1. Welcome PPG Network Meeting

2. NHS Long Term Plan Nicola Lester, Director of Transformation
Since the NHS was created in 1948, the population has grown and people are living longer. Many people are living with long-term conditions such as diabetes and heart disease, or suffer with mental health issues, and may need to access their local health services more often.
To meet these challenges, primary care has led the way in doing things differently, collaborating in some areas across the country through primary care networks to develop care that is more joined-up, personalised and proactive.
The GP Forward View set out a vision in 2016 of stronger, redesigned primary care to meet these challenges, built on at-scale working and making best use of the full staff team.
Primary care networks and other models such as ‘primary care home’ are now showing what this looks like in action, supporting GPs, community pharmacists and others to work together in new, more sustainable ways that respond better to patient need.
They are operating with a backdrop of closer collaboration between organisations. Since 2016, NHS organisations and local councils in England have joined forces in sustainability and transformation partnerships (STPs) and, in some cases, these have matured to become integrated care systems (ICS). Covering the full range of NHS and council teams across a locally-agreed geographical area, these are helping our organisations to plan and coordinate services better, and to invest in ways to prevent illness and keep people out of hospital.
April 2019

3. Everyone gets the best start in life
Aims:
Everyone gets the best start in life
World class care for major health problems
Supporting people to age well
How:
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
The importance of all of this work is recognised in the NHS Long Term Plan, which highlighted the importance of primary care networks as a means to deliver primary and community care in future; supporting their consolidation, backed up with an investment of £4.5 billion into primary medical and community care over the next five years.
The announcement of the new GP Contract shortly afterwards gave more detail on this.

4. Long Term Plan in summary…1
Do things differently, through a new service model 2
Take more action on prevention and health inequalities 3
Improve care quality and outcomes for major conditions 4
Ensure that NHS staff get the backing that they need 5
Make better use of data and digital technology 6
Ensure we get the most out of taxpayers’ investment in the NHS
Your community, Your care : Developing Buckinghamshire together

5. Questions??
Questions were asked about the GP Federations in Bucks. There are two: Medicas in the north of the county covering about 6 practices and FedBucks in the south covering the rest of the 50 practices in Bucks. Federations are organisations set up by local GPs to act as their voice to the ICS and they also hold some contracts for services such as the GP Out of Hours Service.
The link to resources available on NHS England’s website is:
We were also asked what evidence there is to support the benefits for Primary Care Networks. The material we have is below:
Where is the evidence that large scale networks are more financially sustainable than individual practices?
Joint working between practices is nothing new. The new Network Contract DES provides significant funding to support practices to formally work together, irrespective of their individual motivations for doing so. There have been a number of reports conducted into the sustainability of primary care networks all over the world.
A selection of these can be found below:
National Association of Primary Care (2015). Primary Care Home: An Overview
Dunbar R (2010). How many friends does one person need? London: Faber and Faber
Ham C (2010). GP budget holding: Lessons from across the pond and from the NHS University of Birmingham HSM
Martin S, Rice N, Smith P (1997) Risk and the GP Budget Holder York: Centre for Health Economics
Bachmann M, Bevan G (1996) Determining the size of a total purchasing site to manage financial risks of rare costly referrals: computer simulation model British Medical Journal
To read about the research completed on continuity of care and primary care networks:
How can we get better at providing patient centred care: does continuity matter?
Divided we fall: getting the best out of general practice.
Personalising care for patient sub-groups in general practice.
Your community, Your care : Developing Buckinghamshire together

6. PPGs and Primary Care Networks
GP practices in Bucks are already working in collaboration to offer evening and weekend appointments. They have also started to work in a more integrated way with community, mental health, social care, pharmacy, hospital and voluntary services in their local areas. New national plans and GP contracts released on 31st January 2019 will take this further faster with the introduction of Primary Care Networks.
Dr Raj Bajwa, Clinical Chair (Weds 3rd April) Dr Rebecca Mallard-Smith, Clinical Director, (Fri 5th April)
April 2019

