hampshire and isle of wight primary care strategy...primary care model alongside supporting and...

Hampshire and Isle of Wight

Primary Care Strategy June 2019

DRAFT: version 1.7

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About this document

This document sets out a vision and ambition for primary care services in Hampshire and Isle of

Wight. Primary care services include general practice, community dentistry, optometry and

community dental services.

This strategy is written within the context and framework of the emerging Hampshire and Isle of

Wight (HIOW) Long Term Strategic Delivery Plan and describes the future of primary care services,

how they will work with partners and the contribution they will make to the following system-wide

objectives and goals:

Supporting people to stay well. We will work together to prevent ill-health and promote self-

care. Citizens, patients, service users and communities will be better empowered and

technology will be harnessed more effectively to support wellbeing;

Joining up care locally. We will strengthen and join up care in local neighbourhoods. We will do

this by integrating health and social care teams to better support the needs of the local

communities they serve, use technology to revolutionise people’s experiences and outcomes,

ensure we have a sustainable primary care workforce, and deliver care in the right place at the

right time to reduce reliance on hospitals and care homes;

Specialised care when needed. We will improve services for people who need specialist care by

identifying, understanding and reducing unwarranted variation in outcomes, clinical quality and

efficiency and through the consolidation of more specialised care on fewer sites.

The Hampshire and Isle of Wight Long Term Strategic Delivery Plan [LTSDP] will set the vision and

strategic direction for our health and care system over the next five years. This is currently in

development and due to be published in the autumn 2019.

For this reason, this strategy is iterative. It will both inform the development of, and evolve in

response to, the ambition, objectives and plans that will be described for the whole system over the

coming months.

Approach

This first iteration is a synthesis of existing strategies and plans that are already described for the

local health and care system. This includes but is not limited to:

CCG Primary Care and Out of Hospital Strategies

HIOW Operational Plan 2019/20 and aligned local delivery plans

Fully implementing cluster teams in Hampshire and IOW ( maturity matrix)

Local authority based joint strategic needs assessments and health and wellbeing strategies

It also responds to the direction of travel outlined in key national policy documents including:

The NHS Long Term Plan

Investment and Evolution: A five-year framework for GP contract reform to implement The

NHS Long Term Plan

GP Five Year Forward View

NHS Interim People Plan

The GP Partnership Review

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RCGP Fit for the Future: A vision for general practice

The content will further evolve in response to stakeholder feedback and the development of the

HIOW Long Term Strategic Delivery Plan.

Stakeholder Engagement

This initial version of the strategy will be a mechanism for engagement and participation of key

stakeholders over the next few months. This process will be aligned to the engagement and

communication process underpinning the development of the HIOW Long Term Strategic Delivery

Plan.

Many of the source documents for this initial version of the strategy have had the extensive

engagement of key stakeholders, including the public. This strategy is consistent with this narrative

and will be further tested and refined as part of the wider stakeholder engagement process. An

outline engagement and communication plan is described in the next steps.

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Contents

1. Introduction .................................................................................................................................... 5

2. Primary care in Hampshire and Isle of Wight ................................................................................. 6

3. Case for change ............................................................................................................................... 9

4. The vision for Primary Care services ............................................................................................. 13

5. Delivering our vision: Strengthening the foundations of primary care ....................................... 18

6. Delivering our vision: Implementing future models of integrated care ...................................... 25

7. Delivering our vision: Partnership working to reduce inequalities and improve outcomes ........ 34

8. Enabling our vision: Workforce development ............................................................................. 40

9. Enabling our vision: Digital transformation ................................................................................. 45

10. Enabling our vision: Fit for purpose estate .............................................................................. 47

11. Enabling our vision: Primary care workforce plan ................................................................... 50

12. Enabling our vision: Investment ............................................................................................... 53

13. Delivery, assurance and decision-making ................................................................................. 55

14. Next steps: Planning for successful delivery ............................................................................ 58

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Introduction 1.Primary care is the cornerstone of the NHS, providing the first port of call for the majority of people

who require health advice or treatment, and acting as the gateway into other health and care

services. It is highly valued by those that use it and widely acknowledged as the key to delivering

effective and efficient healthcare.

However, like other parts our local health and care system, it continues to be under strain. The

increasing numbers and complexity of people requiring care and support, coupled with the

persistent challenges of securing the necessary workforce and investment required to meet this

demand, are putting pressure on the whole system. As the front door to the NHS, primary care is

feeling these challenges most acutely and the current model is not sustainable without support and

change.

Our Hampshire and Isle of Wight Long Term Strategic Delivery Plan (LTSDP), to be published in the

autumn 2019, will describe our ambition for a transformed and sustainable model of health and care

that:

Supports people to stay well by preventing ill-health and promoting self-care

Provides care that is joined up and delivered in the right place at the right time

Reduces unwarranted variation in outcomes and clinical quality

Primary care is at the core of this transformed system, sitting at the heart of integrated place-based

teams that have a collective focus on proactively managing the health and care of their local

populations, shaping services around local need and empowering people to take responsibility for

their own health and wellness.

This strategy describes how we will retain and build on the strengths and values of the current

primary care model alongside supporting and enabling its transformation and growth as part of a

sustainable model of care. To achieve this, we will focus in three key areas:

1. Strengthening the foundations of primary care

2. Implementing future models of integrated care

3. Partnership working to reduce inequalities and deliver improved outcomes

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Primary care in Hampshire and Isle of Wight 2.

2.1. Primary Care Services in HIOW: Headlines

Serving a population of circa 2 million people across HIOW, there are circa:

160 general practices

317 community pharmacies

220 providers of dental services providing a range of general dentistry and orthodontics1

191 providers of optometry services providing mandatory services (eye tests and optical

appliances).

These collectively provide primary care services for the local population, and are supplemented with

additional and specialist services commissioned by NHS England and Clinical Commissioning Groups

in each area:

CCG area Registered

Population

No of

general

practices

No of

community

pharmacies

No of opticians

providing

mandatory

services

No of

general

dentist

providers

No of

orthodontics

providers

Average population per general practice

Fareham and

Gosport 204,837 17 34 24 27 2 12,049

Isle of Wight 144,802 16 30 16 15 4 9,050

North

Hampshire 227,385 15 35 19 24 4 15,159

Portsmouth City 232,571 16 41 14 24 4 14,536

South East

Hampshire 216,677 20 43 29 28 3 10,834

Southampton

City 289,850 27 41

15 22 1 10,735

West Hampshire 567,427 49 93

59 52 9 11,580

2.2. Primary Care Networks

We have 42 Primary Care Networks (PCNs) in Hampshire and Isle of Wight. These have been

established as a Direct Enhanced Service (DES) under the new GP contract, with general practice

leading their configuration and development (supported by other partners). PCNs will be the

building block of the future health and care system.

A Primary Care Network consists of groups of general practice working together and with other local

health and care providers around natural local communities. Their purpose is to offer more

personalised, co-ordinated health and social care to their local populations. They will:

1 Dental providers that hold more than one contract for the same specialism in the same CCG areas are only counted once; where a provider offers more than one specialism, each service is counted separately.

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Provide care in different ways to match different people’s needs, including joined up care for those with complex conditions.

Focus on prevention of illness and personalised care, supporting patients to make informed decisions about their care and look after their own health, by connecting them with the full range of statutory and voluntary services.

Use data and technology to assess population health needs and health inequalities; deliver care; support clinical decision making; and monitor performance and variation.

Make best use of collective resources across practices and other local health and care providers to allow greater resilience, more sustainable workload and access to a larger range of professional groups.

Our 42 PCNs cover populations of between 28,000 and 85,000, and many have evolved from existing

arrangements established under the national Vanguard programme, Better Care programme and

local cluster development. Participation in all of these programmes has laid firm foundations on

which to build PCNs going forward.

2.3. Integrated Care System

Hampshire and Isle of Wight is on a trajectory to become an Integrated Care System (ICS) by April

2021 (and in shadow form from April 2020). Becoming an ICS will enable commissioners and NHS

providers, working closely with primary care networks, local authorities and other partners, to take

shared responsibility (in ways that are consistent with their individual legal obligations) for how they

operate their collective resources for the benefit of local populations.

Within our ICS footprint, there are four Integrated Care Partnerships (ICP), based around the

footprint of our acute hospitals, who will focus on aligning the work of the primary care networks,

community services, acute and specialised physical and mental health services. Local ICP plans will

set out their collective priorities, aligned to ICS objectives, and focus on designing and implementing

optimal care pathways that ensure all HIOW citizens have access to the same high quality care. ICP

plans will reflect local needs. PCNs are a key partner in both the design and delivery of these plans.

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Roles and responsibilities in the ICS

HIOW Integrated Care System (2 million people)

System strategy and planning

Oversight of performance

Care System (Aligned to local authority footprints)

Integrate council and NHS planning and delivery

Support PCN development, ensure consistency of practice, reduce unwarranted

Integrated Care Partnership (Based on acute hospital catchments)

North and Mid Hampshire

Southampton and South West Hants

Portsmouth and South East Hants

Isle of Wight

Integrated care delivery in PCNs and local systems

Design and implement optimal care pathways

Manage operational, quality and financial performance

Primary Care Network (communities of 30 – 50k people)

The foundation of the local system

Strengthening primary care

Delivering integrated health, care and wider services to local population

Proactively managing the population health needs

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Case for change 3. The entire health and care system is under strain both in terms of increasing demand and complexity of care. At the same time, the workforce is reducing and funding and resources remain constrained. As the first point of contact for most of the population, primary care, and general practice in particular, is particularly challenged. This chapter articulates some of the key challenges that primary care and the local system is facing, and how this strategy will respond and address to these. Population growth The population of Hampshire, Portsmouth and Southampton is forecast to increase from 1,850,900 to 2,005,700 by 2025 (8.4%). In some areas, this increase in expected to be as high as 12% (Eastleigh, Winchester and Test Valley). Population on the Isle of Wight is expected to grow by 5% over the same time period. Aligned to this is an increase in the number of dwellings with an 8.9% increase projected in Hampshire, Portsmouth and Southampton by 2025, equating to an additional 70,450 homes. This number is as high as 14% in some parts of Hampshire (Rushmoor, Eastleigh, Winchester). More significantly, the age profile of the area is changing with the forecast increase disproportionately reflected in the older age groups, and over 85s in particular. The forecast increase in this age group is 22.4% in Hampshire, Portsmouth and Southampton, with some areas projecting increase as high as 37% (Test Valley) and 32% (Basingstoke). The position on the IOW is ever more marked with a projected 40% increase in over 85s by 2025. In some parts of our area, the proportion of older people compared to children is also changing. This is most significant in the New Forest where there is expected to be 192.5 elderly people for every 100 children by 2025. Fareham and East Hampshire are projected to have a similar profile (144.9 and 139 elderly people respectively). Growing complexity of need All areas anticipate significant growth in over 75s over next ten years; this means more people living in good health, but often with complex needs and co-morbidities. The proportion of people in HIOW diagnosed with long-term conditions such as diabetes, dementia and Chronic Obstructive Pulmonary Disease (COPD) is increasing. The rising frailty and complexity of patients has a direct impact on their utilisation of health and care resources across all sectors. People with long-term conditions account for about 50 per cent of all GP appointments, 64 per cent of all outpatient appointments and over 70 per cent of all inpatient bed days.

The demand for the prevention and management of multi-morbidity is likely to be greater than that of single diseases in the future.

