working together – a healthier Richmond for everyone
Working collaboratively across the London Borough of Richmond-upon-Thames to deliver our Health & Wellbeing Strategy 2016–2020
2016–2020
RICHMOND CLINICAL COMMISSIONING GROUP (CCG)
JOINT PRIMARY CARE STRATEGY
CONTENTS
01 Purpose and scope of strategy page 4
02 Definitionofprimarycare page 8
03 Currentservices page 9
04 Whydoweneedaprimarycarestrategy? page 11 05 Enablers page 12
06 Priorityobjectives page 16
07 Stakeholderengagementtodatein developmentofthisstrategy page 18
08 Benefitsandoutcomesofproposedservices page 19
09 Roadmapforchange page 22
–JOINT PRIMARY CARE STRATEGY
3
This is a joint strategy with Richmond Council in recognition of Richmond Health and Wellbeing Board’s aspiration for integration and joining up of services. The Council is a commissioner of primary care services, as well as a commissioner and provider of social services, and therefore a key partner in supporting patients to remain well and independent in their local community.
We are fortunate in the borough of Richmond to have stable and highly-skilled general practices, delivering care to thousands of patients every day. As Richmond CCG takes on responsibility from NHS England for delegated commissioning of general practice services, we wish to make the most of the opportunities this presents to transform primary care. We aim to undertake an audit of current services and to review the scope for future improvements to the delivery of more integrated, patient-centred and holistic care.
The future of our services will be shaped through collaboration, engagement and co-design with general practices, health and social care professionals, patients via local patient participation groups (PPGs) and the wider local community.
In particular, we wish to support primary care’s ability to enable our population to ‘Start Well’, ‘Live Well’ and ‘Age Well’, to strengthen our opportunities to prevent future ill-health (or the exacerbation of existing conditions) and to develop patients’ abilities for self-care via access to appropriate information from community pharmacies, GP practices and the voluntary sector. We will also work collaboratively with HealthWatch Richmond, and other local stakeholders groups including: Richmond Council, voluntary and charitable organisations, provider organisations including Kingston Hospital, West Middlesex University Hospital, London Ambulance Service (LAS) and professional bodies.
The objective of this strategy is to ensure that primary care is equipped and supported to provide sustainable, accessible, pro-active and co-ordinated care close to a patient’s home. This was highlighted in the ‘NHS Five Year Forward View’ and most recently in the ‘General Practice Forward View’. The challenge for the local and national NHS, and the wider public sector, is to deliver continuous improvements in quality and preventative care while demonstrating value for money.
We will continue to work closely with and support our GP federation (the Richmond General Practice Alliance, a partnership of all GP practices in the borough) and Richmond Community Education Provider Network, as a means of developing local collaboration, training and workforce development opportunities across general practices.
This document details the current primary care provision in the borough of Richmond, the proposed direction of travel, the strategic drivers and the current challenges we face. It also sets out a proposal for the priority actions to be taken, the investments required and a work-programme consistent with delivery of the GP Forward View, London’s Strategic Commissioning Framework and South West London’s Transforming Primary Care programme as part of our Sustainability and Transformation Plan (STP), and Richmond’s Joint Health and Wellbeing Strategy.
Richmond CCG does not commission community
pharmacies, dental and optometry services. This
strategy is for GP practices and community services.
4 5
01PURPOSE AND SCOPE OF STRATEGY
OUR VISION
To put patients at the heart of service delivery using their experience to reshape, improve and transform services, whilst ensuring the service is sustainable and affordable.
–JOINT PRIMARY CARE STRATEGY
01 PURPOSE AND SCOPE OF STRATEGY
6 7
–JOINT PRIMARY CARE STRATEGY
WHERE WE ARE
Strawberry Hill
Teddington
Richmond
StrawberryHill
Hampton Hill
Hampton Wick
St Margarets
