DATE: 24 September 2015 Title

Bexley Primary Care Strategy

This paper is for Decision

Recommended action for the Governing Body

That the Governing Body: Approve

1. The attached Bexley Primary Care Strategy.

Potential areas for Conflicts of interest

The strategy sets out plans to transform primary care and therefore has implications for our GP members as providers. Co-commissioning plans are also included where there is a need to carefully manage conflicts. The CCG has robust processes in place to safeguard against the increasing number of conflicts arising from co-commissioning.

Executive summary

The attached strategy serves as a refresh and update of the previous primary care strategy that was approved by the Governing Body in May 2014. This was felt necessary given there have been so many changes and developments in primary care, with the commencement of co-commissioning and a range of new strategies which place ever increasing importance on the role of primary care and the changes necessary to ensure general practice remains sustainable in the long-term. The formation of the strategy has been clinically led and through engagement with a breadth of stakeholders including practice staff, the London Borough of Bexley, patient/lay members and NHS England. The draft strategy has been shared with all these partners as well as Oxleas NHS Foundation Trust and the LMC. Comments received have been reviewed and incorporated where possible. The strategy is organised to first set out our starting point, outlining the national, London-wide and local strategic context, an outline of Bexley’s demographics and health needs, an overview of what we know about the current primary and community care landscape and sets out the main factors leading to the need of a clear strategy as follows: 1: Variability in quality and outcomes

ENCLOSURE: H Agenda Item: 141/15

Governing Body meeting (held in public)

2: Primary care services are under pressure 3: Responding to financial pressures and creating a sustainable local

health service for the future 4: Supporting the integration of services across localities 5: Addressing key health issues and reducing health inequalities 6: Significant population growth planned for North Bexley Our strategic priorities then set out how we aim to transform services in Bexley over the next five years organised into the six themes in bold: • Taking a more proactive, population health management

approach to focus more on prevention of ill-health, wellbeing and supporting people to self-manage

• Improving access to primary care • Better care co-ordination by strengthening service integration • Use primary care co-commissioning to help secure high quality

services and reduced variation in quality and outcomes • Ensure that the necessary IT, workforce and estate infrastructure is

in place to enable transformation • Facilitating organisational development in general practice to move to

new models of provision that sit within local care networks The strategy outlines key actions that the CCG will take forward against each of our strategic objectives, in order to support transformation in primary care under these priority areas. It also summarises the resource and implementation plan for making the strategy a reality.

How does this paper support the CCGs objectives?

Patients: Improving access and quality of primary care. Improved health outcomes. Improved self-care and management of conditions.

People: Dedicated primary care development staff to facilitate delivery of strategy.

Pounds: Using minimal CCG resources or funds available centrally (e.g. infrastructure funding) to facilitate delivery of the strategy.

Process: This strategy aligns with the Our Healthier SE London Strategy, Strategic Commissioning Framework for Transforming Primary Care Services in London. It sets out plans to improve health outcomes and patient experience.

What are the Organisational implications

Key risks

Lack of investment to support transformation; capacity within practices; the national PMS review.

Equality

Ensuring that primary care services align to varying health need and demographics across the borough.

More consistent provision across localities in access and outcomes.

Financial

Uses existing resource assigned to primary care development. Small investment available. However, limited resources could become a limiting factor in progressing the strategy.

Data

There are no new data requirements resulting from the strategy that are not already being progressed by the CCG.

Legal issues None.

NHS constitution

Robust primary care to prevent crisis situations arising.

Engagement

• Primary care strategy workshop held on 9th July with members of the Primary Care Development Working Group (clinical lead, Practice Manager locality representatives, GP locality representatives, Primary Care Tutor and Nurse lead, Healthwatch, community pharmacy, Lay member for public and patient engagement, LBB and Bexley Voluntary Services Council), as well as NHS England.

• Commissioning intentions and primary care strategy engagement event on 23rd July with Bexley Voluntary Forum, organised by BVSC.

Audit trail Draft strategy shared with all attendees of the strategy workshop, the LMC, internal CCG staff and Oxleas for comment. Comments reviewed and incorporated where appropriate.

Comms plan Following approval the strategy will be published on the CCG’s website. An update on the strategy is to be shared with the patient Council on 15th September 2015.

Author: Sarah Birch, Head of Primary Care Development

Clinical lead: Dr Nikki Kanani Primary Care Development Lead

Executive sponsor: Theresa Osborne Chief Financial Officer

Date 8 September 2015

Primary care strategy 2015/16

Bexley Primary Care Strategy 2015/2016 – 2019/2020

Contents Version control ...................................................................................................................... 3

Executive Summary .............................................................................................................. 1

1. Introduction ....................................................................................................................... 2

2. Strategic context ............................................................................................................... 4

3. Bexley’s population and health needs ............................................................................... 8

4. Current primary and community care provision ............................................................... 10

5. Drivers for change ........................................................................................................... 14

6. Our strategic priorities for primary care ........................................................................... 19

7. Our strategic plans .......................................................................................................... 21

8. Local care networks ........................................................................................................ 23

9. Primary care co-commissioning ...................................................................................... 23

10. Primary care infrastructure - Workforce Development ................................................... 24

11. Primary care infrastructure - Estates ............................................................................. 26

12. Primary care infrastructure - Information Technology .................................................... 27

13. Implementation approach .............................................................................................. 29

14. Organisational development of primary care ................................................................. 30

15. Finances ....................................................................................................................... 31

Appendix A: Implementation Plan

Excellent healthcare – locally delivered

Version control

Name Date Version Reason Status

Sarah Birch 7th August 2015 V0.1 Consultation Draft for comments

Sarah Birch 9th September V0.2 Following comments

Feedback from N Wheeler, LMC, N. Lemic, Theresa Osborne, GBeard

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Executive Summary Primary Care is the first point of contact with the NHS for most people. GP Practices are often described as the ‘bedrock’ of a high quality health service, providing continuity of care for people from birth through to end of life. General Practice has served patients well but with advances in medicine and technology, patients’ life expectancy, needs and expectations have changed. General Practice now needs to care for and support a population that lives longer and have multiple long-term conditions that need ongoing management. For General Practice to be sustainable we need to change the way we design and deliver high quality care locally within an increasingly pressured environment. Over the last year we have taken some significant steps towards this ambition by progressing plans on how as practices we can do more together. By supporting practices to work together, we now have delegated prescribing budgets at a locality level and there is also an e-learning platform in place across Bexley allowing staff to undertake their mandatory training without leaving the practice.

