Collaborating for Integrated Primary Care Transformation

2. An ideal world: thinking big about collaboration with primary care Chair:Vincent Sai, Chief Executive Officer, Modality Partnership Speakers:Andrew Ridley, Chief Executive, Central London Community Healthcare NHS Trust Dr Mina Gupta, Group Clinical Chair, Modality Partnership Thea Stein, Chief Executive, Leeds Community Healthcare NHS Trust

3. Speaker:Vincent Sai, Chief Executive Officer, Modality Partnership

4. Go to www.slido.com Input event code NHS19 and select Breakout 3A Select “POLLS” 4

5. Introducing Modality … • Largest National GP Super-Partnership in the UK serving over 450K patients across 8 regions and growing • Nationally recognised innovator and leader in transforming primary care AWC 8 Sites - 88K Hull 6 Sites - 61K Walsall 10 Sites - 71K Wokingham 2 Sites - 26K Birmingham & Sandwell 15 Sites - 97K Lewisham 3 Sites - 36K 5 East Surrey 3 Sites - 36K Mid Sussex 4 Sites – 33K

6. In PCN Terms … • A Super-PCN covering more than 1m patients across the country • Working in Partnership with Non-Modality Practices, Acute Trusts, and Other Stakeholders Modality AWC 88K Walsall West 1 32K South 1 34K North 1 51K South 2 39K East 1 33K East 2 42K West 2 45K Hull 70K Wokingham 47K Modality Birmingham & Sandwell 72K Kingstanding 30K Citrus 30K Small Heath 30K Modality Lewisham 36K 6 East Surrey North Tandridge 36K Horley 37K Mid Sussex East Grinstead 48K Burgess Hill – 40K

7. QUICK POLL HOW WOULD YOU RATE YOUR LEVEL OF KNOWLEDGE ABOUT PRIMARY CARE NETWORKS? 7

8. Expectations Are High … What transformational role should PCNs play? Source: NHS England and Improvement September 2019

9. The First 100 Days … 1250 99% 1250 40k Source: NHS England and Improvement September 2019

10. Evolution (not Revolution) … Opening Game Mid Game End Game • Forces are in action; however, historical industry structure and market predominate • Initiatives by leaders to build capabilities and experiment with new business models • Leading players experience virtuous cycle of growth and strengthening capabilities • Winners and losers begin to emerge as competitors grow share rapidly organically and through mergers • New competitors emerge with powerful new business models • Growth slows • Last move mergers happen with “winners” establishing themselves and “losers” exiting • Stable and concentrated industry structure emerges Maturity 2021-23 2019-20 2024+ Time

12. Speaker:Andrew Ridley, Chief Executive, Central London Community Healthcare NHS Trust

13. Andrew Ridley CEO Your healthcare closer to home

14. Some key facts about CLCH Some Key Facts about CLCH We work in 11 London Boroughs and Hertfordshire We provide 74 services including 255 rehab and palliative care beds We care for Over 2 million patients with 10 million patient contacts each year. Segment 1 Trust NHS Improvement Single Oversight Framework (Top 15% of 238 Trusts) We operate in 4 STP/ICS areas and 12 ICPs Kate Granger Award for Compassionate Care 2017 Special Recognition Award We have Over 4,200 staff working from 500+ sites And we are part of 86 Primary Care Networks

15. Why collaborate with primary care? To work towards greater integration of out of hospital services as a means to: Deliver person-centred coordinated and more joined up care Build local “place-based” care and support systems for local communities Create system leadership for integrated care Challenges and opportunities Maturity and readiness of PCNs Trust and relationships Shift from competition to collaboration Availability and sharing of data Wider system change

16. Integrated Community Teams in West London • Patient cohort: • Aged 65+ • Under 65 with • complex needs

17. Key features • Improved communication between primary care/community provider and patients • Overlap of roles reduces duplication and improves continuity - case managers with a district nursing background will pick up some district nursing tasks for their patients, likewise, district nurses will use their training to provide case management • No matter “who” (DN/CM/SCM) same offer – agreed / aligned approach to the patient / practice • Daily huddle with 1 or 2 Lead(s) per PCN who have visibility of the clinical system and E-roster to manage demand and capacity within the PCN • Huddle leads provide the interface / point of contact for practices, with a “helicopter” view of the PCN, managing inputs from specialist services, District Nursing, Case Managers and the impact of staff absences • A clearer distribution of specialist roles within the PCN – especially case managers with a Mental Health or Social Work background • Staff employed by the Trust and voluntary sector

