CLINICAL COMMISSIONING GROUP (CCG) PRIMARY CARE CO-COMMISSIONING COMMITTEE (PCCC)
Tuesday 17th September 12.30 – 2.00 p.m. Board Room, Fusion House AGENDA
Member Agenda Item Report Responsible PUBLIC PARTICIPATION
The meeting will be digitally recorded in line with the Primary Care Co Commissioning Terms of Reference 1. Chair’s Welcome Graham Burgess Verbal
2. Apologies for Absence and Confirmation of Quoracy Graham Burgess Kathryn Lord Verbal 3. Declarations of Interest Graham Burgess Verbal 4. Questions from Members of the Public
Please note that questions must be submitted in advance of the Graham Burgess Verbal meeting, in line with the protocol which can be found on the CCG website.
BUSINESS ITEMS
5. Draft minutes of the meeting held on Tuesday 23rd July 2019 Graham Burgess Attache d
6. Action Matrix Tuesday 23rd July 2019 Graham Burgess Attached
7. Matters Arising Graham Burgess
8. Primary Care Update Report Peter Sellars Attached
9. Primary Care Estates Strategy Peter Sellars Attached
10. Developing the General Practice Workforce Sarah Danson Attached
11. Primary Care Quality Processes Sarah Danson Attached FOR INFORMATION
12. Primary Care Financial Summary Month 4 Roger Parr Attached
13. Primary Care Work Plan Attached 14. AOB
15. Date and Time of Next Meeting Tuesday 19th November 2019 12.30 – 2.00 p.m. Board Room, Fusion House EXCLUSION OF THE PRESS AND PUBLIC – ‘That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest’ (Section1(2)Public Bodies(Admission to Meetings)Act 1960) Member Item: Agenda Item Report Responsible PART 2 A/20 Draft minutes of: Part 2 of the meeting held on 23rd July 2019 Graham Burgess Attached B/20 Action Matrix 23rd July 2019 Matters Arising Graham Burgess Attached C/20 Practice 1 Roger Parr Verbal
D/20i Practice 2 D/20ii Sarah Danson Attached E/20 Practice 3 Sarah Danson Attached E/20i F/20 Practice 4 Attached Sarah Danson G/20 Practice 5 Peter Sellars Verbal
FOR INFORMATION G/21 QOEST 18/19 Year End Assurance Report To Follow
Type of Description Interest Financial This is where an individual may get direct financial benefits from the consequences of a commissioning Interests decision. This could, for example, include being: A director, including a non-executive director, or senior employee in a private company or public limited company or other organisation which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations; A shareholder (or similar owner interests), a partner or owner of a private or not-for-profit company, business, partnership or consultancy which is doing, or which is likely, or possibly seeking to do, Type of Description Interest business with health or social care organisations. A management consultant for a provider; In secondary employment (see paragraph 56 to 57); In receipt of secondary income from a provider; In receipt of a grant from a provider; In receipt of any payments (for example honoraria, one off payments, day allowances or travel or subsistence) from a provider In receipt of research funding, including grants that may be received by the individual or any organisation in which they have an interest or role; and Having a pension that is funded by a provider (where the value of this might be affected by the success or failure of the provider). Non- This is where an individual may obtain a non-financial professional benefit from the Financial consequences of a commissioning decision, such as increasing their professional reputation or Professio status or promoting their professional career. This may, for example, include situations where the nal individual is: Interests An advocate for a particular group of patients; A GP with special interests e.g., in dermatology, acupuncture etc. A member of a particular specialist professional body (although routine GP membership of the RCGP, BMA or a medical defence organisation would not usually by itself amount to an interest which needed to be declared); An advisor for Care Quality Commission (CQC) or National Institute for Health and Care Excellence (NICE); A medical researcher. Non- This is where an individual may benefit personally in ways which are not directly linked to their Financial professional career and do not give rise to a direct financial benefit. This could include, for Personal example, where the individual is: Interests A voluntary sector champion for a provider; A volunteer for a provider; A member of a voluntary sector board or has any other position of authority in or connection with a voluntary sector organisation; Suffering from a particular condition requiring individually funded treatment; A member of a lobby or pressure groups with an interest in health. Indirect This is where an individual has a close association with an individual who has a financial interest, Interests a non-financial professional interest or a non-financial personal interest in a commissioning decision (as those categories are described above). For example, this should include: Spouse / partner; Close relative e.g., parent, grandparent, child, grandchild or sibling; Close friend; Business partner.
CLINICAL COMMISSIONING GROUP (CCG) Minutes of the Primary Care Commissioning Committee (PCCC) held on Tuesday 23rd July 2019 Board Room, Fusion House PRESENT: Mr Graham Burgess CCG Chair Dr Nigel Horsfield Lay Member (Deputy Chair) Mr Roger Parr Deputy Chief Officer /Chief Finance Officer Mrs Kathryn Lord Director of Quality & Chief Nurse Dr Geraint Jones Lay Member Secondary Care Doctor (Retired) Mr Paul Hinnigan Lay Member Governance
IN ATTENDANCE: Mrs Catherine Lawless Primary Care Support Assistant (Minutes) Mr Peter Sellars Primary Care Transformation Manager Dr Stephen Gunn GP Education Lead Mrs Sarah Johns Blackburn with Darwen Healthwatch
Min No: 1. Chair’s Welcome
The Chair welcomed everyone to the meeting and gave a short briefing with regards to the content of the agenda.
The Chair reminded members that the meeting will be digitally recorded in line with the Primary Care Co Commissioning Terms of Reference. 2. Apologies for Absence and Confirmation of Quoracy
Apologies for absence were received from: David Massey, Dr Preeti Shukla, Sarah Danson and Lysa Hasler
The meeting was confirmed as quorate. 3. Declarations of Interest
The Chair reminded Members of their obligation to declare any interest that they may have on any issues arising at Committee Meetings which might conflict with the business of BwD CCG. The Chair asked members if they would like to declare any Conflicts of Interest (CoI) relating to items on the agenda.
Declarations declared by members of the PCCC are listed in the CCG’s Register of Interests. The Register is available, either via the Secretary to the GB or the CCG website via the following link:
http://www.blackburnwithdarwenccg.nhs.uk/about-us/registers-interests/
The Chair reminded those present that if, during the course of discussion, a CoI became apparent, it should be declared at that point.
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4. Questions from the Public
No questions had been received from members of the public. 5. Draft Minutes of the Meeting held on 21st May 2019
The minutes of the previous meeting were reviewed and accepted as an accurate record.
RESOLVED That the minutes of the meeting held on 21st May 2019 were approved as an accurate record. 6. Action Matrix
Actions noted. 7. Matters Arising
Matters to be discussed as agenda items. 8. Primary Care Co Commissioning Terms of Reference – The Chair asked Committee members to note the amendments to the membership which now include the Joint Chief Officer and the Director of Quality & Chief Nurse.
CONCLUSION: That the Committee approved the amendments. ACTION: CL - Terms of Reference to go to Blackburn with Darwen CCG Governing Body. 9. Primary Care Update Report
Mr Peter Sellars presented the Primary Care Update report which brought to the attention of members National and Local Primary Care news and information.
Blackburn with Darwen Primary Care Networks (PCN) – PS advised that all 23 Blackburn with Darwen GP practices have now signed up to the Network Contract Directed Enhanced . Services Directions (DES). The focus for PCN’s in 19/20 is to support the establishment of Primary Care Networks, the recruitment of a new workforce and to develop their governance arrangements with a decision making framework. PS advised that the PCN’s membership across Blackburn with Darwen has been slightly amended and advised that Little Harwood Health Centre is now in the West PCN. It was noted that Little Harwood Health Centre’s Practice Manager works across the two sites and also advised that their practice population is also in the West area. Hollins Grove Surgery is now in the North PCN. PS advised that this is due to Dr Zaki Patel becoming the new contract holder at Umar Medical Centre in the North with plans at a later date to merge both practices.
Digital Update: Apex/Insight Tool – PS advised that NHSE have temporarily paused deployment of the Apex tool until NHS England work through their position on an information governance query. The CCGs Data Protection Officer (DPO) Lead is currently reviewing the equality impact assessments and once validated will go the CCGs Senior Information Risk Owner (SIRO) for final approval. The NHS England funded offer includes the use of both Apex and Insight at ‘Enterprise’ level. The Enterprise tools allow users to conduct workforce planning and activity analysis across a group of practices – these could be Networks, Federations and CCGs . A meeting is planned in August to discuss next steps.
iPLATO/MyGP App – PS advised that deployment is progressing well for Blackburn with Darwen GP Practices. The app allows patients to register remotely and once signed up, they can book and cancel appointments, set medication reminders and make use of a secure instant messaging service. PS further advised that this also assists practices in achieving their NHSE requirements for online consultation. Blackburn with Darwen CCG has purchased SMS credits for Blackburn with Darwen GP Practices for the year for use with iPlato. The credits have been shared out according to practice list size as of 31st March 2019. Practices will be
Page 2 of 4 responsible should they exceed their allocation. Practices have been asked to promote the myGP App as much as possible as there is no cost to the practice.
Medicines Management Update – PS advised that despite supply issues driving costs up for a number of key medicines, the prescribing budget was kept under control throughout 2018/19 ending the year with a spend of nearly £1 million less than the previous year.
Prescribing Hub – PS advised that the Blackburn with Darwen Federation run the prescribing hub at Barbara Castle Way Health Centre which started in 2018. There are currently 4 practices involved with the remaining practices to come on board by March 2020. Early analysis of the prescribing data shows a downward trend in prescribing since October 2018.
Community Pharmacy Referral Scheme – PS advised that the Darwen PCN was one of two PCNs across Lancashire and South Cumbria Integrated Care Systems (ICS) to be selected by NHSE to take part in the pilot, whereby patients requesting appointments for minor illnesses are referred digitally to a community pharmacist for consultation. The pilot has shown a considerable shift in helping GP practices to free up appointments to deal with more patients with long term conditions.
West Scheme: Following the last Committee meeting PS advised that the outline business case (OBC) is to be reviewed and will be brought back to the September meeting of the Primary Care Co Commissioning Committee.
Blackburn with Darwen Workforce Data: PS advised that Blackburn with Darwen practices are required on a quarterly basis to input their practice data on to the National Workforce Reporting System. Unfortunately some practices have been unable to log on and as such the data supplied is incomplete. PS advised an accurate data collection on Blackburn with Darwen workforce will not be available until the end of November 2019. KL advised that Anne Greenwood at NHSE has been working on developing a baseline for workforce nationally and could help with data on workforce for Blackburn with Darwen. PS further advised that the next steps for Apex is looking at the Enterprise tools which allow users to conduct workforce planning and activity analysis across a group of practices and could also be used to get a better understanding of workforce requirements. ACTION: Agenda Item November – Baseline Assessment on BwD Workforce. Apex Tool: An update to be provided on what the tool can do and also what the CCG will be able to extract from the tool to help inform on workforce across Blackburn with Darwen.
Questions and answers followed:
Primary Care Networks: The Chair raised concern on how the changes in membership to the West and Darwen PCN’s will effect working arrangements with other local authority services, and asked that a report be written on how they will link together geographically. ACTION: PS to provide a report how other services in the borough will be able to link in with neighbouring PCNs. The Committee asked that key areas/milestones of PCN development be supplied to the Committee in order for them to be assured that Blackburn with Darwen is on target. ACTION: PS to develop a plan of PCN achievement/milestones.
Community Pharmacy Pilot – ACTION: Evaluation of pilot to be brought to the attention of the PCCC.
CONCLUSION: That the PCCC noted the contents of the Primary Care Update Report.
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10. Practice Relocation Proposal – PS asked the Committee to note the contents of the report and approve the proposed template business case for use in all other GP practice relocation applications. Committee members made comment that this would be useful document to use going forward. It was requested that the benefit to patients should form part of the template.
CONCLUSION: That the PCCC approved the business case for GP relocation applications once the amendment is made. ACTION: PS to speak to LH at NHSE. 11. PMS/GMS/APMS Contracts Update: PS advised that there are currently two APMS practices and three PMS practices. The three PMS practices have all been written to and are in the process of receiving their financial statements. It was noted that one practice Hollins Grove wishes to convert to a GMS practice so they can merge at a later date. It was noted that the APMS Contract for extended access runs until 2021 and then the funding will be transferred to Primary Care Networks.
CONCLUSION: That the PCCC noted the update on the PMS/GMS/APMS Contracts 12. Mellor Surgery – PS confirmed that SD has contacted the district valuer with regards to Oakenhurst branch Surgery in Mellor. 13. Primary Care Financial Summary Month 3 – For Information
CONCLUSION: That the PCCC noted financial position for Primary Care Services as of month 3. 14. Physicians Associate Case Studies 14.1 Job description Physicians Associate 14.2 Job description Paramedic
CONCLUSION: Job description Physicians Associate/Job description Paramedic That the PCCC noted the job descriptions for both the physicians associate and the paramedic and made comment there is no information as to the whether the practice offers support and mentorship and that there is also no information on career development. ACTION: PS to feedback comments to Darwen Health Care.
CONCLUSION: That the PCCC noted the case studies for the physician’s associate role and asked that they be shared with other practices as the physician’s associate role has made a positive impact on the practice. ACTION: PS to feedback comments to Darwen Health Care.
15. Primary Care Work Plan – That the PCCC noted the Primary Care Work Plan. AOB There was no any other business noted. 13. Date and Time of Next Meeting The next meeting is scheduled for Tuesday 17th September 12.30 – 2.00 p.m. Board Room, Fusion House.
The Chair thanked everyone for their attendance and input and stated that the meeting would now move into Part 2.
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PRIMARY CARE CO-COMMISSIONING COMMITTEE (PCCC) - ACTION MATRIX Action Origin Date Item Owner Due Date Status Ref Blackburn with Darwen SD- Baseline Assessment to be carried out across BwD General 11 21.05.2019 Workforce Report SD Sept 2019 Practice workforce. Agenda Item
PS – Report on how other services will link in with neighbouring PCNs. PS - PCN report on achievements/milestones to date. PS – Community Pharmacy Pilot evaluation to come to PCCC. 9 23.07.2019 Primary Care Update PS Sept 2019 Apex Tool: PS to provide an update to be on what the tool can do and what the CCG will be able to extract from the tool to help inform on workforce across Blackburn with Darwen. Agenda Item
LH – To amend proposal to include what the benefit will be for 10 23.07.2019 Practice Relocation Proposal LH Sept 2019 patients. Physicians PS to feedback PCCCs comments as to whether the practice offers 14. 23.07.2019 Associate/Paramedic Job PS Sept 2019 support and mentorship and career progression opportunities in Descriptions these new roles.
PRIMARY CARE CO-COMMISSIONING COMMITTEE
GOVERNING BODGOVENING B PRIMARY CARE UPDATE REPORT
Date of Meeting SEPTEMBER 2019 Agenda Item Item 8 TING CCG Corporate Objectives
Through better commissioning, improve local health outcomes by addressing poor outcomes and inequalities To work collaboratively to create safe, high quality health care services To maintain financial balance and improve efficiency and productivity To deliver a step change in the NHS preventing ill health and supporting people to live healthier lives To maintain and improve performance against core standards and statutory requirements To commission improved out of hospital care CCG High Impact Changes Delivering high quality Primary Care at scale and improving access Self-Care and Early Intervention Enhanced and Integrated Primary Care and Better Care Fund Access to Re-ablement and Intermediate Care Improved hospital discharge and reduced length of stay Community based ambulatory care for specific conditions Access to high quality Urgent and Emergency Care Scheduled Care Quality
Clinical Lead: Dr Preeti Shukla Senior Lead Manager Mr Peter Sellars Finance Manager Mrs Linda Ring Equality Impact and Risk Assessment completed: n/a
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Is a Data Protection Impact Assessment No Required? Data Protection Impact Assessment No completed: Patient and Public Engagement n/a completed: Financial Implications n/a Risk Identified n/a Report authorised by Senior Manager: Mrs Julie Kenyon
Y
Decision Recommendations
That the Primary Care Co Commissioning Committee (PCCC) is asked to receive this report and to note the items as detailed.
Y
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PRIMARY CARE CO-COMMISSIONING COMMITTEE
September 2019
PRIMARY CARE UPDATE
1. Introduction
1.1. This report provides the Primary Care Co-Commissioning Committee (PCCC) with an update on national and local Primary Care news and information, highlighting areas not covered elsewhere on the agenda.
2. General Practice QOEST
2.1 The Quality and Outcomes Enhanced Services Transformation (QOEST) 2019/20 plan now being fully implemented / operationalised. Discussions are due to commence regarding the future QOEST framework and plan, taking into consideration the new GMS contract and Primary Care Network (PCN) Direct Enhanced Service (DES) and the future shape of the commissioning environment structures (Pennine Lancashire).
3. Blackburn with Darwen Primary Care Network DES
3.1 The Network Contract Directed Enhanced Service (DES) Directions were released on the 1st April 2019, requiring GP practices to sign up and commence implementation from 1 July 2019. The Network Contract DES is intended to remain in place until at least 31 March 2024, with the specification evolving over time, subject to annual review and development.
3.2 The first year of the Network Contract DES, covers the period 1 April 2019 to 31 March 2020. The focus in 2019/20 is to support the establishment of primary care networks (PCNs) and the recruitment of new workforce, with the bulk of service requirements coming on line from April 2020 onwards.
3.3 It has been agreed that four Primary Care Networks will operate across the existing Blackburn with Darwen Primary Care Neighbourhood/locality footprint; however they must work closely and collaboratively together to deliver all aspects of the contract which includes personal and organisational development.
3.3.1 Timeline / Milestones / Achievement
30 June 2019 - The completed network agreement should be signed by all PCN member GP practices, including the schedules. The PCNs must confirm to the commissioner that the fully completed network agreement has been signed by all PCN member GP practices. Completed Note that the contract states: There is no requirement for the network agreement to include collaboration between practices and other providers, but this will need to be developed over 19/20 and to be well developed by the beginning of 20/21 when the network agreement will need to be updated to reflect the new network contract specification. Work in Progress
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30 June 2019 - Data sharing arrangements and, if required, data processing agreements for PCNs must be in place, where required, to support delivery of Extended Hours Access services. A national data sharing agreement template and a national data processing template are currently being developed. In the absence of these nationally developed agreements, appropriate historic arrangements for extended hours access services could stand temporarily. Data sharing agreements in Place
1 July 2019 - Network DES services go live in approved PCNs subject to network agreements and data sharing arrangements being in place. Practices should receive the £1.76 Network Participation Payment per weighted patient from this date and the nominated PCN payee should receive the £1.50 CCG allocation per patient per year for network services. Completed. Payments going to LPC as nominated PCN payee
1 July 2019 - Clinical Directors’ salary contributions from CCG to be paid monthly in arrears from July 2019, with the first payment on or by the end of July 2019. Completed
1 July 2019 - Additional roles’ reimbursement for Clinical Pharmacists and Social Prescribing Link Workers are claimable following the start of employment from July 2019; contribution from CCG to be paid monthly in arrears from July 2019, with the first payment on or by the end of July 2019. Work in Progress. No new personnel yet employed. First additional pharmacist starts on 16 September.
