Achieving sustainable primary care in West Essex Peter Wightman, Director of Primary Care and Localities 25 April 2017

The pressures on primary care are well documented Workload Workforce Care design Investment Infrastructure Unsustainable workload Difficulty recruiting and retaining staff Forecast peak in retirements of practice nurses, GPs and managers Falling partnership incomes Practices handing back contracts Higher charges for new premises or premises not fit for purpose

How would we recognise sustainable primary care? For patients Consistent standards & best outcome for every resident Confident in managing their own health Positive experience accessing services For staff Manageable workload Providing effective care personally & as member of a team Continuing professional support & development For system Able to meet population needs consistently in community Connected to specialist resource & enabling optimum use Affordable & efficient

Future context Population growth Ageing population Demographic changes in workforce New workforce skills Aim to maximise community care and optimal (right-size) future hospitals Pressure on partnership model

Key challenges to overcome - requires work at all levels Workload Workforce Care Design Investment Infrastructure High stress primary care – pressure increasing Sustainable primary care Patient – Practice – Neighbourhood – CCG - National

Care Design - 10 High Impact changes

Social Prescribing in West Essex Care Partnership Service Care Navigators work with patients needing time limited intervention to enable patients (and their carers) to work with volunteers to achieve their personal independence goals. Support Employment Info and Advice Income maximisation Mobility issues Social inclusion Home adaptations Safety and Security Multiple Needs Healthier Lifestyle Practice call 0300 303 9988 Or email westessexcarenavigation@nhs.net Provide Lifestyle Service Community Agents Age UK Front line: info@uttlesfordfrontline.org.uk 01371878400 Other voluntary sector services

Developing the wider team Receptionist Practice nursing Healthcare assistant Paramedic & Emergency Practitioner Mental health worker Clinical pharmacists Designing future models of care? Defining training requirements? Agreeing joint work with Essex Partnership University Trust

Epping Forest Planning Context

Epping Forest Population 121,740 Epping & Ongar Abridge Surgery 3771 High Street Surgery 7180 Limes Medical Centre 18671 Ongar Health Centre 11958 41580 Waltham Abbey   Nazeing Valley Health Centre 3382 Keyhealth Medical Centre 6936 Market Square Surgery 7586 Maynard Court 3864 Limes (Waltham Abbey patients) 21768 Loughton Forest Practice 10593 The Loughton Surgery (High Rd/Trapps Hill) 10556 Loughton Health Centre 12136 33285 Buckhurst Hill & Chigwell Chigwell Medical Centre 8686 River Surgery 4203 Palmerston Road 4722 Kings Medical Centre 7496 25107

Epping Forest – forecast growth to 2033 Settlement Homes People Buckhurst Hill 135 331 Chigwell 612 1,500 Chipping Ongar 752 1,842 Epping 1,790 4,386 Fyfield 108 265 High Ongar 37 91 Loughton/Debden 1,492 3,655 Lower Nazeing 321 786 N. Weald Bassett 1,427 3,496 Theydon Bois 380 931 Thornwood 150 367 Waltham Abbey 932 2,283 Total 8,139 19,933 Market Square Surgery Limes GP Practice Development site

Epping Buckhurst Hill and Chigwell Epping and Ongar Waltham Abbey Name 1st 5 years 5-10 years 10-15 years Total Buckhurst Hill and Chigwell 222 11 276 509 Epping and Ongar 788 1125 1688 3601 Waltham Abbey 87 306 403 796 Loughton 307 630 255 1192

CCG Commissioning Offer

Commissioning Goals Enable transition to sustainable primary care Introducing systematic case management for high and moderate risk frail patients Reducing variation Improving patient satisfaction

Ensuring systematic care of high and moderate risk frail patients Neighbourhood support enhancements Strengthen Neighbourhood governance & leadership Risk stratification at practice level Care co-ordination and case management Enhanced input by practice MDT Community health service access & capacity Social prescribing Community geriatrician support Urgent Care in the Community Targeting rising risk patients Rising Risk 4-6%

Funds available

As fully delegated commissioners, we have a clear indication of total resources available to commission primary care

