Indemnity Welcome! PCN South East Event - PowerPoint Presentation

1. IndemnityWelcome!PCN South East Event

2. IndemnityPrimary Care Networks The ContractEd WallerNational Director | Strategy and Innovation NHS England

3. Investment and evolution:A five year framework for GP contract reform to implement The NHS Long Term Plan

4. 4Published in January 2019 by NHS England and the BMA General Practitioners Committee in England Five year framework: 2019/20 GMS Contract changes and joint proposals for the four subsequent yearsThe Framework sets direction for primary care and seeks to address the core challenges facing general practice.A five year framework for the GP services contractSummary of agreement Addresses workload issuesBrings a permanent solution to indemnity costs and coverageImproves the Quality and Outcomes Framework Introduces a new Network Contract DESHelps join-up urgent care servicesEnables practices and patients to benefit from digital technologiesDelivers new services to achieve NHS Long Term Plan commitmentsGives five-year funding clarity and certainty for practicesTests future contract changes prior to introduction

5. Investment 5Resources for primary medical and community services will increase by over £4.5 billion by 2023/24.Funding for the core practice contract is fixed for each of the next five years, and increases by £978 million in 2023/24.In 2019/20, indemnity expenses are removed and there is a 1.4% uplift to practice contract funding. This includes:Pay uplift Expenses uplift, including £20m for subject access requests 1% linked to 2018/19 pay uplift and contract agreement in 2019, via SFE£105m Funding for practices to engage in establishing networks, via the SFE£30m into GS as part of extended access changes and NHS 111 direct booking£5 per patient MMR catch-upUplift to S7a immunisation programmes (e.g. flu) in line with other immunisations Up to £1.799 billion will flow nationally through the Network Contract DES by 2023/24. This will include funding for the new additional role reimbursement scheme, network support and access

6. IndemnityIndemnity

7. Indemnity7The new Clinical Negligence Scheme for General Practice will start from 1 April 2019. It will be operated by NHS Resolution. From 1 April 2019 everyone working in general practice will be automatically covered for all liabilities from clinical negligence in general practice. There are no membership or registration requirements.Coverage of the scheme will extend to all GPs and all other staff working in delivery of primary medical services. This covers all GPs (including salaried and locum) and all other staff working in general practice (including the new network workforce) All NHS work is covered. This includes out-of-hours, local authority, public health etc. Individuals will still need MDO cover for private work, professional services and additional advice. There will be a one-off permanent adjustment to the global sum figure that takes account of the existing contributions from general practice for indemnity.Investment in the practice contract overall will still rise by 1.4% in 2019/20, accounting for the indemnity change.As per last two years, payments will be made direct to practices to fund the increase in fees for the previous year (i.e. via SFE on an unweighted per patient basis).

8. IndemnityQOF

9. In line with the findings of the QOF review (published July 2018), 28 indicators will be retired from April 2019. These account for 175 points and 31% of QOF:COPD (annual FEV1 and O2 stats)Dementia (test results)Diabetes (middle HbA1c target, see next slide)Mental health (cervical screening test, lithium)Osteoporosis (both indicators)Stroke and transient ischaemic attack (record of referral)Palliative care (3 monthly MDT case review meetings)Peripheral arterial disease (BP, anti-platelet)Smoking (providing literature and therapy)Contraception (removed in full)Cervical screening (protocol and audit)9QOF indicators removed

10. In line with the findings of the QOF review (published July 2018), 15 indicators will be added or amended, accounted for 101 points:Blood pressure (CHD, HYP, STIA) – split for ≤79 (140/90), ≥80 (150/90)Diabetes indicatorsamended to account for moderate and severe frailtycholesterol target replaced by prescription of statinMental Health indicator to record BMI instead of alcohol consumptionCOPD – offer of referral to pulmonary rehabilitationCervical screening – split for ages 25-49 and 50-54 – in line with 3 and 5 year recall frequency. The QOF point value will increase by 4.7% to £187.74. This is to reflect increased list size and population growth.10QOF indicators introduced

11. Personalised care adjustments will be introduced, replacing exception reporting. This will allow practices to differentiate between five reasons for adjusting care and removing a patient from the indicator denominator. Practices will be required to use more personalised correspondence with patients when sending invitations for care, including using the patient’s preferred method of communication. Practices will be required to send two invitations for care, rather than three as presently (except for a few exceptions).74 points will be used to create a new Quality Improvement domain. For 2019/20, the modules will cover prescribing safety and end of life care. These topics will change on an annual basis. 11QOF personalisation and quality improvement

12. IndemnityPrimary Care Networks

13. Practices will be offered a new Network Contract – this is a Directed Enhanced Service (DES).The DES will provide funding for practices to form and develop networks, as well as for additional workforce and services to be delivered by the network.Networks will cover a typical population of 30-50,000 patients. There will be flexibility if required over or below this (for rurality). Networks can be structured in a number of ways depending on how the network members wish to employ staff and work togetherAll Networks will have a Network Agreement. It will outline how the practice will work together, how funding will be allocated and how services and workforce will be shared. A template will be provided for this. CCGs and Integrated Care Systems will play a role in approving the formation of networks and commissioning services they will provide as well as providing ongoing support.CCGs to provide £1.50/head in cash to support PCN development from the general allocation19/20 is a set up year.13Primary Care Networks

