/
Primary care locality place based plans Primary care locality place based plans

Primary care locality place based plans - PowerPoint Presentation

pamella-moone
pamella-moone . @pamella-moone
Follow
353 views
Uploaded On 2018-12-13

Primary care locality place based plans - PPT Presentation

How we are delivering the plans across Oxfordshire Based on plans at January 2018 Foreword 2 The NHS is facing unprecedented challenges with growing demand workforce shortages and constrained resources at every level in both the health and social care systems Primary care is no exception It ID: 740817

patients care oxfordshire primary care patients primary oxfordshire locality plans access services health practices support patient population clinical priorities

Share:

Link:

Embed:

Download Presentation from below link

Download Presentation The PPT/PDF document "Primary care locality place based plans" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.


Presentation Transcript

Slide1

Primary care locality place based plans

How we are delivering the plans across Oxfordshire

Based on plans at January 2018Slide2

Foreword

2

The NHS is facing unprecedented challenges with growing demand, workforce shortages and constrained resources at every level in both the health and social care systems. Primary care is no exception. It is the lynchpin of the health

service,

seeing 90% of the system's

patients, but it is now stretched to breaking point. In order for primary care, and the wider NHS, to continue to provide high quality services into the future, fundamental change is required.Six Oxfordshire locality place based plans have been developed to tackle some of our biggest challenges. They provide an exciting vision for the future of primary care in Oxfordshire and aim to deliver a high quality, resilient system for our growing communities.The plans are a culmination of ten months of insight and ideas gathered from GPs, practices, patients and the wider health and social care system. They have had input from the public, elected representatives and community organisations. They have also been informed by countywide strategic documents such as the Oxfordshire Primary Care Framework and the work of the Oxfordshire Transformation Programme. In this way, each plan forms a crucial link between the overall strategic vision and the specific needs of each individual locality.The plans are dynamic documents and will develop as part of an iterative process. This approach will ensure that the plans stay relevant in the face of change. They will also continue to involve patients and stakeholders - after all, these complex issues affect all of us and we will benefit most by ploughing the same furrow."The vital thing is to roll our sleeves up, get practical, and together begin to make a tangible difference, now, for practices and for our patients." Simon Stevens GP Forward View 2016

Dr Kiren Collison

Chair, Oxfordshire CCGSlide3

3

Areas of significant housing growth

10

year growth by

locality:

Primary care is the cornerstone of the NHS in Oxfordshire, GPs are the first point of contact for most people and they play a co-ordinating role for each patient’s journey across clinical pathways and provider organisations. There are significant challenges. These include: A changing population with a dramatic projected increase in the number of older people presenting with multiple and complex conditions - the number of people aged over 85 in Oxfordshire is predicted by ONS to increase by 88% - and a more ethnically diverse population;Plans for rapid growth in housing fuelling demand for GP appointments and a greater co-ordinating function within primary care

Overall high satisfaction with primary care across the county masks some variability in access with 29%

of patients reporting their length of wait as unacceptable

front-line delivery pressures that are contributing to recruitment and retention challenges, whilst lowering the morale of GPs and their primary care colleagues; and

Concerns around estate buildings need updating

These and other challenges require fundamental changes to the design and delivery of primary care, within the context of Oxfordshire’s wider transformation programme.

70 GP practices

600 GPs

145 practice nurses

300 other clinical staff

On average 10,000 patients per practice

All practices in federations

Over 5,000 additional appointments per month

Some of our achievements so far:

Extended access:

Local GPs, working in federations, are providing more than 5,000 more appointments a month to patients as a result of the Extended Access to GP Services scheme. These are provided from locality-based hubs and provided at times when practices are usually closed at evenings and weekends.

Sustainability and Transformation:Home Visiting Teams comprising emergency care practitioners are assisting GPs in much of the county, responding to requests for urgent same day home visits and provide the capacity to enable more proactive visiting.Patient survey results Satisfaction with GP services in Oxfordshire was at 89% in 2017. This is higher than the national average at 85% and in line with Oxfordshire’s results over the past 5 years, ranging between 88% and 90%. Patient forums Oxfordshire CCG supports six locality patient forums who have all been involved in the development of the locality plans. In June 2017, the CCG also ran a PPG awareness week to highlight the benefits of patient engagement and their importance to planning process.CQC ratings Of the 44 practices inspected by CQC by September 2016, 3 had received outstanding ratings, 35 were rated good, 6 require improvement ratings and none were deemed inadequate. More practices were rated outstanding than nationally (+3%) and fewer practices required improvement (-3.5%).

21%

34%

8

%

24%

20%

33%

How we are delivering against the Buckinghamshire, Oxfordshire and Berkshire West priorities:

The BOB STP outlined 8 key priorities. The Locality plans respond directly to 6 of them: Shift the focus of care from treatment to preventionAccess to highest quality Primary, Community and Urgent CareMental health development to improve the overall value of care provided Establish a flexible and collaborative approach to workforceDigital interoperability to improve information flow and efficiency Primary Care at scale

Case for change

3Slide4

Core priorities and outcomes set out in the place-based locality plans

Oxfordshire Primary Care Framework: Operating Principles

Oxfordshire

system-wide

vision

4

How the plans core objectives fit with the wider Oxfordshire strategy

4

Buckinghamshire, Oxfordshire and Berkshire West objectives

Innovative

We participate in

healthcare innovation to the benefit of our-selves and our communities

Responsible

We are responsible

for and are enabled to take control of our own and each other’s health

Expert

We have equitable access

to healthcare at home and

in our communities

Delivering appropriate services at scale

Delivering care closer to home

A collaborative, proactive system of care

Delivered by a multidisciplinary neighbourhood team

Supported by a modernised infrastructure

Sustainable

Primary Care

Caring for frail and elderly people

Access to right care at the right time

New ways of caring for people with Long Term Conditions

Prevention

, increased self care and health and wellbeing

Reduce deprivation and inequalities

“When I am in need of care, it is safe and effective

*

“I want to have a good experience and be treated with respect and dignity

*

I am able to see the right health professional at the right time”

“I want to be helped to be as independent as possible in the best place for me

*

“I want to be helped to be healthy and active

*

“I can expect the same health outcomes wherever I live”

Personal

We receive urgent, and/or complex care in the right place at the right time

Locality Driven Priorities

Countywide vision

“I

can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me.” –

National Voices

,

Person Centred Coordinated Care

*

“I statements” distilled

from patient

feedback as part of the Outcomes Framework for Older People that reflect

how

patients in Oxfordshire want

to feel during and after receiving

healthcare. Slide5

How do the plans fit into the wider Oxfordshire CCG strategy?

