primary medical care plan west leicestershirepolitics.leics.gov.uk/documents/s97387/appendix 1 west...

Primary Medical Care Plan West Leicestershire

Patients, practices and partners working together to create the bestvalue healthcare for the population of West Leicestershire

West LeicestershireClinical Commissioning Group

Patients, Practices, Partners

2.0

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2.0 | Primary Medical Care Plan West Leicestershire | 2

Table of Contents

Issued by West Leicestershire CCG.

Issue date: 12 November 2014 version 2.0 — Release version

Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .122. Case for Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

The Local EnvironmentThe External Environment Primary Care Perspective

3. Our Ambition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Our commitment to the patientWhat Primary Medical Care will look like five years from now

4. Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .275. Enablers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Federated Localities – making general practice thriveBetter Collaboration and Reducing BureaucracyHelping Practices Be Attractive Places to WorkInvestment in PracticesExploiting TechnologyListening to and increasing the participation of patientsImproving Quality and Patient Outcomes by IntegratedWorking

6. Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .417. Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .458. Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

Risks9. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

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Executive Summary

1. IntroductionThis document is a system-change plan which responds to thechallenge set out by Better Care Together of a ‘left-shift’ from acutecare to out-of-hospital care, and responds to the key principlesestablished by an extensive engagement process with clinicians,stakeholders and patient representatives. The CCG builds on a strongbase of achievement, but recognises that it must pay special attentionto governance, systems for managing conflict of interest, funding,workforce issues and effectively managing the ‘left-shift’ so that itsees a genuine movement of resources and activity.

2. Case for ChangeWest Leicestershire CCG covers about half the area and population ofLeicestershire County. From a primary care perspective, key issues arean ageing population, rising demand, increased prevalence of longterm conditions, and clinical quality concerns in specific areas.Additionally, an ageing GP and practice workforce will lose 1/3 of itsnumbers to retirement in the next fifteen years. There are substantialissues with premises which must be addressed. The health economyas a whole faces a 21% funding gap within five years. However,working through the Better Care Together partnership and with otherpartners and stakeholders, the CCG is actively participating in aprogramme to manage these issues, in which this plan plays a keyrole.

3. Our AmbitionThe CCG’s promise to the patient is Consistently High Qualitywhich is Responsive and Accessible, Integrated, Sustainable andPreventative. Currently we have not fully realised the potential ofgeneral practice and too often patients receive care in hospital thatcould be safely provided in the community, coordinated through theirgeneral practice, supported by the wider health and social care teams.We have a clear vision for the future of primary care in our CCG inwhich general practice is the foundation of a strong, vibrant andjoined up health and social care system.

We believe that the vast majority of health problems in thepopulation — including mental health — could be dealt with byprimary and community care. To achieve this, the changes we envisionwill mean that primary medical care will in five years’ time be moreintegrated and federated, with patients co-designing services andtaking increased responsibility for their own health. This new system ispatient centred, and provides accessible high-quality, safe, needs-based care. This is achieved through expanded — but integrated —primary and community health care teams, offering a wider range ofservices in the community with increased access to rapid diagnosticassessment and co-located specialists. This will require a shift of

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resources from the acute sector, investment in facilities, and a greaterrole for nurses, pharmacists and healthcare assistants.

4. ModelOver the next five years our new model for general practice will berealised - the practice and the primary healthcare team will remain thebasic unit of care, with the individual practice patient list retained asthe foundation of that care. However, whilst a large proportion ofcare will remain within a patient’s own practice, an increasinglysignificant proportion will be provided by practices coming togetherto collaborate in federations, using their expertise, sharing premises,staff and resources to deliver care for and on behalf of each other. Inthis way, it will be possible to improve access and provide an extendedrange of services to our patients at scale.

The benefits of this model have been carefully analysed in terms ofthe challenge laid down by Better Care Together and the principles setdown through the engagement process.

5. EnablersA number of enabling strategies are necessary for us to achieve thissystem change. These include the development of Federations whichwill support practices to thrive and in time take a greater role in co-delivering services. Opportunities offered by Co Commissioningenhance our ability to co-ordinate and integrate care and improvecurrent administrative processes. The level of system changes requiredto implement the plan will require funding. This will require usingexisting resources to work differently and more efficiently supportedby one off sources of funding to support transition.

6. PlanA high level set of actions with time scales, measures and who isresponsible to complete them has been developed which will take theCCG from its current model of care to the new model of care by2018.

7. ResourcesWe have established the base-line of overall resource needs to achievesystem change, along with the benefits accruing. These resources arefinancial, material, staffing and equipment.

8. GovernanceWest Leicestershire CCG has established robust mechanisms ofgovernance, and is supporting the federations to develop equivalentmechanisms. A programme of monitoring, evaluation andimprovements will be put in place, and the whole will be supportedby effective communications. A number of risks to the plan have beenidentified, and mechanisms developed to manage them.


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9. ConclusionThe primary medical care plan sets out the system change required totransform out of hospital care and the pivotal role of general practicein this context. Care will be commissioned for the individual which isright for their needs, good value to the public purse, and whichcontributes to the ongoing renewal of the services. Supplementedwith the enabling strategies, this will allow the CCG to support athriving and resurgent General Practice which is attractive to newentrants to the profession, and attractive to colleagues in other partsof the country considering relocation. The result will be the re-establishment of the Practice at the heart of the community, and astrengthening of GP-patient confidence. We will provide a betterservice which reflects the changing needs and aspirations of WestLeicestershire people.


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1. Introduction

Our journey so farThis plan continues the work that we started three years agowith our mission ‘Patients, practices and partners workingtogether to create the best value healthcare for the populationof West Leicestershire’.

Our commissioning intentions and planning process have beeninformed and influenced by the people of West Leicestershire and ourclinical leaders, as well as by national and local priorities. This ensuresthat it is driven by the needs of our local population, and is ownedlocally. Aligned with our Operational Plan, it gives us a solidfoundation on which to proceed.

Running through our Operational Plan is a commitment to five areas:

First, we are determined to support our hard-working 50 GP•member practices so that they continue to respond to patients’needs by further improving the quality of primary medical careservices.

Second, we want to transform the management of long term•conditions such as diabetes and chronic obstructive pulmonarydiseases (COPD) as well as the proactive management of frailolder patients with multiple morbidity who frequently experiencea medical crisis. To this end we will develop a range ofintermediate care services such as ‘step up’ to ensure rapidassessment of ill patients in the community without the need togo to hospital.

Third, we want to take public and patient involvement to the next•level to ensure that we understand and capture the current anddesired experiences of patients, carers and healthcareprofessionals, and what matters most to them, particularly in theplanning of federations and within the CCG planning of healthand social care.

Fourth, we want to ensure that our patients receive the best•possible care wherever they are treated in CCG-commissionedservices — be that in hospital, community services, or out ofhours (OOH). This means exercising our influence and leadershipto manage provider performance, and forging strong partnershipswith our local authority colleagues at Leicestershire CountyCouncil.

Finally, to do all this, we need to develop our CCG as an•organisation so that we can continue to innovate to deliver realimprovements for the people of West Leicestershire.


Primary Care PlanSystem Change CCG level

Better Care TogetherLLR 5 Year Strategic Plan

Operational PlanCCG Operation & Management

Above:The Primary Medical Care Plan meetsthe needs established in the LLR 5 YearStrategic Plan by introducing systemchange based on the Federationapproach to CCGs developed in theOperational Plan.

Purpose of this documentThe Primary Medical Care Plan is asystem-change plan which sits betweenthe Leicester, Leicestershire and RutlandBetter Care Together 5 YearStrategic Plan, and the CCG’s ownOperational Plan.

Better Care Together sets out whatwill be required for the whole healtheconomy to be sustainable over thenext five years, in the face of anincreasing funding/expenditure gap.This includes requirements for primarycare to take on work currentlyconducted in acute hospitals.

The Operational Plan sets out theprogramme by which the CCG’s ownvision and mission are beingaccomplished.

This Primary Medical Care Plan setsout how the system change required byBetter Care Together will be achieved,in the context of the work alreadytaking place in the CCG, of which thecritical component, as set out in theOperational Plan, is working infederations.

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Our Primary Medical Care Plan builds on our commitments in thesefive areas and sets out how — working with patients, practices andpartners — we will move forward.

Local progressOver the last three years we have made solid progress working withour member practices to get the basics right in primary andcommunity care in order to create the platform for more significanttransformational change.

Our focus was on:

Enhancing the resources in the community, such as virtual wards,•to support primary medical care in order to improve themanagement of long-term conditions and move activity in thoseareas from urgent episodes to planned interventions: this wetermed ‘Proactive Care’.

Supporting people who were not known to local health services•through the use of a risk stratification tool with services that werealso based in the community. Those services would be designed toavoid unnecessary emergency admissions to hospital, and to allowpeople to return home as soon as they were medically fit to do so.

Expanding community urgent care response services to reduce•pressure on emergency services.

Integrating discharge and reablement support to maximise•recovery and independence.

Strong and effective primary medical care is a critical aspect of aneffective and high performing health care system. The challenges ofincreasing demand from elderly and frail patients living with multipleand complex chronic diseases are placing an increasing strain onpractices. How our practices respond over the next two years will becrucial to the delivery of our future plans.


We need to explore ways to help practices function and thrive and reduce the overall workload to maintain and improve quality.

General Practice is at full capacity in its present form.

We need to support investment in practice premises and invest where it is most needed.

We recognise that meeting and also controlling patient demand is an important factor in the success of our vision. We will work to create and agree realistic expectations of General Practice by our patients.

We need to work together to make West Leicestershire CCG GP practices attractive to work, increasing the number and calibre of people applying for positions.

We need to reduce the bureaucratic burden via shared back office functions, simplified payments systems and appropriate QoF and QIPP outcomes.

We need to greater utilise the skills of our wider community teams and the voluntary sector.

These challenges are too great for individual practices to respond to effectively.

We need to have effective IT communication and move to one GP system.

We need to share our skills across practices to benefit our patients, capitalising on specialist knowledge and skills.

General Practice needs to respond to the challenges affecting the wider health and social economy.

We understand that the local health economy is heading for a £400 million deficit over the next five years, if we do not radically rethink how care is delivered.

We need to explore how the recently formed Federations can contribute to help General Practice thrive.

A potential solution is collective co-operative working between practices.

Below:The Practice Survey, showing stronglyagree, largely agree, neutral, largelydisagree, strongly disagree, sets out keyareas of concern for our GPs.

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How we have gone about producing this planIn developing the Primary Medical Care Plan, we have worked hard toensure that the views of our member practices, patients andstakeholders have informed it.

This process has been driven by a Steering Group, made up of clinicalrepresentation from our four localities (GP Board members and 4locality GPs), public health, Local Medical Committee, Public HealthNHS England and CCG managers. The group has co-ordinated:

Two large engagement events, attracting over 250 representatives•from among GPs, practice managers, admin staff, practice nurses,PPG members and our local partners.

Harnessing of our monthly locality meetings in August and•September to shape and develop the plan.

Sharing of progress and refining actions at a Board Development•session.

Findings of the Engagement ProcessAdditionally, through the engagement process, clinicians, partnersand public put forward a coherent set of requirements as to how theCCG should go about meeting the challenges. These have beengrouped under the following headings:

Federations making general practice thrive•

Better collaboration and reducing bureaucracy•

Helping practices to be attractive places to work•

Investment in practice premises•

Exploiting technology•

Listening to, engaging and increasing participation of patients•

Improving quality and patient outcomes by integrated•working

At the conclusion of the section outlining our model of care, we willanalyse what it achieves in terms of these ‘how’ criteria, before goingon to consider the enabling strategies which are required by themodel, and those which must be introduced in order to fully meetthese requirements.


Making General PracticeThrive

Reducingbureaucracy

Practicesattractiveto work

Investmentin premises

Exploitingtechnology

Engaging patients

Improving Quality

Above: Principal issues identified by theengagement process.

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Key considerationsIn meeting the challenges laid down by Better Care Together and bythe findings of the engagement process, there are five areas whichwe see as requiring special attention.

GovernanceThe governance arrangements for Federations must be completedand tested in order for them to effectively function as required by theplan. Furthermore, in seeking co-commissioning powers, the CCG willneed to demonstrate enhanced governance which is sufficientlyrobust for a Legislative Order to hand over co-commissioning anddelegation powers from NHS England so that the CCG can work atthe pace necessary and with appropriate alignment to manage, forexample, investment in premises development necessary forimplementation.

