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

2. Wider NHS landscape and primary care networks National picture

3. 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 5

4. 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

5. 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 7

6. 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 k
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+

7. 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

8. Wider NHS landscape and primary care networks West Essex picture

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

10. 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

11. 9 neighbourhoods in West Essex
PAH catchment
CUFT
MEHT
Barts

12. 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

13. Overview of Primary Care Networks guidance and DES

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

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

16. 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.

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. Key Questions: Geography?

24. 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

25. What geography for PCNs in West Essex?

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

27. Opportunities of Additional Roles

28. 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

29. 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

30. 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

31. 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.

32. 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

33. 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.

34. 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.

35. 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

36. 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)

37. 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.

38. 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.

39. 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.

40. Key Questions: How does PCN organise itself?

41. 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

42. 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

43. 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

44. 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

45. 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.

46. 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

47. Further Opportunities for PCNs

48. 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

49. 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

50. Next steps

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

52. 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

53. 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

54. 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

55. 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