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
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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.