Oversight and Governance Chief Executive’s Department Plymouth City Council Ballard House Plymouth PL1 3BJ

Please ask for Amelia Boulter T 01752 668000 E Democratic Advisor www.plymouth.gov.uk/democracy Published 07/11/18

GP SELECT COMMITTEE REVIEW

Thursday 15 November 2018 10.00 am Warspite Room, Council House

Members: Councillor Mrs Aspinall, Chair Councillor Mrs Bowyer, Vice Chair Councillors Hendy, James, Laing, Dr Mahony and Parker-Delaz-Ajete.

Members are invited to attend the above meeting to consider the items of business overleaf.

This meeting will be webcast and available on-line after the meeting. By entering the Warspite Room, Councillors are consenting to being filmed during the meeting and to the use of the recording for the webcast.

The Council is a data controller under the Data Protection Act. Data collected during this webcast will be retained in accordance with the authority’s published policy.

For further information on webcasting, attending Council meetings and how to engage in the democratic process please follow this link http://www.plymouth.gov.uk/accesstomeetings

Tracey Lee Chief Executive GP Select Committee Review

1. Apologies

To receive apologies for non-attendance submitted by Members.

2. Declarations of Interest

Members will be asked to make any declarations of interest in respect of items on this agenda.

3. Chair's Urgent Business

To receive reports on business, which in the opinion of the Chair, should be brought forward for urgent consideration.

4. Minutes (Pages 1 - 6)

To confirm the minutes of the meeting held on 29 November 2017.

5. Response to GP Select Committee Recommendations (Pages 7 - 40)

6. Scoping Document (Pages 41 - 42)

7. Healthwatch - User Experience (Pages 43 - 52)

8. Primary Care Programme Report (Pages 53 - 56)

9. Attracting GP's to Plymouth

a. Living and Working in Plymouth (video clip) (Pages 57 - 68) b. Living and Working in Plymouth (Pages 69 - 76) 10. Health and Wellbeing Hubs

11. Pharmacy Developments

12. Peninsula School of Primary Care

13. Recommendations Page 1 Agenda Item 4

Select Committee Review

Wednesday 29 November 2017

PRESENT:

Councillor Mrs Aspinall, in the Chair. Councillor James, Vice Chair. Councillors Mrs Bridgeman, Carson, Dann, Dr Mahony, Sparling and Tuffin.

Also in attendance: Mark Procter - Joint Director of Primary Care, South Devon and Torbay and NEW Devon Clinical Commissioning Groups and Head of Primary Care, NHS England South (South-West – Devon, Cornwall and Isles of Scilly), Nicola Jones - Head of Commissioning, Craig McArdle - Director of Integrated Commissioning and Dr Dafydd Jones, NEW Devon CCG, Ruth Harrell - Director of Public Health, Karen Marcellino and Anthony Gravett, Healthwatch Plymouth, David Bearman - Devon Local Pharmaceutical Committee, Ross Jago – Lead Officer and Amelia Boulter – Democratic Advisor.

The meeting started at 1.00 pm and finished at 4.12 pm.

Note: At a future meeting, the Panel will consider the accuracy of these draft minutes, so they may be subject to change. Please check the minutes of that meeting to confirm whether these minutes have been amended.

1. Declarations of Interest

In accordance with the Code of Conduct the following declarations of interests were made –

Member Minute Reason Interest Councillor James Minute 3 Chair of the Personal Patient Participation Group, Glenside Medical Centre Councillor Mrs Minute 3 Chair of the Personal Aspinall Patient Participation Group, Freedom Health Centre Councillor Carson Minute 3 Patient at Freedom Personal Health Centre

2. Chair's Urgent Business

There were no items of Chair’s Urgent Business.

Select Committee Review Wednesday 29 November 2017 Page 2

3. Witnesses

The Committee heard from Mark Procter, Joint Director of Primary Care, South Devon and Torbay and NEW Devon Clinical Commissioning Groups and Head of Primary Care, NHS England South (South-West – Devon, Cornwall and Isles of Scilly).

The Committee were provided with a presentation and heard that;

a) nationally and locally primary care faces many issues such as limited investment, increasing pressure from an ageing population and attracting workforce into the South West;

b) Primary care was one of the main priorities for the Devon Sustainable Transformation Partnership;

c) Hyde Park, St Barnabas and Saltash Road closed in March 2017 and an interim provider, Access Health Care took over the contract for Ernesettle, Mount Gould and Trewlawny GP surgeries;

d) more recently Access Health Care took on the contract for Freedom Health Centre and Ocean Health;

e) following two failed procurement exercises they were unable to secure a GP surgery in Barne Barton, an option for this area could be a pharmacy-led service with GP input;

f) Glenside Medical Centre and Beacon Medical Group merged in 2017;

g) NEW Devon CCG had worked with nearby partners to support patients moving to another surgery by 31 March 2018 following a retirement at Leypark Surgery. Leypark Surgery would then close;

h) the NEW Devon CCG, Western Locality in partnership with NHS England would be undertaking the following immediate actions:  encouraging GPs to return to practice;  telephone triage service;  recruitment of GPs from overseas;  Plymouth workforce/recruitment campaign.

The Committee heard from Nicola Jones, Head of Commissioning, Craig McArdle, Director of Integrated Commissioning and Dr Dafydd Jones, NEW Devon CCG.

The Committee were provided with a presentation and heard that;

i) the CCG are the commissioners for primary care and acknowledge that they have a bigger role to play with regards to joint commissioning and delegated commissioning;

Select Committee Review Wednesday 29 November 2017 Page 3

j) this was part of a wider system which includes reviewing the workload, workforce, infrastructure and sustainability and to reflect that they were part of the 5 year forward view and the STP;

k) the Primary Care Improvement Plan had been produced in partnership with various stakeholders such as NHS England, PHNT, Livewell, GP Practices and Devon Local Pharmaceutical Committee;

l) one of the urgent highlights within the primary improvement plan was recruitment and they were working with Plymouth City Council to better enable GP practices to be able to recruit;

m) in the near future most practices would be undertaking social subscribing using the non-health voluntary organisations;

n) the winter plan initiatives included the relocation of Robin Unit, increasing domiciliary care capacity, maximise bed use for patient flow and added in additional capacity;

o) Stay Well Campaign, a guide to health and care services in Plymouth has been distributed across the city;

The Committee heard from Ruth Harrell, Director of Public Health.

The Committee were provided with a presentation and heard that;

p) they were working closely with NHS England and NEW Devon CCG and recognise the challenges;

q) in conjunction with the Medical School trying to attract more people into Plymouth and to increase exposure for trainees to visit GP Practices in deprived areas to understand primary care within these areas;

r) practices that were struggling were in the more deprive areas and this was not typical to Plymouth;

s) people were living longer with chronic illnesses and within the deprived areas these illnesses were developed earlier. They were looking at whether the funding within deprived areas was sufficient enough to attract GPs into those areas;

t) the Carr-Hill formula needs to be updated with a higher weighting to take account of deprivation;

u) the system as a whole was aware of the risk of harm to patients and they were looking at how this would be managed.

The Committee heard from Karen Marcellino and Anthony Gravett, Healthwatch Plymouth;

Select Committee Review Wednesday 29 November 2017 Page 4

The Committee were provided with a presentation and heard that;

v) they had carried out engagement with patients of the recently closed GP surgeries and since then engagement with patients had improved dramatically;

w) they looked at call back and triage system but this piece of work was still progressing, feedback included that patients were not aware that this had been implemented and how it would affect them;

x) they were working alongside the Western Locality Overview Group and NHS England looking at the challenges around GP recruitment, contract handback and how patients can be involved.

The Committee heard from David Bearman, Devon Local Pharmaceutical Committee.

The Committee were provided with a presentation and heard that;

y) there was a clear need to change and for pharmacies towards to move forward and integrate into general practice work moving side by the side for the future population;

z) there was a shortage of pharmacists within the South West but they were working collaboratively to stop the poaching and to recruit outside the south west;

aa) looking at how to we assist GPs with the aim to make pharmacy a key contributor to the sustainability of primary care both through direct support in the practice and by the redesign if community pharmacy to be the key partner within a community service provision;

bb) recognise the way we work with pharmacists in hospitals, in practice and communities to help glue the system together;

cc) they were leading the way nationally on this agenda.

4. Recommendations

The Committee agreed that;

1. the Committee, via the Chair, receives further reports on every future change to GP Surgeries in Plymouth which include information on engagement and consultation activities with patients at the earliest stage;

2. the Select Committee requires a progress report on the projects as outlined within the Western Locality Primary Care Improvement Plan at its next meeting;

Select Committee Review Wednesday 29 November 2017 Page 5

3. that partners in the Health and Social Care System lobby for review of the Carr-Hill Formula funding and identify how more funding would benefit GP Surgeries within the most deprived areas of Plymouth, reporting progress to the next meeting of the Select Committee;

4. the Select Committee requires an update on the work being undertaken by partner organisations to attract GP’s to Plymouth but more specifically on how we attract and retain GP’s within the most deprived areas of the city at next meeting of the Select Committee;

5. the Select Committee to receive a report on from Health and Social Care commissioners on how Pharmacy will be a key feature of new models of working and how pharmacists can alleviate the pressures currently being faced within primary care at next meeting of the Select Committee.

Two additional recommendations were agreed at the Wellbeing Overview and Scrutiny Committee on 13 December 2017. It was further agreed;

6. that the Chair on behalf of the Committee will write to the Secretary of State requesting that Plymouth is included as part of the Targeted Enhanced Recruitment Scheme which has been offered to Cornwall to attract GPs into the area.

7. to explore Primary Care Co-commissioning and future plans for Integrated Primary Care Service to be managed more locally.

Select Committee Review Wednesday 29 November 2017 This page is intentionally left blank Page 7 Agenda Item 5

Wellbeing Select Committee Nov 2017 General Practice Recommendations and actions

The committee agreed that: Response and output needed Chair of Wellbeing OSC is a member of NHS England's Western Locality 1. the Committee, via the Chair, receives further reports Overview Group regarding material changes in general practice. NHSE and on every future change to GP Surgeries in Plymouth CCG will liaise with the Chair outside of these meetings for early notice of which include information on engagement and potential, likely or actual changes. consultation activities with patients at the earliest stage;

2. the Select Committee requires a progress report on the projects as outlined within the Western Locality Primary Report attached (1): Primary Care Improvement Plan Care Improvement Plan at its next meeting;

3. that partners in the Health and Social Care System lobby for review of the Carr-Hill Formula funding and identify how more funding would benefit GP Surgeries Paper attached (2): Carr Hill formula within the most deprived areas of Plymouth, reporting progress to the next meeting of the Select Committee;

4. the Select Committee requires an update on the work Update contained in Workforce section of Primary Care Improvement Plan (1). being undertaken by partner organisations to attract GP’s A presentation will be offered to the 28th February Select Committee meeting to Plymouth but more specifically on how we attract and containing further detail and examples of, in particular, the work done with retain GP’s within the most deprived areas of the city at Plymouth City Council to promote Plymouth to healthcare professionals and an next meeting of the Select Committee; update on International Recruitment of GPs.

5. the Select Committee to receive a report on from Health and Social Care commissioners on how Pharmacy will be a key feature of new models of working Paper attached (3): Developments in pharmacy and how pharmacists can alleviate the pressures currently being faced within primary care at next meeting of the Select Committee.

Two additional recommendations were agreed at the Wellbeing Overview and Scrutiny Committee on 13 December 2017. It was further

6. that the Chair on behalf of the Committee will write to the Secretary of State requesting that Plymouth is included as part of the Targeted Enhanced Recruitment Targeted Enhanced Recruitment Scheme has been offered to Plymouth. Scheme which has been offered to Cornwall to attract GPs into the area.

7. To explore Primary Care Co-commissioning and future Paper attached (4): Report to CCG Governing Body and process/timeline for plans for Integrated Primary Care Service to be managed progression to Joint Commissioning more locally. This page is intentionally left blank WESTERN LOCALITYPage SYSTEM 9 IMPROVEMENT BOARD

PROGRAMME REPORT

Programme Name Primary Care Programme Lead SROs: Dr Shelagh McCormick and Mark Procter; Programme Lead: Nicola Jones Reporting Period To 24th January 2018

Programme Overview: Aims and Objectives

Aim: To develop and redesign primary care as part of the system of health and wellbeing

Objectives:  To achieve sustainability in primary care with respect to workforce, funding, IM&T and premises to ensure patients' access to high quality primary care provision and self-care – and at the interface of community and acute care  To support, influence and enable design and implementation of new models of primary care built around a community with integration between primary care, secondary care, the voluntary sector and the community and provided efficiently and effectively 'at scale' where appropriate while maintaining access and continuity where important.  To maximise and influence investment and resource opportunities, prioritising according to the needs of the population and the needs of the health and wellbeing system, whilst supporting innovation

Key Issues, Risks and Actions for Escalation Risks (as reported through Western Locality Risk Register):  Current and forecast significant challenges to sustainability of general practices including workforce, demand and capacity  Variable and limited capacity in general practice and practice groups to transform to improve sustainability and enable system wide developments without support  As with general practice there are now challenges to the sustainability of the community pharmacy network that need to be reflected  Lack of evidenced change to new models  Insufficient change capacity at all required levels  Lack of proven ability to plan and mitigate for high risk failure in primary care WESTERN LOCALITY SYSTEMPage 10 IMPROVEMENT BOARD

Workstream Activity Progress Updates and Key Milestones (Projects) (a) Improving practices’ capacity to For (a) and (b): transform at scale with investment of Progress updates: £120k funding for a year and aligning  Proposal developed (Sep 17) commissioner and provider staff to each  Proposal shared with each practice group and LMC for group for collaborative working to deliver feedback – positive reception (Sep/Oct 17) change more rapidly  Supported and iterated at Primary Care Programme Group (b) Aligning and strengthening delivery of (3/10/17) primary care transformation by forming  Circulated to GP Collaborative Board members for views a Partnership, bringing together the (10/10/17) Leadership and Primary Care Programme Group and  Finalised with Primary Care Programme Group governance for Western GP Collaborative Board) to  Launched at GP Forum (17/10/17) transformation hold and drive the primary care  Letter to practices and other invitees for Partnership programme, reporting to the System meeting (21/11/17) Improvement Board  Western Primary Care Partnership commenced (12/12/17)  Launch meeting with partners

