1

Warrington Primary Care Draft Strategy 2015

2

Contents 1 EXECUTIVE SUMMARY……………………………………………………………………………………………………………………..4

2 WARRINGTON CCG PRIMARY CARE PLAN ON A PAGE ........................................................................8

3 GENERAL PRACTICE IN 2015…………………………………………………………………………………………………………….9

3.1 Role of general practice .................................................................................................................9

3.2 Current state national picture ..................................................................................................... 9

4 PRACTICE CHARACTERISTICS WARRINGTON………………………………………………………………………………….14

4.1 Size of Practices in Warrington .................................................................................................. 14

Cheshire, Warrington and Wirral comparative list size ranges ........................................................ 14

4.2 Registered populations .............................................................................................................. 14

5 STRATEGIC CONTEXT AND DEVELOPMENT OF THE STRATEGY...........................................................17

5.1 History and context ......................................................................................................................17

5.2 National policy directions .......................................................................................................... 19

5.3 NHS England Area Team Strategy .............................................................................................. 20

5.4 Five year forward view............................................................................................................... 22

5.5 Local priorities ............................................................................................................................ 23

5.6 Summary – strategic framework for the strategy ..................................................................... 23

6. TOWARDS THE PRIMARY CARE HOME ……………………………………………............................................ 25

6.1 Development to date ................................................................................................................. 26

6.2 Vision for the Primary Care Home ............................................................................................. 29

6.3 Expected outcomes .................................................................................................................... 30

6.4 Leading the change .................................................................................................................... 31

6.5 Summary..................................................................................................................................... 31

7 THE WARRINGTON BRAND…………………………………………………………………………………………………………….35

7.1 How QOF works – current state................................................................................................. 36

QOF points .................................................................................................................................... 36

7.2 Co-Commissioning elements of Warrington Brand .................................................................. 37

Objectives ..................................................................................................................................... 41

7.3 Local commissioning for extended primary care ...................................................................... 44

Extended Primary Care (Cluster) CCG Commissioned.................................................................. 44

7.4 Summary..................................................................................................................................... 45

8. FINANCE AND INVESTMENT STRATEGY PART 1 CO-COMMISSIONING ELEMENTS........................ .46

8.1 BACKGROUND ............................................................................................................................ 46

8.2 GMS CONTRACTS........................................................................................................................ 47

3

8.3 PMS CONTRACTS ........................................................................................................................ 48

8.4 ADDRESSING INEQUITY IN WARRINGTON - ANALYSIS ....................................................... ………58

8.5 SUMMARY .................................................................................................................................. 60

9. ENABLING STRATEGIES………………………………………………………………………………………………………………….62

9.1 Care Coordination ...................................................................................................................... 62

9.2 Accountable Care Team approaches ......................................................................................... 63

9.3 Enabling technologies ................................................................................................................ 63

10 APPROVALS………………………………………………………………………………………………………………………………….65

11. REFERENCES………………………………………………………………………………………………………………………………...67

APPENDIX 1……………………………………………………………………………………………………………………………………….68

POPULATION PROFILES…………………………………………………………………………………………………………………….68

APPENDIX 2……………………………………………………………………………………………………………………………………….82

WARRINGTON QOF PROFILES 2013-14…………………………………………………………………………………………….82

APPENDIX 3……………………………………………………………………………………………………………………………………….91

PRIMARY CARE MEASURES……………………………………………………………………………………………………………….91

4

1 EXECUTIVE SUMMARY Primary Care is “The provision of first contact, person-focused, ongoing care over time that

meets the health-related needs of people, referring only those too uncommon to maintain

competence, and coordinates care when people receive services at other levels of care.” 11

This document sets out Warrington CCGs vision for Primary Care for 2015-2019, focussing on general practice. The document reflects the ambitions of the previously published commissioning intentions and NHS Warrington CCGs Strategic Commissioning Plan 2014-

2019, and builds on the new opportunities provided through primary care co-

commissioning. This is an ambitious programme of large scale change recognising the importance of primary care to our entire health system.

Scope

It is fully acknowledged that there is a wider imperative to integrate the role of pharmacists,

dentists, ophthalmologists and other parts of the system. These will form the basis of

further strategic development following the adoption of this strategy. This strategy is

presented as a key building block for wider system reform recognising general practice is at

the heart of the health system.

The vast majority of people in Warrington are registered with a local GP. Most people will

see their GP 8 times a year. The GP record is the only place where all of an individual’s health

data is coordinated, thus containing the best potential to deliver integrated and coordinated

care.

Warrington CCG has focused on Primary Care transformation since its inception, and has

created significant momentum for change through membership engagement over the last

three years. This strategy builds on that momentum, and sets out a vision for Warrington

with primary care at the centre of system transformation. General Practice is best placed to

be the cornerstone of system reform, to deliver care coordination and preventive public

health approaches, complex case management, and to manage effective utilisation of

medicines and referrals for the system.

The strategy sets out the basis of a ‘Warrington Brand’ of Primary Care, to be achieved

through new co-commissioning arrangements with NHS England. Patients in Warrington

should have the knowledge that irrespective of their Practice of choice, they will receive a

standard of care that is equitable across the borough. All Practices will continue to provide

nationally set standards, with the additional assurance of a local set of standards. In

Warrington the principle of the Warrington ‘Brand’ has been developed as a driver for

equity, to enable local variation to be addressed and to deliver more focus on preventive

services and will support integration of services around Practice clusters. The Warrington

1 Starfield B (2008) The importance of primary health care in health systems

5

‘Brand’ will include national standards with the addition of a locally agreed set of measures,

to deliver a Warrington ‘price per patient’ based on weighted patient.

The strategy also recognises the need to invest in primary care in order to shape the

structure of system supply towards the national aspiration of care closer to home.

Primary care is of vital importance to the whole health system. Most health system contact

begins and ends in primary care, nine out of ten NHS contacts are in primary care of which

eight are in general practice2. The majority of people have a family doctor and attend

regularly3 (average 8 times a year).

The research and development that was undertaken in Warrington in 2013 led to a big

conversation on primary care sustainability. It was clear that primary care as we know it is

under threat from a substantial increase in the number of appointments required, the

complexity of presenting problems, plus associated workforce and economic pressures. The

response to the findings from the baseline research in Warrington led to the establishment of

a primary care programme group led by local GPs, and to whole system conversations and

events throughout 2013. This was the groundwork for innovations in primary care and for the

development of a strategy for a primary care home model that was signed off by Warrington

CCG in December 2013 and which led to a successful bid by Warrington GP Federations to the

Prime Ministers Challenge Fund.

In Warrington the development of GP clusters since April 2014 provides cohesive population

based clusters of Practices that have the ability to work together across a larger footprint of

delivery, and to obtain economies of scale through collaboration. This cluster model has been

working in shadow form and now needs to be consulted on to be developed further. The enablers

set out in this strategy support the development to maturity of these clusters and the benefits

that can accrue from integrating services around registered list based populations. Enablers

include new technologies, organisational development, and cost per weighted patient that will

support emergent organisational structures and opportunities, acknowledging that the new

cluster based delivery structures have the potential to maximise new ways of working such as

care coordination and integrated systems around the registered lists.

Key elements of this strategy:

Investment in 2015/16 and subsequent years across Warrington to deliver:

2 http://www.hscic.gov.uk/primary-care 3 Nuffield Trust figure on total number of consultations – this rose by around 11 per cent and the number of consultations per person per year registered on a practice list also rose – from 7.6 to 8.3.between 10/11 and 13/14 previous NHS IC data shows 6 per person up to 2008

6

₋ The Warrington Brand of Primary Care (common quality provision enabling every

citizen to get a common offer of care irrespective of registered practice)

incorporating priorities for primary care improvement defined by the GP

membership of the CCG.

₋ An agreed common price per weighted patient for delivery of the Warrington brand

elements above and beyond national core elements.

₋ The continued implementation of the Primary Care Home model delivering

collaborative primary care provision at scale, the home of system integration and

care co-ordination, with implementation support through the Prime Minister’s

Challenge Fund during 2015-16 creating the building blocks for system

transformation. This is recognising that over the last two years local clinical leaders

and Practices have created a vision for collaborative primary care at scale which has

become the basis for system transformation in Warrington.

₋ A focus on innovation to achieve leading edge primary care delivery supported

through enabling technologies.

₋ The establishment of a primary care skills taskforce working with local providers to

ensure that the system attracts and retains quality clinical staff.

₋ Establishment of an integrated commissioning group to redesign the commissioning

approach to urgent care recognising the need to integrate the commissioning

approaches with this primary care strategy creating a new integrated commissioning

approach to access incorporating out of hours and urgent care.

₋ Establishment of a local assessment panel for local tariff co-commissioning of

primary care.

₋ Establishment of a primary care commissioning unit of the CCG.

Response requested: Commitment to a level of allocated funding for 2015/16 and thereafter of CCG funding in primary care to be invested as proposed in the strategy to achieve:

₋ Warrington ‘Brand’ of primary care to be introduced over the next two years

through a recurring investment in co-commissioned provision replacing the current

disparate commissioning approaches to include core and nationally defined

provision plus local elements to include referrals practice, elderly care, complex case

management, and an agreed standard of access.

₋ Continued investment in primary care at scale investing in the Primary Care

transformation programme for 2015/16 in areas such as primary care cluster

working, Occupational Development (OD) and enablers

₋ The latter to be replaced by an investment of local primary care plus commissioning

to include extended access available in clusters including evenings and weekends

which can be contracted from any accredited primary care part B clinical providers

either at GP Provider, practice or cluster level, and to include implementation of

transformation schemes that have proven to be successful.

7

₋ NHS England is requested to work with the CCG in co-commissioning the elements of

the Warrington brand.

₋ A reference group to be established to report to the Primary Care Quality Committee

of the CCG, to agree and consult on the measures to be adopted in a balanced score

card approach to commissioning primary care.

₋ Following publication of final proposals a formal consultation to be undertaken during

2015/16 with a view to commencing the provision of primary care against the

Warrington standards in April 2016

Executive Sponsor:

Dr Andrew Davies

Acknowledgements:

The CCG would like to acknowledge the work and leadership of the Warrington CCG

membership from 2013 to date in engaging in the design of local strategy for primary care

transformation.

The work was taken forward through the Warrington Primary Care Programme Group 2013-14: Dr Andrew Davies, Dr Neil Fisher, Dr Justin McCarthy, Dr Ipsita Chatterjee, Lorraine Stratulis, Alison Holbourn, Helen Pressage, Sheila Williamson, John Wharton.

The support of Suzy Angeluk and Mark Wilson is also greatly appreciated.

2 WARRINGTON CCG PRIMARY CARE PLAN ON A PAGE Needs and Drivers for Change Priority Plans for Primary Care System Transformation Strategic aims and outcomes Enablers

Demographics: Warrington is a growing town. Some parts of the town have rapid growth of housing and more children and families. It is also projected that Warrington will have 19,000 people aged 75+ by 2020, which is 8% higher than the national average (Joint Strategic Needs Assessment). Older people in Warrington experience a greater excess burden of ill-health, compared with average for England. There are health inequalities - people on low income or living in deprived areas more likely to be affected by LTC.

Nine out of ten system contacts occur in primary care settings.

Patients in Warrington want better access to excellent services and want better coordinated care

Workforce: research on current primary care work pressures shows upwards demand trends and work/life balance pressure for clinicians - a key risk for the system if we do not achieve significant change.

Ten priorities for Primary Care transformation: Access, demand and capacity; Medicines management and prescribing; Care Homes (Nursing and residential); Primary care quality – the ‘Warrington Offer’; Whole system/right care – role of primary care central in the effective utilisation of the whole system resource (care coordination and maximising the benefit of the registered list); Complex care including long term conditions and cancer rehab; Promoting prevention and self-care; Mental health; Workforce development and sustainability; Public engagement and communications in primary care.

Care is coordinated and integrated – patients with complex needs have access to a named care coordinator, there is a single integrated care plan for those that require it (see acuity model attached) and a named GP for patients over 75.

The Primary Care Home: implementing the Warrington Primary Care Home model across the system: Clusters of Practices co-working

in accountable care populations of 30,000 to deliver excellence in primary care

Extended access and care coordination available across Warrington in Primary Care Homes

Enables shift of more services to out of hospital settings

Enables the expansion of named MDTs around registered lists providing continuity of care

Improvement methodologies including NHSI Productive General Practice and Dr First/Patient Access systems

Investment strategies to achieve the transformation and to deliver more equitable investment across primary care provision linked to the Warrington Brand, and capital/premises investment.

All Warrington residents have access to comprehensive high quality care that is consistent across the town defined in the Warrington Brand

Care takes place in the right setting measured with acuity qualification tools.

There is an integrated care coordination system across Warrington and single care plan system.

Community services, preventive health services, social care and mental health services are provided around registered lists in primary care home settings providing continuity of care and integrated coordinated services delivered by MDTs.

Access to GPs from 8am to 8pm within a local

population, at least one site within each local

‘primary care home’

Extra children’s nursing services in primary

care

A dedicated team for care home patients

Locally based ECG and ultrasounds and blood

tests

Greater co-ordination of health and social care

to those most vulnerable residents – this

means care is co-ordinated across medical sub-

specialities, hospitals, home health agencies

and nursing homes

More scope for self-management and primary

prevention support, integrating with local

government and third sector services

Systems for wellness health checks and social

prescribing, for example, activity classes.

