achieving excellence in general practice in tower hamlets our strategy for change … · integrated...
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Our Strategy for Achieving Excellence in General Practice/Author: Lisa Henschen, North and East London Commissioning Support Unit. 22nd January 2014v2
Achieving Excellence in General
Practice in Tower Hamlets
Our strategy for change
2014/15 – 2017/18
“Our vision for General Practice in Tower Hamlets is for consistent high
quality care, delivered by resilient and healthy Practice teams, who
work with patients and their carers to understand them and their lives,
and support them to take control of their health. General Practice will
work to coordinate patient centred care that brings services together
so that people can achieve the outcomes that are important to them”.
Version: 2.0
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Our Strategy for Achieving Excellence in General Practice/Author: Lisa Henschen, North and East London Commissioning Support Unit. 22nd January 2014v2
OUR STRATEGY FOR ACHIEVING EXCELLENCE IN GENERAL PRACTICE
FOREWORD BY THE CLINICAL LEADS
The reason we took on the role as Clinical Leads for the Achieving Excellence in General Practice programme was because we recognised the difficulties and challenges of providing good local primary care in Tower Hamlets. We have been asked in our engagement to date whether the Clinical Commissioning Group (CCG) in Tower Hamlets is serious about change, or whether this work is just a tick box exercise. We believe that the CCG is serious, and would not have signed up as leads for this project if we did not. Our experience to date is that the work is being prioritised, that we are being listened to, supported and given freedom to explore the real issues. The four of us in our respective practices have felt the increasing strains and burdens that impact on us personally but also in our effectiveness to provide good care for our practice populations. We understand from our consultation period that we are not alone and this is universally felt across primary care in Tower Hamlets. We recognise that providing good care is a combination of many variables some of which are complex and out of our control but there are other factors which we know we can improve on. We feel the status quo is not an option and that this document is the beginning of a journey that will allow us to build on the strengths of what we have achieved but also to look forward and make changes that can sustain us both personally and the primary care system as a whole. We would like to thank all of the people who have generously given their time and insight to support us in the development of this strategy.
Simon Brownleader, George Farrelly, Mike Fitchett and Liliana Risi
Clinical Leads for the Achieving Excellence in General Practice Programme
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Our Strategy for Achieving Excellence in General Practice/Author: Lisa Henschen, North and East London Commissioning Support Unit. 22nd January 2014v2
EXECUTIVE SUMMARY
This strategy for achieving excellence in General Practice sets out the start of a journey of change for General
Practice in Tower Hamlets, to support the sustainability of General Practice into the future through delivering
the following five objectives:
This is a three year strategy, with an accompanying implementation plan, to be refined and refocused over this
time period based on what we are learning and what we are hearing from local Practices. Based upon the
changing national and local context in which this strategy is being produced, the following working principles
have been set out for the strategy deliver
We will be led by the patient in the
development of General Practice services.
This, we believe, we serve as the catalyst
for the effective integration of services.
This is a strategy designed to support
General Practice in the challenges they
currently face.
This is a strategy that will be delivered in
collaboration with local Practices, not
imposing or dictating action to them.
This is a strategy to support development
of the entire General Practice workforce
A strategy that is flexible and evolving
taking into account the changing context
at this time this was written.
This strategy proposes testing and
piloting approaches and new ways of
working, and will seek to provide initial
investment to support local innovations
that will develop solutions to the issues
1. To create and nurture an environment of leadership and innovation
for General Practice to deliver patient centred care.
4. To ensure that General Practice in Tower Hamlets is supported by
strong infrastructure to allow it to develop, grow and deliver high
quality, equitable services for patients.
3. To address the unprecedented levels of demand for General Practice
services, supporting Practices to meet patient needs.
2. To secure the role of the General Practice teams as the expert
generalists in the wider healthcare system, who works with other
providers to integrate services for patients.
5. To maximise what we can achieve through working collaboratively
across Practices and with local communities within the network
arrangements.
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Our Strategy for Achieving Excellence in General Practice/Author: Lisa Henschen, North and East London Commissioning Support Unit. 22nd January 2014v2
faced by General Practice. As the strategy
develops over the three years, we will be
communicating results and advocate for
change in the areas that have shown to
be most effective.
Our strategic direction will be informed
by evidence where this has been
possible. Where it has not, we will
support innovations, alongside evaluation
and monitoring to build up our local
evidence base.
This strategy underpins broader strategic
developments underway in Tower
Hamlets, particularly the developments in
integrated care.
This strategy seeks to define what excellence in General Practice means to patients, GPs and Practice teams in
Tower Hamlets, and set this out as our aspiration through the delivery of this strategy. An overview of the
Case for Change is provided, setting out why change is needed to address demand, to support the General
Practice team as the expert generalists in the healthcare system and to build on current network
arrangements in place.
Taking into account the current national policy context for General Practice, as well as the local context; a
growing population experiencing high levels of economic deprivation and multiple-morbidity, this strategy sets
out the change that is needed to deliver the five objectives. In summary, these changes are:
A broader programme for leadership in Tower Hamlets, encompassing the full
General Practice workforce, with structured pathways and roles for General Practice
leads that will support and nurture a local culture of innovation
Ensuring a robust infrastructure is in place for General Practice, encompassing a strong and adequately resourced workforce, good
communication and engagement which embrace technological solutions, training
and personal development that focuses on building resilience and planning for
population growth with adequate financial resources.
Addressing demand in General Practice through new ways of working, with the introduction of an innovation fund for
General Practice, which will create the right environment for General Practice to
respond to the challenges that it faces.
Supporting the General Practice team as the expert generalists in the system, working so
that the patient leads the integration of health services across organisational and
professional boundaries and health professionals work towards common goals
for patients.
Building our network teams in Tower Hamlets, basedon our successes to date and
continuing to build networks as strong, functioning teams to create opportunities
for greater collaboration and opportunities to work at together to create efficiencies and respond to population level health
needs.
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Our Strategy for Achieving Excellence in General Practice/Author: Lisa Henschen, North and East London Commissioning Support Unit. 22nd January 2014v2
Specifically, this year we will:
Fund 20 places for people working in Tower Hamlets to access training in solution-focused
approaches, to support people in building better relationships with patients, and unburden clinicians
of the responsibility they feel to cure everything.
Fund 20 places for people working in Tower Hamlets to access development opportunities in
mindfulness, as a way of improving the health of clinicians as well as patients.
Develop the GP intranet site to support General Practice in accessing information about referral
routes, clinical pathways, frequently asked questions, discussion forums for sharing ideas and on line
education and videos.
Provide support to Practice to enable them to come together to plan how they might develop “Micro-
teams” – to support continuity of care for patients and build peer support within Practices.
And we are developing our plans and in the process to secure funding for developments such as:
Establishing a leadership programme across the General Practice workforce in Tower Hamlets.
Establishing an innovation fund for General Practice in Tower Hamlets to create an environment that
will support change and testing new ways of working.
We will measure the impact of the change that we are implementing to ensure that it delivers the outcomes
that are needed for General Practice to sustain high quality in the system. In summary, the measures and
outcomes that we will be tracking are:
Processes Outcomes
Clinical leadership programme in place and a representative group of
the General Practice workforce recruited to it.
Strong leadership for General Practice across Partners and the sessional workforce, nursing and
Practice Management, with a structure and process in place to build leadership for the future.
Clinical advice services in place across all secondary care specialities,
innovative technological solutions piloted to improve timely access to services for patients and formal and informal opportunities taken up to
develop relationships across the healthcare system.
Greater and more effecitve collaboration across providers,
reduced admistrative burden and improved patient experience across
the pathway.
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Our Strategy for Achieving Excellence in General Practice/Author: Lisa Henschen, North and East London Commissioning Support Unit. 22nd January 2014v2
Practices piloting new ways of working through the innovation fund, with
spread of successful initiatives. Social prescribing in place to improve the response to patient's social needs.
Practices who are able to flex adequately to meet the needs of their population, with an improved patient
experience.
Local and up to date picture of the workforce, clinical information
repositorites in place with active engagement from the General Practice team, pro-active planning to respond
to population growth and micro teams operating to deliver continiuty of care
Healthy and resilient Practice teams, a sustainable future workforce and adequate resources for General
Practice.
Training needs analysis completed within networks, development plans in place, mechanisms in place for sharing Best Practice and robust planning for
real and meaningful community engagement.
Equity in clinical and patient experience indicators, greater
dissemination and uptake of Best Practice across networks and strong
community engagement.
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Our Strategy for Achieving Excellence in General Practice/Author: Lisa Henschen / Version 0.4
OUR STRATEGY FOR ACHIEVING EXCELLENCE IN GENERAL PRACTICE
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1. To create and nurture an environment of leadership and
innovation for General Practice to deliver patient centred care
4. To ensure that General Practice in
Tower Hamlets is supported by strong
infrastructure to allow it to develop,
grow and deliver high quality,
equitable services for patients
3. To address the unprecedented
levels of demand for General Practice
services, supporting Practices to meet
patient needs
Support for the key infrastructure required for change in General Practice:
- The General Practice workforce - Communication, engagement and technology - Training, development and building resilience
- Population growth and financial resources
Building network teams in Tower Hamlets and creating opportunities for enhancing collaboration across Practices to drive equity across services and create efficiencies through working at
scale.
Strong leadership for General Practice across Partners and the sessional workforce, nursing and
Practice management, with a structure and process for building
leadership for the future
2. To secure the role of General
Practice teams as the expert
generalists in the wider health care
system, who works with other
providers to integrate services for
patients
5. To maximise what we can achieve
through working collaboratively
across Practices and with local
communities in the network
arrangements
Healthy and resilient Practice teams,
a sustainable future workforce and
adequate resourcing for General
Practice
Piloting, evaluating and implementing new ways of working to address demand for General Practice services. For example: - Better information for patients to manage expectations
- Social prescribing - Developing micro-teams to improve continuity of care
- Using technology to create efficiencies
Create systematic pathways for leadership across the entire General Practice workforce that encourages and creates
space for local innovation
Practices who are able to flex
adequately to meet the needs of
their population, with an improved
patient experience
Greater and more effective
collaboration across providers,
reduced administrative burden and
improved patient experience across
the pathway
Create equity in clinical and patient
experience indicators, greater
dissemination and uptake of Best
Practice across Networks and strong
community engagement
Creating clinical communities in Tower Hamlets to support the role of the GP as the expert generalist, supported by other
providers, who work towards common goals for patients, innovate to support whole system collaboration which place patients at the
heart of quality improvement and provide co-ordinated care, closer to home.
