General practice as the foundation of the NHS · practice inborough All boroughs in north central London offer access to primary care appointmentsbetween 8am-8pm seven days aweek.

General practice as the foundation of the NHS

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A strategy for North Central London

DRAFT

This strategy aims to consider what is important to andfor the people living in north central London, and sets outthevision from a patient and system perspective. It recognisesthe challenges facing general practice in NCL and acknowledges that we must preserve the strengths of general practice, including continuity of care, a real understanding of the family or personal support network that patients are part of, and the relative ease and accessibility ofservices.

Our story so far…

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DRAFT

General practice is facing unprecedented pressure. Funding for general practice services, as a proportion of NHS funding has fallen, yet evidence suggests that demand has increased and is set to increase further as people live longerwith greater complexity and patient expectation grows.

These pressures are further compounded by an aging workforce,fewer doctors and nurses choosing general practice as theirdestination of choice, and losing newly qualified general practicestaff to other more attractive health services across the globe.

There are new and increased challenges in terms of building, recruiting and retaining sufficient numbersof healthcare professionals to work in general practice, and more GPs are opting for salaried positions and portfolio careers, meaning a need to consider new and alternative employment models. There have been significant advances in technology, with the introduction and increased use of patient apps, the ability to book appointments online,and products such as Symptom Checker.

The context and landscape have changed significantly since the previous strategy, including an increasing financial challenge, with the ‘do nothing’ gap for north central London expected to be £811m deficit by 2020/21. Sources of information, advice and support regarding patients’ health and wellbeing are more varied, and patient expectations have changed with social and technological developments. General practice has a greater role in providing and coordinating care.

There is an increased focus oncollaboration,

both within general practice, and with other partners, and working at scale to deliver the best benefits for the population and for practices.

There is an increased focus in general practice on quality improvement, with local investment in dedicated quality improvement support teams aiming to reduce unwarranted variation in each CCGarea.

...the story so far

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DRAFT

The NHS was established 70 years ago at a time when

services were mainly provided to manage diseases in hospital. The roles of health and care services have changed significantly since then, and society is changing; there are over 15 million people with long term conditions in England and care for these people equals about 50% of all GP appointments and 70% of all inpatient hospital episodes.

Partners in north central London (NCL) have a history of collaborative

working on primarycare, including the production of previous strategiesfor primary care. The previous NCL strategywas

produced in 2012 and

expired in 2016.

In December 2017, leaders of the five clinical

commissioning groups (CCG) and GPfederations agreed to nominate representativestoco-produce a refreshed strategy for NCL.

...the story so far

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Introduction: where we are now

Instead of people only being able to access their own GP during core hours, people now have access to appointments with general practice from 8am-8pm seven days a week (since April 2017 in NCL).

There may be opportunities to promote these services even more widely, so that everyone is aware of them. We also know that some people still report dissatisfaction getting through to their practice on the phone, and there is more progress to make in theseareas.

There are six GP federations in NCL, four of which are co-terminous with theborough, with two federations in Camden.

Most practices now work in anintegrated way, to some extent, and many of the GP federations hold contracts ranging from Ear Nose and Throat and community gynaecology services to providing quality improvement support teams, or focusing on GP retention.

Also in place are Care and Health Integration Networks (health and care partners working together to deliver care to a cohort of patients).

PLACEHOLDER: DIGITAL

Appointmentswith general practice available 8am-8pm seven days a week

Most practicesnow work in anintegratedway

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PLACEHOLDER: DIGITAL

Our context: the challenges facing general practice

Growing demand for services: many people

have more complex needs, health inequalities persist and there are high levels of long terms conditions and rising

expectations of general practice. The population is growing and people are living longer but in poor health andwith

greater complexity; older people in north central London are

living their last 20 years of life in poor health, which is worse than the England average. The King’s Fund has shown how

consultations are outstripping population growth

(source: King’s Fund- Strategic Commissioning Framework).