Clinical leadership and

membership engagement

Primary Care Home as key

enabler for whole system

transformation

IM&T – telemedicine enabling

self-monitoring and

management, integrated

IM&T across the system,

ACG based risk stratification

tools, acuity and qualification

tools, Integrated care records,

shared governance

arrangements

Commissioning intentions –

Warrington primary care

brand, integrated

Commissioning. CCG Co-

commissioning of Primary

Care contracts ensuring

system alignments

Whole system engagement

and partnership working

processes

Communications – extensive

public and professional

engagement

8

3 GENERAL PRACTICE IN 2015

3.1 Role of general practice

General practice exists to contribute to preventing ill health, providing early diagnosis and

treatment and as a universal service is accessible to all citizens. Primary care provides the

first point of contact for people with a health related concern.

Provision of primary care through general practice has been the cornerstone of UK health

systems since 1948, the foundation of NHS care provision. The majority of NHS contacts

take place within it. GPs and their teams provide care, coordinate care and also commit

system resources through prescribing and referral decisions. An important role of primary

care clinicians is acting as the patient’s advocate. This involves signposting people who

require specialist or additional health support and or co-ordinating the care of people who

have multiple health problems to community, secondary or tertiary health services. The

role of UK general practice provision thus incorporates:

₋ Improving population health, particularly among those at greatest risk of illness or

injury;

₋ Managing short-term, non-urgent episodes of minor illness or injury; ₋ Managing and coordinating the health and care of those with long-term conditions; ₋ Managing urgent episodes of illness or injury; ₋ Managing and coordinating care for those who are nearing the end of their lives; ₋ Maintaining independent living.

It is a universal service, providing the first-point-of-access advice, diagnosis and treatment for

patients, however UK general practice is facing significant challenge. The financial challenge

on the health and social care systems when demand is rising due to more people living

longer with multiple long-term conditions is unprecedented. Primary care demand has

increased significantly over the last decade.

3.2 Current state national picture The scale of the challenge faced is illustrated by the figures overleaf:

Primary care provides 90% of NHS contacts with only 9% of the budget4

Consultations in general practice increased by 75% between 1995 and 20095

There has been an increased clinical workload in general practice of over 40% since 20086

with evidence of;

o Increasing disease prevalence and diagnosis

o More patients dying at home

o Patients living longer with disease

4 Fairer investment needed for general practice 'to keep NHS sustainable', Royal College of General Practitioners, June 2013 5 Office for National Statistics, cited in Howard and others, 2013, p 6

9

10

There has been a growth in new technologies, enabling patients to have greater access to

information and therefore involvement in their care and new innovative treatments

(medicines and therapies) that enable patients to be cared for at home or close to home.

These together with a number of other factors are driving primary care transformation and

include:

Increasing patient expectations

Increasing demand for GP appointments

Increasing pressure for general practice to resume responsibility for out-of-hours care

Increasing workforce pressures, such as ageing workforce, insufficient trainees to meet

future need and demands on GP time to support clinical commissioning.

Trends: Figure 1 below is an NHS Institute for Innovation graphic representing the four

key pressures driving workload in primary care:

The Pressures on General Practice (NHSI)6

Population Age Central

Regulatory Requirements

Expectations of General Practice

Lifestyle Related

Illnesses

Funding pressures

6 NHS Institute for Innovation and Improvement Productive General Practice 2012

11

Figure 2 below shows the most recent NHS Health and Social Care Information Centre

(HSCIS) data on consultation trends. The demand for consultations against the available

resource has been rising steadily, with no commensurate increase in resource.

From NHS HSCIS data, the most recent of which is 2008/9, the overall crude consultation rate in England rose from 3.9 consultations per person-year in 1995 to 5.4 consultations per person-year in 2008. The overall median practice rate rose from 4.1 consultations per person-year in 1995 (with inter-quartile range (IQR) 3.4 to 4.8 consultations per person- year) to 5.4 (IQR 4.8 to 6.2) consultations per person-year in 2008. 7

Crude consultation rates per person/year

A more recent study by the Nuffield Trust but with smaller number of Practices than the

NHS HSCIC analysis - 337 GP practices in England between 2010/11 and 2013/14 revealed

that the total number of consultations by practices as a whole increased by around 11%,

while the number of consultations per patient per year increased from 7.6 to 8.3.8

7 NHS Health and Social Care Information Centre 2009 Trends in GP Consultation Rates 1995 - 2008 8 Dayan, M.,Arora, S., Rosen, R., and Curry, N. Is General Practice in Crisis? Nuffield Trust November 2014

12

The facts and figures below illustrate a picture of general practice in 2015, and underline

the need for an effective local response:

WORKFORCE Growth in general practice is lagging behind that of other clinical staff for example

between 2006 and 2013 GP numbers grew by just 4% while the number of

consultants in hospital and community services grew by 27% nationally the number

of new doctors going in to general practice is not meeting expectations.

Health Education England has estimated that half of all medical students need to

specialise in general practice by 2016 but in 2013 the actual figure was one fifth less

than this figure and figures from 2014 suggest that 1 in 10 slots for new GP trainees

were left empty. Figures show that doctors are leaving the profession in greater

numbers. In 2012 the number of GPs under 50 stating that they intend to quit direct

patient care in the next five years rose by a third, and in GPs over 50 the numbers

intending to leave in this timeframe has hit 54%.

This is consistent with the findings of the Warrington General Practice Survey 2013

which revealed a picture of unsustainable workload, dissatisfaction with work-life

balance, coupled with a workforce analysis that showed 37% of GPs on the town’s

performers would be eligible to retire within five years. The workforce is changing

with the number of salaried GPs increasing and the number of partners reducing.

Local Practices are finding recruitment of GPs very difficult, and GP numbers in

Warrington have fallen in recent years to 124 headcount and 95 whole time

equivalent (December 2014).

Nationally Warrington is in the worst quartile for GP: patient ratio with a ratio of one

full time GP: 2188.29, the national average is 1:1,680 If benchmarked to the

national average of 1:1680 GPs per 1000 weighted patients this means that

Warrington is under-doctored by 29 GPs.

This factor, alongside the rising trends of demand, a flat line income profile, rising

costs of employing salaried GPs and reluctance of new GPs to enter partnerships,

would leave the conventional model of delivery under substantial pressure. This risk

was recognised in Warrington in 2013 and the transformation towards practice

cluster collaborative systems is well underway with local clinical leaders at the

forefront of the changes. In January 2015 the NHS announced a £10 million

investment to kick start a new plan to expand the general practice workforce. The

money will be used to recruit new GPs, retain those that are thinking of leaving the

profession and encourage doctors to return to general practice to better meet the

needs of patients now and for the future. Warrington is likely to benefit from this

when detail is known however the ability to

13

attract and retain GPs to the level needed in Warrington remains a very significant

challenge.

PRACTICE SIZE

Nationally, general practice is starting to look very different, the number of single

handed practices halved between 2006 and 2013 while the number of GP Practices

with more than 10 GPs increased by 76% in the same period.

FINANCE

The last couple of years has seen a financial squeeze for GP services, in 2013/14

spending on GP services fell by 3.8%, a fall of £287 million nationally. There is

currently a substantial variation in cost per head of funding to primary care providers

in Warrington which is set out in detail in Section 8, national policy is seeking to

address variation through a transition to equitable capitation funding over time. The

majority of Practices in Warrington are Personal Medical Services (PMS) contract

Practices and have recently responded to an NHS England PMS review on PMS growth

funding. Nationally there have been policy announcements of the intention to invest

in general practice arising from the NHS Five Year forward view which may provide

more funding after 2016.

Since the formation of NHS Warrington CCG, all of these factors have been recognised as

highly significant to our local health system. The health care system in Warrington is an eco-

system with general practice at the heart of that eco-system. Early in the life of the CCG,

having conducted a system wide survey in Warrington, it was clear that the system shape

needed to change and that some of the solutions would come from collaboration ‘beyond the

practice walls’. To recognise the increasing demands of complex clinical needs on primary care

activity, and to promote effective care coordination and system integration, local GP Leaders

have developed the Primary Care Home vision for Warrington which is now well advanced in

its design and implementation, well supported by all stakeholders. International research on

‘the Medical Home’11,12 identifies the financial benefits of having a senior physician led care

model supported by an extended Multi-Disciplinary Team (MDT). This ambition, along with

the ambition for a ‘Warrington brand’ of health care to address variation, is at the heart of

this commissioning strategy to respond to the serious challenges that have been set out in this

section.

11 Starfield, B. Epidemiology and Community Health 2001; 55:452-4 12 “Health Policy Brief: Patient-Centered Medical Homes,” Health Affairs, September 14, 2010 http://www.healthaffairs.org/healthpolicybriefs/

14

4 PRACTICE CHARACTERISTICS WARRINGTON 4.1 Size of Practices in Warrington National distribution (Practice size)

Practice Size National Cheshire,

Warrington and

Wirral Local Area

Warrington

Up to 20,000 7488 174 28

20,000-30,000 56 2 -

30,000-60,000 25 - -

60,000-100,000 8 - -

100,000+ 3 - -

Cheshire, Warrington and Wirral comparative list size ranges:

CCG >5,000 5,000-

10,000

10,000-

15,000

15,000-

20,000

20,000-

25,000

25,000-

30,000

<30,000

Eastern

Cheshire CCG

South

Cheshire CCG

Vale Royal

CCG

Warrington

CCG

Western

Cheshire CCG

2 11 8 1 - - - 5 4 6 2 1 - - 1 9 1 1 - - 8 13 5 2 - - - 11 21 4 1 - - -

Wirral CCG 28 29 3 - - - -

Total

Cheshire,

Warrington

and Wirral

54 87 27 6 2 - -

4.2 Registered populations

Warrington’s registered population is fairly varied across Practice lists. For example for older

people the range of the distribution in the CCG, 15 of the practices in the CCG are in the

lowest quintile with less than 8% of the population aged over 75 whereas a smaller number

of Practices have a significant older population and more patients resident in care homes .

There does appear to be significant differences in the CCG’s practices in the proportions of

the populations aged over 75:

15

Figure 3 % populations over 75 by Practice: Warrington has significant variation between the age distributions amongst Practices,

reflecting the history of the town as a new town. There are some Practices as shown above

with a significant number of older people. Similarly the graph below shows that some

Practices are serving populations with more children and young people:

% population under 18 by Practice: The gradient across the patch is quite shallow except at the very ends of the distribution and

the range in the rates is relatively small. Within this ‘track’ Warrington has its practices more

concentrated toward the upper end of the distribution. In fact, 10 of the practices are in the

top quintile overall. From NHS England 2014 data, it seems that 55% of registered patients

are recorded as having a long term condition.

As with other parts of the country, Warrington’s GP profile is changing. Warrington has too

few doctors as set out in Section 3.2. NHS Warrington CCG has above average percentages

of female GPs compared to the local NHS England area as a whole. The range across the

CCGs practices is quite large, as a whole nine of the CCGs practices have less than 50%

female GPs and one practice is shown as having none.

Appendix 1 provides detail of the patterns of disease in the town which reveal significant

differences in disease and demographic patterns driving the work of the Practices

16

Figure 4 Index of Multiple Deprivation 2012

The Index of Multiple Deprivation provides a composite measure of deprivation due to a

combination of factors including health, income, housing, crime etc. Higher scores are

indicative of communities with considerable challenges. Deprivation is believed to be a

major contributor to poor health and to social problems.

There are seven practices at or above the upper quintile threshold and a group of eight

practices around the threshold level of the lowest quintile. The chart demonstrates

substantial differences in deprivation patterns across the CCG, further information is

contained in Appendix 1.

Quality performance of Warrington’s practices is generally high measured against QOF

however there are variations in performance in some areas, detailed in Appendix 2 and

Section 7. There is significant variation in terms of WTE clinical time and appointments

available between Warrington Practices.

17

5 STRATEGIC CONTEXT AND DEVELOPMENT OF THE STRATEGY

5.1 History and context From the commencement of its work in 2013 NHS Warrington CCG has prioritised the

strategic development of primary care. In common with much of primary care provision in

the UK it was recognised that primary care in Warrington was characterised by increasing

workload pressures, flat line or decreasing investment, significant variation in price per head

funding, and significant variation in provision between Practices, not necessarily

proportional with funding patterns. In addition the foundation work in 2013 established that

37% of GPs in Warrington at that time were potentially able to retire over the next few years.

The CCG established a programme group for primary care to lead thinking on potential

solutions. The group conducted a town wide survey in 2013, which primary health care

teams across Warrington used to contribute views on a change agenda. The picture that

emerged, as set out in Section 3, was one of rising challenge and unsustainability of the

status quo, leading to big conversations in 2013 and the emergence of key elements of this

strategy:

₋ The Warrington Brand of Primary Care (defined quality of provision enabling every

citizen to get a common offer of care irrespective of registered practice)

incorporating the ten priorities for primary care improvement defined by the GP

membership of the CCG

₋ The Primary Care Home model (collaborative primary care provision at scale), the

home of system integration and care co-ordination

The graphic on page 8 overleaf shows the process of emergence of this thinking in

Warrington. A number of whole system engagement events in 2013 built on the work

undertaken by the GP membership, from which care coordination and integration emerged

as whole system aspirations, and the development of a conceptualised model of care

(Acuity model p28) that enables system integration around a primary care population.

Section 5.2 sets out the national strategic context for primary care, which emerged during

2013 while Warrington CCG was leading these discussions locally, reflecting the national

picture of pressure in primary care and the need to change, and reflected our local findings.

In December 2013 the CCG adopted the Primary Care Home vision and agreed to support the

emergence of the Primary Care Home and fund the model in two initial ‘clusters’. A

consultation in early 2014 led to the establishment of GP ‘clusters’ in Warrington covering

populations of c. 30,000 signed off in May 2014, which are detailed in Section 5.