The plans occupy an important position within the wider Oxfordshire strategy developed using both a bottom up and top down approach. The bottom up approach to the plans’ development has been locality driven and looks internally to the specific challenges and opportunities of each locality to present the case for change and strategies for the future. In addition to this, however, the plans have also been developed with the top down, county wide objectives front of mine. This two-pronged approach to developing the plans ensures that the specificity of each of locality is captured whilst maintaining consistency and cohesion across all 6 plans and the wider Oxfordshire strategy as articulated through the Oxfordshire Primary Care Framework and ultimately the county wide transformation programmes.

5

How the plans fit into the wider transformation programme

Figure 3: Oxfordshire CCG Strategy and Locality Plan Alignment

The overarching structure of Oxfordshire CCG’s strategy, and the role of the locality plans within it are represented in Figure 3.

How will the plans evolve over time?

The

plans

are intended to be dynamic

documents and will be developed iteratively in response to patient feedback, changes in population across the county or the impact of national government policy on the way we deliver healthcare. We will work with patients and clinicians to ensure that primary care remains responsive, accessible and of high quality.

How have we ensured the plans are relevant and practicable?

The plans have been tested against the priorities set out in the Oxfordshire CCG Primary Care Framework, the opportunities outlined in the GP Forward View and local transformation programmes.

Proposals

with funding consequences have been further assessed according to need across Oxfordshire.

Some elements of the plans will undergo their own individual consultation processes separately.

5Slide6

6

The Oxfordshire Primary Care Framework sets

the strategic direction of Primary Care over next 5-10

years. Approved by the CCG Board in March 2016, it aims to provide

a General Practice that is fit for the future and at the heart of the NHS and Oxfordshire Transformation.

The new model of primary and community care in Oxfordshire sets out a number of operational principles:Delivering appropriate services at scaleOrganised

around geographical population-based need

Delivering care closer to homeA collaborative, proactive system of care

Delivered

by a multidisciplinary neighbourhood team

Supported by a modernised infrastructure

Our aspiration for all patients is:

GP appointments, where appropriate, are for 15minutes

Routine appointment within one week where appropriate although not necessarily with a GP

Planned visits at weekends for those patients identified as clinically unstable

Older

peoples multi-disciplinary teams in the communityGPs

with access to locally based diagnosticFully

interoperable patient records.

The Oxfordshire vision for primary care:

“To

provide a 21st century modernised model of care that works with patients across neighbourhoods and locality populations to provide enhanced primary care, extended primary care teams, and more specialised care closer to home delivered in partnership with community, acute and social care colleagues.”The model of care proposes organising services around populations (see figure 1). This will provide benefits from economies of scale as practices work together through federations to share resources, workload and to provide a better service. This model will support practices to better manage demand and build on what has been demonstrated to work well in general practice. Figure 1: Population segmentation in a localityBackground to the Oxfordshire Primary Care FrameworkDiffering models of care will be provided according to the relative needs of the patients in the locality, with different services provided at general practice, neighbourhood and locality level (figure 2).Figure 2: Population basedapproach to delivering servicesSlide7

How we have developed the plans

7

How have we included patients in the plans development?

Patient engagement has been an integral part of developing the locality plans and the plans have been developed closely with practices, public and the wider clinical community to ensure they closely reflect the specific needs of the localities:

Members of the Locality forums (locality patient groups) provide input into the monthly locality meetings when the priorities were developed.

During the production of the plans between May and November the Locality Forums and CCG hosted events with the public to discuss the priorities set out in the plans. An online survey was published alongside the plans in December giving people the opportunity to comment on the published draft plan.Feedback from patient engagement is included within the plans published in January 2018

June

July

August

September

October

November

December

Talk to practices

How much space do our practices have?

What are retirement / recruitment plans?

How do they work with other services?

Talk to patients

What is important to our patients?

What is their experience of health services?

What would they like to change?

Develop priorities What can we do differently?How and by when?What will it cost?Assess Priorities Is it affordable?Is it achievable?Does it meet our future needs for patients and practices?Talk to practices againReassess prioritiesTalk to patients againAre these the right priorities?Finalise prioritiesPublish draft for public consultationPlan Development Timeline

Assess Population Needs

How heathy is our population?

How do they use our health services?How will our population change over time?

January

Publish final documentMobilisation of workstreams

2017

2018

Who informed the plans? The six locality place based plans draw on the knowledge and experience of clinicians, patients and the wider health system across

Oxfordshire. The Locality Clinical Directors (LCDs) have been leading the development of the plans through locality meetings which have received input from Oxford Health Foundation Trust, GP Federations and Patient Forum representatives as well as the locality practices. District councils and the county council have also provided input into the case for change and key priorities. Slide8

Patient feedback is a core component of each of the 6 locality plans. Patients have been engaged at multiple stages throughout the plans’ development and their input will continue to inform the direction of the plans, as part of the dynamic, iterative process. This will ensure that the plans stay relevant to the communities they serve both now and in the future.

After the first draft publication of the six plans in December 2017, patient feedback was incorporated into the publications in January 2018.

As the plans developed during 2017, feedback was sought from GPs at locality meetings, which include patient representatives. They communicated the outcomes of the meeting back to the patient participation group.

Patient engagement events throughout November 2017 generated feedback which was then added into all six of the locality plans in advance of their first publication in early December.