There is still a lot more that we can do - this strategy sets out the CCG’s plans to improve coordination of care, access to services and take a more proactive approach to our patients’ health and wellbeing. This is set in the context of the specific challenges that Bexley faces such as a growing and ageing population, variability in access, overuse of hospital services, significant health inequalities, high obesity rates and an ever increasing prevalence of dementia.

This strategy also recognises that change cannot happen without having the necessary workforce, estate and technology infrastructure in place, so plans on how we can make meaningful change in these areas is also detailed.

Whilst this strategy has been driven by local need and circumstances, it responds to a range of national, London-wide and South East London strategies that all place a significant focus on the change needed in Primary Care. Most notably the Five Year Forward View, Better Health for London and the Strategic Commissioning Framework for Transforming Primary Care in London have all provided the strategic context for this Bexley strategy.

In my role as CCG Vice Chair I now look forward to making this strategy a reality and ensuring that we work to relieve the pressures on practices by working differently and, in doing this, make care better for all our Bexley residents.

Dr Nikki Kanani GP, Vice-Chair of NHS Bexley CCG and Lead for Primary Care Transformation

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1. Introduction

High quality primary care services are critical for the NHS, playing a vital part in improving population health and preventing ill-health. Primary care services often provide the first point of contact for people when they become unwell and, together with community based services, co-ordinate the care of people with long term conditions, older people and those reaching the end of their lives. Primary care services also provide some of the most important universal services for babies and children in their early years, supporting parents to keep their children well. The continuity of care and holistic role that primary and community care services provide is valuable for managing population health effectively. We know that Bexley residents’ value primary and community care services, and that they increasingly want to be able to access a wider range of community services without having to attend hospital. As more and more care is provided in, or close to, patients’ homes, we need to ensure that Bexley’s services are fit for the future and can take up the challenge of providing excellent and innovative care, centred around individuals, as well as being able to continue to provide the range of core services which are an essential part of the NHS system. The main focus of this strategy is on primary care services delivered by GP practices, although we recognise the broader workforce and the role in health promotion, screening and the provision of health advice and treatment. In developing this strategy, the CCG has engaged with practices, the London Borough of Bexley, the voluntary sector, patients, Health Watch, NHS England and community pharmacy to agree the commissioning intentions for primary care. The CCG believes that the changes we have outlined in this plan will have a positive impact on equalities, and help to reduce health inequalities and improve access for different patient groups. We will carry out the relevant equality, quality and privacy impact assessments for all new developments and service change. The table overleaf summarises the statutory responsibilities of each organisation in terms of their role in the commissioning and delivery of primary care services.

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• Fulfilling the responsibilities of their General Medical Services (GMS) or Personal Medical Services (PMS) contract for providing primary care services to their registered population. • To be registered with the health care regulator for GP services, the Care Quality Commission (CQC) • Determining the business and organisational structure of the practice and its relationship with provider organisations.

• Statutory duty to assist and support NHS England in securing continuous improvement in the quality of primary medical services • From 1 April 2015, level 2 co-commissioning of primary care (joint decision making) with NHS England • Contracts with primary care providers for diabetes, care homes and the Primary Care Improvement Fund (PCIF) • Commissions NHS health services (acute, community, mental health) for the Bexley population where primary care plays a key part of the system – has a common interest in improved standards for general practice.

• Responsible for the commissioning and contracting of primary medical services • Responsible for contract and performance management of primary care. • Responsible for commissioning of other primary care contractor services (pharmacy, optometry, dentistry) • Working with the CCG as joint decision making co-commissioners

•A statutory duty to improve the health of their population •Are mandated to ensure NHS commissioners receive the public health advice they need, provide appropriate access to sexual health services, protect the health of the local population, National Child measurement Programme, NHS Health Check Programme.” •Contracts some health improvement services from general practice •Responsible for many social, economic and environmental determinants of health, e.g. housing, education, community safety etc. •Commissions voluntary sector to provide a range of prevention/ early interventions services that complement primary care •Improving primary care is a health & wellbeing priority.

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2. Strategic context

Bexley’s strategy for primary care sits within our overarching responsibility for improving health outcomes for our population by ensuring that general practice is fit for the future in the long-term. This strategy sits within the context of a number of national, London-wide and local strategies that are summarized within this section. Five Year Forward View

The NHS Five Year Forward View starts the move towards a different NHS, recognising the challenges and outlining potential solutions to the big questions facing health and care services in England. It was published in October 2014 by NHS England, and was developed in partnership with the bodies that deliver and oversee health and care services nationally with patient groups, clinicians and independent experts. The significance of primary care is recognised with key points being:

• Stabilise core funding for general practice and review how resources are fairly made

available • Give CCGs more influence over the NHS budget – investment: acute to primary &

community • Provide new funding through schemes such as the Challenge fund – innovation, access • Expand as fast as possible the number of GPs, community nurses and other staff • Design new incentives to tackle health inequalities • Expand funding to upgrade primary care infrastructure and scope of services • Help the public deal with minor ailments without GP or A&E • Potential new care models such as Multispecialty Community Providers (MCPs) and

Primary & Acute Care Systems (PACS) Better Health for London

The London Health Commission was launched by the Mayor of London in December 2013, and reported in November 2014. It sets out ten aspirations for the capital, with the main aim of making London the healthiest major city in the world. The report made a series of recommendations, including measures to tackle childhood obesity, get people living healthier lives, better support for people with mental illness, improving GP access and more

support in the community for people with long term conditions.

• Increase the proportion of NHS spending on primary and community services • Invest £1billion in developing GP premises • Set ambitious service and quality standards for general practice • Promote and support general practices to work in networks

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• Allow patients to access services from other practices in the same network • Allow existing or new providers to set up services in areas of persistent poor provision Transforming Primary Care in London: A Strategic Commissioning Framework

The Framework was developed by the London Primary Care Transformation Board with input from clinicians, commissioners and patients. It was published in 2015 to act as a platform where CCGS can build to find solutions to the challenges for general practice in London and to support the healthcare community to make care better for all Londoners. It focusses on function rather than form, and does not replace the need for local planning. The Framework captures some of the core aims of primary care transformation for CCGs to reflect in their own locally developed plans. Implementation is expected to take place over a five year period beginning in April 2015.

