jkjkjkjk Front Sheet
Primary Care Strategy 2014-19
Hertfordshire and South Midlands Area Team
June 2014
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Contents
1. Executive Summary Page 3
2. Our Vision Page 5
3. Primary Care Transformation Page 5
4. Out of Hospital Care Vision Page 6
5. CCGs Primary Care Vision Page 10
6. Promoting self managed care, health and wellbeing Page 13
7. National Context Page 14
8. Local Context Page 16
9. Financial Overview Page 17
10. Objective 1 Page 22
11. Objective 2 Page 26
12. Objective 3 Page 30
13. Scope of Commissioning Responsibilities Page 32
14. Patient Experience Page 38
15. Enablers Page 40
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1. Executive Summary
Over a year into the new commissioning system, it is the right time now for sharing a framework to support the strategic development of primary care across Hertfordshire and South Midlands over the next 5 years. It is important to note that the intention is that this document provides a strategic framework against which local strategies and developments can move forward.
The strategic vision for the services commissioned across Hertfordshire and South Midlands is driven by three key objectives:
1. Improving quality and access
2. Improving health outcomes and reducing health inequalities
3. Developing and implementing new integrated models of care
In order to achieve these objectives, we will need to focus on key enablers including premises, workforce and IT development with a more longer-term view/approach required. A key theme is to ensure that existing resources in people, buildings and IT are used as effectively as possible, whilst determining priorities for development. More robust workforce planning will be led by Health Education England, through the LETBs in supporting local and regional programmes.
There is a clear and strong alignment between our local CCG Primary Care Strategies and the above key objectives. This shared purpose will provide the strong foundations for the co-commissioning of primary care moving forward. It is important to emphasise that co- commissioning is a “way of working” to deliver improved outcomes for local populations. Last month, expressions of interest were formally sought from CCGs nationally with consistent benefits in achieving greater service integration, more cohesive systems of out- of-hospital care, raising standards of quality, enhancing patient and public involvement and tackling health inequalities.
Early proactive discussions have confirmed a genuine commitment and willingness to work together across Hertfordshire and South Midlands, with positive dialogue held to date with CCGs, Providers, LMCs, Public Health England, Health and Wellbeing Boards etc. Co- commissioning is providing us with a local vehicle to deliver changes which have both already started, or planned, through working differently and in a more joined-up way. A spectrum exists of potential forms that co-commissioning could take. Current consensus is for greater local CCG involvement in influencing commissioning decisions made by the Area Team, moving towards more joint and delegated arrangements. It is essential that reflection is built in following the submission of expressions of interest, with a local joint process having been agreed to progress next steps and local plans.
Across our Patch, groups of Practices come together in different forms i.e. Localities, Neighbourhoods, Clusters etc. In order for implementation of our strategy, there is a clear challenge for groups of Practices to be collaborating effectively with the aim of delivering improved outcomes to their specific local populations. Our commissioning challenge will
3 clearly require us to be more innovative and targeted in our approach, for example realising opportunities to increase screening and immunisation uptake.
Reducing variation is a key driver to our local strategy, i.e. clinical variation, outcome variation and variation in inequalities across our geography. Across the majority of quality indicators, the variation within Practices, across Practices within CCGs and between CCGs, both locally and nationally, is significant which needs to be understood and addressed. As we move forward with improving services locally, it is essential that we develop further an ethos of sharing and learning across Hertfordshire and South Midlands.
Robust and more strategic contract management will be required to support us moving forward. PMS Reviews will be consistently implemented with a timescale for completion by March 2016. Again, significant variation exists across Practices and CCGs, which will need to be considered as implementation progresses, with the intent to maintain investment released within primary care. A more strategic approach with procurement needs to be taken in line with local strategies, with a significant number planned to be tendered during 14/15 and beyond.
It is important to reiterate that our current Primary Care Transformation workstreams of Improvement (Quality) and Innovation (New Models) are aligned to the Regional Programme. As an Area Team, we are engaged in both regional workstreams and it is vital that influence at this level continues moving forward.
Exciting opportunities have been created with the emergence of Local Professional Networks in Pharmacy, Eye Health and Dental Services. Again, our consistent key objectives apply, with a co-commissioning role for us in ensuring service are joined-up and integrated locally across our communities.
This is both a challenging and exciting time for primary care in both developing, and most importantly delivering, our local primary care strategy together. It is important that we continue to focus on delivering high quality services and improved health outcomes for our patients within financial allocations, through clinically-led commissioning across Hertfordshire and South Midlands.
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2. Our Vision
To provide leadership and strategic oversight for health across Hertfordshire and South Midlands Area Team to improve quality and consistency of care through:
• Effective commissioning of primary and other care • Supportive collaboration with partners • Developing and using systems of assurance • Efficient use of all available resources • Encouraging innovation and communication • Ensuring Parity of Esteem • Effective systems to deliver patient engagement and participation.
3. Primary Care Transformation
Nationally a number of issues are emerging that necessitate a transformation in primary care.
• An ageing population • Increasing patient demand • Increasing patient expectation • Economic constraints • New treatments and technologies
The required change in primary care services, given current known challenges needs to have the following:
1. Proactive, coordinated care : anticipating rather than reacting to need and being accountable for overseeing your care, particularly if you have a long-term condition. 2. Holistic, person-centred care : addressing your physical health, mental health and social care needs in the round and making shared decisions with patients and carers, e.g. accountable GP for over 75s, services tailored for children and young people. 3. Fast, responsive access: giving you the confidence that you will get the right support at the right time, including much greater use of telephone, email and video consultations. 4. Health-promoting care: intervening early to keep you healthy and ensure timely diagnosis of illness, engaging differently with community to improve health outcomes and reduce inequalities. 5. Consistently high quality care : removing unwarranted variation in effectiveness, patient experience and safety in order to reduce inequalities and achieve faster uptake of the latest knowledge about best practice.
We believe that these are most likely to be achieved by commissioning wider primary care at scale. In collaboration with CCGs we have a vital role in supporting localities, clusters and practices to work within the Framework to decide, and agree which model will achieve the required objectives.
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We have identified four possible models for delivery of GP primary care services and these are outlined overleaf on page 9. The models are in line with current national, regional and local thinking
We will be developing these models with CCGs, through localities, clusters and practices to move to a position where new ways of working are planned and implemented.
The strategic vision for the services we commission across Hertfordshire & South Midlands Area Team is underpinned by three specific objectives.
1. Improve quality and access 2. Improve health outcomes and reduce health inequalities 3. Implementation of new models of care
For the strategy’s objectives to be achieved we need to undertake work on a range of enablers.
• Premises • Workforce • Health Informatics • Quality Framework • Communications and Engagement • Strategic contract management • Governance
This strategy sets out a vision for Out of Hospital Care and provides a framework outlining options for new GP primary care models, offering some design principles.
The strategic framework starts to explore these three specific objectives and sets out the work streams in place to develop the enablers.
4. Out of Hospital Care Vision
Primary care cannot be seen in isolation, it is at the heart of the wider health and social care system.
Our vision for Out of Hospital Services sees care provided at the same high quality service, seven days a week wherever people access it. Thereby supporting patients who require urgent care to be seen in the most appropriate setting and ensuring the most vulnerable in our community engage with services. This vision is a framework in which primary care transformation will flourish.
The diagram overleaf details the vision for Out of Hospital Care.
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Vision for Out of Hospital Care
Urgent Care Hub Frail Elderly Team Urgent Care Centre Hot clinics, direct access diagnosis Ambulatory Care Unit Discharge Teams Care Management Ambulance Services 111, Out of Hours, Mental Health Crisis Team Community Paediatric Nurses Step up Assisted Living, Community Hospital GP Practice (new models)
Co-Commissioning The Patient Health & Wellbeing Prevention Hub Collaborative Care Teams GP Practice (new models) Care delivered in patient's homes Childrens Centres care co-ordinator, care plans developed Voluntary Sector e.g Age UK, MIND (avoiding unplanned admissions) Sexual Health Service Social Care Substance Misuse, Physical Activity Therapists Smoking Cessation Community Nursing Planned Care - eg Dermatology, MSK Practice Nursing Cardiac and Pulmonary Rehab Pharmacy Community Dental Voluntary Sector Mental Health and Wellbeing Cardiac and Pulmonary Specialist Teams Community Pharmacy Nursing and Residential care home support Wellbeing Navigators Mental health teams Population Stratification
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At the centre of our vision for Out of Hospital Care is the aim for better outcomes for patients. We believe this will be best achieved by services being developed that focus on three clusters, namely:
• Collaborative Care Teams • Health and Wellbeing Prevention Hub • Urgent Care Hub
Collaborative Care Teams At the centre of the new model is a virtual hub that brings together and co-ordinates the care to be delivered to the patients with Long Term Conditions. This needs to link with the new unplanned admissions enhanced service and the proactive management of 2% population who are at high risk of hospital admission. These will often be frail elderly and patients with co-morbidities who need care provided by primary care, community services, the voluntary sector and social care. Key to the success of the hub is the seamless co- ordination of care that is responsive and delivered whenever possible in the patient’s home.
Urgent Care Hub There are a range of services that are in place to provide urgent or unscheduled care. This cluster brings them together regardless of the provider and at times will mean the co- location of services. These services are not instead of Accident and Emergency departments for the acutely ill but are to support patients needing access to an urgent opinion and diagnosis. This will also promote more collaborative working allowing for step up facilities and enhanced diagnostics for GPs and community teams.
