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A primary care strategy fit for the future 2017 and beyond This document is the refreshed strategy for Newham CCG for the period 2017 - 2019. It is a plan for the whole Primary Care health (and social care) community and is designed to deliver our collective vision of a healthier population, with fewer inequalities with health services that are high quality, cost effective and sustainable. The plan is based on a 2017 JSNA analysis of the strengths and weaknesses of the local health and social care system, and the needs of the changing population. It sets out a strategy for moving Newham to a position where it can deliver high quality standards of health and social care in all settings, whilst also delivering financial sustainability. This plan is ambitious for patients and the public. It focuses on improving outcomes for older people, people with chronic diseases and those suffering from the consequences of health inequality. It focuses particularly on improving the access for these patient groups to primary, urgent and integrated urgent care services, in order to help them avoid unnecessary hospital admissions. The plan also recognises the need to improve the quality of people’s experiences of health (and social) care services. Our most significant improvement interventions are therefore focussed on integrating services around the patient – wherever possible pulling services closer to the patient’s home. This programme will deliver improvements in the integration of health and social care and the integration of people’s physical and mental health care. It will deliver closer working between GP practices so that they can drive the integration of primary, community, secondary and social care around the needs of each patient and their family.

This plan recognises that we need to do much of our core business more efficiently and effectively reflecting tight finances and difficulties in recruitment. In particular we have described the steps we will take to tackle health inequalities, to place more equal value on our mental and physical health care, to involve the public in our work and to meet quality and safety expectations. This plan is a draft, and will be finalised following the April PCCC meeting and then presented to the Board as the Governing Body.

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Contents Primary Care Strategy on a page ..................................................................................................... 4

Key facts ....................................................................................................................................... 8 Our population .............................................................................................................................. 8 Latest growth projections.............................................................................................................. 9 Where will the growth come from? ............................................... Error! Bookmark not defined. JSNA and borough priorities ....................................................................................................... 10 The JSNA on a page .................................................................... Error! Bookmark not defined. Top three causes of ill health and death ..................................................................................... 12

The top three causes of death ................................................................................................ 12 The top three causes of ill-health ............................................................................................ 12

Our approach in 2014 ................................................................................................................. 16 The Newham 2020 vision for primary care ................................................................................. 17 Primary Care Strategy refresh .................................................................................................... 18

The thinking behind the refresh – new directions to consider ................................................. 18 Key considerations - what stays as is from the 2013/4 strategy ............................................. 18 Key considerations - what needs to be added since the 2013/4 strategy Error! Bookmark not defined. Background ............................................................................................................................. 18 The benefits expected via co-commissioning ......................................................................... 19

TST ............................................................................................................................................ 21 The house of care model ........................................................................................................ 22

The Sustainability and Transformation Plan ............................................................................... 22 Our six key priorities under STP ............................................................................................. 22

Delivering changes to access ..................................................................................................... 24 Managing demand ...................................................................................................................... 25

Technology as an enabler – for the patient ............................................................................. 28 Technology as an enabler for the practice .............................................................................. 30 The need to develop practice capacity and efficiency ............................................................. 32

Patient online .............................................................................................................................. 33 Social prescribing ....................................................................................................................... 34 Workforce ................................................................................................................................... 34

Significant workforce shortages, retention and recruitment challenges .................................. 34 Sustainable and potentially larger practices ............................................................................... 36 Workforce mix ............................................................................................................................ 37 MCPs and MDTs ........................................................................................................................ 38 Co-commissioning and new models of care ............................................................................... 41 The contracting approach ........................................................................................................... 42 The changing nature of demand and demand shift .................................................................... 42 Self-care ..................................................................................................................................... 43

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Estates Strategy - the June 2016 draft considers plans until 2025 ............................................. 44 Premises – fewer sites, better utilisation, more shared facilities, improved standards and less isolation ................................................................................................................................... 45 Estates plans – priorities and the financial gap ....................................................................... 46 The June 2016 estates strategy is to: ..................................................................................... 48 Quality improvement ............................................................................................................... 52 Insert Annex - See quality dashboard - Procedure subject to approval .................................. 52 Quality of staff ......................................................................................................................... 53

Principles underpinning our work ............................................................................................... 53 Annex ......................................................................................................................................... 54

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Primary Care Strategy on a page To ‘do nothing’ is not an option – to do what we would like to given our current tight funding situation is “not an option” but should remain our goal despite limited availability of resources. Delivering all our goals will be dependent on having a clear set of priorities. The population growth in our borough is unprecedented. Therefore the local health and social care system needs to work with funding bodies to understand whether transformational investment can be provided ahead of further population growth so that the required infrastructure, including any capital investment requirements, can be prepared in time and put in place for a preventative health care system to be ready and meet our obligations to the public and. Develop resilience and sustainability in Newham General Practice Support the creation of a strong sustainable hospital Think on a larger more “Integrated” scale across the STP footprint Implement TST, Move more Care Closer to Home and Building Healthier Communities Increase mobility, reduce smoking, reduce alcohol consumption and support active living Adopt new models of commissioning/delivery of services ACO, ACS, Federation, MCP Improve practice access capacity and efficiency, simplify the Access pathway providing the

Newham version of 8-8 Improve patient satisfaction with Primary Care in Newham focussing on Access Develop patient Self-Care, increase the ability to Self assess, develop an SPA for

information and signposting, encourage patients to take responsibility for their own care and Self- Management, utilise and promote MiDos.

Create a clinical and access hubs model around 5-6 Health & Wellbeing Centres Support the development of demand management both in practice and via referral Adjust and support the creation of an adaptive workforce with a varied skill mix Train and up-skill existing staff Develop a TST/STP wide recruitment, retention & development programme for General

Practice Create a GP succession plan providing opportunities for new GP’s and encouraging the

creation of more Training practices Support and Invest in sustainable practices/Collaboratives of 10k or more patients In the long term create a consolidated estate that meets the needs of modern healthcare

delivery & future growth requirements with increased efficient utilisation of existing facilities Adopt an Estates development programme to bring NCCG premises up to an acceptable

standard across the area via investment into existing sites and funding new sustainable developments seeking out capital from all available sources.

Create equity of patient service offer across practices Transition toward equity in practice funding in 4 years as MPIG is phased out IT – increase provision of real time Patient data exchange across and between providers, Increase direct access to appointment booking, EPS and electronic patient records Develop a model for a sustainable CEPN programme Expand the utilisation of Multi-disciplinary teams and care plans Incorporate the 3rd sector into primary care hub based services while also including

Community and formerly secondary Acute based services

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NCCG’s ambition is for a service model with a number of key themes:

1. Improve patient experience and better manage demand, joining local primary, community and acute care services together through integrated care pathways, help people prevent and manage long term conditions, promote resilience and health independence, while securing high quality acute services at Newham University Hospital for patients with acute needs.

2. Recognise the central role for general practices as providers, delivering a cradle to grave

prevention and treatment service, (primary, secondary and tertiary) with the GP as the named and accountable clinician for patients and ensuring continuity of an individual’s care.

3. Ensure meaningful, high quality collaboration exists between clinicians and social care

workers across settings and provider boundaries, both in managing the care of individual patients and in reviewing and optimising practice. Supported through connected shared technology and increased multidisciplinary team working.

4. Develop a primary care model which enables a wide range of services to be offered

more locally across an appropriate population and ensuring there is the necessary estate and workforce to deliver the out of hospital care.

5. With patient consent and via compatible information technology systems make real time

data available that supports the care of patients by the clinician and ultimately provides data to the patient wherever and whenever care is being delivered or planned.

6. Building and harnessing commissioning expertise of member practices in

neighbourhood clusters to get best access and healthcare outcomes for residents.

7. Working with LBN, community groups, third sector, charities and self-help groups to ensure care pathways support the patient.

