NHS Great Yarmouth and Waveney, North Norfolk, South Norfolk, Norwich and West Norfolk. Clinical Commissioning Groups

NHS Great Yarmouth and Waveney, North Norfolk, South Norfolk, Norwich and West Norfolk Clinical Commissioning Groups GPFV Norfolk and Waveney STP Workforce Plan (Narrative) 2017/19 V1 Draft

Version control Document Purpose: Authors Tracey Parkes, Senior Primary Care Workforce Manager Great Yarmouth and Waveney CCG tracey.parkes2@nhs.net Date Version Initials Summary of Amendments 29.9.2017 1 TP Review Date: Review Completed:

Contents Version control... 2 1 Forward... 4 2 Executive summary... 5 3 National Context... 6 4 Norfolk and Waveney local context... 8 5 Current and future models of care... 12 6 Workforce demand and supply... 22 7 GPFV workforce plan delivery... 25 8 Governance and assurance... 25 9 GPFV workforce plan review... 28 10 GPFV workforce initiatives... 28 11 GPFV workforce financial impact... 28 12 Appendices... 30

1 Forward Our local partnership approach The primary care workforce plan is submitted on behalf of the 5 Clinical Commissioning Groups (CCGs) across the Norfolk and Waveney STP who have worked in collaboration to co-produce this plan. The five CCG areas and their populations are listed below: CCG Area Population Size Great Yarmouth and Waveney 238,230 North Norfolk 172,895 Norwich 232,896 South Norfolk 238,086 West Norfolk 174,023 The five CCGs in Norfolk and Suffolk are committed to working together on the production and implementation of the key initiatives to develop primary care. We have also engaged with our local primary care clinicians, Health Education England, The Norfolk and Waveney Local Workforce advisory board, and Community Education Provider Networks and the Local Medical Committees (LMC). Ambitious plans have already been made to improve workforce across the Sustainability and Transformation Plan (STP) footprint areas. By collaborating to deliver key elements of the General Practice Five Year Forward View (GPFV), we will continue to further strengthen our strategic relationships. We believe that this will result in not only more efficient use of resources but that better outcomes for patients will be delivered through collaborative working, too. Norfolk and Waveney have proven experience of working together on integrated workforce projects. Examples include collaborative working led by our CCGs across NHS provider organisations and social care with county council and district council involvement leading to the development of integrated health and social care roles, job descriptions and competencies. In 2014/15, funding was also received via Health Education England for a Health and Social Care Workforce Transformation Lead. This project led to a number of innovative initiatives involving clinicians and Social Care professionals that have helped shape workforce plans for the future, including the development of a set of integrated working principles and the collation of workforce data across the Health and Social Care systems in Norfolk and Waveney to help inform our workforce plans. With its highly skilled workforce, effective multi-disciplinary teams and well-developed IT systems, the NHS is in an unparalleled position to develop a modern primary care system that is truly world class. The Future of Primary Care: Creating Teams for Tomorrow - Primary Care Workforce Commission We are pleased to introduce this Primary Care Workforce Strategy for Norfolk and Waveney. Primary Care is at the heart of the NHS and the public has high levels of trust in their GP and practice team. However, we know that Primary Care is under increasing pressure due to a growing number of patients with complex health needs and rising public expectations. Norfolk and Waveney CCG s have a clear vision for primary care to enable it to transform in a

way that is sustainable and fit for the future. Our Primary Care Strategy recognises that workforce development is a key enabler for primary care transformation. The Norfolk and Waveney Sustainability and Transformation Plan (STP) vision is to support people to live as full a life as possible with the maximum time at home and sets out our approach to improve health and wellbeing across the patch and remove health inequalities We are committed to working with our partners to develop a highly skilled, flexible workforce which can deliver the ambitious objectives detailed in the plan to provide more integrated services, closer to home. This means that we must support the primary care workforce to train, learn and work differently. We know that practices are finding it increasingly difficult to recruit GPs and Practice Nurses, so we will work collaboratively with our partners to make Primary Care in Norfolk and Waveney an attractive place to live, learn and work. Our goal is that practices can recruit and retain the best primary care professionals in the right numbers to meet local needs. At the same time, our aspiration is to expand the skills within primary care by developing new roles and new ways of working to complement the traditional general practice team. Norfolk and Waveney has a strong history of innovating and collaborating to improve the quality of services delivered in primary care. A number of activities and local projects have already been initiated to support the development of the primary care workforce, including the introduction of Clinical Pharmacists and physician associate roles into primary care and the development of a pilot for GP Careers Plus operating across a number of practices across Great Yarmouth and Waveney with a proposal to expand across all practices in the STP. 2 Executive summary Primary care has been described as the foundation of the NHS and general practice is at the heart of our communities. However, the demands on general practice are increasing, particularly for people with multiple, complex problems. The Five Year Forward View describes a vision for developing new models of care, with primary care working more closely with community services and hospitals to integrate services around the person and deliver more care closer to home. Following this, the recent General Practice Forward View defines a plan to stabilise and transform general practice to enable it to deliver high quality services as part of these new models of care. Alongside national drivers, the Norfolk and Waveney Sustainability Transformation Plan (STP) plan sets out a strategy to support people to live as full a life as possible with the maximum time at home. The development of an integrated care system across Norfolk and Waveney provides both opportunities and challenges for primary care. One of these challenges is a chronic shortage within the general practice workforce, specifically for General Practitioners and Practice Nurses. It is recognised that the transformation of primary care at scale and pace will not happen without workforce transformation. This Primary Care Workforce Development Strategy (for the purposes of this strategy, primary care refers to General Practice) describes how Norfolk and Waveney STP will enable the development of a multi-disciplinary workforce. This is built around the needs of a defined population, with the right knowledge, skills, values and behaviours to deliver high quality care within general practice, leading to increased choice, improved access and better outcomes for patients. The Strategy provides a comprehensive outline of how the five CCGs will work with partners within primary care and across the locality to:

Ensure the requirements are met for future supply of GPs, primary care nurses and the wider workforce Up-skill the current primary care workforce, including both clinical and non-clinical roles Develop new roles and new ways of working within the general practice team Develop primary care leadership and support cultural change This Strategy sets out how Norfolk and Waveney STP will support providers to develop their workforce and ensure that there is sufficient capacity. It will also have an effective skill mix to deliver emerging new models of care. National and local strategies are demanding more out of hospital care, meaning that primary care will need to collaborate with partners to develop new models of care as part of an integrated health and social care system. However, the demands on general practice are increasing, particularly for people with multiple, complex problems. Workload projections suggest that older people with long term conditions, including people with frailty, will be the major source of increasing work for primary care in coming years. In addition to this, patients and the public have rising expectations in relation to access and treatment. The situation is amplified by chronic shortfalls in the general practice workforce, specifically in terms of numbers of general practitioners (GPs) and practice nurses. Our Primary Care Strategy recognises the need to support and develop primary care to deliver a service that addresses its population needs and to ensure that it is sustainable for the future. The strategy highlights that workforce development as a key enabler for primary care transformation. This Primary Care Workforce Strategy sets out how Norfolk and Waveney CCGs will support and enable primary care providers to develop a multi-disciplinary workforce, in the right numbers with the appropriate knowledge, skills and values, to provide high quality primary care for the residents of Norfolk and Waveney. 3 National Context The Five Year Forward View, published by NHS England in 2014, sets out a new shared vision for the future of the NHS based around new models of care. It describes how the NHS needs to adapt and evolve to meet new challenges of people living longer with more complex health needs, and to take advantage of the opportunities that science and technology offer patients, carers and those who serve them. It specifically seeks to address gaps in three areas: The health and well-being gap The care and quality gap The funding and efficiency gap The Five Year Forward View emphasises that primary care will remain the foundation for the NHS, but recognises that a new deal is needed to expand and strengthen general practice. The GPFV strategy also sets out the need to reduce the divide between primary care, community services and hospitals to integrate services around the patient and highlights how primary care is a key element within new models of care, whether these are multi-speciality community providers or primary and acute care systems. The Forward View acknowledges the need for a suitably skilled workforce to deliver these new models of care. It highlights that whilst there has been a growth in the overall healthcare workforce since 2000, this growth hasn t been equitable across all parts of the system, with

hospital consultants having increased around three times faster than GPs. The new deal for general practice includes a commitment to expand as fast as possible, the number of GPs in training while training more practice nurses and other primary care staff. General Practice Forward View Building on the Five Year Forward View, the General Practice Forward View, published by NHS England in 2016, sets out a plan to stabilise and transform general practice through additional investment and support in relation to workload, workforce, infrastructure and care redesign. The document sets out how NHS England, in partnership with Health Education England (HEE), Royal Colleges and other stakeholders, will grow the GP workforce whilst accelerating use of the wider, multi-disciplinary workforce. It sets out a bold ambition to create an extra 5,000 doctors in general practice and a further 5,000 non-medical staff over the next 5 years. In relation to the GP workforce, the Forward View describes plans to increase recruitment and retention of GPs by: Increasing training capacity Promoting general practice as a career choice Offering flexibility of career paths Supporting post CCT (Certificates of Completion of Training) fellowships Developing a new portfolio route for GPs with previous UK experience Addressing workload concerns to support GPs to stay in practice Investing in leadership development, coaching and mentoring skills Offering targeted financial incentives to GPs to work in areas of greatest need The plan recognises that the success of general practice in the future will also rely on the expansion of the wider non-medical workforce, including investment in nurses, pharmacists, practice managers and administrative staff and the introduction of new roles, such as physician associates and medical assistants. The plan describes how NHS England and HEE will: Invest in general practice nurse development, including support for return to work schemes, improving training capacity in general practice and increasing the number of pre-registration nurse placements Extend the clinical pharmacist programme to enable every practice to access a clinical pharmacist Invest in additional mental health therapists to work in primary care Provide funding to support reception and clerical staff to play a greater role in care navigation Invest in practice manager development Health Education England Workforce Plan The role of Health Education England (HEE) is to provide system wide leadership and oversight of workforce planning, education, and training. The overarching aim of HEE is to support the delivery of excellent healthcare and health improvement to the patients and public of England by ensuring that the workforce of today and tomorrow has the right numbers, skills, values and behaviours, at the right time and in the right place. In addition to investment into GP training, HEE acknowledges that a wider, multi-professional workforce is required in primary care. The Workforce Plan highlights that new clinical roles such as Physicians Associates, Clinical Pharmacists and Paramedics and the creation of the