The framework includes three “specifications” on proactive care, accessible care and coordinated care and subsumes the work of taking forward General Practice: A Call to Action as well as incorporating the recommendations made in the Five Year Forward View and Better Health for London. The framework recognises that to deliver the specification, larger primary care organisations will be necessary as well as Multispecialty Community Provider (MSP): organisations that align to a single population catchment. This strategy sets out Bexley’s approach to delivering the framework. Our Healthier South East London Our Healthier South East London is a five year commissioning strategy which aims to improve health, reduce health inequalities and ensure all health services in south east London meet safety and quality standards consistently and are sustainable in the longer term. The way health services are delivered needs to change in order to meet the emerging needs of an ageing population in which many more people live with long term conditions. This means that more resources must be directed towards services based in the community, keeping people out of hospital unless they really need to be there. The strategy sets out a whole system integrated model with Local Care Networks being the foundation to providing person-centred services to populations. The diagrams overleaf set out the vision for local care networks and all that they must encompass. General practice working at scale is a key component of the model. Each CCG within South East London is responsible for ensuring that the Local Care Network strategy is developed and implemented locally. This strategy sets out Bexley’s approach to Local Care Networks in section 8.

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Bexley’s Health and Wellbeing Strategy (2013) The Health and Wellbeing Board is responsible for improving population health and wellbeing in Bexley. The Board’s remit is to promote working across the local authority, health and other agencies to reduce health inequalities and address the wider determinants of ill health, such as poverty, joblessness and other social issues. The health and wellbeing priorities have been drawn from the Bexley Joint Strategic Needs Assessment (JSNA), information from the Public Health Outcomes Framework (including adult and child health benchmarking data) and consultation with residents. Using this evidence base, the following health priorities that impact most on the wellbeing of people in Bexley are: • Tackling childhood and adult obesity • Supporting people with addictions – including smoking, alcohol and drugs • Dementia • Diabetes The strategy set out the need to make the following key changes in how health and social care services are delivered in Bexley: • Improving services at Queen Mary’s Hospital in Sidcup • Joining up health care with social care and keeping more people out of hospital • Improving primary care • Investing in prevention services The key themes identified in the Health & Wellbeing Strategy that relate to primary care include: • Improving awareness of services and support that are available within the borough, so that

patients are aware of the broader range of care and support which is available • Optimising access to general practice • Development of new integrated multi-agency delivery models • Strengthen the role of preventative services where people have more control of their health. Bexley CCG’s Commissioning Intentions – Our Plans 2016-2018 This is the CCG’s main strategic plan and sets out what is to achieved from 2016-18. It is built on the foundation of the strategy ‘Healthier South East London’, and sets out how these plans and aspirations will be implemented in Bexley over the next two years and beyond. Like the south east London strategy, commissioning intentions are organised into the following areas: • Planned care • Urgent and emergency care • Children and young people • Maternity • Cancer (including end of life care) Under each area, local Bexley initiatives supplement all that is to be delivered across south east London to improve these services for all and address the inequalities in access and patient experience currently present. The focus is not only on secondary care services. Bexley’s commissioning intentions, like the SEL strategy, places considerable emphasis on developing local care networks to provide the foundation for the healthcare system locally. Through local care networks all primary care services come together, to provide person-centred health care in a joined up way to the population of Bexley. The work of the LCN is underpinned by communities themselves, which are being strengthened and encouraged to provide care and support to residents through the voluntary sector.

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3. Bexley’s population and health needs

Bexley’s Population The latest GLA borough population projections recorded Bexley’s resident population at 240,644, in 2015. The population of Bexley’s registered population is slightly lower at 233,654 as at June 2015. Key characteristics of Bexley’s population as identified in the 2011 census include the following: • the population aged 90 and over increased by 37% 1,700 between the 2001 and 2011

censuses • adults aged 35-39 decreased by17% to 15,000 over the same period • children aged under 5 increased by 14%. The population pyramids (below) created using census 2011 resident population data, show pictorially how Bexley’s population has changed.

The population is predicted to increase by 9% between 2011 and 2020, compared to a national estimated increase of 7.8%. This increase is predicted to continue beyond 2020, rising to 280,000 by 2035, an overall increase of 22% compared to projected overall increase of 17% across England. The increase is expected to be seen across all age bands with the most significant increase being those aged 65+ with a much smaller increase for those of working age (16-65 years). This is shown in the following graph.

Source: Population Projections Unit, ONS. Crown copyright 2012.

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Health challenges for Bexley The health of people in Bexley is good when compared to other areas in England. However Bexley residents do experience health inequalities, and there are some health measures where we are performing less well. In Bexley, the Joint Strategic Needs Assessment (JSNA) shows that: • Life expectancy for men living in the least deprived parts of the borough is nearly 6 years

higher than for men living in the most deprived parts of the borough. In women, the difference is over 4 years.

• The changing make up of our communities, especially the aging population overall and the growth in black and minority ethnic (BME) communities, particularly in the north of the borough, will have an impact on how we deliver against our priorities.

• Life expectancy in Bexley is steadily increasing in line with the trends nationally and in the London region and has been constantly higher than both the London and national averages

• As with the rest of the UK the main causes of death in Bexley are cancer, cardiovascular disease, COPD and digestive disease.

• Mortality from circulatory disease has fallen dramatically in recent years and there has been a steady fall in cancer mortality but this has not been as dramatic.

• Mortality from digestive disease in Bexley has increased by 4.5 per 100,000 population compared to a national fall of 2.9 per 100,000

• Mortality from chronic obstructive pulmonary disease (COPD) has decreased at a faster rate in Bexley (5.9 per 100,000 decrease) compared to a fall of 2.9 per 100,000 nationally

• Bexley has lower levels of deprivation than the England average with less than 10% (9.2%) of its population living in the most deprived quintile and approximately 53% living in the two least deprived quintiles (24.3% in least deprived). Bexley is ranked 166 out of 326 local authorities in England (1= most deprived) and is placed in decile 4 (1 being least deprived and 10 being most deprived).

Primary care therefore needs to be tailored to reflect the following key messages from the JSNA: • To target inequalities • To increase levels of physical activity and reduce obesity in adults and children • To improve early detection of illness • To better co-ordinate end of life care The CCG and its partners have identified the following health challenges which this strategy sets out ways to tackle: -

Obesity – adults and children

Levels of physical activity for children and adults are low, reflecting one of the fastest growing obesity rates in the capital

Diabetes More than 12,000 people live with diabetes in Bexley and the figure is rising

Addictions – smoking, alcohol and drug abuse

The on-going challenge of addictions needs focused intervention

Dementia The number of people over 75 occupying hospital beds with a secondary diagnosis of dementia is above the national average

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4. Current primary and community care provision

Primary Care There are 27 GP practices in Bexley with a combined registered patient list of 233,654 operating from 41 sites. GP practices are grouped into three localities. These are long-standing geographically coherent groupings which map onto ward boundaries and align with distinct populations. The North Bexley, Clocktower and Frognal localities are shown below. The locations of the GP practices main and branch sites are shown on the map below. The map below shows differences in deprivation levels in the Bexley. The dark pink areas are the most deprived and light pink are the least deprived.