Conflict of InterestGPs and practices are currently involved in a range of commissioningand provision activities, the fruit of the changing arrangements overthe last fifteen years of primary care. To proceed, it is essential that weput in place robust arrangements for the management of conflict ofinterest, to give freedom for CCG members on the one hand to makeappropriate and ambitious decisions, and on the other to excludethemselves from particular discussions when necessary.

FundingThe NHS in Leicestershire is facing a 21% funding gap within fiveyears. This plan, responding to the overarching Leicester,Leicestershire and Rutland strategy of Better Care Together, createsmechanisms by which this can be substantially alleviated. However,this system change itself requires funding, both for the changesthemselves and also for the inevitable double-running costs whilecommunity based services are ramped up and acute services tapered.

WorkforceIn common with the rest of the NHS, West Leicestershire has asignificant proportion — one third — of GPs due to retire in the nextfifteen years, with similar trajectories among other practice staff-groups. However, in order to achieve the changes put forward in thisplan, West Leicestershire must go significantly beyond this inattracting staff who can work in integrated services to be organisedby Federations.

Out-of-hospital Care

There is a widespread acceptance across the NHS that a ‘left-shift’from acute care to non-acute is necessary both from the point of viewof clinical benefit and from the perspective of managing care withinthe funding available. However, a number of trial and pilot projects


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across the NHS over the last ten years have demonstrated that thebenefits of left-shift are only realised when the programme operatesat a population scale, and when it involves the decommissioning ofwork in the acute sector, with the corollary of reduction in staffingnumbers and repurposing, transfer or withdrawal of premises.

EngagementInsights from patients, carers and health professionals have informedus this far in defining what primary medical care will look like in fiveyears time. However, the insights have been limited by the fact thatparticipants to date have been self-selecting and may not berepresentative of the whole community. West Leicestershire needs toimplement a methodology that reaches out to a broader range ofpatients, carers and stakeholders ensuring that services are co-designed based on insights which are demographically representativeof the whole population including seldom heard groups.


Mental HealthCurrent SituationA 30 year old lady comes to the GP witha combination of relationshipbreakdown problems and financialdifficulties leading to depression. Afteran assessment the GP offers a referral tothe IAPT ( Improving Access toPsychological Therapies) service andprescribes antidepressants. He advisesthe patient to make an appointmentwith the Citizens Advice Bureau (CAB) inthe local town. The earliest IAPTappointment is in six weeks time. Thepatient’s condition deteriorates and 1month later the GP feels he needs torefer her to the local psychiatrist, butthere is at least a month’s wait for anappointment. The patient deterioratesfurther and appears suicidal. The GP

contacts the CRISIS team but they arebusy and cannot offer to see the patientwithin 24 hours and advise sending herto casualty. This is difficult for thepatient as she has no transport, buteventually a friend is found that cantake her. Once there she is assessed bythe liaison psychiatrist who decides sheis not an immediate risk and arrangesfor review by the CRISIS team the nextday. The CRISIS team support the patientfor a few weeks and she is then takenover by the outpatient team to whomshe was originally referred.

The New WayIn the future, the Local GP Federationhas secured the presence of the CAB inlocal surgeries so that financial advice isavailable and the patient can book anappointment there and then when firstseen. The IAPT service is also workingmore closely with the local GPfederation to ensure waiting times arenot affected by absent workers orreferral differences between practices,so the patient can be seen morepromptly. If there is a deterioration, theFederation has access to a SpecialisedCommunity Psychiatric nurse who canassess patients in need of referral andtriage them both to the correct serviceand in a timely manner, so that moreurgent cases are seen before they reacha crisis.

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Map


Area:North West Leicestershire: 326 km2

North Charnwood: 76 km2

South Charnwood: 197 km2

Hinckley and Bosworth: 374 km2

Population:North West Leicestershire: 99,611North Charnwood: 76,991South Charnwood: 75,792Hinckley and Bosworth: 121,783

ONS Mid-year estimates 2012, LSOAs

Broughton Astley

Sharnford

Sapcote

Aston FlamvilleBurbage

Croft

Huncote

Stoney Stanton

Earl Shilton

Barwell

DadlingtonStoke Golding

Higham on the Hill

Witherley

Fenny Drayton

ThurlastonStapleton

UptonRatcliffe Culey

Primethorpe

Castle Donington

GP Practice

Isley WaltonWilson

Diseworth

Kegworth

Breedon on the Hill

Worthington Belton

Long Whatton

Hathern

Cotes

Hoton

Wymeswold

Burton on the Wolds

Prestwold

Blackfordby

Lount

Coleorton

Newbold

Thringstone

Osgathorpe

Nanpantan

Thorpe Acre

Woodthorpe Barrow upon Soar

Walton on the Wolds

Seagrave

Moira

Donisthorpe

Norris Hill

Oakthorpe

Packington

Swannington

RavenstoneWoodhouse Eaves

Woodhouse

Quorn (Quorndon)

Swithland

Mountsorrel

Cossington

Sileby

Thrussington

East Goscote

Rearsby

Chilcote

Appleby Magna

Stretton en le Field

Snarestone

Normanton le Heath

Heather

Ellistown

Stanton under Bardon

Field HeadNewtown Linford

Cropston

Thurcaston

Birstall

Wanlip

Rothley

Appleby Parva

Norton-Juxta-Twycross

Newton Burgoland

Shackerstone

Odstone

Nailstone

Barlestone

BagworthThornton

Ratby

Groby

AnsteyThurmaston

Orton-on-the-Hill

TwycrossCongerstone

WellsboroughMarket Bosworth

Branch Surgery

Carlton

OsbastonNewbold Verdon

Botcheston

Desford

Sheepy Magna

Sheepy Parva

SibsonShenton Sutton Cheney

Kirkby Mallory

Bardon

Newtown Unthank

HINCKLEY

ASHBY-DE-LA-ZOUCH

SHEPSHED

COALVILLE

LOUGHBOROUGH

The four localities of WestLeicestershire:

North West Leicestershire North Charnwood South Charnwood Hinckley and Bosworth

Footnote:The precise geographical centre ofEngland is located between FennyDrayton and Higham on the Hill

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2. Case for ChangeGeneral Practice is at full capacity in its current form, and thelocal health economy is facing a £400 million deficit over thenext five years if we do not radically rethink how care isdelivered. The challenges are too great for individual practicesto meet, with rising patient demand, an increasing populationand a predicted 19% growth in the 60-84s over the next eightyears. If there are no changes to the model of care or tofunding, the NHS across Leicester, Leicestershire and Rutlandwill face an income-expenditure gap of £398 million by2018/19, which is an additional 21% on its income.

The Local EnvironmentWest Leicestershire CCG is made up of four localities: North WestLeicestershire, North Charnwood, South Charnwood, and Hinckleyand Bosworth. North West Leicestershire covers an area approximatelythe same as North West Leicestershire District Council, with theaddition of the area around Stanton under Barton and Field Head.North Charnwood covers Shepshed, Loughborough, Nanpantan andHathern, while South Charnwood covers most of the rest of theCharnwood District Council area, excluding the areas of Syston,Barkby, Beeby, Quenisborough and South Croxton. Hinckley andBosworth covers the entire area of Hinckley and Bosworth DistrictCouncil, excluding the Stanton under Bardon and Field Head elementswhich are in North West Leicestershire, and takes in Primethorpe andBroughton Astley which come under Harborough District Council, aswell as Elmesthorpe and the surrounding villages as far north asThurlaston which come under Blaby District Council. All localities fallunder Leicestershire County Council.

The CCG area is generally prosperous, but with pockets of highdeprivation around Coalville and Loughborough. Loughborough is auniversity town.

90+ 0.20% 0.56%

85-89 0.53% 0.97%

80-84 1.03% 1.43%

75-79 1.47% 1.71%

70-74 1.96% 2.02%

65-69 2.67% 2.75%

60-64 3.40% 3.40%

55-59 3.12% 3.10%

50-54 3.35% 3.37%

45-49 3.80% 3.80%

40-44 3.73% 3.84%

35-39 3.15% 3.20%

30-34 2.75% 2.81%

25-29 2.74% 2.87%

20-24 3.78% 3.36%

15-19 3.43% 3.08%

10-14 2.91% 2.73%

5-9 2.76% 2.60%

0-4 2.86% 2.74%

0 014.2 14.23.6 3.67.1 7.110.7 10.7

Scale (x 1,000)

West Leicestershire 2011 mid-yearby Age and Sex

Sex Ratio (m/f): 0.986Males: 183,838 Females: 186,406

ONS mid 2011 by CCGTotal Population: 370,244

UGHEH SHED LED OOOOOLOOOOOOLD GHBOROUGHD LOUGHLLLLLLLLLLLLOOOLOLOLLLOOLOLOLHE SHESHSHEPS

ACOA VIC

A BA LA CHDEB A ZZOE-LA-DEHB A ZZOE HBBBBBBBBB

AAALL

BBHB

A

HBBYBBHB

COOAAAO LLOA

YAS YYY-DE-LA-Z

C

HZOUCH

VILLELLVLVAAAAA

YY-BBASHBBB

1 16

or below

8.6

11.8

-16.9

16.9+

CKCKLEHININHINNCK EYN EY

IMD MD

5.9 o

5.9-8

1.8-1

11.8-

MD

HINCKLEY

ASHBY-DE-LA-ZOUCH

SHEPSHED

COALVILLE

LOUGHBOROUGH

22.4% or more

19.2%-22.4%

15.4%-19.2%

Below 15.4%

CharnwoodNorth WestLeicestershire

Hinckley& Bosworth

Blaby

Harborough

Below:Left: population pyramid 2011 mid-yearMiddle: over sixty fives by quartile, perLSOA (ONS)Right: Indices of multiple deprivation byquintile.

Above:The CCG covers about half of theLeicestershire County Council area.

Below:The CCG covers the districts of NorthWest Leicestershire, Charnwood, andHinckley & Bosworth, and overlapssome areas of Blaby and Harborough.

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Compared to England as a whole, the area sees higher rates ofhypertension, asthma, heart failure, atrial fibrillation and chronickidney disease, and substantially higher rates of depression. Overall,the CCG is in the Prospering UK cluster, with substantially fewerpotential years of life lost (PYLL) from causes amenable to healthcare.However, proportionately fewer people report that they are supportedto manage their own conditions.

AgeingThe population is projected to grow by 10% over the next eightyears, with 60-84s growing by 19% and the over 85s growing by42%. This will bring associated increases in complex and multiplelong-term conditions (LTCs) such as dementia, cardiovascular diseaseand Alzheimer’s, often compounded by frailty.

Care homes The characteristics of care home residents have been changing forsome time, with many older people making the decision – or having itmade for them – to move into care homes later in life, frequently withmore complex health needs. At a national level this has led to anincrease in the number of nursing home places provided by privateand voluntary sector organisations which has risen from 20,300 in1970 to not far short of 200,000 in 2010 (Laing & Buisson).

In West Leicestershire there are currently 22 nursing homes; 77residential homes; 2 combined nursing /residential homes and 3


90+

85-89

80-84

75-79

70-74

65-69

60-64

55-59

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

0-4

0 04% 4%1% 1%2% 2%3% 3%

Leicestershire County and RutlandONS 2008 based Sub-National Population Projections

2030 Female

2010 Female

2030 Male

2010 Male

Above:Sub-national projections forLeicestershire County and Rutland,2010 and 2030.

Ageing data: JSNA

Ageing in detailIn 2010 there were approximately85,500 people aged over 60 in WestLeicestershire CCG, and 16,400 agedover 80. The CCG’s over 60 populationis estimated to increase by around60% by 2030.

In 2007-09 life expectancy for men atage 65 in West Leicestershire is 18.4years. However, the 2001 Censusestimated that healthy lifeexpectancy at 65 was 12.9 years. Thiswas higher than the England average(12.5 years).

In 2007-09 life expectancy forwomen at age 65 in WestLeicestershire is 21 years. However, theCensus 2001 estimated that healthylife expectancy at age 65 was 14.8years. This was higher than theEngland average (14.5 years).

Around 14,300 people aged over 75 inWest Leicestershire lived alone in 2010,and this number is predicted to rise to26,400 by 2030 (85% increase).

In 2010 there were around 28,740people in West Leicestershire over theage of 65 with a limiting long termillness. By 2030 this is estimated to riseto around 48,330, an increase of68.2%.

