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Haringey Primary Care Strategy

Investment Plan 2013/14

1. Introduction The North Central London Primary Care Strategy was developed between August 2011 and January 2012. The strategy is set out in “Transforming the primary care landscape in North Central London” published in January 2012 and the Haringey Primary Care Development Strategy Implementation Programme (January 2013).

2. Localising the Strategy in Haringey 2.1 Haringey CCG’s Commissioning Strategic Plan (CSP) for 2013/14 – 2015/16,

highlights how Primary Care has a pivotal role to play in reducing use of secondary care for basic healthcare provision and in improving population health and acknowledges that radical change is required to improve quality, capability and productivity further, and to create capacity within primary care. In Haringey, there are currently 52 General Practices covering a registered patient population of approximately 293,000 patients (at April 2013).

2.2 One of the CCG’s key strategic aims is to create a transformation of the health economy by reducing the amount of care in hospital and increasing the provision of community-based care delivered by primary care teams. The first pre-requisites are to re-design the care pathways and to prepare the primary care teams to take on an enhanced role. The primary care strategy funding is being used to provide the additional resources required to carry out this work.

2.3 The pathway re-design projects will include a clear statement (ie specifications

and protocols) of precisely what General Practice and the wider primary care teams are expected to deliver and the resources required. The next stage is to provide the necessary education and training to equip GPs and other clinicians in practices/networks to respond to the specifications. The investment in primary care provides the resourcing opportunity for practices to choose to work together as providers of more and higher quality community-based services.

2.4 Allied to, but also in addition to the pathway re-design work, there are a number of specific QIPP projects which require pump-priming investment in order to generate subsequent returns. These are grouped under:

Admissions avoidance and Integrated Care Urgent and Unscheduled Care GP referral management

2.5 The investment in the delivery of the Primary Care Strategy is therefore an

essential enabler to facilitate this transformational change in Haringey and to create a sustainable health economy. As well as the Primary Care Strategy, the whole system transformation includes Integrated Care, Urgent Care, and the BEH (Barnet, Enfield and Haringey) Clinical Strategy. The strategic links with primary care are highlighted in the CSP “Plan on a page”

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Enable the people of Haringey to live long & healthy lives with access to safe, well co-ordinated & high quality services

• Stakeholder engagement & clinical leadership

• Implementation of key enablers i.e. primary care strategy, prescribing & organisational development

• Establishment of clinical commissioning e.g. strong leadership, wide clinical engagement, addressing authorisation conditions, CCG

collaboration

Care closer to patient’s

home

Reduced reliance on hospital

based care

Greater access to

psychological therapies

Physical health needs of

people with enduring mental

health problems improved

Integrated primary and

community care

Services delivered through

integrated models, supported

by specialist expertise & GP

clinical networks. Optimising

the use of IT

Acute care

Implementation of the BEH

Clinical Strategy and

Whittington Health ICO

Reduced use of acute

services

Improved acute productivity

System re-

configuration

Needs & drivers

for change

Significant

inequality in male

life expectancy

with CVD & cancer

as main causes

High number of

smokers

Increase in alcohol

related harm

74% of over 65s

with LTCs

Increased usage

of adult social care

High level mental

health problems

More use of A&E

than GP services

High child obesity

rates

Strategic priorities

Prevention• Implementation of the H&WB strategy

• Every child has the best start in life,

• A reduced gap in life expectancy

• Improved mental health and well being

Integrated Care

• Establishment of MDT, risk stratification & decision

management support, patient monitoring in homes

• Commissioning primary & community services to

support patients with LTC e.g. diabetes

Planned care / care closer to home

• Implement clinical pathways for alternate non-hospital

based provision in cardiology, gastroenterology,

urology, T&O

• Referral & pathway GP education/support for targeted

services

• Reduced inappropriate outpatients referrals

Mental health & learning disabilities

• Aligning plans with the local authority to ensure we

commission comprehensive, integrated &

personalised services

Urgent care

• New models of unscheduled care including UCC at

local trusts. Implementation of 111 and OOH service

Children and young people

• Meeting H&WB priorities, minimise hospital

admissions for children with disabilities and complex

health needs. Re-establishment of the full healthy

child programme(0-5)