Key milestones:  Agree use of £30k funding with each group and fully implement.  Second practice group GP Forum to review actions from first GP Forums and refresh action plans (by Mar 18) (a) Implement a model for provision of (a), (b) and (c): primary care to people living in care Progress updates: homes. Implementing this will maximise the easing of workload and  Scoping and action planning (CCG and NHSE) (Sep 17) workforce pressures and reduction in with order of priority agreed as care homes, then home impact to urgent care system (by Dec visiting and integrated telephone triage 17).  Installation from Aug 17 of telephone triage capacity (b) Develop a model for provision of (Devon Doctors) at Ocean Health Group (use for learning) home visits. Implementing this will  Scoping with Devon Doctors for potential options complete. maximise the easing of workload and Planned for 5 days over Christmas / New Year for Devon workforce pressures and reduction in Doctors to provide. Not implemented due to governance Model of Care: impact to urgent care system (by Dec concerns. Other remote support offered instead.  At Scale Model 17). (eg Primary (c) Develop a system of integrated Key milestones: Care Home) telephone triage for practices.  Following feedback received at a meeting with GP Implementing this will maximise the  Pathways of practices, medical cover for patients in intermediate Care easing of workload and workforce Home beds provided by Devon Doctors from 22/1/18 with Care (eg Care pressures (by Dec 17) and reduction Homes) support for practices requiring capacity for services for care in impact to urgent care system (by home patients Dec 17).  For telephone triage, review to either close or explore in (d) Review benefits of Primary Care other ways. Home initiatives at Beacon Medical Group and determine whether Primary Care Home is a good model for wider Western (scale to be determined) (d) (e) Review financial risk management Key milestones: barriers and opportunities for GP  Evaluation of Beacon Medical Group Primary Care Home practices to enable system integration (e) through development of an ACO. Progress updates: (f) Review the boundaries for GP practice federations to ensure they  Beacon ACO working group meets monthly WESTERN LOCALITYPage SYSTEM 11 IMPROVEMENT BOARD

enable integrated primary care and Key milestones: development of health and wellbeing  To be determined through Beacon ACO group (ongoing) hubs. (f) (g) Develop a single team / single point of Key milestones: contact approach for mental health.  For discussion and agreement of milestones at Primary (h) Finalise and implement Livewell’s Care Partnership (Dec 17) (NB interdependencies with offer of resource Health and Wellbeing Hubs, development of integrated (i) Maximise opportunities for Community primary care) Pharmacy to reduce demand on (g) General Practice Key milestones: (j) Develop triage to community pharmacy by 111 using DDocs  Being progressed by the Mental Health Commissioning Team (k) Implement online consultation (h) (l) Take opportunities to use IT effectively to enhance patient care Key milestones:  Discussed at Primary Care Programme Group (Oct 17) Progress updates:  Implementation in line with relevant priorities (as plan) (i) Key milestones:  Scope with Primary Care Partnership (by Mar 18) (j) Progress updates:  Submitted application to Integrated Pharmacy Fund (k) Progress updates:  Project Plan in place Key milestones:  Review interest from Practices  Support Practices with roll-out (l) Key milestones:  Liaise with colleagues in IM&T to align delivery of relevant strategies (a) Reduce patient demand on general (a) practice where a better alternative is Progress updates: available  Social Prescribing will be available in all Plymouth and (b) Ensure appropriate services are some South Hams and West Devon Practices from early available in relation to demand 2018 (c) Inform patients and redirect demand  Training of Care Navigators where appropriate from Urgent Care. Increase capacity within the system Key milestones: (d) Ensure plans and funding for  Develop scope, priorities and trajectory for reduction in Access and extended access (w.e.f. Apr 19) align workload over the next 2 years (March 18) Workload with national specification and funding  Deliver project (timescales TBC but should have some criteria/dates and the aims and measurable positive impact by spring 18) objectives of this programme (b) (e) Review DRSS to address practice Key milestones: concerns that DRSS creates a barrier  Scope for each tranche of service change between primary and secondary care (c) rather than an aid to efficient referral management and relationships Progress updates: (f) Eradicate duplication in patient  CCG, NHSE, PHNT and Livewell regular liaison with experience for QOF (across GP, actions WESTERN LOCALITY SYSTEMPage 12 IMPROVEMENT BOARD

pharmacy, PHNT, Livewell, Devon Key milestones: Doctors etc)  Further analysis at practice level to ensure mitigations are (g) Expand the Single Trusted effective (monthly monitoring) Assessment used by PHNT and (d) Livewell to general practice to avoid Progress updates: delays in discharge from hospital  Initial scoping of extended access take-up (current DES), (h) Facilitate practices sub-contracting mapping with potential hubs and development of primary with each other for the full range of care at scale enhanced services (all commissioners) Key milestones:  STP-wide preparation of opportunities to meet national requirements (Jan 18)  Plans developed through Primary Care Partnership (by Jan 18) in liaison with other programmes, particularly urgent care and mental health (e) Key milestones:  Determine project lead (Jan 18)  In liaison with planned care, prepare project plan (Jan 18)  Deliver project (timescale TBC in project plan) (f) Key milestones:  Scope opportunity and prepare project plan (Jan 18)  Deliver project (timescale TBC in project plan) (g) Key milestones:  Determine project lead (Jan 18)  In liaison with urgent care, prepare project plan (Jan 18)  Deliver project (timescale TBC in project plan) (h) Key milestones:  Summary proposal to Primary Care Partnership meeting (Dec 17)  Identify opportunities (websites) for practices to inform others of asks and offers (Dec 17)  Identify administrator and protocols (Jan 18)  Implement (Apr 18)

(a) Develop a system Workforce Plan Progress updates: (b) Determine ‘Workforce Gap’ (ie  Workforce workstream leadership in place difference between current workforce and future workforce needs)  Primary Care Conference supported (Nov 17) (c) Arrange clinical interface opportunities  Positive discussions with PHNT and Medical School to (e.g. evening sessions) for GPs, create best environment Workforce practice nurses, consultants, specialist  Variety of pharmacy roles in practice with various funding nurses and others mechanisms (Practice, CCG, NHSE) (this section to be aligned with STP (d) Enable portfolio careers by finding  CCG/Livewell/PHNT agreement for system working in Workforce Plan) how the system can allow trainees to Pharmacy to improve recruitment and retention of work across organisations, eradicating pharmacists. Inaugural meeting of System MO and barriers and duplication Pharmacy Board to oversee (19/10/17) (e) Simplify career navigation such that  Good liaison with proactive LPC the clinical workforce are enabled to  HEE funding received make career changes which meet a Key milestones: workforce need in our local system (f) Enable GP career changes for joint  Set delivery plan within STP-wide primary care workforce WESTERN LOCALITYPage SYSTEM 13 IMPROVEMENT BOARD

primary/secondary care roles required strategy by the system  Continue to deliver HEE funded-plan for Plymouth (g) Describe the role of Physician Assistant and determine whether this is useful locally (h) Arrange action learning sets for training grades / all clinicians (i) Implement a health passport across the local system so the workforce can share and not duplicate mandatory training across organisations (j) Enable and increase placements of student nurses in practices (k) Find a way to join up recruitment across organisations (l) Ensure maximum advantage is taken of the GP international recruitment national programme in partnership with PHNT and the Medical School (m) Better understand, optimise and secure the role of clinical pharmacists and pharmacy technicians

(a) Progress updates:  Data being exchanged between organisations ad hoc, with appropriate information governance, through various projects including practice dataset (May 17), Beacon ACO (ongoing) Key milestones: (a) Data exchange between  Finalise information sharing protocols commissioners and providers (CCG,  Implement within projects across organisations NHSE, PHNT, Devon Doctors, Livewell, pharmacies practices, (b) Data, Quality AHSN) and decisions taken as a Progress updates: and Safety result  CCG medicines optimisation and NHSE liaising (b) Improve outcomes for patients with  Action plan developed (11/10/17) chronic pain  Positive Practice Engagement meeting (14/11/17) (c) Promote benefits of intra operability  Pilot commenced (23/11/17) Key milestones:  Pilot evaluation (c) Key milestones:  Liaise with colleagues in IM&T to align delivery of relevant strategies (a) (a) Ensure practices’ delivery of At Scale Progress updates: and Resilience plans is embedded in  Supportive review taking place with practices (ongoing) relevant activities in each workstream Key milestones: Change Support and that practices are using At Scale and Resilience funding to best effect  Ensure next tranche of funding implemented to support (b) Recruit Change Manager to support delivery of this programmes aims and objectives (in practices and practice groups to make progress) required change more rapidly  Practice specific priorities agreed for 17/18 (b) WESTERN LOCALITY SYSTEMPage 14 IMPROVEMENT BOARD

Progress updates:  CCG/NHSE urgently exploring potential for joint post to better integrate opportunities and levers for change Key milestones:  Recruitment (timescale TBC)

(a) Progress updates:  PCC OPE working with Beacon Medical Group (a) Ensure live ETTF projects will deliver (b) (b) Create a plan for infrastructure (estate Progress updates: Resource and IT) change required with  Primary care estate sub-group of health and wellbeing Enablers consideration of whole system (urgent hubs programme group developed care, elective care, mental health etc)  Crafting initial plan for IT and telephony liaising with other programmes etc Digital Roadmap Key milestones:  Develop project plans ensuring estate and IT are planned together (Feb 18) Progress updates:  Initial scoping of immediate opportunities with CCG complete (Sep 17)  Primary care commissioning input to winter plan communication (Sep/Oct 17)  Winter comms plan shared with practices (13/10/17)  MP briefings (Sep/Oct 17) (a) Ensure change is supported by  Western GP Forum (17/10/17) Communication communication and engagement – and scope is all stakeholders (public,  Health navigation information now included on Engagement patients, providers, voluntary sector, Practice phone messages national) supporting all workstreams  Teleconference CCG and NHSE with practices re messaging and channels to support practices (19/10/17)  Z Flyer distributed to 70,000 Plymouth homes (Dec 17) Key milestones:  Continue implementation of communications plan and engagement with practices to inform (ongoing)

Note – this plan is under review by the Western Primary Care Partnership. Page 15 PLYMOUTH CITY COUNCIL

3. That partners in the Health and Social Care System lobby for review of the Carr-Hill Formula funding and identify how more funding would benefit GP Surgeries within the most deprived areas of Plymouth, reporting progress to the next meeting of the Select Committee;

A number of areas of work are ongoing, not specifically triggered by the Select Committee but part of the response to the issue, focussing on different opportunities to influence.

 The Carr-Hill formula review is underway and is being led by technical experts. The timeline for reporting findings has been extended several times, with a current date of April 2018. I have explored whether we could provide information and insight to this review team, but membership of the group has not been made public. However, previous review findings agreed with the view that deprived populations are underfunded using the current formula, and this is evidenced through published research papers, and so it is reasonable to anticipate that recommendations will be in favour of increasing funding to primary care in our most deprived areas.

 Through the Primary Care Committee (which involves NEW Devon CCG, NHS England and public health), an ‘Atypical practices’ workstream (considering the specific factors that lead to a practice being essentially underfunded for its population) has been in place for some time. An initial review of the literature highlighted deprivation as a key factor but one that would be addressed as part of the Carr-Hill work; however, as it became clear that this was not going to result in any alteration to funding in the near future, a paper was prepared to support additional funding for deprivation. This was agreed, and in total £100k was provided to GP practices who have the highest population in the most deprived decile (10%), when compared to the average England population.

 The issue of funding has been raised with local politicians, along with updates around the position of primary care in Plymouth. There is awareness of the issues and that insufficient funding for the complex issues faced in deprived populations is almost certainly a contributory cause. This is of course in the context of inequity of funding across the NEW Devon CCG with the Western Locality area receiving a lower share of funding.

There are a number of papers that have discussed this within them. I have pulled together the issues into one short paper which is attached.

Director of Public Health

OFFICIAL Page 16 PLYMOUTH CITY COUNCIL CARR-HILL FORMULA ODPH

The current GMS global sum formula, developed with the support of a number of academic teams including Professor Roy Carr-Hill of York University, provided the basis for the distribution of global sum payments by calculating each practice’s fair share of the total global sum resource. The formula did not determine the total global sum resources available nationally. The Carr-Hill formula is based on analysis of consultations in the General Practice Research Database between 1999 and 2002. The current formula takes account of six key determinants of practice workload and circumstances: (i) patient sex and age for frequency and length of surgery and home visit contacts (ii) nursing and residential home status (iii) morbidity and mortality (iv) newly registered patients (v) unavoidable costs of rurality (vi) unavoidable higher costs of living through a MFF applied to the costs associated with employing practice staff. In particular, this compensates for those additional costs involved in delivering services in high cost-of living areas such as the south east of England. The main concern with the formula is that it is based on consultation / workload data which are now more than twenty years old. The role of the GP, the services they link to and the communities around them have not remained static during this time. There are two factors in particular of interest here; the age weighting, which is likely to shift funding away from deprived areas unfairly since the higher the deprivation, the younger the age at which ill health, frailty and death occurs; however, the factor for morbidity and mortality should account for this. It is not possible to understand this without looking afresh at new data on workload and the formula. However, there is considerable qualitative data that suggests that this does not adequately account for the additional complexity of these patients, in terms of wider social determinants of health. This is reflected in analysis of consultation rates by Boomla et al [1] in East London which found that an individual aged 50 years in the most deprived quintile consults at the same rate as someone aged 70 years in the least deprived quintile, and in relation to the funding; We then recalculated the age-sex workload element in Carr-Hill by weighting the population by the observed consultation rates in each deprivation quintile. For Tower Hamlets, one of the top five deprived boroughs in England, we estimated that a fair formula that allowed for the additional workload would provide 33% more funding.[1] A review was carried out, reporting in 2007 [2]. This found that, although the use of mortality and morbidity was a proxy measure for deprivation, the use of the index of multiple deprivation (IMD) was more appropriate. The findings from this review were not implemented, and in 2015, NHS England began undertaking a new review of the Carr-Hill formula, with a focus on addressing the adjustments for deprivation in particular. The review was expected to report in late 2016, since delayed to April 2018. [1] Boomla et al GP funding formula masks major inequalities for practices in deprived areas, BMJ 2014;349:g7648 [2]http://www.nhsemployers.org/~/media/Employers/Documents/Primary%20care%20contracts/GMS/ GMS%20Finance/Global%20Sum/frg_report_final_cd_090207.pdf

OFFICIAL Page 17

The Select Committee to receive a report on from Health and Social Care commissioners on how Pharmacy will be a key feature of new models of working and how pharmacists can alleviate the pressures currently being faced within primary care at next meeting of the Select Committee. - 'Report stemming from STP new models of care, Primary Care Strategy and potentials

Alleviating pressure and supporting workload in GP practices

To support the transformation outlined in the Five Year Forward View, and to contribute to the Government’s required efficiencies, a new Pharmacy Integration Fund was set up by NHS England in October 2016. More information is available at: https://www.england.nhs.uk/commissioning/primary- care/pharmacy/integration-fund/

The fund is focused on integrating and supporting the development of clinical pharmacy practice in a wider range of primary care settings, to create a more effective NHS primary care patient pathway.