NHS SOUTH CHESHIRE CCG

NHS VALE OF YORK CCG

NHS EAST LEICESTERSHIRE AND RUTLAND CCG

NHS LINCOLNSHIRE WEST CCG

NHS SOUTHERN DERBYSHIRE CCG

NHS WEST LEICESTERSHIRE CCG

NHS NORTH STAFFORDSHIRE CCG

NHS SOUTH WORCESTERSHIRE CCG

NHS MID ESSEX CCG

NHS NORTH EAST ESSEX CCG

NHS GUILDFORD AND WAVERLEY CCG

NHS SOUTH CHESHIRE CCG

NHS VALE OF YORK CCG

NHS EAST LEICESTERSHIRE AND RUTLAND CCG

NHS LINCOLNSHIRE WEST CCG

NHS SOUTHERN DERBYSHIRE CCG

NHS WEST LEICESTERSHIRE CCG

NHS NORTH STAFFORDSHIRE CCG

NHS SOUTH WORCESTERSHIRE CCG

NHS MID ESSEX CCG

NHS NORTH EAST ESSEX CCG

NHS GUILDFORD AND WAVERLEY CCG

CCG Comparator Group

The Office of NationalStatistics has placed WestLeicestershire in the‘Prospering’ group, with tenother comparator CCGs.

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learning disability homes. Together they provide care to over 1500people. With multiple co-morbidities and multiple medication use,patients in care homes are often the most complex group of patientsin the community. Improving care for these complex patients placesan increased demand on general practices. Practices have moved to a“one practice, one home” model and the CCG has commissioned arange of services to support patients in care homes including specialistnursing support services, medicines management optimisation andreviews and a Community Based Service and Specification for CareHomes for general practice.

Housing developmentsThe Leicester and Leicestershire Housing Developments Study 2011estimates 3,500-4,500 new homes per annum for 2006-2031. Basedon previous allocations, this would be expected to be 790 inCharnwood, 450 in Hinckley & Bosworth, and 510 in North WestLeicestershire, mainly in Coalville, or something in the region of 1750new dwellings per annum over the 25 year period, of whichapproximately half would need to be affordable housing. The needfor housing is driven partly by ageing and fertility, and partly by netmigration, which for Charnwood, Hinckley & Bosworth and NorthWest Leicestershire averages 1800 per annum (1999-2009). Housingdevelopments clearly place pressure on General Practice, but they alsounlock S106 monies, discussed below (Section, Enablers).

Increasing demandThe CCG has lower than typical admissions and prescribing rates, butis nonetheless facing pressures of rising demand and increasing cost.

The CCG has a lower than average non-elective admissions rate,•with has a historic growth (2007-2011) of 1.4% annually, abovethe national average of 1.2% but below the comparator group’smedian of 1.8%.

The CCG has an exceptionally low rate of outpatient attendances•following a GP referral, with 122 per 1,000 population comparedto 179 comparator group median and 188 national average.Furthermore, this rate fell at an annual rate of 0.6% from 2007 to2011, compared to a comparator rise of 4.1% and an Englandaverage rise of 4.6%.

Elective admission rates are low at 109 per 1,000 population in•2011, but rising at a rate of 3.7%. Although this is still lower thanthe comparator median of 4.8% and the England average of4.4%, it is, in absolute terms, a cumulative increase of 44% if thistrend continues over a ten year period.

The CCG’s prescribing spend rate was £73 per person compared•to a comparator median of £78 and an England average of £79.This was falling by an annual 0.5% from 2007 to 2011.


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15.1-17.1

17.1-19

19-20.9

20.9-23

23.25.2

25.2-27.6

27.6-30.7

30.7-35.3

>35.3Above: Modelled smoking prevalence 2003-05(ONS) by decile.

“The trend based projection, after areduction in projected internationalmigration, gives rise to a higher level ofhousehold growth than any other partof the region. Although local economicdevelopment strategies propose thecreation of more jobs than trend basedeconomic forecasts suggest, levels ofnet in-migration are expected to beconsistent with labour requirements atthe level of housing provisionproposed.”

Regional Spatial Strategy RSS8,Appendix 8, Regional HousingProvision, Leicestershire

183

Long-term conditionsWe have a high number of people who are smokers, are subject toalcohol-related harm or to obesity. These contribute to our higherrates of cancer, heart failure and atrial fibrillation, cardio-respiratoryconditions, stroke and cardio-vascular disease. Despite being in theoverall ‘prospering CCGs’ ONS cluster, we have pockets of deprivationin Greenhill and Agar Nook, Coalville, and Hastings and Shelthorpe,Loughborough, as well as invisible inequalities among ethnicminorities, travellers and those in rural poverty.


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End of life care Current situationA 65 year old man is diagnosed withmetastatic lung cancer. He is also apoorly controlled diabetic on insulin. Helives with his wife who is the main caregiver. He is called back to hospital on afairly regular basis for follow up anddifferent regimes of therapy which donot appear to be helping. He requirestransport for these appointments andthey end up taking the whole day andmaking him exhausted. He is becomingincreasingly depressed and anxious. Hiswife is finding it increasingly difficult tocope. He is becoming frailer and nowrequests GP visits on most days of theweek to deal with symptoms ofbreathlessness and cough. He accessesthe out of hours service on a regularbasis with the same symptoms. Onseveral occasions he has been sent toA&E as the wait to see the out of hoursdoctor was too long. He has an end oflife care plan in place agreed with his GPand wishes to die at home butunfortunately following a furtherdeterioration in his condition he is againadmitted and dies in hospital.

The New WayThe man is diagnosed with metastaticlung cancer at the local hospital. Hisown family doctor, a single handed GP,receives an electronic clinic letter thesame day and flags his records to discusshis ongoing care with the localintermediate care team. This team isheaded by a local GP in the Federationwith a special interest and dedicatedtime. After a telephone discussion, andconsent from the patient to access hismedical records, this doctor arranges tosee him at home. He visits within theweek and undertakes a comprehensiveassessment of both the man’s and hiswife’s concerns and needs, and starts toput in place an end of life care plan. Inview of the multiple health problemsand the strain on his wife, the GPorganises a community Multi-Disciplinary Team meeting at theFederation office. He brings in membersof the community team and, viateleconference, the oncology consultant.A treatment plan is agreed and his careplan is updated to reflect what has beenagreed.

The man continues to deteriorate and

his breathlessness becomes his mostworrying symptom. He becomes bed-bound and has an increased package ofcare. He is still determined to stay athome and is well supported by thecommunity teams. As his night-timesymptoms increase the Federation GPaccesses the night sitting service whichis made up of volunteers and trainednursing staff.

One night the man dies peacefully in hissleep with the night sitter and his wifeat his side.

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The External Environment

PartnersThe CCG recognises that it operates as a part of the widerhealth and social care system of Leicester, Leicestershire andRutland, and all parts of that system must achieve financialstability, in a time of financial constraint.

West Leicestershire CCG works closely with its district councils andthe county council, particularly through the Health and WellbeingBoard, and across Leicester, Leicestershire and Rutland with other NHScommissioners through Better Care Together. Its other key localcommissioning partner is NHS England, supported by Public HealthEngland.

UHL and Leicestershire Partnership NHS Trust are its key acute andcommunity health providers, respectively. Subsidiary providers areGeorge Eliot, Burton and Derby acute hospitals, and East MidlandsAmbulance Service. Non-NHS providers include DHU, CNCS, Arrivaand a variety of voluntary sector providers.


UHL

LeicestershirePartnershipNHS Trust

George Eliot

Burton

Derby

EMAS

DHU

CNCS

Arriva

Voluntary Sector

Public

Health

England

England

Better care together

CountyCouncil

DistrictCouncilsLe

icest

ershire Health and Wellbeing Board

Right:Non-NHS Commissioners in green. NHS Commissioning partners in blue.NHS providers in pink.Non-NHS providers in yellow.

Partners in Better CareTogether

Better Care Together is the principalcommissioning partnership for theLeicester, Leicestershire and Rutlandhealth economy.

The partners in Better Care Togetherare as follows:

NHS Leicester City Clinical•Commissioning Group (LCCCG)

Leicester City Council•

NHS West Leicestershire Clinical•Commissioning Group (WLCCG)

Leicestershire County Council•

NHS East Leicestershire and•Rutland Clinical CommissioningGroup (ELRCCG)

Rutland County Council•

University Hospitals of Leicester•NHS Trust (UHL)

Leicestershire Partnership Trust•NHS Trust (LPT)

Leicester City Health and•Wellbeing Board

Leicestershire Health and•Wellbeing Board

Rutland Health and Wellbeing•Board

Healthwatch (across LLR)•

NHS England Local Area Team.•

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Financial situation and local performanceLeicester, Leicestershire and Rutland (LLR) faces a 21% funding gapbetween income and expenditure by 2018/19 if the current model ofcare continues and there are no radical changes to allocation. This isin keeping with a wider NHS funding gap of £30 billion by 2020/21,or 22% of projected costs.

This health economy is one of eleven “financially challenged”economies identified by NHS England. Financial pressures manifestthemselves particularly clearly in a deficit at University Hospitals ofLeicester NHS Trust (UHL). The health economy also faces challengesin key operational measures such as referral to treatment times andthe 4 hour wait in A&E which do not meet national standards.

Local authorities in the LLR system face significant financial pressuresresulting from the continued reduction in funding allocations. By2018/19 Leicestershire County Council faces a savings requirement of£110m.

The CCG as commissioner will need to make phased savings to deliverinvestments in the model of care described in this plan. The scale ofthe financial challenge facing LLR can only be addressed through afundamental redesign of services coupled with provider costimprovement programmes.

Better Care Together has identified a basket of programmes to bringthe health economy into balance. However, this work relies on theability of primary care to accept a ‘left-shift’ of activity from the acutesector, and relies on the ability of commissioners to effectivelymanage the decommissioning of those same services in secondaryand tertiary care.

It is therefore essential to strengthen primary medical care, togetherwith community and voluntary sector providers to deliver integratedcare, maximise the use of physical assets, support self-care and ensurecare is provided in appropriate, cost-effective settings.


The Health EconomyPerspective

The case for change – value formoney

“All health and social careorganisations in LLR need to achievefinancial sustainability, in a time offinancial constraint.

Commissioners will need to makephased savings to deliver investmentsin the models of care that will providethe highest quality and best outcomesfor patients and citizens.

The scale of the financial challengefacing LLR can only be addressedthrough a fundamental redesign ofservices coupled with provider costimprovement programmes.

Strengthen primary, community andvoluntary sector care, to deliverintegrated care, maximising the use ofphysical assets, supporting self-care,exploiting IM&T, ensuring care isprovided in appropriate cost effectivesettings, reducing duplication andeliminating waste in the system.”

From the Better Care Together strategy,p 34.

0

500

1000

1500

2000

2500

18/1917/1816/1715/1614/15

£millions

Above:For the entire health economy, thepredicted gap between expenditure(red) and funding (blue) will be £398million by 2018/19, 21% more thanthe total available budget.

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Primary Care Perspective

Quality of Primary Medical Care in West LeicestershireGeneral Practice in West Leicestershire has a strong history ofdelivering high quality care to its patients and a track record ofworking collaboratively at locality level. Our practices have access tocomparative real time data through our Individual Practice profiles andnational sources to enable them to benchmark the quality of caretheir patients receive.

External to the organisation the Primary Care Web Tool which ismonitored by NHS England currently demonstrates that none of thepractices within West Leicestershire CCG are outliers in six or more ofthe indicators and therefore do not require a contractual visit.


Left and Below:Strong and effective primary medicalcare is acknowledged to be a criticalaspect of an effective and highperforming health care system. TheCCG is accountable for continuallyimproving the quality of our primarymedical care services, and this is aresponsibility that the CCG takes veryseriously. Our practice appraisal processdemonstrates year-on-year the highcalibre of the vast majority of ourpractices, but within that, thereremains variation in clinical thresholdsand patient experience. As a practicemembership organisation, ourapproach is to support the capacity andcapability of our practices to enableconsistency in the care given.

NHS England has a systematic approachto quality improvement and publishes awide range of data both for patientsand commissioning organizations. Thefollowing data is taken from theClinical Commissioning GroupOutcomes Indicator Set (CCG OIS) andprovides an overview of the CCG’sperformance in a range of nationaloutcome areas.

