NHS Kingston Clinical Commissioning Group Primary Care Strategy Achieving excellence in primary care Version control Version 1 020615 Version 2 100815 Shared with PM Version 3 170815 Shared with PM, RB, NJ Version 4 090915 Comments from RB incorporated. Changes to section 7 Version 5 250915 Changes to sections 7, 8, 9 & 10 Version 6 281015 Changes to sections 1, 3, 4, 6, 7, 8 & 9 Shared with PM, PC, RB, NJ, TM, YR, Version 7 051115 Changes to sections 3, 4, 5 Version 8 121215 to 090116 Changes throughout. Shared with PM, NJ, RB and TM. Version 9 270516 Version 10 270616 Combination of the primary care strategy and primary care commissioning strategy Kathryn MacDermott Director of Planning & Primary Care 1
Contents page Contents page... 2 1. Foreword... 3 2. Summary... 4 3. The case for change... 6 3.1 The local context... 6 3.2 Right Care / Commissioning for Value... 7 3.3 The London Strategic Commissioning Framework... 9 3.4 The GP Forward View... 9 4. The Kingston Strategy: Quality in Primary Care... 11 4.1 The vision for primary care in Kingston... 11 4.2 Our strategic objectives... 12 5. Engaging Patients and the Public in strategy development... 21 6. Equality and Diversity... 21 7. Delivery... 21 7.1 Background... 22 7.2 Kingston Medical Services... 22 8. Outcomes of the strategy... 24 2
1. Foreword This strategy seeks to define what quality in Primary Care in Kingston means. It starts with a focus on quality in General Practice and will evolve to include quality across all primary care services. Primary care has received both national and London-wide attention, as an area where increasing focus and investment is likely to relieve significant pressure in the health and social care system. As confirmed through the recent publication of the GP Five Year Forward View. This five year strategy describes our plans for primary care in Kingston, and sets out what and how we will be doing to meet the Kingston, London and national transformation agendas. We started the conversation on our Primary Care Strategy in September 2015 which included a series of public engagement events. We have also taken iterative drafts to the CCG Council of Members, Kingston Health & Wellbeing Board and the Primary Care Quality & Development Group. It has been an exciting conversation and we have moved our thinking forward and now clearly state out ambition to provide the best primary care in London. We know that our primary care teams, including wider primary care professionals, are working under increasing pressures and demand for their time. Primary care has been a key contributor to efficiency in the NHS and our local healthcare economy, and we need to ensure that we continue to promote this. We know that general practitioners and their teams will work differently in the future if we are to achieve the best outcomes for our local populations, and therefore we need to support general practices and wider primary care providers to adapt and innovate. Kingston CCG want to create the culture and conditions for primary care services and staff to deliver the highest standard of care and ensure that valuable public resources are used effectively to get the best outcomes for individuals, communities and society for now and for future generations. We are working with the Royal Borough of Kingston to introduce new models of integrated care. Primary care services are integral to the development and delivery of these new models and we strongly believe that new models of care, including the Kingston Multispecialty Community Provider (MCP) will be GP led. This strategy sets out what is needed to enable primary care fulfil its role now and in the future. Transforming primary care includes all services delivered by primary care including routine, urgent and any other services delivered in primary care. It includes the provision of specialist care by GPs with a specialist interest where this is commissioned directly by NHSE and specialist care commissioned locally as enhanced services or local incentive schemes. The transformation of general practice in Kingston is a key strategic priority to support the full implementation of the South West London Sustainable & Transformation Plan (STP), Kingston s Coordinated Care programme, and Kingston Urgent and Emergency Care Strategy. Improvements in quality and accessible primary care can enable reductions in A&E attendances and non-elective admissions, as well as deliver holistic care planning, co-ordination and continuity which are founding principles for general practice in the UK. 3
2. Summary This is a five year strategy, with an accompanying implementation plan, to be refined and refocused over the five years to reflect what we learn, achieve and what we want to add. The strategy: Seeks to set out what excellence in General Practice means to GPs and Practice teams in Kingston Sets out a summary of the local, London and national context Explains the rationale for the strategy, its outcomes and objectives Sets out the transformation required to deliver the strategy Commits to key outcomes that this strategy will achieve Includes a high level implementation plan that that allows the reader to understand some of the key actions we intend to take. This strategy for achieving excellence in Kingston Primary Care continues the journey that General Practice in Kingston has been on. Based on the engagement that has been undertaken as part of the strategy development, we have focussed on quality as the framework within which we intend to transform primary care services in Kingston. We have identified four domains within which we intend to set specific and measurable quality outcomes to drive the direction of travel and pace of change. These domains are: (1) Service quality (2) Patient perspective and experience (3) Health outcomes (4) The effort of practices working to improve quality. To deliver on these four domains we have set ourselves five system objectives that will enable us to achieve the outcomes set in each of the four quality domains. The system objectives for General Practice are: 1. To create and nurture an environment of leadership and innovation for General Practice to deliver patient centred care. 2. To secure the role of the General Practice teams as the expert generalists in the wider healthcare system, who works with other providers to integrate services for patients as part of Kingston Coordinated Care. 3. To address the unprecedented levels of demand for General Practice services, supporting Practices to meet patient needs. 4. To ensure that General Practice in Kingston is supported by strong infrastructure to allow it to develop, grow and deliver high quality, equitable services for patients. 4