In June and July 2017 the localities introduced their intentions for the locality place based plans to their Patient Participation Groups (PPGs) to gather feedback on key

priorities

4

2

3

1

Examples of how patient feedback was incorporated into the plans

Feedback from the events and the draft publication in November 2017 has helped to shape and

inform the locality

plans. Examples include:

All plans:

Funding implications of delivering the plans

Further clarity on the decisions regarding future primary infrastructure for new estates

Oxford City locality

Considerations

around contract review of the Luther street homeless service so that it is accessible for patients at the right time

Additional information on improved

skillmix to support access, in particular using mental health link workers and other community agencies. North localityFurther clarity on the decisions regarding future primary infrastructure for new estates, in particular Heyford Park and Chipping Norton Retention of primary medical services from the Banbury Health Centre site Strengthening of locality intentions on prevention Proposals to strengthen primary care sustainability in Banbury and maintaining access for patients.North East locality Further clarity on the decisions regarding future primary infrastructure for new estates, in particular Heyford Park Proposals to improve urgent access to primary care, in particular for working adults and children, and to improve continuity of care. West locality Strengthening the role of prevention, including with partners in the voluntary sector, the council and schoolsAdditional information on greater skillmix, in particular through clinical pharmacists, and training for non-clinical staffProposals to reduce waiting times for routine appointments through expansion of the urgent access hubs and making more use of the emergency multidisciplinary unit in Witney.South West localityUpdating

information on the process regarding decisions on primary care infrastructure in line with the latest district council plans and patient feedback

Impact

on children of strengthening primary care access South East locality

Updated housing projections in line with updates from SODC including incorporating

Chalgrove into projections and estates Additional

information on proposals to pilot care navigation. How we have engaged patients in the production of the plans

8Slide9

Priority

What patients want

Oxfordshire-wide workstreams

Services

based on local needs

What will

the

CCG do?

Sustainable primary care

Projects working across a locality that support practices to work better together

New clinical roles working across practices to bring services closer to patients

Support requests for mergers of GP practices to enable economies of scale

Workforce

Together with health and social care partners, the CCG is developing a workforce to:

increase staff capacity in primary care

increase skills among existing staff through training and development

introduce and expand new roles.

We will support this with funding

to design new teams and support for other

workforce, including clinical pharmacists

and mental health workers.

Caring for frail and elderly people

New approach to caring for frail patients

through a joined up service

7 days a week working acros

s the NHS, social care and the voluntary sector. Provides routine care, proactive monitoring and assessment with 24/7 rapid response.

Expand the Primary Care Visiting Service so more patients can be visited at home and have appropriate support to avoid them being admitted to hospital.

Review community assessment services providing rapid access and treatment.

NHS, social care and voluntary sector working much closer together to support patients.

Access to right care at the right time to meet growing demand

Oxfordshire standard for urgent appointments with a clinician on the same day for all patients who need it.

Over time, appointments will be booked by NHS 111 or direct with the GP practice.

GPs, working together, to provide more appointments at times convenient

for working people and parents

.

More appointments

for patients who need to can be seen on the same day.

Physical infrastructure and estates

Investment

in current buildings or in new

buildings to meet future growth.

Support developing

shared space in the community so staff from health and social care and others can work together in teams.

Identify

where

financial efficiencies can be made, for example by moving paper records online so reducing storage needs.

New ways of caring for people with long term conditions

Integrated diabetes service

for outpatient and community services. The same for other services over time.

Musculoskeletal (MSK) hubs, bladder and bowel service, minor eye conditions service. 

More

care in the GP practice for people with breathlessness / COPD / asthma

Groups of practices working together to

offer

more care

,

building on current successes such as dermatology service

in south east Oxfordshire

.

Prevention,

increased self care and health and wellbeing

‘Social Prescribing’ for patients with long term conditions

or who are isolated

. Includes working with voluntary

and community organisations and district councils (NE, W) community champions (SE) and employing care navigators (City)

City Health and Wellbeing hub

Spreading learning from the Healthy New Town projects in Bicester and Barton.

Digital and IT

Focus on enabling patient records to be shared so all care providers have access to information they need. This includes access to records for care home staff.

Finance

Core primary care funding; funding

from allocations as becomes available, including to address deprivation. Aim to shift funding from secondary care (hospitals) into the community.

Reduce deprivation and inequalities

Expansion of services that support areas of high deprivation

Extension of minor ailments service in pharmacies

Focus on link workers and care navigators in areas of high deprivation“I want to be helped to be healthy and active”“When I am in need of care, it is safe and effective”“I want to have a good experience and be treated with respect and dignity”“I am able to see the right health professional at the right time”“I want to be helped to be as independent as possible in the best place for me”

“I can expect the same health outcomes wherever I live”

Draft locality plans on a page

9Slide10

Priority

b

enefits

Practice resilience to help reduce GP time spent on less clinically critical work

Additional clinical capacity to enable local primary care to enact system leadership role

Peer support and better distribution of workload

Patients requiring home visits

will be seen more quickly and have appropriate support to avoid them being admitted to hospital.

GPs’ time will

be

used more

efficiently allowing them to concentrate on continuity of care.

Increased GP provision for patients at times such as before work and after school

More same-day

appointments for patients

Working at scale to provide specialist care for patients with conditions such as breathlessness/ COPD and asthma

Increased levels of provision for patients created through practices working together

Reduced isolation, improved mental health wellbeing and greater empowerment

Care navigators wil

l clearly signpost services, enabling patients to make better use of the services available

Increased provision

for the most vulnerable communities in Oxfordshire Extended minor ailment service to help people take pro-active steps to manage their health needs without a GP

How

patients, practices and

the

wider healthcare system will benefit

Priority

Sustainable primary care

Caring for frail and elderly people

Access to right care at the right time to meet growing demand

New ways of caring for people with long term conditions

Prevention,

increased self care and health and wellbeing

Reduce deprivation and inequalities

Workforce

Physical infrastructure

and estates

Digital and IT

Finance

Enabler

Enabler benefits

Facilitates a shift to a more collaborative approach to workforce which provides greater system resilience

Increased resource

will help to meet growing demand

A more diverse skill mix from different types of clinician will enable patients’ needs to be met more efficiently

Sufficient estates capacity to meet projected future growth

More collaborative working will provide opportunities for improved financial efficiency

Patient records will be accessible to more care providers leading to more joined up care and better integration

Access

to records for care home staff will improve the quality of care provided for frail and elderly residents

Making the most of available funding in primary care

and the community

Overa

ll benefits

Patients:

Fewer avoidable admissions, fewer A&E attendances and fewer bed days

More consistent access for patients at convenient times, including after school and work

Reduced isolation, improved mental health wellbeing and greater empowerment

Better care co-ordination through effective information sharing

More care closer to home

General Practice:

Practice resilience to help reduce GP time spent on less clinically critical work

Additional clinical capacity to enable local primary care to enact system leadership role

