Primary Care Strategy

2017 - 2022

1

2

Foreword by the CCG Chair Welcome to the Isle of Wight CCG’s Primary Care Strategy. This strategy supports our vision for a safe, sustainable and high quality primary care service, provided in modern premises that are fit for purpose. We need this strategy because we want to help patients to stay well for longer, connect people to sources of community support and ensure people receive joined-up out of hospital care. We want people to experience a similar service no matter which practice they are registered with and how that practice is run. We want to see greater integration between community services and primary care particularly focused on the needs of people with complex conditions or who are increasingly frail. Finally we want to ensure that those with urgent needs are seen and treated in as timely a way as possible. All this requires resilient primary care services at the core of local communities, playing a leading role not only in the provision and co-ordination of high quality medical care and treatment, but also in supporting improved health and well-being. It means we need enough health professionals across the Island to deliver high quality services for our whole population working in the most efficient and effective ways possible. The pages that follow set out the challenges we face in realising this vision, such as increased demand, a growing and ageing population with more complex needs and workforce pressures. We need to find ways to use the opportunities we have to play to our strengths and, wherever possible, meet these challenges with local solutions supported by local clinicians and local communities. We know that our primary care sector remains strong because despite the very real pressures that exist, there continues to be high levels of patient satisfaction with access to clinicians and evidence of good outcomes for patients. We also know however that there is a lot to do to maintain this position; and unless we find and implement solutions particularly to the workforce issues that we will not maintain this state. In response, there is a growing resolve and common purpose amongst primary care professionals on the Isle of Wight to explore new ways of working to protect and enhance primary care services. Our strategy therefore, which has been developed with input from clinicians and patients, will guide the way in which the CCG will commission Primary Medical Care over the next five years.

3

Contents

Page Number The Island Context 4

Rising Demand for GP Services 5

Challenges in Primary Care 6

Vision for General Practice 7

System Transformation 9

Improving Access 10

Urgent Care 12

Chronic Disease Management 13

Workforce 14

Workload 15

Digital Enablement 16

Estates 17

CCG Facilitation and Support 18

Patient and Public Engagement 19

Implementation Timetable 20

Investment Plan 21

4

The Island Context

Accessible only by sea/air (weather dependent)

Small, remote island 23 miles wide by 13 miles long

Single system, single boundaries (1 CCG, 1 Trust, 1 Council)

Low earnings; higher than average long term unemployment; 20% children live in poverty; low GCSE attainment (45%)

Population of 142,000; est’d £300m health & social care budget

2.5m visitors p.a.; multiple festivals and events

Increasingly elderly population; 26% over 65 (17% england average) and over 12% over 75 (8% england average) 4% over 85 (2% england average)

Recruitment and retention issues

5

In 2015, the CCG commissioned work to understand what the future of primary care would look like in 10 years time if no action was taken. This showed that demand for GP services is going to rise significantly whereas the numbers of GPs and other professionals will fall. This means that as an Island we urgently need to support the recruitment and retention of primary care staff and we have to think about different ways to deliver primary care services on the island to make sure that people get the care that they need.

“The number of over 65s per practice is around 90% higher than the national average. Given the large forecast growth in this age group this raises issues about the sustainability of

the primary care sector, especially when considered alongside the age profile of the current GPs.” (KPMG)

By 2024/25 a significant increase in GP & Nurse led appointments is predicted:

By 2024/25 a significant increase staffing is required:

57,372 Additional GP appointments, 10%

increase

29,258 Additional Nurse led appointments, 10%

increase

9 Additional GP’s (on top of 10 GP vacancies currently required, and turnover of potentially

30 GPs)

Rising Demand for GP services

6

Challenges in Primary Care Primary Care, like many parts of the health service is under increasing pressure and is struggling to deliver ever more complex services. In developing this strategy and working closely with GPs and patients, the CCG has identified the following challenges in primary care which the strategy needs to address: • Maintaining high quality primary medical care services in the face of increasing demand for services and reducing budgets

• The perception of reduced access to GPs from patients combined with growing expectations of what primary care will deliver

• The need to provide integrated services across the Island across community, primary care and social care, breaking down barriers between different parts of the health and wellbeing system to support patients.