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Our Strategy for Achieving Excellence in General Practice/Author: Lisa Henschen / Version 0.4
INTRODUCTION
This strategy for achieving excellence in General Practice sets out the start of the journey for General Practice
in Tower Hamlets. Based on the extensive research and engagement that has been undertaken as part of the
strategy development, we have identified the following objectives for General Practice to be delivered over
the three years of this strategy:
This is a three year strategy, with an accompanying implementation plan, to be refined and refocused over this
time period based on what we are learning and what we are hearing from local Practices.
The process that has been applied in the development of this strategy is shown in figure 1.
This strategy sets out the change that will be needed against each of these objectives to be able to deliver the
vision for excellence in General Practice and the outcomes that we will seek to achieve as a result. The
strategy:
Describes the working principles for strategy development;
Seeks to define what excellence in General Practice means to GPs and Practice teams in Tower
Hamlets, and set this out as our aspiration through the delivery of this strategy;
Summarises the case for change for General Practice in Tower Hamlets;
Sets the context in which this strategy is being produced, locally, regionally and nationally;
Sets out the rationale for the objectives of the strategy;
1. To create and nurture an environment of leadership and innovation
for General Practice to deliver patient centred care.
4. To ensure that General Practice in Tower Hamlets is supported by
strong infrastructure to allow it to develop, grow and deliver high
quality, equitable services for patients.
3. To address the unprecedented levels of demand for General Practice
services, supporting Practices to meet patient needs.
2. To secure the role of the General Practice teams as the expert
generalists in the wider healthcare system, who works with other
providers to integrate services for patients.
5. To maximise what we can achieve through working collaboratively
across Practices and with local communities within the network
arrangements.
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Our Strategy for Achieving Excellence in General Practice/Author: Lisa Henschen / Version 0.4
Sets out the change that is required to deliver the strategy;
Sets out the outcomes that will be delivered as a result of the strategy;
Describes the implementation plan that will be put into place to deliver the strategy.
Figure 1: Developing the Strategy for Achieving Excellence in General Practice
WORKING PRINCIPLES FOR THE DELIVERY OF THIS STRATEGY
Based upon the changing national and local context in which this strategy is being produced, the following
working principles have been set out for the strategy delivery:
We will be led by the patient in the
development of General Practice services.
This, we believe, we serve as the catalyst
for the effective integration of services.
This is a strategy designed to support
General Practice in the challenges they
currently face.
This is a strategy that will be delivered in
collaboration with local Practices, not
imposing or dictating action to them.
This is a strategy to support development
of the entire General Practice workforce
A strategy that is flexible and evolving
taking into account the changing context
at this time this was written.
This strategy proposes testing and
piloting approaches and new ways of
working, and will seek to provide initial
investment to support local innovations
that will develop solutions to the issues
faced by General Practice. As the strategy
develops over the three years, we will be
communicating results and advocate for
Establishing a project team
Understanding the current state
Developing a Case for Change
Testing ideas for change
Our Strategy for Achieving Excellence in General Practice
Four clinical leads supported by
project management with oversight from a
Programme Board
106 survey responses, 15 interviews, and 24 people attending focus groups , along with robust data analysis to produce the Current State Position
paper (Appendix A)
Case for Change paper produced in November
2013 (Appendix B)
Over 50 local people attending a workshop to
discuss ideas for change and 2 “Time and Space to Innovate” workshops held for General
Practice teams (Appendix C – delivery of the engagement
strategy). Best Practice review and evidence base for change
proposals produced (Appendix D)
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Our Strategy for Achieving Excellence in General Practice/Author: Lisa Henschen / Version 0.4
change in the areas that have shown to
be most effective.
Our strategic direction will be informed
by evidence where this has been
possible. Where it has not, we will
support innovations, alongside evaluation
and monitoring to build up our local
evidence base.
This strategy underpins broader strategic
developments underway in Tower
Hamlets, particularly the developments in
integrated care.
EXCELLENCE IN GENERAL PRACTICE
“Our vision for General Practice in Tower Hamlets is for consistent high quality care, delivered by
resilient and healthy Practice teams, who work with patients and their carers to understand them
and their lives, and support them to take control of their health. General Practice will work to
coordinate patient centred care that brings services together so that people can achieve the
outcomes that are important to them”.
Significant engagement has been undertaken in Tower Hamlets with patients and Practice teams to discuss
what excellence in General Practice means to them, in order to shape the vision for General Practice. It has
been widely acknowledged that the concept of excellence is in many respects aspirational, when taken in the
current context of resources and demand in General Practice. For many people we have spoken to, providing
a consistent good level of service can be related to more than the concept of excellence. However, this
strategy seeks to challenge the status quo and support General Practice to move to a position where it can
deliver the care that they currently aspire to deliver. Based on our discussions with patients and Practice
teams, this “excellence” state consists of the following components:
Contuinity of care
Supportive infrastructure (workforce, IT and
estates)
Access
Communication
Clinical quality
Innovation Collaboration
Teaching and training
Synergy with the wider health and social care system
Caring, compassionate and
holistic care
Supportive work environement
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Our Strategy for Achieving Excellence in General Practice. Author: Lisa Henschen, North and East London Commissioning Support Unit. 15th January 2014,v2.0
Figure 2: The components of excellence
Component Description
Continuity of care Continuity of care with a named GP or team of clinicians, to support, in
particular, people with long term conditions.
Supportive infrastructure
(workforce, IT and estates)
Strong infrastructure to support General Practice services: having the
workforce in place that is needed for the delivery of services, a strong and
supporting IT infrastructure and premises that are fit for purpose.
Access Patients are able to access the GP of their choice in a timely manner.
Communication The delivery of good communication across the board – between members
of the Practice team, between health professionals and patients and
between practice team members and secondary care, community teams and
social care.
Clinical quality Consistent high quality clinical services with good clinical outcomes for
patients.
Innovation Having the time, space and opportunity to nurture innovation, enabling the
continual improvement of General Practice.
Collaboration A general practice that collaborates well with their local community, other
health and care services, the voluntary and community sector and Practices
in their local area.
Teaching and training A strong focus on training and personal development, to ensure the delivery
of high quality, safe and evidence based care and a teaching and training
ethos within a Practice.
Synergy with wider health
and social care system
A system where all providers of services work together, are well functioning,
reduce time consuming chasing and delays for patients. A system with
shared goals which supports each other in the delivery of services to improve
outcomes for patients.
Caring, compassionate and
holistic care
A service which focuses on the whole person, delivers preventative care and
takes into account their social context, as well as their presenting clinical
issue.
Supportive work environment An environment where time with colleagues is valued, colleagues have
opportunities for information discussions and feedback, both within and
outside of the practice environment.
Table 1: The components of excellence
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Our Strategy for Achieving Excellence in General Practice. Author: Lisa Henschen, North and East London Commissioning Support Unit. 15th January 2014,v2.0
We have identified three overarching themes that we believe are the outcomes of the delivery of excellence in
General Practice teams. These are:
System and individual resilience: Relating to a productive and satisfied workforce in General Practice that is well supported to respond flexibly and creatively to challenges faced. Tower Hamlets clinical leaders have engaged with local GPs, to explore definitions of excellence in primary care, barriers to delivery of excellence, and a vision for future models for general practice with the aim of delivering co-ordinated person-centred care to an aging population with multi-morbidity and greater need. ‘Unhealthy perfectionism’ was a common theme and when combined with GPs who had an external locus of control there was overwhelming pessimism and isolation consistent with national figures that show more than 50% of GPs suffer burnout. However, some GPs expressed positive attitudes identifying collaboration as a solution. This strategy will seek to support General Practitioners in building resilience to the challenges faced now and in the future.
Patient experience: Both in relation to traditional measures of
experience relating to access and care continuity, as well as
experiencing holistic and compassionate care.
Equitable outcomes: That patients should receive the same, high quality of care, irrespective of
where they live in Tower Hamlets, in line with the principles set out in the NHS Constitution (Appendix
E).
THE CASE FOR CHANGE
In November 2013, Tower Hamlets CCG agreed their Case for Change for Achieving Excellence in General
Practice, which set the direction for the development of this strategy. The Case for Change sets out what we
have heard about why change is needed in General Practice to meet the challenges currently faced and begins
to explore some possible solutions and options for delivering this change.
Based on our review of practice locally, nationally and internationally, the document proposes what the
potential solutions might be. The challenges and potential solutions presented are summarised on the next
page. These solutions set the basis for further consultation to inform the development of this strategy.
“Feeling satisfied at the end of each session/day that I have addressed the needs of each of the patients I have seen or any
information about them with the appropriate attention and care, that I have worked well with my team, that I have had
time to look up information that I don't know in a timely way or find information quickly, that I know and have support
when I have reached the limits of my knowledge.
That I get constructive feedback about how I am working, that I feel cared for within my team, that everyone says hello and
good bye, that they look up and smile when I approach, that problems are approached in a way that allows for solutions
and that everyone realises that even a simple offer of a cup of tea can make a world of difference in restoring energy and
attention in a very long working day dealing with suffering”
- Response to “what does excellence mean to you?” in the Tower Hamlet’s GP Practice Survey
“I don’t want to feel like a prescription
is being written for me before I have
even sat down.” - Local patient
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Our Strategy for Achieving Excellence in General Practice. Author: Lisa Henschen, North and East London Commissioning Support Unit. 15th January 2014,v2.0
Achieving Excellence in General Practice Case for Change: Overview
Why change is needed Potential ways forward
We need to urgently address the increasing demand for General Practice services
The supply of, and demand for, General Practice no longer matches. Services cannot flex
adequately to meet the needs of our complex population.
Teams have gone beyond their maximum levels of working.
Our population is growing.
The 10 minute consultation model is rarely adequate for our population.
We need to be able to provide good access as well as continuity of care.
GP appointments are not always used “appropriately”
Addressing demand for General Practice services
Managing boundaries and expectations of General Practice.
Actively managing demand through improved systems.
Changing Practice team models to support access and continuity through micro teams
and using technology as an alternative to the face to face consultation.
Moving away from a single condition focus to a focus on multiple long term conditions
with appropriately long consultations along with support for self-care.