Inequalities Most of the population in Hampshire and Isle of Wight live in good health but there are significant pockets of deprivation within and across CCG areas which are linked to poorer lifestyle choices, poorer health outcomes and shorter life expectancy. Multi-morbidity is more common among

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deprived populations – especially those that include a mental health problem. Addressing these inequalities will be a critical part of population health management approach:

20% of children in Portsmouth and Southampton and 18% of children on the IOW live in low income families; compared to 10% in wider Hampshire.

Life expectancy is lower than the England average for men in Portsmouth and Southampton and for women in Portsmouth; it is generally higher than the England average for the rest of Hampshire and the Isle of Wight

Southampton and Portsmouth have higher levels of under 75 mortality rates linked to cancer and Cardiovascular disease (CVD) than the rest of Hampshire and the England average.

There is also inequality within local areas and districts:

Life expectancy in Havant is 10.4 years lower for men and 8.5 years lower for women in the most deprived areas than in the least deprived areas. This compares to 6.4 years and 4.9 years for Hampshire as a whole.

For Portsmouth, the difference is 8.8 years for men and 7.2 years for women

For Southampton, the difference is 8.2 years for men and 5.1 years for women

Current workforce

Overall, the primary care workforce in HIOW has declined by 8.8% since 2015. GPs and practice staff are leaving the workforce earlier than anticipated and it is getting more difficult to recruit. Use of locum and temporary workforce is increasing as a result.

We have an ageing workforce and when they leave, they will take their skills and knowledge

with them. In HIOW, 19.2% of GPs and 36.1% of primary care nurses are aged over 54 years.

The GP workforce survey, undertaken as part of the GP Partnership Review, indicates that o 10% of GPs are planning to retire early within the next 2 years. o 36% are intending to reduce the number of sessions worked. o 9% are intending to stop clinical practice in the next 2 years.

Later career GPs represented the majority of those planning to retire or stop clinical practice in the next 2 years but the responses for those planning to reduce hours were consistent across early career, mid-career and later career GPs which reflect a growing trend toward part-time working. Only 4% intend to increase the number of sessions worked.

For those planning to reduce their clinical commitment or stop clinical practice, workload was the most cited reason followed by stress/burnout. This was consistent across all stages in the career. Issues with workforce and recruitment and family commitments were also reasons to stop clinical practice across all generations of GP. Pensions are given as a significant reason for stopping clinical practice in the later career GPs.

For primary care nursing, a Wessex LMC survey indicates that 32% are were planning to

retire within the next 5 years; of these 28% are qualified nurses. This is an area of

significant risk, particularly when reviewed in the context of a NHS-wide nursing shortage

which is disproportionately impacting primary and community nursing.

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Future workforce

The numbers of newly qualified clinical staff joining general practice as a first destination role is declining, and the numbers that do join are insufficient to counter the exit of the older workforce retiring or leaving practice.

The new generation of GPs are looking for a different work-life balance. Newly qualified GPs are increasingly opting for ‘porfolio career’ or part-time work. Only 11% of GP trainees intend to do full-time clinical work five years after qualification and up to 11% of early GPs intend to stop clinical practice, emigrate permanently or leave NHS work.

The need to look after children and also elderly relatives means that more GPs require, expect and hope for greater flexibility in their working lives to allow them to undertake these family responsibilities. Lack of flexibility in the working week was considered an issue by a significant number of GPs.

The falling number of GP providers (and corresponding increase in salaried GPs) reflects the declining popularity of the partnership model. This is largely on account of the associated workload pressures and perceived financial risk associated with this model. The GP Partnership Review makes recommendations to address this and encourage a new generation of GP partners.

Workload

By far the biggest challenge facing general practice is that it doesn’t have enough people to do the work required. This is creating unsustainable workload pressures. There has been an average increase in workload in general practice of around 2.5% per year since 2007/8, taking account of both volume and acuity.

Changes in other parts of the system such as community nursing, mental health and care homes are putting additional pressure on general practice. Mental health management has become a much larger part of general practice’s workload yet there is significantly less access to mental health services and a lack of support and practice level.

The lack of social care has a direct impact on practice workload and finally as hospitals have seen an increase in workload more work has fallen to general practice as a result of poorer access to hospital based services.

For people working in general practice, the working day has become too long, the intensity of work too great and GPs do not have sufficient time to manage complex patients appropriately. All of this leads to increased levels of stress and burnout and will in turn compound the workforce shortage.

Public satisfaction Whilst overall public satisfaction with general practice remain high, patient satisfaction with

access has declined, particularly amongst 16-25 years.

The acceleration of new technology is changing the way people access services and interface

with health and care professionals and the pace at which they want results/solutions.

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England Fareham

and Gosport

IOW North Hants

Portsmouth South East Hants

Southampton West Hants

% positive experience of GP practice

83.8% 78% 83.6% 85% 81.4% 84% 77.9% 87.6%

% satisfied with phone access

70.3% 56.5% 71.7% 74.7% 66.7% 71.7% 62.8% 82.7%

% satisfied with practice appt times

65.9% 53.3% 65.1% 61.4% 59.5% 64.3% 61.6% 68.6%

% reporting good overall experience of making appt

68.6% 57.1% 68.8% 67.1% 62.7% 70.7% 62.5% 74.7%

Investment

The increase in workload has not been matched by a transfer in the proportion of funding or staff, which has compounded the challenges that primary care is facing.

The NHS Long Term Plan and new GP contract commit significant investment into primary and community care over the next 5 years is a move to redress this.

What does this mean for how we plan and support primary care services in the future?

More investment and capacity is needed in primary and community care to manage increasing population and growing complexity

A new approach to attracting staff into general practice and better supporting their career aspirations and working requirements is needed if we are to stabilise the workforce

There is a need to develop an extended primary care team

We need new ways of supporting people to access the health and care support they need quickly and efficiently, using digital platforms where this is appropriate.

Providing care and support that is preventative, proactive and anticipatory will be critically important to helping to manage growing demand in an increasing population

Continuity of care will continue to be vitally important for an ageing population with complex needs; but we need more flexibility in how we deploy our workforce to meet their needs

Action is needed to close the inequalities gaps in local areas and the system as a whole; this means tailoring interventions to meet the needs of the local population and proactively targeting those groups at the highest risk of ill-health

This strategy sets out how we will respond to these challenges optimising the use of national support offers and developing co-ordinated local responses to ensure we have a thriving primary care service that works effectively with other parts of the system to deliver world-class outcomes.

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The vision for Primary Care services 4.

The future model of care in Hampshire and Isle of Wight will be premised the following design

principles:

A shift from hospital to community-based care which is centred and co-ordinated around the

footprints of Primary Care Networks. People will only spend time in hospital when they require

the skills and facilities that are only available on these sites.

A greater focus on the prevention of ill-health and enabling people to better look after their

own health and wellbeing. People will have access a range of digital and physical support

resources to help them live healthier lives.

Care will be organised and co-ordinated around the needs of individuals and the communities

in which they live. Those at greatest risk of poor health and/or deterioration will be proactively

supported to prevent avoidable illness or hospitalisation. Continuity of care will be protected

where this is important to a person’s overall health and wellbeing.

Access to on the day (urgent) and specialist care will be better co-ordinated and simplified,

making it easier for people receive timely and effective support and advice when they need it.

Personalised care will be the organising principle in every interaction – a focus on ‘what

matters to me’ and not simply ‘what is the matter with me’. This means looking at more than

just the presenting condition and building resilience in individuals, communities and systems to

support improved health and wellbeing.

Evidently, the future model of care for Hampshire and Isle of Wight is dependent on more than just

primary care services. However, primary care and Primary Care Networks will provide the

foundation for this new way of delivering care.

The vision for primary care services described in the RCGP “Fit for the Future” report provides a

compelling picture of the future health and care system. Whilst its focus is general practice, there

Intensive support

Integrated care

Access to specialists

Choice and control

Proactive support

Continuity of care


Supported self-care

Prompt access to support

and advice

Support to keep well

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are clear synergies with the ambition and future state of other primary care services and

opportunities for improved relationships and delivery with wider health and care partners.

We will use this vision as the basis for further discussion and engagement with key stakeholder

groups as part of further developing this strategy and informing the development of the wider

Hampshire and Isle of Wight Strategic Delivery Plan.

4.1. For people living in Hampshire and Isle of Wight

The GP surgery will continue to be the central point of contact with the NHS for most people. Every person will continue to have a named GP who is accountable for their care but may be supported and treated by another member of the extended practice team who can best meet their needs. These multi-disciplinary teams will ensure that care and support is joined up and co-ordinated around the person.

Whilst care may be delivered in different ways, people will continue to receive the continuity of care that is so valued in primary care. Their electronic care record will be accessible to all professionals involved in their care and they will not have to keep repeating their story.

People will be able to access care and support more quickly and have a greater choice in how and when this happens. Consultations will be delivered both face-to-face in a practice or community-based clinic or remotely through video, online or telephone. There will be enhanced access to appointments in the evenings and at weekends. Some care will be delivered at home.

People will be treated as equal partners in their own care, with shared decision-making as the norm between the person, their carers and professional. Care will be personalised with greater focus on ‘what matters to me?’ and not just ‘what is the matter with me?’. Care will be planned in ways which reduces the burden of treatment and fits around their lives.

Patients will be supported to take greater control and responsibility for their own health and wellbeing, and equipped with the tools to manage their own conditions and to live as well as possible

People will understand and trust the skills and expertise of each member of this extended team and have confidence that they are being seen by the professional that is most appropriate for their needs. Trust and satisfaction with primary care services will be at an all-time high

4.2. For people working in primary care services

People working in primary care will have the skills, resources and time they need to meet the health and care needs of the population. Primary care will work in collaboration with health and care partners to proactively improve the health outcomes of the populations they serve, enhance access and tackle health inequalities.

Primary care networks are fully established, all additional roles are recruited to and the boundaries between primary and community care are dissolved. Services will be delivered by multi-disciplinary teams that include a range of clinical and non-clinical roles, offering a wider range of services tailored to the needs of the local population and helping to reduce the

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pressure on small teams.

There will be more staff working in primary care and PCNs. New and extended roles will complement the skills of the GP, enabling local practices to better support patients to manage their conditions and to remain in good health. This will include

o Expanded teams with the capacity and skills to deliver education and support for self-management and behavioural health improvements.

o Integrated care teams working together to provide proactive and co-ordinated care to patients with the most complex needs.

o Social prescribing schemes which offer parallel support to core general practice, helping to address social isolation and connect patients to community and voluntary services.

Continuity of care will remain a core value of general practice. GPs will continue to provide holistic care and establish long-term, therapeutic relationships with patients, particularly with those with complex needs or multiple health conditions.

Services will be delivered in modernised, technology-enabled and fit for purpose premises offering a range of digital services that includes video consultations and remote monitoring to enable the delivery of more proactive and preventative care.

PCNs will be working in partnership with secondary care teams to improve access to specialist advice and support, improve capability and skills in PCN teams and reduce requirements for hospital referral and attendance.

General practice operating at scale through PCNs will increase their resilience through greater pooling of expertise, resources and back office functions.

Workloads will be manageable on account of PCNs and multi-disciplinary team working, an increased focus on self-care and more flexible channels of communication that allow more time to care. Professionals will have more time to care and to continuing professional development. Their overall health and wellbeing will improve.

Staff satisfaction will be higher and staff turnover will be lower. A more stable primary care workforce will protect the continuity of relationship between practice and patients that is so highly valued.

General practice will be the career destination of choice for growing numbers of professionals and there will be more career development opportunities for professionals working in primary care that fit with their aspirations and life circumstances.