5. To maximise what we can achieve through working collaboratively across Practices and with local communities through Kingston GP Chambers. Based upon the changing national and local context in which this strategy is being produced, the following working principles have been set out for the strategy deliver: We will be led by the patient in the development of General Practice services. This is a strategy designed to support General Practice in the challenges they currently face. This is a strategy that will be delivered in collaboration with local Practices, not imposing or dictating action to them. This is a strategy to support development of the entire General Practice workforce A strategy that is flexible and evolving taking into account the changing context at this time this was written. This strategy proposes testing and piloting approaches and new ways of working, and will seek to provide initial investment to support local innovations that will develop solutions to the issues faced by General Practice. As the strategy develops over the five years, we will be communicating results and advocate for change in the areas that have shown to be most effective. Our strategic direction will be informed by evidence where this has been possible. Where it has not, we will support innovations, alongside evaluation and monitoring to build up our local evidence base. This strategy underpins broader strategic developments underway in Kingston, particularly Kingston Coordinated Care This strategy includes the action required by Kingston primary care to support the delivery of the South West London STP The Kingston health and care system will: 1. Start with the needs of people in Kingston as stated by them: understand me; give me more control; be coordinated; and provide consistently high quality care. Put these firmly at the centre of its culture, skills, processes and structures. 2. Focus on supporting people in Kingston to achieve the goals that matter to them 3. Actively support people to stay healthy, well and independent, be resilient and meet their own needs 4. Enable staff to do the best job they can and feel rewarded for doing so 5. Have good practice and lean principles at the centre of its design and constantly challenge all forms of complexity, duplication and waste 6. Be sustainable and provide best possible value for money The role of primary care within this is to: Give people the confidence that their general practice can offer the level of continuity which enables them to receive high quality routine care 5
Allocate the right amount of time, attention and skill to all patients including those who are most vulnerable in society or at risk of losing their independence Allocate the right amount of time, attention and skill to those who have significant health and/or mental health conditions Take responsibility for co-ordinating holistic care of people suffering with multiple LTCs, and includes helping people to identify and seek further help for associated mental health conditions or accessing services which will increase their social welfare Utilise care co-ordination, case management, risk stratification process and multidisciplinary working, joining community teams, social care professionals and specialists to deliver joined up care for people with long term conditions and complex needs Allocate the right amount of time, attention and skill to helping people to self-manage their condition or to improve their health and wellbeing overall Deliver frontline care in premises which are safe, suitable and facilitate multidisciplinary working between health and social care professionals where possible, a physical space in the community associated with health and wellbeing Provide increased uptake and equity of access to immunisation and health screening Signpost and provide opportunities for people to learn and be empowered to manage their condition, where appropriate, from self-limiting or minor illness to chronic conditions impacting on long long-term quality of life Primary care will need to respond to the new models of care challenge with a service model that delivers an increased range of services to patients and integrates primary health care with other services including social care, on a population health basis, that: Provides Multi-disciplinary Teams to populations of c. 50,000 Reduces variation in access and quality for local populations Delivers demonstrable benefits in terms of quality and value for money Makes primary care a more attractive place to work, and reinvigorates existing staff Drives innovation and achieves both local and national strategic objectives 3. The case for change In 2014, Kingston CCG agreed their key principles and areas of transformation focus as part of contributing to the South West London 5 year plan. In 2016 the SWL 5 year plan has been updated and sets out clearly why change is needed in General Practice to meet the challenges currently faced and begins to explore some possible solutions and options for delivering this change. Building on that work, and the feedback from the engagement exercise this strategy sets out a number of key immediate and medium term next steps. The challenges and proposed actions are summarised below. 3.1 The local context The Public Health England Health Profile for Kingston upon Thames for 2015 indicates: The health of people in Kingston upon Thames is generally better than the England average. Deprivation is lower than average, however about 12.3% (3,700) children live in poverty. 6
