primary care commissioning committee board pap… · the purpose of the primary care action plan is...

PRIMARY CARE COMMISSIONING COMMITTEE

Date of Meeting 16 November 2016

Agenda Item No

4 Title

Draft Primary Care Action Plan Purpose of Paper

The purpose of the Primary Care Action Plan is to inform relevant stakeholders of the schemes design to support and develop General Practice across the City. This plan is separate to (but will inform) the General Practice Forward View plan which will accompany the CCG operating plan for 2017-19.

Recommendations/ Actions requested

The committee is asked to discuss the draft plan and to make recommendations regarding further areas for development.

Potential Conflicts of Interests for Board Members

-

Author

Terri Russell / Mark Compton

Sponsoring member

Katie Hovenden

Date of Paper

November 2016

Improving health services…

Transforming General Practice in Portsmouth

A plan of action for creating a new Primary Medical Care service with traditional NHS values

DRAFT Version 1

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CONTENTS VISION OF PRIMARY CARE IN PORTSMOUTH PAGE 3 THE CURRENT STATE PAGE 4 PORTSMOUTH PATIENTS TELL US PAGE 6 PORTSMOUTH DEMOGRAPHICS PAGE 7 QUALITY IMPROVEMENT PAGE 8 INVESTMENT PAGE 13 WORKFORCE PAGE 15 WORKLOAD PAGE 20 PRACTICE INFRASTRUCTURE PAGE 25 CARE REDESIGN PAGE 29

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VISION OF PRIMARY CARE IN PORTSMOUTH Our vision is for everyone in Portsmouth to be enabled to live healthy safe and independent lives, with care and support that is integrated around the needs of the individual at the right time in the right setting. We will do things because they matter to local people, we know they work and we know they will make a measureable difference to their lives.

We will strive to improve health and wellbeing through our General Practice (GP) surgeries as members, working with our patients, the public and our partners. We will commission a sustainable health system that delivers person-centred care, achieves a shift in focus from acute care to community and primary care, and early intervention; in partnership with Public Health (PH) tackles the lifestyle issues which contribute to our community’s major health problems.1

Primary Medical Care is central to this strategy, with the GP as the basis for a modernised Primary Care service and a wider workforce wrapped around practices. Practices will come together to form super-practices or will work across traditional boundaries as part of an alliance, creating new models of care. These new models of care will deliver flexible, convenient and person-focussed care to the Portsmouth population giving patients a service fit for the 21st Century, grounded in the traditional NHS values of a comprehensive, high quality service, free at the point of delivery.

Be sustainable with a varied and valued

workforce

1 Portsmouth CCG Operating plan 2016-17

Utilise technology to maximum effect

Offer timely access in

accordance with patient need

Utilise buildings

that are fit for purpose

£

£

£

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THE CURRENT STATE

In England we have a growing and ageing population with complex multiple health conditions and as a result personal and population-centred primary care is more important than ever for our health system. However there are many challenges ahead and, as stated by the Five Year Forward Year, if General Practice fails the NHS fails.2

Nationally primary care has suffered significant shortfalls compared to secondary care, with investment falling well behind hospital funding and the numbers of GPs increasing by only 14% whilst consultant posts have almost doubled (2003 to 2013).3 Overall the number of GPs per head of population has decreased in this time and there are major problems with recruitment and retention. The national plan recognises that simply increasing GP training placements will not be enough.

In response to the challenges facing primary care, member practices within Portsmouth have already begun making changes to the way they are structured and how they deliver services. There is a growing trend of smaller practices merging into single, larger entities operating from fewer premise sites in order to create greater economies of scale and increase their organisational resilience.

NHS Portsmouth CCG, with delegated responsibility for commissioning General Practice, will continue to work with practices to ensure that the benefits of coming together are realised and that potential risks are understood and mitigated against. The CCG is also providing advice and support around meaningful engagement with patients and community groups to ensure newly formed partnerships are in the best interests of the populations they serve.

In addition to this, practices have formed locality-based working arrangements to: improve communication; develop more effective relationships; and enhance service co-ordination. The Portsmouth Primary Care Alliance has also established itself on behalf of member practices to act as a vehicle for city-wide primary care service delivery.

In response to clinician shortages practices within Portsmouth have already begun diversifying the traditional workforce model, testing extended primary care teams consisting of pharmacists, physiotherapists, and mental health workers. To accommodate these teams, and to enable improved integration of community and primary care services, some practices have actively engaged in the possibility of moving to a ‘hub’ based model of care delivery.

Practices, in an attempt to adapt to the current climate faced by general practice, are already engaging in the possible movement towards a Multispecialty Community Provider (MCP) model in Portsmouth, which would help underpin a number of changes already being undertaken. Due to the unprecedented threats facing general practice it is unlikely traditional, smaller practices, disconnected and unengaged with current changes and developments, will continue to be sustainable into the future.

2 General Practice Forward View, April 2016 3 The Future of Primary Care – Creating Teams for tomorrow, July 2015

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A WEEK IN THE LIFE OF OUR 20 PORTSMOUTH PRACTICES

ROUTINE (NON-URGENT) CARE

MORE THAN 5400 FACE TO FACE GP APPOINTMENTS BOOKED MORE THAN 1500 TELEPHONE CONSULTATIONS WERE BOOKED, 3600

NURSE APPOINTMENTS, 1700 HEALTHCARE ASSISTANT APPOINTMENTS

AND 300 SLOTS WITH OTHER HEALTHCARE PROFESSIONALS RESULTING

IN: 11,000 CONTACTS FOR ROUTINE PRIMARY MEDICAL CARE IN A

WEEK 1,100 DID NOT ATTEND (9%)

URGENT (SAME DAY) CARE

APPOINTMENT AVAILABILITY IN SOME PRACTICES IS UNLIMITED WITH

MANY PRACTICES OFFERING WALK-IN OR SIT AND WAIT APPOINTMENTS

OR A TRIAGE SERVICE PRACTICES SAW IN EXCESS OF 2400 PATIENTS FOR FACE TO FACE GP

CONSULTATIONS, OVER 300 NURSE APPOINTMENTS AND NEARLY 1600

TELEPHONE CONSULTATIONS FOR AN URGENT NEED IN ADDITION PRACTICES CARRIED OUT NEARLY 400 HOME VISITS (NOT

INCLUDING THOSE CARRIED OUT BY THE ACUTE VISITING SERVICE)