The model proposed through the primary health care strategy (2013-18) combines a range of interventions for multiple conditions along the full disease lifecycle, spanning prevention, diagnosis, self-care, disease management, the management of co-morbidities and palliative care. The long term conditions of focus include diabetes, cardiovascular disease, respiratory disease, cancer and tuberculosis and long term mental health conditions such as dementia.

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Newham’s primary healthcare care strategy proposed that a range of extended GP primary care contracts be developed to deliver better health outcomes for:

• Diabetes, covering the pre-diabetes annual check and the diabetes SMI pilot • CVD, covering heart failure, hypertension, lipid control, atrial fibrillation and

anticoagulation/warfarin services • Chronic Obstructive Pulmonary Disease (COPD), covering identification of those with

the disease and its management • Mental Health, covering SMI • Self-care, covering tuberculosis prevention • Integrated care, covering planning for high risk patients

To ensure equitable access for patients any GP unable to deliver the full range of services within their practice will be encouraged to provide services across the localities through a group service or via collaboration. The stretch ambition is that access will be provided to a standard range of primary medical services via bookable appointments 8am to 8pm, 7 days a week delivered via a combination of GP practice, extended hours and Out of Hours services each having full access to a patient’s notes irrespective of how or where access occurs. This will include use of technology to deliver shared appointment booking systems, provide non-face-to-face consultations such as video, email consultation and telephone triage for the majority of appointment requests using group practices (access hubs) Practices will also be encouraged to develop web or app based self-analysis and utilise alternative service providers such as Pharmacy First, Clinical Pharmacists and Physiotherapists.

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Key facts and the case for change: (see also plan on a page above) Residents over 65 are projected to rise by 43% by 2026. The anticipated rise in prevalence of long term conditions associated with this will create substantial additional clinical demand; Londoners with complex conditions are expected to rise by a third in the next ten years. Newham is still one of the most highly deprived areas of London and indeed the country, with the additional burden of an overall negative patient weighting and a relatively large population for a CCG adding financial and workload pressures. Considerable churn in registered patients across the area with some practices reporting 20-25% increases workload. Soft intelligence indicates a potentially high unregistered population. Newham continues to be a first point of landing for many in the country creating a highly diverse ethnic mix and language challenges for community providers and general practice. Multiple occupation of poor quality housing in the rental sector contributes to overall ill health alongside crime, environment and economic deprivation. Ethnic mix: Principal population groups are: White British and White Other (mainly Eastern European); Asian, Black African and Caribbean, each with their own health risks and health behaviours. In 2015 Newham was recorded as one of the lowest four boroughs in London Poverty Profile, the main factors affecting this being:

• Low pay and pay inequality • Homelessness • Unemployment

Our population Despite high practice turnover many residents stay within the borough (indicating the potential for efficiency improvement). Newham has a complex mixture of ethnic groups who have genetic predispositions to certain disorders such as diabetes and hypertension. These ethnic predispositions are overlaid with different religious and cultural norms which do not always follow ethnic lines. Nearly 1/5 of the black population is Muslim whilst 2/3 are Christian. Ethnic groups are often found in pockets of settlement grouped together generating additional demands on providers for translation/length of appointments. Newham’s young population averages 31, 9 years younger than the rest of the country with a high number of working age males. The years of potential life lost (PYLL) by dying under aged 75 from causes amenable to health care is high in Newham. Women rank in the worst 2% of all CCGs in England, men in the bottom 37%. There was a rise in PYLL in women in 2013 due to more than expected early deaths from strokes in women of African and Caribbean origin under 65 years and > than expected ischaemic heart disease deaths in all women under 75, in particular Asian women. Resident numbers; Not all residents are registered with a Newham GP (98% are1) Not all people registered with Newham GPs live in the borough (91% do)2.

JSNA Practice List Size- NHSE Weighted List Size

Practice List Size- NHSE Raw List Size 01/01/16

Grand Total 356,395 370,990

1 October 2014. Number of people registered with a GP in Newham and living in Newham =336,664; Newham residents recorded with any GP=343,673. Percent Newham residents registered with a Newham GP =98% 2 October 2014. Number of people registered with a GP, living in Newham =336,664. Total number of people registered with a Newham GP, living anywhere =371,162. Percent Newham GP registered population that lives in Newham =91%

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Currently registered patients @ 1st April 2016 is 381,870 as per EMIS for all practices in Newham (source – CEG). Finance figures (below) indicate a 3354 increase in weighted population in the 3 months to end March 2016 representing a 3.75% growth p.a. Growth concentrated in certain areas of the borough referred to as the arc of development running from Stratford down through Canning Town to the Docks in the South – observationally we know developments have been built but are held empty in the expectation that capital gains are made examples being developments in the former Olympic Village, Unex Tower and Dockside :

CCG

Normalised weighted list as at 01/04/2015

Normalised weighted list as at 01/04/2016

Year on Year % Move-ment

Normalised weighted list as at 01/01/2016

Movement on 01/01/2016

% Move-ment

Newham 359,626 361,625 0.6% 358,271 3,354 0.9%

1 October 2014. Number of people registered with a GP in Newham and living in Newham =336,664; Newham residents recorded with any GP=343,673. Percentage of Newham residents registered with a Newham GP =98% 1 October 2014. Number of people registered with a GP, living in Newham =336,664. Total number of people registered with a Newham GP, living anywhere =371,162. Percentage of Newham GP registered population that lives in Newham =91% Latest growth projections Fig. 1 shows growth concentrated in the six wards bordering the Western & Southern Borough boundaries and also within the boundaries of the London LAN Opportunity Areas (red boundary and cross hatching) - Newham’s ‘arc of opportunity’. Where will the growth come from?Figure 1 Population growth 2015-2025 by ward (GLA 2014 round SHLAA Capped Projection)

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Table2 sets out the actual population change figures which underpin the map. Ward 2015

Pop’n 2015-2025 Change (10 Yrs)

2015-2020 Change (5 Yrs)

2020-2025 Change (5 Yrs)

2015-2035 Change (20 Yrs)

Stratford& New Town 28,066 25,116 10,810 14,306 37,214 Royal Docks 13,311 9,998 4,599 5,399 15,638 Canning Town South 17,717 5,767 3,923 1,844 6,433 Beckton 15,589 5,074 3,611 1,463 10,581 Custom House 14,081 3,610 610 3,000 5,071 Canning Town North 16,592 2,990 1,611 1,379 4,647 Forest Gate South 18,011 945 362 583 1,168 Little Ilford 17,397 925 382 543 1,411 West Ham 16,030 712 433 279 701 East Ham Central 16,440 584 352 232 1,111 East Ham South 16,087 356 229 127 824 Plaistow South 16,760 296 392 -96 485 Plaistow North 16,077 38 187 -149 -138 Green Street East 16,651 -21 188 -209 -13 Green Street West 15,745 -54 75 -129 -138 Boleyn 16,547 -66 -118 52 -198 Wall End 15,451 -128 101 -229 -219 Manor Park 15,591 -177 23 -200 66 East Ham North 14,037 -371 -208 -163 622 Forest Gate North 16,420 -451 -130 -321 -472

Total 332,600 55,143 27,432 27,711 84,794 Table 4.2 Population Growth by Ward (GLA 2014 round SHLAA Capped Projection) 12 wards predicted to increase by 2030 and 8 to decrease. 2 (Stratford and Royal Docks), are predicted to increase >100% (125% and 104%) by 2030.

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The JSNA on a page:

Wider determinants of health Newham has moved from being the 2nd most deprived borough in England in 2010 to 25th in 2015 as measured by the Index of multiple deprivation (IMD). As these measures are relative and not suitable for time trends, it cannot be said for certain how much is absolute change. Based on the 2015 IMD, Newham is performing well on education similar to other London boroughs, and falls in the middle range for employment and health based on the proportion of small areas in Newham falling in the 10% most deprived decile in the country. It ranks lower in income and ranks the worst for crime and barriers to goods and services. About 20% of all adults and 25% of all older people were income poor. The median annual household income in Newham was £28,780 (2012/13) being £10,000 lower than the London average but comparable to that of NW England. Historically, Newham has had very low median income and even with the 60% increase from 2002/3, it remains comparatively low. The low income combined with higher house prices in London results in poor housing affordability for most of the residents. Newham ranked 4th worst in the country for housing deprivation. Newham along with its neighbours Tower Hamlets and the City of London had the highest proportion of households living in overcrowded conditions. About half of all the households living in private housing live in overcrowded conditions and 20% in social housing.

