Primary Care Models

1. Primary Care Models February 2016

2. Primary care model development

3. Northumberland Vanguard: Empowering our communities to live long and healthy lives at home What matters to you? Living healthily and independently at home Healthy resilient communities Supported carers and families

4. The Primary Care Strategy for Northumberland 2015-2020 Clinicians are working in practices they are proud of, delivering care to patients in a wider truly integrated team. Networks of practices are working together; integrated with care teamsfrom community, secondary care, social care and the voluntary sector. New structures and workforce models are in place to allow clinicians to spend more time with their patients,with greater continuity of care and higher quality care for their patients. The system allows easy access to the right clinician at the right time, whilst patients with complex needs are managed proactively in the community by a wider multidisciplinary team headed up by their GP and appropriate specialist. Everything is underpinned by a shared clinical record.

5. Why change? We need to… • Reduce reliance on A&E and hospitals – outlier in the country • Improve patient outcomesexperience & quality of care • Share clinical information effectively and in a timely way • Improve access to primary care in hours and deliver extended and seven day care on our own terms • Reduce variation in practice and duplication across the system • Create better continuity of care and have more time to see our complex patients • Create a sustainable workforce toincrease patient benefits and improve staff recruitment & retention • Deliver more care closer to home • Create empowered patients who effectively self manage

6. The Northumberland system is expensive – due to over reliance and use of hospitals

8. What will be delivered?

9. What is primary care going to deliver? • Develop effective access models where needed (in hours, extended, seven day) • Scale up & reduce duplication through hubs, flexible hubs and networks • Provide continuity of care to our complex patients • Develop new workforce models that strengthen primary care and the wider MDT • Create one shared clinical record with read and write access in real time • How do we wrap community teams around primary care to support these patients?

10. How will we know we have been successful? Release of funding from hospital services into prevention & of hospital care Shared clinical record across the system – with read and write access in real time Universal same day access to primary care for those who need it seven days a week • Reduced reliance on hospital care with activity delivered in communities More people living longer healthier lives independently at home Sustainable workforce in primary care • Empowered patients who effectively self manage • Duplication and variation in practice significantly reduced Better patient outcomes and reduced inequalities

11. Capacity and Demand Analysis • 3 Waves of training with all but 5 practices signed up (wave 3 12th Jan) • Data capture complete for Waves 1 and 2 • Data is now available (subject to change) • Solutions meetings being arranged • Different levels of enthusiasm and scepticism • 2 practices have expressed an immediate interest in implementing Dr First

12. Mapping • Mapping baseline for activity and resources • Capturing acute care only at this point • What are we trying to show? • What are we trying to understand? • What / Who will we use the information to influence? • Where are Northumberland residents accessing urgent / acute care services? • identify the patient cohorts and highlight the priority areas for further analysis • produce a summary of the demographic demand on urgent care services and set a baseline • produce a summary of the demographic demand on urgent care services and set a baseline • produce a pathway map and provide a one page visual

13. MIG • Main objective of the MIG deployment was to get 50% of the practices across Northumberland and North Tyneside through the information governance process by December • 59% of the population will be covered initially • Practices who have not signed up will need to consider the 7th Caldicott principle: “The duty to share information can be as important as the duty to protect patient confidentiality” • Concerns raised, mainly in the west where only 1 practice signed, regarding the lack of benefit for primary care and the impression Northumbria is leading the process

14. Primary Care IT Interoperability • Establishing an IT solution across all GP practices is considered as a priority under PACS • Under the GPSoC framework practices are permitted to choose their preferred clinical software system • 27 practices currently operating EMIS, 16 SystmOne and a single practice using Vision • Initial options are: • Do nothing and maintain GP independent choice of clinical system • Wait the outcome of the current pilot of interoperability between SystmOne and EMI to see if the solution negates the need for change • Develop an external commercial bolt on application to enable all the clinical systems to share data • A PACS preferred primary care clinical system to be applied as below: • Individual Practices consider the PACS preferred option and retain independent choice of clinical system • Collaborative working – group of practices to identify one system to be used considering the PACS preferred option • Request and support all practices throughout Northumberland to actively change onto the PACS preferred clinical system • Next steps: NECS to develop a fully costed options appraisal for consideration by the Vanguard Board and JLEB in January