Helping Recovery Rate of avoidableemergency admissions foracute conditions

Emergency admission ratefor children with lowerrespiratory tract infections

In the best 25% of CCGs(874.2 admissions per100,000 people)


Long TermConditions

Unplanned hospitalisationfor chronic ambulatorycare sensitive conditions

Unplanned hospitalisationfor asthma, diabetes andepilepsy in under 19s



Preventing Early DeathPotential years oflife lost totreatable diseases(Females)

Potential years oflife lost totreatable diseases(Males)

Under 75mortality ratesfromcardiovasculardisease

Under 75mortality ratesfrom respiratorydisease

Under 75mortality ratesfrom liver disease

Emergencyadmission ratealcohol relatedliver disease

Under 75mortality ratesfrom cancer

In the best 25%of CCGs (1466.3potential years oflife lost per100,000 females)

In the middlerange (2113.4potential years oflife lost per100,000 males)

In the middlerange (66.19deaths per100,000 people)


In the best 25%of CCGs (11.88deaths per100,000 people)

In the middlerange (18admissions per100,000 people)


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Workforce

GP WorkforceThe GP census lists 262 GPs Full Time Equivalent (FTE), includingsalaried, part time and long term locums, in the CCG area, at anaverage list size per practice of 7,400. Calculated on a like-for-likebasis (figures, HSISC), the CCG is in the band of 6.0-6.5 GPs per10,000 head of population. This is a better than average number ofGPs than for England as a whole. The median for our comparatorgroup is the 5.5-6.0 band. However, 18% of our GPs are 55 or over,and 32% are over 50.

Practice WorkforceOf a total practice workforce of 970, 250 (26%) are aged 55 or over.

PremisesIn Leicestershire as in many areas of the country there has beenlimited investment in primary care premises since 2004. Work by theBMA, ‘The Future of GP Practices’, identified the following issuesacross England:

Three in five practices say their doctors have to share consulting•rooms, and of these, half say this restricts treatment.

More than two thirds believe their premises limit the GP services•and community services they can provide.

More than half of respondents have not seen significant•refurbishment to their premises since 2004.

In Leicestershire the last strategic premises review was completed in2009 and prioritised projects according to need. Subsequently anumber of the projects identified have been completed although asignificant number remain incomplete.

The case for change — conclusion

Primary medical care in West Leicestershire is performing strongly,both by comparison with the national average and within its owncomparator group. However, with an ageing workforce, under-investment in premises, and very significant challenges aheadresulting from demographic change, rising costs of healthcare andincreasing demand, it is clear that the situation is not sustainable overthe next five years. In the long term, it is absolutely clear that asubstantial change of model is required, rather than merely anefficiency drive. Furthermore, as the case studies scattered throughthis document show, patient experience of their care pathway is oftenpoor, and there are opportunities for improvement. In the next sectionwe will articulate our ambition for a 21st Century health system inWest Leicestershire, and, subsequently, our means to achieve it.


6.5 or higher

6.0-6.5

5.5-6.0

5.0-5.5

0

3

6

9

12

15

65605550

Above: The CCG is above the median GPs per10,000 patients for its comparatorgroup.

Below: 18% of our GPs are 55 or over; 32%are over 50.

Bottom: 26% of all practice staff are over 55.

0

50

100

150

200

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300

350GP Partners

Salaried GPs

Nurses

HCAs / Phlebotomist

Practice Management

Clerical Staff

Receptionists

55+46-5431-4520-30

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3. Our AmbitionPrimary care is the foundation of a high performing healthcaresystem. Our ambition is for a health system in WestLeicestershire that everyone can be confident of — public,patients, clinicians, NHS leaders, stakeholders and partners —where primary care plays a strengthened role responding tothe health needs of the population, particularly the ageingpopulation and those with long term conditions.

Historically general practice, primary and community health teamshave developed piecemeal. Funding streams and national initiativeshave been introduced at various times and this has resulted in servicesthat sometimes overlap, sometimes leave gaps, but rarely worktogether in a co-ordinated manner.

Currently too many people use emergency acute services becauseprimary care is perceived as inaccessible where and when they need it.60 to 70% of emergency admissions are of people with long termconditions or frailty. These patients are known to the system andparticularly to general practice. Active care planning ought to preventunnecessary admissions, and expedite discharge whenever a hospitalstay cannot be avoided.

Our ambition is to correct this situation and apply measures andpathways that make primary care the first choice for people.

We do not believe that the status quo will enable GPs to delivereverything that our patients need in the 21st Century. A new modelof health and social care is required that builds on the needs ofpatients and the strengths and values of general practice.

We believe that the vast majority of health problems — includingmental health issues — could be dealt with by primary andcommunity care. We have not yet fully realised the potential ofgeneral practice, so too often patients receive care in hospital thatcould be safely provided in the community, coordinated through theirgeneral practice, and supported by the wider health and social careteams.

We will redress this imbalance and make out-of-hospital care amuch larger part of what the NHS in West Leicestershire provides. Ouroverarching philosophy is that admission to secondary care shouldonly take place when it is clinically unavoidable, and that dischargehome from acute care should be achieved as quickly and efficiently aspossible. In our model we will increase the proportion of care patientsreceive close to home through effective, timely interventions. This willrequire increasing access to seven day — and, where appropriate, 24hour — care management, developing flexible models that enablecare to be provided in both a scheduled and unscheduled manner tomeet the clinical needs of patients.


189

The role of the acute hospital is for short term referral for moreserious clinical problems, specialist interventions, care and procedures.

We have a clear vision for the future of primary care in our CCG inwhich general practice is the foundation of a strong, vibrant, joinedup health and social care system. This new system is patient centred,engaging local people who use services as equal partners in planningand commissioning, which results in the provision of accessible high-quality, safe, needs-based care. This is achieved through expanded —but integrated — primary and community health care teams, offeringa wider range of services in the community with increased access torapid diagnostic assessment and, crucially, patients taking increasedresponsibility for their own health and well-being.

Over the next five years our new model for general practice will berealised. The practice and the primary healthcare team will remain thebasic unit of care, with the individual practice patient list retained asthe foundation of that care. However, whilst a large proportion ofcare will remain within a patient’s own practice thereby recognisingthe importance of the therapeutic doctor-patient relationship, anincreasingly significant proportion will be provided by practicescoming together to collaborate in federations, using their expertise,sharing premises, staff and resources to deliver care for and on behalfof each other. In this way, it will be possible to improve access andprovide an extended range of services to our patients at scale.

Our model is based on the GP as expert clinical generalist working inthe community, with general practice being the locus of control,ensuring the effective co-ordination of care. The GP has a pivotal rolein tackling co-morbidity and health inequalities but increasingly theywill work with specialists co-located in primary and communitysettings, supported by community providers and social care to createintegrated out of hospital care. For general practice to be optimisedthere is an increasing need for non-admssion pathways withimmediate access to diagnosis and specialist opinion, and ambulatory

emergency care with immediate access to diagnosis and interventions.

Our ambition recognizes that our emerging federations provide theopportunity for general practice to be delivered at population scaleproviding many of the tests, investigations, minor injuries and minorsurgery currently only provided within the hospital setting.


Right:Our ambition is to shift the care systemso that the bulk of work is donethrough scheduled care, as opposed tothe current situation where it is inurgent care.

Planned care

Urgentcare

Scheduledcare Unscheduled

care

190

The federations, though in their infancy, have the ambition to

shift a significant amount of outpatient consultations and•ambulatory care to out of hospital settings

employ secondary care specialist on a sessional basis to support•the expansion of clinic based care

lead community hospitals jointly with the teams that currently run•them

coordinate locally out of hours provision particularly for patients•with long-term conditions and those at end of life

further develop models of in reach care to our 22 care homes and•77 residential homes building on our practice/one home approach

exploit technology to enable the safe sharing of patient care•plans.

In order to achieve our ambition, we need to shift investment fromacute sector to primary and community care, as we will discuss laterin the Resources section of our plan. It is recognised nationally thatprimary care services have been under-resourced compared tohospitals and funding needs to be stabilised to enable primary care togrow.


Left: Federations

North Charnwood GP CommunityNetwork Ltd

Hinckley and Bosworth MedicalAlliance

North West Leicestershire GP Ltd

South Charnwood GP Network Ltd

Population by locality:North West Leicestershire: 99,611North Charnwood: 76,991South Charnwood: 75,792Hinckley and Bosworth: 121,783

While practices work with list sizes of6,000 to 15,000, Federations workwith practice-based populations of75,000 to 122,000 co-terminus withtheir localities. Federations, which willdeliver services as Multi-SpecialtyCommunity Providers, arecommissioned by the CCG.

191

Our commitment to the patient

Consistently High Quality

Wherever you live in West Leicestershire, you can expect to have•easy access, on-line or in person, to information, advice andsupport. This will be through national programmes such as 111and local services.

You will be confident that the advice and care provided by your•primary care professional is consistent with best practice.

Variation in the delivery of primary care will be identified through•national data, and the commissioners will work together tosupport practices to provide core standards of care.

You will be seen and treated by highly trained healthcare•professionals who are committed to delivering the best qualitycare to the patient.

You will be treated as an individual by professionals and respected•at all times.

This will link with all other services when you need continued,•consistent care to keep you at home.

Responsive and Accessible

The way you are able to access information and be directed to•appropriate services will be transformed through the use of newtechnology and social media.

You will be able to access primary care services at weekends in•access points not currently available. This may not necessarilymean seeing a GP or nurse in the traditional way.

You will be able to have access to a primary care professional•within 24 hours whenever you feel your primary care need isurgent.

You will not have to wait more than five days for a routine•appointment with a GP.

You will have access to high level quality indicators for General•Practice, so that you can make an informed choice of GP practice.You will be able to change practice easily if you wish.


192

Integrated

You will find that services are working seamlessly together with•you to co-ordinate your care and deliver the support you need tomanage your condition. Holistic care will be delivered thataddresses people’s physical, mental health and social care needstogether and not separately. There will be no duplication.

The voluntary sector, pharmacists, nurses and social care will be•more involved in providing your care.

The way health services and local authorities work will change•radically. Services will align more closely, which will mean thatprimary care and social care deliver a seamless service.

We expect to see a range of initiatives that unite health and social•care such as respite prescriptions for carers.

Sustainable

You will be confident that Primary Medical Care in Leicestershire is•financially well-run, and that the system has been designed todeliver the right care in a way which is affordable to the NHS andthe tax-payer for the foreseeable future.

You can be confident that decisions made about the way care is•provided will be made because they benefit patients the most,within available resources.

Preventative

Primary Care Professionals will act as community leaders who•provide your health care.

You will be actively involved in the management of your own•health and care.

You will receive more information on maintaining your health and•we need you to use this information to prevent ill-health that canbe avoided.

Underpinning this is the need for services to be innovative and•continuously evolve and learn.


Care Homes Current SituationMrs S is a frail 86 year old lady in a CareHome. She has a Do Not AttemptResuscitation (DNAR) in place and hasexpressed the view she would like to dieat the home. She is demented but thestaff have noticed that her urine has anoffensive smell and she is febrile and ismore agitated than usual. She wasadmitted with a UTI 6 months ago andthey feel she has a recurrence. They ring

the Out of Hours Service (OOH) as theywant a GP to visit — it is 2pm on aSaturday — and provide antibiotics.Unfortunately the OOH does not have aGP available to visit immediately andadvises a visit may not be possible for sixhours. The relatives rightly think this isunacceptable. The home rings the 999ambulance service, and the patient isadmitted to hospital.

The New WayThrough the ‘one practice one homescheme’, the local general practice hasdocumented a care plan for Mrs S, andall the care home staff are aware of it.Through the Acute Visiting Service, thecare home refers directly to a locality-based emergency care practitionerwhom they know. They visit, andthrough their extended scope, prescribeantibiotics and follow up the patient thenext day to check on progress.

193

What Primary Medical Care will looklike five years from nowIf this plan is fully implemented, we envisage General Practice in WestLeicestershire looking like this:

Practices will work collaboratively, and there will be full•integration with community and social care services, and withacute services.

Community nurses and other health and social care professionals•employed by Federations working at practice, virtual ward leveland in locality/federation level initiatives.

Stronger Federations will have improved efficiency in member•practices through more effective use of existing resources, e.g.centralised Human Resources, Payroll.

Local healthcare professionals and specialists will provide locality•based services to meet the needs of patients.

We will listen to patients and help them access appropriate care,•taking greater responsibility for their own health and well-being.

Greater numbers of nurses will support ward and locality services.•

Implications of this approach:

Primary care providers will work at a larger scale building on our•current model, including federations and virtual wards.

Further integration of services with a wider range of partners•including social care.

