REPORT TO THE WEST CCG EXECUTIVE HEALTH AND CARE COMMITTEE

Agenda Item:

Date of Meeting: 20 November 2014

Title of Report: Primary care planning process

Author: Peter Wightman, Interim Director of Primary Care and Localities Presented by: Peter Wightman, Interim Director of Primary Care and Localities Purpose of Paper and key Present for HCC approval a process for working with practices areas to note to: - establish key planning issues for each practice including a baseline of premises and workforce issues for each practice - identify the opportunities for practice cluster working - where appropriate develop plans for each cluster

This is in the context of key pressures on the delivery and sustainability of primary care services, NHS ’s Essex Primary Care Strategy and the CCG’s aim to be a delegated co-commissioner of primary care from April 2015

Fit with CCG Primary care is a key enabler for the delivery of each of the strategy/objectives transformation programmes

Risks identified Identifies needs and expectations for change that cannot be met by resources. Resource implications Consumes time for practices and the CCG

CCG Committees / Primary Care Commissioning Committee discussed the Groups previously principles and approach consulted

View of the Patients, The CCG has discussed this direction of travel at public Carers or the Public and events. There are patient members of the Primary Care the extent of their Commissioning Committee. Patient involvement would take involvement place should ideas for significant change emerge from this process Equality Impact No equality issues foreseen Assessment

Recommendation to The Executive Health and Care Committee is asked to: Executive Health and  Agree to the proposed process for planning with Care Committee practices

Practice Planning Process

1 STRATEGIC CONTEXT

Pressure for Change in Primary care

1.1 Sustainable high quality primary care is essential if West Essex is to achieve its transformation goals for mental health, older people, children & families and adults of working age. Primary care needs to adapt in the future to manage the combination of - increasing demand, including some pockets of high population growth - reductions in funding for many practices - changing technologies/pathways/evidence - changing patterns in the workforce and difficulties in recruiting and retaining staff - patient and government expectations: 7 day working, access satisfaction.

Future service models

1.2 Work nationally by NHS England with key bodies in 2014 concluded that primary care needs to work at a greater scale in the future to respond to these changes. NHS England Essex Area Team’s strategy (‘Transforming Primary Care in Essex- The Heart of Patient Care’ June 2014) describes a vision for the creation of Primary Care Hubs, within which primary care will be provided on a larger scale, each covering a suggested minimum of 20,000 population. The hubs would facilitate an integrated approach to the delivery of primary care, community health services and social care for a registered population. The strategy explains that hub models will vary and be developed locally for best fit for patients and practitioners. The strategy identifies a number of critical actions which will be undertaken on a pan Essex basis, including a review of primary care premises and a number of initiatives to attract additional primary care staff.

1.3 This is potentially a period of major strategic change for primary care. Nationally Nuffield Trust has undertaken a review of the drivers for change and potential models for the future of primary care (http://www.nuffieldtrust.org.uk/publications/securing- future-general-practice) looking at four routes to achieving benefits of greater scale in General Practice:

- Networks or federations - Super-partnerships - Regional or national multi-practice organisations - Community organisations

1.4 NHS England published in October 2014 their five year forward vision (extract in appendix 1). This shows a support for the registered list, Royal College of General Practitioners description of the need for General practice to evolve and two potential models for health services which could affect primary care in relation to the organisation of community health services.

1.5 In West Essex: - Practices circumstances and views on the future vary reflecting their history and variation in list size, rurality and the needs of the populations served. Some practices are already pursuing their own mergers () or successful procurements (High Rd /Trapps Hill, Limes/Greenyard/Nazeing) - The formation of GPO Provider Companies presents practices with new options for joint working

- The CCG has described in its commissioning intentions the geographic practice clusters that should form the basis for consistent organisation of community health and care services in the future to enable integration.

Role of the CCG

1.6 The CCG already has specific responsibilities to support primary care: referral management; IM&T; Medicines management and commissioning local enhanced services. The CCG works more closely with NHS England in this capacity. The CCG is applying to take this further and receive delegated responsibility for co- commissioning of primary care from April 2015, to better integrate plans and commissioning decisions for primary care with other local health and social care services (e.g. premises commissioning).

