Hammersmith and

Fulham’s

primary care strategy Developing primary care as the foundation for

better population health across the borough

September

2017

# Chapter Page

1 Foreword – an introduction from Dr Tim Spicer and Dr David Wingfield 3

2 Our vision for an integrated health and social care system 4

3 Developing primary care at scale for the benefit of local residents – towards accountable care 9

4 Appendices

16

Purpose and content

This document describes how the CCG and GP Federation in Hammersmith and Fulham will work with each other and their partners to further develop

the standard of primary care for residents of the borough. We will do this by creating primary care networks which will work with other care services on

which our patients rely. This will provide the foundation for a more unified and co-ordinated care system for local people, which we describe as

‘accountable care’.

2

FOREWORD: Improving primary care to achieve better population health

Primary care in Hammersmith and Fulham is improving, based on what

local people have said about the need for more patient-centred care

closer to home.

What we have achieved so far:

• Access to doctor appointments seven day a week

• Access to primary care through digital technology, as local practices

trial smartphone apps.

• Access to many more services in primary care including enhanced

support for mental health, warfarin monitoring and more diabetic care

and support

• Improved investment in buildings: Parkview Centre for Health and

Wellbeing was completed in 2014 and now provides primary and

community care to more than 17,000 people.

What we need to do:

Primary care is a key force in delivering the following areas of the

Sustainability and Transformation Plan (STP):

• radically upgrading prevention and wellbeing

• eliminating unwarranted variation and improving the management of

long-term conditions

• achieving better outcomes and experiences for older people

.

3

1 2 3 4

This is what our local residents have told us they require from

primary care:

We want to harness the energy and ideas of people who deliver and

receive care in Hammersmith and Fulham to create a system that works

seamlessly for everyone in the borough.

Within the limited resources we have, we are aiming for steady but

material improvement over coming years. This will be based on

sustainable changes in how local GP Practices will work together and with

other health and care services.

The end result will be a local care system that uses the collected expertise

and compassion of all of our local care organisations to deliver the health

and wellbeing outcomes that we and our residents want.

Dr Tim Spicer

Chair, Hammersmith

and Fulham CCG

Dr David Wingfield

Chair, Hammersmith and

Fulham GP Federation

“I want to access care easily and in the way most

convenient for me, either in person or by using technology.

I want the range of people who provide my care to all work

together, communicate effectively, and have clear roles

that I understand. Together, they can provide me with

seamless care”

Our vision for care and the role of primary care in achieving it

We are ambitious for how good local primary care can be and how it can

help to build a truly integrated service for patients and rewarding careers

for staff.

Expectations for how primary care should develop are set out in London’s

Strategic Commissioning Framework (2014), the GP Forward View

(2016), and the Sustainability Transformation Plan (2016), which are

already resulting in change on the ground.

The way forward

General Practice has worked more collaboratively over the past few years

through the practice networks. In order to deliver population health

benefits and improved experiences of care we need to move to the next

stage. In the future, we want primary care to be better integrated with

social care, voluntary care and other community services (i.e. district

nursing, community independence service).

4

1 2 3 4

“I want my GP and his/her colleagues to be linked in closely to all the other people and organisations who

provide care for me and support me in other ways”

The way forward for Hammersmith and Fulham

Improvements will be based on understanding local residents’ needs

Source: NWL Local Services strategy 5

1 2 3 4

Our journey towards an integrated system known as ‘accountable care’

6

Stage 3: forming an MCP, with the extended networks as its delivery level

• Principles of joint working are well

established through integrated

community care teams

• There is clarity about local need and

local resources and agreements are in

place which facilitate local flexibility

• The integration of services around

people is extended across health and

social care

• Links with local charities are established

to increase the services available locally

• One person, one service, one team,

one budget approach

• Improved access to community

and specialist care

• Community-facing consultants

• Greater focus on driving better

health outcomes for local residents

with payment systems linked to this

• More services delivered closer to

the patient's home

• Practices are working in larger

established networks to provide

services at scale for the local

population

• Practices work towards

reducing variation and

unnecessary admissions

/referrals through an agreed

common set of outcomes and

quality standards

• A shared workforce across

practices is established that

allows a greater range of

services to be delivered in

primary care

• Practices work

together effectively

in local groups

• Multi-disciplinary

team (MDT) working

is established as

well as the sharing

of learning and best

practice

• Low level of cross

practice shared

services

• No shared workforce

1 2 3 4

What are aims are for our residents and workforce?