14. Through a new Additional Roles Reimbursement Scheme, Networks will be guaranteed funding for an up to estimated 20,000+ additional staff by 2023/24:Clinical pharmacists (from 2019/20)Social prescribing link workers (from 2019/20)Physiotherapist (from 2020/21)Physician associates (from 2020/21)Community paramedics (from 2021/22).The scheme will meet a recurrent 70% of the costs of additional clinical pharmacists, physician associates, physiotherapists, and community paramedics; and 100% of the costs of additional social prescribing link workers. Each network appoint a Clinical Director, chosen from within the network. Funding will be provided for this role based on the network size; 0.25 WTE funding per 50,000 population size. Funding will be set nationally based on Agenda for Change scales, but there is no requirement locally to employ on the AfC contractThe network can agree how the new workforce is employed and deployed across practices. 14New network workforce“£4.5 billion of new investment will fund expanded community multidisciplinary teams aligned with new primary care networks based on neighbouring GP practices” NHS Long Term Plan

15. Seven new services will be introduced in line with the NHS Long Term Plan primary care goals, and phased into the DES over the coming years. The specifications for these will be developed with stakeholders during 2019/20 and negotiated with GPC in annual contract negotiations.2019Extended Hours access integrated into networks – same requirements as the DES, for 100% of network population2020Structured medication reviewEnhanced health in care homesAnticipatory care (with community services)Personalised careSupporting early cancer diagnosis2021Cardiovascular disease prevention and diagnosis, through case findingAction to tackle inequalities15New network services

16. Up to £1.799 billion will flow nationally through the Network Contract DES by 2023/24. This will include funding for the new additional role reimbursement scheme, network support, access and new Investment and Impact Fund.16Network investment(£ millions)2019/202020/212021/222022/232023/241. Additional Roles Scheme 1102574156348912. Network Support £1.50 per head from CCG general allocation9090919192GP PCN leadership (0.25 WTE per PCN, starts July 2019)31424344453. Access   Extended Hours Access DES 6687878787Improving Access to General Practice at £6 per head  3673763854. Investment and Impact Fund075150225300TOTAL PCN FUNDING2965521,1531,4571,799

17. 17Timeline for establishing PCNsDateActionJan-Apr 2019PCNs prepare to meet the Network Contract registration requirementsBy 29 Mar 2019NHS England and GPC England jointly issue the Network Agreement and 2019/20 Network ContractBy 15 May 2019All Primary Care Networks submit registration information to their CCGBy 31 May 2019CCGs confirm network coverage and approve variation to GMS, PMS and APMS contractsEarly JunNHS England and GPC England jointly work with CCGs and LMCs to resolve any issues1 Jul 2019Network Contract goes live across 100% of the countryJul 2019-Mar 2020National entitlements under the 2019/20 Network Contract start:year 1 of the workforce fundingongoing support funding for the Clinical Director ongoing £1.50/head from CCG allocations Apr 2020 onwardsNational Network Services start under the 2020/21 Network Contract

18. IndemnityDigital

19. Requirementsall patients have online access to their full record, as the default position from April 2020 with new registrants having full online access to prospective data from April 2019. at least 25% of appointments available for online booking by July 2019.all patients to be able to access online correspondence by April 2020 no longer use fax machines for NHS work or patient correspondence by April 2020 offer and promote electronic ordering of repeat prescriptions and using electronic repeat dispensing for all patients for whom it is clinically appropriate by April 2020have an up-to-date and informative online presence by April 2020SupportChanges to the GP IT Operating Model, including provision of Data Protection Officers from CCGsGP IT Futures will replace the current GP Systems of Choice (GPSoC) framework from December 2019. This will include capability for digitisation of records, cyber security and transfer of patient records.19Digital – requirements and support

20. All patients will have the right to online and video consultation by April 2021. Amendment to rurality index so that it applies to only those patients within the practice boundaryAmendment to London Adjustment so that it applies to only those who are resident in London (rather than those who are registered with a London-based practice)Out of Area registrations and digital first access will be reviewed in 2019.20Digital-first“Digital-first primary care will become a new option for every patient improving fast access to convenient primary care ” NHS Long Term Plan

21. IndemnityAccess and other changes

22. The current Extended Hours Access DES will continue until 30 June 2019. From 1 July 2019, the funding will transfer into the Network Contract DES and PCNs’ constituent practices will deliver extended hours access to their collective registered population. By April 2021 we intend that the funding for the existing Extended Hours Access DES and for the wider CCG commissioned extended access service will fund a single, combined access offer as an integral part of the Network Contract DES, delivered to 100% of patients including through digital services such as the NHS App.NHS England will work with stakeholders including GPC England on a single coherent access offer that PCNs will make, for both physical and digital services. This will deliver convenient appointments ‘in hours’, reduced duplication and better integration between settings such as 111, urgent treatment centres and general practice. The review will start in 2019, for full implementation by 2021/22, but we expect local Integrated Care Systems and their Primary Care Networks to go faster and we encourage them to do so. In addition in 2019/20, 1 practice appointment per day, per 3,000 patients will be made available for direct appointment booking by NHS111.22Improving access

23. From 2019 it will no longer be legal for any NHS GP provider, either directly or via proxy, to advertise or host private paid for GP services that fall within the scope of NHS-funded primary medical services.A review of Vaccination and Immunisation procurement, arrangements and outcomes will take place in 2019 with its output implemented through the 2020 and 2021 contracts.From 2019-20 GP practices will be required to support six national marketing campaigns on an annual basis, where the GP contractor will be required to put up and display in their premises, campaign materials six times every 12 months. From October 2019, where GPs choose to apply the NHS primary care logo in relation to their NHS provided services, they will be required to adhere to the NHS Identify guidelines and apply the NHS primary care logo to all information and materials about their NHS services.Transparency of Earnings: GPs with total NHS earnings above £150,000 per year will be listed by name and pay (NHS income before tax) in a national publication, starting with 2019/20 income.Shared parental leave will be added to the SFE reimbursements for locum coverThe contraceptive services Additional Service will cease and its requirements rolled into Essential Services23Other contractual changes