Services will be provided, where appropriate, seven days a week,•with local primary care solutions to support care in the out-of-hours period.

Federations, localities and patients will play a greater role shaping•how primary care is provided to patients.

Based on patient needs, primary care will be provided in different•ways to patients. This will initially focus on changing how care isprovided to patients with long-term conditions and, in time,extend to other areas such as mental health.

To support this there will be a shift of resources and work from•acute hospital settings to primary care.

We will seek to improve primary care facilities and the utilisation•of community-based facilities in localities.

The primary care workforce will change with a greater role for•nurses, pharmacists and healthcare assistants. Where practical thiswill be driven at a locality level.


194

4. ModelThe challenge of Better Care Together is that we create asystem which can accept movement of care from the acutesector to primary care at a population level, while retainingprimary care’s efficiencies. Furthermore, commissioners musthave effective tools allowing them to commission care in thesetting most appropriate to complexity and condition. Toachieve this, our model constructs a new layer of community-delivered care, with integrated services organised, managedand contract-funded by the CCG’s established Federations.

The model outlines the central role of the GP as part of a widercommunity response, identifying where the GP can add most clinicalvalue and how the wider practice and community teams activelysupport the delivery of care.

Our model places the patient and their General Practice at the centreof care provision. We have a strong sense of locality within the CCGand promote the concept of neighbourhood commissioning. Throughthis we are shaping services with our practices, patients andcommunities that are coordinated and integrated at a locality level tomeet their needs.

Our four localities are the geographical unit at which care iscommissioned, coordinated and provided. Through our establishedproactive care approach, our community teams are aligned with eachlocality, then subdivided into virtual wards which support eachpractice within a locality. We are now working with our social care


Safety, Effectiveness, PatientExperienceThe safety of patients is always ourhighest priority. Within that, we wantour care for them to be effective inbringing about the health outcomesthat matter to them most. When thereare choices between different ways ofoffering safe, effective care, thepatient’s experience is the decidingfactor.

366,000Patients

50 Practices

10 Virtual Wards

footprints

4FederationsDelivering

Services

‘Left shift’ from acute andsecondary care

195

partners to align social care provision across the same geographicalfootprint. This will enable the full integration of our practices with ourcommunity and social care teams to support out of hospital care.

Fully implementing our model will require a joint focus on the deliveryof care that meets the needs of the local population, with teamswhich share priorities and goals. Federated General Practice willprovide leadership for integrated population-level health including theoptimal organisation of urgent care services — both in- and out-of-hours, and long-term condition management. This is central to thedevelopment of multi-specialty community providers.

We will build on current structures to achieve this and establishforums led by our federations where community and social careproviders regularly come together to review and enhance local serviceprovision. Over the past two years we have developed a range of newservices within the community but as yet they are not fully utilised orsufficiently coordinated.

Delivery of Model and Levels of Care

In our model, our 366,000 patients are empowered to greater levelsof self-care, aided by informational and educational programmes andcommunity pharmacies. Our fifty primary medical practices remaintheir first point of contact with the NHS. For those requiring ongoingcare, either diagnosed through the surgery or by pro-active screening,our ten virtual wards enable the patient to remain at home while re-ceiving integrated care to manage long-term conditions and preventescalation. For more complex co-morbidities, the four federations willprovide more specialist care, integrating a wider range of clinicians, al-lied health professionals and social care workers.Acute and other secondary and tertiary care is therefore freed tofocus on emergency and specialised care, as well as routine surgerysuch as hip operations.


What is integrated care?Integrated care combines a range ofdisciplines across the NHS, socialservices and voluntary organisations tocreate person-centred care, rather thancondition-centred or patient-centredcare.

Condition-centred care, the•original model in the 1948 NHS,treated individual conditions, buttook no account of complex co-morbidities. Nonetheless, it was asignificant advance on what waspreviously available.

Patient-centred care, originating in•the 1990s, was a move to treatthe whole patient, taking accountof the impact of multipleconditions.

Person-centred care recognises•that an individual is best placed tomake decisions about their ownlife-style, and the level andlocation of treatment they areprepared to undertake. Person-centred care was first pioneered inpalliative care, for examplethrough the Gold StandardsFramework.

Integrated care involves a significantrange of NHS, local authority, privatesector and voluntary sector inputs,including acute care. However, where itis successful, integrated, person-centred care will tend to keep a personin their own home for as long aspossible, and focus on proactiveprevention strongly led by the person’sdesires and wishes, with a broadspectrum of choice.

Virtual Wards and Federation-deliveredservices are both examples ofintegrated care, but, properly speaking,it is our entire suite from self-care toacute care which is integrated.

Greaterrisk and complexity

Practice

Patient

Acute

Locality(Multispecialty

Community Provider)

Emergencyand/or specialisedSelf-care

CorePrimaryCare

EnhancedPrimaryCare

Integratedprimary andcommunityspecialised care

Right:The commissioning decision is at eachpoint to treat the patient in a settingwhich matches their risk andcomplexity.

196


Admit

MDTmanagement

Self management

Prevention

Admitfor

surgeryor LTC

management

CaseManagement

Routine GP contacts

Exercise

Emergency Attendance/Admission

Crisis support

Urgent GP contacts

Immunisation

Routineprimary care contacts

(skill mixed)

Exercise

Self-managementwith telehealth

Prevention Immunisation

GP- led

crisis management

Risk based primary care

contact

ElectiveAdmission

LTC management

Federated localitiesEnhanced primary care

inter practice referrals / scale

EmergencyAdmission

MDTRapidAccess

Level 3:Specialist

Intervention

Level 2:Case Management

Level 1:Point of Access:

Disease Management

Level 0:Population-wide Prevention and Self-Care

Left: ideal modelIn the ideal model, need, setting of careand intervention are matched in a fourtiered approach.

At Level 3, complex, high-risk or unsafeconditions are managed throughspecialist interventions in speciallyequipped units.

At Level 2, patients benefit from longerterm case management of theircondition.

At Level 1, patients access primary careas their key initial point for diseasemanagement.

At Level 0, population-wide preventionand self-care is self-organised bymembers of the public.

Below left: today’s situationThe situation in real life is more complicated. Care is providedas planned care and as urgent care, and, in urgent care, thereis often a mismatch between need, setting and provision ofservice. People are admitted inappropriately to A&E, oradmitted for a condition which need not have deteriorated tothe point of needing emergency care if it had been proactivelymanaged earlier. For this reason, a greater than necessaryproportion of activity and cost is in urgent care, with much ofthe provision at Level 4 being for conditions which mightbetter have been treated elsewhere.

Below right: our new modelIn our new model, strengthening of the lower tiers andgreater attention to proactive care management mean that wecan invest to a much greater extent in scheduled care, with asubstantial reduction in inappropriate or unnecessaryemergency attendance and/or admission. Resources expandfor the lower tiers, along with capacity created by our Multi-Specialty Community Providers (Federations), which create avirtuous spiral, since the cost of interventions is lower and somore patients can be supported at the most appropriate level.

Urgent Care

UnscheduledCarePlanned

Care

ScheduledCare

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Benefits of this approachThe key to this approach is that care should be commissioned for thesetting which matches the risk and complexity of the patient’s need.

By creating two settings of care between the primary medical practiceand acute, we now have a range of options for commissioningappropriate care which are more likely to help a patient maintain orimprove their health without the disruption of a spell in hospital, orthe need to attend the emergency department.

The benefits:

less disruption for the patient•

care closer to home•

long term care for long term conditions•

acute is freed to focus on complex and specialist cases•

overall cost reduction to the NHS•

monies are released for further development of services, creating•a virtuous spiral of increasing capacity and decreasing cost.


Planned CareCurrent SituationA 49-year-old woman presents withrecurrent bouts of abdominal pain in theright upper quadrant. The GP suspectsgallstones and requests an abdominalultrasound, which is done after nineweeks. This confirms gallstones and thepatient is referred to general surgery.After a wait of 13 weeks the patient isput on a waiting list for laparoscopiccholecystectomy. In the interim she haspresented on two further occasions withsimilar pain to the accident & emergencyunit of the local hospital where she hasbrief admissions. She has the operationsix months later. She is discharged,develops a fever and presents to her GP.The practice has not received adischarge summary. Later in the out ofhours period, the patient is admittedonce again to hospital with sepsis.

The New WayA 49-year-old woman presents withrecurrent bouts of abdominal pain in theright upper quadrant. She sees hernamed GP in her practice and has on-site, same-day liver function tests and anultrasound is arranged for the sameweek at a local practice that has thefacilities in the federation. This confirmsthe diagnosis of gallstones and an emailis sent to her named GP. The patient canaccess the results on-line and schedulesa virtual Skype consultation. Her GPdiscussed information about providersand surgeons, the patient elects tochoose her hospital and is directlybooked under a care pathwayarrangement for a laparoscopiccholecystectomy.

A patient adviser gives support andinformation of what to expect and

consent is obtained using shareddecision making. On discharge, asummary is delivered electronicallywithin 6 hours copied to the patient. Anafter care discharge matron working forthe federated locality arranges aproactive review. 5 days later the patientdevelops a fever and is expertly assessedat an 8-8 primary care centre run bylocal GPs who have full access to all therecords. A simple post-operative UTI isdiagnosed and the patient is easilymanaged with a successful outcome.She automatically receives a text basedquestionnaire to determine hersatisfaction and outcomes which iscollected directly by the commissioningorganisation.

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5. Enablers

Federated Localities – making generalpractice thrive

Our four localities in West Leicestershire have a strong and positivehistory of collaborative working. The practices recognised theopportunity to exploit this, and in 2014 each locality has formed alegally constituted federation, established as companies limited byguarantee.

Our practices recognised the local and national challenges facingthem and the impact on the long-term sustainability and viability ofgeneral practice in its current form, particularly with regard to thepressure to deliver more services despite decreases in funding and theimpact of an ageing population on consulting times and demand.

The federated model enables practices to form, in the first instance,small-scale flexible alliances that can adapt as the needs of patientschange over time. It retains individual practice autonomy whilstcapitalising on the benefits of working in a federated way:

By increasing the opportunity to develop a wider range of•community services whilst making more effective use of resources,including staff and premises

By using their collective strength to enable practices to offer•Commissioners services that cater for larger patient cohorts over awider geographical area.

As the federations develop they aspire to progress from being thecoordinator of community services for their given population, tocoordinating and co-delivering services through a contract fundingand employment mechanism. This is currently being tested throughour 7 day services pilots where our federated localities are in effectemploying GPs on a sessional basis to deliver targeted support toidentified patients at weekends across the locality. Ultimately this maylead to federations becoming a focal point for a wider range of careneeded by their registered population, fully delivering integratedservices as a multi-specialty community provider (MSCP), taking onthe employment and direct management of other services.

The CCG wants federated localities to thrive, and will commit bothmanagerial and financial resources to support their development.


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Better Collaboration and ReducingBureaucracyThere is widespread agreement amongst GPs, practice managers andthe CCG that the level of bureaucracy at practice level needs to bedrastically reduced freeing up valuable clinical time in the process.There is a sense that reducing bureaucracy should be a principle ineverything that is done, “cutting out” administrative tasks that addlittle or no value to patient care. There are a number of ways this canbe achieved:

Back-office functions could be moved to the federated locality•level in order to reduce the burden on individual practices,increase efficiency and make practice-work more attractive. Thiscould include centralisation of administrative processes, HR andpayroll services for member practices, and procurement of primarycare support services such as telephony

Streamlining the reporting and audit requirements of local•schemes and payment processes. Currently practices have threepay masters: the CCG, the NHS England area team, and LocalAuthority, all with differing reporting and audit requirementswhich need to be rationalised and streamlined.

Key actions (see Section 6 Plan) for this year include scoping of whichfunctions would generate the greatest benefit if conducted at thefederation level.

Co-commissioning of Primary Medical Care

In the light of newly announced flexibilities, the CCG is seeking totake onfull delegated responsibility for the General Practice contractfrom April 2015. This is currently the responsibility of the Area Teams.This will give the CCG a more direct role in the commissioning andcontractual arrangements for practices, helping create a joined=up,clinically-led system that delivers seamless, integrated out-of-hospitalservices based around the needs of the local people. Our governingbody considers this an exciting opportunity to improve outcomes forour patients by providing the system leadership to transform primarycare at scale and at pace. This will enable us to:

Improve services and outcomes for our patients•

Enhance our ability to coordinate and integrate care•

Give greater opportunity to commission new, more integrated•models of out of hospital care to support “left shift” and improvepatient outcomes

Build upon our work to date with our member practices to•support capacity and capability at practice level and thereby


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improve quality and reduce unwarranted variation

Improve efficiency of current administrative processes, thereby•releasing capacity at practice level

Provide greater influence on system enablers (e.g. estates and•workforce development)

Provide the potential to deliver better value for money from•existing spend.