CCG’s profile for increased spending of £7-10 per head   2017/18 2018/19 2019/20 2020/21 Source £000 PMS premium (carry forward) 1164 Released PMS premiums 941 1345 1542 1737 CCG resources for transformation (required by GP5YFV) 456 Use of full delegation budgets 500 Total spending increase on 2016/17 3061 2401 2042 2237 Forecast population 309,449 312,707 316,022 319,378 £ per head 9.9 7.7 6.5 7.0

CCG’s profile for increased spending of £7-10 per head   2017/18 2018/19 2019/20 2020/21 Source £000 PMS premium (carry forward) 1164 Released PMS premiums 941 1345 1542 1737 CCG resources for transformation (required by GP5YFV) 456 Use of full delegation budgets 500 Total spending increase on 2016/17 3061 2401 2042 2237 Forecast population 309,449 312,707 316,022 319,378 £ per head addition to 16/17 9.9 7.7 6.5 7.0 Use existing contract forms 2017/18 Consult, develop & offer unified contract from April 2018

Primary care finance plan 2017/18 Item Spending £ per head Recur ring Service commissioned N’hood extra spending £000    Variation improvement 307 1.0 NR Practices commissioned to reduce variation in agreed area specific to n’hood variation Multi-morbidity case management 691 2.3 R £3 Coordinator role; additional long appts & management for multi-morbidity cases. Primary care transformation 921 3.0 N'hood schemes to make transformational change in primary care 1,919 6.3 Practice level spending 2016/17 LES full year effect 392 R (includes FYE care homes, diabetes) Repeat prescribing Systematic approach to repeat prescribing with patient partnering approach Anticoagulation 40 Level 1 anti-coag service Touchscreen renewal 150 Replace touchscreen & Jayex in practices 889 2.90 West-wide transformation Practice resilience 100 Where NHSE resource not available Training & workforce  Structured approach to workforce using E&N Herts model including Contingency e.g. template development  TOTAL ADDITIONAL 3,157 10.3

Buckhurst Hill & Chigwell Resources available 2017/18 subject to neighbourhood plans Item Waltham Abbey Epping & Ongar Loughton Buckhurst Hill & Chigwell Variation reduction 21,768 41,580 33,285 25,107 Rising risk case management 54,423 108,041 62,114 51,054 Primary care transformation 65,304 124,740 99,855 75,321 Total 141,495 274,361 195,254 151,482

Premises Planning Committed Schemes 2017/18 2018/19 2019/20 Lister Medical Maynard Court Osler House Thaxted Limes Future pipeline? 2018+ Felsted Saffron Walden (Crocus +?) Dunmow Loughton Buckhurst Hill

NHS England held budgets As well as these new CCG resources there are other opportunities to increase resources for practices CCG held budgets NHS England held budgets CCG commissioning budgets Neighbourhood proposals Practice level contracting - LES performance West wide e.g. training support   Fully delegated budgets 2017/18 QOF and DES performance Major premises schemes Accessed by practice bids Clinical pharmacists GP Practice resilience Mental health therapists (details awaited) Estates and Transformation Fund (further waves) Joining national “releasing time to care” programmes National terms: Indemnity costs

Primary care Plan – End of June Support practices to develop a plan for future primary care for Uttlesford by end of June 2017 which includes: Definition of key challenges Primary Care design transformation plans Workforce Workload & capacity Variation reduction & preventing hospital activity Proving services some practices define as “outside core” Plan for systematic care for high and moderate risk frail patients Plan for working with Essex Partnership Trust Future Infrastructure needs and plans This will inform West Essex-wide primary care plans

CCG-wide primary care plan We aim to use neighbourhood primary care plans to inform West-wide plans for primary care development Primary care workforce development support Premises planning Better define commissioning requirements for wider services

Develop primary care plan including neighbourhood proposals Timeline Services 17/18 Contracts 18/19 Contracts Now to 30 June Develop primary care plan including neighbourhood proposals Sign off 17/18 proposals 1 July – 30 September Implement service Consult on contract for services over core for 18/19 1 Oct – 31 dec Finalise contract 18/19 1 Jan – 31 Mar Evaluation and shared learning and Review achievement and payment 1 Apr 18 New contract start