7. And PCNs are key to the future
Practices as
teams of teams
Aligned incentives
Personalisation and improved outcomes
Informed and enabled patients
Growing motivated and enabled staff
Integrated primary care service
Digitally enabled working
Primary Care Networks (PCNs) are small enough to give a sense of local ownership, but big enough to have impact across a K 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.
What are primary care networks?
Primary care networks form a key building block of the NHS Long Term Plan. Bringing general practices together to work at scale has been a policy priority for some years for a range of reasons, including improving the ability of practices to recruit and retain staff; to manage financial and estates pressures; to provide a wider range of services to patients and to more easily integrate with the wider health and care system. 
While GP practices have been finding different ways of working together over many years – for example in super-partnerships, federations, clusters and networks – the NHS long-term plan and the new GP contract, which will take effect in this month, put a more formal structure around this way of working, but without creating new statutory bodies.
All GP practices are expected to come together in geographical networks covering populations of approximately 30–50,000 patients by May 2019 if they are to take advantage of additional funding attached to the GP contract which will commence on 1st July 2019, although many of the new services will not start until later.
Your community, Your care : Developing Buckinghamshire together

8. Example Primary Care Network (PCN)
Today:
3 practices working independently
Practice A - 17,500 patients
Practice B - 20,000 patients
Future (by 2023/24):
3 practices working together (50,000 patients)
Existing teams of doctors and nurses to be complemented in a typical PCN with:
Social prescribing link workers x 4
Clinical pharmacists x 6
Physiotherapists x 4
Physicians Associates x 3
Community Paramedics x 2
As well as support from:
Community Healthcare Teams
Mental Health Community Teams
Adult Social Care
Voluntary Sector
Community geriatricians
Hospital services outreach
Additional funding for Digital Technology
Practice C - 12,500 patients
Key Features:
Populations of 30 – 50,000 registered patients
Neighbouring practices
Practices decide who belongs to PCN
Each network will be led by a clinical director
Funding increases over next 5 years – indicative increase £1.47m per annum
NHS England expects that most networks will be geographically based and will, between them, cover all practices within a clinical commissioning group (CCG) boundary.
NHS England has expressed the view that 30,000 is a firm lower limit for population size, except in areas of extreme rurality, but the upper limit could be more flexible. NHS England is clear that the entire population must be able to access network-based services. 
While practices are not mandated to join a network, they will lose out on significant extra funding if they do not, and their neighbouring networks will be funded to provide services to those patients whose practice is not covered by a network. Where a single practice meets the size requirements of a network, they will be able to function as a network if the CCG agrees.
Your community, Your care : Developing Buckinghamshire together

9. What will PCNs do? Structured Medication Reviews (2020)
New Roles
Seven National specifications:
Structured Medication Reviews (2020)
Enhanced Health in Care Homes (2020)
Anticipatory Care (2020)
Personalised Care (2020)
Supporting Early Cancer Diagnosis (2020)
Cardiovascular Disease case finding (2021)
Tackle Health Inequalities (2021)
Integrated Care
NHS England has significant ambitions for primary care networks, with the expectation that they will be a key vehicle for delivering many of the commitments in the long-term plan and providing a wider range of services to patients. 
Primary care networks will eventually be required to deliver a set of seven national service specifications. Five will start by April 2020: structured medication reviews, enhanced health in care homes, anticipatory care (with community services), personalised care and supporting early cancer diagnosis. The remaining two will start by 2021: cardiovascular disease case-finding and locally agreed action to tackle inequalities.
To do this they will be expected to provide a wider range of primary care services to patients, involving a wider set of staff roles than might be feasible in individual practices, for example, first contact physiotherapy, extended access and social prescribing. Networks will receive specific funding for clinical pharmacists and social prescribing link workers in 2019/20, with funding for physiotherapists, physician associates and paramedics in subsequent years. 
They will also be the footprint around which integrated community-based teams will develop, and community and mental health services will be expected to configure their services around primary care network boundaries. These teams will provide services to people with more complex needs, providing proactive and anticipatory care.
Primary care networks will also be expected to think about the wider health of their population, taking a proactive approach to managing population health and, from 2020/21, assessing the needs of their local population to identify people who would benefit from targeted, proactive support. 
Primary care networks will be focused on service delivery, rather than on the planning and funding of services, responsibility for which will remain with commissioners, and are expected to be the building blocks around which integrated care systems are built. The ambition is that primary care networks will be the mechanism by which primary care representation is made stronger in integrated care systems, with the accountable clinical directors from each network being the link between general practice and the wider system.
Your community, Your care : Developing Buckinghamshire Together