Health and Wellbeing Prevention Hub The wider primary care network of voluntary sector and local authorities have a significant role in providing health services to deliver key health promotion and health improvement activities e.g. NHS Health Checks. Integration of primary and secondary care services for outpatient facilities will also provide upskilling of GPs and better understanding of primary care across the system. This cluster would bring these services together and provide an opportunity to respond in a joint way to the priorities of the Health and Wellbeing Boards.
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Primary Care Transformation: Options for new GP models Vertical Integration Merged Delivery GP practice working with non GP provider e.g acute, local authority GP practices merging to form a larger practice - More collaborative working across primary, - Efficiency of working at scale secondary, community and vol sector - GP skill sets can be shared -Platform for outcome based pathways across - Sustainability of general practice providers - Strong foundations for co-commissioning Patient
Combined Delivery Bigger Delivery GP practices not merging but working more closely Already existing super partnerships expanding together e.g. federation further to take over smaller practices - Allows practices to work in collaboration without merging - Practice able to recruit team with large skill set. - Efficiency of working at scale - Risk sharing without merging - Sustainable general practice - GP skills set can be shared . - Efficiency of working at scale
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5. CCGs Primary Care Vision
We are working closely with CCGs as they develop their primary care strategies, below is a high level summary of their thinking which was shared amongst stakeholders at a meeting in May 2014.
Their detailed strategies will be submitted in June. We are confident that the primary care transformation model described in this strategic framework is complimentary to the local CCG plans and supports them as an important partner in delivering this strategy.
Bedfordshire Clinical Commissioning Group’s Primary Care Vision
• Primary Care to be delivered at scale e.g. networks of Providers, federation, super- practices • Patients’ able to register with Practices outside traditional boundaries • Friends and Family Test to be introduced to GPs December 2014 • Patients to have access to their own records by April 2015 • Named, accountable GP for the over 75s • A Direct Enhanced Service (DES) for unscheduled care reduction • Re-commissioning of community nursing services provides opportunity for full integration between primary care and community nursing services. • Single IT clinical system for all care providers. • GP practices acting as provider arm for local community services and work together to provide extended services.
East and North Herts’ Clinical Commissioning Group’s Primary Care Vision
• Single IT clinical system for primary and community service providers. • Hub style model of care with single point of access. • Separation of acute and LTC care. • Co-commissioning with Area Team • Commission services from smaller number of larger providers • Localised approach in agreeing vision to meet challenges • Integrated primary care teams working in partnership with patients and carers • Training and development strategy for GPs, practice nurses and practice managers.
Herts Valley Clinical Commissioning Group’s Primary Care Vision
• Proactive approach to management of chronic disease with more integrated models of care. • Improve primary care through benchmarking and peer review. • Develop ‘Primary Care Plus’, by identifying high risk elderly patients and targeting input into them. • Drive up quality of primary care through protected time for education/training including motivational interviewing for all clinicians in practice. • Practices to sign up to either: provide the service or agreed to jointly provide with another practice or nominate another practice to provide services on their behalf.
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• Support practices coming together, around a defined geographical area with community, social care and specialist services.
Luton Clinical Commissioning Group’s Primary Care Vision
• First step is for practices to form 4 commissioning cluster groups. • Each practice to have ‘wrap around multi-disciplinary team’ including district nurses, social services and community mental health • Encourage mental health teams and other HCPs, e.g. OT and community pharmacists to align to new clusters. • Encourage federation of practices to deliver extended community/primary care with contracts at scale. • Local acute trust to work with clusters to offer ‘community geriatricians’. • Continue to build clinical leadership
Milton Keynes Clinical Commissioning Group’s Primary Care Vision
• Encourage practices to work together to deliver at greater scale. • Out of Hospital strategy sets out ambition to commission more care in the community and home settings. • Develop formal hub and spoke model of care. • Work with Area Team to define satisfactory quality standards, for primary care. • Harness skills of wider primary health care and social care teams.
Northamptonshire- Nene and Corby Clinical Commissioning Groups’ Primary Care Vision
• Improved access to general practice • Ensure access to broader range of local care services in community settings thereby improving services for patients with complex needs. • GP Federations • Development of portfolio careers for GPs and practice nurses with opportunity to specialise. • Creation of Local Clinical Partnerships which will consist of primary, community and secondary care clinicians delivering pathways based care in a more integrated way. • Workforce development strategies to increase GP training posts and placements for practice nurses. • Review estates with a view to rationalising and increasing funding.
The CCG strategies have a number of common threads, which are aligned with the vision and strategic framework, namely:
• GP practices coming together to either work in a hub and spoke model or share workload • Common IT platforms to facilitate service being able to share information. • Integrated teams between primary and community services. • Continued close working with the Area Team.
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Hub and Spoke Model
Close work with Area Team
Common IT Integrated Platform Team
Prime Ministers Challenge Fund
We have one successful applicant for the Prime Minister’s Challenge Fund to trial improvement in GP access. The ‘Watford Care Alliance’ pilot covers 92,315 patients and is based around 2 hub sites, Colne House and Bridgewater House. The project has three main themes:
• New technology – including the establishment of Telehealth Hubs • Extended hours 8-8 7 days a week. • Extended clinical capacity: increased GP, nurse, phlebotomy and sexual health hours • New GP led multi-disciplinary team (including a social worker)
Local nursing homes will be linked to the Telehealth Hubs – this will allow open lines of communication between homes and GPs and will facilitate virtual ward rounds. Training for nursing home staff is included in the bid.
The Area Team received 14 other submissions for the Challenge Fund. The majority of the submissions describe a desire to move to new models of care for primary care. The new models focus on integrated provision between primary care, community and social care. The new models would be supported by increased utilisation of IT to assist with the sharing of records and data.
We want to encourage practices and localities to build on the bids as they are a useful foundation and we do not want to lose the enthusiasm the Challenge Fund created.
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6. Promoting Self-Managed Care, Health and Wellbeing
A central foundation for all our CCG Primary Care strategies is the promotion of ’I Care’ and access to preventative services. It is well accepted that self-managed care not only supports patients having control of their health but has shown to be cost effective. An excellent description of self-managed care is found in the Declaration of the World Health Organization (1978): Using the ‘I Care’ Framework healthcare professionals will discuss with individuals the balance between self–managed care and professional support, this will then be recorded in an individualised care plan.
‘I Care’ means looking after yourself in a healthy way, whether it’s brushing your teeth, taking medicine when you have a cold, or doing some exercise.
For individuals with long-term conditions, making changes to diet and different types of exercise can lead to improved health outcomes and the reduction of complications.
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7. National Context
This strategic framework aligns with the NHS Mandate, Outcomes Framework and NHS Ambitions
NHS Mandate
Domain 1: Preventing people from dying prematurely
Domain 5: Treating and Domain 2: Enhancing quality caring for people in a safe of life for people with long- environment; and protecting term conditions them from harm
Domain 4: Ensuring that Domain 3: Helping people to people have a positive recover from episodes of ill experience of care health or following injury
Five offers from ‘Everyone Counts: Planning for patients for 2013/14’
Offer 1 NHS Services, Seven Days a Week; Offer 2 More Transparency, More Choice Offer 3 Listening to Patients and Increasing their Participation; Offer 4 Better Data, Informed Commissioning, Driving Improved Outcomes Offer 5 Higher Standards, Safer Care.
The seven NHS ambitions from ‘Everyone Counts: Planning for patients 2013/14’
Ambition 1 Securing additional years of life for people with treatable mental and physical conditions Ambition 2 Improving the health related quality of life for people with one or more long-term condition (including mental health conditions) Ambition 3 Reducing the amount of time people spend in hospital through better and more integrated care in the community, outside of hospital
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Ambition 4 Increasing the proportion of older people living independently at home following discharge from hospital Ambition 5 Increasing the number of people with mental and physical health conditions having a positive experience of hospital care Ambition 6 Increasing the number of people with mental and physical health conditions having a positive experience of care outside of hospital, in general practice and in the community Ambition 7 Making significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care
The Strategic Framework and objectives directly link with the five domains and offer a practical way to ensure that the Ambitions and Offers can be realised.
Encouraging concentration of skills and expertise in hubs Domain 2 Domain 3
Joint work with local authorities and voluntary agencies to provide Domain 1 health and wellbeing services
Encouraging models of practices working together to improve access Domain 4
Planning for collaborative care to be based in patient’s homes Domain 5
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8. Local Context
The Area Team holds responsibility on behalf of NHS England to commission Primary Care and Public Health. Our partners in this are:
• 7 Clinical Commissioning Groups. • 6 Upper tier or unity local authorities and associated Health and Wellbeing Boards • 7 NHS Acute Trusts • 6 Health and Wellbeing Boards • 6 Community Trusts • 3 Ambulance Trusts • Range of Independent Sector organisations. • 3 Local Professional Networks for Pharmacy, Eye Health and Dental. • 2 Commissioning Support Units (CECSU and GEM) • 4 AHSNs • 3 Senates/Strategic Clinical Networks • 3 HEE LETBs • Public Health England • Neighbouring NHS England Area Teams
Geography and Demography
The Area Team covers a population of 2.8 million across the 7 CCGs and is one of the largest Area Teams (regionally and nationally).