North Sheen
East Sheen
Twickenham
Castelnau
Petersham
Mortlake
Hampton
Whitton
Barnes
Ham
Kew
RichmondPark
Old DeerPark
Royal BotanicGardens,
KewSyon Park
The LondonWetlandCentre
MarbleHill Park
Fieldsand Common
Crane park
Ham Lands
Bushy Park
Hampton Court Park
KemptonNatureReserve
Lower Mortlake Road
Roe
am
pton
Lane
Great West
Road
Maltr
oke
Ro
ad
Kingston RoadCher
tsey R
oad
Chertsey Road
Cedars Road
Wel
ling
ton
Ro
ad
Wal
deg
rave
Roa
d
Petersham Ro
ad
ichm
ond Road
Kingston Road
Kin
gston
Hill
Ho
un
slo
w R
oad
Han
wor
th R
oad
Staines Road
Ham
pton
Roa
d
Lon
do
n R
oad
London Road
London Road
Hig
h St
reet
High Street
Church Road
Sheen Road Sheen Road
Hurst Hurst Road
Heath Road
Park Road
Cas
teln
au
Kew
Roa
d
Kew
Roa
d
Ho
spital B
ridg
e Ro
ad
San
dyc
omb
e R
oad
Mill Hill Road
Mill Hill Road
Richm
ond Hill
Lons
dale Road
Whitton Road
Stan
le y Road
Qu
een
's R
oad
Queen's Ride
Kneller Road
Qu
eens Road
Ealing
d
Church Road
Sandy Lane
Lower Hampton Road
Wen
sleydale Ro
ad
Powder Mill Lane
Rivers ide Drive
Rive
rside D
rive
Glouc
este
r R
oad
Hanworth Road
Suffolk Road
Dukes AvenueBurtons Road
Prio
ry L
ane
Nelson Road
Mogden Lane
Sandy Lane
Ru
gb
y Road
Percy Road
Oak Avenue
Kin
gs R
oad
Kings Road
Broom Road
Broad Lane
Lock Road
Fife Road
Acr
e Ro
ad
Meadw
ay
Roa
h
R
Road
Upper Richmond RoadUpper Richmond Road
Great Cherts
ey Road
Great Chertsey Road
Hampton Court Road
Hampton Court Road
Bear Roda Sw
anRo
ad
Hampton
Kew Bridge
Barnes Bridge
Whitton
Barnes
Hounslow
Hampton Wick
Teddington
St Margarets
Syon Lane
Mortlake
Chiswick
North Sheen
Richmond
Twickenham
Brentford
Isleworth
NorbitonKingston
Fulwell
Kew Gardens
Strawberry Hill
M4
A205
A205
A205
A308
A308A308
A316
A316
A316
A316
A316
A316
A316
A4
A4
A4
A3050
A3063
A3304
A305
A305
A305
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A315
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A312
A316
A312
A3050
A306
A205
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B306
B322
B350
B350
B350
B351
B352
B353
B358
B358
B358
B361
B361
B531
TeddingtonMemorial Hospital
iGP practicesii
45 Barnes Surgery 020 8748 7574
46 Essex House Surgery 020 8876 1033
47 Glebe Road Surgery 020 8748 7398 020 8222 9355
48 Kew Medical Practice 020 8487 8292
49 Lock Road Surgery 020 8940 1400 020 8940 8922
50 North Road Surgery 020 8876 4442
51 Paradise Road Practice 020 8940 2423
52 Parkshot Medical Practice 020 8948 4217
53 Seymour House Surgery 020 8940 2802 020 8940 3228
54 Sheen Lane Health Centre Doctor Jezierski & Partners 020 8876 3901
55 Sheen Lane Health Centre Doctor Johnson & Partners 020 8876 4086
56 The Richmond Green Medical Centre 020 8332 7515
57 Vineyard Surgery 020 8948 0404
iPharmaciesii
58 Barnes Pharmacy 020 8876 5224
59 Boots, Bessant Drive 020 8876 6192
60 Boots, George Street 020 8940 1691
61 Boots, Upper Richmond Road 020 8876 1227
62 Dumlers Pharmacy 020 8876 4603
63 Forward Pharmacy 020 8748 1774
64 Kanset Pharmacy 020 8948 0601
65 Kew Pharmacy 020 8940 0698
66 Lloyds Pharmacy, Station Parade 020 8940 5800
67 Nima Chemist 020 8940 1861
68 Pharmacare 020 8940 7918
69 Prime Pharmacy 020 8748 3147
70 Richmond Pharmacy, Lower Mortlake Road 020 8928 8811
71 Richmond Pharmacy, Sheen Road 020 8940 3930
72 Round the Clock Pharmacy, Church Road 020 8748 9695
73 Round the Clock Pharmacy, Upper Richmond Road West 020 8876 4364
74 Sainsbury’s Pharmacy 020 8876 9554
75 Spatetree Pharmacy 020 8255 1717
76 Springfield Pharmacy 020 8940 2304
77 Superdrug Pharmacy 020 8876 1861
iGP practicesii
1 Broad Lane Surgery 020 8979 5406
2 Crane Park Surgery 020 3458 5300
3 Cross Deep Surgery 020 8892 8124
4 Fir Road Surgery 020 8898 0253
5 Hampton Hill Medical Centre 020 8977 0043
6 Hampton Medical Centre 020 8979 5150
7 Hampton Wick Surgery 020 8977 2638
8 Jubilee Surgery 020 3458 5400
9 Oak Lane Medical Centre 020 8744 0094
10 Park Road Surgery 020 8977 5481
11 Richmond Lock Surgery 020 8892 2543
12 Staines Road Medical Centre 020 8894 2722
13 Thameside Medical Practice 020 8614 4930
14 The Acorn Group Practice 020 8891 0073
15 The Green Surgery 020 8894 6870
16 The York Medical Practice 020 8744 0220
17 Twickenham Park Surgery 020 8892 1991
18 Woodlawn Medical Centre 020 8894 4242 020 8894 1730
iPharmaciesii
19 Boots, Broad Street 020 8977 2699
20 Boots, Hanworth Road 020 8894 4980
21 Boots, King Street 020 8892 3079
22 Boots, Priory Road 020 8979 5275
23 Boots, Station Approach 020 8979 5559