24. By the end of March 2019, NHS England and DHSC will have published:A new Statement of Financial Entitlements amendment covering the global sum, QOF £ per point and the network participation payment New DES directions including the new Network Contract DESNetwork Contract DES service specification and Network AgreementRevised V&I service specificationsGMS guidance covering all of the contract agreement for 2019/20Guidance to commissioners on implementing changes in PMS and APMS contractsTechnical guidance on codingRegulations and Directions will come into force in October 2019, and new contract documentation will be published afterwards.24GP Contract documentation

25. Questions25

26. Discussions26

27. LUNCH!Please sign in for the Afternoon Session, which will begin promptly at 12:45pm27

28. Caroline Temmink, Regional Head of Primary Care, NHS EnglandRyan O’Campo, Senior Manager, Primary Care and System Transformation, NHS EnglandPrimary care networks: where are we now?

29. 29The changing health needs of the population are putting pressure on the health and social care system in England.Ageing populationBetween 2017 and 2027, there will be 2 million more people aged over 75.Chronic conditionsThe main task has changed from treating individual episodes of illness, to helping people manage long-term conditions.The steady expansion of new treatments gives rise to demand for an increasing range of services.New TreatmentsAnd our expectations are changing too.Things are changing…

30. General Practice Forward View lay foundations for change in general practice…GPFV published in 2016:Represented a turning point in investment in general practice – committing an extra £2.4 billion a year to support general practice services by 2020/21Ambition to strengthen and redesign general practiceVision built on the potential for transformation in general practice:Enabling self care and direct access to other servicesBetter use of the talents of the wider workforceGreater use of digital technologyWorking at scale across practices to shape capacityExtended access to general practice including evening and weekend appointments.

31. Now continuing through the NHS Long Term Plan, placing primary care at the centre …31Aims:Everyone gets the best start in lifeWorld class care for major health problemsSupporting people to age well How:Primary care networks as the foundation for Integrated Care SystemsPreventing ill health and tackling health inequalities Supporting the workforceMaximising opportunities presented by data and technologyContinued focus on efficiency

32. Do things differently, through a new service model1Take more action on prevention and health inequalities2Improve care quality and outcomes for major conditions3Ensure that NHS staff get the backing that they need4Make better use of data and digital technology5Ensure we get the most out of taxpayers’ investment in the NHS6Long Term Plan in summary…

33. How will the Long Term Plan support delivery of primary care networks?

34. Put in place seamless care (for both physical and mental health) across primary care and NHS community services, and remove the historic separation of these parts of the NHS.Deliver care as close to home as possible, with networks and services based on natural geographies, population distribution and need rather than organisational boundaries.Integrate across primary care networks and secondary care/place-based care with more clinically-appropriate secondary care in primary care settings.Assess population health - focusing on prevention and anticipatory care - and maximise the difference we can make operating in partnership with other agenciesPromote and support people to care for themselves wherever appropriateBuild from what people know about their patients and their populationBecause we want to make a tangible difference for patients and staff alike, with:improved outcomes for patients and an integrated care experience for patients;more sustainable & satisfying roles for staff, & development of multi-professional teams.a more balanced workloadWhat are we trying to do?

35. 35Primary care networks (PCNs) are central to delivering our visionA working definitionPrimary care networks enable the provision of proactive, accessible, coordinated and more integrated primary and community care improving outcomes for patients. They are likely to be formed around natural communities based on GP registered lists, often serving populations of around 30,000 to 50,000. Networks will be small enough to still provide the personal care valued by both patients and GPs, but large enough to have impact through deeper collaboration between practices and others in the local health (community and primary care) and social care system. They will provide a platform for providers of care being sustainable into the longer term.The core characteristics of a primary care network are:Practices working together and with other local health and care providers, around natural local communities that geographically make sense, to provide coordinated care through integrated teamsA defined patient population in the region of 30,000-50,000Providing care in different ways to match different people’s needs, including flexible access to advice and support for ‘healthier’ sections of the population, and joined up care for those with complex conditionsFocus on prevention and personalised care, supporting patients to make informed decisions about their care and look after their own health, by connecting them with the full range of statutory and voluntary services Use of data and technology to assess population health needs and health inequalities, to inform, design and deliver practice and population scale care models; support clinical decision making, and monitor performance and variation to inform continuous service improvementMaking best use of collective resources across practices and other local health and care providers to allow greater resilience, more sustainable workload and access to a larger range of professional groups

36. Primary care networks are small enough to give a sense of local ownership, but big enough to have impact across a 30-50K population. They will comprise groupings of clinicians and wider staff sharing a vision for how to improve the care of their population and will serve as service delivery units and a unifying platform across the country. And PCNs are key to the future

37. Anticipated benefits of integrated care systems and primary care networksFor patientsFor general practice and other providers of careFor the whole health and care systemMore coordinated services where they do not have to repeat their story multiple timesAccess to a wider range of services and professionals in the communityIn a single coordinated appointmentAccess to appointments that work around their lifeshorter waiting timesdifferent ways of accessing appointments using technology and face-to-face optionsMore influence when they want it, giving more involvement and decision making opportunities over how their health and care are planned and managedAccess to personalised care and with a focus on self care and prevention, living healthily, recognising what matters to the person and how their individual strengths, needs and preferences can support better outcomesGreater resilience across primary care by making the best use of shared staff, buildings and other resources, they can help to balance demand and capacity over time Better work/ life balance with more tasks routed directly to appropriate professionals, such as clinical pharmacists, social prescribers, physiotherapistsMore satisfying work with each professional able to focus on what they do bestImproved care and treatment for patients, by expanding access to specialist and local support services including social care and the voluntary sectorGreater influence on the wider health system, leading to more informed decisions about where resources are spentMore coordinated care through collaboration and cooperation across organisational boundaries and teamsWider range of services in a community setting, so patients don’t have to default to the acute sectorA more population-focused approach to systemwide decision-making and resource allocation, drawing on primary care expertise as central partnersGreater resilience across the health and care system