The CCG, in partnership with Livewell South West has supported GP practices covering approximately 180,000 population to bid and successfully secure funding from the Pharmacy Integration fund for clinical pharmacists working in GP practices. This will not only provide additional capacity to those practices but also enable more people to benefit from the clinical expertise of pharmacists.

In addition the CCG has also made further resource available to GP practices in Plymouth to invest in both pharmacists and pharmacy technicians ensuring best use of pharmacy expertise and skill mix.

Livewell South West are employing 5 pharmacists and 4 pharmacy technicians on behalf of these practices further supporting integration into the wider community health and care teams.

Where pharmacists and pharmacy technicians are already in post they are undertaking a range of roles to reduce pressure on the GP practices including face to face patient care, dealing with medicines queries, supporting repeat prescribing processes, undertaking medication reviews and liaising with pharmacy colleagues in community pharmacies. In addition a number of the pharmacists are supporting care in care homes with positive results.

The CCG has recently supported further GP practices covering a further 60,000 population of Plymouth to submit bids for a further tranche of funding from the Pharmacy Integration fund for support recruitment of two further pharmacists. The outcome of these bids is expected shortly. Page 18

Facilitating integrated working and improved communications Where practice based pharmacists and pharmacy technicians are in post this has facilitated improved communication between GP practices and community pharmacies. In some areas this has progressed to reviewing existing services; modifying and enhancing care through a more integrated and efficient approach. The nationally recognised “Caring for care homes” programme continues to encourage working together to improve the safe use of medicines in care homes and to have a closer understanding across the interface between GP practices, community pharmacies and care homes facilitating more efficient and joined up services. More information is available at:

https://www.newdevonccg.nhs.uk/information-for-healthcare-professionals/care- homes-caring-for-care-homes-team-101665

Developing future joint working relationships

 Joint educational work is being developed to ensure that pharmacy staff are more integrated into the primary care workforce in terms of consistency and flexibility. Joint courses in navigation and conflict resolution have been planned or delivered with further courses focussed on educating pharmacy teams to be able to support primary care delivery to a higher extent including an increase in the numbers of prescribing pharmacists.  A project examining joint learning activities between pharmacists and medics has been launched with a particular focus on creating joint clinical learning networks supported by technology

Supporting urgent care

Since December 2013 the CCG has commissioned Community Pharmacies in Plymouth to supply of a limited range of Prescription Only Medicines (POMs) to treat urinary tract infections, impetigo, nappy rash and bacterial conjunctivitis reducing pressure on GP practices, out of hours and the urgent care system to treat these conditions. Plans to further integrate and utilise community pharmacy to reduce pressures and support delivery of primary care A NHS Urgent Meds Supply Advanced service commissioning community pharmacies to supply urgent repeat medications for patients following referral from NHS111 is soon to be launched in this area. The local system has been proactively lobbying nationally regarding extension of referrals from NHS111 to community pharmacy for minor self-limiting ailments. A bid has been submitted nationally to pilot in this area. Page 19

The CCG is currently working with Devon Local Pharmaceutical Committee to develop services which will be commissioned as pilots from a cohort of community pharmacies in Plymouth from April. The services will focus on:  Supporting patients to manage chronic pain ensuring optimal use of medication  Supporting patients with respiratory conditions to achieve maximal benefit from their inhalers Consideration is being given to the potential of developing a community pharmacy in greater alignment with local GP practices to reduce demand. Similarly, work is in early conceptual stage to examine if there could be any role within the community pharmacy setting to support practice extended hours provision. This is very early stage work and as a consequence may not necessarily result in a change in the approach to provision but its mere consideration shows a significant change in attitude to the potential of community pharmacy. This page is intentionally left blank Page 21

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GOVERNING BODY COMMITTEE IN COMMON

Report title: Membership Engagement for NEW Devon CCG to become Joint Commissioners of General Practice

Date of committee: 25 January 2018 Date report produced: 15 January 2018 Supporting Executive: Author (s) Name and Title: Name and Title: Mark Procter – Joint Director Primary Care Mark Procter – Joint Director Primary Care Contact Details: Report Approved by: [email protected] Name and Title: Mark Procter – Joint Director Primary Care Date 15 January 2018

Public or Private (Governing Body only): Public Private

Please state reason for inclusion as a private paper (and mark as CONFIDENTIAL):

Purpose and scope of report: Consultation Approval Information

Does this report place individuals at the centre? Yes No Executive Summary:

To outline the timeline and approach to engaging with the NEW Devon Clinical Commissioning Group’s (CCG) membership to seek their approval to move to Joint Commissioning of General Practice.

Strategic risk: (include risk number if on register) Mitigating Actions: N/A N/A Management of Conflict of interests: Conflicts of interests are recorded on the register of interests, at each committee a list of recorded declarations is provided and confirmations of declarations are requested and noted. Any new declarations must be fully recorded and included in the minutes of the meeting and notified to your own organisation via either [email protected] or [email protected] to update the central register.

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Committees that have previously discussed/agreed the report and outcomes:

The Primary Care Committee reviewed the proposed timetable and approach to engaging with the membership at its January meeting and approved recommending to the Governing Body that the CCG should go out to engage with its membership about becoming joint commissioners of General Practice.

Key recommendations and actions requested:

It is recommended that Governing Body approve engaging with NEW Devon CCG’s membership to seek their approval to apply to become joint commissioners of general practice in accordance with the proposed timeline.

Reference to other documents or accompanying papers:

Appendix A – BMA Update on co-commissioning of primary care: guidance for CCG member practices and LMCs Appendix B - JOINT COMMISSIONING ACTION PLAN - NEW DEVON CCG

Have the legal implications been considered?

N/A

Equality Impact Assessment:

  Who does the proposed piece of work Patients Carers affect? Staff  Public  Yes No

1. Will the proposal increase discrimination for people in protected groups?  2. Will the proposal reduce discrimination for people in protected groups? N/A 3. Is the proposal controversial in any way (including media, academic, voluntary or sector specific  interest) about the proposed work?

4. Will the patients or workforce be disadvantaged as a result of the proposed work? 

5. Is there doubt about answers to any of the above questions (e.g. there is not enough information  to draw a conclusion)? If the answer to any of the above questions is yes (other than questions 2 and 3) or you are unsure of your answers to any of the above, you should provide further information using Quality and Equality Impact Assessment. If an equality assessment is not required briefly explain why and provide evidence for the decision.

**Please add N/A if any of the sections are not relevant The CCG has made every effort to ensure this report does not have the effect of discriminating, directly or indirectly, against employees, patients, contractors or visitors on grounds of race, colour, age, nationality, ethnic (or national) origin, sex, sexual orientation, marital status, religious belief or disability.

1 PC Joint Commissioning report cover sheet cd.docx Overall Page 276 of 279 Page 25

If a decision is South Devon and Torbay CCG required please indicate which CCG is being asked to Northern, Eastern and Western Devon CCG X approve this report

Membership Engagement for NEW Devon CCG to become Joint Commissioners of General Practice

1. Executive Summary

1.1NEW Devon CCG is working hard and innovatively to improve the quality of care to patients and has some ambitious plans for the next five years. Co-commissioning can support the delivery of these plans through providing a more joined up commissioning approach, especially around;

 delivering care closer to home for those with long term conditions,  addressing health inequalities, and;  developing integrated working across the health, social care and voluntary sector.

1.2In addition, it will allow the CCG the opportunity to support its GP member practices to drive quality improvement within primary care, support the development of sustainable services and ensure, as a membership organisation, that the CCG has a greater influence on decisions affecting primary care locally.

1.3The Primary Care Committee has discussed joint commissioning of general practice and since meeting in common with South Devon CCG’s Joint Primary Care Committee has seen first-hand how joint commissioning works.

1.4The Primary Care Committee reviewed the proposed timetable and approach to engaging with the membership at its January meeting and approved recommending to the Governing Body that the CCG should go out to engage with its membership about becoming joint commissioners of General Practice.

2. Purpose of report

2.1 To outline the timeline and approach to engaging with the NEW Devon Clinical Commissioning Group’s (CCG) membership to seek their approval to move to Joint Commissioning of General Practice.

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3. Background

3.1 In the guidance Next steps towards primary care co-commissioning (released in November 2014), co-commissioning is described as; “One of a series of changes set out in the NHS Five Year Forward View . Co-commissioning is a key enabler in developing seamless, integrated out-of-hospital services based around the diverse needs of local populations. It will also drive the development of new models of care such as multispecialty community providers and primary and acute care systems. The introduction of co-commissioning is an essential step towards expanding and strengthening primary medical care.”

3.2NEW Devon CCG is working hard and innovatively to improve the quality of care to patients and has some ambitious plans for the next five years. Co-commissioning can support the delivery of these plans through providing a more joined up commissioning approach, especially around;

 delivering care closer to home for those with long term conditions,  addressing health inequalities, and;  developing integrated working across the health, social care and voluntary sector.

3.3 In addition, it will allow the CCG the opportunity to support its GP member practices to drive quality improvement within primary care, support the development of sustainable services and ensure, as a membership organisation, that the CCG has a greater influence on decisions affecting primary care locally.

3.4NHS England invites CCGs to take on greater responsibility for general practice commissioning through one of three models:

1. Greater involvement – an invitation to CCGs to work more closely with their local NHS England teams in decisions about primary care services

2. Joint commissioning – enables one or more CCGs to jointly commission general practice services with NHS England through a joint committee

3. Delegated commissioning –an opportunity for CCGs to take on full responsibility for the commissioning of general practice services

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3.5As of 1 April 2017, 197 (out of 207) CCGs have some form of co- commissioning agreement with NHS England. 174 CCGs have delegated commissioning arrangements and 23 CCGs have joint commissioning arrangements. South Devon and Torbay CCG have been joint commissioners since October 2016.

3.6NHS England state that they are increasingly learning that delegated commissioning is delivering the most benefit for local populations. As a result, they are encouraging all CCGs to take on delegated commissioning responsibility in the future.

4. Primary Care Committee

4.1The Primary Care Committee has discussed joint commissioning of general practice and since meeting in common with South Devon CCG’s Joint Primary Care Committee has seen first-hand how joint commissioning works.

4.2The Primary Care Committee reviewed the proposed timetable and approach to engaging with the membership at its January meeting and approved recommending to the Governing Body that the CCG should go out to engage with its membership about becoming joint commissioners of General Practice.

5. Recommendations

7.1 It is recommended that Governing Body approve engaging with NEW Devon CCG’s membership to seek their approval to apply to become joint commissioners of general practice in accordance with the proposed timeline.

Report author and job title: Mark Procter, Director of Primary Care Executive Lead: Mark Procter Job Title: Director of Primary Care Date of Approval by Executive:

NHS organisations involved: Northern, Eastern and Western Devon Clinical Commissioning Group South Devon and Torbay Clinical Commissioning Group Version 1 September 2017 2 NEWDJtCommGBJan18 (3) cd.docx Overall Page 279 of 279 JOINT COMMISSIONING ACTION PLAN - NEW DEVON CCG Month Action Lead To be completed by Retrieve previous information / paperwork completed by SDT CCG PB Determine the roles of Governing Body and the primary care committee in CCG approval and oversight MP Complete Complete confirmed decision can be made by local area NHS England to confirm the process required and approval process MP team Early discussions with the LMC MP / PB Seek Governing Body approval to start membership engagement about moving to joint commissioning MP 25th January 2018 Take early opportunities to 'warm up' the membership about the benefits of joint commissioning at MP/PB/JR/TB meetings the team are attending. Script / presentation development and Q&A MP / PB January Discuss with key individuals about the benefits of joint commissioning Set evening dates, sort venues and issue invites for events JR - LMC attendees or hosts? (MP to confirm) Slots at Locality Boards MP/PB/TB Where possible attend Jan/Feb/March dates Slots at Practice Manager groups if possible MP/PB Where possible attend Jan/Feb/March dates ToR for vote -1 vote 1 practice MP/PB

- Majority of responses to support Page 28 - Majority of practices (50%) 3 events to take place w/c 19th Feb 2018 23rd February February LMC to run the Vote MP Result beginning/Middle of March NHS England sign off MP March CCG Approval to move to Joint Commissioning MP Governing Body Meeting - 22nd March APRIL - COMPLETE Page 29

Update on co-commissioning of primary care: guidance for CCG member practices and LMCs

British Medical Association bma.org.uk

Page 30

This paper is an update of previous GPC (general practitioners committee) guidance for GP practices and LMCs (local medical committees) about options for your CCG (clinical commissioning group) to take greater commissioning control (called “co-commissioning”) including the commissioning and performance management of general practice contracts. Since the previous guidance, 114 of the 209 CCGs in England have assumed delegated commissioning responsibilities. If your CCG is thinking of doing the same it is important that you understand these changes and their implications. As a practice it is important you are aware of what is happening in your area so you can exercise your rights as a member to democratically infuence the decision of your CCG. November 2016

Key points for CCG member practices and LMCs

1) Make sure you understand the diferent co-commissioning models and their implications for your practice, including the benefts and risks of each model.

2) Engage your CCG Board. Discuss with them: – What do they see as the benefts of delegated commissioning in your area? – What are their views on holding and performance managing member GP contracts? – What will the membership of “joint committees” and “primary care commissioning committees” look like? [See ‘What do the diferent co- commissioning models mean’ for more information on these] – How will CCGs manage and mitigate the risks from conficts of interest? – What frameworks is your CCG putting in place for arbitration processes?

3) CCGs must consult their membership and obtain a mandate from members before making any decisions about co-commissioning and before submitting proposals to NHS England. GPC thinks this should take the form of a formal democratic vote of member GPs/practices.

4) CCGs should have consulted their LMC well in advance of making any decisions about co-commissioning.

