Commissioning Development Programme

1. Commissioning Development Programme COMMISSIONING DEVELOPMENT PROGRAMME Local Professional Networks Briefing Pack

2. In this local professional networks takeaway pack we aim to provide information on the following What local professional networks are intended to be Why we are developing this idea as part of the primary care commissioning proposals The emerging proposals What we’re trying to achieve What the operating model could look like Proposed functions of local professional networks The story – how this should work How we will be testing the proposals and how you can get involved

3. A wide range of commissioners, clinicians and others have been involved in developing these proposals to date This pack has been produced to provide more information about the proposals for the involvement of dental, pharmaceutical and optical clinicians in the commissioning of primary care through local professional networks embedded within the single operating model of the NHS CB The pack sets out proposals to date developed through co-production through discussions and a series of workshops with clinicians, commissioners, national representative bodies BDA, PSNC and LOCSU and other key stakeholders. We have identified a number of questions and issues we need to test. Our testing and co production in PCT clusters will contribute to the final proposition for the direct commissioning of primary care.

4. The proposal for local professional networks has been developed to embed clinical expertise in the operating model • Working as part of the NHS CB field force team, the vision is for local professional networks to • Provide a vehicle for clinically led and clinically owned delivery of; • - Quality improvement • - Best outcomes for patients that reflects local need • - Best use of NHS resources • - Planning and designing integrated care pathways • - Strategies for service planning and health improvement • - Leadership and engagement • Ensure clinical leadership at the heart of the local operating model • The design proposals for LPNs describe those functions where clinical expertise and leadership could add most value within local commissioning operating model • Provide a system for commissioning managers and clinicians to deliver NHS CB vision together to a common purpose • Note: there is a read across to some of the expectations of the CCG in improving quality in primary medical care.

5. Local professional networks would form a core part of the NHS CB local commissioning team, with a clear role and functions • NHS CB Central • Functions could include:- • Developing strategies and frameworks for implementation across primary care based on an aggregation of local need • Producing and maintaining all contract documentation for use by the local teams • Setting the parameters for local team working through standard policies, procedures and processes • NHS CB Field Force • Functions could include:- • Providing the interface with primary care contractors within a defined health community • Contract management and performance management. • Drawing in clinical expertise – as required – from dentists, pharmacists and optical professionals through local professional networks • NHS CB local professional networks • Functions could include:- • In conjunction with CCGs and HWBs, providing the clinical interface and expertise to develop the primary care commissioning strategy • Bringing local clinical intelligence into the commissioning decision making process • Quality improvement in primary care

6. We are exploring how local professional networks would best be organised in practice to facilitate this quality improvement The proposals for involvement and integral roles within LPNs sees inclusion of a broad range of clinicians – generalists, specialists and public health – other key local stakeholders such as HWBs and CCGs, patients and the public and commissioners. The draft operating model outlines a small core team, made up of commissioners, a small resource of part-time clinicians (employed by the NHSCB), that utilises a wider network or pool of clinicians to lead and deliver outcome based objectives. LPN functions could be discharged via a number of networks across the field geographical area, some operating on an on-going basis and some with specific time limited projects that would operate as ‘task and finish’ groups e.g pathway project. Some of this clinical resource would be remunerated by the NHSCB ( where clinicians are not paid elsewhere) – anticipated to primarily be PC clinicians. Utilising clinical input from this ‘pool’ of clinicians locally would mean that the NHSCB can draw upon this clinical expertise when required, ensuring clinically led commissioning, whilst managing this in the most efficient and cost effective way

7. The LPN and their supporting networks would also coordinate input and engagement with all providers and performers locally All primary care providers (influence, communications, roll out, embedding) Relationship with the NHS CB through local teams Local clinicians (‘pool’ of clinical expertise for ‘task and finish’ projects, quality improvement, pathway re-design, strategic development and planning) Clinical engagement and leadership Local variation where justified by health needs Core Clinical Commissioning Team (commissioning managers, clinical quality and network leaders, public health) Consistency in approach to commissioning

