1. health and fitness

Part: Public
Paper 6.3
Cover Sheet: Governing Body
Date
15th Jan 2014
Title of paper
Draft – Primary Care Delivery Strategy
Presenter &
Organisation
Kathryn Magson/ Mohini Parmar
NHS Ealing CCG
Author
Mohini Parmar, Chair, NHS Ealing CCG
Responsible director/ Mohini Parmar, Chair, NHS Ealing CCG
Clinical Lead
Confidential
Yes
No
The Governing body is asked to:
Note and approve the draft Ealing Primary Care Delivery strategy including our vision for primary care and
various enablers that are in place to deliver our model of care
Summary of purpose and scope of report
This Primary Care Delivery Strategy covers the role of general practitioners and independent contractors
within the current and future health system. Specifically this document sets out:
Challenges and opportunities presented in reshaping the local NHS
How health services delivered outside of hospital will be organised in the future
How the services will meet the needs of patients across the whole of Ealing and what these changes
will mean for General Practitioners.
Our plans to establish the enablers required to help delivery this strategy.
This delivery strategy builds upon and progresses the commitments made in Ealing’s 2012 out of hospital
strategy, Better Care, Closer to Home. It also supports the reconfiguration of acute services across North
West London set out within Shaping a Healthier Future.
GPs and their practices will play an important role in influencing the strategy and will need to understand
how it will affect their commissioning decisions for acute, mental health and community services. The
strategy will succeed with the clinical ownership of GPs and working in conjunction with our local authority
and health partners.
Supporting documents
This document needs to be read in conjunction with the NHS Ealing CCG’s Out of Hospital Delivery Strategy
document.
Quality & Safety/ Patient Engagement/ Impact on patient services:
Through the development of this strategy we have listened to the needs of patients across Ealing to
understand their preferences for service provision. The key themes arising from our engagement to date
include:
Patients want the ability to ‘take control of their own health and care needs
Accessible services is a consistent theme and include; transport, language and the availability of
appointments
Patients want to experience care that is co-ordinated and joined up
Throughout this document we have set out what this means for patients and GPs across Ealing. This will
enable us to :
Improve access to services
Increase range of service delivered locally
Reduce variability in quality
Equality / Human Rights / Privacy impact analysis
This strategy addresses both quality and access to primary care services for all groups. As the Out of
Hospital Delivery Strategy and SSDP are delivered, specific activities will take into consideration the needs
of different groups. This includes assessing estates based on accessibility and mapping different needs
across the borough.
Financial and resource implications
This strategy supports the realisation of the CCGs Commissioning Intentions and QIPP programme by
improving service outside of hospital.
Risk
None relating to this paper – risks will be considered in the SSDP
Governance and reporting (list committees, groups, or other bodies that have discussed the paper)
Committee name
NHS Ealing CCG Executive
Management & Innovation
Committee
Date discussed
18/12/2013,
08/01/2014
Outcome
Strategy discussed and minor changes
suggested ( now incorporated)
Primary Care Delivery Strategy
NHS Ealing CCG
Edition: 2.1
Date 02/01/2014
Approved by [NHS Ealing CCG] [date]
Page 0
Contents
1.
PURPOSE OF THIS DOCUMENT................................................................................................... 2
2.
THE CASE FOR CHANGE .............................................................................................................. 3
2.
VISION FOR PRIMARY CARE FROM NOW TO 2016 ................................................................... 5
2.1.
GENERAL PRACTICE ................................................................................................................ 7
2.2.
COMMUNITY PHARMACY, DENTISTRY AND OPTOMETRY .................................................. 8
2.3.
SUPPORTING QUALITY AND PERFORMANCE IN PRIMARY CARE ................................... 10
3. OUR MODEL FOR PROVIDING CARE AND THE ENABLERS THAT WILL HELP US
IMPLEMENT .......................................................................................................................................... 12
3.1.
OUR MODEL FOR PROVIDING PATIENT CARE.................................................................... 12
3.1.1.
EASY ACCESS TO HIGH QUALITY AND RESPONSIVE PRIMARY CARE ...................... 15
3.1.2.
DELIVERING HIGH-QUALITY PLANNED CARE OUT OF HOSPITAL .............................. 16
3.1.3.
RESPONSIVE URGENT CARE ............................................................................................ 19
3.2.
PRIMARY CARE INFORMATION MANAGEMENT & TECHNOLOGY ................................... 20
3.3.
ENHANCED SERVICES ............................................................................................................ 22
3.4.
GOVERNANCE AND NETWORK PERFORMANCE REVIEW ................................................ 24
3.5.
INTEGRATED AND CO-ORDINATED CARE ........................................................................... 27
3.5.1.
HEALTH AND SOCIAL CARE INTEGRATION .................................................................... 27
3.5.2.
BETTER CARE FUNDS (BCF) ............................................................................................. 30
3.5.3.
WHOLE SYSTEMS INTEGRATED CARE (WSIC) ............................................................... 31
3.6.
7 DAY WORKING ...................................................................................................................... 33
3.7.
PRIMARY CARE ESTATES ...................................................................................................... 35
3.8.
WORKFORCE ........................................................................................................................... 37
3.9.
COMMUNITY TRANSPORT...................................................................................................... 38
4.
PRIMARY CARE DELIVERY PLAN ............................................................................................. 40
4.1.
PRIORITY INITIATIVES FOR 2014-16 ..................................................................................... 40
4.2.
COMMUNICATIONS ................................................................................................................. 40
5.
NEXT STEPS ................................................................................................................................. 42
5.1.
SUMMARY ................................................................................................................................. 42
5.2.
OTHER DOCUMENTS IN PRODUCTION ................................................................................ 42
5.3.
FUTURE ENGAGEMENT .......................................................................................................... 42
APPENDICES ........................................................................................................................................ 43
1.1
1.2
1.3
1.4
1.5
1.6
1.7
APPENDIX 1: HEALTH OF EALING POPULATION ........................................................................... 43
APPENDIX 2: GP PRACTICES AND NETWORKS IN EALING ............................................................ 44
APPENDIX 3: GP LOCATION AND INDICATIVE LIST SIZE ................................................................ 46
APPENDIX 4: CASE FOR CHANGE............................................................................................... 47
APPENDIX 6: DELIVERING OUR NATIONAL EXPECTATIONS ............................................................ 48
APPENDIX 7: INITIAL LIST OF SERVICES FOR INCLUSION IN THE LOCAL HOSPITAL AND HUBS ........... 49
APPENDIX 8: ENHANCED SERVICES DECISION TREE ................... ERROR! BOOKMARK NOT DEFINED.
Page 1
1.
Purpose of this document
NHS Ealing Clinical Commissioning Group (CCG) recognises that good Primary Care is the
bedrock of a cost-effective healthcare system for its population. Primary Care healthcare is
the first point of contact for over 90% of patients and service users to access care. General
Practitioners (GPs) play a crucial role in coordinating chronic disease management, health
promotion, diagnostics and early intervention, and treatment information management.
Primary Care independent contractors include General Practitioners, pharmacists, dentists
and optometrists – all of whom play an important part in delivering healthcare services to the
people of Ealing.
This Primary Care Delivery Strategy covers the role of General Practitioners and
independent contractors within the current and future health system, and will closely link with
other existing and emerging strategies such as the Joint Strategic Needs Assessment, Public
Health Annual Report, Out of Hospital Delivery Strategy, North West London Shaping a
Healthier Future Transformation Programme (SaHF) and the Health and Wellbeing Strategy.
This strategy recognises the variety of Primary Care in Ealing, characterised by a high
number of single-handed or small practices, and the delivery mechanisms required to
effectively drive forward the implementation of our Out of Hospital strategy and QIPP plans.
We are in the process of working across North West London to increase access and capacity
of GP out of hours service. This piece of work will be informed by a review of current
arrangements and take into account the interdependences between NHS 111 and urgent
care services.
The commissioning of enhanced services post 2014 will take place across North West
London in line with the commissioning framework for local out of hospital services. The
framework will support us, as a CCG, to make open and transparent decisions, which align
with our commissioning intentions. The contracting route for these services will be the NHS
standard contract. This will be used irrespective of the commissioning route which precedes
it (i.e. whether contracts are awarded with or without competitive tender).
GPs and their practices will play an important role in influencing the strategy and will
need to understand how a Primary Care strategy will affect their commissioning
decisions for acute, mental health and community services. The strategy will succeed
with the clinical ownership of GPs and working in conjunction with our local authority
and health partners.
The strategy aims to help address the challenges and opportunities presented in reshaping
the local NHS. It should be read in conjunction with Ealing CCGs Integrated plan, Strategic
Services Delivery Plan (SSDP) and Out of Hospital Delivery Strategy.
Page 2
2. The case for change
Our vision for excellence in Primary Care is built on a compelling case for change with a clear
set of reasons for improvement.
The national priorities provide a clear steer
The national priorities align with what we already know about patient expectations, reflecting
the need for better co-ordination, better access and higher quality.
The NHS’s Call to Action and NHS England’s case for change for Primary Care in
London have both made it clear that in future we must shift away from a system of
reactive, episodic treatment and towards co-ordinated, long-term care, with GPs
increasing operating as the central point of continuity across the system.
By 2015/16 the whole NHS will pool £3.8bn through Better Care Funds (BCF), which
is “a single pooled budget for health and social care services to work more closely
together in local areas, based on a plan agreed between the NHS and local
authorities”.
The Department of Health is supporting fourteen ‘pioneer’ sites, which will lead design
of integrated health and social care. Together with all the 8 NWL CCGs, the 8
Councils in North West London have committed to developing pioneer whole system
plans as part of this transformation.
Improved and transformed access to Primary Care has also been recognised as a
critical improvement needed across the system. The £50m Challenge Fund
announced in October 2013 has challenged GP practices to identify ways of
delivering services more flexibly and innovatively between 8:00 a.m. and 8:00 p.m., 7
days a week. This aligns with our commitment, through SaHF, to 7 day working
across the system and points to an enhanced and modernised role for Primary Care
in future.
Ealing faces a number of demographic and health challenges
Locally, Ealing is a large London Borough with a unique set of demographic and health
challenges:
Ealing’s population: set to rise to 372,000 by 2020
A predicted increase of 48% in over-85s
A quarter of our population is aged under 20
High proportion of children living in poverty
Significantly increasing demands on and need for carers of children and older people
Increasing prevalence of long term conditions in deprived areas
The main causes of death in the borough are; Cardiovascular disease – 31% of all
deaths, Cancers – 30% and Respiratory disease – 14%
High rates of emergency admissions for heart attacks, strokes, and mental health
problems
High prevalence of diabetes – 20,000 patients diagnosed, set to double in the next
ten years
High rates of substance misuse and alcohol-related hospital admissions
Emerging Public Health Issues are likely to have a significant impact on the health service
requirements for Ealing:
The estimated level of adult physical activity is worse than the England average. Low
levels of physical activity have adverse implications for health1.
Ealing is statistically worse than England for overweight and obese children aged 1011 years.
Ealing has the 7th highest estimated prevalence of opiate and/or crack use in London
The rates of Gonorrhoea in Ealing have increased by 40% between 2009 and 2010
1
JSNA Ealing 2012-13
Page 3
Demand for carers to care is rising
Access to and quality of care is variable across Ealing
Ealing CCG serves a registered population of 390,000 and comprises membership of 79 GP
Practices2. At present, access to care and the quality of care are variable across the
borough. For example;
Too often our care is fragmented and we have an over-reliance on hospital care.
Many hospital admissions could be prevented or treated in a community setting that is
better for patients.
People can end up staying in hospital longer than they need or wish to, due to a lack
of adequate supported discharge. We need to have more planned care and earlier
interventions outside of hospital, and access to and quality of care that people receive
can be variable.
Delivering our strategy and meeting expected standards / requirements, will require changes
in how services are provided. This spans primary, community, mental health and social care.
But in particular, changes will need to happen across GP practices. To enable GPs to make
the changes they need to (e.g., offering enhanced access, care co-ordination or new
services), networks are a critical enabler. These networks can support GPs to deliver OOH
services and meet relevant standards and requirements.