The partnership model is revitalised and attracting a new generation of GP partners who are drawn to the autonomy and opportunity that partnership offers, with the support of wider networks.

4.3. For the wider health and care system

Primary care networks will be fully formed and mature, providing the primary delivery vehicle for integrated place-based care and contributing to the development and delivery of wider

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system plans. PCNs will look out and not in – and dissolve the divide between primary and community services.

Primary care networks will have a comprehensive understanding of the health needs of the population they serve, undertake risk stratification and work at both an individual and community level to tackle health inequalities. This will enable more equitable provision of care and a wider range of primary care services in a defined geography.

Through a better understanding of their population, primary care networks will proactively identify groups of people at risk of developing chronic illness without intervention and support. PCNs will work with individuals and local services and teams to take action that supports better health and wellbeing in the longer term.

Clear and measurable improvements in outcomes a result in the additional investment in PCNs over the next 5 years:

o Improved early diagnosis of cancer o Early detection and improved management of hypertension and atrial fibrillation o Reduced polypharmacy o Improved support and quality of service in care and residential homes o Personalised care in every interaction

There will be a cultural shift in the focus of healthcare: from treating disease and prescribing medication to addressing a person's psychosocial needs and improving their quality of life. Professionals will be empowered to respond to the needs and preferences of the person.

General practice will routinely host a wider range of prevention, wellbeing and social action projects and services, all of which will help to tackle health inequalities and build strong, resilient communities. There will be strong connections to local government to enable this.

The traditional boundaries between primary and secondary care will have become more blurred. More services, diagnostic tests and treatments, currently delivered in hospitals, will be provided closer to home in community settings. There will be more specialists attached to primary care networks.

Service design and quality improvement will be co-produced by primary care teams and the communities they services the health and care system will permit rather than restrict this bottom-up approach.

Real-time data will be used to monitor demand and service delivery, as well as technology to help direct patients to the most appropriate services or professional.

Unwarranted variations in the quality and safety of care will have reduced and all parts of the health and care system will be operating efficiently and in the best interest of the population we serve.

Primary care will be a key partner in the delivery of world class services and outcomes for the people of Hampshire and Isle of Wight.

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4.4. What difference will this make?

Benefits for people:

People are supported to stay well and have the tools and motivation to look after their own health and

wellbeing

People can easily access support and advice that is timely, delivered close to home and with the right

professional to meet their needs

People with chronic or complex illness receive care that is consistent, joined up and centred around their

needs and wishes, with fewer hand-offs and reduced duplication

People are only in hospital for the acute phase of their illness and injury and are supported to regain/retain

independence in their usual place of residence

People have greater choice and control over decisions that affect their own health and wellbeing

People are treated as individuals, not a set of symptoms

People have more years in good health and a better quality of life

Benefits for workforce:

Staff feel valued, supported and members of a team

Workload is manageable, staff have more time to care and are empowered to have conversations with

people about what matters to them

There is less duplication , waste and hand-offs - barriers are removed

Staff have more time for career development and are supported to increase their capabilities and skills in

line with their career aspirations

Staff have access to range of career pathways that are flexible and tailored to their needs

Staff are happy and produce of the care they deliver and the system they work in

There is a positive culture of working and learning together across professional and organisational

boundaries

Benefits for the system

Improved population health outcomes, reduction in preventable disease and reduced health inequalities

Reduction in unwarranted variation in access and outcomes

Activated individuals and communities looking after their own health and wellbeing and releasing capacity

in the system

Increased capacity in primary and community care to manage local health and care needs

Primary care is sustainable and thriving, leading to improving recruitment and retention rates

Attract and retain the right workforce in all sectors

Optimised resource utilisation as a result of better health and better managed chronic conditions

Reduction in rate of acute non-elective activity growth and demand for urgent care services

More efficient bed use and fewer delayed transfer of care

Fewer permanent admissions to residential and nursing care

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Delivering our vision: Strengthening the foundations of primary care 5.

Our future health and care system is dependent on a strong foundation of primary care services. The

shift to provide more care closer to home, rather than in hospital, and the increased focus on

preventative and anticipatory care as the means to improve outcomes and better manage demand

relies on a thriving and resilient primary care offer.

However, the current model of care is not sustainable. Like other parts of the country, population

growth, more people with long-term conditions, increasing complexity of need and a propensity

towards community-based care is leading to ever-increasing demands on primary care teams in

Hampshire and the Isle of Wight. This increasing workload is leading to higher levels of stress and

burnout, driving the current primary care workforce to leave practice earlier than anticipated and

discouraging people from joining the service on account of the challenges it face. The result is a

perpetual cycle of increasing workload with fewer staff to manage it, which carries risk for both the

quality of care people receive and how quickly they can access it.

In order to break this cycle, we will provide additional support and investment into primary care

services coupled with new approaches to delivering care that helps to reduce workload whilst

maintaining a high quality, person-centred service. Staff working in primary care will feel better

supported and valued, have greater opportunity to develop new skills, and feel proud of the service

they provide. At the same time, we will look to the future in terms of both increasing resilience in

primary care services through enabling new business models and developing the workforce of the

future.

5.1. General Practice

5.1.1. Reducing Workload

General practice has repeatedly identified workload their single biggest concern, and this was re-

confirmed as a key issue in the 2019 GP Partnership Review. There has been an average increase in

workload of around 2.5% per year 2007/8, taking account of both volume and acuity. The shift

towards more community-based care is going to increase this pressure further unless we take action

to reduce workload to manageable levels. We will look to support general practice to reduce this

pressure in the follow ways:

Increasing the workforce – Investing in additional workforce and extending the roles of the general

practice team is essential to increase the capacity required. Wider members of the practice-based

teams, which will include therapists, pharmacists and others, will play an increasing role in providing

We will strengthen the foundations of primary care by taking action to

Reduce workload by extending practice teams, using technology to improve access and

supporting people to look after their own health and wellbeing

Improve retention and recruitment of staff through new and targeted approaches to career

development and support

Enable practices to become stable and resilient

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day-to-day co-ordination and care. This will include but is not limited to basis triage, This will be

funded through additional investment in the core practice contract in addition to the funding

available for key roles in Primary Care Networks will be shared across groups of general practice.

Making more effective use of the existing workforce – Building integrated primary and community

care teams is a key commitment of the NHS Long Term Plan. Community services, and community

nursing in particular, will in the future be configured around the footprint of the PCN. We will

support community providers and primary care to work together as a single MDT, enabled by a

shared record and co-location where appropriate. Removing the historic divide between primary

and community care will help resilience and workload in both areas, leading to better outcomes for

people.

To support this, PCNs will be encouraged to access the national Time for Care development

programme which describes ten High Impact Actions that can help to ease workload pressure:

1. Active signposting

2. New consultation types

3. Reduce Did Not Attend (DNAs)

4. Develop the wider team

5. Productive work flows

6. Improve personal productivity

7. Greater Partnership working

8. Social prescribing

9. Support self-care

10. Develop QI expertise

Expanding digital-first primary care - Implementing and extending new ways of accessing support

and advice from general practice will have the dual benefit of providing more choice and flexibility

for people as well as releasing time for professionals. Key areas of development in Hampshire and

Isle of Wight are:

Online consultation - Hampshire and Isle of Wight is a national leader in the deployment of

online consultation with 80% of our practices already using the service. This is currently

delivering in the region of 8,000 consultations per month and we will support and encourage

both people and practitioners to further increase its usage.

Video consultations - The provision of video consultations will support general practice to offer

greater accessibility and flexibility for people and practitioners. It also creates opportunity for

GPs to have easier access to specialist advice and support which can support better and more

efficient clinical decision making. We are currently piloting the technology in our community

providers with a view to wider roll-out across general practice in line with national timescales.

Online self-management support and signposting - In the past year we have successfully

implemented both NHS 111 Online and the NHS App. Both enable people to check their

symptoms online and find out what they need to do when they need help urgently. This

supports improved self-care and helps to direct people to the right service response. We will

continue to develop these services to improve integration with surrounding services and

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applications. This will include the ability to book and manage appointments at the GP practice.

All practices using TPP or EMIS systems will be connected to the NHS App by July 2019.

NHS 111 - From 2019, NHS 111 will commence direct booking into general practice. Hampshire

and Isle of Wight is a first-of-type site for direct appointment booking from NHS 111.

Primary care at scale - General practice is already successfully working together at scale to provide

extended access to routine appointments at evenings and weekends. These hub models provide

more choice and flexibility for people and professionals and enable the pooling of capacity across

primary care teams.

General practice in HIOW has a history and reputation for developing innovative solutions, and

enabled by national development programmes including Vanguard and Better Care, we have

developed other local models that are premised on collaboration between practices and with other

health and care partners. This includes the development of Same Day Access Services, Acute Home

Visiting services and enhanced multi-disciplinary support to care homes. Our GP Federations have

been key in supporting and enabling these developments.

The advent of Primary Care Networks provides an opportunity to both optimise this approach (in line

with the national review process) and explore new ways of pooling capacity and expertise across

practice footprint and using the extended primary care team to enable delivery.

As a system, we will support and enable PCNs to share and spread successful models of care, and to

develop new and innovative service offers where there is a dual benefit of improving access and

outcomes for people, and supporting a more manageable workload.

Education and supported self-management - Increased capacity will only have an impact if we can

also develop a new relationship with the local population that stems the growth in demand by

supporting people to have the skills and confidence to look after their own health and access care at

the right time in the right place.

A system priority is to shift care towards prevention, early intervention and self-care as a means to

improve quality, reduce variation in outcomes and better manage local demand for services. We will

look to expand and build on the range of initiatives and support offers already in place at practice

and local system level to support local people to be in good health for longer and to equip them with

the skills and confidence to better manage their own health and care needs. This includes:

Deployment of signposting and care navigation roles in GP practices to assist people in navigating the local system and directing them to support groups and networks within their local communities that contribute to improved health and wellbeing

Training primary and community teams in health coaching and patient activation techniques to support and enable people with long term conditions to better manage their own health and wellbeing needs, and prevent exacerbation

Use of assistive technology to support independent and supported living, and access to online consultation and advice

Proactive care planning for those identified at highest risk of hospitalisation (frail/ co-morbidities) which considers both social and medical needs, and the co-ordination of resources within systems to maintain wellness for as long as possible

Activation of community assets and proactive education programmes (diabetes, falls) to support behaviour change and healthy lifestyle choices

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Embedding a personalised care approach in every interaction with our population will be key to

effecting the shift in health behaviours and confidence that individuals need to look after their

health and wellbeing needs, and know when and how to access support appropriately. As a national

demonstrator site for roll-out of the universal model for personalised care, we will prioritise

increasing the strength and scale of this approach in every part of the system, including general

practice and Primary Care Networks.

5.1.2. Supporting career development

Reversing the trend of practitioners leaving general practice early and increasing the appeal of

general practice as a career destination are key priorities to ensure we have the workforce required

to stabilise general practice, deliver new models of integrated care and to meet current and future

demand.

We will support general practice to become a better place to work by developing more targeted

approaches to recruitment that attracts the best staff, underpinned by a supportive and enabling

working environment that keeps people working in general practice in HIOW.

Retaining our workforce - Our priority is to keep the workforce we have. By continuing to work in

partnership with Health Education England Wessex, the Local Medical Committees and local GP

federations, we will expand the range of career development opportunities available at every career

stage, providing greater opportunities for flexible working and portfolio career development as well

as developing the multi-disciplinary team working that is essential to managing future demand.