Strategic aims

& outcomes

High quality,

valued and

responsive

services

Best use of

available

resources

Promoting

wellbeing

Reducing health

inequalities

Improving health

outcomes

Commissioning

integrated health

& social care

Delivering care

closer to home

Patient

experience &

feedback

•C

ontro

l of a

cute

over p

erfo

rmance

•Q

IPP

savin

gs u

nder d

eliv

erin

g

•T

ransitio

nal c

ost o

f change to

the h

ealth

sys

tem

•M

ain

tain

ing fin

ancia

l contro

l thro

ugh th

e

transitio

n

•E

nsurin

g q

uality

•A

bility to

imple

ment th

e re

quire

d le

vel o

f

transfo

rmatio

nal c

hang

e

•S

tability o

f local p

rovid

ers

Strategic

risks

Financial

risks

Primary Care Strategy

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3. Investment 3.1 Based on the strength of the Primary Care Strategy, North Central London

Cluster PCT secured pump priming funding of £47m over 3 years from April 2012 to March 2015. In Haringey the indicative share was set at £9.9m for that period. As part of the NHS transition from PCTs to CCGs those funds have been included in the Risk Share agreement between the five North Central London CCGs and will be subject to annual review and distribution.

3.2 In the first year of the strategy Haringey invested £1.3m. The initial plan for 2013/14 required £3.7m but the Risk Share agreement for 2013/14 has allocated £2.5m to each CCG including Haringey. An investment prioritisation exercise has been carried out to identify which projects are to be funded and the revised plan was approved by the Haringey CCG Primary Care Investment Panel on 4th July and by the North Central London CCGs on 11th July. The final list of projects is included as Appendix 1.

3.3 The strategy set out 9 investment domains to achieve transformation of primary

care: 1. Integration 2. Clinical services 3. Information technology 4. Public health 5. Premises 6. Productivity 7. Workforce, leadership and team development 8. Commissioning 9. Communications

Supported by:

Contract performance management from NHS England.

4. Progress to date and proposed investments 4.1 Domain 1 – Integration

Integration is fundamental to the transformation. The long-term aim is to overcome organisational boundaries and to replace them with networks of service delivery along care pathways. There are four identified levels of integration:

Practice to practice. Individual GP practices grouped geographically into networks of around 30,000/50,000 registered patients, coterminous with a number of London Borough wards

Extended Primary Health Care Teams attached to the GP networks providing the standard range of community services

Integration at appropriate population level (based on disease prevalence), with specialist services

Integration between health and enhanced self-care and social care. How an integrated care network might look is illustrated in the model:

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4.2 Integration - Progress to date:

Clinical leads have been appointed to provide clinical leadership within each of the 4 initial networks, which match the locality collaborative. The clinical leads are supported by 4 network coordinators. The Clinical leads and coordinators also have matrix responsibilities for leading on the other domains.

Although the network co-ordinators and clinical leads are in post, the provider networks have not yet been established in their own right. Most activity has been based on working through the existing commissioning collaboratives. The anticipated ongoing development of smaller provider networks will take time to emerge, but with the support now available it needs to happen.

The CCG’s aim of shifting care from secondary to primary settings will depend significantly on the ability of practices to maximise the opportunity. 4.3 Integration - Investment plan for 2013/14:

Having established the infrastructure to support integrated care networks, the 6 month costs in 2012/13 were £324,000, mainly in staff payroll costs. This indicates a full year investment of £650,000 in 2013/14.

4.4 Domain 2 - Clinical Services The strategy describes how the traditional model of primary care has treated

individuals in a reactive manner that has often been centred on the clinician rather than the patient and not the population.

Haringey GPs and HCCG Commissioners will be able proactively to use practice/network level public health profiles, combined with a risk stratification tool, to address the prevalence gap and any other identified issues for local

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populations. Greater use of targeted diagnostics combined with increased use of near patient testing will be an important feature.

4.5 Clinical Services - Progress to date: During 2012/13 seven projects have been developed: Primary Care Alcohol Hubs Project

- Based in four GP surgeries, HAGA’s weekly hubs offer residents from any practice, or those without a GP, alcohol specialist interventions.

Welfare Advice Hubs - Funding four pilot sites for Citizens Advice Bureau to provide advice in GP

surgeries on the new benefit system changes. Active for Life

- To increase the physical activity levels of the most inactive adults and those who have the most to gain from making such increases, namely disadvantaged people.

Healthcare BP/BMI monitors - Funding of BP/BMI monitors in 27 practices.

Clinical Pharmacy Support to Care Homes & Frail Elderly Patients - Funding for a Clinical Pharmacist to provide pharmacy services aimed at

improving the pharmaceutical care of nursing home patients and frail elderly patients on high risk medicines.

Increasing Medicines Management Support to Collaboratives - Funds two extra Medicine Management Support Pharmacists to enable

alignment of support to each of the collaboratives, thus embedding medicine management support within the networks.