1 July 2019 - Extended Hours Access service goes live. PCNs will be required to deliver additional clinical sessions outside of core hours to all registered patients within the PCN. This equates to a minimum of 30 minutes per 1,000 registered patients per week in continuous periods of at least 30 minutes on a regular basis in full each week. A reasonable number of these appointments are to be face-to-face with the rest provided by telephone, video or online consultations. PCNs will be eligible for payment of £1.45 per registered patient for delivering this aspect of the Network Contract DES. Completed.
30 September 2019 - Deadline for transferring staff from the Clinical Pharmacist in General Practice Scheme or the Medicines Optimisation in Care Homes Scheme to the Additional Roles under the Network Contract DES scheme (this can extend to March 2020 for pharmacists employed under the Medicines Optimisation in Care Homes Scheme). Work in Progress. Four current pharmacists being transferred. Will be completed before deadline.
April 2020 - National Network Services start under the 2020/21 Network Contract DES. Practices will need to update their network agreement based on the new DES specification. The specifications that are expected to appear in 2020/21 are for Structured Medicines Review and Optimisation and Enhanced Health in Care Homes. It is expected that the Network Contract DES will be updated annually until at least 31 March 2024, during which time CCGs are required to provide the £1.50 per registered patient to PCNs. CCGs cannot vary the National DES, although they can develop local Supplementary Service Specifications in agreement with PCNs and LMCs. For BwD, this could be a re-engineered QOEST type of contract. Future Work to commence
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3.3.2 Additional 2019/20 monitoring requirements
In line with existing requirements for practices, PCNs must report new workforce employed via the Network Contract DES through NHS Digital’s National Workforce Reporting System.
Member practices will be required to manually input data into CQRS in relation to management accounts.
Referrals to Social Prescribing Link Workers and activity relating to clinical pharmacists’ consultations will be required to be recorded within GP clinical systems using the new national SNOMED codes.
3.3.3 Contractual requirements beyond April 2020
Whilst data collection, sharing and aggregation across the member practices is not yet a contractual requirement for 2019/20, it is advised that consideration and preparatory work begins as soon as possible in anticipation of measures which could be introduced from April 2020.
The PCN clinical directors are planning development and strategy meetings over the next few weeks to determine governance around decision making, mobilisation at pace and a clear way forward which will include future additional workforce employment i.e. Social prescribers and clinical pharmacists in year, followed by paramedics, first contact physios and physician associates in the coming 4 years.
Further contractual timelines and deadlines beyond April 2020 will be outlined in future updates.
4. Linking services between PCN’s
4.1 All Lancashire Care Foundation Trust (LCFT) community teams align their caseloads to GP Practices in their PCN footprint where possible. This includes the recent ‘relocation’ of practices to different Neighbourhoods. For District Nurses (DN) visiting, a pragmatic approach is taken to patients living ‘outside’ of the Neighbourhood where they are registered, so patients may be visited by a nurse from a different team if this helps capacity and efficiency for DN allocation of visits. This will remain consistent throughout the episode of care.
4.2 For any Multi-Disciplinary Team (MDT) or Integrated Neighbourhood Team (INT) discussions, DNs and all community staff (e.g. respiratory, therapists etc.) work within the PCN alignment.
4.3 This model is consistent with the allocation of social workers. DNs and social workers are co- located in West and North teams (Barbara Castle Way HC) and Darwen (Darwen Health Centre), soon to be followed by co-location of the East team in Shadsworth Children’s Centre.
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5. APEX / INSIGHT Enterprise update
5.1 In 2018 NHSE procured support to assist General Practice, Primary Care Networks and the Integrated Care System to adopt a robust consistent approach to analysing workload and workforce requirements within Primary Care.
5.2 ‘Apex Insight’ offers practices a comprehensive workload analysis and workforce planning capability to make informed decisions about the future. Practice-level information can be consolidated at Locality, Federation, CCG and STP level to inform strategic planning and system-wide solutions to these challenges. The Apex Insight Tool can identify viable transformation opportunities by looking at workload and can develop robust and sustainable workforce plans.
5.3 Apex Insight at Enterprise level enables current and future workload and workforce plans to be aggregated across groups - for example across Primary Care Networks. Practices can be members of multiple Enterprises which means Apex Insight can be used to explore opportunities for delivery at scale through collaboration; and so can help with decisions about future workforce at neighbourhood sector, federation, CCG or STP Level.
5.4 For Blackburn with Darwen 100% of the practices have signed up to installation of the tool and have received their initial training. To date there are 2 Blackburn with Darwen practices who have completed the installation and training process and a further 8 practices midway through. Apex Insight was temporarily paused in April 2019 whilst NHS England worked through their position on an information governance query.
5.5 NHSE are now satisfied that the query has been resolved satisfactorily and that they have no concerns relating to the GP practices’ ability to use their care record information for practice management purposes (workload analysis and workforce planning). NHSE recommended that, for accountability purposes, each CCG needed to complete a local approval of the Data Privacy Impact Assessment (DPIA). This has now been completed and deployment of the tool to the remaining 13 practices has now commenced.
5.6 The CCG and the Primary Care Network Clinical Leads are now in the process of discussing how they would like the Apex Insight at Enterprise level products to be used across Blackburn with Darwen. This will include an Enterprise demonstration taking place in early November to the CCG and Primary Care Network Clinical Directors.
5.7 Topics for discussion will include what data processing agreements will need to be in place for practices, so that practices and Enterprise can control access to the information, no patient identifiable data is utilised in either system and that the data that is shared removes patient identifiable data, pseudonymising the dataset before transferring it outside of the GP practices clinical system.
5.8 No data will be shared with other practices, CCG, PCNs, STP without the consent from the practice who will remain the Data Controller. It is envisaged that once the necessary data sharing agreement are in place the CCG will be able to see the aggregated data for all Blackburn with Darwen practices which will include workforce numbers, nature and skill mix. Workload, the type of presentations, the numbers of patients and where/how seen for example by visit, face to face, telephone call or online and also seen by whom.
5.9 A further update will be provided to the PCCC in November following the Enterprise Planning Workshop.
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6. Community Pharmacist Consultation Service
6.1 As previously reported, Darwen PCN was been selected by NHSE as one of only two PCNs across the Lancashire & South Cumbria ICS footprint to take part in a pilot whereby patients requesting appointments for minor illnesses are referred digitally to a community pharmacist for a consultation.
6.2 All practices have now had their training and all community pharmacists across Darwen have signed up to deliver the service. The service went live on the 23rd August and should be well embedded before winter.
6.3 The current Minor Illness PGD pilot being run with two pharmacies in Darwen is to be amalgamated into the CPCS pilot so that patients can access this service from any Darwen pharmacy. This service offers a one-stop shop to patients who present with a sore throat, urinary symptoms or conjunctivitis and who need antibiotics for these conditions. Whilst all costs for the CPCS pilot are picked up by NHSE, discussions are being undertaken as to whether drug costs for the PGD service can also go through this service. The CCG may be asked to pick up these costs as the service simply shifts GP prescribing (which the CCG funds) to a community pharmacy supply.
6.4 NHSE are monitoring referrals through the CPCS on a weekly basis and relaying this information to the PCN.
6.5 The CPCS was highlighted in the new Community Pharmacy Contractual Framework, which was published last month. From October 2019, the CPCS will take referrals from NHS111 initially, with a rise in scale with referrals from other parts of the NHS to follow, based on results from national pilots (eg Darwen).
7.0 Online consultations - myGP App
7.1 Through the Primary Care Exemplar programme led by the ICS digital team, BwD CCG and partners have been deploying IPlato through the myGP app as part of a national online consultation programme funded through the GPFV.
7.2 Nationally the ICS is leading the way with IPlato online consultation deployment, with CCGs from across Lancashire and South Cumbria generating the most significant uptake across England.
7.3 Full deployment across Blackburn with Darwen commenced on 1st August 2019 and the following outcomes have been achieved in just one month:
All practices in BwD CCG are signed up to using IPlato, 20 of the 23 are fully switched on, 22 of the 23 are enabled for myGP and PreGP and 19 of the 23 practices are actively recruiting new patients to use the myGP app.
In April 19, practices had 2204 appointments available to book online with the myGP app, in August this has more than doubled to 4835
In the same period, myGP users have increased from 5810 to 16271 users
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During Aug, 1431 patients booked 2681 appointments via the myGP app, 1788 of these bookings triggered additional information for patients, advising of suitable other alternatives i.e pharmacy (162 appts), sick notes (27) and other local services (442).
392 of these appointments were subsequently cancelled by the patient, who chose to use the alternative service. This is often an opportunity to raise awareness of the other places that people can receive help that they may not have been aware of.
Of the 1431 patients, 281 were under 24, 1071 were age 25-64, 79 were age 65+
1122 appointments were booked using the myGP app during surgery opening hours, but 666 were booked when the surgery was closed
20% of all messages and automated appointment reminders are now being sent via myGP app
7.4 It should be noted that BwD CCG has been applauded for the speed and success of deployment. No other area has deployed it so successfully after one month.
8.0 Recommendation
8.1 That the Primary Care Co Commissioning Committee (PCCC) is asked to receive this report and to note the items as detailed.
.
Peter Sellars Primary Care Transformation Lead September 2019
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PRIMARY CARE CO-COMMISSIONING COMMITTEE
GOVERNING BODGOVENING B Blackburn with Darwen Estates Strategy
Date of Meeting Agenda Item Item 9 TING CCG Corporate Objectives
Through better commissioning, improve local health outcomes by addressing poor outcomes and inequalities To work collaboratively to create safe, high quality health care services To maintain financial balance and improve efficiency and productivity To deliver a step change in the NHS preventing ill health and supporting people to live healthier lives To maintain and improve performance against core standards and statutory requirements To commission improved out of hospital care CCG High Impact Changes Delivering high quality Primary Care at scale and improving access Self-Care and Early Intervention Enhanced and Integrated Primary Care and Better Care Fund Access to Re-ablement and Intermediate Care Improved hospital discharge and reduced length of stay Community based ambulatory care for specific conditions Access to high quality Urgent and Emergency Care Scheduled Care Quality
Clinical Lead: Dr Stephen Gunn Senior Lead Manager Mr Peter Sellars Finance Manager Mrs Linda Ring Equality Impact and Risk Assessment completed: To be determined dependant on scheme
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Is a Data Protection Impact Assessment No Required? Data Protection Impact Assessment No completed: Patient and Public Engagement To be determined dependant on scheme completed: Financial Implications To be determined dependant on scheme Risk Identified To be determined dependant on scheme
Report authorised by Senior Manager: Mrs Julie Kenyon
Y
Decision Recommendations
That the PCCC note the updated Primary Care Strategy.
Y
Primary Care Co-Commissioning Committee Page 2 of 2
Blackburn with Darwen Clinical Commissioning Group (CCG)
Estates Strategy
August 2019
Contents
Introduction ...... 2 Population Overview ...... 2 Estates within a National Context ...... 3 Drivers for Change ...... 4 Estates Overview ...... 4 Alignment of the Estates Plan to the Primary Care Strategy ...... 5 Intentions of the Estates Plan ...... 6 Stakeholder Engagement and Partnership Working ...... 7 Financial Summary ...... 8 Risks ...... 8 Conclusion ...... 9 Appendix B: Estates Map including proposed new housing developments ...... 11
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Introduction
Blackburn with Darwen CCG has undertaken a review of the Primary Care estates in the CCG’s area in order to align the future estate with commissioning service requirements. This will deliver both clinical and financial benefits, through a more accessible service model and increased utilisation of existing estate. Pennine Lancashire Strategic Estates Group has set savings targets, with each of its two CCGs (East Lancashire and Blackburn with Darwen) developing their own strategic estates plans.
The estates plan will be service led and as such, any estate development will naturally be driven by the service delivery model, the expectation being through larger “hub” sites, whilst continuing to support development of the smaller “spoke” surgeries closer to where people live, within each of the four localities.
The estates plan adopts a system wide view, reinforcing the importance of integrated services within any future Primary Care estates development. It is also critical that new estates are fit for the future and able to provide services within a new model of care.
Population Overview The latest ONS mid-year population estimates for Blackburn with Darwen are for 2018, and indicate a total population of 148,9421. In June 2019, there were around 177,181 patients registered with a GP in Blackburn with Darwen2.
28.4% of residents in the borough are aged under 20, which is the sixth highest proportion in England. Only 14.5% of residents in Blackburn with Darwen are aged 65 and over, compared to 18.6% in the North West and 18.2% in England1.
For Blackburn with Darwen, a 1.6% decrease is projected over the 25 year period (2016 to 2041), resulting in a reduction of 2,351 residents which will result in a total population of 146,111 by 2041. By 2041 there is projected to be 29,390 people aged 65+ living in Blackburn with Darwen. In total an additional 8,281 older people are projected to be living in the borough (2016-2041), which is an increase of 39.2%. Older people as a proportion of the total population is projected to increase from 14.2% to 20.1%3.
The 2015 Index of Multiple Deprivation ranks the borough as the 15th most deprived authority in England (on the rank of average score). However, the summary indicator which is now most widely quoted is the proportion of LSOAs in the Borough falling within the 10%
1 ONS (2018) Population estimates: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/data sets/populationestimatesforukenglandandwalesscotlandandnorthernireland 2 NHS Digital (2019) Patients registered at a GP Practice, June 2019: https://digital.nhs.uk/data-and- information/publications/statistical/patients-registered-at-a-gp-practice/june-2019 https://digital.nhs.uk/data-and-information/publications/statistical/patients-registered-at-a-gp- practice/february-2018 3 ONS (2016) Subnational population projections for England: 2016-based projections https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bul letins/subnationalpopulationprojectionsforengland/2016based#nearly-all-local-authorities-are-projected-to- grow-by-mid-2026
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most deprived in England. In BwD, the proportion was 31% in 2015, which makes it the 12th most deprived borough4.
The 2011 Census states that 30.8% of the borough’s population are from Black and Minority Ethnic groups5. In 2018/19 around 970 foreign nationals living in the borough applied for National Insurance Numbers6.
Health
Life expectancy in the borough in 2015-2017 had increased to 76.6 years for males and dropped to 80.1 years for females. It has the 8th lowest life expectancy in England for males and the 5th lowest life expectancy for females. Within the borough, life expectancy in the most deprived 10% of the borough is 12.3 years lower for men and 8.5 years lower for women compared to the least deprived 10% of Blackburn with Darwen7.
Over the last 10 years, early deaths from cardiovascular disease and cancer have fallen, but early deaths from all-cause mortality rates have begun to rise recently, and Blackburn with Darwen continues to remain worse than the England average7.
Estates within a National Context
The NHS is facing extremely challenging times. Demand for services is rising faster than funding. The cost of drugs and new medical technology continue to rise. The population is changing, with an increasing number of older people, often with greater health and social care needs. The traditional approach of targeted service improvements and contract variations has in the main been successful to date. However it is now necessary to find new, transformational solutions to meet this unprecedented challenge.
In October 2014 NHS England’s Five Year Forward View was published setting out a clear direction for the NHS in respect of whole system integration of services, implementation of alternative care delivery models, a greater emphasis on prevention and self-management, and improving the quality of services by using its resources more effectively. The ‘Forward View’ clearly set out the financial challenge facing the NHS and the actions required. In addition, NHS England’s ‘Everyone Counts: Planning for Patients 2014/15 – 2018/19 identifies GPs and other Primary Care providers being at the heart of integrated care. Also in line with the NHS Long Term Plan 2019 and the Investment and Evolution (GP Contact Framework) 2019
As the NHS works to redesign the delivery of services in response to the Forward View / Long Term Plan, high quality local estates planning is crucial and will require all parts of the NHS to work together to enable system wide transformation. It will be necessary for the
4 Blackburn with Darwen ISNA – Summary Review 5 Nomis (2013) Census 2011: https://www.nomisweb.co.uk/census/2011/qs211ew 6 Lancashire County Council (2019) National Insurance number registration by non-UK nationals: https://www.lancashire.gov.uk/media/899550/national-insurance-registrations.pdf 7 PHE (2019) Health Profiles: https://fingertips.phe.org.uk/profile/health-profiles
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estate to be reconfigured to accommodate the associated increase of services in the community and to provide opportunities for greater integration. Although the benefits for patients, and the NHS as a whole may be clear, implementation of the Forward View will inevitably place additional pressure on existing primary and community services and the estate from which they operate. The NHS estate is therefore both a key enabler and risk to the delivery of the objectives set out in the Forward View through its impact on quality and patient experience and its potential to deliver efficiencies.
In June 2015, the Department of Health (DH) issued guidance on the development of Strategic Estates Plans. A substantial improvement in the management of the NHS owned and occupied estate is required to respond to the challenges of the NHS Five Year Forward View.
The NHS Constitution (Department of Health 2012) includes a requirement for health services to be delivered in fit for purpose, accessible, clean, and safe environments protected from the risks associated with unsuitable and unsafe premises.
Drivers for Change
Within this strategy a number of drivers for change in terms of strategic plans, changing populations and associated housing developments and clinical capacity requirements have been identified.
An initial Gap Analysis has been undertaken based on core strategies, commissioning plans and the most recent surveys of current estate, and the CCG has identified priorities for development.
Estates Overview
The reorganisation of the NHS has seen the ownership of the NHS Estate change. Property is now owned by Community Providers, NHS Property Services, Community Health Partnerships or Acute Trusts and independent contractors (GPs Dentists, Optomotrists). The challenge faced by the system is to ensure that the NHS Estate responds to the needs of the local population and is used to support providers to deliver services that are accessible to patients and service users.
Across the Blackburn with Darwen CCG area there are 23 GP practices covering a total registered patient population of approximately 174,500. GP practices and community providers operate from a mixture of old and new properties in varying conditions. Space utilisation is often perceived as an issue with many providers across the patch reporting a lack of space having an impact on their ability to effectively deliver services. A significant number of GP practices still operate from premises that they own, some in converted domestic properties which are over 100 years old. Others are located in rented accommodation, comprising a mix of NHS Health Centres, some of which are approaching 50 years old, and private developments.
