Implementing Primary Care Networks in West Essex Peter Wightman 2 April 2019 GP Shutdown

Wider NHS landscape and primary care networks National picture

Things are changing… The changing health needs of the population are putting pressure on the health and social care system in England. And our expectations are changing too. Between 2017 and 2027, there will be 2 million more people aged over 75. Ageing population The main task has changed from treating individual episodes of illness, to helping people manage long-term conditions. Long term conditions The steady expansion of new treatments gives rise to demand for an increasing range of services. New Treatments www.england.nhs.uk 5

Current systems need to adapt: Workforce shortages in traditional roles Little historical investment in primary and community care Multiple organisations and IT = provision is fragmented This is getting in the way of providing person centred holistic patient care 6

The NHS Long Term Plan responds to this, and places Primary Care at the centre … Aims: Everyone gets the best start in life World class care for major health problems Supporting people to age well => Primary care networks as the foundation for Integrated Care Systems Preventing ill health and tackling health inequalities Supporting the workforce Maximising opportunities presented by data and technology Continued focus on efficiency www.england.nhs.uk 7

How will that look within a local system? Each person can access joined up, proactive and personalised care, based on ‘what matters’ to them and their individual strengths, needs and preferences Individual • Practices continue to provide core services Network Contract DES provides practices opportunity to work collaboratively with other practices health, social care and voluntary partners to deliver services Practices and other health, social care and voluntary partners collaborate as primary care networks, providing additional services that can’t be delivered on a smaller scale Network 30-50k Primary care interacts with hospitals, mental health trusts, local authorities and community providers to plan and deliver integrated care In some systems, federations support efficiencies of scale and provide a voice for primary care Place 250-500k Primary care participates as an equal partner in decision making on strategy and resource allocation Action is taken to ensure collaboration across hospitals, community services, social care and other partners, helping to join up and improve care Data is used to deploy resources where they can have the maximum impact System 1m+ www.england.nhs.uk

And PCNs are key to the future Primary care networks are small enough to give a sense of local ownership, but big enough to have impact across a 30-50K population. They will comprise groupings of clinicians and wider staff sharing a vision for how to improve the care of their population and will serve as service delivery units and a unifying platform across the country. Practices as teams of teams Person- alisation and improved outcomes Aligned incentives Informed and enabled patients Growing motivated and enabled staff Integrated primary care service Digitally enabled working #GPforwardview www.england.nhs.uk

Wider NHS landscape and primary care networks West Essex picture

System Level Hertfordshire and West Essex STP Commissioners and Providers Closer working between 3 CCGs 1.5m population => Integrated Care System by April 2021

Integrated Care Partnership Current members: Primary Care, EPUT, PAH, ECC Current scope includes whole West Essex CCG and all services serving this population Future scope includes working with East Herts Priorities so far COPD, MSK, PAH front door Further priorities Respiratory, CVD and diabetes, frailty, outpatients, ophthalmology

9 neighbourhoods in West Essex PAH catchment CUFT MEHT Barts

Lot of progress with neighbourhoods in W Essex Practices working together Extended access hubs Primary care transformation projects Assigned EPUT and Social care staff Close work with districts and voluntary sector – care navigators

Overview of Primary Care Networks guidance and DES

Investment and evolution: A five year framework for GP contract reform to implement The NHS Long Term Plan 31 January 2019

Further guidance published 31 March 2019* Network Contract Directed Enhanced Service Guidance Contract specification Mandatory Network Agreement

Purpose of 5 year framework for GP contract reform Secure and guarantee extra investment for primary care; Practical changes to help workforce and workload problems in general practice; Deliver quality and improvement goals of The NHS Long Term Plan; Show value for money for taxpayers and rest of the NHS; Get better at local testing before national roll out.

Primary care networks overview Practices to work together and form Primary Care Networks (PCNs) of 30,000 to 50,000 in size. Phased implementation over 5 years Ongoing further guidance will be published

National Service Specifications Delivery expectations National Service Specifications PCNs to deliver specified standard processes, metrics & benefits introduced over 5 years Structured medication review and optimisation Enhanced care in care homes Anticipatory care Personalised care Supporting early cancer diagnosis Cardiovascular prevention and diagnosis Inequalities April 2020

Delivery expectations Access Coherent virtual and physical offer for access to primary care in each practice across PCN 2019/20 July 2019 extended hours 1 appt per day per 3000 patients booked directly by 111 in hours (extended access) National consultation on access specification 2021/22 April 2021 extended access £6 per head April 2021 publish monthly appointment volumes

Access - Extended Hours* Provision of extended hours access appointments is a requirement of the Network Contract DES from 1 July Separate to extended access services (evenings and weekend service) Available to all reg patients in PCN Held at times that consider patients preferences 30mins per 1,000 reg patients per week Reasonable number face to face, rest telephone, videos, online In West Essex 15 of 32 practices currently not providing extended hours

Extended Access Service PCN entitlement £6 per head April 2021 West Essex Integrated Contract with HUC until April 2024 CCG is one of a number nationally with long term contract CCG seeking advice and to clarify before Summer

Digital offer by primary care Delivery expectations Digital offer by primary care   2019 April 2020 April 2021 Standard 25% of appointments available online (July) MHRA CAS alerts system in place to receive and confirm action (Oct) Online presence e.g. access to directory of services No fax machine in General Practice Patients access online to correspondence All patients have a right to online and video consultation

Key Questions: Geography?

