Primary and Community Care Services Strategy

West Yorkshire and Harrogate

2019/2024

Primary and Community Care Services Strategy

1 | Contents

Contents

Summary ................................................................................................. 2

West Yorkshire and Harrogate Health and Care Partnership ................... 6

Introduction ............................................................................................. 8

Primary care plan, vision and aims ........................................................ 11

1. Transformation .................................................................................. 19

2. Workforce .......................................................................................... 29

3. Premises and digital ........................................................................... 39

4. Investment ......................................................................................... 49

5. Access and resilience ......................................................................... 53

6. Dental, community pharmacy and eye health ................................... 62

Delivery.................................................................................................. 74

Communications and engagement ........................................................ 77

Appendix 1. List of abbreviations ........................................................... 78

Appendix 2. References ......................................................................... 80

2 | Summary

Summary

This is our first West Yorkshire and Harrogate Health and Care Partnership Primary and Community Care Services Programme Strategy, to be read alongside the following key National and local documents, reflecting key National Policy and National and local deliverables;

• NHS Long Term Plan • Five-Year Framework for Contract Reform • West Yorkshire and Harrogate Health and Care Partnership “Our next steps to

better health and care for everyone (2018) • West Yorkshire and Harrogate Health and Care Partnership 5 Year Plan (2019). The NHS Long Term Plan has provided the strong foundation in which to build our strategy, recognising that Primary Care is often the first point of contact in the healthcare system, acting as the “front door” of the NHS.

Introducing our strategy describes the current primary and community care landscape for West Yorkshire (including all our Primary Care Contractor Groups) and the case for change, reflecting the ageing population and the increasing need for self-management of long-term conditions.

In West Yorkshire and Harrogate, we strive to be the best we can be in Primary Care; supporting care closer to home, improving patient outcomes and the experience of our staff, volunteers and carers and our West Yorkshire and Harrogate vision for Primary Care reflects how a transformed workforce and services will be built around supporting people to stay well at home and in their communities. Fundamental to this is digitalisation and technology.

Our vision recognises the need to support the closing of the three gaps; Health and Wellbeing, Care and Quality and Finance and Efficiency. This will be done through the delivery of our five strategic themes; the right scale, working together, to target population health, reduce unwarranted variation and empowering our people and communities.

We want to achieve system delivery by transforming primary care. Our strategy reflects General Practice working in partnership with health and social care in areas serving approximately 30,000 to 50,000 people (Primary Care Networks) to deliver improved outcomes for the population they serve as defined in the NHS LTP.

Our Primary Care Networks will be our platform for;

• Supporting population health management to reduce health inequalities • Enabling personalised care and social prescribing to ensure care needs of our

patients are met • Reconfiguring hospital and outpatient services • Focusing on continuous improvement and reducing variation • Being the best we can possibly be, delivering fair and equitable services.

3 | Summary

Our strategy targets how we must tackle the pressures our staff face, while making our funding go as far as possible and in doing so, accelerate the redesign of patient care to future proof the NHS.

Our overarching actions are detailed in each of the following headed sections:

Component 1. This section builds on the good work already achieved in our places, articulating the aims for the transformation of care and improved health and social care outcomes for patients, building on the establishment and development of Primary Care Networks to enable resilient and sustainable models of care, maximising the skills of the wider workforce and delivering at scale solutions providing a platform for priorities such as personalised care to flourish. Quality Improvement is seen to be core at practice and network level supporting primary care working in partnership in implementing new service specifications, maximising opportunities to address variation and influence future service needs.

Component 2. Here, we set out how we will attract, retain and train our workforce so we are fit for purpose and able to meet the needs of the population we serve. Our workforce ambition describes our aims to support and evolve the primary and community care workforce. To achieve our vision will require a different skill mix, new types of roles and different ways of working and not simply more of the same. To achieve this and secure a system resilient workforce requires a one approach to workforce partnership plan across our system including Primary and Community Care, Acute Trusts and Local Authorities, our Training Hubs and Universities and Health Education England.

We want West Yorkshire and Harrogate to be a vibrant place to work with a fit for purpose workforce that will help our people to live their best lives. Our Primary Care Strategic workforce priorities clearly set out our initial aims for 19/20 and 20/21.

Component 3 of our strategy explains how we will strive to improve premises and digital to make sure our buildings are suitable and fit for modern healthcare. In West Yorkshire and Harrogate, we know we need a more cohesive system wide approach to prioritising and securing capital to support our estate and to ensure our estates plans are robustly aligned to service strategies. We recognise that not only do we have to ensure our patients can access services from modern, safe and secure environments we also need to ensure we build in adequate training capacity to train, educate and secure our future workforce. A digitally enabled primary care is what we will be working towards in line with the NHS Long Term Plan. We will be working in partnership to building a change programme to support our staff and communities in how to access primary care in alternative ways.

Component 4 of our strategy takes account of the National Investment package including the GP Contract reform over the next 5 years for primary and community care that will allow us to deliver at scale system initiatives to meet the commitments set out in the NHS Long Term Plan and GP Contract Reform. £4.5 billion of new national investment will fund expanded community and multidisciplinary teams aligned with the new PCNs.

4 | Summary

We know that by working together we can often maximise opportunities and funding and it is recognised that we must work together to support the financial challenges ahead of us and to release where possible further resource both at place and system wide to support system transformation. As the ICS continues to receive further responsibility and additional flexibility we can ensure resource is directed to best effect and in areas of most need.

Component 5. We will continue to learn more about how patients wish to access services and improve the patient experience at all levels. Our strategy informs of our goal to achieve fair and equitable access to Primary Care Services including choice, convenience and preferences. Access to general practice appointments continues to present many challenges and despite high levels of investment there remains considerable variation and poor levels of satisfaction. We recognise there is much more work to be done to improve access to Primary Care. Approximately 40% of activity carried out in general practice does not always require GP intervention and work is being undertaken to implement solutions such as social prescribing and signposting patients to more appropriate services. New workforce roles in primary care will most certainly free up capacity enabling a more resilient primary care.

Primary Care and PCNs will play a significant role in helping to support pressures on urgent and emergency care services. There is a need to transform the urgent and emergency care system to new integrated care models that will join up urgent and primary care services in the community. The new national service specifications for Enhanced Health in Care Home and Anticipatory care will support more joined care delivered by Primary and Community care partners.

Component 6 of our strategy recognises the important role of other primary care contractor groups; Dental, Pharmacy and Eye Health. We want to ensure that integration of dental and oral health service with wider primary care, working with Primary Care Networks and Emergency Care Systems building on links to the wider health and social care provision where appropriate. We are aware that patients are struggling to access primary care dental services across part of West Yorkshire and Harrogate. Our aim for 20/21 is to develop a coherent dental strategy that will set out clearly; how oral health will be improved, and inequalities reduced, improve access in areas of greatest need whilst ensuring equitable and timely access.

We recognise community pharmacy can be the most appropriate point of contact for patients with minor conditions and look forward to building on the contribution community pharmacy can make to the wider system both part of primary and urgent care. We are working hard to ensure that Community Pharmacists are actively engaged as part of PCNs working alongside practice- based pharmacists. This section describes the important role Community Pharmacy plays in system integration supporting the urgent and emergency care agenda and the valuable contribution in workforce strategies and planning.

In West Yorkshire and Harrogate, we will strive to ensure a consistent and equitable offer for General Ophthalmic services including hard to reach groups. We shall build on the eye health care capacity review work undertaken to date in shifting secondary care activity closer to home and transforming eye health care services.

5 | Summary

Our approach to delivery aims to overcome silo working, making connections between programmes and place. Our strategy recognises the need to work together as a system, taking opportunities to share solutions and to do things once where appropriate to do so.

The Primary and Community Care Programme Board provides strategic direction, overseeing programmes of work to ensure strategy implementation. The Board is supported in its delivery by several sub groups and task and finish groups such as the West Yorkshire and Harrogate Primary Care Workforce Steering Group, and West Yorkshire and Harrogate Primary Care Leads.

Cutting though our strategy is a commitment to building on new environments such as Primary Care Networks, and ways of working to improve the interface between primary and secondary care, reduce workload and improve on shifting inappropriate pressure from hospitals to general practice. Quality and service improvement will be at the forefront of transformation at practice, network and system level and we are excited about forming stronger relationships with our partners to support strategy implementation.

At West Yorkshire and Harrogate Health and Care Partnership we are in the best possible position to make pace with the Primary and Community Care Strategy and we are ready to commit to delivering results for the people of West Yorkshire and Harrogate.

6 | West Yorkshire and Harrogate Health and Care Partnership

West Yorkshire and Harrogate Health and Care Partnership

The West Yorkshire and Harrogate (WY&H) Health and Care Partnership (HCP) is the collective of all commissioner, provider and partner organisations working together to improve services covering a population of ~2.6 million people. The WY&H HCP vision is that places will be healthy and local people will have the best start in life, so they can live and age well. The HCP will bring together local organisations to redesign care and improve population health, creating shared leadership and action. This will be a combination of national and local priorities for care quality and health outcomes, reductions in inequalities, implementation of integrated care models and improvements in financial and operational performance.

Primary and Community Care is one of the 11 priority programmes that WY&H HCP is working collaboratively with key partners. The current landscape of primary care within WY&H HCP is built up with GP practices, dental, eye care and pharmacy services. This is illustrated in Figure 1. Primary care is also a host to community, mental health and social care services.

The NHS Long Term Plan1 (NHS LTP) provides the foundation of our strategic plan and supports our vision of delivering improved health outcomes for patients as well as providing high quality and safe patient care.

Primary Care services including; community and voluntary sector services, dental, eye care, pharmacy and general practice are central to bringing care closer to home, managing long term conditions, preventing unnecessary hospital admissions and helping people stay well and healthy. Our patients want better access to GP and wider primary care services; to be better informed about self-care and health services generally and wrap around joined up care when needed.

The West Yorkshire and Harrogate (WY&H) Health and Care Partnership (HCP) approach in this strategy will reflect work undertaken in each of our local 6 places culminating in an aggregated Integrated Care System (ICS) strategy that will deliver a sustainable shift in care through new ways of working. This is an overarching strategy, focussing on what can be done through partnership working to enable system improvements. Successful implementation will however require actions to be delivered at different levels reflecting on role of the ICS and the important of place in its implementation. The context of “we” in this strategy therefore refers to the ICS Partnership and relevant stakeholders.

1 National Health Service (2019) NHS Long Term Plan. Available [online] https://www.longtermplan.nhs.uk/ [24/06/2019]

7 | West Yorkshire and Harrogate Health and Care Partnership

The NHS LTP and GP Contract Framework2 outlines an investment package to deliver primary care reform now through to 2024, which recognises the role that General Practice must play in leading and designing health and care services as professionals in general practice have a unique perspective into what their patients need at a local level. Our strategy is built around General Practice working in partnership with health and social care in area of approximately 30,000 to 50,000 people to deliver improved outcomes for the population they serve. Our delivery model for this will be Primary Care Networks (PCNs) as defined in the NHS LTP.

Figure 1. Primary Care Landscape in West Yorkshire and Harrogate August 2019

2 National Health Service England (2019) A five-year framework for GP contract reform to implement The NHS Long Term Plan. Available [online] https://www.england.nhs.uk/publication/gp-contract-five-year-framework/ [21/06/2019]

8 | Introduction

Introduction

Our Primary and Community Care strategy builds on the WY&H principles for delivering primary and community care outlined in our ICS next steps response “Our next steps to better health and care for everyone in 2018. This plan builds on what we have successfully implemented, describes what we will deliver in 19/20 and 20/21 (detailed on page 16) and lays out the foundations for delivering the commitments in the LTP over the next 5 years

Our strategy will dovetail with other programme strategies for example Mental Health, Urgent and Emergency Care, Improving Population Health, Personalised Care and Planned Care. These important interdependencies will be addressed through more integrated working through Primary PCNs.

Our strategy is iterative and will change over time to take account of national and local developments, reflecting and contributing toward the WY&H HCP five-year strategy that is due in Autumn 2019. During the life of this strategy we will aim to deliver against all the high-level ambitions identified in each section. Specific actions will be implemented in accordance with the delivery and project plan.

Primary Care Networks (PCNs) are an essential building block of every Integrated Care System, and under the new Network Contract Direct Enhanced Service (DES), general practice takes the leading role in every PCN. Our aim is for successful integration of care, improving health and social care outcomes for patients. To achieve this requires much closer working and bringing together all staff in manageable sized teams to provide integrated models of care based on population health need.

Whilst there is a strong focus on transforming general practice in this strategy, it should be acknowledged that this is a Primary Care Strategy and makes appropriate links to the contribution of community services, dental, eye care and pharmacy services.

9 | Introduction

Our key stakeholders

Our Partnership key stakeholders in relation to this strategy are:

West Yorkshire and Harrogate General Practice Providers • West Yorkshire and Harrogate Primary Care Networks • Local Workforce Advisory Board • Health Education England • NHS England and Improvement (NHS IandE) • Local Reference Committees: - Medical, Dental, Pharmacy, Optical • Local Professional Networks: - Dental, Optical and Pharmacy • West Yorkshire Association of Acute Trusts • Voluntary Sector and Community Providers • Bradford District Clinical Commissioning Group • Bradford City Clinical Commissioning Group • Airedale, Wharfedale and Craven Clinical Commissioning Group • Harrogate Clinical Commissioning Group • Leeds Commissioning Group • North Kirklees Clinical Commissioning Group • Greater Huddersfield Clinical Commissioning Group • Wakefield Clinical Commissioning Group • Calderdale Clinical Commissioning Group • Local Authorities •

We engaged with all partners on the content and delivery of this strategy between June 2019 and September 2019 and ensured it appropriately reflects and is aligned with our key stakeholders’ direction of travel.

The case for change

Our need for change is driven by the changing needs of our local populations and by the need to ensure that we consistently offer the best services. The changing health needs of the population are putting more pressure on the health and social care system. Between 2017 and 2027 there will be 2 million more people aged over 75 in the UK. The main task has changed from treating individual episodes of illness to helping people to better manage their own health and long-term conditions, supporting people to care for their own health where appropriate.

Patients rightly expect: high quality, locally designed services in settings that are accessible and convenient; delivered by healthcare professionals who are known to them and who provide continuity of care. Patients also want to be able to receive services in a very different way to that which their parents and grandparents did.

10 | Introduction

Our citizens tell us they want easier access to services closer to home, increased use of technology and other ways that enable them to take greater control of their health and well-being3. The continued rise in demand, the population living longer, more complex needs and the shift from secondary to primary care place a significant amount of pressure on general practice. The model of primary care must transform changing how services will be delivered.

Workforce is a key driver for change within our ICS system. Having staff with the right skills and competencies in the right locations is key if we are to achieve our ambitions as a system. The quality of some of our existing primary care estate also provides a challenge. Our aging primary care estate and inadequate space in some of our health care environments does not meet the requirements for our future needs. It is also recognised that if we continue to deliver care in the same we do today, with no change and no efficiencies we would face significant financial pressures.

3 Health Watch Leeds (2019) What would you do? Available [online] https://www.wyhpartnership.co.uk/application/files/9515/6208/4733/LTP_Summary.pdf [03/09/2019]

11 | Primary care plan, vision and aims

Primary care plan, vision and aims

Figure 2. Our WY&H Primary Care Plan- Adapted from NHS England (2018) Maturity Matrix

The WY&H HCP sets out a vision for strengthening and transforming primary care. It is aligned to the ICS Five Year Strategy which has been developed to deliver against the requirements of the NHS Long Term Plan. Strong primary and community care are one of the cornerstones of our plans. Our vision depends on people being supported to stay well at home and in their communities, and primary and community care services have a critical role in ensuring that this happens.