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Geographical access to GP practices across the area is generally good. However the population across the CCG district is set to rise over the next few years. In addition plans to increase the local housing stock, both within the borough and in neighbouring authorities, will add significant pressure to existing health and local authority services with an inevitable impact on the estate (see Appendix C).
All GP surgeries across Blackburn with Darwen have undergone a Six Facets Survey, this has identified future requirements regarding their future suitability. Additionally the Pennine Lancashire Estates group continues to undertake a process of measuring current estate utilisation. This has identified potential space that could be utilised by incoming practices and or services in our two existing large health centres, namely Darwen Health Centre and Barbara Castle Way. Work is underway to maximise utilisation of these buildings.
Alignment of the Estates Plan to the Primary Care Strategy
Blackburn with Darwen CCG’s vision for Primary Care is to function within an integrated health and social care system, with providers working together and supporting each other for the benefit of patients and staff. This is likely to include primary and secondary care, social care, community nursing and the voluntary sector and will be enabled by integrated IT, aligned incentives and contracts and a change in culture (staff and the public) to provide high quality, cost effective services.
In addition to developing General Practice, GPs are starting to work with other professionals as part of locality based integrated Neighbourhood teams through the structures of the 4 Primary Care Networks / Neighbourhoods (PCNs).
Delivery of services will be close to home, where safe to do so within modern fit for purpose premises based on a hub and spoke configuration (ie larger facilities with satellite surgeries to provide local care depending on need), or in the patients home when required. Community bed provision may be required depending on the ultimate model of care. Primary Care will be accessible on a 24/7 basis through core, extended and out of hours services, utilising the best in digital communication to improve access and convenience. Improvements in IT will include access to patients’ own records, ordering prescriptions, making appointments, online consultations and accessing medical advice and information on line.
This vision will create the foundation of a Local Integrated Care Partnership, with General Practice at the centre and operating at scale through the development of larger practice groups. In this system there will be a reduced reliance on hospital based care with more care (and thus resources) in the community.
This ‘new’ form of Primary Care delivery, will provide the best of General Practice as well as offering a greater range of services through working with other community based services, the third sector, consultant colleagues etc. Staff will again want to work in Primary Care due to improved job satisfaction, career prospects and work life balance.
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Intentions of the Estates Plan
The Primary Care Strategy clearly states “the service delivery model is expected being through a hub and spoke model within each of the 4 localities”. The estates strategy priorities reflects this strategic aim of having 4 larger health centres with smaller spokes available dependant on need. Currently there exist two large health centres i.e. Barbara Castle Way and Darwen Health Centre leaving a gap of two further builds across the borough, these would be in West and North Blackburn.
Prioritisation
New builds and refurbishments will be prioritised to ensure they comply with the Primary Care Estates Strategy, The Primary Care Strategy and NHS policy (e.g. 5 Year forward View, GP Forward View Long Term Plan etc.). The status of the existing estate will also be a factor in deciding where to invest in new estate (so for example it is a priority to rehouse practices that are operating from converted housing, old facilities that are not fit for purpose etc.). The location of the new builds will be determined by the needs of the population taking into account future housing developments.
As a result the CCG have prioritised the following developments;
1. New GP and community care facility in Blackburn West – three GP practices to be relocated who currently operate from old converted housing and who wish to merge. The area is currently not served by a large health centre.
2. Extension and refurbishment of Bangor St Health Centre (Build due for completion Oct 2019)
Further Considerations in Developing the Primary Care Estate
A modern primary care estate will have to accommodate any new developments such as;
Primary Care Networks and GP Federation
• New organisational models combining traditional General Practice with community nursing, mental health and social care will require suitable estate solutions to maximise their ability to manage people’s health and wellbeing and reduce reliance on hospital based care.
Integrated Neighbourhood Teams (INT) Co-location
• Opportunities to co-locate four health and social care teams across health and Local Authority estates in each of the localities.
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Intermediate Care
• Feasibility into how intermediate care requirements of the CCG’s emerging care closer to home plans can be delivered through an improved primary care estate utilising existing and future premises in both health sector and other public sector services.
Acute Hospital Master-planning
• Options to re-purpose land/buildings at East Lancashire Hospital Trust (ELHT) acute site to help deliver the strategic visions of the Trust, CCG and wider health and social care economy.
Healthier Lancashire and Combined Authority and Other Future Developments
• Developments across Lancashire and beyond will need to be considered in terms of how the strategy may need to evolve. However these are unlikely to alter local requirements in the estate going forward.
Information Technology (IT)
This strategy relates to current information technology developments nationally and locally,in particular the Lancashire Digital Road map. A key requirement is that there will be a common shared record across all services involved in the care of the population. There also needs to be greater access for the public both to their own records and to health and care information. Improved communications via email, social and other media will be required along with alternative methods of accessing care such as via various digital Apps such as Iplato / myGP for online consultations etc. Tele health / Telemedicine will facilitate consultations and monitoring of patients, with tele care increasingly supporting peoples' independence. Decision support software for clinicians will increasing be utilised to improve diagnosis and treatment of diseases. The estates strategy will enable the infrastructure to facilitate the deployment of these services.
Stakeholder Engagement and Partnership Working
The CCG has developed strong clinical relationships and local partnerships as the foundation for successful redesign of clinical pathways and is focussed on developing closer clinical engagement and integration between primary care, secondary care, community services, social care and voluntary sector.
The CCG has a communication and engagement strategy which details the locally agreed approach with patients, public and local partners. The values, strategic objectives, local plans and priorities evolve from listening to patients, the public, partners and other stakeholders.
The CCG has established patient fora which include representatives from each GP Practice’s Patient Participation Group. In addition to engaging with patients and carers, the
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CCG work with local stakeholders including the Borough Councils, healthcare providers and voluntary sector members, this includes close working with Primary Care Networks.
In developing plans, the CCG reflects the priorities detailed in the Health & Wellbeing Strategy and Better Care Fund Plans. All draft plans are consulted on with internal committees and external stakeholders. Every opportunity is taken to work collaboratively with local partners and providers to redesign and integrate care pathways and improve outcomes.
The CCG will continue to engage with the public and all stakeholders on planning and on each specific estates proposal once the design process commences. This is all dependant on any bids being accepted for funding by NHS England.
Financial Summary
The estate in Blackburn with Darwen CCG is made up of properties owned by Community Health Partnerships, NHS Property Services and GP owned premises. The two health centres operated by Community Health Partnerships (Barbara Castle Way and Darwen Health Centres) have revenue costs of £5.893m in 2019/20 across all tenants. The other Health Centres owned and managed by NHS Property Services across Blackburn with Darwen are estimated to cost £1,156k for 2019/20. GP owner occupier reimbursements are estimated to cost £899k in 2019/20. The reimbursable costs to GP practices (rent, rates and water rates) for their occupancy in these properties and for those that are owned by the GPs themselves are funded through the delegated budget under Primary Care Co- commissioning.
The CCG is developing a summary of the capital resources required to implement the strategy, including revenue consequences and any potential revenue savings associated with improving the estate. These will be included in the CCGs’ financial plans going forward. The CCG has in principle agreed to fund any increased rent and rates reimbursement costs of the new builds. The capital funding will be provided by NHS England as a result of the bidding process. The new GP premises builds are working to a figure of 40%. New premises directions are awaited from NHS England to confirm the funding contribution. Capital Funding planned over 2019/20 to 2020/21 is shown in Appendix C
Risks
The key risks are;
Progressing the strategy.
The property landscape in the NHS has changed considerably since the last re-organisation when the Health and Social Care Act 2012 came into force. CCGs have no ownership or operational responsibility for premises which fall within the remit of a number of different bodies including NHS Property Services, Community Health Partnerships, NHS acute and community providers and GP practices. This complex picture of property ownership presents a number of issues, including the availability of good quality data and financial information on
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which to base the identification of priorities, barriers to development and operation of facilities and lack of control over revenue costs.
Funding streams are required to allow any developments to be initiated and the CCG would only progress schemes once appropriate funding mechanisms have been identified. This would include attempts to attract capital monies via government sponsored schemes including the current Estates Technology Transformation Fund (ETTF). If any bid for a capital grant was unsuccessful other options would be explored such as, Third Party developer (3PD), Local Investment Finance Trust (LIFT) and the new Phoenix scheme, which is the government proposed property development initiative.
Not Progressing with the Strategy
Not implementing this Estates Strategy would mean that Primary Care would be restricted in what it can provide in the community, preventing the increased range and scale of services required to improve outcomes yet remain within financial targets. It would also impact on workforce development and recruitment.
Note: Scheme dependent risks please see appendix D
Conclusion
This strategy outlines the vision for the Blackburn with Darwen Primary Care estate taking account of recent NHSE publications, related strategies and the CCG’s commissioning plans. The CCG has identified two critical Primary Care schemes to ensure the development and sustainability of primary care and to increase the range and scale of services delivered closer to patients homes. The strategy promotes maximising utilisation of existing premises and the wider public service estate, improving integration wherever possible and using a prioritisation process to identify appropriate developments.
The Local Estates Strategy has an important role to play in enabling the significant changes the NHS will have over the next five years and beyond, delivering savings, reducing running costs and ensuring that all investment, including the Estates Technology Transformation Fund (ETTF) (formally PCTF) is properly targeted.
The Local Estates Strategy is fully aligned with commissioning plans for the area, including the Health & Wellbeing Strategy, Primary Care Strategy, and Pennine Lancashire Local Delivery Plan and also reflects local health needs.
The CCG will continue to consult with the local population and local stakeholders, to set the future direction for development, investment and disinvestment in the primary care estate.
The strategy will evolve into the future ensuring it continues to meet the needs of patients and the health and care system.
Peter Sellars
Primary Care Transformation Lead
August 2019
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Appendix A: Commissioning Overview
Drivers for Change Estates Impact
Blackburn with Darwen CCG • In order to enable delivery of the Strategic Strategic Estates Plan Plan, a more strategic approach to estates and property management is required. • The Strategic Estates Group has started to work more collaboratively and this system wide approach should allow greater efficiencies to be made to benefit the health and social care economies moving forward. • Ensure estate aligned to locality model (4 localities).
Primary Care Strategy • Estates are key to aiding the transformation and development of primary care, with significant investment required to deliver Blackburn with Darwen’s Primary Care Strategy. • Enable the development of Primary Care Networks / Multi-Speciality Community Provider (MCP) Transformation of health care • Improve quality and capacity of the primary services across Blackburn with care estates. Darwen CGG. • Further the development of the Federation and collaboration of GP practices • Creation of community and service care hubs across Blackburn with Darwen CCG – locality model. • Relocation of services from multiple locations to the hub model • Relocate services from an acute to a community setting – identify space following utilisation studies.
Reduce estates costs • Increase utilisation to make core estate more efficient and allow consolidation of services. • Consolidate accommodation where possible, preventing duplication.
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Appendix B: Estates Map including proposed new housing developments
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Appendix C
Capital Funding
2019/20 2020/21 £000 £000 Blackburn West 0 3,494 Improvement 150 150 Grants GP Information 244 242 Technology
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Appendix D
Risks Scheme Risk Risk Level Mitigating Actions / Comments West Failure to Deliver Low Central additional OBC support being given along with Specialist design / scheme input and CCG facilitation West Practices withdrawn Low Practices committed from the Scheme to working together. Recognise current buildings are not for future purpose. CCG supporting practices’ ambitions to merge and supporting scheme development West CCG does not Low CCG has committed support notional rent to fund and rate reimbursements reimbursement West ETTF funding not Medium It is assumed that the being available full estimated grant funding will be available for the scheme, but if not the scheme would probably continue fully funded by the GPs though this would have an impact on higher rent reimbursements West Planning permissions Low/Medium The Council have and conditions been fully involved in the scheme development it is unlikely that planning consent would not be granted Other future Future schemes not Low/ Medium The CCG will take a schemes and compliant with new robust view on any refurbishments models of care / new proposal to Estates Strategy ensure that it would be compliant with strategic intent and new models of care delivery
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PRIMARY CARE CO-COMMISSIONING COMMITTEE
GOVERNING BODGOVENING B Developing the General Practice Workforce
Date of Meeting 17th September 2019 Agenda Item 10 TING CCG Corporate Objectives
Through better commissioning, improve local health outcomes by addressing poor outcomes and inequalities To work collaboratively to create safe, high quality health care services To maintain financial balance and improve efficiency and productivity To deliver a step change in the NHS preventing ill health and supporting people to live healthier lives To maintain and improve performance against core standards and statutory requirements To commission improved out of hospital care CCG High Impact Changes Delivering high quality Primary Care at scale and improving access Self-Care and Early Intervention Enhanced and Integrated Primary Care and Better Care Fund Access to Re-ablement and Intermediate Care Improved hospital discharge and reduced length of stay Community based ambulatory care for specific conditions Access to high quality Urgent and Emergency Care Scheduled Care Quality
Clinical Lead: Dr Preeti Shukla
Senior Lead Manager Mr Peter Sellars Finance Manager Mrs Linda Ring Equality Impact and Risk Assessment completed: n/a
Primary Care Co-Commissioning Committee Page 1 of 6
Is a Data Protection Impact Assessment Yes No Required? Data Protection Impact Assessment Yes No completed: Patient and Public Engagement n/a completed: Financial Implications n/a Risk Identified n/a Report authorised by Senior Manager: Mrs Julie Kenyon
Y
Decision Recommendations
The Committee is asked to support the proposals outlined in this paper to develop the General Practice workforce within an agreed realistic timeframe
Y
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Developing the General Practice Workforce
September 2019
1. Introduction
1.1. The purpose of this paper is to outline the current position in relation to GP workforce within the Blackburn with Darwen CCG footprint and to explore possible approaches for recruiting and retaining General Practitioners (GPs) within Blackburn with Darwen . It also details how this learning could be extended across Pennine Lancashire.
1.2. It has been estimated that Blackburn with Darwen require approximately 20 GPs to fill the current vacancies/demand on primary care services. This is based on a recent report issued by the National Workforce Reporting System (NWRS) which is compiled from information submitted by practices on a quarterly basis. This information resonates with other areas across Lancashire and South Cumbria as well as other areas across England who are also experiencing the same issues with both recruitment and retention of GP’s. NHS England and NHS Improvement North West, in partnership with Health Education England, are developing a Workforce strategy to look at how to address these issues, taking into account how the new roles coming into primary care through the Primary Care Network Direct Enhanced Service (PCN DES) contract will impact the overall workforce situation.
1.3. A detailed analysis of the current workforce position has been compiled. This is attached as Appendix 1
2. Initiatives currently available - GP retention
2.1 Integrated care systems (ICS) and sustainability and transformation partnerships (STPs) will receive £12m in 2019/20 and a further £12m in 2020/21 to support GP retention. NHS England has also developed a new GP Retention toolkit (attached – Appendix 2) to help improve retention of GPs called “Making General Practice a Great Place to Work”.
2.2 The new toolkit is based on findings from seven 'GP retention intensive support sites', which were established across England last year 'to "hothouse" local support at different levels. Three of these sites were in Lancashire and South Cumbria - Blackpool, West Lancs and Morecambe Bay - thus affording an opportunity to look closer at the data gathered, lessons learnt and the evaluation from the programme once it concludes in September 2019. ICS/STPs have been mandated to include recommendations from the toolkit as part of local planning to improve GP retention. Lancashire and South Cumbria ICS and NHSE/I are currently reviewing implementation of the toolkit and its initiatives and this will be monitored by the NHSE/I Workforce Steering Group.
2.3 The toolkit sets out steps that the NHS can take at ICS/STP, practice, PCN and individual levels. It argues that GPs need support at all stages of their career, including when they are newly-qualified, if they are to remain working in the NHS. The intensive support sites found that 'person-level' career support can have the greatest impact for GPs in the early stage of their career. ICS/STPs will receive further funding this year to develop the two-year fellowship plan that was advocated in the GP partnership review and which NHS England supported in its long-term plan.
2.4 The fellowship is aimed at supporting newly-qualified GPs as they make the transition to independent practice and to encourage them to take on substantive roles in primary care rather than opting for locum work. The fellowship incorporates the Targeted Enhanced Recruitment Scheme (TERS) in which 43 places have been allocated across Lancashire and South Cumbria. These Primary Care Co-Commissioning Committee Page 3 of 6
places are in Blackpool (16), Lancaster (19) and South Cumbria (8) as they are recognised as areas that are particular difficult to both recruit and retain GPs. At the time of writing, there are 9 remaining places from the 43 allocated.
2.5 A second scheme - the ‘New to Practise Programme’ aims to support practices, PCNs and systems with recruitment of newly qualified GPs and practice nurses by offering more attractive roles. Systems are empowered to ‘grow their own’ workforce that is fit for the future. Additionally, this programme supports nurses to recognise general practice as being a first destination career option.
2.6 The Programme is of a nationally agreed construct, but with local autonomy around the design and delivery specifics. Each element of the national model will be available to participants, with initiatives to deliver those agreed locally, building on existing provision so that familiar good practice is not lost.
2.7 Each ICS/ STP has received national funding on a weighted capitation basis at month four to deliver the requisite local support, activities and opportunities. The offer is available to any newly-qualified GP or Nurse who is interested in the benefits the scheme brings, so is not mandated nor a supplement to the length or content of formal training. Rather it is a permanent proposal to join a practice/ PCN through a substantive position funded by the employer, with a guaranteed level of support and flexibility through having the programme offer attached. The programme is available to all interested individuals, regardless of number of hours contracted. All participants will spend the majority of their time as a ‘jobbing’ GP or Nurse undertaking clinical duties, and thus be compensated at the appropriate pay rate. Any practice/ PCN participating in the programme does so with the understanding that the individual will have some time released for funded training, development and support activities, which may be away from the practice.
2.8 There are two tiers to the programme:
1. The ‘Universally Available’ tier which should be accessible to all newly-qualified GPs and Nurses who are interested in participating in the offer; funding allocated £278k for Lancashire and South Cumbria
2. The ‘System Leadership’ tier which is available to a small number of participants by a locally administered application process. There is local flexibility on the content of this, which should be supportive of building the leadership pipeline, such as an opportunity to undertake a MBA, or lead a piece of research on behalf of the PCN. Funding allocated £355k for Lancashire and South Cumbria
2.9 Across Lancashire and South Cumbria, a digital solution has been proposed to assist in retaining GP’s. There are two cohorts that this offer is available for;
• those who are close to retirement and wish to continue working, but not full time
• those with young families or other commitments who wish to increase their hours and return to practice in a flexible way.