Stage 3: forming an MCP, with the extended networks as its delivery level

1 2 3 4

7

“People who have low care needs can be managed by other care professionals to give GPs more time to

care for people with complex needs”

New investment in primary care will support GPs to meet local needs by improving standards

Primary care in Hammersmith and Fulham has been historically under-funded, in comparison with other areas of the country.

This is now being rectified and over the next four years, the CCG will be receiving accelerated growth monies as shown in the table below:

2016-17 2017-18 2018-19 2019-20 2020-21 2016-17 – 2020-21

£24.9m £27.2m £28.8m £30.0m £31.1m + 25%

This provides an important opportunity to address current inequalities in care provision and therefore to improve population health outcomes.

The CCG and GP Federation will work with local people and other partners to develop a suite of primary care standards that it will expect to be met for

all patients in the borough.

The core standards will focus on improving:

• improving patients’ experience of care

• radically upgrading prevention and wellbeing

• eliminating unwarranted variation and improving the management of long-term conditions

• achieving better outcomes and experiences for older people and people with mental ill-health

• reducing the number of unnecessary admissions to hospital

• ensuring high quality services are delivered in primary care, in line with the requirements of the Care Quality Commission (CQC)

.

8

1 2 3 4

Developing Primary

Care at scale for the

benefit of local

residents – towards an

accountable care

partnership

9

The networks have made significant progress: we now need to stretch our ambitions further

Recruitment problems

and other workforce

issues mean that we

have no choice but to

work at greater scale –

that is the only solution.

Relationships are key to

making the networks

function properly – so

we need to make sure

that they continue to be

based around practices

that work well together.

As a small practice, we value our

independence and autonomy – and

we want to be able to preserve this

within larger groups.

Working at scale affords benefits

in terms of freeing up GPs’ time to

do clinical work by having a larger

team with a greater distribution of

skills (including business and

management skills).

Working in larger groups

needs to be able to

preserve the continuity of

care for those patients that

need it.

This primary care strategy builds on the network system to support

practices to work more closely both with each other at scale and with a

wide range of other services.

Building on the benefits of network collaboration

There are currently five networks in the borough.

The formation of networks was an important step in enabling practices to

provide better care that meets local people’s expectations.

Networks have:

enabled General Practice to see beyond the boundaries of their own

practices

established multi-disciplinary working across practices and the sharing

of learning and best practice. This directly benefits patients in terms of

the quality of care

We are now aiming to extend this collaborative way of working to fully

develop primary care networks, which are already being tested locally

and showing positive results around the country for patients, practitioners,

and their wider systems.

The role of the CCG and GP Federation is to lead this process so that the

benefits can be delivered as quickly and uniformly as possible.

Such collaboration has already been embraced by many practices. We

recognise that there is both value and challenge in working in larger

‘primary care networks’ – a snapshot of feedback from GPs is shown

opposite. We will work with GPs to ensure that the implementation of this

strategy reflects both their ambitions and concerns.

Source:

CCG Members’ Meeting,

27 April 2017

10

The focus needs to be on clinical

outcomes - without stipulating a

single operating model,

1 2 3 4

“My practice works with other organisations to support me to maintain my physical and mental wellbeing –

and to support me when I am ill”

Reinvigorating the existing GP networks with the principles of the ‘primary care home’ concept to become ‘Primary Care Networks’

The ‘primary care home’ concept preserves and

improves the features of general practice that many

patients and GPs value most:

an integrated workforce, with partnerships spanning primary care, secondary care,

social care, and the voluntary sector

provision of care to a defined, registered population of between 30,000 and 50,000

a combined focus on personalisation of care with improvements in population health

outcomes

aligned clinical and financial drivers through a unified, whole population budget with

appropriate shared risks and rewards

• a first point of contact for all new health needs

• person-centred and continuous lifetime care

• comprehensive care provided for all needs

within a local population

• co-ordination and integration of care where a

person requires special services or provision

from secondary or tertiary care

11

The ‘primary care home’ concept also sets out

principles and a series of practical ways in which the

networks in Hammersmith and Fulham can work:

• they are developed, implemented, and led by

providers

• initiatives are planned and implemented at a

deliverable scale

• staff become the drivers of positive change

• fosters collaboration across local systems

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The primary care home model was launched by the National Association of Primary Care

(NAPC) and is based on improving joint working within and beyond general practice. The

model which was developed over more than a decade by clinicians around the country

provides GPs with the platform to drive the improvement of care right across the system.