The vision and aims for Primary Care in West Yorkshire and Harrogate are to;

Deliver a new model of primary care • Improve population health • Use our resources better. •


Our vision will support the aim of closing three gaps in health care;

The care and quality gap • The health and wellbeing • The finance and efficiency. •

We will do this by delivering on strategic themes; Primary care at the right scale, working together in integrated teams that target services based on the understanding of population need and resourced to reduced unwarranted variation with empowerment of people in primary and community care. Triple integration cuts through our strategy, bridging the gap between primary and specialist care, physical and mental health and health with social care.

In WY&H we plan to transform primary and community care by enabling the integration of services by strengthening our workforce, infrastructure and harnessing the power of the community around local population need.

We want to achieve system delivery by transforming primary care. Our Primary Care Networks working in Local Care Partnerships will be the platform for this;

Supporting population health management to reduce health inequalities • Enabling personalised care and social prescribing to ensure care needs of our •

patients are met Reconfiguring hospital and outpatient services • Focusing on continuous improvement and reducing variation so that as a system •

we can be the best we can possibly be, delivering fair and equitable services.

Our outcomes will result in: Improved care experience for patients with patients receiving appropriate and •

timely access, advice and care Consistent high quality care • Joined up, person centred care, holistically addressing physical and mental health • Support to self- care with access to the right technology and community support • Empowered Communities involved in service developments, with localised more •

accessible solutions.

For our system we will be the best we can be in primary care delivering;

Improved experience of our staff, volunteers and carers with more staff recruited, •retained, resulting a more sustainable workforce

Improved financial sustainability • Reconfiguring hospital and outpatient services to support care closer to home and •

system sustainability Improved population health • Improved patient outcomes • Reduced health inequalities. •


Fundamental to this strategy is the left shift concept. Wherever possible we want to move towards self- managed care encouraging people who have a health condition potentially taking an increasing role in looking after their own health. This will be influenced by the interface between general practice and secondary care providers to best use clinical time and NHS resources, but ultimately ensuring that patients receive high quality care.

Figure 3. Image representation of ‘Left shift’

This asset- based shift will see more people looking after themselves, reducing variation and increasingly influencing the way services will be commissioned in future. More information about the benefits of the ‘left shift’ can be found in this report, but the intent that this will lead to better health and wellbeing, better quality of care as well as making sure services meet people’s needs now and in the future.

Our approach

Our strategy content encompasses our five overarching strategic themes of transformation:

1. The Right Scale (both large and small)

2. Working together better (integration)

3. Understanding population need (targeted care)

4. Resourced to reduce unwarranted variation (quality improvement)

5. Empowerment of people in communities (patients and staff).

To achieve our end state will we focus on At Scale provision and integrated new modes of care, delivering a person-centred (holistic) approach and our Primary Care Networks and Care Partnerships will be the platform for this.

https://www.wyhpartnership.co.uk/application/files/4315/3797/1031/presentation_Nov_2017.pdf


There are a number of components and key enablers that form part of this strategy of which many include an example highlighted as a ‘Focus on’ case study. These include:

Transformation: PCNs will be the platform for transformation, enabling service and workforce integration. This section will include our approach to supporting population health management through PCNs in West Yorkshire and Harrogate, personalised care, including social prescribing and community asset development and Mental Health.

Workforce: Our local workforce priorities and actions which supports the development of an expanded workforce and multidisciplinary teams and sets out the strategy to recruit and retain staff within primary care and general practice.

Premises and digital: Maximising and improving premises and technology to increase access for patients to primary care services. Primary care estates priorities that will be delivered to provide improved accessibility to enable self-care and easy equitable access to clinical and non-clinical care and support.

Investment: Working in partnership, investing in opportunities and making the best use of our pound to deliver the ambitions outlined in this strategy.

Access and resilience: Drawing on opportunities for maximising a consistent equitable offer to patients, improved patient experience with joined up quality care through integrated team and digital approaches.

Community pharmacy, dental and eye health care: Working collaboratively, recognising the important contribution of Community Pharmacy, Dental and Optical in delivering Urgent and planned care. Drawing on leadership and support from all primary care contractors and their professional bodies to maximise opportunities to improve patient care and delivery specific priorities for the PCN population.

These components are not separate from each other but are mutually supportive to enable a new model of provision and to transform primary care.


National policy and key deliverables

The NHS LTP reflects the success and pride in the NHS, the shared social commitment, and recognises the challenges about funding, staffing, increasing inequalities and pressures from a growing and ageing population. It also states there has been optimism about the possibilities for continuing medical advance and better outcomes of care. The plan describes how we must tackle the pressures our staff face, while making our funding go as far as possible and, in doing so, accelerate the redesign of patient care to future proof the NHS for the decade ahead. Achievements and enablers to support implementation include:

A secure and improved funding path for the NHS, averaging 3.4% a year over the •next five years, compared with 2.2% over the past five years

Wide consensus about the changes now needed, confirmed by patients’ groups, •professional bodies and frontline NHS leaders

An acknowledgement that work that commenced after the NHS Five Year Forward •view is now beginning to bear fruit, providing practical experience of how to bring about the changes set out in the Plan.

The five-year framework for GP Contract Reform translates commitments in the NHS LTP into a five-year framework for the GP services contract and confirms the direction for primary care for the next ten years. The five main goals are:

Secure and guarantee the necessary extra investment • Make practical changes to help solve the big challenges facing general practice, •

not least workforce and workload; Deliver the expansion in services and improvements in care quality and outcomes •

set out in The NHS LTP, phased over a realistic timeframe; Ensure and show value for money for taxpayers and the rest of the NHS, bearing •

in mind the scale of investment; Get better at developing, testing and costing future potential changes before •

rolling them out nationwide.

A summary of the high-level deliverables and contract changes over the next 5 years are detailed in Table 1.


Summary of national deliverables and contract changes outlined in 5 year GP Table 1:contract 2019

2019/20 2020/21 2021/22 2022/23 2023/24

Prim

ary

care

net

wor

ks

All Primary Care Networks submit registration information to their CCG

CCGs confirm network coverage and approve variation to GMS, PMS and APMS contracts

Network Contract goes live across 100% of the country

National entitlements under the 2019/20 Network Contract start

Establishment of National PCN development programme

Design of new national network service specification begins

National Network Services start under the 2020/21 Network Contract

Dashboard developed to monitor progress on network metrics

National Network Investment and Impact Fund launched

Cardio vascular case finding begins

Prevention and inequalities requirements start

Wor

kfor

ce

Develop a workforce plan with trajectories by March 2020 which links to the national targets.

Additional Role Reimbursement Scheme

Clinical Pharmacists and Social Prescribers

Physicians Associates and First Contact Physiotherapists

First Contact Community Paramedics

Increasing the number of doctors in general practice by a net extra 5,000 as soon as possible’.

International recruitment

Retained Drs

GP retention programmes

The Practice Resilience Programme

Specialist Mental Health Service for GPs

Time for Care National Development Programme

Design of two-year primary care fellowship programme for newly qualified nurses and doctors

Introduction of two-year primary care fellowship programme for newly qualified nurses and doctors

Working with Health Education England, NHS England will establish primary care training hubs

Acce

ss

Extended House Access DES requirements introduced across all practices in every network

NHS 111 direct appointment booking into practices introduced nationally

Review of wider access arrangements

Start transition of new access arrangements

All patients will have the right to online and video consultations by April 2021

New access arrangements fully implemented

Patient reported access and waiting times data published monthly

Dig

ital

Digital requirements introduced including access by patients to online record

Requirement for Electronic ordering of repeat prescriptions and electronic repeat dispensing

Practices to ensure at least 25% of appointment are available for online booking

Practices to ensure that by March 2020, 75% of practices are offering online consultation to their patients

Online presences to give patient access to online correspondence

Digital first support offer


Our primary care and community services key deliverables for 2019/ 2020 and 2020/ 2021

Transformation

A demonstrable improvement in PCN growth of maturity achieved through; •– Continued support to the development of networks and highlighting and

implementing opportunities for At Scale working – PCN development plans and identified priorities – linked to population health

needs and the Long -Term Plan Successful implementation of the national service specifications supported •

through a collaborative approach with other ICS programmes Improved integrated models for Primary Care Access • PCN workforce plans in place. •

Workforce

Production of Training Needs Analysis to enable more effective commissioning of •the future workforce requirements; (skills and competencies)

Increase our primary care workforce numbers specifically; •o Increase in GP International recruitment numbers o Increase the number of MH Therapists co-located in primary care o Partnership rotational and preceptorship models for PAs and Paramedics in

primary care • Robust PCN and system workforce plans support through the workforce tools

such as Apex/Insight workload/workforce tool • Expansion of our workforce training hubs demonstrating an improvement in

maturity, with aligned priorities with WY&H workforce plans • Implement “In at the Deep end” At Scale retention initiative, supporting

Health Inequalities in areas where recruitment is more problematic

Access resilience and workload

• Improved access to primary care, supported by; o Increased usage of online consultations and self- care digital options o An agreed systematic, consistent approach to Improving access, patient

experience and education o A consistent approach to addressing the findings of the national access

review o Delivery of the national standards identified in the GP Contract Framework

and the Long-Term Plan o Support Increased utilisation rates for Extended Access appointments


o Enable PCNs to support Access and resilience in Primary and Urgent Care through new models and access to the national network Impact Assessment fund.

Quality improvement

• Improved quality of care at PCN level; o Increased implementation of Carers Quality Markers in practices and PCNs o Reduce variation in Screening and Immunisation including Learning

Disabilities at PCN level o Increasing the uptake in the QOF domains and o Delivery of national service specifications such as medication reviews and

Enhanced Health in Care Homes in 2020 o Support place-based population health management to enhance

knowledge and understanding of population health management.

19 | 1. Transformation

1. Transformation

“We will build on the work we have already invested in and provide a continuum of support to enable our Primary Care Networks to flourish” This section includes our approach to supporting population health management through PCNs in West Yorkshire and Harrogate, enabling personalised care, social prescribing and community asset development and mental health support. We reflect on progress to date, service workforce integration, quality improvement, future aspirations and the support required to accelerate, learn and innovate. 1.1 Primary Care Networks (PCNs) are an essential building block of every Integrated

Care System, and under the new Network Contract DES, general practice takes the leading role in every PCN. Our aim is for successful integration of care, improving health and social care outcomes for patients. To achieve this requires much closer working and bringing together all staff in manageable sized teams to provide integrated models of care based on population health need.

1.2 The NHS LTP and changes to the GP Contract have encouraged and to some extent mandated the establishment and development of PCNs. PCNs provide a platform for integrated models of care, building on a place-based approach and extending across primary, community and social care elements of secondary care, mental health and third sector provision. PCNs working in partnership will develop person and community centred approaches to health and social care. Clinicians describe this as a change from reactively providing appointments to proactively caring for the people and communities they serve.

1.3 PCNs will decide on their own delivery model giving some consideration to relationships and the extended workforce. A number of our PCNs have adopted the National Association of Primary Care (NAPC) Primary Care Home Model (PCHM). The PCHM is one model for working as a PCN. It may be that more of our Networks decide to use the PCHM to support them as they continue on the journey.

1.4 This strategy recognises the work already progressed to deliver the different models already in place and working across the area these include the Community Partnerships across Bradford, Primary Care Homes in Wakefield and Calderdale and the Local Care Partnership model in Leeds. As our models emerge we are seeing different partnerships strengthen.

1.5 This strategy notes the delivery of ‘at scale’ provision across groups of GP practices and there are examples of this in primary medical care recognising the delivery of primary care services through larger organisations for example GP Federations delivering GP Extended Access. The provision of ‘at scale’ models and development of ‘at scale’ organisations will enable further resilience in primary care and support PCNs where this is needed.


1.6 This strategy notes the delivery of ‘at scale’ provision across groups of GP practices and there are examples of this in primary medical care recognising the delivery of primary care services through larger organisations for example GP Federations delivering GP Extended Access. The provision of ‘at scale’ models and development of ‘at scale’ organisations will enable further resilience in primary care and support PCNs where this is needed.

PCNs in West Yorkshire and Harrogate

1.7 WY&H HCP has invested in the establishment and on-going development of Primary Care Networks in 2018/19. Approximately £1 per head was allocated to support practices establish Primary Care Networks across the partnership.

1.8 313 GP Practices have been aligned to 56 PCNs across the WY&H HCP. Each PCN has a designated Clinical Director(s) who will provide strategic and clinical leadership for the ongoing development of each network.

PCNs in West Yorkshire and Harrogate Table 2:

CCG PCNs CCG PCNs Airedale, Wharfedale and Craven 2 Harrogate and Rural District 4 Bradford City and Districts 10 Leeds 19 Calderdale 5 North Kirklees 4 Greater Huddersfield

5 Wakefield 7

1.9 PCNs need to embrace a much wider approach than the traditional model of general practice. In addition to core general practice it is expected that all PCNs will incorporate the following within the scope;

• The network approach will focus on the prevention agenda with the aim of reducing the need for complex care in future years

• Personalised Care - Patient choice and self-care, supporting patients to make choices about their care and look after their own health by connecting them with the full range of statutory and voluntary services

• Networks will assess population health - focusing on prevention and anticipatory care, Quality Improvement, health inequalities and operate in partnership with other agencies to address the wider determinants of health. Networks will provide a platform for peer review which will enable quality improvement within our primary and community care providers

• Improving Access, support wider system resilience and addressing Health Inequalities through integrated models of care.


Personalised care

1.10 The NHS Plan makes personalised care business as usual across the health and care system. Personalised care means that people will have choice and control over the way their care is planned, based on what matters to them, their individual strengths, needs and preferences. Personalised care takes a whole-system approach, integrating services including health, social care, public health and wider services around the person. It provides an all-age approach from maternity and childhood, through living with frailty, older age and end of life, encompassing both mental and physical health and recognises the role and voice of carers. It recognises the contribution of communities and the voluntary and community sector to support people and help build resilience.

1.11 We know that approximately 40% of patients do not require GP Intervention. Social prescribing and community empowerment through personalised care will be a key feature of primary and community care delivery which will enable more self-care and more resilient communities, enabling more capacity in GP practices for complex care.

1.12 The staying Well service in Calderdale supports and signposts people to local support organisations and groups. The funding the service has received will help local groups and organisations to reach further into communities which we've previously not been able to support as easily as others. Staying Well is also developing a digital/web-based product to enable more people to access information on self care, local health and care groups and services.

1.13 The HCP is working with NHS EandI as one of 11 national "Level 1 Personalised Care Demonstrator Sites for 2018/2019" which provides a good foundation for embedding personalised care across the wider system. Continued work with patients, using the intelligence we have about our communities will support the design of network services in the future.

Quality improvement

1.14 Quality improvement will be core at practice and network level. Networks over time will increasingly take on the role of quality improvement, maximising opportunities to address variation and influence future service needs through peer led audit and evaluation.

1.15 Our aim is to;

• Reduce variation in screening and immunisation for people at a PCN level including patients with learning disabilities

• Support place-based population health management approaches, enhancing knowledge and understanding of population health management

• Support PCNs in the preparation and implementation of the Tackling Neighbourhood Inequalities national service specification

• Implementation of carers quality markers in practices and PCNs.


1.16 Nationally the focus on Quality Improvement has been supported by the review of the Quality and Outcomes Framework (QOF) with the introduction of the Quality Improvement (QI) domain which will be set annually.

1.17 In WY&H we will continue to support our local systems in the implementation of the national frameworks and review of quality improvement measures. The QOF will continue to be reviewed through the life of this strategy with focus aligned to more strategic directions for both primary and community care and the wider system. We know that in 2019/20 the Heart Failure, asthma and COPD indicators will be reviewed with a review of the mental health domain in 2020/21. These reviews may bring about more changes in the way primary and community care is enabled and encouraged to work alongside the outcomes of the LTP.