38. Practices continue to provide core services Network Contract DES provides practices opportunity to work collaboratively with other practices health, social care and voluntary partners to deliver servicesPractices and other health, social care and voluntary partners collaborate as primary care networks, providing additional services that can’t be delivered on a smaller scalePlacec.250-500kPrimary care interacts with hospitals, mental health trusts, local authorities and community providers to plan and deliver integrated careIn some systems, federations support efficiencies of scale and provide a voice for primary carePrimary care participates as an equal partner in decision making on strategy and resource allocationAction is taken to ensure collaboration across hospitals, community services, social care and other partners, helping to join up and improve care Data is used to deploy resources where they can have the maximum impactEach person can access joined up, proactive and personalised care, based on ‘what matters’ to them and their individual strengths, needs and preferences Neighbourhoodc.30k~50kSystemc.1+mIndividualHow will that look within a local system?

39. And in reality its already happening……..andwe are learning from experience Case study 1 : Thinking creatively about primary care in LutonIn Luton, practices are working together in groupings covering 30,000 - 70,000 patients, joining up different types of clinicians and bring together community services, social care, and mental health services around the practices to provide better care for patients. Watch this case study at https://www.youtube.com/watch?v=YLntGo-BhPc

40. Plan: Plan in place articulating clear vision and steps to getting there, including actions at network, place and system level.Engagement: GPs, local primary care leaders, patients’ representatives, and other stakeholders believe in the vision and the plan to get there.Time: Primary care, in particular general practice, has the headroom to make change.Transformation resource: There are people available with the right skills to make change happen, and a clear financial commitment to primary care transformation. The network is taking the opportunities that GP network contract affordsThere is a clinical director is for the network.Practices identify PCN partners and develop shared plan for realisation. There is joint planning underway to improve integration with community services as networks mature Analysis on variation in outcomes and resource use between practices is readily available and acted upon.Basic population segmentation is in place, with understanding of needs of key groups, their needs and their resource use Integrated teams which may not yet include social care are working in parts of the system. Plans are in place to develop MDT ways of working, including integrated rapid response community teams.Standardised end state models of care defined for all population groups, with clear gap analysis and workforce planSteps taken to ensure operational efficiency of primary care delivery and support struggling practices.Primary care has a seat at the table for system strategic decision-making.PCNs are engaging directly with population groups, and with the wider communityFunctioning interoperability within networks, including read/write access to records, sharing of some staff and estate. All primary care clinicians can access information to guide decision making, including risk stratification to identify patients for proactive interventions, IT-enabled access to shared protocols, and real-time information on patient interactions with the system.Early elements of new models of care in place for most population segments, with integrated teams throughout system, including social care, mental health, the voluntary sector and ready access to secondary care expertise. Routine peer review.Networks have sight of resource use and impact on system performance, and can pilot new incentive schemes.Primary care plays an active role in system tactical and operational decision-making, for example on UECNetworks are developing an extensive culture of authentic patient partnershipsFully interoperable IT, workforce and estates across networks, with sharing between networks as needed.Systematic population health analysis allowing PCNs to understand in depth their populations’ needs and design interventions to meet them, acting as early as possible to keep people well.Fully integrated teams throughout the system, comprising of the appropriate clinical and non-clinical skill mix. MDT working is high functioning and supported by technology. The MDT holds a single view of the patient. Care plans and coordination in place for all high risk patients. New models of care in place for all population segments, across system. Evaluation of impact of early-implementers used to guide roll out.PCNs take collective responsibility for available funding. Data is used in clinical interactions to make best use of resources. Primary care providers full decision making member of ICS leadership, working in tandem with other partners to allocate resources and deliver care.The PCN has built on existing community assets to connect with the whole community. FoundationStep 1Step 2Step 3The journey of development for primary care networks in a health system – maturity matrixOur learning to date tells us that primary care networks will develop and mature at different rates. Laying the foundations for transformation is crucial before taking the steps towards a fully functioning primary care network. This journey might follow the maturity matrix below.

41. We are looking to those in local systems, CCGs, ICS and NHS England teams to fully support the development of primary care networks – your role is crucial!This work will be key to local systems as they develop plans to deliver the Long Term Plan, and system wide strategic planningHow we support development will be key - supporting the development of PCNs isn’t about mechanics, we need to keep the vision in mind and focus on fostering a different type of culture in organisations and relationships between peopleResponsibility for this ultimately resides locally, but NHS England’s national and regional teams will do all we can to support it – tell us what you need to make it work41Our roles in supporting PCNs

42. What will be available to support PCNsOn establishment we have clear dates from the GP contractWE WILL NEED TO SUPPORT LOCAL AREAS TO FOLLOW A TIMETABLE AHEAD OF JUNE 30 2019 TO ESTABLISH THEMSELVES THIS WILL ENABLE PCNs TO TAKE THE FIRST STEP AND BENEFIT FROM THE NETWORK DES AND LAY THE FOUNDATION AS THEY (CONTINUE) TO MOVE WIDER THAN GROUPS OF PRACTICES WORKING TOGETHER TO WORK COLLECTIVELY WITH ALL THOSE WHO CARE FOR PATIENTS AND THE COMMUNITYDate Action Jan-Apr 2019 PCNs prepare to meet the Network Contract registration requirements By 29 Mar 2019 NHS England and GPC England jointly issue the Network Agreement and 2019/20 Network Contract By 15 May 2019 All Primary Care Networks submit registration information to their CCG By 31 May 2019 CCGs confirm network coverage and approve variation to GMS, PMS and APMS contracts Early Jun NHS England and GPC England jointly work with CCGs and LMCs to resolve any issues 30/6Sign up by practice through CQRS1 Jul 2019 Network Contract goes live across 100% of the country Jul 2019-Mar 2020 National entitlements under the 2019/20 Network Contract start: year 1 of the additional workforce reimbursement scheme; ongoing support funding for the Clinical Director; Ongoing £1.50/head from CCG allocations