We will focus on the learning and successes of schemes already in operation, and use this

intelligence to both spread good practice and encourage innovation in other areas. This will be

enabled through deployment of national GP retention funding as available. Current initiatives

include:

Early Year Retention of GPs and Flexible Working (Southampton and SW Hampshire)

Targeted at GPs who want to work more flexibly and in different care environments e.g. home visiting services, frailty services, GP streaming

Provides variety of opportunity and experience and support local system resilience

Link Specialty Programme (North and Mid Hampshire)

Joint initiative between GP Federation and acute trust to provide opportunities to develop a special interest by working in the hospital one session per week

Dual benefit of increasing skills and building relationships between primary and secondary care

Next Generation GPs (Wessex LMC)

National scheme implemented with local support

Purpose is to engage, empower and energise emerging GP leaders

Triple E Programme (Wessex LMC)

Eleven GPs recruited to lead small peer groups focused on personal and professional development

Aim is to improve networking and build resilience within general practice

GP Supporters (Wessex LMC)

Experience GPs are recruited to provide support to struggling practice as both a hand-on GP and as GP leader

Benefit for practices receiving support as well as for GP that are retired or at later stage of their career to work more flexibly and use skills and experience for mentoring and education

GP Retention Intensive Support Scheme (Isle of Wight)

One of seven sites in national support programme

Interventions include coaching and mentoring of existing staff, portfolio career development, collaborative workforce ‘bank’ and web-based

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recruitment hub

Opportunity to use learning and successes to support spread across whole system

We will offer support to GPs to who are experience difficulties through schemes such as the Wessex

LMCs GP Support and Development Scheme. This provides access to coaching, counselling and

mentoring services for individuals who are feeling unsettled and at risk of leaving the profession.

At the same time, we will continue to maximise uptake and participation in the national GP

retention scheme to provide financial and educational support to experienced doctors who might

otherwise retire or leave the profession. Retained GP will be supported to work more flexibly in part-

time roles that are better suited to their career and life aspirations.

Retention and development of wider practice team

The ambition is for each PCN to have access to training hub services to support its objectives in implementing the multidisciplinary team. Our three Primary Care Training Hubs will enable the development of the wider primary care workforce, with a key focus on supporting professionals to develop advanced clinical skills and work at the ‘top of their license’ which has dual benefits for both multi-disciplinary working and individual career development. A key area of focus is the retention and development General Practice Nurses. We already run a

successful general practice nursing programme and currently have in excess of 20 general practice

nurses in training to become advanced nurse practitioners.

We also support a Wessex wide general practice nurse leadership course and nurse mentors in

general practice have increased from to over 180 in the past two years. Return to practice for

general practice nurses is established across Wessex. We have the first general practice nurse Fellow

in Wessex undertaking her fellowship in the Training Hubs alongside 3 GP Fellows. We will

participate in the national retention programme for general practice nursing when launched.

Practice managers will be supported through the Wessex LMCs Practice Manager Supporters programme. There are currently 9 Practice Manager Supporters across Wessex who provide ad hoc advice and support to their practice manager colleagues, and offer learning opportunities to support Continuous Professional Development for PMs. The PM Supporters offer coaching and mentoring to new and experienced practice managers, and have specific training to enable them to appraise fellow practice managers.

Training and recruitment

We will continue to work closely with the Wessex School of General Practice to support the

recruitment, training and continued professional development of all GPs in the area. As part of this

we will optimise our participation in national programmes to increase workforce supply. This

includes:

The international recruitment scheme to secure GPs and nurses from overseas

The new Primary Care Fellowship Programme to offer newly qualified GPs and nurses a secure

contract of employment for two years that is tailored to their aspirations and interests

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Continued participation in the induction and refresher scheme to support GPs to return to

practice

Training Hubs are also working with higher education institutes and local practices to provide enable

more trainees to be placed in general practice and in Primary Care Networks. We will support

Primary Care Networks to take on more responsibility for trainees in the future which could include

apprentices, medical students, nursing students, paramedics and pharmacists.

5.1.3. Enabling practice stability

The combined effect of an increased workload, a reducing workforce and many years of

underinvestment has led to higher number of practice closures and a decline in the number of GP

partnerships. The 2019 GP Partnership Review found that an increasing level of personal financial

risk is one of the major reasons that GPs were opting not to join partnerships, or leaving them

prematurely.

We want to reverse this trend. We will support all general practices in HIOW to become more

sustainable through developing more efficient ways of working that reduce the risk to practices and

partners. This in turn may lead to more GPs establishing partnerships in the future. Our approach

will include:

General Practice Resilience Scheme - We have adopted a pan-HIOW approach to supporting

practice resilience, building on our experience and learning from the past two years of accessing the

national scheme. We will provide support to practices at risk of closure or going through significant

change to enable them to become more sustainable. Our key areas of focus are:

Practice planning or going through mergers or significant change

Practices where there are local concerns (as identified by CCG, LMC or NHSE)

Practice where CQC rating is inadequate or requires improvement

Practice already receiving support and risk negative impact if stopped

Practices previously identified as vulnerable but did not take up offer

We will work with vulnerable practices to develop support offers and solutions that are tailored to

their needs and share learning across the system to improve our overall resilience and sustainability.

GP Supporter Scheme – GP supporters are highly experienced GPs who work in and with struggling

practices for a time-limited period to help them address their challenges which can be clinical or

managerial or both. They will work with the practice to assist with clinical sessions, provide

headspace to think about different ways of working and to help explore working at scale or merging.

They can also advise on practice finance and governance issues.

Primary Care Networks – PCNs provide an opportunity for practices to work together to improve

their collective resilience and sustainability. This will include opportunities to provide services at

scale, sharing resources and managing collective demand; there is also scope for practices to pool

back office functions to reduce costs and workload. In the future PCNs are expected to become the

primary delivery vehicle for new community-based services which will attract further investment.

We will support PCNs in HIOW to become mature and effective vehicles for change.

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Premises - Financial risk linked to premises is one of the major deterrents for GPs joining or

remaining with a partnership. We will respond to the outputs of the national primary care premises

review when published and ensure this is reflected in our HIOW Estates strategy and plans to better

support GPs in managing this risk.

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Delivering our vision: Implementing future models of integrated care 6.

The future model of health and care in Hampshire and Isle of Wight is premised on providing care

and support that is planned and organised around the health and wellbeing needs of individuals and

communities. This will see a greater join up between the different partners in the system in order to

deliver more co-ordinated and proactive care, reduce reliance on hospital-based care and deliver

better outcomes and a more sustainable system.

Health and wellbeing needs will be different for individuals and groups of individuals and we are

committed to developing models of care that responds to their specific needs. At the heart of this is

the need to dissolve the traditional boundaries between primary and community services and

develop a team based multidisciplinary way of delivering care, where general practice is working

alongside colleagues in primary, secondary and community care to make the best use of the skills

available.

The NHS Long Term Plan commits an additional £4.5 billion of investment into primary and

community care to enable this. It also establishes PCNs as the vehicle for delivering this new model

locally-focus integrated delivery. Under the Network Contract Direct Enhanced Services (DES),

We will implement new models of integrated care by enabling and supporting the

development of 42 Primary Care Networks in HIOW

Our PCNs will work with community and social care partner to provide integrated care teams

that deliver proactive ,anticipatory and preventative care for local populations.

The voluntary and community sector, and secondary care teams will be key partners in

delivery

People will have better access to car that is planned and co-ordinated around their needs

Intensive support

Integrated care


Choice and control

Proactive support

Continuity of care


Supported self-care

Prompt access to

support and advice

Support to keep well

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general practice will take taking a leading role in every PCN but its success will be dependent on

establishing effective partnership with other community health and care teams.

Both of these developments present an opportunity to strengthen and accelerate the work that is

already happening across Hampshire and Isle of Wight. Our 42 PCNs are at the heart of our future

delivery model and we are committed to enabling their success. We will invest in their workforce

and infrastructure; address the barriers that that prevent integration and enable our teams to work

in a different way with each other and with local people to deliver the best care possible.

6.1. The future model of integrated primary and community care

Primary Care Networks will become the primary vehicle for the delivery of integrated primary and

community care. Resources will be organised to respond to the needs, priorities and assets of the

people that live in the locality.

PCNs will work with other system partners to deliver more care at home and in the community,

provide additional capacity into primary care, reduce hospital admission rates and enable people to

be discharged from hospital when they are medically fit. People will be supported to remain

independent in their own home for as long as possible. A key objective for PCNs is to shift the

pattern of care and services to be more preventative, proactive and local for people of all ages.

In order to deliver the required outcomes, PCNs will be organised around a common set of

principles:

• A persistent emphasis on the wellness of the whole person with the needs and wants of the

individual driving what happens to them

• Access to and co-ordination of services is simplified and easy to use for people and other

care professionals

• A proactive approach to the identification and management of local people who are at the

greatest risk of poor health and care outcomes

• Minimal hand offs and maximised co-ordination to reduce duplication and waste

• Resources and services are optimised to support sustainability and consistency of delivery

6.2. Supporting people to stay well

We will support PCNs to increase their capacity and capability to enable people to take greater

control of their own health and wellbeing. This will include:

Using local data and intelligence to assess the health needs of their communities and determine

local priorities for prevention activity

Utilising behaviour change interventions (Making Every Contact Count), person activation tools

(PAM) and education programmes that support healthy lifestyle choices

Delivering social prescribing services which are focused on better understanding an individual’s

overall needs and goals, and work with community support group and voluntary organisations to

respond to these

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Supporting people with long-term physical and mental health conditions to build knowledge,

skills and confidence through supported self-care and community-centred approaches

Working with local authority partners to tackle wider determinants of health e.g. housing,

education, employment

Delivery of this approach will require new skills and capacity in the PCN workforce and closer

working with other health and care partners. This will include:

Social prescribing link workers, working as part of PCNs teams, will empower people to take

control of their health and wellbeing and connect them to community groups and statutory

services for practical and emotional support. This is particularly key for people with long term

conditions (including support for mental health), people who are lonely or isolated, or have

complex social needs which impact on wellbeing.

Link workers will initially receive referrals from PCN member practices (in 2019/20) extending to

wider agencies (from 2020/21) including pharmacies, hospital discharge teams and job centres.

They will have a role in educating PCN staff on what services and support is available in the

community and how can they be accessed. We already have a well-established social prescribing

network in HIOW and we will ensure that link workers and PCNs are appropriately connected

into existing offers and infrastructure.

Building community capacity - Link workers will also work with local communities, enabling local

voluntary, community and social enterprise (VCSE) organisations and community groups to

receive social prescribing referrals and providing support to set up new community groups and

services, where gaps are identified in local provision. We will support the VCSE.

Case finding and behavioural change - Developing skills and technology in the wider PCN team

to support improved case finding of people at most risk of ill-health or chronic illness and to

have better conversations with individuals that are premised on behavioural change techniques.

Targeted prevention - Closer working with system partners, including the Cancer Alliance and

public health to improve access and uptake of cancer screening programmes, immunisations and

vaccinations and improved health literacy, with a particular focus on hard to reach populations.

PCNs are uniquely place to understand what will work best for their communities and to develop

tailored solutions to meet those needs.

Access to online support, advice and education - This will include access to NHS 111 and the

NHS app for self-care advice and signposting for health management but also to a central

repository for signposting to for community wellbeing and support services. Connect to Support

in Hampshire is a key example of this.