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Table 1: Map of Bexley GP practices against index of multiple deprivation

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Community services Community services, describes a range of health services which are not based in traditional acute hospitals or form part of the core general practice offering. Many community services are provided on a domiciliary basis, in patients own homes. Community services play an important part in the transformation agenda to better integrate and expand the range of services available in out of hospital settings. This section provides a brief overview of the current community services landscape.

Service and provider

Locations Overview of service

Out-of-hours/ urgent care (Hurley Group)

• A 24-hour, 7days a week urgent care centre and out of hours service provided out of Queen Mary’s Hospital

• An urgent care centre at Erith Hospital, open seven days a week from 8am to 10pm.

• Minor ailment and minor injuries • Access to diagnostics • A tier 2 deep vein thrombosis service • Paediatric specialist nursing • GP out of hours cover

Community health services (Oxleas NHS Foundation Trust)

Domiciliary and various community based settings including some practices

• Adult speech and language therapy • Continence • Diabetes • District nursing • Health visitors • Services for looked after children • Podiatry (including pilot project aimed to

improve services and identify unmet need)

• Respiratory • Tissue Viability • Twilight Services • Virtual Ward • In-patient and outpatient neuro-

rehabilitation • Specialist Children’s Services • Integrated Care for Adults and Older

People (jointly commissioned with London Borough of Bexley)

a. Rapid Response (admission avoidance) b. Intermediate Care Beds (including

reablement beds) c. Community Geriatrician Service d. Community Assessment and

Rehabilitation Teams (CAR)

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Service and provider

Locations Overview of service

Community mental health services (mainly provided by Oxleas NHS Foundation Trust)

Domiciliary and various community settings

• Child and Adolescent Mental Health (CAMHS) and Adult Learning Disability Services

• Forensic and prison services • Older People Mental Health Services • Working Age Adult Acute Mental Health

Services • Working Age Adult Complex Needs and

Recovery Mental Health Services Improving Access to Psychological Therapies (IAPT) provided by Mind

16 practices Primary care counselling service for patients with mild to moderate anxiety and depression

GPs with special interests (GPwSI)

• Bexley Group • Erectile dysfunction • Slade Green • Vasectomy • Crook Log Surgery • Endoscopy • Albion • Dermatology

Community cardiology service

• Bexley Medical Group

• Bexley Group practice

• Barnard • Slade Green

• Consultant clinic • Diagnostics • Heart failure clinic

Anti-coagulation provided by Cotter-Laubis

• Barnard • Bellegrove • Good Health • Lakeside • Plas Meddyg • The Albion

• Anti-coagulation

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5. Drivers for change

There are a number of factors leading to the need for a clear strategy for changing the way that services are delivered in Bexley. These drivers for change are: 1: Variability in quality and outcomes 2: Primary care services are under pressure 3: Responding to financial pressures and creating a sustainable local health service for the

future 4: Supporting the integration of services across localities 5: Addressing key health issues and reducing health inequalities 6: Significant population growth planned for North Bexley Each of these drivers is described more fully below. Driver for change 1: Variability in quality and outcomes We know that there is also variability in the quality of care provided by GP practices and some community services. This is not uncommon across the UK, but is still something that results in unwarranted variation in outcomes for patients. Patient survey The national patient survey results (July 2015) show that in the majority of measures, Bexley practices performance has declined from the previous year. Headline messages from the Bexley survey results are: • 59% of respondents stated that it was easy to get through to someone on the phone

compared to a national average of 71%. This is a 6% drop from the previous year and there is significant variation between practices, ranging from 26% to 95%

• 64% of respondents stated that their overall experience of making an appointment was good compared to a national average of 73%. Practices ranged from 40% to 96%

• 79% of respondents stated that they had success in getting an appointment to see or speak to a GP or nurse compared to the national average of 85%. This was a 2% drop since last year.

• 78% of respondents described the overall experience of their GP surgery as good compared to a national average of 85%. There is significant variation between practices ranging from 56% to 96%

• 81% of respondents stated that the GP receptionists were helpful compared to a national average of 87%. This is a 4% decline from 2014 data.

• 51% of respondents to the GP patient survey stated that they do not normally wait too long to be seen compared to national average of 58%. There was a considerable difference between the lowest practice (12%) and the highest (78%) practice

• 70% of respondents were ‘satisfied' with their GP practice opening hours compared to 75% nationally

• 33% of respondents stated that they always or almost always see or speak to the GP they prefer (national average is 37%)

• 69% of respondents stated that they would recommend the GP surgery to someone who has just moved to the local area (national average is 78%)

• 69% of respondents stated that the last time they saw or spoke to a GP, the GP was good at involving them in decisions about their care (national average is 74%).

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• 75% of respondents stated that the last time they saw or spoke to a nurse, the nurse was good or very good at treating them with care and concern (national average is 77%).

• 90% of respondents to the GP patient survey stated that they have confidence and trust in the GP that they saw or spoke to (national average is 92%)

• 84% of respondents stated that they have confidence and trust in the nurse that they saw or spoke to, national average is 85%.

Healthwatch Bexley Healthwatch completed enter and view visits to ten Bexley practices in October 2014. Key findings were: • Around two third of respondents (65%) are satisfied with the appointment system at their

GP practice, although this varies significantly across practices. However, the qualitative analysis overwhelmingly suggests the majority of patients would like to improve the appointment system at their GP practice.

• The majority of respondents (64%) reported being able to obtain an appointment fairly quickly, although a third reported being unable to do so within two working days, with a lack of available appointment times cited as the most common reason for this.

• Accessing GP practices via telephone, including speaking to a GP or nurse on the phone, is highlighted as an area for improvement, as only one third of respondents reported it being ‘very’ or ‘fairly’ easy to get through on the telephones.

• Just over half of respondents (60%) reported being satisfied with the consultation provided by the GP during a visit, and the qualitative analysis suggests that a significant proportion would like to see a GP of choice, in addition to seeing the same GP consistently.

• The majority of respondents (70%) stated that reception staff provided a good service, although this varies significantly across practices.

• The majority of respondents (65%) were unaware of an internal or external complaints procedure.

Care Quality Commission (CQC) reports Since 2013, the CQC has had responsibility for inspecting and rating GP practices and GP out-of-hours providers. Specialist inspection teams, including GPs or practice nurses and trained members of the public, use professional judgement, supported by objective measures and evidence, to assess services against five key tests: • Are they safe? • Are they effective? • Are they caring? • Are they responsive to people’s needs? • Are they well-led?