24 Boots, Tangley Park Road 020 8941 5275
25 Boots, Whitton High Street 020 8894 7858
26 C Goode Pharmacy 020 8892 1614
27 Charles Harry Pharmacy 020 8892 1846
28 Crossroads Pharmacy 020 8755 1952
29 Day Lewis Pharmacy 020 8892 1526
30 Hampton Hill Pharmacy 020 8979 9084
31 Health on the Hill 020 8977 2539
32 Herbert and Shrive 020 8977 1967
33 Herman Pharmacy 020 8894 2000
34 K C Pharmacy 020 8977 1351
35 Kirby Chemist 020 8977 5509
36 Lloyds Pharmacy, Hampton Road 020 8977 0630
37 Maple Leaf Pharmacy 020 8898 5033
38 Medco Pharmacy 020 8977 6140
39 Minal Pharmacy 020 8894 7933
40 St Margarets Pharmacy 020 8892 2434
41 Strawberry Hill Pharmacy 020 8894 3532
42 Teddington Pharmacy 020 8977 2391
43 Twickenham Pharmacy 020 8892 1376
44 Whitton Corner Pharmacy 020 8894 2006
Teddington, Twickenham and Hampton
Richmond and Barnes
1
23
45
67
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18
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58
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6162
63
6468
67
71 76
70 74
65 66
69
72
737577
02DEFINITION OF PRIMARY CARE
8
Primary care is care provided in the community for people making an initial approach to a medical practitioner or clinic for advice or treatment. In the NHS this is usually general practice (GP services). Other primary care services include dental practices, community pharmacies and optometrists, allied health professionals, physician’s assistants and nurses.
In the borough of Richmond, there are 28 general practices with a total registered population of 214,155 patients (Jan 2017).
Overall, the general health and wellbeing of our local population is above average and we will seek to build on and optimise this further. The local joint Health and Wellbeing Board strategy includes a number of initiatives that are important for delivery of good health outcomes.
Richmond – healthy, safe and asset-rich• Population 193,585• Life expectancy at birth •81.9yearsformen(1.9yearsgreaterthanLondon) •85.9forwomen(1.8yearsgreaterthanLondon)• A borough with some of highest performing primary
and secondary schools in the country• Safest London borough for violent crime •4thoutof32forcrimeoverall• 79.6% working-age adults are in employment
– the highest rate in London• 49% volunteer – highest rate in London (26%)• Open spaces •1/3rdgreenspace,100+parks,21milesofriverfrontage •23,000bikejourneysperdayintheborough,
2nd out of 33 in London
Among the national challenges facing the NHS and those of particular relevance to the borough of Richmond, are our ageing population with an increasingly higher life expectancy, growth in the number of people with long-term and complex health conditions, increases in social isolation across socio-economic groups, and a corresponding rise in public demand and expectations (Darzi 2008; NHS Five Year Forward View, 2014).
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03CURRENT SERVICES
02 DEFINITION OF PRIMARY CARE
03 CURRENT SERVICES
We will build upon the work we inherited from NHS England commissioners to provide a quality improvement tool to support us to reduce variation, improve performance and support practices to undertake actions required to achieve high quality care. Primary care needs to be fit for purpose and able to adapt and respond to the transformation of urgent and emergency care and the out of hospital strategy.
It is the intention of Richmond CCG and the Council to develop a primary care dashboard aligned with our overall strategic vision to achieve high quality primary care for the benefit of all our population.
Our key principles are to ensure our general practice services are:
• Safe• Improving the patient experience,
including accessibility• Effective in delivering key outcomes• Providing value for money• Working to reduce health inequalities• Monitored regularly to ensure
all the above
General practices in the borough of Richmond already provide a good standard of care. Quality care is achieved by focusing on the three domains of quality which are: patient safety, clinical effectiveness and patient experience. Quality will also be the thread linking each work stream of the primary care strategy to ensure that we:
• Embed quality in the design stage of the service• Ensure quality in delivery• Provide quality assurance
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04WHY DO WE NEED A PRIMARYCARESTRATEGY?
