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South Southwark Primary Care Network

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South Southwark Primary Care Network South Southwark Primary Care Network South Southwark PPG: March 2020 Primary Care Networks (PCNs): recap • Fantastic opportunity for general practice which builds on collective working that has delivered significant improvement for our population • Over five years (2019 to 2024) we will – Recruit additional roles into Southwark (including social prescribers, pharmacists, paramedics focusing on local populations – Deliver of national specifications including Structured Medication Reviews, Cancer and Care Homes this year – Lead the redesign of services across the borough and delivery in our 9 neighborhoods “The building block to every Integrated Care System” • Initial focus on developing strong PCNs locally, that can deliver what we need them to What are Primary Care Networks and what does this mean for local residents • A Primary Care Network is a group of general practices working together with local services (including across primary care, community services, social care and the voluntary sector) to offer more personalised and coordinated health and social care to their local populations • https://www.youtube.com/watch?v=W19DtEsc8Ys&f eature=youtu.be South Southwark PCN Camberwell (34,377) Dr Roger Durston Peckham Camberwell Green St Giles-Begley Dr Aru Surgery Melbourne Grove & Hambleden Parkside St Giles-Roseman St Giles-Begley Peckham (41,098) Dr Kishor Vasant Camberwell Acorn & Gaumont Dr Aru Lister Queens Road Dulwich St Giles-Rosemen Dulwich & Nunhead Villages (35,396) Brenda Donnelly 306 Dulwich & Nunhead Villages Elm Lodge Gardens Lordship Lane Nunhead Dulwich (34,002) Dr Gavin McColl DMC-Chadwick DMC-Crystal Palace Forest Hill Sternhall Lane What do PCNs mean for patients • General practice in strong position to design what services look like in Southwark • Additional multi-disciplinary workforce of over 20 staff across South Southwark to deliver care for our populations • Improving patient care through working together Where are we now • We’ve been meeting over the past year, building really good relationships and agreeing how we could work more closely together • Extended Primary Care Service providing GP/nurse appointments, 8-8, 7 days a week • Population Health Management contract focusing on supporting people with complex needs and screening for long-term conditions • Practices to work together to deliver services and improve care e.g. End of Life Care, prescribing and diabetes 41.1% to 47.9%! 47.9%! to 41.1% from improved London across highest Southwark 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% Improvements in diabetes care in diabetes Improvements 0.0% Southwark Lambeth Camden ranked ranked % achievement of 8 care processes across London (2018/19*) London across processes care of8 % achievement City & Hackney Wandsworth third third Barking & Dagenham Haringey – Tower Hamlets Redbridge Kingston 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 0.0% Islington Newham Camden Central London (Westminster) Enfield Croydon Southwark Sutton Richmond Lewisham Havering Lewisham (2018/19) London across Targets 3 Treatment of achievement % Havering Barnet Bexley Hammersmith & Fulham Hillingdon Bexley City & Hackney Hillingdon Tower Hamlets Bromley Harrow Richmond Hounslow Harrow Kingston Merton Lambeth Ealing Brent Greenwich Haringey Brent Barnet Hounslow Newham Waltham Forest Redbridge Enfield Sutton Bromley 78.7%! to 56.9% from improved London across ranked Southwark Croydon Greenwich Barking & Dagenham Ealing Central London… – Islington Wandsworth TOP TOP Waltham Forest Merton Hammersmith & Fulham Delivering for our patients Improvement in delivery year on year Key performance indicators Commission Activity (population health activity management) Ambulatory BP 1142 1447 + 26% monitoring NHS Health Checks 4010 4262 +6% ≥ 65 & LTC with pulse 2800 4789 +71% check Pre-diabetes annual 1856 2944 +59% review Asthma/COPD inhaler 600 2651 +441% review Co-ordinated care 1080 1486 +37% pathway, Case M’ment Focusing on our local populations • Focus on Black Afro-Caribbean men, delivering blood pressure monitoring and advice from barbers shops (project with Race Equality Foundation) • Holistic support to enable confidence to return to work (project with Dept of Work and Pensions -DWP) • Focus on HIV patients to diagnose and return to treatment (project with Elton John Aids Foundation) • Musculoskeletal (MSK) and mental health project: supporting return to work • Listening to our patients – neighbourhood PPG s in Dulwich, Camberwell and Peckham South Southwark PCN We have focused Roadmap Established 2 x PCNs on setting up the Primary Care Networks: agreeing how we will work together, make decisions, manage Neighbourhood & Overseeing Groups issues established Four PCN Clinical Clinical Directors in Directors were post recruited in August Each of the neighbourhoods meet monthly to discus plans and progress Big focus recruiting additional staff that will be part of our Recruiting PCN teams practice teams, work across the neighbourhood and provide care First Contact Physio for our patients Practitioners This year we have been Social Prescribing Link Workers recruiting • Pharmacists • Social prescribers https://www.youtube.com/watch Met all requirements of Extended Access Services ?v=O9azfXNcqD8&feature=youtu. Clinical Pharmacists be Next year and beyond: we will be plan what further staff we recruit including physiotherapists and other roles including community paramedics (home visits) and mental health practitioners What we will be working on • Deliver services for our patients – Providing Extended Hours for whole population – New services including • Medication reviews for people on many medicines • Supporting early cancer diagnosis • Personalised care and anticipatory care: identifying people that need support at the right time and providing what they need • Continue recruiting and expanding our PCN team • Explore opportunities to improve care for our residents • Consider what could help us e.g. the estates we need, how we use digital technologies etc Delivering PCN Service Specifications • Structured Medication Review and Medicines Optimisation, Enhanced Health in Care Homes and Supporting Early Cancer Diagnosis service specifications have now been significantly improved – will start in 2020/21 • The remaining four service specifications – CVD diagnosis and prevention, tackling inequalities, personalised care and anticipatory care - will be introduced in 2021/22, following negotiation with GPC England. • A new care home premium payment worth £120 per bed per year will be introduced when the service goes live from 30 September 2020 (£42,000 based on 350 beds part year effect) • Additional staff roles to that will support delivery of these services are now to be 100% funded: though still a shortfall (e.g. London weighting etc) and there are a wider range of staff funded PCN workforce: additional staff roles Additional roles to be Nationally they are also funded exploring whether or not it is feasible to include Subject to satisfying three Advanced Nurse criteria Practitioners in the 1. sufficient expected scheme, bearing in mind available supply supply constraints. nationwide; 2. demand from general practice for the roles; and 3. it must be operationally Associates Physician Physician feasible to guarantee the Additional Role (2020) roles are additional to Reimbursement (band 7) (band In addition to these six, those that are already in Scheme place. mental health , Dieticians ,Dieticians and Podiatrists practitioner roles – including Improving As long as meet the criteria Access to Psychological above we can now have a Therapy (IAPT) broader range of roles in practitioners - will also be primary care for the new roles included in the Scheme detailed in orange segments from April 2021 Questions and Answers.
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