5400

2400 2700

3100

400 2000 Routine face to face GP

Urgent face to face GP

Face to Face nurse appointments

Telephone consultations

Home Visits

HCA and other

16,000 Primary Medical Care Contacts in 1 week *The above information is likely to be an under-representation of actual activity as practices have manually submitted data

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PORTSMOUTH PATIENTS TELL US…. In our 2014/15 listening event the largest number of comments we received related to patients’ experience of General Practice. This is to be expected with almost 90% of health care being provided in Primary Care and something which almost everyone has some experience of. The biggest issues reported were around the following:

• Access to GP and nurse appointments • Waiting times in the surgery • The need for extended opening times • Requests to extend/improve health education and awareness

The General Practice Patient Survey:

The information below reflects one of the key results for NHS Portsmouth CCG, based on the July 2016 publication (for the periods from July to September 2015 and January to March 2016) - 6,398 questionnaires were sent out, and 2,337 were returned completed – a 37% response rate.

The survey does have limitations: sample sizes at practice level are relatively small and qualitative data is not included, however it uses a consistent methodology so is comparable across organisations and over time.

Portsmouth fares better than the National Average for overall experience of General Practice with 87% reporting their experience of their GP surgery is fairly good or very good. However there is a great deal of variation with the lowest performing at 67% and the highest with a ‘good’ rating at 95%.

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PORTSMOUTH DEMOGRAPHICS Health in summary4 The health of people in Portsmouth is varied compared with the England average. Deprivation is higher than average and about 23.5% (8,500) children live in poverty. Life expectancy for both men and women is lower than the England Average. Registered Population - April 2016: 223,124

4 Public Health England ‘fingertips’ profile, June 2015 – www.healthprofiles.info

0

20

40

60

80

100

England Portsmouth

Deprivation This chart shows the percentage of the population who live in areas at each level of deprivation

Least deprived quintile

Most deprived quintile

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QUALITY IMPROVEMENT

The NHS has been through a prolonged period of hyperactive policy making and competing beliefs on how to improve quality of care, largely in response to reviews of services that were deemed to have failed patients or consistently delivered poor care and/or poor outcomes. The current paradigm is a focus on increased regulation and inspection, coupled with faith in the role that patient choice, market forces and ‘naming and shaming’ can play in improving quality.5

Within its Quality Strategic Framework, the CCG has adopted the following guiding principles in its approach to quality:

• We will listen to our patients, their families and friends and hear what they are telling us

• We will act quickly when we know that something is not right • We will be honest if things go wrong • We will strive for continuous improvement & learning • We will not rely on tick boxes to assure ourselves of quality

Quality improvement in healthcare should not just based on quality assurance and measurement. It must also encompass principles of staff engagement, small scale trials, teamwork and cooperation with robust clinical leadership. In terms of primary care CCG considered the following of upmost importance: the furtherance of a culture of continual learning and improvement in patient care, providing challenge and support to practices without prejudice and listening to what patients tell us about what is important to them. The CCG is also committed to lessening the administrative burden placed on practices, to reducing stresses and improving the working lives of practice staff which will in turn have a positive impact on patient experience.

Quality Improvement Portfolio:

Key:

System outcomes (Resources and utilisation)

People outcomes (Patients and staff)

Health outcomes (Care and quality)

Intervention Outputs Outcomes short term (1yr)

Medium term (1-2yrs)

Long term (2yrs+)

Quality Improvement Framework

Assessment and assurance process

Improved understanding of quality in General Practice

Improved patient outcomes

Culture of continuous quality improvement Improved patient

experience Primary Care CQUIN

Incentivised actions to support quality improvement and transformation

Practice engagement in quality improvement, system resilience and transformation


System change – ensuring the sustainability of Primary Care

Improved patient and staff experience

5 Improving Quality in the English NHS – A strategy for action, Nuffield Trust, 2016

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Long term (2yrs+)

Diabetes LCS Specific focus on increasing referrals to patient education, prediabetes registers & combined 3 care processes

Patients empowered to manage their own condition

Reducing emergency admissions

Reduction in Type II prevalence

Improved Blood glucose control

Reduced premature mortality More efficient use of

resources

LD Health checks

Increase in the numbers of patients receiving LD Health checks

Reducing inequalities Improved patient outcomes

Reduced premature mortality for people with a learning disability

Improved patient experience

Cancer –Screening and early diagnosis

Implement a number of initiatives to increase cancer screening uptake and drive earlier diagnosis

Reducing inequalities Improved patient outcomes and survival rates

Reduced premature mortality



Dementia Diagnosis

Maintain current high Dementia diagnosis rates in the city

Better use of resources


Better quality of life

Improved experience for patients, carers and staff

Quality Improvement plans:

Scheme Name: Quality Improvement Framework for Primary Medical Care

Start date: April 2017 End date: Ongoing

Funding/Scheme Value: 17/18 = N/A 18/19 = N/A The change being introduced What it will involve Why it is better for patients The development of a Quality Improvement framework for Primary Medical Care to ensure that the CCG has the means to: • Assess the quality of

general practice • Support quality

improvement activities • Be assured of the quality of

services being provided to patients

The CCG will need to ensure that General Practice is able to deliver (and continue to deliver) a high quality primary medical care service whilst facing increasing external pressures and during a period of significant transformation

• Working with stakeholders to design a tool to assess the quality of primary medical care

• Agreeing local metrics and standards where there are no national values

• Utilising support programmes available as part of the GPFV national offer to increase knowledge and skills in quality improvement methodologies and techniques

• Implementing a process for gathering evidence, sharing best practice and supporting practices to make quality improvements

The CCG has a number of improvement goals it aims to achieve as a result of the initiative. Improved: • Patient experience • Patient safety • Clinical effectiveness and

reduced unwarranted variation

• Staff experience • Value for money

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Scheme Name: Primary Care CQUIN Start date: April 2017 End date: March 2019

Funding/Scheme Value: 17/18 = £ 18/19 = £ The change being introduced What it will involve Why it is better for patients The aim of the Primary Care CQUIN is to improve the quality, safety, and efficiency of patient care via GP practices identifying and implementing alternative ways of working and delivering care.