What this means for GPs in Ealing:
A larger range of services will need to be delivered closer to patients homes
Improved access to primary care across Ealing at times convenient to patients is crucial
There is an opportunity for ECCG member practices to influence these changes
2
Ealing CCG NHS – 2012-2015
Page 4
2.
Vision for Primary Care from now to 2016
We have a vision of reform which moves the system from a responsive to a proactive system
that delivers care in a planned and coordinated way. At the heart is the empowerment of
individuals, carers and families. We have also set out a number of strategic goals that we are
working to deliver and standards against which we will measure our success.
The foundations to deliver patient centred care are already in place in Ealing
There is a strong commitment to the principles of integrated care developing nationally and
shared across North West London. Our focus is on developing the right care outside hospital
as a key part of maintaining the provision of quality and cost effective care for the residents
of Ealing. We have ensured that our initiatives will be inclusive, integrated and sustainable.
We want to improve the quality of care for individuals, carers and families, empowering
and supporting people to maintain independence and to lead full lives as active
participants in their community, supported by 3 key principles:
People will be empowered to direct their care and support and to receive the care they
need in their homes or local community
GPs will be at the centre of organising and coordinating people’s care
Our systems will enable and not hinder the provision of integrated care
North West London of which Ealing is a part has been awarded Pioneer Status for Integrated
Care and an early adopter of 7 day working. This gives NWL the opportunity to explore the
potentials of integrated care further and push the boundaries of the current system in which
Health and Social Care are delivered.
In North West London, there are a number of drivers to support the delivery of Integrated
Care. These include SaHF programme, Out of Hospital Strategy and the alignment of
community nursing, social care teams and community based mental health teams, which will
all support he delivery of the Integrated Care vision for Ealing.The SaHF programme aims to improve NHS services for the two million people who live in
North West London. The principal changes aim to centralise specialist services for people
who are seriously ill; localise the most common services people need for everyday illnesses
and injuries; and integrate all of these services together with other services such as social
care.
We expect that the main areas of benefits from SaHF will be:
Improved clinical outcomes for patients.
Improved experiences for patients and their carers.
Improved experiences for staff, due not only to improvements in patient care, but also
improved team and multi-disciplinary working, improved integration across primary
and secondary care, and increased opportunities to maintain and enhance skills.
Operating financially sustainable services.
Ealing CCG is working closely with the SaHF programme and an ‘Ealing Zone’ has been
established which is responsible for co-ordinating and oversight of the activities required
locally for successful implementation.
In line with the North West London SaHF Programme, Ealing CCG’s vision as set out in our
out of hospital strategy, ‘Better care closer to home’, is to ensure that our health care system
keeps patients well and at home. When patients do become unwell, our services will provide
cost-effective, evidence based and timely care in the right place appropriate to the patient’s
needs.
Page 5
Figure 1: OOH Strategic Goals
Nationally, the BCF”3 will be a catalyst for change to deliver more integrated services at scale
and pace with a shared accountability and vision across health and social care. The use of
the fund is being determined locally, but there is a commitment from both Health and Social
Care that this fund will be used to support the delivery of the vision for integration in Ealing.
BCF will be utilised to support the next phase of development of Primary Care and support
for Primary Care health networks in Ealing.
The enablers to deliver patient centred care are already in place, with a strong Integrated
Care Pilot which involves 75 of the 79 practices in Ealing already, a growing consensus that
Primary Care teams and in particular GP practices are going to find it increasingly difficult to
deliver high quality and safe care in the current way within the resources currently allocated.
Ealing CCG has a great working relationship with Ealing Social Service teams with a long
history of collaborative working.
Our vision for Primary Care
Ealing CCG is not responsible for the commissioning of Core Primary Care services
(GMS/PMS/ APMS) with the exception of enhanced Primary Care. However, we do have a
statutory duty to secure continuous improvement in the quality of primary medical services.
High quality, equitable and accessible Primary Care is central to our vision. This strategy
need to be linked with community, acute, mental health and third sector strategies in a way
that patient care is integrated. Improving health outcomes and significantly reducing
inequalities remain a key driver and Primary Care access, clinical effectiveness and patient
experience are the foundation stones.
This strategy recognises the variety of Primary Care in Ealing which is characterised by a
high number small practices and made up of a wide ranging group of staff; GPs (Partners,
Salaried and Locums), Nurse Practitioners, Practice Nurses, Health Care Assistants,
Practice Managers, Receptionists and Administrative Staff.
3
Statement on the health and social care Better Care Fund, NHS England and LGA; 8th
August 2013; http://www.england.nhs.uk/wp-content/uploads/2013/08/BCF-aug13.pdf
Page 6
2.1.
General Practice
General Practice providers are in a unique position as both members of commissioning
organisations and provider of healthcare services. Our vision is to create a sustainable
Primary Care service operating in a federated way on a single clinical system.
GPs role as a commissioner
Ealing CCG as a membership organisation is only as strong as it constituent member
practices. Its purpose is to improve the effectiveness of clinical care and patient experience,
and develop care pathways through better understanding of activity and related costs.
Members are expected to actively engage as commissioners by contributing to the redesign
of clinical pathways drawing by drawing on the healthcare needs of the local population they
represent.
GPs role as a provider
As providers, general practices are independent organisations, responsible for their own
viability and for the delivery of NHS services as set out in the national contract.
Ealing CCG will play its part to ensure that the differing roles that that general practice plays
within the new NHS architecture are managed in such a way that potential conflicts of
interest are avoided.
The future
If general practice is to meet its new responsibilities and maintain its international reputation
for excellence, it will need to adapt significantly over the next few years.
General practices will need to have a focus on improving quality of care to patients,
supported by the proactive use of data and information. Quality improvement needs to
balance and combine external scrutiny and regulation with locally-driven, peer-led and usercentred approaches. The key to achieving this balance is transparency. Reporting on quality
– to patients, between peers, to other care partners, and to commissioners and regulators –
will help inform and create quality improvements. Clinical Commissioning will provide a new
platform through which improvements in the quality of care in general practice can be driven.
This strategy supports the transformation of a the Ealing health care system through the
development of a geographically population-based network model of Primary Care that is
integrated with both community and social care providers. Ealing CCG believes that this will
ultimately result in better Primary Care and a reduced dependency on hospital based care in
a way that effectively drives forward the implementation of Ealing CCG’s Out of Hospital
strategy and QIPP plans.
Ealing CCG will continue to work in a way that engenders a shared sense of responsibility
and capacity to support the implementation of this Primary Care strategy.
What this means for GPs in Ealing:
A more extensive range of services will need to be delivered closer to patients homes
Improved access to primary care across Ealing at times convenient to patients
Greater co-ordination of patient care across different providers with named healthcare
professionals supporting them will require greater collaborative working
Patients will be supported to manage their own care through the provision of relevant and
accessible information which will need to be owned and maintained by GPs
Page 7
2.2.
Community Pharmacy, Dentistry and Optometry
Community Pharmacy
There are 72 pharmacies in Ealing. They provide Essential services to patients who walk in
without the need for registration. (Essential services include dispensing, repeat dispensing,
receipt of unwanted medicines for safe disposal, support for self- care, health promotion,
signposting to other service provision and clinical governance.) Pharmacies are located
across the area providing good access to all patients.
Pharmacies provide services across the week from early morning (6.00am) until midnight
Monday to Saturday and also over several hours on a Sunday. The extended opening of
the pharmacies is valued and needed at the current locations.
As well as Essential Services many pharmacies also provide Additional Services including
Medicines Use Reviews (MURs). This is a consultation with the patient to discuss how they
use their medicines, identifying any issues and supporting compliance. 75% of pharmacies
accredited to provide MURs actually deliver this valued service. Most pharmacies also
deliver Local Enhanced Services – which are commissioned locally as needed. These are
now mainly commissioned by Public Health at the Local Authority:
stop smoking support
supply of emergency contraception to teenagers
needle exchange and supervised consumption
In addition Ealing CCG commissions a minor ailment service
The development of community pharmacy services is based on the Pharmaceutical Needs
Assessment. Responsibility for this document transferred to the Local Authority in April
2013.
Dentistry
There are General Dental Services (GDS) contracts and Personal Dental Services (PDS)
contracts for the provision of orthodontic treatment in Ealing. The GDS contracts are on a
rolling basis whilst the PDS contracts are time limited and have recently been extended to
March 2014. NHS England also has an agreement for the provision of the salaried dental
service which provides a range of services to patients who find it difficult to access high
street dentistry.
All dental pathways are commissioned by NHS England and will be influenced by the Local
professional Network. Thus the opportunities for Ealing CCG to work with dental
colleagues may be limited.
Optometry
NHS England has taken over responsibility for commissioning General Ophthalmic Services
(GOS) from 1 April 2013. There are 59 GOS contracts in Ealing. This breaks down to 23
Mandatory contracts (i.e. premises) and 36 Domiciliary Visit contracts that include Ealing.
Optical contractors are commissioned to carry out a sight test for a fee. This includes an
examination of the external surface of the eye and its immediate vicinity, an intra-ocular
examination usually either by means of an ophthalmoscope or a slit lamp and any additional
examinations the optometrist believes are clinically necessary. A prescription for glasses is
issued at the end of the sight test and, for some eligible patients, an NHS optical voucher
towards the cost of glasses.
Page 8
Unlike GPs and dentists, optical contractors limited responsibility for screening and refining
their own referrals under the GOS. They are not paid through GOS to manage patients in
their own practices within the limits of their clinical competency. Normally they will refer all
patients who show signs of injury, disease or abnormality in the eye, or elsewhere, and
require medical treatment or are unlikely to see satisfactorily with corrective lenses. This is
required by their GOS contract and it demonstrates a focus of the nationally commissioned
service on using standard eye-tests for screening.
However, there are opportunities locally to commission services that are beyond the scope of
the national contract so that Ealing CCG can ensure local eye services meet the needs of the
population. These arrangements would be outside the GOS contract and the service
specifications and remuneration will be negotiated by the commissioner. Ealing CCG will
seek further links with the local contractor committees (LMC, LDC, LPC, LOC) and build on
their knowledge and experience.
Page 9
2.3.
Supporting quality and performance in Primary Care4
Contractual management of primary medical services is the sole responsibility of NHS
England Area team (for Ealing this is the North West London Area Team). They are
responsible for commissioning core primary care medical services as well as Additional
Services, Directed Enhanced Services (DES) and the Quality and Outcomes Framework
(QOF). This team from NHS England has contributed the following information and
commentary to support the production of this document.
NHS England (London) seeks to commission effective, safe and high quality primary medical
services. Delivery of this requires CCGs to play an active role in supporting NHS England to
drive improvements in primary care. CCGs have a statutory duty to assist NHS England in
the quality improvement of primary medical services and have an active interest in doing so
for the effective delivery of their overall commissioning strategy.
Performance of Ealing Practices
“The national GP Assurance Framework developed by NHS England, pulls together a range
of demographic and performance information about practices. Performance indicators under
the framework include A&E attendance and admissions, measures assessing long-term
condition management and patient reported satisfaction of GP services.
The framework highlights practices that have 5 or more indictors for which they are outliers
(i.e. outside 2 standard deviations of the mean). This is considered significant and may
represent unwarranted variation in these practices. These practices are referred to as
outlying practices.
GP Assurance Framework - Number of Outlying Points
by Practice in Ealing CCG
Number of Outlying points
16
14
12
10
8
6
4
2
0
79 42 56 82 29 50 19 62 16 25 36 63 6 14 30 45 54 66 70 77 4 12 22 31 39 59 65 80
Ealing Practices
The chart above demonstrates that the majority of Ealing practices (88%) are within the
normal range of performance across most indicators. However, the tool identifies 10 outlying
practices (12%) within Ealing, where performance may be considered significantly below the
expected levels.
The chart below demonstrates that this percentage of outlying practices is high compared to
the London and national averages. In addition, amongst the Ealing practices highlighted by
this tool as outliers, the number of indicators where they are outliers is high; of the 10
4
This section has been written by NHS England’s North West Area team responsible for
Ealing
Page 10
practices in London with the highest number of outlying indicators, three of them are Ealing
practices.