The rate of sexually transmitted infections is worse than average Rates of statutory homelessness and excess winter deaths are worse than average. The Royal Borough of Kingston JSNA indicates: Kingston more healthy overall than the national or London population but these figures mask stark differences between local areas; o Cambridge Road Estate is in the most deprived 20% of areas in England; o The differences in the life expectancy between the most deprived and the least deprived sections of the population of Kingston are 5.8 years for males and 3.7 years for females; Cardiovascular disease (CVD) which includes heart attacks and strokes is one of the major causes of death in Kingston o 27.5% of deaths at all ages o 23.6% of deaths in people aged under 75; Cancers account for 26.4% of all deaths in Kingston but are responsible for 40.1% of deaths in people aged less than 75; The third main cause of deaths is respiratory disease (which includes pneumonia, bronchitis, emphysema and chronic obstructive pulmonary disease). These diseases cause 17.7% of all deaths and 10.6% of deaths in people aged under 75; All three major causes of death have preventable risk factors which include smoking, diet, exercise and excess alcohol consumption. Action to address these should be prioritised and will involve primary care working in partnership with Royal Borough Kingston and Your Healthcare to maximise the outcomes for Kingston population. The GP Patient Survey 1 measures patients experiences across a range of topics, including: Making appointments o 26% of patients do not find it easy to book appointments over the phone o C. 90% of patients had not used the online facility o Over 50% do not know about the online booking facility Waiting times o 35% of patients felt they waited too long for their appointment Perceptions of care at appointments, confidence & trust o Very high 95 to 96% Practice opening hours o 10% reported dissatisfaction with the opening hours of their practice We know that the general practice workforce is under pressure. Specific challenges include significant cohorts of GPs approaching retirement, GPs reducing their clinical practice for commissioning and other roles, the salaried workforce choosing to do fewer sessions or more locum work, and a greater reliance on GP locums. Difficulties in recruiting practice nurses are also reported. 3.2 Right Care / Commissioning for Value A key principle of any commissioning is to secure the best possible outcomes within available resources. Part of the commissioning cycle involves looking at what is already 1 GP Patient Survey January 2016 7
provided and making commissioning decision on whether the current service or pathway represents the best outcomes for patients. The Right Care and Commissioning for Values tools indicate opportunities for both improving quality and improving the value for money in what we commission (spend) in a number of areas. The illustration below shows the areas that the Right Care analysis indicates we could improve in both quality and spend. Each of these areas that can be influenced by primary care and are included in our Primary Care commissioning strategy: Spend & Outcomes Outcomes Spend Circulation Respiratory Musculoskeletal Endocrine Circulation Circulation Mental Health Endocrine Trauma & Injuries Genito Urinary Endocrine Cancer Royal Borough of Kingston public health analysis of the prevention opportunities suggests that we should be prioritising both primary (preventing disease) and secondary prevention (detecting disease early) in the following areas: Diabetes prevention & detection CVD prevention, detection and management Hypertension detection and treatment Dementia detection and management Cancer screening & prevention Smoking cessation Obesity prevention Physical activity promotion Alcohol reduction Mental Wellbeing Promotion NHS Workforce Health promotion 8
The key messages we have taken from all of the above analyses include: There is work to do with primary care improving the detection and optimal management of LTCs, particularly diabetes, cardiovascular disease including atrial fibrillation and hypertension, and dementia, and respiratory disease (particularly asthma) Reinforces the need to invest in primary care to support the redesign of ambulatory care pathways Mental health is a recurring theme with opportunities for improvements in outcomes, quality and savings, reinforcing the need for the current training in primary care on mental health, highlighting the need to redesign the whole pathway Screening and early detection of cancer could be improved A deep dive is required on Musculoskeletal for adults and children to understand the divers for higher spend, hospital attendances and outcomes A deep dive into complex patients is required to understand the appropriate interventions to make the largest impact 3.3 The London Strategic Commissioning Framework A London wide case for change has been developed to respond to the specific challenges faced in London. At the heart of the document are key changes required of general practice grouped into three main areas: Accessible care Coordinated care Proactive care Kingston CCG has an implementation plan in place to deliver the London Strategic Commissioning framework as part of this strategy. The SWL STP includes appendices on Primary Care and lists initiatives that Kingston is already taking forward, or has plans to. 3.4 The GP Forward View The GP Forward View covers five areas: 1) Investment 2) Workforce 3) Workload 4) Practice infrastructure 5) Care redesign The Kingston CCG Primary Care Strategy puts us well placed for a number of the outputs listed in the GP Forward View. The developing Primary Care workforce strategy will need to take account of the GP Five Year Forward View and we are currently developing an integrated approach to primary care access, the urgent and emergency care system and Kingston Coordinated Care. 9