Increasing appointment length for patients who need it.
We must refocus on the role of the GP as the expert generalist who is supported by the wider healthcare system
Administrative problems between secondary and primary care are a major cause of
frustration for clinicians and patients.
There is a lack of synergy in goals and common purpose of care for patients across
organisations, a lack of clarity and insight regarding the limits each and a lack of support
across the system in the best interest of patients.
Supporting the GP as the expert generalist
Making fundamental changes to the way we work with other parts of the health care
system, to integrate and work with mutual regard towards shared goals to improve
outcomes for patients.
Improving secondary care admin systems and communication mechanisms.
Reducing unfunded work flowing from other partners especially secondary care.
Greater use of the multidisciplinary team outside of the Practice to integrate services.
We need to build on our successful Network model so that we can meet challenges by operating at scale
There is significant variation in quality across and within Networks.
The Network’s role in education, training and development is highly valued, particularly
multidisciplinary forums for sharing information and learning sets.
Population health and anticipatory healthcare planning needs cannot be delivered at
Practice level and needs a Network approach.
There are greater opportunities to push boundaries through innovation.
Scaling up our organisational support model
Developing population health and anticipatory care planning at a Network level.
Enhancing peer support to reduce variation in outcomes and give moral support.
Developing strong Practice Management within Networks to support improved
business process.
Creating headspace / time to encourage and support local innovation.
Creating systems for real and valuable community engagement.
To achieve equitable outcomes for our patients: “I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me." (Defining integrated care: National Voices) http://www.nationalvoices.org.uk/index.html
Table 2: Overview of the Case for Change
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Our Strategy for Achieving Excellence in General Practice. Author: Lisa Henschen, North and East London Commissioning Support Unit. 15th January 2014,v2.0
CONTEXT
LOCAL CONTEXT
Historically, primary care in Tower Hamlets was underfunded and was in the lowest fifth quintile for PCT
spending prior to 2009, despite the high morbidity within the population and wide variability in the delivery of
care between practices. Earlier work from within the PCT and papers published by the Royal College of General
Practitioners had suggested a federated model such as the formation of networks of care to foster
collaboration, improve quality and reduce variability. As a result of the ‘Primary Care Investment Program’ in
2009 funding was available to realise this strategy.
PCT funding in 2009 provided each network with funding for management
infrastructure to oversee collaboration between practices and increasingly
with local stakeholders such as the local authority, schools and charities. The
networks are geographically-based and aligned with the local authority local
area profiles, each network consisting of four or five practices that collaborate
and work together to achieve outcomes for specific care packages.
This Strategy for Achieving Excellence in General Practice is driven by the
vision for Tower Hamlets CCG overall, as outlined in the NHS Tower Hamlets
Clinical Commissioning Group prospectus: our plans for 2013/16, as follows:
Developing integrated services around individual needs: The development of General Practice services to
meet current and future challenges are faced will underpin developments to deliver integrated care for
patients.
Delivery of high quality health and social care services: General Practice leads will work to develop and
support the spread of innovations in General Practice to improve the quality and responsiveness of services.
A vibrant and stable health and social care system: The General Practice leads will work with teams to build
resilience and positivity for the future of General Practice. The delivery of this strategy will secure the legacy
of General Practice in Tower Hamlets through the delivery of the change that is needed.
The “where are we now” picture for General Practice in Tower Hamlets is provided in detail in the Achieving
Excellence in General Practice: Current State Position paper (September 2013 – Appendix A ). Here we bring
together a summary of the key messages in the current state position paper, highlighting the achievements
made and challenges we need to collectively address. We have summarised this here using the life-course
approach as, being a universal service, General Practice services are delivered to people of all ages, and we
know at each stage there are critical factors that affect health that General Practice will be responding to.
The latest GLA population projections forecast a strong
population growth in Tower Hamlets. Between 2011-21
population is expected to rise by an extra 75,000 people to then
slowing down between 2021-31 (+40,000 people) and 2031-41
(+30,000 people).
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Our Strategy for Achieving Excellence in General Practice. Author: Lisa Henschen, North and East London Commissioning Support Unit. 15th January 2014,v2.0
The growth in the population is not evenly distributed within
the Borough and some areas are more affected by others. Also,
the projected growth is not constant over the time and often it
is concentrated during the first five years. The LAP Area with
the highest increase is Blackwall and Cubitt Town & Millwall
which is expected to grow by an additional 26,000 people over
the next 20 years.
We have a higher proportion of babies being born with low
birth weight (9%), compared to the rest of London (7.5%). This
is a high-level indicator of health of local babies and is strongly
influenced by maternal health.
There are high levels of economic deprivation across the
borough: General Practice will be addressing the health and
social implications of this. This will have an impact across the
life-course.
There have been significant achievements made in Tower
Hamlets in relation to the childhood immunisation programme,
moving from the bottom 25% of performers in London to the
top of London in relation to coverage.
The rate of emergency admissions in under-19s for asthma,
diabetes and epilepsy is one of the best in the country and
significantly better than the England average.
There is a young population, as well as high population churn,
which have an effect on GP list management.
There are high levels of childhood obesity in Tower Hamlets,
although the data is showing that the rising rates have
plateaued.
There is considerable evidence linking proximity of hot-food
takeaways to schools with childhood obesity. A recent British
review of the research evidence found that “children in schools
are exposed to more fast-food outlets than expected and this
has important policy implications”.
There are 37,900 5-19 year olds in Tower Hamlets, representing
16% of the total population (higher than the inner London
average). There are also 196 takeaways, equating to one
takeaway for every 193 young people. Moreover, there are 89
schools (75 primary and 14 secondary) within the borough, of
which 45 primary schools and eight secondary schools (60 per
cent) are currently within 200m of a hot-food take-away.
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Our Strategy for Achieving Excellence in General Practice. Author: Lisa Henschen, North and East London Commissioning Support Unit. 15th January 2014,v2.0
Local intelligence has indicated specific patient education in this
area is needed to ensure that young people use their General
Practice service appropriately and are educated to self-care
when this is appropriate.
We have a high and growing prevalence of long term conditions
in the borough – particularly diabetes as well as under-
diagnosis of dementia.
The Network-led approach of delivery of care packages have
shown significant success in supporting people with long term
conditions, particularly in diabetes care.
There is growth in the rates of obesity as recorded on practice
registers, as well as variation in other health promotion areas;
flu vaccination and cancer screening (breast and cervical).
We need to build on the pockets of excellent performance
locally in relation to comprehensive care plans being in place
for people with mental health needs, to address the variation of
65.7% to 100% performance in Tower Hamlets Practices.
There is significant local variation in relation to dementia
indicators, particularly in the use of anti-depressants; whilst
acknowledging overall that Tower Hamlets compares favorably
with England and London positions.
General Practice is providing support for the growing number of
patients with multiple long-term conditions, which has
implications in terms of the complexity of care needed in a
primary care setting by the patient. Variation in patient survey
results also indicate that supporting people to manage their
long term condition may also benefit from being a focus area.
Practices have indicated an increased need for home visits for
housebound frail and elderly patients, which are increasing the
pressure on services.
For many, the last years of life will be marked by frequent
hospital admissions with little attention to the natural history of
multiple morbidity. Most people, when asked, would prefer to
die at home but few achieve this. The last days and hours of life
for most will be unplanned and unsupported.
Tower Hamlets CCG has set out an ambitious integrated care
programme which is centred on holistic care, delivered through
a care planning approach (includes carers/ family) which is not
split up by diseases (convenient for providers) but rehabilitative
and shaped around what is important to the patient (goals). It
builds on the patient’s personal skills and resources and the
assets of the individuals and the community around them
(capabilities) and to support self-management wherever
possible.
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Our Strategy for Achieving Excellence in General Practice. Author: Lisa Henschen, North and East London Commissioning Support Unit. 15th January 2014,v2.0
Issues relating to the infrastructure supporting General Practice apply
across the life-course model. Key issues identified in our current state
document are:
We are seeing variance across Tower Hamlets Practices in the
provision of GP FTE provision per 100,000. We need to
investigate further the impact on outcomes and experience this
may be having.
67% (236/ 350) of the GP workforce are employed as
‘sessional ‘GPs in a variety of contracts by individual practices
which include salaried, locum or retainer posts.
Variations in funding levels for General Practice services exist,
which are likely to be impacting some practices in terms of how
they are able to respond to the challenges faced.
We are seeing capacity issues in relation to workforce planning
for Practice Nurses in Tower Hamlets.
There is significant growth in list size across Tower Hamlets
Practices with implications for capacity in General Practice,
both now and in the future.
Premises issues have been highlighted as a key challenge for
General Practices. It will be essential for primary care
development initiatives to link with other strategic plan for
capital developments of GP premises.
We need to consider the levels of clinical and non-clinical
staffing within Practice teams to investigate what an optimal
staffing level might look like.
We must focus on maintaining and building on the examples of
excellence seen in good team working within Practices.
The current state of General Practice has been a strong driver in the development of this strategy, to ensure
that in Tower Hamlets we build on our strengths, address areas for improvement and plan on the basis of
evidence.
STRATEGIC AND CONTRACTUAL CONTEXT
General Practice is playing a central and prominent role in national and
regional health policy development, and this has important implications for
the development of a local strategy for Tower Hamlets CCG, along with
recent changes to the GMS Contract. This section of the strategy brings
together some of these key areas for change.
National context: NHS Planning Guidance and a Call to Action in Primary
Care
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Our Strategy for Achieving Excellence in General Practice. Author: Lisa Henschen, North and East London Commissioning Support Unit. 15th January 2014,v2.0
NHS England will publish a strategic framework for the commissioning of General Practice services in 2014.
This will set out action to support commissioners in developing joint strategies for primary care as part of their
five year strategic plans. The key aim of this will be the integration of General Practice with other services.
There is a strong signal in NHS planning guidance for new models of primary care than can operate at scale –
working together to meet the needs of larger population groups. NHS England will produce a strategic
framework for supporting this approach. This 2014 planning guidance references the GMS Contractual
changes, in particular that there is will be a named GP for all people aged over 75 years, and signals that
similar arrangements will apply for all people with long term conditions in the future. It states that GPs should
be supported in their role as the accountable person for the over 75s and services should be commissioned
that support this role. The planning guidance references a need for greater individual Practice influence over
commissioning of community services and end of life care and more systematic arrangements for risk profiling
and proactive case management, under the supervision of a named GP for patients with complex health and
social care needs.