04 WHY DO WE NEED A PRIMARYCARESTRATEGY?
But areas to improve• Maximising prevention opportunities• Reducing health inequalities• Minimising harms and threats to health• Planning for demographic change
and promoting independence
Start well• 2,935 children in Richmond are
living in poverty• 36% young people have tried
smoking – the highest rate in England• 25% young people report being
drunk in the previous month• 19% young people report having
tried cannabis• 4th highest rate of hospital
admissions for self-harm in 10-24 year-olds in London
Live well• 17,000 adults smoke• 38,000 adults drink alcohol
at increasing or higher risk levels• 22,000 people have a common
mental disorder, such as depression and anxiety
•Thesamenumberofadults with obesity (22,000)
• The number of new diagnoses of gonorrhoea has tripled since 2011
Age well• 13,000 to 23,400: the projected
increase in number of over-67s between 2015 and 2035
•57%ofover-75shavethree or more long-term conditions (including dementia)
•50%ofover-75slivealone• 2,000 emergency admissions
annually are potentially preventable •costing£4.2millionperyear• 15,800 carers, only a fraction
are known to services
TOP FIVE DIAGNOSED CONDITIONS IN THE BOROUGH OF RICHMOND COMPARED TO LONDON AND ENGLAND
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–JOINT PRIMARY CARE STRATEGY
Condition Year England London Richmond
Hypertension 2014/15 13.79% 11.05% 10.06%
Asthma 2014/15 5.99% 4.73% 4.38%
Depression (18+) 2014/15 7.33% 5.33% 4.02%
Obesity 16+ 2014/15 9.03% 7.25% 4.01%
Diabetes Mellitus (17+) 2014/15 6.37% 6.14% 3.57%
–JOINT PRIMARY CARE STRATEGY
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05 ENABLERS
CURRENT OPPORTUNITIES AND CHALLENGES FOR PRIMARY CARE IN THE BOROUGH OF RICHMOND
Extended Access The traditional model of offering 10 minute appointments cannot be sustained as demand continues to increase. Local practitioners maintain that as needs become more complex, sufficient time is required to undertake holistic care to reduce the frequency of appointments. Other patient groups may require less than 10 minute appointments or advice slots, and alternative models, e.g. offering telephone, email or video-based Skype consultations may help to facilitate this.
Our experience from the first year of extended GP access, offering GP consultations from 8am to 8pm seven days a week, shows the benefits of commissioning some general practice services ‘at scale’ to serve the whole population, provided by local high-calibre clinical practitioners.
The Richmond GP Alliance (RGPA) has developed an integrated IT system to allow record sharing between all general practices within the borough and we hope to build on this further to facilitate record sharing between primary and secondary care. Also, our achievements with GP Online Services, through which people can book GP appointments, order repeat prescriptions and view aspects of their medical records online, has allowed us to build on IT opportunities and streamline access to care.
Patient and resident engagementRichmond CCG and the Council are aiming for a single systemic approach to measuring and responding to local voices. We have engaged numerous stakeholders in the development of this primary care strategy, through consultation via the CCG clinical network meetings, practice manager and practice nurse networks, the Local Medical Committee (LMC), Council, Public Health Richmond, social care and community teams, the Community Involvement Group (CIG), HealthWatch Richmond, and our patient participation group networks (PPGs). We have benefited from the genuine commitment and willingness from all parties to work together across the borough.
Further work will continue via our key stakeholders with an emphasis on hearing the voice of local communities and patient groups, using patient input to strengthen the work of our pathway redesign work and to develop an ongoing conversation on the future of primary care. WorkforceThe creation of our Community Education Provider Network (CEPN) enabled the start of:
• A systematic approach to improving workforce development, introducing and expanding student placements and co-ordinating access to continuing personal and professional development (CPPD) for all staff
• Facilitation of enhanced partnership working between practices, the CCG, higher education providers and Health Education South London
• Enhanced sharing of resources and partnership working
While significant progress has been made to increase placement capacity and facilitate expansion of the practice team to include student nurses and community pharmacists (amongst other innovative experiments in interprofessional supervision), Richmond CEPN’s long-term vision is to:
“ create a sustainable infrastructure which integrates workforce planning and development with service requirements for the benefit of the population that we serve, across primary and community care providers.”
The CCG and Council, recognise the workforce challenges that local GP practices currently face, and will increasingly face as staff approach retirement. We need to address the immediate pressures while improving recruitment and retention, supporting succession planning and seek to expand the role of other primary care professionals, including physician associates, practice and community pharmacists, care navigators, nurse practitioners, and other allied practice staff. Our planning needs to consider links to all healthcare professionals within an integrated health and social care model including hospital and community services, pharmacists and the wider community workforce.
Delegated commissioningIn May 2014 NHS England announced an option for Clinical Commissioning Groups (CCGs) to co-commission primary care in partnership with NHS England. From April 2016, Richmond CCG has assumed responsibility for general practice commissioning from NHS England, with a shared role on a number of functions. We recognise that general practice can no longer be commissioned in isolation from other parts of the health economy and there is a commitment across south west London (SWL) to work with local providers, service users and the public to develop solutions that will deliver safe, high quality care for everyone. Part of our vision is to ensure that patients and service users not only experience better single episodes of care, but a higher quality experience of overlapping parts of their care.
We are using the opportunities of delegated commissioning, alongside flexibilities within locally commissioned services, to explore the overlaps between the different aspects of our primary, community and secondary care commissioning. Delegated commissioning will strengthen our out of hospital strategy, help us to manage demand on acute services and provide more appropriate care in the community. This will support our pro-active care vision to enable people to live well and manage their conditions before escalation or crises arise. The outcomes based commissioning (OBC) route will drive the pathway redesign to deliver more services closer to home.