Peer support and better distribution of workload

Retains funding in primary care through reinvestment into community & GP services

Makes Oxfordshire an attractive and supportive place to work

System

:

Shift in settings of care and cost releasing savings through reductions in A&E attendances, emergency admissions and delayed transfers of care

Anticipates future ACO model

Facilitates a shift collaborative approach to workforce which provides greater system resilience

10Slide11

Priority

Case for change

Sustainable primary care

Parts of Oxfordshire have difficulties in

recruiting clinical staff

There is an expected shortage of over 100 GPs by 2026 to meet the needs of population. This is unlikely to be met

from current recruitment patterns

Changing career patterns mean fewer GPs want full time partnerships

Many staff have expressed concern about burnout

Caring for the frail and elderly

Population aged 60 and over is expected to increase by 58,100 by 2032

There is a longer length of stay

in care homes in Oxfordshire

There is a potential to prevent admissions in care homes

Greater support is required to keep frail / elderly at home

Need to integrate community services to deliver high quality care.

Access to right care at the right time to meet the growing population

There is

a s

ignificant housing growth of over 60,000 new dwellings in the next 10 years (100,000 homes planned between 2011 and 2031)

There is increasing demand on primary

care services There is high A&E attendance in parts of Oxfordshire (North, City) much of which can be dealt with in primary care.

New models of care for people with long term conditions

Cardiovascular disease, cancer and depression have a higher than average prevalence in Oxfordshire

Oxfordshire is in the highest quintile for additional risk of mortality among people with Type 1 and Type 2 diabetes compared with the general population.

Prevention,

i

ncreased self care and health and wellbeing

An estimated 60% of people in Oxfordshire aged 16+ were classified as overweight or obese.

Many diseases

affecting Oxfordshire residents can be avoided if high risk factors are eliminated.There is great potential to promote wellbeing with support from the local community: family, school, voluntary sector and business.

Reduce deprivation and inequalities

Oxford city and Banbury have higher rates of deprivation.

There is a strong correlation

between deprivation and poor health outcomes – Carfax ward has the highest number of deaths <65 and Littlemore has the highest level of childhood (year 6) obesity in Oxfordshire, Buckinghamshire and Berkshire West.

Health needs assessment:

Why we have focussed on these priorities

Oxfordshire Population by gender

2017 vs 2032 (ONS)

Significant increase in age bands above 60 years

Overall Index of Multiple Deprivation 2015

% of OCCG patients in each deprivation quintile

Change in the average number of primary care consultations per patient per year in England 1995 to 2008

Hospital episodes per person by age – Oxfordshire, 2005-06 to 2015-16

A&E attendance by locality 16/17

11Slide12

Overview of place based plans at locality level

- Oxford City locality summary- North Oxfordshire locality summary- North East Oxfordshire locality summary

- West Oxfordshire locality summary

- South East Oxfordshire locality summary

- South West Oxfordshire locality summary

12Slide13

Oxford City Locality Plan:

13

 

Challenges :

 

High deprivation areas with inadequate fundingLack of ambulatory care for patients with high needs that could keep them out of secondary care

Increase in number of patients seeing GP means it is increasingly difficult to manage emergencies among housebound patients

High use of A&E from patients that could be directed elsewhere more appropriately

High cost of housing which makes recruitment difficult

How

will we meet our priorities?

Urgent visiting service for frail patients (in hours) and proactive nurse led care (at weekends)

Strengthened care home service

Neighbourhood teams clustered around GP practices

Build on success of minor ailments pharmacy scheme

Health and wellbeing hub

Expanded social prescription model – care

navigatorsAdditional funding for deprived areas

What

are our priorities?

Improve care for the frail and vulnerableAddress deprivation and health inequalities

Ensure sustainable primary careCreate neighbourhood teamsSlide14

 

North Oxfordshire Locality Plan:

14

Challenges :

 

The locality has an older than average and ageing population with pockets of deprivation in Banbury

Significant housing growth of over 6,000

homes in the next 5 years and 9,800 in

the next

10

years

Use of urgent care services is particularly high in Banbury with confusing access points

The primary care workforce is varied across

the locality

: traditional model of care in rural cluster, but high number of vacancies and significantly under pressure.

How

will we meet our priorities?

Wider skillmix, including building on successes of pharmacists and mental health workers

Expanded primary care visiting serviceSupport to staff for recruitment

Social prescribing initiatives working with community groups and the district councils

Better and more consistent urgent access

in BanburyBetter use of estates to ensure care closer to home and to meet growth in population. What are our priorities?Ensure sustainable primary careImprove outcomes for the frail / elderly Access to the right care at the right timeAddress deprivation and inequalities Slide15

 

Challenges :

 

Significant planned population growth in the locality

Higher than average A&E attendance

High cost of living is a barrier to recruitmentA need for changes in estates and infrastructure to deliver a new model of primary care

A background of significant loss of primary care funding through national reduction in MPIG which disproportionately affects NE practices.

How

will we meet our priorities?

Increased extended access

Support for practices to work in larger

units, including better use of estates

Use of different skillmix

Continue new models of care for planned

care

Enhanced

primary care visiting serviceSocial prescribing

Learning from Bicester Healthy New Town

What

are our priorities?

Ensure sustainable primary care

Increased capacity to manage housing growthNew models of care for long term conditionsNew models of care for frail / elderly Increased self-care and health and wellbeing 15North East Oxfordshire Locality Plan:Slide16

 

Challenges :

 

Rapidly growing population, in particular Witney, Carterton and

Eynsham

Parts of the locality have a significantly older

population who live in rural areas; this presents challenges

for transport and access to

services

There is a shortage of

staff to meet changing

demographics (growing and ageing population)

How

will we meet our priorities?

Gerontologists in the community and proactive care in care homes / assisted

living

Maximise benefits of Emergency Multidisciplinary unit in Witney

Increased primary care visiting service

Improved self-care and social prescribing

Enhanced signposting roles for receptionists

Estates prioritisation

Increased same day primary care access in Witney and Carterton.What are our priorities?Meet the needs of the ageing populationEnsure safe and sustainable primary careSupport access for an increased populationDeliver improved preventionWest Oxfordshire Locality Plan:16Slide17

 

Challenges :

 

A much older population than average and largely rural, creating challenges for

access

There is no single population centre and care is quite dispersed

Several practices are close to capacity, both in terms of rooms and

clinicians

Patient numbers will rise due to the increased housing developments.