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Top three causes of ill health and death To change outcomes at a population level the priorities for health improvement need to impact on large numbers. Using 1 in 10 of the population being affected (or having a health behaviour) as the cut-off point gives the same 4 priorities for women and men.. For women: 1. Inactivity (52,000) For men: 1. Inactivity (44,000) 2. Obesity (31,000) 2. Smoking (36,500) 3. High BP (19,000) 3. Obesity (21,500) 4. Smoking (17,500) 4. High BP (18,000) 119,500 120,000 To be effective the CCG needs to work on a list of conditions considered amenable to healthcare (as published by ONS April 2012) see Annex 2. Given high levels of employment an opportunity exists for a strong work place health prevention programme to be developed

The top three causes of death 2011-2013 Men In 3 years Women In 3 years CVD 593 Cancer 507 Cancer 528 CVD 470 Respiratory Disease 271 Respiratory Disease 269 Men 1975 Women 1792

The top three causes of ill-health 2011-2013 Men In 3 years Women In 3 years Mental Ill-Health –

Anxiety , Depression 16,000 est. Mental Ill-Health –

Anxiety, Depress. 23,000 est

Diabetes (Diagnosed) 11,500 MSK. (up to 13k knee & hip arthritis)

30-35,000

MSK. (up to 9k with knee & hip arthritis)

25 -30,000 Diabetes 10,000

Total Men 52 -57,500 Women 63 -68,000 GP recorded proportion of people with diabetes 2010 - 2015. Newham compared to England & deprivation comparators. Newham’s Diabetes gap widens v London & England between 13/14 and 14/15

Increase physical activity to strengthen joints &

increase mobility

Focus on Mental Wellbeing

Focus on Diabetes and Hypertension

Focus on Women and the Middle Aged

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The age group with the greatest proportionate increase is 65-74 years. This is age group has a predicted 74% increase when looking forward to 2030 (albeit from quite a low base) but has a major impact on services. Preventing onset of illness in the 65-74 age group and tackling risk factors in the 55-64 age group should have high priority.

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A revision of the JSNA (Jan 2017) identified some key facts and reconfirms the areas of focus: Newham has made very good progress in improvements in life expectancy for men and women but overall poor progress on improving healthy life expectancy in step with this. Taken together these two indicators show Newham having a widening period of unhealthy life before death. This has a major impact on the wellbeing and resilience of the population and most significantly on uptake of healthcare services Newham has a relatively young but unhealthy population. By focussing on middle aged 40 - 65 year olds we can help prevent serious ill-health and problems. There are four priorities for action:

For the borough as a whole these elements need to be supported by continuing to tackle poverty; cold homes; overcrowding and crime as the significant contributory factors to poor or ill health – a joint LBN/NCCG challenge. The JSNA suggests we start with “tackling physical inactivity”.

Get people Moving Reduce Obesity Stop Smoking Reduce Hypertension

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Using a “Mini JSNA” or Practice Profile for each practice or population area; Working in conjunction with the PH team from the local authority the Primary Care team plan to adopt the use of local and area/cluster based versions of “mini” JSNA documents which look at the

• Overarching indicators such as life expectancy and % population not in good health • Practice demography i.e. Age, Sex, Growth groups, ethnicity • Wider determinants of health such as Mental Health, mortality, Diabetes, CVD

Source: PHE PHOF 2015 and LBN PH team

0

1

2

3

4

5

6

7

8

9

%

2.17 - Recorded diabetes

Newham

Comparators

London

England

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Our approach in 2014 NCCG PCCC held several development sessions to create a Strategic vision for Newham using the following as the start point:

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The Newham 2020 vision for primary care How we see and define primary care:

• The primary care system moves beyond more conventional definitions of general practice and is rather more seen as the system of community health and social care services delivered by statutory and non-statutory sector. Primary care needs to be seen within the context of a much greater base of health and social care services and resources

• The GP still plays a key leadership role especially for those with complex conditions • Many members of the community will be enabled to identify and access directly a range of

services. They will have prime relationships with a number of individuals who play a leading role in planning and accessing services for the individual. Individuals become more skilled themselves.

• The patients and their families are actively involved in planning and supporting care • There will be a much greater prevention focus • We think pathway and the pathways are made explicit with some joint understanding of the

triggers for help •

The system on the ground in local communities • Neighbourhood hubs are accessed by users and their families to get information and social

support from a range of statutory and non-statutory providers. • Healthcare hubs will coexist and provide a platform for the organisation and delivery of a

range of community based services with secondary care services also being provided there How people work together

• Multi-disciplinary teams will be working on a local basis. It will feel much more like the John Lewis partnership with professionals feeling a great sense of common identity and common purpose. There will be a much greater blurring of boundaries

• There may be multi-agency local organisations to bring together services • There is much greater dissemination of information across the system to enable

understanding of the wealth of local resources and how to access them • There are big implications of this vision for behaviour ( patients, families and professionals)-

there is a more active social contract between the community and professionals with more realistic mutual understanding of contributions/offers

• There is a considerable development of social infrastructure locally. • The GP does not feel responsible for everything • There are a number of known triggers along the pathway for the engagement of services

The use of technology

• There will be joined up records accessed by professionals but also owned by patients • Technology will be used for the distant monitoring of health and wellbeing and used by

patients and their families to monitor their own progress and to engage with the care system when needed

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Primary Care Strategy refresh The thinking behind the refresh – new directions to consider The original Primary Care Strategy was developed in December 2013 by Dr Margaret Chirgwin. Since then the PCCC agreed the following strategic documents should have their content included in a refresh to reflect the range of guidance published since the original strategy was created. Effectively we are using these developments to build on the foundations laid down in 2013 taking the following into consideration:

1) STP plan – key drivers 2) TST Plan - key drivers 3) 5 year Forward View 4) General Practice Forward View 5) Making Time in General Practice 6) Better Health for London 7) Newham’s H&WB Strategy 8) Transforming Primary Care - a Strategic Commissioning Framework 9) NCCG Estates Strategy 2016 10) Revised JSNA Draft July2016 11) IT Roadmap 12) London GP Development Standards 13) HUDU Healthy Urban Development Unit

Background the Case for Change The 2012 Health and Social Care Act changed the primary care commissioning landscape. Primary Care Trusts and SHA’s were abolished, from April 2013 responsibility for primary care contracting moved to NHS England. CCGs also took functions including planned hospital care, rehabilitative care, urgent and emergency care (including out-of-hours), most community health services and mental health and learning disability services. NCCG has responsibility for the development of primary care services. Local authorities have assumed responsibility for public health, shared responsibility for Adult & Children’s Health, Social Care and Health and Wellbeing boards. The diagram below set out the new organisations in the health system. In May 2014 NHSE announced an option for CCG’s to co-commission primary care in partnership with NHS England. In January 2015 Newham along with Waltham Forest and Tower Hamlets (WEL) CCG’s submitted an application to manage primary care contracts and assumed that responsibility from April 2015. Newham CCG now taking a lead role in decision making as fully delegated commissioners

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Transferring the decision making function for commissioning GP services to NCCG provided us with greater influence in managing the local health economy and the ability to achieve greater integration of health, care and social care services in the borough. The benefits expected via co-commissioning

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Improved access to primary care and wider out-of-hospital services, with more services In November 2014, NHS England published “Transforming Primary care in London a Strategic Commissioning Framework” providing strategic direction for London health economies listing 17 specifications under three areas

• Proactive care • Accessible quality care and • Co-ordinated care.