Primary Care Based Counselling for Those With Alcohol and a Mental Illness 4.6 Clinical Services - Investment Plan for 2013/14

Clinical services project costs in 2012/13 were £191,000, with ongoing forward commitments into 2013/14 on existing projects of £467,000. The priorities for the year are to focus on: Support of £513,000 for:

o the development of new care pathways to move more care from secondary to primary and community services

o support for the MDT admissions avoidance and integrated care scheme for patients with long term conditions

Addressing the Prevalence Gap. Proactively seeking partnerships with local third sector/not-for-profit providers. Improvements within Primary Care clinical services will also require significant investment in training and education of the whole primary care team. This is addressed in the Workforce, leadership and team development domain.

Support for redesign projects and MDT, which when added to the ongoing projects makes the total required investment in 2013/14 of £980,000.

4.7 Domain 3 - Information Technology

IT is one of the domains which were programme-managed by NCL across the five boroughs to achieve economy and efficiency of scale. Additional capital

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funding of £5m across NCL has been made available from NCL IT to cover the majority of capital purchase costs.

4.8 IT - Progress to date: Migration of all practices to a web enabled, inter-operational technology,

based on either EMISWeb or Vision 360. It is expected all practices will have migrated by the target date of August 2013.

Text Messaging. The majority of practices have signed up to IPLATO, a SMS text messaging software. The initial focus will be to use the technology to confirm appointments and to reduce “non-attenders”. Over time the technology can also be incorporated into specific care pathways.

Additional Information Technology equipment such as document scanning and other specialist hardware and software has been offered to all practices and will be provided over the next few months.

4.9 IT - Investment Plan for 2013/14

Haringey IT priorities will be delivered by a service level agreement with the CSU: To technically enable GP Practices with web enabled clinical systems

bybuilding on the successful migrations to EMIS Web or Vision 360 systems

To develop change management projects to exploit the functionality of their web enabled clinical systems for the purposes of sharing patient data.

Implementation of the remaining GP practices without Docman and upgrading all practices with Docman 7, intellisense and EDT by August 2013

To develop plans and identify change management projects for data sharing and information governance post Aug 2013

The revenue investment of £289,000 charged to Haringey was less than the budgeted £473,000, but was supplemented by £1,000,000 of NCL capital expenditure making an in year investment of £1,289,000 on IT. The proposed investment for 2013/14 is £104,000, to cover the costs of the above service level agreement with the CSU.

4.10 Domain 4 - Public Health Profiles To enable Primary Care to proactively address the health needs of their

population, practices have been provided with Practice level profiles of public health demographic data and long term conditions prevalence.

4.11 Public Health Profiles - Progress to date

Practice profiles are being launched during July. Haringey GPs and HCCG Commissioners are now able proactively to use the profiles, combined with a risk stratification tool, to address the prevalence gap and any other identified issues for local populations.

4.12 Public Health Profiles - Investment Plan for 2013/14

There is an annual contract in place with LBI to provide an ongoing service. However, as a result of the later than anticipated launch, the investment prioritisation programme has assumed that there will be no investment required for the remainder of 2013/14.

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4.13 Domain 5 - Premises The Primary Care Strategy highlights that while the strategy will not be premises

led, the quality and suitability of premises icontributes to the delivery of high quality care and an improved patient experience. During 2012/13 this is one of the domains which were programme-managed by NCL across the five boroughs to achieve economy and efficiency of scale.

4.14 Premises - Progress to date

During 2012-13 NCL commissioned two different surveys for all practices: 6 Facet Survey. Reviewed the condition, suitability and performance of the

premises against the NHS Estate code. Many Haringey practices were surveyed in 2010, with only 7 required in this latest batch.

CQC Readiness surveys. Although the responsibility for CQC compliance rests with individual practices, the strategy has funded these surveys to give practices the opportunity to rectify non-compliant facilities.

15 bids were submitted for Improvement Grants to fund minor works during 2012, of which 11 were approved at an anticipated cost of £151,000, but only 9 were completed at a final cost of £102,000. It is important to note that these Improvement Grants were administered under the governance of North Central London Cluster of PCTs.