How

will we meet our priorities?

Continue to retain

trainees

Develop locality expertise in services that keep patients out of hospital

Estates expansion

Expansion

of ambulatory care for frail / elderly

Test care navigation in practices

Expansion of care home initiative

Better integration with social care

What

are our priorities?Sustainable primary careCare for the ageing populationDeliver increased preventative and self careSouth East Oxfordshire Locality Plan:17Slide18

 

Challenges

:

 

The population of South West Oxfordshire is rapidly growing – in the three years to April 2017, the practice registered population increased by 5%.

The proportion of older people is also increasing.There are small pockets of deprivation in South Oxfordshire, whose residents are affected by poorer health and well-being outcomes.

There is a requirement to build and staff new premises to accommodate the additional services

required in the future.

How

will we meet our priorities?

Expansion and new estate; some agreements in place for capital investment

Efficiency of use of estates

Greater

skillmix

and working at scale

Expansion

primary care visiting service across the locality

Care home initiative for more patients

What

are our priorities?

Expansion of premisesExpansion and integration of clinical workforceEfficiencies through shared servicesIntegration of clinical recordsImproving health outcomes for frail patientsSouth West Oxfordshire Locality Plan:18Slide19

Oxfordshire Wide Priorities

- Establishing a frailty pathway across Oxfordshire- Consistent access to primary care across Oxfordshire

-

Care

for patients with Long Term

Conditions19Slide20

Establishing a frailty pathway across Oxfordshire

Lead SRO: Sara Wilds 20

Overall Objectives

Patients who are at risk of admission will receive:

Appropriate services that are rapidly available to assess patients if they deteriorate at home;

Access to rapid diagnostics in an appropriate place to reduce admission; Support for the frail and vulnerable at home for transient exacerbations/illnesses.

Deliverables

Develop business case for frailty pathway Agree scope for pilot Phased

r

ollout of the proposed

virtual wards

Benefits

Frail

and elderly patients receive care more quickly and cared for in the most appropriate setting for their needs.

Fewer avoidable admissions

Fewer A&E attendances

Fewer bed days.Outcome

Measures Fewer emergency and A&E admissions

Lower DTOC levels

Fewer bed days

Patient high risk and unstable assessed by GP/ANP/ECP or returning from acute care setting

Too unstable to hold at homeUnstable but non-intensive stepped up input requiredUnstable but can be held at home with high inputAdmit via MAU/EDVirtual Ward – Silver

Engage

N

eighbourhood

Team to deliver enhanced support plan (includes

nursing and social care input)

Discharge to GP/normal care. Review dPCP

Needs more diagnostics/ambulatory care/EMU/AAU and can be turned around in same day

Seen in AAU or EMU/ frailty hub

If needed admit to appropriate setting inc Community beds

Clarify care plan and return home with enhanced input support

Virtual Ward – Gold

At home – assessed

by rapid assessment

team, who draw up and deliver detailed high input care plan until stepped down

Enhanced home care by

H

igh

I

nput

P

rimary

C

are

T

eam supported by

Neighbourhood team

Stabilised.

Step down to Silver or

d

ischarge to GP/normal care. Review dPCP

Too unstable to hold at home.

If needed admit to appropriate setting including bed based care

Potential New Frailty Model

Pilots in the City locality will involve establishing a working neighbourhood, forming a virtual ward and looking at a more integrated High Intensity Team for gold rated patients. The City locality has the highest rates of emergency admissions.Slide21

Rapid response to acutely ill housebound patients 7/7 and referral into virtual ward

Routine care and proactive monitoring and review of patients in the virtual ward 7/7

Draws in specialist expertise and additional resources from locality level teams as needed

24/7 rapid response, stepped-up assessment and acute care for high need patients (Gold)

Support to Neighbourhood Teams when intensive home care is required

Extended hospital at home capability with more risk-holding capacity

Regular proactive reviews, care navigation and care planning for care home residents

Training and skills development programmes for Care Home staff

2017/18

2018/19

2019/20

2021/22

City

North

North

East

West

South West

South East

Frailty Pathway roadmap – high level integrated view

21

Mobilisation TimelinePrimary Care Visiting TeamIntegrated Neighbourhood Team High Input Primary Care Assessment Team

Care Home Support Team

Metrics & Evaluation

Patient and staff feedback

Number of visits by locality

Impact on A&E attendances and admissions

The proposed new frailty pathway will operate as one integrated service,

7

days a week. Strengthened locality based working will be core to its success within a local practice-based population of 30,000-50,000 people.

It will be delivered by four integrated teams:Expand ambulatory careExpand Primary Care Visiting Team (PML)New PCVS (Abingdon)Develop PCVS Pilot pathway

Rollout pathway drawing on lessons from pilot

Provider readiness

Develop Care home support

Evaluate

To

give expert support to neighbourhood clusters with frail complex

multimorbid

patients

To run the virtual ward across the clusters to make sure all unstable patients are identified (RAG rated) and supported by appropriate teams/ workers to try and maximise the chances of keeping at home

To give medical support to rapid assessment teams/H@H

dealing

and assessing subacute patients being held at home

To give medical support to any frailty hubs/ UTC/AMU/AAU in locality

To give medical support to care homes

esp

CHSS and Paramedics called to transport patients to hospital.

To liaise with Acute settings re return of unstable patients back into the community with appropriate plans and community work force in place

Develop relationship to support Neighbourhoods

Role of

Consultant

G

erontologistSlide22

Consistent access to primary care across Oxfordshire

Lead SRO: Julie Dandridge / Sara Wilds

22

Overall Objectives

Create a

standard to reduce variation to access to primary care across Oxfordshire, whether through same-day urgent care, prebookable appointments or the requirement for home visits.Undertake review to understand the benefits, cost implications and likely future location of urgent treatment centres Comprehensive front-door clinical streaming by GPs at A&E

Integration of access to urgent care through 111, ambulance services and GP hub appointments

Design and agree model for enhanced care for young people

Benefits

Helps

patients to receive care in the most appropriate setting

Provides increased GP provision at times that are more convenient for people such as after school hours and before work

Hubs allow practices to resource and plan extra sessions efficiently

Access standard across the localities will reduce variations in service ensuring patients receive the same high quality care

Additional appointments offered per week in Oxfordshire localities

Urgent and Emergency Care Review: Urgent Treatment Centres (UTC)

NHS

England is committed to rolling out standardised new Urgent Treatment Centres (UTCs) across the country, all operating to minimum standards by December 2019. These include:

Open 12 hours a day, GP – Led with simple diagnosticsConsistent route to access urgent appointments within 4hrs, through 111, ambulance services and GPsAccess to routine and same-day appointments and Out of Hours at the site

Part of the locally integrated urgent and emergency care services.The CCG is undertaking a gap analysis and options appraisal on existing identified sites against UTC standards. All six MIUs and FAUs (highlighted in the map below) are within scope for consideration to converting to a UTC. The final decision will depend on the most effective use of resources.