GP Assurance Framework - Percentage of Outlying
Practices
16.0%
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
CCG
It must be recognised that this performance tool can only indicate where practices are
outliers, a more in depth investigation into the performance of these practices, is necessary
in order to establish if there are real concerns about the level and quality of services being
provided by these practices and delivery of their contracts.
Managing variance
The analysis above demonstrates that the vast majority of practices in Ealing are providing a
high level of service to patients, which meet expected standards of service delivery.
However, it also highlights that there is significant variation in the performance of practices,
which may indicate an unacceptable variation in the quality of services being delivered to
patients across Ealing.
As part of a programme of assurance and performance management, NHS England will
review other key performance information held about those outlying practices, such as
clinical capacity, complaints and patient feedback and Care Quality Commission (CQC)
reports. This will reveal if there are any broader concerns relating to performance or
compliance at those practices.
Using this information NHS England will approach practices and require them to produce a
performance improvement plan. Improvement plans will be regularly monitored to ensure
improvements are being implemented. Where there are trends or themes emerging that
indicate issues with quality or levels of services across a wider area or Ealing as a whole,
NHS England will highlight these to Ealing CCG to include in their primary care improvement
plans.
There are several tools and levers that NHS England can use to address unsatisfactory
levels of service provided by practices. The interventions used by NHS England will depend
on the level of concern there is about a practice, and will range from asking CCGs to facilitate
improvement through networks and peer support, to using contractual levers to compel
action by the practice. NHS England will decide upon the most appropriate intervention,
having worked with CCG colleagues to ensure practices are provided support and guidance
to improve.
Where it is believed that the level of service provided by a practice is inadequate to meet its
contractual obligations and the practice is not demonstrating improvements, NHS England
will use contractual levers, such as breach notices and contract sanctions to drive
improvements to services.”
Page 11
3.
Our model for providing care and the enablers that will help us
implement
3.1.
Our model for providing patient care
In 2011, Ealing CCG published its Out of Hospital strategy entitled ‘Better Care, Closer to
Home’. It underpins Ealing CCG’s aspiration to deliver healthcare using the ‘Right Care,
Right Time, Right Place’ approach. The strategy aims for both physical and mental health
care to be delivered in the lowest intensity settings that are consistent with high quality care,
as close to home as possible Investment and Delivery is being closely monitored to be able
to demonstrate to member practices, patients and the public that out of hospital services are
ready to support wider changes to the health and social care system e.g. SaHF.
Our approach will focus on patients with complex health and social care needs, such as
the frail elderly, patients with long term conditions and frequent users of health and
social care services. We will work across organisational and professional boundaries to
ensure that we deliver health and social care interventions in a coordinated patient-centred
way to the most vulnerable patients in our communities. A process of stratification will be
used to group patients, and from this most appropriate care services will targeted.
GPs will be at the centre of organising and coordinating people’s care and will act as
the people’s champion; ensuring people receive high quality integrated care that helps
them achieve their own goals. GPs will work with other providers in integrated networks and
will be able to draw upon all the services and resource they need to meet people’s care
goals. Whilst not all care or coordination has to be delivered by individual GPs, the GP’s
patient register will be the organising principle that guides how care is co-ordinated between
agencies.
Care co-ordinators will be accountable for ensuring that all of our out of hospital
standards relating to care planning and co-ordination are met. They will ensure that
patients always know who to turn to, without having to worry about which agency is
responsible for any particular need, or which budget it might relate to. They will be based in
our seven care networks, allowing them to align with our existing multi-disciplinary groups
(MDGs) and support the virtual ward networks, but will build and maintain very strong links
with practices.
Local Hubs and the Local Hospital will support multi-disciplinary groups and care
networks who will provide a number of services across all settings of care. Multi-disciplinary
teams, aligned with our networks will provide holistic care for patients with LTCs or complex
Page 12
health needs. These teams will be comprised of local GPs working with community health
and social care practitioners such as district nurses, community psychiatric nurses, and
social workers.
Systems will enable and not hinder the provision of integrated care. The financial model
will pay for people’s health and social care needs on a basis that rewards outcomes not
contacts. Commissioning budgets will also be pooled where this would be beneficial for the
population. To enable seamless delivery, information about people’s care will be shared with
them and, with their permission, across the organisations that are responsible for providing
their care. Leaders will no longer accept ways of working that are silo-based and do not
consider the needs of people beyond their own part of the pathway of care. Providers will be
responsible for taking joint accountability for achieving a person’s outcomes and goals and
will be required to show how this delivers efficiencies across the system.
What this means for GPs in Ealing:
GPs will be at the centre of organising and coordinating people’s care and will act
as the people’s champion
Patients with complex needs will have care co-ordinators who will be accountable
for ensuring that the standards relating to care planning and co-ordination are met
Multi-disciplinary teams will be aligned to networks and support the delivery of
holistic care for patients with LTCs or complex needs
Each setting will provide a range of services that will allow residents across Ealing to access
the full range of health and care support.
In the future more services, particularly for planned care, will be delivered within out of
hospital settings. The table below provides a summary of the services that Ealing CCG aims
to provide in each of these settings:
Page 13
The diagram below show the majority of support will be delivered in an out of hospital setting.
This is supported by the acute and tertiary care settings which will provide support those
patients who are most ill.
What this means for GPs in Ealing:
GPs will continue to provide core GP services and will act as the named point of contact
for co-ordinating the care for their patients
Improved access to GP appointments with local GP practices and hubs and will have access
to an increased range of services
A greater number of planned care services locally
Responsive urgent care when needed to keep patients out of hospital settings
Patients with the most complex cases will continue to be seen in a major or specialist
hospital as they will have access to more specialist services
Page 14
3.1.1. Easy Access to High Quality and Responsive Primary Care
We are committed to improving access to primary care so it meets patients’ expectations.
Improving access will mean opening at convenient times, offering a wider-range of services
and being located in the right places. We also want to improve quality which means ensuring
that care is being delivered to the right clinical standards, in good facilities.
Progress to date
We have made significant progress improving the way patients are able to access services.
These include:
Scheme
Development of Health
Networks
Progress to date
Establishment has continued at a strong pace across the
borough. Organisation of practices into networks across
Ealing,
Networks are supported by Clinical CCG Executive leads
and Network Relationship Managers
Urgent Care Centre at Ealing
Hospital
Practice based mental health
teams
Our Future Plans
Services provided at GP practices
We aim to support patients to self-manage as much as possible. We know that a
significant proportion of service users would value an increased role in the management of
their own care, but that the current system does not provide patients with the information,
advice and support they need to self-manage.
Practices remain the centre for most routine primary care. GPs will act as the named point
of contact for co-ordinating care for their patients.
Every practice will continue to offer core primary care services, as well as working with
other practices in their care network to provide additional services. GP practices will also
continue to have access to and provide the diagnostics and tests that they do currently such
as blood tests.
We are working with GP practices to identify ways of delivering services more flexibly
and innovatively with extended hours, 7-days a week. 7-day working is expected to have
a number of benefits:
De-risking for patients accessing health services outside of ‘core hours’, leading to
better outcomes
Improved patient experience
Greater access to out of hospital services outside of ‘core hours
Services provided at a hub or across a GP Network
GP networks will support GPs in Ealing to provide extended hours services so that
patients can access services within a GP practice from 08:00 to 20:00. Specific
practices in each locality will offer appointments during extended hours on behalf of their
locality. An agreed number of practices per network will also be open on Saturdays,
Sundays and Bank Holidays to provide extended care on non-working days. Patients will also
be able to access GP services extended hours GP services at Hubs. .
Page 15
Patients will also be able to access a broader range of primary care services than is
available in their practice. Practices will collaborate at network level to share staff
resources and skills, referring between practices so that all of our patients can access a wide
range of ‘enhanced’ services in primary care.
What this means for GPs in Ealing:
GPs will continue to provide core GP services and will act as the named point of
contact for co-ordinating the care for their patients
Improved access to GP appointments with local GP practices and hubs and will
have access to an increased range of services
3.1.2. Delivering high-quality Planned Care out of hospital
Our vision is for an increasing number of patients to be seen in community facilities and
settings so they do not have to travel to hospital for outpatients. These will be underpinned
by robust and clear care pathways.
Progress to date
Since our original OOH strategy was published in 2012 we have made significant progress
improving the way patients are able to access services. These include:
Scheme
Outpatient and elective
procedures will be moved
out of hospital
Progress to date
Diabetes: We have invested in new care pathways and
clinics to enable Ealing patients with diabetes to access
specialist diabetes experts in a wider range of settings. This
year we have moved over 100 patients from a traditional
hospital setting to new locations closer to home
MSK: Our investment in MSK services has improved
quality, reduced waiting times for patients and lowered the
requirement for hospital based care. This service now has
waiting times near four weeks and we are seeking to
expand it further.
Pulmonary Rehabilitation: This service, provided by
Ealing ICO, has been in operation for over a year now and
has enabled over 400 patient contacts for the delivery of an
enhanced model of care
Our future plans
Services provided by a GP
Individual GPs will retain responsibility for referring patients to specialist services and
are expected to ensure that all referrals are clinically necessary and appropriate to patient
need.
Before making a referral, GPs will have access to relevant consultants via email and
telephone and will be further supported by services delivered across a network or hub.
This will offer the GP a specialist opinion before they make a referral, to ensure that all
referrals are appropriate, and that patients receive the right care in the right setting.
The continued expansion of the referral facilitation service will continue to work with GP
practices in Ealing to ensure that patients are directed to the most appropriate setting in
which to receive on-going treatment and management of their conditions. As new care
Page 16
pathways and services are developed the RFS will be involved in ensuring that these are
delivered.
Services provided at a hub or across a GP Network
Hubs and networks will enable a wider range of services to be delivered locally. These will
include various diagnostic and outpatient services. It also means that within networks,
patients will be referred between practices as well as to secondary care.
Patients currently receive a number of services at their own, or at another local GP
Surgery. We have recently reviewed the services that are currently commissioned using an
agreed framework5. The aim of this review has been to improve the quality and reduce the
known variation while ensuring a thriving and successful primary care service which best
meets the needs of our local population. The services that will be commissioned and
delivered at a either an individual practice or at a network:
Ambulatory Blood Pressure Monitoring
Anti-coagulation and NOAC
Diabetes support
ECG Scheme
Insulin Initiation
Minor Surgery
Near Patient Testing
Phlebotomy
Post Discharge Procedures
Gynaecology - Ring Pessary
We plan to extend the current range of planned care services as well as introduce new
services that can be accessed from the appropriate out of hospital settings. These
include:
Dermatology Assessment and Outpatient Services
Musculoskeletal Services including physiotherapy
Cardiology Outpatient and Simple Diagnostics
Anticoagulation outpatient and monitoring
Comprehensive Community based Diabetes Service
Non-complex Gynaecology and Sexual Health
Those patients with the most complex cases will continue to be seen in a major or
specialist hospital as they will have access to the largest range of services.
The provision of these services in each hub will require access to the appropriate
diagnostics facilities. Hubs could host some diagnostic equipment such as ECG. Where
additional or more specialist diagnostics are required they will be delivered from the
relevant hospital of your choice. Diagnostic results will be shared electronically between
care providers, to ensure continuity between different settings, especially when a patient is
referred between providers or services
The transition of these services will support the wider changes taking place across NWL and
will ensure that patients across the borough have equality of access to a range of
services.
5
From April 2014 CCGs will no longer have the ability to commission local enhanced services from primary care providers;
providers; instead CCGs will be required to commission any out of hospital services required using an appropriate and
proportionate procurement process and the NHS Standard Contract as the contracting mechanism. As a consequence CCGs
have reviewed all the local enhanced services that have been commissioned have concluded which services they wish to retain.