Helping Practices Be Attractive Placesto Work

Our workforce

General Practice will not be sustainable or fit for purpose for the nextdecade without change and crucially without support to grow itsworkforce. A competent and skilled workforce is a key enabler inimplementing the plan to support out of hospital care to the scalerequired. We cannot address the current GP shortage in isolation:increasing the capacity and capability of practice nurses, practicemanagers and other health care professionals is crucial if we are toaddress the increased demand on primary care.

Workforce planning and modelling assumptions in primary care needto incorporate new, emerging and more sustainable models ofprimary care. We need to develop a primary care workforce which isfit for purpose now and in the future rather than merely increasingnumbers.

The development of our local workforce will be based on anassessment of local need, taking into account our new model ofdelivery – practices working in federated localities, integrated withwider primary and community teams.


Primary Care Current SituationA 56 year old gardener presents with afairly acute onset of pain in his rightshoulder which has started to interferewith his work. Examination of theshoulder is clearly abnormal but shows afairly complex series of findings.

The patient is referred to Orthopaedicout-patients where he is seen after eightweeks, during which time he is unableto work and the shoulder becomesrather stiffer. The consultant arrangesan ultrasound scan which takes placethree weeks later. The scan shows a

mixed picture of tendon injury withsome impingement and capsulitis. Thepatient is sent an outpatientappointment for a further four weeks,when the shoulder is injected. Thepatient is then referred to physiotherapywhich starts six weeks later. Theshoulder slowly settles and the patientreturns to work after a total of sixmonths absence but the family areunable to have a holiday that year.

The New WayThe GP rings a local Federation GP witha special interest (GPWsi) who decideshe can manage the problem. The

patient sees the GPWsi who works froma local practice (not his own) wherethere is ultrasound scanning on site.The scan is done on the same day andthe GPWsi receives the scan report acouple of days later. He is satisfied thatthe shoulder can be injected and thepatient makes an appointment with oneof the four local GPs trained to injectshoulders. Physiotherapy is carried out inone of the local practices with provisionin the surgery. The patient loses threeweeks from work and there is relativelylittle economic impact on the family.

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Developing primary care services that span different professionalperspectives and work across the traditional primary care/secondarycare interface is vital. The findings of our engagement programme todate indicate that we must:

Target the existing primary care workforce to improve recruitment•and retention but equally important to identify new capabilities,competencies, skills and behaviours required to make anenhanced primary care offer.

Identify new roles/capabilities in new staff groups — There is an•urgent need to focus on alternative professional roles that supportintegration, increase capacity and reduce admissions by freeing upGPs time to manage increasing complexity. Such roles includeprimary care physicians’ assistants.

Identify roles and competencies currently that sit outside of•primary care that will be required to support the left shift. Suchroles include primary care paramedical staff, communitypharmacists, emergency care practitioners, and specialists rolessuch as geriatricians.

Actively support undergraduate medical training and GP training•at a federated level to promote our practices as positive places towork to aid recruitment and retention.

To this end we will work with our federated localities, ourneighbouring CCGs, local universities and Health Education EastMidlands (HEEM) to undertake a workforce survey to identify currentskills and extended skills that could benefit more patients and gaps.

The working environment

The environment in which GPs, practice staff and wider communityteams work needs to change. Currently, many of our surgeries requireinvestment and expansion and are not designed in a positive orergonomic way that encourages wellness to visitors or is attractiveand practical for staff. Furthermore, many primary care premises arenot physically capable of offering the range of services that will needto be developed to support out of hospital care (see Investment inPractices, below).

Investment in Practices

It is anticipated that significant additional funding will be required,both recurrently and non-recurrently, to enable the transformation inprimary care which is planned. The non-recurrent elements of this arebeing worked through in further detail but are likely to be brokendown into:


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Short to medium-term non-recurrent funding

During the period where capacity is increasing in primary care,additional non-recurrent funding will be required as new servicesdevelop and new staff are trained. This funding will cover thefollowing categories:

Clinical time to deliver new models of care for a ‘double running•period’ whilst other services are stepped down

Education and training•

IM&T improvements and alignment to support development of•hubs

Management costs, including legal expertise•

New equipment.•

Broad estimates have been made on the overall level of non-recurrentfunding required to support this shift, on the assumption that the leftshift will require a similar level of support for primary care as in othercare settings.

Practice Infrastructure

Data and information are at the heart of any drive to improve qualityand patient outcomes. Across West Leicestershire there is a need toalign GP systems. Having all practices, community services and urgentcare centres on the same system would enable clear informationsharing and ability to manage patients appropriately first time withoutany delay. West Leicestershire CCG estimates that it will cost £500k tomove all practices to one IT system.

Estates

Investment in primary care premises is crucial to the successfulimplementation of this plan. Investment is needed both in terms ofbringing existing primary medical facilities up to date, addressing thegrowth in the number of new homes and associated population, andin ensuring there are appropriate facilities to support the wider healtheconomy transformation. In order to make this a reality wherepossible we will explore with our partners options for utilising existingfacilities more effectively. However there is still a clear need for capitalinvestment in primary medical estate to support primary medical careto work at a greater scale as outlined in the Better Care Together 5Year Strategy.

In West Leicestershire it is estimated that £8.5m is required to supportthe redevelopment and expansion of practices previously identified inthe 2009 premises audit as requiring improvement. The CCG iscommitted to carrying out a review of all practice premises to gain an


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up to date understanding which will support the federated localitiesin the development of their local improvement plans.

IMPORTANT: The source of funding required is not confirmed. Thiswill be subject to the acceptance of the Better Care Together StrategicOutline Case (SOC) and national decisions regarding available funds.However, the CCG is committed to supporting out of hospital careand the central role of primary care, and would therefore need toidentify local resource if external funds were unavailable. While thiswould impact on the achievable scale of transformation, the strategicdirection would remain.

Using Contractual leversThe CCG will work with our federated localities to ensure that aswork transfers into primary care appropriate controls are put in placeto ensure that transfer of funding occurs alongside. Currently theAlliance Contract provides one such mechanism, enabling the transferof resources for planned care activity into primary care fromsecondary care as work is undertaken. Further innovative contractualforms will need to be developed to support the scale oftransformation required.

S106 monies for premises improvementThere are currently 34 premises improvement schemes identified asnecessary or already in progress. A key mechanism for premisesimprovement is S106 monies, where property developers agree tocontribute towards the cost of upgrading health premises in line withthe increased demand expected from their developments. These arebeing brokered by the NHS England Local Area Team and the relevantlocal authorities.

Monies so far secured, by district council area and relating to theCCG’s practices, are:

Hinckley and Bosworth Borough Council £302,000North West Leicestershire District Council £752,000Charnwood Borough Council £1,240,000

These monies are held by the relevant local authority, and drawndown when expenditure against a project is due.

Changes to regulations mean that all requests for PlanningObligations in future will be judged against the three tests set out inthe NPPF and the CIL regulations. The tests are as follows:

necessary to make the development acceptable in planning terms; (a)

(b) directly related to the development; and

(c) fairly and reasonably related in scale and kind to the development.


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Feedback from our practices that the current process of accessingS106 monies is time consuming, bureaucratic and the release of anyfunds is lengthy. The CCG is committed to working with our localauthority partners to ensure housing development plans are shared atan early stage to enable federations and individual practices toconsider the impact on the services they provide and secure any S106resource that becomes available.

Exploiting Technology

Continuity of careAs patients increasingly receive care from more than one providertimely communication of relevant information between and withincare providers and with patients and carers is critical. Goodcommunication and co-ordination is needed, both within andbetween professionals, teams, care systems and institutions. Generalpractice is leading the development of individualised care plans forpatients with multiple long term conditions and frailty. Whilst this ispositive from a patient and carer perspective, enabling them tomanage and understand their disease better, the informationcontained within the care plan needs to be readily accessible to allclinicians treating the patient outside the patient’s own practice.

Through Better Care Together our local health economy is working onan IT solution that will better support the sharing of informationacross health and social care providers within Leicestershire. The Keybenefits of this approach are outlined below:

Increased clinical data available within urgent care settings,•community care settings, acute and mental health services

Greater patient safety — key clinical data available to clinicians•treating the patient when they need it.

Patient Empowerment — patients have a greater say in who has•access to their information

Replacing paper-centric processes reliant on faxes, etc., for the•transfer of patient information on both internal and externalorganisation bases

Reduction in the ad-hoc, unstructured communications and•administration overhead of requesting information betweenprimary and Secondary Care

Empowering Health and Social Care professionals to make the•right decisions for patient care by having rich data available forthat patient.


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Online consultations and use of new technologiesGP Practices are technologically equipped for a wide range ofpotential services, and these have been trialled both locally andnationally. However, uptake of internet usage is lowest among the65+ age group, despite a 13% increase over the last four years. Inintroducing new technology to patients, we are aware of the ‘earlyadopter’ curve, which shows that key groups of people embracetechnology enthusiastically, while other groups are late adopters. Forthis reason, we expect to see relatively rapid take-up of telephone-based interventions, such as telephone triage, a slower uptake ofonline services, such as receiving test results online, and the slowestuptake, both by patients and by practices, of virtual consultationsusing Skype or other video-conferencing technology.

Uptake of video-conferencing is also subject to availability of super-fast broadband. By 2016, it is expected that 96% our patients will bein super-fast broadband areas. Leicestershire County Council iscurrently working to secure further coverage.

Listening to and increasing theparticipation of patientsLocal communities across the West Leicestershire ClinicalCommissioning Group (CCG) area need to understand the rationalefor change outlined in the Primary Medical Care Plan for WestLeicestershire; why practices working collaboratively and beingfederated will help local communities improve their healthcare – andhow the community needs to change the way it engages with anduses general practice to contribute to sustainability.

We have ensured during the production of the Primary Medical CarePlan that we engaged with GPs, practice managers, administrativestaff, practice nurses, Patient Participation Group (PPG) members andother local partners. We also engaged the community in aconversation about primary care in March 2014, and more recently,through the Experience Led Commissioning (ELC) approach, whichthe CCG has adopted to co-design change in communities, indeveloping a case for change in Hinckley. However, more work mustbe done in understanding how to involve the wider community andservice users.

We need to build on existing community assets, agreeing a sharedpurpose and common values so that we can co-producte improvedoutcomes with people and families who use primary care.


0

20

40

60

80

100

65 +55-6445-5435-4425-3416-24

%

Use the internet at least weekly, 2013, by household.

Growth of internet usage among 65+,individuals

0

5

10

15

20

25

30

35

40

2014 Q1 2013 Q1 2012 Q1 2011 Q1

Figures: ONS

Telephone triage Test results online Skype virtual consultation

Fast broadbandavailability byspring 2016

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By taking this approach from the start we will maximise our chancesof the community supporting change now and in the future, evenwhere decisions might be controversial.

For West Leicestershire, we already have an archive of insights intowhat matters to people. By supporting a cohort of people tounderstand how to apply these insights, member practices and theCCG can ensure that the patient voice impacts on the developmentand delivery of primary care services and that what we know mattersto people resonates through everything we do. This will also providethe challenge needed before plans are implemented.

This group of community champions could also provide additionalcapacity supporting practices to engage the community, also using anExperienced Led Commissioning approach to gather further insights.

Benefits of this approach

Build a group of ‘community leaders with lived experiences’ to•work with those leading federations and other change developersto ensure that federations in West Leicestershire have a relentlessfocus on building person-centred primary care services thatrespond to what people and families tell us matter

Act as champions for change and lead engagement and•communication with local people to explain the rationale for anew way of delivering primary care

Act as group to test thinking and ideas for service development•

Create community experts in community experience who can use•West Leicestershire’s insights and advocate change that alignswith what matters to local people

Build capability and capacity so that community leaders can•contribute to delivery and facilitation of the co-design element offuture Experience Led Commissioning programmes, oftenreaching out to hard to reach communities

Act as vehicle to transmit messages to friends, family, colleagues,•neighbours and their wider communities and raise awareness.

