Primary Care Development Day Trish Haines Chair of

Primary Care Development Day Trish Haines Chair of the Countywide Primary Care Commissioning Committee, Worcestershire CCGs

Welcome & aim of today’s event • ‘To review progress across the county with regards to Primary Care Development and the General Practice Forward View. We hope you will use this afternoon as an opportunity to consider, and plan, future developments’.

Primary Care Development Day Simon Trickett Accountable Officer 29 th November 2018

Some reflection • Three relatively stable CCGs with strong joint working • CCG finances mostly in order, plans in place for next year • PCE contract developing and attracting envious glances! • Neighbourhood Teams and Practices working together excellent foundation But: • Real challenges across the local system, particularly in the acute sector • Workforce gaps becoming a reality • Some pressure will come on NT structures to deliver, ongoing wider engagement critical • CCG 20% running costs reduction will present a challenge

Priorities for next year • New national ‘Long Term Plan’ • Year 2 of 2 year PCE contract • Reduce unwarranted variation • Further embed the NT structures and work • Encourage working at scale that supports primary care resilience • Support improvements to acute sector quality and financial performance • Financial resilience

The STP and integrated care • More CCG ownership and direction of the STP process • Changing role of NHS England NHS Improvement • Continue a journey to an ‘integrated care system’ • • Different ‘system wide’ approach to contracting Single financial recovery and ‘cost out’ plan Collective approach to and ownership of challenges Seek opportunities to invest in prevention and out of hospital care • Strategic commissioning journey of further reduced duplication and increased efficiency through working with Herefordshire

General Practice Forward View - update Lynda Dando Director of Primary Care, Worcestershire CCGs

National Priorities Stimulate development of at scale providers for improved access Resilience -Successful bid for additional funds £ 78 K -10 practices supported Improved Access 100% across Worcestershire – 10 hubs x 1, 000 appointments weekly Healthcare Navigators 386 staff trained across Worcestershire Document Handling 160 staff trained across all 3 CCGs since April 2018 Transformation Funding for 18/19 £ 894, 384 Implementation of the 10 high impact actions to free up GP time Secure sustainability of general practice Workforce -Retention & Recruitment -GPN 10 point plan -Workforce Survey -185 Practice managers trained Continuing projects from 2017 -2018 ETTF Bids • 8 schemes, approx. £ 3. 75 m Primary Care IT and Telephony -Docman 10 -Wifi -New Telephony -Online Consultations Social Prescribing 6 pilots – 700 referrals first 6 months General Practice Support Team rebranding November 2018 Neighbourhood Teams - Strengthened sustainable General Practice

GPFV Transformation Funding 2018/19 • £ 894, 384 - £ 641, 397 unspent • Criteria: • Improving Access, both in and extended hours • The 10 high impact Actions • Development of Provider Board • Practice Nurse Facilitator

GPFV Transformation Funds 18/19 – Some Examples EBBI Active Monitoring – Springfield Mind: Active Monitoring is based within the GP surgeries enabling GPs and other clinical practice staff to directly refer patients to the service as soon as they present with symptoms of anxiety, low to moderate mental health problems Case Study: patient attended 36 consultations with gp in 6 months prior to Active Monitoring. Patient attended 5 sessions with Active Monitoring practitioner over 8 weeks. Consultations with gp reduced to 8 appointments for medical issues “Active Monitoring is really beneficial, it’s great to be able to see a named person in the surgery and be able to talk to them straight away if needed” (GP, Merstow Green)

GPFV Transformation Funds 18/19 Some Examples Upton, Pershore & Abbottswood Development of a Health and wellbeing care hub: • 3 staff are allocated dedicated time from each practice as leads for the project to work with the patient champions and other voluntary sectors and link to council and national initiatives. • New initiatives introduced are: • AGE UK twice weekly presence at Upton Surgery • Telecare promotion from site Upton Surgery • Reconnections Live Lounge event Pershore Medical Practice and Upton Surgery • The Big Get Together with St Richards Hospice and 3 other social support partners • Established monthly Tea and Talk sessions at Abbottswood Medical Centre • Audiology impairment day - Upton Surgery • 2 new patient champions recruited • GP Champion identified Redditch & Bromsgrove Funding a Courier Service on weekends to deliver extended access appointments Davenal House Working with a digital health care provider (silicon practice) – GP Practice Websites re-imagined