Primary care’s role in the mental health agenda

1.18 One of the priorities in the LTP and WY&H HCP is Mental Health. We know that a large proportion of patients attending primary care is either directly due to Mental Health and illness of a Mental Health component. We recognise the important contribution that PCNs will bring to this agenda to ensure a better developed and more coordinated response to people with mental illness. There are a number of key targets such as Improving Access to Psychological Therapies (IAPT) in Long Term Conditions, dementia diagnosis, and Learning Disability health check that heavily rely on primary care for delivery.

1.19 It is envisaged that PCNs will play a key role in ensuring a joined up approach to the delivery of mental health issues in primary care. The success of the PCNs integration and alignment to the priorities of the LTP, specifically relating to Mental Health and Learning Disabilities is their work to involve local authority partners and the voluntary sector in local network discussions and service design.

1.20 One of our areas of focus will be improving access and quality of care for unpaid carers. Identifying carers in primary and community care so they can be supported more appropriately is one of six key areas in the West Yorkshire and Harrogate Unpaid Carers Programme.

1.21 All six places within WY&H have processes in place within GP practices to identify carers and signpost them to the appropriate support for example:

Leeds and Wakefield have purchased and promoted the Carers Digital Resource •across Primary Care (letters to GP surgeries, newsletters, attending practice nurse meetings, comms etc.)

1.22 In line with the HCP unpaid carers programme objectives, we will ensure unpaid

carers are supported within primary and community care through social prescribing and personalised care. This will be complemented by:

The expansion of the primary and community care workforce particularly the •role of care navigators and primary care link workers


Providing opportunities where ever possible to strengthen the voice and role •of the Voluntary and Community Sector at Place and PCN level.

1.23 Following the publication of 'Supporting Carers in General Practice; a Framework

of Quality Markers'4 we will support primary care to embed the ethos of the quality markers into day to day services as necessary.

1.24 Further opportunities to support Quality Improvement will be incentivised through the Network DES clinical specifications which will be further supported by working with wider stakeholders and aligned to developments through the new Community Pharmacy Contractual Framework.

1.25 We will support our PCNs in their local delivery of the seven national service specifications when released in 2020 /2021;

• Structured medication review and optimisation • Enhanced health in care homes • Anticipatory care requirements • Personalised care • Supporting early cancer diagnosis • CVD prevention and diagnosis • Tackling neighbourhood inequalities.

1.26 PCNs will be expected to implement the medication review and enhanced health in care homes in April 2020 which presents a huge opportunity to build on the local system work already in place to support these workstreams.

Population health

1.27 Work is already progressing at pace across HCP to support local places to deliver Population Health Management. The HCP benefits from a focused programme on Population Health Management and this strategy recognises the interdependency of Primary Care with the Improving Population Health Management Programme. There has been work already progressed to pilot ways of working in Population Health Management in network/partnership geographies for example in Leeds where the learning will benefit the wider partners across WY&H. The HCP Population Health Management and Primary Care Programme Boards are working closely together in offering their support to PCNs.

4 National Health Service England and Improvement (2019) Supporting carers in general practice: a framework of quality markers. Available [online] https://www.england.nhs.uk/publication/supporting-carers-in-general-practice-a-framework-of-quality-markers/ [26/09/2019]


Access and integrated model of care

1.28 The LTP envisages PCNs joining up the delivery of urgent care in the community. Funding and responsibility for providing the current CCG commissioned enhanced access services transfers to PCNs via the Network Contract Des by April 2021. This will provide networks greater opportunities for delivering models that meet the requirements of their population and address local health inequalities.

1.29 A major new national network Investment and Impact Fund will be available in 2020 as a means of supporting Integrated Care System delivery of The NHS Long Term Plan. The Impact and Investment Fund (IIF), is expected to provide additional funding to PCNs which go further faster to deliver the national service specifications and provides an incentive to PCNs to reduce unwarranted demand on NHS services including inappropriate A&E attendances.


Focus on: Community Care Partnership in Bradford

Community Partnerships (CPs) are Bradford District and Craven’s way of working differently with people and communities to deliver improved health and wellbeing outcomes for the population. Covering 14 communities of approximately 30-60,000 population sizes, the CP’s bring together Health, social care voluntary sector and other local services to focus on health and wellbeing. Recognising the impact that wider determinants have on the health and wellbeing of people, the CP’s adopted a strength-based community developed approach to service redesign. Community based staff and local people have the opportunity to say what is important to them based on local information, to ensure that future health, care and wellbeing services meet their needs. Across this geographical footprint there are 14 CPs with the majority of these being established in 2017 and being on a development journey since this time.

Community partnership are the fundamental building blocks of the Bradford District and Craven place, and local leadership is via two health and care partnership Boards.

The system vision is for people to be happy healthy at home. This will mean that people are better supported to stay healthy, live well and be as independent as possible throughout their lives. This support will not only come from community-based staff but people’s own families and their wider community. Wherever possible, people will be encouraged to make healthy lifestyle choices and care for themselves, with support.

Each CP has a community leadership team who are working together to share their knowledge, ideas and expertise to support each other in understanding their roles and how they can work better together to improve the lives and experiences of people in the local community. This new way of working enables CPs to involve and empower their local teams to design, develop and set up new ways of delivering health, care and wellbeing services which they lead on. It provides opportunities for community staff to work in different ways with other organisations. This will overcome some of the long term issues and help us to deliver better care and support that people working and living in communities have told us they want.

The CP leadership teams include people from a variety of health, social care and third sector organisations and include staff from GP practices, community nursing, mental health services, community pharmacy, care homes, home care, voluntary organisations, social workers, the council ward officers, local Councillors and hospital staff.

We recognise the importance of everyone having access to core services across Bradford district and Craven and through the implementation of the CP model it enables these services to be tailored and enhanced to better meet the needs of the local community

The CCGs have provided funding to support the local voluntary sector and grassroots organisations to develop and deliver initiatives to improve health and wellbeing outcomes across our communities for example: yoga sessions to help people to relieve anxiety, stress, fight depression, reduce chronic pain and improve sleep quality, well-being bags filled with health, hygiene and mood boosting items to support service users who are homeless or rough sleeping and support for Bangladeshi woman who face loneliness and isolation, to become physically active. Other local initiatives include young people’s mental health project initiated by the Wharfedale community partnership that has now been adopted more widely and a focus on loneliness and isolation in Craven.


System progress: where we are now

1.30 To support the development and acceleration of PCNs, in 2018/2019 WY&H HCP committed £1 per head of population to each CCG, to accelerate and develop local approaches. This resource incentivised and supported the use of the NHS England Maturity Matrix as a tool to review the maturity of our PCNs and at scale models and enabled capacity for PCNs to attend Local Events bringing together GP and wider stakeholders to focus on development of PCNs.

1.31 We have examples of Providers working together to deliver GP Extended Access and Integrated Services for example the provision of Extended Access in Greater Huddersfield working with the GP Federation, My Health Huddersfield and Local Care Direct.

1.32 Developments and success in the development of establishing wider community partnership models, for example; Airedale Wharfedale and Craven multi-agency partnership approach to working towards establishing a single place based primary and community led ‘system of care’ enabling collaboration between provider organisations. The development of Local Care Partnerships in Leeds working closely with the GP Confederation and Leeds Community Services Provider.

1.33 Bradford City and District CCGs supported by National Association of Primary Care (NAPC) have developed local communities of between 30,000 – 60,000 populations which cover the entirety of the Bradford population.

1.34 Examples of wider representation in PCNs and Primary Care Home models for example Community Pharmacy (supported via Community Pharmacy West Yorkshire).

1.35 We have supported work locally to deliver organisational development to the GP Federations in place across WY&H recognising their role in the transformation of primary care.

1.36 Population Health Management – Places are being supported to develop specific priorities based on local population need.

1.37 NAPC have provided dedicated support to several places and Networks to develop the Primary Care Home model.


Systems actions: what we will do

1.38 We will build on the work we have already invested in and provide a continuum of support to enable our PCNs to flourish. This will include;

• PCN Development Support Offer. The HCP will continue to work closely with places to help shape the support directed to PCNs through both the NHS E&I funding and any potential local offers of support

• We will explore with Clinical Directors and PCNs the development of a local tool to capture more effectively the maturity and progression of each PCN

• Sharing Learning – as part of this strategy there is a clear commitment to facilitate the learning across the WY&H area. There is expected to be 56 PCNs across WY&H all delivering different models and at varying maturity levels. This creates a huge opportunity to share the learning across our patch creating a ‘ready-made’ support network within our local area.

1.39 We will ensure a strong focus on supporting and developing current and future

PCN Clinical Directors:

• We will look to establish a peer network for Clinical Directors; initially to explore options for working together and the potential to develop a consistent offer

• We will explore approaches to ensure Clinical Directors (if GPs or nurses) engage with Pharmacy, Eyecare Local Professional Network (LPN) leads.

1.40 As described as part of the Workforce section of this strategy we recognise the

need for PCNs to be supported by good clinical and managerial leadership and that in some cases this will require development. Places will understand their ‘skills gap’ and be able to define how as WY&H this can be addressed. We will support our PCNs to look at their workforce beyond their own GP practices and to the wider health and social care partners within their own neighbourhoods.

1.41 We will support PCNs in their approach to Population Health management. The WY&H HCP will explore how best to support PCNs with the right level of information/population health data to define their health and social care needs and are then supported in how best to manage this data to deliver true population health management.

• To kickstart this we will hold place events in collaboration with the Improving Population Health workstream and NAPC. This strategy recognises the role of Population Health to the Health Inequalities agenda and the potential level of support PCNs can offer in addressing Health Inequalities.

1.42 We will support delivery and infrastructure for the new PCN Workforce Roles.

This will be supported through the Primary Care Workforce Steering Group in collaboration with HEE, Training Hubsi and LWAB.


1.43 We will support our PCNs in their local delivery of the seven national service specifications when released in 2020 /2021. We will engage and work collaborative with all WY&H priority programmes to support approaches to delivery of the service specifications and other priority projects.

1.44 We will work in partnership with Voluntary and Community Sector to explore opportunities for supporting PCNs, enabling closer links with communities aligning closely to the requirements of the LTP in areas such as Mental Health and Learning Disabilities. At partnership level we will enable PCNs to ensure their development and specifically their organisational development focuses on the key partners involved in their population health priorities.

1.45 Personalised Care Leadership, WY&H HCP through links with the personalised care teams will implement a pilot at PCN level looking at how personalised care can be embedded through network working. It is the ambition of HCP to integrate the work of PCNs with personalised care linking closely to Population Health Management to target personalised care approaches.

1.46 We will explore opportunities for PCNs to work more effectively with Dental professionals contributing toward clinical pathway changes and care closer to home. We will aspire to have one of our Primary Care Homes integrating with the Dental Agenda.

1.47 We will work collaboratively with the Mental Health programme to support the delivery of 75% delivery of LD health checks in PCNs.

iTraining Hubs (THs) are funded and their governance is monitored by HEE via primary care school and the post graduate dean. TH are jointly accountable for workstreams developed in collaboration between HEE and NHSE nationally and to Sustainability and Transformation Partnerships (STPs)/ Integrated Care Systems (ICSs)

29 | 2. Workforce

2. Workforce

“WY&H HCP aims to support the Primary and Community Care Workforce to have the right values, skills and behaviours to work with people as equal partners in their health and care delivering positive outcomes for patients, staff and the population. WY&H will be a vibrant place to work with a responsive, passionate, engaged, compassionate, diverse and fit for purpose workforce with great opportunities. Our workforce will help our people to live their best lives!” This section includes our local workforce priorities and actions which supports the development of an expanded workforce and multidisciplinary teams and sets out the strategy to recruit and retain staff within primary care and general practice. 2.1 WY&H HCP aims to support the Primary and Community Care Workforce to have the

right values, skills and behaviours to work with people as equal partners in their health and care delivering positive outcomes for patients, staff and the population.

2.2 WY&H will be a vibrant place to work with a responsive, passionate, engaged, compassionate, diverse and fit for purpose workforce with great opportunities. Our workforce will help our people to live their best lives.

2.3 The Primary and Community care workforce will be responsible for raising workers with competencies to deliver population-based outcomes and will be integral to the success of Primary Care Networks (PCNs). This strategy focuses on how to attract the workforce in to Primary and Community Care, retain and train. The priorities outlined in this strategy align to these high-level objectives.

2.4 The sustainability and development of the primary and community care workforce is a key priority reflected in the Local Workforce Advisory Board (LWAB) Strategy and recognised by the HCP Primary and Community Care Board. The vision for Primary Care Workforce looks to the ultimate enablement of PCNs and the ‘left shift’ii as described by local HCP workforce leadership. In WY&H there will be a strong focus on ensuring that we develop a skills based workforce, reflecting our priorities and the wider transformation agenda in primary care.

2.5 In WY&H the challenges of recruiting and retaining a skilled primary care workforce are no different to many other areas. A growing ageing population with complex needs, poor health outcomes and deprivation levels place additional pressure on our localities which means our future workforce needs to look different from how it does today.

Across WY&H we will ensure that our workforce strategies look to support the wider system in addressing health inequalities. Our focus to attract, retain and train will look to ensure that we support the workforce in our most deprived communities.

30 | 2. Workforce

2.6 Delivering on the vision for primary care as set out on the LTP will not simply require more of the same but a different skill mix, new types of roles and different ways of working. PCNs will be key to delivering this vision and will start to develop their own workforce plans to reflect the service required and skill mix for the population they serve which will dovetail with place priorities.

2.7 Nationally specific workforce targets have been set and both local and HCP wide plans will reflect these targets in planning assumptions. This strategy recognises the interdependencies with wider Workforce forums for example the Local Workforce Advisory Board and the importance of complementary strategies to increase and retain the overall primary care workforce. The targets and trajectories are recognised as ambitious and challenging, the HCP in this strategy identifies the need to both focus on delivery of the trajectories but support the transformation of the workforce demonstrating an overall increase in capacity.

2.8 Working together with West Yorkshire LWAB (including Health Education England colleagues) the WY&H HCP aims to develop ‘one’ approach to workforce and through working as a system aims to;

• Deliver integrated working models across organisational boundaries • Develop a stable workforce with the right knowledge and skills and

competencies.

2.9 The WY&H HCP Primary and Community Care Board is currently supported in its delivery of the Workforce agenda by the WY&H Primary and Community Care Workforce Steering Group and six place- based groups (Leeds, Airedale and Bradford, Calderdale, Harrogate, Kirklees and Wakefield). This structure recognises the need for work to be taken forward at local place level whilst creating the opportunity for HCP wide workstreams for example the WY&H International Recruitment Programme.

2.10 The Steering Group enables all partners and places to come together in the delivery of Primary Care Workforce trajectories and transformation. This strategy has been co-produced with that Steering Group. The Steering Group recognises the importance of collaboration and communication and has representation from the WY&H HCP, NHS E&I, Health Education England, Place Based Workforce Leads, Training Hubs, West Yorkshire Excellence Centre and LWAB.

2.11 The delivery of a workforce strategy relies on working closely with the interdependent groups and structures including Training Hubs (previously named Advanced Training Practices). The LTP and GP Contract notes an increasing role for the Training Hubs in the delivery of training and development in Primary Care. Across WY&H there are four Training Hubs working across places, with one hub, the Bradford and Harrogate Hub, coordinating strategic representation on behalf of all hubs across WY&H. The WY&H HCP will continue to support the Hubs in their evolving and emerging role linking closely to the work of the Steering Group.

31 | 2. Workforce

2.12 Improving how community services are delivered, and preparing the workforce to enable the ‘left shift’ is essential to achieve the aims of the NHS LTP. The integration of primary and community care is important for our workforce, service stability and patient choice. We will explore further opportunities for Community Services and Voluntary and Community Sector to support PCNs by facilitating local conversations and provider presence. WY&H HCP plan to build on the relationships with community providers with a view to enhance existing community delivery methods. We aim to respond and agree a WY&H approach to NHS Improvement’s recently published Community Services Operating Model Guidance5 that sets out recommendations to achieve the ambitions of the NHS LTP, in particular for improving response time, quality of care and productivity of the workforce.

