achieving excellence in general practice in tower hamlets our strategy for change … · integrated...

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


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


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.


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.


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.


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.

Our Strategy for Achieving Excellence in General Practice/Author: Lisa Henschen / Version 0.4


Ou

tco

me

s th

at w

e w

ill s

ee

Ou

r o

bje

ctiv

es f

or

the

thre

e y

ear

s o

f th

e s

trat

egy

Ho

w t

his

will

be

ach

ieve

d

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.


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.


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;







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.



arrangements.


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)


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

of 47

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

of 47


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

of 47


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

http://www.nationalvoices.org.uk/index.html

of 47


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).

of 47


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.

of 47


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.

of 47


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

of 47


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.

of 47


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

of 47


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.

of 47


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

of 47



Ou

tco

me

s th

at w

e w

ill s

ee

Ou

r o

bje

ctiv

es

for

the

th

ree

ye

ars

of

the

str

ate

gy

Ho

w t

his

will

be

ach

ieve

d

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.


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.

of 47


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.



“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;

of 47


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.


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




“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

of 47


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



arrangements.

of 47


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.

of 47


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

of 47


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.

of 47


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.


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:

of 47


“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.

of 47


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

of 47


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.


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:

of 47


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%

of 47


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

of 47


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

of 47


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

of 47


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.


Review across primary and secondary care and update where necessary communication mechanisms to ensure the intended outcomes are delivered.

of 47



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.


Review across primary and secondary care and update where necessary communication mechanisms to ensure the intended outcomes are delivered.


Evaluate impact of refreshed training programme in line with the outcome measures within this strategy.


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.

of 47


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

of 47


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.

of 47


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.


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.

of 47


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

of 47


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


Outcome 2: Greater and more effective collaboration across providers,

reduced administrative burden and improved patient experience

across the pathway

of 47


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)


Outcome 3: Practices who are able to flex adequately to meet the needs of

their population, with an improved patient experience

of 47


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


Outcome 4: Healthy and resilient Practice teams, a sustainable future workforce

and adequate resourcing for General Practice

of 47


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


Outcome 5: Create equity in clinical and patient experience indicators,

greater dissemination and uptake of Best Practice across

networks and strong community engagement

of 47


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.

achieving excellence in general practice in tower hamlets our strategy for change … · integrated...

Documents