Improving Quality and PatientOutcomes by Integrated WorkingThe CCG strongly believes that the formation of federations ofpractices will make it easier to align the work of health and social careteams to the needs of the population they serve. Ian Sturgess, in hisOctober 2014 review of the urgent care system across Leicestershire,Leicester and Rutland stated that, ”The development of skill mixwithin this much expanded team of GPs, practice nurses, specialistnurses, planned and unplanned teams and social care teams has the


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potential to extend the capacity of the local system to manage thestreams of patients presenting to primary care as well as theopportunity for coordinated health promotion and prevention.”General practice is well positioned to take a population healthapproach because the registered GP list provides GPs with a stablecohort of patients who live in a defined geographical area, both atindividual practice and locality level. Equally important, GPs and theirteams are an integral part of their local communities and use thisknowledge to access and develop local services that meet the needsof their patents.

We will support our four federated localities to lead the integration ofteams at local level and the development of services that support theavoidance of admissions to, and facilitate early discharge from,secondary care.

Investing in integrated workingA key component of the CCG operational plan has been to secureinvestment in local integrated services. To date we have developedand commissioned community teams through our Proactive Careapproach that work alongside our practices at locality level. Throughthe Better Care fund we want to transform and improve theintegration of local health and care services. The first draft submissionof the BCF plan was approved by the Health and Wellbeing Board inFebruary 2014. The four central themes of the BCF are as follows:

Unified Prevention Offer for Leicestershire’s Communities•

Integrated, Proactive Care for those with Long Term Conditions•

Integrated Urgent Response•

Hospital Discharge and Reablement•

The Better Care Fund mechanism manages monies from the baselinesof each CCG, and leverages a further £4 million direct financialbenefit to West Leicestershire as a result of integration. This funding isdirectly supporting access to seven-day primary and communityservices across our localities.


Elderly CareThe current situationA 92 year old lady lives alone in herterraced house in Loughborough. Herchildren live away and she suffers from amultitude of chronic conditionsincluding, anxiety and depression withall over body pain, recurrent bouts ofundiagnosed (but fully investigated)illness. Over the last year, despite havinghand held records which never seem tobe adequately updated, she has hadmultiple admissions to UHL for various

pains and for which she calls 999 in theearly hours.

The New WayThe 92 year old lady is a lot less isolatedas she has regular visits from the localbefriending service. She has a regularappointment with her Primary CareNurse who is able to advise and reassureher on her long term conditions and isalso able to visit as necessary (Districtand GP nurses have been amalgamatedinto Primary care nurses and are basedin Practice where they are part of the

Primary Health Care Team whichincludes a Federation employed socialworker).The patient has a care plandetailing her treatment regime.

Technology improvements mean thatEmergency Care Practioners, Out ofhours Doctors and the ambulanceservice can access her care plan, GP andhospital notes immediately. They are alsoable to contact geriatricians for Skypeadvice, preventing recurrent admissions.

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6. PlanCode Name Description Measurable Result Start Finish Cost Who is

responsible

1 Federationsmaking generalpractice thrive

1.1 Governance CCG to review constitution withparticular reference togovernance and internalstructures to reflect the impact offederated localities and theaccountability for thecommissioning of generalpractice.

CCG Board Structuresrevised in line withdevelopment offederations and cocommissioning

Oct-14

Apr-15 Legalcost tbc

CCG

1.2 Develop a concordat between theCCG and Federated localities tooutline respective roles,accoutabilities and responsibilities

Concordat agreed andformally approved by theCCG Board and FederatedLocality Boards

Dec-14

Apr-15 n/a CCG/FederatedLocalities

1.3 Review the current engagementprocesses with practices to reflectthe role of federated localities

More effectiveengagement withlocalities and Federations

Oct-14

Apr-15 n/a CCG/FederatedLocalities

1.4 Resources CCG to identify resources tosupport the development ofFederations.

Agreed plan to supportdevelopment ofFederations

Oct-14

Jan-15 see re-sourceschapter

CCG

2 Bettercollaborationand reducingbureacracy

2.1 Collaboration Federated localities to develop astrategic plan and supportingbusiness case to identify actionsto share skills/expertise and backoffice functions to improveefficiency and effectiveness.

Identified priorities withreinvestment of resourcein primary medical care

Jun-15 Mar-15 tbc FederatedLocalities

2.2 Establish task group to review theQuality QIPP programme anddevelop commissioning intentionsto allocate the spend tofederated localities.

Revised Q QIPP proposalagreed by CCG Board andimplemented from April2015

Dec-14

Mar-15 £1.7m CCG

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Code Name Description Measurable Result Start Finish CostWho isresponsible

Federated localities to developproposals and supportingbusiness case to access QIPPinvestment.

Business cases producedand approved by the CCGBoard

Dec-13

Feb-15 asabove

FederatedLocalities

Streamline the reporting andaudit requirements of localschemes and payment processes.

Agreed reporting andaudit requirementsdeveloped andimplemented

Jan-15 Jun-15 n/a CCG/ NHSEngland/LocalAuthority

Explore oportunities offered byco-commissioning to reducebureaucracy and improveoutcome through local QOF,review of direct and communitybased services.

Improved outcomes andreduction in bureacracy

Jan-15 Apr-16 tbc CCG/ NHSEngland/LocalAuthority

2.3 Co commissioning CCG and AT to agree scope, rolesand responsibilities for co-commissioning of primary careand the transfer of AT resourcesto the CCG.

Agreed structure andgovernance for phasedimplementation of co-commissioning of primarycare

Dec-14Apr-15 tbc CCG / NHSEngland

3 Helpingpractices to beattractive placesto work

3.1 Workforcedevelopment

To commission and complete aworkforce audit to identifycurrent and future workforcerequirements and inform thedevelopment of CCG / federatedlocalities workforce plans.

Local workforce gapsidentified and used toinform trainingprogramme

Jan-14 Apr-15 tbc Localities/HEEM

3.2 Skill enhancement To develop and implement localworkforce plans targetting,locality medical student teachingprogrammes, salaried GP, practicemanager nurse / HCAdevelopment programmes.

Co-ordinate support,training and investmentacross localities in WLCCG.

Jul-15 Mar-16 tbc CCG /Localities,HEEM

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3.3 To develop skill mix andmultidisciplinary working withinpractices and across the locality

Improved skill mix tosupport development ofnew services and existingservices delivered in adifferent way

Sep-15 Mar-17 TBC CCG/Federated localities

4 Investment inpractices

4.1 Premises Strategy Commission a primary medicalcare premises audit to inform thedevelopment of CCG and localitybased premises strategy.

Identified investmentpriorities

Jan-15 Aug-15 25k CCG

Alignment of all practices andcommunity services onto one ITsystem

Improved integrated andcollaborative working atboth practice and localitylevel and reducedadministration associatedwith monitoring.

Apr-16 Mar-19 500k CCG

Work with Local Authoritypartners to increase awareness ofand access to S106 monies tosupport practice developments.

Process for accessing S106funds improved andincreased funding securedby practices.

Jun-15 Mar-16 n/a CCG/Federatedlocalities/LocalAuthority

4.2 Premises investment Secure capital funding andnotional rent to implementprimary medical care premisesstrategy

Investment plan agreed Apr-15 Mar-19 9.25 m CCG/ NHSEngland

5 Exploitingtechnology

5.1 Support the further developmentand implementation of PRISM inall practices

Improved adherence toagreed pathways andgreater awareness of outof hospital servicesthrough directory ofservices

Nov-14Mar-16 60k peran num

CCG /Federations

5.2 Implement the agreed IT solutionfor sharing informationparticularly for care plans acrosshealth and social care providers toimprove the continuity of patientcare

Initially care plans andthen wider patientinformation shared acrossorganisations to ensurecontinuity and safety ofcare.

Dec-14Apr-16 BCTfun ded

CCG /Federations/BCT

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5.3 Explore and agree plan to usenew technology to improve online and virtual consultations

Agreed plan in place toincrease use of technologyto support care closer tohome.

Apr-15 Mar-17 150k CCG, GEM,Federations

6 Listening toand increasingparticipation ofpatients

6.1 Co-designing Services To support each federated localityto broker a new conversationbetween people who use servicesand those who provide them, bydeveloping and implementing acommunications and engagementstrategy that helps to recruit andmobilise a representative army ofpeople who are ready and willingto work with them to improveservices.

Community championsidentified and trained fromeach locality.Communication andEngagment strategydeveloped, approved andimplemented.

Jan-15 Nov-15 TBC CCG/FederatedLocalities/PPG

6.2 Develop a set of agreedexpectations between ourpatients, carers, stakeholders andour practices.

Apr-15 Sep-15 CCG/FederatedLocalities/PPG

7 Improvingquality andpatientoutcomes byintegratedworking

7.1 Care Closer to Home. Identify opportunities at localitylevel to develop out of hospitalservices exploiting localitypremises and skills to support carecloser to home.

Agreed locality approach Apr-15 annualreview

see re - sour ceschap ter

CCG, NHSEngland,Federations

7.2 Through collaborative workingwith community, social care andvoluntary sector colleaguesfurther develop the integratedteam approach to patient carewithin each federated locality.

Agreed locality approachwith new communitybased services in place

Apr-15 annualreview

see re-sour ceschapter

CCG, NHSEngland,Federations


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7. ResourcesAt a time when the CCG and wider health economy is facingenormous financial challenges our Primary Medical Care Planneeds to be both realistic and clear about the level of resourceavailable and where funds may come from.

It is important to recognise that the level of system change required toimplement the plan will require funding, but that new resources inorder to do this will be substantially limited. Potentially greateropportunities for resources to support the change required will comefrom non-recurrent (one off) sources of funding and from redirectingresources from other areas of spend rather than recurrent additionalinvestment. Equally important will be the ability to use existingresources to work differently and more efficiently and to ensure thatany freed up resources are redirected/ reinvested into patient care.

Our Primary Medical Care Plan is an integral component of the BetterCare Together (BCT) 5 Year Strategy and sets out how the systemchange required will be achieved. The partners engaged in BCT havedeveloped a Strategic Outline Case (SOC) to appraise whether theBCT programme is the best way of addressing the local case forchange. In assessing the programme against a range of critical successfactors it finds that the path laid out in the five year strategy is theonly viable way of achieving clinical and financial sustainability in LLR.The SOC makes the case for the external funding that will becollectively required through the transition period from 2014/15-2018/19. The SOC includes non-recurrent capital and revenueinvestment for primary medical care but as previously stated thisfunding has not been confirmed and is subject to national decisionsregarding available funds.

Capital Support Assumptions Investment is needed both in terms of bringing existing primarymedical facilities up to date, addressing the growth in the number ofnew homes and associated population, and in ensuring there areappropriate facilities to support the wider health economytransformation. In order to make this a reality we will explore wherepossible with our partners options for utilising existing facilities moreeffectively. However there is still a clear need for capital investment inprimary medical estate to support our ambitions.

In West Leicestershire it is estimated that £9.25m is required to bothupdate and expand a number of high risk premises and to utiliseexisting estate better. Funding requested reflects the findings ofprevious primary care estates surveys together with more recent localknowledge of the requirements in each locality.


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Capital Investment Requested as part of Better Care TogetherStrategic Outline Case

Non Recurrent Revenue Support AssumptionsOur CCG is aiming to increase recurrent spend in primary care servicesover the next 4 years as part of the move to increase out of hospitalcapacity and treat more people in their communities and homes.

During the initial period where capacity is increasing in primary care,additional non-recurrent funding will be required as new servicesdevelop and new staff are trained. This funding will cover thefollowing categories:

Education and training•

IM&T improvements and alignment to support development of•hubs

Management costs, including legal•

New equipment•

Clinical care costs during a period of “double running” where•new services are set up before resources are withdrawn fromexisting services.

Non Recurrent Investment Requested as part of Better CareTogether Strategic Outline Case

2015/16 2016/17 2017/18 2018/19

£k £k £k £k

NorthCharnwood 249 749 749 749

SouthCharnwood 203 610 610 610

North WestLeicestershire 222 666 666 666

Hinckley andBosworth 249 749 749 749

2015/16 2016/17 2017/18 2018/19

£k £k £k £k

Premises Audit £25

IM&T (GPSoC) - 100 200 200

IM&T VirtualConsultations 75 75

Managerial &ClinicalLeadership 450 450 - -

Primary MedicalCare DoubleRunning Costs


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Better Care Together Primary Medical Care Phasing of TransformationAn increase in recurrent expenditure is expected to take place during2016/17 and 2017/18, with a period of double running in 2015/16and 2016/17 to support expansion during the phase when newservices are being set up. The recurrent increases in funding will needto be sourced through a reduction in activity and cost taking place inother settings of care. The table below sets out the time lines thatsupport the areas where transitional (non-recurrent) funding isrequired.