Anticipated benefits

Improved self-confidence and resilience to manage own health and wellbeing

Reduction in risk taking behaviours (leading to improved health outcomes)

Reduction in health inequalities

Improved quality of life and length of life

Reduction in preventable ill-health and exacerbation (leading to fewer GP visit)

Increase in community cohesion and activation

6.3. Improving access to on the day demand for primary care

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We will support PCNs to improve access to urgent and planned primary care through:

Provision of same day/urgent triage and home visiting services for people at risk of

admission

Delivery of extended access to primary care appointments in evenings and weekend

Provision of alternatives to face to face appointments e.g. on-line consultation, telephone

triage, 111 online

Clinical assessment by the most appropriate professional and managed accordingly

This might include advice on self-care/management or access to appropriate support to

enable people to remain safely at home e.g. rapid response

General practice will continue to provide main route of access into routine primary care but PCNs

will be able to offer additional support and capacity to improve access and help manage demand.

This will include:

Improved management of in hours capacity in general practice by developing single points of

access a PCN footprint (e.g. telephone triage) and consolidates same day access services that

operate across practice boundaries. This will include bringing together the current extended

hours and extended access offers provided by general practice to provide a single, unified and

flexible for people requiring evening and weekend appointments in primary care.

Appropriate redirection of people presenting in general practice who could be best managed in

another setting. This will include, for example, community pharmacists through local ‘pharmacy

connection’ schemes or similar.

Access to First Contact MSK Physiotherapist who will see patients without prior contact with

their GP to establish a rapid and accurate diagnosis and management plan. They will liaise with

community and secondary care MSK services, as required, to support the management of

patients in primary care. They will work independently and help to release current GP workload.

Access will be via self-referral or by network members. We are currently piloting similar models

across the system and will look to align and integrate these offers to the PCN offer.

Access to Physician Associates who will work as part of the medical team to provide an

alternative first point of contact for people presenting in primary care with undifferentiated,

undiagnosed problems. They will provide assessment, diagnosis and treatment under the direct

supervision of a doctor. We are currently supporting the development of these roles via the

Primary and Community Training Hubs and in conjunction with Higher Education Institutes

Access to advanced paramedic practitioners who will work autonomously within the

community to provide first point of contact for people presenting with undifferentiated,

undiagnosed problems relating to minor illness or injury, abdominal pains, chest pains and

headaches. They will provide an alternative model to urgent and same day GP home visit.

Practitioners will assess, triage and treat in line with clinical guidelines as well as signposting and

onward referral to other services as appropriate. We already piloting this approach in some

parts of the system and will look to scale up in line with national policy direction.

Joining up the delivery of urgent care in the community – PCNs will facilitate the delivery of

convenient appointments ‘in hours’, reduce duplication and facilitate better integration with

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other urgent and emergency care services including NHS 111, urgent treatment centres and GP

streaming services provided in accident and emergency departments.

Expected Benefits

Improved access to primary care (routine and urgent)

Fewer hand-offs and better experience of care

Better join up of urgent care services

Increase in primary care resilience and sustainability

6.4. Proactively join up care for those with ongoing needs

We will support Primary Care Networks to develop integrated multi-disciplinary teams that will:

o Proactively identify people who are vulnerable or have complex needs and are at risk of

deteriorating using risk stratification tool and combined local intelligence

o Jointly assess and plan to meet primary focus for joining up care and assign an appropriate

key worker/lead professional from the cluster team

o Support people to have more informed choice and control over the decisions that impact

their health and wellbeing

o Co-produce a personalised care plan with the individual that is tailored to their needs and

views, including escalation plans and plans for maintaining health and wellbeing This could

include education, social prescribing and assistive technology. It may also include decision

for non-intervention

o Provide a single point of contact for people to navigate complex services. This will typically

be a care coordinator/navigator who will provide regular and frequent contact with the

individual to reduce the risk of crisis events

General practice will continue to focus on the routine provision of care to vulnerable/ complex

people where continuity of care is particularly important but PCNs will be able to offer additional

capacity and support to:

Long-term condition management, including frailty and mental health, , to include routine

and preventative interventions to reduce risk of avoidable deterioration/increasing

complexity. This includes accessing advice /input from specialists to inform personalised

care planning.

• Care home residents who will benefit from anticipatory care planning and MDT

management, and to advise /upskill staff the management of complex

illness/comorbidities. The Enhanced Care in Care Homes model is already being

implemented in some parts of the system and we will look to extend this to provide 100%

coverage to care home in line with NHS Long Term Plan commitments.

• People at the end of life will be supported to make informed choices about their care and

receive care that is joined-up and tailored to their wishes, preferences and needs.

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Clinical pharmacists will have a critical role in enabling this model, working as part of the PCN to

support the proactive management of people with complex polypharmacy and/or chronic disease,

including those in care homes and people with learning disabilities. Through structured reviews,

clinical pharmacists will support patients to take their medicines to get the best from them, reduce

waste and promote self-care.

To enable this, integrated care teams will be developed as part of all PCNs to deliver proactive and

anticipatory care that meets the needs of the local population. The model of care will be developed

locally in response to local needs and existing infrastructure but there will be common features

across all ICTs:

• Core ICT membership will include primary care, community nursing, community mental

health, pharmacists and social care with easy access to therapists and community and acute

specialist support as required. Voluntary and community partners will also be clear

• The ICT will meet at least weekly to review and co-ordinate a shared caseload and have

access to a shared care record to facilitate joined up and seamless care. There will be a

single point of referral to the ICT to simplify access

• The team will be community-based, delivering care in and around GP practices, local hubs

and/or in people’s homes (including care homes). Some care will be delivered remotely

using digital technologies

We will work with emerging PCNs and community and social care providers to align and integrate

resources to PCN footprint and create a culture and environment that support integrated working

and removes the barriers between primary and community care.

Expected Benefits

People feel more in control of their health and wellbeing, have choice over the decisions that affect

their care and are more confidence/resilience

People receive consistent service and continuity of care maintained

Care is planned and organised around the individual

Fewer exacerbations/crisis events (improved outcomes)

Staff are enabled and supported to deliver proactive care

Reduced need for emergency or unplanned intervention

Improved quality of care and fewer avoidable admissions from care homes

Reduction in permanent admissions to residential homes (including people of working age)

Slower growth in hospital utilisation

Reduced pressure on social care, including independent sector providers

6.5. Improved access to step-up and step-down care

PCNs will work with other health and care partners to facilitate supported discharge from

acute and community hospitals, including inreach service and/or discharge to assess models

where appropriate. This will include the new community-led urgent response and

reablement service as set out in the NHS Long Term Plan.

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PCNs will have clear access routes to a range of step-up and step-down services including

integrated rapid response services, intermediate care beds, integrated rehabilitation,

reablement and recovery services delivered in people’s homes.

Expected Benefits

People are only in hospital for the acute phase of their illness/injury

Shorter LOS and reduced DTOC

Greater opportunity to retain/regain independence (quality of life)

6.6. Improved access to specialist care

We will support PCNs to work with acute physical and mental health services and community

specialist services to improve access to care and support a shift from hospital to community-based

care. This will include:

Timely access to specialist advice to assist in the management of people in the community,

including input to personalised care plans

Specialist input to ‘one stop’ community clinics for people with LTCs or complex need,

and/or digital solutions that support the provision of care remotely

Support for transition planning between hospital and community (or vice-versa)

Routine review of referrals for specialist care to support improved care pathways

PCNs will develop closer working relationship with specialist teams, facilitated through video

consultations and digital solutions as part of developing care and treatment plans for individuals and

to support follow-up care. Specialists will also work with PCNs to develop team capabilities and skills

to better manage specific conditions in a community setting and reduce the need for onward

hospital referral.

Expected Benefits

People experience more joined up care with fewer hand-offs and reduced duplication

Reduction in unnecessary follow-up appointments

Quality of care is improved leading to better outcomes/fewer exacerbations

Optimised use of resources between acute and community services to meet local need

6.7. HIOW Models of Care Programme

The HIOW Models of Care programme seeks to support the development of PCNs and enable HIOW-wide delivery of this new model of integrated primary and community care delivery. Key functions include

Shaping and influence the design and delivery of system-wide enablers to PCN development

(‘do it once’ approach), liaising with other HIOW programmes as appropriate

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Facilitating collaborative problem solving and issuer resolution which impact multiple PCNs

and local systems. This will include setting up time-limited task and finish groups where

appropriate.

Supporting shared learning between PCNs, local systems and national best practice.

To develop proposals for the deployment of HIOW-wide transformation/non-recurrent

funding and resources to support PCN and models of care development.

Tracking progress in both the development and impact of PCNs and models of integrated primary and community care across HIOW.

To support this we have co-developed a HIOW maturity matrix with system partners which describes the journey of development for primary care networks, recognising that they will develop and mature at different rates. This is aligned to national guidance and the new contractual framework, and provides a common framework to enable benchmarking of progress between PCNs and systems, to facilitate shared learning and to support the channelling of national investment and support offer into priority areas for development.

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Delivering our vision: Partnership working to reduce inequalities and 7.

improve outcomes

As an aspiring integrated care system, Hampshire and Isle of Wight is committed to delivering

measurable improvements and reducing unwarranted variation in access and outcomes for the local

population. At the heart of our vision is a commitment to support people to lead healthier lives, to

promote wellbeing in addition to treating illness and to enable people to take greater responsibility

for their own health and care. We will deliver this within a health and care system that ensures

people have access to high quality, consistent care 24/7 and as close to home as possible.

PCNs are an essential delivery partner in realising this ambition. By bringing together the values,

skills and resources of general practice with other health and care partners to serve a defined

population, we will support our PCNs to bring a clear local focus for improving health and well-being

and reducing inequalities in access and outcomes.

7.1. Population health management

Population Health is an approach aimed at improving the health of an entire population. It is about

improving the physical and mental health outcomes and wellbeing of people, whilst reducing health

inequalities within and across a defined population. It includes action to reduce the occurrence of ill-

health, including addressing wider determinants of health, and requires working with communities

and partner agencies.

Population Health Management improves population health by data driven planning and delivery of

care to achieve maximum impact. It includes segmentation, stratification and impact modelling to

identify local ‘at risk’ cohorts - and, in turn, designing and targeting interventions to prevent ill-

health and to improve care and support for people with ongoing health conditions and reducing

unwarranted variations in outcomes.

In HIOW, PCNs will contribute to and benefit from participation in the system-wide Population

Health Management programme and delivery of an enhanced analytical capability will continue in

2019/20.

Initially, the ongoing work to provide PCN-level data and dashboards will continue to support the

availability of primary care data analytics; these will be existing data sets reconfigured at PCN level,

We will support Primary Care Networks to be at the forefront of developing and delivering systems

–wide goals, bringing their skills and capabilities to :

Develop interventions that improve health and wellbeing outcomes and reduce health

inequalities within and across local communities

Embed a population health management approach at every level of planning and delivery to

ensure that resources are targeted at areas of greatest need

Ensure that every interaction with the health and care system is focused on what matter to the

individuals and to local communities

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with a target expectation that PCN-level dashboards will be in place by the end of Q1 2019/20. Data

packs are also being rolled out which include public health data alongside activity metrics, etc. Risk

stratification tools are in use in most areas, although uptake/application is variable.