Continued over
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05ENABLERS
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–JOINT PRIMARY CARE STRATEGY
Continued from over
Information management and technology (IM&T)IM&T is essential to improving and supporting the patient experience and pathway within primary care.Theprimaryhealthcareinformation/recordssystem provides vital clinical records support, as well as a public health and quality (QOF) overview of a practice’s population. In addition, it assists clinical staff to manage conditions safely and systematically. If systems are clinically supported, they should have a focus on patient care rather than administrative processes. Richmond CCG, in consultation with GP practices, suppliers and key stakeholders, will aim to ensure that all practices have robust, well-functioning clinical systems. Feedback from practice managers and clinicians indicates that our developing IM&T strategy has to be reinforced with effective plans for good quality user support, advice and system maintenance, as well as a process that delivers the timely replacement of basic IT equipment such as hardware and printers.
EstatesOur vision for estates is that there needs to be a strategic and proactive estates planning process, which can support both the sustainability of local primary care services and the cost-effective investment across the NHS estate. This work will be driven by the Richmond local estates strategy, which will focus on future requirements to ensure that both general practice and the wider health estate are fit for purpose and strategically located. To ensure that Richmond CCG maintains a clear overview of GP estate issues, a regular GP premises group has been established, with membership from NHS England, the Healthy Urban Development Unit (HUDU), NHS Property Services (NHSPS) and the London Borough of Richmond-upon-Thames (LBRuT). Through the GP premises group, Richmond CCG aims to support and enable:
•Better service integration which improves patient experience and service efficiency, and helps to deliver better health outcomes for patients
• New service models to deliver more services in community settings
• The release of savings and achievement of value for money through the optimum use of healthcare premises, conveniently located for patient services and able to accommodate the appropriate skill-mix of clinicians in the right care setting
Strategic planning for general practice (and the wider NHS community and secondary estate) has been fragmented over recent years, with changes in organisational responsibility for estates affecting the system’s ability to plan strategically. Our responsibility to commission local services through the powers of delegated commissioning brings an opportunity to improve the co-ordination of estates planning and to respond to some of the associated challenges and opportunities locally. These include:
•Acting on the results of the ongoing condition and utilisation surveys of general practice premises
•Using the opportunity of the Estates and Technology Transformation Fund to submit appropriate bids for central investment in local estates and IM&T facilities
London’s ambitious vision outlined in the Strategic Commissioning Framework can only be delivered through providers working ‘at scale’ in larger primary care organisations, to enable them to increase their capacity and capability and support sustainability across the NHS. This new way of working will enable providers to benefit from shared economies of scale across services, functions or infrastructure.
The Transforming Primary Care programme (TPC) is supporting providers to develop in their maturity and put in place the infrastructure required for greater integration to enable them to contract with commissioners of primary care to deliver services such as extended access.
QualityAcross primary care, there are a range of measures available to understand local performance and quality; some based on patient experience (for instance the annual GP patient survey, or the regular friends and family test), and others based on clinical reporting.
Quality and outcomes framework (QOF)QOF is an annual reward and incentive programme; it rewards practices for the provision of quality care and helps standardise improvement in the delivery of primary medical services.
To support CCGs to measure their progress against the ambition set out in the Strategic Commissioning Framework, the TPC programme has developed a measures dashboard. This dashboard currently analyses a number of the general practice patient survey (GPPS) measures, along with data from areas such as Patient Online, General Practice Outcome Standards (GPOS) and e-Declaration responses. Richmond CCG aims to reduce unwarranted variation in all aspects of quality and to bring measurable standards up to those of the best of local and national general practice.For patients and the public this will mean:
•They will receive the same high quality, safe service regardless of where they are registered or who they see
•They will have an improved experience of accessing general practice
•Their views are welcomed and are seen as part of the solution to supporting successful general practice.
For practices this will mean:
•Assurance that there is a focus on meaningful measures of high quality care
•An increase in the amount and quality of patient views
•Ensuring the sharing of learning from incidents, complaints, etc.
•Supporting the implementation of new national guidance and local best practice.
In partnership with local practices, and our Quality Committee, we will develop a quality framework to inform the work of our new Primary Care Commissioning Committee. This will focus on a range of key quality domains to improve quality and safety, as follows:
Safety and effectiveness•Reduction in medication errors•Improved management and learning
from serious incidents•Understanding and fulfilment of
safeguarding responsibilities•Understanding and fulfilment of infection
control responsibilities•Care Quality Commission (CQC) compliance•Increase in screening and immunisation uptake•Improved management of long term
conditions (LTC)•Reduction in delayed diagnosis (including
appropriate two-week cancer referrals)
We are also in the process of developing a menu of ‘gateway interventions’ to support quality improvement in primary care that are intended to assist the delivery of improvements in quality and safety across the four NHS domains. A sample practice-profile (Table 2) will be developed, to assist the Primary Care Commissioning Committee in its commissioning approach.