CCG relationships and communication with practices

1.7 Practice visits by the primary care team to date indicate a lack of communication between the CCG and practices since the reorganization and cessation of locality manager roles. The CCG primary care team is reintroducing a senior primary care manager role for each locality. Two managers are in post (one part –time) and all three will be in full time post by January 2015. The managers are looking to visit surgeries to develop the relationships and understand practice key issues. The visits need to tie into the practice planning process.

2 KEY ENABLERS

2.1 The CCG has identified six key enablers to support practices to move from the current position to a highly sustainable primary care service in the future, able to provide the highest standards of care for patients, shown in the diagram below:

- Workforce – training and retaining future workforce, making the wider team a reality (district nurses, health visitors, social workers)

- Premises – fully utilising the premises that exist and exiting unnecessary buildings, prioritising new premises changes including population growth, enabling desired future models and integration

- IM&T systems – systems that allow quick & efficient access to integrated patient records, guidance and evidence, communication with other providers (including virtually all practices moving to EMIS web (north) Systmone (south)

- Practice operations – models of how surgeries work in future including opportunities for working together, maximise efficiency, systems for optimising access and patient satisfaction, how to access pathways and make referrals.

- Self-care – empowering patients to manage their own health where appropriate, particularly for long term conditions and common minor urgent problems. Utilising technology to assist the process.

- Resources: sufficient funding provided to practices for work undertaken including additional work moved from secondary care.

2.2 The CCG needs to work with NHS England to support practices with these key enablers. Co-commissioning would give the CCG greater direct influence over these enablers. Progress with enablers is also highly dependent on national decisions.

3 PROPOSED PROCESS FOR WORKING WITH MEMBER PRACTICES

3.1 In this context, the CCG proposes to lead a process of working with practices to help think through the key planning issues and help practices and groups of practices develop plans for the future. This will be largely dependent on practice appetite for CCG support and CCG resources to support practices.

Practice visits

3.2 It is proposed for a series of practice visits with each practice in the area to

(a) Strengthen the relationship and communication between the practices and the CCG

(b) Build a baseline of key planning information for each practice including a. Current and future premises issues b. Current and future workforce issues c. Potential major registered list population changes

(c) The practice’s views of the key issues and options for the practice for the next 2 years and next 6 years (when practice contract value equalization is complete); specifically including practice interest in options for working together differently with other surgeries

Cluster workshops

3.3 Meet with each group of cluster practices after the practice visits to explore options for the future in terms of how practices may wish to work together and how they wish

to work with community health services serving the cluster. The sessions need to be led by practice interest in working together and will vary by cluster.

Further support

3.4 This is the beginning of a planning process. The CCG should give consideration to further support including:

- External speakers on future models of primary care - Support to practices with premises requirements - External facilitation support for practices looking to undertake major change

3.5 This will be coordinated by the Primary Care Commissioning Committee. Additional shutdowns (facilitated, staggered, individual/cluster etc) may be required to facilitate planning.

4 RECOMMENDATION

4.1 The Executive Health and Care Committee is asked to:  Agree to the proposed process for planning with practices

APPENDIX 1 - NHS ENGLAND FIVE YEAR FORWARD VIEW EXTRACT

A new deal for primary care

General practice, with its registered list and everyone having access to a family doctor, is one of the great strengths of the NHS, but it is under severe strain. Even as demand is rising, the number of people choosing to become a GP is not keeping pace with the growth in funded training posts – in part because primary care services have been under-resourced compared to hospitals. So over the next five years we will invest more in primary care. Steps we will take include:

 Stabilise core funding for general practice nationally over the next two years while an independent review is undertaken of how resources are fairly made available to primary care in different areas.  Give GP-led Clinical Commissioning Groups (CCGs) more influence over the wider NHS budget, enabling a shift in investment from acute to primary and community services.  Provide new funding through schemes such as the Challenge Fund to support new ways of working and improved access to services.  Expand as fast as possible the number of GPs in training while training more community nurses and other primary care staff. Increase investment in new roles, and in returner and retention schemes and ensure that current rules are not inflexibly putting off potential returners.  Expand funding to upgrade primary care infrastructure and scope of services.  Work with CCGs and others to design new incentives to encourage new GPs and practices to provide care in under-doctored areas to tackle health inequalities.  Build the public’s understanding that pharmacies and on-line resources can help them deal with coughs, colds and other minor ailments without the need for a GP appointment or A&E visit.

Here we set out details of the principal additional care models over and above the status quo which we will be promoting in England over the next five years.