• Finding an increasing amount of time in an already busy day to spend on preventing people from becoming unwell

• Ensuring that the number of people having a positive experience of care in primary care and in the community is increased

• Dealing with the pressing need to change the workforce, reduce workload and increase recruitment and retention across all professionals in primary care

• Ensuring continuous quality improvement in core care, delivered consistently across primary care

• Moving from working as individual practices to system working and delivering primary care “at scale”

• Ensuring that buildings are fit for purpose and in the right places to meet the needs of our changing demographics

• Simplifying the way in which services are contracted– including developing outcomes based contracting and enabling new models of care

7

Vision for General Practice • To address the challenges that we have identified, the CCG together with patients and local professionals has developed the following

vision for primary care

By 2022 we will…

…develop a seamless system of primary and community care based around locality and neighbourhood services that meet people’s needs

…sustain and improve access to primary care, increasingly through digital means. Self management will be supported wherever possible. There will be access to GP services in the evening and at weekends

…ensure premises and IT are fit for purpose

…improve the way we support people with urgent needs, but not always with a face to face appointment. Technology will be in place to support people to achieve the care they need

…ensure that people with complex and long term conditions will experience joined up coordinated care. Patients will be at the centre of the care they receive, with their GP surgery working as part of an integrated locality services

…improve patient outcomes as professionals increase their skills, knowledge and competence

…ensure that primary care professionals will feel supported and fulfilled as we reduce bureaucracy, develop new job roles, and enable professionals to reduce personal liabilities

…ensure practices are run with sustainable business models

8

To achieve our vision we will...

During the consultation phase in developing this strategy, patients and professionals have told us that it is important we bear in mind five key principles against which we should test our proposed work programmes. These will be used to help us decide how we go about implementing this strategy.

The five principles that we will work to are to:

• support and enable innovation in the organisation and delivery of care for patients

• develop primary care infrastructure specifically in relation to premises and IT that sustains innovation, quality and patient satisfaction

• increase the available workforce and resources for primary care and support improved work-life balance

• maintain high levels of patient satisfaction with primary care services • ensure that we maintain the high quality of care that patients receive,

ensuring that the CCG delivers its statutory requirements to support continuous quality improvement and choice

9

System Transformation • There are a number of overarching enabling objectives that need to be delivered to support the wider system transformation. These will

be delivered early in the strategy and will underpin the more operational changes envisaged by this strategy. • Between 2017 and 2019, the CCG will use dedicated project support and investment to enable the CCG to change the way it works and

support primary care providers to deliver these objectives. • The CCG will support the primary care community to:

– develop the GP federation and encourage collaboration between member practices to deliver services at scale across localities and the Island

– develop the workforce to enable staff to undertake new and extended roles

– undertake recruitment of GPs, nurses and wider professionals in primary care

– create common procedures across Island GP practices that reduces variation and supports high quality care

• The CCG will:

– support the development and delivery of the model for integrated community and primary care services based on three localities

– issue contracts that reflect new ways of working across multiple practices and organisations (such as alliance/prime provider contracts)

– implement technology that allows staff to work remotely and across multiple sites and patients to access services electronically

– support and enable new models of practice ownership where that will secure sustainable and effective services.

10

Improved Access For patients timely access to primary care services is one of their highest priorities and while access to GPs on the Island has historically been very good, the annual IPSOS MORI survey of patient satisfaction shows a slow decline in satisfaction with access to primary care. There are a number of ways in which we will seek to improve access. • The CCG will preserve and improve opening hours

– We will seek to maintain core opening hours of 8.00am – 6.30pm Monday-Friday in all GP practices – We will continue to commission practice-based extended hours from those practices who wish to provide this service. Practices

choose to provide at different times according to their patient profile. These could be after 6.30 in the evening, on a Saturday morning or for some early morning

– We will commission seven day routine and urgent access to primary care (see next page)

• As well as improving opening hours, the CCG will support practices to implement strategies that reduce demand whist improving the patient experience including:

– increase the ability of patients to do things for themselves including extending online booking; prescriptions; queries and implementing online triage across all practices. We will explore how to create a shared back-office for GP practices including call management to speed up communications for patients

– implement new ways of consulting including using telephone and e-consulting, so patients can access primary care without needing to travel to a surgery unnecessarily

• GP practices report that many of the demands made of them are not part of the services they are commissioned to provide. We will work with Patient Participation Groups and public to measure how effectively demand is met and define a “reasonable need”.

11

7 Day Primary Care Services • As part of the Five Year Forward View for Primary Care, the CCG will commission seven day access to primary care from September 2017.

