advisor SN Practices continue to develop a rolling programme for Receptionist sign posting, anticipated to commence Jan / Feb 2017. The CCG continues to liaise with NHS E as to the programme. The CCG to seek clarification from NHS E. Need to ensure clear alignment with LDR & STP and clarity as to funding stream. The CCG to seek clarification from NHS E. An NHS E Pilot in operation between 2015 and 2017, Has been superseded by the GPRF. The CCG continues to liaise with NHS E as to the programme. CD to seek clarification from A-L S. NHS Sustainable Improvement Team Development Advisor NN Practices have established a plan to deliver this by April 2017 by joint working. The CCG continues to liaise with NHS E as to the programme. The CCG to seek clarification from NHS E. Need to ensure clear alignment with LDR & STP and clarity as to funding stream. The CCG to seek clarification from NHS E. An NHS E Pilot in operation between 2015 and 2017, Has been superseded by the GPRF. The CCG continues to liaise with NHS E as to the programme. 16

ETTF 900 million 5 years CCG bids to NHS England PMs GP Access Fund 500 million 5 years National funding provided to CCGs (process unknown) CCG is working with Cohort 1 Practices and NHS E re PID submission. The CCG awaits detail from NHS E as to the next submission round. The CCG in conjunction with North, Norwich and West CCG have submitted a bid to NHS E for the 5 th Dec. 2016. The CCGs continues to liaise with NHS E as to the programme. The CCG continues to liaise with NHS E as to the programme. CCG is working with Cohort 1 Practices and NHS E re PID submission. The CCG awaits detail from NHS E as to the next submission round. 17

References: 1) NHS England, Five Year Forward View, October 2015, 2) NHS England, Sustainability & Transformation Footprints, March 2016, Gateway Reference 04902 3) NHS England, General Practice Forward View, April 2016, Gateway Reference 05116 4) NHS England, Our 2016/17 Business Plan, March 2016, Gateway Reference 04910 5) NHS South Norfolk Clinical Commissioning Group, Operational Plan 2016-17 6) NHS England, Technical Guide to Allocation Formulae and Pace of Change, April 2016, Gateway Reference 05100 7) Barid B., Charles A., Honeyman M, Maguire D., and Das P. (May 2016) Kings Fund Understand Pressures in General Practice 8) NHS South Norfolk Clinical Commissioning Group, Estates Strategy (draft) April 2016 9) NHS Constitution or England, July 2015, 10) Department of Health, NHS Outcomes Framework, April 2016 11) Department of Health, Transforming Primary Care, 2014. 12) BMA, Focus on funding and support for general practice, Sept 2016 18