5) Any CCGs taking forward delegated commissioning must update their constitutions, in collaboration with member practices.

6) If these steps have not taken place then your CCG should not be going forward with delegated commissioning. The deadline for applying for delegated commissioning in April 2017 is 5 December 2016.

British Medical Association Update on co-commissioning of primary care: guidance 1 Page 31for CCG member practices and LMCs

Contents

What is co-commissioning?...... 2

What won’t CCGs be able to do? ...... 2

What do the diferent co-commissioning models mean? ...... 3 1. Model A: Greater involvement ...... 3 2. Model B: Joint commissioning ...... 3 3. Model C: Delegated commissioning ...... 4

Conficts of interest ...... 5

Weighing up the pros and cons ...... 6

FAQs ...... 7

Policy environment update ...... 8 2 British Medical Association Update on co-commissioning of primary care: guidance Pagefor CCG 32member practices and LMCs

What is co-commissioning?

Co-commissioning refers to the process whereby CCGs can directly commission primary medical services and performance manage practices (but not individuals).

This was frst introduced in November 2014 in the document Next steps towards primary care co-commissioning for CCGs to take up from April 2015. NHS England ofered each CCG the opportunity to adopt one of three commissioning models:

– Model A: Greater involvement – Model B: Joint commissioning – Model C: Delegated commissioning

In the frst year 63 CCGs took on full delegation, with another 51 CCGs opting for it the following year. At present the number of CCGs who have opted for some form of co- commissioning are:

– Model B: Joint commissioning – 60 CCGs – Model C: Delegated commissioning – 114 CCGs

The list of CCGs and details of which co-commissioning model they are using is available here. We have assumed that the 35 remaining CCGs will have adopted model A by this point and will be working closely with their NHS England regional team.

At present, CCGs are not obliged to apply for any of the co-commissioning models. Before making any decisions and before submitting proposals to NHS England, CCGs must consult their membership and obtain a mandate from members. GPC believes that this should take the form of a formal democratic vote of member GPs/practices.

This is supported by the NHS England application pro forma requiring the CCG Accountable Ofcer and Audit Committee Chair to confrm that the ‘membership and governing body have seen and agreed to all proposed arrangements in support of taking on delegated commissioning arrangements for primary medical services on behalf of NHS England for 2017/18.’ If CCGs do not properly follow this process, including allowing enough time to consult with members, it is questionable whether any changes are valid and can be implemented.

Any CCGs taking forward co-commissioning must also update their constitutions, in collaboration with member practices.

It is critical that CCGs consult their LMC well in advance of any decision about co-commissioning and, if they decide to take it forward, involve them fully in the process.

What won’t CCGs be able to do? CCGs – regardless of the commissioning model adopted – will not have any additional powers over the performance management of individual GPs, including the medical performers’ list, appraisal or revalidation.

CCGs will not have any additional powers over the commissioning of dental, community pharmacy and eye health. NHS England are exploring options for expanding co-commissioning into wider primary care areas in the future. British Medical Association Update on co-commissioning of primary care: guidance 3 Page 33for CCG member practices and LMCs

What do the diferent co-commissioning models mean?

1. Model A: Greater involvement Greater involvement in primary care co-commissioning is an invitation to CCGs to collaborate more closely with their NHS England regional teams to ensure that decisions taken about healthcare services are strategically aligned across the local health economy. This level involves no CCG decision making on GP contracts and no conficts of interest.

We would expect all CCGs to be at least at this level.

2. Model B: Joint commissioning A joint commissioning model enables one or more CCGs to assume responsibility for jointly commissioning primary medical services with their NHS England regional team.

The functions joint committees cover are: – GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing breach/remedial notices, and removing a contract) – Newly designed enhanced services (LES and DES) – Design of local incentive schemes as an alternative to the QOF – The ability to establish new GP practices in an area – Approving practice mergers – Making decisions on ‘discretionary’ payments (e.g. returner/retainer schemes).

Within this model CCGs and NHS England regional teams can create a pooled funding arrangement to increase investment in primary care services.

Governance: Joint commissioning requires a “joint committee” or “committees in common” to make commissioning decisions. This could be with one or more CCGs and the NHS England regional team. It is for regional teams and CCGs to agree the full membership. Representatives from the local Healthwatch and Health and Wellbeing Board also have the right to join this committee as non-voting members.

NHS England’s guidance on conficts of interest does not go into a lot of detail with regards to mitigating conficts of interests for the joint commissioning model. They expect that the joint role of NHS England in decision-making will provide an additional safeguard in managing conficts of interest. However, CCGs should still satisfy themselves that they have appropriate arrangements in place in relation to their role in the decision-making process. See the governance section for the delegated commissioning model for more detail on what this could look like.

How to apply: There is no longer a formal approval process for joint commissioning; arrangements should be taken forward locally. The next go-live date for joint commissioning is 1 January 2017. All agreements and documentation should be in place before this point. 4 British Medical Association Update on co-commissioning of primary care: guidance Pagefor CCG 34member practices and LMCs

3. Model C: Delegated commissioning Delegated commissioning ofers an opportunity for CCGs to assume full responsibility for commissioning general practice services. Legally, NHS England retains the liability for the performance of primary medical care commissioning so will expect assurance that its statutory functions are being discharged efectively. This requires good communication between the CCG and the NHS England regional team. NHS England suggests CCGs taking on delegated commissioning consider collaborating or merging with other CCGs to receive requisite support.

– The functions CCGs with delegated authority cover are: – GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action, such as issuing breach/remedial notices, and removing a contract) – Newly designed enhanced services (LES and DES) – Design of local incentive schemes as an alternative to the QOF – The ability to establish new GP practices in an area – Approving practice mergers – Making decisions on “discretionary” payments (e.g. returner/retainer schemes).

These are the same functions that that the joint committee has responsibility for in the joint commissioning model. The main diference here is that the responsibility and decision- making for these functions lies solely with the CCG, as opposed to jointly with the NHS England regional teams. This means that primary care investment decisions that fall within the functions above will not require approval by the NHS England area team.

Within this model CCGs have greater fexibility to “top up” their primary care allocation with funds from the main CCG allocation.

NHS England is explicit that there is no possibility of additional administrative resources going to CCGs who apply for this model. However, they accept that pragmatic and fexible local solutions need to be agreed by CCGs and regional teams to ensure that CCGs have access to a fair share of the regional team’s primary care commissioning staf resources. It is important to hold them to account over this.

Governance: Delegated commissioning requires CCGs to create a PCCC (“primary care commissioning committee”) to oversee the exercise of delegated functions. It is for CCGs to agree the full membership of this committee. However, it is required to have a lay Chair and lay majority within both the committee and the executive. Representatives from the local Healthwatch and Health and Wellbeing Board also have the right to join this committee as non-voting members.

NHS England’s guidance on conficts of interest recommends that CCGs do not have voting rights on the PCCC. One way to ensure that this doesn’t limit clinical involvement in commissioning is by having GPs from other CCG areas and non-GP clinical representatives (such as the CCG’s secondary care specialist and/or governing body nurse lead) as voting members on the committee. The CCG may wish to consider a reciprocal arrangement with other CCGs to enable efective, but not conficted, clinical representation within the committee.

GPC recommends that LMCs also have a seat on the PCCC.

How to apply: The deadline for submissions for delegated commissioning in April 2017 is 5 December 2016. CCGs should already be having discussions with their NHS England regional team and fnance leads. They should also have consulted their membership, as well as their LMC, well in advance of making any decisions about co-commissioning and/or amending constitutions. GPC thinks this should take the form of a formal democratic vote of member GPs/practices. British Medical Association Update on co-commissioning of primary care: guidance 5 Page 35for CCG member practices and LMCs

Conficts of interest

Whilst moving to a joint or delegated commissioning structure undoubtedly raises issue around conficts of interests, there are ways of mitigating these by putting in place specifc measures in the CCG constitution. CCGs must consult with member practices about any necessary changes to their constitutions.

In order to avoid confict of interest issues, CCGs need to put in place measures that are robust, transparent and command confdence amongst member practices. This needs to happen from day one, and needs to be regularly reviewed given the changing policy environment. It is important that they involve the LMC throughout this process. As a minimum we believe that GP members of CCG boards must not be involved in any investment or performance management decisions afecting member practices.

As a number of CCGs have already started delegated commissioning there are examples of how this can be done successfully. Your NHS regional team should be able to work with your CCG to make sure arrangements are satisfactory.

GPC have published specifc guidance covering conficts of interests in co-commissioning, which includes suggested changes to CCG constitutions.

In June 2016, NHS England published revised statutory guidance on conficts of interest, specifcally aimed at CCGs exercising delegated authority. 6 British Medical Association Update on co-commissioning of primary care: guidance Pagefor CCG 36member practices and LMCs

Weighing up the pros and cons: The co-commissioning models and their implications for GP practices

Opportunities Threats

Greater – CCGs have more infuence in the – Commissioning decisions remain slow involvement development of general practice and fragmented. without any of the risks of direct – CCGs (and practices) are less able to make responsibility or accountability. changes to general practice services – Removes the risk of increased conficts than those who have decided to take of interest. on greater responsibility (widening gap between practices). – CCGs have minimal infuence over national strategy – they will not be able to design local incentive schemes to replace QOF and DES. – Risk of further deterioration of the quality of GP commissioning with remote, regional NHS England teams – Inconsistent with the direction of travel for place-based plans that support the needs of the local area.

Joint – Greater and direct infuence in the – Risk that joint structures will have no real commissioning development of and investment in accountability to individual CCGs (and general practice. member practices). CCGs must ensure – Ability to design local schemes to that they are a signifcant and equal replace QOF and DESs. partner. – Could create better collaboration – Local schemes to replace QOF and DES with neighbouring CCGs as they work may result in increased workload as together on joint commissioning practices are likely to still be expected to groups. This is consistent with wider adhere to QOF indicators which are also policy on increased collaboration across monitored as part of the CQC inspection localities through initiatives like STPs process. (sustainability and transformation – Increased exposure to conficts of interest plans). (whether real or perceived). – CCGs (and member practices) are – Could worsen tensions where the historic relatively less exposed to confict relationship between member practices of interest issues compared to full and CCG is poor or dysfunctional. delegated responsibility. – NHS England regional teams are remote – CCGs may not have the management and do not have the necessary local capacity for the workload involved in knowledge to use resources in the most delegated commissioning. efective way.

Delegated – Opportunities for GPs in CCGs to have – It can be an additional strain on resources responsibility direct leadership to infuence the for CCGs, which will inevitably have an development of and investment in impact elsewhere in the system. general practice. This should allow – CCGs commissioning, holding and for more timely decision-making for managing GP contracts could worsen practices. tensions where the historic relationship – CCGs are best placed to commission between member practices and CCG is primary/community/secondary care in poor or dysfunctional. a holistic and integrated manner. – Local schemes to replace QOF and DES – Ability to design local schemes to may result in increased workload as replace QOFs and DESs, which are practices are likely to still be expected to aligned with local strategic intentions. adhere to QOF indicators which are also – CCGs will have more power to drive monitored as part of the CQC inspection forward the development of new GP process. provider models and the fve year – Responsibility for any defcit including forward view agenda. outstanding legacy payments/debts – It fts with wider strategy to develop as well as secondary and tertiary care place-based commissioning to best overspends and defcits. support the needs of local populations. – Even more exposure to conficts of – Ofers opportunities to improve out-of- interest (whether real or perceived). hospital services and support a shif in – Paradoxically, the strict governance investment from the acute to primary structure required to mitigate the and community care setting. This is conficts of interest issue could lead to something that is being put forward in less true infuence by GPs, practices and most STPs. CCGs in commissioning general practice. – Ability to make redesign decisions As GPs continue to work at scale this across a portfolio of providers and so will become even more of an issue [See across pathways of care tailored to local ‘Policy environment update’ for more need. Opportunity to be more patient information on this]. focussed in commissioning. British Medical Association Update on co-commissioning of primary care: guidance 7 Page 37for CCG member practices and LMCs

FAQs

Are any other changes to Yes. commissioning likely? NHS England has been clear that co-commissioning reforms were the frst step towards turning CCGs into organisations which may use a capitated budget to deliver care to defned populations.

Is it true that CCGs are also soon Specialised services are still commissioned by NHS England, to be commissioning specialised although they are taking a more collaborative approach with CCGs. services? It is possible that this will change in the future.

How will local incentive schemes/ Any migration from a national standard contract could only be contracts align with national afected through voluntary action. CCG Boards cannot compel arrangements? practices to change from a national contract to a local contract. National monitoring for all QOF indicators via CQRS (Calculating Quality Reporting Service) will continue (practices should be mindful that this may put them at risk of doing new work without stopping any QOF obligations).

Will there be a formal process for No. CCGs developing local incentive There will be no formal approvals process for any CCG wishing to schemes or enhanced services? develop a local QOF scheme or local alternative to a DESs. Any proposed new incentive scheme should be subject to consultation with the LMC, and must be able to demonstrate improved outcomes, reduced inequalities and value for money.

Are CCGs bound by national Yes. regulations and/or directions with The terms of GMS contracts – and any nationally determined regards to the GMS/PMS contract? elements of PMS and APMS contracts – will continue to be set out in the respective regulations and directions and cannot be varied by CCGs or joint committees.

Are CCGs bound by national plans Yes. for MPIG (Minimum Practice Income CCGs will be required to adopt fndings from PMS and MPIG reviews. Guarantee) and PMS reviews? Any locally agreed schemes will need to refect the changes agreed as part of the review.

Do CCGs who take on additional No. responsibility have access to There is no possibility of additional administrative resources being additional resources? deployed to CCGs. Pragmatic local solutions will need to be agreed by CCGs and NHS England local teams. 8 British Medical Association Update on co-commissioning of primary care: guidance Pagefor CCG 38member practices and LMCs

Policy environment update

Since the guidance was frst published in December 2014 there have been a number of changes to the environment that co-commissioning takes place in. These may afect the way that CCGs and practices are thinking about co-commissioning. This section sets out some of these changes and considers how they might relate to co-commissioning.

Working at scale Since our previous guidance the number of GPs working at scale has continued to increase. In a recent BMA survey 43% of GPs in England reported that their practice had joined a federation or network. Whilst we support this development, it creates additional risks of conficts of interest issues for co-commissioning. There is a risk that the line between practices as members of a CCG and practices as providers within GP networks/federations or local integrated care systems will become increasingly blurred. For example, some networks could in theory cover an entire CCG area.