8. In addition to the core LPN team and network arrangements, there will be mechanisms to draw on specific areas of expertise • The design plans see dental, pharmacy and optical LPNs establishing their own core teams within the field force and network arrangements as well as securing specific clinical and professional expertise to deliver their objectives and functions. • Leadership and accountability for LPNs would come from within their core teams and link closely to senior commissioners within the field force • Discussions so far have suggested that LPNs would include the following clinical and professional input from an identified ‘pool’ of clinicians to feed into their work; • Primary and Secondary Care Commissioners • Public Health (resourced from LA/PHE) • Quality and Performance Improvement Leads • Clinical and Professional Expertise • Generalist Clinical Input – primary care clinicians • Specialist Clinical Input – secondary care • PC clinicians with a specialist interest • Clinical Skill Mix (e.g. pharmacy technicians, dental nurses) • Local Representative Committees • Workforce and Development – deaneries, CPPE • Patient and the Public Representation • CCG Representation • Interdependencies to support as appropriate – e.g. Informatics, Finance, PC regulatory experts

9. There is opportunity – but also new risk – with increased involvement of clinicians in commissioning decisions • In developing the proposals for LPNs, we need to balance conflict of interest issues and with the right incentives for clinicians to be involved in LPNs locally. • For dentists, pharmacists and optical professionals, the proposals provide an opportunity for them to influence positive change at local and national level. • For many clinicians, the involvement in LPNs may offer significant career and personal development opportunities. • Quality improvement strategies that are clinically developed and clinically embedded, with peer support and transparent sharing of information, are more likely to succeed and for all providers, as well as patients, result in a ‘level playing field’ in service delivery. This has been seen as a major incentive for clinicians to want to be involved. • However, as part of the testing, we have set out an objective for some test LPNs to focus on these issues to develop robust mechanisms to mitigate against potential issues of conflicts of interest. Clinicians who have been involved in the proposal developments are keen to address these effectively.

11. Continuous quality improvement with underpinning clinical input is a major feature of the new arrangements Primary care commissioning is not just about contract compliance. Indeed the detail of the contract is rarely discussed except when performance is seriously off track or providers feel that the expectations of them are well beyond that which could be considered reasonable. Continuous quality improvement to secure better outcomes is a major feature of the new arrangements. For primary medical care this is seen as a shared activity between CCGs and the NHSCB. For dentists, optics and pharmacists the field force will need to facilitate those discussions and local professional networks of these clinicians should drive this process

12. We envisage LPNs working as an integral part of the NHS CB field force, developing close working relationships with CCGs and HWBs Health and well being boards HEE local networks Clinical Commissioning Groups Peer support, peer review and benchmarking Informing needs, demand, supply in primary, community and secondary care Local professional networks Maximising performance Local intelligence, clinical expertise, innovation and development of integrated care pathways NHSCB local Implementation and development plans to reflect local circumstances NHSCB national Aggregation of need and assurance of performance Strategy, policy, contract, procedure and assurance of achievement of outcomes

13. Local professional networks could be designed with flexibility to discharge their functions at a number of different levels • The levels at which LPNs could discharge their functions might be seen broadly at 3 levels; • Strategic and Planning • Operational and Delivery • Engagement and Support LPNs would need flexibility within their structures and resourcing to align engagement networks and ‘task and finish’ groups for the delivery of functions to best fit local circumstances. Health and wellbeing boards and JSNA/PNA planning processes as well as natural community boundaries, secondary care services, patient population and numbers of primary care providers within locations will be an important factor in how this is aligned. cont.

14. Local professional networks could be designed with flexibility to discharge their functions at a number of different levels Note (a):at this stage we do not know the size of the population/contractor base covered by the field force but we know that PCT clusters form the initial footprint. Note (b): PCT clusters may feel an LPN works better at greater or lesser scale than a PCT cluster and we’d be interested in pros and cons of both.