NHS England’s The NHS belongs to the people “The call to Action” paper sets out 4 key themes for primary
care:
Improving the quality of NHS care
Maintaining financial sustainability within the allocated and available resources
Meeting of everyone’s needs and expectations
Building on the excellent NHS of today for future generations
The Call to Action sets out that general practice should play an even stronger role at the heart of more
integrated out-of-hospital services that deliver better outcomes, more personalised care and excellent patient
experience. Debate within local communities to achieve this is encouraged, amongst GP practices, area teams,
CCGs, health and wellbeing boards and other community partners as to how best to develop general practice
services. The paper focuses on ensuring that in supporting reform of primary care, we must take great care to
build on the strengths of UK general practice through registered lists, generalist skills, management of long
term conditions and highly systematic use of IT.
Changes to the GMS (General Medical Services) contract in England for 2014/15
Important changes have recently been made to the GMS Contract, to be implemented from 1 April 2014 GP
practices will be contractually required to:
Provide more proactive care for people with complex health needs, empower patients and the
public, give parity of esteem to physical and mental health.
Named, accountable GP for people aged 75 and over who will have overall responsibility for their
care.
Promote more consistently high standards of quality and reduce inequalities.
More personal care for older people and those with complex health needs.
Out-of-hours services becomes a contractual duty for GPs to monitor and report on the quality of
out-of-hours services and support more integrated care, e.g. through record sharing whilst aiming to
reduce unplanned admissions through an enhanced service scheme.
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Our Strategy for Achieving Excellence in General Practice. Author: Lisa Henschen, North and East London Commissioning Support Unit. 15th January 2014,v2.0
Include the NHS number as the primary patient identifier in all clinical correspondence; and provide
an automated upload of their summary information on a daily basis to the Summary Care Record, or
have a published plan in place to achieve this by 31 March 2015.
Use the ‘GP2GP’ facility to transfer patient records between practices, or have a published plan in
place to achieve this by March 2015.
And from October 2014:
Allow for choice of GP practice. All GP practices will be able to register patients from outside their
traditional boundary areas without a duty to provide home visits.
In addition to the Contractual changes, the NHS Services, Seven Days a Week directive is also important to
note in relation to General Practice services as the standard aims to support services, both in the hospital and
in primary, community and mental health settings in the provision of seven days a week to ensure that the
next steps in the patient’s care pathway, as determined by the daily consultant-led review, can be taken.
It also states that Primary and community care services should have access to appropriate senior clinical
expertise (e.g. via phone call), and where available, an
integrated care record, to mitigate the risk of emergency
readmission.
Regional context: The London Case for Change
In addition to the National Call to Action for Primary Care, a
London Case for Change has also been developed to respond to
the specific challenges faced in the Capital. Primary care has
been the cornerstone of the healthcare system in London and
an important commitment is made in the London Case for
Change to maintain the integrity of the core purpose of general
practice within the current constrained mode through a series
of key functions:
Coordinated care
Accessible care
Proactive care
The key areas of change that are proposed in the London Call to Action are:
Issue What needs to happen
Population
London’s population growth and complexity are placing unprecedented levels of demand on general practice and the current service is struggling to respond effectively to rising health needs.
London needs urgent action to tackle health inequalities. General practice will need to adapt to rising levels of demand, proactively preventing ill health and coordinating care for people living with complex health needs in challenging social circumstances.
Economic London needs to commission for a general practice service that is delivered by sustainable and financially
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Our Strategy for Achieving Excellence in General Practice. Author: Lisa Henschen, North and East London Commissioning Support Unit. 15th January 2014,v2.0
London faces a significant financial challenge.
Practice finances are declining in real terms, exacerbating their inability to invest in service
improvements. Delivering smaller pump‑prime investment in primary care initiatives has the potential to release greater cost efficiencies over time.
effective organisations.
London needs to deliver an economic analysis that identifies the cost efficiencies that can be achieved by investment in building primary care capacity and capability.
Service changes
London CCGs are leading ambitious proposals to reconfigure local services to improve care that hinge heavily upon the ability to increase the capacity and capability of primary care services.
London needs to be bold in its ambition in order to deliver the capacity and capability shift required for primary care services.
Coordinated care
Patients with long term conditions account for more than 50 per cent of GP appointments and consume more than 75 per cent of the total health and social care spend. Improved care coordination has been shown to deliver better health outcomes, more satisfied patients and at a lower cost, vital for people living with multiple complex conditions.
London needs a primary care service that can provide greater continuity of care, more time with patients who need it, case management, multidisciplinary working and care planning in partnership with other parts of the health system.
Accessible care
Patients in London find access more challenging than in the rest of England.
Access impacts on patient experience and the quality of care they receive and also matters to practices whose workloads can become unmanageable if access is not managed in a systematic way. If patients find it hard to access their general practice then their diagnosis and treatment may be delayed, or they may choose to go to A&E because it is open and available.
London needs to respond to these challenges by shaping and developing new models for access that deliver convenient and reliable unscheduled care as well as coordinated and high quality continuity of care to a population with diverse needs.
Proactive care
Stark health inequalities exist across London. Many London boroughs fall below the England average on key preventative measures. Health promotion and primary prevention by general practice working in partnership with others will be key to reducing morbidity, premature mortality, health inequalities, and the future burden of disease in the capital.
London needs a more proactive approach targeting high-risk groups to improve the uptake of preventative services and to encourage them to present early. London needs a primary care service that can systematically enable patients to self-care, provide behavioural change support and/or referring to those who can assist with improving health and wellness for all.
Primary care needs to take action to overcome demographic challenges to improve levels of immunisation, diagnosis and screening in order to protect the health of Londoners.
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Infrastructure
Most practices in London remain relatively small, and could benefit from shared economies of scale. London has an especially high number of single-handers and GPs nearing retirement as well as a significant practice nurse shortage. The use of other primary care roles such as physician’s assistants and health trainers is patchy. Existing digital health opportunities are not being well utilised.
London has a higher than average proportion of smaller general practice premises, mainly in converted residential housing or older, purpose built, health centres.
London needs a primary care service that has the capacity and capability to provide the best care possible in a modern environment that enables multidisciplinary working and training, and in which the use of technology is maximised to better support patient care.
Primary care commissioning changes
Change to NHS organisational structures over the last few years have resulted in important differences for the
primary care commissioning landscape. Primary Care Contracting is now led by NHS England through its
regional teams. Primary care development remains a core Duty of Clinical Commissioning Groups, therefore
requiring a partnership approach across these two organisations.
Tower Hamlets CCG have a strong commitment to their role in primary care development and will ensure they
keep up the momentum that has been built over many years for supporting excellence in General Practice in
the delivery of high quality primary care, integrated care and out of hospital services
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Our Strategy for Achieving Excellence in General Practice. Author: Lisa Henschen, North and East London Commissioning Support Unit. 15th January 2014,v2.0
OUR STRATEGY FOR ACHIEVING EXCELLENCE IN GENERAL PRACTICE
Ou
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ctiv
es
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ree
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Ho
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his
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ieve
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1. To create and nurture an environment of leadership and
innovation for General Practice to deliver patient centred care
4. To ensure that General Practice in
Tower Hamlets is supported by strong
infrastructure to allow it to develop,
grow and deliver high quality,
equitable services for patients
3. To address the unprecedented
levels of demand for General Practice
services to meet patient needs.
Support for the key infrastructure required for change in General Practice:
- The General Practice workforce - Communication, engagement and technology - Training, development and building resilience
- Population growth and financial resources
Building network teams in Tower Hamlets and creating opportunities for enhancing collaboration across Practices to drive equity across services and create efficiencies through working at
scale.
Strong leadership for General Practice across Partners and the sessional workforce, nursing and
Practice management, with a structure and process for building
leadership for the future
2. To secure the role of General
Practice teams as the expert
generalists in the wider health care
system, who works with other
providers to integrate services for
patients
5. To maximise what we can achieve
through working collaboratively
across Practices and with local
communities in the network
arrangements
Healthy and resilient Practice teams,
a sustainable future workforce and
adequate resourcing for General
Practice
Piloting, evaluating and implementing new ways of working to address demand for General Practice services. For example: - Better information for patients to manage expectations
- Social prescribing - Developing micro-teams to improve continuity of care
- Using technology to create efficiencies
Create systematic pathways for leadership across the entire General Practice workforce that encourages and creates
space for local innovation
Practices who are able to flex
adequately to meet the needs of
their population, with an improved
patient experience
Greater and more effective
collaboration across providers,
reduced administrative burden and
improved patient experience across
the pathway
Create equity in clinical and patient
experience indicators, greater
dissemination and uptake of Best
Practice across Networks and strong
community engagement
Creating clinical communities in Tower Hamlets to support the role of the GP as the expert generalist, supported by other
providers, who work towards common goals for patients, innovate to support whole system collaboration which place patients at the
heart of quality improvement and provide co-ordinated care, closer to home.
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Our Strategy for Achieving Excellence in General Practice. Author: Lisa Henschen, North and East London Commissioning Support Unit. 15th January 2014,v2.0
OUR OBJECTIVES FOR THE STRATEGY
We have five key objectives in the delivery of this strategy. The objectives and the rationale for them are as
follows:
Tower Hamlets has a strong foundation for clinical leadership,
developed over a number of years to support innovation and
development of services. Recent changes to the commissioning
landscape have resulted in an enhanced model of clinical leadership
through Tower Hamlets Clinical Commissioning Group. Building on a
strong foundation, leadership for General Practice is the first objective based on our identification of the
following needs that have been identified:
Tower Hamlets has a workforce that is made up of 67% (236/ 350) employed as ‘sessional ‘GPs in
a variety of contracts by individual practices which include salaried, locum or retainer posts.
When looking at GP Partners and Salaried GPs, salaried GPs make up 60% of the headcount of the
workforce and 46% FTE hours. This is in addition to the Practice Nursing, Practice Management
and administrative workforce who are currently not well represented in leadership roles. This
workforce is a potential untapped resource in relation to clinical leadership for General Practice
that through this strategy, we will seek to engage and develop.
There is a need to ensure that with GPs in Tower Hamlets taking on additional roles in leading
commissioning, that the leadership for General Practice service delivery remains strong and
visible on the ground.
There are currently no clear pathways for aspiring leaders for General Practice in Tower Hamlets.