Several GPs in Pennine Lancashire have expressed an interest in pursuing this online approach, and Dr. Fiona Ford form ELCCG is currently piloting this way of working.
2.10 Some areas across the country have implemented bursaries to support training in the local area, often with retention clauses meaning candidates have to work within the area for a set period of time or risk a claw back of the funding. Additionally some have tried to attract GPs to their area by Primary Care Co-Commissioning Committee Page 4 of 6
offering bonus payments and or packages to support moving house, schools for children etc. (‘Golden Hello’s’). However, the evidence for return on investment, particularly for areas like Pennine Lancs, is not compelling. What does seem to work is having a supportive practice environment, with opportunities for development and training, team based working and involvement in the running and direction of travel of the practice. The CCGs together with GP Federations could support practices to be able to offer this way of working.
2.11 Similarly payments and bonuses offered to GPs to remain in active practice have struggled to be effective, not least because the underlying issues persuading the practitioner to leave often have not changed. Additionally, pension and tax concerns associated with increases in income mean this is not a realistic option for many. For this cohort alternative working models must be developed, for example, working specifically with certain patient groups e.g. older people, whilst not undertaking acute work or on call duties. Others may wish to just do on the day work or chronic disease management etc. This in itself may require additional funding given practices or PCNs would have to backfill the practitioner.
3. Possible Approaches
3.1 In order to improve both recruitment and retention, it is important that a whole system approach be deployed to ensure a sustainable improvement in the number of GPs. This whole system approach must include active strategic transformation in how General Practice functions and operates and include increasing collaboration between practices and other services through both development of Primary Care Networks (PCNs) and supporting mergers of practices into more ‘at scale’ provider organisations.
3.2 As the ‘new’ primary care/practice offer is developing, opportunity exists to develop portfolio working which could include a range of employment options through current traditional employers or developing new potential through GP Federations in collaboration with PCN’s. This could then provide a platform for developing a new consultant type of contract which both new and current GP’s could be offered and which could include options for working within different environments and or within specific clinical, educational or management roles. This type of contract (fulltime) would consist of 10x4 hour programmed activities in the ratio of 7.5 direct clinical work and 2.5 non clinical which would include administration etc. and would allow GPs protected time to do reports, read letters and action any results. Therefore the contract would have time built in for that person to study or take forward any research opportunities. These contracts would better support work life balance and could also include job shares, varying the number of sessions delivered and how the sessions are delivered, i.e. using digital methods to deliver video consultations remotely.
3.3 In alignment with changes in delivery mechanisms, further efforts to improve the estate is also required to ensure that GPs and other professions can practice 21st century medicine in fit for purpose buildings. Across BwD, this work is ongoing, in line with both the Primary Care and Estates strategies; however, further developments will need to be considered going forward.
3.4 In developing any learning experience it would be appropriate to work closely with the University of Central Lancashire (UCLAN) and with Health Education England to develop appropriate skills and knowledge programmes. Closer working with our training hubs is also required to scope the potential increase in the number of training places and GP trainers in practice needed to support the development of the primary care workforce - this could include offering financial support to recruit trainers, as several are planning to retire shortly.
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4. Proposal
4.1 Recognising the need to recruit as well as retain GPs and other health professionals, this paper proposes that a wide ranging approach be undertaken to include all the elements highlighted. To be successful, this process would require a dedicated programme management approach to systematically design clear structures and opportunities in collaboration with primary care employers and academia. This would also need to be in alignment with the ICS and NHSE strategic direction / plans and built into a realistic timeframe. Taking this approach and linking to the “Making General Practice a Great Place to Work” toolkit could see Blackburn with Darwen / Pennine Lancashire becoming a pilot site for testing new approaches e.g. consultant style contract.
4.2 A robust advertising programme and media campaign would need to be designed and implemented on behalf of all practices / primary care organisations. This would need to highlight positive aspects of working and living in Pennine Lancashire as well as a full menu of employment options such as portfolio working etc.
4.3 The programme management team would need to identify the full costs of the recruitment and retention workforce plan, which would be based on a mixed economy plan to include newly qualified GP’s and those who could be retained or who could be encouraged to move into the area.
4.4 The CCGs need to consider the best approach to facilitate supportive environments in practices, with opportunities for development and training, team based working and involvement in the running and direction of travel of the practice. Practices must be supported to be able to offer this way of working. Similarly, payments and bonuses offered to GPs to remain in active practice need to be reviewed to ensure that any payments are effective at encouraging practitioners to take up the offer.
5. Conclusion
5.1 This paper has explored national and local initiatives aimed at increasing and/or retaining the current GP workforce across Blackburn with Darwen and Pennine Lancashire. It recognises the need to undertake a whole system approach to tackle this issue positively and sets out a broad proposal requiring a robust programme management approach.
6.0 Recommendation
6.1 The Committee is asked to support the proposals outlined in this paper to develop the General Practice workforce within an agreed realistic timeframe
. Peter Sellars Primary Care Transformation Lead August 2019
Primary Care Co-Commissioning Committee Page 6 of 6
Quartile Ranking for FTEs No. QUARTILE RANKING OF STAFF PER 1000 POP (1 = Highest FTE/000, 4 = Lowest FTE/000) Worst Quartile Practice Other Non Total GP Nurse LOCALITY Code Practice Name List Size DPC Clin Score Darwen P81051 Darwen Healthcare Darwen HC 12618 2 1 1 1 5 0 Darwen P81140 Darwen Health Link Darwen HC 16700 3 1 3 2 9 0 Darwen Total Darwen P81633 Spring-Fenisco Healthlink 3121 1 3 4 3 11 1 32439 2.0 1.7 2.7 2.0 8.3 1 East P81058 St. Georges Surgery 8916 3 2 3 2 10 0 East P81167 Audley Health Centre 5474 1 2 1 2 6 0 P81707 William Hopwood Street Surgery 5504 2 3 3 4 12 1 East P81709 Roman Road HC 4736 4 1 4 4 13 3 u 18551 3 1 3 1 8 0 East P81724 Pringle Street Surgery 2196 4 4 4 3 15 3 East Y02657 Bentham Road HC 7428 3 4 2 3 12 1 East P81734 Cornerstone Practice Shadsworth S East East Total 52805 2.9 2.4 2.9 2.7 10.9 8 North P81155 Brownhill Surgery 4815 1 1 1 2 5 0 North P81204 Ewood Medical Centre 4827 3 4 2 3 12 1 P81622 Shifa Surgery Bangor Street 10786 4 3 3 3 13 1 North P81683 Olive Medical Centre 7640 2 4 3 4 13 2 North P81704 Blakewater Healthcare 11183 4 2 1 1 8 1 North P81721 Hollins Grove Surgery 2324 3 1 4 3 11 1 North P81771 Primrose Bank Medical Centre 4999 4 4 4 1 13 3 North North Total 46574 3.0 2.7 2.6 2.4 10.7 9 West P81005 Little Harwood HC 11637 3 3 3 1 10 0 West P81022 Witton Medical Centre 10255 3 2 4 4 13 2 West P81061 Redlam Surgery 4744 1 3 1 3 8 0 West P81125 Oakenhurst Surgery BCW HC 10106 1 3 2 4 10 1 West P81214 Limefield Surgery 4117 1 2 1 1 5 0 West P81694 The Family Practice BCW HC 4697 4 4 2 4 14 3 #REF! West Total 45556 2.2 2.8 2.2 2.8 10.0 6 Grand Total 177374 Conclusions Register Sizes • 13 practices with <15% of register aged 65+ • 7 with 15 to 20% aged 65+ • 3 with >20% aged 65+ GP Age Profile • 10 practices with <=20% of GPs aged 55+ • 4 practices with 20 to 30% of GPs aged 55+ • 3 practices with 30 to 40% of GPs aged 55+ • 6 practices with >=40% of GPs aged 55+ Conclusions GPs per 1000 Population • CCG average = 0.441 FTE per 1000 Population • Wide variation (0.09 to 0.96) Practices In Lowest Quartile for FTE Per 1000
GP FTEs / Locality Practice Code Practice Name List Size GP FTEs 000 Pop North P81704 Blakewater Healthcare 11183 3.04 0.272 East P81709 Roman Road HC 4736 1.07 0.225 North P81622 Shifa Surgery Bangor Street 10786 2.42 0.225 East P81724 Pringle Street Surgery 2196 0.48 0.220 West P81694 The Family Practice BCW HC 4697 1.00 0.213 North P81771 Primrose Bank Medical Centre 4999 0.423 0.085 Conclusions Nurses (Practice Nurses, Advanced Nurses, Specialist Nurses etc-) FTE per 1000 Population • CCG average = 0.255 FTE per 1000 Population • Wide Variation = 0.00 to 0.40 Practices In Lowest Quartile for FTE Per 1000
Nurse FTEs / Locality Practice Code Practice Name List Size Nurse FTEs 000 Pop East Y02657 Bentham Road HC 7428 1.17 0.166 North P81204 Ewood Medical Centre 4827 0.75 0.155 North P81683 Olive Medical Centre 7640 1.09 0.143 West P81694 The Family Practice BCW HC 4697 0.53 0.114 East P81724 Pringle Street Surgery 2196 0.24 0.109 Primrose Bank Medical North P81771 Centre 4999 0 0 Conclusions Other Direct Patient Care (Mostly Health Care ) Assistants) FTE per 1000 Population • CCG average = 0.103 FTE per 1000 Population • 6 Practices with 0, highest = 0.47 Practices with 0 (= Lowest Quartile) Other DPC Other DPC FTEs Locality Practice Code Practice Name List Size FTEs / 000 Pop Primrose Bank Medical North P81771 Centre 4999 0.00 0.000 North P81721 Hollins Grove Surgery 2324 0.00 0.000 West P81022 Witton Medical Centre 10255 0.00 0.000 East P81724 Pringle Street Surgery 2196 0.00 0.000 East P81709 Roman Road HC 4736 0.00 0.000 Darwen P81633 Spring-Fenisco Healthlink 3121 0.00 0.000 Conclusions Non Clinical Support (NCS) Staff Inc. Management) FTE per 1000 Population • CCG average = 1.24 FTE per 1000 Population • Less Variation than for Clinical (1.11 to 1.24) Practices In Lowest Quartile for FTE Per 1000
NCS Staff NCS Staff / Locality Practice Code Practice Name List Size FTEs 000 Pop West P81125 Oakenhurst Surgery BCW HC 10106 11.04 1.09 William Hopwood Street East P81707 Surgery 5504 5.87 1.07 West P81022 Witton Medical Centre 10255 10.37 1.01 North P81683 Olive Medical Centre 7640 7.71 1.01 West P81694 The Family Practice BCW HC 4697 4.48 0.95 East P81709 Roman Road HC 4736 4.40 0.93 Conclusions 6 Practices ranked in the lowest Quartile for 2 or more of the FTE Per 1000 Rankings
GPs Nurses Other DPC Non Clinical Quartile Ranking for FTEs No. Practice / 000 / 000 / 000 / 000 Other Non Total Worst GP Nurse Code Practice Name List Size FTE Pop FTE Pop FTE Pop FTE Pop DPC Clin Score Quartile P81709 Roman Road HC 4736 1.1 0.23 1.7 0.37 0.0 0.00 4.4 0.93 4 1 4 4 13 3 P81724 Pringle Street Surgery 2196 0.5 0.22 0.2 0.11 0.0 0.00 2.7 1.23 4 4 4 3 15 3 P81683 Olive Medical Centre 7640 4.3 0.56 1.1 0.14 0.6 0.08 7.7 1.01 2 4 3 4 13 2 P81771 Primrose Bank Medical Centre 4999 0.4 0.09 0.0 0.00 0.0 0.00 6.8 1.35 4 4 4 1 13 3 P81022 Witton Medical Centre 10255 4.0 0.39 3.3 0.33 0.0 0.00 10.4 1.01 3 2 4 4 13 2 P81694 The Family Practice BCW HC 4697 1.0 0.21 0.5 0.11 0.5 0.11 4.5 0.95 4 4 2 4 14 3
These practices tend to have young populations: 5 to 10% aged 65+: P81709, P81724, P81683, P81694 10 to 15% aged 65+: P81771 15 to 20% aged 65+: P81022 Conclusions 3 Practices ranked in the lowest Quartile for both GP and Nurse FTEs Per 1000 Rankings
GPs Nurses Other DPC Non Clinical Quartile Ranking for FTEs No. Practice / 000 / 000 / 000 / 000 Other Non Total Worst GP Nurse Code Practice Name List Size FTE Pop FTE Pop FTE Pop FTE Pop DPC Clin Score Quartile P81724 Pringle Street Surgery 2196 0.5 0.22 0.2 0.11 0.0 0.00 2.7 1.23 4 4 4 3 15 3 P81771 Primrose Bank Medical Centre 4999 0.4 0.09 0.0 0.00 0.0 0.00 6.8 1.35 4 4 4 1 13 3 P81694 The Family Practice BCW HC 4697 1.0 0.21 0.5 0.11 0.5 0.11 4.5 0.95 4 4 2 4 14 3
The practices above have young populations: 5-10% aged 65+: 2 Practices (P81694 & P81724) 10-15% aged 65+: 1 Practices (P81771) Appendix 1
All / Exc. Practice 15 to 45 to 65 to Exc. 1000 Exc. Locum Under 35 to LOCALITY Code Practice Name List Size 0 to 14 44 64 74 75+ All Locum All Pop Locum / 1000 35 45 45 to 55 55 to 65 65 + Darwen P81051 Darwen Healthcare Darwen HC 12618Patient Age 17% Profile 38% 28%GP 11% Headcount 7% GP 8 Full Time 8 Equivalent 5.8 (FTE) 0.46 5.8 GP 0.46Headcount 25% - Age 38% Profile 13% 25% 0% Darwen P81140 Darwen Health Link Darwen HC 16700 17% 37% 28% 10% 8% 6 6 5.8 0.35 5.8 0.35 0% 17% 17% 17% 50% Darwen P81633 Spring-Fenisco Healthlink 3121 14% 34% 31% 11% 10% 3 3 2.9 0.92 2.9 0.92 67% 0% 0% 0% 33% 32439 17% 37% 28% 11% 7% 17 17 14.5 0.45 14.5 0.45 18% 12% 0% 12% 0% East P81058 St. Georges Surgery 8916 19% 37% 26% 9% 8% 7 5 3.3 0.36 2.5 0.28 43% 29% 0% 29% 0% East P81167 Audley Health Centre 5474 24% 44% 22% 6% 5% 5 3 3.3 0.61 3.0 0.55 0% 0% 20% 20% 60% East P81707 William Hopwood Street Surgery 5504 24% 47% 21% 5% 4% 3 3 2.7 0.49 2.7 0.49 0% 33% 0% 0% 67% EastDarwen P81709 Total Roman Road HC 4736 25% 44% 22% 5% 3% 1 1 1.1 0.23 1.1 0.23 100% 0% 0% 0% 0% East P81724 Pringle Street Surgery 2196 29% 45% 17% 6% 3% 4 3 0.5 0.22 0.5 0.22 75% 0% 0% 0% 25% East P81734 Cornerstone Practice Shadsworth S
u 18551 23% 43% 23% 7% 4% 14 12 6.7 0.36 5.9 0.32 7% 43% 36% 14% 0% East Y02657 Bentham Road HC 7428 24% 43% 21% 7% 5% 5 2 2.7 0.37 1.6 0.22 20% 40% 0% 40% 0% East Total 52805 23% 42% 23% 7% 5% 39 29 20.2 0.38 17.2 0.33 15% 23% 15% 13% 15% West P81005 Little Harwood HC 11637 19% 37% 26% 9% 10% 3 3 3.2 0.27 3.2 0.27 67% 33% 0% 0% 0% West P81022 Witton Medical Centre 10255 17% 36% 29% 10% 8% 4 4 4.0 0.39 4.0 0.39 0% 50% 50% 0% 0% West P81061 Redlam Surgery 4744 15% 34% 30% 11% 11% 3 3 3.0 0.63 3.0 0.63 0% 0% 33% 67% 0% West P81125 Oakenhurst Surgery BCW HC 10106 18% 36% 26% 11% 10% 10 10 7.6 0.75 7.6 0.75 10% 40% 30% 20% 0% West P81214 Limefield Surgery 4117 21% 38% 24% 8% 9% 3 3 2.5 0.62 2.5 0.62 33% 0% 33% 33% 0% West P81694 The Family Practice BCW HC 4697 22% 53% 19% 4% 3% 1 1 1.0 0.21 1.0 0.21 0% 0% 0% 100% 0% West Total 45556 18% 38% 26% 9% 9% 24 24 21.3 0.47 21.3 0.47 17% 29% 29% 25% 0% North P81155 Brownhill Surgery 4815 17% 35% 30% 10% 8% 5 4 4.6 0.96 4.0 0.83 20% 60% 0% 20% 0% North P81204 Ewood Medical Centre 4827 20% 41% 26% 8% 5% 2 2 1.8 0.38 1.8 0.38 0% 50% 0% 50% 0% North P81622 Shifa Surgery Bangor Street 10786 26% 48% 19% 5% 2% 3 2 2.4 0.22 2.1 0.19 33% 33% 33% 0% 0% North P81683 Olive Medical Centre 7640 26% 49% 18% 5% 3% 5 5 4.3 0.56 4.3 0.56 0% 40% 40% 0% 20% North P81704 Blakewater Healthcare 11183 21% 41% 24% 7% 6% 4 2 3.0 0.27 1.4 0.13 25% 25% 25% 25% 0% North P81721 Hollins Grove Surgery 2324 18% 42% 28% 8% 5% 1 1 1.0 0.43 1.0 0.43 0% 0% 100% 0% 0% North P81771 Primrose Bank Medical Centre 4999 20% 41% 24% 8% 6% 1 1 0.4 0.09 0.4 0.09 0% 100% 0% 0% 0% North Total 46574 22% 44% 23% 7% 5% 21 17 17.6 0.38 15.0 0.32 14% 43% 24% 14% 5% Grand Total 177374 20% 41% 25% 8% 6% 101 87 73.6 0.42 68.1 0.38 17% 29% 20% 17% 11% Appendix 2
Nurses Full Time EquivalentAdv (FTE) Ext. TotalOther Direct Patient CarePharm Non Clinical SupportMed (NCS) Staff Practice Prac' Nurse Spec Role Nurse HCA -acist Other Manag Seret- Recep - Ancill- LOCALITY Code Practice Name List Size Nurse Pract' Nurse NurseNurse FTEs FTE FTE FTEDPC Total -erial ary tion aryNCS Total P81051 Darwen Healthcare Darwen HC 12618 2.0 1.9 0.0FTEs 0.0 / 4.7 0.37 2.1 1.0FTEs 0.9 / 5.9 0.47 3.1 2.6 10.2 0.0per 18.9 1.50 P81140 Darwen Health Link Darwen HC 16700 3.3 2.1 0.01000 0.0 6.4 0.38 0.5 0.51000 0.0 1.0 0.06 1.0 3.2 14.0 0.01000 21.4 1.28 P81633 Spring-Fenisco Healthlink 3121 0.6 0.0 0.0Pop 0.0 0.6 0.21 0.0 0.0 0.0Pop 0.0 0.00 1.0 0.0 2.8 0.0Pop 3.9 1.23 32439 5.9 4.0 0.0 0.0 11.7 0.36 2.6 1.5 0.9 7.0 0.21 5.1 5.9 27.1 0.0 44.2 1.36 P81058 St. Georges Surgery 8916 2.1 1.0 0.0 0.0 3.1 0.35 0.3 0.0 0.0 0.3 0.03 1.0 0.8 7.7 0.0 11.5 1.29 Darwen P81167 Audley Health Centre 5474 1.3 0.0 0.2 0.0 1.5 0.28 0.8 0.0 0.0 0.8 0.15 1.0 0.0 5.7 0.1 7.0 1.27 DarwenP81707 Total William Hopwood Street Surgery 5504 1.1 0.0 0.0 0.0 1.1 0.19 0.3 0.0 0.0 0.3 0.05 0.8 1.1 2.9 0.0 5.9 1.07 P81709 Roman Road HC 4736 1.7 0.0 0.0 0.0 1.7 0.37 0.0 0.0 0.0 0.0 0.00 0.7 1.0 2.6 0.0 4.4 0.93 P81724 Pringle Street Surgery 2196 0.2 0.0 0.0 0.0 0.2 0.11 0.0 0.0 0.0 0.0 0.00 0.7 0.0 1.9 0.0 2.7 1.23 P81734 Cornerstone Practice Shadsworth S
East
u 18551 5.4 1.5 0.0 0.0 6.9 0.37 1.9 0.0 0.0 1.9 0.10 4.9 1.4 16.3 3.0 29.4 1.59 Y02657 Bentham Road HC 7428 1.2 0.0 0.0 0.0 1.2 0.16 1.0 0.0 0.0 1.0 0.14 1.1 0.5 3.4 1.0 8.3 1.12 East Total 52805 12.9 2.5 0.2 0.0 15.7 0.30 4.3 0.0 0.0 4.3 0.08 10.3 4.8 40.6 4.1 69.2 1.31 P81005 Little Harwood HC 11637 2.0 0.0 0.0 0.8 2.8 0.24 0.9 0.0 0.0 0.9 0.08 2.9 1.2 7.7 0.0 15.3 1.32 P81022 Witton Medical Centre 10255 1.5 1.9 0.0 0.0 3.3 0.33 0.0 0.0 0.0 0.0 0.00 2.7 1.0 4.6 0.0 10.4 1.01 P81061 Redlam Surgery 4744 1.2 0.0 0.0 0.0 1.2 0.25 0.8 0.0 0.0 0.8 0.17 1.0 1.0 2.0 1.8 5.8 1.22 West P81125 Oakenhurst Surgery BCW HC 10106 2.1 0.0 0.0 0.0 2.1 0.20 1.4 0.0 0.0 1.4 0.14 1.8 1.9 7.3 0.0 11.0 1.09 P81214 Limefield Surgery 4117 1.3 0.0 0.0 0.0 1.3 0.32 0.8 0.0 0.0 0.8 0.19 0.0 0.7 4.3 1.0 6.8 1.65 P81694 The Family Practice BCW HC 4697 0.5 0.0 0.0 0.0 0.5 0.11 0.5 0.0 0.0 0.5 0.11 2.1 0.0 2.3 0.0 4.5 0.95 West Total 45556 8.6 1.9 0.0 0.8 11.2 0.25 4.4 0.0 0.0 4.4 0.10 10.5 5.8 28.4 2.8 53.8 1.18 P81155 Brownhill Surgery 4815 1.9 0.0 0.0 0.0 1.9 0.40 0.8 0.0 0.0 0.8 0.17 0.0 0.0 5.2 1.1 6.3 1.31 P81204 Ewood Medical Centre 4827 0.7 0.0 0.0 0.0 0.7 0.15 0.5 0.0 0.0 0.5 0.11 0.8 0.0 4.9 0.0 5.7 1.19 P81622 Shifa Surgery Bangor Street 10786 1.2 1.0 0.0 0.0 2.2 0.21 0.9 0.0 0.0 0.9 0.08 4.3 1.0 3.7 3.3 12.3 1.14 P81683 Olive Medical Centre 7640 1.1 0.0 0.0 0.0 1.1 0.14 0.6 0.0 0.0 0.6 0.08 1.0 0.0 6.7 0.0 7.7 1.01 North P81704 Blakewater Healthcare 11183 1.9 1.0 0.0 0.6 3.5 0.31 2.6 0.0 0.0 2.6 0.23 2.0 1.0 13.4 0.0 16.9 1.51 P81721 Hollins Grove Surgery 2324 0.9 0.0 0.0 0.0 0.9 0.40 0.0 0.0 0.0 0.0 0.00 0.9 0.0 1.7 0.0 2.7 1.15 P81771 Primrose Bank Medical Centre 4999 0.0 0.0 0.0 0.0 0.0 0.00 0.0 0.0 0.0 0.0 0.00 1.7 0.7 4.3 0.0 6.8 1.35 North Total 46574 7.8 2.0 0.0 0.6 10.4 0.22 5.5 0.0 0.0 5.5 0.12 10.7 2.7 40.0 4.4 58.4 1.25 Grand Total 177374 35.2 10.4 0.2 1.4 49.1 0.28 16.8 1.5 0.9 21.1 0.12 36.7 19.1 136.1 11.3 225.6 1.27 Making general practice a great place to work A practical toolkit to improve the retention of GPs
This toolkit is aimed at system leaders and clinical leads working across primary care to develop robust local retention action plans that provide GPs with the support they require to develop fulfilled careers in general practice. It also aims to tackle issues at practice, network and system level that may be impacting on local GP retention.