2.13 Workforce is a key enabler of the NHS LTP and more specifically the direction of travel for Integrated care and PCNs. Our strategy will support the local foundations we have built with our partners to maximize efficiencies for an effective workforce. The shift in services from secondary to primary care present opportunities for improved integration working more closely with our secondary care partners. Flexible employment and rotational models will support service and workforce integration, enabling a system wide approach to some of our workforce challenges.

2.14 We recognise the important contribution to workforce that the community provides, such as volunteers and unpaid carers and are committed to supporting this. The WY&H HCP aspires to be a place where carers are recognised and given the support they need to manage their caring role and remain in work or education. An example of this has been supported is a working carer’s passport that has been agreed across West Yorkshire and Harrogate Association of Acute Trusts and learning is being shared across Primary care.

2.15 The HCP is required to develop a workforce plan with trajectories by March 2020 which links to the increases in workforce required as part of the national targets. The table below describes the baseline position of September 2015 across GP practices in WY&H and the latest reported position of December 2018. This data is taken from NHS Digital from GP practice based reporting systems.

2.16 Our plans will encompass workforce planning and transformation which covers strategies to support both our clinical and our non- clinical workforce in primary care. As a partnership we recognise the value of roles such as Allied Health Professionals and the important contribution they play in the wider Multi- Disciplinary team to support patient flows. We will ensure our strategies are aligned to the wider Partnership strategies and workforce plans. We aim to ensure that the primary care workforce is considered and viewed by stakeholders as the wider workforce delivering and supporting services in primary care. PCNs will be key in how we view primary care as a community and the delivery of holistic healthcare will be underpinned by a wide variety of roles in general practice, community pharmacy, dentistry and optometry.

5 NHS Improvement (2019) Community Services Operating Model Guidance. Available [online] https://improvement.nhs.uk/resources/community-services-operating-model-guidance/ [24.06.2019]

https://improvement.nhs.uk/resources/community-services-operating-model-guidance/

32 | 2. Workforce

Workforce Baseline Position of September 2015- GP Practices Table 3:

FTE Workforce: Current position compared to baseline at Sept 2015

Latest Difference from Sep’ 15 baseline

Latest reported position as at Dec 18

FTE per 1,000 weighted population

General practitioners (excluding Registrars) England -640 28,596 0.49 Yorkshire and the Humber -56 2,853 0.49 West Yorkshire and Harrogate 15 1.327 0.49 All Nurses within General Practice England 1,143 16,384 0.28 Yorkshire and the Humber 297 2,003 0.34 West Yorkshire and Harrogate 129 889 0.33 All Direct Patient Care England 1,975 12,858 0.22 Yorkshire and the Humber 371 1511 0.26 West Yorkshire and Harrogate 135 607 0.22 Details of West Yorkshire and Harrogate Direct Patient Care Health Care Assistants 49 391 Dispensers 3 67 Phlebotomists -1 30 Pharmacists 56 62 Podiatrists 0 0 Physiotherapists 0 0 Therapists 1 1 Physicians Associates 0 2 Paramedics 3 3 Nursing Associates 4 4 Apprentices 20 20 Other Direct Patient Care 2 27

33 | 2. Workforce

Focus on: Workforce transformation showcase The Showcase provided all areas across West Yorkshire & Harrogate the opportunity to network and come together to share innovative workforce transformation models. Presentations were made by;

• Locala CIC on their Volunteering Programme. • Bradford CCGs on their Practice Nurse Leadership Programme. • Pudsey Locality around new ways of working - Emergency Care Practitioners and Physiotherapists in

Primary Care. • YOR LMC on the GP Mentorship Pilot Project & Practice Manager appraisals. • NHS England on International Recruitment within West Yorkshire & Harrogate.

The event was well attended by all stakeholders including CCGs, Community Services, LWAB, NHS E&I, Training Hubs and the West Yorkshire Excellence Centre. The Showcase evaluated well with a 100% of attendees stating that there is a place for this type of network within the system and they would like to see further showcases organised. Suggestions made for future Showcases were for more information on nurse development, linked up working and leadership roles. The Partnership are looking to organise another Showcase for October 2019 working closely with the Steering Group in its delivery.

34 | 2. Workforce

Focus on: Wakefield General Practice Resilience Academy Wakefield is supporting a locally sustainable, resilient general practice workforce by growing its own staff, owning and delivering the training and support they require and providing good career and personal development opportunities with the expansion of skills, development of new roles and new ways of working. Wakefield CCG responded to the growing pressures within the primary care workforce by launching the Wakefield General Practice Resilience Academy (Academy). The team is funded by the CCG and NHS England GP Resilience monies. The Academy is enabling a productive and resilient workforce by transforming learning and providing direct support to GP Practices. It provides and facilitates local, affordable, innovative and high quality training and education that meets the current and future needs of our changing workforce across General Practice It has developed a ‘Virtual Practice’ model which focuses on training, advice and intensive support. The virtual team is made up of a GP, Practice Nurse and Practice Manager. In addition to providing assistance to individual practices the team supports primary care networks on planning and business models. Where required, the team will work with other teams in the CCG to provide tailored and targeted support in the following areas:

o Diagnostic reviews where there are identified areas for development o Development of remedial action plans o Change management support o Signposting to specific support including education and training o Direct advice and mentoring to clinical and administrative staff e.g. practice managers o Team building and development o Targeted reviews within the Practice on issues that have been highlighted during the diagnostic

phase o Consultancy services on training support, business skills, human resources and estate

management The benefits of this service are that GP practices are more resilient; they understand their workforce and are better able to plan for the future. More importantly the CCG is now able to not only identify practices in need of additional support but also provide them with follow-up support where appropriate. Wakefield has already seen a small but steady increase in overall GP and nursing numbers from 2015-2018.

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2.17 The transformation and development of Primary Care Workforce is not a new agenda and there has been significant progress at both local CCG and place level and across the wider HCP. This strategy reflects on some of the key achievements to date, creating a sound foundation on which to deliver our national and local priorities.

2.18 Establishment of a WY&H Primary and Community Care Workforce Steering Group supported by six place-based groups

2.19 Improvements in skill mix and new roles;

• Clinical Pharmacists working at scale within General Practice to support the delivery of care and releasing GP time

• Training of and active utilisation of Care Navigators and Medical Assistants.

2.20 GP recruitment and retention initiatives utilising NHS England transformation funding, including a co-produced bid for International GP recruitment.

2.21 Training and development support;

• Wakefield Resilience Academy and the 4 Primary Care Hubs across WY&H • Supported development of the West Yorkshire Excellency Centre (WYEC) to

support training of band 1-4 workers across primary and community care providers

• Innovation and shared Learning through the delivery of LWAB and HCP Workforce Transformation Showcase to enabling sharing of best practice across the local area.

2.22 Support for workforce planning and forecasting through supported roll out of the

Apex Insight Workforce and Workload tool for General Practice and PCNs.

2.23 Testing and learning from the concept of system working with community services by exploring scalable solutions with podiatry services and emergency planning and resilience teams.

System actions: what we will do

2.24 We will work together with key partners including; NHS E&I, Health Education England, Primary Care Training Hub, PCNs and community providers, to maximise the

36 | 2. Workforce

use of system levers to support the joint planning and delivery of workforce solutions and to mitigate workforce risk across primary care.

2.25 This strategy describes the work we will support and undertake at a system level. It is recognised that in addition to HCP Programmes of work it is necessary for certain initiatives to be implemented locally but still feed into the HCP work as part of enablement. These are described as;

• Workforce planning at primary care network level – the discussion and support for Primary Care Networks to plan their own workforce will be supported and driven forward by places but it is recognised that to support effective PCNs local workforce themes and outputs would be remain beneficial to review at HCP level through the steering group. Across HCP we will ensure that workforce planning at network level is supported to look beyond GP practice roles and look at the wider provision of primary care. We will also ensure that our PCNs look beyond Primary Care when reviewing their workforce and capacity enabling involvement with the social care, community care and independent sector care workforce.

• Placement capacity – local systems identified the capacity for training placements for roles in primary medical care (GP Practices) did prove challenging in some areas and that in some cases although addressed through place could be supported across the HCP in managing some of the gaps. We will work with our training hubs to maximise potential for increased placement capacity.

• Apex insight workforce tool – the roll out of Apex Insight is considered more appropriate at a place/CCG level and is currently in progress in most areas however the Steering Group would support discussions later in the year regarding continued access to the tool and the value to the wider system.

2.26 A summary of the key Strategic Priorities and examples of work aligned to the ‘attract, retain and train’ principles for our Primary Care Workforce programme are described in the table below. The WY&H Primary and Community Care Workforce Steering Group are working on developing and embedding these priorities for delivery across the WY&H HCP.

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Examples of work aligned to attract retain and train Table 4:

Priority Attract Retain Train Understanding the Baseline – Gather local intelligence, collating a more accurate baseline to inform local and ICS workforce planning and strategies for Attracting, Retaining and Training initiatives. Amalgamation of PCN workforce plans for analysis at local and ICS level. Support for implementation / utilisation of a consistent workforce tool.

Effective communication to all in understanding our current workforce and the role of transformation in attracting new people into the workforce.

Focused retention initiatives based on an understanding of gaps for example; GP Retention workstreams. Support for GP practices, PCNs and CCGs to enable effective workforce planning linking to more resilient GP practices and retention.

Training and development programmes mapped to the baseline and trajectories. Support to target investment.

Primary Care Nursing – development of a WY&H Partnership approach to the training and development of Primary Care Nursing aligning to the ten-point plan. Enable access to future funding streams and support our partners (HEE, Training Hubs, CCGs) to deliver programmes of support that are consistent with the needs of the workforce.

GPN Ready Rotational Models and Portfolio working Career Fairs Nurse Associate Programme

Educator roles within PCNs Development of Career and Training Pathways

Nursing Leadership programmes Long Term Condition training (WY&H led through Training Hubs) Work with HEI and Delivery Group in coordination of training offers.

Training Needs Analysis – support for local systems to understand the Training and Development needs of the Primary Care Workforce across the Partnership aligning to the wider system priority of Primary Care Networks and Population Health Management.

Coordinated approach to primary care training recognising the role of PCNs workforce plans and educators to attract new workforce.

Support for retention with programmes of training linked to career development and retention – focus on ‘mid’ career roles.

Delivery of an effective training programme at place and Partnership level linking to identified training needs.

Engagement with Education Providers – Engagement with education providers across the Partnership to develop effective links with those training and developing the workforce. Enabling a focus on the ways of working in primary care and helping individuals to understand primary care roles

Development of career pathways for primary care roles. Work with HEIs in the training of new workforce roles i.e Physicians Associates, raising the profile of primary care. Careers events and fairs.

Ensure development and training opportunities are effectively communicated to the existing workforce.

Work to enable HEIs to deliver training that supports individuals in primary care roles – linking to the transformation of the workforce across WY&H.

38 | 2. Workforce

and potential career pathways at an earlier stage in working lives. Apprenticeship Levy – Support for places to access the Apprenticeship Levy through working with the West Yorkshire and Harrogate Excellence Centre.

Raising the profile of the levy and enabling access through WYEC in attracting more apprenticeship level roles in primary care.

Effective support and development for apprentice roles to enable retention in primary care linking to career pathways.

In role training and placements to be effectively and consistently delivered to apprentice level roles.

Preceptorship Models and New Ways of Working – development of a Partnership approach to Preceptorship models and infrastructure support for the new roles in Primary Care.

Task and Finish Group for PA Preceptorship model in WY&H enabling more placements in primary care and better engagement with HEIs in supporting the additional roles at PCN level. Work with partners in the delivery of new workforce roles (through the Steering Group) for example Yorkshire Ambulance Service and paramedics in primary care.

Creation of infrastructure for new roles within primary care – delivery of peer networks through the PCNs.

Use of educator role within PCNs to support delivery of ongoing training and development for new ways of working – both with those undertaking new roles and the wider primary care workforce.

Organisational Development – organisational development for systems to enable co-production of workforce strategies at place and Partnership Level.

Recognised need for effective organisational development across the wider system to enable co-production and collaboration delivering the workforce strategies. The Workforce Steering Group and place-based working are in a stage of development with a need to embed the interaction between place and WY&H. The impact and delivery of the strategic intentions will need to be based on sound relationships and trust across organisational boundaries.

39 | 3. Premises and digital

3. Premises and digital

“If we are to deliver the transformation priorities outlined in this strategy we need to enable the infrastructure including fit for purpose estate” Primary care estates priorities that will be delivered to provide improved accessibility to enable self care and easy equitable access to clinical and non- clinical care and support. Maximising and improving premises and technology to increase access for patients and primary care services.

3.1 Making sure our buildings are suitable and fit for modern healthcare is an important part of our plan in ensuring an equitable offer for all patients for the quality of healthcare environment and premises.

3.2 If we are to deliver the transformation priorities outlined in this strategy we need to enable the infrastructure including fit for purpose estate.

Funding routes

3.3 For Primary Care General practice the Estates, Transformation and Technology Fund (ETTF) and Business as Usual Capital (BAU) are currently the primary funding sources to enable transformation and improvement of the Primary Care Estate.

Estate technology and transformation fund

3.4 ETTF is a multi-million-pound investment (revenue and capital) that was introduced as part of the commitment to improving general practice premise and technology infrastructure to support primary care transformation between 2015/2016 to 2020/2021.

3.5 Some examples of what ETTF has supported in WY&H include:

• During 2015/2016 - 2017/2018 schemes progressed have mainly been Digital and Technology schemes that have supported CCG system transformation/improvement and some relatively small GP premises improvements

• 2017/2018 to date have seen a progression of larger GP premises improvement schemes with 11 schemes either completed; in delivery or final due diligence stage prior to start in site. A further 11 schemes are being assessed

• 8 new build schemes remain at early stages of consideration.

3.6 In 2019/2020 plans CCG across WY&H are submitting proposals to secure circa £6.4m of ETTF capital funding to support schemes.


Business as usual

3.7 BAU (Capital funding only) is available each year for CCGs to propose capital requirements for more routine primary care requirements and can include:

• GPIT hardware requirements • Corporate IT requirements • Learning disability premises schemes • GP premises improvement works.

3.8 In 2019/2020 plans CCG across WY&H are submitting proposals to secure circa £6m of BAU capital funding to support schemes.

3.9 Overall capital investment has culminated in;

• New consulting and treatment rooms to provide a wider range of services for patients, including improved reception and waiting areas

• Building new facilities to deal with minor injuries • Creating better IT systems to improve the way information is shared between

health services in the area • Extending existing facilities to house a wider range of health staff • Building new health centres which have a greater range of health services for

patients in one place.

3.10 Whilst we can demonstrate some success through ETTF we recognise that not all identified schemes will be delivered in the lifetime of ETTF and that ETTF will not be a source of funding post 2020/21.

3.11 Where schemes have not progressed as yet we know this can be due to (one or more of) a range of challenges including affordability; complexity and number of stakeholders; skills, experience and/or capacity for both commissioners and providers to progress; national constraints (GMS Premises Costs Directions)6 etc.

3.12 We know that a number of schemes on the current primary care capital pipeline will still therefore require a potential source of capital funding beyond ETTF.

3.13 In 2019/2020 we have moved to fair shares capital allocation for ETTF and BAU. Whilst this presents some opportunities in relation to planning and spend in the

6 NHS England (2013) The National Health Service (General Medical Services Premises Costs) Directions. Available [online] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/184017/NHS__General_Medical_Services_-_Premises_Costs__Directions_2013.pdf [25/06/2019]


medium to long term there is a requirement for WY&H to have one pipeline for all primary care estates projects to enable strategic prioritisation.