43. We will also have larger programmes of work in development to support the short and the longer termTo be successful PCNs will need the time, space and support to develop and matureWe are developing a strong PCN development offer. We have: Engaged extensively over the autumn/ winter Learnt from ICS and reviewed the maturity matrixEnsured continued dialogue with stakeholders and partnersWe expect a comprehensive offer to be available from 2019/20 that will develop capacity to help create and sustain networks, both how the PCN works and what it delivers as a new workforce collaborating together, as well as support to emerging leaders (regardless of profession)We are working towards a framework of support that can be drawn down flexibly to support PCNs and responds to their development need as they mature and their plans for the future.We want to support the specifics for PCNs, but to connect with the wider system development to ensure coherencePopulation Health Management and using data effectivelyWorking with communitiesWorkforceEnablers – estatesTechnical solutions – like indemnityAnd some learning together, advice and help

44. Considerable engagement has already taken place and continuesSystems and key stakeholders have asked that the development support offer focusses on providing capacity for OD and change management support and leadership developmentIt has been agreed that PCN development funding will flow to ICS/STPs (with regional oversight) so that they can either:draw in support from public sector partners who are focussed on PCN development ordraw down specific capacity and support from the lead provider framework orcontinue to fund the support that they already have in placeAn accelerated solutions event is being planned with key stakeholders to co-produce development support modules that meet the needs of the system (describing what goods look like) and is aligned to the maturity matrix. This will reflect support needed in the next 6 months and over the next 5 years.PCN development support offer

45. Through your CCG/local team and the PCN national team at england.PCN@nhs.net Through the PCN collaboration platform (FutureNHS) includes a range of slides and documents focused on PCNs and is available to join – please request access to the site by emailing england.PCN@nhs.netThrough webinars and events is helping to share best practice and advice. Full details at www.england.nhs.uk/pcnWhere to find information?In materials to help communicate why PCNs and their benefits like animations to help explain what a primary care network is. You can watch this animation and view further details at the following webpage: www.england.nhs.uk/pcn

46. Thank youEmail: england.pcn@nhs.netVisit www.england.nhs.uk/pcn for more information

47. How are primary care networks making a difference to patient carePresentations from PCNs

48. Dr Johnny Marshall OBERegional Primary Care Home LeadNational Association of Primary Care

49. 3rd April 2019Dr Johnny Marshall Regional Primary Care Home Lead, NAPCPopulation Health Approach to PCNs

50. The NHS LTP strategic intent“At present, NHS bodies are bound, rightly, by strong duties to provide or arrange high quality care and financial stewardship as individual organisations, and they have statutory duties to co-operate with one another when performing their functions.”https://www.longtermplan.nhs.uk/wp-content/uploads/2019/02/nhs-legislation-engagement-document.pdfExtract from NHS LTP Legislation Engagement Document

51. The NHS LTP strategic intent“This is not enough on its own, however, to ensure that local health systems plan and deliver care across different organisational boundaries in ways that secure the best possible quality of care and health outcomes for local communities.”https://www.longtermplan.nhs.uk/wp-content/uploads/2019/02/nhs-legislation-engagement-document.pdfExtract from NHS LTP Legislation Engagement Document

52. The NHS LTP strategic intent“Despite the duties of co-operation, organisations can still make isolated and disconnected decisions, rather than working together to consider the potential wider impact of organisational decisions on services and financial sustainability both in their local community and with neighbouring health systems.”https://www.longtermplan.nhs.uk/wp-content/uploads/2019/02/nhs-legislation-engagement-document.pdfExtract from NHS LTP Legislation Engagement Document

53. The NHS LTP strategic intent“We believe therefore that NHS bodies should have shared responsibility for wider objectives in relation to population health and the use of NHS resources.”https://www.longtermplan.nhs.uk/wp-content/uploads/2019/02/nhs-legislation-engagement-document.pdfExtract from NHS LTP Legislation Engagement Document

54. Segmentation

55. Generally wellLong term conditions / Long term needsComplexity of LTC(s)and/or disabilityLow riskHigh riskLow riskHigh riskLow riskHigh riskChildren and Young PeopleWorking Age AdultsOlder People

56. Generally wellLong term conditions / Long term needsComplexity of LTC(s)and/or disabilityLow riskHigh riskLow riskHigh riskLow riskHigh riskChildren and Young PeopleWorking Age AdultsOlder PeopleMultidisciplinary Team with generalist values

57. Are you in a team?1. Does your team have clear objectives?2. Do you have to work closely with other team members to achieve the team’s objectives?3. Does the team meet regularly to discuss its effectiveness and how it could be improved? West, M.A. (2004). Effective Teamwork: Practical lessons from organizational research. Oxford: Blackwell/British Psychological Society

58. Working in teams - job satisfactionwww.nhsstaffsurveys.com

59. Six elements approachUnderstand need (current and future)Agree care functions Develop skill mix and poolBuild and embed team based cultureDeliver the education and training requiredDevelop plan for future supply

60. EngagementUnderstand Population Health Data and NeedsCare Model DevelopmentWorkforce, education, culture and planningGovernanceEvidence and evaluation123456PCH Development support

61. BLMK ProgressAligned population health managementIntegrated working Clinical leadership GovernanceFunding Digital On track with PCH developmentEngagementUnderstand Population Health Data and NeedsCare Model DevelopmentWorkforce, education, culture and planningGovernanceEvidence and evaluation123456

62. Critical success factorsAligned leadership strategies, messaging and focus Start where our people are at, not where you think they should beRelationships / networksLeadership

63.