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9. Financial Overview
The Area Team operates in what is recognised as one of the most financially challenged and complex health systems in the country. The constituent CCGs collectively have the largest gap to target funding in England, at over £225m in 2013-14; the historic basis of funding this largely reflects is also an issue for the directly commissioned services across the patch, with a funding shortfall of 2.5% or £16.1m. This position was exacerbated for the Area Team in 2013-14 due to baseline funding errors relating to GP IT services in excess of £8m, and also the suspension nationally of delivery of PMS QIPP targets. In order to deliver financial targets, "headroom" reserves that were intended to be used for transformational investments had to be severely curtailed. These errors have been corrected from 14-15 onwards, although a material funding gap remains. The strategy below recognises this risk and sets out mitigations to enable delivery. However, while the challenge is a tough one, the Area Team has delivered its financial targets and will continue to do so. The CCGs are under pressure but most of these are delivering surplus positions on or around target, with only one of the seven CCGs in actual deficit in 2013-14.
Financial Summary
The five year plan shows the Area Team meeting all financial requirements over the period. The position is set out in the table below, and the most significant issues, including the Area Team contribution to the current national funding gap in 2014-15, are identified and accounted for.
Key financial issues for each direct commissioning programme are set out below:
I&E 2013/14 2014-15 2015/16 2016/17 2017/18 2018/19 £000s £000s £000s £000s £000s £000s Surplus/(Deficit) 1,758 8,028 (3,713) 69 103 109 Surplus/(Deficit) Cumulative 1,758 9,786 6,074 6,142 6,246 6,355 Net Risk/Headroom (4,176) (3,874) - - - Risk Adjusted Surplus/(Deficit) 5,611 2,200 6,142 6,246 6,355 Surplus % 8,028 (3,713) 69 103 109
Underlying position - Surplus/(Deficit) 6,206 21,434 20,075 23,330 21,833 22,113
Contingency 3,330 3,426 3,468 3,527 3,587
QIPP Savings 2013/14 2014-15 2015/16 2016/17 2017/18 2018/19 £000s £000s £000s £000s £000s £000s Recurrent 9,531 5,650 6,000 6,000 5,900 Non-Recurrent 3,068 - - - - Total 12,598 5,650 6,000 6,000 5,900 Financial Resources Available to the Area Team
The plan year plan reflects Area Team allocations announced for each of the next two financial years.
The gap in funding for the Area Team and surrounding CCGs is planned to reduce over the initial two years of the five year plan. The "Pace of Change" funding adjustment to close the
17 gap has improved the position, however in 2016-17 it still remains significant at £200m+ per annum for CCGs and at circa £12m per annum (1.9%) re: directly commissioned services. For directly commissioned Services the five year plan the period 2016-17 to 2018-19 assumed resource growth equates to RPI rates of 1.8% in 2016-17, and 1.7% in 2017-18 and 2018-19 – the Direct Commissioning Plan between 2016-17 and 2018-19 makes no assumption re increased funding re Pace of Change.
Primary Care & Secondary Dental Primary Care & Secondary Dental Plans are compliant with planning business rules, summaries are shown below:
Primary Care Finance Plan Summary Revenue Resource Limit £ 000 2013/14 blank1 2014/15 2015/16 2016/17 2017/18 2018/19 Recurrent 527,069 546,403 558,315 568,365 578,027 587,853 Non-Recurrent 5,758 2,638 9,400 5,680 5,743 5,838 Total 532,827 549,041 567,715 574,044 583,769 593,692
Application of Funds GP Services 320,005 320,663 328,125 330,619 333,232 336,068 Dental Services 103,997 104,928 107,656 110,455 113,327 116,273 Ophthalmic 24,853 25,046 25,697 26,365 27,051 27,754 Pharmacy 75,154 76,827 78,824 80,874 82,976 85,134 NHS Property Services 1,068 600 630 662 3,883 695 Other 7,553 8,833 14,006 10,657 11,851 13,047 Reserves 0 0 4,258 5,800 2,693 5,812 Contingency 0 2,745 2,839 2,870 2,919 2,968 Total Application of Funds 532,630 539,641 562,035 568,302 577,931 587,751
Surplus/(Deficit) In-Year Movement 197.28 9,202.23 (3,719.86) 62.91 95.63 102.67 Surplus/(Deficit) 197.28 9,399.51 5,679.65 5,742.56 5,838.19 5,940.86 Surplus/(Deficit) % 0% 2% 1% 1% 1% 1%
Secondary Dental Revenue Resource Limit £ 000 2013/14 Blank12014/15 2015/16 2016/17 2017/18 2018/19 Recurrent 38,885 38,050 38,880 39,580 40,253 40,937 Non-Recurrent - 505 387 394 400 407 Total 38,885 38,555 39,267 39,973 40,652 41,344
Application of Funds Community Dental 9,724 9,624 9,879 10,057 10,228 10,402 Secondary Care Dental 28,894 28,352 28,798 29,317 29,815 30,322 Reserves ------Contingency - 193 196 200 203 207
Total Application of Funds 38,618 38,168 38,873 39,574 40,246 40,930
Surplus/(Deficit) In-Year Movement 267 120 7 6 7 7 Surplus/(Deficit) 267 387 394 400 407 414 Surplus/(Deficit) % 0.69% 1.00% 1.00% 1.00% 1.00% 1.00% Key assumptions: The 2014-15 financial plan incorporates the impact of the 'Actions to Close the Gap’ i.e. the requirements of all Area Teams to assist in reducing the current financial gap identified in the national funding position. These are:-
‹ a £6m of non-recurrent reserves have been set aside; ‹ a £3.4m notional benefit associated with the DDRB uplift has been reflected in an increased surplus requirement; this was a particular issue for the Area Team as the
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perceived "benefit" deducted from resources is significantly higher than that actually experienced locally and as such constitutes a cost pressure.
The financial strategy assumes that both these adjustments are non-recurrent.
The remaining balance of the reserve is committed to securing the Area Team’s overall financial position and primary care transformation priorities.
The residual balance is committed to support pressures associated with legacy GP IT asset depreciation charges and to mitigate any emerging risks including GP Services MPIG and Seniority transition in years 1 & 2.
The Area Teams ability to invest in further transformational schemes over the five year period is being examined in line with QIPP opportunities and the emergent co- commissioning strategy being established with local CCGs. It is the intention to put maximum available resource into this area; however this will be tempered by the calls already being made to support a national funding gap should this continue beyond 2014-15. At this point availability of transformational funding is deemed to be low and therefore short term “self-funding” schemes are being developed.
Public Health
The Public Health Plan is compliant with planning business rules, a summary is shown below:
Public Health Revenue Resource Limit £ 000 2013/14 Blank12014/15 2015/16 2016/17 2017/18 2018/19 Recurrent 73,365 78,151 78,151 79,558 80,910 82,286 Non-Recurrent - 319 0 0 0 1 Total 73,365 78,470 78,151 79,558 80,910 82,287
Application of Funds Screening (Non-Cancer) 5,686 5,714 5,331 5,427 5,470 5,514 Screening (Cancer) 14,976 17,141 16,892 17,196 18,062 18,995 Flu vaccination 4,585 4,814 4,910 5,156 5,259 5,364 Health Promotion 0 0 0 0 0 0 Immunisation and vaccination - other 10,015 10,570 10,481 11,005 11,225 11,450 0-5 Programmes - Health Visiting 34,107 36,561 36,561 36,561 36,561 36,561 0-5 Programmes - FNP 1,084 1,379 1,800 1,800 1,800 1,800 Child Health Information Systems 1,619 1,677 1,655 1,662 1,652 1,642 Reserves - 223 129 353 476 549 Contingency - 392 391 398 405 411
Total Application of Funds 72,071 78,470 78,151 79,558 80,909 82,286
Surplus/(Deficit) In-Year Movement 1,294 (1,294) 0 (0) 1 (1) Surplus/(Deficit) 1,294 0 0 0 1 0 Surplus/(Deficit) % 1.76% 0.00% 0.00% 0.00% 0.00% 0.00% Key assumptions:
The impact of transfer of the 0-5 Healthy Child Programme to Local Authorities in October 2015 is not reflected in the plan.
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Investments associated with expansion to the following programmes have been matched with additional resource in 2014-15 - this includes £2.7m for Health Visiting, £0.3m FNP and £0.1m Meningitis C. The financial implication of the full year effect and additional investment in Section 7a programmes after 2014-15 has not been incorporated into financial plans. The five year plan therefore assumes there will not be an unfunded pressure at Area Team level associated with the full year effect of Health Visitor and FNP expansion in 2015-16.
Cost pressures associated with AAA (risk, £0.6m) and Bowel Screening (risk, £0.7m) have not been matched with sufficient allocation and while these pressures are incorporated in the plan, they represent a significant risk to the delivery of the target control total.
QIPP
Hertfordshire and South Midlands Area Team delivered £17.7m of savings in 2013-14. However, this level of QIPP delivery by the Area Team in 2013-14 has largely been realised through reliance on transactional efficiencies, and applying contracting rules vigorously and consistently across the system. QIPP plans for 2014-15 currently remain largely transactional. Nonetheless, as CCG QIPP plans evolve, they will increasingly become transformational in nature. The Area Team will need to recognise these changes, and work jointly across Health and Social care to plan for shifts in the settings of care and improvements in planned care pathways – this will present both risk and opportunities to the financial position of NHS England.