Same day access plans across localitiesSlide23

Consistent access to primary care across

Oxfordshire – high level integrated view23

Mobilisation Plan

Locality plans contain plans to deliver

responsive access to primary care

. This will be backed up by an Oxfordshire wide standard to provide same day urgent access to a consultation with a clinician for all patients with a clinical need.

This will be supported through national plans to offer consistent access to urgent appointments whether booked through NHS 111 or directly through general practice.

Design specification including number

of appointments and expected workforce

Agree

place of delivery

Assurance on impact of delivery on appointments elsewhere in Oxfordshire

Agree scope of standard that will ensure consistency of access to primary care services

Agree wording of the standard with stakeholders

Design

monitoring approachModel change required to deliver standard

Gap analysis and options appraisal on existing sites against

UTC standardsModel future patient flows and impact on other servicesQuantify costs and

benefitsMobilisation of agreed sites

Metrics & Evaluation

Patient feedback

Number of appointments made availableUtilisation of appointmentsTimeline17/18 Q418/19 Q1

18/19 Q2

18/19 Q3

18/19 Q4

19/20

Q1

Gap analysis

and

options

appraisal on

existing sites

against

UTC standards

Agree Access

Standard

Urgent

Treatment

Centres

Access

Standard

Access

Hubs

Options

appraisal

Agree

spec

Implement changes

Roll out changes

Access to right care right time

Roll out changes

Mobilisation of upgrade to

UTCs, with all services

designated as UTC

to be meeting minimum standards

by Dec 2019

ReviewActivities required under each of the three workstreams:

Access HubsAccess StandardUrgent Treatment CentresPatient feedbackPractice audit

Patient feedback

Impact on A&E

Impact on other servicesSlide24

Care for patients with Long Term Conditions (LTC)

Lead SRO: Sharon Barrington

24

Overall Objectives

Following indications

of improvement from the local diabetes service in the North East Oxfordshire locality, we will consolidate the service with an alliance contract for the provision of all outpatient and community services between the federations, OUH and OH to deliver an integrated diabetes service. Over time we will provide the same for other services. These principles

will be used to develop similar services for:

Respiratory Cancer

MSK

Benefits

Improved

uptake of structured education

Improved quality of life and self care for patients and their carers

Reduction in ambulance call outs & admissions/readmissions for patients with airways disease, and breathlessness from end-stage lung disease

Empowered patients who believe in their ability to effectively manage their conditions

Improved care processes

Better accessReduce avoidable admissions across LTCs

Interdependencies

Future models will aim to:

Build on the work that is being piloted with diabetesEncourage the spread of clinical expertise – using experts in primary care and community nursing as a source of advice

Consider other ways of consulting e.g. group sessions, webinars, Skype

Encourage the use of expert patients Involve non practice staff using practice space to provide care/run clinicsBe led locally Objectives – Respiratory 20% reduction in emergency respiratory admissions 20% reduction in emergency respiratory re-admissions within 30 days20% reduction in respiratory length of stay (LOS)30% reduction in respiratory outpatient appointments both new and follow up Projected achievable prescribing cost savings over the course of the project Smoking cessation within defined cohort Reduce the differential between expected and observed prevalence of COPDYear of Care Case Study – Improved care for patients, fewer appointments and reduced cost The new model allows patients to attend fewer appointments in order to receive their treatment and at a reduced cost to practices. In two out of the three pilot practices during the 2008 Year of Care pilot project, practices offered the same or more contact time at reduced or neutral cost. The practice diagrams below show the number of visits, amount of contact time and cost per patient before and after the pilot. Slide25

Long term conditions roadmap – high level integrated view

25

Mobilisation Timeline

The Diabetes Dashboard was implemented for the

North East

Locality in July 2017. At that point the North East Locality achievement for 8 care processes (over the previous 12 months) was 49.79% and 38.14% for the Triple Target. The latest Dashboard for the North East Locality up to October 2017 was issued on 9/11/2017 and the achievement for 8 care processes (over last 12 months) was 52.99% and for the Triple Target it was 38.84%. Therefore, there has been a 3.2% improvement for 8 care processes and an improvement of 0.7% for the Triple Target over the period.

Preventing or delaying Type 2 Diabetes (NDPP)

Delivering Diabetes transformation Funding (DTF) workstreams Implementing a new integrated model of diabetes care focused on delivering outcomes

Mobilisation

of all practices in referring pre-diabetes patients to NDPP

Using DTF effectively to implement initiatives for structured education, treatment targets and multi-disciplinary diabetic foot care team

Achieve a single governance framework

Improvement in 3 NICE diabetes treatment targets

Improvement in 8 diabetes care processes

Reduced diabetes admissions

Increased patient empowerment and education

Improved physical activity of people with pre-diabetes and diabetesBetter diabetic footcare outcomes

National Diabetes Audit

Oxon Diabetes Dashboard National Diabetes Footcare

Audit National Diabetes Inpatient Audit

Timeline

17/18 Q418/19 Q1

18/19 Q2

18/19 Q3

18/19 Q4

19/20

Q1

Develop model

in NE

Respiratory Model roll-out – 18 month pilot with countywide offer by Apr. 2020

Supporting

Patients with LTCs

October – Commencement of Integrated Diabetes pathway

S

can model’ for detecting early cancers running

Diabetes – A closer look

Develop model

Objectives

Deliverables

Benefits

Outcome Measures

Cardiovascular /

Heart failure

End of Life

Cancer

Respiratory

Diabetes

Ongoing NE pilot and evaluation

Refine model and mobilise

model of care

Evaluate and roll-out

Pilot new community model of care in the South

Evaluate and roll out

Develop model

Refine model and mobilise

model of careSlide26

Key enablers to making our plans a success

- Workforce- Physical infrastructure and estates- Digital and IT

- Financial implications

26Slide27

Workforce

Lead SRO: Julie Dandridge and Sula Wiltshire 27

Locality

level activities

Assess the specific needs of the population

and define the most appropriate clinical and non-clinical team to provide careIdentify training needs and support in delivering training

Enable practices through federations

to use resources flexibly, including support with employment contracts and locum banks

Leadership, staff involvement and culture change

Oxfordshire wide activities

Plans to recruit, retain and encourage returners in line with locality-defined need.