NHS Publishing Approval NHS England and NHS Improvement Reference 000430 Foreword
As working GPs ourselves, we see first-hand how in the face Ultimately however, achieving growth relies on cultural change. of rising demand for our services, many GPs are feeling under In line with the vision set out in the Interim NHS People Plan, enormous pressure, causing them to leave the profession early or we need to make general practice – and wider primary care reduce their hours to achieve better balance between their work – both a destination of choice and a better place to work. and family life. Issues around pensions and indemnity have also Supporting GPs to realise fulfilling, rewarding and exciting been key factors influencing their career decisions. careers in general practice can’t be achieved through national programmes of work alone, and we need to work together Keeping these GPs in the workforce, and making sure they feel to embed local ownership of this agenda. GP retention in this valued and supported is a key challenge facing our NHS. From context is an absolute priority. the newly qualified GP who locums due to the lack of a local offer for the more varied, flexible career they seek, through Those working in Integrated Care Systems and Sustainability and to the more experienced GP who is considering giving up their Transformation Partnerships have already been asked to set out partnership in the face of longstanding failure to recruit. clear action in this year’s planning for primary care to retain as many GPs in the workforce as possible. This toolkit aims to help Progress to achieve an increase of 5,000 GPs in this context has you in your efforts to do this, based on learning from close work been challenging but we are committed to delivering this as between a range of colleagues from across the system – and soon as possible. Many GPs are now seeing their indemnity costs some fantastic engagement from local GP leaders. reduce through the new national scheme. More new GPs are now being trained than ever before and we continue to work Last year, we supported the start-up of a range of GP to recruit more qualified GPs into the workforce – both from retention initiatives across the country. This was an example overseas and by supporting others to return to practice. At the of fantastic collaboration between national and local teams point this toolkit is published, the Government is consulting on and has shown us that alongside national work on system- changes to make pension rules more flexible for senior clinicians. wide issues, local efforts can make a genuine difference to the working lives of GPs.
2 Foreword
Truly inspiring examples, such as Barking, Havering and deliver even better care for patients. I hope this toolkit helps you Redbridge CCG offering GPs an opportunity to develop their own to achieve this, and we encourage you to continue to be a part portfolio working role are featured later in this toolkit. Having of the conversation around sharing learning, resources and good both pursued the option of portfolio working in our own careers practice with your system colleagues. We look forward to seeing - combining our work as GPs with our roles at NHS England and how you translate this into real change. NHS Improvement – we are pleased to see this as a key focus of the toolkit alongside wider support for GPs. Importantly, the toolkit also encourages a strong focus on work at practice and system level to unblock issues that are affecting GP workload.
To support implementation of this toolkit, £12 million is being made available to STPs this year with further funding to follow in 2020/21. This is part of a wider approach and further guidance will follow on the introduction of fellowships for newly qualified GPs, the development of the local training hub infrastructure to support local activity, and development of the multi-disciplinary team, building on strong growth to date. Emerging primary care networks also provide key opportunities to create a more sustainable footing for the workforce. Dr. Nikki Kanani MBE Dr. Raj Patel MBE As we see a much welcomed increase in funding for primary care GP, Bellegrove Surgery GP, The Brook Surgery through the GP contract and these related initiatives, we have a Interim Medical Director Deputy National Medical huge opportunity to make changes for the better – changes that for Primary Care Director for Primary Care
3 About this toolkit
Last year, NHS England invested around £18 Key lessons learnt from the GPRISS • Multi-level interventions million* to support GP retention, which was Whilst support for individual GPs is 80% more than originally planned. This was • Importance of local support essential to a good retention approach, used to encourage and support local action National support is key to getting many critical issues (e.g. workload) to reduce loss from the GP workforce. interventions off the ground quickly need to be unblocked through Most of this funding was released via the (e.g. by providing access to funding), but additional interventions at practice Local GP Retention Fund which built on the ultimately success in improving retention and system level. existing national offer of the National GP locally relies on local engagement and Retention Scheme – and earlier piloting of support being in place. more flexible working opportunities for GPs who received individual, practice, • Taking a broad view of retention GPs – to provide extra help for areas of the and system level support were twice as Whilst interventions that offer support country that needed it most. Over 200 GP likely to report feeling ‘supported’ as a direct to GPs are essential (e.g. retention initiatives have been established result of GPRISS than those who received mentoring), those which target the across the country as a result of this fund. only one level of support (e.g. only wider workforce and practice managers individual support). Seven GP Retention Intensive Support Sites were found to be equally important to (GPRISS) were also established across the addressing factors which can improve the country to ‘hothouse’ local support at different work life balance for GPs. Find out more about the work of the GPRISS: levels – person, practice and system – with the aim of making general practice a better place • Taking a whole career approach to work. This toolkit interprets the GPRISS A broad spectrum of support across the approach into a set of resources that can be GP career pathway is needed to provide applied locally. An independent evaluation of continuity of support and avoid ‘cliff the GPRISS approach is also available. edges’ – particularly at times of transition. This includes tailored support for trainees, The Operational Planning newly qualified GPs, early-mid career GPs Guidance 2019/20 requires that and those approaching retirement. recommendations from this toolkit are incorporated into local planning.
*Indicative figure subject to the completion of the 2018/19 annual audit. 4 GP Retention Improvement Cycle
The GPRISS approach centred on bringing together local stakeholders, e and emp ngag ower system and GP leaders to jointly develop an evidence-based local action E plan to improve GP retention.
Learning and recommendations from the GPRISS and related local work Know the local have now been translated into a ‘GP retention improvement cycle’. This GP workforce
forms the focal point of this toolkit and sets out steps to develop a robust
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local action plan to improve GP retention, with a strong focus on local i
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Who should use this toolkit? s E
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i GPs: By clinical leads, GPs and their appraisers to inform what good d Refine your Assess the c a r action plan support gap looks like and understand the potential contribution of different levels e
e r of the system towards making general practice a better place to be. F ir st Practices and networks: By local workforce leads to consider and f iv es respond to the support needs of their GPs, how they should engage N ew with designing the action plan and what funding is available. ly qua lifie d System leaders: to understand the issues and key actions needed to Cre ge ate ca chan improve GP retention and to ensure that these play a prominent part of pacity to the local primary care strategy and supporting action plan.
Note: The acronym ‘ICS/STPs’ is used throughout this document and stands for ‘Integrated Care Systems / Sustainability and Transformation Click on each section of the Partnerships. Further information is available here: cycle to find out more https://www.england.nhs.uk/integratedcare/ 5 Click to return to the GP Creating capacity for change Retention Improvement Cycle
Make GP retention a priority support will help to identify where to target essential. This might include some administrative GP retention is a key issue affecting many this funding. Practices and networks that have particular issues with retention should and communication support to GPs and practices, and must be seen as be considered a priority. co-ordinate and manage take-up a priority. The requirement for a well of the schemes, and any associated developed GP retention action plan is An important lesson from the GPRISS – and procurement activity. expected to feature prominently in all local the wider Local GP Retention Fund – was primary care workforce strategies. the value of having access to dedicated Primary Care Networks ICS/STPs will also be expected to evidence funding to kickstart initiatives. Feedback Primary Care Networks (PCNs) will play a through standard assurance processes that from 2018/19 activity equally highlighted key role in creating a sustainable workforce learning from this toolkit is being applied to the value of providing funding over a across primary care through the creation improve GP retention locally. longer period to support the sustainability of satisfying roles for staff, development of of schemes. ICS/STPs have been advised to multi-professional teams and more balanced Consider how you will resource your expect follow-up funding of a further £12 workload for all, with a focus on preventing ill action plan million in 2020/21 to support GP retention. health and tackling health inequalities. Funding Leadership and resource Significant development support funding will flow to ICS/STPs to work with their Building on last year’s investment, a Planning and implementing an action plan PCNs to agree the most effective way to further £12 million has been allocated to improve retention takes time, effort ensure the workforce can access high quality across ICS/STPs in 2019/20 to support the and leadership. implementation of this toolkit, alongside development support. This presents a real Engaging enthusiastic clinical leads for GP additional funding for other GPFV opportunity for PCNs with a significant retention means they can play a key role in programmes (Practice Resilience, Reception focus on providing capacity and support helping to champion change, generate new and Clerical Staff Training and Online to enable the primary care workforce ideas and offer a link to ‘what’s happening Consultation Systems). including GPs to access career progression on the ground’. opportunities and step into leadership roles. Using the GP Retention Improvement Cycle Dedicated project and change management A PCN development support prospectus and associated tools to identify local need, resource at system and/or network level to will be made available on the FutureNHS map the existing activity against the three co-ordinate the design and implementation Collaboration Platform in due course. levels of support, and address any gap in of the action plan is also considered 6 Click to return to the GP Creating capacity for change Retention Improvement Cycle
Primary Care Training Hubs A training hub brings together education and training in primary and community care The NHS Long Term Plan set out plans to with the aim of developing a sustainable workforce. Specifically training hubs will: develop the training hub infrastructure to deliver training and education for the primary and community care workforce. Support Help retain GP Whilst they are currently at varying stages Assist PCNs and Develop educators to and primary of maturity, going forwards training hubs the wider ICS/ capacity for make the PCN care workforce will be ideally placed to support workforce STP in workforce training within ‘the best place’ at all stages of planning and the delivery of GP retention planning PCNs to learn their career and career support initiatives locally. Further guidance is due to be published.
We recommend that the local hub is engaged at an early stage of developing the GP retention action plan to consider Coordinate Support GPs and Support the how they might support the delivery and education Help introduce primary care continued resourcing of the plan going forwards. programmes and embed new workforce at all professional to support Case studies demonstrating the role that staff stages of their development of service delivery training hubs can play in regards to GP career all staff retention can be accessed on the FutureNHS ambitions Collaboration Platform.
7 Click to return to the GP Engage and Empower Retention Improvement Cycle
The GPRISS have shown that strong local engagement, leadership and collaboration is key to successfully improving GP retention. In particular, those responsible for developing the Local Medical Committees GP retention action plan should consider how to: Appraisers • Engage your stakeholders in design • Ensure GPs have room to engage Bringing system leaders and local and develop Local Workforce Advisory partners together is essential to promote Consider from the outset how you are Boards (LWAB) understanding of the issues and to create going to create room for local GPs to solutions that work. Encouraging open participate in career development activity. Secondary care dialogue between your stakeholders – This might mean structuring interventions perhaps through focus group sessions to minimise the impact on clinical work GP Federations and more formal project governance or considering more radical solutions such GP GPs (at all stages of career) arrangements – also helps to foster a as using pooled working arrangements Retention culture of collaboration and continuous to provide backfill for local GPs. Potential Suggested Local / regional NHS improvement. A full range of impact on the workload of other practice contributors England-NHS Improvement stakeholders should be engaged in action staff should also be considered. to the planning activity. HEE action plan • Encourage take-up of the offer Newham Health Collaborative created ICS /STP leads Action plans are expected to provide a sustainable, dual-purpose solution by a comprehensive support offer but if making use of a staff bank of experienced RCGP representative introducing several new initiatives at GPs to provide cover for GPs participating once it may be best to stagger the roll in their quality improvement leadership Practices and networks out and communication of these to programme. For more information visit: avoid overloading your GPs and wider www.england.nhs.uk/gp/gpfv/workforce/ Clinical Commissioning Groups stakeholders with too much information retaining-the-current-medical-workforce/ at once. This should also encourage gp-career-plus/newham/ better take-up of the support offer. Training hubs
8 Click to return to the GP Know the local GP workforce Retention Improvement Cycle
The first step of developing GP Trainees Qualified workforce the GP retention action plan should be to take time to profile Loss during training: Loss during transition Loss from qualified and understand the needs of Newly qualified • Failure to progress into the workforce: workforce: local GPs to determine what • Switching speciality • Emigration • Emigration support is required. A good Mid career understanding of local workforce • Deferrals • Return to home • Voluntary early country (for retirement data is key – combined with local Wise years understanding of the context. international students) • Change in career It should be noted that loss • Gap years direction from the GP workforce occurs in different ways along the GP Loss can occur throughout the GP career pathway due to: career pathway. • Reducing working hours due to: • To undertake more varied work across caring commitments, managing multiple settings workload (e.g. working as a locum) • Burn out or ill health
Surveys and focus groups • How many GP trainees do you • How many GPs do you need to retain successfully retain locally post training? in the workforce in line with local Focus group sessions are a hugely valuable workforce plans? way to drive understanding of the issues • How many experienced GPs are you losing being faced locally. to early retirement or other factors? Snapshot surveys of local GPs are also a useful way to understand their ambitions • How many GPs are opting to work on a Questions to consider include: and stressors, and to gauge the impact of part-time or locum basis? • What is the profile of your workforce? current support provision. Templates are What issues are they facing? available and can be issued using readily available online tools. 9 Click to return to the GP Know the local GP workforce Retention Improvement Cycle
Measuring the impact setting (e.g. the proportion of time a GP of retention may contribute to the local urgent care or about the participation rates of different extended access service for example), NHS groups of GPs in the general practice setting. Retention can be difficult to measure Digital is due to start surveying CCGs for and it will take time for the impact of this information from July 2019. A ‘GP STP Demand and Supply Tool’ is initiatives to show in workforce figures. also available to model expected inflows Workforce data however provides huge Planning future requirements and outflows of GPs at Regional, STP and insights into local trends and should be Complementary tools to help interpret the CCG level in line with the commitment monitored closely. NHS Digital data are also developed by to ensure a growth of 5,000 full time Quarterly primary care workforce statistics NHS England-NHS Improvement and can be equivalent GPs as soon as possible. are published by NHS Digital and provide accessed via the FutureNHS Collaboration All ICS/STPs have agreed primary care data on staff working in the general Platform. These are particularly relevant for workforce plans for 2019/20 which set practice setting. Reports produced via the planning at regional and STP level. out how many GPs and other staff they NWRS are helpful at all levels of the system This includes a ‘retention impact estimation are planning to recruit and retain over – from practices through to ICS/STP. tool’ to help estimate the potential impact the year. The GP Retention Action Plan is Whilst these statistics don’t currently of initiatives that provide direct support expected to support delivery of these include a count of the primary care to GPs (e.g. portfolio working for newly plans with ongoing activity informing workforce outside of the general practice qualified GPs) based on what is known future requirements.