SAMPLE PRACTICE PROFILE
Capacity GP per 000 population
Extended hours
Responsibility for care home
Workforce Single-handed
Skills mix / GP with special interests (GPwSI)
Current / forecast vacancies
Premises ‘Fit for purpose’ – RAG
IT Systems upgraded
Evidence of active use of mobile working
Quality A & E attendances (per weighted 000 population)
Out of hospital (OOH) attendances/calls
First outpatients (OP) referrals (per 000)
Outliers on Primary Care WebTool
Friends and Family Test
Patient/public engagement – active PPG
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06 PRIORITY OBJECTIVES
Primary care is fundamental to the delivery of effective out of hospital services across Richmond and south west London and it is important in tackling the issues that we know our local populations. We have a vision that supports localised general practice (list-based care) that is quality driven, minimises variation and provides a consistent offer but also provides the opportunity to work ‘at scale’ to deliver:
• Accessible care that is timely, responsive to individual needs for routine and urgent advice and care and is not limited to consultations in the practice
• Co-ordinated care that is holistic, provides continuity and reassurance for patients whose condition and complexity of care require it
• Pro-active care that focuses on prevention, encourages self-management, patient activation and supports the overall health and wellbeing of the population
Priorities for primary care in south west LondonRichmond CCG is proud to be part of the South West London Primary Care Collaborative to support primary care that:
•Isenabledtotakecollectiveresponsibilityforthehealthofthe population and support a consistent, quality driven ‘offer’ across our patch
•Demonstratesanincreaseintheuseoftechnologytocreateadditional capacity and access
•Iskeytoco-ordinatingcareincommunitiesandworkingmorepro-actively with community services, mental health, dental, ophthalmic, social care and specialist services, amongst others.
•Embracesnewrolessuchasphysicianassociates,practicepharmacists and care navigators and supports practice nurses, practice managers, PAs and receptionists who in turn can better assist GPs in their role
•Deliversthe17specifications(below)thatformtheLondonprimary care strategic commissioning framework (accessible, proactive and coordinated care) and form a key component of delivering our vision.
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06PRIORITY OBJECTIVES
Q2 2018 100% delivery across SWL
Q1 2019 100% delivery across SWL
Q4 2019 100% delivery across SWL
Access specifications Co-ordinated specifications Pro-active specifications:
1 Choice 1 Case finding and review 1 Co-design
2 Contacting the practice 2 Named professional 2 Developing assets and resources for improving health and wellbeing
3 Routine hours 3 Care planning 3 Personal conversations focused on individual’s health gains
4 Extended hours 4 Patient supported to manage their health and wellbeing
4 Health and wellbeing liaison and information
5 Same day access 5 Multi-disciplinary working 5 Patients not currently accessing primary care services
6 Urgent emergency care
7 Continuity of care
DELIVERY OF 17 PRIMARY CARE SPECIFICATIONS ACROSS SOUTH WEST LONDON
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07STAKEHOLDER ENGAGEMENT TO DATE IN DEVELOPMENT OF THIS STRATEGY
07 STAKEHOLDER ENGAGEMENT TO DATE IN DEVELOPMENT OF THIS STRATEGY
Patient and public engagement began with the Call to Action and Better Care Fund engagement heldin2013/14,whichtogetherwithotherengagement activities informed Richmond CCG and Council’s joint overarching Better Care Closer to Home (Out of Hospital) strategy. Since then we have continued to receive feedback on primary care as part of broader engagement work locally and the South West London Collaborative Commissioning (SWLCC). This included the community research and engagement project to inform an outcomes framework for a new outcomes-based out of hospital health and care contract.
The views and comments of patients and the public are important to Richmond CCG and Richmond Council. We regularly encourage patients and the public to give us their views at local forums, community events and patient groups and through opportunistic feedback. This information is used to inform on-going service improvement and commissioning plans. We have undertaken a range of stakeholder engagement approaches to inform this strategy.
We aim to deliver:
Accessible care through general practice, community pharmacies, out-of-hours services, access-hubs (offering seven day access, 8am – 8 pm general practice services), with additional services available through NHS 111. We aim for patients to be able to book appointments online and via the use of mobile apps and to be able to access and input into their medical records in a similar manner. Using touchscreens in practices to allow patients to check in on arrival will also become more prevalent. Such measures will reduce the burden on reception staff and the frustration that patients experience when trying to access healthcare.
Pro-active care through our outcomes based commissioning work on pathways for the care of frail elderly patients, peoplewith diabetes, respiratory and
cardiology conditions, and end of life care. This work is already underway, co-designing pathways with clinicians, patients and their carers with direct knowledge of our local services, and bringing together primary, community and third sector organisations to work collaboratively. We will be working closely with the Council on preventative work-streams to reduce the burden on healthcare services in the longer term. As an example, improved detection of hypertension and atrial fibrillation with blood pressure (BP) machines in GP practice receptions, community pharmacies and shops and opportunistic pulse checks will help us to proactively detect and manage these conditions and reduce the incidence of strokes. We will look at investing in self-management via the use of apps such as symptom checker and sign post appropriately so that patients are encouraged to take
some responsibility for their own health thereby reducing some of the demand on GP appointments.
Co-ordinated care to identify patients who would benefit from care continuity, provide them with a named clinician responsible for their care co-ordination and the development of a holistic care plan, which will be shared with appropriate services involved in the patient’s care. Patients will be regularly reviewed by a multidisciplinary team involving health and social care professionals who will co-ordinate the care they receive from the GP practice as well as linked services. We will link into the local ambulance service to identify frequent attenders and work closely with practices and community services to identify how we could manage them better in primary care.