Within the next two years, CQC will have inspected and rated every general practice in England as “Outstanding”, “Good”, “Requires Improvement” or “Inadequate” to help people make informed choices about their care and encourage improvement in quality. At the time of writing the strategy, the CQC had completed a number of inspections of Bexley practices with further planned but had not finalised any reports. NHS Bexley CCG will work with NHS England to follow the NHS England Framework for responding to CQC inspections of GP practices.

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Driver for Change 2: Primary care services are under pressure • Demand for healthcare increases every year, as a result of a combination of factors

including; population growth, an ageing population, increasing expectations of patients and advances in medical science.

• There has been significant growth in the over 90 and under 5s population in Bexley with this trend expected to continue. These age groups typically place greater demand on primary care than the working age population.

• The general practice workforce census (September 2014) showed Bexley to be the borough with the lowest number of GPs per 1000 registered population, nationally. The combined GP and Nurse WTE is slightly higher but still places Bexley 24th out of 32 London boroughs and 10th lowest, nationally.

• A significant proportion of the practice nursing workforce is due to retire over the next ten years

• The figure below summarises the key pressures faced by primary care. These demands could become overwhelming for primary care professionals, unless there is a change in how services are provided.

Driver for Change 3: Responding to financial pressures and creating a sustainable local health service for the future • The costs of providing care are rising much faster than the funding available because the

NHS is now treating more people with more complex conditions and people are living longer.

• Over the next five years the NHS is facing a £30billion financial challenge. The NHS in south east London faces these same challenges and organisational plans indicate that the affordability gap facing the health services across south east London would be about £1bn by 2019/20.

• The South East London strategy sets out the need to do things differently if we are to continue to deliver the best possible care for patients in the years ahead.

• Strong primary care services can help us by preventing the need for more expensive treatments and by moving some care out of hospital, where it can be safely and more cost effectively be provided in a primary or community care setting.

• Primary care services can focus on prevention, keeping people well and the early identification and diagnosis of health problems, all of which have positive benefits in terms

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of people’s well-being, as well as helping to avoid the costs of more expensive treatment in a hospital setting.

• Approximately 50% of the CCGs 15/16 budget allocation is assigned to acute care but this needs to reduce so that a greater proportion is shifted to community and primary care services.

Driver for Change 4: Supporting the integration of services across local care networks (localities) • Currently patients and carers find it frustrating to have to continually provide the same

information to different people. • Different parts of the NHS do not always communicate effectively with each other or with

social services. Patients with complex conditions are often passed from one service to another so patients’ treatment is often not joined up.

• To be able to fully adopt new ways of working in the interests of better patient care, relationships between organisations and professional boundaries need to change. Integrated care for the future needs to be based around the care of local populations, and to take a more person-centred approach. This places growing importance on the need for primary and community care staff to work even more closely with a range of other professionals and agencies to co-ordinate the care of individuals in response to their needs.

Driver for Change 5: Addressing key health issues and reducing health inequalities The Our Healthier South East London strategy sets out the following diagram which breaks the population into five broad groups. people known to be nearing the end of life (1%), people with

three or more long term conditions (LTCs, 9%), people in the early stages of a long term condition (25%), people experiencing inequalities at risk of developing long term conditions (50%) and people who are healthy and well.

The higher up the ‘tree’ a group is, the more money is spent on them. Our aim is to help more people to move towards the trunk of the tree, in the healthy and well group. The diagram is a helpful way for thinking about communities. Only about one in six people are healthy and well without being at risk of poor health. Half of all people are at risk of having a long term condition (a disability or an illness like diabetes, a heart condition or a long term mental illness). As people get older, they are often more likely to develop long term conditions. Primary care needs to be

equipped to address unhealthy lifestyle behaviours and we know in Bexley that obesity in both children and adults is higher than the national average leading to a high proportion of the population being diagnosed with diabetes. The most modifiable lifestyle risk factors are higher in the north of the borough where there is greater deprivation. The primary care web tool identifies that Bexley is underperforming in the following areas: • The percentage of patients aged 65 and older who have received a seasonal flu

vaccination.

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• The percentage of patients aged between 6 months and 65 years in the defined influenza clinical risk groups that received the seasonal influenza vaccination.

• Long term conditions screening and management (diabetes, cardio-vascular and respiratory)

• Mental Health support and mental health reviews in primary care. • Patient satisfaction with both quality and access • Non-steroid anti-inflammatory drugs (NSAID) prescribing Driver for change 6: Significant population growth planned in North Bexley Population growth pressures are already being felt in the borough and this is going to continue. Bexley is already flagged as one of the borough’s most able to respond to London’s pressing need for more housing and is at the heart of a South East London/North Kent ‘Productivity Hub’ which embraces the North Bexley opportunity areas, the Garden City at Ebbsfleet and the associated Paramount leisure theme park development at the Swanscombe peninsula .The London Borough of Bexley has developed its emerging vision for growth over the next 15-20 years that sets out plans for the delivery of at least 24,500 new homes, 10,500 new jobs and supported by significant investment in transport infrastructure. The figure overleaf summarises the vision for Bexley which is still subject to consultation.

This growth will have implications about the level of primary care provision that is needed within the development areas. Ensuring there is the health infrastructure and sufficient workforce to meet this increased demand needs to be planned in line with the growth strategy.

Indicative growth figures: 1: 5,000 new homes

2: 11,000 new homes

3: 2,500 new homes

4: 2,000 new homes

5: 1,000 new homes

Rest of the borough: 3,000 new homes

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6. Our strategic priorities for primary care

The figure overleaf sets out pictorially at a high level our commissioning priorities for the next two years that responds to the challenges faced in Bexley.

Our vision Bexley residents to stay in better health for longer, with the support of good quality integrated care, available as close to home as possible, backed up by accessible, safe and expert hospital services when they are needed.

Our key challenges

• Growing population, particularly in the north of the borough • Declining patient satisfaction with general practice • Variability in access to primary care • Overuse of hospital services • Primary care workforce shortages • High childhood and adult obesity rates • Increasing prevalence of dementia • Care is not joined up between services • Significant health inequalities • Ageing population that is at risk of developing long-term

conditions • High rate of population growth projected in 0-15 age group • Financial pressures across the NHS

Our strategic priorities describe how we aim to transform local primary care services in Bexley over the next five years:

• Taking a more proactive, population health management approach to focus more on prevention of ill-health, wellbeing and supporting people to self-manage

• Improving access to primary care • Better care coordination by strengthening service integration • Use primary care co-commissioning to help secure high

quality services and reduced variation in quality and outcomes • Ensure that the necessary IT, workforce and estate

infrastructure is in place to enable transformation • Facilitating organisational development in general practice to

move to new models of provision that sit within local care networks

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7. Our strategic plans

This section sets out in more detail the plans that underlie the commissioning priorities of proactive care, accessible care and coordinated care. Within these priorities, there is a focus on improving outcomes in the specific clinical areas where we know that Bexley is an outlier. The priorities of local care networks, primary care co-commissioning and primary care infrastructure are all enablers of the strategy which are addressed in section 8 to 12.