25%

A workforce under pressureNCL faces significant challenges for its future workforce from GPs to general practice nurses and other primary care professionals. 25% of the GP workforce is over 55and therefore likely to retire within the next 10 years. A recent NCL Local Medical Committee (LMC) survey collected data showing that 45% of responding practices are due toloseone or more GPs to retirement in the next three years.This, along with an ever-growing and more diverse population, demonstrates the need to develop and grow the NCL GP workforce significantly over the next fewyears.

Fewer GPs are looking for partnerships, and there are recruitment and retention challenges. There are low numbers of GPs per patient in Barnet, Enfield and Haringey, and low numbers of practice nurses in all CCGs in north central London. Low morale is not unusual; GPs, nurses and practice managers report being more stressed than ever before. We need to value the existing workforce and attract and retain new professionals.

of the GP workforce

is over 55 and likely toretire within the next 10years

There are poor indicators of health for children –childhood

obesity is high while immunisation levels are low.Investment has fallen and the unwarranted variation in

outcomes and historical funding need to be addressed. We

will not be able to manage the expected growth in demand

for healthcare if we do nothing.

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An evolving health and carelandscapeSources of information, advice and support regarding patients’ health and well-being are more varied; patient expectations change in line with social and technological advances. There is renewed importance on the role of general practice in providing and coordinating trusted accessible, proactive care that is integrated across all parts of an increasingly complex health and care system. Patients are being increasingly supported to self-care and there is more technology available to support this and health services more generally. More services are moving to being provided in the community (not in hospitals)

A financialchallenge

Unwarranted (unnecessary) variation, ranges from patient satisfaction in how easy it is to get an appointment to availability and use of technology for GP services, to unwarrantedvariation in clinical outcomes, e.g. identification and anticoagulation of peoplewith atrial fibrillation. There is also variation in the historical levels of funding in primarycare, to variation in funding for locally commissioned services.

There is variation in the condition of primary care estate e.g. only23% in Islington is in good condition. There is also variability in ownership of the primary care estate across individual GPs, GP partnerships, private sector, NHS Property Services (NHSPS) and Community Health Partnerships(CHP).

...the challenges facing general practice

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Our context: patient experience of accessing general practice

100%

90

80

70

60

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40

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20

10

0Barnet Camden Enfield Haringey Islington

Highest performing practice in borough

All boroughs in north central London offer access to primary care appointments between8am-8pm seven days a week.

The National GP Survey data shows that on average, two thirds of patients find it easy to get through to their GP practice on the phone.

However, when we compare data at an individual practice level, there is lots of variation between practices, which tell us that some practices are performing much better thanothers against this measure of patient experience.

Understanding the reasons behind this variation, and learning from the highest performing practices ineach borough will be key to reducing this variation and making patient experience moreconsistent.

Lowest performing practice in borough

CCG average performance

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Our context: patient experience of using online GPservices

Increasing patient awareness and uptake of online GP services is a priority area for General Practice. Nationally there is still a long way to go to achieve this. Our results show that we are in line with the national averages for patients using online services, although we know that some of our NCL GP practices are much further ahead than the rest of the country.

The survey tells us that there is a lack of awareness of online GP services across NCL, and improving this will be key to increasing their uptake amongst patients. However, there is also a cohort ofpatients who are aware of online GP servicesbut choose not to use them, and morewill need to be done to understand theexperience of this group.

Source: 2018 National GP Survey

100%

80

60

40

20

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Patient awareness/uptake of online GP services to view medical records

Barnet Camden Enfield Haringey Islington

Patient awareness/uptake of online GP services to bookappointments100%

80

60

40

20

0

Barnet Haringey Islington

Barnet Camden Enfield Haringey Islington

Patient awareness/uptake of online GP services to order repeatprescriptions100%

80

60

40

20

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Not aware

Camden Enfield

Using service Aware but not using

DRAFT

Our vision: what people want now

What would this look like?