The primary care home model implements change from within general practice, rather

than being overly prescriptive.

Primary care homes are designed around the needs of their local population and are

commonly characterised by the following four features:

Initially, fifteen sites across the country were chosen to test the principles of the primary

care home. There are now more than ninety. Appendix 3 provides examples of primary care

homes across the country and the benefits for patients, primary care teams and the wider

health and care system.

Hammersmith and Fulham GP Federation is a member of the NAPC’s community of

practice. Drawing learning from the ‘primary care home’ concept the GP Federation is

developing primary at scale across groups of local GP practices.

This way of working will benefit patients and primary care teams

1 2 3 4

12

WORKFORCE

INNOVATION

FINANCIAL SUSTAINABILITY

Workforce enhancement - practices can

address their workforce issues more

comprehensively than when working

alone, including recruiting for a wider

range of roles and across multiple

practices. This can improve retention by

allowing for more collaborative ways of

working such as improving clinical

processes.

More varied careers - GPs and nurses

can specialise if they wish, because there

is sufficient demand across multiple

practice lists. This allows people to

perform ‘to the top of their licence’ which

can help with recruitment and retention.

New structures for collaboration provide

more robust means of sharing learning

and best practice.

Broader multi-disciplinary teams that

brings together all expertise to deliver

better population health outcomes.

Practices can join forces to innovate

through investment in technology, as

care through digital care becomes more

effective over larger groups of people.

Patient records can be shared across

all practitioners involved in providing

care.

General Practice will be able to

influence change as they decide how to

collaborate and innovate, based on

their patients’ needs.

This may result in smoother pathways

from General Practice into a wider

primary care offer, as well as into social

care and voluntary services.

New service initiatives, based on the

needs of the networks’ registered

population.

Sharing back-office functions can

improve operational efficiency and

financially sustainability. It can also

free up GPs’ time to be spent with

patients.

Greater efficiency savings will be

realised through practices operating at

scale delivering centralised business

and clinical functions (i.e. patient

recalls)

£

Next steps

1 2 3 4

13

As explained previously the following steps will be undertaken to further improve care for local residents:

• Stage 1 as described previously involves the reinvigoration of existing General Practice networks to become primary

care networks

• Stage 2 brings primary care networks together into a unified approach to provide community based care – this will be

through the platform of a Multispecialty Community Provider (MCP); and

• Stage 3 adds acute services to the MCP for a co-ordinated, outcome- based borough-wide approach to all care – this is

accountable care.

Accountable care is our end-point ambition for Hammersmith and Fulham. This means continuing furthering our work in bringing services

together into a single, co-ordinated approach to deliver:

• high-quality care that is aligned to outcomes, for the whole population;

• good patient experience of health care; and

• cost-effective care, within the given budget.

The North West London Collaboration of CCGs have developed a ‘Provider Maturity Assessment’ tool which the CCG and GP Federation

will jointly use to understand the readiness of local primary at scale organisations to take on the delivery and leadership of community-based

care as part of an MCP and an Accountable Care organisation. Appendix 5 provides more detailed information on the ‘Provider Maturity

Assessment’ tool.

The GP Federation has been working towards accountable care since January 2016, when it led the establishment of the Hammersmith and

Fulham Integrated Care Programme. This is a partnership of four organisations committed to integrated healthcare: the GP Federation,

Imperial Healthcare Trust, Chelsea and Westminster Foundation Trust, and West London Mental Health Trust. The partnership is also

working with the council on a range of issues, including the extension of partnership working into adult social care.

“I have a clear say in how my care is delivered and can access different services by using my personal

budget”

Multispecialty Community Provider:

1 2 3 4

14

“As a patient with multiple health conditions, I would like to have all my health care providers to work together”

Hammersmith and Fulham will take learning from the MCP vanguards to understand the evidence base for different approaches. In

particular, it will seek evidence about how best to extend the MCP model from health care into adult social care and public health, both

of which are commissioned by the council. This is being done in a phased way in other parts of the country.

An MCP’s core aim is to build on the primary care networks to increase the breadth of services and depth of interventions delivered in

primary care and the wider community

There are a number of options for this, which range from:

• an alliance of relevant service providers with no new contractual arrangements (a virtual MCP)

• a more formal arrangement in which all relevant budgets, including core general practice, are put within a single contract. In this

case, GPs are able to reactivate their core contracts at the end of the MCP contract period.