10. What difference does this make for Practices?
The best bed is your own bed!
The contract contains major new investment in staffing. The ambition to recruit more GPs and nurses remains, but the contract recognises the difficulties of achieving this given the ongoing challenge of retaining existing staff. It therefore focuses attention on recruiting staff where there will be more supply. Just as changes to the GP contract in the 1960s and 1990s saw significant investment in practice nurses who became a core part of the service, this investment will mean patients attending their general practice in years to come may also see a pharmacist, paramedic or physiotherapist, with advanced training in diagnosis and treatment in their specialist areas. This signals a fundamental change in how patients will experience general practice, expanding general practice to much more of a ‘team sport’ that is better suited to meeting patient needs.
The contract also puts a great deal of emphasis on digital channels for access to general practice, including and video consultation, improved access to records and electronic prescribing.
The timelines attached to their development are extremely ambitious and the scale and complexity of the implementation challenge should not be underestimated. The development of networks has implications that reach far beyond primary care as community health and community mental health services will be expected to ‘align’ around networks. To be successful, network development will need to be seen through a broader lens than just general practice, involving other providers of community-based services as well.
Your community, Your care : Developing Buckinghamshire Together

11. Questions??
Questions were asked as to whether the money available was new funding. CCGs are required to find £1.50 per head of populations from their existing budget, but all other monies for the extra staff and the payments directly to practices are additional funds amounting, over 5 years, to circa £1.47million for a PCN of 50,000 patients.
Your community, Your care : Developing Buckinghamshire together

12. What difference will PCNs make for patients?
Primary care networks have the potential to benefit patients by offering improved access and extending the range of services available to them, and by helping to integrate primary care with wider health and community services. 
Previous research on the impact of larger scale general practice on patient experience found mixed views. While some patients prioritise access above all else and are interested in the potential of larger collaborations to improve that access, others are more concerned about continuity and trusting relationships and are concerned these may be lost. Practices will need to work with their patient participation groups and the wider local community if they are going to address the needs of their local population. 
Your community, Your care : Developing Buckinghamshire Together

13. Your community, Your care : Developing Buckinghamshire together
This recently published Maturity Matrix shows what engagement and involvement is expected of patients and the public. Detail is shown on the next page.
Your community, Your care : Developing Buckinghamshire together

14. Patient Involvement in PCNs
Engagement: GPs, local primary care leaders, patients’ representatives, and other stakeholders believe in the vision and the plan to get there
Foundation
PCNs are engaging directly with population groups, and with the wider community
Step 1
Networks are developing an extensive culture of authentic patient partnerships
Step 2
The PCN has built on existing community assets to connect with the whole community
Step 3
Your community, Your care : Developing Buckinghamshire together