Social Prescribing Worcestershire Model • Six pilot sites created using the basic model shown - investment made by both the three CCGs and Public Health • Pilots delivered by the Community and Voluntary Sector (VCS) • Social Prescriber (“link worker”) role in each model supporting individuals on a one to one basis • Referral made by any healthcare professional in Primary Care for those identified as ‘in need’ • Majority of models and prescribers are linked to Neighbourhood Teams • Person centred, motivation discussion with signposting tailored to the individuals needs • Feedback given to the referrer on patient outcomes 13

Wyre Forest: Worcestershire Association of Carers 2 x part time Social Prescribers receiving referrals from primary care, signposting to local services and groups Redditch: Worcestershire Association of Carers 2 x part time Social Prescribers receiving referrals from primary care, signposting to local services and groups Malvern & The Rural practices: Malvern CAB, 1 x part time Social Prescriber receiving referrals from primary care, signposting to local services and groups Worcester City: Age UK H&W, 2 x part time Social Prescriber receiving referrals from primary care, signposting to local services and groups 14 Redditch (2): St Stephens member of staff, upskilled. Social Prescriber receiving referrals from two practices, signposting through telephone support to local services and groups Droitwhich & Ombersley: Onside Advocacy, 1 x part time Social Prescriber receiving referrals from primary care, signposting to local services and groups

Referrals by Reason – combined Q 1 & Q 2 Other Money/debt/finance 12% Social isolation 22% Housing issues 7% Learning/training/ development Weight 7% Relationships Physical activity Drugs/alcohol, other addictive behaviours Healthy Eating Anxiety/stress/ depression/low mood 29% 15

What Next? • 3 Years Left! • NHS Long Term Plan • Primary Care Networks – 30 -50, 000 • Local Transformation Fund?

Primary Care Workforce Nikki Marriott Primary Care Workforce Lead, Worcestershire CCGs

GP Practice Workforce Survey Highlights Purpose To establish a baseline, identify what and where our workforce issues are to enable us to focus available resources effectively to support recruitment and retention. Key Findings GP workforce remains the highest risk assessed by 30% of practices to be high. Herefordshire is the highest risk area where the percentage of GPs 50 years or over is significantly higher at an estimated 64% compared 45% for Worcestershire. Most practices have less full time equivalent (FTE) GPs per 1, 000 population than the national average of 0. 57.

GP Practice Workforce Survey Highlights GP trainee numbers are reducing, the headcount of trainees has reduced by 14%, placements by 38%. Pre-registration nurse placements need to grow to establish a secure workforce pipeline for newly qualified nurses and to pave the way for Return to Practice Nurses and Nurse Associates in the future. Access to formal training programmes needs to be improved for new roles, working with our Training Hub and HEE colleagues to support this.

GP Practice Workforce Survey Highlights The skill mix across practices varies considerably between Neighbourhood and Primary Care Home teams. Apprenticeships which offer low cost training and employment options seem to be underutilised, particularly for Health Care Assistants (HCA) where they are absent. The number of work experience placements varies across the four CCGs.

GP Practice Workforce Survey Highlights The skill mix across practices varies considerably between Neighbourhood and Primary Care Home teams. Apprenticeships which offer low cost training and employment options seem to be underutilised, particularly for Health Care Assistants (HCA) where they are absent. The number of work experience placements varies across the four CCGs.

GP Practice Workforce Survey Highlights Survey findings suggest our long term sickness rates are fairly minimal at this point in time. Over the next 12 months there will be 29 GP and 9 nurse vacancies. Some practices are considering replacing these vacancies with alternative roles , a significant number are looking to replace ‘like for like’. The workforce pipeline in Herefordshire and Worcestershire isn’t as healthy as is needs to be.