Whatever decision local GPs make about their own contracts, the centrality of GPs to each primary care network means that they will

be a key voice within whatever organisational form underpins the MCP. The implications and opportunities for GPs under each MCP

model are described in more detail in ‘GP participation in a multispecialty community provider’ (NHSE, 2016). There is a link to this

document in Appendix 2.

Both options will bring together providers of care delivered in the community to decide how a unified budget for the care they provide

should be invested; in order to meet the outcomes set by commissioners.

An accountable care system brings together all local providers of care,

with primary care networks at its heart

1 2 3 4

15

“More of my care needs can be delivered within primary care, without the need to visit the hospital”

Primary care networks are the building blocks to establishing an MCP and then an accountable care system in Hammersmith and

Fulham. Accountable care will bring together the MCP with the acute and mental health trusts into a single budget for all care

commissioned by the CCG (and, potentially, from the local council as well).The importance of a single approach towards shared goals is

understood by all parties. The CCG, the GP Federation, and the other Integrated Care Programme partners began developing this

single approach over the period of May to July 2017, to confirm:

• shared goals, objectives and milestones (including developmental stages) for accountable care development

• the necessary workstreams to deliver the work

• the resources needs and timelines - Appendix 7 provides a high level delivery plan for the implementation of the strategy

The approach agreed will provide the development framework for accountable care, based on the stages shown below.

Vision and model Scope and impact Contractual analysis Financial analysis Contractual approach

Review Monitoring Contract Financial

framework Specification

April 2019

NHS England has recently published contractual guidance on Accountable Care Partnerships, a link to this publication can be found in

Appendix 2. The CCG will work with NHS England to incorporate this guidance into the development of its contracting approach for

accountable care. This will be done to ensure that local integration agreements reflect the national view; in terms of the level of integration

required between primary care and other services in order to deliver integrated care.

APPENDICES

16

o Appendix 1 - Glossary – acronym

and abbreviations

o Appendix 2 - Links to documents

referenced in this strategy

o Appendix 3 - Key benefits and results

from the primary care home test sites

o Appendix 4 - Examples of the

difference that the strategy will make

to patients’ experience of care

o Appendix 5 - Introduction to North

West London Collaboration of CCGs’

Maturity assessment tool

o Appendix 6 - Developing the optimum

network configuration for primary at

scale

o Appendix 7 - High level delivery plan

for the implementation of the strategy

o Appendix 8 - Local Engagement

undertaken for the development of the

strategy

o Appendix 9 - List of Hammersmith

and Fulham GP Practices

Appendix 1 – acronyms and abbreviations glossary Appendix 2 – links to documents referenced in this strategy

1

2 Five Year Forward View (2014) www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

Transforming Primary Care in London: A Strategic

Commissioning Framework (2015)

www.england.nhs.uk/london/wp-content/uploads/sites/8/2015/03/lndn-prim-care-doc.pdf

NHS England’s publications on Accountable Care Models https://www.england.nhs.uk/publication/?filter-category=new-care-models

The GP Forward View (2016) www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf

NWL Sustainability and Transformation Plan (2016) www.healthiernorthwestlondon.nhs.uk/sites/nhsnwlondon/files/documents/nwl_stp_octob

er_submission_v01pub.pdf

GP participation in a multispecialty community provider (2016) www.england.nhs.uk/wp-content/uploads/2016/12/gp-participation-mcp-contract-5.pdf

Next Steps on the Five Year Forward View (2017) www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-

YEAR-FORWARD-VIEW.pdf

‘Does the Primary Care Home make a difference? Understanding

its impact’ (2017)

www.napc.co.uk/control/uploads/files/1490953667~NAPC_Does_the_primary_care_hom

e_make_a_difference_March_2017.pdf

17

CCG Clinical Commissioning Group

GP General Practice / General Practitioner

MCP Multispecialty Community Provider

MDT Multi-Disciplinary Team

NAPC National Association of Primary Care

NHS National Health Service

PCH Primary Care Home

STP Sustainability and Transformation Plan

1 2 3 4

Appendix 3: Key benefits and results from the primary care home test sites

Evaluating the impact of the first primary care homes

The National Association of Primary Care (NAPC) has recently evaluated

the early impact of three of the primary care home test sites.

In line with the approach of fostering provider-led innovation designed to

meet the specific local needs, the sites have introduced a range of

initiatives.