Support to

bring teams together from across different employing organisations

Support for mergers, where

requested by practices, to provide a greater level of

sustainability.

develop a network of education and training providers through the Oxfordshire Training Network.

Primary care workforce

Additional GPs required to meet growth

GPs

(FTE

)

GP vacancies

(FTE

)

Practice nurses (FTE)

HCAs /

phlebotomists (FTE)

5 years

10 years

North

53.8

11.3

20

18

8.6

10.0

North East

45.8

2.1

17

8

6.5

16.3

Oxford City

119.0

2.8

36

20

6.1

11.0

West

47.0

0.1

17

9

5.0

11.0

South East

51.5

1.0

20

12

5.5

10.0

South West

74.2

4.2

34

19

14.0

26.3

Oxfordshire

CCG

391.2 21.4

145858.610.0Shortfall (excludes retirements)

67.2106.0Workforce and staff vacancies derived from practice surveys in August 2017.Population derived from district council local plan housing submissions at 2.4 persons per dwellingCurrent workforce, GP vacancies and predicted future requirements: Our workforce challenge and objectives in Oxfordshire: Over 100 additional GPs will be required in the next ten years in Oxfordshire to meet the expected growth in population as a result of the ambitious plans for housing growth. This is unlikely to be met on current trends:The current workforce is ageing and facing a ‘retirement bubble’ – nearly 20% of GPs in Oxfordshire are aged over 55.The profile of GPs is changing, with a growing preference for portfolio careers to traditional partnership models.Nationally, demand for appointments has risen by about 13% over the last five years.A new approach to workforce is required with the objectives of:A broader skill mix including new roles in general practiceUpskilled staff who can provide more services and enjoy increased professional developmentIncreased capacity through recruitment and retention of the valuable staff already in placeSlide28

Workforce roadmap – high level integrated view

28

Designing

a workforce around population health needs

Modelling and planning the workforce

Personalisation of careLeading change

Involve and engageCollaborative

leadership

Workforce

redesign

Design of team and roles

Education and training

Technology

Mental Health Workers

Non-clinical staff

Social Prescribing / care navigation

Support for clinical pharmacists to work across general practices, as appropriate to the locality. Examples include audits, medication changes and long term conditions clinics.

Depending on the local need, this may include wellbeing

link workers

based

in practices, employed

by a 3rd sector organisation with a track record in mental health and knowledge of services available in the wider community.Training for receptionists in signposting and access to a directory of information about services to help them direct patients to the most appropriate source of help or advice. This may include services in the community as well as within the practice.Social prescribers working in general practice for patients with defined need (eg isolation, long term conditions, frequent attenders); different models appropriate to local needs, working with district councils and the voluntary sector. Metrics & EvaluationPatient feedbackStaff feedbackImpact on use of healthcare servicesOxfordshire wide support for workforce will be built around the following three areas:

Some practices in Oxfordshire are leading the way in developing new models of

skillmix

to enable resilience. The CCG will provide support, either as initial set-up funding or recurrent, for new clinicians at cluster / neighbourhood level, including:

Clinical PharmacistsSlide29

Physical Infrastructure and Estates - enabler

Lead SRO: Julie Dandridge 29

Overall Objectives

The Primary Care estate across Oxfordshire needs considerable investment to make it fit for the future: some practices require capital investment now and large areas of housing growth will mean that infrastructure will need to be improved in order to deal with the population increase.

To support the prioritisation of schemes for estates developments in line with the overall resourcing available, we will need

a strategy for estates which will cover: A review of strategic locations for delivery of primary care services, balancing economies of scale with the need to provide locally accessible services

The criteria we will apply to assess options

for investment Efficiencies in current estates through better use of primary care premises harnessing the benefits of technology.

Benefits

Improved capability and capacity for Primary Care provision.

Premises compliant with equalities legislation and environmental standards

Best use of estates within the financial envelope for delivery of services

Better service integration and support for new models of care models

Reduced risk and improved service resilience at local and system levels.

Increased efficiencies, through the better use of community and central estate.

Interdependencies

Agreement

on housing developments and developer infrastructure funding, where relevantAgreement from NHS E on ETTF funding Necessary primary care allocations to meet increase in population

Assess options and produce strategy

Confirm funding source

Prioritise

Guidance and criteria for assessment (by March 2018)Produce structure, process and guidance for primary care estate projectsConfirm prioritisation criteriaDevelop an Oxfordshire wide estates strategy.Assess options for sites, expansion ability and delivery mechanism, linking with other system-wide estates priorities Each estates scheme will need to identify the funding source of either NHS capital or private sector (CIL / S106 funds)Schemes will be prioritised according to published criteria. Process for prioritisation:Case studies

: Other options to deliver efficiencies in estates

Room utilisation planning in SW Oxfordshire

SW locality is

working with practices to increase the daily utilisation of each consulting room in the practice and carry out other administrative tasks across a smaller footprint, for example in a communal

office with “hot-desking”. This model also has

advantages for patients: appointments are spread more evenly through the day

and a visiting GP is available in the mornings and late afternoons.