This paper sets out the process by which CCGs in the Collaboration will re-commission enhanced services
Page 17
During the development of this strategy, CWHHE collaboration CCGs have been working
closely with Imperial Hospital to review improvements and transform planned care. This has
been supported by the NHS IQ development programme. The aims of this programme are
to:
Achieve a visible patient record across clinical systems across primary and secondary
care
Increased communication between clinicians to manage patient care plans
Reduction in the need for multiple appointments
Direct access to specialists for urgent reviews to avoid A&E presentations
Expansion of referral facilitation services: patients treated in most appropriate settings
Children and Young People
In our commissioning intentions for 2014-15 we outline our intention to explore ‘Connecting
Care for Children’ which has been developed by ICHT and CCGs from the CWHHE
Collaboration. The scheme ensures that
-
There will be a provision of telephone consultancy for GPs to speak with a consultant
paediatrician
Community based clinics will become available which are delivered by a Consultant
Paediatrician delivered in community settings
Multidisciplinary team reviews – children centres, GPs, social workers, community
paediatricians etc.
Development of “best practice champions” which are non-clinical patient and carer
experts to help drive behavioural change of patients and their carers
This will be delivered using clusters of GP Practices across the borough of Ealing.
The benefits of this approach are being tracked across CWHHE and further examination of
the scheme will be held early in 2014. We recognise that the successful implementation of
this programme will require a substantial engagement and communications programme with
our primary care delivery organisations.
Link between schemes
Ealing CCG is also working with London Borough of Ealing and ICO to develop plans for and
then to implement an “Up to 5” service which will be multidisciplinary, community based
scheme to give children a better start in life. This service model currently comprises social
workers, outreach workers, speech and language therapists and potentially community
paediatricians. The service aims to provide a more holistic service to children under five
years old and their parents with the early identification of health issues and advice to parents
and carers. Engagement events are taking place to aid the development of this service and
we aspire to have this fully implemented and operational by April 2015.
What this means for GPs in Ealing:
A greater number of planned care services locally
Patients with the most complex cases will continue to be seen in a major or
specialist hospital as they will have access to the largest range of services.
Hubs will require access to the appropriate diagnostics facilities. Hubs will host
some diagnostic equipment such as ultrasound and ECG. Where additional or more
specialist diagnostics are required they will be delivered from the relevant
hospital of your choice.
The transition of these services will support the wider changes taking place across
NWL and will ensure that patients across the borough have equality of access to
a range of services
Page 18
3.1.3. Responsive Urgent Care
Our aim is to respond rapidly to urgent needs so that fewer patients have to access hospital
based emergency care. If a patient has an urgent need that requires a clinical response we
aim to commission services that will respond within two hours.
Progress to date
Since our original OOH strategy was published in 2012 we have made significant progress
improving the way patients are able to access services. These include:
Scheme
Progress to date
111
Intermediate Care Ealing
(ICE) and rapid response
team
The ICE Service has delivered strong results for integrated,
intermediate care which has kept over 1,000 patients out of
hospital and improved the quality of care for our patients
Our future plans
GPs will continue to support the continuation of the process to address frequent users of
emergency services (FUES) including Ambulatory, Mental Health, Social Services and ICE.
GPs will monitor lists and take appropriate actions in order to reduce admissions.
Ealing CCG has commissioned a comprehensive intermediate care service known as the
Intermediate Care Service Ealing (ICE). We intend to continue the development of the
service and:
proactively seek referrals for patients who require intermediate care.
extend direct referrals to all clinicians, including nurse practitioners and practice
nurses
Share electronic patient information
Continue working with GP practices and raise the profile of the service with primary
care.
As supported discharge is an essential service that GPs need to provide; we will be
commissioning supported discharge for patients discharged from the hospitals (bedded and
non- bedded) from 2014.
The Local Hospital will include an Emergency Care Centre that will be open 24 hours a
day, 7 Days a week. Patients needing urgent care will be able to access this service directly
or will be referred by the 111 service or their GP.
What this means for GPs in Ealing:
Responsive urgent care when needed to keep patients out of hospital settings
Improved access to Out of Hours services and advice
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3.2.
Primary Care Information Management & Technology
Ealing CCG’s strategy will be to continue to extend the principle of one electronic patient
record across all settings of care. This is in alignment with existing and anticipated IT
strategies published by the Department of Health and its associated bodies. As well as the
local IT strategy currently under development for the whole systems implementation within
the framework of SaHFs strategy.
The objective is to implement three layers of clinical information exchange where at least one
of the following is in place in any setting of care:
Level 1 - There is access to and two way information exchange within a common
clinical IT system and a shared record between the GP and the care provider.
Level 2 - Where the above is not possible due to technical, operational or financial
constraints that as a minimum, the respective IT systems in Primary Care and
elsewhere are interoperable and in full conformance with the current Interoperability
Toolkit (ITK) standards (or other common messaging standards) as defined by the
Health and Social Care Information Centre (HSCIC).
Level 3 - Where neither of the above is relevant or feasible then the Summary Care
Record is enabled, available and accessible particularly where patients are receiving
care out of area.
Ealing CCG will work towards the sharing of clinical records in different settings of care within
robust information governance frameworks and processes across the health and social care
community. More specifically Ealing CCG will continue working with CWHHE CCG’s to
implement a single IT system across GP practices and several directly commissioned
services where appropriate. Current and future providers will be required to work within the
frameworks and opportunities that a single IT system across Primary Care can offer. This will
be translated into more granular service specifications, service improvement plans and/or
CQUIN’s where relevant. The overriding objective is to improve standards of care facilitated
by the accurate, timely and appropriate information exchange.
Ealing CCG will in addition focus on these areas:
Continue working to improve the timeliness and quality of information sent to or
accessible by providers from GP practices via clinical IT systems and to ensure the
most up to date, relevant and accurate information is always sent.
Continue working with providers to enable safer and more efficient electronic methods
of communication between them and Primary Care, building on the previous work and
solutions around real time information.
Implementing the diagnostic cloud across the North West London health economy,
ensuring the principle of one patient, one diagnostic record across North West
London. Initially focused on pathology but extending to other diagnostic services e.g.
radiology. Ensuring that ordering tests and receiving results for Primary Care are
almost exclusively done electronically. As well as ensuring that access to a
comprehensive chronological patient diagnostic record is enabled and actively in use
in different settings of care.
Work with social services to develop an interface between IT systems and more
robust information exchange within common information governance frameworks.
Principally that all providers use the NHS number as the unique identifier of the
patient for all services in order to integrate records.
Informing and enabling patients to improve their understanding and access to their
medical records and taking a proactive role in their own care through the use of
technology solutions that will improve access to their own records and interaction with
care providers. In effect, enabling self-care planning tools and solutions where
appropriate and particularly targeted at patients with long term conditions.
Developing tools for GP clinical IT systems to provide integrated systems and
processes such as in common clinical templates, status alerts and searches that will
Page 20
highlight key patients requiring further attention. Providing a patient risk stratification
tool within (rather than outside) GP clinical systems, integrating more closely with
other IT systems where the patient may have a record. In addition Ealing CCG will
seek to implement (or make better use of) during 2014/15 and the following years,
strategic IT systems such as :
o Choose and Book and its replacement system e-Referrals.
o Electronic prescribing system.
o Coordinate my care system.
o Summary care records.
Amongst the immediate information management and technology initiative are:
The implementation of the new GP IT system from SystmOne in practices in Ealing.
We expect that all providers from whom we commission services will implement plans
to be able to have access to this system for the purposes of
Access to shared care records, particularly in emergency departments, urgent care
centres and community services.
The full role out of a software package to enable clinical decision making in acute
trusts. This will enable medical professionals to track patient flows in real time and
support decision making to place them in the most appropriate setting.
The further role out of the Coordinate MyCare system.
The implementation of a diagnostics cloud for the order and results communication
between provider and practices for direct access pathology and radiology tests.
The full use by all providers of real time systems for the purpose of sending A&E
attendance, admission, discharge and outpatient notifications and letters to GPs.
Page 21
3.3.
Enhanced services
Ealing CCG’s in North West London are working together to deliver transformed, sustainable
primary care. At the heart of this work is the intention to improve the quality of general
practice and reduce the known variation while ensuring a thriving and successful primary
care service which best meets the needs of its local population.
From April 2014 CCGs will no longer have the ability to commission local enhanced services
from primary care providers; instead CCGs will be required to commission any out of hospital
services required using an appropriate and proportionate procurement process and the NHS
Standard Contract as the contracting mechanism. As a consequence Ealing CCG has
reviewed all the local enhanced services that have been commissioned by them and have
now concluded which services they wish to retain.
This has been done in line with the other four CCGs in CWHHE. Ealing CCG is seeking to
be constructive in the way that it approaches this task to ensure that it does not destabilise
primary care, but instead ensures that it remains sustainable and viable as a key part of its
strategy to deliver of out of hospital services.
The arrangements have not as yet been finalised and hence are subject to review however,
Ealing CCG expects to apply the following principles in relation to its decision making
processes:
High quality, financially sustainable primary care is vital to the strategic direction of Ealing
CCG and so no financial savings will be sought through the review. Current levels of
expenditure across CWHHE will be at least maintained and it is envisaged that further
investment will be made in some areas.
All services are being considered from patient perspective. Ealing CCG will therefore be
seeking to integrate care and provide it as holistically and as close to home as possible
where this is in the best interest of the patient and where value for money can be
demonstrated. It will be ensuring that where appropriate, the integration of services for
the patient will outweigh the fragmentation of service provision through procurement.
Services that are currently commissioned through LESs will be either decommissioned;
recommissioned in their current form using a standard NHS contract or recommissioned
to a different service specification using a standard NHS contract.
CCGs across NWL have developed a draft Commissioning Framework to support
decision making for the re-commissioning of Local Enhanced Services based on the draft
guidance issued by Monitor. This will be subject to review as and when the Monitor
guidance is finalised.
Future models of primary care are currently being developed. As a CCG we are currently
exploring ways of working across networks of practices to best provide care for our
patients – this is likely to lead to many of the services currently provided through LESs
funding being provided in the near future by a network of practices; providing services to
their own patients and/or on behalf of other practices within the network. This model is
seen as a key to the delivery of whole systems integrated care and initial reviews suggest
that there are a number of services where primary care is most capable and 'best able' to
deliver those services
In line with this, where practices are commissioned to provide services at scale for their
patients or for patients from other practices within or across networks, the practice will be
required to meet minimum quality standards before they will be able to do so.
All CCGs will be working towards commissioning a common bundle of services that will
be provided by individual practices or by groups of practices across localities or networks.
Page 22
CWHHE CCGs will aim to commission services using a service specification and pricing
structure agreed across CWHHE. CWHHE CCGs will be working together to fund the
required investment in primary care. The out of hospital framework will be used to
support this process. Whilst it will seek to standardise as far as possible, CWHHE
recognises that different CCGs have populations with differing needs. Therefore, where
appropriate, there may be some local variation in the out of hospital services
commissioned by individual CCGs.
It is anticipated that there will be a competitive process for some services that are
currently commissioned using the LES contracting mechanism. However it is anticipated,
at this stage that this will potentially relate to only a limited number of services.
The CWHHE CCGs will look to commission services from all providers of general medical
services but will work with NHS England to ensure that there is no duplication of service
or payment in relation to PMS or APMS providers who deliver services above and beyond
the requirements of the general medical services contract.
The above intentions are subject to further assessment and testing by CWHHE CCGs
and the individual CWHHE CCGs may amend these as further work is undertaken. This
will likely include an initial assessment of the groupings that services might fall into and
where initial assessments indicate that General Practice may be the most capable
provider. The draft Out of Hospital Framework will be used to further test this.
Page 23
3.4.
Governance and network performance review
Ealing CCG has made a commitment to commission high quality, co-ordinated health
services, as set out in our out of hospital strategy, ‘Better Care Closer to Home’. Our vision is
to increase joint working and co-ordination between the different parts of the health and
social care systems, improve access to Primary Care services, co-ordinate packages of care
for patients with long term conditions, and improve support to patients being discharged from
hospital. To this effect we have initiated a number of specific actions which are the building
blocks of our efforts to strengthen primary health care teams.
Ealing CCG constituent practices have now been structured into seven health networks
covering populations between 50,000 and 70,000 each. It is envisaged that these networks
will play an integral role in the delivery of consistent out of hospital care. The health networks
are a key driver for the delivery of the Outer North West London integrated care programme.