new administrative support roles will ensure an integrated, diverse workforce for the emerging service models. The Future of Primary Care Creating Teams for Tomorrow In 2015, HEE commissioned an independent review of the primary care workforce, led by Dr Martin Roland. The Primary Care Workforce Commission was asked to identify workforce solutions that would meet present and future needs of the NHS primary care workforce. Through the submission of evidence, site visits and conversations with local and national organisations, the commission found that many areas had created new and innovative ways of working and recommended that these examples of good practice be rolled out more widely. The report The future of primary care creating teams for tomorrow includes three key recommendations A multi-disciplinary workforce. The report sets out how new clinical and support roles can enhance the skill mix in primary care. It specifically highlights the contribution that clinical pharmacists, physician associates, physiotherapists, paramedics and medical assistants can make to patient care within general practice Better use of technology. With advances in technology, the report emphasises that education and training will need to reflect the different skillsets required for alternative forms of consultation Organisational changes to the NHS primary care system. The commission recommended that networks or federations of practices will enable primary care to offer a wider range of services, as well as better opportunities for staff development and training and the creation of new roles. It also highlighted that the primary care workforce has historically been relatively unengaged in NHS opportunities for leadership development and that this must be readdressed 4 Norfolk and Waveney local context National data demonstrates that Norfolk and Waveney has some of the lowest GP provision in the country, with the geographically challenged rural locations impacting the desirability of working in the region. The aging population demographics are increasing primary care workloads, but the workforce is shrinking. For various reasons including workload, income, pension changes and demography, we are facing accelerated loss from the primary care workforce, including both GP and nurse positions. At the same time, intake to GP training schemes is suboptimal across the East of England and across the EoE the number of training programmes have been expanded in an attempt to offset the accelerated losses but with newly trained doctors choosing not to train as GPs, the loss rate is resulting in a shortfall of GPs to meet the needs of the NHS. Whilst historically GPs look after an average 2,000 patients, the workforce challenges will require this figure to be closer to 3,000 in the future and as such practices will need to adopt new methods of working. Locally the practices feel the challenges are around practices dependant on locums rather than substantive staff, restricted hours and shared cover arrangements, decreasing access for patients to their own GPs and mergers and acquisitions of practices. Significantly it is increasing the stress on the partner pool we still have, thus accentuating the workforce challenges. As part of the GPFV planning across Norfolk and Waveney, workforce data has been reviewed to determine the requirement in line with both local demand and the national target

of recruiting 5000 extra GPs in primary care. With this, it has been determined that the East represents 8.8% of the national requirement of which Norfolk and Waveney represent 23% Of the total East requirement (this is based on population data as shown in the table below). CCG Estimated registered population % of total population NHS Great Yarmouth and Waveney CCG 238,230 5% NHS North Norfolk CCG 172,895 4% NHS Norwich CCG 232,896 5% NHS South Norfolk CCG 238,086 5% NHS West Norfolk CCG 174,023 4% By using this data, we can determine that Norfolk and Waveney will require an additional 88 WTE GPs to meet the national target. This does not take into account retirement and other leavers which gives an even more challenging recruitment target of 234 WTE GPs. This is somewhat better if we take into account the number of newly qualified GPs forecast to be available to the system which gives a recruitment target of 106 WTE. However the figures do not take into account a rising population with more chronic conditions. Please see appendix 1 for further information on the CCGs individual workforce data summary. The chart and table below outlines the data commissioned by the Norfolk and Waveney Local Workforce Advisory Board which shows the current health and social care workforce profile in Norfolk and Waveney. Over half of the workforce works in social care. This highlights the importance of engaging this sector in discussions about future changes. The numbers exclude the large range of unpaid workers, such as informal carers and volunteers. Sector Staff in Post FTE Mar'17 % Vacancy Mar'17 Acute 11,882 7% Ambulance 932 4% CCG 267 n/a Community 3,154 8% Mental Health 2,180 13% Primary Care 2,674 9% Social Care 28,000 6% (Sep 15) Total 49,090 8% (NHS) 57% Staff in Post by Sector, Mar'17 24% 6% 4% 2% 1% 6% Acute Ambulance CCG Community Mental Health Primary Care Social Care Source: Staff in Post: ESR (Mar 17), General Practice Tool (Mar 16), Skills for Care NMDS (Sep 15); Establishment forecast for Mar 17: NHS Trust Operating Plans (Dec 16), Workforce Plans (Jun 16) (Vacancies = Establishment Staff in Post) The diagnostic review commissioned by the Norfolk and Waveney Local Workforce Advisory Board highlighted the following local workforce challenges: General practices have difficulties recruiting GPs due to high retirements and low local training fill rates especially in West Norfolk and Great Yarmouth & Waveney. Current GP vacancy levels are around 10%. Increasing NHS Vacancies 1,500 FTE posts were vacant in March 2017 (8%), including 500 nursing and 200 medical posts. Mental Health, Community and