GP Practice Workforce Survey Highlights Survey findings suggest our long term sickness rates are fairly minimal at this point in time. Over the next 12 months there will be 29 GP and 9 nurse vacancies. Some practices are considering replacing these vacancies with alternative roles , a significant number are looking to replace ‘like for like’. The workforce pipeline in Herefordshire and Worcestershire isn’t as healthy as is needs to be.

GP Practice Workforce Survey Highlights

GP Practice Workforce Survey Highlights What is being done? NHSE GP retention scheme - aimed at doctors who are seriously considering leaving or have left general practice , support for GP and practice GP Portfolio Roles - successful bid to NHSE to support 4 salaried GPs to increase hours to develop portfolio roles with local Trusts, roll out December International Recruitment – bid submitted to NHSE , waiting to hear when scheme will start General Practice Support Team - to help practices and GPs with coping strategies around the challenges, a focus of current IQSP visits.

GP Practice Workforce Survey Highlights What is being done? 4 General Practice Nurse Mentors - Training Hub working in partnership with University of Worcester to support pre-registration nurse placements and implementation of new NMC supervision and assessment standards. Practice Nurse Forums - A Practice Nurse Clinical Lead appointed by Worcestershire CCG to re-establish the Practice Nurse Forums in Worcestershire Centralised Practice Nurse Training - The Training hub will be working with Practice Managers and Lead CCG Practice Nurses to develop a more cost effective and easily accessible nurse training programme for 2019 across our STP. Training Hub Recruitment – free service to support practices advertising their vacancies

GP Practice Workforce Survey Highlights What is being done? PA Preceptorship - Training Hub are supporting practices to achieve the necessary criteria for preceptorship with the Physician Associate Preceptorship programme which includes frameworks, guidance and clinical supervision. Currently 4 Worcestershire practices are signed up to join the programme which will be launched in January 2019. Other practices can join at any point Advanced clinical practice – 5 nurses nominated and accepted for HEE funded MSc Advanced clinical practice in 2018

GP Practice Workforce Survey Highlights Opportunities • For practices to work together to employ staff across practices or within their Neighbourhood teams e. g. HCA apprentice • Vacancies may offer an opportunity for a joint community post e. g with Worcestershire Health and Care Trust • Apprentice schemes offer 90% training costs and are a key building block of our workforce pipeline • Use of national opportunities such as NHSE Clinical Pharmacist funding

GP Practice Workforce Survey Highlights Next Steps • Work with NHSE and HEE colleagues to develop a plan/bid to improve GP training position • Work with HEE and Training Hub colleagues to develop nurse training programmes • Work needs to be undertaken to understand what support practices need to increase uptake of apprentice schemes and work experience placements • Repeat survey and monitor trends

Connecting Colleagues & Sharing Ideas General Practice Support Team Dr Gillian Farmer, Dr Pamela Smith, Lisa Luke

How to get in touch • Phone or email us: • LMC Office Tel. 01527 65082 Email gfarmer@worcslmc. co. uk Email lsiembab@worcslmc. co • Sally Everton Tel. 01905 681952 Email sally. everton@nhs. net

The Team Leads Dr Gillian Farmer, LMC Sally Everton & Hollie Hastings, CCG Support Leads GPs Practice Managers Dr Louise Bramble, Chaddesley Corbett Surgery Lisa Luke, St Stephen’s Surgery Dr Gemma Moore, Ombersley Medical Centre Helen Garfield, Northumberland House Dr Caroline Heath, York House Medical Centre Jackie Evans, Pershore Medical Practice Dr Anil Joshi, St Stephen’s Surgery Don Beckett Dr Pamela Smith, Davenal House Surgery Dr Moheb Shalaby, Hollyoak Medical Centre Practice Nurses Dr Simon Parkinson, St Stephen’s Surgery Karen Wade Amelia Day Advice: Nina Lealan – Practice Nurse – nlealan@nhs. net

Digital General Practice of the Future Dr Roy Williams, Sandra Heyward, James Harley, GP Team Net, Ben Furlow, Lynda Dando, Alan Luckman