I want to be listened to andheard

• I won’t have to rely as much on my GP tointerpret information for me

• I’ll be able to access the information and advice I need to make more decisions for myself

• I’ll understand which services to use and when

• I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me

Services will work better for me

• My health records will be up to date and servicesthat help me will be able to access them

• I will tell my story once

• The professionals involved with my care talk to each other; we all work together as a team

I’ll have easier access to the support I need to staywell

• I won’t have to go to hospital somuch

• Investigations such as blood tests and ECGs can be done in alternative places to the hospital

I’ll be able to do moreonline

• I can book and cancel appointments online, when it suits me; I won’t haveto visit the GP, miss appointments I don’t need or wait for the post to get my test results

• I can order repeat prescriptions online; I don’t need to make a special trip to my surgery to place the order

• I can see my health and care records and can decide who to share them with. I can correct any mistakes in the information.

We want to do more for ourselvesWe recognise the NHS is under pressure, but we can help by playing abigger role in looking after our own health andwellbeing

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Our vision: what we want to deliver

Given the needs of the local population and the challenges facing generalpractice, over the next three years we want toachieve:

Resilient, sustainable and thriving general practice

Resilience: a systematic and data-driven approach to practice resilience, using local intelligence and NHSE data, reducing the need for CCG intervention –developed by GP federations working in partnership with their CCGs

At scale working: For federations to collaborate to develop at scale solutions to drive efficiencies and productivity, e.g. education and training, GP retention, back office functions, delivery of outcomes, population health management

Resourcing: To be in the top x% of STPs nationally in our investment in primary care (£ per patient), working to reduce variation between boroughs in north central London

High quality, equitable and person-centred safe care

Access: To use a Safer Staffing tool (or similar) to identify and agree on the minimum safe healthcare professional staffing levels in general practice, and work towards achieving these over the life of this strategy; to achieve (% of respondents reporting good on ease of access or telephone access to appointments)

Quality improvement: For all NCL practices to be in the top 25% of best performing practices over xperiod on agreed markers

Estates: To keep services local in premisesthat are fit for purpose for the delivery ofprimary care services

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...what we want to deliver

Proactive, accessible and coordinated care

Access: To see a step change in the roll out and uptake of digital technology in general practice (for patients and professionals), recognising the scope of digital technology to be used from ordering repeat prescriptions online, to online booking, the abilityto check symptoms and have a consultation with a healthcareprofessional

Strengths-based approach: GP practices to supportpeople to address the social determinants of health,with the aim of everyone with a long term conditionto have the opportunity for an annualcare planning conversation

Integrated services that respond to the needs of the patient and thepopulation

Strengths-based approach: GP practices to supportpeople to address the social determinants of health,with the aim of everyone with a long term conditionto have the opportunity for an annual care planningconversation

Resourcing: integrated working between GP practices and other community-based providers, supporting new roles into the wider GP team

Prevention: To systematically embed high impact prevention interventions into everyday practice, in order to prevent ill health and promotewellbeing, with a focus on smoking, blood pressure, overweight, physical inactivity, and alcohol

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Our vision: resilient, sustainable and thriving generalpractice

For GP federations to work in partnership with their CCGs to develop a systematicand data-driven approach to practice resilience, using local intelligence and NHSEdata, reducing the need for CCG intervention

For federations to collaborate to develop at scale solutions to drive efficiencies and productivity, e.g. education and training, GP retention, back office functions, delivery of outcomes, population health management

To be in the top x% of STPs nationally in our investment in primary care (£ per patient tbc), working to reduce variation between boroughs in north central London.