For patients using this service, they will be able to have a similar experience to that which they would receive in their own surgery. In 2017/18, the CCG must commission 72 hours of this new service per week rising to 107 hours thereafter.

• There are a number of national requirements for this service must meet including: – providing access to routine and urgent primary care services – be available from 6.30 – 8pm each day and on Sat, Sun and Bank Holidays according to local demand – include online booking and new ways of working such as online consultation – directly bookable by patients and widely advertised. – specifically address areas of health inequality

• Following consultation with patients and professionals, the service will be delivered as a single service across the whole island during the

weekends, with locality based services during weekday evenings. The CCG will seek to let a single contract to commission this service. • This service will be GP led and staffed by a team of professionals, so patients will see a mixture of GPs, nurses, healthcare assistants,

pharmacists and musculoskeletal practitioners.

• The GP medical records of patients choosing to attend this service will be available offering a seamless link between a person’s registered GP and this service.

• In order to tackle health inequality, the CCG has identified key routine services where outcomes could be improved through longer

opening hours. The ambition is to deliver a range of services offering better choice and opening hours for patients, particularly the young and those who work. This first services offered could include:

– Sexual health services – Chronic disease management clinics, particularly focused on working age and younger people – Childhood vaccinations – Phlebotomy – Leg ulcer management

12

A new approach to urgent care In the longer term, the service provided to people who have an urgent care need will be reshaped. This needs to happen in response to the rising demand from patients and the increasing trend to use a team of healthcare professionals. Over time, we anticipate that practices will start to work together to deliver urgent care, particularly in the larger towns where there are multiple practices. The CCG will seek to support these trends To do this we will: • Redesign in-hours urgent care to support practices to manage increasing workload, including:

– Implement signposting in primary care, enabling patients to see the most appropriate professional to meet their need – Support workforce redesign to enable greater streaming of patients in primary care – Implement software which supports patients to access appropriate urgent care on-line – Support the implementation of locality clinics in hours to share pressures of increasing patient demand – Implement island-wide common approach to urgent care triage working with the GP Federation – Implement an acute visiting service

• The CCG will redesign and recommission Primary Care Out of Hours to enable:

– A simplified approach to accessing services out of hours – services to be accessed in the community rather than operating from a hospital setting – Integrated out of hours with the new 7- day primary care service

13

Chronic Disease Management A chronic disease is defined as a long term physical health condition that requires ongoing management over a period of years or decades. As we all live longer, it is increasingly common for people to have more than one chronic disease and this poses challenges for healthcare professionals in balancing treatment regimes and patient expectations. Extreme old age and frailty poses similar issues for primary healthcare professionals. The majority of chronic disease management takes place in primary care with practices delivering structured care across the major disease groups. While this approach has worked well against individual disease indicators, it is increasingly failing to deliver the integrated person-centred care that is now required. As part of the Whole Systems Integrated Review conducted in 2016, Island professionals considered how services for people with chronic diseases should be organised and delivered. As a result of this work, the CCG will: • Implement a wellbeing model of chronic disease management characterised by

– developing a cadre of health coaches actively supporting behaviour change – Investing in services that support patient activation – Encouraging self care with patients taking greater responsibility for their own health

• Support primary care professionals to spend more time with the most complex and vulnerable patients by implementing island-wide care planning and risk stratification

• Safeguard continuity for people who require the most complex care input by recognising the centrality and importance of the named GP for those patients

• Support the development of Multi-Disciplinary Teams across primary and community care that support more complex or frail patients • Ensure that our contracts incentivise the management of complex patients in the community rather than in hospitals

14

Workforce

A significant driver for change in primary care is the changing nature of the work that needs to be done and a nationwide shortage of GPs. Primary medical care has been synonymous with “seeing the GP” since the inception of the NHS, however the nature of the work is changing such that a team approach is now required. This means that while services will be GP led, they may not always be GP delivered, relying instead on other healthcare professionals. In addition to the national drivers, there are also some particular issues that we have locally focused on our geography and local economy which makes attracting people to work on the island more difficult. Our assessment is that if we did not change the workforce in primary care, practices would need to recruit a minimum of 39 Whole Time Equivalent GPs to the island by 2021 just to stand still. This is unlikely to be achievable so thinking more creatively about how primary care works is absolutely vital to its future sustainability The CCG has already begun investment in workforce development funding both Advance Nurse Practitioners and Pharmacists in general practice and is working with three island practices to pilot Physicians Assistant roles. In addition four practices in West and Central Locality have been working with a Musculoskeletal practitioner to see if direct access to this kind of professional would take pressure off GP appointments. All of this work is changing the nature of the work that the GP undertakes freeing them to focus on more complex care. In addition to the work we are already undertaking, the CCG will: • explore setting up a local bursary scheme aimed at making the island more attractive to the GP community • increase the number and range of clinicians working in primary care such as Advanced Nurse Practitioners, Pharmacists and