Digital General Practice of The Future Membership: Lynda Dando Director of Primary Care Nigel Higenbottam Practice Manager, Redditch & Bromsgrove Ben Kent Practice Manager Upton Dr Roy Williams GP Gavin Canty IT lead. WFHP Ben Furlow CCG Claire Gibbs CCG Alan Luckman CSU

Projects • NHS App • On-Line Consultation-Single portal • Telephony • Mjog • Cloud storage solution • Emis User Group • Emis Clinical Development Group • Training Needs Digitalhealthforum. co. uk

Telephony X-ON Surgery Connect • New CCG wide procurement • VOIP provider • Calls included • Integrates with EMIS • Call centre technology • Dashboard/ monitoring

NHS App “Single Simple Secure” Patient Access to NHS Services On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 38

NHS App Features üSecure Identification and Login üIntegration with GP IT Systems üNHS 111 and NHS Symptom Checker üAppointment Booking, Repeat Prescriptions üGP Medical Record Access üOrgan Donor Registration üSelect Data Usage Preference On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 39

NHS App Benefits üDigital Registration Process üSingle access to NHS Services üMobile App for SMART Phone / Tablet üA Desktop Webpage üPatients can continue to use GP Online Services if preferred üImprove Access to Healthcare Services üFuture Proofs Promotion of Commissioned Digital Services On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 40

NHS App Future Developments üSupport for Online Consultations üIntegration with Apps üIntegration with Wearables üBiometric Security üPharmacy Finder ü End of Life Preferences On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 41

NHS App Feedback • Feedback of Usability, Function and Practice/Patient Impact via GP Practice Staff and Patients • NHS App improvements made prior to National Public Beta Launch On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 42

NHS App Next Steps 3 Worcestershire Practices Testing • GP Practice Pilot sites complete Private Beta Testing (Sept/Dec 18) • GP Practice Pilot sites transition to Public Beta Testing (Dec 18/Mar 19) • National Rollout and Promotional Campaigns across England (Mar/Apr 19) On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 43

NHS App Further Information https: //digital. nhs. uk/services/nhs-app Sandra Hayward - Project Liaison Phone – 07818 015489 / Email – sandra. hayward 1@nhs. net On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11/2018 44

Online Consultation On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11/2018 45

Online Consultation Desired Outcomes üEngagement in 'digital first’ and the GPFV üAchieving some of the key High Impact Statements; üBetter Signposting for Self Care and Social Prescribing üDevelop the Team, Productive Workflows, Personal Productivity, üReduce DNA’s, New Consultation Types On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 46

Online Consultation Aimed Benefits üIncrease online usage, reduce unnecessary appointments üReduce waiting times and length of some appointments üRestructure Clinician/Patient time, manage demand, balance capacity üRight Clinician, right Care, increase efficiencies üIncrease Patient satisfaction, have a positive impact on the workforce On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 47

Online Consultation Worcestershire Trials On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11/2018 48

Worcestershire Trials Progress • 3 Practices within the Worcestershire CCG’s took part in trials during end of 2017 to early 2018 • Online Consultations increased significantly over a period of 5 to 6 weeks with positive feedback On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 49

Worcestershire Trials Number of Online Consultations Period 01 Period 02 % Increase Practice 1 57 144 152% Practice 2 16 94 488% Practice 3 42 74 76% On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 50

Worcestershire Trials Online Consultation Utilisation 400 350 300 250 200 150 100 50 0 8 th Feb 2 nd Mar 6 th Apr Medical On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 20 th Apr Admin Totals Total 29/11//2018 51

Worcestershire Trials Online Consultation Feedback • • • System viewed as alternative communication route Admin queries dealt with efficiently Higher uptakes where “Dr First” in place Success relies on quality of patient submitted data Returned calls from practice when patient data poor Opportunity to increase system promotion at each patient contact • Pre recorded phone message capability is important On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 52

Online Consultation Conclusion • • One system does not fit all practices Suppliers have developed systems further A decision not to procure a single system Worcestershire to select a system of choice On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 53

Online Consultation Expanded Pilot On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11/2018 54