Great Yarmouth & Waveney are particularly affected. Current vacancy hotspots: A&E Doctors (23%), Acute Medicine (20%) and Diagnostic Radiography (18%). Nursing and medical workforce supply shortages are predicted to continue over the next 3 to 5 years based on current service and supply models. Forecast supply gaps for year 2021, especially in Psychiatric Nursing (27%) and Paediatric Surgery (48%), Acute Internal Medicine (35%), Child & Adolescent Psychiatry (31%) and Dermatology (28%). Forecast over-supply of Psychologists, Midwives and Paediatrics Consultants. Ageing workforce imminent retirements. Nearly a quarter of carers and 17% of adult nurses are due to retire in the next 5 years. Medical retirement hotspots: Psychiatry (30%), Obstetrics & Gynaecology (27%), Medicine (19%) and General Practice (23%). Retention/avoidable losses (non-medical) In 2016/17, 9% of NHS staff leavers left for a better work-life balance, 7% for promotion elsewhere and 2.5% cited lack of opportunities. Work-life balance is a particular issue for clinical support staff (11% left for this reason). Social care turnover is particularly high (28%), especially domiciliary care worker (46%). 19% of paid carers leave social care with no job to go to. Over-reliance on international recruitment and agencies to fill supply gaps. - Need to look at alternative solutions due to Brexit and caps on migration and agency spend. Shrinking pool of potential young employees (number of 15-24 year olds is predicted to reduce by -4% over 5 years, whilst the total population is expected to grow by + 3%). - A more targeted approach is needed to attract young people to health and social care. Need to use the workforce more effectively to deliver savings, review skill-mix to bridge supply gaps and clarify future service delivery models and join up plans across health and social care to determine longer term workforce demands. NHS operating plans forecast -5% reductions in posts over next 5 years to meet financial challenge (above Midlands & East average of -3%), whilst the population is expected to grow by 3%. The above data highlights workforce challenges across all areas of health and social care and these together with some more specific changeless in primary care highlighted below need to be considered as key interdependencies. Workload in practice has increased substantially in recent years and has not been matched by growth in either funding or in workforce creating the following challenges; Current supply does not meet demand A four year or longer time lag until new professional clinical workforce supply is created Practices are finding it increasingly difficult to recruit and retain GPs. GPs reaching the end of their careers are choosing to retire early in response to workload pressures GPs have also been affected by changes to the tax treatment of pensions which create disincentives to work when the lifetime allowance for pensions has been reached. Deprivation Rurality Differing financial position of practices, largely linked to dispensing non-dispensing Ageing workforce

Increasing workload leading to GP burnout and a reluctance for clinicians to work full time Increased tendency towards part time or portfolio careers for GPs Rising indemnity costs are off-putting for clinicians Intake to general practice schemes is dropping, with recent schemes being undersubscribed Dependency on locum workforce, which causes a decreased access for patients to see their own GP and increases stress on partner pool Primary care workforce data collection The Health and Social Care Act 2012 places a duty on all organisations that deliver care funded by the NHS to provide data on their current workforce and to share their anticipated future workforce needs. NHS England has developed a workforce census module within the Primary Care Web Tool (PCWT) which practices can use to fulfil the requirements of the workforce minimum data set and provide details of their current workforce. In the East Midlands, HEE has also developed a General Practice Workforce Data Collection tool, which feeds directly in to the WRaPT tool. This collects workforce information which meets the requirement of the minimum data set (as above), but also collects additional data around roles, skill sets and vacancies. The HEE GP Workforce Tool therefore provides a richer level of information and for this reason, practices across Norfolk and Waveney have been encouraged to submit their workforce data through this method. Practices are currently asked to refresh their workforce data every six months. The CCGs have worked closely with the Health Education England (HEE) team using their new primary workforce care tool as this allows many more parameters to be adjusted to reflect our particular skill mix, including locums, etc. Their conclusion was: The basic (default) scenario forecasts a shortfall for GPs in the East of England area: the supply will grow at 4% whereas the population-based demand will grow at 9% over the next 5 years, which means the gap will worsen without workload transfer / role substitution or recruitment schemes. Workforce modelling tool Under the current HEE modelling assumptions, the forecast for Norfolk and Waveney STP is a shortfall of 106 GPs, the breakdown of supply elements is provided in the table below. A number of recruitment measures are being planned to bridge the gap of 106 FTE, these include: 50 GPs to be recruited through the international recruitment scheme over the next 2 years; plus additional 20 GPs to be recruited through the international recruitment scheme as part of phase 3; On the retention side, it is expected that some GPs, who would otherwise retire or leave the profession, could be retained on a part-time basis contributing around 15 FTE to the supply as a result of the implementation of the GP Careers+ initiative. Further measures and the exact figures will be included in the final workforce plan to be submitted by 31 October. Meeting set up on the 5 October to work with HEE to match our initiatives with target numbers. Planning period of 3.5 years from baseline of March