Physiotherapists who can undertake some of the role currently done by GPs • support practices to further develop team working procedures to reduce reliance on GPs • increase training in primary care professional workforce such that the island can become more self reliant • offer career development as locality working and collaboration become a reality.

15

Workload

The GP 5 Year Forward View highlights workload as another of the key areas that needs to be tackled to make primary care more sustainable. There are numerous other tasks that GPs do that are essentially hidden from view, primarily associated with paperwork. Through the Prime Minister’s Challenge Fund, Brighton and Hove GPs developed a way of safely enabling their non-medical workforce to take on some of that workload through careful training and standard operating procedures. This has demonstrated that it is safe and effective to develop medical assistants –administrative staff who are supported and trained to undertake reviews of basic clinical correspondence on behalf of GPs. Based on the experience from Brighton and Hove where 15% of GP time was freed up, we estimate that 100 hours a day of GP time could be released across the Island to spend with patients or on planning care. To achieve this level of efficiency, the CCG will: • develop non-medical workforce to undertake greater range of tasks in practice including undertaking some administrative

tasks currently undertaken by GPs and nurses

• implement signposting and care navigation at first contact with the practice

• simplify NHS bureaucracy by reducing the number and complexity of transactions between commissioners and practices using the functionality of TPP (the GP IT system) to best effect

• simplify access to information for practices through better use of electronic and internal communications

16

Digital Enablement

Historically Primary Care has been at the vanguard of adopting new technology in the health service, however it has not yet embraced the opportunities arising from a connected society, the internet and changing ways of communicating. As the population changes, it is important that primary care changes to match. In doing this, practices will be able to release time both clinically and administratively that can be redeployed to manage demand more effectively. Working as part of the wider Wessex Sustainability and Transformation Plan, the CCG will: • Implement the Hampshire Health Record to facilitate record sharing between primary care and mainland hospitals during 2017 • Install Wi-Fi access in all GP surgeries for both staff and patients supporting more efficient working practices and self management by

2018 • Ensure that 100% of patients are able to ask for access to online records, digital prescriptions and appointments and progressively

increase the number of patients who are using that facility by 10% during each year of this strategy. • Actively support and increase the ability of patients to use the self-service functions described above • Increase ability of other primary care professionals, such as community pharmacists, to access GP summary care records to improve

patient care • Implement e-consulting across primary care for those who would like interact with their GP practice digitally by the end of 2018 • Fully implement e-referral moving by 2018 to a completely paperless referral process between primary care and other services • Work with communities who have limited or no broadband to ensure that they have equitable access to digital health services

During the consultation on this strategy, we received strong feedback that not all people wish to or can engage with their GP practice through a digital platform. This must therefore remain an option for people rather than an expectation. In implementing this agenda the CCG will be mindful of the potential impact of creating parallel streams of access into primary care. It will commission support to practices to change their processes to ensure that both digital and traditional access routes are treated with equal importance.

17

Future Primary Care Estate Some of the buildings that we currently use to deliver primary care are not fit for purpose, and some of our smaller practices will struggle to survive as the complexity of care and demand from patients intensifies and existing GPs reach retirement age. Having looked carefully at the demographics on the Island, transport links and the existing building stock, we have identified three strategically important locality areas and nine further neighbourhoods. • In line with the My Life a Full Life strategy, the localities will in time deliver extended primary care

services. Some more specialist services will also be delivered from these locations including services for highly vulnerable patients, group consultations and in time outpatient appointments. New locality Hubs in Newport and Sandown will be developed under the “One Public Estate” work programme.

• GP practices servicing identified neighbourhoods will deliver core family medicine 5 days a week

and may also deliver some extended community care such as telemedicine monitoring. In time larger sustainable practices are likely to emerge which will allow registration areas to be extended creating greater choice for all patients on the Island.