15. Questions??
PPGs are encouraged to speak with their practice to ask what network their practice is proposing to go with. The CCG recognises that the formation of a network is a matter for practices but the CCG will need to support these as part of the registration process that goes to NHS England and knowing that patients are largely supportive of the proposed network for their practice would be helpful.
After 1st July, as PCNs start the work of developing their vision, their business plan and setting up their governance arrangements, we would expect to see PPGs very involved as the first line patient representatives. Over time, we would expect to see diversity of representation to the PCN.
We advised attendees that there is to be a Protected Learning Time event on 22nd May which will be dedicated to the development of PCNs. One agenda item will be ‘what can PPGs do for PCNs?’. Both PPG meetings on 3rd and 5th April considered this question and both agreed that:
It would be helpful to form PPG networks using the PCN footprint (once they are known) to develop as PPGs and collaborate on initiatives
That PPG representatives should be invited to support the PCN ‘board’
That PPGs could support the assessment of need and design of PCN services
Your community, Your care : Developing Buckinghamshire together

16. Timescales Date Action Jan-Apr 2019
PCNs prepare to meet the Network Contract registration requirements
By 29 Mar 2019
NHS England issues the Network Agreement and 2019/20 Network Contract
By 15 May 2019
All Primary Care Networks submit registration information to their CCG
By 31 May 2019
CCGs confirm network coverage and approve variation to contracts
Early Jun
NHS England works with CCGs and Local Medical Committees to resolve any issues
30/6
Sign up by practice
1 Jul 2019
Network Contract goes live across 100% of the country
Jul 2019-Mar 2020
National entitlements under the 2019/20 Network Contract start, i.e.: Year 1 of the additional workforce reimbursement scheme; funding for the Clinical Director; £1.50/head from CCG allocations
Your community, Your care : Developing Buckinghamshire together

17. Other Recent Changes in Bucks…
Improved Access
Out of Hours GP Services
NHS 111 Online
Ask NHS
NHS App
Your community, Your care : Developing Buckinghamshire together

18. Improved Access
Appointments with a GP, nurse or other healthcare professional are now available in the evenings and weekends. Contact your GP practice for more information.
Your community, Your care : Developing Buckinghamshire Together

19. Out of Hours GP Services
When your GP practice is closed, call NHS111 for an urgent GP appointment Services across Bucks are now provided mostly by our local GPs
Your community, Your care : Developing Buckinghamshire Together

20. NHS 111 Online 111 Online is free and easy to use available 24/7
more than twice as quick as the phone service
helping to manage increasing demand on 111 telephone services
Your community, Your care : Developing Buckinghamshire Together

21. Ask NHS - Online self Triage - LIVE
Ask NHS provides:
An online symptom checker (IOS & Android app)
Self-Care advice (nhs.uk)
Fully integrated into the GP Clinical System
Appointment booking (following triage)
Call backs, GP appointment
Access via Windows PC coming soon
Service Finder (National DOS)
Admin requests to GP Practice
17 Practices offering this to patients NOW!
Ask NHS is powered by Sensely. A simple online and mobile solution that provides improved access to local NHS services and is live now.
Your community, Your care : Developing Buckinghamshire Together

22. NHS App Use the NHS App to: check your symptoms
The NHS App will be activated in local practices to allow patients to use it if they wish by July but the main comms campaign will be in the Autumn to allow us to focus on Ask NHS prior to then.
Use the NHS App to:
check your symptoms
find out what to do when you need help urgently
book and manage appointments at your GP surgery
order repeat prescriptions
securely view your GP medical record
register to be an organ donor
choose how the NHS uses your data
This is an alternative to patient access/patient online the system people already use to book appointments and repeat prescriptions. In time, there will be only one point of access via a single portal using one single log-in to all NHS digital content.
Your community, Your care : Developing Buckinghamshire together

23. The Long Term Plan Survey

24. How can you help? Complete and share the survey
Go to
From there, scroll down, and choose between the general survey, and the one on long-term conditions
cancer, mental health conditions, heart and lung diseases, long-term conditions, such as diabetes and arthritis, learning disabilities, autism, and for people as they get older and experience conditions such as dementia
General -
Long term conditions - would-you-do
More information
Go to
Easy Read and BSL surveys available on the website

25. Contact Details Buckinghamshire CCG Website address
Bucks PPG Mailbox address
Your community, Your care : Developing Buckinghamshire Together