What geography for PCNs in West Essex Questions What geography for PCNs in West Essex Guidance says: “typically serve a population of at least 30,000 people”. “not tend to exceed 50,000 people… 50,000 is a suggested upper level, not a strict requirement.” “Each Primary Care Network must have a boundary that makes sense to: (a) its constituent practices; (b) to other community-based providers, who configure their teams accordingly; and (c) to its local community “Normally a practice will only join one network” – collaboration where a practices catchment area spans more than one network.” Practices to consider and propose their network CCG/LMC to ensure coherent overall – one CCG submission for whole W Essex

What geography for PCNs in West Essex?

Factors to consider Branch surgeries Community team logistics Hospital catchments Natural patient communities and needs Long term approach

Opportunities of Additional Roles

Additional Roles Reimbursement Resources Additional Roles Reimbursement Roles type 2019/20 2020/21 2021/22 2022/23 2023/24 Social prescribing (100%) Y Clinical pharmacy (70%) First contact physio. (70%)   Physicians associates (70%) Paramedic (70%) £ per 50,000 £92,000 £213,000 £342,000 £519,000 £726,000 PCNs will have a total budget with freedom to claim more or less from one staff group

Additional Roles Staff delivering additional network services can be employed by a member of the PCN, or another body (eg. GP federation, voluntary sector, Local Authority, NHS Trust) PCN and it’s member practices are responsible for ensuring the services are delivered in line with DES

Workforce – Additionality* Baseline - Commissioners and practices confirm staff employed across 5 roles as at 31 March 2019 Workforce baseline to be agreed as part of PCN registration process PCN reimbursement claims will be assessed against baseline Intended to protect existing commissioner investment Information submission requirement of DES Exception to baseline - pharmacists employed via 2 national schemes prior to 31 March 19

Social Prescribing – Role Overview Identifying unmet needs and providing support Spending time getting to know patients and their carers: Direct support - phone or home visits, Open invitations to the surgery for a ‘catch up and cuppa’ Referring patients to appropriate VCS Build knowledge of local VCS groups / organisations Attend practice MDTs First contact for care homes e.g. prescription requests, visit requests and post-discharge coordination of services and medication.

Social Prescribing - Benefits To patients additional, non-clinical support options via primary care improved health and wellbeing less socially isolated and more independent. To practices Social prescribers can significantly reduce GP consultations (by as much as 28%) One in five GPs regularly refer patients to social prescribing Recognition that social support can be an alternative to medication Simple referral processes To the wider NHS positive impact on GP consultation rates, A&E attendances, hospital stays, medication use and social care

West Essex - Care Navigation Partnership GP level service (Smartlife) established as a pilot in 6 practices in 2014, rolled out to all practices in 2015. Partnership established in 2017 to maximise the service offer by including community agents and Provide Lifestyle Service. Single service offer for all patients requiring access to non-medical needs. Home visits undertaken where required.

Options for PCNs to develop link workers Expansion of Care Navigation Partnership model Different employer but integrated working with existing service, options might be: Employed by practice Employed by voluntary sector organisation Employed by provider organisation other Further conversations can follow based on individual PCN preferences – CCG are happy to support these conversations.

How can Clinical Pharmacists help? Workload, Safety, Patient Experience Takes time to implement in partnership E.g. Polypharmacy reviews Answering medicine queries Medicines reconciliation Supporting achievement of the prescribing safety specifications such as safe anticoagulation prescribing

Clinical Pharmacists* Minimum employment 0.5 WTE (to allow for training requirements and working across practices in a PCN) Enrolled in or qualified from Clinical Pharmacist training pathway Part of a clinical network and supervised by senior clinical pharmacist and GP clinical supervisor Clinical Pharmacists in General Practice Scheme ends April 19 – guidance specifies how in most cases these funded roles can transfer to PCNs and be claimed (p12)

Medicines optimisation in Care Homes Scheme and PCNs* The Medicines optimisation in Care Homes Scheme will end 31/3/20 Staff employed and in post 31/3/19 will be included in baseline (exception to additionality) PCNs may claim reimbursement for any staff that transfer during 19/20 (up to max) Expectation that when national scheme ends, staff will be employed under terms of PCN DES to support delivery of national service specification Further conversations can follow based on individual PCN preferences – CCG are happy to support these conversations.

Physiotherapy West Essex CCG 100% funded service is being implemented by EPUT for all practices by October 2019. This is integrated into the MSK pathway There are guarantees for practices for service level Services supplied after April 2019 are eligible for claim in 2020/21 Further conversations can follow based on individual PCN preferences for the future of services.

