NHS Long Term Plan, New GP Contract & Partnership Review Opportunity or Diversion

THE STATE OF GENERAL PRACTICE

THE KEY RISKS RISK Loss of Income GPs leaving prematurely Stress & Burnout Premises – Last Man Standing Practice Failure Indemnity Collapse of the Partnership Model Unlimited Personal Financial Liability

How will these national initiatives address your personal situation, your practice and your health community? Are they an opportunity to make things better What challenges to they bring? What is the starting position in your ICP and where does it need to get to?

THE NHS LONG TERM PLAN Five Major Changes to the Model of NHS Care To boost out of hospital care and dissolve the historic divide between primary and community care Redesign and reduce the pressure of hospital emergency care People will get more control over their own health and their personalised care when they need it Digitally enabled primary care and outpatients Local NHS organisations will have greater focus on population based and health partnerships with local authority funded services through integrated healthcare systems everywhere in England.

Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan Consolidation and implementation of recommendations of the Partnership Review and NHS Long Term Plan

Workforce – The Top Priority 5000 Extra Doctors still promised Extended Programmes to 23/24 International recruitment Retained doctors (from retiring) GP retention programme (retain rather than reduce) Resilience programme GP Health Time for Care Programme

Workforce 2 Increased numbers of primary care nurses – guaranteed placements for undergraduate nurses, increase in apprenticeships, ANP credentialling, retention scheme Two year primary care fellowship programme for newly qualified doctors and nurses Primary Care Training Hubs from 20/21 Major expansion of Community Mental Health Workers – aligned to PCNs Consideration of Partial Pension Option Expansion of the MDT through additional roles reimbursement

Workforce 3 5 Roles created to be an integral part of core general practice Clinical Pharmacists @70% reimbursement 19/20 Social prescribing Link Workers @100% reimbursement 19/20 Physician Associates @ 70% 20/21 First Contact Physiotherapists @70% 20/21 First Contact Community Paramedics @70% 21/22 One of each per network in 19/20 Up to 20,000 new staff by 2024 on a network capitation basis

Workload – Not addressed directly, but: Increased workforce to relieve pressure PCNs to provide more integrated wrap around Digital solutions Eventual integration and control of urgent primary care services

Resources Direct to Practice Global sum uplift by 1% (£0.92 per patient) £20m into global sum for SARs £30m into global sum for NHS 111 Direct Booking Weighted SFE Payment of £1.76 to each practice for network participation Relief of Indemnity Costs £5 per patient MMR catch up Vacc & Imm increased to £10.06 Taken together this will deliver a 2% pay uplift for GPs and practice staff

Resources Paid in Year 1 to PCN Bank Account £1.50 per patient Network DES £1.45 per patient extended hours funding 0.2 wte Clinical Director £34,113 Social Prescriber £37,810 Clinical Pharmacist For a Network of 40,000 population this amounts to £203,000, of which £103,500 is for network decision

Growth in Additional Role Reimbursement Funding INTENDED FUNDING FOR ADDITIONAL ROLE REIMBURSEMENT   19-20 20-21 21-22 22-23 23-24 National Total (£m) £110 £257 £415 £634 £891 Average maximum per 50k typical network (£000) £92 £213 £342 £519 £726

Investment and Impact Fund Against performance on PCN Dashboard, the 7 service specifications and their impact on hospital usage 20/21 £75m 21/22 £150m 22/23 £225m 23/24 £300m £54,545 £109,091 £163,636 £218182 Potential Income for a 40,000 PCN

Integrating Extended Access, Extended Hours and Urgent Care Extended Hours payable at £1.45 per head immediately Extended Access @£6.00 per head payable from 21/22 Payable on implementation of the Access Review

Addressing the weaknesses in QOF Seen as tick box medicine Exception Reporting Crude Adapting to the Changing evidence base Link to NHS Long Term Plan Priorities Retiring 175 points (31%) Recycling 101 into more clinically appropriate areas Remaining 74 points recycled into 2 Quality Improvement Modules Personalised Care Adjustment

IT & Digital Requirements From April 2019 practices will be required to: Provide new patients with full online access to prospective data from their patient record (using/referring to national NHS Login identity verification) Reserve appointments for NHS 111 clinicians (not lay call handlers) to book patients into. This will be 1 appointment per day, per 3,000 patients (rounded down, with a minimum of 1), eg: 1500 patients = 1 appointment 5900 patients = 1 appointment 6001 patients = 2 appointments These should be spread evenly through the day and the practice can decide how to manage patients booked into these appointments These appointments may be freed for others to book if not booked.