This objective for clinical leadership directly impacts all areas of this strategy, and will be key to the successful
implementation of the subsequent objectives and proposals for change.
1. To create and nurture an environment of leadership and innovation
for General Practice to deliver patient centred care.
“It’s like being a Tesco’s manager but
only ever working on the tills” - Tower
Hamlet’s GP
2. To secure the role of General Practice teams as the expert generalists
in the wider healthcare system, who works with other providers to
integrate services for patients;
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Our Strategy for Achieving Excellence in General Practice. Author: Lisa Henschen, North and East London Commissioning Support Unit. 15th January 2014,v2.0
A major cause of frustration and
low levels of morale, for both
General Practice teams and
patients is the interface with
secondary care, relating to both
administrative and clinical issues.
We believe that many of these issues are a result of a lack of synergy in the goals and purpose of care for
patients between primary and secondary care services. Through this strategy, we will seek to remove the
organisational and professional boundaries that are currently in place, which prevent a joint focus on the
needs of the patient and the common goals that professionals need to deliver in order to meet these needs.
The average number of appointments per patient in general
practice has risen from 3.6 to 5.5 between 1995 and the most
recent measure in 2008 (NHS England 2013). Tower Hamlet’s
population is growing at a fast rate and General Practice is facing
substantial pressure from an increasing prevalence of long-term
conditions and co-morbidity. This is creating an unprecedented
level of demand on General Practice services, as reported in our
Case for Change. Doing nothing when faced with this is not an
option. This strategy sets out changes that could be made for
managing this demand.
We have heard consistently from the
General Practice workforce in the
development of this strategy that whilst
there are important changes that need
to be made to the way in which General
Practice operates, changing working practices alone will not be enough to deliver the change that is needed.
General Practice is dependent on infrastructural factors, such as its workforce, income levels, technology,
communication and engagement mechanisms, training and development. External factors such as population
growth have a direct impact on how resilient General Practice can be to address the issues that it faces now
and in the future. Building this strong infrastructure is therefore a key objective of this strategy.
3. To address the unprecedented levels of demand for General Practice
services, both to support Practice teams and to meet patient’s needs.
“It’s brutal out there in terms of the
pressure” - Tower Hamlets GP
4. To ensure that General Practice in Tower Hamlets is supported by
strong infrastructure to allow it to develop, grow and deliver high
quality, equitable services for patients.
“Team work, communication, sharing information, supportive environment, work-life balance, expanding own skills and developing special interests - getting funding and support for this”
- Tower Hamlets GPs on what excellence means to them.
“I would like to see someone take over-all responsibility for my
care…whether that is a GP, a nurse, a consultant…I don’t care…I just need
some help pulling it all together. A lot of focus goes to the hospitals but if
we’re talking about ‘managing’ my condition then surely that is a primary
care thing?” – Local patient
“Doctors always say that we shouldn’t
talk about more than 1 issue per
appointment. If we can’t openly talk to
our doctor and feel rushed we will feel
more unwell and then what do we do?”
– Local patient
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National and regional policy in relation to General Practice services is very much signalling the view that the
traditional GP partnership model, which currently serves a national average of around 6,650 patients per
practice, is too small to respond to the financial and demographic challenges facing the NHS (Smith and others,
2013).
Tower Hamlets already operate an innovative system of Networks of General Practice, which have delivered
significant achievements in developing a more cohesive primary care community and reducing variation in
quality, for example seen in QOF results, diabetes care and childhood immunisation performance.
With the increasing complexity of our population and the number of people with co-morbidities and long term
conditions, working at scale – Practice collaborating to deliver services to a larger population base - will
become even more important in addressing these challenges. Enhancing the current system of General
Practice networks is a way in which this could be achieved, and potential areas for this collaboration are
explored within this strategy.
DELIVERING THE ACHIEVING EXCELLENCE IN GENERAL PRACTICE STRATEGY
To achieve the objectives of this strategy, we are setting out five key areas for focused change.
1. GENERAL PRACTICE LEADERSHIP AND INNOVATION
A key objective of this strategy is to create systematic pathways for General Practice leadership across the
entire primary care workforce that helps the system as a whole to innovate to create new ways of working,
using this leadership as encouragement to test new ideas, communicate the outcomes and support other to
adopt where these have been successful.
To achieve this, we will introduce a General Practice Leadership Programme for GPs, Practice Managers,
General Practice nursing staff, healthcare assistants and administrative teams with the objective of innovating
for and leading the change that has been identified as being needed
within General Practice. We believe that this leadership programme
would be best delivered within the current network arrangements.
The Tower Hamlets General Practice leadership programme will:
Identify the future leaders for General Practice in Tower Hamlets through establishing and raising
awareness, including through appraisals, of clear pathways for leadership across the entire
General Practice workforce;
“How can we put patients first unless we put ourselves, our staff and our own practices and organisations in order?” - Tower Hamlets GP
5. To maximise what we can achieve through working collaboratively
across Practices and with local communities within the network
arrangements.
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Deliver a blended programme of clinical leadership training, incorporating formal training, peer
support and mentoring from existing General Practice leaders, delivered through network
arrangements;
Develop the skills that are needed for future General Practice leadership, including:
o Creating space for and encouraging innovation amongst the General Practice workforce;
o Developing partnerships and clinical communities with provider services and the local
authority that support service integration;
o Utilising effective business management techniques to improve efficient operation of
General Practice;
o Seizing opportunities for closer collaboration within and across networks;
o Identification and spread of Best Practice;
o For clinicians, focusing on new ways to manage multiple-morbidity, supporting patients
with long term conditions and supporting new approaches to managing solution focused
consultations.
Focus specifically on those parts of the General Practice workforce that are not currently well
represented in a leadership role – in particular sessional GPs, the Practice Nursing, Practice
Management and administrative workforce.
To strengthen leadership for the Practice nursing workforce through transitioning the current Open
Doors Nursing team into the Achieving Excellence in General Practice programme and supporting this
team to act as the mentors for Practice nursing in Tower Hamlets.
Action to be taken to develop leadership across the General Practice workforce is:
Year 1 Design and establish the programme for clinical leadership in Tower Hamlets, in partnership with both current clinical leads and representatives of groups that the programme will aim to specifically focus on.
Identification of peer support structures and mentors for the programme within the network arrangements.
Recruit first cohort onto the programme. Formalise the identification of future leaders within the appraisal process. To transition the Open Doors nursing team to the Achieving Excellence in General
Practice programme, establishing them as the mentors for the Practice Nursing workforce. A remit of this work will be to look at incentives for Practices to train student nurses.
Year 2 Implementation of leadership programme and monitoring against the target groups for the leadership programme.
Year 3 Continuation of the roll-out of the leadership programme through Tower Hamlets networks.
Create formal roles for new General Practice leaders identified. Evaluation of the programme against the aims of the scheme.
Investment implications
Investment proposal to be submitted to support the leadership programme.
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2. CREATING CLINICAL COMMUNITIES IN TOWER HAMLETS TO SUPPORT THE
GP AS THE EXPERT GENERALIST IN THE SYSTEM
General Practice teams have a pivotal role to play in the coordination and continuity of care for
patients, and their role as this coordinator within the wider healthcare system needs to be recognised and
supported.
We believe that cultural change is needed first and foremost in the ways the different parts of the healthcare
system interact with each other, as well as improvement to administrative and communication processes.
Creating clinical communities in Tower Hamlets
This strategy is closely aligned with the “creating clinical communities”
programme in Tower Hamlets. The creating clinical communities
programme has been driven by the need for clinical engagement to deliver
day to day improvements to healthcare services, not just needing to be in
place to deliver programme of whole scale, system wider change. The
programme seeks to remove the organisational and professional
boundaries that are currently in place, which prevents a joint focus on the needs of the patient, and the
common goals that professionals need to deliver in order to meet these needs.
Patients are the central part of this clinical community in Tower Hamlets. Where there is synergy in goals for
patient care, based on the outcomes that they want to be delivered, these outcomes can be the driver and the
lever for service integration.
The creating clinical communities programme in Tower Hamlets is focused on cultural change that is needed.
We believe that this cultural change will deliver the required communication and administrative change that
has been identified by Practices, and through this strategy we will maintain a focus on these issues, which are
specifically:
An aim to end all paper-based methods of communication
across healthcare agencies, with communication in the future
being delivered solely through electronic means.
Communication between agencies which is clear about roles,
responsibilities and the need for follow-up of issues, for
example, for there to be a clear communication of expectations
when GPs are copied into abnormal results.
To ensure prescribing is appropriate as patients move across organisational boundaries and does not
result in an administrative burden elsewhere in the system.
Increasing access to secondary care guidance and advice
Access to secondary care advice that is consistent across all specialities, timely in nature and maximises the
opportunities technology provides in enhancing this is central to supporting General Practice teams in their
“Patients should push, chase and follow
up their hospital appointments, but
people need more information about
their role and how to do this.” - Local
patient
“I spent an hour last week sorting out just one patient’s problem because of secondary care issues.” – Local GP
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role as the expert generalists within the wider healthcare system. To achieve this, the following change is
needed:
The email advice and guidance function provided to General Practice from Barts Health NHS Trust
needs to be formalised across all specialities, along with set timescales for specialist response. This
support should be reflected within contractual agreements.
Creating online forums for clinical engagement, building on the clinical information repository
proposed in the communication, technology and engagement section of this strategy. These on-line
forums should provide a mechanism for formal advice and guidance, as well as informal networking
and relationship building across organisations.
To pilot using electronic imaging across primary and secondary care, starting with dermatology with a
view to evaluating the impact that this might have on out-patient referrals.
Greater collaboration between General Practice and Community Health Services
Community Health Services are a central part of health services to local communities, particularly for
vulnerable, frail and elderly patients, and the integration of these services with General Practice is central to
supporting the care coordinating role of the GP.
The Coordinated Care Network Improved Service (NIS) will be a key driver in joint working across General
Practice and provider services, in particular Community Health services and palliative care. This NIS sets out a
process of pro-active care planning, delivered in partnership with community health services, targeted towards
high risk patients and delivered through a generalist and holistic approach. The refocus on General Practice
teams as the expert generalists within the broader healthcare system is reflected within this NIS, advocating
an approach to delivery of care that is not split up based on disease, but that is rehabilitative and shaped
around patient goals, builds on their personal skills and resources and the assets of individuals and
communities around them.