Health networks are also a key driver for enabling collaborative and integrated communitybased services. To support network development further and faster we will appoint a network
relationship manager for each of the localities.
The networks are also being used to as an opportunity for external peer review. Practices
within their networks are being required, through the use of data, to benchmark performance
across a range of care pathways. The outputs of this work will enable practices to focus on
areas in which they could improve and acknowledge those in which they already performing
well. From a commissioning perspective this information will be used to inform future service
design/improvements.
We want to provide care as close to home as possible so that people can get easier and
earlier access to care. To achieve this will deliver health and care services from a number of
different settings that will be located across the borough.
Our aim is to provide services as locally possible where it is both safe and affordable to do
so. To support the assessment about where services should be located we have
considered the following factors:
Quality of Care
Clinical quality
Patient safety
Patient experience
Affordability
Level of activity
Cost of provision
Deliverability
Workforce
Estates
Equipment
Clinical and Non-Clinical Dependencies
Accessibility
Ability and need to access services
Patient choice
Page 24
Patient care within Ealing will be delivered at one of the following settings:
The role of GP Practices
Patients will continue to be registered with their GP and use them as their main point of
access to the health system.
GP practices will continue to deliver the full range of core services and will offer a variety of
systems for walk-in access, telephone triage, same day and pre-booked appointments.
Where appropriate GP practices will also provide a range of services including procedures
such as minor surgery. GPs will also have access to services commissioned on a borough
wide basis in order to reduce variability and achieve value for money such as access to pathology
services.
The role of GP Networks
Figure 2: GP Networks in Ealing
GP Practices across Ealing are structured into seven
health networks covering populations between 50,000
and 70,000 each (Appendix 2).
By working in health networks we will be able to offer a
wide range of Out of Hospital Services in each area.
These services will be delivered in a number of local
settings within a network, including GP surgeries,
however they will not be provided by all GP surgeries.
This means that patients may receive care from a
different location than their registered practice.
GP networks are central to collaborative and integrated community-based services. To
support network development further and faster we will appoint a network relationship manager for
each of the localities
The role of Local Hubs:
Hubs will enable and support the delivery of a wider range of services locally. It will achieve this
by:
o Localising the most common services people need for everyday illnesses and injuries
o Integrating and joining-up clinical services with others such as social care to intervene
earlier along the patient pathway and reduce hospital admissions over the longer term
o Centralising services currently delivered locally, where access allows, achieving
economies of scale.
o Providing the appropriate infrastructure so that some services currently delivered in
hospital can be delivered locally.
Hubs will include a range of services including out-patient appointments, diagnostic and
rehabilitation services.
There will be a number of hubs located across Ealing. The size and location of these services is
currently being determined
The role of the Local Hospital
SaHF agreed that Ealing Hospital will become a Local Hospital from 2017/18 meaning that it
will provide a different range of services that at present. The Local Hospital will be a part of
the pathway of care for the residents of Ealing.
The Local Hospital will act as an intermediary and point of transition between primary and
community care settings and specialist and acute care settings. As such the local hospital will
form part of the wider Out of Hospital service provision and will be interconnected with GP
practices and other providers.
Page 25
The local hospital will support those patients with more complex conditions by providing a
range of services that, while non-acute, cannot be delivered in a more local setting
The Local Hospital will also act as a hub. As a result patients will be access services delivered
from the Hospital at the hubs across the borough.
Services specific to the Local Hospital are included in the Local Hospital specification and are
therefore not set out in this document.
What this means for GPs in Ealing:
Patients will continue to be registered with their GP and use them as their main point of
access to the health system
GP networks and Local Hubs will allow patients to access a wider range of services locally
rather than in a hospital setting
The local hospital will support those patients with more complex conditions by providing
a range of services that, while non-acute, cannot be delivered in a more local setting. The LH
will also operate as a hub.
Page 26
3.5.
Integrated and Co-ordinated care
We want Ealing residents using community health and care to experience coordinated,
seamless and integrated services using evidence-based care pathways, case management
and personalised are planning. Integrated care will underpin our approach to the delivery of
all services across all settings of care.
3.5.1. Health and Social Care Integration
A key enabler of health and social care integration is the North West London Integrated Care
Pilot (ICP). Since its launch in Sept 2012, ICP has demonstrated clear benefits by using risk
stratification, care plans, case conferences and multi-disciplinary groups (MDGs) to improve
the co-ordination of care.
Progress to date
Scheme
Roll out the Integrated Care
Pilot
Progress to date
75 of the 79 practices are currently involved in the ICP. Integrated
Care Pilot (ICP) operating since 2012 has demonstrated clear
benefits by using risk stratification, care plans, case conferences and
MDGs to improve the co-ordination of care.
Across Ealing a number of enablers are being explored and tested
such as care planning, assisted living technology (telehealth and
telecare), sharing of information between professional groups, IT
data systems, and the Better Care Fund.
The Health and Wellbeing Board in Ealing has agreed a shared
commitment to implement integrated care at scale and pace, building
on existing partnerships. Our approach to health and social care
integration is based on the registered GP list, organised around the 7
GP Networks based in 3 localities.
From a commissioning perspective in order to facilitate the integration of health and social
care, we expect the following measures to be in place.
Risk stratification (as a health identifier) will be used to identify the most vulnerable
people that require support, and additional assessment methods will be sought to
identify people with more social needs which impact on health outcomes.
The care being delivered in people’s homes will be provided by a single dedicated
team of staff aligned to the patient’s GP. It is anticipated that the team is likely to be
made up of staff from multiple providers, but it is expected that all care will be
integrated and co-ordinated by named key professionals (supported if necessary by
case co-ordinators and/or care navigators). Patient’s will be expected to have a
named care co-ordinator or care navigator (key worker/single point of contact)
working for them and their GP; to coordinate all health and social care delivery.
Where patients require specialist diagnostic and health and social care input this will
be delivered around the patient and co-ordinated to prevent the patient making
multiple trips to hospitals. We expect that a named key professional will ensure
continuity of care between, primary, community, social and secondary care
(supported if necessary by case co-ordinators and/or care navigators).
When patients are admitted to hospital, Ealing CCG expects that the GP will be
informed within 24 hours and directly involved in discharge planning for the patient.
Discharge planning should commence at the point of admission.
Where patient transport is required Ealing CCG will expect this to be co-ordinated
between health and social care and delivered in most accessible form for the patient.
Detailed care plans will be produced and co-designed with full patient and carer
engagement. The care plans will describe the actions the patient takes to look after
themselves. Ealing CCG expects clinical teams to use the care plans in order to
Page 27
agree the package of care for each individual. There needs to be a continual cycle of
annual care planning for individuals in order to assess current needs and monitor
changes in the persons’ physical, mental and social condition. Ealing CCG expects
care plans to be discussed and agreed with the appropriate MDGs and all relevant
providers will be expected to provide appropriate input into the MDGs.
Care plans will be expected to be shared across SystmOne with other providers
(with patient consent). Currently, not all GP Practices are on SystmOne but there is a
rolling programme to get all GP Practices onto this integrated information system.
Ealing CCG actively encourages and expects to see new innovations incentivised
across providers in order to close the gaps in health and social care provision and to
reduce inequalities.
Over the last year we have begun to develop an emerging vision for integrated care in
Ealing:
“In Ealing care organisations will work seamlessly to promote and deliver healthier
communities to deliver positive experiences and improved health outcomes.
Patients, service users and their carers will be at the heart of decisions about their
health and wellbeing.”
We have also worked with our partners to develop a set of design principles and what we
consider to be success factors.
Practices in Ealing are now organised into 7 Health Networks, each serving a population of
40 - 60k, and with between 5 and 16 practices per network. ICP has been a key driver in
establishing these networks as practices have been meeting regularly as part of the MDGs to
discuss complex patients in order to improve care and outcomes. These meetings have
helped in establishing strong relationships between practices within networks, social care,
acute specialists from a number of hospitals and specialities surrounding Ealing, community
nursing teams and mental health consultants. More recently local community pharmacists
have also started attending the MDGs in order to improve relationships. The Local
Pharmaceutical Council (LPC) has also been working with community pharmacists to
organise around the Network configuration.
We are already working with the London Borough of Ealing to commission a range of
service for children and young people. ICP has also helped establish care planning as a
part of care delivery to patients that have long term conditions and those that are over 75.
The care planning against agreed care pathways and in partnership with patients,
Page 28
discussions with specialists on complex cases and structured case based education as a part
of the MDGs will result in improved and standardised care around Ealing.
Our future plans
In order for the Primary Care to be able to respond to the increasing demands, the networks
need to be supported. We are looking to see the networks as a way to deliver our Out of
Hospital strategy. We are currently scoping a program to see how we can develop networks
more formally.
The Ealing Executive Committee have mandated a working group with representation from
providers, commissioners and lay partners to work together to develop the wider integration
plans across Ealing. This working group has developed a number of steps to align services
in line with the future architecture of Ealing.
Integrated Architecture for Ealing
Individual Patient
Patient will be responsible for working with a named professional to develop a plan of
care that is developed in partnership
Support and education will be provided where possible to ensure that the care
planning process is a partnership agreement process and the resultant care plan is a
shared agreement with clear goals, roles and responsibilities
GPs
Episodic care will be delivered at individual GP practice level, with support provided
by the MDG and Network of primary care as required.
Support and education will be provided where possible to ensure that the care
planning process is a partnership agreement process and the resultant care plan is a
shared agreement with clear goals, roles and responsibilities
Care navigators provided by the voluntary sector be aligned to individual practices or
small groups of practices to advise and sign-post individual patients to services that
will support individual patient needs.
Networks
Social Care, community nursing teams, voluntary sector organisations and local
community pharmacists will organise and align around the agreed 7 GP networks.
These teams will work very closely with each of the networks, developing models of
care that improve outcomes of individuals.
There will be a named health and social care coordinator for each patient.
The network will ensure a single point of access for an individual that requires
intensive support and a named individual that will coordinate the care – ensuring that
individuals only need to tell their story once.
Localities (groups of 2 or 3 networks)
More specialist services will be aligned to localities rather than networks as necessary
to achieve efficiency of scale.
The single point of access for health and social care will be aligned to the localities.
Borough
Services will be commissioned by Ealing CCG as a Borough to ensure that learning is
quickly shared across Ealing and mobilised where shown to be effective, in a quick
and efficient manner. This will ensure that there is no difference in care across
Ealing.
North West London
Models of care that are developed across NWL will be shared with the networks in
Ealing and vice versa.
Page 29
SaHF will be led by NWL. This is a key enabler to ensure that this transformative
programme is successful and the infrastructure required to deliver the integrated
system is successful.
NHS England
Ealing CCG will work closely with NHS England to ensure that services are
commissioned in a fair and transparent manner and there are no conflicts of interest
in the decision making. Ealing CCG will also work with NHS England to support the
plans and find solutions to some of the difficult contracting decisions that will be
required.
3.5.2. Better Care Funds (BCF)
The Transfer of £3.8 billion (nationally) to the Better Care Fund (pooled budget) is a
national initiative across England announced by Health Minister Norman Lamb in
June 2013 and confirmed in the Government’s Autumn Statement 2013. All health
and social care economies across England are expected to comply with this initiative
so that integrated health and social care becomes the norm by 2018.
The aims of the ICP are to empower patients to self-manage, make joint decisions, and
receive appropriate screening and early interventions. It also sets out to create a culture of
re-ablement and prevent dependency, resulting in proactive rather than reactive health and
social care provision. It is Ealing CCG’s intention to utilise the learning from our engagement
with the ICP to develop a more ambitious approach to health and social care integration
across Ealing. This will be facilitated by our work on the Better Care Fund (BCF) with Ealing
Council and our partners.
The Better Care Fund will support the delivery of the wider health and social care integration
programme and ensure a sustainable but managed shift to an integrated system.
Ealing CCG and Ealing Council are developing a local plan by January 2014, which will set
out how the pooled funding will be used and how the national and local targets attached to
the performance-related £1 billion will be met. This draft will be discussed and signed off in a
special meeting with the Health and Well-being Board on 11 February 2014.