The Area Team have identified the QIPP schemes that total £12.6m in 2014-15; this total includes £3.1m of schemes that remain in development. Across the remaining planning period the plans are still in process of being developed but in broad terms stand at approximately £6m or 1% per annum. This figure, while significantly reduced from the opening period, will never-the-less represent a serious challenge across the bulk of the expenditure budgets, as some 90% of the spend is controlled by nationally mandated contracts and fall outside local control.
Capital Expenditure
The strategy recognises the need for increased investment in capital assets, particularly within GP IT and Primary Care infrastructure. It is considered a major enabler to support co- commissioning and to develop “Primary Care at Scale”.
The first part of the strategy has required an assessment of committed schemes that the Area Team has inherited from PCTs; an investment pipeline has been developed in conjunction with regional colleagues and NHS Property Services to include these hereditary commitments and required future investments. The revenue consequence of these investments is recognised within the 5 year Strategic Plan.
The Area Team is working with CCGs, and in particular Health and Wellbeing Boards, to identify further opportunities and investment needs; and is seeking wherever possible to attract external funding such as Section 106/Community Infrastructure Levy in conjunction with Local Authorities. At this point availability of capital funding for the period is not confirmed, but it is assumed it will remain consistent with previous periods.
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Summary
The financial position is one of significant challenge across the system and to the Area Team in respect of our Direct Commissioning responsibilities. We have spent time in our first year establishing our capacity and capability and in engaging with the wider system to assist in the provision of financial control and assurance. The Finance Team are closely aligned with the overall strategic direction being set out and are at the forefront of developing the opportunities and meeting the challenges this involves.
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10. Objective 1: Improve quality and access.
Current Situation
The information below indicates that there is a significant need for the Area Team, CCGs and practices to work together to improve access and experience of GP services.
Results of GP Patient Survey Jan13 - Sept13 - by CCG within Herts & South Midlands AT
England average 79% 80% 89% 81% 82% -0.6%
Ease of Overall 6 Mth Overall Recommend GP getting experience Average Change National Ranking experience surgery to someone PCT name through of making of 4 in % (vs Rank by of GP who has just moved on the an indicators July12- (211) quartile surgery to the local area phone appointment Mar13) NHS 23% BEDFORDSHIRE 83% 84% 91% 83% 85% -0.6% 49 CCG NHS HERTS 45% 79% 81% 90% 83% 83% -0.7% 96 VALLEYS CCG NHS CORBY CCG 81% 78% 88% 80% 82% -2.3% 120 57% NHS NENE CCG 76% 78% 87% 79% 80% -0.7% 151 71% NHS EAST AND 85% 71% 74% 87% 80% 78% -1.2% 180 NORTH HERTS CCG NHS LUTON CCG 73% 74% 85% 75% 77% 0.5% 190 90% NHS MILTON 98% 62% 67% 81% 73% 71% -1.8% 208 KEYNES CCG
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There is a variation in quality in GP services. The national NHS England Primary Care Web Tool which identifies practices that require (quality assurance visits) i.e. those practices that have 5 or more outlying indicators has initially identified 13 practices (4%) across the Hertfordshire and South Midlands. The table below details the spread of the 13 practices across the CCGs.
Practice Total number of CCG Name Outliers practices No Yes Bedfordshire 54 2 56 Corby 6 6
East & North Hertfordshire 60 60
Herts Valley 68 2 70 Luton 25 7 32 Milton Keynes 27 1 28 Nene 69 1 70 Area Total 309 13 322
The graph below shows the percentage of practices with data points significantly worse than the national average (>2 SEM) in the AT and England (i.e. a trigger). The data points are split by domain and are only presented in one domain if they are duplicated in others.
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Asthma Prevalance COPD Prevalance Diabetes Prevalance AF Prevalance H&SM % Health checks for mental illness National % Two Week Wait Immunisations in at risk patients Diabetes BP monitoring Domain 1 Domain Cervical Smears AF on anticoagulation CHD Prevalance Immunisations in over 65s Cancer Admissions Diabetes HbA1C monitoring COPD Diagnosis Diabetes Admissions Asthma Diagnosis CHD cholesterol monitoring Diabetes Cholesterol monitoring CHD Admissions Dementia Admissions COPD Admissions Asthma Admissions Exception Rate Ezetimibe Prescribing Insulin Prescribing Antidepressants A+E Attendances Emergency Admissions Antibacterial prescribing
3Diabetes Retinal 2 Domain Screening
Domain ACS Admissions Getting through by phone
4 Patient experience
Domain Making an Appointment Hypnotics prescribing
5 Cephalosporins and Quinolones
Domain NSAIDS prescribing 0% 2% 4% 6% 8% % of practices with trigger
Vision for Objective 1
Within 5 years to demonstrate improvements in all areas of quality, including the five domains of the NHS outcomes framework and five offers from ‘Everyone Counts: Planning for Patients’. We will have a particular focus on achieving consistently high quality services and reducing unacceptable variation .
What we are doing
Our approach has been to firstly ensure that we have a fit for purpose governance model which sets outs the systematic processes in place to monitor and improve primary care quality. Alongside this work we have started to co-commission with CCGs (with the support
24 of the LMC) those activities which will enable and facilitate quality improvement leading to a positive patient experience. High quality data and information are at the heart of this work. Using openly and transparently good data will support our understanding of the individual patient experience, drive improvements in clinical effectiveness and help shape future clinical models.
The national programme of visits will be undertaken following analysis of the national Primary Care Web Tool, in addition we are developing Primary Care Web Plus tool sharing more up to date qualitative and quantitative information about challenged practices so that we have a shared understanding and agreement as to primary care quality and the challenges faced. The implementation of this tool is with engagement of CCGs and also our local Beds/Herts and Northampton LMCs. The joint work has resulted in strong commitment to the visits.
We, and the CCGs, with the support of local LMCs are testing an embryonic joint solutions based support team with the focus on constructive collaborative working with practices. This work will begin first in Luton and Milton Keynes CCGs, in line with our overall Primary Care Strategy challenges. A co-commissioning approach is imperative if this improvement work is to have the legitimacy needed to bring about fundamental sustainable quality improvements.
There is a growing momentum and ownership of our quality assurance and improvement work, all CCGs are actively engaged and have agreed to share best practice across the Area Team geography. This local Area Team repository of good practice will support both Regional and National development.
We continue to operate a robust system for managing poor performance of practitioners in primary care. We operate a performance screening group and performers list decision group to respond to concerns raised. We continue to work hard to meet 95% GP appraisal rates and meet the revalidation workload.
We have senior clinical involvement in the regional and national work happening over the summer in 2014 between NHS England and the CQC. This work will inform how the two organisations with work together to support an effective primary care inspection regime and offer the appropriate development, support or intervention to those services who are found to be non-compliant.
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11. Objective 2: Improve health outcomes and reduce health inequalities
Current Situation
Health Needs Across the patch over two thirds of the LSOAs are in the average or least deprived. 575 out of Area Team’s 1590 LSOAs are in the 20% Most Deprived LSOAs in the country. Meaning that nearly a third of LSOAs in the Area Team are the “most” deprived areas in the country. These are concentrated in Luton.
The life expectancy of the majority of our local authority areas are similar to the England average. The area where is consistently worse than England is Luton.
AREA: LA Life expectancy at birth Gap in life expectancy between most & least deprived
Male Female Male Female
Bedford 78.9 82.6 11.3 9.1
Cen Bedfordshire 79.5 83.0 7.4 5.5
Hertfordshire 79.9 83.3 7.4 5.3
Luton 77.7 80.9 8.9 6.4
Milton Keynes 78.1 82.2 7.3 6.0
Northamptonshire 78.6 82.6 9.4 5.8
Hertfordshire & South Midlands AT has a higher proportion of 0-14 and 30-54 year olds in its population than the England average, and a lower proportion of residents aged 65+.
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This means that over the next 10-20 years there will be an increase in the number of over 65s compared to England.
The population as a percentage of the total in age bands for Hertfordshire & the South Midlands compared to England (Census 2011)
90 and over 85 ‒ 89 80 ‒ 84 75 ‒ 79 70 ‒ 74 65 ‒ 69 60 ‒ 64 55 ‒ 59 50 ‒ 54 45 ‒ 49 40 ‒ 44 Age band Age 35 ‒ 39 30 ‒ 34 25 ‒ 29 20 ‒ 24 15 ‒ 19 10 ‒ 14 5 ‒ 9 0 ‒ 4 10 5 0 5 10 Percentage of total population
Male Hertfordshire & the South Midlands Female Hertfordshire & the South Midlands Female England Male England
Public Health
We are committed to ensuring that the services we commission to improve immunisation and screening rates deliver. The localities with the lowest rates of immunisation and screening are those with the highest levels of deprivation, namely Luton and parts of Milton Keynes. There are also different systems for the asking for, recalling and follow up for childhood immunisation. These range from practice based to using Child Health Systems.
Cervical Screening: Across all CCGs the number of women attending for screening in the age bands 25-49 is dropping and of particular concern within the 25-29 year olds.