Proactive care • Roll out a social prescribing project across Bexley that reflects different localities health and wellbeing priorities

• A targeted self-management support initiative to be scoped and delivered in each locality

• Community Health and Wellbeing Champions trained and working in each Local Care Network

• Active support of screening programmes by contacting patients who have not attended bowel, breast or cervical screening invites

• Targeting health promotion/ awareness raising activities • Reducing the proportion of the population that are unregistered • Childhood obesity prevention programme • Joint prevention programmes with schools to improve

health/attendance of school age children • Encourage practice’s patient participation groups (PPGs) to play a

greater role in supporting the health and wellbeing agenda • Strengthen links between practices and Bexley Voluntary

Services Council (BVSC) directory of services (i.e. asset register) that details all the voluntary sector organisations available within the borough

Accessible care • All practices open during routine hours where building unlocked, practice receptionists answering phones and appointments running

• Explore and extend usage of new ways of working such as telephone triage, web consultations, walk-in services etc. so that all patients in Bexley have same day access to a GP/nurse

• Up-skilling the workforce so that HCAs, Nurses, Pharmacists can take on more workload allowing GPs to deal with most complex patients

• Work with practices to improve ease by which patients can get through on the phone

• Every practice to give patients option to book appointments four weeks in advance with flexible appointment lengths

• A locality/borough-wide model developed for delivering extended hours

• Every practice has a hearing loop in use by March 2016 • Every practice has access to sign language interpretation

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Coordinated care • Integrated care plans and case management in place for those at risk of an acute exacerbation

• Patients newly diagnosed with a long-term condition receive self-management/self-care support

• A comprehensive system and process in place for practices to utilise community geriatrician resource to assess the most complex frail elderly

• Encouraging best practice with the avoiding unplanned admissions DES contract

• Encourage roll out of an e-frailty tool to support case finding and early identification of frailty

• Third sector organisations contracted to take on case management of patients frequently being admitted to hospital

• Social care reorganisation to better align to practices and support MDTs virtually

• Implementation of virtual multi-disciplinary team meetings for patients frequently being admitted to hospital, involving acute consultants, community geriatrician, community services, social care, and relevant GPs

• Collaborative care planning training

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8. Local care networks

As part of the CCG’s aim of bringing care closer to home and the broader south east London strategy, primary, community and social care services need to be more accessible and better integrated, supporting a preventative and holistic approach to patient care over time. There is a commitment to strengthen joint commissioning arrangements with the council to ensure that the full complement of services is joined up around the patient along pathways of care. Primary care plays an integral role in delivering our strategic priorities, whether as a provider within the care pathway, or by ensuring that there are good processes in place for referral and management of patients following their interaction with more specialist acute or community services. In Bexley there are three local care networks that align with the existing locality networks of practices. There is a single GP federation, Bexley Neighbourhood Care Community Interest Company (CIC), where all practices are members. Working through the Local Care Network programme board, the CCG with the London Borough of Bexley and provider partners seeks to expand and enhance the service offering around populations.

9. Primary care co-commissioning

From the 1 April 2015 NHS Bexley Clinical Commissioning Group (CCG), along with the other CCGs in south east London, has taken greater responsibility and involvement in the design, shaping and commissioning of local general practices, in a joint commissioning arrangement with NHS England, known as co-commissioning.

This arrangement allows the CCG to work more closely with those responsible for securing the provision of general practice, NHS England, and will support local plans to improve primary care services in the borough. The committee meets regularly in public to consider and take decisions on local services.

Our priorities under co-commissioning are:

Primary care co-commissioning

• A review of Personal Medical Services (PMS) contracts will take place in 2015/16, led by NHS England with CCG input

• Existing local enhanced services to be reviewed, considering opportunities for commissioning on a locality level

• Work with the Local Authority to commission a consistent extended service offering for all patients, e.g. health checks, diabetes, sexual health

• Work with practices and NHS England to address quality concerns

• Continuation of the existing primary care improvement scheme to make greater progress an improving end of life care, obesity, dementia and medicine management considering opportunities to facilitate closer locality working

• Supporting member practices to prepare for CQC inspections, meet minimum statutory compliance standards and deliver improvements/recommendations resulting from inspections

• Following NHS England’s Framework for responding to CQC inspections of GP Practices, including working with NHS England

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and practices to develop any necessary improvement plans and identifying resource available that may assist the practice.

• Address variability and non-compliance with NHS England’s patient registration operating principles for primary care

• Launch and quarterly refreshes of the Primary Care Activity Reporting Tool (PCART) to give practices increased awareness of their performance and activity in a user friendly format.

• Roll out practice development plans, providing up to date performance information to practices highlighting where they are outliers

• Develop the effectiveness of patient participation groups • Practice development visits to practices to support quality and

outcome improvements • Undertaking all current co-commissioning responsibilities and

preparation for taking on delegated responsibility where the CCG would have full responsibility for commissioning primary care services

10. Primary care infrastructure - Workforce Development

Development of the primary care and community workforce has been recognised as a priority by Health Education England (HEE) and forms part of Health Education South London Workforce Skills and Development Strategy. Community Education Provider Networks (CEPNs) have been proposed by Health Education South London as a key delivery arm for supporting the development of the existing and future workforce.

Bexley has been developing a Community Education Provider Network over the last 2 years. A project manager was appointed and a steering group established. CEPN’s are designed to improve the quality and localisation of education for health professionals. They aim to empower community organisations to work with higher educational institutions to assess workforce training needs, expand capacity for training in the community, innovate in the field of training and deliver multi-professional training. It is anticipated that Bexley Health Neighbourhood Care CIC will take on hosting arrangements for the CEPN, once all appropriate infrastructure and governance is in place. The role of the CEPN is continuing to grow and is considering future workforce planning requirements to align with the direction of travel for primary care transformation. It seeks to support all learners to come together for multi-professional education where they also have the opportunity to network and build relationships. There are opportunities to seek investment from central sources to develop pilot training hubs, where groups of GP practices can offer inter-professional training to primary care staff, extending the skills base and developing a workforce which can meet the challenge of new ways of working. These hubs will be the basis for training/supporting medical students, foundations doctors, GP registrars, physician's associates, nursing students both pre and post grad. As the workforce enabler group it is seeking to deliver the following priorities:

Infrastructure – workforce

• Improve the GP to patient ratios by linking with NHS England and Health Education England (HEE) to ensure that Bexley practices

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development benefit from the GP workforce 10 point plan of “Recruit, Retain, Return.”