2017 baseline, March 2017 561 other leavers -59 retirements -87 newly qualified joiners 124 forecast supply 539 target 645 shortfall to recruit to meet the target -106 5 Current and future models of care Across Norfolk and Waveney we are working closely with our practices to develop new models of care. The table below summarises the key areas we are working on which are linked with the 10 impact actions. Each CCG is exploring different models of delivery for primary care at scale such as locality and federation models depending on the needs of the local population. As an STP we are committed where we can to deliver new models of care at scale where appropriate. Please see appendix 2 for further details on each CCGs approach to new models of care across Norfolk and Waveney. High Impact Actions STP workforce Initiatives Active signposting New consultation types Reduce Did Not Attend (DNAs) Develop the team Productive work flows Personal productivity Partnership working Social prescribing Support self care Develop QI expertise Care Navigation and Active Signposting for Reception Staff Project New Consultation Types Project, Patient OnLine Project Patient OnLine Project, Improved Access Project, Eclipse Project Building Resilience in the General Practice Workforce Project, Pan-locality nursing team, CEPN led workforce training and development, New role development i.e. Clinical Pharmacists, Physician Associates e-prescribing Project, Digital Clinical Communication Project, GPwSI led community respiratory clinic, Workforce optimisation project - GP letters Productivity project, Primary Care home team New Model of Care and Associated Operational Projects, Enhanced Care in Care Homes Project, Shared Patient Record Project GP based Social Prescribing pilots Community Assests Project, Telemedicine Self-Management Project Clinical Variation Project, Eclipse Project New delivery models Across the patch we are working on new models of care and as individual CCGs we are developing new models as described below.

Within Great Yarmouth and Waveney we are working with our practices looking to work closely together across 4 geographical localities, one locality is developing plans to extend their newly launched urgent care team. The team is based at a hub practice, but cares for patients from three sites. The UCT is made up of a paramedic, nurse practitioner, physician associate, mental health nurse, ED nurse and lead doctor, with two additional doctors on standby to help out during busy periods. Time for Care Programme: This four-week pilot encouraged people to self-care to free up GP appointments for those in greater clinical need. It saw receptionists refer 100 people to their local pharmacy if they rang to book an appointment for a condition they could care for at home. Of these patients, only 45 got back in touch with the practice later to say they still wanted an appointment, which means 55 were able to receive the care they needed at the pharmacy, in turn saving around 10 hours of doctors time. The results of the pilot are now being analysed in more detail to find out more about the conditions which prompted patients to return later for an appointment and why. Bringing services closer to patients: The hubs are working together to try and bring services closer to home so that deprived communities can access them more easily. Several examples of this are already in place; such as one practice, which hosts Norfolk Recovery Partnership, tuberculosis and retinal screening clinics. We are also exploring with some practices where the number of GP s to patients is reaching 1:4000, the idea of developing GP teams consisting of a lead GP, Advanced Nurse Practitioners and Health Care Assistants and supported by mental health workers, social prescribers and care navigators. Locality posts A number of localities have looked at shared posts to address high activity or managing excessive workload. One such idea is to recruit an Advanced Nurse Practitioner to support housebound patients across 6 practices. Practices within South Norfolk CCG s Mid Norfolk locality are working together at scale to share workload, develop services and improve resilience within their locality. They are taking steps towards becoming a legal entity (Mid Norfolk Health Ltd) to enable them to better serve their patients, and to develop a single voice for Mid Norfolk. Successes to date include a new pan-locality nursing team that visit care home residents. The team are based in one of the surgeries but visits patients from all locality surgeries to provide an at-scale resilient resource. The Breckland Alliance new model of care within South Norfolk CCG. This involves practices from the Breckland locality working together to support each other and to provide resilience against the rising demand, and to enable them to explore new ways of working to meet the challenges within primary care. In 2016 Breckland Alliance became a Primary Care Home pilot site and the practices are now building on the outcomes from this. Within North Norfolk CCG all 19 practices have come together to form North Norfolk Primary Care Ltd, a legal entity that will be able to develop services and enable working at scale through collaborative working. By working together the practices will have a strong, single voice that will enable them to affect the changes required to develop primary care services and meet the rising demand within North Norfolk.