Online Consultation “ The Right Fit” your Practice, your choice, to suit your needs On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 55

Online Consultation Pilot Worcs Funding Per Practice ü£ 1000 - Supports Operational Change üMinimum 1 Year Service - Delivery, Support and Maintenance üEstimated 50% Contribution to 2 nd Year - Support and Maintenance On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 56

Online Consultation Pilot The Systems On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11/2018 57

Online Consultation Pilot Next Steps 1. Practices confirm their intent to participate Early December 2018 2. Practices select their system of choice December 2018 On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11//2018 58

Online Consultation Pilot Further Information http: //www. digitalhealthforum. co. uk/gponline-consultations/ Sandra Hayward - Project Lead Phone – 07818 015489 / Email – sandra. hayward 1@nhs. net On behalf of: NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG 29/11/2018 59

Cloud Storage Solutions • • Information everywhere! Emis Docman Shared drives CCG portal APC guidance Online guidance Email

One solution § § § § Wyre Forest Health Partnership Good engagement Good search facility Feedback mixed System complex (and expensive) Not tailored to General Practice But single storage system idea remains…

Refreshment Break

Integrated Care & Neighbourhood Teams Ruth Lemiech & Dr Jonathan Thorn Director of Strategy, Worcestershire CCGs & Chair, South Worcestershire Alliance Board

Outline plan for our Integrated Care System Worcestershire Acute Hospitals NHS Trust Worcestershire Health and Care NHS Trust Private sector providers holds out of county contract Relationship with GPs as providers / Provider board

Evidence derived principles of integrated care Relationships are key. Not just for peoplefocused activities but for structural change. Time and space is critical. For shared engagement, reflection, discussion, deliberation and continuous improvement. Demonstrable impact is elusive. Timescale of at least five years. Turner A, Mulla A, Booth A, Aldridge S, Stevens S, Begum M & Malik A. The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis. Health Serv Deliv Res 2018; 6(25)

Alliance Boards & Neighbourhood Team Initially core teams consist of: • • GP lead WHCT lead Social Care lead Nurses (including DNs, PACT/Matrons/ECT) Therapists Health Care Assistants UPI staff Administrative staff

Worcestershire Case studies: summary findings • Design: Neighbourhoods activities designed according to their population health profile. • Delivery: There are clear mechanisms for referring patients to multidisciplinary teams. • Management: Monthly neighbourhood meetings are attended by key local health and care providers; engagement and relationships observed to be strong. • People and Communities: Neighbourhoods have input from other stakeholders e. g. VCS. • Workforce: Local resource restraints impact on workforce for delivery. For example, whilst there is some engagement with mental health, more input would be beneficial. • Leadership: Neighbourhoods have dedicated leadership and time allocated for those leaders to undertake neighbourhood work. This has benefitted the coordination and progression of neighbourhood activity. • Technology and Innovation: The inability to easily share information (technological barriers) is currently limiting the possibilities of delivering integrated coordinated care. • Knowledge and Learning: More shared learning of neighbourhood working to help design and prioritise activity, facilitated by the Alliance, has been requested.

BUT: The evidence for neighbourhood models is limited • Integrated Care Teams (ICTs) are being assessed according to their impact on hospital use. Impact on other outcomes, such as health and wellbeing, are not currently well examined (for example, Health Foundation, 2018) • ICTs do not reduce emergency admissions for high risk populations in the short-medium term (Bower et al, 2018; Health Foundation, 2018). • Given commitment, there can be rapid success in establishing integrated ways of working (White et al, 2017). However delivering mechanisms of integration at sufficient scale to have a large impact on patient outcomes could take time (Bower et al, 2018). Bower P. et al. ’Improving care for older people with long-term conditions and social care needs in Salford: the CLASSIC mixed-methods study, including RCT. ’ Health Serv Deliv Res. 2018; 6(31) Lloyd, T. et al. The impact of integrated care teams on hospital use in North East Hampshire and Farnham: Consideration of findings from the Improvement Analytics Unit. The Health Foundation. 2018. White J. M. et al. ‘Front-line perspectives on ‘joined-up’ working relationships: a qualitative study of social prescribing in the west of Scotland. ’ Health Soc Care Community 2017; 25: 194– 203.