In February 2014 the Primary Care Home model was also submitted as a bid from

Warrington GP Federations to the Prime Ministers Challenge Fund Initiative and was

successful in achieving a £4.4m investment to achieve whole system Primary Care Home

implementation at scale and pace through a one off investment funding the change. This

work commenced in July 2014 and has significantly changed the delivery potential for

18

primary care in Warrington creating primary care populations that could serve as a platform

for fully integrated services around the registered lists. This strategy builds on this potential

from a commissioning perspective.

Figure 5

Primary Care Programme Journey

The Primary Care Programme aims to ensure

an equitable and excellent primary care provision across Warrington

JAN 2013

SURVEY OF MEMBERSHIP

JULY 2013 NHSI PRODUCTIVE GENERAL

PRACTICE PROGRAMMES

UNDERWAY 9 PRACTICES

SEPT 2013 INNOVATION PILOTS:

NURSING

HOMES, GUIDED

CARE, CANCER

REHABILITATION

JULY 2014 PMCF SUCCESS

CICFORMED

JUNE 2013

SEPT 2013 PILOTS- IMPROVED

ACCESS

2014/15/16

PRIMARY CARE

HOME MODEL SURVEY OF

PREMISES & STAFF

RESOURCES COMPLETED

JUNE 2013 WHOLE TOWN

EVENTS

DEC 2013 CCG AGREED PRIMARY

CARE HOME MODEL

CO-COMMISSIONING

FOR WARRINGTON

BRAND

JUNE 2013 REVIEW LITERATURE &

EVIDENCE OF EFFECTIVE PC

INTERVENTIONS COMPLETED

18

5.2 National policy directions

Significant national attention has been focused on primary care strategy in recent years, as

it has become increasingly evident that the demographic changes and needs of the

population are creating unprecedented demand on the system13. The national ‘call to

action’ (NHS England, August 201314) identified general practice as the cornerstone of the

NHS, with roughly one million people visiting their general practice every day. ‘Improving

general practice – a call to action’ (NHSE) called for transformation of services in local

communities and looked to stimulate debate on how general practice could be supported

to improve outcomes and tackle inequalities, for both todays and future patients. It echoed

the case for change made by other organisations, such as the Royal College of General

Practitioners’ ‘GP 2022 Vision for General Practice in the Future NHS’15 (May 2013). NHS

England published the outcomes of the consultation in a phase 1 outcomes report 16 which

sets out a series of high level ambitions:

Five Ambitions for Primary Care

Ambition one: proactive, coordinated care: anticipating rather than reacting to need and

being accountable for overseeing your care, particularly if you have a long-term condition.

Ambition two: holistic, person-centred care: addressing your physical health, mental health

and social care needs in the round and making shared decisions with patients and carers.

Ambition three: fast, responsive access to care: giving you the confidence that you will get

the right support at the right time, including much greater use of telephone, email and

video consultations.

Ambition four: health-promoting care - intervening early to keep you healthy and ensure

timely diagnosis of illness - engaging differently with communities to improve health

outcomes and reduce inequalities.

Ambition five: consistently high-quality care, removing unwarranted variation in

effectiveness, patient experience and safety in order to reduce inequalities and achieve

faster uptake of the latest knowledge about best practice.

All of these strategy documents reflect the Royal College of General Practitioners (RCGP) recognition that the sustainability of general practice for the future may require delivery at greater scale.

13 Deloitte Primary Care Today and Tomorrow 2012 14 NHS England ‘Call to Action’ and Evidence Pack August 2013 15 RCGP GP 2022 May 2013 Vision for General Practice in the Future NHS 16 IMPROVING GENERAL PRACTICE: A CALL TO ACTION – PHASE ONE REPORT NHS ENGLAND MARCH 2014

19

20

5.3 NHS England Area Team Strategy The local NHS England Primary Care Strategy for Cheshire Warrington and Wirral reflects

these national objectives17, defining key elements for primary care strategy:

Our joint strategic commitments for Cheshire, Warrington and Wirral 2014-18:

These are the key commitments across Cheshire, Warrington and Wirral, expressed as

outcomes statements recognising that the ‘how’ is different within the differing health

economies:

Quality, safety and patient experience of care

Primary care providers will consistently provide high quality and safe care that promotes

good patient experience. This will be evidenced by appropriate quality assurance systems

and the production of transparent, publicly available benchmarking data. All providers will

be expected to participate in significant event reviews, incident reporting, peer-review and

quality improvements.

Access and responsiveness

We will deliver easy access to high quality responsive primary care services, including rapid

response for urgent care needs so that fewer patients reach crisis and requiring hospital

emergency care.

Multidisciplinary Care

Patients will have access to an integrated care team designed around their own health needs

to ensure that their conditions are managed effectively (including those with long term

conditions, specific diseases, end of life, vulnerable, mental health, alcohol or drug needs and

complex multi-morbidities).

Care co-ordination

Primary care is a natural home for care coordination. Risk stratification will help to identify

the patients in need of active care coordination within primary care. Care coordinator

resources should be focussed around primary care teams and ensure that the most complex

patients have a named GP and care coordinator.

Patient centred care

We will provide clear and understandable evidence based advice and care pathways with the

patient always at the centre. Patients will have choice, access to their own care records and

be provided with accessible information in order to work as partners with professionals to

manage their health and achieve a good patient experience.

17 NHSE Cheshire Warrington and Wirral Primary Care Strategy 2014

21

Preventive care

Our vision is to empower and support communities in Cheshire Warrington and Wirral with

self-care and healthy living to adopt healthy living behaviours. Primary care is central to the

achievement of this ambition working in partnership with Public Health

Technology

Our vision is to use technology to better empower patients in their own care and to integrate

the provision of care around the patient’s individual needs reducing fragmentation of services

and improving the efficiency of the system.

Enablers

The strategic commitments are common across Cheshire, Warrington and Wirral. This is a

developing strategy and we are continuously updating it to reflect our engagement with

partners and stakeholders. We are also working to understand the impact of the strategy

and to develop implementation plans accordingly.

The achievement of the primary care ambitions is key to the ability of the whole system to

transform, delivering increased out of hospital care closer to home. This change needs to

take place incrementally while supporting our workforce, maintaining services and building

the necessary culture change.

NHS England has emphasised that primary care professionals are best placed to make

proactive, effective and preventative interventions and to impact positively on the quality

and efficiency of the whole health service to deliver a consistent offer to patients that is of

high quality, person centred and builds on the very best practice to deliver continuous

improvements in health and care outcomes. Clinical Commissioning Groups are well placed

to drive greater integration between primary care and other services. The registered list

held in every practice is the foundation of individual and population health and social care

needs and therefore must be the corner stone in redesigning integrated and preventive

services in Warrington.

CCG outcome benchmarking information nationally suggests that:

GP services are in the main valued by their patients

Some people feel unsupported in managing their own condition

Some wide variation in quality in primary care (for example the provision of diabetes care

or dementia screening)

Some high non-elective care admissions and lengths of stay and 30 day readmission rates

22

The current primary care system will not be able to deliver effective care with the rising

disease prevalence, ageing population and associated rising costs. The increasing demand

on primary care requires a change in how primary care is delivered that:

Responds to the increasing demands of complex clinical needs

Promotes effective care coordination and system integration based around both the

needs of different patient groups (for example the frail elderly or children/adults with

complex disabilities, End of Life) and also based around the personal needs of individual

patients within those groups.

Seeks to provide care to communities that reach beyond the traditional core primary care

offer.

Warrington GPs have already responded to these pressures in co-designing the Primary Care

Home Model defined in Section 6, which has successfully achieved national recognition

through the Prime Ministers Challenge Fund. It is important that the direction of travel and

progress achieved since 2013 is now reflected in primary care commissioning intentions

taken forward collaboratively with NHS England through co- commissioning,

It is clear from NHS England’s strategy, that the direction of travel for sustainability includes

primary care at scale which is consistent with the cluster model and the implementation of

the Primary Care Home model described in Section 6.

5.4 Five year forward view The NHS five year forward view published in 2014 recognises the importance of general

practice and primary care:

“The foundation of NHS care will remain list-based primary care. Given the pressures they

are under, we need a ‘new deal’ for GPs. Over the next five years the NHS will invest more in

primary care, while stabilising core funding for general practice nationally over the next two

years. GP-led Clinical Commissioning Groups will have the option of more control over the

wider NHS budget, enabling a shift in investment from acute to primary and community

services. The number of GPs in training needs to be increased as fast as possible, with new

options to encourage retention.”

To date, a £10 million investment plan has been announced nationally to expand the general practice workforce. The money will be used to recruit new GPs, retain those that are thinking of leaving the profession and encourage doctors to return to general practice to better meet the needs of patients now and for the future.

NHS England funding will be used to develop a range of initiatives in collaboration with

Health Education England (HEE), the Royal College of General Practitioners (RCGP) and the

23

British Medical Association (BMA) to increase the number of GPs and develop the role of

other primary care staff such as nurses and pharmacists.

Simon Stevens, Chief Executive at NHS England, said: “Primary care is the bedrock of the

NHS and the Five-Year Forward View makes clear that it will play an even greater role in the

future. We need greater investment in GP services, extending to community nursing,

pharmacy and eye care services. This £10 million will kick start a range of initiatives to drive

that forward so every community has GP services that best meets its health needs.”

5.5 Local priorities

Following baseline surveys in Warrington in January 2013 the CCG membership analysed the

findings in two design events and arrived at ten priorities for primary care in Warrington

which have driven activity to date and are at the heart of our primary care commissioning

strategy and transformation strategy. GP members defined their top ten priority areas for

action as:

Access, demand and capacity

Medicines management and prescribing

Nursing and residential homes

Primary care quality – what is the ‘Warrington Offer’

Whole system/right care – role of primary care in the effective utilisation of the

whole system resource through system integration

Complex care including long term conditions (and cancer rehab interface)

Promoting prevention and self-care

Mental health

Workforce

Public engagement and communications in primary care

5.6 Summary – strategic framework for the strategy This section has set out the national and local strategic framework for the Warrington

Primary Care Strategy. General practice is at a crossroads. Clinical Commissioning Groups

are committed to delivering the transformational change and integration agenda across the

whole health economy. Thus in developing this strategy, NHS Warrington CCG recognise the

need to develop resilience within primary care in order for it to meet the increasing and

differing needs and expectations of our communities. The ability to implement

transformation programmes of this scale whilst still providing high quality, safe effective

care on a daily basis will be a significant challenge for all.

NHS Warrington CCG has been at the forefront of thinking about primary care futures

since its inception, and has already taken substantial steps with the Warrington GP

membership to recreate primary care at the heart of the system locally. Warrington has

24

successfully achieved additional funding from the national PMCF initiative, recognising

the importance of the local vision. GP Practices in Warrington are all engaged in the work

of transformation. Local GPs have formed a mutually owned not for profit provider social

enterprise, and are working together in clusters of Practices around populations of 30,000

people. The work that has been undertaken since 2013 now needs to be supported

through our commissioning strategy to achieve maturity.

25

6. TOWARDS THE PRIMARY CARE HOME This section sets out the transformational model for primary care that has emerged since

2013 through clinical leadership and membership engagement. A consultation document in

early 2014 led to the establishment of populations for primary care delivery – groups of

Practices working collaboratively to deliver care in Primary care clusters. The successful bid

from the GP federations to the Prime Ministers Challenge Fund (PMCF) has led to a

transformation investment of £4.4 million in 2014-15. NHS Warrington CCG had already

supported the roll out of the primary care home model in a phased approach prior to the

announcement of PMCF however the funding has allowed the implementation of this model

at scale and pace.

Warrington has a growing population as a new town, and has a distribution of ages across

different parts of the town, overall encompassing areas with younger profiles with more

families and children. It is estimated that the general population in Warrington will have

19,000 people aged 75+ by 2020 (increase from 14,000 in 2011), which is 8% higher than the

national average (Joint Strategic Needs Assessment). Older people in Warrington experience

a greater excess burden of ill-health, compared with the average for England (measured

using mortality rates). In Warrington there are both affluent and economically deprived

areas and evident health inequalities associated with long term conditions with people on

low income or living in deprived areas more likely to be affected. The ‘primary care home’

creates a new system for health care that is highly relevant to the individual needs of the

population, and allows more services to be delivered closer to home around Practice-

registered list based populations.

6.1 WHAT IS THE PRIMARY CARE HOME?

The ‘primary care home’ is an accountable care population of around 30,000, which is a

population size supporting the delivery of primary care across Practice boundaries and

enables the alignment of wider services around the registered patient list. These include

care coordination, extended primary care (the Warrington brand), and more access within

the primary care home setting. Groups of local Practices will be the heart of the Primary care

home, and the commissioning intentions of the CCG will ensure that commissioned services

are ‘wrapped around’ these populations, re-booting the multi-disciplinary Primary Health

Care Team around the registered Practice populations, and enabling a new relationship with

secondary care and community providers with services finding a cohesive home for out of

hospital services and integrated health and social care services. The proposal builds on a

direction of travel which has been developed by the Warrington GP membership over

more than 18 months. This model provides more services around primary care, close by and

relevant to that local population.