In addition to delivery of this Coordinated Care NIS, there is a general need for improved collaboration
between General Practice and community health services. We will seek to extend the influence of individual
Practices in the commissioning of associated community services, community nursing, especially district
nursing, and end of life care, so that accountable or named GPs can discharge their responsibilities and ensure
that these services are co-ordinated with the services and provide integrated care for patients. This aligns with
recent planning guidance issued to the NHS (NHS 2013: Everyone Counts: Planning for Patients 2014/15 to
2018/19.). To achieve this, in the first instance Tower Hamlets CCG will raise awareness amongst all Practices
and their teams of the requirements and standards that form the community health services contract and set
out a process for raising queries where these Contractual obligations are not being met.
Action to be taken for supporting the GP as the expert generalist is as follows:
Year 1 First year implementation of the creating clinical communities programme across Tower Hamlets CCG and Barts Health NHS Trust.
Formalise specialist email advice support function in contractual negotiation.
Tele-dermatology pilot to commence.
Building on the current system of service alerts, to issue guidance to all Practice in Tower Hamlets regarding the community health service contract and set out a process for raising contractual queries in relation to Community Health Services.
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Year 2 Monitor key outcomes from the clinical communities’ programme that is supporting this strategy, in particular the move to electronic communication across organisations as standard.
Consider outcomes of tele-dermatology pilot and consider how technology could be used to improve communication across primary and secondary care for additional specialties.
Year 3 To be agreed following review of year one and two.
Investment implications
The actions required will be supported by investment funding secured from complementary work programmes:
o Coordinated Care Network Improvement Service - £1,200,000 o Planned Care – tele-dermatology pilot £18,640
3. ADDRESSING DEMAND FOR GENERAL PRACTICE SERVICES
Addressing the unprecedented levels of demand for General Practice, to support Practices to meet patient needs, has been a key driver for the development of this strategy. In our case for change, we have shown the evidence of pressures faced by General Practice as a result of this demand. We have also seen innovative solutions developing for how this demand can be addressed, locally, nationally and internationally. All elements of this strategy are focused on developing solutions to addressing this demand, whilst focusing on delivering high quality General Practice services. We believe that Practices in Tower Hamlets, either collaboratively or in their own right, have the skills and capabilities to addressing demand for services within a context which:
Supports General Practice to have the time and space to look at their business processes to identify solutions;
Allows best practice that is showing positive outcomes to be shared and understood in a local context;
Supports Practices through an initial pump priming resource investment to test new ways of working. To achieve this, an innovation for excellence in General Practice fund will be established to create the context that this needed for change, when supported by the other elements of this strategy. The innovation fund will resources those who want to be creative and try something new, which can be tested and brought to other Practices if successful. This innovation fund will be available to all Practices in Tower Hamlets, in their own right or as part of a collaborative arrangement with other Practices or in their network arrangements to pilot new approaches to managing demand. We encourage new innovations from Practices, as well as bids for piloting approaches where we have seen evidence of effectiveness to date and which we have had confirmed interest from Practices for trialling as potential solutions . Appendix D brings together the evidence that we have for these approaches, which in summary are:
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“Fundamentally this will make people
better and genuinely empower them to
have some control of their lives.
It feels like I am doing more
preventative care, primary prevention
and secondary prevention. That is very
satisfying and it would be satisfying for
most people.” - Tower Hamlets GP on
social prescribing
Proposal Description Trials of this proposal to date
Innovations to support pre-consultation planning
Contacting all patients before a routine appointment to check they are seeing the right healthcare professional and all routine tests they might need are completed.
Midlands Health Network, New Zealand.
GP telephone triage, healthcare assistant or receptionist led triage.
Aberfeldy Practice and Jubilee Street Practice, Tower Hamlets.
Requesting information from patients in advance of their appointment about the purpose of the visit to get them to the right healthcare
A number of Practices locally and nationally.
Providing information in the Practice, and in patient information packs, on the healthcare professionals in the Practice and who to see for what condition.
A number of Practices locally and nationally.
Intelligent waiting rooms
Receptionists working with iPads in the waiting room to collect information from the patient about their visit and sign-post them to services where needed.
None aware of – new innovation.
Enhancing pharmacy input across Practices
Possibly in a network model, providing with medication management support to GPs and medication reviews with patients.
Midland Health Network, New Zealand
Using technology to create efficiencies in General Practice
On-line support for self-care care
Opportunities for on-line consultation.
Currently being piloted in Tower Hamlets Practices – evaluation pending.
Supporting efficiencies within networks
Rationalising administrative costs
Improving coordination of back-office functions
Some examples of new models of care for General Practice have included developments of efficiencies across General Practice.
Whilst problems with consultation length featured strongly in the Case for Change from the perspective of
patients and Practice teams, we have not made explicit investment proposals within this Strategy for
extending consultation length. We consider that investing in
initiatives to improve efficiencies and ways of working in General
Practice through the innovation fund is an approach that is more
sustainable and the most effective use of available resources. It is
also expected that the outcomes delivered through the innovation
fund developments to support demand management, will support
Tower Hamlet’s urgent care programme, particularly in relation to
a reduction in A&E attendances.
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In addition to the innovation fund, we are proposing through this strategy some specific initiatives that would
have benefit to all Practices in Tower Hamlets. These are as follows:
To extend the social prescribing scheme, currently operating at the Bromley-by-Bow Health Centre to all
Practices in Tower Hamlets, based on the evidence of effectiveness from evaluations to date (Appendix
D).
Social Prescribing acts as a mechanism for linking patients with non-medical sources of support within
the community, maximising collaboration between agencies by providing a stronger focus for joint
commissioning and provides an adjunct to traditional treatments such as antidepressant prescribing
and talking therapies. It also provides considerable scope for improvement in mental health and
wellbeing for vulnerable individuals, groups and communities, especially for those with mild to
moderate mental illness, low income single parents, the bereaved and those with a long-term physical
health condition.
The evidence has shown this is an important intervention in addressing demand, providing high
quality services and meeting the social needs of patients, which has been reported as a high priority
through our engagement with Practice teams to date.
We are proposing a staged rolled out of social prescribing, commencing 2014/15.
To take a proactive role in managing patient expectations for General Practice services through the
production of information for patients detailing what General Practice will and will not provide, as well as
the responsibilities for patients and how they can get the best out of General Practice services and the
broader healthcare system.
To explore opportunities to address issues around prescribing and the management of minor ailments in
General Practice, for example, through the production of a CCG wide policy on the GP’s role in managing
minor ailments e.g. paracetamol and vitamin D prescribing. The current Pharmacy First scheme will also
be reviewed within this context to ensure that this is providing the best possible service to support the
management of minor ailments.
Supporting Practices in their bids for the Prime Minister’s Challenge Fund, where their bids align with the
CCG’s strategic objectives. On 1 October, the Prime Minister announced that there would be a new £50
million Challenge Fund to stimulate innovative ways of providing primary care services. There will be at
least nine pilots covering an overall total of half a million patients, with at least one in each region of
England, to support the spread of innovation. The pilots are intended to test a range of options for
improving access to general practice, such as extended hours, weekend opening and better use of
‘telecare’.
Action to be taken for addressing demand for General Practice services is as follows:
Year 1 Establish the processes for application and allocation of innovation funding for Practices in Tower Hamlets.
Agree evaluation requirements for pilot programmes.
Allocation of first year of innovation funding.
Staged roll-out of social prescribing to commence.
Develop and issue the guide of managing patient expectations for General Practice services.
Provide feedback to NHS England on the emerging issues around prescribing and the
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management of minor ailments in General Practice and feed into their review the Pharmacy First scheme.
Year 2 Evaluate first tranche of innovation funding projects. Based on evaluation, applications to be made for any funding that might be
associated with wider roll out of successful schemes. Review success of scheme and make decision on whether a second year of an
innovation fund would be of benefit to Tower Hamlets Practices. Full roll-out of social prescribing to be completed. To take forward plans for addressing issues around prescribing and the management
of minor ailments in General Practice.
Year 3 To be determined based on a review of years 1 and 2.
Investment implications
Secure funding for the innovations fund through an investment proposal for this strategy. Securing funding and resources for patient information packs about General Practice to be
developed as a consistent template version, that can be localised at a network level (2013/14 funding)
Support from investment funding secured from complementary work programmes: o The roll-out of social prescribing across all Practices in Tower Hamlets which will be
incorporated into the investment proposal for £500,000 for a 'high risk patient’ investment fund.
4. A STRONG INFRASTRUCTURE FOR GENERAL PRACTICE
This section focuses on the change that is needed to support the infrastructural
requirements for General Practice in relation to the workforce, income, technology,
communication and engagement, training and development as well as external factors such
as population growth.
THE GENERAL PRACTICE WORKFORCE IN TOWER HAMLETS
Workforce planning
The General Practice workforce is an essential enabler of the delivery of both primary care and integrated care
services in Tower Hamlets.
Tower Hamlets CCG maintain records of the local General Practice workforce, at a Practice and network level,
detailing the number of GPs, nurses and healthcare assistants in each Practice, the status of GPs, in relation to
principle, salaried and locum GPs and the status of GPs in relation to the performers list.
This data shows that there are:
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To enable effective workforce planning, the CCG in its role supporting primary care development needs to
have accurate and up to date information about the local workforce. Whilst the numbers of staff working in
Practices is useful, the full time equivalent hours worked by this staff makes the information meaningful to
understand the capacity in General Practice, as well as having a detailed understanding of the skill set of this
workforce. How this relates to Practice income, as well as any variation in clinical outcomes is also important
information.
At present, the CCG’s access to workforce data is limited. To be able to effectively support General Practice in
primary care development, we believe that establishing processes for obtaining up to date, accurate and
relevant data about the GP workforce, held by the CCG is needed and is the priority in the first year of the
strategy, with any development action necessary to follow in subsequent years.
Named General Practitioner approaches
In addition to having effective management information about the workforce in Tower Hamlets, there are
evidence based changes that can be made to the configuration
of the workforce in General Practice to support team and
individual resilience and continuity of care for patients. The
concept of micro-teams in General Practice has been reviewed
in a variety of publications (see Appendix D). Micro-teams
offer a way of providing care continuity where there is a
notable part time workforce and significant demands of access
to General Practice appointments.