Capital Estate Strategy

3.14 A separate HCP Strategic Estates Plan exists which provides a comprehensive plan for the HCP Estate across all aspects of NHS Estates including Primary Care to support clinical and service strategies and include proposals for a pipeline of possible capital investments. These plans need to account for a continually growing population and support changing service delivery arrangements to ensure services are delivered in the best way possible that are sustainable. Plans will also take account of increasing use of technology which change or enhance the way services are both delivered by clinicians and used by patients.

3.15 Whilst the WY&H HCP Capital Estate Strategy sets out a collaborative integrated approach to capital planning and prioritisation it is recognised that capital and estates will be driven through place as a key enabler for service re design.

Focus on: Leeds Hillfoot Surgery, Pudsey Hillfoot Surgery is a 4 partner practice providing primary care services to approximately 7,000 patients living in Pudsey and surrounding areas in Leeds. The practice is a two-storey practice built approximately 25 years ago and the aim of the application to the ETTF funding was to provide additional capacity to reflect the expansion of primary care services. Specifically the ETTF application included the development of: • An additional 3 consulting rooms via an extension to the existing surgery • An additional 8 parking spaces to car park • Overall improvements to the surgery to improve patient experience and staff morale ETTF provided a grant for 66% of the costs of the improvements totalling £220,000. Hillfoot Surgery is an active partner in the Pudsey Primary Care Network and the improvements at the surgery also support the PCN to co-locate some of the following additional services such as dressing clinics, new workforce roles (paramedics and physiotherapists and Occupational therapists).



3.16 The HCP Estates and Capital programme board has been established to understand capital priorities across WY&H, linking these with transformation and clinical service strategy, enabling a whole system approach.

3.17 A Strategic Estates Plan developed providing a comprehensive plan for the HCP Estate across all aspects of NHS Estates including Primary Care to support clinical and service strategies and include proposals for a pipeline of possible capital investments. For example, eye care service transformation projects currently in development will require premise capacity in primary care.

3.18 Each CCG has established a Local Estates Board and each developed local Strategic Estates Plans (SEP).

3.19 Plans have been developed with all CCGs to access national primary care capital (BAU and ETTF) for both 2019/2020 and 2020/2021 to support priority investments for primary care projects (e.g. GPIT, Digital, Learning Disabilities, Premises).


3.20 Take a whole system approach to Estates ensuring estates and investment priorities are linked to place service strategies and transformation. This will require CCGs to review their local SEPs to ensure alignment with service strategies and bringing together all Estate and capital Information to inform a cohesive plan for WY&H Estate.

3.21 Enable progression - Identify and access to resource, skills and technical expertise to support primary care to accelerate schemes to a point for further consideration and progression. This includes defining our priorities for future capital ensuring projects are transformational.

3.22 Work with CCGs to identify tangible support measures and any relevant enabling funds to progress priority schemes at pace.

3.23 Maximise opportunity to secure national funding (ETTF, BAU, STP Capital etc) for schemes within the HCP, by identifying the most relevant and advantageous delivery and funding route for each scheme. This will promote that primary care will have equal opportunity to both support wider HCP strategic ambition and access to funding.

3.24 Strive to ensure new schemes (large and small) consider design and environment that is sensitive and supportive to meet the needs of our most marginalised patient groups.


3.25 Alignment of Services and Estates. Link with clinical service strategies reviews in the shift of out of hospital to ensure the impact on primary and community care estate is quantified.

3.26 Support the development of solutions that will maximise use of space within existing healthcare premises (both those within NHS ownership or under lease arrangements with third parties) supporting At Scale and Out of Hospital service changes. This will have a number of benefits and opportunities to consider; including;

• Utilisation of unused space and reduction in void costs • Maximising opportunities through supported agreement of Co-location of

services (e.g. Therapists) - and sharing workforce • Enabling hub working • Supporting Increased training • Provide physical capacity for increasing and changing workforce.

3.27 We await changes to the national (GMS premise Cost Directions) to enable capital

grants to certain GP premise new build schemes (not currently allowed).

Technology 3.28 Our work is underpinned and supported by technology. As is experienced in everyday

life, technology is transforming the way people receive and use services, and the way that services and organisations connect with each other to improve joined up working. This component of the strategy sets out the vision for the digital transformation of primary care across West Yorkshire and Harrogate.

3.29 In order to support primary care transformation we will need to deploy digital tools to support self- care management, active signposting and new types of consultations such as On line and video consultations. Access to more convenient forms of consultation will reduce the demand on general practice as well as supporting more flexible working arrangements, impacting positively on GP retention plans.

3.30 Digital technology is a way to extend and enhance care, support clinicians and other staff to deliver care more effectively. This will not only enable clinicians to release more time for more complex care, but also give patients and carers more options on accessing healthcare.

3.31 Our approach is based on the 'anytime, anywhere, any place' philosophy. This will allow health and care professionals to work across public sector buildings and ensure that patients have equitable opportunity to make best use of new technology to enhance service provision and experience.


3.32 NHS England's Long -Term Plan sets out significant plans for investment to upgrade technology and digitally enabled care across the NHS. This includes enabling an NHS system:

• Where digital access to services is widespread • Where patients and their carers can better manage their health and condition • Where clinicians can access and interact with patient records and care plans

wherever they are, with ready access to decision support and AI, and without the administrative hassle of today

• Where predictive techniques support local Integrated Care Systems to plan and optimise care for their populations

• Where secure linked clinical, genomic and other data support new medical breakthroughs and consistent quality of care.

3.33 In tandem NHS England's framework for GP contract reform places great emphasis

and investment to enable GP practices and patients benefit from digital technologies.

3.34 We have seen national substantial capital investment through the GPFV funding and that has enabled improvements to the primary care digital infrastructure.

3.35 In West Yorkshire and Harrogate we aim to transform primary and community care by ensuring these new investments are secured to deliver the required changes locally to enable best use of technology. This will enhance the provision of healthcare services, improve the health of our population and support our GP practices to provide the best care that they can 'at scale' by utilising the most appropriate technology and digital tools.

3.36 We recognise that delivery and effective use of digital approaches does not require a set of metrics but is much more about changing heart and behaviours to embrace new ways of working for both patients and our workforce.

GPIT Operating Model- securing excellence in GP IT Services 16/18; 18/19 addendum7

3.37 NHS England is accountable for the delivery of GP IT services, delegating responsibility for delivering key elements of GP IT services to clinical commissioning groups (CCGs). The model seeks to establish a vision and aims:

• To provide an equitable and appropriate finance model that supports a best value Information Technology service for, or on behalf of, all GP practices

• Provides GPs with the funding they need to secure appropriate support for the operation of these systems within each practice

7 National Health Service England (2018) 2018/19 Addendum to the GP IT Operating Model. Available [online] https://www.england.nhs.uk/digitaltechnology/digital-primary-care/addendum-gp-it-operating-model/ [25/06/2019

https://www.england.nhs.uk/digitaltechnology/digital-primary-care/addendum-gp-it-operating-model/


• A Digital Primary Care Strategy that sets out a vision for the role of technology for GP IT

• Choice of systems to GP practices that will evolve, ensuring systems that are capable of supporting that vision

• Adherence to GMS contract obligations in respect of information systems.

3.38 A revised version of the Model is awaiting and due to be published in 2019.

Digital first primary care

3.39 In the Long Term Plan "Implement digitally-enabled primary and outpatient care" is one of the five major, practical, changes to the NHS service model to meet the challenges facing health systems.

3.40 The Long Term Plan also commits that every patient will have the right to be offered digital-first primary care by 2023/24.

3.41 Primary care is increasingly under pressure from rising demand, complexity and expectations. Primary care needs to be transformed to provide the right environment not just for our workforce, but in order for patients to receive the quality care that they need.

3.42 The digital first primary care programme is vital to both support and lead this fundamental change. Key points to note:

• Significant national funding stream - c£450m over five years (19/20 is year 1) • Aim is to deliver integrated digital primary care at a health system level and

deliver digital GP Contract commitments • Health System (ICS/STP) should be driving strategy and service design • One programme across NHS England and NHS Improvement, NHSX and NHS

Digital to deliver digital primary care, under the umbrella of 'digital first' • Regional delivery model - regional teams to work with ICSs/STPs/CCGs to enable

delivery • Learning model - health systems to share learning and experience.


Figure 4. The vision for digital first primary care

3.43 What can patients expect?

• The use of digital channels will be at the choice of the individual patient, with those who can't or don't wish to use digital tools still able to access services over the phone or in person

• Patients should be able to easily access advice, support and treatment from primary care using digital and online tools

• These tools should be integrated to provide a streamlined experience for patients, and direct them to the right digital or in-person service for their needs

• In practical terms, patients should be able to use online tools to access all primary care services, such as receiving advice, booking appointments, having a consultation with a healthcare professional, receiving a referral, obtaining a prescription etc.


Figure 5. The digital first patient journey.


3.44 Single HCP plan for enabling Online Consultation capability for every practice across 2019/2020 and 2020/2021. WYH HCP has worked collaboratively in procuring online consultation solutions for all our GP practices with planned roll-out throughout 2019/2020. The WY&H project team support the enablement and the delivery of online consultations.

3.45 Each CCG has developed a Local Digital Roadmap setting out how they will achieve the ambition of Paper-free at the Point of Care by 2020.

3.46 Through the national Estates, Technology and Transformation Fund (ETTF) WY&H HCP has supported several primary care digital transformation schemes such as the unified communication system in Leeds.

3.47 We have successfully become 1 of 5 national exemplar areas known as a LHCRE [local health and care record exemplar], based upon the experience and technologies already used locally within the WY&H HCP. This will provide a major boost to our strategy to join up health and care information for improved direct care across our 'places'. It will also allow us to pursue a 'person held record' for our population and forms the foundation for joining up data to help us better manage the health and care provision for our populations.

3.48 We have delivered primary care technology improvements that have improved access to services and general practice workload.

3.49 We have seen Leeds Digital Achievement 2017/2018 schemes progress .

https://www.wyhpartnership.co.uk/application/files/9915/2415/4305/Leeds_Digital_Achievements_2017-18_INTERACTIVE.pdf


3.50 £24m investment secured to focus on digital transformation projects.

3.51 The regional Digital Technology team in collaboration with the national Health System Led Investment programme and regional ICS digital leads have recently completed the funding agreement process for significant investment in digital transformation. This work has enabled £24 million to be invested into 66 digital projects across 40 providers in 2018/2019. This will focus on the digitisation of secondary care providers and information sharing to support direct patient care.


3.52 Deliver on the digital and technology priorities that will provide improved accessibility to enable self-care and easy equitable access to clinical and non-clinical care and support.

3.53 Encourage organisations across the HCP working together to develop business cases (i.e. 'do once') to support progression of our wider objectives for GP practices working at scale.

3.54 Pool resources wherever appropriate (working together).

3.55 Demonstrate from baselines improvements in digital forms of access in primary care.

3.56 Promote locally the use of the NHS App.

3.57 In 2019/2020 all our GP practices will be fully enabled to provide NHS app capabilities to their patients by 31 July 2019; although user uptake is not prioritised in this initial phase.

3.58 We will use every opportunity to promote the use of technology for both clinicians and patients.

3.59 Continue to support the existing LHCRE (Local Health and Care Record Exemplars) project across Yorkshire and Humber to ensure other relevant primary care providers (e.g. community pharmacy) to improve access to patient records.

3.60 We will work collaboratively with the WY&H Digital Programme to support digital and technology enhancements that will enable improved access, quality of care and choice.

49 | 4. Investment

4. Investment

“Working in partnership across West Yorkshire and Harrogate we aim to invest in opportunities to deliver at scale system initiatives to close the gaps identified in the 5 Year Forward View” Working in partnership, investing in opportunities and making the best use of our point to deliver the ambitions outlined in this strategy. 4.1 Working in partnership across WY&H we aim to invest in opportunities to deliver at

scale system initiatives to close the three gaps identified in the 5 Year Forward View (i.e. health and wellbeing; care and quality; finance and efficiency) and deliver the commitments set out in the NHS LTP through the five-year framework for the GP services contract: - Investment and Evolution.

4.2 A detailed, costed package of investment and reform for primary care is set out in the NHS LTP and GP Contract Reform from now through to 2024. These reforms will be backed by a new guarantee that over the next five years, investment in primary medical and community services will grow faster than the overall NHS budget. This commitment creates a ringfenced local fund worth at least an extra £4.5 billion a year in real terms by 2023/2024. The £4.5 billion new investment will fund expanded community multidisciplinary teams aligned with new PCNs based on neighbouring GP practices that work together typically covering networks of 30-50,000 people.

GP five year contract arrangement

4.3 The national agreement translates commitments in The NHS LTP into a five-year framework for the GP services contract. The agreement has a number of overarching aims:

• Secure and guarantee the necessary extra investment • Make practical changes to help solve the big challenges facing general practice,

not least workforce and workload • Deliver the expansion in services and improvements in care quality and outcomes

set out in The NHS LTP, phased over a realistic timeframe • Ensure and show value for money for taxpayers and the rest of the NHS, bearing

in mind the scale of investment. 4.4 The requirements placed upon the system to enable delivery of the commitments in

the NHS LTP and the implementation of the Network Contract Directed Enhanced Service (DES) pose a significant challenge to the primary care system and all its participants. A revised set of Clinical Commissioning Groups (CCGs) allocations have been published which both demonstrates the NHS' intention to continue to invest heavily in Primary Care Services and to take the investment in Primary Care beyond

50 | 4. Investment

the levels originally detailed in the GP Forward View. However, funding the GP contract reforms are higher than anticipated by CCGs (such as the establishment of the national state-backed clinical negligence scheme for general practice), impacting on opportunities to support further PCN and transformation investment, including recurrent resource that will be required to support the estate and digital transformation.

4.5 In support of PCNs, commissioners in accordance with the GP Contract reform must also invest £1.50 per patient. The contract DES details specific funding for the five additional workforce roles with the discretion of CCGs or PCNs to top this up. CCGs may also add local investment through the Supplementary Network Services.

4.6 It is recognised that delivering the commitment in the LTP will take additional local investment in primary care from commissioners and providers across the WY&H system and so there is a need to understand commissioner future investment plans, so we can explore opportunities for HCP investment support to deliver system transformation.

4.7 HCP additional investment will be considered subject to;

• CCG's invest in full 100% of their Delegated Co-Commissioning allocations on Primary Medical Care Services

• CCG's invest in full 100% of any allocation received for GPFV in accordance with the National Directives pertaining to those allocations

• CCG's invest on a recurrent basis £1.50 per head of population from their Core Allocations in accordance with the planning guidance for PCNs

• CCG's maintain their existing investment in Primary Care and where financially viable invest further in Primary Care using CCG Core Allocations

• CCG's collectively agree to pool resources when and where appropriate across WY&H.

4.8 As part of NHS England's new operating model, increasingly more responsibility and

ability to take decisions locally, will sit at HCP level. Primary Care General Practice Forward View (GPFV) Transformation funding will from 2019/2020 flow directly to the HCP for four specified programmes enabling the HCP and commissioners to decide collectively how best to deploy funds for maximum benefit. When appropriate to do so we will consider pooling budgets and investment opportunities if this would enable at scale at system level.

4.9 Investment to date in primary care has primarily been through nationally allocated funds to support transformation. Examples are; GPFV, the GP Contract reform, Pharmacy Integration Fund (PhIF).

4.10 CCGs across WY&H have been successful in securing funding from the national primary care Estates, Technology and Transformation Fund (ETTF) in support

51 | 4. Investment

transformational projects for digital and GP premises improvement schemes. (See further information in Component 4 - Improving estates and technology)

4.11 In addition, CCG commissioners have invested additional monies (e.g. reinvestment of PMS premium, or other CCG resources) in developing local commissioned schemes to support transformation. Examples of such schemes (not exhaustive) include:

• Standard access • Bundle of services (e.g. diagnostics, shared care, treatment) • Enhanced primary care • Winter pressures • Primary Care Gynaecology Services • Care Homes Primary Care • Polypharmacy • Quality improvement • Individual and organisational development • Self care champions.