26

The idea of a list based registered population is central to UK health systems, this is at the

heart of the concept of primary care home or medical home. The concept of ‘medical home’

is the subject of extensive health policy analysis and is internationally recognised as the basis

of cost effective high quality care which is physician led, managing complexity, utilising the

skills of a multi professional primary care team and referring only those aspects that require

specialist or highly technical input.18

6.1 Development to date In 2013 the CCG membership defined their top ten priority areas for primary care

development:

Access, demand and capacity

Medicines management and prescribing

Nursing and residential homes

Primary care quality – what is the ‘Warrington Offer’

Whole system/right care – role of primary care in the effective utilisation of the

whole system resource through system integration

Complex care including long term conditions (and cancer rehab interface)

Promoting prevention and self-care

Mental health

Workforce

Public engagement and communications in primary care

In June 2013, the whole town vision events led to a consensus that care coordination is a key

priority. A vision for a system which prioritises care coordination has been developed

through 2013 with the CCG and membership, Transformation Board and Health Summit.

Warrington residents have been consulted at a number of forum events and public

consultations undertaken in 2013-14, the need to achieve good care coordination has been a

central aspiration for people in Warrington. The significant potential of the GP registered list

to achieve this coordination has been part of the drive towards the primary care home

model. The graphic in Figure 6 on page 29 is a conceptual model for this.

The primary care home provides the opportunity for whole system alignment and integration,

utilising care coordination within the primary care home setting. The model enables Practices

to retain their individuality and integrity as they see fit, but to have access

18 Royal College of General Practitioners. The 2022 GP: compendium of evidence. London: Royal College of General Practitioners, 2013

27

to shared resources and relationships within a primary care home that can achieve the

benefits of working ‘beyond the practice walls’, and provides extended resources around

the registered population. These local populations provide a vehicle for care coordination

that includes integrated social care, community services, public health, mental health and

third sector services, thus the primary care home becomes an enabler for whole system

integration and coordination.

FIGURE 6

29

29

6.2 Vision for the Primary Care Home The Primary Care Home works as a key building block to achieve this vision and to achieve our

wider aspirations for the population:

• A population base allows health and social care, and care coordination

professionals to integrate in a primary care home setting

• Practices work within a wider team of practices in collaboration, benefiting both

workforce and communities

• Extended access

• GPs with specialist skills

• Separates acute and complex care, manages complex care proactively with MDT

input around PC Home

• Has shared care coordination resources (key workers or care coordinators) incorporating health and social care for complex case management

• Has rapid access diagnostics

• Has more ambulatory care available dependent on the needs of that population

• Has more community based mental health services

• Has shared multi-disciplinary care home services

• Provides a home for dedicated medicines management

• Provides more scope for self-management and primary prevention support,

integrating with local government and third sector provision for a preventive public

health focus

Our shared vision for extended primary care Warrington ‘Brand’ is that all patients will have access

within their 30,000 patient primary care home to ECGs, phlebotomy, complex wound care,

advanced direct rapid access diagnostics (e.g. ultrasound), urgent care, minor injuries, proactive

management for complex care needs (long-term conditions and comorbidities).

The Primary Care Home will enable the utilisation of extended roles and new job plans e.g.

GPs with special interests working across the primary care home, able to draw upon

Consultant outreach support (e.g. community outreach geriatrician) and lead physician for

specific conditions.

Advanced access including innovative access systems.

Redesign of Out of Hours will extend access to general practice for the 30,000 registered

Primary Care Home population from 8am to 8pm within a Primary Care Home (within the

home, not in every Practice site)

Mental health services close to the patient, Improving Access to Psychological Therpaies

(IAPT) and outreach Community Psychiatric Nurse (CPN) within the Primary Care Home

Specialist nursing home primary care team

Shared approach to quality across the Primary Care Home providers

A shared IT platform to access patient data across practice boundaries with patients will access

30

facilitating shared decision making

Systems for wellness health checks and social prescribing available in every Primary Care Home,

and referral to public health trainer services and Guided Care nursing, and

Active patient engagement and involvement, leading to better system management and more

fulfilling working lives by creating a sustainable system where GPs may choose to use their skills

appropriately and where there are options for job planning around individual needs and skills, as

envisaged in the whole town vision events in 2013.

It has become evident as the primary care programme has progressed since 2013, that the potential

benefits can include the reduction of fragmented assessment processes, and enables integrated care

planning and coordination. The populations also provide the building block for the transition of more

services to local close to home environments where they do not need to be provided in acute settings

6.3 Expected outcomes

With maturity this innovation will change the experiences of our patients, service users, carers

and their families. They will experience:

• models of care based on service user led pathways with no organisational boundaries and systems that work for patients

• more care delivered closer to home • individuals supported to better manage their own conditions • integrated care plans and assessment processes • care coordination for those with more complex needs • more appropriate signposting to services, particularly in moments of crisis • more use of individual and pooled budgets • more use of existing support networks and third sector organisations

Our criteria for success for the primary care home initiative will be that we improve outcomes for patients in the following areas:

• Improved access to see designated primary care physician • Improved medicines management for the patient • Reduction in polypharmacy (the use of four or more medications by a patient) • Holistic assessments undertaken for top 2% patients risk stratified as being in need • Active care plans in place for all patients and families in “at risk group”, complex care

including long term conditions and cancer rehab • In reach proactive care model to nursing and residential homes • Reduced preventable admissions for these groups of patients • Greater Promotion of prevention and self-care • Improved primary care quality – the delivery of ‘Warrington brand’ at both Practice and

cluster level • Improved work life balance for primary care physicians • Effective working beyond “practice walls”

31

6.4 Leading the change The work that has been undertaken to date needs to be built upon to achieve the benefits

described in 6.3 above. In December 2013 the CCG adopted this direction of travel and invested

resources to set up the first two clusters. However, having supported the federations bid to PMCF

in early 2014 the successful outcome of the bid has led to development at scale and pace such

that all GP Practices in Warrington are now involved in cluster working, and the model has

become a vehicle for others in the system to mobilise towards integration. Warrington has

benefited from strong clinical leadership in the development of this work to date, and from

additional organisational development funding from PMCF to achieve the change. The full

realisation of these benefits requires the full maturity of the cluster working arrangements and

the continued support for clinical leaders to take this agenda forward at a time when resources

are stretched. Figure 7 below is a representation of the maturity process, in reality there are

many more steps and the pace of maturity will be different within clusters dependent upon local

factors.

However, to date the emergence of the clusters has been funded by the external monies that

have been attracted in to our system to support our visionary approach to this work, the work

is of national importance in demonstrating a replicable approach to primary care large scale

change. The CCG has identified primary care funding for the year 2015-6 to support the

maturity of systems beyond the initial start-up period. The long term sustainability will be

achieved through commissioning strategies that build upon this whole system change.

Figure 7 maturity model schematic

Clusters of Practices formed for defined populations

Clusters of Practices working collaboratively on local projects

Some service alignment with clinical working across boundaries

Community nursing alignment and care coordination

Full alignment 'acuity model'

Cohesive integrated provision across populations of 30,000

6.5 Summary This section has set out the emergence of a primary care led delivery model for system

transformation which has been led by the primary care programme established by the CCG

and developed through wide engagement with its membership body.

32

This strategy supports the emergence of the primary care home model at scale by:

• Continuing the work of PMCF by supporting additional cluster maturity and organisational development in 2015-16 with the identified resources ring fenced through the Better Care Fund

• Creating a level playing field for primary care investment and delivery through further investment from 2016 which will be invested through:

• Utilising co-commissioning to achieve a consistent primary care quality offer for core services – Warrington ‘Brand’

• Utilising local commissioning to achieve extended primary care delivered in populations of c.30,000

Figure 8 overleaf shows the strategic direction for system transformation enabled by the

Primary Care Home model.

To achieve the continued maturity and embedding of the cluster based model the table

below outlines areas where proposed investment will consolidate the work of establishing

clusters beyond PMCF. From

16/17 the commissioning approach is to specify Warrington primary care plus elements

beyond a local contract price for the Warrington brand set out in Section 8.

Year Purpose

2015/16 Expand care coordination system in all clusters

focussing on older people in 15/16 other groups

2016/17 – model detailed in Section 10 (It is envisaged

that transformational change will deliver additional

care coordination resource through role re- design)

2015/16 Consolidate the PMCF achievements by building

cluster level capacity & infrastructure, expected to be

sustained by clusters thereafter through maturity at

cluster level and economies from working at scale,

replaces the short term project management

infrastructure from PMCF

2015/16 Extended access in clusters including core hours plus

evening and weekends

2015/16 System wide OD to support the consolidation of

system alignment around the primary care home –

stakeholder working and co-design, training and

development for multi-professional teams, care co-

ordination and guided care

2015/16 Clinical time back fill contribution

2015/16 Investment in stretch implementation in two clusters

– full realisation of benefits plus independent evaluation

Paediatric Acute Response Team(PART)

Primary Care Home Delivery Team

‘Primary Care Home’

(Multi disciplinary team including community

nursing/mental health/care coordinator/GP for

nursing homes etc.)

Clusters of Practices work collaboratively;

other provider services

refocused around the registered list

Non bed-based acute services

Intermediate Care Facility (bed bases)

Hospital Services GP Practice

GP Practice

(With Care Coordination)

Figure 8 Our Map to the Future – Overview

7 THE WARRINGTON BRAND This section sets out the approach to achieving a common definition of quality in primary

care provision and what a Warrington Citizen should expect irrespective of place of

registration.

The brand will include both process and outcome indicators. The brand enables

commissioners to commission from any primary care provider for a unified standard of care

for Warrington residents, this can be commissioned from a single practice, a cluster of

practices, a primary care provider organisation, and any applicable alternative provider

organisation. The brand will set out local Key Performance Indicators (KPIs) to be adopted on

top of existing nationally negotiated terms and standards common to PMS/General Medical

Services (GMS) contracts:

Figure 9

CCG Commissioning

Extended primary care

Co-commissioning

Warrington brand indicators

National QOF essential &

additional medical services

From 2015 the CCG has the opportunity to closely influence primary care commissioning in

order to achieve wider system objectives, representing a significant move to more local

commissioning of primary care. The process for the change from NHS England area teams

commissioning primary care began in 2014, CCG’s were afforded the opportunity to express

interest in local arrangements for co-commissioning.

This section outlines the proposed direction of travel towards a Warrington quality standard

or brand of primary care. It does not set out the final detail of this brand as it is proposed

that an expert reference group is constituted as a sub group of the CCG’s Primary Care

Quality Committee to finalise the standards and agree measures to be approved by the

Primary Care Quality Committee prior to formal consultation (2015-16), agreement with

NHS England and implementation (2016-17 onwards).

35

36

7.1 How QOF works – current state

The national quality and outcomes framework for general practice (QOF) has a range of

national quality standards, based on the best available, research-based evidence

covering four domains. Each domain has measures of achievement, known as

indicators, against which practices score points according to their level of achievement.

Practice payments are calculated on the points achieved and prevalence (see prevalence

below).

The domains are:

• Clinical - this domain has indicators across different clinical areas e.g. coronary heart

disease, heart failure and hypertension.

• Public health (PH) - this domain has indicators across clinical and health improvement areas e.g. smoking and obesity.

• PH including additional services sub domain - this sub domain has indicators across the two service areas of cervical screening and contraceptive services.

QOF points

For 2014/15, there were a maximum of 559 points available to practices across QOF, which

in turn determine payments to Practices. The key payment dates each year are:

by 31 March - practices are paid retrospectively for points achieved in the previous

year. The value of a QOF point differs across Wales, Scotland and Northern Ireland.

by the end of June - payments should be completed, although they can be made

earlier when they have been agreed by the practice and commissioner.

Payments are subject to certain thresholds (targets) and take account of the national

prevalence of diseases, by applying a standard calculation to all practices.

Prevalence - A practice's achievement payments, are based on the number of patients on

each disease register, known as ‘recorded disease prevalence’. In certain cases, practices

can exclude patients which is known as ‘exception reporting’ - more details are available in

the Statement of Financial Entitlements19. Strict criteria are used for this process and

practices may be required to provide evidence of any patient that is ‘exception reported’.

The full set of indicators of achievement are outlined in the latest QOF guidance20, published

by NHS Employers, which is updated for each year.

19 https://www.gov.uk/government/publications/nhs-primary-medical-services-directions-2013 20 http://www.nhsemployers.org/~/media/Employers/Documents/Primary%20care%20contracts/QOF/2014- 15/14-15%20General%20Medical%20Services%20contract%20- %20Quality%20and%20Outcomes%20Framework.pdf

37

QOF results are published annually for the following countries, by the Health and Social

Care Information Centre21

The most recent QoF attainment data for Warrington is shown in Appendix 2. For the most

part Warrington Practices perform well and for some indicators there is uniform attainment.

There is some variation, overall QoF performance is shown in Figure 10 below:

100%

Figure 10 QOF 13/14

98%

96%

94%

Warrington Average

92%

90%

88%

86%

84%

82%

7.2 Co-Commissioning elements of Warrington Brand In developing the Warrington brand, the proposed strategy is to commission ‘QOF Plus’ as a

quality benchmark for Warrington, Practices will continue to deliver to QOF standards and

to report on them, and their performance against these will be part of a balanced score card

o be commissioned against a price per capita as set out in Section 8. Research on QOF

performance nationally shows a correlation between good patient experience and high

scoring in clinical quality indicators22. On top of the QOF attainment it is proposed that the

Warrington Brand is annually reviewed and may be varied according to population need,

local priorities to be addressed are set out in this section with indicative measures.

However, following agreement of the strategy it is proposed that a reference group is set up

as a sub-committee of the CCG Primary Care Quality Committee, to review detailed

21 http://www.hscic.gov.uk/primary-care 22 Kings Fund 2014 Improving GP services in England

38

objectives and measurements prior to formal consultation, with a view to implementation

by April 2016.

Following implementation, a clinical review panel will be established by the CCG to assess

compliance and audit qualification for payment.