Bowel Screening: Nationally performance is dropping and this is true in Hertfordshire and South Midlands. The providers delivering the programmes are performing well but the
27 number of people taking up the opportunity to be screened is falling. It is believed that part of the reason for the drop in uptake is due to the nature of the test. Nationally there is a long term pilot of a new form of the test.
As a patch we deliver against the majority of childhood immunisation targets. As with any areas there is some variation, these practices/areas are identified and followed up.
The Family Nurse Partnership roll out is continuing in the patch, with Luton and Bedford in the last wave (8c).
Vision for Objective 2
Reduce the gap in life expectancy between the most and least deprived areas within local authority areas.
Move to parity of esteem, making sure that we are just as focussed on improving mental health as we are on physical health. To ensure people with mental health problems or those with learning disabilities do not suffer health inequalities.
What we are doing
CCGs in the Area Team have programmes that aim to deliver equal value for mental and physical health. These programmes includes work to deliver our mandate commitments on Improving Access to Psychological Therapies (IAPT), improving diagnosis, treatments and care of people with dementia and improving crisis care and waiting times.
Evidence demonstrates the a focus on cardiovascular disease factors in terms of prevention result in prevention of a wide range of diseases, with the resultant improvement in not only cardiovascular health but also prevention in areas of respiratory, mental, gastrointestinal, cancer and urological, neurological (including dementia) and endocrine areas. This justifies a concerted attempt to deliver NHS Health checks to all of the population. We will work with local authority colleagues who commission these checks to optimise NHS Health Checks.
Using Child Health profiles to identify specific areas of need e.g. Luton and rates of obesity. Target commissioning and contract management activity to meet these needs, in partnership with CCGs, Public Health and local authorities.
Immunisation and Screening
Developed a tool that provides immunisation and screening data by practice to identify practices that are failing to meet their targets. These practices receive targeted intervention to improve their rates.
There is a need to better understand the systems for calling and recalling patients for childhood immunisations and their impact on uptake. Future consideration will be given to the system that is most efficient and effective and we will work with providers to move to the desired model.
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To understand the reasons for the drop in cervical screening figures in 25-49 year olds the Area Team have commissioned the University of Hertfordshire to interview women to understand why they are not attending for screening. We want to understand the specific reasons. It may be related to limited access to screening opportunities and/or changes in what sexual health services provide.
Depending on the outcome of the national pilot of new test for Bowel screening, we will work with programme providers to implement the new test.
Primary care providers have a vital role in the promotion of screening and they should use the opportunities available to them to encourage attendance. We will work with CCGs to ensure practices use the opportunities open to them to encourage attendance. We will also consider if, in addition to general practice screening and immunisation it should be delivered by other providers e.g. family planning services, to maximise the opportunities for increasing uptake.
Public Health
Support implementation of FNP in the roll out areas. Continue to undertake co- commissioning with the local authorities in preparation for the transfer for responsibility of health visitors and FNP services in October 2015.
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12. Objective 3: Implementation of new models of care
Current Situation
To make the necessary improvements in provision of care services will have to be commissioned and provided in a different way. New models will have to be implemented that are sustainable, well co-ordinated, of a consistent high quality and responsive. In order to meet the challenges highlighted above and throughout this strategy, we will require a strong collaborative approach with all partners.
The commissioning for value packs provided to each CCG show that all our CCGs could make improvements in quality, outcomes and efficiency in the areas of circulation problems and the respiratory system, and five of them could make improvements in cancer.
In support of this, the greatest contribution to the gap in life expectancy, between the most and least deprived quintiles in each local authority, by disease type is most commonly CHD, with cancer the second most frequent contributor.
Number of CCGs which have opportunities in each area
The Area also has a number of challenged health systems which will need strategic change to deliver sustainable service models for the future, in particular ensuring a robust urgent care system that will drive efficiency and improvements in patient experience, improve outcomes and manage expectations. These strategic changes will only be possible with a change in how primary care and community services operate.
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Vision for Objective 3
Health and social care systems that meet patients’ needs routinely and in times of peak demand. Sustainable service models including planned and unplanned care.
What we are doing
Primary Care Working in collaboration with the CCGs when reviewing and consulting on APMS contracts to ensure their urgent/unplanned care leads are involved in the decision making of managing un-registered activity, whilst ensuring congruence with CCG Urgent Care Plans. Continue to support planning by being part of the local urgent care working groups and boards.
Urgent Care Supported CCGs and providers in implementing new models to deliver urgent care, for example co-location of urgent care centres at Kettering General Hospital; co-location of out of hours service to stream primary care patients accident and emergency department in Northampton.
Working with CCG to ensure it meets strategic plans for management of urgent care at new QE2 in Welwyn Garden City. This will involve establishing a new model of care.
Service Reconfiguration This has a specific focus on the development of sustainable services across Northamptonshire and Milton Keynes/Bedfordshire, the success of which will be dependent on new, innovative systems of primary and community service delivery.
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13. Scope of Commissioning responsibilities
Below we have highlighted key facts on the services we are responsible for commissioning.
Primary Care Services
We are responsible for significant number of contracts.
• 317 GP contracts
CCG Number of practices Bedfordshire 55 Corby 5 East and North Herts 60 Herts Valley 70 Luton 31 Milton Keynes 27 Nene 69
• 450 Eye health contracts • 450 dental contracts • 552 Community Pharmacy contracts
Public Health
We ensure the delivery of NHS England’s statutory responsibility for the commissioning of certain public health services including:
• Screening and Immunisation • 0-5years Healthy Child Programme • Public health for people in places of detention • Sexual assault services • Child Health Information (CHIS) • Focussing on achieving positive health outcomes for the population and reducing health inequalities • Ensuring that services offer increased value for money and productivity within the resources allocated
Local Professional Networks (Pharmacy, Dental and Eye Health)
We have started to work with the three Local Professional Networks to develop a vision for services including identifying key priority areas. These are summarised below and we will continue to refine and make the linkages between the networks and general practice. This work will be supported by a future event, involving the LPNs and engaging them in the development of the vision/future models and implementation of work streams
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Pharmacy Services
Vision Recognition and integration of community pharmacy into care pathways and service redesign.
Development of clinical skills in community pharmacy to manage care of patients with long term conditions.
Improved networking and collaboration between community pharmacy and hospital pharmacy to provide seamless transfers of care with respect to medicines across boundaries.
Development of a network of community pharmacies as health living pharmacies to promote healthy lifestyles and provide accredited public health pharmacy services (e.g. stop smoking, sexual health services, vaccination, weight management, alcohol awareness).
Use of community pharmacy as first port of call for self- care, to avoid inappropriate use of A&E.
Promotion of community pharmacy as a first line option from 111.
Case for Change 1. Need to increase the capacity and capability of primary care to managed patients with complex health needs and long term condition 2. Need to deliver medicines optimisation priorities, to ensure patients gain optimal benefits from medicines within the resources available 3. Need to develop a culture of public health, health promotion across primary care 4. Current mode of delivery of health services is financially unsustainable Benefits to be Patients realised • Improved medicines safety and better patient experience • Improved transfer of care
Others Integration of pharmacy and medicines optimisation services into care pathways to avoid duplication of effort or omission of important service/information, and allow more patients to be cared for out of hospital
National Objectives Medicines optimisation – make better use of the significant investment in medicines to improve patient outcomes, safety and experience
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Key Priority Areas 1. Develop pharmacy workforce to meet the future challenges – including pharmacists as prescribers. 2. Review of skill mix across the workforce 3. Raise quality of community pharmacy through a common accreditation process for Health Living Pharmacies across the Area Team. 4. Refresh national contractual framework for community pharmacy (engagement with NHSE/DH)
Enablers 1. Good engagement with the pharmacy community across the Area Team – through the Local Professional Network 2. Work with local schools of pharmacy, LETBs and workforce development teams 3. Collaboration with Public health teams and CCGs 4. Engagement with NHSE/DH Chief Pharmacist and team 5. Robust and comprehensive PNAs identifying local opportunities for community pharmacy Challenges 1. Leadership to support change 2. Lack of understanding of commissioners of the opportunities and potential of community pharmacy workforce 3. Lack of evidence to demonstrate effectiveness/efficiency of new services provided by pharmacy
Eye Health
Vision Improve access, safety, effectiveness, efficiency and quality of ophthalmic care across the Area.
LEHPN will engage with stakeholders to ensure that patients’ needs are met in a joined up and user focussed model of care, with avoidance of waste and duplication.
The NHS Outcomes Framework will be used to ensure that people have a positive experience of care in a safe environment, protecting them from harm – particularly for people with long term conditions with co-existing provision of acute eye care.
Communications with partners will be improved and developed to facilitate care delivery when this is supplied across different providers. Screening and health promotion will be encouraged to reduce the disease burden and the numbers of missed opportunities for early intervention. Hard to reach groups will be targeted by imaginative initiatives in the community to promote eye health care.
Governance in primary/secondary/community care will be tightened to ensure that national standards are met.
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Culture of team working across the Area will be fostered with the help from communication from the area team about successes, challenges and plans to address the area’s health needs.
A more collaborative approach to care will be developed at local and team levels to optimise the patient journey and experience.
Care should be delivered by the most appropriate person(s) with the requisite training and expertise and right equipment in the most patient convenient setting. Reconfiguration of patient pathways with enhanced communication should strip out waste and non value added steps. The care pathway should deliver convenience, quality and excellence and be lean and needs focussed. Costs should be reduced to allow the continued delivery of high quality care across the region.