Using the PMS to GMS funds North Norfolk have developed a GPwSI led community respiratory clinic service that all practices can refer into. The service is hosted on a rotational basis by practises and patients may visit the most convenient location. In South Norfolk the PMS to GMS funds were allocated to each of the four localities, who developed the following proposals: All 21 GP practices in West Norfolk have committed to working collaboratively through a company to which they are all members West Norfolk Health Ltd. West Norfolk CCG and West Norfolk Health Ltd have already been working together to develop plans for the future and see the GPFV as being a supportive tool in this regard. Many of the requirements of the GPFV will be delivered as a result of this working relationship. A key area of focus within the GPFV is the professional development of the existing workforce. OneNorwich GP Alliance Norwich is leading a series of Training Needs Analysis (Doctors, Nurses and Practice Managers). This will identify local training gaps and provide a scope for planning future training requirements. This will be undertaken with the support of a local and STP network and within the context of a strengthened joint-working relationship with Health Education England, via the establishment of a Central Norfolk Community Education Provider Network (CEPN). This project will support a system wide plan to access training and maximise funding opportunities. Expanding capacity within the Future Norwich General Practice Workforce is a key area of focus within the GPFV is to provide additional capacity and improve patient access to core services in line with local population needs. Locally validated data indicates that 26% of the current GP workforce in Norwich is over 54 years of age and due to retire from practice within 5 years. Similarly, 38.5% of the current Nurse Practitioner and Practice Nurse workforce in Norwich general practice are over 54 years of age and due to retire from practice within 5 years. This data highlights a significant risk to the success of the delivery of the New Model of Care, should the existing skilled workforce decline significantly. This project will support a system wide plan to create a clear specification for the Norwich General Practice workforce which utilises local, National and International recruitment opportunities and aligned with the shape of new, innovative, evidence-based models of delivering care. Opportunities for integrated working across healthcare provision in the community will also be key to strengthening our approach to building sustainability. Please see appendix 2 for further details of CCG initiatives across Norfolk and Waveney. Workforce Implications of proposed model of care Novel roles in primary care are being developed nationally and our area is also introducing new roles, alongside efforts to improve and increase the retention of the GP workforce, and increasing primary care nurse training. The CCG will help our practices to make the most of opportunities available through developing a new workforce, ensure it is established, and operating in a more effective way. This will require a certain amount of organisational development for some practices to help them alter workflows and integrate new roles into their teams. New ways of working

Introducing new roles into the general practice team will provide additional capacity in primary care. In addition to this, there are several options which will reduce demands on GPs and other clinical staff through new ways of working. The CCGs would wish to identify and explore options for new ways of working with primary care providers and other stakeholders. Currently the CCGs are exploring a number of new roles to support practices and GP workload including the following; Clinical Pharmacists There has been considerable interest over the last few years in the role of clinical pharmacists within the general practice team. Pharmacists are able to support patients to self-manage their well-being and long term conditions, through optimising medicines, and enabling improved medicine related communication between general practice, hospital and community pharmacy e.g. on admission and discharge and at other interfaces of care. This therefore means that GPs can focus their skills where they are most needed and frees up GP time. The Primary Care Workforce Commission recommended that there should be greater involvement of clinical pharmacists, including prescribing pharmacists, in the management of people on long-term medication and people in care homes. This role is best carried out in the GP practice in order to allow full access to the patient record and to maximise interaction between the pharmacist and other clinical staff in the practice. NHS England is rolling out a general practice clinical pharmacist programme and, through the General Practice Forward View, has committed to a further roll out of this scheme. Currently as a system there are 8 clinical pharmacists employed and commitment to bid for more clinical pharmacists as detailed in our plan. Physician Associates A physician associate is a new healthcare professional who, while not a doctor, works to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and treatment within the general practice team under defined levels of supervision. Physician associates provide generalist clinical care in general practice, typically seeing people with acute minor illness. They have two years post-graduate training, following a minimum of a 2:1 science degree. This training follows the model of a medical qualification. Working under the supervision of a GP, physician associates can make a significant contribution to practice workload The development of an MSc Programme in Physician Associate studies at the University of East Anglia (UEA) was a regional response to the workforce challenges facing primary care. The first course is being funded by Health Education England and commenced in 2016. We have secured primary care placements in 2017 and will continue to promote permanent employment to this new role. Although we do have a few Physician Associates in our practices this is where there is a real opportunity to recruit new recruits into primary care. In recent years the new graduates have been recruited by the acute sector because primary care have not committed to roles. Further engagement into the potential of this role is required and will form part of our action plan. Paramedics Paramedics are autonomous practitioners who are registered with and regulated by the Health and Care Professions Council. The Paramedic Career Framework (2015) recognises that many paramedics are now moving away from the traditional ambulance.