15. We are developing individual LPN proposals for pharmacy, dental and optics – but there are commonalities in what they could deliver To ensure that patients are at the centre of commissioning Develop a structure, organisational arrangements and processes to ensure that the patients voice and involvement is central to planning and designing care pathways, improving and assuring quality Local quality improvement and assurance programmes – LPNs would be well placed to establish clinically led quality improvement strategies to support the shift of emphasis for local health improvement to clinicians. Service re-designand improving patient pathways – LPNs could lead or provide significant contribution to re-design programmes across care pathways, such as secondary to primary care shift, redesign of salaried dental services and care pathways with CCGs and HWBs to deliver health improvement through working across primary and secondary care Ensuring effective integration of primary care serviceswithin planning and delivery strategies – LPNs would need to establish effective relationships with emerging HWBs and CCGs to ensure effective expertise, advice and contribution is included in the JSNA and PNA processes and developing integrated primary care strategies. Clinical leadership and clinical engagement structures – in order to allow influence and ownership of local commissioning agendas across all primary care providers and performers, LPNs would develop effective and efficient models of delivering leadership and engagement across their geographical footprint to ensure the involvement of and support to all practices.

16. Specific functions where dental local professional networks could add most value to commissioning locally To ensure local implementation of NHSCB dental strategy Provide and coordinate clinical oversight to the delivery of strategy at field level, ensuring local strategic fit of national policy and acting as a conduit for intelligence from and to the central NHSCB Ownership of Oral Health Strategy for dental services and Oral Health Improvement Implementation of strategy in response to need assessment; identify inequalities in access to dental care, quality and outcomes and align local plans appropriately to address; ownership and development of field force implementation plans for dental services; interface with the key stakeholders of HWB to help develop and deliver agreed local agenda of oral health and dental services improvement. Improving and Assuring Quality Monitor and support improvements to dental services in relation to; quality, outcomes, patient experience and activity; work with clinicians and patients to review effectiveness of services and improve patient pathways; assess quality of patient experience to inform improvement activities and support practices to improve patient involvement; discuss comparative information with dental practices to improve quality and outcomes; provide professional support to providers in assisting under-performing practitioners; advisory role to the NHSCB of local variation and sensitivity; ensure consistency in quality improvement approaches, including benchmarking, peer review, Quality Framework delivery, appraisal, review and governance requirements. Planning and Designing Local Care Pathways and Dental Services Articulate commissioning strategy at local level in response to need assessment and associated commissioning plans, locally manage the resources for dental/oral health components of secondary care contracts, salaried dental services, and emergency dental care including Out of Hours for residents and oral health improvement initiatives Clinical and Professional Leadership and Engagement Provide local professional leadership and specialist dental public health advice, developing and supporting development of clinical and professional practice, define and coordinate clinical engagement models, including local implementation, ‘task and finish’ groups, with the wider profession, Workforce Development Planning and Education

17. Specific functions where pharmacy local professional networks could add most value to commissioning locally To ensure local implementation of NHSCB Medicines Optimisation strategy where it relates to pharmaceutical services To ensure that the NHS CB Medicines Optimisation Strategy where it relates to the provision of pharmaceutical services is integrated into local H&W Board and CCG strategies and operating frameworks locally. Provide and coordinate clinical oversight to the delivery of strategy at field level, ensuring local strategic fit of national policy and acting as a conduit for intelligence from and to the central NHSCB Develop PNA in partnership with local H&W Boards and develop and implement strategy to ensure identified needs are met Implementation of community pharmacy strategy in response to need assessment; identify inequalities in access to pharmaceutical care, quality and outcomes and align local plans appropriately to address; ownership and development of field force implementation plans for pharmaceutical services; interface with the key stakeholders of HWB to help develop and deliver agreed local agenda of health and wellbeing advice and information and public health services from local pharmacies. Improving and Assuring Quality Monitor and support improvements to pharmaceutical services in relation to; quality, outcomes, patient experience and activity; work with clinicians and patients to review effectiveness of services and improve patient pathways; assess quality of patient experience to inform improvement activities and support pharmacies to improve patient involvement; discuss comparative information with pharmacies to improve quality and outcomes; provide professional support to providers in assisting under-performing practitioners; advisory role to the NHSCB of local variation and sensitivity; ensure consistency in quality improvement approaches, including benchmarking, peer review and governance requirements. Planning and Designing Local Care Pathways and Pharmaceutical Services Ensure personalised support for medicines taking is designed into all locally agreed care pathways. Work with clinical networks of the NHS CB and locally with CCGs and others to ensure effective communication regarding medicines and their use is provided at transfers of care and that patients have access to support and information to optimise the outcomes from their medicines. Clinical and Professional Leadership and Engagement Provide local professional leadership and specialist pharmaceutical advice, developing and supporting development of clinical and professional practice across boundaries of care, define and coordinate clinical engagement models, including local implementation, ‘task and finish’ groups, with the wider pharmacy workforce; Workforce Development Planning and Education