Our vision, as outlined in the Strategic Commissioning Framework, is for a general practice that operates without borders, and in partnership with the wider health and care system. Primary care teams in London (and the borough of Richmond) are working in new and innovative ways, and practices in our local areas are working together; either within clinical networks to achieve joint improvements in care, or within Richmond General Practice Alliance (RGPA) to work collaboratively ‘at scale’.
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08BENEFITS AND OUTCOMES OF PROPOSED SERVICES
08 BENEFITS AND OUTCOMES OF PROPOSED SERVICES
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HOWWILLWEDELIVERTHISVISION?
We will collaborate with colleagues in south west London to create a sustainable model for general practice that can:
Work ‘at scale’ – the key to transforming services is to deliver primary care ‘at scale’ covering the whole population, supporting providers to make the necessary change in infrastructure by forming federations or networks in order to benefit from shared economies across services. There are currently 57 federations in London, covering 91% of the population of London . The Transforming Primary Care programme is supporting providers by building a bespoke 12-month development programme that will support the growth of ‘at scale’ primary care organisations across London.
Demonstrate multi-disciplinary working – general practice is increasingly working in a multi-disciplinary way with other health, social, mental health, community and voluntary organisations. The model of care to achieve this varies across London and is owned by local commissioners.
Deliver more effective ways of working – the vision for primary care in London requires innovative new ways of working, doing more with the resources available to us and sharing learning and best practice with other localities.
Use technology for the benefit of patients – work is underway by the Healthy London Partnership and local teams to support the roll out of inter-operable solutions for primary care. In addition, work is in progress to increase usage of GP Online Services making more appointments available to be booked online, and a public campaign to encourage more local people to sign up and use it.
STRATEGIC OBJECTIVES OVER THE NEXT FIVE YEARS
HOW WILL RICHMOND CCG ACHIEVE THE OUTCOMES
IMPROVEMENT AREAS
OVERARCHING ACTIONS – WE WILL
Proactive care
Increase the use of technology to enable patients to be better equipped to manage their own conditions, and access support and advice on-line
Improved primary care services that involves patients and builds capacity. Patients will be empowered to take control of their care to stay healthy
Self management Power to commission local services
Improved access
Proactive care
Integrated careImproving the quality of primary care
Utilising mordern technology
Development of Providers to provideservices
Fully utilised estates
Workforce development
Accessible qualitive care
Work with the GP Providers and other Providers to increase access to Hubs and address demand
Premises to be utilised to ensure the premises that are being used for primary care services have the capability
A quality accessible service that responds to different patient needs and preferences
We will provide opportunities for primary care to work in collaborative ways with other providers to increasingly offer services in the community
Providing patient centred, co-ordinated care
Co-ordinate care
WORK AREAS
OUTCOMES
WHAT THE SPECIFICATION WILL MEAN FOR OUR POPULATION
We are fortunate in having a thriving Community Education Provider Network (CEPN) to support issues of retention, training and workforce development. We aim to support our local practices to:
•Increasetheirresiliencethroughnewwaysofworkinganddeveloping a skilled, energised and sustainable workforce
•Facilitatemoreflexibleworking•Developpeersupportnetworksandorganiseworkloads
effectively to facilitate attendance and learning from these•Developaflexibleworkforcemadeupofskill-mixedteams
and extended teams that reflect the needs of the population•Positionthemtoimplementnewapproachestothedelivery
and organisation of care such as integration, extended roles in risk stratification, care planning and case management
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09 ROAD MAP FOR CHANGE
In Richmond, we plan to make progress on these improvements, as follows:
Priority projects for
Year 1 2016–2017
Year 2 2017–2018
Year 3 2018–2019
Accessible care
Delivery of primary care access hubs, with clear and streamlined links to urgent care and A&E provision, with choice of appointments bookable, in a range of settings, and across the 8 am – 8 pm seven day timescale
Website and health app development to support patient education and communication
Telephone triage schemes in place, providing back-up to the risk-stratification schemes at practice-level
Ongoing roll-out of GP Online Services
Active signposting to provide a single point of contact to services, online, access to solutions and suggestions for self-care, and support by community navigators
Extended care rolled out (including mental health, physiotherapy, occupational therapy and care navigators) to support general practice locally
Infrastructure availability and review for accessibility (e.g. hearing loops)
Website development at practices to provide email consultations
Triage schemes such as Doctor First or AskmyGP being piloted in parts of south west London if successful would be adopted
Full implementation of an outcomes-based commissioning framework in primary careFull implementation of named GP with responsibility for ongoing care coordination and continuity
Review of e-consultations and virtual appointments
Scoping services and options for identifying patients not currently accessing primary care services
Implement ways to reach vulnerable patients