Continuation of CCG InvestmentThe CCG currently invests in primary medical care through a range ofinitiatives including £5 per head of population £1.7m Quality QIPP,Community Based Services £2.8m, seven day services £500k andAcute Visiting Service £533k. We are committed to continuing toinvest in these areas and we will seek to utilise this funding tocontinue the implementation of the primary medical plan.

As outlined previously, the CCG is seeking to take full delegated

2015/16 2016/17 2017/18 2018/19

£k £k £k £k

(includingeducation andtraining) 450 700 400 400

Double RunningCosts IntegratedCommunityServices 675 400 400


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responsibility for the co-commissioning of primary medical care fromApril 2015. This will present further opportunities to use resourcesdifferently to support the implementation of the primary medical careplan and will require the development of a comprehensive financialinvestment and savings plan. The absence of a clear long termfinancial plan (for recurrent expenditure) at this point is a clearomission which will need to be resolved as the co-commissioningagenda progresses and the CCG is able to take ownership of PrimaryCare budgets from the NHS England area team in their entirety.

Improving the efficiency of Primary Medical CareWithin our plan we have identified the need to use existing resourcesto work differently and more efficiently and to ensure that any freedup or new resources are redirected/ reinvested into patient care.Although more work is required in this area we think that significantclinical time could be saved through better organisation and aredesign of the general practice model:

It may be possible to stop up to 10% of GP contacts by•organising better and improving access to other healthprofessionals, allowing GPs to focus their time on those patientswho need them the most.

A significantly greater number of patients could be empowered to•self-care by an increasing focus on well-being and prevention.

The model of funding and delivering primary care is complex with•Core, DES, Local investment and Community-Based services allpaying for elements of the service provided. Any changes willenable simplification and scale, reducing duplication and non-clinical staffing requirements. This will create an opportunity forre-investment into new or differently skilled clinical staff tosupport the practices / federated localities.

The new model will require a broader range of clinical skills both•within general practice and in the ancillary services. Withingeneral practice there will need to be more highly trained nursesand GPs with broader skills for both scheduled and unscheduledcare. This will potentially require new investment alongside thereinvestment of any efficiencies.

Delivering the same GP system across all practices, community•services and urgent care centres across the CCG will enable clearinformation sharing and ability to manage patients appropriatelyfirst time without any delay.


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Criteria for Investment decisions In further developing the financial elements of the primary care planthe following criteria for investment will be used to ensure value formoney and improved patient outcomes.

It will be important to ensure that these criteria are used;

As a basis for making investments into Primary Care where(a)required, which can be evidenced when set against otherorganisational priorities.

For some protection for the CCG Board in making the decisions(b)from any (perceived or real) conflicts of interests.

1 Investments will be made to support Primary Care to realiseefficiencies for reinvestment.

E.g. investment to support the work required to move to sharing somefunctions across practices, given that this will in turn release someefficiency for reinvestment.

2 Investments will need to recognise efficiencies generated in primarymedical care.

This links into the point above – efficiencies generated should be shownexplicitly within any investment plans to ensure that the full scale ofinvestment can contribute towards improved patient care.

3 Investments will support more efficient models of care for patients(and therefore the CCG)

It may be easier to find resources to support investments which contributeto delivery of CCG QIPP savings targets.

4 Investments will be made into more effective clinical models of care.

This means that investments should not be made which do not have a clearbeneficial impact on patient care.

5 Investments made into community services/primary care should beintegrated to achieve maximum benefits

This means that it will be important to consider primary care and othercommunity investments collectively and ensure they are joined up andconsidered as one.

6 Investments will include reinvestment of efficiency savings intoservice provision

We will need to recognise the efficiency being generated by primary careand how that is increasing value for money and service provision.

7 Investment decisions will be made with reference to alignment withother parts of the system strategy and patient needs

E.g. JSNA, CCG Goals, Better Care Together Strategic Direction, etc.

8 Investments will need to demonstrate Value for Money

As all CCG investments.

9 Investments will be subject to overall CCG affordability

Emphasises the limitations of our ability to invest based solely on the abovecriteria. The key to maximising investments within primary care (like anyother area) will be based on the CCG’s ability to deliver significantefficiencies each year.


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8. Governance

West Leicestershire CCGWest Leicestershire CCG has robust systems of governance inplace, with three sub-groups and two formal committeessupporting the Board’s work, and regular developmentsessions to ensure that the CCG continues to improve itscorporate life.

The Board has in place robust decision making arrangements toenable it to establish and implement joint strategies with the otherLeicester, Leicestershire and Rutland CCGs, via the CommissioningCollaborative Board, and to manage any conflicts of interest whichmay arise.

To support and drive the implementation of the plan the CCG willestablish a Primary Medical Care Plan (PMCP) Implementation Group.The group will be a sub-group and report on progress directly to thePlanning and Delivery Board sub-committee.

Terms of reference have been agreed and members of the task groupthat have supported the initial development of this plan will form itscore membership. This will enable each locality and federation to berepresented together with lay, LMC, public health and Area Teaminvolvement. The CCG will provide managerial support with the ChiefOperating Officer acting as the SRO supported by colleagues fromOperations and Delivery, Finance, Quality and Communications.

The PMCP Implementation Group will be responsible for:

Establishing a framework to provide direction, scope and•oversight of the programme

Ensuring expert clinical advice and stakeholder engagement•

Providing challenge, and coordination of initiatives•

Performance managing delivery through the project task groups.•


WLCCG BoardBoardDevelopmentSessions

Financesub-group

Planning and Delivery sub-group

Primary Care Contract sub Group

PrimaryMedical CareImplementationGroup

Quality andPerformancesub-group

Remunerationcommittee

Auditcommittee

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Monitoring, Evaluation, ImprovementsThe implementation programme will be underpinned by a robustperformance and governance process, through the establishedProgramme Management Office (PMO). Through the PMO the CCGhas well established processes including Business Case Development,Project Initiation Documentation, performance managementdashboards and risk registers, all of which will support effectiveprogramme delivery.

In order to ensure effective monitoring of the programme and anyindividual task groups that are established a clear reportingmethodology will be instigated enabling a monthly progress report tobe provided to the Planning and Delivery Group for review. This reportwill be an exception report, RAG rated and will detail missedmilestones or deliverables together with requests to review the scopeof the programme/task groups if required.

Elements of the plan will be implemented in a phased way, in order todeliver quality benefits as soon as possible. The implementation isplanned in five phases:

Phase 1: July 2014 – October 2014. The initial phase has•supported the development of the draft plan informed bymembers, partners and local stakeholders.

Phase 2: October 2014 – December 2014. The second phase•allows us to engage more widely with stakeholders and to furtherdevelop the plan.

Phase 3: January 2015 – March 2015. This phase will enable the•implementation group to be formally established, supportingprogramme management structures to be put in place. Markers ofsuccess are to be agreed.

Phase 4: April 2015 – March 2017. This phase will commence•tangible change programmes laying the foundations forrealisation of the plan.

Phase 5: April 2015 – March 2019. This phase will consolidate•and embed change programmes into main stream activity.

Transformed primary medical care will demonstrate a number ofmarkers of success which will be quantifiable and perceptible topatients — performance trajectories and projected improvements inperformance as a result of this transformational programme will beagreed and established in phase one of the programme.


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Federated Localities, Co-Commissioning, and Management ofConflict of InterestWe recognise the importance in making decisions about the serviceswe commission in a way that does not call into question the motivesbehind which the decisions have been made. Our Constitution setsout how conflicts of interest are to be managed so that wecommission services in a manner that is open, transparent, non-discriminatory and fair to all potential providers.

In recent governing body meetings it has become increasinglyapparent that our Board GPs, through their practices’ membership ofthe four legally constituted locality federated localities, are likely attimes to be conflicted when conducting particular aspects of thebusiness of the CCG, particularly in respect of procurement andaward of contract decisions.

Furthermore co-commissioning, where the CCG will assume greaterresponsibility and accountability for the commissioning of primarymedical care, reinforces the need to review our governance

arrangements to ensure they remain fit for purpose.


Urgent CareCurrent Situation An 87 year old lady with a history ofhypertension and mild depression suffersfrom episodes of mild confusion butmanages to live alone with the help offriendly neighbours. Following a viralurinary tract infection she develops aproductive cough, becomes a little moreconfused and trips and falls injuring herright wrist.

The visiting GP finds some signs of chestinfection and in view of the wrist injurysends the patient to A&E. At A&E thewrist X-ray does not show a fracture,although the patient is unable to use her

wrist fully. Chest X-ray shows a littlehazy shadowing and electrolytes adegree of hyponatremia. In view of thecombination of problems, the patient isadmitted. Following admission the newsurroundings increase the degree ofconfusion to the extent that the patientis eventually discharged to temporarynursing home placement. This changeagain increases the degree of confusionand she becomes permanently placed inthe home.

The New WayThe GP uses the local Urgent CareCentre/X-ray pathway to send thepatient to X-ray with the X-raysreviewed in the Urgent Care Centre. The

test show the hyponatremia. The UrgentCare Centre immobilises the wrist, andin view of the hyponatremia andconfusion seeks advice from the FrailOlder Persons Unit up the corridor. Theconsultant there stops the citalopramand bendroflumethiazide.

Arrangements are made to dischargethe patient with the overnight sittingservice and follow up with the intensivenurse support. The patient responds toantibiotics and changes in medicationwhile remaining in her own home.Longer term management includes theproduction of a care plan which includessocial support from voluntary services.

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RisksCurrently identified risks to the plan are set out below. These risks arebeing actively managed, and will be monitored through thegovernance processes above.


5 Catastrophic

4 Major

Failure tosufficiently engagepatients with self-management

Lack of resources tosupport out ofhospital care andthe implementationof the plan

Lack of clarity withregard to the co-commissioningresponsibilities andaccountabilities ofthe CCG and AT

3 Moderate

Lack of robustprocesses tomanage conflicts ofinterest – includingreviewing theconstitution of theCCG

Lack of ownershipby practices of theneed to change

Federationsdeveloping atdifferent rates ineach locality withvarying degrees ofengagement fromtheir memberpractices andleadership

2 Minor

1 Negligible

Impact / Likelihood

1 Rare

2 Unlikely

3 Possible

4 Likely

5 Almost Certain

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9. ConclusionThe Primary Medical Care Plan has two underlying tenets:sustainability, and transformation.

In the ‘Case for Change’, we set out the issues facing the CCG: ourhealth economy is facing a deficit of 21% within 5 years, GeneralPractice is already working at capacity and cannot in its current formaccommodate a ‘left-shift’ from the acute sector to increase out-of-hospital care, population is rising, with over 65s a particularly fastrising group, and, despite overall reductions in ill-health, demand forservices continues to grow.

It is always tempting to address the problem of the deficit head-on,taking whatever action is necessary to manage it. However, thismerely throws the problem onwards by five years. We cannotaccurately predict the future, but we can be confident that the futurewill see more disruptive change, new patterns of need and access, achanging demographic and new pharmaceutical and technologicalapproaches to currently intractable conditions.

We have therefore pursued a ‘virtuous spiral’ approach. Resourcesreleased by moving care from acute will be re-invested, expertisedeveloped in implementing the plan will be reapplied, the governancestructures we are creating will be agile to identify changing aspirationand need at an early stage, and the organisational momentum willmake further change easier to instigate and manage.

This is the reason why we conducted an engagement process withclinicians, stakeholders, patients and partners, and why its sevenoutputs have played a key role in forming this plan. In setting out tomeet these aspirations, and in clearly setting our ambition for PrimaryMedical Care in five years time, we have designed our system-changearound a ‘best health system’ approach, rather than ‘cover the deficitat all costs’.

Our measurable results will be in terms of monies saved, clinicalstandards met, quantity of care delivered and meeting therequirements placed on us by other partners. However, the lesstangible rewards are likely to have far more impact. We expectGeneral Practice in West Leicestershire to become steadily moreattractive to medical students and to clinicians relocating fromelsewhere. Practices will become desirable places of work, known fortheir community atmosphere, common goals and shared values.Patients will feel substantially more confident of their ability tomanage their own conditions, more knowledgeable about how toaccess care appropriately, and more certain that the care programmethey receive is designed around their lives, rather than vice versa.


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