This document has been influential in NCCG’s development and strategic direction. There are a range of other national, cluster and borough wide strategies that will impact on primary care. These are outlined in the table below.

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TST

The WEL CCGs* worked closely together to develop the Transforming Services Together (TST) plan which is aligned to the 5 Year Forward View and more recently the NEL Sustainability and Transformation Plan or STP

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The house of care model

The TST Vision highlighted above is to transform the System requiring a change in cultural mind set particularly around Self Care. As most behavioural scientists will tell you this requires a significant repeated push to change habits and establish new ones. Strategically we need to place more emphasis on the joint LBN/NCCG Self Care agenda using the technology we already have available to support people taking a more active role in their own health care. The Sustainability and Transformation Plan The five year strategy for the transformation of primary care in North East London (NEL), covers WEL plus City & Hackney and Barking & Dagenham, Havering & Redbridge (BHR). A plan for sustainability, to deliver high quality services and improved outcomes for local patients via integrated service models – where high quality ‘at scale’ primary care plays a leading role. The plan proposes population based contracts to deliver health outcomes for the local population alongside local delivery models. The STP takes the best elements of local models and scales them up over the NEL footprint. NCCG’s Primary Care team will therefore need to operate in a highly collaborative matrix structure. Our six key priorities under STP

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Delivering changes to access Generally poor patient experience of access Around 40% of those asked in the GP National Patient Survey report they cannot see a GP of choice and over 30% report finding it difficult getting through on the phone3. Local WEL analysis to date has confirmed what the London Call to Action4 highlighted; significant variation in access to primary care services in East London. Work completed suggests that supply is not meeting demand and core-hour sessions are not offering enough appointments to meet patient need. For example:

• Analysis of opening times suggests that up to 50% of practices in some areas of East London shut at lunchtime. NCCG requires a strategic review of opening times against contracted hours and per 1000 population as part of a broader understanding of demand and the knock on effects this has on other services

• Patients’ experience of GP out of hours services is ranked in the bottom quintile of boroughs in England5 for all East London boroughs. Engagement via PPG meetings indicates a degree of confusion about which services are available when. Strategically a simpler and easier to communicate offer with the same service available at the same time for all practices and therefore patients is an aim for the CCG.

• GP practices across Newham are not always able to offer patients a choice of access to a female GP. In some areas in East London the male/female ratio of GPs is 70/30, whereas by 2017 the London average is expected to be 50/50. By working together in clusters the CCG believe we can go some way towards alleviating this issue.

• Several Newham practices face issue in relation to phone line capacity. The CCG should endeavour to resolve the physical barriers to accessing a practice through the use of smart phone systems, online access and potentially a change in the way appointments are made available at practices via the application of demand management techniques to reduce peak period pressure and avoid the stampede for appointments to beat others to an appointment.

• Newham’s Overall patient satisfaction was recorded in June as 75% one of the lowest in London. NCCG will need to support practices (subject to funding availability) in a number of phases as part of a strategy to tackle access.

o Resolving some of the physical access issues – e.g. flexible phone systems, on-line appointment booking, EPS

o Tackling some of the issues in relation to getting to see a GP – increasing the skill mix, making a range of appointment methods available e.g. telephone, face to face, on-line/Skype subject to appropriate governance being in place.

3 GP National Patient Survey (2014) 4 https://www.england.nhs.uk/london/engmt-consult/ldn-call-to-action/ 5 CCG Outcome Indicators, Public Health analysis (2015) (see page 4)

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Managing demand The average number of general practice appointments per person p.a. in England has risen from 3.6 to 5.5 between 1995 and 2008, with the reported current average being 6.1. If this rise in demand continues, workforce constraints will mean the quality of service available will be greatly affected. GPs in the future will need to concentrate more time on those with long term conditions and complex needs while the wider primary care team supports the treatment of those with Minor ailments. This puts the demand level for appointments in Newham a figure of approximately 2 – 2.2m p.a. using the National figure NCCG will support practices in conducting capacity and demand audits, by area, by cluster to help efficiency improvements in meeting demand created by population growth. Looking at days of the week, seasonality, hours of the day, use of telephone triage and workforce options.

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Potentially avoidable clinical demand Data submitted by 56 GPs for over 5,000 consultations is summarised below. In total, 26% of appointments were judged to have been appropriate for diversion or handling differently.

The most common potentially avoidable consultations were amendable to action by the practice, often with the support of the CCG. The biggest three categories were where the patient would have been better served by being directed to someone else in the wider primary care team, either within the practice, in the pharmacy or a ‘wellbeing worker’ (e.g. care navigator, peer coach, health trainer or befriender). Together, these three, which could be improved by more active signposting and new support services, accounted for 16% of GP appointments. An additional 1% were to inform a patient that their test result was normal and no further action was needed. A further 1% of appointments would not have been necessary if continuity of care or a clear management plan had been established.

The second most common issue lay within the control of hospitals. Demand created by hospitals accounted for 4.5% of appointments. The largest category, creating 2.5% of appointment, comprised problems with outpatient booking (either a lapse in the outpatient booking process, such as failure to send a follow-up appointment, or a patient failing to attend an appointment, necessitating an entirely new GP referral and, incidentally, allowing the hospital to charge twice for the appointment. The other, creating 2%, was the result of hospital staff instructing the patient to contact the GP for a prescription or other intervention which was part of their hospital care.) The CCG strategy allows for patients to be signposted to their local pharmacy for episodic minor illnesses – However this can only apply where there is a suitable consulting or private space to maintain patient confidentiality. The TST plan is to create shared care records to allow providers outside of general practice to view the care needs of patients with long term conditions. In addition, a pilot is planned where community pharmacy providers are able to input information directly to EMIS.

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Most of our population access services for episodic care; approximately 50% of appointments are for people with long-term conditions. By proactively planning care around an individual’s needs, we could significantly reduce the number of unnecessary visits a person has to make. This will enabled by:

• A significant investment in technology to ensure there are innovative ways to access advice (phone, Skype, text, website)

• Making sure 20% of total appointments are longer to suit the needs of patients with complex long term conditions

• The establishment of multi-disciplinary teams who can proactively plan care around the needs of individuals

• Investment in OD to support the workforce to work together to establish integrated working across the health and social care system

NCCG intend to work with clusters on identifying more ways to avoid unnecessary referrals to acute and try to manage demand through identification of areas where referrals might be dealt with at practice level using GP to Consultant direct communication and reducing the actual number of referrals where the acute sector can identify those which are not required. NCCG will also share information across practices and clusters to ensure adoption of best practice. One of the first significant areas NCCG will focus on will be Dermatology where the use of technology and GPwSI can help support increased activity in the Primary Care community and avoid secondary care referrals.

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Below is a summary of the initiatives the CCG is planning to adopt in primary care to manage RTT demand.

ENABLERS:

1. Technology as an enabler – for the patient and for the system

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The principle of increasing the speed of introduction of technology into NCCG and its stakeholders organisations and pathways has been recognised for some time. A specific Primary Care based plan for the introduction of technology according to a set of priorities has been developed to move the STP toward digital maturity

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and support the introduction of technological advances including:

1.) Self and proactive care, e.g. through online wellbeing assessments, remote monitoring and testing, health improvement resources or support communities

2.) Improved access, via online service portals, telephone triage and email appointment systems

3.) Better coordination, with interoperable systems allowing clinicians to share agreed information across organisational boundaries

4.) Modern care such as remote monitoring of long term conditions and house bound patients and self-diagnostic remote devices.

5.) The CCG are currently evaluating via a pilot of e-consult which will require evaluation

Technology as an enabler for the practice Greater focus is required on using technology to drive increased efficiency in practices for 5 areas: 1.) To improve the efficiency of GP practices and providers and aid long term sustainability. Help

cope with administration and regulatory requirements e.g. Policy Library, EMIS templates, documentation, in practice self monitoring.