The scheme will include the following elements for 2017/19: • CCG Engagement (continued

contribution to the CCGs commissioning agenda)

• Access – a number of initiatives to improve access to General Practice

• Use of Technology – maximising use of technological tools and systems

• Quality Improvement – incentivising actions that relate to the quality improvement framework above

• Collaborative Working – developing improved working relationships across practices and with community partners

• Efficient use of resources – peer review and systematic audit of referral and prescribing data and ensuing actions

The scheme enables General Practice to contribute to the development of the Portsmouth Health and Care Plan (Blueprint) as well as focussing on care and experience for individuals

Scheme Name: Diabetes LCS Start date: April 2017 End date: March 2019

Funding/scheme value 17/18 = £ 18/19 = £ The change being introduced What it will involve Why it is better for patients Increased focus within the Diabetes LCS on pre-diabetes registers, diabetic foot care, referral for education and ensuring management is optimised for patients as per NICE guidance

• Specify the creation of an NDH/IFG register and onward referral

• Local monitoring of 3 care processes at patient level

• Incentivised stretch target for referral to education (above QOF thresholds)

• Further education and support regarding foot care pathway

• Improve the quality of jointly agreed care plans and ensure they are shared where appropriate

• Prevent disease progression

• Empowering patients to manage their own condition

• Better control of disease resulting in improved outcomes

• Reduction in amputation rates

Scheme Name: LD Health checks Start date: April 2017 End date: March 2019

Funding/scheme value 17/18 = £ 18/19 = £ The change being introduced What it will involve Why it is better for patients

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Development of a local action plan aimed at improving uptake of LD Healthchecks

• Agree a revised LD Healthcheck template, including Health Action Plan and ensure practices link with the Learning Disability team at Solent to validate LD patient lists

• Agree the content of - and promote - the training offered by the Solent LD team for practices

• Share examples of good practice gleaned from practice intelligence

• Ensure there is a GP champion/clinical leader for LD within the CCG

• Promote policy of phoning patients/carers on day of appointment to reduce DNAs

• Continue to review any national guidance and work with stakeholders to adjust our approach to LD Healthchecks

A recent report by NHSE suggests there is strong evidence that targeted health checks for people with learning disabilities leads to better outcomes compared to non-targeted health checks.

Scheme Name: Cancer screening and diagnosis Start date: April 2017 End date: March 2019

Funding/scheme value 17/18 = £ 18/19 = £ The change being introduced What it will involve Why it is better for patients Development of processes to enable General Practice to effectively and efficiently increase the number of people receiving cancer screening. Better support for GPs and education for the public to enable earlier diagnosis.

• Contacting relevant patients through the iPlato text messaging system to encourage screening uptake

• Exploring all evidence and implementing best practice examples that will result in an increase in screening uptake

• Including an element within the Primary Care CQUIN that focusses on education and tools to improve cancer diagnosis and screening uptake

• Working with Healthwatch and the communications team to improve public awareness of the importance of screening and accessing health care earlier (where necessary)

• Cancer screening can detect the disease at an early stage resulting in improved mortality rates or even cure

• Earlier diagnosis can result in better quality of life for patients and improved survival rates

Scheme Name: Dementia Diagnosis Start date: April 2017 End date: March 2018

Funding/scheme value 17/18 = N/A 18/19 = N/A The change being introduced What it will involve Why it is better for patients

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NHS Portsmouth CCG practices have consistently maintained high diagnosis rates (compared to predicted prevalence) for this population. Work will continue in order to sustain the position and ensure patients and carers are accessing appropriate care and support.

• Continue to share benchmarked data on a monthly basis with Portsmouth practices

• Supporting practices to implement best practice advice (e.g. regular review of coding, training for staff)

• Provide regular updates on services and education for clinicians (e.g. through TARGET)

• Improved access to services when required

• Support for carers at an early stage

• Better care planning resulting in improved experience (both patient and carer) and quality of life

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INVESTMENT There is a national plan to increase the proportion of investment into general practice to over 10% (of the NHS pot) by 2020/2021. Linked to this is the expectation that CCGs will also make significant investments into general practice and new models of care, with Primary Medical Care at the heart of those developments. The following are some of the National initiatives that will be linked to increased investments from 2016/17

• Uplift to the core contract of 4.4% • STP’s to include the sustainability and stability of general practice • Practice resilience programme (builds on the vulnerable practice programme) • Investments in workforce development (included under workforce section below) • Capital investments (ETTF)

In addition there is an ongoing piece of work to review the Carr-Hill formula with a view to making the distribution of funding to practices much fairer. NHS England are also in talks with medical and defence organisations to tackle the rising costs of indemnity, taking into account different ways of working (e.g. extending the usual hours of service, skill mix of staff etc)

Investment schedule

Portsmouth Investment Portfolio:

Key:






Long term (2yrs+)

General Practice Resilience Programme

Resources to secure viable / sustainable general practice provision

Understanding of the support and interventions required to keep practices viable

Move towards Primary Care at scale

Sustainable local health economy

Improved patient and staff experience

Quality care for patients

PMS Reinvestment Strategy

Equitable investment in practices in Portsmouth across a range of activities and services

Improved outcomes for patients

Improved care pathways

Standardisation of care across pathways

Better accessibility and patient experience (in GP Practice rather than hospital)

More sustainable General Practice

Investment plans:

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Scheme Name: General Practice Resilience Programme

Start date:

September 2016

End date: Ongoing Funding/Scheme Value 17/18 18/19 The change being introduced What it will involve Why it is better for patients Implementation of a scheme to ensure future viability of General Practice. Practice across Wessex have been assessed against an agreed set of criteria in order to prioritise investment through the programme

• Practices identified and contacted in 2016/17

• Initial diagnostic activity to be carried out to identify required support (through NHSE)

• CCG to support implementation of the process where necessary

• Primary Care is vital for the health of the population and this initiative will ensure patients can continue to access convenient, high quality Primary Medical Services

Scheme Name: PMS Reinvestment Start date:

September 2016

End date: Ongoing Funding/Scheme Value 17/18: 18/19: The change being introduced What it will involve Why it is better for patients Expansion of the Basket of services LCS, including additional cancer screening activities and a wider range of shared care protocols. Continued investment in the Diabetes and respiratory LCSs Development of a care homes scheme to support this vulnerable client group in nursing and residential homes

• Increasing the funding available under the Basket of Services LCS scheme linked to a slight increase in the range or amount of activity included in the specification

• Continued commitment to fund the Diabetes and Respiratory Locally Commissioned Services from April 2017 – March 2019

• Scoping potential options for a dedicated care homes services

• Developing and funding a care homes scheme to better support patients in care homes and decrease the burden on individual practices

• Funding practices to carry out additional activities improves patient experience (e.g. wound management and ambulatory or home BP monitoring)

• Improved outcomes for patients (NICE/best practice guidelines for Long Term Conditions)

• Better care planning and continuity of care (for individuals in care homes)

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WORKFORCE Many practices across the country are facing workforce issues, with a high proportion of older GPs expressing a wish to retire early, greater reliance on locums and temporary members of staff and a shortage of medical school graduates choosing to join general practice. NHS England hopes to create an extra 5000 doctors working in general practice over the next five years but recognises that this needs to be coupled with similar growth in the non-medical workforce; nurses, HCAs, Pharmacists, Mental Health workers and others.

NHS England, HEE, the RCGP and the GPC developed a 10 point action plan in 2015/16 aimed at addressing the widespread workforce issues in general practice. The plan covers:

• Delivering a marketing campaign to encourage F2 doctors to choose general practice • Launching a bursary scheme for trainees to move to areas where GPs are in short

supply • Establishing new post-CCT fellowships for areas of poorest GP recruitment • Developing multidisciplinary training hubs • Introducing a national refresher and returner scheme • Investing in practice nurse development • Increasing leadership development and coaching for GPs • Piloting new ways of working and new roles in general practice

Moreover HEE is working with the Medical Schools council to increase the profile of general practice. They have also recruited a number of campaign ambassadors and will be launching a major international recruitment drive to attract up to 500 training and qualified GPs in this year. Further initiatives include;

• Proposals, by July 2016, to tackle rising indemnity costs in general practice • Extra investment in new specialist mental health services, starting in December

2016, to support GPs suffering with burn out and stress • A new Pharmacy Integration Fund to help further transform how pharmacists, their

teams and community pharmacy work as part of wider NHS services in their area

Portsmouth Workforce portfolio:

Key:






Long term (2yrs+)

Outreach Nursing

Commissioned service providing city-wide outreach nursing support to

Improved medication adherence

Improved holistic patient care

Integrated nurse service provision

Reduced hospital admissions

Reduced fragmentation of

Stabilisation of practice workload

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be integrated with practice and community nursing services

services

Reduced pressure on practice staff

Improved patient satisfaction

Improved patient outcomes (from more proactive care planning)

Pharmacist / Medicines management developments

Jointly developing new roles and opportunities for Pharmacists (and technicians) within General Practice

Managing resources Improved recruitment and retention (better opportunities for staff)

Improved patient outcomes (right care, right time)

Stabilisation of GP workload

Improved access for patients Sustainable workforce across Primary Care

HCA accreditation and mentoring

Provide HCA’s with a formal qualification / accreditation (NVQ Level 3)

Improved quality of clinical care

Improved recruitment and retention (better opportunities for staff)

Improved access for patients

Better skill mix (improved capabilities and competency of HCA staff)

Improved outcomes for patients (right care right time)

Practice receptionist training

Introduce workflow redirection/ optimisation for reception staff in Portsmouth

Efficient management and coding of correspondence in the practice

Improved recruitment and retention (better opportunities for staff

Standardised (and potentially centralised) processes across all practices in the city

Freeing up GP time

GP and Nurse recruitment

Initiatives to increase training placements in General Practice and ensuring Portsmouth is an attractive option for clinicians

Reduction in costs (recruitment fees) through local advertising

Improved recruitment and retention (better opportunities for staff)

Improved patient outcomes (right care, right time) Improved patient and staff experience Sustainable workforce across Primary Care

MSK integration

Physiotherapists working within General Practice to manage MSK-related demand.




Improved patient access to same-day primary care services

Improved patient outcomes (from improved MDT working)

Integration of provider workforces

Reduced GP burnout

Mental Health Integration including Psychological therapies

Mental health workers working within General Practice to manage psychological-related demand.





Improved patient outcomes (from improved MDT working)


Reduced GP burnout

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Workforce plans:

Scheme Name: Outreach Nursing Start date: September 2016 End date: Ongoing

Funding/Scheme Value 17/18 = tbc 18/19 = tbc The change being introduced What it will involve Why it is better for patients The commissioning of a primary care outreach nursing service to provide more proactive and preventative care to patients in their own homes, especially those who do not meet the community nursing criteria

• A review of the current outreach nursing pilots being undertaken by several Portsmouth practices

• Commissioning of a city-wide service delivered on a locality basis

• Future integration with primary and community nursing services

• More care provided closer to home

• More time spent with primary care professionals planning their care

• Improved communication and engagement with primary care workers

Scheme Name: Pharmacist/Medicines Management developments

Start date: September 2016 End date: Ongoing

Funding/Scheme Value 17/18 = 18/19 = The change being introduced What it will involve Why it is better for patients Engage with practices to identify the scope and demand for developing joint employment roles for Medicines Optimisation Pharmacists and technicians. In addition, increasing the number of pharmacist Prescribers in the Medicines Management Team working in General Practice.

• Identifying GP and practice workload with individual practices that may be transferred to pharmacists or technicians.

• Identify suitable candidates within the current Medicines Management Team and GP mentors in practice to support candidate through the prescribing course.

• Better access for patients by increasing the workforce and reducing pressure on GPs

• Improved patient safety (medication reviews)

• Better patient experience (EPS etc)

Scheme Name: HCA training/accreditation and mentorship programme

Start date: March 2017 End date: March 2019

Funding/Scheme Value 17/18 = 18/19 = The change being introduced What it will involve Why it is better for patients In 2016/17 a training scheme will be secured for 15 HCAs in the city with the aim of raising the standard of academic achievement and competence in General Practice. HCAs will be further supported through an ongoing mentorship programme.