• Working with acute providers to explore Physician Associate roles and developing a sense of community amongst medical students while they are placed in the borough

• Working with practices and localities to consider options for addressing the GP/Nurse workforce challenges such as employing practice-based pharmacists.

• Leadership development for practice managers • Development of a wider skill mix, including training for health care

assistants and introduction of the HCA Care Certificate • Mentorship and coaching skills for practice managers and practice

nurses • Expanding the roles of receptionists and administrative staff to

work more flexibly minimising skill gaps when practices are short staffed

• Expanding the nurse placements programme to involve more practices

• Expanding apprenticeships for receptionists, administrative and HCA staff into primary care.

• Enhancing the Vocational Training Scheme (VTS) GP training scheme and making general practice more attractive in Bexley to help retention

• Seeking to broaden roles within primary care such as Community Pharmacists, Community Health & Wellbeing Champions and care coordination

• Motivational skills and health coaching for primary care and voluntary sector professionals.

• Up-skilling four practice pharmacists to undertake patient consultations

• Ensuring that clinical staff undergoing formal training to expand their skills have the opportunity to apply learning in their practice

• Making mandatory training and some CPD (continuing professional development) updates accessible to practice staff via a web-based e-learning platform

• Increasing the number of nurse mentors and placement opportunities within the borough to address the future anticipated shortage in this area

• Establishing relationships with Greenwich and Bromley CCGs to share the cost of external training, where appropriate (e.g. HCA training) and to try to achieve maximum workshop attendance

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11. Primary care infrastructure - Estates

It is critical that public sector organisations locally make the most efficient and effective use of their estate so that over the long term, there is the required infrastructure to support the delivery of services, in the locations that best responds to the need. There is a requirement for all CCGs to have a primary care estates strategy in place by December 2015. Bexley CCG has formed a joint estates working group to provide a strategic overview of the future estates requirement and to prioritise investment within the borough. The following priorities will be delivered by the group:

Infrastructure - estates

• To identify and document current primary and community estate assets

• To identify future estates requirements arising from commissioning plans and population growth and regeneration plans

• To identify and support opportunities to manage and modernise the estate

• To have a robust borough wide primary care estates strategy including development and disposal plans and intentions

• To co-ordinate projects and prioritise investment and make recommendations to all parties

• Identify funding sources to develop community hubs and primary care estate in line with agreed models of care, maximising sources of funds from community infrastructure levies and regeneration

• To develop and support business cases for premises investment in accordance with the NHS England approval process

• To explore opportunities for joint asset management and co-location of services

• To recommend the use of capital and revenue expenditure to support premises proposals

• To encourage and support practices in making bids to secure investment for infrastructure improvements and to recognise their future infrastructure needs.

Sites of key strategic importance within Bexley include Queen Mary’s Hospital in Sidcup and Erith Hospital in the north of the borough. Oxleas NHS Foundation Trust owns the Queen Mary’s Hospital site, and there are a range of providers operating from the site to deliver the range of services shown in the diagram overleaf:

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In December 2014 the government announced a £1billion Primary Care Infrastructure Fund that would be made available over four years to accelerate improvements in GP premises and infrastructure like Information Technology. Practices bidding for funds had to demonstrate how their infrastructure scheme would achieve the following: • Accelerate improvements to the practice’s premises and increase capacity in primary care; • Enable better access to general practice; • Provide the foundation for possible integrated care services within the community; • Ensure DDA compliance; • Improve services for the frail and elderly, reducing the need for urgent care services and reducing the reliance on emergency care; Seven Bexley practices made applications in the first round of funding being released that were all successful and now need to be progressed to implementation.

12. Primary care infrastructure - Information Technology

The next 3-5 years will see the increased use of information technology benefiting both patients and practices in Bexley. The emphasis will continue to be on reducing the paper processes within practices and putting in place systems and procedures that will speed up services whilst at the same time improving data quality and data capture. The IT strategy for primary care seeks to build on the following priority areas over the coming few years:

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Infrastructure - IT

• Bexley Linked Care project - integrated digital records to enable practices to share their data with each other to support the advent of seven day working. By deploying the Vision 360 clinical systems portal across Bexley – all practices, Vision and EMIS, will be able to securely share and exchange agreed information across the healthcare community.

• Video consulting - to reduce the amount of travelling between practices but to also support the opportunity to provide additional methods of communication and access to Bexley patients.

• Social prescribing – providing the technology and access to our GPs and voluntary sector providers to support Bexley patients further into the community within the confines of the appropriate information governance framework.

• Implementation of Iplato for practices enabling them to enhance their service offering to patients by texting appointment reminders and appointment cancellations integrating directly into their practice systems, which ensures that new available appointments can be seen in real time as well as reducing their DNA rates. This will continue to be contracted by the CCG for as long as funding is received from NHSE and responsibility remains with the CCG.

• Implementation of the Iplato text based system for collecting friends and family responses enabling practices to eliminate the administrative burden of collating paper returns.

• Online access to GP medical records. This allows patients to view an online summary of medications, allergies and adverse reactions.

• Support practices to make the most effective use of their online tools and software that is integrated into their practice systems to help improve practices efficiency. This includes DXS, e-referrals, GP to GP, QAdmissions, the online appointment booking system and online ordering of repeat prescriptions.

• Flexible IT solutions to support mobile working and case conferencing between multi- agency professionals using the omnijoin web conferencing facility. This supports inter-agency multi-disciplinary team meetings.

• Development of shared clinical systems to support the integrated care agenda.

• Collaborative working with the South East London Strategy work to ensure that any primary care systems implemented in Bexley integrate to the wider health community and the systems in place across the whole SEL health and care environments. Work progressing with Lewisham & Greenwich Trust Connect Care system and Dartford & Gravesham’s Vision 360 to link GP and hospital data.

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13. Implementation approach

The work to deliver this strategy will be led by Bexley CCG and will feed into the wider collaboration that forms part of the South East London community-based care programme. The organogram below sets out the Bexley governance structures.