64. Dr Shelley CarterGP, Clinical PartnerSouth Coast Medical Group

65. Dr Shelley Carter, GP Partner South Coast Medical Group (SCMG)Tailor-making services for different communities

66. The Growth of Providence Surgery into SCMGProvidence surgery 7644 patientsCrescent surgery 3487 patients Strouden surgery 3030 patientsWest Moors surgery 1480 patientsMarine & Oakridge surgeries 9137 patientsGrove surgery 6035 patients Rating: Outstanding (2018)

67. Night Shelter serviceHomeless BusGP service within local schoolLife Coaching/advocacyParamedic visiting servicePharmacy teamIn house diagnostics (INR, D-Dimer, ultrasound)FACT teamIn-house physiotherapyAdapting to the needs of our populations

68. School Project. Background-High levels of deprivation and mental health / emotional problems within the local young population-High number of adolescents who struggle to access resources and/or to engage with health services -Local provision for school nurses is poor-Potential solution / help health resources at the school

69. School ProjectAvonbourne trust: Avonbourne College (girls 11-16): 799 Harewood College (boys 11-16): 508 6th Form: 144About 60% registered with South Coast Medical Group

70. School Project. Challenges-No available benchmark-Information governance-Parental involvement / consent-Student engagement-Admin

71. School Project. PDSAhttps://qi.elft.nhs.uk/resources/

72. School ProjectService has been provided by a General Practitioner who attend Avonbourne College (year 7 to 6th Form) one morning a week to deliver:  One to one consultationSmall group discussion of common health problems – mainly emotionalOffer support and liaison with pastoral team and parents

73. School ProjectSeptember 2017 – July 2018 review: 49 one-to-one initial appointments 22 one-to-one Follow up appointments13 intervention groups deliveredReferral to CAMHS, Social services, bereavement and Dorset Rape CrisisMeeting with parents

74. Intervention Groups

75. Testimonials. GroupsY11 student “She was really chilled, helpful and understanding, it was helpful getting to know about people who you can relate to. I also saw her 1-1, we should keep the service” Y11 student: “Was very helpful, she gave me tips on how to relieve stress” Y11 student “She gave us tips on how to deal with stress and exams, in a group you know there are other people who feel the same way” Y8 student “Isi was really understanding and kind. It was really helpful, people were open and felt the same way” Y8 student “It was good to talk about my anxieties” Y11 student “The group was really nice and calm, it was helpful to see the GP 1-1 too” 

76. Testimonials. One-to-one“”I could tell her anything, she was like a trusted adult friend, it was very helpful” Y10 student “It was a really good opportunity and helpful. I couldn’t talk to my parents or another teacher” Y11 student “It was helpful, I could say how I felt” Y11 student “ I like the GP, I never talk to anyone, she gave me tips, it was helpful” Y9 student “She listens and gave me a lot of advice. I wouldn’t have gone to my own GP about my sleeping problems

77. School Project. The FutureImprove links with school nursesPastoral team to trial anxiety groupContinue extending help into Harewood CollegeUse of CPN recently employed by South Coast Medical GroupGP communicationMETRICS (SurveyMonkey® – key question)

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80. Dr Joe McMannersGP, Clinical AdvisorNational Programme & Oxfordshire CCG

81. Barton Healthy New Town ProjectAn OX3+ Network collaborationPresenter: Dr. Joseph McManners Date: 03.04.2019

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83. Healthy New Towns ProgrammeA three-year NHS England programme which began in 2016 looking at how health and wellbeing can be planned and designed into new places.Objectives:Planning and designing a healthy built environmentCreating innovative models of healthcareEncouraging strong and connected communities Emphasis on encouraging partnership working between councils, developers, healthcare providers and communities.

84. New models of careIdentification of long term health conditions and referrals by doctors Social prescribingTeam Around Patient

85. Social Prescribing Health and Wellbeing Partnership Partnership of two local GP surgeries: Manor Surgery and Hedena Health with local services and groupsUsing the GP data to identify clients who has long-term health conditionsUsing grant funding to create community groups to deliver activities at the Barton Neighbourhood Centre:Breakfast and Lunch ClubsHealthy Cooking ClassesCommunity CupboardExercise Classes: Dance to Health, Bone to BalanceSending invitation to the identified clients Partnership with Getting Heard - Appointment Buddies to remove any transportation obstacles