Investment and impact fund

4.12 A major national network Investment and Impact Fund will start in 2020 as a means of supporting Integrated Care System delivery of The NHS Long Term Plan, with funding rising from £75 million in 2020/21, to a minimum expected £300 million in 2023/24. The purpose of the Investment and Impact Fund is to help PCNs plan and achieve better performance against metrics in the network dashboard. Part of the Fund on wider NHS utilisation will be dedicated to The NHS Long Term Plan commitment to the principle of ‘shared savings’.

System wide investment in primary care

• In 2017/2018 WY&H HCP have invested £5.2m, to develop and accelerate PCNs. • Transformation funding supporting new workforce roles • Transformation funding to support Population Health Management for PCNs • Additional funds have been invested for workforce initiatives from the Local

Workforce Advisory Board and Health Education England. • Funding to develop Community Pharmacy involvement in PCNs. • Investment to support running collaborative events between NHSE and LPC on

GPFV and understanding wider context of primary care for Community Pharmacy.


4.13 We have invested significantly in PCN development.

52 | 4. Investment

4.14 We have pump-primed workforce initiatives from example; Physician Associates in General Practice.

4.15 We have worked with WY&H CCGs to agree common principles for PMS/GMS equitable funding and reinvestment.

4.16 Working with other WY&H HCP programmes and commissioners encouraged pooling of capacity and resources where appropriate to do.

4.17 CCGs pump priming initiatives that will enable system wide delivery and transformation.

4.18 Pooling of GPFV funding for GP Retentions and Resilience to deliver At Scale initiatives.


4.19 Explore potential investment opportunities to support strategy implementation.

4.20 Encourage organisations across the WY&H HCP working together to develop business cases (i.e. 'do once') to support progression of our wider objectives for practices working at scale.

4.21 We will ensure a robust baseline and capture system and local investment to demonstrate the commitments detailed in the NHS LTP and the GP contract Reform are delivered.

4.22 Ensure we use various enabling funds to support transformation subject to agreed principles.

4.23 Pool resources wherever appropriate (working together) - an example of this can already been seen with WY&H CCGs working together to develop a single plan for enabling Online Consultation capability for every practice across 2019/2020 and 2020/2021.

4.24 We will through robust prioritisation and evaluation make better use of capital investments to drive transformation (e.g. Estates and digital workstreams) and ensure effective use of resource.

53 | 5. Access and resilience

5. Access and resilience

“Patients will be able to manage their health and illness, with appropriate support from a range of community resources. Patients and their carers will have easier access into the healthcare system giving them more control of their health and wellbeing” Drawing on opportunities for maximising a consistent equitable offer to patients, reduced unwarranted variation, improved patient experience with joined up quality care through integrated team and digital approaches. 5.1 We want people in WY&H to have responsive, fair and equitable access to primary

and community care services. Our aim is to make it easier for all patients to access more convenient services based on their health need and preferences. Patients will be given increased choice about how and where to access services both in and out of hours.

5.2 Patients will have improved resilience and self-sufficiency to manage their health and illness, with appropriate support from a range of community resources, enabling patients and their carers to have more control of their health and wellbeing and be fully engaged with decisions made about their health.

5.3 Access to more convenient services is integral to the transformation of general practice, enabling self-care with direct access to other services, better use of the wider workforce, greater use of technology and working at scale across practices to shape capacity. Access to appointments was the single most mentioned theme in our Healthwatch Report published in June 2019 with 18% or respondents citing access as the biggest thing the NHS could do different to help support them to stay well and healthy. People want the option of longer appointments, more appointments outside working hours, more appointments available to book online (including same-day appointments) as well as more availability of virtual and telephone appointments.

5.4 In WY&H we have been able to build on the learning and successes of the National Access Fund as well as the acceleration sites in Leeds, Wakefield and Harrogate, which enabled many of our patients to access more timely and convenient care and accelerate the achievement of the national expectations for extended access in primary care.

5.5 Since October 2018, 100% of our population have been able to access GP services on evenings and weekends culminating in over 137,000 additional appointments being made available to patients in General practice since that time. In 2018/2019 £11.5m of national funding was invested in Primary Care to Improve Access. Although we compare favourably with national satisfaction rates, locally there remains considerable variation in terms of experience in accessing services and in some areas in West Yorkshire and Harrogate poor patient satisfaction rates with choice and waiting times for an appointment. We know there is still much work to do with


commissioners and providers to ensure that patients are aware and consistently offered appointments in and outside of normal hours and to ensure that the range and type of appointments reflect the needs of patients.

Figure 6. GP Patient Survey Results 2018/2019

5.6 The wide variety of access points into the system does present confusion and challenge, for example; "In hours" GP, "Out of Hours" GP, extended access hubs, 111, Urgent Treatment Centres, A&E, means patients can struggle to understand what services to access, how and where.

5.7 Data, local intelligence and patient feedback suggests;

• Patient feedback continues to identify inequalities in accessing services and that hard to reach groups particularly continue to struggle to access services in a timely manner

• Urgent and emergency care is too often relied on because other services are not there or responsive to patient needs. A significant proportion of activity carried out in A&E or out of hours primary care setting is often of a routine nature and could be managed more appropriately in a different setting

• Approximately 40% of activity carried out in general practice does not always require GP intervention. GPs say that the proportion of time they spend dealing with non-health issues Is increasing and this affects their workload and quality of life. Self Care and Prevention work can support General Practice to deal with some of this demand with solutions like social prescribing - signposting patients


to more appropriate services and interventions that can more effectively deal with their needs.

5.8 Whist we know there are many reasons for this, including patient knowledge and

behaviour, primary care workload and workforce issues, we believe that a number of interventions for example; patients accessing services through one single point, would have a positive impact. The ability to direct book patients into services both in and out of hours will streamline access points ensuring less interaction with a range of services, improving patient experience and satisfaction levels.

Health inequalities

5.9 Patient feedback shows that hard to reach groups particularly continue to struggle to access services in a timely manner; this was highlighted by work undertaken by the West Yorkshire and Harrogate Local Eye Health Network (LEHN) and which resulted in the introduction of an eye health service for people who are homeless in Leeds. Information about this service can be found under component 6 dental, community pharmacy and eye health and also in the WY&H Healthwatch report recently published. Engagement with local Healthwatch groups will further help us understand how we can ensure the views of our patients are known and addressed in our plans.

5.10 Identifying issues of inequalities is a key priority for the NHS and is also highlighted as one of the seven core requirements for implementing improved access in primary care (NHS Operational Planning and Contracting Guidance 2017/2019). We will work with primary care and PCNs to ensure issues of inequalities in patients' experience of accessing general practice is improved by implementation of actions plans where population health requires and local equality impact assessments have identified actions are required.

The role of primary care in reducing pressure on urgent and emergency care services

5.11 A key priority for the partnership is to transform the urgent and emergency care system, including integrated primary care models, to ensure timely care in the most appropriate setting.

5.12 The NHS Long Term Plan envisages PCNs joining up the delivery of urgent care in the community. To support this, funding and responsibility for providing the current CCG-commissioned enhanced access services transfers to PCNs through the Network Contract DES by April 2021 at the latest. Following an Access Review in 2019, a more coherent set of access arrangements will start being implemented in 2020. It is


expected that PCNs will be tasked with implementing a single coherent access offer for both physical and digital services which will deliver convenient appointments 'in hours', reduced duplication and better integration between settings such as 111, urgent treatment centres and general practice.

5.13 PCNs will be expected to work with community provider partners in identifying those most at risk of hospital admission and will proactively put in place plans to manage the particular issues identified; this will be far and wide reaching to include ill health, social care needs and determinants wider than health such as housing and debt. 2 out of the 4 strategic priorities for community health services, outlined in the LTP requires a joint enterprise between community services and GP practices as part of PCN delivery. The framework to support this is through the national services specifications for enhanced health in care homes and anticipatory Care.

5.14 The NHSE new care model - enhanced health in care homes framework is being rolled out and the framework aims to maximise benefits of existing works to improve the quality and safety of care for residents living in care homes. Many of these elements will support hospital avoidance.

5.15 Through the national Impact and Investment Fund (IIF), PCNS will have the opportunity for additional funding to support wider system resilience including addressing inappropriate A&E attendances.

Focus on: Greater Huddersfield Integrated Partnership The Out of Hours Provider and the local GP Federation are working in partnership to provide a more integrated delivery model for the provision of Extended Access and Urgent and Emergency Care. The model is hub provision at Huddersfield Royal Infirmary, clinics at two physiotherapy locations with a number of GP practices acting at satellites. The service commenced in March 2018, initially providing GP appointments at the central hub and a variety of appointment types at the satellite sites including Practice Nurse, Health Care Assistant, Clinical Pharmacy and Advanced Nurse Practitioner appointments alongside GP appointments. The hub service has since expanded and now includes physiotherapy and phlebotomy appointments. This model supports an integrated workforce and service delivery model. Utilisation rates are consistently high, with monthly utilisation rates ranging from 80-100%. The obvious advantage of the close partnership working with the local Out of Hours provider is that the hub GP appointments are fully open and directly bookable by the out of hours provider and NHS111, enabling the wider healthcare system to appropriately support patients to access the system at the most appropriate point. The service was evaluated by HealthWatch in October 2018 and a further survey was undertaken by the providers in April 2019. Findings from both surveys show that the service is highly valued by patients.


Opportunities: improving access, workload and workforce

5.16 The new GP Contract (from 2020/2021) provides the platform through PCNs for a more integrated approach to provision of Primary Care Services, improving patient access and ensuring patients are seen by the most appropriate clinician in the most convenient place, regardless of day or time. Aligning extended access into the wider urgent care system will support the system to continue to meet the needs of the local population whilst enabling partners to deliver a service that meets the needs of the most vulnerable patients in our community.

5.17 We will support our networks in their increasing role in the delivery of access to GP services across WY&H. This will be embedded through the results of any local and the national access review and how PCNs integrate into the wider system. Nationally we expect our PCNs to have access to a 'shared saving' scheme (Impact Assessment fund) which will incentivise how providers work together to enable better and more appropriate access for patients.

5.18 We recognise that many of the challenges surrounding access to services is generally a result of workforce, workload and resilience in our systems. For GPs to diagnose earlier and to manage complex disease including multi-morbidity, they need to spend more time with patients. This will require longer consultations and increased support from a wider clinical and administrative team working differently with a range of appropriate interventions.

5.19 Through PCNs it is envisaged that;

• Access will be more specifically focussed to address population needs • Improved integration enabling wider health, social care and Voluntary services to

deliver holistic, proactive personalised care • Supporting left shift through encouraging patients to self-care when appropriate

and when required access services in a different way. This shift will free up important hours for clinicians to manage more complex issues thus improving the quality of primary and community care and long-term condition management

• The additional workforce role reimbursement scheme introduced as part of the GP Contract Framework will support workforce, workload burden, greatly enhancing skill mix and integrated working in primary and community care.

High impact changes in general practice

5.20 The General Practice Development Programme (GPDP)8 was established as part of the GP Forward View to spread the best innovations, helping all practices use the 10

8 National Health Service England (2016) General Practice Development Programme. Available [online] https://www.england.nhs.uk/gp/gpfv/redesign/gpdp/ [25/06/2019]

https://www.england.nhs.uk/gp/gpfv/redesign/gpdp/


High Impact Actions9 to release capacity in general practice. The 10 High Impact Actions are a collection of ways to improve workload and improve care through working smarter, not harder. Implementing actions such as; Active signposting, social prescribing, developing the team and Quality Improvement has shown to have a positive impact. Examples in our local areas include;

o West Wakefield’s active signposting initiative which is designed to connect patients more directly with the most appropriate source of help or advice. An accredited online training course was created in line with the Health Education England Competency Framework for Care Navigation (published in 2016)

o Calderdale’s focus on Productive Workflow resulted in a Correspondence Management protocol. Training was rolled out to all GP practices following a 90% reduction in correspondence received by GPs in a successful trial of the Correspondence Management protocol

Digital approaches

5.21 We know that more and more patients are choosing to access care more conveniently through digital solutions. Patients being able to access their own records can be very empowering. Informed, engaged patients tend to manage their health more effectively, and are involved in joint decision-making about their care.

9 National Health Service England (2016) General Practice Development Programme: Releasing Time to Care: Ten High Impact Actions. Available [online] https://www.england.nhs.uk/gp/gpfv/redesign/gpdp/ [25/06/2019]

https://www.england.nhs.uk/gp/gpfv/redesign/gpdp/


5.22 Progressing digital approaches will greatly enhance the way patients and clinicians interact with services, bringing about improved access and experience, a positive impact in practice workload, care closer to home, and better utilisation of the primary care estate. We will improve access for patients ensuring that practice and PCNs consistently review, adapt and deliver the national initiatives that will improve patient choice and facilitate greater more convenient access to service through;

Access to online consultations • Patients to have online access to their full record • All GP practices offering and promoting electronic ordering of repeat prescriptions •

and using electronic repeat dispensing All GP practices will ensure at least 25% of appointments are available for online •

booking by July 2019 A roll out the NHS App which for many patients will become the normal 'gateway' to •

access many services.

Focus on: Social determinants of health in primary care The Living Well programme is a part of North Yorkshire County Council and was set up initially as community-based provision in 2015 targeted towards people on the cusp of health and social care. The aim of the service is to prevent, reduce and delay the need for higher-level services to be involved in people’s lives, helping people to live as independently as possible for as long as possible. In 2017/18, the CCG worked with the Living Well team to bring appointments into primary care settings to enable closer working with primary care teams and to enable more preventative interventions by engaging with people further ‘upstream’. Appointments are directly bookable by GP practices and offer an initial appointment of up to one hour. An appointment being offered within GP a practice enable trust to be developed and ensures that people are ready to engage more effectively with the service and have already identified some of the needs of support. This has encouraged openness and a trust has already been built after spending time with the LWC at a GP practice and then sees the same coordinator for the ongoing support. Living Well Coordinators have developed excellent relationships with community and voluntary groups. They help people to connect with the groups, working with people to increase confidence in accessing these groups by offering physical and emotional support. The team will continue to work with primary care teams, linking with PCNs and the CCG to ensure patients receive appropriate support.


5.23 Our approach to using technology to support transformed care and service delivery is described in more detail in Section 3.

System progress – where we are now

5.24 Every patient in WY&H has the option of an Extended Access appointment if required including evenings, weekends and bank holidays.

5.25 111 Direct booking enabled in 23% of Extended Access hubs with a trajectory of 100% to be enabled by March 2020.

5.26 We have through the NHS England Clinical Pharmacy Pilot tested the potential for Clinical Pharmacists to reduce workload in General Practice

5.27 Care Navigation delivered in every practice.

5.28 Development of different access models for example;

The "virtual" service in Leeds provides access to MSK, pharmacy and mental health •appointments by telephone only

Population health management approach in Bradford sees patients being able to •access more than traditional primary care services in "extended hours" as well as "in hours". The voluntary and community sector (VCS) support patients in practice to manage their wider health care by providing mental health services.

5.29 Through the national Estates, Technology and Transformation Fund (ETTF) WY&H HCP has supported several primary care digital transformation schemes such and the unified communication system in Leeds.

5.30 We have successfully become 1 of 5 national exemplar areas known as a LHCRE (local health and care record exemplar), based upon the experience and technologies already used locally within the WY&H HCP.

5.31 WY&H are piloting e-Referral Service (eRS) roll out in ophthalmology where community optometrists will be able to refer directly into hospital eye services where required, impacting positively on workload for GP Practices.

5.32 Single WY&H HCP plan for enabling Online Consultation capability for every practice across 2019/2020 and 2020/2021.

System actions – what we will do

5.33 We will support the wider system by ensuring that Providers including PCNs enable improved choice and options for patients; including;

• On line and skype consultations


• Online access to appointment booking and medical records.