In June 2016, NHS England published updated statutory guidance on conficts of interest, taking on board learning from the frst wave of CCGs to opt for delegated commissioning. This should help provide CCGs with the necessary toolkit to put in place measures to restrict and negate conficts when making decisions on matters of primary care commissioning. Recently, NHS England have established a cross system task and fnish group, which the BMA has a representative on, with the aim of strengthening conficts of interest management across the NHS. Once this has concluded it is possible that NHS England’s guidance will need to be updated.

GP forward view In April 2016, NHS England published the general practice forward view, setting out a general programme of support for general practice over the next fve years. This strategy follows strong lobbying and calls for action from GPC, including our paper on ‘Responsible, safe and sustainable: our urgent prescription for general practice’. As part of the GP forward view, NHS England have committed to invest a further £2.4bn a year by 2020/21 into general practice services, representing a 14% real terms increase. They have also committed £508 million for a fve year sustainability and transformation package. This includes a £56 million practice resilience programme starting in 2016/17, £206 million for workforce measures and £246 to support practices in redesigning services. For more information on the potential opportunities for general practice from the GP forward view see our ‘Focus on the NHS England General Practice Forward View’ and ‘Focus on funding and support for general practice’.

CCGs have been asked to submit a GPFV plan to NHS England on 23 December 2016. These are expected to refect local circumstances but must, at a minimum, set out: how access to general practice will be improved; how funds for practical transformational support will be created and deployed to support general practice; how ring-fenced funding being devolved to CCGs to support the training of care navigators and medical assistants, and stimulate the use of online consultations, will be deployed. It is important to hold your CCGs to account over these plans.

The additional fexibility delegated commissioning gives CCGs puts them in a better position to create and carry out these plans. It will also make it easier for practices to hold CCGs to account over their support for general practice over the next fve years, as they will be responsible for making decisions over the funding of general practice rather than either a remote NHS England regional team or a joint committee where it is unclear who has ultimate responsibility. British Medical Association Update on co-commissioning of primary care: guidance 9 Page 39for CCG member practices and LMCs

New care models When co-commissioning was frst introduced the fve year forward view had recently been published. It promoted several new care models that break down traditional divides between primary, secondary, and community care and between health services, social care and mental health services. One example of these models is a MCP (multispecialty community provider), a new type of integrated provider that has general practice at its heart and combines the planning, budgets and delivery of primary and community care. It delivers care to the whole population, based on the registered lists of GP practices, using integrated, multi-disciplinary teams. Three diferent voluntary MCP contractual options are currently in development.

Since then, these models have been developing and the frst few are expected to “go live” during 2017. However, for these models to successfully bring about transformation they need to be matched by an equally integrated locality-based commissioning model. CCGs are responsible for the majority of healthcare commissioned services so, to work most efectively with integrated provider models, they need to have access to the full range of commissioning possibilities, including primary care.

The delegated model provides the greatest fexibility to do this in a way suited to local need as CCGs have the ability to choose how to invest from their whole budget. In the joint model, there is the option to set up a pooled budget arrangement with NHS England but there will need to be agreement across the “joint committee” or “committees in common” about how this money is spent.

For example: A CCG commissions district nursing services from its community provider. In the delegated model, the CCG could consider pooling the funding for this service with its primary care funding and arrange for district nursing services to be commissioned as part of primary care linked to GP practice nursing. This arrangement would work well for GP services that might be ofering some wider primary care services within their practice or network.

Place-based systems of care Another important development is the creation of STPs (sustainability and transformation plans), new place-based planning systems. Health and care organisations within 44 footprint areas, covering the whole of England, were tasked with creating these STPs during 2016. Among other things, STPs are expected to outline how integration across healthcare and with local authority services, including public health and social care, will be improved.

This move towards ofering more integrated care is likely to involve changing the traditional payment mechanisms used across the system. Capitated payments are one way that CCGs might approach this, particularly for patients with several complex long term conditions. Capitated payment means paying a provider or group of providers to cover the majority of the care provided to a target population, across diferent care systems. This is slightly diferent to the model currently used for primary care budgets where the payment goes to a single provider and only covers primary care activity. If there is a move to more patients having capitated budgets across wider systems of care, including primary care, then CCGs having responsibility for the majority of the health budget puts them in a better position to manage this. Page 40

British Medical Association BMA House, Tavistock Square, London WC1H 9JP bma.org.uk

© British Medical Association, 2016

BMA 20160928 Page 41 Agenda Item 6

SELECT COMMITTEE REVIEW PLAN Overview and Scrutiny

SELECT COMMITTEE TOPIC GENERAL PRACTICE IN PLYMOUTH Raised by - Health and Adult Social Care Overview and Scrutiny Committee Date - 15 November 2018

Purpose of Review The issues of General Practice in Plymouth has been of continuing concern to the Committee and by building on the previous sessions and the return of contracts by significant service providers, the Committee will review general practice services for the people of Plymouth.

The Committee to consider the current state of primary care to include:

 Progress report  Workforce Development Plan and recruitment of GPs to Plymouth  Peninsula School of Primary Care (how do we retain newly qualified GPs in Plymouth)  Health and Wellbeing Hubs  User experience  Extended Access  Digital (Skype Appointments)

The Committee to also receive an update on the following recommendations as agreed at 29 November 2017 Select Committee and 13 December 2017 Wellbeing Overview and Scrutiny Committee:

1. the Committee, via the Chair, receives further reports on every future change to GP Surgeries in Plymouth which include information on engagement and consultation activities with patients at the earliest stage;

2. the Select Committee requires a progress report on the projects as outlined within the Western Locality Primary Care Improvement Plan at its next meeting;

3. that partners in the Health and Social Care System lobby for review of the Carr-Hill Formula funding and identify how more funding would benefit GP Surgeries within the most deprived areas of Plymouth, reporting progress to the next meeting of the Select Committee;

4. the Select Committee requires an update on the work being undertaken by partner organisations to attract GP’s to Plymouth but more specifically on how we attract and retain GP’s within the most deprived areas of the city at next meeting of the Select Committee;

5. the Select Committee to receive a report on from Health and Social Care commissioners on how Pharmacy will be a key feature of new models of working and how pharmacists can alleviate the pressures currently being faced within primary care at next meeting of the Select Committee.

6. that the Chair on behalf of the Committee will write to the Secretary of State requesting that Plymouth is included as part of the Targeted Enhanced Recruitment Scheme which has been offered to

V2 01/08/16 OFFICIAL Page 42 PLYMOUTH CITY COUNCIL Cornwall to attract GPs into the area.

7. to explore Primary Care Co-commissioning and future plans for Integrated Primary Care Service to be managed more locally.

Select Committee Membership Councillor Mrs Aspinall (Chair) Councillor Mrs Bowyer (Vice Chair) Committee members from Health and Adult Social Care OSC

Process Methodology/Approach Initial evidence session to be held in the Council House with invited witnesses, presentation from officers and relevant paperwork. Further sessions to be determined by the review group.

Sources of User experience – Healthwatch Information/Evidence Councillor newsletter – any feedback from Councillors Consultation Exercises N/A Witness/Expert Participation Representatives of NHS England, NEW Devon CCG, Healthwatch, Peninsula Medical School and Public Health will be called as initial witnesses. The group may decide to call further witnesses as appropriate. Site Visits None identified. Resource Requirements Will be met through existing scrutiny resources.

Post Review Reporting Process The Select Committee will operate under powers delegated by the Health and Adult Social Care Overview and Scrutiny Committee and will make recommendations directly to Health Service Organisations. Anticipated Completion Date TBC Draft Report Deadline TBC Meeting Frequency TBC Dates of Meetings TBC Further Information TBC

SELECT COMMITTEE REVIEW PLAN Page 2 of 2 Page 43 Agenda Item 7

Healthwatch Plymouth - GP Patient Experience report November 17 to October 18

November 2018 Page 44

The information contained in this report remains the property of Healthwatch Plymouth and may not be reproduced without prior permission. Page 45

Report for GP Select Committee Over the past 12 months, Healthwatch Plymouth have received 393 pieces of feedback about 40 GP Practices in Plymouth. This majority of this feedback has been taken during our engagement programme in the city, but also via telephone calls to our freephone number and via our feedback form on the Healthwatch Plymouth website. Our engagement programme has seen us visit the following GP Surgeries during the period of this report

 Lisson Grove (2 visits)  Stirling Road (3 visits)  Mount Gould Medical Centre  Oakside (2 visits)  St Neots (2 visits)  Devonport Health Centre (4 visits)  Elm  Crownhill (2 visits)  Southway (4 visits)  Estover (2 visits)  Ernesettle Medical Centre (2 visits)  Church View ( 2 visits)  West Hoe (2 visits)  Adelaide Street (2 visits)  Knowle House  St Levans Road  Plympton Health Centre The top 10 surgeries where feedback has been given is as follows:

A full breakdown is available at Appendix A.

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Feedback Overview During the analysis process Healthwatch Plymouth, assigns Themes, Sub-Themes and the Sentiment of those themes to each piece of feedback received. This allows Healthwatch Plymouth to monitor trends. Equally once feedback has been approved, it is also subjected to an automatic analysis process that takes the context of the feedback and applies sentiment to it. This process also produces a positive and negative word map where the larger a word is portrayed the more times it has been used. GP Surgery Feedback overview November 2017 – October 2018 The overview below shows the automated sentiment analysis of all 393 GP reviews, the associated word maps and the overall star rating of GP services as given by the public.

The average public rating of GP Services in Plymouth remains relatively high at 3.8 Stars for the last 12 months compared with the average rating of 3.9 stars covering the period January 2015 – October 2018. However, it should be noted that this is an average rating and individual Surgeries will be scored above or below.

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Feedback Themes As mentioned above, Healthwatch Plymouth assigns Themes and Sub-Themes to all feedback received. The diagram below shows the sentiment against those themes for all 393 reviews (Note: a review can have a maximum of 5 Themes).

Based on the table above, the negative themes being raised are predominately about the process for Booking Appointments including the triage process and lack of Routine Appointment availability, accessing the surgery by Telephone, being able to see the same GP and waiting times in the Surgery. Equally issues around requesting repeat prescriptions including delays in prescriptions getting to the pharmacy, being treated with dignity and respect, poor communication from the surgery and receiving results from diagnostic testing have also been raised. Feedback also reflects on the attitudes of some receptionists and these are often commented upon in a negative or neutral way and can be seen by patients as a barrier to accessing the GP. Once seen by a GP, Practice Nurse or other health professional, comments by patients are generally favourable about the treatment and care received and the health professional they were seen by.

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Some examples of patient feedback The Nurse was friendly and approachable, she was very efficient. When needed, I can get an appointment. It would have been useful to have been made aware that I needed a blood test before I booked - for my 5 year check. Ernesettle Primary Care Centre December 2017 My wife attends Barton Surgery. A few months ago they changed the frequency of her repeat prescription. The first month she got far too much of one item and not enough of another. I went to the Surgery and they changed the prescription. The same happened the next month. Each month since the same thing happens no matter how many times I tell them. Barton Surgery March 2018 You cannot get hold of anyone on the phone or get through the receptionist who tries to triage you. I have been refused a call back because I would not give my details, apparently "personal" is not enough. Plympton Health Centre –Pathfields Practice May 2018 I was a patient at Tothill Surgery. They were brilliant. But since merging with Beaumont Villa I have had problems. I had the flu bug over Christmas, I received a diagnosis of a throat virus over the phone. I waited 7 weeks to see my doctor. Then when the results of my ultrasound came in, I found out from the receptionist that my doctor had retired. I have just tried to make an appointment and have been told I can’t make an appointment until 16th July as they are changing their systems. I can honestly say I am so disheartened with the lack of help or communication. I am going to have to change surgeries. I am so frustrated and disappointed with Beaumont Villa Surgery. Beaumont Villa Surgery July 2018 I needed an appointment re: my neck. Could not move it so could not drive. Impossible to get through on the phone and when you do all the appointments are gone. The Reception staff are quite rude as well. I understand they are under a great deal of pressure but they could at least be polite. They recently made a mess of my prescription, sending me the wrong tablets. When I told them they said it was my fault. I asked them to check and they had made a mistake. They did however apologise for this. Church View Surgery August 2018 I think it would be difficult to see the same Doctor but I do not really need this. I find the Nurse appropriate. The surgery has improved dramatically since the new group have started running it. Last year appointments were emergency only but it has improved. Stirling Road Surgery August 2018

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GP Medical Groups – Patient Feedback Mayflower Group - Access Health Care – Since Access Health Care took over the running of the former Ocean Health Surgeries (Stirling Road, Chard Road, Collings Park) in October 2017, Healthwatch Plymouth has gradually seen more positive feedback from patients about accessing services and GP availability at Stirling Road Surgery. However, there remain challenges particularly around the phone system. Healthwatch are aware that the phone system is due to be upgraded at the end of November. Some patient feedback still comments on the poor attitudes of some front desk staff. Overall it would appear that Access Health have turned a corner with the delivery of the service to a large patient population, predominately within the St Budeaux area. As part of the Mayflower Group, Healthwatch Plymouth is involved with NHS England’s Patient Reference Group and Project Delivery Group as part of the commissioning process for a new permanent provider. Pathfields Medical Group – Patient feedback about booking appointments and appointment availability within the Surgeries of this group remains quite negative. Whilst the group will try to offer an appointment at another surgery where capacity may exist, it is not always easy for the patient to travel. The decision about Crownhill Surgery and Beaumont Villa Surgery becoming members of the group, appears not to have been communicated well to patients. This has led to an initial period of quite negative feedback, particularly by Crownhill Surgery patients, who believe that the services they had previously been used to, had become a lot worse especially when trying to book appointments. Healthwatch Plymouth have been engaged by Pathfields around a proposal to withdraw services from Tothill Surgery and the University Medical Centre to then centralise at Beaumont Villa Surgery. We met with them to discuss a consultation exercise that Healthwatch were happy to assist in publicising to patients. We have also helped publicise a proposal to formally merge Plympton Health Centre, Laira, Efford, Crownhill and Armada Surgeries under a GMS contract from 1 January 2019. The purpose of this is to improve how the Group operates. Healthwatch understand that patients will not see any change to services provided or how they are accessed.

Healthwatch Plymouth GP Access Survey 2018 Healthwatch Plymouth conducted a survey between January and April 2018 around access to GP Services for Urgent and Non-Urgent appointments. We received 424 responses to our questions, the analysis of these are in the diagrams below.