2.) To improve demand management and help tackle access issues 3.) To improve detection and improve patient outcomes 4.) Increased access to information and enable Self Care 5.) To allow information exchange across an area and between providers

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The CCG will need to evaluate developments in online services such as: Symptom checkers help patients confirm their GP is the right service for their situation Self-help guides and videos about the commonest general practice conditions Sign-posting to alternate offers e.g. pharmacy and online counselling 24/7 phone advice within 1 hour by requesting a call back using a web form on the practice website (arranged through the local 111 provider) E-consults in which patients use their practice website to submit condition-based questionnaires to their own GP for a response within 1 working day, potentially avoiding the need to attend the practice.

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The need to develop practice capacity and efficiency The NCCG Strategy for the Future of General Practice will incorporate the following principles captured in this table from NHS Networks:

Ten high impact actions to release capacity in general practice

The service specification (NCCG - patient offer) Proactive care – supporting and improving the health and wellbeing of the population, self-care, health literacy, and keeping people healthy Accessible care – providing a personalised, responsive, timely and accessible service Coordinated care – providing patient centred, coordinated care and GP/patient continuity where desired NCCG approach will be improved access for patients who need it most – prioritisation based on need. The CCG in collaboration with the Federation are aiming to direct any funding which becomes available toward:

• Reception and clerical staff training (expected 2016) • Online consultation systems (2017) • Practice manager development

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https://www.networks.nhs.uk/nhs-networks/releasing-capacity-in-general-practice Patient online

Many Newham GPs offer online services . Since April 2016 all GPs have been required to provide their patients with online access to their GP record with a current requirement to make available at least 10% of appointments online. NCCG recognise there are limitations with having such as small % of appointments available online – namely that with such a small % patients who do try and use this service will not feel they have much choice of times to meet their needs, if the process is repeated several times patients become disillusioned and stop using the system. This could result in misinterpretation of the patient need for online appointment booking. The CCG are recommending this figure be higher (40-100%) giving confidence to patients and encouraging uptake. Online activity reduces pressure on front line staff and increases time with patients either face to face or on the phone. A system which also allows patients to cancel appointments as well as self-booking has a much higher tendency to secure appointment attendance and therefore reduces DNAs. Examples in Devon have reduced DNA’s to virtually zero , however 3 factors affect this which need to be considered and tackled – demographics, administration and relationship. Adopting techniques such as reporting attendance, getting people to write their own appointment cards and reading back the appointment time and date all contribute to facilitating cancellation. Online services are expected to compliment not replace traditional ways of contacting a GP practices. They offer an additional more convenient way to interact. Being able to book and cancel appointments any time of the day, order repeat prescriptions from home or at work, saves patients a trip to the GP practice, allows patients to look up medications online and saves GP workload. Increasing utilisation of online services helps free up phone lines for people without internet access enabling GP practices to manage appointments and telephone calls more efficiently. There are currently three transactional services available:

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1. Booking appointments 2. Ordering Repeat prescriptions 3. Access to GP records

Social prescribing The CCG will (funds permitting) develop cluster based navigators to direct patients to a range of services available in the community. Close affiliation with LBN through the BCF will aid in developing the program of activities further depending on the success outcome of the current programme and it is the CCG expectation that practices will be able to develop self-help groups capable of offering support and advice to patients with complex LTC. Workforce

Newham has 220 GP’s (as at 19.9.16) of which 124 (56%) are male and 96 (46%) Female plus a population of 78 Nurses. A high proportion of the GP workforce are at or approaching, retirement age; 38% of male GPs in Newham (and 32% of male GPs in Waltham Forest) are aged 60 and over, many want to reduce their hours. Almost 30% of GPs in Newham want to reduce their workload over the next 5 years and 15 (7%) of Newham’s GPs operate as single handed practices meaning that they do not have direct colleagues to hand over their workload to. Nationally NHS England reports that by 2021 another 16,000 GPs will be needed. Analysis shows that without changing our model of care, we would require an additional 195 GPs across East London; something that is a major challenge given this is a national shortage area. There are also recruitment and retention challenges associated with primary care nursing staff as well as the skills shortages in primary care. Only 31% of the capital’s GPs believe they have received sufficient training to diagnose and manage dementia and only half of all GP associates in training have the opportunity to work in secondary care paediatric services to gain experience of identifying and managing sick children. Some GPs and nurses, including those in training, indicate they feel dissatisfied with the lack of career and development opportunities available to them. This has led some to consider not working in the area long term. In Newham only 3 GP Vocational Training Scheme staff out of 15 obtained salaried positions last year. TST Focus groups have highlighted East London’s nurses are also frustrated by the lack of career and pay progression opportunities in the area.

Significant workforce shortages, retention and recruitment challenges Newham (and WF) have below average numbers of GPs compared to the rest of London. The high cost of housing and increasing demands on practice workload make recruitment of New GP’s and retention a severe challenge.

Engagement indicates the challenges for those who come includes workload pressures, complexity of governance and administration procedures and the responsibilities of dealing with a population which contains a wide variety of ethnicities, has high churn, high deprivation and includes high numbers of new patients with limited or no clinical record often requiring translation services. Newham also has a large proportion of single handed practices combined with a very high proportion of GP’s over traditional retirement age (41 GP’s 65 or over and 10 of these over 65 y/o GP’s being single handers). There are also 16 GP’s between 60-65 who are approaching

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retirement age which clearly demonstrates the need for the development of succession planning and possible consolidation of smaller practices as well as a need to make Newham a relatively attractive place to work (given the challenge of high property prices making partnership in a practice a further challenge). Number of GPs (headcount) per practice by CCG, 2013

Full- time equivalents per 1000 CCG population (London CCGs, 2013)

Source: Health and Social Care Information Centre (2013)

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Sustainable and potentially larger practices Sustainability of general practice in Newham is a significant issue with a number of practices struggling with recruitment, retention, facing challenges to their revenue together with various business and commercial challenges. NCCG strategy as outlined in the Draft Estates Strategy currently being finalised, proposes that practices should aim to be of a minimum size of between 8 and 10,000 either individually or acting together as a single organisation. NCCG accept that although size is no guarantee of sustainability or quality the direction of travel toward more area based commissioning and reduced individual practice access to funding will make it important that practices achieve a high enough level of income to maintain sufficient staff and practice staffing to be profitable and therefore sustainable in the long term. The CCG also need to achieve the most effective use of their spend on premises and this means that a certain degree of scale is required to ensure we achieve this. Where costs are spread over a larger area the cost per m2 falls. Operating at the 10k+ level or being able to achieve it over a 2-3 year period should provide practices with the ability to spread workload and spread front and back office costs. Additionally this “scale” enables GP’s within a practice to work in a collegiate manner, sharing learning, providing sickness and holiday cover for each other sharing the responsibilities with a number of colleagues while providing an environment which will be attractive for younger GP’s and new partners to join where which they feel comfortable and which is fit for the delivery of modern day health care. GP practices that support multidisciplinary working through hub and spoke models and sustainable networks collaborations will be crucial in realising our vision. In order for this to happen, investments in facilities such as SLG , Centre Manor Park and Canning Town will be prioritised as part of the estates strategy. At key sites the CCG will look to develop “Health and Wellbeing Centres” supporting 50-80k patients with a broad range of services including former acute based services that have been transferred out into the community setting combined with voluntary and Social services subject to local need and funding constraints. NCCG will where funding permits support practices in improving resilience by helping develop the

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skills to conduct continuous improvement and attain QI expertise. The CCG will help practices develop greater resilience with packages of support focussed on a number of measures from succession planning, recruitment and retention, business management, efficiency, QI , performance measurement , rapid cycle improvement, Continuous improvement to reducing unnecessary documentation and tasks. Where possible the strategy will be to consolidate across the TST or STP area the different sources of funding and knowledge to improve consistency and stretch the spend while linking with strategic partners such as NHSEL HLP, HEE, HENCEL,UCL Partners , the CQC, LMC and RCGP Workforce mix NCCG are aware they have a seriously ageing workforce, many are single handed and potentially face large increases in patient demand. The strategic approach to dealing with this is to concentrate on actively managing the demand and link this to a shift in the workforce mix. This will include the use of up skilled staff such as reception staff being trained to HCA and Medical Assistants along with the broadening of the workforce via Physicians Associates, Clinical Pharmacists, Physiotherapists, Mental Health practitioners and increased use of pharmacies.