National Workforce Reporting System
The National Workforce Reporting System (NWRS) is run by NHS Digital have recently relaunched this system which now NHS Digital to collect and present primary care workforce includes reporting functionality and there are plans for further based data, using data supplied by practices and networks in development of the system. More information about the NWRS is line with contractual requirements. available here: http://bit.ly/NWRS_Webpage
10 Click to return to the GP Assess the support gap Retention Improvement Cycle
Through the Local GP Retention Fund alone, over What scale is best? 200 retention support initiatives were established for GPs across the country last year. The GP As this toolkit is published, ICS/STPs will be in the process of finalising their primary Retention Action Plan is intended to build on this care strategy for 2019/20. As part of GP contract reforms, practices will also be existing activity but bolster it through additional grouping into primary care networks, which will be at varying levels of maturity. To support across the three levels of intervention. support local ownership and innovation, GP retention action plans are ideally held at practice and network level but should feed into a combined plan at ICS/STP level Armed with a detailed understanding of their to maximise opportunities to collaborate across networks and groups of practices. workforce, ICS/STPs should audit their current activity against these three levels to assess gaps in support. When undertaking this review it would The three levels of intervention be useful to assess: Career support for GPs • Progress of schemes established via the Local GP Retention Fund (Source: FutureNHS Tailored career support provided direct to a GP according to need. GPs are Collaboration Platform). individuals and their support needs will evolve as they progress through their career. The best support provision takes this into account. • The uptake of the national GP Retention scheme across the area (Source: NHS Digital). Practices and networks • How many practices have participated Interventions to address issues at practice and or network level that are in NHS England’s General Practice affecting GP retention. These initiatives will be aimed at individual practices Development Programme. or groups of practices and will include work to address GP workload and build the multi-disciplinary team. • Engagement with other schemes run through wider partner organisations (e.g. British Medical System Association and Local Medical Committees, Interventions to address system-wide issues affecting GP retention. These Health Education England, Royal College of GPs). may be at ICS/STP level or across groups of networks and should include Tools and templates are available. See ‘Checklist’ work to improve links with secondary care. for further details.
11 Click to return to the GP Refine your action plan Retention Improvement Cycle
Gaps against the support needs of local GPs or across the three levels of intervention should now be evident and can start to be addressed through action planning. For each level of intervention, the following sections of this toolkit present:
FutureNHS Collaboration Platform and Goals Local must do’s National support we will be continuing to work with local systems and areas going forwards to A set of aspirational Elements that need to National support and collect and share this good practice. goals for each level of feature as part of your guidance available Equality and health inequalities intervention. action plan to help that should be achieve these goals. reflected in your All initiatives – and particularly where they action plan. provide support to individual GPs – should be screened to ensure that due regard has been given to eliminate discrimination, The goals set out under each of the three is essential that this is combined with more harassment and victimisation, to advance levels have been developed based on the targeted support at a local level. Templates equality of opportunity, and to foster work of the GPRISS. Both these, and the are available to support this activity. good relations between people who action plan essentials are by no means share a relevant protected characteristic Case studies exclusive and set out the minimum that is (as cited under the Equality Act 2010) and required to improve GP retention locally. To aid development of the local action those who do not share it. Consideration Through discussion with stakeholders, plan, exemplar case study examples should also be given to the need to reduce local areas are encouraged to agree from the work of the GPRISS and Local inequalities between patients in access and add onto these goals to ensure GP Retention Fund are also presented to, and outcomes from GP services, and they capture the key issues that need for each level of intervention. Whilst to ensure services are provided in an to be addressed locally. In a similar some of these schemes are still in integrated way where this might reduce fashion, whilst all action plans are expected relatively early stages, they give a health inequalities. Further guidance is to maximise the opportunities available great indication as to what is possible. available at www.england.nhs.uk/about/ through national programmes of work, it Further case studies are available on the equality/equality-hub/
12 Career support for GPs
Our goal: Local GPs... Action plan essentials Available national support feel engaged with and valued by the area Opportunities for GPs to engage with Resources for GP appraisers and system within which they work the local GP retention strategy Plan put in place to stay in touch with GPs GP Improvement Leads Programme have opportunities to connect with other GPs throughout their career
Peer support networks have the opportunity to access career advice National 1:1 GP coaching and support when they need it Tailored support for GPs across their career – from training through to retirement GP Career support Pack can access training and leadership opportunities Support for GPs returning back to practice to support their career progression
Portfolio careers and flexible working GP Health Service have the option to work flexibly and across a range of different settings if they want to Coaching National GP Retention Scheme feel supported to return back to practice Leadership development after time out of the workplace Mentoring Induction and Refresher Scheme (Return to Practice) can access a support programme in their first Two year support programme for newly two years of independent practice qualified GPs
Supportive GP appraisal
13 Career support for GPs Newly GP trainees Early-mid career ‘Wise fives’ What good looks like – case studies qualified
Returners Newly qualified GPs
A key finding of the GPRISS was that person-level support can have the greatest impact for GPs in the early stages of their career. The NHS Long Term Plan committed that ‘newly qualified doctors and nurses entering general practice will be offered a two-year fellowship’. The aim of this offer is to support GPs as they transition into independent practice and give them the best possible start in their career. Further funding will be allocated to STPs during the year to support development of their approach, supported by national guidance. Support offered to newly qualified GPs will build on existing best practice which is starting to emerge across the country, and strong alignment between this and the wider local GP retention action plan is expected, with a view to creating a continuum of support across the career pathway.
GP Salaried Portfolio Innovation Scheme
In response to the difficulties in recruiting newly qualified GPs to substantive roles and feedback gained from a local GP survey, Barking, Havering and Redbridge (BHR) CCGs together with HEE developed the GP Salaried Portfolio Innovation Scheme (GP SPIN). GPs are offered a permanent salaried role which consists of 4-7 sessions working in general practice, and the remaining two sessions being used to undertake a role in an alternative setting. Within BHR opportunities have included sessions with acute / mental health / community trust specialisms, CCG-based leadership opportunities, and educational fellowships. GPs also have access to dedicated peer support sessions, facilitated by an experienced GP educator. The peer support sessions are an important aspect of the GP SPIN model, as they are designed to provide a continuum of support from training into, and throughout the first year of post-qualification experience. In 2018, the GP SPIN scheme recruited seven newly qualified GPs into salaried GP roles. The scheme is now in its second year, and work is underway to introduce the scheme across other areas of London.
14 Career support for GPs Newly GP trainees Early-mid career ‘Wise fives’ What good looks like – case studies qualified
Returners
Black Country STP Mentoring Scheme
The Black Country’s mentoring scheme has been achieved by adapting and up-scaling a popular pre-existing scheme, taking advantage of the skills and knowledge of experienced GPs within the area. This allows for younger GPs to receive guidance from mentors who have encountered similar issues and challenges specific to the area and helps re-energise the mentor’s career and allows them to “give back” to the profession. The mentoring covers a wide array of topics including: physical and mental wellbeing, professional development, For more information advice about partnerships, practice process improvement, financial advice, sandwellandwestbhamccg. regulatory affairs, and ways to avoid or deal with burnout. Recipients have nhs.uk/sustainability-and- reported notable benefits, stating that they feel more supported and are transformation-partnership- optimistic about their careers. Importantly, there are early signs that a STP-wide stp/gp-retention culture of coaching and mentoring is forming.
15 Career support for GPs Newly GP trainees Early-mid career ‘Wise fives’ What good looks like – case studies qualified
Returners Early-mid career
Somerset Primary Healthcare Ltd Peer Support Scheme Somerset CCG and Somerset LMC developed a scheme that provides six months of paid, facilitated peer support sessions to experienced GPs who are seriously thinking of leaving or who have recently left. Nine GPs were recruited onto the scheme in the first seven months and GPs surveyed responded that they had improved morale and a reduced sense of professional isolation as a result of being on the scheme.
For more information www.england.nhs.uk/gp/ gpfv/workforce/retaining- the-current-medical- workforce/gp-career-plus/ somerset/
16 Career support for GPs Newly GP trainees Early-mid career ‘Wise fives’ What good looks like – case studies qualified
Returners Early-mid career
Black Country STP Portfolio Scheme The Black Country STP have developed a portfolio career scheme that offers flexible career options for GPs to enhance their skills and knowledge in areas of interest (e.g. dermatology, GP education, frailty). A key benefit of portfolio roles is that patients are able to receive care without the need for specialist consultations in secondary care. It is believed that this will reduce the burden of hospital appointments, resulting in reductions in waiting lists and savings across the wider healthcare system. Up to £10,000 has been made available for each GP to support development of their portfolio roles in the Black Country. The scope of employment and the balance between each GP’s clinical and specialist sessions is agreed on a case by case basis. CPD accreditation and points are attained through learning/reflective logs, as well as successful completion of any training programmes enrolled on as part of the scheme. For more information Within the first six months, the scheme received 66 applications and has supported sandwellandwestbhamccg. 24 GPs, with GPs who sign up to the scheme expected to stay in the Black Country nhs.uk/sustainability-and- for two years. GPs have responded favourably to the scheme, stating that it provides transformation-partnership- a welcomed opportunity, not only to pursue an interest, but to upskill (by gaining stp/gp-retention/ qualifications and experience) and provide more services in general practice. incentivising-portfolio- careers
17 Career support for GPs Newly GP trainees Early-mid career ‘Wise fives’ What good looks like – case studies qualified
Returners Early-mid career
Newham Health Collaborative (NHC) Leadership Development Programme NHC working with the NHS Leadership Academy developed an innovative five-day Primary Care Leadership Programme for GPs in Newham which was based on one that had been delivered for Thames Valley and Wessex Leadership Academy. The five-day programme ran over four months and covered: what is leadership and leadership styles, the current NHS picture and evolving challenges, influencing and negotiation skills and leading and managing change. 30 GPs and 20 primary care staff have participated in the leadership programme to date. Through an evaluation GPs have indicated they have gained the skills to improve the effectiveness of their teams, understand and know how to engage in the wider health and social care system and have greater confidence to take up or continue with their partner, portfolio or new clinical director role.
18 Career support for GPs Newly GP trainees Early-mid career ‘Wise fives’ What good looks like – case studies qualified
Returners Early-mid career
NHS England National 1:1 coaching Throughout 2017 and 2018, NHS England rolled out a national coaching programme to support GPs experiencing challenges in the workplace or considering leaving general practice. GPs who undertook the coaching received three confidential 90-minute sessions run by highly experienced and qualified coaches to help tackle particular challenges and identify their future career options. An evaluation undertaken in 2018 showed that for GPs who had undertaken the coaching there was a 28% reduction in the likelihood of leaving with 98% of GPs reporting a positive impact.
For more information For national coaching offers, contact: england. [email protected]
19 Career support for GPs Newly GP trainees Early-mid career ‘Wise fives’ What good looks like – case studies qualified
Returners Wise fives
Great Yarmouth and Waveney CCG - GP Bank The CCG have developed a scheme that involved creating a ‘bank’ of experienced GPs that supply cover for clinical sessions for both long and short term needs. Extensive one to one engagement with GPs was a key factor to the success of the scheme to understand what would stop GPs from leaving. For GPs it was not about the money but what the CCG could do to make them feel supported and to take away the hassle and administration so that they could concentrate on meaningful clinical appointments. In order to attract experienced GPs onto the scheme (who were at risk of leaving) a range of incentives were offered. These included: indemnity cover, longer 15 minute appointment times, access to a facilitated peer support network and a training budget to use for specialist interests and mandatory training. In the first seven months, five GPs were retained who would have otherwise left and the scheme has been able to For more information support local practices to fill vacant sessions and free up capacity for partners to www.england.nhs.uk/ focus on wider workforce planning. gp/gpfv/workforce/ retaining-the-current- medical-workforce/gp- career-plus/great-yarmouth- and-waveney-ccg/
20 Career support for GPs Newly GP trainees Early-mid career ‘Wise fives’ What good looks like – case studies qualified
Returners Wise fives
Isle of Wight CCG Legacy Five Scheme The Isle of Wight CCG developed a ‘Legacy 5 scheme’ that supports GPs who are within five years of retirement to make informed decisions about their futures. The scheme highlights career opportunities which may result in GPs working beyond their identified retirement dates. The scheme involves workshops focussing on financial planning and career development opportunities. GPs have access to a fund to undertake a range of training that would enable them to cultivate skills and provide care beyond their projected retirement dates.
21 Career support for GPs Newly GP trainees Early-mid career ‘Wise fives’ What good looks like – case studies qualified
Returners Return to practice
Dorset STP - one-day returner’s course Dorset STP has developed a one day course for GPs returning to the workplace after a period of absence, typically but not exclusively for GPs following parental leave or long term sickness. The course offers GPs the opportunity for simulated face to face and telephone patient consultations, with feedback from experienced GP Educators available. Participants are offered the opportunity for follow on coaching over the return to work process, through the Primary Care Workforce Centre’s coaching facility. Up to 16 GPs can attend each course and the key benefit has been that GPs who wouldn’t have returned have, due to the increased support available.
22 Career support for GPs Newly GP trainees Early-mid career ‘Wise fives’ What good looks like – case studies qualified
Returners Return to practice
NHS England / Health Education England (South West) Short Placement Scheme NHS England and HEE SW have jointly designed a short placement scheme to support GPs returning to practice. This scheme returns GPs to practice who have been out of practice for more than one year but less than two. The scheme includes a two week placement with a supportive GP trainer who exposes the GP to up to date practice and protocols, advice on using the software system, and consulting with patients. Following this they are re-energised and confident to get back into independent practice. Through this scheme the SW has successfully returned 20 GPs to practice.
23 Practices and networks
Action plan essentials Available national support Our goal: Practice and networks... As per career support section, plus: As per career support section, plus: actively look to achieve Local action plan for GP retention, General Practice Development Programme: better work life balance for which feeds into an overarching plan at • GP Online consultations fund local GPs through continuous system level • Releasing time for care improvement, service redesign • Building capability for improvement and development of the multi- Local arrangements are in place to • Training for reception and clerical staff disciplinary team keep in touch with GPs especially in times of transition • Practice manager development know and understand the GP Retention Toolkit and related needs of GPs working across Communicating support opportunities resources on FutureNHS including PCN the network and create that are available to GPs locally opportunities to support their Development Support Prospectus career development Promoting and developing the practice / National Workforce Reporting System collaborate with GPs and others network as a great place to work across the system to make local GP Career Support Pack general practice a great place to Developing the multi-disciplinary team (local versions can be created) work and identify opportunities in primary care to release GP capacity to collaborate and reduce workload To be published during 2019: engage with their local training • Guidance on two-year support offer hubs to inform development of the Regular review and maintenance for newly qualified GPs local infrastructure to support future of workforce data in line with • Guidance on developing the GP retention contractual requirements multi-disciplinary team
24 Practices and Networks What good looks like – case studies
The Beacon Medical Group Multi-Disciplinary Team
The Beacon Medical Group in Plymouth cut the average waiting time to see a GP by six days by introducing a multi-disciplinary urgent care team, an enhanced care home service and redesigning care pathways for dermatological and musculoskeletal (MSK) conditions. These initiatives are all staffed by a range of practitioners including paramedics, pharmacists and nurse practitioners. The introduction of the urgent care team has ensured patients seeking an urgent same day appointment can now do so. The introduction of the multi-disciplinary team has meant that GP workload has reduced which has improved morale and enabled GPs to provide their expertise into further initiatives.
For more information modelsofcare.co.uk/ casestudy
25 Practices and Networks What good looks like – case studies
Waterside Medical Centre Active Signposting
Waterside Medical Centre along with a group of 13 other practices took part in the Learning in Action element of the Time for Care programme. Active signposting was an action the group identified to take forward. Over six months the practice attended six Learning in Action workshops, where the group was introduced to various tools and techniques to identify ways of reducing the number of patients seeing a GP with problems that could be dealt with by other practice staff or the wider health economy. Active signposting has helped the practice release 11% of inappropriate GP appointments, equating to 80 appointments or 13 hours of GP time per week, giving GPs more time to focus on those patients that need their time (e.g. those with more complex care needs), as well as improving access for patients who need to be seen.