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Q1 How long do you wait for a non-urgent appointment? All Responses

How long do you wait for a non-urgent appointment?

3-4 Weeks

2-3 Weeks

1-2 Weeks

Within a week

0 50 100 150

Top 11 Surgeries by number of responses

If requested by patient, Routine Appointment offered within 2 weeks

St Levan 78% Peverell Park 75% Dean Cross 58% Beaumont Villa 69% Ernesettle PCC 86% Plympton HC Beacon 47% Lisson Grove 63% Adelaide Street 68% Stirling Road 54% West Hoe 77% Church View 24%

0% 20% 40% 60% 80% 100%

By Medical Group/Alliance

If requested by patient, Routine Appointment offered within 2 weeks 80% 67% 70%

60% 52% 50% 42% 43% 40% 30% 20% 10% 0% Access Health Care Beacon Medical Drake Medical Pathfields Group Group Alliance

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Q2 If you requested to see a Doctor urgently, what were you offered?

If you requested to see a Doctor urgently, what were you offered?

Other 26

Next day appointment 26

Same day call back 235

Same day appointment 149

0 50 100 150 200 250 Q2b. If offered a face-to-face appointment following a call back, when was it offered to you?

If offered a face-to-face appointment following a call back, when was it offered to you?

Other 30

Within 2 weeks 29

Next day 39

Same day 138

0 50 100 150

Top 11 Surgeries by number of responses

If required, appointment offered within 48 hours of Surgery call back

St Levan 100% Peverell Park 100% Dean Cross 100% Beaumont Villa 100% Ernesettle PCC 100% Plympton HC Beacon 100% Lisson Grove 89% Adelaide Street 95% Stirling Road 67% West Hoe 96% Church View 93% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 110%

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By Medical Group/Alliance

If required, appointment offered within 48 hours of Surgery call back 100% 100% 93% 96% 90% 83% 80% 70% 60% 50% 40% 30% 20% 10% 0% Access Health Care Beacon Medical Drake Medical Pathfields Group Group Alliance

WESTERN LOCALITYPage SYSTEM 53 IMPROVEMENTAgenda Item 8 BOARD

PRIMARY CARE PROGRAMME REPORT

Programme Name Primary Care Programme Lead SROs: Dr Shelagh McCormick and Mark Procter; Programme Lead: Reporting Period To 31st October 2018

Programme Overview: Aims and Objectives

Aim: To develop and redesign primary care as part of the system of health and wellbeing

Objectives:  To achieve sustainability in primary care with respect to workforce, funding, IM&T and premises to ensure patients' access to high quality primary care provision and self-care – and at the interface of community and acute care  To support, influence and enable design and implementation of new models of primary care built around a community with integration between primary care, secondary care, the voluntary sector and the community and provided efficiently and effectively 'at scale' where appropriate while maintaining access and continuity where important.  To maximise and influence investment and resource opportunities, prioritising according to the needs of the population and the needs of the health and wellbeing system, whilst supporting innovation WESTERN LOCALITY SYSTEMPage 54 IMPROVEMENT BOARD

Activity Work stream Progress Updates and Key Milestones Status (Projects) a) Western Primary Care Partnership operational - WPCP operational. Participation from CCG, local GP's, (accountable to the Western System Improvement practice managers, LMC and partner groups including C o m plet e Board) and driving forward Primacy care strategy for UHP, Livewell, Pharmacy, and Plymouth and Devon County (D ec -17) Western Councils - Chair to transfer from CCG lead to GP provider lead D ec -18 December 2018 b) Local Care Partnership Board operational to ensure - LCP Board operational C o m plet e alignment across partner organisations c) Practice Manager Liaison Meetings operational to - PMLM operational enable co-development of ideas, review progress of - Meeting purpose, scope and attendee list reviewed and C o m plet e activities in flight and understand & resolve barriers to modified September 2018 (Sep-18) change d) Participation in strategic STP, network and ad hoc - Annual Western GP forum took place October 2018 events to keep abreast new opportunities - Participation in Internation GP Recuitment Fair October Leadership and C o m plet e governance for 2018 (Oc t -18) transformation - Attendance at the Workforce development workshop September 2018 e) Western Primary Care strategy development - Strategy for General Practice (2017-2021) document C o m plet e approved March 2018 by Joint Governing Body (J ul-18) - Western strategy workshop conducted in July 2018 - Plymouth Health and Wellbeing System Strategic C o m plet e Commissioning Intentions 2018-20 developed July 2018 (J ul-18) - Development of "What Good Looks Like" for Western (to J an-18 cover f) Leadership Training - For practice managers C o m plet e (J ul-18) - For clinicians N o v -18 g) Communication & engagement - Supported by above mentioned for a - Newly fortnightly bulletin sent to all practice managers by C o m plet e (Oc t -18) Western Primary Care Team a) Primary Care Network (to aligned to the place and - Project initiation and feasibility assessment J an-18 neighbourhood service delivery and leveraging key - Development of a strawman for place and neighbourhood D at e T B A learnings from Primary Care Home pilots) in the Western system b) Development of Health and Wellbeing Hubs - Four Greens hubs opened C o m plet e (Oc t -18) - Mannamead hub to be opened N o v -18

c) Co-ordinated Care Home visiting - Intermediate Care Home cover provided by DDOC C o m plet e operational (J an-18) - Temporary Residents visiting scheme extended C o m plet e (Sep-18) - LES for Care Home visiting to be developed J an-19 d) Mental health transformation Single team / single point of contact for mental health. N o v -18 - Proposal from Livewell to be presented to WPCP e) Community pharmacy transformation Process improvement review - Process review completed, workflows and processes C o m plet e Models of Care modified with prositive results observed. Presentation to (Oc t -18) e.g. Western PCP Integrated Care Community pharmacy triage facility N o v -18 Models - Digital Minor Injuries Service (DMIRS) project go live Care Pathways f) Long term conditions transformation Diabetes Programme C o m plet e - Community physician now in place to support virtual (Oc t -18) clinics and diabetic specialist nurses Respiratory Pilot - Pilot commenced October 2018 for respiratory consultant In pro gres s to work with one practice group g) Prescibing transformation Respiratory Home Oxygen Review C o m plet e - Review to identify prescribing fund re-investment (Oc t -18) opportunities Spirometry Review N o v -18 - Kick off meeting with practices scheduled in November h) Use of technology to enhance models of care - UHP review of system one as a possible solution to C o m plet e integrated technology across providers (Oc t -18) - Primary care working group to be set up to understand N o v -18 requirements WESTERN LOCALITYPage SYSTEM 55 IMPROVEMENT BOARD

Activity Work stream Progress Updates and Key Milestones Status (Projects) a) Reduce patient demand on general practice where a Social Prescribing Pilot better alternative is available - Twelve Practices across Plymouth participating in Social Prescribing Pilot with Wolesely Trust. Four additional In pro gres s practices to be added Autumn 2018. - Pilot assessment due mid-October Care navigation training - Four Practices participating in 6 month Pilot at Four In pro gres s Greens Hub (Care Coordinator Role) First contact practitioner (physio) N o v -18 - Principal agreed with UHP, pilot practice to be identified eConsult - Presentation at Western annual GP forum C o m plet e - Inclusion (where appropriate) of eConsult within (Oc t -18) tranformation fund submissions eConsult Access and D ec -18 - Scoping by practice groups Workload DRSS workload impact to primary care review C o m plet e - Review found that workload was reduced for practices (Sep-18) Repeat prescibing utility (hub) pilot - Call centre supported by DRSS for Drake/Pathfields, pilot N o v -18 to commence Single Trusted Assessment for hospital discharge N o v -18 - Third post advertised b) Improved access for patients Improved access live across Western population C o m plet e - Services provided by Beacon Medical Group and DDOC (Oc t -18) - Early visiting and care home support schemes for winter N o v -18 to be agreed - DDOC access to full patient record (EMIS & System One) D ec -18

- DDOC provision to be rolled out across multiple locations M ar-19

a) Develop primary care specific plan of activities which - Scoping exercise to be completed align with Western and STP Workforce Programmes N o v -18

b) Participation in GP recruitment initiatives - Good level of attendance at International GP recruitment C o m plet e Workforce event (Oc t -18) (aligns with STP c) Improving clinical interfaces Twinning activities Workforce Plan) - In progress to share knowledge and understanding across In pro gres s organisations (lead J Cope) Medical Executive Committee tabled a discussion on this, Mark Procter tasked with leading future work In pro gres s - Future activities to be identified a) Development of data exchange between - Data workshop held with BI commissioners and providers (CCG, NHSE, PHNT, Data, Quality In pro gres s Devon Doctors, Livewell, pharmacies practices, AHSN) and Safety with agreed response mechanisms b) Improve outcomes for patients with chronic pain - Future activities to be identified N o v -18 a) Transformation Funding Activities - Transformation fund 2018/19 meetings concluded and MOUs drafted (Oct 2018) In pro gres s - Monitoring of progress (on-going) b) Resilience Fund Activities - Resilience fund 2018/19 discussions concluded and Change Delivery MOUs drafted (Oct 2018) In pro gres s - Monitoring of progress (on-going) c) ETTF Activities - Kick off calls/meetings took place (2018) In pro gres s - Monitoring of progress (on-going) This page is intentionally left blank Page 57 Agenda Item 9b

LIVING AND WORKING IN PLYMOUTH

“To overlook this city would be to miss out on its rare charm and cultural scene which, given upcoming multimillion-pound investments, is set to flourish.” The Times “The coolest little city by the sea. Discover Plymouth first and retain bragging rights forever” GQ “One of the top 10 growth clusters in the UK. ‘Britain’s Ocean City’ is not just picturesque, it is making waves with an early stage cluster of science and digital tech businesses too.”Tech Nation 2017 Page 58 AN EXCITING TIME TO WORK IN PLYMOUTH Located at the heart of the South West, Plymouth is a city by the sea with so much to offer. With an amazing quality of life, stunning waterfront location, buzzing city centre and fascinating maritime history, there is quite simply nowhere better to live, work and play than Britain’s Ocean City. Plymouth is an ambitious city with huge growth potential and exciting major changes ahead. We have already seen the growth of the university, the redevelopment of Royal William Yard and Millbay, one of the UK’s top 50 regeneration projects. Theatre Royal Plymouth is the Over the next five years Plymouth will see an ambitious capital best attended and largest regional investment programme, driven by Plymouth City Council, with circa producing theatre in the UK £100m each year to be invested into providing developments and infrastructure to support a thriving environment for businesses and residents.

AN OUTSTANDING QUALITY OF LIFE Plymouth offers an outstanding quality of life, with its fantastic location by the sea and the dramatic expanse of Dartmoor National Park as a backdrop. The sheltered waters of Plymouth Sound and adjacent rivers offer the perfect location for a huge range of water-based activities from sailing, paddleboarding, wakeboarding to scuba diving the many wreck sites. Plymouth has hosted a range of internationally recognised events, such as the Rolex Fastnet Race, the British Firework Championships, MTV Crashes Plymouth; and holds annual events such as Plymouth Half Marathon, Armed Forces Day, Mega Ride, Seafood Festival, and Bonfire Night, to name just a few. Theatre Royal Plymouth is the Plymouth is the greenest city in largest regional producing theatre in the UK, attracting some of the the UK, with 40 per cent of the top touring shows in the UK and has recently undergone a £7m city being green space. refurbishment. Plymouth is also positioned perfectly for playing a round of golf, being surrounded by nine courses. If cycling is your passion, Plymouth is great for getting out on your bike; it’s on the crossroads of National Cycle Network routes and on the edge of Dartmoor where some of the most amazing and challenging slopes for mountain biking can be discovered. Page 59 A GREAT PLACE TO LIVE A wide choice of housing is available in Plymouth and the surrounding area and, with water surrounding approximately two-thirds of the city and moorland and countryside the remaining third, many residential areas have spectacular waterfront or country views. The city offers a wide variety of housing with large Victorian style houses in areas such as Stoke, Peverell, Mannamead and Hartley, all within close proximity to the city centre. For more modern living with character and fantastic views, we have Royal William Yard, the former Royal Naval victualling yard and Mount Wise, Plymouth’s new village by the sea. Just outside the city, areas such as Plympton and Plymstock offer a Average house prices in Plymouth wide range of housing with excellent community facilities such as are around 31 percent cheaper shops, schools, libraries etc. than the national average. Towards the north of the city is Derriford which is also home to Plymouth Hospitals NHS Trust, the largest hospital in the South West, and also only 10 minutes away from Dartmoor National Park. A wide selection of large detached properties can be found within this area. Just outside of Plymouth is the South Hams, a region of rural and coastal Devon. To the north side it stretches to the edges of Dartmoor National Park, to the south it covers one of the most beautiful stretches of coastline in the UK from Torbay to Plymouth.