15. Toolkit • Providing the tools for primary care to work differently • Will offer practices with: • A practical checklist - “How will we deliver services to each other’s patients?” • The “tools” to fulfil contractual requirements • The technical processes to be followed • Progress • Contact made with PMCF and other vanguards • Northumbria Primary Care documents and lessons learned – in progress • NHS England contract team have been asked to: • undertake an analysis of the GMS / PMS contract • highlight the areas potentially impacted by any new ways of working in primary care • provide solutions or processes for all practices to follow to ensure requirements are met • Medicines management investigating routes for prescribing • NDUC and Northumbria have worked up solutions for insurance cover • Beachcroftto • prepare template contract documents • offer alternative solutions to test delivery of new models and flexible ways of working

16. Northumberland: the priorities Northumberland Enhancing access to primary care Integrating primary, community and acute care Reducing duplication in the system and reliance on hospital settings DELIVERING THE CHANGE • Model of care development • Access model review by each practice following analysis of capacity and demand & future access models agreed by practices where needed • Clearing of backlog in primary care – if required • Implementation of the MIG • Decision made on PACS system of choice and implementation • Creation of primary care toolkit for application in local hubs • Develop primary care leadership and workforce • The Target Population • Acute: • Frequent users of A&E • Children, young families, younger adults • Patients with complex needs • Non Acute: • Working age and children with LTC • Multiple LTC and complex elderly • County-wide short term outcomes • Creation of appropriate primary care access models • MIG implemented across all primary care • IT PACS system of choice decision implemented • Payment systems and contracts that encourage collaborative working in place (enhanced service) • Primary care toolkit implemented in local hubs • Primary care leadership framework and career start in place

17. West Locality: the priorities West Develop collaborative working between primary care, secondary / acute and community teams to ensure patients have high quality care, in the right place at the right time DELIVERING THE CHANGE • Model of care development • Create collaborative complex care team in the Hexham hub with direct admissions • Explore flexible hub model in Prudhoe area for extended access • Expand the role of the community paramedic, nursing workforce • Create local care pathways for complex frail elderly supported by complex care team – providing continuity of care closer to home • Expand elderly assessment and use more proactively • The Target Population • Acute: • Patients requiring specialist input without the need to admit • Patients appropriate for early discharge from acute bed to usual place of residence needing some support • Non-acute: • Patients requiring assessment – remaining in usual place of residence • Residential / care home residents – proactive reviews • Complex frail patients in the community • West locality short term outcomes • Collaborative complex care team established • Seven day primary care Hexham hub developed including booked appointments at weekends for primary care • Flexible hub development in Prudhoe for extended access • Expansion of the community paramedic role

18. Blyth Valley Locality: the priorities Blyth Valley Develop collaborative working between practices to manage demands in primary care, create an efficient use of resources and reduce pressures on acute services to ensure patients have high quality care, in the right place at the right time DELIVERING THE CHANGE • Acute: • Patients requiring specialist input without the need to admit • Patients appropriate for early discharge from acute bed to usual place of residence needing some support • Non-acute: • Patients requiring assessment – remaining in usual place of residence • Residential / care home residents – proactive reviews • Complex frail patients in the community • Model of care development • Create integrated flexible hubs for patients with complex care needs/ extended hours (Cramlington, Seaton Valley) • Integration with community/ acute services • Local minor injuries service that is primary care led and acute hub - Blyth • Care home alignment with primary care including proactive care planning • Exploration of practice mergers on core services to enhance and extend primary care • Proactive management of LTCs and reduction in variation in practice/ outcomes • Blyth Valley locality short term outcomes • Integrated hubs up and running offering extended hours • Blyth acute hub expansion to include other practices, MIU delivery and acute home visiting • Greater focus on continuity of care and holistic care at the point of access • Reduced duplication of delivery