Prescribing practices should be aligned across primary and secondary care and across the region to reduced costs and reflect the evidence base.
Low clinical priorities should be determined and aligned over the Area to allow resources to be best employed.
Access to emergency and urgent eye care should be improved and minimum standards defined. Community, primary emergency assessment and referral schemes will be developed to reduce costs and pressure on secondary care whilst maintaining patient safety.
Particular high volume pathways will be redesigned and aligned to smooth patient flow and unnecessary patient inconvenience.
Planning should take note of recent increases in demand for eye care – there has been a 26% rise over the last six years for admissions and a corresponding rise in outpatient activity.
Commissioners will push for 7/7 access to allow patient choice and increased capacity. Training will be integrated within care delivery to ensure that tomorrow’s carers are in place for tomorrow’s patients.
Case for Change • Variability of access • Wasteful patient pathways • Poor use of community resources • Lack of cohesion and planning • Lack of team working and engagement with stakeholders • Increased threats to both clinical and financial stability with
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a rising population with increased health needs • Rising numbers of interventions particularly in AMD • Poor screening protocols for glaucoma • Unfettered access without commissioning control is unsustainable. Key Priority Areas • Sight testing and PPV • AMD pathway • Cataract pathway • Glaucoma • Diabetic retinopathy screening / adherence to the national screening programme • Children’s sight screening • Health promotion / disease prevention / public education • Emergency and urgent eye care • Cost reduction and cost control • Enhanced triage and referral refinement with increased advice and guidance Enablers • Agreed plans for implementation • Commissioning levers applied to align services and drive forward outcomes • Shared best practice • Ambassadors for change • Patient satisfaction – PROMS • Stakeholder engagement • Patient representation / patient forums • Third sector involvement Challenges • Ingrained and entrenched behaviours • Distrust between providers • Resistance to change / experience of change • IT communications • Instability created by current political context and reluctance to invest due to uncertainty over the medium term. • Poor relationships and under developed networks • Self interest amongst providers • Lack of public education regarding eye health • Cost pressures vs. gold standards • Data protection / data storage • High capital costs • Need for continual medical education and training provision vs. service requirements • Challenges with governance across integrated pathways / different providers • Gaming incentives • Under developed patient representation
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Dental Services
Vision Increase number of 24 hour, seven day services across the Area Team.
Improve access to NHS dentistry both general and specialist services.
Understanding need through needs assessment and asking patients to ensure we commission to improve oral health.
Case for Change • Limited access to seven day services. • Complex or unclear referral pathways. • Inconsistent offer to patients with regard to minor oral surgery. • Need to develop systems that support referrals to specialist services. Benefits to be • Reducing variation in provision and access. realised • Improving access to care for vulnerable people. • Consistent offer to patients regardless of their address.
Key Priority Areas • Improving patient experience. • Obtain better value for money. • Review of sedation services and implement innovative approach to the commissioning of Anxiety Management Services.
Enablers • Better use of technology to improve the speed and responsiveness of services. • Tightening of contract management processes to be consistent with the NHS England Assurance Framework. • Robust contract monitoring processes. • Domiciliary Services contracts in Hertfordshire will be replaced with a pilot scheme to ensure continuity and to test a model for care across the whole Area Team.
Challenges Involving clinicians and networks in service improvements through LPNs and “Call to Action”
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14. Patient Experience
We have a strong focus on patient experience and alongside overall improvements in the quality of services commissioned we are working to improve the overall experience of patients in across the Area Team as well as focus on specific areas where experience is below average.
In 14/15 we will continue to focus on the roll out of the Friends and Family Test, in particular work to ensure that there is full roll out to GP practices by December 2014 and Dentists by March 2015. To enable this work to be implemented we have established an internal programme board to oversee the implementation with support from the Strategic Projects team. Once data is available for each practice this will be included in the wider quality dashboard to help determine where the focus of improvement activity will be.
We manage at local level the complaints made to NHS England about primary care contractors. The team was established during 13/14 and has focused on internal systems and processes to manage complaints effectively to resolution. An improvement plan has been agreed with set KPIS to enable the team to demonstrate progress against the national measures of 3 day acknowledgment and 25 day completion. In 14/15 local patient satisfaction surveys will commence. The quality of complaints responses are recognised as important. Proxy measures of number of local resolution meetings and cases accepted by the PHSO will be used to assess the outcome of the complaint as there are currently no defined patients’ measures. The improvement plan also focusses on the need to improve the overall patient experience and includes locality based work to improve complaints management and practice specific work to address more specific issues with complaints management. Pohwer our local advocacy service have started work with the team on improving the information provided to complainants to enable them to access support. Plans are in place for joint training with Pohwer in 14/15 as part of the improvement plan.
Directly managing complaints has enabled us to get first hand an insight from the patients and public on areas needing improvement. The table below highlights some of the actions that have already been taken in response to feedback from patients. This information will continue to be used to inform the Strategic Framework and Quality Framework.
You said What the area team has done What will we be doing in the future We don’t like to use 0845 We wrote to all practices using We will monitor the use of 0845 telephone numbers 0845 numbers to ask them to numbers and remind practices enable patients to use a local of their contractual number and to not renew responsibility. contracts with providers of these services
Access to appointments is We have worked with practices We will continue to work with difficult to review their booking systems practices where access is and current access raised as a concern by patients. arrangements. We will work with Healthwatch We have worked with to agree how we can support Healthwatch Hertfordshire on a the implementation of the research project in Bishops findings of local research Stortford.
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You said What the area team has done What will we be doing in the future Patient was not advised Changes have been made in properly about the impact of the practice to enable them to parvovirus on her pregnancy refer to obstetrics cases of pregnant women exposed to parvovirus. We have informed all practices of the need to take action when a pregnant woman is exposed to the virus. The needs of patient with We facilitated feedback from the We will work with the advocacy Learning Disability were not patient and her advocate to the service to support training for addressed when receiving dental practice who reimbursed practices dental care costs incurred by the patient
Over 900 patients responded We have committed to work We will build the to Luton Healthwatch in their with Healthwatch and the recommendations regarding review of GP services in Luton practices to support the premises into the wider work we implementation of the are doing to implement our recommendations primary care strategy.
We have agreed with the LMCs to jointly provide in 2014/15 complaint training on serious incidents for GP practices. It will focus not just on getting a robust process in practices but ensuring that learning is utilised and embedded.
During 13/14 we have made contact with the 6 Healthwatch groups within our area and have established a regular meeting with all 6 groups and Healthwatch England. This has enabled us to share learning and develop ways to share intelligence. Work in 14/15 will focus on sharing intelligence on complaints to improve the overall assessment of patient experience in the area. We are working with Luton Healthwatch on the delivery of recommendations of their audit of GP practices in Luton. The audit focused on the patient experience and each practice was provided with a set of recommendations as a result. We have supported Herts Healthwatch on a focussed piece of patient experience work in Bishops Stortford. The work to date has looked at the issue of access to GPs and will identify some areas for improvement by the practices.
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15. Enablers
In order for us to achieve the strategic objectives a number of workstreams must be delivered. Below are listed the relevant workstreams and what we doing to deliver them
Premises
We are clear that the premises developed over the next five years across Hertfordshire and South Midlands must support the implementation of the strategic framework.
The quality of GP premises varies in the patch. There is a portfolio of premises with 66% of properties being purpose built and CCG areas having a range of average patients per square metre (see table below). The Area Team works on the basis that 22 is an acceptable level. Within each CCG, variation will also clearly exist across Practices.
East and Herts Luton Bedfordshire Nene Corby Milton North Valley Keynes Herts 22.36 23.35 18.85 19.01 18.73 15.97 22.24
A number of areas across the Patch are expecting significant population growth due to new housing developments.
The table below details expected number of dwellings by CCG area projected to 2031 which need to be considered within our future planning.
East and Herts Luton Bedfordshire Nene Corby Milton North Valley Keynes Herts East Herts Hertsmere Luton Houghton Kettering 7,000 Corby: Milton 15,000, 4,000 11,500 Regis 11,000 Wellingborough 10,600 Keynes Stevenage Dacorum Wixams 4,500 9,000 18,500 5,3000 11,320 Central Beds West Northants North St Albans 3,100 41,760 Herts 4,250 Bedford 11,000 Watford 3, Borough Welwyn 529 12,000 and Three Rivers Biddenham Hatfield 1792 Loop 1,250 6,800 38,100 24,891 11,500 32,850 57,760 10,300 18,500
The impact of this growth is significant, particularly in areas which have high average patients per square metre, i.e. East and North Herts, Herts Valley and Milton Keynes.
Due to changing picture with regard to capital it is likely that there will be a limited amount of new investment and so we will focus on getting maximum use from current estate, making sure it is working efficiently and to minimise or eliminate empty space and “void”
40 costs. We will also ensure that any capital schemes are sustainable from a revenue perspective.
Soon after coming into existence we clarified the new premises schemes in the ‘pipeline’ and gained legal opinion that informed us that we were committed to all the schemes lawfully approved. As at April 2013 there were 21 revenue schemes that had been approved by PCTs and that the Area Team will continue to support.