GOOD FOOD To relax and soak up the waterfront views and city’s atmosphere Plymouth has a burgeoning reputation as a foodie heaven. Royal William Yard with its Grade I Listed former Royal Naval victualling buildings is coming alive with cafés, bars, restaurants and art galleries, including Le Bistrot Pierre, Wagamama and Las Iguanas to name a few. Plymouth boasts the second Make the most of the city’s fantastic local food produce by enjoying highest number of Gold Anchor freshly caught fish, the UK’s best Fish and Chips and a fantastic array marinas in the UK offering some of artisan bread, locally brewed beer, home grown wine and the most of the best berthing facilities. delicious cream teas, cream first of course! Plymouth is home to the second largest fish market in England, and sells over 6,000 tonnes of fish each year! A fantastic place to get the freshest locally caught fish. Page 60 IN GOOD COMPANY Plymouth benefits from a vibrant mix of innovative, globally leading businesses ranging from marine and high tech manufacturing, healthcare to research, digital, arts and creative industries. There are plenty of opportunities to develop your career. HEALTH Derriford Hospital, Plymouth is the largest teaching hospital trust in the south west. It employs more than 6,500 staff working in 350 different roles, plus hundreds of volunteers. It has a number of specialisms making it an exciting place to further your career, including supporting an aging population. There are also a number specialist medical companies operating at Plymouth Science Park. Plymouth has a strong pipeline of 10,000 construction jobs demonstrating the city’s growth From a professionals perspective... potential and commitment. Peninsula Postgraduate Medical Education “consistently receives some of the best feedback and exam pass rates in the country”. We have been top of the National Deaneries in the GMC survey for the last six years. This is a survey of all GPs in training across the country. The Plymouth area had a 97 per cent satisfaction rating from our trainees. Our local scheme achieves these results from registrars due to the quality of trainers practising in the area, the patients, the practice teams and the fantastic surroundings combined with all that is on offer. Many doctors like to have a special interest and we encourage this; you can undergo further training to become a GP with a specialist interest (GPSI). However, you do not need this additional qualification to work some sessions in hospital in your preferred specialty as a Staff Grade doctor. You can now become a trainer for new doctors after one year practising as a GP. I studied in Scotland and then moved to Devon to train in general practice. After practising in the South East, I came back to Devon as soon as it was possible to return. The attraction was somewhere 12% of Plymouth jobs are in the warmer to live with a better quality of life. In a recent cold snap when manufacturing industry, exceeding it was minus 12 degrees in the Midlands, and snow bound in Oxford, the national average of 8.3% we had 12 degrees plus and sunshine here in Plymouth. Plymouth has a long history of adventure and exploration. Now it’s your adventure to come and explore medicine in primary care. Dr Peter von Eichstorff Page 61 CULTURE AND CREATIVE Plymouth is home to an eclectic and diverse creative industries sector, which includes creative and digital media, audio-visual, design TV and film production, visual arts, music technology and games development. Made up of a vibrant mix of cultural businesses including the award winning theatre production centre TRP, a rich programme of arts and cultural performances across the year and a growing number of artists and creators the city’s reputation as a centre for high quality creative industry is growing. With nationally and internationally recognised companies, such as Two Four Productions, Bluestone 360 and Sponge, having headquarters in Plymouth it’s clear to see the growing creative and digital sector within the city has huge potential. Creative industries are increasingly becoming an important ingredient to enhance productivity in Plymouth’s traditional key sectors such as 90% of Plymouth postcodes are marine, manufacturing, medical and healthcare through the integration covered by Ultrafast broadband, of creative technologies from enhanced design, to computer rating Plymouth as the 5th in the modelling, artificial Intelligence and gamification. country for broadband connectivity With major significant cultural activities on the horizon, including the £34m development to create ‘The Box’ Plymouth’s cultural and heritage hub, and the internationally significant Mayflower 400 commemoration in 2020, Plymouth offers a bright opportunity for businesses to thrive.

VISITOR AND LEISURE Plymouth is a major driver in the wider regional visitor economy acting as a key centre from which leisure, business and studying visitors can explore Cornwall and Devon. With plans to commemorate the 400th annniversary of the sailing of the Mayflower in 2020, the city has advanced regeneration plans for the railway station, plans for a new £50million investment boutique hotel on Plymouth Hoe and a new £50million investment by British Land to create a new leisure destination in Plymouth city centre. The city’s visitor and leisure economy is growing and offers exciting opportunities for the future. A global centre of excellence for marine science and technology and SKILLED AND ADAPTABLE has one of the largest clusters of WORKFORCE expertise in the world. With two award winning universities, a thriving Art College and the expanding City College Plymouth, the city continues to develop and grow new talent and a business-focused potential workforce. The new £13m Regional Centre of Excellence for STEM facility at City College Plymouth will be vital for helping Plymouth employers meet their needs for highly skilled employees of the future. Page 62 A GREAT WORK LIFE BALANCE Plymouth is not only a great city to work, with close proximity to the Moors, the water and a vibrant city centre offering everything from retail to food and arts and culture you’ll be spoilt for choice with the leisure opportunities on your doorstep.

SHOPPING If shopping is your thing, you’re in luck. The city centre, with its mix of large department stores, high street staples and boutique shops, is a Plymouth ranks third for its quality spacious pedestrianised precinct, easy to access and navigate. of life against 20 of Britain’s largest cities according to the Sustainable The West End offers a mix of small retailers, cafés and galleries, Cities index 2010 and the 150-stall indoor Plymouth Market where goldsmiths rub shoulders with produce growers and specialist delis. To the east is Drake Circus, winner of UK Shopping Centre of the Year 2017, with all you would hope for or expect from a modern undercover mall experience – easy parking, more than 60 shops including top brands and a food court to refuel. The Elizabethan streets of the Barbican, by contrast, offer a quirky treasure trove of artisan makers, arts and crafts, prints, paintings and sculpture.

ARTS AND CULTURE Plymouth is the West Country’s cultural and entertainment capital with a dazzling year round variety of performance, music and art venues, festivals and events. Headline acts amongst these include the Theatre Royal Plymouth, the UK’s largest regional producing theatre, featuring a diverse programme of stage shows in its two auditoria. Plymouth’s Drake Circus shopping The Barbican Theatre offers drama and contemporary dance in an centre won the accolade of UK intimate setting, while Plymouth Pavilions presents an exciting mix of Shopping Centre of the Year 2017. top comedy and music performers. Plymouth University’s Peninsula Arts and The Gallery at Plymouth College of Art curate an eclectic range of contemporary art and culture, with a cutting edge theatre and dance programme in The House. You can also catch the latest independent cinema and art exhibitions at Plymouth Arts Centre, on the Barbican. Celebrated artists associated with Plymouth include George Passmore (half of the collaborative duo Gilbert and George), Beryl Cook, Robert Lenkiewicz and Royal Academy founder Sir Joshua Reynolds. Today, the art scene is as dynamic as ever, supported by renowned independent galleries and represented by the many artists and craftspeople working in the Barbican and at Ocean Studios in Royal William Yard. Page 63 HERITAGE The Barbican alone boasts more than 200 listed buildings; turn any corner or explore any cobbled lane and you’ll be faced with a Tudor or Jacobean gem, such as the facades of Merchant’s House on St Andrews Street and Elizabethan House on New Street. Another of those jewels in the city’s crown – or perhaps the olive in its Martini – is the world-famous Plymouth Gin Distillery on Southside Street, a former Black Friar monastery dating back to the 1400s. Take a tour, see how it’s made – and taste the tipple. With Plymouth investing in the development of a new History Centre due to open in 2020 as the flagship building for the Mayflower 400 commemorations there’ll be even more Plymouth is surrounded by nine opportunities to find out more about Plymouth’s rich and colourful golf courses - two more than St history. Andrews, Fife, the home of golf.

OUTDOOR PURSUITS Whether you’re keen to explore by foot or by water, Britain’s Ocean City has a fantastic array of outdoor pursuit options to help you make the most of your time outside of the office. Swim outdoors in style at the beautifully renovated Art Deco seawater Tinside Lido on the Hoe foreshore, or the free family Mount Wise pools; the less hardy might prefer the superb indoor swimming and diving facilities at the Plymouth Life Centre, where Tom Daley and Tonia Couch have trained. For the adventurous, the Mount Batten Water Sports and Activities Centre offers courses in kayaking, coasteering, climbing, stand up paddleboarding, powerboating and dinghy sailing.

Offshore, divers flock to explore wrecks and reefs – as do anglers Whitsand Bay, a short drive from keen to get among the conger, pollack and bass they hold. Plymouth, is home to Scylla Reef, The cruising waters of the Sound and the rivers Plym, Tamar and created by the controlled sinking Yealm are, understandably, also a huge draw for sailors – particularly of Royal Navy frigate HMS Scylla. as Plymouth has such fine berthing facilities. On land you can enjoy the green expanse of Plymouth Hoe, Saltram House or Mount Edgcumbe on a sunny afternoon, or take a walk along the South West Coast Path to enjoy nearly nine scenic miles across Plymouth. Offering a taste of the countryside beyond the city, the 10-mile but easy-going Plym Valley Trail follows the route of an old Great Western Railway track. Further afield you’ve got the wild expanse of Dartmoor offering idyllic walks, rugged Tors and great terrain for walking, cycling or horse riding, whatever takes your fancy. Page 64

Plymouth has been rated as one of the best place for families to live according to The Sunday Times

Plymouth is the ‘coolest little city by the sea’ according to GQ and COMMUTING AND ranked as one of the coolest places TRANSPORT to live by The Times. Plymouth is easily accessible via main transport networks, including road, rail and sea and is just two hours by road from Bristol and three hours by train from London. Plymouth has a central train station situated just a short walk from the city centre, where the newly built Plymouth Coach Station can also be found. There are 24 daily services running each way between Plymouth and London during the working week, three of which are high speed services offering journey times of just over three hours. The latest rail timetables for the Tamar Valley and Looe Valley lines and other rural branch lines in Devon and Cornwall can be downloaded at www.greatscenicrailways.co.uk Visit www.nationalrail.co.uk for more information on trains serving Plymouth. Page 65

Plymouth benefits from an award winning local transport network.

The largest Naval Base in Western Europe the HMNB Devonport and home to luxury boat builder An extensive choice of international flights is available from Exeter Princess Yachts International and Bristol airports located just one and two hours away respectively. Bristol offers connecting flights to over 110 destinations via Dublin, Brussels, Germany and Amsterdam. Exeter airport - www.exeter-airport.co.uk Bristol airport - www.bristolairport.co.uk Britain’s Ocean City location also offers the opportunity to pop to France or Spain for the weekend on one of the frequent Brittany Ferries services from Plymouth to Roscoff and Santander. And with developments underway for a new Railway station and Cruise Liner facilities, Plymouth is set to offer even more transport options in the next few years. Page 66 SCHOOLS IN PLYMOUTH Plymouth benefits from a wide range of education options including academies, grammar schools, free schools and schools specialising in engineering, health and sport. The city also contains further and higher education colleges, private fee paying schools and two Universities. We have a diverse and comprehensive offer of education designed to meet the needs of all young people. To find schools in Plymouth visit www.plymouth.gov.uk/ plymouthschoolsdirectory . Children in the city benefit from having the opportunity to enjoy high quality early years education to ensure an excellent start to 86% of Plymouth Primary and their learning. 97% of three year olds take up the offer of an early Secondary Schools were judged education place. We place high importance in helping children ‘good’ or ‘outstanding in August to achieve a flying start to their learning and provide early years 2016 providers with a range of support measures designed to enhance their offer to children and parents. This positive start is successfully built upon by primary schools that put learning at the centre of all that they do and who work in partnership to raise standards. Parents and carers have a 90% chance of obtaining their choice of primary school. Led by some of our outstanding primary schools, school leaders have well established arrangements for improving learning across the city. The curriculum offered by primary schools is rich, broad and balanced, and is designed to embed the basic skills needed for success in later life. Culture awareness is encouraged and all children are encouraged to be actively involved in our Mayflower 400 Commemorations. Secondary schools ensure that the city’s young people continue to make progress by offering a curriculum that is relevant to meet the needs of a modern economy. Pupils enjoy a well-rounded education but at the same time can specialise in subjects such as engineering, health and sport. Plymouth schools have been successful in helping In Plymouth, there is a wealth pupils to progress to become Olympic swimmers and divers and of high quality STEM education over 95% of Post 16 pupils’ progress into employment, education or available from primary school to training, which is above the national average. university. All schools are well supported with a range of services allowing pupil to progress through the key stages. Well established arrangements are in place for children whose first language is not English and provision for children with special educational needs and disabilities is highly effective with a strong local offer from good and outstanding providers. Page 67 FURTHER AND HIGHER EDUCATION Plymouth University - With more than 32,000 students, the University is the 9th biggest in the country and ranked among the top 10 modern universities in the UK. A winner of the Queen’s Anniversary Prize for Higher and Further Education and shortlisted for University of the Year in 2012, the institution has come a long way since it was founded as a School of Navigation in 1862. www.plymouth.ac.uk

University of St Mark and St John - Awarded university status in 2013 meaning Plymouth is now home to two universities providing full and part-time higher education with a range of courses from foundation degrees and progression courses to honours degrees and Plymouth has over 50,000 students postgraduate study. studying in the city, potentially www.marjon.ac.uk providing a highly skilled and adaptable workforce City College Plymouth - One of the largest professional, vocational and technical colleges in the South West and rated Good with Outstanding features, the College has a national reputation for promoting enterprise and employability. The skills needs of the region are a priority for the College’s new £13million state-of-the- art Regional Centre of Excellence for STEM (science technology, engineering and mathematics) and complements their other first class provision across all industry sectors. City College is one of the best places in the country to be an apprentice, with an achievement rate 14% above the national average.

Plymouth College of Art - A specialist independent Higher Education Institution (HEI) run by artist for artists. Founded in 1856, the college offers a range of Undergraduate, Postgraduate and Pre-Degree study across Art, Design and Digital Media – combining over a 160 years of history with up-to-the-minute thinking and cutting-edge facilities, including Fab Lab Plymouth in the college’s new £8m Craft, Design and Fabrication Workshops. www.plymouthart. ac.uk Plymouth’s digital sector is a growth industry and ranks as the eighth highest location for job growth in DEVELOPING YOUR CAREER digital industries in the UK. If you’re ambitious and keen to further develop your career prospects, Plymouth is well placed to support you. With a wide variety of higher and further education offers, apprenticeships and a well-defined STEM Plymouth strategy the city offers a multitude of ways that professionals can grow and develop.

Numerous networking groups and support providers including STEM Plymouth, Building Plymouth, Plymouth Area Business Council, Plymouth Manufacturing Group, Plymouth Social Enterprise Network, Devon Chamber of Commerce and the Federation of Small Businesses are also prevalent in the city, offering business support, networking opportunities and growth avenues for businesses. Page 68

INTERESTED? If you would like more information, advice or support about relocating to the city please contact Plymouth City Council’s Economy, Enterprise and Employment team

01752 307360 [email protected] www.plymouth.gov.uk/invest www.investinplymouth.co.uk

@investplymouth Page 69 Agenda Item 10

WELLBEING HUBS Update and timeline

Version 1 23 October 2018 OFFICIAL: Page 70 PLYMOUTH CITY COUNCIL

Aims of wellbeing hubs What we are seeking to do with wellbeing hubs; 1. Align services so that they work better for people, giving them a coherent ‘journey’ through the services that they may need to improve and promote their own health and wellbeing. This is particularly aimed at helping people to find services that are more appropriate for their need than a GP/A&E. 2. Help people and communities to support each other, by bringing the current CVS services and opportunities to meet and take part into contact with more people. This will support a shift from GP to wellbeing service, from wellbeing service to community support, then from user of community support to a volunteer supporting others generate more volunteers and therefore widen the opportunities and the benefits. Both of these aims result in finding the most cost-effective intervention for the person when they need it. It should be noted that the hubs have been designed to reduce spend from the commissioned contracts; saving approximately £200k per annum. There is an initial investment, in the order of £260k.