18. Delivery of QI for PCNs With the aim of building capability across the system, includes: • Access to CLCH QI training programmes • Introduction to quality improvement (½ day) • Foundations of improvement (3x 1 day modules) • Quality Coach programme*(in development) • Access to QI masterclasses (various topics) • Access to QI facilitators • Support improvement planning • Support systems/local QI projects • Coach/mentor local QI leads • Development of bespoke QI programmes

19. Current areas of focus • Building and strengthening relationships with the PCN Clinical Directors and GP Feds • Aligning our planned services around the new PCN geographies • Creating local integrated community teams with case management, District Nursing/ Night Nursing, and Health & Social Care Assistants • Developing the CLCH Academy offer for PCNs, access to training for practice nurses, facilitation and QI • Providing pharmacy expertise and support, potential for joint roles/rotational posts across primary, community and secondary care

21. Speaker:Dr Mina Gupta, Group Clinical Chair, Modality Partnership

22. Eve’s Care Management Nurse supports her to make healthy lifestyle choices and achieve her health goals. Eve’s is reassessed as she starts to adopt healthier behaviours. Recruit (Day Zero) 1 Eve’s living life more fully and receives semi-annual calls to help her stay on the path to her optimal health. Eve is identified for the service through health analytics Biannually 8 1 Health Review (Month 1) One-time 2 She is invited to the service by her GP and decides to enroll. Care Management Nurse contacts her to conduct an initial health assessment. Feeling more confident in her ability to self-care, Eve graduates from the service. Behavioural Change (Months 2-6) 3 7 Transform (Months 7-8) 4 Quarterly 6 2 Weekly Using motivational interviewing, Eve’s health coach helps her identify health goals. She continues to receive support but is consistently making healthy choices on her own. Case Review (Month 9) 5 Her nurse sets up regular calls and sends Eve info about her health conditions. 5 Maintain (Months 12-15) 6 3 Fortnightly Graduate (Month 18) Monthly 4 7 Outreach (On-going) 8 Personalised Journey De-Medicalisation “It was a pleasant surprise that I could keep the pain under control without a knee replacement” How can we reverse the chronic pattern of over-diagnosis and over-treatment? Patient Preferences “I didn’t need this new hip. All I needed was a bannister so I could get down to see the postman!” How do we ensure patient preferences matter? Social Determinants “You forgot to ask about the dog. It died. That’s why she doesn’t get out or take care of herself as much” How do we account for patients’ life circumstances as context for decision? * Illustrative - each patient’s journey will vary as the care plan will be tailored to their unique needs

23. Embracing Digital Real-time consumer friendly appointments system improving access and convenience Enhanced Risk Stratification and Predictive Analytics, and Telemonitoring Systems Real-time Access to Personalised and Actionable Information promoting Health Literacy and Engagement Care Management Acute Interface Wellness, Prevention & Community Resilience Enhanced Primary Care Referral Facilitation Hospital at Home Self-Care Enablement Healthy Communities Enhanced Primary Care (Physical & Virtual) Complex Case Management Nursing Home / Residential Care Advanced Illness Condition Management Acute Inpatient Front Door A&E 24/7 Single Point of Access Sub-acute Care Intermediate Bed Interim Bed Specialist Services (Outpatients) Bed Management (Discharge Planning) 24/7 Single Point of Access Artificial Intelligence triage and signposting driving operational efficiency and effectiveness Advanced care and monitoring systems Social media and Community Support Development (Crowdsourcing, blogs, etc)

24. Primary-Secondary Collaboration Pathways Finance Analytics Workforce Simplified to Deliver Right Care, First Time, Every Time • Actionable Insights Drawn from Single Source of Truth Re-balanced to Create Long Term Ownership & Sustainability Collaboration Takes Us Further Than Competition

25. Speaker: Thea Stein, Chief Executive, Leeds Community Healthcare NHS Trust

26. QUICK POLL HOW MUCH POTENTIAL DO PCNS HAVE TO SUPPORT INTEGRATED CARE? 26

27. QUICK POLL WHERE DOES COLLABORATING WITH PCNs SIT ON YOUR PRIORITY LIST? 27

28. QUICK POLL WHAT HAS YOUR EXPERIENCE BEEN SO FAR? 28