The PHM programme will work towards delivering:

a technological system that has the right data available (note the STP Digital Programme and current plans for CHIE and CHIA)

a process to support staff to generate and understand insights from data and analytics

a culture of evidence-based decision making across HIOW, supported by a shared understanding of how data can help improve care delivery and health outcomes

capabilities and capacity at PCN level to analyse and respond to the above data

7.2. Prevention and early diagnosis

Cardiovascular disease

Cardiovascular disease remains the second largest burden of mortality and Disability Adjusted Life

Years (DALYs) in the United Kingdom (UK), a picture replicated locally despite the people of

Hampshire enjoying generally better health than elsewhere in the UK. 80% of heart failure is

currently diagnosed in hospital, despite 40% of patients having symptoms that should have triggered

an earlier assessment.

CVD is largely preventable, through lifestyle changes, and early detection and treatment of CVD can

help people to live longer, healthier lives. In HIOW we will work with Primary Care Networks and

wider systems partners to promote healthy behaviours and target screening and interventions at

those with the highest risk. This approach will include:

Working with voluntary sector partners, community pharmacists, PCNs and GP practices to

provide opportunities for the public to check on their health, through tests for high blood

pressure and other high-risk conditions

Greater access to echocardiography in primary care to improve the investigation of those

with breathlessness, and the early detection of heart failure and valve disease

Working with community, voluntary and public health services to promote healthy

behaviours and lifestyles; and developed tailored behavioural change interventions to

support individuals to make the changes required.

Supporting pharmacists and nurses working in PCNs to case find and treat people with high

risk conditions. People with heart failure and heart valve disease will be better supported by

multi-disciplinary teams as part of PCNs.

To support and enable improved capability in PCNs, we will deliver a HIOW-wide CVD programme

that is targeted at:

1. Increasing the appropriate use of statins in the secondary prevention of CVD in those with prior CVD.

2. Increasing the appropriate use of statins for the primary prevention of CVD in those identified at high risk (>20%) of CVD and/or high cholesterol.

3. Using the existing PRIMIS tool to screen people at risk of Familial Hypercholesterolemia (FH) and offer referral to the Wessex FH service for further testing – aiming to identify at least 25% of those with FH in Hampshire in line with The NHS Long Term Plan

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The project is built on learning from the nationally recognised work performed as part of the

Bradford Healthy Hearts scheme, utilising prescribing pharmacists in line with approaches described

in the NHS Long Term Plan. It will initially work with two PCNs who have the highest burden of

cardiovascular disease in HIOW. The learning from the pilot will be used to extend the project to the

whole of system over the next two years, with potential expansion to optimise prescribing for Atrial

Fibrillation and Hypertension.

This HIOW-wide programme will complement and enhance local approaches to increase AF

detection and better management of hypertension in primary care and PCNs.

Cancer

One of the biggest actions the NHS can take to improve cancer survival is to diagnose cancer earlier.

Primary care networks will be required to help improve early diagnosis of patients in their own

neighbourhoods by 2023/24, working alongside the Cancer Alliance and other local partners.

Cancer screening programmes will be critical in diagnosing cancer earlier, including for bowel cancer

using FIT, HPV primary screening and the extension of lung health checks. We will support practices

and PCNs to play key role in helping ensure high and timely uptake of screening and case finding

opportunities within their neighbourhoods. This might for example include direct engagement with

particular local groups of their community where there is the greatest opportunity for making a

difference; all staff to play a role in raising awareness of symptoms and the importance of screening;

changes in clinical practice e.g. referrals; as well as working with their local ICS to tackle diagnostic

bottlenecks.

We will work with Primary Care Networks to help ensure that all their GPs are using the latest

evidence-based guidance to identify people at risk of cancer; recognise cancer symptoms and

patterns of presentation; and make appropriate and timely referrals for those with suspected

cancer.

7.3. Personalised care

Personalised care is an underpinning principle of the future model of care in HIOW. It means people

will have choice and control over the way their care is planned and delivered, based on ‘what

matters’ to them and their individual strengths, needs and preferences. Successful delivery of

personalised care means creating a system that harnesses the expertise, capacity and potential of

people, families and communities in delivering better outcomes and reducing health inequalities.

Benefits for local people and communities Benefits for health and care system

Improvement in health and wellbeing outcomes and experience of care through involving people more fully in designing the support around their individual needs and circumstance

Improved community resilience and people

are enabled to be more independent, happier and locally connected

People are enabled to have greater choice

Reduction in unplanned hospital and institutional care through prevention of avoidable crises

Reduced demand for health and care

services as people are kept in better health and well in the community

Increased resilience and impact of

community support offers - increasingly known about, better trusted and more

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and control over decisions that affect their own health and wellbeing

People are supported to stay well and have greater confidence to take greater responsibility for their own health and wellbeing

People with chronic or complex illness receive care that is consistent, joined up and centred around their needs and wishes, with fewer hand-offs and reduced duplication

People are supported to regain/retain independence following the acute phase of their illness/injury

widely used

Improved capacity in primary and community care to manage local health and care needs

Optimised resource utilisation as a result of better managed chronic conditions and reduction in preventable conditions

Fewer permanent admissions to residential and nursing care

Increased workforce resilience, leading to improved right workforce in all sectors

Improves value through quality improvements, better integration of care and reduction in demand and cost

There is no ‘one size fits all’ model for personalised care with the emphasis on empowering users of

NHS and social care services to access services in a way that fits them as an individual, and which

enables the service to be tailored to their particular needs. This includes:

A whole population approach to support people of all ages, and their carers, to manage their physical and mental health and wellbeing and make informed choices and decisions when their health changes

A proactive and universal support offer to people with long term physical and mental health conditions to build knowledge, skills and confidence through supported self-care and community-centred approaches

Intensive approaches to empowering people with more complex needs to have greater choice and control over the care they receive

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As a national demonstrator site, Hampshire and Isle of Wight is committed to accelerating and

strengthening our approach in this area, working with PCNs and other health and care partners.

We have already made significant progress to develop this approach for key population cohorts. We

will now extend this to PCNs, recognising their critical role in developing and promoting this way of

working through their focus on preventative and proactive care. We will support professionals

working in and with PCNs to develop the skills and infrastructure required to strengthen and embed

personalised care at every interaction. This means:

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7.4. System planning and sustainability

Primary Care Networks are a fundamental building block of our Integrated Care System and will be

essential to delivering the future care model and contributing to the delivery of system goals.

Successful delivery will require greater system collaboration and a leadership approach that is

systems-based, cross-sector and multi-professional. Our collective focus will be on delivering place-

based healthcare that both integrated care and improves population health.

Our PCN Clinical Directors will play a critical role in shaping and supporting their Integrated Care

System (ICS), helping to ensure full engagement of primary care in developing and implementing

local system plans to implement the NHS Long Term Plan. These local plans will go much further

than the national parts of the Network Contract DES in addressing how each ICS will integrate care.

We will support and enable PCN Clinical Directors to participate effectively in this space, recognising

the expertise and skills they bring in representing their PCN members and the health and wellbeing

needs of their communities.

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Enabling our vision: Workforce development 8.

Workforce development is vital to ensure that we have the right skills, capabilities and numbers working in the right places to deliver our transformed care system now and in the future. We are working with all system partners, NHS England and Health Education England (Wessex) to scope and plan for future workforce requirements. Our focus in primary care and general practice is to:

Extend the primary care team to include staff from all sectors that are equipped with the skills and experience to work in multi-disciplinary and integrated locality-based teams who are focused on those with the greatest health and care needs. This includes supporting the recruitment and support of new roles employed under the PCN contract.

Develop our whole workforce to have a greater focus on empowering people to stay healthy for as long as possible, having healthy conversations at every contact and developing asset-based approaches in our local communities which promote a holistic approach to addressing prevention.

Develop new roles and ways of working that release capacity in primary care plus training in technology that enables new ways of communication and working with patients, carers and other health and care professionals.

Adopt a system-wide approach to recruitment and retention that will address gaps in skills and people to deliver transformed care models. This includes maximising participating in national and regional support offers, optimising supply routes for future GPs and primary care staff and implementing a greater skill mix as part of extended primary care team development.

At the same time, we are giving equal focus to how we can best support our primary care workforce through this change process in order that they feel empowered and enabled to adopt new ways of working with other people and with the population they serve.

8.1. Primary and Community Care Training Hubs

Primary and Community Care Training Hubs are networks of education and service providers (NHS and non-NHS) based in the community. There are three training hubs across Hampshire and IOW these, which provide both training and education of the both the medical workforce and non-medical workforce in the hub locality. HIOW Training Hubs are based around the existing GP education network offices in:

Winchester (mid Wessex)

We will ensure that there are sufficient numbers of staff with the right skills in the right location to

deliver the new model of care by

Developing the skills and capabilities of the extended primary care team , enabling people to

work at the ‘top of their license’ and creating new career development pathways in primary

care

Supporting the new PCN workforce employed under the PCN DES, ensuring they have the right

support and local peer network to flourish in these roles

Developing our PCN leadership teams to fulfil their role in their local communities and wider

system

Enabling a new culture of team –working that spans professional and organisational boundaries

and facilitates the delivery of integrated care

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Southampton and New Forest

Portsmouth and Isle of Wight

Each locality has a learning environment lead (LEL) – a healthcare professional who will lead and support the development of the Training Hub. The professional focus of the LELs will reflect the four areas of:

Registered nurses

Allied health professionals and physicians associates

Clinical pharmacists

Bands 1-4 (non-registered workforce) The purpose of training hubs is to provide an opportunity to meet the educational needs of the multi-disciplinary primary care team, bringing together NHS organisations, community, local authorities and education establishments. They are tasked with increasing the capacity for future healthcare workforce training in the training hub, developing current and future workforce around the needs of a geographically defined population. They are key to enabling primary care to fulfil its full potential in educating and training the current and future multi-disciplinary workforce. The ambition is for each PCN to have access to training hub services to support its objectives in implementing the multidisciplinary team to work within the training hub. By March 2020, the core functions of the Primary and Community Care Training Hub will include:

Workforce planning - to support the understanding, co-ordination and realisation of health and wider social care workforce across the system

Develop and manage placement capacity - creating innovative and high-quality clinical placements for all learners, to meet the workforce needs of “the place” in line with the Long Term Plan and, thus maximising the effective use of educational resources. *work currently being undertaken includes GP specialty trainees, foundation doctors and medical undergraduates

Recruitment - Develop, expand and enhance the recruitment and development of the capabilities of multi-professional educators that supports the delivery of high-quality clinical learning placements

Support the development and realisation of educational programmes to develop the primary / community care workforce at scale to address identified population health needs, support service re-design and delivery of integrated care for example through rotational placements / programmes and integrated educational programmes

New roles – to enable, support and embed new roles within primary care

Retention - to support retention of the primary care workforce across all key transitions including promoting primary care as an employment destination to students, through schools and higher education institutions

Clinical Placement Tariff - enable both workforce planning intentions, placement co-ordination through active management of clinical placement tariffs including place based tariffs

8.2. Behaviour Change Development Framework

Managing demand and improving health and wellbeing outcomes for our population will require a

different way of planning and delivering care with people that gives them more control and choice in

the care their receive, enables them to better look after their own health and care needs, and

develops a new partnership between the individual and the professional looking after their care.

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To enable this, we will roll-out a development framework for behaviour change tools that provides

training and support that is tailored to the requirement of our workforce. Our ambition is that every

member of staff is equipped with the skills and confidence to have an effective dialogue with an

individual in their care. Training will be delivered through a combination of face-to-face and e-

learning with ongoing mentoring support as appropriate.

Linked to this will be the roll-out of the Wessex Activation and Self-Management tool which is focused on helping team to assess their capability and capacity to deliver personalised care and behaviours change interventions. We will be piloting this with a small number of PCNs in 2019/20 with expectation of wider roll-out to support the delivery of the personalised care service requirement from 2020/21 onwards.