Additional skills and capacity in general practice–patients will benefit from increased availability of clinical time and resources

Development of new employment models; the workforce will change; a greater role for specialist nurses, pharmacists, physicians’ associated, health care assistants, mental health workers and other healthcare professionals

A valued and motivated workforce with training and development for a variety of roles including specialists and portfolio careers

Staff enjoy their work and achieve a good work life balance; NCL isthe destination of choice for healthcare professionals in training

Collaborative and integrated working will deliver economies of scale and increased sustainability

Increased security of service provision as a result of longer contracts, results stable primary care teams

”There is arguably nomore important job than thatof the family doctor […] ifgeneral practice fails, thewhole NHS fails”

Simon Stevens, Chief Executive,

NHS England, 2016

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Our vision: high quality, equitable and safe, person-centred care

For all NCL practices to be in the top 25% of best performing practices over x period on agreed markers, reducing unnecessary variation in general practice so patients know what to expect from their GP, wherever they choose to access services

GP practices to support people to address the social determinants of health, with the aim of everyone with a long term condition to have the opportunity for a care planning conversation.

Improved outcomes, experience and patient satisfaction

Consistent high-quality care across general practice; safer, less (unwarranted) variability and better quality, consistent care delivered by highly trained GPs, nurses and other professionals, with appropriate continuity of care

Care will be centred around each person so they won’t need to have multiple appointments about different long term conditions

Patients will have the knowledge, skills and confidence to enable them to work in partnership with their health care professional

All practices achieving good or excellent CQC ratings

Shared good practice (policies, procedures,protocols)

Technology used to support long-term conditions management and safe hospitaldischarge

Staff enabled to work at the top of their licence, soincreasing productivity and efficiency and avoidingduplicationor waste

Collaboration through partnership working with patients who are informed and engaged, will result in improved utilisation of GP services so ensuring health care professionals experience less demand and an improved work lifebalance

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Our vision: proactive, accessible and coordinatedcare

A step change in the roll out and uptake of digital technology in general practice (for patients and professionals), recognising the scope of digital technology to be used from ordering repeat prescriptions online, to online booking, the ability to check symptoms and have a consultation witha healthcare professional

To use a Safer Staffing tool (or similar) to identify and agree on the minimum safe healthcare professional staffing levels in general practice, and work towards achieving these over the life of this strategy

Keep services local in premises that are fit forpurpose for the delivery of primary care services

Proactive care - supporting

and improving the health and wellbeing of the population,self-care, health literacy, and keeping people independent and healthy

Accessible care - providing

a personalised, responsive, timely and accessible service

Coordinated care -supporting and improving the health and wellbeing of the population,self- care, health literacy, and keeping people independent and healthy

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We will:

• Develop care registries across networks; people at risk of developing disease will be identifiedsystematically; those with medical conditions will be supported to live longer in good health

• Improve information sharing to support 24/7 access to care

• Ensure that face to face appointments are offered to those who need them; clinicians should assess the requirement for face to face appointments

• Encourage the use of programmes to for GPs to manage demand and supply –a balancebetween access and continuity of care

• Encourage practices to work together to deliver a full range of services to patients in their localcommunity

• Improve access to general practice including in person, on the telephone and digitally; making sure that everyone can access their GP surgery during the core hours (currently 8am-6.30pm) recognising that different people may prefer different means of access

• We will support the uptake of new technology to improve access, and will ensure that services are well-publicised

• Ensure that 20% of all practice patients are registered for GP Online, with 80% of all patients with repeat prescriptions registered fore-prescribing

• Ensure that new premises developments are designed with the future of integrated general practice in mind (e.g. RCGP Roundhouse)

• In line with local priorities, we will support projectmanagement, service charge tapers and paying offleases for general practice developments

• Continue to work closely with local authority andpublic health partners to ensure a more effectivepreventionand healthy living offer

• Ensure that services provided within the core and enhanced contracts are available to the population of north centralLondon, whether this is at a patient’s own practice, or nearby

...proactive, accessible and coordinatedcare

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...proactive, accessible and coordinatedcare

Better patient experience through more use of digital technology, with more responsive care, deliveredina range of ways, e.g. online, email and telephonenot just face-to-face - and improved access to general practice