19. Central Locality: the priorities Central Enhancing access to primary care Integrating primary, community and acute care Reducing duplication in the system DELIVERING THE CHANGE • Model of care development • Wansbeck hub for weekends including booked appointments for chronic care/ LTCs • Remove duplication of base site, NDUC, PCAC, primary care delivery • Core primary care 8am – 5pm • Flexible hubs for extended hours (Morpeth, Ashington, Bedlington) - testing extended hours’ models 5pm – 8pm • Complex care team ‘super service’ aligned with primary care with single point of access • Expansion of primary care workforce models such as physiotherapy and pharmacy • The Target Population • Acute: • Frequent users of A&E • Children, young families, younger adults • Patients with complex needs • Non Acute: • Working age and children with LTC • Multiple LTC and complex elderly • Central locality short term outcomes • Seven day primary care delivered from Wansbeck hub with reduced duplication of delivery and increased efficiency • Flexible hubs up and running for extended access • Expanded primary care team including pharmacy and physiotherapy • Complex care team established • Single IT system

20. North Locality: the priorities North Develop collaborative working between practices to manage demands in primary care, create an efficient use of resources and reduce pressures on all services to ensure patients have high quality care, in the right place, first time DELIVERING THE CHANGE • The Target Population • Acute: • Patients requiring specialist input without the need to admit • Patients appropriate for early discharge from acute bed to usual place of residence needing some support • Non-acute: • Patients requiring assessment – remaining in usual place of residence • Residential / care home residents – proactive reviews • Complex frail patients in the community • Frequent attenders of primary care needing more social and emotional support • Model of care development • Possible creation of two hubs • Proactive management of complex patients in their place of residence with a focus on social prescribing/ social and emotional support – Alnwick hub • Integrated approach to minor injuries and use of clinical pharmacist – Berwick hub • Care home/ complex care model development with plan for expansion– Coquet • One telephony system • Workforce development for GPs and nurses • Alignment and use of premises and estate • North locality short term outcomes • Remove duplication in MIUs - reduced duplication of delivery • One telephony and communication system • Hub working across practices - two hubs • Upskilled nursing workforce with specialist skills for long term conditions • Workforce recruitment & development programme for GPs

21. NDUC • NDUC modular proposals for further consideration • Call management • A single call centre has some merit in managing general practice in hours access. • Reducing duplication and maximising our GP resource across 7 days • NDUC and FT currently run a central management for GP sessional resource.  There may be potential to widen the scope of this and manage GP sessional resources for extended access, hubs and how they might interoperate. • Acute home visiting • The CCG would require practice agreement and conditions to manage continuity of patient care and an understanding where complex patients fit within the model. • Patient self-booking • This may be something to consider in the offer to practices following the capacity and demand analysis. • This may also link to the national Patient Online programme

22. Complex Care Team • Purpose: • To case manage adults 24 / 7 with complex health needs / at risk of deteriorating or being admitted to hospital • To develop a ‘think family’ approach and consider the impact on all family members • To manage patients at the interface of community and hospital • To bring together expertise around decision making and treatment to form a unified interdisciplinary team working closely with primary care • Patient mix: • High risk patients: those with multiple co-morbidities, physical and mental health • Staffing components • Nursing: • Enhanced care nurse practitioners (clinical and prescribing skills, physical and mental health training ideally), Community Matrons. • Medical: • Enhanced care GPs • Care of Elderly/ General Medicine / mental health / palliative care Consultants • Other professionals: • AHP’s, Social workers, paramedics

23. Complex Care Team • Types of intervention: • Clinical care: • -Levels of intervention: advice, one off assessment, short term enhanced • intervention, • -Shared care with GP • -Referral management system with other secondary care teams (organ/ system specific) • -Individual case management: self management / anticipatory evolving plans, diagnose and treatment (medication (including im/ iv)/ procedures) • -Direct referring rights to community hospitals (Step-up)? management, and to base site CoE/ PCU wards • Navigation: • -Close links with all other health and social care community services both in and out • of hours. • Infrastructure required • - Diagnostics: What do we need available in a locality for immediate results- point of • care blood tests, imaging • - Integrated clinical record and telemedicine technology • -Access to support workers

25. Any questions?