7.2.1 Constraints and assumptions

In order for this specification to have the full impact across Warrington all practices need to

be signed up to deliver the Warrington Brand, to enable an equitable approach to quality

and delivery. It is recognised that Practices have different staffing and resources at present

therefore the standards may be provided either by an individual practice or through a

cluster delivery model, building on the local direction of travel.

In the event that any individual practice declines to sign up to deliver the specification, they

will only be commissioned to provide their core services and any directed enhanced service

that are commissioned centrally. They will not then be commissioned for any of the QOF

Plus or locally commissioned services.

It is assumed that all practices will continue to provide the full range of additional services,

to the national specification, that are included in their contract, these are:

Cervical Screening

Vaccinations and Immunisations e.g. Holiday vaccinations

Child Health Surveillance

Maternity Medical Services, excluding intra partum care

Minor Surgery Procedures of cautery, cryocautery and curettage

Contraceptive Services

It is also assumed that Practices will continue to deliver the enhanced services elements in

existing service agreements and funding, and that these will be delivered across all Practice

providers. These are extended hours, alcohol, childhood flu, childhood vaccination and

immunisation, learning disability, minor surgery, patient participation, rotavirus, seasonal

flu, seasonal pneumonia, shingles routine and catch up, pertussis, TD of dementia, Hepatitis

B and Meningococcal C.

7.2.2 Co-commissioning specification outline

The Warrington specification will cover all patients on a registered list in Warrington.

The specification recognises that services can be commissioned at Practice level or cluster

level.

39

7.2.3 What are we trying to achieve?

The specification seeks to realise some of the key stated outcomes in the ‘ten priorities’ locally defined by the CCG membership, and to deliver equitable high quality provision across Warrington. The cluster development in Warrington enables many of these outcomes to be achieved collaboratively. The CCG wishes to use its commissioning intentions to support

quality primary care and to maximise the services that can be delivered in integrated primary

care clusters and has already flagged this up to providers in its published commissioning intentions.

This section identifies the additional standards that we expect any primary care provider

delivering the Warrington ‘Brand’ to deliver.

The locally contracted Warrington Brand in particular seeks to achieve through co-

commissioning:

1) Advanced Access and Alternative Access (Practice and Cluster based) to achieve

parity of provision and reduce pressure on the wider system

2) Effective utilisation of system resources (Includes – effective management of

referrals, utilisation of MCAP, medicines management and collaborative working in

clusters)

3) Complex case management (includes adoption of Warrington wide care coordination

practice protocols, active utilisation of ACG risk stratification system, availability of

guided care appointments at Practice or cluster level)

4) Effective management of older people’s health needs (includes named GP, proactive

assessment and reviews, same day appointments for over 75s for problems triage-

assessed as urgent, and enabling access to local MDT team for care homes)

5) Public health (includes delivery of local campaigns, health education material, health

checks enablement, referral to mentors and cancer rehabilitation)

6) Mental health (includes meeting specification of Level 1 IAPT, enabling local access

to mental health services through local referral protocols plus dementia diagnosis

and shared care medication)

These will create whole system impact and will enable a standard offer to be available for

any patient in any part of Warrington irrespective of size of Practice.

7.2.4 Measurement

There is an imperative to measure outcomes and processes for impact. The approach set out

for co-commissioning the Warrington brand is a balanced scorecard which incorporates both

QOF attainment and additional attainment against Warrington brand. The final detail is to be

determined by the Primary Care Quality sub-committee established for the purpose however

it will include both process and outcome measures. Nationally there has been debate on the

best measures to use for a full impact assessment of primary care, and

40

example of useful measures available is set out in Appendix 4, the CCG will need to respond

to national decisions and evidence on best outcomes to collect however it is important that

this is achievable from existing general practice systems and does not create major

administrative burden for Practices. An example set of measures against the commissioning

objectives is included below, these are exemplar at this stage as these decisions will be taken

forward through the designated sub-committee of the CCGs primary care quality committee. The table overleaf sets out the six areas, plus a separate indicator on staffing.

41

Objectives Example measures

1) Advanced Access and Alternative Access (Practice and Cluster based) to achieve parity of provision and reduce pressure on the wider system

Advanced access in primary care that reduces bottle-necks, increases capacity and promotes streamlined access to GP’s whilst differentiating between patients with complex and acute needs and enables proactive management for those with complex needs. Advanced access measures could include: -appointments per 1000 weighted patients per week e.g. the practice offers 70 GP / Nurse Practitioner / telephone consultation appointments per 1000 weighted patients per week, with a minimum of 10 minutes per appointment (face to face and the appropriate length for telephone consultations). -mix of telephone, face to face and e mail appointments available -non-urgent appointments available to 8pm and weekends 8-8 through cluster delivery -number of urgent appointments available same day following assessment as urgent -patient ratings of ease of access -longer appointments for complex case management and LTCs through cluster delivery model Number of appointments per 1000 patients -type of appointments per 1000 patients (includes telephone appointments, internet appointments, face to face appointments for undifferentiated presenting problems) -available pre bookable appointments -evening and weekend appointments available within cluster -patient satisfaction measures on ease of appointment -patient surveys, friends and family measures -innovation e.g. tele-healthcare and integrated phone systems -practices can offer patients the choice of a bookable appointment with either a male or a female member of the primary health care team when requested -The Practice offers 25 Practice Nurse appointments per 1000 (weighted) patients per week, with a minimum of 15 minutes per appointment. -ABCD software measures productive primary care -practices offer a late evening to 8pm one day a week or a Saturday morning session -there are appointments available across all ten clinical sessions staffed every week

42

2) Effective utilisation

of system resources

(Includes – effective

management of

referrals, utilisation

of MCAP, medicines

management and

collaborative

working in clusters)

-rate per 1000 hospital weighted population of in hours, self-referred, minor attendances at AED where procedure code was recorded as guidance and advice; none (consider guidance and advice); other consider alternatives; prescription only -rate per 1000 hospital weighted population for admissions for a selection of Ambulatory Care Sensitive conditions (Angina, Asthma, Cellulitis, COPD, CHF, Diabetes complications, ENT, Influenza and Pneumonia, convulsions and epilepsy) as primary diagnosis -pan-mersey prescribing guideline measures

3) Complex case

management

(includes adoption of

Warrington wide

care coordination

practice protocols,

active utilisation of

ACG risk

stratification system,

availability of guided

care appointments

at Practice or cluster

level)

4) Effective

management of

older people’s health

needs (includes

named GP, proactive

assessment and

reviews, same day

appointments for

over 75s for

problems triage-

assessed as urgent,

enabling access to

local MDT team for

care homes)

-% of patients indicated through ACG risk stratification to have care coordination requirements that have a named care coordinator -% of active care plans utilising local protocols -% of patients indicated accessed guided care appointments Quality proxy indicators from QOF: Diabetes core processes (DM2-4, DM6-9, DM 12 and DM14) Chronic Obstructive Pulmonary Disorders reviews (COPD3) Care plans for patients with severe mental illness (MH2) Quad- medication following Myocardial Infarction (CHD6) -Practices will have robust communication mechanisms in place, including team meetings, with involvement of attached staff. -Procedures for sharing and recording information about patients between members of the extended primary healthcare team are agreed, transparent and made known to staff. -% of patients over 75 seeing named GP -% of patients classified as urgent seeing GP same day -% care plans and review > 1 year -% medication review -% frail elderly people identified through risk stratification with a care plan

43

5) Public health

(includes delivery of

local campaigns,

health education

material, health

checks enablement,

referral to mentors

and cancer

rehabilitation)

6) Mental health

(includes

specification of Level

1 IAPT, enabling

local access to

mental health

services through

local referral

protocols plus

dementia diagnosis

and shared care

medication)

-local public health campaigns are provided in every

Practice

-health checks and health mentor referrals and outcomes

-smoking status recorded for patients with long term

conditions (SMOK2)

-cancer rehabilitation referrals and uptake

-dementia incidence & prevalence

-emergency admissions per 100 for dementia patients

-shared care medication

-care coordination uptake for patients with a condition

that would benefit from care coordination including

depression

-delivery of IAPT level 1 indicators in general practice

7) Workforce,

additional measures

-The Manchester University DH GP morale survey is partly

based on Sibbald et al and the methodology may be

directly transferrable

-Staff turnover by staff group

-Dr-patient ratio

-Nurse-patient ratio

In summary, this co-commissioning element of the strategy involves a ‘QOF Plus’ approach,

which can be delivered for an agreed sum per weighted patient as set out in Section 8

financial analysis. This creates a commissioning framework which would work at individual

practice level or any emergent provider level. This encompasses core primary care services

(essential medical services provided through the primary care act) plus a Warrington

standard designed to deliver equity and quality within the system. Section 7.3 overleaf sets

out additional local commissioning intentions for ‘add-ons’ from local commissioning

towards delivering extended primary care and to create sustainability of innovations in

cluster delivery beyond the PMCF.

44

7.3 Local commissioning for extended primary care

Extended Primary Care (Cluster) CCG Commissioned

In addition to the co-commissioning objectives set out in 7.2, the CCG also wishes to use its

commissioning intentions to support extended primary care to maximise the services that

can be delivered in integrated primary care clusters and has already flagged this up to

providers in its published commissioning intentions. We envisage collaborative integrated

accountable care teams providing continuity of care through attached extended (multi-

disciplinary) Practice Teams with the support of care coordinators.

As a direction of travel we would like all registered Warrington patients to have access in

primary care settings to:

Phase 1 2016-17:

(To be commissioned as local CCG commissioning at cluster level from primary care

providers as part of the Warrington Brand).

-Services such as ECGs, phlebotomy, complex wound care, minor injuries that are

elements of primary care delivery not currently available across Warrington in primary

care settings; it is intended that such services are available at practice or cluster level

accessible to all patients.

₋ Care coordination (additional provision of care coordinators embedded in Practice

Teams across Warrington) it is estimated that 2% of the population identified

through risk stratification may benefit from access to care coordination. As part of

the Warrington transformation strategy and Better Care Fund (BCF), a definition of

care coordinator competencies is being developed. This will deliver both

designated and non-designated care coordination.

₋ Extended access; following successful evaluation of the PMCF, and the interim year

of additional transformation investment in the model (2015-16) it is intended that

extended access is commissioned at cluster level, enabling all patients to have

access to pre-bookable weekend and evening appointments and to undertake a

review of urgent care and out of hours with a view to delivering an integrated

provision of access to effectively manage both urgent and non- urgent care in an

integrated manner.

₋ Other areas, following successful evaluation, such as Care homes MDT team; to

deliver effective coordinated MDT in-reach primary care for care homes liaising with

practice of origin to provide a seamless service to the local MDT model designed by

the Warrington ageing well reference group.

45

7.4 Summary This section has set out:

1) The direction of travel for the Warrington brand in primary care, to be achieved

through co-commissioning with NHS England. It will achieve a level playing field for

Warrington citizens to access the best primary care quality that can be delivered for

the Warrington pound and will ensure that primary care is able to continue to deliver

a sustainable future for the health system.

2) The ambition for the CCG to extend the impact of primary care through our local

commissioning, both through redesign of existing services around the registered list

cluster populations working with our provider organisations, and through local

investment in the locally agreed priorities detailed above.

The final detail is to be developed in the primary care quality committee reference group

established as a sub group of the committee for this purpose. The following section will set

out the financial arrangements that will deliver this ambition.

46

8. FINANCE AND INVESTMENT STRATEGY PART 1 CO-COMMISSIONING

ELEMENTS

8.1 BACKGROUND Over the recent past, for reasons set out in this document, successful delivery of primary

care has often been maintained at a price of stagnation in income, excessive workload and a

sense of insecurity. Primary care has delivered 90% of the NHS workload for 9% of the

budget. The importance of the role of primary care in future policy directions is clear in the

NHS Five Year Forward View, and recent policy statements prior to the election have

indicated that consideration is being given to additional funding for primary care, at present

none of this is certain. Warrington has a majority of PMS practice contract types. The

outcome of the recent PMS Growth review by NHS England has implications for many

Practices in Warrington. In the face of this uncertain operating environment, this section sets

out:

likely financial scenarios in which primary care may operate in the short and

medium term future

considers the financial and business impact on practices under each scenario

respond to the scenarios by considering the available options for re-engineering

current business models to:

o increase capacity to deliver new or additional services without additional

individual workload; and/or

o reduce running costs

o deliver parity funding on a capitation basis

Local context set out in the previous sections demonstrates the extent of demand and

workforce pressures which locally have led to emergent solutions that look ‘beyond the

Practice walls’, to recognise the increasing demands of complex clinical needs on primary

care activity, and to promote effective care coordination and system integration.

Nationally, workload pressures, an aging GP workforce, unfavourable pension changes and

revalidation may give rise to greater than expected numbers of GPs leaving the system. This

will exacerbate existing recruitment and retention issues and increase the demands for

greater efficiency in the use of GP time.

However, the emergent collaborative work between Warrington Practices may present

opportunities to institute new ways of working within and between practices and new

structures of provision.

47

8.2 General Medical Services (GMS) CONTRACTS

It is NHS England’s stated intention to move to a position where all practices (whether on

GMS, PMS or Alternative Provider Medical Services APMS) receive the same core funding for

providing the core services expected of all GP practices. Any additional funding above this

must be clearly linked to enhanced quality or services or the specific needs of a local

population, and practices should have an equal opportunity to earn this funding if they meet

the necessary criteria.