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87. Barton Healthy New Town- Patients Feedback for Dance to Health Classes at Barton Neighbourhood Centre The patient thoroughly enjoyed it. She said that it is, “fantastic and we have so much fun. Pirates being ballerinas! And it is doing as much as you can. You do not need to do the whole lot – it is a case of sitting down if you need to”. She stated that she thinks it is very worthwhile for the people who do go- that it gets people out, that there is a social aspect to it – and that at the end everyone gets a cup of tea- which most people stick around. The patient stated that she has been on the estate for 43 years and she knows more people from going down there on a Monday than she does from living on the estate for 43 years.  The patient suffers with arthritis and has a dodgy knee – she thought “well the more I can do the better”. She said that the program is well-designed to consider people’s different levels of capacity. She got a letter for Bone and Balance but not Dance to Health, and yet attends both. She stated that, regarding bone and balance, “the fact that the letter came was very good… I think it is a brilliant idea. I don’t go to the community Centre. I saw about the dance to health class when I saw it on Facebook. I went in and asked about the class – and they said you get a letter but I asked if I could come along”.  Regarding both Bone and Balance and Dance to Health, she said that she feels better: “we go there and have a laugh. We feel better for it. The better we feel the less chance it is that we will feel ill”. She said that one of her neighbours has been going and he is the last person she would have expected to attend because he is not very social – yet he is down there and they all have a laugh. The patient found it very good. She went to her consultant and told him how beautiful the class was and what she had learned. I asked her for her favourite part and she said “everything!” She is paralysed on the right side and said, “this is helping a lot a lot a lot!” Sharon from the community centre told her about it when the patient was telling her that she kept falling. The patient said “I am so happy. The lady teaches me how to put my feet down and stand up – and I did not know before!” The patient stated that since that class she has not fallen at all. She said that before it, she had had about 20 falls; been to accident and emergency, sprained her ankles and broken her ribs. The patient has been telling her friends who have falls about the class.  She also said that she can feel a really big shift inside her chest. She said that she could not feel her ankles before the class and now she can, and that also her “knee came back” and then her” thighs and back ad everything”. She stated that she knows it is also helping other people. She said, “I am feeling happy happy happy happy!” She said, “what I am learning now I should have learned a long time ago…Nuffield orthopaedics told me nothing useful comparatively!”

88. What is Team around the Patient?  As part of the Barton Healthy New Town Project, Hedena Health (i.e. Bury Knowle and Barton Surgeries) and Manor Surgery are being supported by NHS England and Oxford City Council in an initiative to provide a person-centred approach to integrating health care and social support services in a cost-effective manner. An individual`s needs and preferences are assessed by a multi-disciplinary team in order to formulate a comprehensive care plan to better support a patient’s health and wellbeing needs. Aim of TAP:TAP aims to identify patients who have needed unscheduled contacts with their GP and or ambulance/emergency department/social services on a frequent basis in the preceding year and to offer them a comprehensive and coordinated assessment plan that addresses their health and wellbeing needs.Who is the service for? The TAP service is particularly aimed at people with chronic, complex medical and mental health conditions who may find it difficult to navigate a fragmented health care system. Some of the Multi-disciplinary Team Attendees:GPDistrict NurseSocial WorkerPractice Care NavigatorSocial ServicesCOPD NurseRecovery NurseConsultant PsychiatristSocial PrescriberTenancy Sustainment Officer South Central Ambulance ServicePulmonary Rehabilitation Programme leadOxfordshire Mind Counsellor Memory Clinic NurseEmergency DepartmentCare Agencies City Integrated Locality TeamUrgent and Ambulatory CareAn attendee`s Feedback about TAP Meeting:“Very informative before client`s specialist assessment. Excellent opportunity to networking and sharing service information. Very happy to attend future meetings to discuss patients with complex needs.”

89. Role of GP in the TAP? To review identified patients as frequent attendees and confirm their eligibility for the project.  To inform the eligible clients about the TAP project and prompt them to be involved to the project. To lead or be part of a multi-disciplinary team currying out a structured discussion on how best to assist the identified client`s needs. How does TAP work?

90. Developing a strong partnership between GP surgeries and other services Core Team for monthly TAP meetings: -DN-GP-Mental Health Service-Social PrescriberLearning PointsLearning PointsLearning PointsLearning Points+ project officer dividing the working time equally between two GP surgeries+Cross surgery working as a basis for future Primary Care Networks-New GDPR regulations with various agencies and organisations in a process of getting to be more familiar with these.-Data sharing agreements proving difficult to get approved based on fear of getting it wrong+ Improved team working and cross sectoral cooperation+ Increased awareness of what others can offer as well as their constraints-Coordination of candidates and managing to get so many service representatives to come to meetings- Identifying one representative of each service who could act or report on behalf of individual officers involved in the clients care

91. The patient is a 71 year old lady who has a background low IQ/learning difficulties (unknown origin), dependant personality/avoidant personality diagnosis in past, previous alcohol abuse (but not for many years) and more recently cognitive decline (but not clear cut dementia). The current problem is she lives alone in a flat with a care package. Frequent of Attendance: GP: 17 – SCAS: 102 Frequent 999 calls, lonely and pain.Knee pain that causing her not able to walk. The carers visit the patient x4 times a day but could not apply ibuprofen gel without receiving the necessary training. During the TAP meeting the care agency mentioned that waiting time for the training would be around 2/3 weeks . The District Nurses highlighted that they can give the Level 2 ibuprofen gel to the carers. The training date was arranged on the TAP meeting and delivered on the same week. Action Plan for NHS NO: 4723080872Attendees: Julie Cooke: Physio CTS Sarah Flexen: Social Prescriber Dr. Khadija Masood: Consultant Psychiatrist Dr. Joe McManners: GP from Manor Surgery Ursula Nicholls: Care Navigator Helga Nitzinger: COPD Specialist Nurse Debbie Poole: Branch Manager at Care Outlook Emma Tucker: Pulmonary Rehabilitation Programme LeadApologies: Mark Browning: South Central Ambulance Service Demand ManagerDate/Time: 23.01.2019 – 12:00-12:30Location: Bury Knowle Health CentreAction ItemOwnerStatusInforming the client about the new care plan and confirming if the client is happy with it.Dr. Joe McMannersCompleted on 23.01.2019District Nurses giving level 3 ibuprofen gel application training to Care Outlook carers.District Nurses Care OutlookCompleted on 28.01.2019Monitoring patient`s knee pain the next two weeks.  Letting know the GP if the pain is not going away with the ibuprofen gel  GP applying injection if the pain is still continuingCare Outlook  Care Outlook  Dr. Joe McMannersCompleted  Completed   CompletedPutting the catheter backDistrict NursesCompleted on 25.01.2019Directing the pads delivery to the Care Outlook Bringing the pads to the client`s houseDistrict Nurses  Care OutlookCompleted  CompletedDistrict Nurses communication with Care Outlook carers regularly and making their visits with carers as much as possibleDistrict Nurses Care OutlookOn-progressAssessing if client has depression Dr. Joe McMannersOutstandingPreparing special notes for the SCAS and Elder-CareDr. Joe McMannersOutstandingEncouraging patient`s personal assistant to buy healthy eating products for the client during the grocery shoppingCare OutlookOutstanding