Why change is needed Possible solutions We need to urgently address the increasing demand for General Practice services There is a growing gap between the supply of, and demand for, General Practice Services cannot always flex adequately to meet the needs of our population. Our population is growing and people s expectations are also growing The 10 minute consultation model is not always adequate for our population. We need to be able to provide good access as well as continuity of care. GP appointments are not always used appropriately Addressing demand for General Practice services Managing expectations of General Practice, better signposting to other appropriate services Actively managing demand through improved patient education, use of technology, appointment systems and prevention programmes Changing Practice team models to support access and continuity of care using technology as an alternative to the face to face consultation. Moving away from a single condition focus to a focus on multiple long term conditions with appropriately long consultations along with support for self-care. Increasing appointment length for patients who need it. We must refocus on the role of the GP as the expert generalist who is supported by the wider healthcare system Administrative problems between secondary and primary care are a major cause of frustration for clinicians and patients. There is a lack of synergy in goals and common purpose of care for patients across organisations, a lack of clarity and insight regarding the limits each and a lack of support across the system in the best interest of patients. Supporting the GP as the expert generalist GPs at the heart of KCC, working towards shared goals to improve outcomes for patients. Improving secondary care admin systems and communication mechanisms. Greater use of the multidisciplinary team outside of the Practice to integrate services. We need to build our GP Chambers so that we can meet challenges by operating at scale There is variation in quality across practices General Practice role in education, training and development is highly valued, particularly multidisciplinary forums for sharing information and learning sets. Population health and anticipatory healthcare planning needs cannot be delivered at Practice level and needs a Chambers approach. Some innovation can only happen at scale Scaling up our organisational support model Developing population health and anticipatory care planning at a Kingston Chambers level. Enhancing peer support to reduce variation in outcomes and give moral support. Developing strong Practice Management to support improved business process. Creating headspace / time to encourage and support local innovation. 10 Creating systems for real and valuable community engagement.
4. The Kingston Strategy: Quality in Primary Care This strategy seeks to define what quality in Primary Care in Kingston means. It starts with a focus on quality in General Practice and will evolve to include quality across all primary care services. As part of developing this strategy we have engaged with patients, public, primary care staff and other stakeholders. Based on the feedback from the engagement events we are suggesting a definition of high quality primary care consists of the following components: Technology-Enabled Care Update of technology-enabled services is a key priority to deliver improved access, increased capacity, continuity of care and coordination of care Primary Care Workforce Planning and developing workforce is a key priority for achieving sustainable services Development of Primary Care at scale Support the development of primary care at scale, working with GP Chambers, to take collective responsibility for the population Kingston Primary Care Primary Care Estates Review and development of estate to ensure primary care is delivered on premises that are safe, high quality and suitable for primary care Coordination of Care Providing patient centred coordinated care for patients with long term conditions or complex needs and GP patient continuity, expert generalist in the Kingston Coordinated Care service model Proactive Care Commissioning and incentivising primary care services to support and improve the health and wellbeing of the population, selfcare, health literacy and keeping people healthy 4.1 The vision for primary care in Kingston We want to deliver the highest quality primary care measured by health outcomes, patient experience and staff morale. 90% of healthcare work is carried out by GPs and other primary care professionals for which they receive less than 10% of NHS funding. Our ambition is to transform primary care & developing better 11
out of hospital care. We will deliver more services in the community and make sure that hospitals work as specialist centres of excellence. Primary Care as a key partner in Kingston Coordinated Care will co-ordinate the care of their patients in the community, working with and through Kingston Care Exchange, local community services, Kingston hospital, mental health services, adult social care services and a range of voluntary and community groups. 4.2 Our strategic objectives To deliver quality in primary care and to be able to demonstrate that we have achieved our vision we have a set of system objectives : 1. To create and nurture an environment of leadership and innovation for General Practice to deliver patient centred care. Kingston has a strong foundation for clinical leadership, developed over a number of years to support innovation and development of services. Recent changes to the commissioning landscape have resulted in an enhanced model of clinical leadership through Kingston Clinical Commissioning Group. Building on a strong foundation, leadership for General Practice is the first objective based on our identification of the following needs that have been identified: Data from the national HSCIC and the Kingston CEPN survey reveals that: Nearly 25% of Kingston General Practice clinical workforce are aged over 55 less than 10% under 30 Nursing workforce flexible & part time across more than one practice Nearly half of Kingston s practices have experience of using apprentices Lack of consistency in using AfC Kingston CCG is developing a workforce strategy that includes consideration of: Agreeing a competency framework such as the NHS leadership academy Leadership framework or Clinical leadership competency framework Moving to a local training contract The utilisation of staff Training opportunities supported by a shared staff bank Action to be taken to develop leadership across the General Practice workforce is: Year 1 Design and establish the programme for clinical leadership in Kingston, in partnership with both current clinical leads and representatives of groups that the programme will aim to specifically focus on. Identification of peer support structures and mentors for the programme within the 12