New care model – Multispecialty Community Providers (MCPs)

Smaller independent GP practices will continue in their current form where patients and GPs want that. However, as the Royal College of General Practitioners has pointed out, in many areas primary care is entering the next stage of its evolution. As GP practices are increasingly employing salaried and sessional doctors, and as women now comprise half of GPs, the traditional model has been evolving.

Primary care of the future will build on the traditional strengths of ‘expert generalists’, proactively targeting services at registered patients with complex ongoing needs such as the frail elderly or those with chronic conditions, and working much more intensively with these patients. Future models will expand the leadership of primary care to include nurses, therapists and other community based professionals. It could also offer some care in

fundamentally different ways, making fuller use of digital technologies, new skills and roles, and offering greater convenience for patients.

To offer this wider scope of services, and enable new ways of delivering care, we will make it possible for extended group practices to form – either as federations, networks or single organisations.

These Multispecialty Community Providers (MCPs) would become the focal point for a far wider range of care needed by their registered patients.

 As larger group practices they could in future begin employing consultants or take them on as partners, bringing in senior nurses, consultant physicians, geriatricians, paediatricians and psychiatrists to work alongside community nurses, therapists, pharmacists, psychologists, social workers, and other staff.  These practices would shift the majority of outpatient consultations and ambulatory care out of hospital settings.  They could take over the running of local community hospitals which could substantially expand their diagnostic services as well as other services such as dialysis and chemotherapy.  GPs and specialists in the group could be credentialed in some cases to directly admit their patients into acute hospitals, with out-of-hours 20 inpatient care being supervised by a new cadre of resident ‘hospitalists’ – something that already happens in other countries.  They could in time take on delegated responsibility for managing the health service budget for their registered patients. Where funding is pooled with local authorities, a combined health and social care budget could be delegated to Multispecialty Community Providers.  These new models would also draw on the ‘renewable energy’ of carers, volunteers and patients themselves, accessing hard-to-reach groups and taking new approaches to changing health behaviours.

There are already a number of practices embarking on this journey, including high profile examples in the West Midlands, London and elsewhere. For example, in Birmingham, one partnership has brought together 10 practices employing 250 staff to serve about 65,000 patients on 13 sites. It will shortly have three local hubs with specialised GPs that will link in community and social care services while providing central out-of-hours services using new technology.

To help others who want to evolve in this way, and to identify the most promising models that can be spread elsewhere, we will work with emerging practice groups to address barriers to change, service models, access to funding, optimal use of technology, workforce and infrastructure. As with the other models discussed in this section, we will also test these models with patient groups and our voluntary sector partners.

New care model – Primary and Acute Care Systems (PACS)

A range of contracting and organisational forms are now being used to better integrate care, including lead/prime providers and joint ventures.

We will now permit a new variant of integrated care in some parts of England by allowing single organisations to provide NHS list-based GP and hospital services, together with mental health and community care services.

The leadership to bring about these ‘vertically’ integrated Primary and Acute Care Systems (PACS) may be generated from different places in different local health economies.

 In some circumstances – such as in deprived urban communities where local general practice is under strain and GP recruitment is proving hard – hospitals will be permitted to open their own GP surgeries with registered lists. This would allow the accumulated surpluses and investment powers of NHS Foundation Trusts to kickstart the expansion of new style primary care in areas with high health inequalities. Safeguards will be needed to ensure that they do this in ways that reinforce out-of-hospital care, rather than general practice simply becoming a feeder for hospitals still providing care in the traditional ways.  In other circumstances, the next stage in the development of a mature Multispecialty Community Provider (see section above) could be that it takes over the running of its main district general hospital.  At their most radical, PACS would take accountability for the whole health needs of a registered list of patients, under a delegated capitated budget – similar to the Accountable Care Organisations that are emerging in Spain, the United States, Singapore, and a number of other countries.

PACS models are complex. They take time and technical expertise to implement. As with any model there are also potential unintended side effects that need to be managed. We will work with a small number of areas to test these approaches with the aim of developing prototypes that work, before promoting the most promising models for adoption by the wider NHS.

Appendix 2

Premises Information to be Gathered Through Interviews

1. Introduction 1.1. The main objectives of this exercise is to work with GP practices within localities, building relationships and preparing individual plans to identify requirements to ensure future sustainability of the services.