8.3. Leadership and team development

Great and sustainable change needs strong foundations and we know that that change initiatives in health and care are most effective when teams can drive and own what needs to happen, ensuring it fits with their context, their priorities, their patients and their communities. Our development model is built around creating a shared purpose, in this case by those in the PCN where individuals align their belief, systems or values with a common challenge, vision or goal. We will deploy the national development support programme offer in order to enable local PCNs to develop from the ground up, providing resource and capacity and therefore ‘head space’ for those working locally to transform how they work. There is recognition that this will be an evolution and that takes time. Leadership development Leadership in the context of PCNs is about individuals being able to ‘lead’ or guide other individuals, teams or entire organisations and assure the help and support of others in the accomplishment of a common task. PCN leadership is not solely the domain of the PCN clinical director but will require equal capability and capacity in community and social care leadership to deliver the new model of care.

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Leadership skills are integral to the overall development and maturity of PCNs. They will have a flat hierarchy and will be largely dependent on fostering good will, building relationships and working collaboratively to achieve locally agreed objectives. It is essential, that there is recognition and understanding of the need for leadership styles which are collaborative, compassionate and an understanding of and development of skills required to work across organisational boundaries, recognising the challenges that this can bring. Recognising that all network members are leaders, development should recognise and seek to challenge traditional leadership hierarchies and power balance. For PCNs to be successful, they will need strong local partnerships with community, acute, mental health, local authority and voluntary services to deliver care to local populations. We will work with local PCN leadership teams to understand their development and support needs and provide appropriate coaching, mentorship and skills development to enable them to fulfil their roles. This will include the development of peer networks across the PCN community to encourage collaboration and shared learning; and to enable the development of a cohesive PCN voice in the Integrated Care System. Organisational and team development

PCNs will work collectively to change the way in which services are delivered to their local

population, as well as the types of health and care services which may be available. This means that

primary care, staff in the NHS and local government, along with those in the third sector and other

partners, need to find new and different ways of working together to continue to build the health

and care system in line with the requirements of the NHS five year forward view and NHS long-term

plan.

Change is fundamental to the success of PCNs. It is about pushing the boundaries of what is possible,

challenging the status quo of existing systems, mobilising others and moving into a new and more

efficient working arrangement. As ways of working and cultures alter through a managed change

process, the need to engage with newer partners will bring with it new challenges, including the

need to develop sustainable partnerships which are built on collaboration, trust and mutual respect.

Experience tells us that change initiatives in health and care are most effective when teams can drive

and own the ‘what needs to happen’, ensuring it fits with their context, their priorities, their patients

and their communities.

Organisational development (OD) will support PCNs to create a shared purpose by aligning their

belief, systems or values with a common challenge, vision or goal across the network. This will help

to understand why the change needs to happen and guide and drive all PCN decisions and actions. It

will enable people to transform systems and enhances the effectiveness of systems through the

provision of interventions that build capacity and capability to achieve collective goals.

An organisational development approach encourages ownership and responsibility so that people arrive at the point where they can face up to what they, as individuals, need to do, to change patterns of working and bring about fresh ways of thinking, new cultures and new solutions. This is how long-term, sustainable change can be achieved.

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OD will also help local PCNs develop from the ground up and ensure there is resource, support and

capacity for those working locally to transform how they work. This will be an evolutionary process

and needs to be coordinated, managed and will take time to deliver.

Leaders within PCNs will need to work in patient-focused systems rather than simply within their

own organisations, and they will need to have collective responsibilities for budgets and services

that are across organisational, clinical and managerial boundaries and hierarchies. This will require

them to put the needs of the system first and the needs of their own organisation or department

second. This will requires specific support and engagement to help them to identify their needs and

the support that will help them.

Broadly the OD focus will be on the following:

Building flourishing teams (multi-disciplinary and cross organisational)

Developing good/healthy/positive environments to work in – creating an environment and culture which is driven by continuous development and support

Setting up to succeed – development of a system-wide learning culture that enables sharing of good practice and growth; both organisational and personal

Working collaboratively and developing trusted relationships with STPs, ICSs and the wider community

PCN clinical directors will be key to shaping the OD agenda for their own networks. They will be supported through their own development offer and will provide clear direction for the wider network development. The following process will be adopted:

Whilst it is anticipated that each PCN will have its own OD plan, based on its specific identified need

and vision, there will be opportunities to bring together those across systems to share opportunities,

to build wider networks and to support each other at all levels.

We will work with PCN Clinical Directors and local system partners to understand their team

development needs and requirements, source and develop tailored solutions and facilitate local

ownership of delivery. We will develop a community of practice across HIOW to enable PCN teams

to share learning and experience.

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Enabling our vision: Digital transformation 9.

We will ensure that primary care and Primary Care Networks are underpinned by the right IT and

digital infrastructure that helps to address the challenges to primary care resilience and enables the

delivery of new model of integrating, realising benefits for local populations, for staff and the wider

system.

Digital maturity and the application of new technology will simplify access to care in the most

appropriate location, ensure that professionals can access and interface with patient records and

care plans wherever they are and enable people to get manage their own health and care.

Our Hampshire and Isle of Wight digital strategy describes how will achieve this establishes the

following priority programmes:

To deliver an integrated health and care record (Care and Health Information Exchange –CHIE)) across HIOW which will provide professionals with seamless access to a shared care record with a rich data set. Hampshire and Isle of Wight (with Dorset) is a Local Health and Care Record Exemplar Site (LHCRE) which provides us with both opportunity and investment to move further and faster in this field.

We will ensure that primary care and PCNs have the right infrastructure to deliver the new models

of integrated care by:

Developing a shared care record that enables the seamless transfer and sharing of information

between all member of the PCN team, and with other health and care partners

Ensuring that data sharing arrangement support and not constrain this approach

Further development and embedding of digital-first primary care, join up of urgent and

emergency care and technology that enables people to have more control of their own health

and care needs

Establishing the infrastructure and analytics capability that supports a population health

managemnet approach at every level of planning and delivery

Enabling the growth of research and innovation, enabling adoption and spread of new ways

of working that improves care delivery

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To support all provides to accelerate digital maturity across the system. For primary care and Primary Care Networks, this means continued investment in our Primary Care IT programme to replace and upgrade general practice infrastructure. This includes HSCN deployment, wi-fi coverage in all practices, deployment of Windows 10 and desktop and server refresh. This will enable our workforce to work flexibly and at a range of locations in line with the integrated model of care. The infrastructure will become consistent with the development of CHIE and the ability to capture health and care information digitally at the point of care.

To ensure equitable access to digital primary care solutions via online and video consultations, online booking of appointment, enhanced 111 services and the development of a personalised health record which enables people to have more choice and control to manage their own health and care.

To enable direct access from NHS 111 to all Urgent Treatment Centres within HIOW in order to maximise the benefit of integrated working. This will include the provision of mental health 111 services.

To support the central development and deployment of the NHS App as mechanism to support a channel shift to as digital first approach. The NHS App will provide access to 111 online and personal health records in addition to booking appointments and connecting people with healthcare professionals.

To further develop the data and analytics infrastructure that underpins the development of our population health management strategy. This will build on the CHIE and CHIA (analytics) infrastructure, and enable primary care networks and local health systems to use predictive techniques in planning care for local populations.

Research and innovation To deliver world class primary care we need a stronger evidence base and better data, as well as ensuring that general practice has the capacity and skills to undertake evaluation and research. The NHS Long Term Plan emphasises the importance of research and the opportunities for greater general practice involvement. Research participation will realise benefits in quality improvement, professional development, and generating income, amongst others. We will work with local Clinical Research Network and Higher Education institutes to enable the development of more research-active GPs and support PCNs to participate in research programmes, contributing to the increased number of people registering to participate in health research. We will continue to work with Wessex Academic Health Science Network (AHSN) to pilot the deployment of new innovation and technologies in primary care that will contribute to better outcomes for local population.

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Enabling our vision: Fit for purpose estate 10.

The provision of good quality, fit for purpose estate is a critical enabler to the transformation and

development of primary care and Primary Care Networks. A significant proportion of GP premises

in Hampshire and Isle of Wight require modernisation or upgrade in order to the meet the increasing

needs of the population and integrated care teams working as part of Primary Care Networks will

need access to both clinical and non-clinical space to enables the delivery of new models of care.

Our Hampshire and Isle of Wight estates strategy continues to iterate in response to these

requirement with the aim to making sure that we prioritise investment in the highest priority

developments, maximise the use of our good quality estate to delivery health and care, and enable

the efficient disposal of estate that is no longer fit for purpose. A Hampshire and Isle of Wight

primary care estates strategy is currently under development and will align to these objectives and

ensure that we have a consistent approach across the system. This will take account of population

growth, future housing developments and funding sources.

10.1. Primary care premises

Hampshire and the Isle of Wight has around 160 properties delivering services across the patch.

There is a wide variation in utilisation, from practices ‘bursting at the seams’ to community estate

with significant underutilisation.

We will continue to work with practices, with Primary Care Networks, with Local Authority partners

and wider Care Partnerships to develop plans that will build the General Practice network to provide

Primary Care at scale and to deliver new models of care. Options for investment and transformation

are beginning to emerge as local plans are developed.

Over the next 5 years we will deliver a limited number of critical GP practice relocations and

improvements in collaboration with NHS England, groups of General Practices and other sector

partners.

We recognise that some surgeries in Hampshire and the Isle of Wight have been built specifically to

provide world-class primary care services, whilst others are converted properties dating back to pre-

1970. We have some buildings that are reaching the end of their life and are not going to be suitable

to provide the right type of space to enable the right care to be delivered. Some buildings are not

being used to their maximum and we are wasting money.

We need to consolidate the number of buildings across our primary and community estate, whilst

continuing to ensure great local accessibility, by bringing together services under one roof, using the

We will ensure that primary care and PCNs are delivered from premises that are fit for purpose and

contribute to the delivery of better care. This means:

Making best use of good quality estate so utilisation is optimised for local service delivery

Addressing poor quality estate through upgrade and/or disposal as part of a strategic estates plan

Providing flexible space that enables integrated, multi-disciplinary team working that meets local

need and facilitates working across organisational boundaries

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buildings more efficiently and increase their use over 7 days. With new practice groupings, more

efficient ways in working and the use of technology, we anticipate the number of buildings needed

across health and care will be reduced.

10.2. Primary Care Networks

As Primary Care Networks move beyond their establishment year and into service delivery from

2020/21, their requirements for space will increase and plans for local PCN ‘hubs’ will become more

defined.

Solutions will focus on optimising the use of space within and between member practices but could

equally look to available space in other health and care premises and in the community sector in

order to provide the most accessible options for the local populations. Requirements are likely to

include:

Regular access to a shared meeting/work space within the local area for the purposes of

planning and co-ordinating delivery of care by a PCN team (weekly/daily huddle, case reviews

etc.).

Flexible access to ‘touch down’ space in a locality for staff that are largely ‘mobile’ and require a

space to work at key points during the day. This will be available irrespective of which

organisation you work for. Wi-Fi/Network access as part of this offer.

Regular clinical space for the delivery of joint clinics between different organisations. This will

include primary, community, voluntary and specialist services including outreach/community

services that would previously have been run on an acute hospital site.

A permanent/regular space (office) to run PCN ‘nerve centre’ -host logistics/analytics/co-

ordination support that enables effective running of the PCN teams.