network arrangements. Year 2 Year 3 Implementation of leadership programme and monitoring against the target groups for the leadership programme. Continuation of the roll-out of the leadership programme across Kingston. Create formal roles for new General Practice leaders identified. Evaluation of the programme against the aims of the scheme. Investment implications: Investment proposal to be submitted to support the leadership programme to be considered by the Primary Care Quality & Development Group, for recommendation to the Primary Care Commissioning Committee. 2. To secure the role of the General Practice teams as the expert generalists in the wider healthcare system, who works with other providers to integrate services for patients as part of Kingston Coordinated Care. A major cause of frustration for both General Practice teams and patients is the interface with secondary care, relating to both administrative and clinical issues. We believe that many of these issues are a result of a lack of synergy in the goals and purpose of care for patients between primary and secondary care services. Through this strategy, we will seek to remove the organisational and professional boundaries that are currently in place, which prevent a joint focus on the needs of the patient and the common goals that professionals need to deliver in order to meet these needs. General Practice teams have a pivotal role to play in the coordination and continuity of care for patients, and their role as this coordinator within the wider healthcare system needs to be recognised and supported. We believe that cultural change is needed first and foremost in the ways the different parts of the healthcare system interact with each other, as well as improvement to administrative and communication processes. Access to secondary care advice that is consistent across all specialities, timely in nature and maximises the opportunities technology provides in enhancing this is central to supporting General Practice teams in their role as the expert generalists within the wider healthcare system. To achieve this, the following change is needed: The email advice and guidance function provided to General Practice from Kingston FT to be formalised across all specialities, along with set timescales for specialist response. This support should be reflected within contractual agreements and delivered through a programme such as Kinesis Creating online forums for clinical engagement, building on the clinical information repository proposed in the communication, technology and engagement section of this 13
strategy. These on-line forums should provide a mechanism for formal advice and guidance, as well as informal networking and relationship building across organisations. Your Healthcare community health is a central part of health services to local communities, particularly for vulnerable, frail and elderly patients, and the integration of these services with General Practice is central to supporting the care coordinating role of the GP. Kingston Coordinated Care will be a key driver in joint working across General Practice and provider services. Kingston Coordinated Care sets out a process of pro-active care planning, delivered in partnership with community health services, targeted towards high risk patients and delivered through a generalist and holistic approach. The refocus on General Practice teams as the expert generalists within the broader healthcare system is reflected within the KCC strategy, advocating an approach to delivery of care that is not split up based on disease, but that is rehabilitative and shaped around patient goals, builds on their personal skills and resources and the assets of individuals and communities around them. In addition to delivery of Kingston Coordinated Care there is a general need for improved collaboration between General Practice and community health services. We will seek to extend the influence of individual Practices in the commissioning of associated community services, community nursing, especially district nursing, and end of life care, so that accountable or named GPs can discharge their responsibilities and ensure that these services are co-ordinated with the services and provide integrated care for patients. Action to be taken for supporting the GP as the expert generalist is as follows: Year 1 Year 2 Year 3 Formalise specialist email advice support function in contractual negotiation. Building on the current system of service alerts, to issue guidance to all Practice in Kingston regarding the community health service contract and set out a process for raising contractual queries in relation to Community Health Services. To be agreed following review of year one. To be agreed following review of year one and two. Investment implications: Investment proposal to be submitted to support the leadership programme to be considered by the Primary Care Quality & Development Group, for recommendation to the Primary Care Commissioning Committee. The actions required will be supported by investment funding secured from complementary work programmes: Kinesis (I&IT) 3. To address the unprecedented levels of demand for General Practice services, supporting Practices to meet patient needs. 14