1.2. Information gathered in a desk top exercise on a Essex-wide basis will be used as a baseline and provides information about development growth, space within practices to cope with growth in terms of Net Internal Area (NIA) and a practice prioritisation list based on current space, level of development growth in the area and the impact this will have on the requirement for space, deprivation and whether the practice may be facing ‘homelessness’ within the next 5 years.

1.3. Information gathered as part of this work stream will further inform the data we have, ensure its accuracy and provide a more detailed insight on the requirements of the individual practices and their plans for future sustainability, including the development of hub working within localities.

2. The Process

2.1. Visits to every main and branch surgery within West Essex will be arranged to enable:  An understanding of current strategic issues  An assessment of current room utilisation and condition (with the use of the self-assessment premises survey tool),  Discussions with regard to potential development growth in the area and how the practice plans to meet the needs of an increased population,  Development of a realistic wish list of improvements to help meet current and future requirements; this will not represent a promise of works but will act as a guide when requesting developer contributions and help with the prioritisation process.

2.2. Practices will be offered the opportunity of a free quotation for the potential premises improvements discussed. This will provide the practice with a realistic idea of the financial implications of any changes proposed. It will also enable the CCG to understand if developer contributions obtained and those sought in the future are adequate to meet the premises requirements in the area as well as focusing expectations so that we aim to deliver the possible and find alternative solutions to those schemes that are currently out of reach or are not in line with the Strategies of the CCG and NHS England.

The visibility of project cost implications will enable the practice to make a decision as to whether they may wish to either undertake some or all of the works at their own cost in order to improve their business or to use the information to provide to NHS England at the initial stage of an application for capital premises cost funding. It will be made clear that this quotation would be for indication purposes only and that to take a project forward a total of three independent quotations would be required for comparison and to ensure value for money.

2.3. On conclusion of the visits an estates and service strategy for each premises will be prepared. These individual strategies will be combined to create an overarching strategy for each of the three localities.

2.4. The individual strategies will include how the practices plan to deliver core services for the existing and future populations within their locality, their ambitions for the future, to include the provision of additional services, hub creation/joint working with other providers, improving and maintaining quality and increasing capacity, the estates implications and risks associated with this.

3. Clinical Follow Up Meetings

3.1 The outcomes of all visits will be made available to Dr K Bishai and Dr R Gerlis to help to prioritise those practices that require clinical advice, help and guidance. The availability of premises information, and how premises may be preventing the practice from reaching its goals and ambitions or is considered a factor in under-performance, will help them to work with the practice to prepare a complete plan of action to enhance and improve service delivery, patient satisfaction and sustainability.

Appendix 3

Practice Clusters and Visit Programme 1. Practice Clusters Locality Sub-Locality/Hub 1. Saffron Walden, including Newport and 2. & Hatfield Health 3. Stansted & Elsenham 4. North Harlow 5. South Harlow Epping 6. Epping, Ongar & Abridge 7. 8. Inner M25 – Loughton &

2. Visit Programme Premises to visit

F Code Name & Address of Practice Main/ Locality Branch Surgery F81043 Limes Medical Centre, The Plain, Epping CM16 6TL Main Epping F81043 North Weald Branch, 67 Wheelers Farm Gardens, North Branch Epping Weald, Epping CM16 6HW F81043 Waltham Abbey Branch, Waltham Abbey Health Centre, 1st Branch Epping Floor, Sewardstone Road, Waltham Abbey EN9 1NP F81043 Thrifts Mead Branch, Popular row, Theydon Bois, Epping Branch Epping CM16 7NE F81048 Loughton Health Centre, The Drive, Loughton IG10 1HW Main Epping F81049 The Ongar Health Centre, Ongar War Memorial Medical Main Epping Centre, Fyfield Road, Ongar, CM5 0AL F81062 Medical Centre, 300 Fencepiece Road, Hainault IG6 Main Epping 2TA F81072 High Street Surgery Epping, 301 High Street, Epping CM16 Main Epping 4DA F81136 High Road Surgery, 113 High Road, Loughton IG10 4JA Main Epping F81152 Forest Practice, 26 Pyrles Lane, Loughton IG10 2NH Main Epping F81152 Station Road Branch, 11 Station Road, Loughton IG10 4NZ Branch Epping F81749 Market Square Surgery, Waltham Abbey HC, 13 Sewardstone Main Epping Road, Waltham Abbey EN9 1NP