The sites analysed are shown opposite.

The evaluation covered three perspectives relevant to

Hammersmith and Fulham:

1. the patient perspective – new services and better experience

3. the system perspective – impact on demand for other services

2. the practitioner perspective – satisfaction, recruitment, retention

The Beacon Medical Group

in Plymouth –

four practices covering

32,500 people

Thanet Health

Community Interest Company –

eighteen practices

covering 47,550 people

Larwood and Bawtry

practices in

South Yorkshire –

two practices covering

30,450 people

18

1 2 3 4

Appendix 3: The first primary care homes - exciting results for patients, GPs and other practitioners

The three primary care homes on the previous page have introduced a

range of new services to meet the needs of their combined practice

populations. Examples include:

• enhanced care home services, including ward rounds, medication

changes, and review of discharge summaries

• a new acute response team to safely manage unwell people outside

of hospital

• the reconfiguration of ‘virtual wards’ to involve community health and

the voluntary sector

• new roles for pharmacists within and beyond practices

• a collaborative flu campaign

• additional GP input into the redesign of care pathways, including for

dermatology and musculoskeletal conditions

Other initiatives in the pipeline include:

• hosting Citizens’ Advice clinics in practices, run by local volunteers

• providing social care clinics to reduce assessment waiting times;

reviewing clinical and non-clinical processes to identify opportunities

for improving productivity

Initiatives have been funded in a variety of ways – from existing CCG

budgets, by practices, and a combination of the two. In some cases, no

additional funding was required.

The patient perspective – new services and better experience The initial combined impact of these initiatives for the patient experience

looks promising, in terms of:

• shorter GP waiting times

• lower A&E attendances

• lower A&E admissions

• more appropriate medication regimes

• slower growth in referrals, demonstrating that more of people’s total

care needs are being accommodated within primary care

The information on this page is taken from ‘Does the Primary Care Home make a

difference? Understanding its impact’ (NAPC, 2017)

19

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Appendix 3: The first primary care homes - exciting results

As part of the evaluation, GPs and their colleagues in the primary care

homes were surveyed about the difference that the new ways of working

have made to their professional lives.

Some of the main results were:

Beacon Medical Group:

• 87% of staff enjoy their job, compared to 61% in 2015

• 90% of staff speak positively of the practice when speaking to patients

or external colleagues, compared to 69% in 2015

Thanet Health Community Interest Company:

• vacancies for community nurses have fallen from 24 to 0 over the

PCH pilot

Larwood and Bawtry:

• 87% of staff feel that the primary care home way of working has

improved their job satisfaction

• 78% of staff over the three sites feel that the PCH model has

decreased or not added to their workload

Overall, the pilot sites reported that the PCH way of working had

activated staff – GPs and others – to become the drivers of positive

change.

The system perspective – impact on demand for other services.

The PCH initiatives have not yet been underway for long enough to

establish a definitive causal link between new ways of working and a

range of system metrics. However, the early results suggest some

exciting results are already being achieved. Across the three primary

care homes, these include:

• reduced A&E attendances and admissions

• reduced lengths of stay in hospital following care home admissions

• a slow-down in the growth rate of GP referrals

• waiting times for GP appointments

• prescribing savings

The report also quantifies the savings realised. In Thanet these were:

• c.£295,000 annual savings from a reduction of 14 A&E admissions a

week following the roll out of the Acute Response Team

• £27,000 expected annual savings from reduced A&E attendances by

cross-practice working to provide extended primary care access on

bank holidays, supported by the shared patient care record

• £165 per care home medication review from a pilot – extended

across the local care home population, this would equate to a

system saving of £216,000

These impacts on the patient experience, practitioner experience, and

system metrics are key means of delivering the triple aim ambitions set

out in the test sites’ local STPs – and the same is true locally.

The practitioner perspective - satisfaction, recruitment, retention The system perspective – impact on demand for other services

The information on this page is taken from ‘Does the Primary Care Home make a difference?

Understanding its impact’ (NAPC, 2017) 20

1 2 3 4

ROD SMITH: Age 53. Diagnosed with Schizophrenia aged 24. Lives with sister, but often sleeps rough especially when

drinking. Prescribed small dose of regular tranquiliser.