How this links with deprivation Need is the ability to benefit from an intervention; demand reflects whether someone with a need presents and asks for the support. The Inverse Care Law shows that people in more deprived areas are less likely to ask for help, even though they have need. In less deprived areas, people will ask for help, and will ask for it earlier, meaning that they are more likely to receive the early intervention services, which we know has a positive effect on health and wellbeing. In our more deprived areas, we want to do two things;  help those who are seeking support by making the right support easily available to them (social prescribing and wellbeing services). This will make GP visits less frequent but more effective as some of the underlying issues are improved  help those who are not currently seeking support but do have high risks (these might be social, or they might be linked to lifestyle, or both). This will help to prevent declining health and wellbeing

WELLBEING HUBS Page 2 of 7 OFFICIAL: Page 71 PLYMOUTH CITY COUNCIL We anticipate that we will see increasing demand for wellbeing services, but some reducing demand for GPs and other medical specialists as we shift to more cost effective care. In areas of lower need, we want to bring the community together to tackle some of those things that will relieve pressures on some of our services. For example, social isolation is as bad for health as smoking but is entirely avoidable if the community work together and are inclusive; and have help to reach the people in need. This provides a reduction of resources needed in these areas allowing a flow towards more deprived areas. LOCATION OF HUBS Targeted Hub Locations A piece of work considered factors which would influence the locations of hubs (there was a desire to have at least one hub in each of the localities used by Livewell SW, to incorporate community services). This looked first at high use of healthcare services (since an aim is to reduce demand to more cost- effective interventions) and need, current provision/assets in the local area, and then suitability of buildings. Key points were;  Populations under 5 years and over 75 years are generally considered to be the highest users of health and care services and so illustrate where additional need may be present over and above that of the general population. o Greatest concentration of under 5 population in West locality – Barne Barton and Honicknowle neighbourhoods. o Greatest concentration of over 75 population in East Locality but with smaller concentrations in North and South. Neighbourhoods with particular concentrations – Colebrook Newnham and Ridgeway, Plympton St Maurice and Yealmstone and Elburton and Dunstone.  The general Index of Multiple Deprivation enables areas to be identified where deprivation is highest. Deprivation is a determinant for many health and care needs. o Greatest concentration of deprivation as measured by IMD is within the West Locality but with significant concentrations in North and South. The most deprived LSOAs [lower super output areas] are within the following neighbourhoods – Barne Barton, Devonport, North Prospect and Weston Mill and Stonehouse.  Asset mapping took place, looking at community facilities already present and what was offered at each one. This identified that, although most areas already had some assets, the city centre and Devonport areas already had considerable assets which could be developed into hubs relatively easily. It was decided that development of hubs in these areas should be part of phase 2/3.

Buildings In order to identify potential buildings for ‘targeted’ hubs, a desktop feasibility study was completed. This considered and scored potential locations based on space, accessibility, sustainability, statutory requirements, current usage, and connectivity. Following that, consultation was carried out with providers and specific groups likely to use hubs as well as the public (led by Healthwatch). The final buildings were agreed at Cabinet in January 2018. The current list of Hubs is as follows, the opening timelines are based on a combination of prioritising deprived areas where needs are greater and opportunistic use of existing buildings where space can be created. Where new builds may be required we will work to deliver an ‘interim’ hub building, estimate openings relate to the ‘interim’ hub openings and don’t reflect any required building works.

WELLBEING HUBS Page 3 of 7 OFFICIAL: Page 72 PLYMOUTH CITY COUNCIL Estimate Opening Specialist Health Hubs The Cumberland Centre is an Urgent Treatment Centre including March 2019 Cumberland locality mental health teams, which will incorporate the full range of Centre Wellbeing Hub Services; it also has a large GP Practice and a pharmacy within the same complex. Mount Gould is subject to a master planning exercise which will result October 2019 Mount Gould in more acute services being delivered here and will include GPs and Local Care wellbeing services. Centre Derriford Hospital is a large teaching hospital serving Plymouth and TBC Derriford nearby areas of Devon and Cornwall. It is a regional trauma centre and Hospital also provides tertiary cardiothoracic surgery, neurosurgery and renal transplant surgery for the South West Peninsula. Many people attending hospital have the capacity to benefit from the services being offered as part of Wellbeing Hubs, and being able to start to support people during an attendance or an admission is likely to help their health and wellbeing as well as having the potential to reduce demand on the hospital. Targeted Health and Wellbeing Hubs Ocean Health is GP Practice, in a deprived area. The Wellbeing March 2019 Ocean element of the hub will be delivered across 3 locations in a hub-and- Health spoke manner; the GP practice, the local library (St Budeaux) and in (Stirling Barne Barton Pharmacy (Barne Barton is an isolated deprived area). Road) In early stages of planning, it is hoped to develop a GP practice, Dental March 2020 City Centre surgery and Wellbeing Hub in a city centre building. This may also include relocation of an existing Young People’s support services providing much better facilities. We aim to locate this in an area in the city centre that is easily accessible and regularly used by our most in- need communities; close to other facilities such as pharmacy and Council ‘First Stop Shop’, Building yet to be identified, will work with GPs and Livewell March 2020 Estover Southwest to identify a building Council owned Youth and Community Centre, OPE plan to redevelop March 2020 Efford TBC site as a health and wellbeing hub including a GP practice and pharmacy, youth and wellbeing facilities A ‘Complex Lives’ hub, based in one of our most deprived areas, which TBC Stonehouse will provide services for people and families with significant health, social and wellbeing challenges (such as the homeless and those with substance misuse issues). This will include a GP practice with specialist skills working with this group. Being led by CVS. Discussions are underway around the development of a ‘Primary Care TBC Rees Youth Home’ Wellbeing Hub to explore further the potential of this model of Centre, healthcare for potential spread across the city. Plympton This is based in one of our less deprived areas, so offers less opportunity for reducing inequalities but does offer potential for shifting demand to lower cost services. Timeline to be confirmed Targeted Wellbeing Hubs Wellbeing Hub in a deprived area, providing full range of support to the OPENED Jan Cutting local community. Includes Head Space, an out-of-hours service for March 2018 Healthy people who consider that they are approaching a mental health crisis. Living This runs in a non-clinical setting with a safe, calm and structured Centre environment, with the goal of de-escalating crises. A Community Economic Development Trust in a deprived part of the OPENED Four Greens city, already includes a Children’s Centre and community activity; is October 2018

WELLBEING HUBS Page 4 of 7 OFFICIAL: Page 73 PLYMOUTH CITY COUNCIL now developing an offer for people with long-term conditions including time banking, education, peer support; is a target area for the National Diabetes Prevention Programme A Wellbeing hub with a specific remit to work across the city to 7th November Improving promote and improve the health of some specific groups in the 2018 Lives, population who are in need, including veterans, carers, people with Mannamead learning disabilities and those with Sensory disabilities. Southway Building yet to be identified, possibly the Council Community Centre March 2020 TBC and Children’s Centre

COMMISSIONED SERVICES BEING REMODELLED FOR WELLBEING HUBS The following list describes services that consultation has suggested need to be available in each hub. There are citywide commissioned services available to provide these services and in some instances the hubs will provide these services themselves. The citywide services will be targeted and aligned to support each hub according to hub requirements and the needs of each community Advice and Information. The citywide commissioned information and advice provider will offer training, consultancy and outreach to the hub. Any service commissioned locally by one of the hubs to provide information and advice will need to work with the citywide commissioned service to ensure that there is good quality information and advice being given. Social prescribing. The Wolseley Trust holds a PCC contract to deliver a social prescribing programme across 12 neighbourhoods in Plymouth. The service will work with each hub as it rolls out to ensure that the social prescribing link worker based in the GP practices is linking people into the appropriate hub. The hubs will be expected to have a good local knowledge about opportunities to support people. Befriending. A befriending service will provide 1-1 and group befriending in the geographical area of the Wellbeing Hub Time banking. The time banking service can support the hub to develop a local time bank and referrals can be made from the Wellbeing Hub to the commissioned time banking service Health Improvement. Livewell Southwest One You Service will provide healthy lifestyles advice and services within the Wellbeing Hub and surrounding areas according to need Mental and Physical Health/Long-term conditions support services. A range of generalist and specialist support will be offered to people using the wellbeing hub with mental health and long-term conditions needs. There will be a clear referral process into these services which are in the process of being reshaped but currently consist of the Stroke Service (Stroke Association), Mental Health Support (Rethink), Recovery College (MIND), the Sensory Support Service (Improving Lives Plymouth) and the Mental Health drop-in (Crossroads). Long-term conditions self-management and education. Commissioners and providers will work with the hubs to offer options for long-term conditions self-management support which will include education programmes and outreach clinics. OTHER RELATED SERVICES Livewell South West will work with the hubs to provide an integrated approach to people needing primary care and adult social care support Carers. The Caring for Carers service will ensure that the hubs understand the support that can be offered to carers and, if possible, some direct support can be provided in each hub including drop-ins and peer support groups.

WELLBEING HUBS Page 5 of 7 OFFICIAL: Page 74 PLYMOUTH CITY COUNCIL Community Connections will work with the hubs to provide information and advice to individuals in housing need or who are victims of anti-social behaviour, will support problem solving in neighbourhoods and community regeneration INVESTMENT IN WELLBEING HUBS Wellbeing hubs are being developed to deliver cost savings. These savings amount to around £200k per year (potentially more). The one-off investment in wellbeing hubs is relatively small (£260k) The delivery of the programme is being carried out with minimal resource. Investment in infrastructure is through partnership working and use of OPE, rather than PCC funding. This requires a collaborative partnership approach. IMPACT The benefits across the system have been considered, and will be evaluated, using a logic model approach; there are a number of outputs which will lead to short term outcomes, which will build into longer term outcomes. In the short term, we would expect to see people’s key issues resolved; evidence of better financial management, housing problems resolved, learning new skills and gaining work experience, for example. Also in the shorter term, we would expect to see more people in specific cohorts engaging in community activities. In the medium term, this should start to show in improvements in wellbeing, in reduced social isolation and loneliness, in healthier lifestyles. In the longer term, we would expect to see health outcomes improving. All of these have beneficial impacts for the health and wellbeing systems as well as individuals and families. We will be taking a formative evaluation approach and are working with University of Plymouth through our Thrive Plymouth evaluation. We are determined that the approach taken will be responsive to local needs and local assets and so we will expect to iteratively optimise our approach. There are some specific programmes and interventions that are evidence –based with known likely benefits; such as smoking cessation, weight management etc. These are already delivered but will be better targeted so we expect to maximise return on investment. In April 2018, social prescribing was made available to 19 practices across Plymouth (with a further widening in the near future). The demand for the service has been high and there were 197 new referrals and 132 people who took up the service, which is 345% of the target and the number of hours of support is at 105% of the target. Since starting there has been an average of 11 cases open at any one time per surgery. It is very early to evaluate any outcome measures; however, of the fifteen people who have passed through the service and completed their journey, thirteen had a significantly improved WEMWBS score at close than at the initial contact; the average metric score for these people at their assessment appointment was 16.4. The average highest metric score during subsequent appointments was 20.56, indicating an overall improvement in mental health and wellbeing for most patients. A range of feedback has been gathered both from GPs and users of the service; GP feedback: “The staff at the surgery find the project very valuable and have had no problems with referring to the service. It’s difficult to say whether it has helped reduce pressure on GPs as the project is still young and cases are only just starting to be closed with positive outcomes. Feedback generally from staff at a recent Sound Health Alliance meeting was that it’s a valuable resource and they would like to see it continue and develop”. Service user feedback;  Nine people felt they had achieved their goal totally while working with a link worker, seven felt they had partially and were still working towards it with support from other organisations.  100% planned to continue using the services they had accessed through social prescribing.

WELLBEING HUBS Page 6 of 7 OFFICIAL: Page 75 PLYMOUTH CITY COUNCIL  Fifteen people said they would recommend the VCS organisation / activity they were accessing, one was unsure.  The average score out of ten for helpfulness of Healthy Futures staff was 9.75.  The average score out of ten for patients to rate their experience of using Healthy Futures social prescribing service was 9.6. Comments included;  ‘Helped a lot with losing weight and contacting groups.’  ‘Getting my life back on track because I wouldn't be here if it wasn’t for the team.’  ‘I feel much more relaxed since seeing Link Worker, she is very friendly and willing to listen, also gave me great advice which has certainly been working, I don’t show any aggression like I used to.’  ‘Made me want to take that step forward. Link Worker has helped me feel more confident and to go out and do it. I feel relaxed and have started eating healthier.’  ‘I have achieved the goals that were set and am feeling I could maybe achieve much more.’  ‘I feel Calmer, plus if I start to get worked up, I think what would Link Worker say, so I seem to calm myself down.’ Evaluation for people who have completed the programme will include a minimum three month follow up. The Sheffield Hallam University evaluation of the Rotherham Social Prescribing Service1, found the following reductions in the use of acute hospital services:  non-elective inpatient episodes reduced by 7 per cent  non-elective inpatient spells reduced by 11 per cent  Accident and Emergency attendances reduced by 17 per cent. Using this evaluation, we anticipate a reduction of 530 non-elective inpatient episodes and 500 A&E attendances per annum, a saving to the system of £702,000 per annum. A review of the evidence2 on the effect of social prescribing on demand for General Practice, found an average 28% reduction in demand for GP services following referral. Based on the above numbers this would mean an annual reduction of 3 visits per year for 825 people i.e. almost 2500 appointments per year (around £50,000). Though our initial phase of rolling out will focus around primary care there are many opportunities to connect across the system, and this would be anticipated to directly impact NHS resources. Models of social prescribing could be based around A&E attenders, or around discharges following admissions. We will be working closely with our clinical colleagues to identify appropriate cohorts of people to consider, and then co-design models.

1 The social and economic impact of the Rotherham Social Prescribing Pilot, Centre for regional Economic and Social Research, Sheffield Hallam University https://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/social-economic-impact- rotherham.pdf 2 University of Westminster, June 2017, ‘A review of the evidence assessing impact of social prescribing on healthcare demand and cost implications’ Polley, M., Bertotti, M., Kimberlee, R., Pilkington, K., and Refsum WELLBEING HUBS Page 7 of 7 OFFICIAL: This page is intentionally left blank