Micro-teams typically are made up of two or more General
Practitioners, and can also include a Practice Nurse. Patients
are assigned to this team of practitioners, rather than an
individual named Doctor. The team provide continuity of care
350 GPs working in Tower Hamlets
•33% are Principle GPs
•67% are "sessional GPs" (salaries, locum or retainer posts)
106 nurses working in
Tower Hamlets
•81 are Practice nurses
•20 are advanced nurse specialists
•The rest work in specialist areas
50 Healthcare assistants working in
Tower Hamlets
A North London Practice has established micro-teams to manage
care continuity. Patients were allocated to the red, blue, green or
yellow team. Percentage of patients seen by their regular GP
rose from 27% to 42%
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to that patient, and support to each other in terms of discussing, reviewing and planning their care. There are
a number of different ways Practices could implement this system, including getting patients to choose their
care team, based on information that is provided to them. We believe that the evidence of this approach is
strong enough for us to advocate this as an approach across Tower Hamlets Practices and to secure resources
that will enable Practices to take this forward as an approach.
Practice nursing
We are aware specifically through the analysis that has formed the current state position paper for this
strategy (Appendix A), that there is a specific issue in relation to the Practice nursing workforce in Tower
Hamlets, which has not been growing in recent years in line with the growth of the population in Tower
Hamlets. Through our engagement in the development of this strategy, we have been made aware that there
are challenges with securing placements for student Practice nurses and the lack of incentives in place for
Practices to take on the student placements. Therefore, a key element of the nursing leadership roles,
including those nursing mentors who are transitioning from the open doors programme, will be to develop
solutions and propose change in this area to ensure that there are appropriate incentives in place.
COMMUNICATION, TECHNOLOGY AND ENGAGEMENT
Communication, technology and engagement are key enablers to the delivery of the vision of this strategy.
There many components within this that relate to the internal operations of General Practice, interaction
between Practices and the way that General Practice interacts with provider agencies. The areas we will focus
on for change are:
Using a clinical information repository on the Tower Hamlets GP intranet site to improve how we
communicate with secondary care
Hold all forms and details of processes for referrals for all specialities and providers in one place on
the intranet that is current and up to date at all times.
Provide a facility for posting of clinical queries between primary and secondary care, with a robust
indexing system so that queries can be stored and searched.
Improve networking and information provision to General Practice in Tower Hamlets
Full engagement of the GP community through on-line blogs, comments pages, instant polling and
information dissemination that ensure people are up to date and influencing discussions and strategy
direction and report on positive example of new ways of working to tackle the challenges that
General Practice face.
Establish mechanisms for sharing of Best Practice across Practices.
Developing innovative ways to engage with General Practice in Tower Hamlets through maximising
opportunities presented through technology– uploading videos onto the intranet site of training or
useful talks and ways for people to share their experiences.
TRAINING, PERSONAL DEVELOPMENT AND BUILDING RESILIENCE
“At the GP reception, good customer service means eye contact, body language, smile, good attitude,
welcoming, helpful, problem solver not gatekeeper, signposting, respecting, listening. Treating someone as
they would want to be treated if they were ill.” - Local patients defining excellence in General Practice
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Our engagement with GPs and Practice teams has signalled the
importance of training and personal development to build the resilience
of General Practice. Training and personal development have been
shown to be highly valued by the General Practice workforce through our
engagement mechanisms as well as a key component of excellence.
Tower Hamlets CCG currently have an extensive and highly valued training and development programme
operating – Protected Learning Time (PLT). PLT is provided for Tower Hamlets Practices one afternoon per
month on a range of clinical topics such as child health and asthma, as well as non-clinical topics such as time
management and HR Law for Practice managers.
It has become evident through our work in the development of the strategy that there is a need for a
refreshed focus on the skill set of individuals working in General Practice to enable them to respond effectively
to the challenges that are currently faced and improve the patient experience. In the main, these relate to
the development of consultation skills and support to build both individual and team resilience to the
challenges that are faced for example:
Developing solution focused approaches as a consultation style;
Working with patients to support them in the self-management of their long-term conditions;
Supporting GPs in the management of multiple-morbidity and taking a generic approach to managing
long term conditions, with a move away from specialisms in single conditions;
Supporting innovations through visioning techniques such as “Six Hats thinking”, where participants
engage a range of thinking roles, metaphorically referred to as hats. This process uncovers all the
potential benefits, creative possibilities, unseen risks and hidden options.
Managing stress and building resilience.
POPULATION GROWTH AND FINANCIAL RESOURCES
The significant population growth in Tower Hamlets has been highlighted in the context section of this strategy
and is further illustrated in figure 3:
“There is a lot of variation in the
consultation skills of Doctors. Some can
make you feel like a burden” - Local
patient
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Robust planning to ensure that General Practice in Tower Hamlets is effectively resourced to respond to this
significant population increase is needed. Tower Hamlets CCG will need to work with NHS England and the
Local Authority to model the impact on General Practice as a result of this growth and secure the resources in
terms of the General Practice workforce that will be needed to support this. This will also need to include
looking at where Practices are working at full capacity in relation to their premises and do not have the scope
to grow. Where this is the case, options for additional General Practice services may need to be considered.
The impact of the GMS Contract changes in relation to choice of General Practice for patients will also need to
be considered in relation to the impact on General Practice capacity in Tower Hamlets, for those Practices who
have opted in to these arrangements.
In addition to planning for population growth, we need to be able to identify and respond effectively to
resources and funding sources that are made available to support General Practice development, particularly
when financial resources are limited.
Funding opportunities present themselves throughout the year, and there are challenges in communicating
these opportunities to General Practice teams. Potential opportunities that could be explored, outside of the
CCG investment routes are:
Funding available for pilot work under the “pioneers” programme for extended-hours.
Greater opportunities for collaboration with other CCGs working across the Barts Health footprint, in
order to share costs across the sector.
Investigate opportunities to better use the budget allocated to Community Health Services through
improved integration on the provider side.
London General Practice Development projects and associated resourcing made available through
this.
Opportunities that might be available through Barts Health Charity, which could be delivered in
partnership with the CEG.
256,012
331,336
371,150
400,146
200,000
250,000
300,000
350,000
400,000
450,000
2011 2013 2015 2017 2019 2021 2023 2025 2027 2029 2031 2033 2035 2037 2039 2041
No
. of
Pe
op
le
Years
Population Projections in Tower Hamlets (2011 - 2041)
Figure 3: Population projection in Tower Hamlets - Source: GLA Ward-Level Population Projections 2012 Round, SHLAA-Based
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Action to be taken for developing the infrastructure for General Practice are as follows:
Year 1 Workforce
To escalate the data sharing issue to a senior level in NHS England through the CCG management team in relation to workforce and financial information sharing.
To propose that data returns on FTE workforce data sent to NHS England are copied to the CCG primary care lead to ensure a routine system is established.
To assign specific responsibility within the CCG for collection and maintenance of this management information, including collecting information about the skill set of the General Practice workforce and career aspirations for the workforce, including looking at which salaried GPs would like to move into Partnership roles.
Advocate and secure the resources to support the development of micro-teams in General Practice to support continuity of care and build professional support within the Practice.
Communication, technology and engagement
Raise awareness of the clinical information repository and work with network teams for necessary information upload.
Launch the information portal with secondary care clinicians and agree working practices for using this as a mechanism for responding to queries.
Develop robust indexing system for the clinical portal.
Establish engagement mechanisms through the GP intranet site.
Training, personal development and building resilience
Undertake, or capture where they already exist, training needs audits in Tower Hamlets, focusing on non-clinical as well clinical skills, and developed a refreshed training strategy as a result of this.
Build awareness of the benefits of non-clinical training (e.g. solution-focused approaches) through talks and taster sessions.
Population growth and financial resources
Take forward joint working between the CCG, NHS England and the Local Authority to ensure robust planning for population growth. Consider options where General Practice in areas of high population growth is at capacity and any additional investment that may be needed to address this.
Communicate through the GP intranet all opportunities for funding and work with networks to develop collaborative bids for funding where possible.
Year 2 Workforce
To triangulate data in relation to workforce capacity, income and clinical outcomes to understand drivers for variation in Tower Hamlets.
Communication, technology and engagement
Review across primary and secondary care and update where necessary communication mechanisms to ensure the intended outcomes are delivered.
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Training, personal development and building resilience
Implement refreshed training strategy for General Practices.
Year 3 Workforce
To consider taking forward plans to set standards within networks in relation to the General Practice workforce. This will be dependent on any national contract negotiations and changes and will involve joint working with the Local Education and Training Boards, who will take a leading role in education, training and workforce development for current and future needs.
Communication, technology and engagement
Review across primary and secondary care and update where necessary communication mechanisms to ensure the intended outcomes are delivered.
Training, personal development and building resilience
Evaluate impact of refreshed training programme in line with the outcome measures within this strategy.
Investment implications
Investment will be needed to support Practices in developing micro-teams – to be included in investment proposals for this strategy.
There is a need to secure a resource for workforce modelling – TBD if this requires investment. Investment needed for a refreshed training programme to be identified following a training needs
audit. There are opportunities to use network training budgets if high needs are identified. There may be a need for investment in General Practice capacity following a review of population
growth. This will be taken forward by the estates working group. Support from investment funding secured from complementary work programmes:
o £195,000 (TBC) to support and evaluation the pilots in Tower Hamlets for on-line consultations and technology solutions for improving contact with secondary care.
o £60,000 (TBC) for Protected Learning Time for General Practice
5. BUILDING OUR NETWORK TEAMS IN TOWER HAMLETS
Our objective is to build on the current systems of General Practice Networks in Tower
Hamlets to enhance collaboration amongst Practices and to support General Practices working a greater scale
to create efficiencies and better meet the needs of local populations is an important area of this strategy.
General practice will play a critical central role in delivering integrated care in Tower Hamlets. This will involve
changes to the way providers in the local health economy work together to deliver patient centred care. To do
this, General Practice will need to develop its leadership role across the borough, its influence and
engagement with other key major health and social care providers and optimise Practice and network
collaboration.
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In light of these drivers for change, General Practice representatives from the eight networks set up a ‘Task &
Finish Group’ to consider how to enhance the networks model already in place to meet some of the emerging
challenges. The group has worked together to develop a shared vision for building the networks model to a
borough level and created the shared infrastructure to engage with other key providers of integrated care
services within the borough and take the integrated care model forward. The planning is currently underway
for the next stage of work to develop the proposal further and grow these new arrangements. As these plans
firm up, the links with this strategy will be explored in more detail to understand where there are common
objectives between the two projects and connect these up appropriately.