In 14/15, all GMS practices received a weighted capitation payment (the global sum) of

£73.56 per weighted patient (which is reduced slightly where practices opt out of some

elements of service provision e.g. minor surgery). Nationally, greater than 60% of practices

receive further top-up (correction factor) payments relating to their historic earnings,

determined at the introduction of the new contractual arrangements in 2004. While the

combination of global sum and correction factor payments delivered the commitment to a

Minimum Practice Income Guarantee (MPIG), it also built in significant inequity in funding.

This inequity in GMS has long been recognised at a national level and much effort has been

made to erode MPIG without great success. However, in 2013 the Government imposed

changes to the financial arrangements for GMS contracts including the abolition of MPIG

over a seven year period. So, from 1 April 2014, GMS practices’ correction factor payments

will be reduced by 1/7th each year and the funding recycled into global sum. At the end of

the transition period, all GMS practices will be paid the same value per weighted patient –

the current national GMS average.

The practices set to gain the most from the abolition of MPIG are GMS practices that do not

currently receive any correction factor payment. These practices will each secure the

expected gain per weighted patient of £3.73 spread over the next seven years. The global

sum price will increase by around 55p above any inflationary uplifts or contract changes to

reflect the recycling of MPIG into global sum each year. However, due to the wide variation

in the size of correction factor payments, although many practices will be better off (those

whose correction factor payments are zero or lower than £3.73 per weighted patient),

nationally the majority of GMS practices will be losers.

However, Warrington is unusual in that only 1 of the 6 GMS practices is currently in receipt of correction factor payments; as noted above, nationally the figure is greater than 60%. The result is that in general Warrington GMS practices have received a lower price per weighted patient for the delivery of primary care than other GMS practices. Given the levels of additional funding identified in PMS, this has meant that over the last decade GMS practices in Warrington have been financially disadvantaged in comparison to their peers elsewhere in the country and almost certainly rank in the lowest quartile nationally for core contract earnings.

48

More positively, the abolition of MPIG will see this trend reversed and in Warrington five of

the six GMS practices will secure increases to their global sum income of around 5.7%

above any inflationary uplifts across the seven years from 1 April 2014. Overall the

Warrington health economy will benefit from the redistribution of MPIG funding through

the global sum.

8.3 PMS CONTRACTS In addition to the six GMS practices there are 19 practices that deliver primary care in

Warrington under PMS arrangements (there are also three Practices covered by a shorter

tem APMS contract). It is recognised both locally and nationally that there is a substantial

level of investment in PMS practices over and above an equivalent global sum payment. The

graph overleaf illustrates the level of PMS Premium in each PMS practice in Warrington as

calculated by the NHSE Area Team (see Annex A).

To provide a more objective comparison the graph on page 50 (Figure 12) shows price per

weighted patient as the benchmark for comparison. As can be seen on the graph below,

across Warrington the PMS Premium per weighted patient ranges from £0.50 to £42.09. The

average PMS Premium in Warrington is £11.68 as compared to the national average of

£11.25.

49

The following graph illustrates the level of PMS Premium in each PMS practice in Warrington as calculated by the NHSE Area Team (see Annex

A).

Figure 11 PMS Premium by value (£)

Warrington PMS Practices

A B C D E F G H I J K L M N O P Q R S

50

Figure 12 PMS Premium value per weighted patient (£pwp)

To provide a more objective comparison the table below uses price per weighted patient as the benchmark for comparison. As can be seen on

the graph below, across Warrington the PMS Premium per weighted patient ranges from £0.50 to £42.09. The average PMS Premium in

Warrington is £11.68 as compared to the national average of £11.25.

Warrington Practices

A B C D E F G H I J K L M N O P Q R S

In general the range of core contract income of PMS practices in Warrington displays the

same level of variation experienced in other CCGs around the country, and a very similar

average level of PMS Premium in comparison to the national average. However, the two

practices with the highest levels of PMS Premium would be considered outliers on a

national view (less than 5% of PMS practices have premiums of greater than £35).

A factor behind the recent review of PMS by NHS England is the significant assumption

underlying these figures is that the practices are not providing services that would be

considered as outside general practice services delivered by the average general practice i.e.

PMS Premium funding does support services which might otherwise be funded as enhanced

services. The process of evaluating the PMS contracts across Cheshire Warrington and

Wirral is in progress at March 2015, the assumption being that any funds deemed to not

remain in Practices budgets will be transferred to local CCG budgets for commissioning

primary care and that there will be a four year period of adjustment.

The development of PMS arrangements pre-dated the arrival of new GMS in 2004 and

particularly the Carr-Hill formula used to determine weighted capitation. PMS arrangements

often attracted additional funding known as ‘growth’ on the basis of very crude assessments

of deprivation and health need. The level of agreed funding reflects the historic earnings of

the practice as well as the individual circumstances reflected in its PMS application. Hence

the identified ‘premium’ funding arises for a variety of reasons, not always related to

‘growth’.

This is demonstrated in the graph overleaf where it can be seen that the levels of growth

funding are not necessarily reflected in the level of PMS Premium. High levels of growth per

weighted patient (the green data points) do not always correspond with high levels of PMS

Premium (blue columns). In some instances the reverse is true.

51

Figure 13 Comparison of PMS Premiums and growth funding per weighted patient.

Comparison of PMS Premiums and growth funding

£45.00

£40.00

£35.00

£30.00

£25.00

£20.00

£15.00

£10.00

£5.00

£-

- Premium pwp -+-Growth pwp

52

53

8.3.1 From the data in the graphs above it can be seen that for the majority of practices in

Warrington growth funding is a contributor to the PMS Premium. However, for the 6

practices with the lowest PMS Premium per weighted patient, growth funding per

weighted patient outstrips PMS Premium. This indicates growth funding has helped

to resolve historic underfunding of these practices.

8.3.2 In relation to the PMS review process, NHS England announced the results of a

national PMS data collection exercise early in 2014 and tasked its Area Teams with:

completing reviews of all PMS arrangements within 2 years (by March 2016);

securing best value from the ‘premium’ element of PMS funding;

giving equality of opportunity to all GP practices to earn ‘premium’ funding; and

where funding is redeployed, deciding on an appropriate pace of change.

8.3.3 In September 2014, NHS England modified its earlier guidance to Area Teams,

specifying that:

Any decisions relating to future use of PMS funding are agreed jointly with CCGs as

part of anticipated co-commissioning arrangements;

Any resources freed up from PMS reviews should always be reinvested in general

practice services; and

PMS resources should not be redeployed outside the current CCG locality (i.e. the

CCG of which the PMS practice is a member).

8.3.4 The revised guidance is highly significant in the context of taking forward plans to

address inequity. These should be focused very much at CGG level now rather than

at Area Team level which has been the case in the past. Arguably it provides the

opportunity to secure agreement from the affected clinicians (the potential losers)

as it can clearly be shown that resources are retained in the local health economy.

8.3.5 The question remains as to how NHS England will address the inequity across PMS

practices and provide equality of opportunity to all GP practices to earn ‘premium’

funding. One option may be to remove all the additional investment from PMS

practices to bring them to a GMS equivalent price per weighted patient by April

2020.

8.3.6 However, each year of MPIG abolition (with the 55p increase in global sum price)

erodes the PMS Premium. While the total value of PMS Premium in Warrington

was £1.7m in 14/15, this should be reduced to £1.2m after taking account of the

increase in global sum from MPIG recycling by 1 April 2020. The graph (figure 14) overleaf sets out the level of funding reduction each practice could expect under this scenario.

54

8.3.7 Of particular note in this scenario shown overleaf are the two practices with PMS

Premiums below £3.1823 per weighted patient. These practices would be better off

returning to GMS during the MPIG abolition period at the point where the global

sum price per weighted patient becomes higher than the PMS payment per

weighted patient. There are two further practices where the differential between

GMS and PMS is low enough to question whether PMS remains financially the

better option – for example list size growth may be sufficient to warrant a return to

GMS.

8.3.8 The current PMS review is therefore an additional driver for the proposed co-

commissioning approach set out in this document as the potential outcomes of

PMS review reductions in practice income of this scale are unlikely to be

accommodated solely through GPs taking reduced earnings. Given that HSCIC data

indicates that, on average, 64% of practice expenses are employee costs,

disinvestment of this size is likely to result in reduced staffing levels as there may

be limited scope for substantial savings in other areas. There will almost certainly

be a diminution of GPs, possibly through accelerated retirement. There is ever

possibility that this will negatively impact patient care within the affected practices

possibly leading to increased costs elsewhere in the system. All of these factors are

relevant to the proposed local strategy detailed at the end of this section

elsewhere to move to a Warrington price per patient.

23 This assumes that the value of 14/15 PMS Premiums calculated by the AT already includes MPIG erosion of 55p for 14/15.

Figure 14 Projected funding reduction where practice receive GMS equivalent funding by 1 April 2020

Projected funding reduction

£350,000 .------------------------------------------------­

£300,000 +---------------------------------------------­

£250,000 +---------------------------------------------­

£200,000 +---------------------------------------------­

£150,000 +------------------------------------------­

£100,000 +--------------------------------------------==--

£50,000 +--------------------­

£0 +------.----.-- ' ----.--- -.--

N81089 Y01108 N81048 N81107 N81065 N81007 N81036 N81083 N81109 N81114 N81056 N81645 N81623 N81028 N81637 N81075 N81012 N81122 N81628

55

A B C D E F G H I J K L M N O P Q R S

8.3.9 As with GMS, it is highly unlikely that any negotiated increase in the value of GP

contracts will be sufficient to fully replace these funds and there is a risk that

affected practices would not be able to restructure sufficiently to adapt to the new

financial environment, ultimately leading to practice failure.

8.3.10 However, this scenario does not reflect the requirement to reinvest any freed up

resources back into general practice. While those resources could be used to

develop and fund enhanced services there is a strong argument that they currently

fund core general practice and that principle should be retained.

8.3.11 Assuming that premium funding is used to increase the price per weighted patient,

analysis suggests that the recycled premium funding could deliver just under £6 per

weighted patient in additional funding to each practice in Warrington (both GMS and

PMS practices). While this represents a substantial gain for those GMS practices

without MPIG it will set off the MPIG loss for the remaining GMS practice. The impact

on PMS practices is variable depending on the size of PMS Premium per weighted

patient. The graph overleaf figure 15 sets out the impact on PMS practices. Please

note that this should be seen as an approximation rather than a definitive outcome.

8.3.12 Throughout this data analysis two practices should be highlighted as significant

outliers in terms of the level of financial loss created by the potential removal of PMS

Premium. In particular even with full redistribution of PMS Premium one practice

ultimately stands to lose £250,000 per annum from its income by 1 April 2020 –

sufficient to fund over 2 full-time GPs.

8.3.13 Set against this is the comparative advantage those practices have enjoyed

compared to their peers over the last decade and probably longer. The question

mark remains as to whether these additional resources have been applied in a

manner that can justifiably continue to be commissioned by the CCG/NHS England

without disadvantaging other providers.

56

Figure 15 Financial impact on PMS practices of redistribution of PMS Premium funding across all PMS and GMS practices in Warrington

(Please note that this should be seen as an approximation rather than a definitive outcome)

57

A B C D E F G H I J K L M N O P Q R S

58

8.4 ADDRESSING INEQUITY IN WARRINGTON – ANALYSIS

Currently, there is very significant inequity of funding across PMS and GMS because the

investment in PMS Premium applies only to PMS practices. The effect of the £1.7m invested

in PMS Premium raises the average PMS price to £85.24 per weighted patient in comparison

to the 14/15 global sum (£73.56 per weighted patient). However, this average hides the

wide range of prices paid to PMS practices identified earlier in this report. At 14/15 prices,

the level of additional investment required to raise GMS practices to the PMS average of

£85.24 is £0.8m. However, the cost of this investment will decrease slightly each year to

2020 as MPIG erosion increases the global sum price but leaves PMS prices unchanged.

Many local commissioners have recognised that inconsistencies in funding and service

provision across PMS and GMS practices are hampering efforts to deliver high quality

primary care and increase the opportunities for out of hospital services within their

localities. A number of CCGs e.g. Liverpool CCG, Somerset CCG, are therefore exploring

with their member practices (both GMS and PMS) an option to use local funding and

any ‘premium’ resources to fund a local contract for core (or core ‘plus’) primary care

delivery at a higher price per weighted patient than the current global sum.

The aim of such arrangements is to resolve inequity of funding and service provision by

paying a locally agreed price for high quality primary care delivery with locally specified

service arrangements and KPIs that reflect the particular needs of the population served. In

many cases the new price looks to resolve local differences in service delivery previously

dealt with through ‘basket’ enhanced services. Broadly the aim is to level up service

provision to that of the best general practices and provide appropriate rewards for doing so.

A further benefit from these local contracts is that by securing a consistent delivery of

primary care across the patch, they provide a solid basis for securing out of hospital services,

whether on a practice by practice or locality basis.

Pricing strategy in Liverpool is delivering to just over £90 and the system has been

operational for two years through locally agreed arrangements. In the context of the

Warrington system and current PMS reviews, investment of this magnitude significantly

increases the funding available to GMS practices, particularly those with little or no MPIG,

while eliminating or significantly reducing the funding loss for PMS practices following PMS

reviews therefore mitigating the risks to the current system from a do nothing option.

A key point to note is that NHS England have set out in guidance that any PMS premium

funding should be redeployed over a minimum four year period (year one being 2014/15).

So if the CCG intends to re-invest PMS premium funds into primary care by increasing the

price per weighted patient from 15/16, funding flows back in to the CCG for local would be

over four years but would eventually offset these amounts. Raising the price per weighted

patient would require significant investment of local resources. The following table sets out

the level of investment required to fund a price of £90.00 per weighted patient gross of any

out of hours deduction (£16.44 above current global sum price of £73.56). It assumes 14/15

59

prices and that the first tranche of investment brings GMS practices to PMS funding levels.