Our premises team responds to all planning applications from 24 LA and they have a detailed knowledge of the developments, i.e. location and number. When considering the impact of new developments we will continue to review the needs in the light of existing premises and contracts to ensure that we implement the most sustainable models to secure suitable accommodation. These reviews will be undertaken with CCGs to ensure that the requirement for primary care premises meet their strategic requirements in line with co- commissioning.
We have developed objective surgery reviews so that there is consistency and a transparent record of what the reviews found. This provides an accurate record of the estate visit and we will continue with our rolling programme.
With CCGs and local planning authorities, we will develop an agreed strategic approach to enable new / redeveloped premises that meet growing populations in some areas and to support ongoing changes to service models (across health care sectors and with social care) elsewhere.
Workforce
Having a workforce that is well trained, in appropriate numbers, motivated with opportunities to develop is key to the success of the strategic framework. There are some challenges in relation to primary care workforce. In common with many areas the patch has a high percentage of doctors in the age bracket for retirement with local reports of significant difficulties in recruitment and retention. A recent survey by Beds and Herts LMC reported that 30% of practices were carrying a vacancy with 25% of these practices having had the vacancy for more than 6 months. There is also a lack of relevant training places for primary care practitioners.
The table below details the number of primary care practitioners per registered population for the Area Team.
Number of Number of Number Number GPs Pharmacies of of Dental Opticians Surgeries outlets
Number 1,954 542 266 361
Rate per 1000 registered 0.70 0.19 0.09 0.13 population
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There is one GP for every 1,434 patients or 0.70 GPs per 1,000 patients, lower than the national rate of 0.74. The figures need further investigation to understand the detail and use of other professionals in primary care.
The rates per 1,000 population for other ATs in the region ranged from: ° Pharmacies 0.18 to 0.25; ° Opticians 0.09 to 0.11; ° Dental Surgery 0.12 to 0.13.
We are working closely with Professor Simon Gregory, Dean of HEEoE (Health Education East of England) and Professor John Howard, Dean of Postgraduate GP Education. Due to our geography we also relate to Dr Helen Mead, who is their GP Dean, HE East Midlands – and – Dr Jill Edwards, HE Thames Valley
The 3 parts of Health Education have input into the Quality Innovation and Improvement work-stream that has an emphasis on the need for increased multi-professional working within Primary Care and development of the workforce from grass roots. Initiatives include:
• working proactively with primary care to increase pre registration student placements and apprenticeships in practices • supporting education for the whole practice team including postgraduate education and clinical skills training for registered nursing and AHP staff and dementia awareness for general practice clinical and non clinical support workforce • East Midlands Practice Nurse Development Programme at De Montfort University BSc/PG Cert – 5th cohort due to commence in September 2014: 16 individuals from Northants and 67 from whole of East Midlands across the 5 cohorts. It is aimed mainly at newly appointed practice nurses. The clinical competencies within the programme are based on the RCGP competencies in General Practice Nursing. Nurses undertaking the programme are supported by a trainer in practice who is responsible for overseeing learning and objectively assessing competence. The programme is 40 weeks and starts with 17 taught days over 16 weeks. The course is available twice a year. • Challenges with 2014 GP Trainee recruitment within the East Midlands – 90 places short – developing a “pre-GP” training scheme using the hospital posts which would otherwise have gaps as a result of this under-recruitment and providing additional targeted training to support individuals with the skills needed for both GP training and selection to training. • Joint working between NHS England, Herts Valley Clinical Commissioning Group (HVCCG) and East and North Hertfordshire Clinical Commissioning Group (ENHCCG) and also the University of Hertfordshire (UH) Student Placement Experience Transformation Project team .
HEEoE (Health Education East of England) are in the process of finalising the detail of a defined workforce transformation projects. For Bedfordshire and Hertfordshire these are:
• A workforce analysis for primary care based on HSCIC data and the narrative feedback at a CCG level • Support for a more extensive workforce analysis in Herts Valleys CCG
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• Support for the Luton GP academic/leadership Fellow posts • Completion of the childrens/young adults pathway work in Luton and dissemination • Supporting the South Beds integrated health and social care named generic primary care worker pilot • Developing a competence framework for Bands 1-4 for generic clinical care worker in general practice
Health Informatics
The delivery of our 5 year plan and our ability to drive forward with the national ambitions for primary care, and the realisation of “Putting Patients First” relies on the innovative and effective use of information technology. It is universally recognised that the changing NHS cannot continue to meet the future challenges and deliver effective clinical services without exploiting both existing IT systems and infrastructure, and embracing new technology to drive new ways of delivering health services beyond traditional boundaries.
For General Practice there are a number of nationally led technology initiatives that will be considered as the building blocks for enhancing and aligning traditional primary care IT systems capability. Delivery of these national digital systems is co-ordinated by HSCIC and practice participation varies across the Patch. Practices should consider each project as a vital step in increasing the maturity their IT systems and reaching a common level of functionality.
These include: • Summary Care Record (SCR participation now a component of the GMS contract) • Electronic Prescription (EPSr2) • Patient Online (Online access to patient records) • GP2GP
Practices will be encouraged to seek full use of the existing functionality which is present in the vast majority of systems in use across Hertfordshire and South Midlands such as repeat prescriptions and online booking of appointments. Use of technology such as online booking of appointments and SMS reminders have been proven to reduce ‘Did Not Attends’ (DNAs) and significantly lessen the required interaction between staff and patients.
It is recognised that CCGs and Practices should consider the opportunities for moving to a more integrated care record across the whole spectrum of health and social care sectors , logically the first step would be joining up the GP system held record at the most logical scale for the area. This will naturally support new and innovative ways of providing primary care services giving practices flexibility to federate or share the provision of key services. Some CCGs in Hertfordshire and South Midlands have already moved to a common GP and Community IT system and are seeing the benefits of an integrated care record and the flexibility a common, hosted system can bring. The table below shows the mix of systems in use across our 7 CCG areas.
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60 50 40 30 20 10
NO. NO. OF DEPLOYED SYSTEMS 0 East & North Herts Valleys Bedfordshire Luton Nene Corby Milton Keynes Herts SystmOne 29 15 52 21 45 5 27 EMISWeb 21 37 0 5 22 0 0 EMIS LV 3 3 2 1 1 0 0 Vision 6 11 1 4 1 0 0 Microtest 1 0 0 0 0 0 0 EMIS PCS 0 1 0 0 0 0 0 PCS SAN 0 0 0 0 0 0 0
The GP systems of choice framework enable GP practices to select from a number of nationally accredited IT systems that are assured to have the required current and future functionality to support the requirement s of the NHS.
Where a common IT system is not appropriate or achievable for a specific CCG or locality there are interoperability solutions available that could bring a comparable level of integration and can deliver the added benefit of providing access beyond primary care, which in turn enhances the availability of clinical information across an entire pathway. These products can vary enormously on complexity, scale and cost and range from simple messaging solutions up to full scale clinical information portals capable of connecting vast numbers of data sources across multiple care settings. Nationally work continues on the “Interoperability Tool Kit” which is an initiative to provide IT system suppliers a common set of standards to allow safe communication/ sharing across clinical IT systems. Whilst this matures and other local options are considered there are systems already available such as the Enhanced Summary Care Record and the Medical Interoperability Gateway (MIG) which will be exploited to their maximum to share data across care settings in the more immediate future.
The better utilisation of existing primary care resources by deploying technology to reduce consumers’ need to travel to provider premises will be pursued. With much of the public having and using social media and other consumer technology, efforts should be made to investigate Tele-health, Tele-medicine and Tele-care, and to make better use of social media technologies along with communications systems such as Skype and / or Face Time. Thought should be given to online consultations; this could be a way to maximise the diminishing resource available and technically could be provided from any location. These solutions can be furthered enhanced to enable GP to acute / specialist consultant level contact and beyond, potentially providing remote triage to further prevent unnecessary acute admissions.
We recognise across primary care and within the Area Team, the power and importance of information. Where possible CCGs and practices will be encouraged to work collaboratively with other providers to move towards unified business intelligence and
44 reporting platform. The richness of data in this type of environment is hugely beneficial for both performance / contracting monitoring and clinical decision support.
Quality Framework
We are committed to co-commissioning for quality. Our work with our CCGs is and will focus on four key quality domains to improve quality and safety:
Safety Effectiveness V Reduction in medication errors V Increase screening and V Improved management and immunisation uptake learning from serious incidents V Improved management of LTCs V Understanding and fulfilment of V Reduction in delayed diagnosis safeguarding responsibilities including appropriate 2 week V Understanding and fulfilment of cancer referrals infection control responsibilities V CQC compliant
Experience Governance and Infrastructure V Improvements in the timeliness of V Performer concerns managed complaints responses and V Capacity to match demand reduced need for local resolution V Premises condition fit for purpose V Ensure getting through on phone V Breach notices used effectively and making an appointment easier V Satisfaction and Confidence in primary care demonstrated through positive Friends and Family results V Satisfaction with opening hours V Overall experience improved
We have also developed a menu of interventions to support quality improvement in primary care (see overleaf) that will assist the delivery of improvements in quality and safety across the four domains.