The average number of appointments per patient in general practice has risen from 3.6 to 5.5 between 1995 and the most recent measure in 2008 (NHS England 2013). Kingston s population is growing and General Practice is facing increasing pressure from the increasing prevalence of longterm conditions and co-morbidity. This is creating an unprecedented level of demand on General Practice services. Doing nothing when faced with this is not an option. This strategy sets out changes that could be made for managing this demand. Addressing the unprecedented levels of demand for General Practice, to support Practices to meet patient needs, has been a key driver for the development of this strategy. In our case for change, we have shown the evidence of pressures faced by General Practice as a result of this demand. We have also seen innovative solutions developing for how this demand can be addressed, locally, nationally and internationally. All elements of this strategy are focused on developing solutions to addressing this demand, whilst focusing on delivering high quality General Practice services. We believe that Practices in Kingston, at an individual level, working in networks with neighbouring Practices or collaboratively through GP Chambers, have the skills and capabilities to addressing demand for services within a context which: Supports General Practice to have the time and space to look at their business processes to identify solutions; Allows best practice that is showing positive outcomes to be shared and understood in a local context; Supports Practices through the local contract to test new ways of working and support pathway redesign. To achieve this, Kingston Practices have access to a Kingston Medical Services contract that supports innovation and change. The Kingston Medical Services Contract aims to provide General Practice with the investment needed to pump prime the transformation of primary care and support delivery of the Urgent and Emergency Care Strategy. This is a unique opportunity for primary care in Kingston to make a real difference to the landscape of healthcare and contribute significantly to making the local health and social care system sustainable. The Kingston Medical Services Contract is available to all Practices in Kingston, at an individual level, when working in partnership with other Practices through a network, or through GP Chambers to pilot and roll out approaches to managing demand. The services being commissioned through the Kingston Medical Services contract are currently being developed but include a Kingston version of the Weekend Additional Capacity KPI, and the Screening, Vaccines and Immunisations KPI. The Kingston version of the Weekend Additional Capacity KPI is significantly different to the London offer in that it incentives Kingston practices to provide same day appointments, booked and walk in, for registered and unregistered patients. Kingston CCG has established a Local KPI Task and Finish Group that is leading this work. Other KPIs currently being developed include: Paediatric same day appointments Respiratory pathway for children (including asthma) Prevention (primary and secondary) for listed certain LTCs 15
MSK / Back Pain / Pain Management Proposal Single point of access to GP appointments Description One phone number for patients to call when making an appointment. Patient is triaged and directed to the right professional / offered a choice of appointments. By April 2017 all patients in Kingston will be able to access a GP appointment on Saturday morning and for urgent appointments all Kingston patients will be able to access a walk in service provided at Surbiton Health Centre. Patient is triaged and directed to the right professional / offered a choice of appointments. We recognise that a significant element of the workload for General Practice could be managed elsewhere, for example by Community Pharmacy, Health Care Assistants, and Community Nurses etc. The key to getting the SPA right, from the patient point of view, is ensuring that the patient see s the right professional in a timely manner. Enhancing pharmacy input across Practices Providing medication management support to GPs and medication reviews with patients. Providing advice and support to patients directed from the SPA. Using technology to create efficiencies in General Practice Social Prescribing Managing patient expectations for General Practice Patients on-line On-line support for self-care care Opportunities for on-line consultations Rationalising administrative costs Improving coordination of back-office functions Social Prescribing acts as a mechanism for linking patients with non-medical sources of support within the community, maximising collaboration between agencies by providing a stronger focus for joint commissioning and provides an adjunct to traditional treatments such as antidepressant prescribing and talking therapies. It also provides considerable scope for improvement in mental health and wellbeing for vulnerable individuals, groups and communities, especially for those with mild to moderate mental illness, low income single parents, the bereaved and those with a long-term physical health condition. To take a proactive role in managing patient expectations for General Practice services through the production of information for patients detailing what General Practice will and will not provide, as well as the responsibilities for patients and how they can get the best out of General Practice services and the broader healthcare system. 16
Action to be taken for addressing demand for General Practice services is as follows: Year 1 Year 2 Year 3 Establish the Kingston Medical Services contract: Agree the local KPIs that support the local contract. Agree the outcomes & performance indicators. Allocate the Kingston Medical Services investment Strat to pilot social prescribing Develop and roll out the communications plan for managing patient expectations for General Practice services. Develop the Primary Care workforce strategy Evaluate first tranche of Kingston Medical Services KPIs Based on evaluation, continue, amend, decommission KPIs to maximise the ability to transform primary care Second tranche of Kingston Medical Services KPIs Full roll-out of social prescribing to be completed. To be determined based on a review of years 1 and 2. Investment implications: Kingston Medical Services Contract has two elements: (1) the reinvestment of PMS KPI funds into the new KPIs (2) a ring fenced GMS+ investment for GMS practices offered for the new KPIs under the Kingston Medical Services Contract. 4. To ensure that General Practice in Kingston is supported by strong infrastructure to allow it to develop, grow and deliver high quality, equitable services for patients. We have heard consistently from the General Practice workforce in the development of this strategy that whilst there are important changes that need to be made to the way in which General Practice operates, changing working practices alone will not be enough to deliver the change that is needed. General Practice is dependent on infrastructural factors, such as its workforce, income levels, technology, communication and engagement mechanisms, training and development. External factors such as population growth have a direct impact on how resilient General Practice can be to address the issues that it faces now and in the future. Building this strong infrastructure is therefore a key objective of this strategy. 17