Table 1 Additional investment required to support funding at £90 per

weighted patient

£90.00 pwp PMS GMS Total

Patients 146k 67k 213k

PMS Premium £1.7m £0.8m £2.5m

Further investment £0.7m £0.3m £1.0m

Total investment £2.4m £1.1m £3.5m

Less: PMS Premium £1.7m

Additional

investment

£1.8m

Increasing funding to a level of £90.00 per weighted patient would significantly increase investment in GMS practices. Data on weighted patient numbers for GMS practices is awaited from NHS England therefore this analysis cannot determine the spread of impact on individual practices. However, given that the investment required is £1.1m across 6 practices the average increase in income is just under £200k per practice.

The impact on PMS practices reflects the wide range of current prices paid to PMS practices

due to levels of PMS Premium. However the number of overall losers is reduced to five

practices, and the scale of losses for 4 of those is reduced to less than £50k. However, as can

be seen on the graph below there is one outlying practice which even at this higher local

funding rate would see an income drop of over £200,000.

NHS England’s stated objective is to “ apply the principles of equitable funding by moving

towards a position where we can demonstrate that all practices (whether on GMS, PMS or

APMS) receive the same core funding for providing the core services expected of all GP

practices. Any additional funding above this must be clearly linked to enhanced quality or

services or the specific needs of a local population...”

So by April 2020, following the conclusion and implementation of any transition agreed as

part of PMS reviews, NHS England will have a single price for primary medical care operating

across both GMS and PMS contracts. Arguably this means that both the contracts and price

will reflect the lowest common denominator of services and quality that all general

practices should achieve. However, we believe there is a significant opportunity for CCGs to

develop aspirational local contracts that reflect the enhanced quality, services or the specific

needs of a local population that CCGs wish to commission and that general practice can

provide.

60

Such local contracts will require additional investment above the national minimum offered

through GMS and, by 2020 PMS, but provide opportunities for CCGs to encourage

development of general practices to meet the challenges of healthcare delivery over the

coming decade. As new models of care (e.g.PACs and MCPs), new models of contracting

(prime provider, alliance contracts) and new funding models (capitated budgets for

providers) develop, general practice will be required to respond.

Consistency of access, service and outcomes are requirements of any service operating at

scale. Local contracts that enable general practice to demonstrate these capabilities will

allow general practice to operate at a unit size that works best for practices and for patients.

8.5 SUMMARY In summary this section of the analysis shows that there is a strong case for moving at speed

to a local weighted patient currency per weighted patient as the commissioning approach for

the Warrington brand. As well as enabling the delivery of a local primary care offer this also

will act as a very positive factor in the collaborative working and sharing of provision that is

emerging in Warrington, is recommended that the CCG moves to consult on this during the

2015-16 financial year

Figure 16.Financial impact on PMS practices of funding at £90 per weighted patient across all PMS and GMS practices in Warrington

Impact on PMS practices of funding at £90pwp

£250,000 .----------------------------------------------­

£200,000 +-==--------------------------------------------­

£150,000

£100,000

£50,000

£0

-£50,000

•Net ain •Net loss

-£100,000 +--------------------------------------------

-£150,000 +--------------------------------------------

-£200,000 +--------------------------------------------

-£250,000 -'-----------------------------------------------

61

A B C D E F G H I J K L M N O P Q R S

9. ENABLING STRATEGIES

This document focuses on the substantial commissioning changes to be made in

transforming primary care. However, the whole system impact that is sought in shifting

more care to out of hospital settings and achieving the vision set out in the acuity model

page 28 requires the wider commissioning approaches set out in the CCGs published

commissioning intentions, utilising the CCGs commissioning role in shaping the system,

ensuring that community nursing services, mental health and consultant pathways are all

embedded to deliver care closer to home, and working with our system partners to align

social care, preventive approaches and third sector services.

In addition to commissioning the change, the strategy set out in this document also relies

upon key enablers. We will drive the adoption of these enablers both through primary care

as set out in this document and through wider commissioning strategies with all providers.

The priority enablers are care co-ordination and Information Management and Technology (IM&T) enabling technologies.

9.1 Care Coordination Care coordination is central to our vision for integrated care enabling care to be ‘wrapped

around’ primary care across larger geographical populations utilising risk stratification to

identify, those patients that are complex, frail or vulnerable. The vision is that identified

patients will be entitled to a care plan that outlines their care requirements and

entitlements. The care coordinator will coordinate and navigate care and advocate for the

patients’ needs, creating the team around the person, working with the named GP,

streamlining access to health and social care, and third sector provision, reducing the

‘assessment merry go round’. At present as part of the transformation programme system

partners are co-designing the Warrington definition of care coordination practice, so that

this can be delivered in a consistent manner across the borough. This will include both

designated and non-designated care co-ordinators, therefore the funding identified in this

strategy is a building block towards implementation of care coordination at the heart of

primary care teams, but it is expected that many existing staff will take on care coordination

for an individual or small case load within their existing professional role.

Care of frail older people with complex needs who are often unable to attend surgery and

inevitable delays in care can result in an emergency admissions are a major focus. The

approaches defined in this strategy will provide rapid assessment and care to patients at risk

of emergency admission. The proactive use of the registered list to anticipate care needs

and identify patients at risk of hospital admission is a key building block for the system of

the future. Critical to this will be a meaningful, coordinated and supportive plan of care is

one that outlines step up and step down support, preferred priorities of care, Do Not

Attempt to Resuscitate (DNAR) and monitoring requirements.

62

63

9.2 Accountable Care Team approaches The primary care home model enables Accountable Care Teams (Extended Practice Teams/

Integrated Neighbourhood Teams/Complex Case Management Teams) who will be

responsible for delivering care on the ground to defined populations. This approach is

integral to the care coordination model. Health systems containing strong primary care

focused multi-disciplinary teams deliver improved continuity of care24. These teams will

focus on care that is person centred as opposed to disease centred, and facilitate solutions

for all common problems and the coordination of care if more complex or specialist care

was required, and so therefore provided higher quality and more cost-effective healthcare.

These solutions can go beyond the traditional health and social care boundaries, as can be

evidenced by the delegation of Personal Budgets to the clients, operated within social

services.

9.3 Enabling technologies

Across the system there is a shared ambition to deliver the Warrington integrated care

record, which is a vital enabler to many of the new ways of working that are set out in this

strategy. This ambition is being developed collaboratively across the system by the

Warrington IM&T Partnership Board. All system partners are involved in supporting this

development and capital funding is being sought to implement the vision.

The PMCF investment has enabled Warrington Practices to form collaborative provider

arrangements as a Community Interest Company and have enabled the development of

data sharing agreements to facilitate working across clusters ‘beyond the practice walls’.

The PMCF investment has enabled a capital investment in 2014/15 to enable the

development of some key enabling technologies including:

ACG based risk stratification system

software using John Hopkins licences

Enables identification of clinical groups for

person centred care and identified patients

that would benefit from care coordination.

MCAP software

Enables identification of qualified place of

care based on detailed clinical algorithms.

Supported effective referral practice.

Productive primary care software Enables detailed understanding of access

patterns and enables provision to be

matched to need.

24 Starfield, Barbara: Primary care and equity in health: the importance to effectiveness and equity of responsiveness to peoples’ needs humanity & society, 2009, vol. 33 (February/May: 56-73)

64

Outreach working MDT kits Enables staff to work across clusters, in

patients homes and in clinical settings such

as care homes

Telehealthcare Piloted through PMCF enables remote

monitoring and assessment of patients in

various locations, and video consultations,

on line consultant advice etc.

Wi-Fi Improved Wi-Fi enablement in all Practices

Patient information booths and patient log

in technologies

Piloted through PMCF to improve access

In addition to these innovations, the Warrington ‘Brand’ access element enables patients to

have better and consistent access to electronic booking and registration, and choice a range

of appointment types including e mail, telephone and face to face.

The CCG will utilise its commissioning strategies to ensure that commissioning and

contracting supports the changes in Practice and the innovations that the system will need

to introduce to ensure these potential benefits are achieved.

9.4 Estates The model for the transformation of primary care set out in this strategy requires fit for

purpose premises for delivery of services by multi-disciplinary teams. A full estates review is

currently underway commissioned by NHS England, the CCG is working with the local

authority, planners, public health and NHS England to develop an estates strategy that fully

encompasses and supports the vision set out in this document, and addresses some key

areas for proposed developments including issues relating to primary health care premises

in Chapelford, Great Sankey Hub, and Burtonwood.

10. APPROVALS

NHS England and NHS Warrington CCG are requested to approve the key elements of

this strategy:

Investment is to deliver: ₋ The Warrington Brand of Primary Care (common quality provision enabling every

citizen to get a common offer of care irrespective of registered practice) incorporating

the ten priorities for primary care improvement defined by the GP membership of the

CCG.

₋ A common price per weighted patient for delivery of the Warrington brand elements

above and beyond national core elements.

₋ The continued implementation of the Primary Care Home model (collaborative

primary care provision at scale), the home of system integration and care co-

ordination), with implementation support through the Prime Minister’s Challenge

Fund during 2015-16 creating the building blocks for system transformation. This is

recognising that over the last two years local clinical leaders and Practices have

created a vision for collaborative primary care at scale which has become the basis for

system transformation in Warrington.

₋ A focus on innovation to achieve leading edge primary care delivery supported through

enabling technologies.

₋ The establishment of a primary care skills taskforce working with local providers to

ensure that the system attracts quality clinical staff and addresses the GP shortfall.

₋ Establishment of an integrated commissioning group to redesign the commissioning

approach to urgent care recognising the need to integrate the commissioning

approaches with this primary care strategy creating a new integrated commissioning

approach to access incorporating out of hours and urgent care.

₋ Establishment of a local assessment panel for local tariff co-commissioning.

₋ Establishment of a primary care commissioning unit of the CCG.

Response requested:

₋ Consideration of CCG investment in primary care as proposed in the strategy to achieve:

• A Warrington brand of an agreed sum per head through investment in co-

commissioned provision replacing the current disparate commissioning approaches

to include core and nationally defined provision plus local elements to include

referrals practice, elderly care, complex case

65

66

management, and an agreed standard of access for any primary care provider in

Warrington

Continued investment in primary care at scale investing in the transformation

programme for 2015/16 investing in primary care cluster working, OD and enablers

NHS England is requested to work with the CCG in co-commissioning the elements of

the Warrington brand

A reference group to be established to report to the Primary Care Quality Committee

of the CCG, to agree and consult on the measures to be adopted in a balanced score

card approach to commissioning primary care

Following publication of final proposals a formal consultation to be undertaken during

2015/16 with a view to commencing the provision of primary care against the

Warrington standards in April 2016

67

11. REFERENCES

Warrington CCG Strategic Commissioning Plan 2014-2019

Improving General Practice; A call to action. Phase 1 report accessed March 2014 at:

http://www.england.nhs.uk/wp-content/uploads/2014/03/emerging-findings-rep.pdf Securing the Future of General Practice; New Models in Primary Care accessed March

2014 at:

http://www.nuffieldtrust.org.uk/sites/files/nuffield/130718_securing_the_future_of_ge

neral_practice-_full_report_0.pdf

The Quest for Integrated Health and Social Care accessed March 2014 at:

http://www.kingsfund.org.uk/publications/quest-integrated-health-and-social-care

Commissioning and Funding General Practice the case for family care networks

http://www.kingsfund.org.uk/publications/commissioning-and-funding-general-practice RCGP GP2022 http://www.rcgp.org.uk/gp2022

Gilburt H, Peck E, Ashton B, Edwards N and Naylor C. Service transformation- Lessons from

mental health. The Kings Fund February 2014.

NHS Alliance, Breaking Boundaries, A manifesto for primary care; 2013

Dayan, M.,Arora, S., Rosen, R., and Curry, N. Is General Practice in Crisis? Nuffield Trust

November 2014

Edwards, N. (Ed) Community Services: How they can transform care; Kings Fund 2014

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/community-

services-nigel-edwards-feb14.pdf

APPENDIX 1

POPULATION PROFILES

APPENDIX 1

This section contains information on the demographics, deprivation, and some long term conditions.25

1. DEPRIVATION

Many of the measures of ill-health and health-related lifestyle factors follow patterns of socio- economic deprivation, with more ill-health in the more deprived areas. Detailed analysis of the pattern of deprivation across Warrington is available in the Warrington JSNA at http://www.doriconline.org.uk/ViewPage1.aspx?C=Resource&ResourceID=962

MAP 1 – Index of Multiple Deprivation (IMD) 2010 Data source: Department of Communities and Local Government (DCLG), Indices of Deprivation 2010, © Crown Copyright.

25 Warrington Public Health Data 2014

2. WARD BASED POPULATIONS

Table 1: Resident Population, Warrington Ward and Neighbourhood Coordination Areas Population estimates from the 2011 census are available at LSOA level from the Office of National Statistics. These have been aggregated to ward and NCA level. Some selected age-bands are shown, as well as overall population.

TABLE 1 POPULATION CENSUS, 2011

Ward

Total popula-

tion

No. Aged

65 and over

% aged

65 and over

No. Aged

75 and over

% aged

75 and over

No.

Females aged 15-44

No.