Telephone triage systems being piloted in a number of GP practices
Priority projects for
Year 1 2016–2017
Year 2 2017–2018
Year 3 2018–2019
Co-ordinated care
Develop multi-disciplinary team (MDT) working, in particular with care home sector
Workforce development to make every contact count
Case-finding to ensure that risk-stratified registers are as accurate as possible in identifying the known and expected individuals at risk
Support vulnerable patients with intermediate care teams, and direct patient/carer support
Data-sharing enabled between health and social care partners
Increased access to diagnostics (e.g. blood pressure monitoring and interpretation) at non-clinical sites
Embedded multi-disciplinary team (MDT) working across all sectors
Named professional in place across all practices
Personal conversations focussed on an individual’s health goals
Developing assets and resources for improving care
Priority projects for
Year 1 2016–2017
Year 2 2017–2018
Year 3 2018–2019
Pro-active care
Development and roll-out of the community access strategy and social prescribing
Identification of critical points on the patient pathway
Systematic primary care support for uptake of lifestyle advice programmes
Introduction of care-navigator role to support single point of access for primary care and links with adult social care
Risk-stratification tools in place
Exploration of training to better support staff to have personal conversations
Active community programmes in place to support Health and Wellbeing strategy
Introduction of expert patient programme and self-management programmes
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09 ROAD MAP FOR CHANGE
PRIMARY CARE FUNDING – FINANCIAL RESOURCES
The primary care funding for the next five years (to 2020/21) was announced in December 2015. The revenue allocations are summarised below:
HIGH LEVEL PLAN – 2016 TO 2020
A sample structure to measure our success in delivering our plan is shown below:
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09 ROAD MAP FOR CHANGE
TABLE 4PRIMARY CARE REVENUE ALLOCATIONS
TABLE 5SAMPLE STRUCTURE TO MEASURE OUR SUCCESS N DELIVERING OUR PLAN
2016/17£m
2017/18£m
2018/19£m
2019/20£m
2020/21£m
Croydon 47,839 50,382 52,255 54,414 57,441
Sutton 24,973 25,578 26,239 27,141 28,448
Merton 28,107 28,595 29,286 30,230 31,638
Richmond 23,536 24,623 25,533 26,515 27,747
Kingston 24,576 25,233 25,916 26,858 28,148
Wandsworth 46,817 47,795 48,905 50,634 52,823
SWL SPG 195,848 202,206 208,134 215,792 226,245
Dimension Outcome Measure
Patients Are equipped to self-manage their condition and daily life independently
Percentage of people with a long-term condition managed solely in primary care
Are enabled to take control and be pro-actively involved in their care
Increased community pharmacy activity on minor alignment
Use new technologies and two way communication to enable support and partnership
Percentage of patients booking appointments online
Increased use of the Health Help Now app
Expect high quality and more integrated services
Receive continuity of care and access to urgent care where they matter most
Reduction of A&E activity
Receive care as close to home as possible Implementation of the Primary Care Home
Professionals A sustainable, skilled, flexible and happy workforce
Working across boundaries for the benefit of patients
Skill mixed teams that reflect the needs of the population Development of the locality team model
General practices that work as part of an extended team and network that understand and know their community
Development of the locality team model
Partnerships Patients as partners
Carers
Voluntary, community and social care providers
Networks focused upon population health
Local groups to support community resilience
Volunteers within extended teams
Sharing good practice
Pooling resources
Premises Innovative use of premises
Fit for purpose and flexible estate that can shift to support service configuration
Understanding of room utilisation to facilitate optimal service configuration
Process Interoperability of systems
Rapid electronic transfer of information
Easy access to expertise, guidelines and decision making tools
Improved communication between professionals
Reduced variation
The differential between allocations and expenditure commitments shifts over time, ultimately generating an investment pool for each CCG by the last year of the five-year period.
Primary care investment poolAn investment pool will exist for all CCGs by 2020/21.Thispoolistheminimumavailablefor investment and could be increased by the following factors:
•Primary care transactional QIPP (list cleansing, value for money on premises costs etc.)
•Redirecting resources from the Personal Medical Services (PMS) reviews (particularly for the above target CCGs)
• Additional transfer of resources from planned reductions/avoidanceofhighcostreactiveacute care
For the boroughs of Croydon and Richmond the initial investment pool resources will be available muchearlierfrom2017/18.TheotherCCGswillretain more immediate flexibility through the PMS reviews.
In addition all CCGs have access to bid for capital funding to support premises or IT developments through the Estates and Technology Transformation Fund (ETTF).
The investment pool will be directed towards the following enabling areas to support service transformation:
• Organisational models (GP federations, optimum clinical networks)
• Workforce development• Workforce growth• Premises development (revenue implications)• IT infrastructure• Incentivising changes in provider behaviour
e.g. outcomes based commissioning and other performance standards.
You can find out more about the CCG at: www.richmondccg.nhs.uk
Follow us on Twitter: @NHSRichmondCCG
Follow us on Facebook: www.facebook.com/RichmondCCG
You can write to us at: Richmond CCG, First floor, Civic Centre, 44 York Street, Twickenham, TW1 3BZ
You can call us on: 020 8734 3000
CONTACT US
–JOINT PRIMARY CARE STRATEGY