Reducing Variation in Emergency Admission Rates – through delivery of NT plans 100 90 80 70 60 50 40 30 20 10 0 Y 1718 rate re ive - Fo - R IP F N W W F H P 2 1 - G l P 1, 718 fewer emergency admissions contracted for in 2018/19 R&B – 18 less a week, SW – 12 less a week, WF 2 less a week st r s ad e 4 F H W or ce st e r C ity 3 ity W or W ce st e r C ce st e te ce s or W r C ity r C rs ho Pe & n 2 1 re l ra to Up M al ve rn T Ru n ow BI EB sle be r m O Dr oi tw ich & ed - R y NT 1 ow h T di tc om NT 4 3 - Br NT NT 2 n W CCG Median sg ro ve Rate / 1000 2017/18 Emergency admission Rate/1, 000 population Neighbourhood Teams

NT - Key Requirements • Leadership (Neighbourhood Team & MDTs) • Engagement across all practices and other providers • Have developed & implemented a plan which reflects local health profile and supports: • the sustainability of general practice, • improvement in health outcomes, and • reduction in variation in emergency admissions

South Worcestershire: Pershore and Upton Key activities • Single Point of Access • MDTs operating in practices with neighbourhood oversight Strengths • High level of engagement across health and social care built on strong historical collaborative working • Strong governance base with confidence that it can deliver additional activity as opportunities arise • Close links between key stakeholders allow for rapid responses for patients • Broad range of voluntary and community services to supplement clinical treatments Challenges • Limited neighbourhood level intelligence • Limited engagement with mental health and acute colleagues • IT infrastructure to coordinate activity across the neighbourhood.

Redditch and Bromsgrove: NT 2 Key activities • Developed HANDi app to support parents in managing common childhood illnesses • Carried out audit of attenders and admissions to identify possible interventions • Co-location of community teams Strengths • High level of engagement across health and social care • Developed strong working relationships; no historical collaboration previously • Commitment to reducing variation at the neighbourhood level from key stakeholders • High confidence in social prescribing and links with local services • Implementation of Healthcare Navigator role Challenges • Lack of engagement from mental health and secondary care • Limited opportunities to learn from other neighbourhoods • Technology a barrier to coordinating care for patients outside of primary care

A Health and Social Care Sorting Office

Hospital Admission Prevention – Future Process Flow

Early positive results: Reduction in Emergency Admissions from care homes Emergency Admissions from Care Homes 250 200 Apr - Aug 17/18 Apr - Aug 18/19 150 100 50 RB 1 RB 2 RB 3 RB 4 Malvern Worcester City EBBI Pershore and Upton Rurals Droitwich & WF Forest WF Glades WF River Ombersley

Next Steps • Continue to support NTs to deliver second year of two year plan • Refine how we frame the Neighbourhood Team opportunities for next year … • Develop relationships and co-operation between NTs and WMAS, 111 • Worcs acute and health and care trust exploring closer working - ‘Provider Alliance’ • Developing a consistent system efficiency plan • GP Provider Board to ensure strong GP engagement

‘System Efficiency Plan’ – aka CIP/QIPP • “. . how you will run your local NHS system using the resources available to you. . ” • Realistic and fully aligned plans between commissioner and provider • Shared ‘open book’ approach • Opportunity not a threat • Promotes mutual ownership and accountability of the financial challenge • Our ‘NHS system’ has a significant deficit – which currently sits with acute providers

GP Provider Board Dr Shaun Pike Chairman, Worcestershire Local Medical Committee

GP Provider Board Providing a voice for GPs as providers within the STP and ICS Dr Shaun Pike, LMC Chairman 29 th November 2018

The Case for Change • The national consensus now is that STPs need to evolve into Integrated Care Systems • GPs in ICS will continue to offer traditional family practice as now under GMS • They are also expected to join together in localities as “Primary Care Homes” serving 30 -50, 000 patients in concert with Community Providers and the VCS / Social Care • Hospital and Community care will also become more integrated. • GPs need a unified provider voice at all levels in this project. • CCGs are not equipped to provide that voice