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PRIMARY CARE QUALITY FRAMEWORK: ‘Menu’ of Interventions to support quality improvement in General Practice
Intervention What How Who Measuring Success Sharing Documents, (e.g. policies, • Targeted intervention - Visiting team Practice is able to guidelines; research findings); following discussion with Quality Leads CCG/AT identify/implement new practical and factual information to practice staff re concerns Peers approaches Promoting evidence support rapid learning and change • Universal intervention – based approaches through GP bulletin or CCG Practices are aware of how to communications, membership access information and support forums etc. Coaching and or mentoring by • Targeted - Commitment to Visiting team to identify peers Completion of personal and peers one or more sessions of face with capacity to support and practice development plans Peer Support (Practice managers, GPs, Nurses) to face discussion and follow practice to agree Buddying with high performers up acceptability/match to need Through appraisal
E.g. referral management • Targeted – to practice quality Pool of ‘Expert’ advisors to be Changes in practice that is initiatives e.g. reviewing concerns where practice is a identified by visiting team and driving outlying quality concerns pathways/experience for individuals ‘negative outlier’ CCG – to be available as a e.g. referrals, prescribing etc. Case Management or vulnerable groups • Avoiding unplanned resource to support challenged admissions DES practices NHS IQ Detailed review of data relating to • Targeted - to collect or review Practice with support as required Confidence in data leading to Intelligence specific or emerging concerns data set for area of concern changes in behaviour, e.g. gathering and over a specific time-frame referrals, prescribing etc. analysis Friends and family Implementation
Learning from complaints and • Universal - protected practice Area Team CQC compliance incidents time for learning; access to E- Health Education England Reduced similar incidents or Education and Safeguarding Learning etc. CCGs complaints by applying learning Training ‘How to’ – e.g. RCA, prescribing • Targeted - Face to face LMC Quality of root cause analysis opportunities within practice College Revalidation? Appraisal? or locally via CCG. Commercial New practice models • Targeted – practice Practice Appraisal
Team capacity and capability organisational and OD plan Organisational Skill mix review • Development Universal - long term changes in models of general practice delivery Warning • Targeted for specific Area Team removal of lever Contractual Levers Remedial Breach concerns Breach
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Linkages to AT/CCG Quality Collaborative
This work links to the wider AT/CCG Quality Collaborative improvement framework (shortlisted for two of the 2014 HSJ National Patient Safety Awards) linking directly to the following work streams: V Infection Control V Elimination of PUs in the community V Framework for provider quality visits V Supporting the role and development of practice nurses
Linkages to national and regional work streams
We are actively involved the Regional Transforming Primary Care work programme and learning from this and national work will inform our local AT/CCG work stream going forward.
At the time of writing this work is likely to include: single set of practice standards, agreed thresholds for a minimum acceptable performance, toolkits of intervention and levers to improve performance and a process of early remediation.
There is currently ongoing work with the CQC reflecting the above, alongside the development of an agreed framework for joint working including pre and post visit information sharing and support.
Communication and Engagement
Hertfordshire and South Midlands have taken a co-production approach to the development of its Primary Care Strategy. The rationale behind our initial communication and enagagement plan has been to ensure a robust approach to the engagement and involvement of all stakeholders and partners, both external and internal to the Area Team. Early proactive discussions have confirmed a genuine commitment and willingness for all parties to work together across Hertfordshire and South Midlands.
Aims of our Communication and Engagement Work
• To ensure that all external and internal stakeholders are identified in what is a complex health and social care system • To raise awareness with all stakeholders of our intention to co-produce a five year strategic plan for primary care • To engage with our stakeholders in a way that is meaningful and ongoing • To create a shared vision, common understanding of purpose and key deliverables
What have we done so far
Positive dialogue through 1-1 conversations and ‘primary care development sessions’ have been undertaken in order to faciliate the co-production of our primary care strategy with: • CCGs, • Providers, • LMCs,
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• Public Health England, • Health and Wellbeing Boards • Healthwatch • Local Professional Networks • Strategic Clinical Networks • Local Authorities
The Area Team hosted an event for the Patients in Control Programme and have agreed to support the CCGs with a joint review of the self –assessments due to be completed in 14/15. Learning from the Involvement Network will be shared across the Area Team and CCGs.
Further work will continue via our key stakeholders with an emphasis on hearing the voice of the local communities and patients. We will use our Patient Leaders to support future service redesign work. All our CCGs have strong patient engagement networks and delivery teams who have agreed to work closely with the Area Team. This is to ensure that all engagement opportunities are optimised and are not just a single event but a continuous conversation.
Strategic Contract Management
One of the levers available is to use the contracts we hold. We are committed to developing a more strategic approach to contract management to encourage innovation and change in service models.
PMS Reviews
There is notable variation between CCGs in the type of contract GPs are likely to have. The proportion of GPs with a PMS contract ranges from 11.7% in East & North Hertfordshire CCG to 66.7% in Corby.
GMS PMS Unknown East & North Hertfordshire 88.3% 11.7%
Herts Valley 84.3% 15.7%
AREA TEAM avg. 63.4% 36.6%
NATIONAL avg. 56.0% 43.8%
Luton 51.6% 48.4%
Milton Keynes 50.0% 50.0%
Bedfordshire 47.3% 52.7%
Nene 47.1% 52.9%
Corby 33.3% 66.7%
0% 25% 50% 75% 100% % of contract type
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We have 102 PMS practices. We will undertake the PMS Reviews consistently, meeting the timescale for completion by March 2016.
To ensure NHS England is able to secure best value from future investment of the premium element of PMS funding, the challenge regionally is to ensure that available resources above funding for core services expected from all GP practices meets the following criteria:
• Reflect the AT/CCG strategic plans for primary care • Services or outcomes that go beyond what is expected of core general practice or improving primary care premises. • Help reduce inequalities • Give equality of opportunity to all practices • Support fairer distribution at a locality level.
This is a significantly greater variation than that experienced in GMS which means that the highest ranked practice receives more than twice as much resource per weighted patient as the lowest. To illustrate the impact of this variation, for an average practice of 7,000 patients this difference would equate to over £600,000 – sufficient to fund the net income of an additional five GPs.
Overall, less than a quarter of the additional investment in PMS practices is attached to extra services/quality i.e. LES. However, there is significant variation in treatment across the PMS practices. The following table sets out how the additional investment in PMS practices is spread across former PCTs:
PMS Premium, breakdown by former PCT
Former PCT PMS Baseline LES PMS Premium BEDFORDSHIRE PCT 2,188,547 1,103,573 3,292,120 HERTFORDSHIRE PCT 387,939 721,028 1,108,967 LUTON PCT -87,462 981,236 893,774 MILTON KEYNES PCT 1,411,753 0 1,411,753 NORTHAMPTONSHIRE 5,819,646 0 5,819,646 PCT Grand Total £ 9,720,423 2,805,837 12,526,260
MPIG erosion We have 3 of the 98 national outliers for MPIG who will be losing more than £3.00 per patient each year for the 7 year erosion period. We have agreed to take a staggered approach to support of the affected practices with the three outliers being treated as Tier 1 priority. It has been agreed that we will consider further practices that are affected to a lesser degree as outlined below:
Tier 2 – Practices that are not national outliers, but considered at risk due to a high reduction in pounds per weighted patient (PPWP). Annual reduction of between £2.00 - £3.00 per weighted patient.
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Tier 3 – Practices that are not national outliers and not likely to be at risk but may need to consider options. Annual reduction of between £1.00 - £1.99 per weighted patient.
Procurement A more strategic approach with procurement needs to be taken in line with local strategies, with a significant number planned to be tendered during 14/15 and beyond e.g. 11 GP practices are due to be competitively tendered during 14/15.
The GP Contract Changes to the current GP contract will be implemented over the lifespan of this strategy. Any change or increased flexibility should be fully utilised to help bring about the strategic change that is needed.
Other contract management • Deliver a primary care contract profile to be used across the Area Team, this will be a live document centrally accessible to the Area Team; • Establish a contract panel to consider applications to which the Area Team has discretion. • Ensure robust processes are in place to manage contracts which under-perform and quickly and effectively address issues of poor performance or patient safety; • We will ensure that across Hertfordshire and South Midlands, all health organisations are meeting their safeguarding responsibilities.
Governance The delivery of the strategic plan is fundamental to the Area Team successfully delivering against its objectives. Therefore the governance of the delivery of the plan and in particular Primary Care Transformation is integrated within the established systems and processes in the Area Team.
Senior Leadership of Area Team
Area Director Jane Halpin
Director of Operations Director of Medical Director Nurse Director Finance Director and Delivery Commissioning Sarah Whiteman Heather Moulder Chris Ford Sharn Elton Dominic Cox
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Primary Care Transformation Governance Structure
The governance structure is based on joint work between the Area Team, CCG, LMCs and LPNs. This will clearly need revising to align with co-commissioning plans moving forward.
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Governance Structure for Primary Care Strategic Framework
Primary Care Transformation Programme SRO: Dominic Cox
Improvement (Quality) Innovation (New Models) AT Director Lead: Heather Moulder AT Director Lead: Sarah Whiteman
Levers - Incentives, Support/Visits Clinical Leadership Provider market Quality Standards Education & Research, Workforce approach CQC and New Models of development, and Variation Planning and Development (Quality Tool ) Care premises & contracts
East and North Milton Keynes CCG Corby CCG Nene CCG Herts Valley CCG Bedfordshire CCG Luton CCG Herts CCG
Enabling Themes: System Partnership, Collaboration, “co-production” with e.g.HWBs, providers, PHE etc
Enabling work streams: Data and information (finance, activity, demand and workforce) and communications and
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