ECPs West Essex CCG 100% funded service continues and is being implemented in remaining areas during 2019. This will be in the workforce baseline Each PCN needs to be confident with existing service, how it operates and if/how it wishes to develop Multiple employer options Claims can be made from April 2021 Further conversations can follow based on individual PCN preferences for the future of services.

Key Questions: How does PCN organise itself?

Management, Leadership and Accountability Resources Management, Leadership and Accountability Funding for PCNs Clinical Director (0.25 w.t.e. per 50,000) Management - £75,000 per 50,000 Nominated practice to receive funds (must hold a primary medical care contract) Funding for practices Each practice receives payment for participation (£1.76) Accountability PCN, with Clinical Director, holds accountability for PCN investment and delivery

Accountable Clinical Director* The clinical director should be a practicing clinician from within the member practices Most likely to be a GP but not an absolute requirement Individual (or job share) from within the PCN, cannot be a shared role between PCNs. Able to undertake the responsibilities of the role and represent the PCN’s collective interests (see DES) PCN to agree who the Clinical Director will be: selection process may include election, mutual agreement, selection, rotation. Will work collaboratively with Clinical Directors from other PCNs

Network Agreement* National Network Agreement has been developed and PCNs will be required to use it Signed by all PCN member practices Agreement to include data sharing arrangements to deliver extended hours Agreement to be completed and signed by 30th June PCN can only be established from 1st July if PCN agreement in place

Data and analytics* Practices in a PCN will need a data sharing agreement to share clinical and non clinical data A template will be shared by NHSE, for PCN use Confirmation that data sharing arrangements have been entered into, is a requirement of PCN DES registration Network dashboard from April 2020 allowing PCNs to see the benefits it is achieving for patients and the community Dashboard will include pop health mgt, urgent and anticipatory care, prescribing and hospital use, and metrics covering the national specs

Maintain and develop wider team General practice takes the leading role in every Primary Care Network, but its important to keep working with the wider network team to achieve the benefits. PCN DES will include collaboration with non- GP providers from April 2020* Working with wider partners has led to real change in neighbourhoods in West Essex.

PCN DES Funding Entitlements* (patient numbers as at 1st Jan 19) Core PCN funding £1.50 pp – replaces neighbourhood backfill Clinical Director contribution - £0.514 pp Staff reimbursement – actual costs up to max amounts Extended hours - £1.099 pp Core PCN funding from CCG, rest from Primary Care Medical Allocations Practices also entitled to Network Participation Payment - £1.761

Further Opportunities for PCNs

Investment and Impact Fund (Starts 2020/21) Resources Investment and Impact Fund (Starts 2020/21) Paid on performance against indicators Scheme managed by STP/ICS Earned funds used to increase workforce (not pay) Performance areas: Avoidable A&E Avoidance emergency admissions Timely hospital discharge Outpatient redesign Prescribing costs Building to £5 per head over 4 years

CCG will continue to commission primary care from CCG funds Resources CCG will continue to commission primary care from CCG funds CCG spends £14.50 per head in 2018/19 Duplication with national funding will develop WECCG proposed primary care spend 2019/20 Opportunity to channel funds all LES funds through PCN agreements

Next steps

PCN Application Which practices Clinical director Next Steps PCN Application Which practices Clinical director Nominated practice to receive PCN funding Map

Next Steps Timelines 15 April - PCNs submit draft registration form to CCG 15 May - PCNs submit final registration form to CCG By 31 May – CCG confirm and approve all PCNs and inform PCNs By 31 May - CCGs and PCNs to agree workforce baseline for roles reimbursement scheme By 30 June practices to sign up to Network Contract DES via CQRS and in writing to the CCG By 30 June Primary Care Network Agreement completed and signed (incl data sharing agreement for extended hours) 1 July if all the above is confirmed, the PCN is formally established and the Network Contract DES (and extended hours provision) commences

PCN first delivery objectives Next Steps PCN first delivery objectives Extended Hours DES and 100% coverage across the PCN Plans for additional roles 2019/20 Social prescribing Clinical pharmacist CCG neighbourhood commissioned services Emergency care practitioner First contact physiotherapy Treatment room and safer anticoagulant prescribing Spirometry model

Table discussion 1 – Establishing PCNs By the end of the afternoon, we suggest you have made progress on the following: PCN and practices within the PCN Who may be interested in the Clinical Director role and process for agreeing this Practice to receive PCN funding And/or agreement on further discussions needed and timetable Note any clarification questions you have on the PCN guidance and/or what support you would like from the CCG over the coming months Templates on the table CCG staff in Boardroom if you have any queries or would like support Tea/coffee available all afternoon

Table discussion 2 – first areas of work Extended Hours DES and 100% coverage across the PCN Plans for additional roles 2019/20 Social prescribing Clinical pharmacist CCG neighbourhood commissioned services Emergency care practitioner First contact physiotherapy Treatment room and safer anticoagulant prescribing Spirometry model