Steps to date • Origins- borrowing a concept from Somerset LMC • Initial conversations- Hereford and Worcestershire LMCs • Next steps- Engagement with Worcestershire Alliances, and Taurus in Herefordshire • Current state- Alliances / Taurus engaging with Neighbourhood Teams and GPPB inviting representation from “At Scale” General Practice to join the conversation

Looking ahead • Working with consultant on drafting Terms of Reference and Deliverables for commissioners. • Aim to stake a claim to represent GPs in emerging ICS to insure we can determine how we work in the new environment. • First priority is insuring sustainability of practices. • Second is asserting autonomy of Neighbourhoods Wherever possible services should be developed within existing contractual arrangements and by mutual agreement between all parties

Next Steps • Agree early deliverables with commissioners • Engage with Practices and Neighbourhoods to insure they feel appropriately consulted and represented. • Secure funding to allow that representation to continue at all levels of the ICS • Support GP providers in engaging with the ICS as practices, Neighbourhoods or other “At Scale” providers.

What we won’t do • Require any individual GP or practice to take on any new work • Bid directly for contracts within the wider ICS

Breakout Session

MSK Services in Worcestershire Dr Anthony Kelly Clinical Chair, Worcestershire CCGs

Countywide MSK Integrated Triage Service Mandated by NHSE by January 2019

Overview of MSK Programme • This project aims to deliver a system integrated solution for MSK / seamless across all providers • The scope of the programme includes MSK, Pain Management, Diagnostics. ) and Post Trauma Care. The scope excludes Rheumatology. • The programme will produce a comprehensive plan to resolve the issues identified and will oversee the delivery of the solutions – including: • Consistent MSK triage service to be provided across the county - NHS England mandate Initially the service model in the south will be extended to WF and R&B localities to be in place by 7 th January 2019. Going forward, this interim triage service will be monitored and reviewed, with the aim of having a single triage service in place by April 2019 to include self referral. • A set of actions to resolve diagnostic capacity constraints • A set of actions to resolve the backlog of acute activity in the most cost effective way • Identification of acute activity that can be managed in a community setting • Optimised and consistent application of self referral, self care and shared decision making with appropriate support • Development of a meaningful demand capacity tool • These solutions will initially be piloted with existing providers , working together to ensure optimum use of specialist resource, the ability to flex capacity across the settings of care, tactical and deliberate use of external capacity – all of which informed by a dynamic understanding of demand capacity. 88

Direct Access MRI Scans and percentage share by CCG / Outpatient First Appointments Where are we now? 1798 (26%) 1912 Key MRI Scans Outpatient First Appointments 2962 (42%) 3269 2250 (32%) 3508

Interim Clinical Triage Service • CCGs will have one email address to access the service with patients being managed seamlessly through the pathway • Patients will be triaged and referred as clinically appropriate to physiotherapy, Advanced Practitioner Service (APP) or secondary care • Imaging will be organised by the APP service • Onward referrals to specialists will be direct from the APP service • APP service will be provided by existing providers with expanded clinical workforce 04/11/2020 90

Longer Term Triage Service • • One county-wide service Integration of pain management Functional restoration available across the county MSK podiatry within Triage Service Strengthened links with secondary care Consistent practice / service delivery Self Referral Co-production of pathways 04/11/2020 91

MSK Integrated Clinical Triage Assessment and Treatment Pathway Red Flag GP FRP Podiatry APOPs Physio Joint Injections Rheumatology Nurse Specialist PMS Rheumatologist Discharge Diagnostics Secondary Care Orthopaedic / Pain / Oncology Clinical Triage Physio Self Help Self-referral GP Amber Flag

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MSK Referral Template (Interim) • A new MSK referral template has been developed for deployment within the WF & R&B CCG’s • SWCCG will continue to use the existing template, although it is anticipated that a common template will be developed for the single triage service. 04/11/2020 95

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Next Steps & Evaluation