Digitisation of notes

Several practices have a significant amount of space that is currently used for patient records. These records only need to be accessed occasionally. Removing the records would enable practices to obtain additional space for computers and thus free up space for other clinical staff. The CCG is exploring options to scan the notes (in accordance with information governance requirements), thus saving the space currently used for patient records, saving clerical time in retrieving the notes and improving access to the patient records.Slide30

D

igital and IT - enablerLead Director: Gareth Kenworthy

30

Overall Objectives

An integrated, longitudinal health and care record for Oxfordshire

Records sharing for cross-organisational care: interoperability of records used across primary, community and secondary care. Citizen facing technology, including aligning portal plans and auditing apps that empower patient self managementRisk stratification and modelling to support care co-ordination, clinical decision support and referral management tools

Infrastructure and network connectivity, including shared network access and access to records by care home staff

Information Governance, developing confidence in primary care over how data is accessed

Benefits

Easier for patients

to access and interact with their care records

Improved clinical access

to patient records across the system

Increased patient empowerment and self-management

Better integration of different clinical teams to improve care co-ordination and decision making Access to records by care home staff to help improve standards of care for residents More joined up mental and physical health care provision through interoperability.

Interdependencies

‘Digital’ has a significant role to play in sustainability and transformation, including delivering primary care at scale, securing seven day services, enabling new care models and transforming care in line with key clinical priorities.

2018

20192020

Primary Care IT roadmap

Success

is also dependent on robust infrastructure and a Primary Care IT roadmap is in place to consider aspects such as: Telephony InteroperabilityCybersecurity Mobile workingOnline triage, Patient online activity“ I want joined-up care regardless of location, with access to information that makes it easier to manage my health.” “ I want access to all the information I need to deliver effective and efficient care, regardless of location.”“ I want integrated information across organisational boundaries in order to optimise models of care delivery.”Operational Group: Overall planning and coordinating programme implementationGovernance Group: Information governance compliance and data sharing agreements Technical Group: Development and deployment of technology solutions For Patients For Providers

For Commissioners

Communications sub-group:

Plans and delivers communication strategy

Authentication / Authorisation sub-group:

Specifies and implements user management solutions

Governance

Why is this important for patients and the system?

Timeline for implementation of the Oxfordshire Health Information Exchange:

a virtual health record of patient information Slide31

Implementation of the plans will require investment either through core funding or through release of funding in secondary care over time. The vast majority of investment in primary care is determined through a nationally agreed formula. However, some additional funding that was secured through the Prime Minister’s Challenge Fund and the subsequent GP Forward View has been invested recurrently in general practice and will continue to be invested as part of the local plans.

The

CCG will support future investment in workstreams that are intended to deliver savings elsewhere in the system subject to a robust business case. This will provide a significant step forward in delivering accountable care, in which resources are allocated according to the needs of the population of Oxfordshire and in which partners in the health and social care system share financial and clinical accountability to deliver better outcomes.

Ultimately, the

locality plans need to be affordable within current NHS financial constraints and

CCG commissioning budgets. 31

Funding requirement identified to deliver the

services above current GMS / CCG

spend

(excluding demographi

c growth) (£000)

Primary care

investment:

Non-recurrent

£680

Recurrent full year

£4,025

Wider system

investment

(subject

to business case)

£3,100Financial implications  Schemes to be funded and relevant localitiesBenefits for patients

Recurrent

(full year) (£000)

Non-recurrent

(£000)

Priority areas

Sustainable primary care

New posts for mental health workers and clinical pharmacists in practice (all localities)

Improved outcomes for patients with mental health

conditions;Proactive reviews for patients with asthma, diabetes and other long terms conditions, better treatment coordination. 

£850

Caring for the frail / elderly

Expansion or introduction of Primary Care Visiting service (N, NE, W, City, SW)

Additional proactive support in care homes (all localities)

More patients at point of crisis assessed in their homes and less likely to be admitted to hospital

£531

 

Access to the right care at the right time for a growing population

Additional overflow appointments (NE, W)

Additional same-day appointments to ensure that patients who need to can be seen on the same day.

£189

£25

Prevention, self-care and health and wellbeing

Social prescribing initiatives (City, N, NE, W, SE)

Health and wellbeing hub (City)

Patients better able to care for their own conditions, reduced social isolation, improved prevention

£337

£55

Reduction in deprivation and inequalities

Expansion of services to address deprivation (all localities)

Expansion of minor ailments scheme (City)

Improved access for patients who do not need to see a

GP;

Improved outcomes for patients in most deprived parts of the county

£100

£36

Enablers Workforce redesign

Headroom to design new teams (all localities)

Workforce more responsive and better designed around patient needs

 

£300

Physical infrastructure

Digitisation of notes (all localities)

Efficient use of space through different work patterns (SW)

Better use of estates for delivery of front line services

 

£410

Total  

£1,157

£1,676Recommended additional funding: 2017/18 and 2018/19The Oxfordshire Primary Care Commissioning Committee (OPCCC) approved a number of service initiatives for additional available funding for 2017/18 and to guide 2018/19 as set out below. This

covers part of a longer term investment over the period of the plans.Slide32

Appendices

- How we are delivering against the objectives of BOB STP

32Slide33

How we are delivering against the objectives of BOB STP

33

1. Prevention Workstreams

2. Access

Workstreams

Social prescribing and care navigation initiatives are being established across Oxfordshire

A population-based approach to health improvement that considers how the family, schools, voluntary agencies and businesses can impact health are being considered as part of the healthy new town projects and brighter futures.

The access hubs are successful examples of extended access to routine and urgent appointments. These are being supplement with additional appointments in parts of the county.

A county-wide

a

ccess standard is being developed, building on the access hubs and the Oxfordshire response to the appraisal on urgent treatment centres.

6. Workforce Workstreams

A workforce model and plan is being constructed for all 6 localities. This will be with the aim of

increasing

capacity in primary care;

upskilling

existing staff; and

bringing

in and expanding new roles.

4. Mental Health

Workstreams

Mental Health workers in practices dependent on the specific needs of the localities. This may include:wellbeing link workers related to neighbourhoods and practices along a social prescription modelCommunity psychiatric nurses who can see patients with more challenging symptoms in primary care.7. Digital Workstreams

Shared patient record accessible to all local

services

Access in care homes to HSCN to allow

sharing of clinical record data directly with care home computers.

Use of websites and directory of services for

signposting

Use of ICT to maximise efficiency of clinical triage.

8. Primary Care at Scale

WorkstreamsProvision of primary care services into a sustainable model for the future, built around bigger practice clusters of 30-40,000 patients.Neighbourhood teams built around the practice clusters to

deliver joined-up, sustainable services for patients with complex needs and frailty.