• The CCG will continue to support existing smaller surgeries while GP partnerships are able to

sustain services from those locations, however we will not normally prioritise new investment into these locations.

• The CCG will not seek to close any surgery building outside the neighbourhoods, however should any of these practices become unviable, for instance because doctors retire or leave, we will seek to disperse patients to the nearest neighbourhood surgeries.

• 3 Localities:

– Sandown – Ryde – Newport

• 9 Neighbourhoods:

– Shanklin – Ventnor – Brighstone rural – Freshwater – Cowes – East Cowes – St Helens – Wootton – Niton rural (as an

Atypical population)

18

CCG facilitation and support The work programme which sits alongside this strategy has implications not just for the GP practices but also for the way in which the CCG goes about its business and organises itself. The CCG needs to focus its resources on supporting practices in the wide ranging operational and cultural changes that are needed to implement this programme. The CCG will: • Assign at least one CCG staff member to each locality to provide:

– Facilitation to GP practices to help develop and implement new ways of delivering services

– Help with change management tools and techniques

– Support project management and planning

– Provide time and energy to drive change

• Actively work to review contracting systems within the CCG to minimise the impact of paperwork and assurance processes on practices • Support innovation and spread of new ideas coming from primary care through locality working, education and all-island events.

19

Patient and Public Engagement Patient and Public Engagement in this change programme is fundamental to its success, both so that people understand the changes that will take place, and also in changing the way in which people use services. The CCG will: • support patient participation in primary care by investing in the development of practice based Patient Participation Groups (PPGs).

This work will be led by Heathwatch in 2017/18. • specifically, seek to engage patient participation groups to help patients understand how best to use primary care services raising

awareness and increase acceptance of new ways of consulting and primary care delivered through the team. • develop a wider communications programme to support this transformation programme which ensures that the CCG is taking notice of

what patients want and need to know. This includes: – Being honest about our intentions and brave in the way we communicate – Celebrate what is good in primary care – Provide a clear explanation of how services will be delivered – Communicate in such a way that we create confidence in new roles – such as Advanced Nurse Practitioners and pharmacists

20

Implementation timeline Q1

17/18 Q2

17/18 Q3

17/18 Q4

17/18 Q1

18/19

Q2 18/19

Q3 18/19

Q4 18/19

19/20

20/21

Deliver 7 day services

Implement e-consultation

Further roll out Patient Online services

Training for clerical staff to support signposting

Workflow redesign to release GP time

Implementation of common processes (TPP benefit realisation )

Development of GP Federation and collaborative working

Primary Care involvement in Integrated locality working

Implement new contracting models

Implement digital enablement programme including Wi-Fi and HHR

Develop and Implement health coaching and Patient Activation

Develop wider Patient involvement in transition and change

Redesign CCG Primary Care Team

Reduced Bureaucracy Programme

Fully implement E-Referral and repeat e-dispensing

Develop and implement estates programme

Primary Care recruitment and retention campaign

Scope and implement Acute Visiting Service

Scope locality based urgent care and implement solution

Workforce development and redesign

21

Investment Plan 17/18 – 18/19

Area 2017/18 2018/19

Primary Care Transformation Fund. To be used to support the programme of change in primary care. This is funded from within existing CCG resources over two years £213,000 £213,000

Extended access fund. New money allocated nationally to support the implementation of 7 day working in primary care £948,000

Active signposting and medical assistants. Non recurrent national allocation to support training of reception staff to signpost patients to the most appropriate service and further training for Medical Assistants £24,000

Workforce development. From existing CCG resources, this fund supports innovation in workforce development and allows practices to experiment with new staff roles £300,000

Online consultation systems . New recurrent money from a national allocation to support implementation of online consultation software in primary care. £37,000 £49,613

Digital Roadmap. Utilising a variety of funds including capital allocations, GP IT funding and the Estates Technology Transformation Fund, this will improve the digital infrastructure in primary care TBD

Estates Strategy. The CCG will be working with a range of third part developers and through the One Public Estate strategy to identify funds streams to support new buildings TBD

Total investment £1,222,000 £562,613

The CCG will make the following investments in primary care over the next two years in line with the 2016/18 Operating Guidance. The table below identifies the monies that have been made available and how they will support the implementation of the primary care strategy. In addition the CCG invested £315,000 during 16/17 to kick start the transformation programme.