• Enable 15 HCAs in the city to access formal accredited training

• Establish action learning sets and mentor guidelines to support the ongoing, quality driven, programme of learning

• Link with HEE (Wessex)

• Improve quality of care and patient safety - Ensuring that staff are appropriately qualified to provide care to patients and equipped to deal all eventualities

Scheme Name: Productive workflows - Practice receptionist training

Start date: December 2016 End date: March 2019

Funding/Scheme Value 17/18 = 18/19 = The change being introduced What it will involve Why it is better for patients

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The GPFV makes provision for receptionist training in workflow redirection and/or care navigation. Portsmouth practices have expressed a wish to prioritise workflow redirection, that will enable admin staff to take a greater role in managing the correspondence that comes into the practice, freeing up valuable GP time

• Training initially for 4 practices in the city with BICS

• The programme will be evaluated and either recommissioned for the remaining practices over 2 years or a different provider sought

• Longer terms aim to standardise a number of processes across practice in the city with a view to potentially developing a centralised service

• GPs able to spend more time with patients

• Improved patient safety as a result of better coding

Scheme Name: GP and Nurse recruitment Start date: December 2016 End date: March 2019

Funding/Scheme Value 17/18 = 18/19 = The change being introduced What it will involve Why it is better for patients Explore a number of initiatives to attract a new clinical workforce into the city, to support practices to increase the number of training placements available and to encourage trainees to stay with the city

• Utilising local opportunities for advertising (e.g. AVS website) to reduce costs

• Developing a range of promotional activities to attract GPs and nurses into the city

• Support practices, in terms of environment and resources to increase training placements

• Developing a programme for clinical leaders to create alternative/additional opportunities (as well as working in practice)

• Creating portfolio career opportunities for clinicians through the range of services being designed and developed (e.g. Clinical triage, LTC hubs etc)

• Creating a GP bank and exploring alternative working arrangements (e.g. telephone consultations from home) to allow more flexible and attractive working opportunities

• Improving access • Improving quality of care • Sustaining General

Practice in the longer term, which is vital for patients

Scheme Name: MSK Integration Start date: March 2017 End date: Ongoing

Funding/Scheme Value 17/18 = tbc 18/19 = tbc The change being introduced What it will involve Why it is better for patients Working in partnership with member GP practices and NHS Solent we will implement a model of care whereby physiotherapists are integrated within general practice as part of an extended primary care team managing patients presenting with MSK-related

• Physiotherapists physically locating themselves within GP practices to assist in managing primary care demand

• Refining and further testing of existing pilot schemes of physiotherapists working within GP practices

• Roll-out to other member

• Ensures patients access the most appropriate healthcare professional first time rather than ‘bouncing’ around the system

• Reduces waiting times for MSK services

• Reduces waiting times for GP appointments

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issues, both routine and urgent. practices within the city • Implementation of a city-wide

integrated physiotherapy model based on localities/hubs

Scheme Name: Mental Health Integration Start date: March 2017 End date: March 2019

Funding/Scheme Value 17/18 = tbc 18/19 = tbc The change being introduced What it will involve Why it is better for patients Working in partnership with member GP practices and NHS Solent we will implement a model of care whereby mental health professionals are integrated within general practice as part of an extended primary care team managing patients presenting with emotional distress and mental health-related issues, both routine and urgent.

• Mental health professionals physically locating themselves within GP practices to assist in managing primary care demand

• Refining and further testing of existing pilot schemes of physiotherapists working within GP practices

• Roll-out to other member practices within the city

• Implementation of a city-wide integrated physiotherapy model based on localities/hubs

• Ensures patients access the most appropriate healthcare professional first time rather than ‘bouncing’ around the system

• Reduces waiting times for mental health services

• Reduces waiting times for GP appointments

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WORKLOAD Workload was identified in the 2015 BMA survey to be the single biggest issue of concern to GPs and their staff. The Primary Care Foundation together with the NHS Alliance have pulled together a very useful report, “Making time in General Practice”, and also delivered a number of workshops, together with NHS England, to stimulate debate around issues and potential solutions and to share some best practice examples. The report looks as some of the biggest issues around the administrative burden, e.g. processes to claim payments and contractual obligations around monitoring and reporting and also identifies that more can be done to redress the balance between capacity and demand in practices. Nationally there has been some negotiation around the burden placed on GPs from secondary care, for example Trusts should no longer automatically discharge patients if they DNA a hospital appointment, which would normally result in the GP having to make another referral. NHS England have also been working to secure a reduction in the number of CQC inspections, including a move to a maximum 5-yearly inspection interval for practices rated as good or outstanding. Conversations are ongoing regarding the future of QOF, with the potential to offer alternative schemes where contracts are based around more holistic team based funding (i.e. the new MCP contract). It is also a national priority to increase practices utilisation of patient online; which includes requesting repeat prescriptions, making and amending appointments and accessing medical records electronically.

Portsmouth Workload portfolio:

Key:






Long term (2yrs+)

Active signposting – 10 high impact actions

Maximise use of patient online and explore use of mobile apps to support signposting

Empowering patients Improving access Supporting paperless NHS aspirations Improving

productivity in General Practice

Reducing GP workload

New consultation types - 10 High Impact actions

See Practice Infrastructure section (below)

Reducing DNAs - 10 high impact actions

Maximise the use of available appointment slots by reducing DNAs

Reducing waste Ensuring patients who need to be seen can be seen

Better capacity/demand management

Developing the Team - 10 High

See Workforce section (above)

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Impact actions

Productive workflows – 10 High impact actions

See Workforce section (above)

Partnership working – 10 high impact actions

See Care Redesign section (below)

Social prescribing – 10 high impact actions

Increasing referrals to services which promote wellbeing and independence

Empowering patients Reducing inequalities Providing holistic, integrated care (as part of hub development) Reducing GP burden Improving health and

wellbeing outcomes

Develop QI expertise – 10 high impact actions

See Quality Improvement section (above)

Personal Productivity (Decision support tools) – 10 high impact actions

Supporting GPs to streamline processes during the clinical consultation in order to improve personal productivity

Improving practice productivity

Reducing variation across practices

Improved outcomes for patients

Improved staff experience

Improved patient experience (improved quality of consultation)

E-referrals Increasing use of e-referrals in line with national aspirations

Improved patient experience (better choice, quicker)

Higher quality referrals


Improved productivity Reducing waste and rework

EPS and repeat dispensing

Increased use of EPS and Repeat dispensing in line with national requirements

Greater choice for patients

Improved patient safety

Reducing impact on out of hours or emergency services (for prescriptions)

Improved productivity Freeing up GP time

Workload plans:

Scheme Name: Active signposting (Patient Online) Start date: September 2016 End date: Ongoing

Funding/Scheme Value 17/18 = 18/19 = The change being introduced What it will involve Why it is better for patients Supporting GP practices in the promotion and offer of online services to patients, including appointment booking, repeat prescriptions and accessing of medical records, offering a more modern, convenient and responsive service to patients keeping them informed and involved in decisions about their own care and treatment.