Action to be taken for developing the infrastructure for General Practice are as follows: Year 1 Workforce To establish a baseline of the primary care workforce in Kingston. Communication, technology and engagement Establish a structure and coherent communications path between the CCG and Practices Training, personal development and building resilience Undertake, or capture where they already exist, training needs audits in Kingston, focusing on non-clinical as well clinical skills, and developed a refreshed training strategy as a result of this. Year 2 Workforce To triangulate data in relation to workforce capacity, income and clinical outcomes to understand drivers for variation in Kingston. Communication, technology and engagement Review across primary and secondary care and update where necessary communication mechanisms to ensure the intended outcomes are delivered. Training, personal development and building resilience Implement refreshed training strategy for General Practices. Year 3 Workforce To consider taking forward plans to set standards within networks in relation to the General Practice workforce. This will be dependent on any national contract negotiations and changes and will involve joint working with the Local Education and Training Boards, who will take a leading role in education, training and workforce development for current and future needs. Communication, technology and engagement Review across primary and secondary care and update where necessary communication mechanisms to ensure the intended outcomes are delivered. Training, personal development and building resilience Evaluate impact of refreshed training programme in line with the outcome measures within this strategy. Investment implications: Investment proposal to be submitted to support the leadership programme to be considered by the Primary Care Quality & Development Group, for recommendation to the Primary Care Commissioning Committee. 5. To maximise what we can achieve through working collaboratively across Practices and with local communities through Kingston GP Chambers. 18
The recently published GP Five Year Forward View dedicates a whole section to primary care working at scale. The national and London policy in relation to General Practice services is very much signalling the view that the traditional GP partnership model, which currently serves a national average of around 6,650 patients per practice, is too small to respond to the financial and demographic challenges facing the NHS. Our own experience locally, when smaller practices have closed, if that new providers are not interested in small list sizes. Kingston has been ahead of national policy and already has a federated model of General Practice provision, which have delivered significant achievements in delivering primary care at scale (winter hubs) and reducing variation (GP Referral Scheme). We believe that working at scale through GP Chambers will provide the innovative ways of delivering the London Primary Care Specifications, the SWL STP Primary Care commissioning intentions and the CCG commissioning intentions. We believe the delivery of high quality, patient focussed services for the population of Kingston requires primary care to work at scale to: Develop more effective services for promoting health and preventing ill-health Ensure the continued viability of primary care in a period when small or single handed practices, operating in isolation, are finding it increasingly difficult to maintain the necessary levels of safety and clinical governance. Continuity of care with patients able to choose between their own GP or another in the Federation Provide better access to GP services with opening hours that reflect the needs of the local community Different ways of accessing services with booked appointments and unscheduled, walk in clinics Services in reassuring GP settings rather than in hospitals Tailored services specifically designed to address very local needs Provide the critical mass to ensure that different GPs can concentrate on different priorities There is a strong case for the transfer of many services (including the appropriate personnel and equipment) from hospitals into primary care settings. As technologies, such as MRI scanning, mature they are suitable for location nearer to the people who need them. Many clinical services, such as dermatology, mental health and diabetes care, do not need to be predominantly hospital based. We require primary care to work at scale to support the transfer of services from the hospital setting to a community/primary care setting. The GPs in Kingston have for a number of years been working together, at scale, as Kingston GP Chambers. Kingston CCG is committed to supporting the development of Kingston Chambers as a crucial element of delivering the Kingston Primary Care Strategy. Our objective is to build on the model of federated working in Kingston to enhance collaboration amongst Practices and to support General Practices working a greater scale to create efficiencies and better meet the needs of local populations is an important area of this strategy. General practice will play a critical central role in delivering the SWL STP, the Kingston Urgent & Emergency Care Strategy and Kingston Coordinated Care programme which will involve changes to the way providers in the local health economy work together to deliver patient centred care. To do this, General Practice will need to develop its 19