Service roles are to work in primary and critical care, including out of hours services, general practice, walk in centres and emergency departments. Paramedics are experienced in prehospital care and are able to assess, diagnose, treat or signpost patients. Paramedics have many clinical skills which are transferable into primary care and have well developed communication skills including supporting patients to self-manage their condition, where appropriate. A number of community and primary care paramedic services have developed across the United Kingdom. Within general practice, there are a number of options for utilising paramedics as part of the primary care team. This may include running clinical sessions, including pre-booked and urgent appointments, telephone triage and home visits. The Primary Care Workforce Commission highlighted that the potential for paramedics to substitute for GPs in the assessment of urgent requests for home visits merits further evaluation. Again this is an area where further exploration and action could see real benefits. Mental health workers Mental health problems are widespread and mental health and physical health are often linked. Many people presenting to general practice have primary mental health needs or secondary mental health problems associated with their physical conditions. As well as impacting on physical health outcomes, individuals with mental health problems are less likely to engage in school or employment, leading to an impact on wider public health services and resources. Nine out of ten adults with mental health problems are treated in primary care, although the primary care workforce may not always feel it has the appropriate level of knowledge and skills to care for these people effectively. Resources for primary care practitioners have increased through the development of IAPT (Improving Access to Psychological Therapies) services, and in some areas nationally, the attachment of primary care mental health workers to practices. The General Practice Forward View has set an ambitious target to ensure there are an extra 3,000 mental health workers in primary care by 2020, providing an average of a full-time therapist for every 2-3 typical sized practices. In addition to this new resource, the primary care workforce needs to be trained to ensure they are fully supported to lead the delivery of multi-disciplinary mental health support in primary care. General practices need links to mental health advice for the wide range of psychological problems seen in both adults and children in primary care. In Norfolk and Waveney there are established pathways of care for people requiring IAPT services and for those with higher level mental health needs. The development of the integrated care system in Norfolk and Waveney provides opportunities to join up general practice, community services and mental health services to provide new models of care delivery for patients with low level mental health needs, through an integrated approach to physical and mental health. We are exploring with NHS England how we can access support to introduce more mental health therapists into practice and will bid for IAPT transformation funding in 2017/18, but in the meantime we have recently confirmed mental health representation on our CEPN Steering Group, this has been really positive and productive. The New Ways of Working CEPN work stream has been working with NSFT to progress a joint post for a Mental Health Practitioner in primary care. In addition to this, our social prescribing pilot has been working well and patients with unmet socio-economic needs such as anxiety through stress are being supported. Health Education England has recently organised some free mental Health training across Norfolk, Suffolk and North Essex we advertised this in our monthly newsletter to encourage participation. To support this, the CEPN is currently exploring

upskilling the workforce in mental health by looking at the facilitation of Mental Health First Aid courses for primary care staff so that they can recognise and understand mental health issues. It is recognised that identifying and treating mental health problems such as depression can impact health needs; releasing time for care. External course providers are being explored such as https://mhfaengland.org/. Physiotherapists Musculoskeletal (MSK) conditions make up to 30 per cent of a GP s caseload, rising to 50 per cent for patients over 75. There is increasing evidence of the role that physiotherapists can take as part of primary care teams to support the management of MSK problems. Physiotherapists are autonomous practitioners able to assess, diagnose, manage and discharge patients. Increasing numbers of physiotherapists are independent prescribers and are able to administer injections or prescribe drugs as part of a treatment plan. However, rapid referral to physiotherapy reduces levels of medication and therefore having access to physiotherapy as part of the primary care team can help to reduce levels of unnecessary prescribing. As autonomous practitioners, physiotherapists can be accessed through self-referral schemes, reducing the demand on GPs. This streamlines pathways of care and saves time and money. Self-referral schemes in physiotherapy have been well evaluated and have been shown to reduce DNAs, increase access, reduce administration costs and increase patient satisfaction. One evaluation found that 85% of MSK patients seen by a physiotherapist in primary care did not need to see a GP. Norfolk and Waveney is keen to identify approaches to enabling patients with MSK problems to access physiotherapy in a more timely and effective way at a location which is easily accessible to them. Self-referral to physiotherapy is one area which is currently being explored and as part of this, the CCGs will consider where these services may be located. Increased collaboration across primary care providers, as part of the development of localities, may offer opportunities to co-locate physiotherapists in practices or for primary care providers to employ them directly. In addition to this, the integrated care system brings opportunities to develop new pathways of care for patients with MSK problems and the CCGs will work collaboratively with secondary care providers to identify where the development of physiotherapy roles may enhance primary care MSK provision. Advanced Practitioners Over recent years, the Advanced (Clinical) Practitioner has become more important in primary care and both the Primary Care Workforce Commission and the General Practice Forward View highlight the contribution that non-medical clinicians with advanced level skills can make to the general practice team. An Advanced Practitioner is an experienced, non-medical, registered professional who has developed their theoretical knowledge and clinical skills to a high standard. Advanced Practitioners bring a unique skill mix to general practice teams, provide patients with a broader range of choice and add capacity to service delivery to better meet demand. They work in addition to, and together with, GPs and the wider practice team. A number of our localities have recognised this role as having an important role in a practice team and are exploring funding opportunities to recruit into a locality. Developing the non-clinical workforce The success of general practice in the future will rely on the development of the wider, nonclinical workforce and we recognise the contribution that practice managers, receptionists and other non-clinical roles make to the practice team. The administrative burden on primary