Currently: Anticipated benefits of Accountable Care:

• Has been discharged from follow up by psychiatrist

• Under care of Community Psychiatric Nurse (CPN) but frequently fails to

attend

• Rod feels he is a nuisance to his sister who works from home. He tries to get

out from under her feet and spends a lot of time wandering the area, smoking,

and sometimes sleeps rough for days or weeks at a time

• Rod sometimes forgets to take his medication. Over the years there have

been a couple of crises that have required urgent visits by a psychiatrist

• Rod doesn't like his current medication. His GP would like specialist advice on

an alternative but Rod is reluctant to visit the psychiatrist

• Rod seems to develop chronic bronchitis rather suddenly. The GP

recommends an urgent hospital investigation but knows that Rod is unlikely to

attend for all the necessary appointments

• CPN is available to see patients locally in one of the GP practices that forms

part of a small, local health and social care network, and can visit patients at

home when necessary

• The Primary Care Collaboration includes various local community

organisations. The CPN has referred Rod to a health and social care

coordinator. After a discussion Rod has joined a local allotment group and

finds he enjoys gardening. He has also joined an art group and smokes and

drinks much less

• The Primary Care Collaboration employs pharmacists who routinely monitor

repeat prescribing systems including Rod’s usage of medication. They can use

the shared computer system to leave messages for GP colleagues, the CPN

and to ensure that someone contacts Rod to check on his wellbeing

• The GP and consultant can both access Rod’s medical record and hold a

‘virtual clinic’ where they discuss the case by video link while both viewing the

record at the same time. They agree on a plan of action including a trial of a

modern medicine with fewer side-effects

• There is a multidisciplinary diagnostic service in the local hospital where the

staff includes GPs from Rod’s local GP network. A care navigator keeps him

informed as the day progresses with various investigations

• The chest specialist and GP compare notes and exclude a diagnosis of cancer.

They make a record in Rod’s clinical notes and agree with Rod that he will

attend for follow up with his GP rather than the hospital

Appendix 4: PATIENT EXAMPLE 1

Highlighting the benefits of accountable care for patients with mental heath needs

21

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DANUTA KOWALSKI: Age 79. Widow. Lives alone. Suffers from diabetes, chronic kidney disease, high blood pressure and mild heart

failure. She has been admitted to hospital recently following some falls. She tries to help her struggling daughter with cash, leaving

her with little money of her own to feed herself properly.

Currently: Anticipated benefits of Accountable Care:

• A heart failure nurse visits Danuta at home, but sometimes Danuta needs to attend the

hospital for tests. She tries to combine visits to her GP for diabetes or blood pressure

review with days when her daughter is available. She can also usually co-ordinate her

hospital visits to the kidney specialist every three months to suit her daughter. She

sometimes misses her appointments

• Danuta frequently needs hospital admissions, for heart failure or worsening of her

kidney condition

• Currently, communication between health care professionals and social care is typically

in the form of letters

• There are frequent mix-ups over medication, when for example one of the specialists

recommends a change, but the letter arrives late at the GP surgery

• Danuta’s daughter is re-housed to another borough following the birth of her child, and

Danuta becomes increasingly isolated. A neighbour suggests she discuss the issue with

social services. She is offered a weekly visit to a day care centre but feels that would

not suit her

• Danuta’s daughter is increasingly pre-occupied and it becomes more difficult for Danuta

to access help or get equipment.

• Danuta sees a GP she has not seen before who is a little concerned to hear about

Danuta's financial support for the daughter. The GP is reluctant to trigger formal

safeguarding proceedings and takes no action.

• Local GPs and social services are combined in an integrated care service. The team is

based in one of the GP practices. The combined team ensures that the same, suitably

trained nurse can provide home visiting for all the various specialist needs in a single,

regular visit. The nurse can discuss Danuta’s case regularly with each of the specialists in

virtual clinics where both have access to the same, shared record system. Hospital visits

become less frequent

• An integrated team as well as shared records allows for better planning and anticipation of

crises, especially by making use of pharmacists who keep track of medication usage.

When crises do occur, they can usually be managed by a community support team that

visits Danuta several times daily including the use of mobile diagnostic equipment

• With health and social care combined in a single, local organisation, communication is

much easier using a shared record and regular meetings

• All the specialists involved have access to the GP record, and changes to medication are

more immediate. Also each integrated local care network will include pharmacists who

can regularly review prescribing and raise issues with the doctors or nurses involved.