18. Specific functions where optical local professional networks could add most value to commissioning locally To ensure that patients are at the centre of commissioning Develop a structure, organisational arrangements and processes to ensure that the patients voice and involvement is central to planning and designing care pathways, improving and assuring quality To ensure local implementation of the NHSCB Eye Care best practice Provide and co-ordinate clinical oversight of the delivery of eye care best practice at field level ensuring local strategic fit acting as a conduct for intelligence from and to the central NHSCB Improving and Assuring Quality Monitor and support improvements to Optical services in relation to; quality, outcomes, patient experience and activity; work with clinicians and patients to review effectiveness of services and improve patient pathways; assess quality of patient experience to inform improvement activities and support practices to improve patient involvement; discuss comparative information with Optometric practices to improve quality and outcomes; provide professional support to providers in assisting under-performing practitioners; advisory role to the NHSCB of local variation and sensitivity; ensure consistency in quality improvement approaches, including benchmarking, peer review, Quality Framework delivery, appraisal, review and governance requirements. Planning and designing local care pathways Devise a work programme at local level which delivers the key eye care pathways in particular those recommended by the Royal College of Ophthalmology and College of Optometrists Clinical and Professional Leadership and Engagement Provide local professional leadership and specialist optical public health advice, developing and supporting development of clinical and professional practice, define and coordinate clinical engagement models, including local implementation, ‘task and finish’ groups, with the wider profession, Workforce Development Planning and Education

20. The proposals described have been developed in co-production - we will now be inviting PCT clusters to test the model to refine the detail The outline functions, structure and high level operating model for LPNs outlined above have been co-designed with commissioners, the professions and the DH We now need to test these plans and assumptions to further refine the proposals, in particular identifying where clinicians can add most value to local commissioning arrangements We aim to draw on ongoing work from a number of PCT clusters across the country, garnering learning to feed into the detailed operating model for the NHS CB Relationships with HWBs, LAs and CCGs will be vital and now is a good time to test the transitional architecture as this wider system is also being established

21. There are a number of specific elements we would like to test over coming months which include the following • Structure and size • Functions and scale of delivery • Cost and value • Relationships with local health economy and HWBs • Cultural change • Manager/clinician partnerships • Practicalities of setting one up – appointments process, engagement, arrangements • Incentives to engage • Conflicts of interest and how to overcome • Clinical capacity and capability and any development needs

22. The testing period also presents the space to address some of the challenges and opportunities for primary care commissioning Shift in culture – local managerial and clinical ownership, but operating within the parameters of a ‘corporate’ model The right incentives to be involved Governance – conflicts of interest/self interest Delivery within the challenges of financial austerity and national operating model Demonstrating the design proposals are worth the investment Clinical capacity to provide robust quality improvement and patient outcomes – level playing field Clinicians in a leadership role within the system that commissions their services Enabling clinicians to design care pathways that best meet patient needs Expertise where best adds value

23. PCT cluster starting point. In many PCTs and PCT clusters, there are already good working arrangements in place where clinicians are well embedded into the commissioning and quality improvement arrangements. Where this is the case, there is much to build on that lends itself to a profession-led/LRC partnership model in the proposals for LPNs. Formalising testing arrangements for LPNs should seek to compliment these arrangements locally rather than replacing or duplicating. This is not the case in all areas however, and partnership working between PCTs and LRCs is inconsistent in some areas. PCT clusters who wish to test the LPN arrangements may want to set out proposals for how the arrangements may be established. Ideally, where either PCT or LRC supported infrastructures are not currently well defined, they may wish to work together to develop proposals of how they might test LPNs, defining areas where LRCs can contribute. Testing of LPNs would enable a view of the merits of both options (and something in between) and we would aim to test a mixture of these approaches.