The Council and CCG are currently working closely together on the following areas to ensure
that the Ealing submission is truly a joint one which meets the needs of the local population
for care and support.
Developing the vision, and ambition for Ealing both in the short and longer term (1-5
years)
Producing a detailed financial analysis to confirm the potential funds in scope to be
pooled across health and social care
Refining joint commissioning, service delivery and payment models that will be
developed to deliver integration over time
Ensuring that Ealing has plans in place to meet the National Conditions set for the
Better Care Fund
Agreeing the key schemes and services that will be funded via the pooled health and
social care funds
Agreeing the key risk share protocols, measures, outcomes and performance
indicators for Ealing
Consulting with stakeholders, service users and carers including Healthwatch
An initial work shop was held between Ealing CCG and Ealing Council on 17th December
2013. At this workshop a clear joint vision of integrated care started to form. This vision will
be further crystallised over the next couple of months.
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3.5.3. Whole Systems Integrated Care (WSIC)
North West London has embarked on an ambitious programme of co-design to tackle some
of the complexities that arise from the discussions around Integrated Care and the changes
that will be required in the system to really deliver change across North West London. This
programme has bought together professionals and lay partners to think through some of the
complex issues that arise from the Integration plans and have therefore established 6
modules.
Populations and Outcomes: Understanding the needs of different population groups
in North West London and really deliver the outcomes that will improve the care for all
population groups
GP Networks: How would Primary Care need to transform in order to meet the
challenges of integrated care, moving away from silo’d working to a more network
based approach
Provider Networks: What infrastructure and governance change is required amongst
the provider landscape including social services in order to deliver the transformation
and change in front line services
Commissioning and Finance: How to commission these services effectively and
pay for services with payments aligned to outcomes and delivery rather than
transactions
Information and Technology: How to align the It infrastructure across NWL to
support the delivery of a more integrated health and social care system
Embedding Partnerships: Underpinning and represented in all of these working
modules is the Embedding Partnerships module that provides a strong lay partner
influence and driver to get this programme right.
Ealing is well represented in many of these modules and regularly inputs into the discussions
through various routes. The first wave of whole systems sites is expected to be live by April
2014. These will work together under ‘whole system’ commissioning and provision
arrangements to improve outcomes for the local population, sharing the learning and how to
overcome some of the obstacles across NWL.
Ealing has established an Executive Group that has executive representation from Social
Services, Ealing CCG, local providers, and lay partners. The group has agreed to put
forward an Expression of Interest to be an early adopter of the WSIC programme and share
the learning across NWL.
Over the next 6 months and as part of the Network development, a co-design
programme for Ealing will enable a more ambitious model on Integration to be
developed for an agreed population identified in the WSIC work-stream. This will be in
collaboration with WLMHT, LBE, EHT and primary care. The models will be developed
by each Network and supported by Ealing CCG. Different models may be tested with a
shadow budget in individual networks.
Initial discussions have started within Ealing CCG and amongst the providers with the
following ideas forming:
1. Identify a population to focus on using already collated information within the ICP
2. Identify the costs associated with this population based on information from primary
care, secondary care, emergency services, community services, tertiary services,
mental health services, social services and any other services
3. This will form the basis of a shadow capitated budget
4. Individual Networks will be supported through facilitated workshops to co-design a
model of delivery for a population within their network
5. This networks will all be given the opportunity to develop the requirements of the
model and worked up into a specification and business case
6. The most ambitious models with the strongest case will be supported to implement
their model, with support for the others to further develop their plans and implement at
their rate
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7. There will however be key common components to each model in line with the wider
Health and Social Care Integration architecture that is being implemented in Ealing.
This model is described in the next section
8. The most vulnerable patients will be cared for under an intensive team, described in a
similar model such as a ‘virtual ward’
9. Each patient will have a care plan that has been co-created in partnership between
the patient and the professional, which includes social, mental and physical screening
10. This care plan will result in an agreed ‘plan of care’ for an agreed time frame
11. Each care plan will document an agreed a) A – Accountable professional, b) R –
Responsible professional/team to deliver the care, c) C - ….. d) I – Named key
Individual responsible for coordinating care
12. The ‘plan of care’ and care plan will be refreshed following any breakdown in agreed
trigger, such as an unplanned admission or attendance at an emergency setting
13. The level of intensity will vary for each individual patient based on their need and
requirements to keep them healthy
14. On referral to a more intensive input team, there will be a joint health and social
assessment with a single point of access, rather than the current multiple
assessments through various organisations
15. There will be no referrals for these patients between services as everything will be
organised by the individual Health and Social Care coordinator. The Care plan will be
used as a referral tool in this system
16. The system will be flexible enough to deliver individualised ‘whole-person’ care
It is important to stress that this is a provider output and will be commissioned by Ealing
CCG.
What this means for GPs:
GPs will be at the centre of organising and coordinating people’s care and will act
as the people’s champion
Patients with complex needs will have care co-ordinators who will be accountable
for ensuring that the standards relating to care planning and co-ordination are met
Multi-disciplinary teams will be aligned to networks and support the delivery of
holistic care for patients with LTCs or complex needs
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3.6.
7 day working
The NW London Strategy and Transformation team have established a programme intended
to support CCGs to develop and test new models of access for ‘General Practice’ type
services – the ‘Seven day access to General Practice programme’. The scope of this
programme includes all ‘General Practice’-type activity across settings of care. If successful,
the programme will enable CCGs to fundamentally reconfigure the way ‘General Practice’type services are delivered such that supply is mapped more closely to patients’ clinical
needs and preferences.
A number of drivers have combined to create a pressing need to transform access to
General Practice in NW London:
Patient expectations: in a recent survey of NWL patient priorities for primary care,
seven of the top ten issues related to improved access.
Implementation of the SaHF programme: The Independent Reconfiguration Panel
(IRP) report on NWL’s SaHF programme requires GP practices in NW London to
move towards a ‘seven day’ model of care.
National policy: the Department of Health has recently established a £50 m.
Challenge Fund intended to encourage the development of new models of access for
General Practice.
Contractual drivers: With effect from April 2014, GMS contractual arrangements have
been amended to reflect an increased emphasis on improved access to General
Practice.
Financial drivers: A consistent, system-wide access model has the potential to reduce
costs for both commissioners (reduced service duplication) and providers (more
efficient use of resources).
Though it may be part of the solution, expanding capacity alone will not improve access to
General Practice. There are several reasons for this:
Funding: It is not possible for every GP practice in NW London to operate 8am – 8pm,
7 days a week.
Workforce: There are not enough GPs and nurses in NW London for every GP
practice to operate 8am – 8pm, 7 days a week.
New demand: Likely that increasing the number of appointments would cater for
unmet need instead of re-distributing existing demand.
More of the same: Still wouldn’t give the public the type of appointments they want
(e.g. doesn’t make use of new technology to offer different types of appointment and
make booking appointments more convenient).
Any strategy for widening access to General Practice must therefore comply with four
overarching goals:
1. System-wide reconfiguration of access to all ‘General Practice’-type services: the
provision of additional urgent appointments outside of core hours is unlikely to lead to
sustainable improvements to access. In order to ensure that we are able to deliver
services that genuinely reflect patient needs and preferences, we need to be thinking
about seven day working across General Practice in its totality.
2. Financially and operationally sustainable: a new model must be affordable and
deliverable. In the long-term this probably means no net increase in cost or workforce.
3. Meets patient expectations: a new model must deliver the type of appointments
patients want, when they want them.
4. Reconfigures both supply and demand such that both are mapped more closely to
clinical need: Though patient choice should be respected, every effort should be
made to ensure that patients receive care appropriate to their clinical condition. This
means mapping capacity more closely to clinical need.
The NW London Strategy and Transformation team has established a programme tasked
with developing and testing possible models of seven day access to General Practice. This
Page 33
programme will form a key element of both the Whole Systems Integrated Care programme
and the ‘Seven day services early adopter’ agenda.
The aim is to support CCGs to develop a new model of access to General Practice
appropriate to their local circumstances. The ultimate output of the programme will be up to
eight General Practice access model specifications, business cases, and the associated
evidence-base used in their development.
The emphasis of the programme is firmly on providing CCGs with the tools they need to
develop a model adapted to their needs. It is neither possible nor desirable to develop a
standard, ‘one size fits all’ pan-NWL model. Individual CCGs will own the completed
deliverables and will be responsible for deciding how best to take their localised model
forward in partnership with NHS England.
The key deliverables for the programme will be:
1. Comprehensive report on access to General Practice best practice – in effect a longlist of possible interventions for CCGs to draw on when designing their preferred
model. Where possible, the likely impact of each intervention will be quantified.
2. Simulation model localised for each CCG – an analytical tool used to test virtually the
likely impact of reconfiguring services on activity, workforce and costs. The simulation
model will be used by CCGs to experiment with possible options.
3. General Practice access model specification for each CCG – CCG-specific access
model, drawing on existing CCG plans, best practice research and simulation model.
It is anticipated that this model will be piloted initially with a single GP network;
however, this is a decision for Ealing CCGs.
4. Access model Pilot business case for each CCG – comprehensive, costed business
case for implementation of new access model with a single named GP network. The
business case will include provision for robust evaluation and knowledge sharing,
including patient-defined KPIs.
5. Access model Pilot implementation plan for each CCG – credible route to pilot
implementation, covering issues such as workforce, IT, governance and contracting.
Page 34
3.7.
Primary Care estates6
To support the implementation of SaHF and also fully realise our ambition to fully deliver our
out of hospital strategy, a Primary Care estates strategy is currently being created. As part of
the North West London SaHF Programme the eight CCG’s have identified Primary Care
development as an essential local priority necessary to underpin Out of Hospital Strategies
and support the necessary transfer of work from secondary to Primary Care. Therefore,
Ealing CCG will focus on reducing the variation in the quality of primary and community care
in Ealing, both in terms of patient environment and service delivery.
At the same time Ealing CCG will take opportunities to improve premises and explore options
that will enable us to support the development of networks. By creating these networks of
Primary Care there is also a greater opportunity to facilitate integration of health and social
care services and in this respect Ealing CCG would expect to deliver a Primary Care estates
strategy that is compatible and coordinated with those of local partners.
Primary Care delivery in Ealing takes place in a varied set of settings, from large GP
practices to single handed deliverers. Ealing CCG will continue to work with NHS England
and support them configure the primary care landscape in the most optimum way for the
highest quality of accessible care for Ealing patients.
We expect that patient expectations will also drive change, with the requirement for practice
based support services such as anti-coagulation, near patient testing, phlebotomy and
counselling. To ensure we delivery our aspirations for our of hospital care it essential that
patients are able to access GP services in a timely and convenient manner.
Having appropriate premises remains a key challenge for Ealing CCG and its GP providers in
trying to deliver its commissioning goals. Any new developments will need to deliver a
premises solution that enables us to provide out of hospital care to scale. We expect this to
be delivered in a networked infrastructure.
Ealing CCG will work closely with those practices occupying unsuitable and non-compliant
premises to agree strategies and workable solutions for either significantly improving their
premises or providing suitable alternative accommodation. This work needs to be undertaken
within the overarching principles of NHS England’s strategy with regard to quality standards
and value for money.
Premises Principles
Services will be provided from appropriate and modern buildings that are designed for the
purpose and well maintained and meet all statutory regulatory requirements including
Disability Discrimination Act (DDA) compliance.
Integrated services will be delivered through the development of community hubs in
prominent locations
Premises will be jointly commissioned where applicable by the Council and CCG and
where co-location has been agreed, taking account of the potential resource implications
in both capital and revenue terms.
Premises will be flexible so that there is capacity for growth and change in services.
Available space will be used to its maximum capacity.
Premises will provide an access point to all services through a common reception.
6
This section has been written by NHS Property Services team
Page 35
Premises will be designed to support the needs and recognised standards for training
and developing staff.
IT systems for all stakeholders will need to be designed to deliver the integrated service
solution.
Premises will be designed to support the needs and recognised standards for training
and developing staff.