• Working with stakeholders on the development of new ways of working and guidance, making it easier for patients to access GP practice services online

• Working with GP practices to ensure staff have access to the latest tools and information they need

• To support practices in the implementation, training and ongoing management of the

Enables patients, their families and carers to take more control of their own health and wellbeing by offering online services such as:

- Making and amending appointments

- Requesting repeat prescriptions

- Accessing of medical records electronically

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The CCG will also support practices to explore the use of mobile apps (e.g. iPlato) that will signpost patients appropriately

iPlato Patient Care Messaging service, giving access to the myGP app enabling patients to access service and support signposting.

• Sharing experiences, good practice, hints and tips on both a local and national level

• The monitoring of national data on the usage of patient online

Scheme Name: Reducing DNAs Start date: April 2017 End date: Ongoing

The change being introduced What it will involve Why it is better for patients DNA’s in General Practice commonly results in between 5 and 10% of appointments being wasted every week. The CCG will work with practices to reduce DNAs and maximise the use of available appointment slots.

• Gaining an understanding of why patients DNA and what might help them to cancel appointments that are no longer required

• Promote use of patient online and iPlato (2-way text messaging)

• Work with Healthwatch, local practices and the communications team to publicise the impact of DNAs

• Supporting practices to utilise evidence based or best practice solutions to reduce DNA’s

• Reducing DNAs will improve access when patients need it

• Empower patient to book slots more convenient to them and easily cancel when no longer required

Scheme Name: Social prescribing Start date: April 2017 End date: Ongoing

The change being introduced What it will involve Why it is better for patients Currently practices are able to refer to an external social prescribing service but uptake has been low. The CCG , practices and voluntary groups will work to improve the offer for patients and increase uptake across the city

• Understanding outcomes from the current scheme and assessing the benefits and challenges

• Working with practices and patients to develop a scheme that is more accessible or appealing

• Non-medical activities can provide patients with health, social and emotional benefits

Scheme Name: Personal Productivity (Decision support tools - Ardens)

Start date: October 2016 End date: Ongoing

The change being introduced What it will involve Why it is better for patients Supporting GPs to streamline processes during the clinical consultation in order to improve personal productivity. Working with Ardens, local stakeholders and member practices on the development, daily management and maintenance of the Ardens system in order to provide practices with the latest decision support tools to

• Linking in with local stakeholders (i.e. commissioners, providers, practices) on the development of new pathways, referral forms and guidance etc.

• Updating and maintaining the Ardens system in a timely manner to ensure practices have access to the most up to date information.

• Working with GP practices to ensure staff have access to the

• Supports the improved management and quality of patient care in the promotion and signposting of the relevant referral pathways, forms and guidance on both a local and national level.

• Supports the streamlining of workflow processes resulting in a more

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support the delivery of improved patient care.

latest guidance and training required to use Ardens to its full potential.

• An active member of the TPP User Group, working with both practices and Ardens on system and template developments, sharing good practice, hints and tips on both a local and national level

• To ensure the latest up to date content is also reflected within the PIP site, for those practices that do not have access to the Ardens Decision Support Tool.

• Agreement of local measures and standards to enable the monitoring of system usage.

improved patient journey. • Facilitates the

standardisation of care across practices.

Scheme Name: E-referrals Start date: September 2016 End date: Ongoing

Funding/Scheme Value 17/18 = 18/19 = The change being introduced What it will involve Why it is better for patients To develop, promote and support GP practice members in the use of the e-Referral system, with an aim to increase usage across the CCG, benefitting practices by reductions in costs and time saving, fewer missed appointments and inappropriate referrals, also shorter referral to treatment times. Advice and Guidance requests are also processed via the e-Referrals system, which will improve the quality of referrals and ensure patients receive the right care at the right time.

- Membership of the local steering and user groups, working with local stakeholders (i.e. commissioners, PHT, CSU, NHS Digital) on future developments and promotion of the e-Referrals system. - Supporting practices on the use of e-referrals, providing training and advice - Sharing experiences, good practice, hints and tips on both a local and national level - Identifying common needs for the e-Referrals system, information resources and future software functionality - Identifying and working with ‘champion’ users in order to provide a support network for all practices across the city - Linking the use of e-Referrals as part of future workflow developments within SystmOne and Ardens - To monitor national data on the use of the e-Referrals system.

Using the e-Referrals system gives patients greater flexibility when booking their first outpatient appointment allowing patients to: - Choose a convenient appointment date and time - Choose a hospital or clinic - Choose a specific hospital specialist (where applicable) - It also results in fewer inappropriate referrals, making the process a much better experience for the patient

Scheme Name: EPS and Repeat Dispensing Start date: Feb/March 2017 End date: March 2019

Funding/Scheme Value 17/18 = 18/19 = The change being introduced What it will involve Why it is better for patients

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Increased adoption of EPS in place of paper prescriptions by extending the project initiated at the end of 16/17

Increased uptake of Repeat Dispensing by extending the project work started in 16/17

• Further engagement of prescribers in practice as to the benefits of EPS

• Local engagement with community pharmacies providing a service with each practice to ensure smooth delivery of service.

• Close working with GP practices and Pharmacies to improve the in house processes for repeat dispensing and to identify suitable patients for RD

• Allows greater choice for patients for community pharmacy and negates the need for patient or patient representative to collect the physical prescription

• Reduces the patient's journey frequency as prescriptions provided at regular intervals.