• Integrated health and social care makes it easier for the nurse and social care to share

information. With more emphasis on prevention and with better communication, this

situation is anticipated much earlier, and a local housing solution is found which allows

Danuta’s daughter to continue providing some support

• Whenever help is required, it is accessed by a single phone call to the same number each

time. Danuta knows her care navigator very well, and since payments for equipment come

directly from a single, unified budget, personalised help and equipment can be accessed

much quicker

• The care navigator is able to connect Danuta to a local visiting service. One of their

volunteers is Polish and subsequently visits Danuta regularly to chat in her native

language

• The GP is very familiar with their social care colleagues who now work in the same team.

They are able to have an informal discussion and the nurse who visits feels able to raise

the issue with Danuta and her daughter and finds a solution that everyone is happy with

Appendix 4: PATIENT EXAMPLE 2:

Highlighting the benefits of accountable care for patients with multiple long term conditions

22

1 2 3 4

Appendix 5 – Introduction to North West London Maturity Assessment Tool

23

1 2 3 4

North West London Collaboration of CCGs are introducing a provider maturity assessment to evaluate

the willingness and capability of at scale primary care providers to deliver future population and

outcomes based contracts.

Appendix 6: Our delivery plans set out a demanding programme of work

24

2017/18 2018/19 2019/20 2020/21

GPFV implementation

Borough-wide primary care homes:

formation, mobilisation, innovation

Borough-wide primary care homes:

scaling and maturity

MCP

Accountable care Development and extension of

accountable care

Accountable care: launch planning

Network plan implementation

Primary care

standards:

development

Primary care standards: implementation

Implementation is under way

Plans included within the primary care strategy

Plans to be developed

Implementation state

Key

Accountable care: development and extension planning

SCF implementation

GPFV implementation

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Appendix 7: Developing the optimum network configuration for primary at scale

The CCG and GP Federation are working with

practices to develop the current network system

into the best configuration for working at scale.

This will be completed by October 2017 and will

be based on a series of considerations, including

existing collaborative relationships, common

challenges, and an appropriate mix of practice

readiness to lead the transformation process.

The map on the right shows the current Network

configuration. The practice names for each

number can be found in Appendix 9.

25

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Appendix 8 – Local engagement for strategy development

26

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Stakeholders / Forum Dates

Hammersmith and Fulham GP Members Meeting 27th April 2017

Hammersmith and Fulham GP Members Meeting 7th June 2017

Patient Reference Group (which included representation from Healthwatch, the London Borough

of Hammersmith and Fulham (LBHF) as well as Community and Voluntary sector organisations)

15th June 2017

Practice Managers Forum 5th July 2017

Primary Care Strategy Patient Focus Group 10th July 2017

Hammersmith and Fulham GP Members Meeting 20th July 2017

Primary Care Strategy Patient Focus Group 27th July 2017

Hammersmith and Fulham CCG and GP Federation have undertaken clinical and public consultation into the

development of the primary care strategy. A series of engagement events were undertaken (including two patient

focus groups) in which discussions were held with GP members, local residents and other stakeholders to gain an

understanding of the improvements they want to see in General Practice and the wider health and care system in

future. The table below provides a list of local engagement events that were carried out.

The outputs from local engagement were useful and have informed the final iteration of the strategy. For example,

a request to see greater emphasis on mental health needs alongside physical health needs has been incorporated

into the strategy.

21 Dr Kukar, Parkview

22 Salisbury Surgery

23 Park Medical Centre

24 The Bush Doctors

25 Brooks Green Surgery

26 Dr Uppal and Partners, Parkview

27 North End Medical Centre

28 Ashchurch Surgery

29 Brook Green Medical Centre

30 Hammersmith & Fulham Centres for Health (two sites)

1 Canberra Old Oak Surgery

2 Ashville Surgery

3 Shepherd’s Bush Medical Practice

4 82 Lillie Road Surgery

5 Parkview Practice, Dr Canisius & Dr Hasan

6 South Fulham Health Clinic

7 Westway Surgery

8 Cassidy Road Medical Centre

9 Sterndale Surgery

10 Lillyville Surgery

11 Hammersmith Surgery

12 Fulham Cross Medical Centre

13 Dr Jefferies, 139 Lillie Road

14 Dr Jefferies, 292 Munster Road

15 Richford Gate Medical Centre

16 The Medical Centre (Dr Kukar)

17 Sands End Clinic

18 Palace Surgery

19 Fulham Medical Centre

20 The New Surgery

Appendix 9 – practice list

3

27

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