For more information www.england.nhs.uk/ gp/case-studies/active- signposting-frees-up- 80-inappropriate-gp- appointments-a-week/
26 Practices and Networks What good looks like – case studies
Isle of Wight CCG Career Roadmaps
The Isle of Wight CCG recognised that there was a lot of information available for GPs but this information was spread across multiple sources, making it difficult for GPs to find and use. Furthermore, the information was not tailored to the local context of the island. With this in mind, the CCG focussed on creating a single point of access that clearly directs GPs to career development opportunities and guidance of how to navigate the local and national system. The online resource provides an overview of opportunities (roadmaps) to GPs according to their roles within general practice (i.e. registrars, salaried GPs, partners and locums).
For more information onewighthealth.co.uk/gp- career-development
27 Practices and Networks What good looks like – case studies
Newham Health Collaborative (NHC) engagement activities
NHC has conducted a range of engagement activities with GPs through a range of events, use of social media (such as WhatsApp) and even visiting GPs for coffee to gain their views. A primary care event was held that attracted over 250 primary care staff including 70 GPs from across Newham. The event celebrated achievements from individuals and teams across Newham and provided the opportunity to connect with GPs and primary care staff enabling the contact details of those attending to be obtained so that they could be alerted about future learning, development and engagement activities. NHC have also engaged with staff via Twitter using the following hashtags #NewhamHealthCollaborative, #ConnectingPrimaryCare and #CareersThiveInEastLondon. Emails and newsletter communications about various retention offers have been followed up with a message on WhatsApp which has been very popular at reminding GPs and wider primary care staff about the offers available.
28 Practices and Networks What good looks like – case studies
Weston and Worle diagnostic
In order to fully understand the needs of GPs working across the locality and impact of any interventions implemented, a start and end diagnostic was commissioned. This involved canvassing practice staff – clinical and non-clinical – and asking a series of questions focussing on their views of the sustainability of the primary care system, their roles within it and how much pressure they felt under. This was further informed by the NHS Digital national workforce data. Using a theory of change, key initiatives were identified to support GP retention across the locality. A repeat of the diagnostic was later undertaken to understand the impact of the various initiatives and further inform implementation going forward.
29 System
Action plan essentials As per career support, Available national support As per career support, Our goals: The local system... practices and networks sections, plus: practices and networks sections, plus: actively works with local GPs, Action plan(s) in place at system, network Implementation toolkit for local systems: practices, networks and system and practice level and robust assurance 2017-19 NHS Standard Contract provisions leaders to ensure the right support is processes in place to oversee delivery across primary and secondary care put in place to improve GP retention Strong engagement with a wide range To be published during 2019: is assured that GPs know about of stakeholders, including training hubs and can access career support and • Guidance for commissioning advice when required services from training hubs Named clinical lead(s), change work with local practices, networks, facilitation support and project system leaders and other stakeholders to management capacity in place actively make and promote local general practice as a great place to work GPs and their appraisers are well informed of the local and national engage with their practices, networks support available, and where appropriate, and training hubs to inform are supported into schemes. development of the local infrastructure to support future GP retention Work across primary and secondary care with a focus on reducing GP workload improved collaboration and working across the interface between primary and secondary care
30 System What good looks like – case studies
Cheshire East GP Retention Project
Cheshire East Partnership in association with the Cheshire and Merseyside Primary Care Academy, have worked with GP practices across Cheshire East to undertake a piece of research to determine the future plans of GPs who are nearing the end of their career. They have developed a ‘Stay Interview’, where experienced GPs (generally over the age of 50) are interviewed by another GP to explore their future career intentions. The outputs from these interviews have been used to create an action plan to help retain these experienced GPs with new opportunities and career pathways across the local area.
31 System What good looks like – case studies
North Midlands appraisals and signposting to bespoke retention packages The ‘Soft re-boot’ of the annual appraisal was taken as an opportunity to change the culture of the appraisal from ‘I’m stressed I need to postpone my appraisal’ to ‘I’m stressed I need to book my appraisal’. This initiative focused on implementing new documentation supporting the revised appraisal process prompting soft discussions about future career choices and focuses the appraisal conversation (where indicated) on retention options enabling signposting to career options and support opportunities which could encourage GPs to stay in service. An annual conference is held where all appraisers across the STP are informed of their role in supporting GPs, understanding their future plans and signposting them to the support available. The national GP Career Support pack has been used as a key tool in signposting GPs to national and local support and was used as part of the event pack for the conference.
32 System What good looks like – case studies
Isle of Wight - recruitment campaign
The Isle of Wight faces particular challenges relating to geography; the island is not readily accessible from the mainland which can lead to considerable travel costs. With this in mind, the CCG has made considerable effort to promote the area as an exciting and beautiful place to live and work. The island boasts a wide array of restaurants, historic and popular attractions, world famous events and festivals, and choices for outdoors pursuits. From a career perspective, the island’s population demographic offers a unique opportunity to practice multiple elements of primary care (e.g. rural and urban medicine, geriatric medicine, medicines optimisation in care homes, and minor surgery) within a small catchment area. The CCG has developed a recruitment programme with a strong emphasis on marketing materials to promote the island using digital platforms and social media. It is also working with local recruitment agencies and has secured ferry discounts for GPs and other primary care staff travelling to and from the mainland.
33 System What good looks like – case studies
Black Country STP GP Clinical Lead
When forming the GPRISS project team, emphasis was placed on the importance of having a GP Clinical Lead. Not only did this give a local GP the opportunity to champion general practice but also enabled the reality of the challenges faced in general practice to be portrayed from personal experiences and those of their peers. The benefits were impressive, through GP to GP conversations and attendance at a vast array of GP forums. The GP Clinical Lead has been able to foster honesty, openness and confidence that in turn enabled wider GP involvement in the co-design of the various projects. Strong links with those forums was maintained and continuation of this role remains a key feature in the success of the Black Country’s Retention Schemes for General Practice.
For more information sandwellandwestbhamccg. nhs.uk/sustainability-and- transformation-partnership- stp/gp-retention
34 System What good looks like – case studies
Mid and South Essex GP Support Service Single Point of Access The GP Support Service Single Point of Access (SPoA) is a dedicated telephone / email service across the Mid and South Essex STP with the aim of providing GPs who require additional support or who are looking to leave or retire with tailored information including signposting to the various retention initiatives Early-mid career across the STP. In the first six months the service has supported 57 GPs to either return back to practice, access vacancies across the STP or take up training and development opportunities.
For more information castlepointandrochfordccg. nhs.uk/about-us/vacancies/ primary-care-careers-in-essex
35 Checklist
The checklist below summarises key steps to creating your GP to network, engage and share resources related to GP retention retention local action plan. It should be used in conjunction with this and the primary care workforce. To request access, email england. toolkit and related national guidance which is due to be published [email protected]. over the coming months on training hubs, the support offer for The full range of national support offered to individual GPs – newly qualified GPs and development of the multi-disciplinary including from key partner organisations such as the BMA and RCGP team. A range of templates, further case studies and data tools are – is also set out in the GP Career Support Pack (see ‘Where to find also available via the FutureNHS Collaboration Platform, including out more’). the PCN development support prospectus. This also provides a space
Have you… Engage and empower undertaken a local stakeholder mapping exercise to identify who to involve? engaged with stakeholders to develop the action plan (e.g. engagement event, focus groups etc.) agreed how you will engage and involve GPs and wider stakeholders to support implementation of your action plan (e.g. pulse surveys, using of social media, posters, local press)? considered how you will ensure GPs have the capacity to participate in career development activity? Creating capacity for change considered how to employ the ICS/STP funding allocation for GP retention in 2019/20 and 2020/21 to support implementation of your action plan, targeted at areas that need it most? engaged clinical leads and have a named clinical lead in place to oversee the implementation of the delivery plan? recruited a project manager to oversee implementation of the retention action plan and consider change management resource, administration and communications support? established a project board to oversee implementation with appropriate stakeholders including GPs, PCN and CCG representatives. considered alignment with wider PCN development support offer? engaged with training hubs locally to engage with their future development and how this will support GP retention going forward? considered how you align your GP retention action plan with the emerging offer for fellowships for newly qualified GPs? 36 Have you… Know the local GP workforce accessed GP workforce data on the National Workforce Reporting System? accessed the workforce data and tools pages on the FutureNHS Collaboration Platform to help interpret the NHS Digital publications? undertaken a survey to understand in more detail the issues being faced locally by GPs? held local focus groups to analyse and interpret published data and local surveys?
Assess the support gap engaged with others who are leading on retention activities locally to understand what’s already available, including schemes set up under the Local GP Retention Fund? This includes schemes that partner organisations may have separately established (LMC, HEE, CCGs, RCGP). assessed uptake of the National GP Retention Scheme across the area and considered the local strategy for promoting this scheme going forwards? assessed how many practices have participated in NHS England’s General Practice Development Programme?
Refine your action plan developed an action plan and ensured plans at practice and network level align at system level? ensured that the action plan essentials are a feature of your action plan with initiatives identified to fill gaps in provision? ensured that the national NHS England offers are part of your action plan? agreed the approach to monitoring the delivery of the action plan?
37 Where to find out more
Future NHS Collaboration Platform
An extensive range of resources are available on the FutureNHS Collaboration Platform Thanks are given to all those whose including templates to help ICS/STPs and PCNs develop a theory of change and action plan, work over the last year has contributed analytical tools to understand the GP demographic and a range of further case studies. to development of this toolkit. To gain access, please the contact [email protected] with details of Particular thanks are extended to: your name, role and organisation. • The Black Country Sustainability and Transformation Partnership
GP Career Support Pack • Mid and South Essex Sustainability and Transformation Partnership Information and contact details for national support offers from NHS • North Kirklees and Greater England and NHS Improvement, and Huddersfield Clinical Commissioning other key partner organisations such Groups as the BMA and RCGP are set out in • Blackpool, Morecambe Bay and West the national GP Career Support Pack: Lancashire www.england.nhs.uk/publication/ Clinical Commissioning Groups gp-career-support-pack/ • Weston and Worle Locality (locality within Bristol, North Somerset and South Gloucestershire CCG)
• Isle of Wight Clinical Further information Commissioning Group • Newham Health Collaborative Ltd For any further help in relation to this toolkit please contact (North East London) [email protected]
38
PRIMARY CARE CO-COMMISSIONING COMMITTEE MEETING
G
Primary Care Quality Processes
Date of Meeting September 2019 Agenda Item 11
CCG Corporate Objectives
Through better commissioning, improve local health outcomes by addressing poor outcomes and inequalities
To work collaboratively to create safe, high quality health care services
To maintain financial balance and improve efficiency and productivity
To deliver a step change in the NHS preventing ill health and supporting people to live healthier lives
To maintain and improve performance against core standards and statutory requirements To commission improved out of hospital care CCG High Impact Changes
Delivering high quality Primary Care at scale and improving access Self-Care and Early Intervention
Enhanced and Integrated Primary Care and Better Care Fund Access to Re-ablement and Intermediate Care Improved hospital discharge and reduced length of stay Community based ambulatory care for specific conditions Access to high quality Urgent and Emergency Care Scheduled Care
Quality
PRIMARY CARE CO-COMMISSIONING COMMITTEE MEETING
Decision Recommendations
The Committee are requested to note the role of the Pennine GP Quality Group in providing assurance with regard to GP primary acre care services commissioned by Blackburn with Darwen CCG and the process in place to respond to CQC reports where practices have been rated as inadequate and or Requires Improvement
Clinical Lead: Dr Preeti Shukla / Dr Stephen Gunn
Senior Lead Manager Mr Peter Sellars Finance Manager Mrs Linda Ring Equality Impact and Risk Assessment n/a completed: Patient and Public Engagement n/a completed: Financial Implications None Risk Identified None Report authorised by Senior Manager: Julie Kenyon
PRIMARY CARE CO-COMMISSIONING COMMITTEE MEETING
Primary Care Quality Processes
1.0 Background
1.1 The purpose of this paper is to provide an update to the Primary Care Co Commissioning Committee in relation to the mechanisms in place to gain assurance with regard to the quality of GP Primary Care Services commissioned by the CCG.
2.0 Pennine GP Quality Group
2.1 The purpose of this group is to develop, implement and monitor a Primary Care Quality Review process for GP Practices in East Lancashire and Blackburn with Darwen CCG’s.
2.2 The group is responsible for discussing and acting upon any concerns within any General Practice across Pennine Lancashire.
2.3 The group is responsible for developing and maintaining a General Practice Performance Dashboard which will highlight where there are quality issues which need supporting to resolution. This dashboard must detail a number of indicators, weighted by severity, to provide a holistic picture of the practices performance.
2.4 The group also considers soft intelligence which may be of concern but not necessarily appear on a quantitative dashboard and therefore may be missed.
2.5 The group is also responsible for following through a standardised process which offers support to practices that are falling below the performance standard for 1 or more indicators. This process is the NHS England Quality Concerns Trigger Tool (See appendix 1).
2.6 Members of the group are expected to be part of a Support Team who will visit GP Practices to discuss the issues and develop action plans to resolve. This team will be decided by the group ensuring that the most appropriate people form the support group dependent upon the issues of concern.
2.7 A copy of the terms of reference for the Group is attached as (See Appendix 2)
PRIMARY CARE CO-COMMISSIONING COMMITTEE MEETING
3.0 Process to Respond to Care Quality Commission Reports
3.1 A process has been developed by NHS England and Improvement (North West Lancashire and South Cumbria) in conjunction with the Local Medical Committee.(LMC) This provides a framework for commissioners to respond to Care Quality Commission (CQC) reports where practices have received a rating of inadequate or requires improvement overall.
3.2 The process has been endorsed at the September meeting of the Primary Care Co Commissioning and Quality Forum . The forum is attended by CCG representatives from across Lancashire and South Cumbria, the LMC and the CQC.
3.3 The process is included as Appendix 3 with this report. (See Appendix 3).
4.0 Recommendations
4.1 The Committee are requested to note the role of the Pennine GP Quality Group in providing assurance with regard to GP primary care services commissioned by Blackburn with Darwen CCG and the process in place to respond to CQC reports where practices have been rated as inadequate or Requires Improvement
Sarah Danson Senior Commissioning Support Manager Primary Care
September 2019
Appendix A Commissioners Quality Concerns Trigger Tool
Routine Quality Monitoring
• CQC minimum standards • Serious incidents/Never events • NHS Constitution/Mandate • Leadership/workforce numbers • Complaints/Friends and Family test • Governance arrangements • MHPS • Delivery against contract specification • Safeguarding • Emergency admissions data and referral rates • GP Outcomes Framework • Contract Review Meetings • Partnership working arrangements
26 June 2015 Quality Assurance Framework
Persistent and/or Increasing Quality Concerns Identified
Step up to Enhanced Targeted Quality Quality Assurance Process /Monitoring Assurance Formal communication to Was assurance gained? Visits Provider via Quality Meetings
No Develop Provider Quality Risk Profile and arrange Enhanced Quality Review Single Item QSG Triggers • Lack of confidence in the providers ability to meeting with commissioners Yes and regulators to determine improve • next steps. Serious patient safety concerns • Serious contract breaches/Contractual notices • Issues outside of providers control • Quality Profile Persistent failure to meet CQC standards Template 22 July 201 • CQC Special Measures Maintain Enhanced • All 5 significant indicators >12 surveillance for a minimum 3 months communication to Was evidence gained that Yes provider concerns would be resolved within a reasonable Share Risk Profile timeframe? No with provider and Yes arrange Single Item QSG Risk Summit Triggers • serious failings within a provider • a need to act rapidly to protect patients and / or staff • a single, material event Increasing assurance / Reducing Risk
RRR/Risk Summit No
The escalation to a rapid response review or risk summit could be instigated at any point in the process if patient safety concerns require urgent action. Appendix 2
NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group
Pennine Lancashire General Practice Quality Grooup
Terms of Reference (JUNE 2019)
Purpose of the Group
1. The purpose of this group is to develop, implement and monitor a Primary Care Quality Review process for GP Practices in East Lancasshire and Blackburn with Darwen CCG’ss.
2. The group will be responsible for discussing and acting upon any concerns within any General Practice across Pennine Lancashire.
3. The group will be responsible for developing and maintainingg a General Practice Performance Dashboard which will highlight where there are quality issues which need supporting to resolution. This dashboard must detail a number of indicators, weighted by severity to provide a holistiic picture of the practices performance.
4. The purpose of this group is to discuss soft intelligence which may be of concern but not necessarily appear on a quantitative dashboard and therefore may be missed.
5. The group will be responsible for following through a standardised process which offers support to practices that are falling below the performance standard for 1 or more indicators. This process is the NHS England Quality Concerns Trigger Tool (see appendix 1)
6. Members of the group are expected to be part of a Support Team who will visit GP Practices to discuss the issues and develop action plans to resolve. This team will be decided by the group ensuring that the most appropriate people form the support group dependent upon the issues off concern
7. The group will support GP Practices to prepare for CQC inspections and provide support following any CQC inspection where the rating is less than good. The group will monitor the progress of inspection ratings in order to gain assurance for all practices.
8. The group will discuss individual practitioner performance concerns and through this group pass them to the Performance Team at NHS England
9. The group will keep an awareness of both the Vulnerable Practice and GP Resilience Funding uptake and progress managed by NHS England.
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Frequency of Meetings
Monthly
Agenda’s and papers will be circulated 1 week before
Membership
1. The group will have a permanent membership as listed below. Locality Managers will be invited as appropriate dependent upon the practices being discussed.
2. All permanent members should send apologies when unable to attend.
3. Resignation from the group should be forwarded to the chair.
4. Each group member is responsible for ensuring that relevant information from the Group is feedback to their peers via an appropriate forum and that information relevant to the Project from each of those forums is feedback to the Subgroup
5. Additional membership of the group should be in line with developments and reflect partnership working.
Membership list
Org. Name Role EL CCG Caroline Marshall (Chair) Head of Nursing and Quality EL CCG Catherine Wright (Deputy Primary Care Quality Lead Chair) BwD CCG Ambreen Bhatti Primary Care Quality Assurance Manager ELCCG Lisa Cunliffe Primary Care Development Manager ELCCG Dr Lisa Rogan Head of Medicines Commissioning LMC David Massey Local Medical Committee Representative EL CCG Dr Umesh Chauhan GP Quality Clinical Lead BwD CCG Dr Ridwaan Ahmed Clinical Director for Quality BwD CCG Dr Stephen Gunn Primary Care GP Lead NHSE Lysa Hasler Primary Care Manager BwD CCG Sarah Danson Senior Commissioning Support Manager NHSE Dr Gareth Wallis NHSE Deputy Medical Director NHSE Margaret Hey/Liz Stott Nursing & Quality Team ELCCG Lakh Gossal Business Intelligence Manager ELCCG Yvonne Jackson Safeguarding [email protected] CQC Tracey Rasmussen Inspector
If any member is unable to attend they must send a representative as a holistic picture will inform the groups discussions as to practice issues and action plans.