care clinicians is well documented and it is estimated that GPs spend 11% of their time on administration. The future of primary care creating teams for tomorrow suggested that new support roles have the potential to reduce the administrative workload of GPs and other clinicians. Historically, the development of this part of the workforce has been overlooked and practice managers have found it difficult to identify appropriate education and training programmes to develop this part of their workforce. Our vision for the primary care workforce is inclusive of non-clinical roles and therefore the CCGs are committed to supporting the development of this part of the workforce. Practice Managers Practice managers provide a crucial senior administrative function within general practice and, although the role can vary from practice to practice, they are usually responsible for a number of key activities including business planning, handling financial systems including payroll, selecting, training and supervising non-clinical staff and the effective use of data and information. Practice managers can gain relevant qualifications through external accredited providers, such as AMSPAR (Association of Medical Secretaries, Practice Managers, Administrators and Receptionists) which offers a Certificate/Diploma in Primary Care and Health Management or the ILM (Institute of Healthcare Management) which provides the Vocational Training Scheme for General Practice Managers. Funding for practice manager development was awarded to the LMC for 2016/17. A training needs analysis was undertaken by our local CEPN with practice managers with a view to developing a training programme for them in 2017 which could be funded by GPFV monies as described. Administrators Administrative roles within general practice are often used as an entry point into the primary care workforce and can be used as a foundation for career development into other roles. Practices cite that they are keen to develop their administration and reception staff into healthcare assistants or into more senior administration roles. We are keen to implement an apprentice model as below to facilitate some of this. Apprentices Apprenticeship programmes can be a cost-effective means of creating a skilled, flexible and motivated workforce. These programmes can also help improve the diversity of the workforce and provide employment opportunities for the local community to enter the healthcare sector. Apprenticeships are work-based training programmes available to anyone over the age of 16. They enable learners to demonstrate their competence while gaining a recognised qualification, which span a range of levels from level 1 (GCSE equivalent) to level 7 (Masters level), achieved through a mix of on the job training and study, whilst at the same time being in employment. The government is committed to increasing the growth of apprenticeships and there is a commitment to achieve 3 million apprenticeship starts in the UK economy by 2020. To facilitate this there has been major changes in apprenticeship national policy and the introduction of some significant reforms. All public sector organisations will have a legal duty to support apprenticeship starts and will be set a target of 2.3% of their workforce. In addition to this, in April 2017 an annual Apprenticeship Levy was introduced and applied to all organisations with a pay bill of 3m or more. Whilst apprenticeships are well established in NHS Trusts, there has been less use of these programmes in primary care, so a targeted approach is currently being deployed by HEE to increase the numbers of apprenticeships within this sector. We recognise the opportunity to

utilise apprenticeships to develop the skill mix within primary care and to specifically develop the non-clinical workforce, including practice managers. The CCGs will work with primary care providers, HEE and education providers to enable an increased usage of apprenticeships within primary care and to support the government s ambition and targets. Important part of our Grow your own programme where we see Health Care Assistants moving through career paths up to Advanced nurse practitioners if they have the skill and support. Medical Assistants Excessive administration in general practice is a major problem and many GPs cite that nonclinical workload is a major factor in them leaving primary care roles. It has been estimated that GPs spend 11% of their time on administrative duties, which could be delegated to other parts of the workforce to enable GPs, and other clinical staff, to focus more time on direct patient care. The Medical Assistant role has been used in American and Australian primary care to provide appropriate skill mix solutions to the demands on GPs. Medical Assistants are trained to perform both clinical and non-clinical duties to support GPs. The future of primary care creating teams for tomorrow report identified Medical Assistants as a key area to pilot and evaluate its impact in primary care. We will continue to work with HEE and primary care providers explore opportunities which this type of role could bring to primary care. Asset-based care and care navigation Socio-economic factors account for 50% of the determinants of health and social isolation is one of the biggest health risks. It is known that GPs spend a fifth of their consultation time on non-health problems. As demand on general practice continues to grow, more interest is being taken in an asset based approach to health and well-being. The aim of asset-based practice is to promote and strengthen the factors that support good health and wellbeing, protect against poor health and foster communities and networks that sustain health. An asset based approach identifies the skills and capabilities within local residents and communities and connects these assets into more formal groups to build strong relationships and reciprocal social networks. The ultimate aim is to mobilise local people to act on the things they care about and want to change. Norfolk and Waveney has a strong sense of community cohesion and a well-developed voluntary, community and social enterprise sector across a lot of it. However, general practice is not yet sufficiently linked into these community assets to take full effect of them. Current projects have commenced across our patch which are in the pilot stages which will being reduce pressures on the primary care system by signposting the population to more appropriate services. Care Navigators or Community Champions are people who are trained to assist patients and member of the public to identify appropriate support services without needing to see a GP. There are different approaches to developing care navigators within general practice. One option is to recruit additional people to work in the practice to specifically undertake a care navigator role. Another option is to up skill the current workforce e.g. reception staff to develop a wider care navigation function across the team. For those individuals with higher needs, a shared point of access can streamline the process to connect people with the services they need. A number of our CCGs are currently developing a training package to support an asset based approach within primary care. This will offer different levels of development for the primary care workforce to support asset based care, care navigation, social prescribing and well-being coaching.