F81165 Palmerston Road Surgery, 18 Palmerston Road, Buckhurst Hill Main Epping IG9 5LT F81169 Kings Medical Centre, 23 Kings Avenue, Buckhurst Hill IG9 5LP Main Epping

F81172 Traps Hill Surgery, 25 Traps Hill, Loughton IG10 1SZ Main Epping F81184 Abridge Surgery, 37 Ongar Road, Abridge, Romford RM4 1UH Main Epping F81725 Maynard Court Surgery, 17-18 Maynard Court, Waltham Main Epping Abbey EN9 3DU F81728 Ongar Surgery, High Street, Ongar CM5 9AA Main Epping Y00268 Nazeing Valley Health Centre, 64-66 North Street, Nazeing, Main Epping Waltham Abbey EN9 2NW Keyhealth Medical Centre, Sewardstone Road, Waltham Epping F81608 Main Abbey F81016 Barbara Castle HC, Broadley Road, Harlow CM19 5SJ Main Harlow F81047 The Hamilton Practice, Keats House Health Centre, Bush Fair, Main Harlow Harlow CM18 6LY F81056 Old Harlow Health Centre, Jenner House, Garden Terrace Main Harlow Road, Old Harlow CM17 0AX F81078 Church Langley Medical Practice, Minton Way, Church Langley Main Harlow CM17 9TG F81106 The Ross Practice, Keats House, Bush Fair, Harlow CM18 6LY Main Harlow F81120 Nuffield House Surgery, Nuffield House, The Stow, Harlow Main Harlow CM20 3AX F81027 Lister Medical Centre, Lister House, Staple Tye. Harlow CM18 Main Harlow 7LU F81181 Addison House Surgery, Hamstel Road, Harlow CM20 1DS Main Harlow F81619 Sydenham House Surgery, Monkswick Road, Harlow CM20 Main Harlow 3NT F81758 The Practice Osler House, Potter Street, Harlow CM17 9BG Main Harlow F81004 Eden Surgery Broomfields, Hatfield Heath, Bishops Stortford Main Uttlesford CM22 7EH F81004 Eden Surgery 17 Cannons Lane, Hatfield Broad Oak, Bishops Branch Uttlesford Stortford CM22 7HX F81009 Gold Street Surgery, Gold Street, Saffron Walden CB10 1EJ Main Uttlesford F81009 Gold Street Branch, School Street, Gt Chesterfield CB10 1NN Branch Uttlesford F81015 Rectory Practice, 18 Castle Street, Saffron Walden CB10 1BP Main Uttlesford F81034 Newport Surgery, Frambury Lane, Newport, Saffron Walden Main Uttlesford CB11 3PY F81053 Stansted Surgery, 86 St. John's Road, Stansted CM24 8JS Main Uttlesford F81090 Angel Lane Surgery, Angel Lane, Gt Dunmow CM6 1AQ Main Uttlesford F81111 Elsenham Surgery, Station Road, Elsenham, Bishops Stortford Main Uttlesford CM22 6LA F81118 John Tasker House Surgery, 56 New Street, Dunmow CM6 Main Uttlesford 1BH F81118 John Tasker House Branch, Braintree Road, Felsted CM6 3DL Branch Uttlesford F81131 Thaxted Surgery, Margaret Street, Thaxted CM6 2QN Main Uttlesford F81195 Steeple Bumpstead Surgery, 10 Bower Hall Drive, Steeple Main Uttlesford Bumpstead, Haverhill CB9 7ED F81210 Borough Lane Surgery, 2 Borough Lane, Saffron Walden CB11 Main Uttlesford 4AF F81210 Borough Lane Branch, High Street, Gt Chesterfield CB10 1PL Branch Uttlesford

F81216 The Rivers Surgery, 16 Rous Road, Buckhurst Hill IG9 6BN Main Uttlesford

3. Outline programme of visits by locality Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Epping Locality Uttlesford Locality Harlow Locality Mop up

Appendix 4

Visit Team

To include at least 2 from the following, but must include JD, KK or KH:-

 Peter Wightman - Director of Primary Care and Localities  Dr Kamal Bishai - Deputy Chair of the West Essex CCG  Dr Rob Gerlis – Chair of the West Essex CCG  Jane Kinniburgh – Director of Nursing & Quality  Kerry Kavanagh - Estate and Locality Development Manager (KK)  Kate Halliday – Estate and Locality Development Manager (KH)  Jezz Davies – Head of Primary Care Development (JD)