The Network system will also be the area of focus for the development of leadership for General Practice, with
Networks taking a lead role in the identification and support for future leaders of General Practice. This
leadership at a Network level will support the innovation needed to build networks teams, enabling them to
be more transformational in the way that they approach scaling up and sharing of resources, through
examples such as shared functions and shared employment arrangements.
Within this strategy, we are not advocating for any particular model of
a scaled-up version of General Practice. There is no strong evidence
for an “ideal size” of General Practice and the appropriate structure of
General Practice should be a matter for local determination. Through
this strategy, we wish to set the foundations for encouraging greater
collaboration and a broader focus on opportunities for shared
functions in the delivery of General Practice services will come from
Networks developing as strong and functional teams, on the basis of:
Gaining trust: as the most important characteristic of a team;
Mastering conflict: encouraging passionate, unfiltered debate about important topics;
Achieving commitment: creating teams that commit to decisions and standards;
Embracing accountability: developing the willingness of team members to remind one another when
they are not living up to the team's performance standards;
Focusing on results: agreeing what the results the team are working to and keeping them visible in
people’s minds.
Adapted from Lencioni (2005) Overcoming the five dysfunctions of a team
To date, action learning sets operating within Networks have been shown to be an effective mechanism for
building trust and commitment to Network teams. Entry into these
Network sets and ensuring that this is available for all General
Practitioners within a network arrangement, including sessional GPs
will be important in ensuring that the benefits of these ways of
working are universally owned.
Building on this approach, our engagement and research of
opportunities for an enhanced model of Network support in Tower
Hamlets has shown greater potential for collaboration in the following
areas:
“Isolation is the worst illness – GPs
should refer to community centres,
support people in getting to know their
neighbours – know who to target for
this type of intervention.”
- Local patient
“If anyone asks me what makes a network tick, I tell them it’s the glue. It’s not just one thing, but many components that make an organisation gel together. Networks have their own personalities and how they function is a composite of the individual units that are brought together.” – Tower Hamlets Network Chair
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Action to be taken for building network teams are:
Year 1 Each Network to consider, as part of the training needs analysis, the organisational development needs of the Network itself, the strength of the network team, breadth of engagement in the Network and any development needs.
Networks to agree the mechanisms that would be most effective for them to increase information sharing and raising awareness of Best Practice within their own and across other Networks.
Population health and anticipatory care planning
• To plan for healthcare needs at a population or community level will require Practices to work collaboratively, within and across their Network areas, and in partnership with the locality based borough teams.
• This will include active engagement of Networks at a strategic level, involvement in the joint strategic needs assessment processes specifically, as well as in the delivery of healthcare and anticipatory health planning approaches.
• The Coordinated Care NIS will be an important vehicle for supporting this collaboration at a Network and multi-disciplinary team level.
Real, valuable and positive engagement with local communities
• Networks are already working in innovative ways to engage with their local communities, for example through “pop-up clinics” in local markets and engagement with local primary schools for the delivery of health promotion initiatives.
• These activities provide a mechanism for creating a good and positive discussion about General Practice in local communities, a process for seeking meaningful feedback about services and how they are meeting the needs, and provide opportunities for education about self-care, self-management and appropriate use of available healthcare services.
Pro-active sharing of Best Practice within and across Networks
• Our engagement with Practices in the development of this strategy has shown pockets of good and innovative Practices across the General Practice community in Tower Hamlets. However, there is a lack of awareness of these initiatives between individual Practices and between the Networked Practice arrangements.
• The opportunities to make better use of the resources for change and innovation already existing within the local General Practice community are significant. To capitalise on this, the development of a greater range of mechanisms for sharing ideas and experiences need to be in place is needed, for example:
• Greater opportunities for informal professional networking;
• Increasing on-line information sharing, using the GP intranet as the primary source;
• Creating opportunities for mentoring in difference Practice environments to see how innovative solutions are working in Practice.
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Networks to set out their plans for real and valuable community engagement, which will include planning how success will be measured and good practice shared.
Year 2 To consider the effectiveness of multi-disciplinary collaboration with Networks and locality areas for the delivery of the Coordinated Care NIS and consider how this approach might be adopted in other areas of joint working.
Year 3 For networks to be implementing a greater range of collaborative working Practices, increasingly at an operational level, sharing resources and developing greater joint functions.
Investment implications
None specifically from this strategy, although investment proposals are being considered to support network developments
Support from investment funding secured from complementary work programmes: o Network management funding £1,200,000 ( £150k x 8 networks) o Training funding £128,000(£16k x 8 Networks)
OUTCOMES OF THE STRATEGY
Measuring the outcomes delivered as a result of this strategy will be of central importance in making sure that
we are on track to deliver the change that is needed for General Practice. In measuring the impact of the
Strategy, we seek to work collaboratively with Tower Hamlet’s Clinical Effectiveness Group to ensure the
investment the CCG already makes to measure clinical effectiveness of initiatives deployed also captures
measurements for high quality, equitable services in General Practice.
There are five key outcomes that have been identified for delivery through this strategy. These outcomes and
the associated measures are detailed below. The methodology for collection of the indicators is detailed
within this strategy’s accompanying implementation plan.
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Established clinical leadership programme
Representative leadership structure in place across
General Practice
At least one sessional GP recruited p/a
Action learning sets in place across all networks,
made up of a representative group from the GP
workforce
At least one Practice Manager recruited p/a
Leaders supporting innovations in General Practice
At least one Practice Nurse recruited p/a
Leaders working together across networks to identify
and spread innovations and Best Practice
No. of formally identified leads for General Practice
by Network, Locality and in total
Peer support processes established
Mentoring processes established
Process measures Outcomes
Outcome 1: Strong leadership for General Practice across Partners and the
sessional workforce, nursing and Practice Management, with a
structure and process for building leadership for the future
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Clinical advice service available across all specialities (process tracked by number of specialities this is available for)
Improved interface between General Practice and the broader clinical community measured by
Reduced complaints
Feedback from patients and GPs
Aligned monitoring with the Coordination of Care NIS.
Electronic imaging in place for dermatology services and plans to extend to other specialities based on the outcomes of the pilot in place
Improved access to services for patients measured by:
Time of response to requests for email advice from GPs
Patient experience of access to outpatient services
Number of DNA s for outpatient services
Number of contractual queries raised about community health services from General Practice
Improved clinical pathways, measured by:
Number of emergency readmissions
Number of GPs involved in OD and professional development programmes with secondary care
Service improvement and transformation, measured by:
Feedback on achieving a cultural shift in how services are planned and delivered
Number of GPs attending informal networking opportunities with secondary care
Process measures Outcomes
Outcome 2: Greater and more effective collaboration across providers,
reduced administrative burden and improved patient experience
across the pathway
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No of Practices who have made successful applications to the innovations fund (target - 25% of Practices per year)
Improvements in patient access to General Practice services, to be observed through Patient Survey results, feedback from Patient Participation Groups and feedback from General Practice teams.
No. of innovation fund pilots adopted as business as usual for Practices (target - 50% of pilots)
Improvements in Continuity of Care, to be observed through Patient Survey results, feedback from Patient Participation Groups and feedback from General Practice teams.
No. of successful innovation fund pilots extended to other Practices
Improvements seen in annual barometer health check with Practices in Tower Hamlets on measures related to addressing demand
No of Practices actively engaged in social prescribing (< 20 referrals per year)
No of Practices issuing information packs for patients on rights and responsibilities (target - 50% of Practices)
Process measures Outcomes
Outcome 3: Practices who are able to flex adequately to meet the needs of
their population, with an improved patient experience
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Local systems established with full and up to date picture of the workforce in Tower Hamlets in place
Improvement in the health and resilience of Practice teams measured through an annual barometer check of the GP workforce
Clinical information repository in place and actively managed to ensure information about local services and referral mechanisms are current and up to date.
Improvements in Continuity of Care, to be observed through Patient Survey results, feedback from Patient Participation Groups and feedback from General Practice teams.
Clinical queries posted on GP intranet site, which are responded to and indexed for future references
Improvements in access for patients, measured by the annual patient survey
Mechanisms for engagement with General Practice are in place and there is active engagement with them across the General Practice workforce
Active and engaged General Practice workforce, with over 50% of Practices communicating and sharing information via the GP intranet site
Information about local Best Practice approaches are uploaded onto the intranet
Training needs of the workforce identified and action plan in place, with a specific focus on non-clinical skills development
Plans in place for responding to impact of population growth
Micro-teams established in Practices of over 6,000 patient list size
Process measures Outcomes
Outcome 4: Healthy and resilient Practice teams, a sustainable future workforce
and adequate resourcing for General Practice
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Each Network has reported as part of their training needs analysis on the development needs of the network.
Equity of outcomes across networks measured by outcome indicators where there is currently significant variation:
Access (Making an appointment and telephone access)
Dementia indicators -anti-depressant prescribing
Comprehensive care plans being in place for people with mental health needs
GP FTE provision per 100,000 registered population
Flu vaccination
Emergency admissions per 1,000 population
Progress against development plans for networks reported and refreshed annually, which include opportunities and progress made against opportunities for greater collaboration
At least four forums per year held to share Best Practice across Networks
Plans for community engagement in place and delivered
Process measures Outcomes
Outcome 5: Create equity in clinical and patient experience indicators,
greater dissemination and uptake of Best Practice across
networks and strong community engagement
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IMPLEMENTATION PLAN
Following the approval of this strategy, an implementation plan will be produced which will contain the detail
around the timescales of the implementation of initiatives and process for monitoring of the outcomes.
The Achieving Excellence in General Practice Programme Board will have responsibility for oversight of the
implementation plan.
CONCLUSION
It is clear from the work undertaken in the development of this strategy that for the development of General
Practice, doing nothing is not an option. It is also clear that within the current economic climate, that
significant investment in General Practice is not a realistic expectation. The purpose of this strategy is to set
out the start of a journey over the next three years, in which we can harness the skills and expertise that exist
currently in our local General Practice community, to create an environment that support innovation to
achieve the change that is needed.
We hope that the strategy and solutions proposed within it create excitement and hope for the future of
General Practice in Tower Hamlets.