Children aged 0-

4

Appleton 10636 2119 20% 1037 10% 1541 403

Bewsey & Whitecross 12339 1180 10% 520 4% 3074 1116

Birchwood 10701 1412 13% 558 5% 2083 639

Burtonwood & Winwick 6348 1343 21% 562 9% 1168 331

Culcheth, Glazebury & Croft 11690 2394 20% 1086 9% 1687 520

Fairfield & Howley 13015 1813 14% 947 7% 3149 959

Grappenhall & Thelwall 9687 2007 21% 991 10% 1589 504

Great Sankey North 6339 1175 19% 462 7% 1138 317

Great Sankey South 10588 1482 14% 506 5% 2092 656

Hatton, Stretton & Walton 3084 432 14% 182 6% 538 190

Latchford East 8134 1114 14% 509 6% 1828 543

Latchford West 6770 1368 20% 581 9% 1358 358

Lymm 12350 2182 18% 890 7% 2162 790

Orford 10618 1546 15% 655 6% 2187 748

Penketh & Cuerdley 8543 2150 25% 893 10% 1423 378

Poplars & Hulme 10528 1357 13% 673 6% 2303 842

Poulton North 10266 1472 14% 563 5% 2145 630

Poulton South 6485 1416 22% 626 10% 1122 314

Rixton & Woolston 9116 1588 17% 607 7% 1566 400

Stockton Heath 6391 1123 18% 547 9% 1164 419

Westbrook 6446 689 11% 298 5% 1272 343

Whittle Hall 12154 852 7% 323 3% 2709 909

Neighbourhood Coordination Area

Central NCA 42295 5830 14% 2784 7% 9467 3092

East NCA 48258 8282 17% 3440 7% 8603 2503

South NCA 48918 9231 19% 4228 9% 8352 2664

West NCA 62757 8871 14% 3564 6% 12876 4050

Warrington 202228 32214 16% 14016 7% 39298 12309

3. GP PRACTICE LOCATIONS BY CLUSTER

Table 4: Warrington population projections (Data Source: ONS)

Year 0-19 20-39 40-64 65+

All People - All Ages

2011 48800 50700 70500 32400 202700

2012 48700 51100 70700 34000 204600

2013 48900 51500 71100 35100 206700

2014 49200 52200 71300 36100 208700

2015 49500 52800 71600 36900 210700

2016 49800 53300 71900 37500 212700

2017 50100 54100 72100 38300 214700

2018 50600 54700 72200 39200 216700

2019 51000 55000 72500 39900 218600

2020 51500 55200 73200 40500 220500

2021 52100 55300 73700 41300 222400

INCREASE FROM 2011 TO 2021 3300 4600 3200 8900 19700

PERCENTAGE INCREASE FROM 2011 TO 2021 7% 9% 5% 27% 10%

Population projections suggest a 10% increase in overall population. Whilst an increase is projected in all agebands, by far the biggest increase (both in terms of percentage increase and in absolute numbers) is in those aged 65 and over.

Map of Warrington Population (all ages) by ward (Data source: ONS census 2011)

Map of Warrington Population aged 65 and over, by ward (Data source: ONS census 2011)

Map of Warrington Population aged 75 and over, by ward (Data source: ONS census 2011)

LIFESTYLE RISK FACTORS

Obesity Map below shows differences in obesity prevalence across Warrington. Lymm and Appleton wards have lowest prevalence, Poplars and Hulme the highest.

MAP of Obesity Prevalence by Warrington Ward, 2013 (Data source: Warrington Health & Wellbeing Survey)

Smoking

The map below shows smoking prevalence by ward. (This includes daily and occasional

smokers.) Many wards have a prevalence of less than 10%.Latchford East has by far the highest

prevalence at

28%.

Map of Smoking Prevalence, by Warrington Ward, 2013

(Data source: Warrington Health & Wellbeing Survey 2013}

Smoking Prevalence (Data source Wallingtoo Heatth & Welbeing Survey 2013}

- 28% (1)

- 19% to 23% (3)

c:::l14% to 18.9% (2)

c::::::::J 10% to 13.9% (5) Culcheth,Glazebury and Croft

c::::::::J s%to9.9% (11)

C'ICfO'M'lCopyright and database right 2013. Ordnance Survey 100022848.

Produced by Publ c Health

Knowledge &lntellgenoe Te m

Warrni gton BoroughCouncil. 01925 443047

Warrington PharmaceuticalNeeds Assessment 2014 Smoking prevalence by ward

(Data source:Warrington Health and Wellbeing Survey 2013)

October 2013

G\HP\GI$0ATA\WORK$PAC\PNA\

PNA_2014\PNA2014_part1.wor & ElpNA\2014 UPDATED PNA\GI$files\ GIS_PNA20i4_ward0a .Jdsx

ILLNESS, DISABILITY, LONG-TERM CONDITIONS

Diabetes Diabetes prevalence is recorded in the Quality Outcomes Framework (QOF) data. In 2012/13, for Warrington it is 6.1% (compared to 6.0% for England). This data is available at a practice level, but not at ward. It only includes patients who are registered by the practice as having diabetes. Some people with diabetes are undiagnosed. Ward level figures were calculated by inputting the ward population structure (by age and sex), and levels of deprivation within the ward. This estimated a prevalence for Warrington overall of 7.8%.

Estimated number of people with diabetes, by ward (Data source APHO & ONS)

Estimated diabetes prevalence, by ward

(Data source APHO & ONS}

Diabetes Prevalence

- 9%to 10% (2)

- 8%to 9% (8)

c::::::J7% to 8% (8)

c:::::::::J6% to7% (3)

c:::::::::J s%to6% (1)

Warrington Pharmaceutical Needs Assessment 2014

Diabetes Prevalence (Data source:APHO diabetes prevalence

model and ONS 2011 census age/sex population structure)

October 2013

G\HP\GI$DATA\W0RKSPAC\PNA\

PNA_2014\PNA2014_part2.wor & E\PNA\2014_UPOATED_PNA\GISfiel s\ GIS_PNA2014_ward0ata.xtsx

Dementia

Estimated number of people with dementia, by ward (Data source: ONS 2011 census populations; prevalence rates from POPPI)

Estimated number of people requiring palliative care by Warrington ward

Percentage of adults with a longstanding illness, disability or infirmity, by ward (Data source: Warrington Health & Wellbeing Survey)

Percentage of adults with a longstanding illness, disability or infirmity which limits their activity (compared with other people their age), by ward (Data source: Warrington Health & Wellbeing Survey)

APPENDIX 2

WARRINGTON QOF PROFILES 2013-14

100%

Clinical QOF Peformance

95% Warrington Average

90%

85%

80%

75%

100%

Public Health

95% Warrington Average

90%

85%

80%

75%

100%

QP

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

100%

PE

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

100%

Total QOF 13/14

98%

96%

94%

Warrington Average

92%

90%

88%

86%

84%

82%

100%

CHD

95%

90%

THIS PAGE IS INTENTIONALLY LEFT BLANK

100%

HF Warrington Average

99%

98%

97%

96%

95%

94%

93%

92%

91%

90%

100%

HYP

90%

80%

Warrington Average

70%

60%

50%

40%

30%

20%

10%

0%

100%

PAD Warrington Average

95%

90%

85%

80%

75%

70%

65%

60%

55%

50%

100%

95%

STIA

Warrington Average

90%

85%

80%

75%

70%

65%

60%

55%

50%

DM

90%

85%

80%

75%

70%

65%

60%

55%

50%

100%

COPD Warrington Average

95%

90%

85%

80%

75%

70%

65%

60%

55%

50%

100%

DEM

95%

90%

85%

80%

75%

70%

65%

60%

55%

50%

100%

DEP

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

100%

MH Warrington Average

95%

90%

85%

80%

75%

70%

65%

60%

55%

50%

100%

CAN Warrington Average

95%

90%

85%

80%

75%

70%

65%

60%

55%

50%

APPENDIX 3

PRIMARY CARE MEASURES

APPENDIX GP HIGHER LEVEL INDICATORS

CCG OUTCOMES INDICATORS SET

Measure Data Source Level

Range and size of practice populations (resident &registered (pyramid); deprivation; under 5, 65+, 75+) HSCIC/NHS E GP/CCG

Patient turnover HSCIC GP/CCG

Number of PMS / GMS / APMS contracts Open Exeter GP/CCG

Open or Closed List Open Exeter GP

Global Sum £ per capita Contracts GP

£PP ATs GP

Number of providers and size of population they cover OoH Service GP

QOF Points Total / % Available HSCIC/QOF GP

Clinical Total Points / Available % HSCIC/QOF GP

Patient Experience Total Points / Available % HSCIC/QOF GP

Additional Services Total Points / Available % HSCIC/QOF GP

Number of practices PC Web Tool CCG

GPs with 5 or more outliers PC Web Tool CCG

Exception rate PC Web Tool GP

AF prevalence PC Web Tool GP

CHD prevalence PC Web Tool GP

COPD prevalence PC Web Tool GP

Asthma prevalence PC Web Tool GP

Diabetes prevalence PC Web Tool GP

Two-week wait PC Web Tool GP

Diabetes BP monitoring PC Web Tool GP

Diabetes cholesterol monitoring PC Web Tool GP

Diabetes HbAIC monitoring PC Web Tool GP

CHD cholesterol monitoring PC Web Tool GP

Flu vaccination in over 65's PC Web Tool GP

Flu vaccination in at risk patients PC Web Tool GP

Health checks for mental illness PC Web Tool GP

Diabetes retinal screening PC Web Tool GP

Cervical smears PC Web Tool GP

AF on anticoagulation PC Web Tool GP

COPD diagnosis PC Web Tool GP

Asthma diagnosis PC Web Tool GP

Antidepressants PC Web Tool GP

Insulin prescribing PC Web Tool GP

Ezetimibe prescribing PC Web Tool GP

Antibacterial prescribing PC Web Tool GP

Cephalosporins and quinolones PC Web Tool GP

Hypnotics prescribing PC Web Tool GP

NSAIDS prescribing PC Web Tool GP

A+E attendances PC Web Tool GP

Emergency admissions PC Web Tool GP

ACS admissions PC Web Tool GP

Cancer admissions PC Web Tool GP

CHD admissions PC Web Tool GP

Asthma admissions PC Web Tool GP

Diabetes admissions PC Web Tool GP

COPD admissions PC Web Tool GP

Dementia admissions PC Web Tool GP

Patient experience of GP surgery PC Web Tool GP

Getting through by phone PC Web Tool GP

Making an appointment PC Web Tool GP

Potential Years of Life Lost (PYLL); c amenable to healthcare (CCG OIS 1.1) HSCIC(PCMD/LE) CCG Under 75 mortality rates from cardiovascular disease (CCG OIS 1.2) HSCIC(PCMD) CCG

Under 75 mortality rates from respiratory disease (CCG OIS 1.6) HSCIC(PCMD) CCG

Under 75 mortality rates from liver disease (CCG OIS 1.7) HSCIC(PCMD) CCG

Under 75 mortality rates from cancer (CCG OIS 1.9) HSCIC(PCMD) CCG

Emergency admissions for alcohol related liver disease (CCG OIS 1.8) HSCIC/HES/HED CCG Unplanned hospitalisation for chronic ambulatory care sensitive conditions (CCG OIS 2.6) HSCIC/HES/HED CCG Unplanned hospital+B65:D92isation for asthma, diabetes and epilepsy in under 19s (CCG OIS 2.7) HSCIC/HES/HED CCG Emergency admissions for acute conditions that should not usually require hosp adm (CCG OIS 3.1) HSCIC/HES/HED CCG

Emergency readmissions within 30 days of discharge from hospital (CCG OIS 3.2) HSCIC/HES/HED CCG Emergency admissions for children with lower respiratory tract infections (CCG OIS 3.4) HSCIC/HES/HED CCG Patient reported outcomes measures (PROMS) for elective procedures (CCG OIS 3.3) HSCIC/HES/HED CCG

Patient experience of GP out-of-hours services (CCG OIS 4.1) GP S/HSCIC GP/CCG

SHMI - Summary Hospital-level Mortality Indicator [under development] HED/HSCIC GP/CCG AAACM - All Age All Cause Mortality (Pooled data) [under development] PCMD/ONS GP/CCG

Elective admissions HES/HED GP/CCG

Weekend admissions HES/HED GP/CCG

MRSA and C.Difficile HPA CCG

PCT (soon

Referrals per prevalence of Population (KPI 3a/KPI 1) Omnibus/HSCIC

Percentage of Children Immunised by their 2nd Birthday HPA COVER pr

CCG) PCT to

CCG

Percentage of Children Immunised by their 5th Birthday (1st dose) HPA COVER pr

Percentage of Children Immunised by their 5th Birthday (2nd dose) HPA COVER pr

PCT to CCG

PCT to CCG

GP register; Expected vs. Prevalence (to be developed when new estimates available)

NHSOF (ENG), TBC

NHSOF (ENG)

Overall experience of making an appointment GP Survey GP

Convenience of appointment GP Survey GP

Satisfaction with opening hours GP Survey GP

GP Service response rate GP Survey GP

Ease of contacting the out-of-hours GP service by telephone GP Survey GP

Know how to contact out of hours GP service GP Survey GP

SUIs, Never events, Complaints

Friends and Family test

Satisfaction with the quality of consultation at the GP practice GP Survey

Satisfaction with the overall care received at the surgery GP Survey

Satisfaction with accessing primary care GP Survey

Monitoring of practices who have declared non-compliance with any element of the self-declaration by AT / Region Assessment of electronic practice catchment areas to determine any gaps in contractual (inner boundary) Primary Medical Service provision by AT / Region

Health Inequalities Measure [In development]

Proportion of new cancer cases referred using 2 week wait pathway

Identifying the prevalence of depression

Diabetes

Stroke (stroke and TIA)

CHD

HF

CVD

COPD

Dementia (Mental Health)