Improved (and less variable) access to general practice services

People will be easily able to book their appointments

Continuity of care for those patients that need it most

Patients will experience better management and care of long-term diseases; when they are frail and elderly, and at the end of life – integrated services supported by shared access to clinical records

Unregistered patients wont fall throughgaps

Reduced duplication of activity through improved sharing of data, will result in improved productivity within generalpractice

Through the development of closer working relationships with the wider MDT, GPs and their teams will feel supported in delivering care, so will feel more able to manage increasing complexity

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Our vision: integrated services that respondto the needs of the patient and the population

To systematically embed high impact prevention interventions into everyday practice, in order to prevent ill health and promote wellbeing, with a focus on smoking, blood pressure, overweight, physical inactivity, and alcohol

GP practices to support people to address the social determinants of health, with the aim of everyone with a long term condition to have the opportunity for an annual care planning conversation

Integrated working between GP practices and other community-based providers, supporting new roles into the wider GP team.

We will:

• Support the development of care and health integrated networks through which teams of professionals and workers can provide innovative, proactive and person-centredcare

• Work with our partners in the system, including other health, local authority and voluntary/ third sector/ charity providers to develop more coordinated and integrated models of care, focusing on patient needs and around a shared vision

• Take a proactive, person-centred approach to delivering this care with our partners, through care and health integrated networks

• Provide general practice with the tools to support patients to navigate their way through care, enabler easier access to appropriate care, with access to health, social care, lay and voluntaryorganisations

• Develop and use and share dashboards across all providers for use at micro, miso and macro levels to support the reduction of duplication and unnecessary variation across the system

• Support the development of at scale provision, including at network, neighbourhood, federation and borough level

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Peter is 12 years old and in Year 7 of secondaryschool. He has had asthma and eczema since earlychildhood.

He lives with his mother, who has mental health problems and a mild learning disability. She does not work. His asthma has previously been well controlled, but he has missed a lot of school during the last year. He has gained weight and is missing sports lessons because of theasthma.

Peter will have access to a nurse specialist in the community. At school he willbe seen by an asthma nurse. This is more convenient, improves Peter’s abilityto self-manage and involves less timein hospital.

Peter and children like him will:

• require fewer A&E attendances and admissions

• become involved in care, and able to manage

• be supported by people who know him and hisfamily

• miss less school

• have improved fitness and confidence

...integrated services that respond to the needs of the patient and the population

CASESTUDY

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...integrated services that respond to the needs of the patient and the population

Patients will be able to access more care locally from a range of service providers/ partners

General practice will remain the gate keeper to care,but patients will be able to access a broader range ofservices throughtheir GP

Enhanced patient experience with as smooth anduncomplicated as possible a ‘journey’ through thehealth and care system

Access to a broader range of clinical skills will enable a multi-disciplinary approach to caring for patients, releasing specialist medical resources

Access to patient information broadened througha common clinical IT platform to enable seamless,integrated service provision

Integration minimises the risk of duplication

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Our enablers

WorkforceFocus on both the existing and new workforce –retain, recruit and develop a new skill mix

Digital vision for digital – health and care information exchange and population health management IT, data systems and information sharing are critical to delivering integrated care and can help to co-ordinate care delivered by professionals across different organisations and even across patients’ wider support networks. Population healthmanagement

EstatesDelivery of our strategy relies our partners –including Local Authorities, CCGs, Trusts, and property companies. At the STP level, our focus is on collaboration and common prioritisation through

our Estates Board, whilst not superseding individual organisational autonomy.

Working at scale Function over form➞ what is therole we want the federations to play in the system?New ways of working and contracting

Quality Improvement – what will the QISTS deliver?

CHINS The care and health integrated networkmodel- Integration between different partners each year. Virtual integration through digital systems; clinicians proactively working together around a register of patients/ local people

Investing in primary care – investment demonstrating variation and primary care investment in the context of the system

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