leadership role across the borough, its influence and engagement with other key major health and social care providers and optimise Practice and network collaboration. Action to be taken for building GP Chambers: Year 1 GP Chambers to consider the organisational development needs of the Federation itself, the strength of the federated model, breadth of engagement with its membership and any development needs. GP Chambers to agree the mechanisms that would be most effective for them to increase information sharing and raising awareness of Best Practice across Kingston. Chambers to set out their plans for real and valuable community engagement, which will include planning how success will be measured and good practice shared. Year 2 Year 3 To consider the effectiveness of multi-disciplinary collaboration with YHC and other partners for the delivery of KCC and consider how this approach might be adopted in key areas to support the delivery of Kingston commissioning intentions. Chambers to be implementing a greater range of collaborative working across Practices, increasingly at an operational level, sharing resources and developing greater joint functions. Investment implications: Investment proposal to be submitted to support the leadership programme to be considered by the Primary Care Quality & Development Group, for recommendation to the Primary Care Commissioning Committee. 20
5. Engaging Patients and the Public in strategy development Kingston CCG has engaged with a range of local people and other stakeholders in the development of this strategy. We have used the outputs from the Voice of the Customer Project as a basis to build on our engagement, as well as, data from patient surveys done at GP practices and enter and view GP practice inspections carried out by Healthwatch. In addition to hearing the views of local service users at bespoke public events, we will also engage with Voluntary Sector networks, Health and Wellbeing Board and Local Pharmacy Committee. Reports from patient engagement events for the strategy can be found at www.kingstonccg.nhs.uk 6. Equality and Diversity In keeping with the vision and values of Kingston CCG, this strategy reflects an appreciation for the diversity that lies within the Kingston patient and carer population. A key defining principle of the strategy is to reduce variation in access and quality in primary care services for local populations. We seek to address these variations by identifying and implementing best practice models of patient access across primary care, giving due regards to protected characteristic groups, while continuing to support the training and development of the primary care workforce as set out in the strategy s objectives (see Section 8). 7. Delivery Kingston CCG (KCCG) membership voted overwhelmingly in favour of delegated commissioning as we believe that the opportunity to assume full responsibility for commissioning general practice medical services enables us to shape the way in which primary care develops and empowers the local health and social care system to improve out of hospital services for the local population and supports the shift in investment from acute to primary and community settings. Delegated Commissioning arrangements give CCGs full responsibility for commissioning general practice services. Delegated responsibilities will include: Contractual GP performance management Budget management Complaints management Design of local incentive schemes as an alternative to QoF and DESs Delegated commissioning arrangements will exclude any individual GP performance management. NHSE will also be responsible for the administration of payments and list management We recognised that the opportunities that come with full delegation arrangements include: GPs in CCGs to have direct leadership to influence the development of investment in general practice Ability to design local schemes to replace QOF and DES contracts based on local knowledge 21
CCGs will have more power to drive the five year forward view agenda Greater freedom for how primary care finances are used Local decisions closer to patients needs Ability to use innovative commissioning to implement local priorities Better care for patients via joined up working Tailored services to meet the local needs of the patient population Local patients have greater opportunities to input and influence As of the 1 st April 2016 KCCG will be responsible for commissioning primary care medical services. We believe that this gives us a unique opportunity to make a difference for local population outcomes. Legally NHSE will retain the residual liability for the performance of primary medical care commissioning. 7.1 Background PMS contracts offer local flexibility compared to the nationally negotiated General Medical Services There is a national mandate to review the services and standards currently commissioned through Local Personal Medical Services (PMS) agreements to ensure equity of provision across all general practices. Kingston CCG is in a unique position in South West London with 11 of the 26 practices in Kingston being PMS practices. This has meant that significant additional investment has been made in general practices in Kingston, supporting additional services and standards to just under half of Kingston s population and provided a unique pool of learning of best practice and innovation. We believe that the PMS review represents a significant opportunity to review and learn from the existing PMS services and standards and commission those services that meet our population health needs and represent best practice across all practices in Kingston. This change in commissioning approach commissioning best value care that meets out population need across all Kingston practices is achievable as Kingston CCG has committed to invest in primary care to bring all practices up to the highest standard possible. 7.2 Kingston Medical Services We will invest in general practice to deliver high quality care for the whole of the Kingston population. The investment will be focussed on outcomes not process. The Primary Care Commissioning Strategy will draw on one local Kingston Medical Services investment fund to support delivery of the Primary Care Commissioning Strategy. The local fund will be targeted at GMS practices in the first instance and is called GMS+. We recognise that both GMS & PMS practices in Kingston have been innovative. The commissioning strategy aims to embed the learning and best practice across all general 22