• Reduces the need for patients to access OOH services (PURMS) to cover forgotten prescriptions etc

• Increases GP availability due to decrease in repeat prescribing workflow.

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PRACTICE INFRASTRUCTURE In 2015/16 NHS England began a multi-million investment programme to support primary care and general practice to make improvements in premises and in technology, as part of the overall estates strategy for the local NHS. For this year CCGs have been invited to put forward recommendations for investment in primary care infrastructure in future years (ETTF). NHS England has articulated the need, in delivering Primary Care at scale, to align and invest in systems and technologies. The national programme will focus on;

• Online access to accredited clinical triage systems for patients when they feel unwell • Actions to achieve a paper free NHS by 2020 • Actions to support practices to offer more online self-care and self-management

services • Achievement of full interoperability across IT systems ensuring practices have the

capability to work collaboratively • Completion of the roll-out of SCR including to community pharmacy by March 2017

In addition NHS England will look to increase the number of suppliers and range of offers available through the GPSoC framework. Furthermore the National Data Guardians review of data security, opt ins/outs and consents, will provide GPs with clarity around data security and IG (Information Governance) standards.

Portsmouth Practice Infrastructure portfolio:

Key:






Long term (2yrs+)

North Cluster Hub

It is hoped a new purpose-built health centre will be constructed in Cosham to serve as a primary and community care hub for the North of the city

N/A (construction phase)


Improved access to services Improved recruitment and retention Improved patient outcomes (through increased MDT working)

Central Cluster Hub

We are working to enable an extension to transform Kingston Crescent Surgery to serve as a primary and community care



Improved access to services

Improved recruitment and retention Improved patient outcomes (through

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hub for the Central Locality.

increased MDT working)

Alliance Development

A robust primary care provider organisation with strong clinical leadership offering improved patient services and enabling more efficient primary care administrative functions

Improved patient outcomes (through new service provision)

More efficient primary care back office functions


Improved integrated working




Improved patient access

Reduced urgent care expenditure

New consultation types

Support practices to purchase an online consultation system

Improving access Making best use of clinicians time

SystmOne and workflows

Benefits realisation - practices, the community provider and local authority utilising a single clinical system

Improved patient experience (e.g. single care plan, better coordination)

Improved patient safety (clinical coding)

Key enabler to MCP delivery

Improved staff experience, better communication and effectiveness

Practice Infrastructure plans:

Scheme Name: North Cluster Hub Start date: March 2017 End date: March 2019

Funding/Scheme Value 17/18 = £2,000k 18/19 = £4,778k The change being introduced What it will involve Why it is better for patients Working with NHS England to acquire funding for a new primary and community care hub in Cosham enabling the co-location of extended primary care teams and the delivery of primary care at scale for the population of Portsmouth North.

• Development of a business case to construct a new purpose-built health centre

• The co-location and integration of primary and community care teams

• Delivering primary care services at scale across a locality basis enabling economies of scale

• Integration of appropriate hospital-based specialities and services with hub-based teams

• Reduced unwarranted variation in care

• Improved access to a wider range of services closer to home

• Improved patient accessibility to premises

• Improved patient care and patient outcomes through increased MDT working

Scheme Name: Central Cluster Hub Start date: March 2017 End date: March 2019

Funding/Scheme Value 17/18 = £900k 18/19 = £1,120k The change being introduced What it will involve Why it is better for patients

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Working with NHS England to acquire funding for a new primary and community care hub at Kingston Crescent Surgery enabling the co-location of extended primary care teams and the delivery of primary care at scale for the population of Central Portsmouth.

• Development of a business case to extend the Kingston Crescent Surgery to become a new primary and community care hub

• The co-location and integration of primary and community care teams

• Delivering primary care services at scale across a locality basis enabling economies of scale

• Integration of appropriate hospital-based specialities and services with hub-based teams

• Reduced unwarranted variation in care

• Improved access to a wider range of services closer to home

• Improved patient accessibility to premises

• Improved patient care and patient outcomes through increased MDT working

Scheme Name: Alliance Development Start date: March 2017 End date: Ongoing

Funding/Scheme Value 17/18 = tbc 18/19 = tbc The change being introduced What it will involve Why it is better for patients Working with the PPCA to help facilitate organisational development to align their strategy, people, and processes to become a more effective and efficient organisation, whilst also supporting the organisation to implement primary care at scale back office functions on behalf of all member practices.

• Providing resources and support to the newly-established PPCA, enabling the organisation to reach self-sufficiency and maturity

• Working with PPCA to identify opportunities for primary care service delivery at scale

• Facilitating PPCA to deliver or co-ordinate at scale back office functions on behalf of practices

A robust, strong primary care provider acting on behalf of all member practices will help introduce new primary care service provision for patients to access, and help alleviate internal pressures within practices enabling them to focus on providing improved patient-centred services.

Scheme Name: New consultation types Start date: April 2017 End date: Ongoing

Funding/Scheme Value 17/18 = 18/19 = The change being introduced What it will involve Why it is better for patients The GPFV announced investment for practices to purchase online consultation systems that will free up GP time and improve access for patients. The CCG will also support practices to explore alternatives to the traditional face to face consultation through technological solutions

• Review evidence from pilot sites and work with practices to identify systems of choice

• Explore commissioning a system across at least the 3 compact CCGs or the wider Hampshire or STP footprint

• Encourage practices to make better use of telephone consultation and explore other types in response to their access audit review at the end of 2016/17

• Empowered to manage conditions where appropriate

• Signposted to alternative, more convenient interventions

• Better access to healthcare professionals when required

Scheme Name: SystmOne and workflows Start date: September 2016 End date: Ongoing

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Funding/Scheme Value 17/18 = 18/19 = The change being introduced What it will involve Why it is better for patients Working with local providers and member practices on the integration of community services within SystmOne, improving workflow by streamlining clinical and administrative processes, sharing information between organisations and ultimately improving patient care and outcomes.