5.34 We will work with partners within the system and across the HCP programmes to align the offer to patients to enable a streamlined access point, making the best use of one workforce.

5.35 Identify PCNs who would benefit from support to accelerate digital access approaches to enable choice, self -care and improve access across all Contractor groups and Community Care.

5.36 We will support an increase in utilisation of appointments in Extended Access hubs by ensuring messages continue to be communicated through the front end of primary care and that services and locations are appropriately reflected on the Directory of Services. We will develop appropriate HCP communications and local messages to educate patients around the improved offer and the appropriate pathways.

5.37 Work collaboratively to support the delivery of the HCP plan to enable online consultations by March 2020.

5.38 Roll out direct booking using GP Connect. The project will continue to ensure every eligible service is configured and live with direct booking from NHS 111 by March 2020. GP Connect will be piloted with one area and then rolled out across the WY&H footprint, coordinated by the Urgent and Emergency Care (UEC) programme but in partnership with the Primary and Community Care programme.

5.39 We will share innovation and spread best practice by showcasing examples of high impact actions including digital and continuously reviewing and highlighting areas of excellence.

5.40 Accelerate a WY&H Access Review, taking steps to map activity across all access pathways including, core and out of hours, Urgent and Emergency Care, utilisation of Extended Access to uncover opportunities for improved integration, increasing capacity and demand and reducing unwarranted variation.

5.41 Agree a robust process for measuring and acting on patient satisfaction outcomes, identifying areas for improvement and focus at a system level.

5.42 We shall consider the findings of the national access review and progress the actions we need to take following publication of the review, which is expected in late 2019.


6 Dental, community pharmacy and eye health

Working collaboratively, recognising the important contribution of community pharmacy, dental and optical in delivering urgent and planned care. Drawing on leadership and support from all primary care contractors and their professional bodies to maximise opportunities to improve patient care and delivery specific priorities for the PCN population. “Development of the Local Professional Network (LPNs) for dentistry, pharmacy and eye health, to provide clinical leadership working with key stakeholders/partners on the development and delivery of priorities”

6.1 In 2012 securing Excellence in Primary Care committed to the development of the

Local Professional Network (LPNs) for dentistry, pharmacy and eye health, to provide local clinical leadership working with key stakeholders/partners on the development and delivery of local priorities to deliver the National Strategy and Policy.

6.2 NHS England is responsible for the direct commissioning of dental, community pharmacy and optometry services across WY&H. The development of LPNs in these areas have helped to ensure that there is collaboration and a forum available to discuss service developments.

6.3 We recognise the importance of collaborative working between medical, social care and the voluntary sector to achieve improved health outcomes. We believe there is also potential for further improvements.

Dental 6.4 NHS England has responsibility for commissioning of the full dental pathway

including primary care general dental services, community dental services (CDS), urgent dental care (UDC) services and hospital based secondary care services.

6.5 Local Authorities hold the responsibility for oral health improvement and are required to provide or commission oral health improvement programmes to improve the health of the local population, to the extent that they consider appropriate in their areas.

6.6 This section will highlight the opportunities that partnership working in a PCNs could support by integrating dental and oral health services with wider primary care systems, such as; working in PCNs and emergency care systems. It is recognised that linking to wider health and social care provision where appropriate will contribute towards improving oral health. For example; Oral health factors that impact on other


healthcare related issues will benefit from greater integration of dental services with the rest of the healthcare system. For example, stabilising periodontal disease in diabetic patients will cause a reduction in glycaemic levels in patients. With this scenario it is easy to see how the diabetes pathway will benefit from sharing good oral health advice and guidance with clinicians involved in the care of diabetic patients and ensuring there is dental access for diabetic patients.

6.7 Good oral health contributes towards a persons health and well-being.

6.8 Dental commissioning for WY&H is undertaken by a Yorkshire and Humber (Y&H) Dental Commissioning team. This has enabled more flexibility in terms of transferring resource to areas that are more in need. To provide primary dental care through the NHS, a contract holder operates through either a General Dental Services (GDS) or Personal Dental Services (PDS) contract.

6.9 We know that access to primary care dental services in WY&H is variable. Areas of high demand, generally in more deprived areas of WY&H continue to pose a challenge and patients are struggling to access primary care dental services. We are seeing a growing number of people who are seeking advice from their medical practitioner or attending accident and emergency departments for oral health related conditions.

Challenges

6.10 All funding is usually committed to existing contracts so there is little opportunity to use recurrent funds more flexibly within primary care. The current contract does not enable a focus on improving and maintaining an individual’s oral health as it provides little incentive for prevention. The contract also lacks incentive for the implementation of skill mix for service provision and development.

6.11 Access/inequalities: Legacy arrangements mean that there is inequitable access to services, both in terms of capacity in primary care and in terms of complex and inconsistent pathways in urgent dental care, community dental services and secondary care.

6.12 Legacy arrangements with funding tied into in perpetuity contracts, restricts commissioners’ abilities to commission on a need basis. There are areas within Y&H, where contracted UDAs are low or where the population do not wish to access dentistry regularly.

6.13 Primary care national contract: rolled out in 2006, this is held by General Dental Practices (GDP) in perpetuity (subject to any performance concerns), with little flexibility for either the commissioner or the provider. The current General Dental Services (GDS) contract, based and measured in Units of Dental Activity (UDA), does not focus on improving and maintaining an individual’s oral health as it provides little incentive for prevention, despite widely accepted national guidance for delivery of preventive advice by dental services. The contract also lacks incentive for the


implementation of skill mix within the dental team for service provision and development, which is further challenged locally by inequity in workforce numbers and skills across Y&H. Commissioners are also restricted in that the budget allocated for primary care dental services is fully committed and therefore there is no scope to permanently rebase contracts.

6.14 Workforce: the challenges of finding and retaining a workforce with the skills and experience to support the dentistry pathway is similar to other parts of the primary care system and is becoming increasingly challenging; posing a significant impact on providers’ abilities to deliver services, particularly in terms of recruitment and retention. Some of the areas with the greatest workforce shortages are those with high dental needs.

Current provision

There are 270 contracts for primary care services in West Yorkshire (there are circa •650 across Y&H as a whole).

There are approximately 3,881,551 UDA contracted for with West Yorkshire based •GDPs.

Primary care dental contracts total £117m each year. • At the end of the 2017/18 year, the average delivery (of each contractor) of the UDAs •

noted above was 95.9%. The average UDA rate (£) in WY is higher than the Y&H average. •

6.15 We recognise the importance of strengthening the working relationship between dental and other partners working in our neighbourhoods to maximise on opportunities to provide more efficient care for people and to improve patient health and experience.

6.16 There are already in place Dental Commissioning principles that outline proposals for how YandH will approach future commissioning.


Commissioning intentions

6.17 NHS England's (Y&H) key commissioning intention is that patients should have access to a regular dentist. The over-arching aims for dental services are to:

Improve oral health and to reduce inequalities in health and well-being • Improve local access to NHS dental services and to improve the experience of all •

patients Develop integrated and consistent services •


Ensure equitable and timely access to primary and elective care, including urgent •dental care.

Investment

6.18 The UDA per capita (above) was one of the formula used to determine areas most in need for the Access Strategy and Investment Plan. Twenty (constituency) areas were identified as being most in need, based on a formula looking at UDA rates per head, numbers of patients seen in the previous 24 months within primary care dentistry, of population and IMDB data. It was not possible to reach agreements regarding additional activity in two of the earmarked areas (in North Yorkshire and the Humber), so the investment planned for those areas was realigned to the remaining 18 constituencies.

6.19 £5m pa has been committed to this for a three-year timeline, totalling £15m over the three years.

6.20 The investment plan was to fund a maximum of an additional 20% of the local contracted activity, to increase the UDA per head of population to as close to the Y&H average of 1.72 UDA per head as possible.

6.21 Across the 18 constituencies, 100 practices across Y&H were awarded additional activity, totalling £5m per annum for three years. 55% was allocated to West Yorkshire Contractors.

Dental investment summary Table 5:

Other key local initiatives

6.22 Locally, actions have been taken to address some of the challenges and inequalities by commissioning additional activity in primary care, funded by local clawback, and taking part in national pilots. These initiatives include the following.

6.23 Locally, actions have been taken to address some of the challenges and inequalities

by commissioning additional activity in primary care, funded by local clawback, and taking part in national pilots. These initiatives include the following.

Number of constituencies highlighted as being ‘most in need’ 9

Number of practices awarded additional activity 55

Number of UDAs commissioned over the three years 289,132 Indicative number of ‘new’ patients over the three years 25,892 Indicative number of ‘new’ patients over the first year (July 18 - March 19) 20,183 Actual number of ‘new’ patients seen in the first year (July 18 – March 19) 69% of indicative (NB

– see note below) Total investment £8,182,436


6.24 In Practice Prevention ('IPP') - This pilot programme was developed in response to the Oral Health Needs Assessment event in 2015, where prevention was identified as the main priority in parts of North Yorkshire and the Humber. Targeted at children with dental decay in areas with 'higher than average' dental disease rates. IPP uses a team approach to prevention delivery using trained Dental Care Practitioners (DCPs) to deliver evidence based, patient centred prevention appointments. Over 250 DCPs have been trained in this initiative through a joint Health Education England / NHS England training programme. IPP is targeted at children (0-16 years) referred for a GA extraction, children with caries and children with risk factors based around contract reform criteria. IPP also has a universal prevention pathway for all 0-3s. This is an ongoing pilot that is being evaluated by Bangor University, local learning to date reflects the following.

6.25 Starting Well - A nationally led pilot, with the aim of reducing oral health inequalities and improving child oral health in the under-fives. Of the 13 local authority areas identified as having the greatest need, two are within Y&H: Hull and Wakefield.

6.26 Seven practices in Wakefield successfully bid to be part of the pilot project. Some of the key deliverables are designated 'Prevention Champions', displays promoting good oral health habits visible in waiting areas, engagement with local partners, integration into local dental networks and establishing locality network/relationships, training for all staff in the principles of Delivering Better Oral Health, Making Every Contact Count and basic oral health messages. An advanced practice must also adopt a setting to work with (for example a local nursey) to promote oral health and work with health professionals (for example Health visitors) to create referral/signposting opportunities.


6.27 Our aim is to ensure the integration of dental and oral health services with the wider primary care systems working in PCNs and emergency care systems ensuring benefits to patient’s oral health, also linking to wider health and social care provision where appropriate.

6.28 We are committed to the production of an oral health strategy for WY&H which will address; prevention, access , resources and integrated working.

6.29 We will encourage cooperative working arrangements with dental and medical professions through LDCs and LPNs.

6.30 The proposal is to embed within Networks or Groups of Networks a Dental, Pharmacy, Eye Health Clinical Lead who will with the WY&H footprint to develop and redesign services in partnership.


6.31 Our intention is to explore opportunities to improve oral health through a Primary Care Home model.

Community pharmacy 6.32 Community Pharmacy provides a huge opportunity to support the wider health care

system in the delivery of primacy and urgent care.

6.33 Nationally community pharmacy is being recognised as the most appropriate point of contact for patients with minor conditions and this is clinically supported by Community Pharmacy more locally through care navigation and implementation of the NHS England Over the Counter Medication Guidance10. The recent nationally led media campaign asked patients to consider using their community pharmacy before accessing Primary Medical or Urgent Care Services.

6.34 We have seen this further recognised more recently with the announcement of the new Community Pharmacy Contractual Framework which sets a clear strategic direction for Community Pharmacy as part of the wider system. The new contract embeds community pharmacy in its role for urgent care, prevention and medicines optimisation.

6.35 Whilst recognising the impact of changes to community pharmacy contract funding and some of the resulting impacts to the overall resilience of community pharmacies across the patch the delivery of an HCP wide primary care strategy will support the system in ensuring the integration of community pharmacy services. The NHS LTP recognises the potential contribution of Community Pharmacy to the wider system both as a part of primary care and urgent care service provision. In WY&H we will reflect on the LTP and consider how the role of Community Pharmacy can be maximised through urgent care, prevention and medicines safety.

6.36 We know that there are examples of work progressed in the North East which demonstrate the value of referral schemes to Community Pharmacy which are referenced as part of the NHS LTP and the new contractual framework sets out a way in which these will be implemented nationally. In WY&H we will work across our partner organisations to effectively implement the Community Pharmacist Consultation Service11 to support the urgent care system.

6.37 Community Pharmacies deliver Essential Services (dispensing medicines, repeat dispensing, promotion of health lifestyles, disposal of unwanted medicines, signposting and support for self-care). Community Pharmacies are also able to provide Advanced Services which are funded and contracted by NHS England (Medicines Use Reviews, New Medicine Service, Appliance Use Reviews, Stoma

10 National Health Service England (2018) Guidance on conditions for which over the counter items should not routinely be prescribed in primary care. Available [online] 11 Pharmaceutical Services Negotiating Committee (2019) Community Pharmacy Consultation Service. Available [online] https://psnc.org.uk/services-commissioning/advanced-services/community-pharmacist-consultation-service/ [from 29.10.19]


Appliance Customisation and NUMSAS which is currently delivered as a pilot). In WY&H it is key that the wider system is aware of the ‘core’ offer of community pharmacy and that this is linked to the development of PCNs to make effective use of Community Pharmacy as part of integrated Primary Care.

6.38 113 (as of June 2019) Community Pharmacies deliver NUMSAS (NHS Urgent Medicines Supply Advanced Service) which has built on the previous successful PURM service in WY&H. The NUMSAS in WY&H provide resilience and access for patients with an urgent need for medication and links to the UEC HCP workstream. NUMSAS has also enabled the roll out of NHS Mail across community pharmacies. The success of NUMSAS locally demonstrates the value of community pharmacy and the need to ensure this work is linked to the relevant workstreams. The success of NUMSAS will enable a platform for delivery of the new Community Pharmacist Consultation Service (which is a combination of NUMSAS and the NHS111 referral into community pharmacy for minor illness).

National deliverables

6.39 The GP Contract Document refers to the successful pilot in the North East where patients were diverted to community pharmacy from NHS 111 for management of minor ailments and urgent medication (Digital Minor Illness Referral Service – DMIRS). The announcement of the new contractual framework for community pharmacy included the intention to roll out the Community Pharmacist Consultation Service as an Advanced Service available to Community Pharmacy. The CPCS would be a combination of both the delivery of NUMSAS and DMIRS.

6.40 By April 2019 all GP practices will be offering and promoting electronic ordering of repeat prescriptions and using electronic repeat dispensing for all patients whom it is clinically appropriate. By April 2020 all community pharmacies will need to ensure they are enabled for Electronic Transfer of Prescriptions.

6.41 By June 2019 there was a requirement for100% population coverage for PCNs. It is the expectation nationally and locally to ensure that community pharmacy form part of all PCNs. The new contractual framework sets a clearer direction for community pharmacy and PCNs, as part of the new Pharmacy Quality Scheme there is a requirement to identify a community pharmacy lead within a local PCN, demonstrating a more integrated approach to the commissioning and contracting mechanisms for community pharmacy and GP practices.

6.42 We know that the community pharmacy has always provided support to the system in the prevention agenda. This has been further strengthened with the new requirement for pharmacies to be a Level 1 Healthy Living Pharmacy by April 2020. It is also expected that community pharmacies will be able to broaden their role in areas like supporting the detection of CVD, smoking cessation and Hep C testing.



6.43 In WY&H we are working to ensure that Community Pharmacists are actively engaged as part of PCNs working alongside practice-based pharmacists. There are already examples across WY&H that demonstrate the active engagement of community pharmacists as part of population health management, but it is also recognised the need to build relationships between GP practices and Community Pharmacists in some places.

• Funding secured to support Community Pharmacists with the skills required for effective engagement with PCNs delivering Population Health Management.