All new developments will include natural ventilation systems and energy saving design.
In current premises the PCT will continue to maintain and invest in good quality systems
to ensure the use of energy is efficient wherever possible.
Criteria for Prioritising Future Estate Development
In order to ensure investment is maximised and commissioning led, NHS England and North
West London collaboration has developed the following key factors which must be assessed
for prioritising all future investment:
Number of GPs in the area in poor premises
Average GP list size in the area
Numbers of patient allocations in the area
Number of GPs in the area who may retire over the next 5 years
Local level of deprivation
Whether the proposal reflects local 5 year projected population changes
Suitability of current premises for out of hospital service provision
Whether the proposals meet local health needs / priorities
Whether the proposal supports the development of integrated modern healthcare
Page 36
3.8.
Workforce
The workforce strategy for North West London, identified that these changes will require new
ways of working, new roles, repurposed and enhanced roles, and significant investment and
training for our existing workforce. Some of these are outlined below.
New roles
Examples of new roles we expect to see in future include:
Case managers (which may be a GP or another professional) acting as the first point
of contact for care and care planning with patients a higher risk of hospital admission.
Care navigators (which may be volunteers) will support patients to navigate between
services
Health and Social Care Co-ordinators (HSCC) will need to develop relationships and
work closely with a range of professional groups to ensure patients receive joined-up
care. The care co-ordinator role will require knowledge and skills in relation to social
care and wider public services, as well as healthcare.
Ealing CCG Network Relationship Managers have been employed to support the
development of GP networks in Ealing.
Case management
Home based rapid response
A range of new and enhanced roles have been identified
▪
Patient /
User
▪
Clinical
case
managers
▪
▪
▪
Provides psychological and/or personal care and
support to individuals
▪
Provide supervision to nurses/case managers for
motivational interviewing and deliver higher level CBT
CBT Mental
Health
Supervisor
▪
▪
▪
Coordinate health and social care packages according to
the care plan agreed by the case manager, individual and
carers; Support individuals’ maintenance of goals
Coordinate early supported discharge from acute to home
and on-going care prior to discharge from rapid response,
including liaising with primary care team, individual, carers,
and social care
Perform specialist assessments / interventions when
requested by Case Manager or Health and Social Care
Coordinator
Provides specialist input into care plans
Shared across both
▪
Carers
Intensive
Home Care
Clinicians
(Nurses &
Therapists)
▪
▪
▪
Intensive
Home Care
Administrator
▪
▪
Health &
Social Care
Worker
Community
Health
Medic
(sessions)
Provides psychological and/or
personal care and support to
individuals
Perform face to face assessment and rapid
interventions at individual’s home for defined
period
Provide on-going care and monitoring,
support reablement or care of the dying,
including using other team members as
appropriate
Provide clinical support for HSCC for
determining appropriate response or referral
Act as a single point of
access for referrers, taking calls from GPs,
ambulance service, and carers (in the case of
palliative care)
Refer individuals to rapid response team or to
most suitable provider
▪
Perform specific moving and handling tasks,
installation of equipment, etc. as needed by
team to support the patient / user
▪
Perform on-going health care, reablement, and
personal care and monitoring, including support
for mental health
Conduct observations and report deviations
Support equipping and liaise with HSCC to
secure health, social care and voluntary
services when unable to provide directly
Handyman
▪
Social
Worker
Act as first point of contact for very high risk individuals
and carers
Perform holistic assessments and initial diagnostics of
individuals’ health and social care needs
Co-create care plan with individuals and carers, using
low-level cognitive behavioural therapy techniques, e.g.,
motivational interviewing
Provide on-going care and monitoring, drawing in
specialist input as needed
▪
Community
Health
Worker
Health &
Social Care
Coordinator
Self-manages care with support
from health and social care
professionals and carers
▪
▪
▪
▪
Provides medical cover to team and specialist
input
Works directly with case managers to monitor
very-high risk LTC individuals
SOURCE: Community workf orce project design group meetings – November 2012, team analysis
1: It is assumed that the teams will in addition have access to condition-specific specialist opinion, and to regular care already provided by in the
community, e.g., primary care, pharmacist support as needed
Figure: Examples of new roles required
Repurposed and enhanced roles
As well as new roles, we will require our existing healthcare professionals to work differently
in the future, for example:
GPs will find their role enhanced, with a greater role in care planning and care coordination. Those with specialist skills may also act as specialists in their local area.
Specialist, community and district nurses and other health professionals (including
health visitors and therapists) will provide more community and home-based care,
and will be aligned with our locality.
Social care teams will begin to align with our locality, working closely with health
colleagues.
Page 37
Consultants could provide clinics in our hubs, ensuring patients receive all the care
they need in a community setting.
111 will be transformed to provide an increasing amount of care and advice remotely,
requiring a significant increase in both the numbers and skills of 111 staff.
Shifting diagnostics, clinics and planned care procedures from hospitals to community
settings will require an increase in community staffing, including some staff moving
from hospital settings.
Establishing learning hubs
We know that these changes will require changes in the skill-mix of our workforce, both for
newly trained staff and for existing staff, which in turn means we need to re-think training. In
order to facilitate these changes, we will need to provide training to our workforce, for
example in:
Multi-disciplinary team collaboration
Referrals standardisation and peer review to manage referrals
Administering tele-care and tele-health
Supported discharge pathways
Mental health care training for primary care staff
Records sharing as new systems are introduced
In addition, practices will work together to extend the services they offer . This will also
include supporting each other to benchmark, audit and review.
3.9.
Community transport
As a part of Ealing CCG’s out of hospital strategy (OOH), we intend to shift a significant
volume of activity from hospital-based care to a range of additional settings in Primary Care,
community services and patients’ homes.
This strategy fully aligns with SaHF which, once fully implemented, will result in many
services being offered to patients away from the traditional hospital setting.
Much of this activity will be delivered much closer to patients’ homes, which should lessen
reliance on transport services to reach appointments with their local clinicians. We do
recognise, however, that the least mobile patients will require additional transport services to
reach local services.
Through Ealing CCG’s Patient and Public Engagement Committee, we have received
significant feedback from patient groups on the range and quality of patient transport services
in Ealing for non-hospital based care.
Many patients have reported that they face barriers to both community and primary care
settings because of the lack of transport for people with mobility or other health problems, in
some cases leading to people presenting at A&E / UCC because they have not been able to
attend appointments elsewhere. Therefore, Ealing CCG recognises that there may be
greater need in the borough for community-based transport as out of hospital activity
increases over the coming years.
We also acknowledge that there is a diversity of need in relation to transport. Carers, for
example, have highlighted parking restrictions as a barrier for them to attend their own
medical appointments, particularly as their caring commitments place restrictions on their
own time and flexibility. Patients with learning disabilities, on the other hand, have requested
training as they would prefer to develop the skills and independence to use public transport,
rather than relying on taxicard or dial-a-ride schemes.
Ealing CCG intends to identify options in this area across the borough of Ealing in 2014/15.
We will examine a range of schemes and suppliers to understand what is feasibly affordable
Page 38
and could be made available to Ealing residents in order to strengthen transport and access
options in the borough. Transport options will be rigorously tested for affordability and value
for money.
We recognise that strengthening patient transport for community services may require us to
work with a number of new organisations such as social enterprises, community and
voluntary services, private companies and individuals. We will ensure that, when we
undertake this work, we will draw on the expertise of groups and individuals through our
Patient and Public Engagement Committee.
A significant amount of work is already underway across North West London to examine
issues and options in this area. The SaHF programme has a fully established transport and
access group (TAG), chaired by an Ealing GP CCG clinical lead. Ealing CCG will feed into
this group and use its outputs to strengthen our own work and understanding in this area.
Page 39
4.
Primary Care Delivery Plan
4.1.
Priority initiatives for 2014-16
A detailed list of priority initiatives and appropriate timeframes will be developed and shared
in the next few months.
4.2.
Communications
Ealing CCG has made an on-going commitment to capturing public feedback and patient experiences.
This information is gathered through a number of conduits, including public stakeholder meetings, the
four local community networks, local voluntary sector forums, partnership boards, a range of patient
and carer-led groups, Healthwatch, complaints, Patient Participation Groups at local GP practices, and
via patient representatives.
Community transport, interpreting
services and support for carers have been
frequently raised through our PPE work.
Patient feedback and research shows that
patients expect a health system that
delivers better quality, more accessible
and more co-ordinated healthcare in and
out of hospital.
Patients have told us what they want from
all out of hospital services and from
primary care their feedback is important in
building our plans to deliver out of hospital
care.
Figure 3: Patient Expectations of Care
We have also undertaken a range of engagement activities to support the development of our Out of
Hospital Strategy and Specification for the Local Hospital. The key events and findings are set out
below and these themes have been addressed throughout the document.
Figure 4: Summary of engagement events to develop the OOH Strategy and Local Hospital Specification
Next steps will be to:
Facilitate co-design workshops with providers, service users and patient and community
groups to develop a patient experience framework that will enable commissioners and
Page 40
local providers (health and social care, including third sector) to capture, act on and
evaluate the impact of patient experience.
Work together with neighbouring CCG’s within the CWHHE Collaborative and invest
resources to:
o Ensure that all patient experience data and community intelligence reflects the
diversity of the local population and is collated, analysed and presented in a
manner that is transparent and accessible to providers, patients, communities
and the public.
o Present back through ‘You said…We did’ to patients, partners and providers how
their feedback influenced CCG decisions.
Our work on embedding equality into the commissioning of health services is underpinned
by engagement with our staff, stakeholders. We believe that engagement with and drawing
on the expertise of residents, patients, services providers and third sector organisations, is
critical in shaping services.
What this means for GPs in Ealing:
Patients want the ability to ‘take control of their own health and care needs and GPs need to
recognise and support this
Accessible services is a consistent theme and include; transport, language and the
availability of appointments
Patients want to experience care that is co-ordinated and joined up
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5.
Next steps
5.1.
Summary
This document sets out a large range of aspirations from Ealing CCG and NHS England for
how primary care provision should be transformed across the borough of Ealing. Much of it
will require substantial changes in thought, development, implementation and support in
order for this to be achieved.
GPs and their practices will play an important role in influencing the strategy and will need to
understand how a primary care strategy will affect their commissioning decisions for acute,
mental health and community services. The strategy will succeed with the clinical ownership
of GPs and working in conjunction with our local authority and health partners. The strategy
aims to help address the challenges and opportunities presented with the greater local
ownership arising from the establishment of Ealing CCG.
5.2.
•
•
5.3.
Other documents in production
Ealing CCG Out of Hospital Delivery Strategy
Ealing CCG Strategic Service Delivery Plan
Future engagement
This strategy will be communicated to the Ealing CCG membership and key stakeholders to
foster ownership of the strategy and agreement about next steps. It will be presented at the
following for discussion and feedback.
Stakeholders to be
engaged:
By when?
Purpose and intended
outcomes:
Ealing CCG Executive
Committee
December 2013.
Sign-off of the strategy by Ealing
CCG’s clinical leadership.
Ealing CCG Governing
Body
January 2014.
Public presentation of the strategy
and final sign-off.
Readership of the Ealing
CCG newsletter (i.e.
member practices and
staff)
January 2014 with
regular updates made
through future editions of
the newsletter.
Ownership and understanding of
the strategy by Ealing CCG’s
members and staff.
Users of the Ealing CCG
extranet (i.e. member
practices and staff)
January 2014 with
regular updates
uploaded to the extranet
throughout 2014..
Ownership and understanding of
the strategy by Ealing CCG’s
members and staff.
Ealing CCG Council of
Members and primary
care network meetings
Regular updates to be
made at the monthly
meetings throughout
2014.
Ownership of the strategy by
Ealing CCG membership,
including their understanding of
the implications for GP practices
and primary care networks in
Ealing, commitment to next steps
and delivery.
Ealing Borough Health
and Wellbeing Board
2014 – date to be
confirmed.
Ownership and understanding of
the strategy by Ealing CCG’s
strategic partners.