IT & Digital 2 During 2019, practices will need to prepare to: provide all patients with online access to their full record including the ability to add their own information from April 2020 make at least 25% of all appointments available for online booking by July 2019 offer online consultations by April 2020, subject to further guidance offer and promote electronic ordering of repeat prescriptions for all patients for whom it is clinically appropriate by April 2020 all patients to be able to access online correspondence by April 2020 no longer use fax machines for NHS work or patient correspondence by April 2020 ensure they have an up-to-date and informative online presence by April 2020

What is a Primary Care Network? A working definition Primary care networks enable the provision of proactive, accessible, coordinated and more integrated primary and community care improving outcomes for patients. They are likely to be formed around natural communities based on GP registered lists, often serving populations of around 30,000 to 50,000. Networks will be small enough to still provide the personal care valued by both patients and GPs, but large enough to have impact through deeper collaboration between practices and others in the local health (community and primary care) and social care system. They will provide a platform for providers of care being sustainable into the longer term.

Where are we going – Primary Care Services? MDT in PCN embedded in general practice Social Prescribing Minor injury service Social Care Care navigation GP led Primary Care Sign posting District Nurses Therapist Care of the elderly New services based in PCN Consider Self Care New capacity based in PCNs MSK Diabetes Dermatology nhs.uk Apps and wearables Clinical Pharmacist Advanced Nurse Practitioner CVS Paramedic MSK Practitioner Patient Activation for LTCS 111 Online and 111 Hubs Physician Associate Mental Health Therapist

The Ask of PCNs A number of network services will be developed in line with NHS England’s Long Term Plan, and phased into the DES over the coming years. 2019 Extended Hours access integrated into networks – same requirements as the DES, for 100% of network population 2020 Structured medication review Enhanced health in care homes Anticipatory care (with community services) Personalised care Supporting early cancer diagnosis 2021 Cardiovascular disease prevention and diagnosis, through case finding Action to tackle inequalities The content, and associated service specifications for these, will be subject to annual negotiation with GPC England

A mature PCN Fully interoperable IT, workforce and estates across networks, with sharing between networks as needed. Systematic population health analysis allowing PCNs to understand in depth their populations’ needs and design interventions to meet them, acting as early as possible to keep people well. Fully integrated teams throughout the system, comprising the appropriate clinical and non-clinical skill mix. MDT working is high functioning and supported by technology. The MDT holds a single view of the patient. Care plans and coordination in place for all high risk patients. New models of care in place for all population segments, across system. Evaluation of impact of early- implementers used to guide roll out. PCNs take collective responsibility for available funding. Data is used in clinical interactions to make best use of resources. Primary care providers full decision making member of ICS leadership, working in tandem with other partners to allocate resources and deliver care. The PCN has built on existing community assets to connect with the whole community.

PCN Clinical Director Role “A Practicing Clinician from within the PCN” Represent the PCNs collective interests Implementing strategic plans Work collaboratively with CDs from other PCNs to shape and support to ICP Strategic & clinical leadership for the PCN Develop a PCN workforce strategy Implement agreed service changes and pathways Develop local initiatives to reflect local needs Develop relationships internally and external to the PCN Facilitate participation by practices in research Represent the PCN at CCG and ICP level Lead role in developing PCN conflict of interest arrangements

The Immediate Tasks to Establish PCNs By 15 May 2019 networks will need to make a brief submission outlining: the names and the ODS codes of the member practices; the network list size, i.e. the sum of its member practices’ lists as of 1 January 2019 (justification required if not 30-50k); a map clearly marking the agreed network area (justification required); the initial Network Agreement signed by all member practices (see below); the single practice or provider that will receive funding on behalf of the PCN; and a named Clinical Director from within the GPs of the network Between May and June - National and local joint work between NHSE, CCGs and LMCs to resolve outstanding Issues 1st July – All networks go live and funding flows

Four Definitive Documents – 29th March The Network Contract DES Network DES Guidance for 19 / 20 Mandatory Network Agreement The Network Contract DES and VAT

Key Messages Immediate issues for PCNs For 2019/20, the network must agree how they will deliver the requirements of the Extended Hours DES for the whole of the network population Need to agree the additional staff roles they require Need to sign a Data Sharing Agreement (Template to follow) Mandatory Network Agreement (to be submitted by 30Th June) needs to specify: Decision Making – What is to be decided, how decisions will be made, who attends meetings, voting arrangements and record of decisions taken Additional Terms the PCN may wish to make (voluntary – but secondary to mandatory clauses) Activities – who does what in terms of network activities – service levels & monitoring Financial Arrangements – who gets paid for what activities, how is income divided Workforce – engaging and employing additional staff roles How the Network works with other organisations

So How Prepared are you in Your Area?