4.15 Premises - Investment Plan for 2013/14 A working assumption was made that a similar amount would be required for an Improvement Grant funding programme, primarily to address CQC-related issues. Practices have been invited to bid for funding on this assumption. However, NHS England have just issued guidance to confirm that, unlike their predecessor PCTs, CCGs do not have any responsibility for GP premises, and are therefore not allowed to invest in Improvement Grants or any other premises projects. Any such investment would breach governance rules and be viewed as a direct conflict of interests. Haringey CCG are seeking urgent clarification from NHS England on whether they will offer Improvement Grant funding and provide the investment required by practices to help them achieve CQC compliance. This situation may take some time to resolve, but it is now very clear that the CCG will not be able to make any investment in premises in 2013/14.

4.16 Domain 6 – Access and Productivity Improving access to primary care is of high importance to patients and the CCG.

The Ipsos-Mori Patient Survey reports widespread dissatisfaction amongst patients with access to general practice in Haringey.

4.17 Access and Productivity - Progress to date

A pilot has been completed in one Practice, working with Productive Primary Care (PPC, Dr. First) to review current demand and capacity and to redesign their practice processes and realign their capacity to more effectively meet the demand. One of the important lessons from this pilot is that the diagnostic and capacity planning phase is essential and fundamental to success.

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4.18 Access and Productivity - Investment Plan for 2013/14 There is a strong case to invest heavily in projects to address access issue across Haringey. It is a CCG priority and links significantly to other strategic aims, including A&E attenders.

We are planning to offer to programmes practices to review and redesign their systems. This will be the PPC programme, but other programme providers, such as Xytal Productive General Practice Programme are being introduced. There is also a growing view that peer group learning and support could address many identified issues. There may also be the need for some targeted bespoke facilitation to practices to enable certain practices to address more complex organisational issues.

The planned investment for 2013/14 is £50,000.

4.19 Domain 7 - Workforce, Leadership, Team Development, Education This domain is an enabler for many of the other domains, ensuring that Primary

Care Teams are equipped to contribute to achieving the strategic aims of the Primary Care Development Strategy and of Haringey CCG. It is in effect the “personal development plan” of the strategy.

4.20 Progress to date

Provision in 2012/13 has included: HCA apprenticeships

- 20 HCA apprenticeships have been funded and recruited. Nurses Training.

- The provision of a menu of nurse training courses to improve practice nurse knowledge and capacity to deliver best practice. Two courses per month are being provided during 2013

Sexual Health in Practice (SHiP training): - Improving sexual health outcomes and access to contraception services in

general practice through improving the knowledge and skill of primary care. Fourteen modules will be run throughout 2013/14.

QIPP Primary Care Education - A three month project to develop an educational strategy that supports the

delivery of Quality Innovation Productivity and Prevention strategy. Practice Manager and Practice Nurse Forums

- Development of forums in each of the 4 networks and a single Borough wide forum

4.21 Investment Plan for 2013/14

An overarching CCG Education and Training Strategy is being developed. Until the strategy is finalised, it is difficult to quantify the total requirements for the next 12 months. A Primary Care Education and Training programme for 2013/14 is being developed and will be completed in August. This programme will require an investment of £289,000 in 2013/14, an increase from the £185,000 in 2012/13.

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4.22 Domain 8 - Commissioning This is the important strategic link within the CCG between GPs as

commissioners and as providers. The strategy describes it as: “It is clearly understood that primary care contracting and performance management will be the responsibility of the new NHS Commissioning Board. However, Clinical Commissioning Groups (CCGs) will have a role to play in primary care commissioning, when as the strategic commissioners, they will want to define their expectations of primary care services. This will include decisions on specifying Local Enhanced Services (LES) to be contracted by the NHS Commissioning Board. It is also likely that CCGs will want to shift the provision of some services from hospital to a community setting and will seek bids from primary care contractors to provide parts of, or whole, new pathways. In this way, with CCG leadership, investment will be redirected from secondary to primary care.”

In Haringey, given that one of the CCG’s strategic aim is to create a transformation of the health economy by reducing the amount of care in hospital and increasing the provision of community-based care delivered by primary care teams, the first pre-requisites are to re-design the care pathways and to prepare the primary care teams to take on an enhanced role. The primary care strategy funding is being used to provide the additional resources required to carry out this work. This investment should be viewed together with the investment proposed in Domain 2, Clinical Services.

4.23 Commissioning - Progress to date

£60,000 was invested in 2012/13. Work has commenced on the pathway re-design, engaging GP leadership and secondary care providers in a series of development workshops.

4.24 Investment Plan for 2013/14

The ongoing work on pathway re-design in 2013/14 will require an investment of £180,000 to the end of September. NB. The proposed service redesign projects will be funded from Domain 2, Clinical Services

. 4.25 Communications

It is vital that the strategy and its implementation are effectively communicated to all stakeholders to ensure engagement of practices and uptake of new opportunities and services that the strategy delivers. It is a good news story for patients, practices and CCG commissioners. It is therefore important that this is widely communicated.