Page 42
Appendices
1.1 Appendix 1: Health of Ealing Population
The chart below compares health of people in the Ealing area with rest of England. Ealing’s
result for each indicator shown as circle. The average rate for England is shown by the black
line, which is always at the centre of the chart. The range of results for all local areas in
England is shown as a grey bar. A red circle means that Ealing is significantly worse than
England for that indicator; however, a green circle may still indicate an important public
health problem.
Page 43
1.2 Appendix 2: GP Practices and Networks in Ealing
Network
Acton
Central Ealing
North North
North Southall
GP Practice Name
Acton Health Centre
Acton Lane Medical Centre
Acton Town Medical Centre
Chiswick Family Practice (Dr Webber)
Chiswick Family Practice (Dr Bhatt)
Churchfield Surgery
Cloister Road Surgery
Crown St Surgery
Hillcrest surgery
Horn Lane Surgery
Mill Hill Surgery
The Bedford Park Surgery
Boileau Road Surgery
The Burlington Gardens Surgery
The Vale Surgery
Western Avenue Surgery
Corfton Road Surgery
Cuckoo Lane Surgery
Dr K K Gyi & Partner
Gordon House Surgery
Lynwood Surgery
Pitshanger family practice
Queen Walk Practice
Brunswick Road Medical Centre
The Argyle Surgery
The Surgery
Barnabas Medical Centre
The Medical Centre (Balachandran) (Doncaster Drive Medical Centre)
Elm Trees Surgery
Greenford Road Medical Centre
Hillview Surgery
Islip Manor Medical Centre
Mandeville Medical Centre
Meadow View Surgery
Perivale Medical Clinic
Allendale Road
The Grove Medical Practice
Chepstow Gardens Medical Centre
Dormers Wells Medical Centre
Jubilee Gardens Medical Centre
K S Medical Centre
Lady Margarat Road Medical Centre
THE NORTHCOTE AVENUE PRACTICE
Saluja Clinic
Somerset Family Health Practice
Somerset Medical Centre
Southall Medical Centre - main branch
St George's Medical Centre
The Town Surgery
South Central Ealing
South North
Woodbridge Medical Centre
The MWH Practice
Ealing Park Health Centre
Elthorne Park Surgery
Grosvenor House Surgery
Northfields Surgery
The Florence Road Surgery
Allenby Clinic
Page 44
South Southall
Broadmead Surgery
Eastmead Surgery
Elmbank surgery
Goodcare Practice
Greenford Avenue Family Health Practice
Hanwell Family Health Practice
Hanwell Health Centre (Dr R Naish)
Mansell Rd Practice
Northolt Family Practice
Oldfield Family Practice
Ribchester Medical Centre
West End Surgery
Westseven GP
Yeading Medical Centre
Belmont Medical Centre
Featherstone Road Health Centre (Bondcare)
Guru Nanak Medical Centre
Hammond Road Surgery
Sunrise Medical Centre
Medical Centre (mangat)
The Welcome Practice
Waterside Medical Centre
Page 45
1.3 Appendix 3: GP Location and indicative list size
Page 46
1.4 Appendix 4: Case for Change
Better Care, Closer to Home set out a clear case for change:
“We need to do this because demographic changes are increasing demand on healthcare
services and the resources available are not increasing at the same rate. As the population
ages and the number of chronic illnesses rises, the way we currently deliver care is
becoming unsustainable.
Improving our out of hospital services will make care better and less expensive. By
intervening earlier, joining up care and supporting patients at home, we will be able to
improve outcomes and patient satisfaction, whilst delivering greater value for money. Better
care, closer to home is an essential way to maintain the quality of care in the face of
increasing demand and limited resources”.
The case for change is now even stronger:
As the population ages and the number of people with a long term conditions (LTCs)
increases; the way we currently use hospital is becoming unsustainable7.
Under our current model of care, we can’t afford to meet future demand. Hospital is
too often seen as the answer and we need to have more planned care, earlier, outside
of hospital.
Improving our out of hospital services will make care better and will cost less. By
intervening earlier, joining up care better and supporting patients at home who are
currently being admitted to hospital, we will be able to improve outcomes, and patient
satisfaction while spending less. Better care, closer to home is our way to maintain the
quality of care in the face of increasing demand and limited resources. In particular,
there is a growing role for primary care.
Continuing financial pressures means we need to achieve longer-term financial
sustainability for our health economy; a growing elderly population is increasing
demands on our healthcare through rising rates of dementia and frailty in the elderly
population, as well as increases in “lifestyle” conditions of childhood obesity and
alcohol related hospital admissions; patients and their families now have greater
expectations of quality and safety; an since we published Better Care, Closer to Home,
we have moved towards integrated care and joint delivery as organising principles of
how we deliver care in the future.
More must be done to address variability in access, Patients across London report
feeling less able to book appointments or order repeat prescriptions online, or make next
day appointments with their GP8.
The NHS “A Call for action9” demands that the NHS must change if services are to
remain free at the point of access. It details a focus on preventative rather than
reactive care services matched more closely to individuals’ circumstances instead of a
one size fits all approach; people better equipped to manage their own health and
healthcare, particularly those with long term conditions; and more done to reduce
inappropriate admissions to hospital and avoidable readmissions, particularly amongst
older people.
7
Better Care, Closer to Home, 2012-2015
Primary Care in London: General Practice, A Case for Change?, NHS England, November 2013
9
http://www.england.nhs.uk/wp-content/uploads/2013/07/nhs_belongs.pdf
8
Page 47
1.5 Appendix 6: Delivering our national expectations
5.2.1 NHS Call to Action
The NHS’s Call to Action and NHS England’s case for change for primary care in London
have both made it clear that in future we must shift away from a system of reactive, episodic
treatment and towards co-ordinated, long-term care, with GPs increasing operating as the
central point of continuity across the system.
Central to delivering this is integration. By 2015/16 the whole NHS will pool £3.8bn through
Better Care Funds, which are “a single pooled budget for health and social care services to
work more closely together in local areas, based on a plan agreed between the NHS and
local authorities”.
5.2.2 Integrated Care
The Department of Health is also supporting fourteen ‘pioneer’ sites, which will lead the
integration of health and social care. As outlined in Section 6, we – together with all Ealing
CCGs in North West London – have committed to developing pioneer whole system plans as
part of this transformation.
5.3.3 7-day working
Improved and transformed access to primary care has also been recognised as a critical
improvement needed across the system. The £50m Challenge Fund announced in October
2013 has challenged GP practices to identify ways of delivering services more flexibly and
innovatively with extended hours, 7-days a week. This aligns with our commitment, through
SaHF, to 7-day working across the system and points to an enhanced and modernised role
for primary care in future.
7-day working supports our OOH vision and is expected to have a number of benefits:
De-risking for patients accessing health services outside of ‘core hours’, leading to
better outcomes
Improved patient experience
Greater access to out of hospital services outside of ‘core hours
Page 48
1.6 Appendix 7: Initial list of services for inclusion in the local hospital
and hubs
All services subject to activity and affordability
Where services are delivered in a hub they will also be delivered from the local hospital
Service Category
Potential Services for inclusion
Assessment unit
Step Up beds (Enhanced monitoring and assessment)
Cancer care services
Outpatient clinic (including Ambulatory care)
Chemotherapy (Ambulatory) and Oncology (no head and Neck or other specialised)
Breast one-stop diagnostic (including 2-week referrals)
Cardiology
Full Outpatient and Diagnostics clinic (30% in LH/Major most complex, 70% in
hubs/community)
Electrocardiogram (ECG) and Echo - specialist / complex in LH/MH
Risk Assessment - complex patients
Community Services
Community Zone
Dermatology
Diabetes (link to
cardio vascular centre,
diabetes,
ophthalmology)
Emergency Care
Centre
ENT
Ealing LH
Y
Y
Y
Y
Y
Y
Y
Community based cardiac rehabilitation (nurse led)
Y
Space for networks of community-based professionals to coordinate cases and
training
Y
Complementary Voluntary Sector Providers e.g. carer support, respite , patient advice
and liaison pals, peer support groups
Y
Civic space e.g. retail, library, technology and internet access
Y
Healing skin care rehab
Y
Outpatient clinic - Tele-health and minor procedures in community
Phototherapy or other simple but intensive treatment (3 days a week)
Y
Young adult diabetes services (transitional adolescent service)
Y
Y
Insulin pump
Complex Patients (Type 1 + 2) including foot clinic
Paediatric diabetes services
Outpatient clinic
Y
Y
Y
Y
Education for all diabetes patients (elements of this should be delivered across all
settings)
Urgent care centre (adults and children)
Y
Minor injuries unit
Y
Outpatients (dependent on activity)
Y
Y
Microsuction
Frail and Elderly
Network
or Hub
Y
Frail and Elderly Assessment Unit that includes: Rapid access, Neurology, epilepsy,
Parkinson, Stroke outpatient work
Y
Rehabilitation e.g. stroke
Y
Home visits (community liaison nurse, occupational therapist and/or physiotherapist)
Memory Management and Dementia
Gastroenterology and
Colorectal Clinic (GI)
Y
Therapeutic and diagnostic endoscopy (to be scoped)
Y
Rectal Screening
Y
One stop clinic which includes full outpatient, upper/lower GI, rectal bleeding
Y
GP Practice
Space for GP practices and GP rooms for shared clinics
GP practices, GP rooms for shared clinics
Haematology
Specialist Outpatient clinic
General outpatient Clinic
Y
Therapeutic Haematology (e.g. sickle cell)
Y
Patients with LTC and
Cancers e.g.
Respiratory, Cardiac,
failure, Cancer care
Maternity
Y
Y
Y
Educating patients and carers and providing access for minor exacerbations of chronic
disease. Preventative care e.g. smoking cessation, conditions support groups
Y
Antenatal, postnatal advice & complimentary support
Y
Antenatal and postnatal outpatient
Y
Midwife led day assessment with link to consultant
Mental Health
Y
Early pregnancy unit
Y
Mental well-being for non-formal psychiatric condition e.g. psychiatric liaison services
supporting and coordinated with other clinical assessments (IAPT)
Y
Outpatients
Assessment & Liaison (community MH)
Y
Page 49
Y
Y
MSK and orthopaedics
Neurology
Ophthalmology
Outpatient clinics including Trauma and Orthopaedics, pain clinic. The majority of
outpatients seen in hubs (see CCG MSK interface spec)
Rehabilitation (depending on volume and dependencies)
Eye Clinic (outpatient and day case) - Specialist Satellite Unit
Y
Y
Y
Community based services
Paediatrics
Emergency and Urgent Care Access
Y
Y
Outpatient clinic (depends on activity)
Y
Paediatrics
Paediatric Day Assessment
Y
Palliative care
Care to include last 7 days, heart failure and COPD
Y
Radiology
CT scanning (to include Urograms)
X-Ray (Inc. Swallow Test)
Y
Ultrasound
Y
MRI
Y
Rehabilitation
Renal
Respiratory
Y
Psychology
Physiotherapy
Occupational therapy
Speech and language therapy
Dietetics
Step Down (Integrated Rehabilitation) - Beds to be available across the borough
Satellite renal dialysis unit (delivered by Imperial)
Outpatient clinic
Specialist nurse-led clinics in asthma, COPD and TB, pulmonary rehab
MDT's Virtual link
Y
Y
Y
Y
Y
Y
Y
Y
Y
Assessments for domiciliary oxygen and nebuliser use
Rheumatology
Y
Y
Y
Diagnostic clinic
Full rheumatology services linking with MSK, Diabetes. Includes joint injections,
podiatry - the majority of these services would be delivered in a hub
Y
Outpatient clinic including Joint Injections and Nurse-led clinic (majority in hub)
Y
Podiatry
Y
Sensitive Conditions
Ambulatory Care for Sensitive Conditions e.g. Cellulitis, DVT, Pyelonephritis
Sexual health and HIV
Health advisers
Y
Psychosexual counselling
Y
Outpatients (includes GUM Clinic, specialised clinics, contraception, HIV and general
Gynaecology)
Y
HIV and STD testing
Y
Y
Social Care
Assessment / Liaison
Urology
Outpatients
Y
Vascular
Outpatients
Y
Y
Page 50