- Regular involvement on the TPP User Group, working with local stakeholders (i.e. member practices, local providers, CSU etc) in order to understand, develop and implement workflow processes within SystmOne. - To work with local practices on the implementation and communication of clear guidelines around new workflow developments and processes - Working with the Ardens Decision Support Tool on the implementation of system templates - Agreement of local measures and standards to enable the monitoring of service progress

Offers a more streamlined service for patients, by: - Providing more joined up care between providers - Enables care to be centred more on the individual patient with tailored care plans and patient directed goals - Improves patient management making it easier to track patient progress i.e. being informed when patient goals achieved

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CARE REDESIGN

Nationally, public satisfaction with general practice remains high however, increasingly patients are struggling to access services and there is a drive from the centre to extend access to core primary medical care services into the evenings and at weekends. The GPFV accepts that a number of the initiatives already articulated in this guidance will be required in order to create the required capacity and acknowledges that practices will have to work at scale in order to achieve the vision. There is also recognition that urgent care systems need to be aligned in order to streamline services and maximise efficiencies, with out of hours providers, other urgent care services, NHS 111 and local clinical hubs. A new multi-specialty provider contract is likely to be shared in the Autumn and there is an expectation that this contract will be used to commission integrated community and primary care services from April 2017. These contracts should be used for new models of care that integrate primary and community care, are based on the GP registered list but include a wider range of services, including specialists where appropriate and necessary. Finally there is national commitment to developing and investing in the Releasing Time for patients programme (following on from the GP Access Fund) that will encourage practices to come together to explore new ways of delivering care, such as telephone consultations or use of other professionals in the general practice workforce (as described under the Workload section above).

Care Redesign Portfolio:

Key:






Long term (2yrs+)

Urgent Primary Care Triage Hub

Effective management of same-day primary care demand and the diversification of workforce resource


Improved patient waiting times for routine appointments

Patients receiving longer GP appointments for complex case management


Reduced GP burnout

Reduced urgent care attendances (A&E and WICs)


MCP Development

Implementation of new contractual models to stimulate integrated working


Reduced duplication of tasks


Reduced fragmentation of care

Increased productivity

Improved staff morale

More care provided closer to home

Improved patient outcomes (through MDT working)

Reduced health system expenditure

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Acute Visiting Service

Commissioned service to provide a more timely response to patients requiring a home visit


Reduced GP burnout Improved system resilience

Increased clinical capacity in the system


Reduced admissions to hospital

Improved patient outcomes (through improved care planning)

111 Integration

Implementation of a local clinical hub to increase clinical triage of urgent care needs

More appropriate healthcare service utilisation


Improved system resilience

Reduced urgent care attendances (A&E and WICs)

OOH Integration

Implementation of a seamless 24/7 primary care service





Reduced urgent care utilisation

Care redesign plans:

Scheme Name: Urgent Primary Care Triage Hub Start date: September 2016 End date: Ongoing

Funding/Scheme Value 17/18 = tbc 18/19 = tbc The change being introduced What it will involve Why it is better for patients Implementation of a local clinical triage service for urgent, same-day primary care demand on behalf of all practices in the city, delivered in locality and city-wide hubs to achieve economies of scale.

• Introducing clinical triage for all same-day, urgent primary care demand

• GP-led clinical triage delivered through telephony, online, and physical access

• Managing patient demand virtually (where appropriate)

• Signposting patients to the most appropriate service

• Managing same-day demand on the basis of clinical need

• Standardised delivery across all practices, reducing unwarranted variation

• Reduced routine appointment waiting times through released GP capacity

• Faster access to advice and support for urgent, same-day issues

Scheme Name: MCP Development Start date: September 2016 End date: Ongoing

Funding/Scheme Value 17/18 = tbc 18/19 = tbc The change being introduced What it will involve Why it is better for patients The introduction of an MCP contractual framework to enable: • pooling of primary and

community health budgets • integration of primary and

community workforces • delivery towards aligned

patient outcomes

• Exploring MCP contractual options

• Assessing services appropriate to place within an MCP contract

• Engaging with member practices to determine appetite for MCP contract options

• Determining priorities for areas of integrated working

The introduction of an MCP contract will help put the necessary financial incentives and levers in place to: • provide more joined up,

integrated, holistic care • reduce fragmentation of

service delivery • provide more capacity in

the local health system to improve patient care

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Scheme Name: Acute Visiting Service Start date: September 2016 End date: Ongoing

Funding/Scheme Value 17/18 = tbc 18/19 = tbc The change being introduced What it will involve Why it is better for patients The commissioning of a GP home visiting service to relieve time and the pressures associated with home visits for GP practices, resulting in increased clinical capacity in the city.

• Review of the outcomes from the current AVS pilot

• Seeking opportunities for further improvements and integration with other services

• Potentially commissioning the AVS on a recurrent basis

• Reduced waiting time for a home visit

• Reduced likelihood of a hospital admission

• Increased clinical capacity within GP practices (resulting in reduced waiting times)

Scheme Name: 111 Integration Start date: September 2016 End date: Ongoing

Funding/Scheme Value 17/18 = tbc 18/19 = tbc The change being introduced What it will involve Why it is better for patients The re-commissioning of 111 services in 2018 will see the implementation of a revised service specification which includes the adoption of local clinical hubs. These clinical hubs will take a more proactive approach to managing patients.

• Defining the specification for the local clinical hubs which will interact with the 111 service

• Commissioning a local service tailored to the needs of Portsmouth registered patients

• Integration of 111 clinical hub with local urgent care triage hub

• Increased number of patients accessing clinical advice

• Assess to local clinicians with local knowledge of Portsmouth commissioned services

• Increased number of patients resolving their issue at point of contact

Scheme Name: OOH Integration Start date: September 2016 End date: Ongoing

Funding/Scheme Value 17/18 = tbc 18/19 = tbc The change being introduced What it will involve Why it is better for patients Movement towards a 24/7 model of primary care provision with a single provider delivering urgent care within central hubs, smoothing and de-fragmenting care between core hours, extended hours, and the traditional out of hours period.

• Recommissioning the OOH service to integrate with the new 111 service and clinical triage hubs

• Redefining the traditional in-hours/out of hours split to ensure urgent primary care demand is managed seamlessly at all times

• Introduces a simpler urgent health system for patients to navigate

• Provides service opening times more responsive to patient preferences

• Reduced fragmentation of care

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