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Quoracy
There must be a GP present if any decisions are to be made.
Co-opted members
Any other colleague from the Health or Social Care who can or is providing insight or support to any General Practice across Pennine Lancashire. This includes Data Quality and Enhanced Services Commissioning
Reporting and Governance Structures (Please see below chart)
1. The General Practice Quality Group reports to the Pennine Lancashire Quality Committee.
2. All GP Practice employed members are required to state a general declaration of interest at the beginning of each meeting and a specific declaration of interest where resource to General Practice is discussed
Pennine Lancs Quality Committee
(Chaired by Michelle Pilling)
Pennine Lancs General Practice BwD Quality Group Primary Care Group
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Appendix 1: Quality Concerns Trigger Tool (November 2016)
Routine Quality Monitoring
• CQC minimum standards • Serious incidents/Never events • NHS Constitution/Mandate • Leadership/workforce numbers • Complaints/Friends and Family test • Governance arrangements • NHS Improvement monitoring • Delivery against contract specification • Safeguarding • Emergency admissions data and referral rates • GP Outcomes Framework • Contract Review Meetings • Partnership working arrangements
Quality Assurance Framework Nov 16.do
Persistent and/or Increasing Quality Concerns Identified
Step up to Enhanced Targeted Quality Quality Assurance Process /Monitoring Assurance Formal communication to Was assurance gained? Visits Provider via Quality Meetings
No Develop Provider Quality Risk Profile and arrange Enhanced Quality Review Single Item QSG Triggers • Lack of confidence in the providers ability to meeting with commissioners Yes and regulators to determine improve • next steps. Serious patient safety concerns • Access QRP Template from Serious contract breaches/Contractual notices • Issues outside of providers control NHS England • Persistent failure to meet CQC standards Maintain Enhanced surveillance for a minimum 3 months communication to Was evidence gained that Yes provider concerns would be resolved within a reasonable Share Risk Profile timeframe? No with provider and Yes arrange Single Item QSG Risk Summit Triggers • serious failings within a provider • a need to act rapidly to protect patients and / or staff • a single, material event Increasing assurance / Reducing Risk
RRR/Risk Summit \\xlcsu.nhs.uk\Userdata$\BWDCCG\Personal\Ashleigh.Davies\My Documents\Print\New folder (12)\ToR__Pennine GP Quality Group_v8_020719_AB.DOCX No
The escalation to a rapid response review or risk summit could be instigated at any point in the process if patient safety concerns require urgent action.
Appendix 3
HS England and NHS Improvement North West Lancashire and South Cumbria
Responding to The Care Quality Commission’s (CQC) Inspection of GP Practices
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NHS England and NHS Improvement North West (Lancashire and South Cumbria) – Standard Operating Procedure Responding to The Care Quality Commission’s (CQC) Inspection of GP Practices
Version number: 3
Version 3 prepared by Sarah Danson Primary Care Manager and Angie Ashworth - Business Manager NHS England and NHS Improvement North West
Acknowledgement: This document is based wholly on the NHS England South (South Central) Standard Operating Procedure Responding to the Care Quality Commission (CQC) Inspection of GP practices originally produced by Rebecca Tyrrell, Quality Improvement Manager, NHS England South Central, Nursing and Quality Directorate and has been adapted to reflect the current structures and processes within the Lancashire and South Cumbria locality.
Special thanks to the following people for their involvement in the development of the localised process flow chart
• Joanne Cooper - Transformation Manager – Primary Care NHS Chorley and South Ribble CCG / NHS Greater Preston CCG
• Louise Andrews - Primary Care Commissioning Manager Blackpool CCG
• Faye Ollis - Executive Lead – Lancashire Coastal - Lancashire & Cumbria Consortium of Local Medical Committees
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1 Introduction
The Care Quality Commission (CQC) inspects GP providers to ensure that they meet standards of quality and safety. GP practices are inspected across five key questions, considering the extent to which they are safe, effective, responsive, caring and well-led. Practices are rated in one of four categories; outstanding; good; requires improvement; or inadequate.
In response to this NHS England published a Framework designed to support NHS England Teams and CCG’s locally to work with practices that are rated inadequate so that there is a consistent approach to avoiding risk to patients and ensure continued patient confidence in the local NHS and primary care services.
As independent contractors, it is ultimately the practice’s responsibility to address any problems identified at inspection and to ensure improvement. However, it is important that NHS England & NHS Improvement - and Clinical Commissioning Groups (CCGs) - ensure there are clear and transparent improvement plans in place and support appropriate interventions if services to patients are at risk.
This paper summarises the locally agreed process by NHS England and Improvement Northwest (Lancashire and South Cumbria) along with Clinical Commissioning Groups (CCGs) based on the NHS England framework. Where CCGs have taken on delegated commissioning responsibility, they will take the lead role in the process supported by NHS England.
http://www.england.nhs.uk/wp-content/uploads/2014/10/frmwk-respond-cqc-insp.pdf.
2 Implementation
This document is a local standard operational procedure for NHS England and NHS Improvement North West (Lancashire and South Cumbria) outlining the governance arrangements for contract and quality assurance for Primary Care Medical Services. It represents the agreed approach taken to respond to CQC inspections where regulation breaches have been identified by practices.
3 Agreed local procedures following CQC inspection finding regulation breaches in GP practice
The local procedure will be determined by the overall rating of the practice to ensure there is a consistent level of intervention, support and relevant assurance.
Process Overall rating i Inadequate – special measures ii Requiring improvement with an inadequate domain iii Requiring improvement
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The key principles for dealing with practices who are rated as • Inadequate overall • Requires Improvement overall • Requires Improvement with an inadequate domain
In relation to overall monitoring and issuing remedial notices are broadly similar. As such one process flowchart has been produced for commissioners to follow in these circumstances.
Where immediate closure is recommended following a CQC inspection Commissioners will need to refer to Part C Section 2 of the NHS England Primary Medical Care Policy and Guidance Manual (PGM November 2017)
3.i Process - GP Practice rated overall ‘Inadequate’
• CQC will notify and then meet with the Delegated CCG to inform them of the GP Practice which has breached regulations and found ‘Inadequate’ following a CQC inspection and draft a report. CQC will advise the date for the draft report to be released to the practice. • Once the practice has received the draft report or notice, the Delegated CCG will contact the practice and provide initial guidance. • Following review by the National Panel, CQC will notify the Delegated CCG and NHS England and NHS Improvement via email/ telephone, to confirm the overall rating as a result of the factual accuracy process and provide a publication date. • NHS England (Primary Care and Nursing and Quality Teams) CCG and LMC will hold an internal meeting prior to meeting with the practice • CCG and NHS England & Improvement (Primary Care and Nursing and Quality Teams), and LMC will then meet with the practice to agree next steps and agree the level of support required. To include: o RCGP support package (accessed via the Transformation Team at NHS England & NHS Improvement) o Delegated CCG dedicated support to develop action plan o Communications strategy o Patient involvement to be implemented o CCG and NHS England support required o Explain quality oversight process
• NHS England & NHS Improvement Medical Directorate to write to individuals on the contract to remind them of their professional obligations • The contractor holder(s) will be required to formally respond to the CQC report and have the opportunity to formally challenge the findings. • On publication the contract holder(s) will be required to prepare an action plan to address the finding of the published report. • Regular oversight meetings to be arranged in line with agreed timescales and organised by the Delegated CCG and NHS England & NHS Improvement Primary Care Team
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The CCG will need to ensure that a review of any contractual issues is undertaken in conjunction with the NHS England and NHS Improvement Primary Care Team. • The contract holder(s) may wish to consider undertaking a mock assessment/ peer review prior to re-inspection. The Local Medical Committee (LMC) will assist with this process. • A full process flowchart is attached as Appendix 1
3.ii Process - GP Practice rated overall ‘Requires Improvement’ with an ‘inadequate’ domain
• A CQC inspection report will be published to notify a GP Practice rated as ‘requires improvement’ with an ‘inadequate’ domain. • The Delegated CCG will arrange an improvement meeting with the practice and agree next steps including guidance for developing an action plan, agree communication strategy, discuss patient involvement and support required from the CCG as appropriate • Delegated CCG, to monitor action plan within the agreed timescale. • Quality Oversight will be considered on a case by case basis • Practice may wish to consider mock assessment/ peer review prior to re- inspection supported by the LMC if required. • A full process flowchart is attached as Appendix 1
3.iii Process - GP Practice found overall ‘Requires Improvement’
• A CQC inspection report will be published to notify a GP Practice rated as ‘requires improvement.’ • The Delegated CCG may (on a case by case basis) discuss with the practice and agree next steps including guidance for developing an action plan, agree communication strategy, patient involvement and support required from NHS England and CCG. • The Delegated CCG as appropriate will the monitor the action plan within agreed timescale. • A full process flowchart is attached as Appendix 1.
4 Contact with CQC and NHS England and NHS Improvement North West (Lancashire and South Cumbria)
Initial contact from CQC will come directly to Delegated CCG by telephone. An agreed list of CCG contacts will be provided to local CQC teams.
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The Delegated CCG will then contact the Identified Responsible Officers (Director of Nursing and Head of Primary Care) at NHS England & NHS Improvement North West (Lancashire and South Cumbria)
• Delegated CCGs in Lancashire and South Cumbria are: o Blackburn with Darwen CCG o Blackpool CCG o Chorley and South Ribble CCG o East Lancashire CCG o Fylde and Wyre CCG o Greater Preston CCG o Morecambe Bay CCG o West Lancashire CCG
Information will be cascaded on a restricted basis to the Nursing and Quality Directorate, Communications (Comms) Team, Primary Care Commissioning (PCC) Team and Medical Directorate within both the Delegated CCG and NHS England & NHS Improvement as necessary.
5 Further Considerations
In response to a CQC inspection that identifies that a GP provider, has breached regulations and improvement is required, a range of meetings, either face to face or via teleconference, will be arranged to share information, manage risk, ensure support is provided and learning is shared.
As referenced in the process flowcharts at Appendix 1 the Quality Concerns Trigger flowchart will also need to be followed to determine if there are any further concerns with the GP provider following the CQC inspections.
A copy of the process for completing the Quality Concerns Trigger flowchart and associated Quality Risk Profile Tool is attached as Appendix 4.
Completion of the Quality Concerns Trigger and next steps should be considered on a case by case basis. It should be noted that this process is in draft format and is still subject to final agreement.
In cases where providers are single-handed Delegated CCGs should consider the impact of adverse ratings on the overall stability of the practice and consider options available to mitigate the risks. (e.g. resilience funding)
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6 References
• ‘Framework for responding to CQC inspections of GP Practices’, NHS England, October 2014 • Guidance for GP Practices rated as inadequate following CQC inspection, NHS England South (South Central), 2016 • NHS England Primary Medical Care Policy and Guidance Manual (PGM) 2017
7 Appendices
7.1.1 Appendix 1 Process flow chart for practices rated as Inadequate overall/Requires Improvement with an Inadequate domain and overall Requires Improvement
7.1.2 Appendix 2: Example Agenda Templates: Initial guidance meeting – Appendix a Internal meeting - Appendix b
7.1.3 Appendix 3: NHS England & NHS Improvement process for contractual action Please Note Flow diagram as published in the Framework for responding to CQC inspections of GP Practices 7.1.3 Appendix 4: Quality Risk Profile Tool Guidance
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CQC will notify CCG Primary Care Note: Communication teams Lead of the outcome Practice visit. to receive updates throughout the process.
CCG Primary Care Lead to notify mutli- disciplinary initially by telephone. Note: Multi-disciplinary teams Timescale – Immediate to within 1 working to include Communication, day Quality, NHSE PC Contracting, Nursing & Quality, NHSE Medical and the Local Medical Committee. CCG receives informal report. Multi- disciplinary team meeting is held to review and prepare for meeting with the Practice. Timescale - Within 5 working days, Practice receives drraaft report followed by an email / phone call within 1 and reviews for accuracy, once working day. agreed, CQC publish report on website
CCG Primary Care & Quality Teams to complete internal reporting templatees
Multi-disciplinary teams to review NHSE to prepare Remedial published report. Contractual and quality Notice for CCG Primary Care issues to be identified. Committee (PCC) for approval as appropriate
CCG Primary Care Team to complete Note: PCC can approvve outside Trigger Tool (if appropriate) and facilitaate of meeting schedule, if nd 2 visit to practice Committee has agreed process to delegate issue / or iif Chair’s Timescale for completion 10 working days Action sought
Practice is required to complete Action Note: CQC will notify practice plan within specified timeframe and submit 2 weeks and one day pprior to with supporting evidence to CCG post six-month revisit. Outcome meeting. will be confirmed to CCG/NHSEs
Requires Improvemennt – CCG to agree ongoing review meetings monitoring to continuue. with tthe practice until the six month CQC Closure (follow closure revisit. Review meetings can be byy process) phone/visit as appropriate.
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APPENDIX 2a
INITIAL GUIDANCE MEETING WITH
Practice Name Date/Time Location Chair
1. Introductions
2. Understand timescales to respond to Factual Accuracy annd publication of notices, report and re inspection 3. Agree NHS England and CCG contacts for the practice
4. Issue guidance document with annex - RCGP support programme - Improvement plan guidance - Action plan template
5. Consider PPG and patient involvement
6. Agreement of immediate actions - Mitigate risks - Assure patient safety 7. Agree next steps to include contact with the practice annd any specific support needs the practice team may have 8. Consideration of any contractuaal issues
9. Agree first elements of communnications plan with communications lead 10. Explain Quality Oversight Meeting process and suggest Quality Oversight Meeting best dates 11. Agree meeting date for action plan support
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APPENDIX 2b
INTERNAL MEETING NHS England (Lancashire and South Cumbria) and CCG
Practice Name Date/Time Location Chair
1. Introductions
2. Confirm publication date and notice dates/responses
3. Overview of regulation breaches and requirements
4. Finalise communications including patient facing FAQs
5. Confirm key contacts in NHS England, CCG and for the practice 6. Updates of support required and immediate actions taken 7. Update of any contract issues/support
8. Update of any CCG issues/support
9. Update of any LMC issues/support
10. On-going monitoring to take place through a Quality Oversight Group – attendees for this group to be agreed. Confirm date
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APPENDIX 3
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APPENDIX 4
Please note that the publication of the updated Quality and Risk Profile Tool Guidance is still being awaited
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PRIMARY CARE CO-COMMISSIONING COMMITTEE
GOVERNING BODGOVENING B Primary Care Services – Financial Summary
Date of Meeting 17th September 2019 Agenda Item 12 TING CCG Corporate Objectives
Through better commissioning, improve local health outcomes by addressing poor outcomes and inequalities To work collaboratively to create safe, high quality health care services To maintain financial balance and improve efficiency and productivity To deliver a step change in the NHS preventing ill health and supporting people to live healthier lives To maintain and improve performance against core standards and statutory requirements To commission improved out of hospital care CCG High Impact Changes Delivering high quality Primary Care at scale and improving access Self-Care and Early Intervention Enhanced and Integrated Primary Care and Better Care Fund Access to Re-ablement and Intermediate Care Improved hospital discharge and reduced length of stay Community based ambulatory care for specific conditions Access to high quality Urgent and Emergency Care Scheduled Care Quality
Clinical Lead: Dr Malcolm Ridgway
Senior Lead Manager Mr Peter Sellars
Finance Manager Mrs Linda Ring
Equality Impact and Risk Assessment N/A completed:
Is a Data Protection Impact Assessment No Required? Data Protection Impact Assessment No completed: Patient and Public Engagement N/A completed: Financial Implications As attached Risk Identified As attached Report authorised by Senior Manager: Mr Roger Parr Y
Decision Recommendations
It is recommended that the Primary Care Co-Commissioning Committee note the contents of this financial summary and the overall position at the end of July 2019, noting the risk.
Primary Care Co-Commissioning Committee Page 2 of 3
Primary Care Services - Financial Summary Month 4 – Period Ending 31st July 2019
Year to Date Full year forecast Budget Actual Variance Budget Actual Variance £000 £000 £000 £000 £000 £000 PC Co-Commissioning 7,369 7,373 4 23,299 23,299 0 Prescribing 8,411 8,411 0 25,232 25,232 0 Enhanced Services 804 808 4 2,491 2,491 0 Home Oxygen Therapy 46 38 (8) 139 139 0 GPIT 231 226 (5) 693 693 0 Resilience Partnerships 618 619 1 1,854 1,854 0 Primary Care 115 114 (1) 346 346 0 Medicines Management 163 161 (2) 488 488 0 GP Forward View 356 356 0 1,109 1,109 0 Total 18,113 18,106 (7) 55,651 55,651 0
Summary Financial Position – At month 4, Primary Care Services are reporting a year to date underspend of £7k and is forecasting a year end breakeven position.
Income and Expenditure Risks Primary care co-commissioning is reporting a small year to date Prescribing expenditure is volatile and is monitored closely by the overspend of £4k with a forecast breakeven position. Medicines Management Team.
Prescribing is reporting a year to date and forecast year end breakeven Capital position. Expenditure for April & May have been received. June and July are based on estimates. A combined bid for hardware replacement of the GPIT Infrastructure, mobility and operating software has been submitted by the Head of GP Forward View – Funding for GP Access £1.068m is forecast to break Digital Services for Lancashire and South Cumbria to NHS England. The even at year end. Additional allocations totalling £41k have been total value of the schemes for 2019/20 is £242k. The capital plan for received for GP Nursing schemes across Lancashire and South Cumbria 2019/20 has been approved by NHS England.
Primary Care Networks (PCNs) – funding for primary care networks is included in the expenditure reported for primary care co-commissioning and enhanced services. The total funding available for PCNs in 2019/20 is £1,194k.
Primary Care Co-Commissioning Committee Page 3 of 3
Item 13
Primary Care Co Commissioning Committee Work Plan
Item Nov Jan March May July Sept Nov Jan March 2018 2019 2019 2019 2019 2019 2019 2020 2020
Business Items
Primary Care Update
Primary Care Strategy
Estates Strategy – Progress Report
Primary Care Services Financial Summary
GP Workforce
GP Contracts APMS GMS PMS Primary Care Co Commissioning Review of Terms of Reference QOEST – Local Primary Care
LPC Quarterly Assurance Report