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MCPs and MDTs The chart below taken from the TST strategy indicates a potential reduction in the number of FTE GP’s offset by an increase in Community workforce. Many of these community/ area based staff may be aligned to a practice but working across a wider geography via at-scale primary care organisations or MDT’s. These organisations will utilise an increasing number of Prescribing advisors, GPs with a special interest (GPSIs), care coordinators, navigators, wellbeing teams, and ‘super practice managers/directors’ with sufficient skills to lead the development and operational management of at-scale primary care organisations For example as part of a wider Multispecialty Community Provider (MCP) including secondary care specialists, social care, mental health a community services team and community pharmacy.

The Newham strategy focuses on multi-disciplinary team and collaborative working, however in Newham 20% of practices are run by single GPs, making it more difficult to accommodate the new ways of working. Due to an increase in primary care demand and high projected retirement rates in the existing workforce and taken against a backdrop of a national shortage of GPs, one of the solutions to this problem is the establishment of a flexible workforce which can contribute to multiple specialties across various patient pathways spanning secondary, primary care and social care.

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For these reasons (and to create a responsive and safe model of patient care) local primary, secondary and social care, providers may wish to employ clinical pharmacists, physiotherapists or physicians associates who can work across several healthcare sectors and a number of patient pathways. They can be used to improve the patient experience and to strengthen multi-professional teams working under the supervision of a doctor or clinical lead.

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End of Life Care NCCG plan to review the services provided in Nursing Homes and focus on improvements to the pathway for End of Life Care in conjunction with the integrated care team. The CCG aim to establish clear patient preference for where a patient wishes to die with improved co-ordinated care in the community

Mental health

The end-of-life care principle for long-term condition care should have a strong mental health focus on emotional support and managing wellbeing in the last years of life.

Pharmacy

Improve the provision of 24/7 community pharmacy services, particularly to support end-of-life care services.

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Co-commissioning and new models of care

Delegated commissioning offers an opportunity for NCCG as a level 3 CCG to assume full responsibility for commissioning certain aspects of general practice services. NCCG will support the development of new models of out-of-hospital care such as: Multi-specialty Community Providers (MCPs) – the model for which is:

• Larger GP practices, potential for a wider range of skills such as hospital consultants, nurses and therapists, employed or as partners. Able to shift outpatient consultations and ambulatory care out of hospital. MCP’s have the potential to own or run local community enterprises and have delegated capitated budgets – potentially incorporating health and social care with the intention being to concentrate the service provision in a small number of Hubs catering for 70-100k plus in the longer term

Primary and Acute Care Systems (PACS). For: ‘vertically’ integrating services:

• PACS provide an increased flexibility for Foundation Trusts to utilise their surpluses and investment to kick-start the expansion of primary care. Contractual changes are coming to enable hospitals to provide primary care services in some circumstances. At their most radical PACs could take accountability for all health needs for a registered list in a similar way to Accountable Care Organisations/Systems - a contracting vehicle will potentially ‘wrap around’ existing national contracts (unless constituent practices opt for a full merger/super partnerships and therefore may voluntarily relinquish their current contract).

The contracting vehicles we use need to be flexible to allow wider collaborations and partnerships with different types of providers to hold capitated budgets and share risk for whole populations. The above options provide the flexibility to commission outcomes by area, create at scale service provision and encourage true end to end commissioning /service provision by removing perverse incentives to protect volumes of activity. NCCG will need to pay particular attention to at scale provision with the emphasis on the TST and more significantly the STP level so as to achieve financial balance and create a sustainable platform for Newham Hospital.

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Federations; NCCG has been supporting provider development encouraging all practices in the area to create a federation. Having done so they are now well positioned for the future to be able to bid and provide services on an outcome or cluster basis across an area with specified sub groups e.g. diabetes in the over 65 age group for the NW1 cluster. This move away from practice based commissioning will need to be reflected in commissioning service specifications. NCCG expectations are that the establishment of a Federation can also create new opportunities for commissioning either through direct contracting or collaboratively with a Federation combining with other providers or as part of an ACS/ACO. The strategic benefits of dealing with a Federation are the simplicity of a single provider v 57 practices, potentially improved quality and efficiency of delivery, consistency across an area. Federations will increasingly be able to self-monitor whereas they drawback is they represent effectively a monopoly on local access which it may initially be a challenge to be sustainable given the revenue required to fund their running cost starting from a zero contract base. There are also challenging issues over governance, clinical negligence and responsibility for shared services, challenges over data sharing and funding to overcome. The CCG will need to ensure that it monitors the Federations development carefully. NHC aim to take a lead role in the Newham Integrated Provider Partnership (NIPP), delivering whole pathways of care across the population within an alliance with health and social care partners. The CCG see the Federation as being able to take a fuller role in the delivery of integrated services and potentially become part of a larger accountable care organisation (ACO). The CCG will need to work closely with the Federation to ensure a degree of alignment of ambitions for the future while supporting where possible their development needs where funding permits and joint objectives can be realised. The contracting approach NCCG will progressively focus on outcomes based specifications designed to deliver across an area or footprint which is capable of concentrating on pockets or areas of disease prevalence. At scale contracts linking providers together will be the direction of travel moving the focus from individual practices to pooled resources focussed on an area with shared risk and incentives. The legal framework and forms are important, successful examples suggest that other factors have to be in place first. E.g. all parties need to buy in to the new way of working, behaviours have to change and ideally the solution has to be genuinely co-created. “When you get into the detail, whether we go down the route of an alliance, prime contractor or ACO/ACS/ICOs every example is different. What the successful ones have in common is a real shift in thinking from organisation to system based.” PMS contracts represent nearly 50% of our general practices (29/57) and 64% of our weighted list. These contracts are at the time of writing subject to review, subject to agreement presenting an opportunity to revise KPI’s to reflect strategic changes toward the aim of equalisation of PMS/GMS and APMS contracts and the transition toward an equitable patient offer so that any patient can receive the same services regardless of where in the NCCG area they are located. The BCF submission was updated in July 2014 and submitted in September 2014 and represents an increasing amount of the funding (£25.6m in 2015/6) allocated to NCCG. The plans were not available when the original strategy was written hence the increased focus on Self Care, Care co-ordination, and Integrated Care in the most appropriate setting. The changing nature of demand and demand shift 1.) As a result of the TST it is projected that over five years 24% of patient appointments will shift

out of general practice.

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2.) This is made up of 14% of activity which will be directed to wider primary care providers (pharmacists, optometrists, counselling physiotherapy and psychology services) and

3.) 10% which will be accounted for by patients being better supported to self-care.

This figure is based on national evidence, guidance and TST engagement to date, and will be achieved by equipping patients with the right advice, health care tools and signposting.