4.26 Communications - Progress to date

The Primary Care Strategy Investment Plan for 2012/13 allocated an investment of £23,000 to enable effective communication of the strategy. A part time dedicated communications expert was seconded from NCL to raise the profile of the strategy with member practices and wider stakeholders and to ensure delivery is effectively communicated. This has included promoting the new

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services available from the approved business cases under an easily identifiable image:

4.27 Communications - Investment Plan for 2013/14

As part of the investment prioritisation it has been decided not to allocate specific funding. To continue to ensure effective communication of the strategy, the new initiatives and services funded through the strategy will be publicised through the CCG communications team.

5. Central Programme Costs There are no central programme management costs in 2013/14.

6. Programme Management and Governance Arrangements The decision to close the central Programme Board means that each Borough CCG has now made their own governance arrangements. The funding allocation will be managed through the Risk Share agreement. In Haringey, the investment approval governance process will be through:

- Haringey Primary Care Strategy Implementation Steering Group - Haringey Primary Care Investment Panel - Haringey Finance Committee.

7. Conclusions Haringey CCG is clear in its key strategic aims to create a transformation of the health economy by reducing the amount of care in hospital and increasing the provision of community-based care delivered by primary care teams. The investment in the delivery of the Primary Care Strategy is therefore an essential enabler to facilitate this transformational change in Haringey and to create a sustainable health economy. The total Investment Plan for 2013/14 in Haringey is £2,500,000 including a new project contingency of £100,000.

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Appendix 1

HARINGEY CCG PRIMARY CARE STRATEGY INVESTMENT PROJECTS 2013/14

PCS DOMAIN / PROJECT Details

Investment 2013/14 £000's

1 Integrated care networks Payroll and other team costs to establish and support GP provider networks and implement PCS programme

£650

2 Clinical services

HA01 Primary Care Alcohol Hubs Project HAGA Counselling service in 4

GP centres £76

HA08 Active for Life 1:1 support (brief interventions and participation in an exercise programme) to people from disadvantaged communities to increase their physical activity levels to improve health outcomes.

£42

HA15 IT Equipment Telemedicine consumables £8

HA17 Medicines Management Clinical Pharmacy Support to Care Homes & Frail Elderly Patients

£74

HA18 Medicines Management Increasing Medicines Management Support to all GP Practices

£120

HA20 PC Counselling MH/Alcohol HAGA Counselling service for patients with dual diagnosis, provided in 4 GP centres

£47

HA21 Minor Ailments Scheme Enhancement of existing scheme to introduce "prescription passports"

£100

MDT Community Matrons service to support patients identified at risk of acute admissions through MDT teleconference and risk stratification

£243

HA29 Rapid Response Service On call HCA/Social care support for patients at home to avoid acute admissions

£106

HA25 O/Night DN Extension of DN service £116

HA25 Daytime Catheter Enhanced DN service £48

TOTAL - Clinical Services £980

3 Information Technology CSU SLA £104

4 Public Health - Practice Profiles £0

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PCS DOMAIN / PROJECT Details

Investment 2013/14 £000's

5 Premises

Relocation/re-development support £0

Improvement Grants £0

TOTAL - Premises £0

6 Access & Productivity

HA05 - PPC (Dr First) / Productive GP External programme providers to address GP access, organisation and productivity issues

£50

TOTAL - Access & Productivity £50

7 Workforce, leadership and team development

HA04 Nurse Forums, Practice Manager Forums and general training

Education and Training Programmes for clinical and non-clinical staff

£62

HA12 - HCAs salary reimbursement Training and subsidised

employment costs for 20 HCAs £96

HA14 Nurse Education Specific/targeted clinical training and education programmes to upskill practice nurses

£101

HA16 Haringey GP Education & Training Clinical pathway re-

design/training workshops £30

TOTAL Workforce, leadership and team dev't £289

8 Commissioning

HA19 Clinical pathway re-design Additional Time Limited Project Resources to Accelerate Delivery of Improvement and Redesign Project Delivery

£180

HA24 Urgent Care LES Costs associated with the Urgent Care LES planning and implementation

£97

HA26 Follow ups in general practice

Costs associated with GP referral follow up LES

£50

TOTAL Commissioning £327

9 Communications and Misc £0

Contingency for new projects £100

TOTAL INVESTMENT 2013/14 £2,500