• Effectively supported the Urgent and Emergency Care agenda through the success of NUMSAS which has enabled the roll out of NHS Mail across community pharmacies. The success of NUMSAS locally demonstrates the value of community pharmacy and the need to ensure this work is linked to the relevant workstreams.

• Delivery of the Academic Health Science Network (AHSN) Community Discharge Projects across participating places in WY&H providing resource and capacity to deliver seamless care.

• Work is ongoing to launch a pilot of GP Referral Digital Minor Illness Services (DMIRS) in the Bradford Districts area led by Community Pharmacy West Yorkshire and the local NHS England team.

• Local Professional Committee representation at the HCP Primary Care Programme Board and WY&H Primary and Community Care Workforce Steering Group.

• Delivery of the 'Walk in my Shoes' project led by the Local Professional Committee supporting the development of closer working relationships between GP Practices and Community Pharmacies.


6.44 Development of the 'Core' offer - to raise system awareness of the core offer available as part of the provision of Essential and Advanced Services. Ensure effective use of care navigation and signposting where appropriate to clinicians and services within Community Pharmacy. The HCP will work on ensuring that the value of Community Pharmacy is recognised as a Community Asset by the system and partners.

Supporting community pharmacy in the new contractual framework

6.45 The HCP will support community pharmacy and its wider partners to effectively implement the requirements of the new community pharmacy contractual framework maximising the available opportunities.


6.46 We will continue to raise the profile of community pharmacy provision in WY&H with stakeholders and ensure we access opportunities to pilot new ways of working that arise from Pharmacy Integration Fund opportunities.

Supporting primary care networks and system integration -

6.47 Support the urgent and emergency care agenda - building on the success of the NUMSAS Pilot (currently contracted to the end of September 2019), community pharmacy can support the wider primary care and urgent care system in providing services to patients. NHS England will ensure that the bank holiday planning for community pharmacy is appropriately integrated into the place urgent care systems and that urgent care leads consider the provision of community pharmacy services in their primary and urgent care service planning.

6.48 Organisational development - led by Community Pharmacy West Yorkshire, building an effective programme for community pharmacists working as part of PCNs across WY&H. The delivery of training and development focusing on those professionals working with PCNs will enable effective engagement with community pharmacy recognising existing support provided to GP practices.

Local pharmacy network

6.49 The LPN for pharmacy in WY&H needs to align more formally to the current workstreams and forums to enable the development of community pharmacy as part of the wider healthcare systems. We will explore options for ensuring community pharmacy is integrated with PCNs through joint working with LPN and Clinical Directors.

Community pharmacy workforce

6.50 Training and development - ensure support offers through training and education organisations is offered consistently to community pharmacists and their teams to maximise integration and system leadership. Training needs analysis and workforce planning to include the community pharmacy workforce.

6.51 Community pharmacy workforce planning - the emergence of new ways of working in GP practices has placed more demand on the pharmacy profession which will need to be considered by the system both in primary and secondary care. We will explore options for supporting the mapping of the Pharmacy against current and future need including the provision of community pharmacy services. There is no current data for community pharmacy workforce in WY&H and a gap in workforce planning for the sector.


Support the digital transformation agenda

6.52 Continue and consolidate the work progressing nationally to improve digital technologies within community pharmacy aligning to the requirements of the GP contract in electronic prescribing.

6.53 Ensure that all community pharmacies have NHS mail accounts and are using these effectively to support roll out of integrated services.

6.54 Work with HCP digital colleagues to support Community Pharmacies to be part of the LHCRE (Local Health and Care Record Exemplars) project across Yorkshire and Humber.

Eye Care 6.55 The HCP will strive that patients will be able to access a consistent and integrated

Primary Eye Care Service within each PCNs across the area and that General Ophthalmic Service (GOS) has an equitable offer for patients to ensure services are accessible to all, including by hard to reach groups.

6.56 The basis of investment in primary care eye health is constrained due to GOS funding being limited to sight tests (for certain patient age groups and low income groups) and limited funding towards the costs of glasses (certain patient low income groups). The nature of GOS national frameworks and regulations provides limited scope to ensure equity of access of service provision.

6.57 To enable practices to have sustainable business models, there is often an associated reliance on private services and income in addition to NHS services offered. Many practices predominantly choose to be located in more affluent locations of high footfall such as busy high street or central town locations or retail parks and not necessarily in areas of highest need (such as deprived areas).

System progress - where we are now

6.58 Community based eye care services in primary care will be developed within each place to shift secondary care activity closer to home. Patients will be able to access a consistent and integrated Primary Eye Care Service within each PCNs across the HCP. An eye health care capacity review led by Planned Care has been undertaken to support service transformation in programmes in:

• Age related macular degeneration - NHS Calderdale CCG and NHS Greater Huddersfield CCG

• Cataracts - NHS Leeds CCG • Glaucoma - NHS Harrogate and Rural District CCG


• Diabetic retinopathy screening - NHS Bradford City, NHS Bradford District CCG and NHS Airedale, Wharfedale and Craven CCG

• Paediatric optometry - NHS North Kirklees and NHS Wakefield CCG.


6.59 Ensure patients will be able to access a consistent and integrated primary eye care service within each PCNs or established group of Networks working at scale.

6.60 Work collaboratively to ensure a consistent approach to optometric workforce challenges .

6.61 Community based eye care services in primary care will be developed within each ICS to shift secondary care activity closer to home.

Focus on: Optometry services in Leeds for homeless people Work undertaken by the West Yorkshire and Harrogate Local Eye Health Network (LEHN), led by the Chair and NHS England Optometry Advisor, identified that people who became homeless and even refugees without access to services, were missing out on eye care. For some people having no glasses means they are unable to fill in application forms and whilst in theory NHS sight testing is available to some of this group, studies show they are worried they will be charged a lot for spectacles. Our LEHN working group morphed into a group of volunteers that worked with a charity, Vision Care for Homeless People www.visioncarecharity.org to set up a regular clinic in Leeds. Vision Care for Homeless People grew out of Crisis for Christmas in London and now has 3 regular clinics in London and 4 other cities in England including Leeds. Measuring the homeless population is very difficult; counting rough sleepers does not include sofa surfers and refugees and the charities who work in this area have identified the need outstrips the supply of services and this is what this has also been seen in Leeds. Vison Care for Homeless People applied to hold a General Optometry Services (GOS) contract and have partnered with a local homeless service, St George’s Crypt https://stgeorgescrypt.org.uk who host other services for this group of people; this model mirrors those for the other areas the charity currently works in. The clinic runs every Monday in Leeds, except Bank Holidays, and the consulting room is equipped just as any other high street service is; all the staff who support the service are volunteers and more recently some of the larger optician chains and local hospital trust have supported with volunteering and optometrists. The service has been operating since July 2017 and to date over 300 people have been seen all with the goodwill of the volunteers who support the service. Around 40% of the homeless people seen are entitled to GOS services however many have too chaotic a lifestyle to apply for benefits or have had their benefits stopped; newly arrived refugees who are not yet eligible for GOS services have also been seen. The charity arranges and subsidies glasses for the remaining 60% of patients seen and also covers the costs of any repairs or replacements that might be required; several large companies provide the glasses frames, glazing for the lenses and clinical equipment which has made a real difference to both the service and the patients. Future plans include expansion of the service into other areas within West Yorkshire and Harrogate with the aim of also been able to offer more support to refugees.

https://www.visioncarecharity.org/

http://stgeorgescrypt.org.uk/


6.62 We will explore opportunities for PCNs to work more effectively with Optometry professionals contributing toward clinical pathway changes and care closer to home.

6.63 We will need to support practices to ensure they can support our wider objectives including increasing opportunity for out of hospital care.

6.64 We will in collaboration with LPNs/PCNs explore opportunities to commission services in areas of need.

74 | Delivery

Delivery

Our approach for delivery aims to overcome silo working and make connections between programmes and place. It recognises the need for work to be taken forward at a local level, to work together as a system on good practice and shared solutions and provides an opportunity to collectively shape and influence regional and national agendas and other key initiatives.

This is achieved by bringing together senior leaders of primary and community care and place representatives from across WY&H in the format of an HCP Primary and Community Service Programme board (Programme board). Programme board members oversee the programme of work and provide support and a direction of travel to achieve the vision and aims outlined in the strategy.

Complementary to this, the programme board works collaboratively with specific forums/groups.

The WY&H primary care leads (PCL) Group. The PCL Group aims to:

• Deliver the co commissioning of primary medical services, • Support NHS England and Improvement in the delivery of the commissioning

wider primary care and • Progress the delivery of the programme board’s areas of work and priorities.

The programme board is also supported in its delivery of its Workforce agenda by the WY&H primary and community care workforce steering group and six place based groups (Leeds, Airedale and Bradford, Calderdale, Harrogate, Kirklees and Wakefield).

The programme is represented on other HCP programmes such as capital and estates, digital and interoperability and urgent and emergency Care and continues to build links and rapport with the wider HCP programmes of work for example, unpaid carers programme, improving population health and personalisation and retains associate membership of other programmes such as maternity and prevention at scale.

As illustrated in Figure 6. the delivery arrangements for the primary care programme allows for place and PCNs level priorities to feed into the HCP system, where there is opportunity to make connections between places and other programmes as well as shape and influence national agendas.

Primary care (GP, pharmacy, dental, eye health services) is mainly delivered at place level, where council, NHS commissioners and care providers plan services work together to improve health and care for the patients and communities they serve. Delivery draws upon clinically led direct and delegated commissioning of primary medical care services.

75 | Delivery

It is recognised that PCNs will build on current primary care services and will allow greater provision of proactive, personalised, coordinated and more integrated health and social care. PCNs will provide a platform for wider services such as pharmacy, optometry and dentistry to improve their relationships and collectively work together to enhance delivery for the communities they serve.

Project plan and delivery plan

Successful delivery of our strategy is underpinned by robust project management tools and procedures to confidently manage and control change. This includes (although is not exclusive to):

• A delivery plan including actions, metrics and milestones for strategy implementation

• A set of established metrics and dashboard • A risk and issue log to minimise error and support escalation and learning • A forward planner for agenda’s, comprehensive minutes and action log • And, as financial implications change for the programme a finance

tracker/spending plan will be adopted.

Governance

The Primary and Community Care programme strives to maintain and deploy good quality governance and contribute to other programmes in WY&H HCP.

Business as usual is a standing item at programme board and includes noting, discussion and management of issues and risk, project and forward planning and priority workstream updates.

Risks are escalated where appropriate to the WY&H HCP via the format of a quarterly (or by exception) highlight reports into a System Oversight and Assurance Group where peer review methodology is deployed to understand progress.

PCL group will take a stronger role in oversight for GPFV delivery programmes and some primary care transformation programmes of work. PCL will make recommendations to programme board for allocation of resource for agreed priority primary care programmes.

PCL will support the programme board with an agreed set of dashboards to enable triangulation of local and regional data to ensure progress in accordance with plans.

76 | Delivery

Figure 7. Illustration of delivery arrangements and governance for WY&H Primary and Community Care Workstream.

77 | Communications and engagement

Communications and engagement

Our Primary and Community Care Services programme recognises the importance of effective communications and engagement as central to the successful delivery of the work programme.

The programme has developed a communication strategy that contains a description of the aims, means and frequency of communication to parties both internal and external to the Primary and Community Services Care Board and wider teams. It facilitates communication with stakeholders through the establishment of a controlled and bi direction flow of information.

The aims are:

• To raise awareness of the Primary Care and Community Service vision and programme of work

• To promote the benefits of working together across WY&H organisations • To ensure all partners and stakeholders of primary and community care across

WY&H have a voice • To ensure all partners and stakeholders are aware of the work and the transitions

being made • To maintain open, two way communications between Primary Care Leads Group,

board, national, regional and local partners • To ensure communications are in line with national and local priorities • To understand what people have already told making the most of existing

communication and engagement channels across WY&H HCP.

In addition to the above, the programme continues to engage with health and social care staff and the public (via place) to further develop the plans, ensuring the involvement of everyone in future conversations around proposals for change.

https://www.wyhpartnership.co.uk/engagement-and-consultation

https://www.wyhpartnership.co.uk/engagement-and-consultation

78 | Appendix 1. List of abbreviations

Appendix 1. List of abbreviations

• A&E Accident and Emergency • AHSN Academic Health Science Network • APMS Alternative Provider Medical Services • BAU Business as Usual • CCG Clinical Commissioning Group • CDS Community Dental Services • DES Direct Enhanced Service • DMIRS Digital Minor Illness Referral Service • ETTF Estates Transformation Fund • eRS e-Referral Service • GMS General Medical Services • GOS General Ophthalmic Service • GP General Practice • GPFV General Practice Forward View • GPIT General Practice Information Technology • HCP Health and Care Partnership (the West Yorkshire and Harrogate

Integrated Care System) • HEE Health Education England • IAPT Improving Access to Psychological Therapies • ICS Integrated Care System • IT Information Technology • LHCRE Local Health and Care Record Exemplar • LPN Local Professional Network • LTP Long Term Plan • LWAB Local Workforce Action Board • NAPC National Association of Primary Care • NHS E&I National Health Service England and Improvement • NHS National Health Service • NUMSAS NHS Urgent Medicine Supply Advanced Service • PCL Primary Care Leads • PCHM Primary Care Home Model • PSNC Pharmaceutical Services Negotiating Committee • PCN Primary Care Network • PhIF Pharmacy Integration Fund • PMS Personal Medical Services • PURM Pharmacy Urgent Repeat Medicine

79 | Appendix 1. List of abbreviations

• SOAG System Oversight and Assurance Group • STP Sustainable Transformation Partnership • UDC Urgent Dental Care • UEC Urgent and Emergency Care • WY&H West Yorkshire and Harrogate • YandH Yorkshire and the Humber

80 | Appendix 2. References

Appendix 2. References

• National Health Service England (2013) The National Health Service (General Medical Services Premises Costs) Directions. Available [online] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/184017/NHS__General_Medical_Services_-_Premises_Costs__Directions_2013.pdf [25/06/2019]

• National Health Service England (2016) General Practice Development Programme. Available [online] https://www.england.nhs.uk/gp/gpfv/redesign/gpdp/ [25/06/2019]

• National Health Service England (2016) General Practice Development Programme: Releasing Time to Care: Ten High Impact Actions. Available [online] https://www.england.nhs.uk/gp/gpfv/redesign/gpdp/ [25/06/2019]

• National Health Service England (2016) General Practice Forward View. Available [online] https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf [21/06/2019]

• National Health Service England (2018) 2018/19 Addendum to the GP IT Operating Model. Available [online] https://www.england.nhs.uk/digitaltechnology/digital-primary-care/addendum-gp-it-operating-model/ [25/06/2019]

• National Health Service England (2018) Guidance on conditions for which over the counter items should not routinely be prescribed in primary care. Available [online] https://www.england.nhs.uk/medicines/conditions-for-which-over-the-counter-items-should-not-routinely-be-prescribed/ [25/06/2019]

• NHS Improvement (2019) Community Services Operating Model Guidance. Available [online] https://improvement.nhs.uk/resources/community-services-operating-model-guidance/ [24/06/2019]

• National Health Service (2019) Long Term Plan. Available [online] https://www.longtermplan.nhs.uk/ [21/06/2019]

• National Health Service England (2019) A five-year framework for GP contract reform to implement The NHS Long Term Plan. Available [online] https://www.england.nhs.uk/publication/gp-contract-five-year-framework/ [21/06/2019]

• NHS England and Improvement (2019) Supporting carers in general practice: a framework of quality markers. Available [online] https://www.england.nhs.uk/publication/supporting-carers-in-general-practice-a-framework-of-quality-markers/ [26/09/2019]

Information accurate at February 2020.

For more information contact:

01924 317659

NHS Wakefield CCG White Rose House West Parade Wakefield WF1 1LT

[email protected]

www.wyhpartnership.co.uk

@WYHpartnership

Primary and Community Care Services Strategy

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