The Primary Care Development Working Group (PCDWG) is a multi-agency group that is responsible for progressing the strategic and operational plans for the future of primary care. It includes representatives from primary care (GPs, nurse, practice managers), the London Borough of Bexley, Bexley Voluntary Services Council, Healthwatch, lay member representative and community pharmacy. This is the main group that oversees the delivery of this primary care strategy. The PCDWG is responsible for ensuring that as plans are developed, there are robustly defined benefits that will be monitored and reported upon to check that initiatives are having the desired impact in terms of improved quality and health outcomes. This group provides regular updates to the Governing Body. The Local Care Network Programme Board sits above this group to drive forward the broader local care network strategy. Representatives from each locality sit on the PCDWG who provide monthly updates at locality meetings. There are also two members (a GP and Practice Manager) who are also Local Medical Committee (LMC) members to ensure there are linkages between the two committees. There are also three enabler groups in place to drive forward the IT and technological changes, estates infrastructure and the workforce transformation programme. The implementation plan in Appendix A summarises at a high level the delivery timescales for the primary care transformation programme. This is fully in line with the South East London programme which incorporates all CCGs timelines. There are a number of factors that pose as risks to the delivery of this strategy that are actively managed by the PCDWG. These are summarised in the table below.

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Risk Mitigation Ongoing engagement of general practice

• Representatives from all localities on PCDWG • Primary care development updates prepared for each

locality meeting • LMC regularly updated at formal or informal meetings • Other communication forums such as GP engagement

event, Practice Managers Forum and other targeted workshops used to communicate key messages

PMS review – investment and requirements of service specification not yet known

• National requirement that all PMS contracts are reviewed by April 2016

• CCG working to ensure there is clarity from NHSE on funding

Lack of investment to make primary care transformation a reality

• Promoting and making practices aware of national investment opportunities such as Primary care infrastructure funding (PCIF) and national pilot schemes (e.g. practice based pharmacists)

• Future opportunity for use of 1% non-recurrent reserves to progress transformation to Local Care Networks

14. Organisational development of primary care

Bexley practices have already demonstrated a commitment to working at greater scale and thinking about different organisational models which could support this change. This change in the way of working is led by practices at a locality level, with the CCG playing a facilitative role. This is both a strategic response to the commissioning framework for primary care but is necessary to mitigate the workload and financial pressures which practices report that they are experiencing. There is scope for more provision to take place within primary care networks and there is a need for practices to devise methods that ease the communication and contractual processes allowing other providers to sub-contract with primary care. Through working at greater scale there is opportunity to ensure that best practice and learning from one practice is shared with the next leading to a consistent offering to patients. Practices have begun to consider different models of the ways in which locality models could work on a larger scale to improve access and make services more integrated. The following activities are planned to progress the organisational change programme: • Delivery of a future model planning workshop to support practices to expand and enhance

their plans for working at scale in localities • Collating examples of best practice and innovation from within Bexley and more widely for

sharing amongst practice managers • On-going improvements to GP Zone to facilitate sharing of information and best practice • Clinical leads taking on greater role around peer review to support practices to address

variation in performance • Facilitating the Practice Managers Forum and Practice Manager Working Group to

support sharing of information and different ways of working • Expanding membership and raising profile of the primary care development working

group to broaden impact

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15. Finances

There are many changes in the financial planning landscape over the next five years. The CCG is expected to achieve a 1% surplus in each of these years. However, in consideration of its distance from target allocation, which remains 3.07% (c£8m) below target in 2015/16, it is only planning to make £151,000 surplus in 2015/16. On current planning, it is believed that 1% will be possible from 2017/18; assuming that plans in 2015/16 and 2016/17 are fully delivered. To achieve these plans, the CCG is planning for £6.3m Quality, Innovation, Productivity and Prevention ( QIPP) savings in 2015/16, £6.3m in 2016/17 and c£5m in the following three years. Although less than in 2013/14 and 2014/15 this will still be challenging for the CCG. Our QIPP plans aim to achieve these cost reductions by focusing on reducing the costs of care through improving prevention and early management of health problems, as well as transforming the way that care is delivered in order to provide improved quality care at lower costs, working in partnership with community services and primary care. In 2015/16, the CCG will be working with partners on implementing the South East London strategy, and our borough based work on developing primary care and local care networks. This work will continue, in conjunction with other South East London CCGs and partners over the coming years. Bexley CCG also operates a Primary Care Improvement Fund (PCIF) whereby a budget of up to £768,000 was available for practices to earn for undertaking activities and achieving targets to deliver quality improvements in primary care, linked to the CCG’s strategy. The CCG has a small budget set aside in 2015/16, to assist with the implementation of primary care initiatives to take this strategy forward. In future years, it is hoped that the 1% non-recurrent reserve will also be available to progress the transformation needed in respect of Local Care Networks. The national Primary Care Infrastructure Fund (PCIF) could also be a useful source of funding to progress the strategy.

Appendix A -Bexley Community Based Care Implementation Milestones

2015/16 2016/17 2017/18 2018/19 2019/20

Milestones Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Federation/Alliances Established

All local GP practices have agreed to an Alliance

The Alliance has a recognised legal identity

Commissioner offer made to Alliance and contract in place following due diligence

3 to 5 year business plan developed

LCN integrated system leadership & management

Local Care Networks defined

LCN leadership team & management structure in place with clear governance and decision-making arrangements

Enabling strategies, e.g. workforce, IM&T, Estates embedded across networks with localised delivery plans

Accessible Care standards and associated big hitters implemented

Improved access to GP practice including 8 to 8 7/7

UCC/walk-in centres

Able to share medical records across federations

Single telephone triage and booking across federations

Reablement (encompassing rapid response and supported discharge)

Same day access to specialist advice and clinics (including diagnostics)

Proactive Care standards and associated big hitters implemented

Local communities and stakeholders actively and routinely involved in priority setting and service redesign across networks

Asset mapping and social prescribing

Care coordinators/navigators/patient liaison across networks

Health & Wellbeing champions across networks

Primary prevention and enhanced public health programmes

Active risk stratification

Training in motivational skills and health coaching

Enhanced call & recall and screening for hard to reach groups

Enhanced support to vulnerable people in care homes, extra care housing and receiving domiciliary care

Coordinated Care standards and associated big hitters implemented

Active care registers within GP practices

Identifying people at risk of developing LTCs

Patient/carer education programmes

See MDT working below, reablement above, care coordinators above, assigned care professionals below

Continuity of Care standards and associated big hitters implemented

All patients have a named GP

Flexible appointment lengths according to patient need commissioned

Assigned care professional in final year of life

Multi-disciplinary teams established within networks

Key:

Milestone

Delivery window