24. Approaches to testing local professional networks Profession-led/partnership models with LRCs • Where existing commissioner/clinical partnership working lends itself to testing LPNs, this may simply mean reviewing current arrangements with a view to the LPN functions and proposed operating model • Reviewing priorities and deliverable outcomes to establish clear shared objectives as well as ensuring wide clinical expertise where required, may also be useful NHSCB-led model (initially via PCT Clusters) • Where existing arrangements are not well defined, PCT clusters have an opportunity to work with their LRCs and local clinicians to establish what best works for them or take the best of what works well in other areas. • The proposed functions and operating model for LPNs gives a good foundation to test from scratch these arrangements • Establishing some short term goals might be useful, for example; • Establishing effective engagement vehicles to enable all providers and performers to contribute to/influence local quality agenda • Establishing robust operating arrangements locally that include clarity on terms of reference, accountability and governance • Establishing priorities areas for LPNs to lead locally, linked to existing or reviewed primary care commissioning strategies, such as quality improvement, supporting service and care pathway re-design NOTE: There are differing views about the extent of engagement of LRC’s. However they are often the only outlet for a clinician seeking leadership & leadership roles so pragmatically it may be hard to test proposals without engagement with LRCs.

26. Learning from and sharing approaches in ongoing and new work around local professional networks • Working on the assumption that LPNs will deliver the range of functions outlined above, it is important that we garner early learning from testing of the proposals as well as on-going feedback on best practice approaches and most effective operating models, structures and delivery of outcomes by LPNs. To ensure we can do this we will; • Work with the national representative bodies, BDA, PSNC and LOCSU and other national stakeholders to gather and share learning as it emerges • Work with SHA PC leads and DCDs to support PCT clusters in establishing testing and learn from what is working well • Identify opportunities for LPN clinical and commissioning leaders to share their experiences through national forums and conferences • Ensure ongoing co-production of proposals so that the best approaches and models are fed into the refined proposals for LPNs in the NHSCB implementation programme by asking for structured feedback on the specific questions and elements around LPNs that we want to invite PCT clusters to test

27. Next steps: getting involved in testing the proposals for LPNs • We would like see a range of PCT clusters test the models for LPNs and move forward with this as soon as they feel ready to commence this locally. • SHA PC leads and PCT cluster representatives have been involved in the development of the plans and will be familiar with the concept of testing these proposals and SHA Directors of Commissioning Development and their teams have indicated their support to PCT clusters who have expressed an interest in testing with us. • Support to PCT clusters can be accessed via SHA DCD teams and SHA PC leads, as well as via the NHSCB Implementation Programme by contacting Sam Illingworth, Jim Barlow or Jill Loader. • We have also enclosed a form for you to let us know if you intend to test these new arrangements and are happy to share your learning with us. This will enable our programme team to provide any support to PCTs and their clinicians in developing their local plans as well as knowing where to come for communications which will help others. • The LPN testing forms should be returned to our lead for LPNs, Sam Illingworth, to samantha.illingworth@northwest.nhs.uk as soon as your local arrangements are clear.

28. Feedback on this pack and the proposals We would welcome feedback and involvement from clinicians and PCT clusters on further refining the LPN proposals and specifically seeking responses and ideas to the questions we pose either as part of testing LPNs or outside of this. Comments and responses should be sent to:- Samantha Illingworth – Lead on dental, optical and pharmaceutical services, NHS CB implementation team. For specific queries on the dental, pharmacy and optical LPNs, contact; Samantha.Illingworth@northwest.nhs.uk – dental LPNs Jim.Barlow@northstaffs.nhs.uk – optical LPNs Jill.Loader@southwest.nhs.uk – pharmacy LPNs