92. 78 years old lives in a 3-bed council house with his cat. diabetic right leg is amputated, wheelchair user hard time using it in his house as the house is not adapted to his new needs. He feels that “nothing is happening” / “there are no adjustments for his current condition”. Isolated from a social life as he can’t go outside.regular falls in the house which end up with him calling SCAS. He feels frustrated and has mentioned ending his life couple of times to the GP and other health professionals. He has a lack of motivation and positive feelings as he believes he is not receiving the necessary level of care he should have.  The TAP meeting held on December with mdt including: GP, Tenancy Sustainment Officer, District Nurse, Adult Mental Health Team, SCAS, City Integrated Locality Team, Social Prescriber. A shared action plan put in on December.Action Plan for NHS NO: 4021369104Informing the client about the new care plan and confirming if the client is happy with it. Reviewing and assessing the patient`s medication list.Checking the client’s medication and informing the patient`s GP about the medication that is being missed/not taken by the client.Getting confirmation from A.J. that the referral has been sent out to the podiatry service.Long term OT assessing the transfer and sitting situation of the client.Requesting an update from community OT.Wheelchair service assessing the patient for a power wheelchair assessment.  The Community OT is contacting the Oxfordshire Wheelchair Service for updates on progress with a power wheelchair referral and review of manual wheelchair.  Requesting an update from OWS.Widening the front door and increasing the accessibility getting in and out of the house.  Moving out of the house the dining room furniture and any other furniture that patient confirmed to be removed. Reviewing the patient`s house on January for any further adjustments.  Updating the attendees when the renovation is completed.Prompting the patient to engage with Archway and Dementia Group once the patient has access to get in/out of his property. The action plan completed on end of January. All the necessary adjustments of the house were completed by the Council. The patient gained accesses in and out of his property. The tenancy sustainment officer gave regular updates to the project officer and the action plan updated and shared couple of times between the attendees with secure email. The patient was monitored by GP closely. GP received regular from DN. The patient`s mood had been improved during the progress and regular updates given to the patient by his usual GP. The patient has been having session with the social prescriber and social prescriber is linking the patient to the most appropriate community groups. The patient called SCAS 36 times between 2017-2018. The last 4 months the calls decreased to 5 SCAS calls. The patient recently spoke with GP and said “everything is all fine, I am feeling okay”.

93. SP pilot scheme in Barton Surgery and Woodfarm SurgeryBHNT Funding for SPCooperating with Manor Surgery to provide the SP service to communityCommunity classes at the Barton Community Centre Creating a strong network between GP, client and volunteer sector201620172017-presentNew Models of CareSocial PrescribingTeam around the Patient (TAP)Data sharing agreements City CouncilOut of HoursEmergency DepartmentConsent Form Self Assessment FormPre-meeting reportsStratification ProcessEMIS search criteriaTAP meeting preparation toolsTAP meetingsNetworkingBuilding bridges between servicesMonthly scheduled MDT meetingsCore TeamLinking people with long term health conditions with community activities, extending social prescribing; identifying gaps in services; trialling a new Team Around the Patient, integrating Primary Care with local communities and voluntary sector, expanding local Primary care Network with Community teams and Council teams.

94. Thank you for listeningAny questions?

95. Coffee Break!Please be back for 14:45

96. Table discussion: Supporting PCNs to develop and thrive

97. Working in tables, discuss current position regarding PCNs, making use of the maturity assessment tool. Individuals to think through what the priorities are for their networks, what can be achieved immediately, where they need support; and who they can turn to access that support.97Supporting PCNs to develop and thrive

98. Close Olivia Falgayrac-JonesNHS England South EastDirector of Commissioning

99. Olivia Falgayrac-JonesDirector of CommissioningNHS England (South East)Primary care networks: what next?

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101. Basingstoke and Alton Health and Well-being Connector Service ManagerDebbie HayterBritish Red Cross

102. Joint commissioned by North Hampshire CCG and Hampshire County Council in February 2018Aim to support individuals affected by long term physical health conditions, physical inactivity and social isolationIntention to support individuals to gain confidence, self manage and reconnect to their communityOverview

103. By working with GP surgeries and Adult Social CareLinking in with community groups e.g.. Carers Hubs, libraries, lunch clubsExpanded to include Hampshire fire service, SCAS (South Central Ambulance Service) How

104. Connected with 210 services usersImpact- Up to 3 month Intensive One to One support. - Up to 4 weeks Introducing/Accompanying. - Information Provision

105. Referral by Social Services (Learning disability team) for advice around healthy eatingWoman in 50’s, currently supported by partner and sister and suffering from anxietyHolistic assessment undertaken to address the whole personCase study 1

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107. Case Study 2Referral by GP to improve his social networks. Gentleman in 60’s, feeling isolated and struggling with mental health suffering with COPDHolistic assessment undertaken to address the whole person

108. Increased Friendships/ Attending GroupsDiet & Exercise