This shift is necessary because the primary care system needs to meet growing demand plus anticipated activity shifts from urgent care and hospital based services. However in the first full year (16/17) it will have limited impact on Primary Care practices given that Ophthalmology is one of the first significant areas of proposed shift followed by Dermatology, Gynaecology, Urology and Respiratory Medicine which have greater impact in 2017/18. Self-care 10% of patients currently accessing primary care services could self-care through supportive online advice and tools. People managing their own health, wellbeing and care have a better experience of care and a reduced demand for high-intensity acute services. However, 40% of people have low levels of knowledge, skills and confidence to manage their health and wellbeing1 and 44% would like to be more involved in making decisions about their care2. NCCG will aim to ensure people living with long-term health conditions or care needs are offered support to improve their confidence and capacity to manage their own health and wellbeing, including:

• Self- management education: formal education or training so people develop knowledge, skills and confidence to manage their own health and wellbeing

• Peer support for each other to understand their condition(s) and to manage its impact • Health coaching: to help people set goals and take action, improving their health and

lifestyle • Group based activities: activities that encourage healthier living and reduce social isolation

(e.g. exercise classes or community choirs). • Funds permitting NCCG will develop alongside MiDoS, access to a directory of information

to support people to self-diagnose and self-care. • Funds permitting NCCG will develop a practice based PH and Self Care information centre

to provide practices with material to share via TV’s/monitors with patients at practices and points of delivery for health, social and community services

NCCG aim to segment the highest cost users (50% of cost is typically incurred by 5% of the population) by need and identify 3 to 5 segments to offer tailored support to (e.g. patients who are frail; at end of life; isolated / feeling lonely; with complex co-morbidities spanning physical health, mental health and social care; patients with dementia). NCCG plan to assess an individual’s capability to self-manage and self-care, undertake structured conversations between people and practitioners to identify individuals’ goals and the support needed to achieve them. Develop single plans that are outcomes based (‘what matters to me’) and owned by the individual. I.e. tailored support based on need, including anticipatory care planning, social prescribing, health coaching and integrated personal commissioning or personal budgets. Our aim is to enable patients to better self-manage through improving information and health literacy, accessing such tools as self-care forum factsheets. See http://www.selfcareforum.org/fact-sheets/ which currently covers the following areas; 1. Low Back Pain 2. Eczema

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3. Heartburn and indigestion 4. Fever in children 5. Constipation 6. Headache and migraine 7. Coughs 8. Acne 9. Sprains and strains 10. Sore throat 11. Otitis media 12. Common cold 13. Sinusitis 14. Urine symptoms in men Estates Strategy - the June 2016 draft considers plans until 2025

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Premises – fewer sites, better utilisation, more shared facilities, improved standards and less isolation Commissioners will invest in buildings which drive economies of scale and able to provide the new model of care which may include the co-location of federated smaller practices all in fit-for-purpose buildings. In order to provide capital investment, underutilised assets that are not suitable for the new model of care, or which are located in areas not experiencing population growth will not attract investment and may be sold. Void space has been proactively reduced since the original strategy was developed and will continue to be targeted while plans have been put in place to maximise the utilisation of the existing estate and rooms through extended use during a potentially longer day. National evidence suggests that smaller GP practices may struggle to sustainably provide all of the services future models of care will be expected to deliver. Our traditional partnership model currently serves an average of 6650 patients per practice. This is widely acknowledged to be too

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small to respond to the financial and demographic challenges facing the NHS6. The London Health Commission’s report Better Health for London also calls for professional isolation in general practice to be addressed7. Our NCCG local recommendation is for a new model of primary care which is financially sustainable and allows primary care to operate at greater scale, through multidisciplinary working is in line with this National direction of travel. Given our workforce and estates challenges, we believe new models of care can only be delivered in primary care centres with list sizes capable of reaching over 10,000,either through smaller practices working together at scale in integrated provider networks, or through collocated facilities at hubs. General practice will need to adapt in line with this new model of care. These changes are likely to mean that some patients need to travel slightly further for primary care, although many more consultations will be provided by telephone or Skype and there will be less requirement for people to travel to a hospital, meaning that a significant proportion of care is provided closer to home which will feature an increase in non-acute Diagnostic services, services such as 24hr BP monitoring, Local bloods, Spirometery, ECG – delivered by practices or in the locality. Hubs are an important part of the future model of care delivery; co-location and partnership working will not be possible without the right scale. Smaller practices face significant challenges in attracting new staff, high rents and service charges can restrict voluntary and 3rd sector participation. Larger buildings provide an opportunity for community collocation and coordination opportunities with the third sector, charities, social and activity based groups rely heavily on proximity which larger buildings provide. With the development of hubs and a consolidation of practices, supporting mergers and alliances together with key developments NCCG expect the overall numbers of sites to drop to circa 36 or less over the next three years. Estates plans – priorities and the financial gap The strategy is an enabler for change, delivering savings, reducing running costs and ensuring that all investment, including the Estates and Technology Transformation Fund - (ETTF), is prioritised and properly targeted. The NHS faces funding constraints and in East London there is currently a significant financial gap across all organisations. Whilst funding will increase due to the rising population, this will not be enough and ways of working will also need to change. To continue to provide safe, high quality and sustainable services in the future, NCCG needs to work effectively and efficiently. The key priorities of the strategy are:

• to achieve a more efficient estate • identifying resources to deliver new service models and • ensure future investments are identified and prioritised through the strategy • Areas where there is underutilisation or inappropriate use of estate need to be identified

and brought into clinical use • The estates strategy contributes heavily to the delivery of Newham CCG’s primary care

strategy as an enabler for the TST programme and “Better Health for London” and addresses some of the financial challenge faced by NCCG and the NHS

NCCG has over 70 buildings delivering primary and community services. Premises are owned by a large number of different organisations and individuals, making change more complex. Many GP

6Securing the future of general practice: new models of primary care. Smith J et al. Nuffield Trust. (2013) 7 Better Health for London. London Health Commission (2014)

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premises are small (less than 200m2) and conversion/further development would not be possible or economical. The strategy consequently sets out its vision to increase the capacity and facilities within a reduced number of premises, encourage the use of shared facilities and increased collaboration through co-location. The majority of the new population will live in 6 wards, within the ‘arc of opportunity areas’. Additional estate and practices will be required for these residents. In parallel, the existing population, many with poorer life expectancy than other parts of England, will be aging and increasingly developing long term conditions. Their needs must be considered in the development of improved facilities. This CCG have submitted prioritised bids to the NHSE Estates and Technology Transformation Fund (ETTF) – for £8.9 million and believes that further developments with an estimated value of £13 million are still being held. The CCG will need to determine the revenue funding and how this can be afforded, looking at opportunities to generate savings from mergers, utilising space more effectively and sharing the facilities and costs with other agencies. Proposed new developments

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The June 2016 estates strategy is to:

• Ensure the CCG submit through the ETTF appropriately weighted and rated bids to NHS England, requesting the desired allocation of its capital investment budget from 2016-2019 to deliver the required developments,

• Plan for the predicted significant population growth in Newham, both with GP practices and LBN regeneration team,

• Plan for the service delivery changes required to move care out of hospital, for what is currently one of the most deprived areas of the UK and facing epidemiological pressures due to an aging population.

• Ensure estates development is considered as part of NCCGs primary health care strategy and incorporated in its strategic commissioning framework intentions

• Address the substantial financial pressure within the local health economy and the saving requirement, which means finding ways to use existing resources more efficiently and effectively as a priority reducing void space, consolidating and sharing facilities where practical.

Newham has 57 GP practices, caring for a total registered population of 370,990 patients (as at 1 April 2016), list sizes range from 1,298 to 16,457 patients. There are currently 49 premises from which primary care is delivered. The figure below shows the geographical distribution of the practices and with a representative of list size by circle size and colour.

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Assuming a patient population of approximately 370k growing to 380k and an potential list size of around 10k being achieved over the next 5-10 years the future Newham provider landscape has been projected as having a profile along the lines indicated in the diagram below.

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This chart is Not for release – Indicative and requires consultation

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Owner/leaseholder Number of properties Number of practices Number of which are

single handed NHS PS

12 15 4

CHP 3 8 (1 branch)

0

3rd party developer/private

18 18 (2 branch)

5

GP owned

24

21

9

NCCG is developing a broad ambition for the service model with a number of key themes:

1. To improve patient experience and better manage demand, joining local primary, community and acute care services together through integrated care pathways, to help people prevent and manage long term conditions, promote resilience and independence, and secure high quality acute services at Newham University Hospital for patients with acute needs.

2. Recognising the central role for general practices, as providers, providing a cradle to grave

prevention (primary, secondary and tertiary) and treatment service, with the GP as the named and accountable clinician for his patients and ensuring continuity of an individual’s care.

3. Ensuring meaningful, quality collaboration between clinicians across settings and provider

boundaries, both in managing the care of individual patients and in reviewing and optimising practice. This will be supported through shared technology and increasing multidisciplinary team working.

4. Developing a model for primary care that will enable a wide range of services to be offered

more locally across an appropriate population and ensuring there is the necessary estate and workforce to deliver the out of hospital care.

5. The availability, with patient consent, through compatible information technology systems of

real time data that supports the care of patients to the clinician and ultimately to the patients wherever and whenever care is being delivered or planned

6. Building and harnessing commissioning expertise with its member practices in

neighbourhood clusters to get best access and healthcare outcomes for its residents.

7. Working with LBN, community groups, third sector, charities and self-help groups to ensure care pathways most support the patient.

The model proposed through the primary health care strategy (2013-18) combines a range of interventions for multiple conditions along the full disease lifecycle, spanning prevention, diagnosis, self-care, disease management, the management of co-morbidities and palliative care. The long term conditions of focus include diabetes, cardiovascular disease, respiratory disease, cancer and tuberculosis and long term mental health conditions such as dementia.

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Newham’s primary healthcare care strategy proposed that a range of extended GP primary care contracts be developed to deliver better health outcomes for:

• Diabetes, covering the pre-diabetes annual check and the diabetes SMI pilot • CVD, covering heart failure, hypertension, lipid control, atrial fibrillation and

anticoagulation/warfarin services • Chronic Obstructive Pulmonary Disease (COPD), covering identification of those with

the disease and its management • Mental Health, covering SMI • Self-care, covering tuberculosis prevention • Integrated care, covering planning for high risk patients

To ensure equitable access for patients GPs unable to deliver the full range within the practices will be encouraged to provide services across localities in groups. The stretch ambition is that access will be provided to a range of standard primary medical services 8am to 8pm, 7 days a week through a combination of GP practice, extended hours and Out of Hours services with bookable appointments and full access to a patient’s notes irrespective of how or where access occurs. NCCG version of this will be 8-8 x5 with at least 4 hours on a Saturday and Sunday opening subject to demand being verified. Access will be extended and improved for those with urgent care needs; through offering more efficient use of appointments during the day, evening and at weekends while offering more appointments via Skype and over the phone. The CCG will aim to have Primary care centres at or near hospital sites, strengthening existing urgent care centres and providing convenient access to those who want primary care in these locations. This will be trialled at one of the hospital sites and if successful implemented across the area. Quality improvement Our health services have many strengths but quality in NCCG remains variable from practice to practice and area to area. There are few direct correlations between the size of or funding of practices and the quality standard of services provided. The CCG are developing a means of monitoring quality across practices using a series of high level indicators as an early indicator of providers who may need further support or fall into the vulnerable category. The CCG will develop a mixed skills group from clinical, primary care, quality and external sources who will then agree and develop a course of action in the form of a turnaround plan enabling the CCG to help in getting practices back on track toward sustainability. Support for practices will be available either through the commissioning team or via a resilience support package focussed on such areas as performance improvement, QOF achievement, contract delivery, financial planning and optimisation of revenue, workforce/succession planning and efficiency improvement. This support may be commissioned via external expertise via independent providers or via the RCGP. Insert Annex - See quality dashboard - Procedure subject to approval CCG Improvement Assessment Framework (CCGIAF) NHS England are introducing a new CCGIAF to replace both the existing CCG assurance framework and CCG performance dashboard. The CCGIAF is a new framework of metrics that will become the principal method by which NHS England holds CCGs to account for their performance. Assessments based on the framework will be carried out annually, with ratings awarded for each of six key clinical priority areas based on a four point scale. Ratings will be moderated by national expert panels. The CCG will align where required with the requirements of the CCGIAF.

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Quality Academy Newham CCG plan to develop their relationship with UCL Partners and create a quality academy consisting of a range of quality improvement development opportunities including face to face training, local support and facilitation, networking events and a central resource portal providing access to evidence based best practice examples. This will be a component part of a broader STP approach to Quality improvement via the Partnership for Quality Improvement Board

Quality of staff If out of hospital programme is to be delivered at pace it will require among other things experts in procurement law, specification writing and project delivery. Do we want to share this resource and if so is it an STP,TST, CCG or CSU employed team? Would it be helpful to have our own CCG procurement team which coordinates the procurement process, sharing existing good practice specifications and bringing together key experts and stakeholders to convert our vision and aspirations into contractual requirements? Principles underpinning our work • Focus on prevention in partnership with LBN and on early detection • Individual empowerment to direct and manage one’s own personalised care and support • Get people engaged in their own health and wellbeing and enabled to self-care • Support and care will be delivered in the least acute setting appropriate for the patient’s need • Care will be delivered outside of hospitals or other institutions where appropriate • Services will be integrated • Subsidiarity – where things can be decided and done locally they will be • Care professionals will work in an integrated way • Care and services will be co-produced with patients and residents • We will focus on people and place, not organisations • Innovation will be maximised • We will accelerate the use of digital technology and technological advances

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END Annex Annex 1 JSNA Draft 2016-07-17 Annex 2 List of conditions considered amenable to healthcare (published by ONS April 2012)

List of conditions

considered amenable Annex 3 NCCG Estates Strategy Annex 4 Newham’s H&WB Strategy Annex 5 STP plan Annex 6 TST Plan http://www.transformingservices.org.uk/downloads/Strategy-and-investment-case/TST-Part-3-High-impact-changes.pdf Annex 7 5 year Forward View Annex 8 GP Forward View Annex 9 IT Roadmap Annex 10 Better Health for London Annex 11 London GP Development Standards Annex 12 HUDU Healthy Urban Development Unit Annex 13 Transforming Primary Care - a Strategic Commissioning Framework Annex 14 Newham Practice list size weighted & unweighted April 2016

Copy of NCCG

Practice List sizes_ Ap Annex 15 Ten high impact actions to release capacity in general practice https://www.networks.nhs.uk/nhs-networks/releasing-capacity-in-general-practice/messageboard/documents/Releasingcapacityingeneralpracticetenhighimpactactionsv2.docx Annex 16 Risks Description of risk Risk

Likelihood Risk Impact

Risk rating Mitigation

1 The payment mechanism to other primary care providers for minor ailments does not currently incentivise transfer

4 4 16 Consider as part of implementation planning in line with payment innovation work

2 Workforce supply will not be sufficient to implement new care model and meet future demand

4 5 20 Launch a joint recruitment strategy across east London health and social care providers

3 Lack of co-ownership, development and co-production of the strategy and implementation plan.

2 3 6 Further development of strategy at Board Development Sessions in December 2015

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4 Lack of a defined clinical lead for primary care improvement within each borough

5 3 15 Consider the appointment of a clinical lead/medical director to take forward primary care transformation in each borough

4 Provider development and readiness 1. Lack of confidence in provider biding contracts 2. Slow progress in bidding at scale. 3. Low levels of network working

4 4 16 CCG led provider OD development programme with appropriate infrastructure, management and governance in place to help them succeed.

5 Potential conflict of interest between CCG Boards and Provider Networks

4 5 20 Each CCG and provider network to ensure robust governance arrangements are in place to manage conflicts of interest

6 Specifics of pathway redesign programme requirements of primary care due to shifts of activity are at present not known

4 2 8 Assumptions of anticipated shift made within modelling assessments and joint implementation planning post-pathway redesign sessions will be necessary

Annex 17 Commissioning Intentions Annex 18 Community Re-procurement specification Annex 19 Children’s re-procurement Annex 20 Integrated Care commissioning Intention Annex 21 Practice Profile Mock up

Practice profile

mockup 20160822.do Annex 22 Mini JSNA – Practice Profile

Practice profile mockup 20160822.do

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