IT will be a critical enabler to the delivery of local hubs – Wi-Fi access, shared care record, telephony

and virtual communications (particularly in rural areas where people may be physically present at

MDTs)

10.3. Area Health Hubs

Optimising the use of our best quality estate is a core objective for the Hampshire and Isle of Wight

system. Local assessments indicate that there is clinical and non-clinical space available on a

number of key strategic sites that could offer solutions to increasing the scale and range of services

available and to further develop integrated models of care.

These area health hubs will typically include diagnostic services and community-based beds for step-

up or step-down care. Some will co-located with Urgent Treatment Centres. Area hubs will typically

serve populations of 100-200k and work closely with PCNs operating within their footprint to

optimise local service offers and streamline pathways.

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Enabling our vision: Primary care workforce plan 11.

11.1. April 2019 workforce plan submission

Our April 2019 workforce plan submission was premised on the anticipated number of GPs and

other healthcare professionals expected to join and leave the primary care workforce over the next

12 months. However, the trajectory should be treated with caution on account that it is:

Largely a top-down construction built our from historical data trends. This was necessary in the

absence of detailed bottom-up primary care workforce plans.

Only inclusive of staff directly employed by general practice (as opposed to those working in and

with general practice but employed by others) and not yet wholly reflective of expected changes

in workforce that are attributable to the development of PCNs.

The large number of retained GPs is reflective of the number of GPs to be targeted local

mobilisation schemes. This is therefore not premised on additionality in the workforce but

reflects numbers of GPs that would otherwise have left the workforce.

Nevertheless, it provides a starting point for local workforce planning discussions and further work is

planned to develop a more robust workforce planning model that more accurately reflects the

future staffing requirements to deliver the new care model.

Current planning assumptions are described below to provide a rationale for the numbers provided.

2019/20 GP inflow

2019/20 Inflow - Headcount 19/20

Planned inflow

Participation rate

2019/20 Inflow – WTE 2019/20

Planned inflow

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

New Fully Qualified GPs 8 48 12 15 83 0.82 6.56 39.36 9.84 12.30 68.06

Induction & Refresher scheme 3 4 4 4 15 0.71 2.13 2.84 2.84 2.84 10.65

International recruitment 1 1 1 1 4 0.82 0.82 0.82 0.82 0.82 3.28

GP Retention Scheme 5 5 5 4 19 0.32 1.60 1.60 1.60 1.28 6.08

Other GP retention initiatives 50 50 50 50 200 0.6 30.00 30.00 30.00 30.00 120.00

Planning assumptions

The majority of newly qualified GPs trained in HIOW will join the local primary care workforce

(10% adjustment for those that do not immediately join the workforce or who opt to work in a

different area.

I&R and GP Retention participation is premised on continuation of previous trends (2017/18

participation rates.

Low numbers expected through international recruitment scheme (in line with national trend.

Participation in other local GP retention schemes in line with trajectories provided for six local six

local schemes supported by national funding.

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Assumption is that all GPs participating in national and local retention schemes would a)

otherwise have left general practice and/or b) intend to stay as a result of the intervention.

2019/20 GP outflow


Planned inflow

Participation rate

2019/20 Inflow – WTE

2019/20 Planned inflow

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Retirement 14 14 14 14 56 0.82 11.48 11.48 11.48 11.48 45.92

Other 3 4 4 4 15 0.71 2.13 2.84 2.84 2.84 10.65


Assumed 5% reduction in WTE GPs per annum due to retirement (based on Dec 17 baseline)

Assumed 1.7% reduction in WTE GPs per annum for other reason (NHSE supply and demand tool)

2019/20 -Other primary care staff - inflow


Planned inflow

Participation rate

2019/20 Inflow – WTE 2019/20

Planned inflow

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Nurses 29 21 23 39 112 0.68 19.72 14.28 15.64 26.52 76.16

Direct Patient Care Staff (excluding PA and pharmacists) 10 10 5 14 39 0.65 6.50 6.50 3.25 9.10 25.35

Physician Associates 0 0 0 0 0 0.65 0.00 0.00 0.00 0.00 0.00

Pharmacists 0 8 18 18 44 0.91 0.00 7.28 16.38 16.38 40.04

Admin Staff 73 71 61 76 281 0.69 50.37 48.99 42.09 52.44 193.89


Nursing, direct patient care and admin staff trajectory is extrapolated from NHSE Wessex figures

for joiners in 12m leading up to Q2 17/18 –. Inflow rate expected to continue as per 12m leading

up to Q2 17/18.

No Physician Associate recruitments anticipated in 2019/20 but two local PA programmes going

live - Bournemouth University in Jan 2019 (estimated 20 students) and Portsmouth in Sept 2019

(20 students). Possible outturn of 40 PAs in 2021.

Pharmacist figures reflect planned increases based on current CCG plans plus assumption linked

to PCN additional roles reimbursement schemes = national funding for 2 pharmacists per 50k

PCN. Assumed 50% uptake in 2019/20.

2019/20 -Other primary care staff - outflow

2019/20 Inflow - 19/20 Participation 2019/20 Inflow – 2019/20

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Headcount Planned inflow

rate WTE Planned inflow

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Nurses

36 19 22 22 14 77 0.68 24.48 12.92 14.96 14.96

Direct Patient Care Staff (excluding PA and pharmacists)

12 8 9 4 8 29 0.65 7.80 5.20 5.85 2.60

Physician Associates

0 0 0 0 0 0 0.65 0.00 0.00 0.00 0.00

Pharmacists

0 0 0 0 0 0 0.91 0.00 0.00 0.00 0.00

Admin Staff

121 65 79 56 65 265 0.69 83.49 44.85 54.51 38.64


Figure is extrapolated from NHSE Wessex figures for leaver in 12m leading up to Q2 17/18 –

outflow rate expected to continue as per 12m leading up to Q2 17/18.

11.2. Next steps

Further work is being co-ordinated through the HIOW Local Workforce Action Board to develop a

more robust and accurate approach to workforce planning that takes account of:

Ongoing recruitment and retention issues in primary and community care that are impacting on services stability and responsiveness

Emergence of PCNs who will directly employ and lead MDTs (Integrated Care Teams) under the new contract

Continued development of ICTs ( led by community and social care) and how this aligns to / integrates with PCN development

A task and finish group has established and is meeting in July 2019 to develop a set common planning assumptions that can be applied to the development of PCN and local system workforce plans. We will support PCNs to develop plans in accordance with these assumptions.

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Enabling our vision: Investment 12.

12.1. 2019/20 funding commitment in CCG operating plans

Total spend on primary care (excluding primary care prescribing) will increase to £308m in 2019/20, an increase of £12m compared to the previous year. This reflect the baseline investment expected as part of the new GP contract and PCN development but include additional provision for the development of new model of integrated primary and community care. In line with national commitment to invest £1.50 per head to support PCN development, over £3m is being invested in PCN development across Hampshire and Isle of Wight in 2019/20. In some areas, this is being augmented by additional investment via Local Commissioning Schemes (e.g. an additional £1.50 per head in Fareham & Gosport, South Eastern Hampshire and the Isle of Wight. Recurrent investment into extended primary care and community based services is being increased by over £3m to just over £32m (e.g. an additional £800k invested in community services on the Isle of Wight and £477k being invested to support nursing homes in North Hampshire.

CCG

Community Based Services

£000

PCN Development (£1.50 per head)

£000

Delegated Co-Commissioning

£000

South East Hants 3,042 325 28,681

Fareham and Gosport 2,813 309 26,378

North Hants 3,063 341 29,240

Isle of Wight 3,410 472 20,841

Southampton 5,426 415 36,999

Portsmouth 2,622 347 30,698

West Hants 11,792 1,191 72,990

TOTAL 32,168 3,400 245,827

12.2. 2019/20 GP Forward View funding (HIOW allocation)

In addition to funding allocated as part of CCG plans, additional funding is available to support improved primary care resilience and sustainability and take forward some of the actions described in this strategy.

Programme 2019/20 2020/21

Practice Resilience £362,866 £262,480

GP Retention £393,600 £393,720

Reception and Clerical £200,000 £314,635

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Online consultation £325,824 £499,950

Practice Nursing £131,240

TOTAL £1,282,310 £1,602,065

Deployment of funding will be co-ordinated through the HIOW Primary Care Programme Board

12.3. Future investment plans

A five year investment plan is under development for the whole system as part of the HIOW Long

Term Strategic Delivery Plan. At the time of writing, detailed plans are not yet available but are

expected to reflect the following in respect of primary care and PCN investment.

Core primary care allocations in HIOW are forecast to rise from £253m in 2019/20 to £301m in

2023/24 in line with GP contractual commitments.

From 2020/21, PCNs will have access to a national Impact and Investment Fund which offers

opportunity to increase investment for workforce expansion and services in return for

demonstrable impact on hospital utilisation and prescribing.

PCNs are expected to become the primary delivery vehicle for integrated primary and

community based care in the future. This will require changes to current contractual models

and funds flow across the system to enable this delivery.

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Delivery, assurance and decision-making 13.The delivery and assurance of the Hampshire and IOW Primary Care Strategy will sit within the

governance framework of HIOW Sustainability and Transformation Partnership, and evolve and align

to the HIOW Integrated Care System governance framework as this develops.

Now in a period of transition, the HIOW STP is evolving towards Integrated Care System (ICS) status

by April 2021, and shadow form from April 2020 as an interim step. Partner organisations will

continue to work at various levels as part of the HIOW ICS, including at ‘place’ with local authorities

and through our Integrated Care Partnership (ICP) footprints, and ‘neighbourhood’ level with PCNs.

Working increasingly collaboratively, health and care commissioners will make shared decisions with

providers on how to use resources, design services and improve population health (other than for a

limited number of decisions that commissioners will need to continue to make independently, for

example in relation to procurement and contract award).

We have recently embarked on a process of defining our journey to ICS in a ‘roadmap’ which sets

out the actions and timescales required to deliver a HIOW ICS. Included within this is our intention to

establish an ICS Board and wider ICS governance structure as well as our ambition to create a self-

governing system that is able to manage performance and oversee the delivery of transformation

programmes including the work set out in our primary care strategy.

13.1. Performance management and oversight of delivery

HIOW Primary Care Programme Board

The oversight and delivery of the HIOW primary strategy will be provided by the HIOW Primary Care

Programme Board which has senior managerial and clinical representation from Clinical

Commissioning Groups, NHS England, Wessex LMCs and the HIOW STP. The role of the Programme

Board is to:

To develop and implement the HIOW primary care strategy, with a focus on co-ordination of key

system-wide enablers to plan delivery and provision of mutual support to CCGs to implement

local plans

To implement an approach to the development of HIOW-wide proposals, bids or returns linked

to primary care transformation, including GP Forward View delivery. This will include but is not

limited to plans for deployment of pooled GPFV funding, HIOW primary care workforce returns

and/or HIOW bids for additional funding to support primary care transformation. Where

relevant/necessary, this will include securing formal sign-off/ratification by each CCG

To assure progress against key deliverables, as defined in the GPFV MOU, and track spend

against agreed HIOW-wide investment and workforce plans

To liaise directly with the regional and national teams of NHS England on matters that are HIOW-

wide. This will include but is not limited to GP Forward View implementation

To promote and champion primary care within the HIOW system, as well as regionally and

nationally

The programme board is accountable to the Boards of the CCGS in HIOW in line with their delegated

responsibilities.

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HIOW Models of Care programme board

This is complemented by HIOW models of care programme board which provides a structure

through which commissioners and providers can support one another to successfully implement

new models of integrated primary and community-based care which are built on and around the

development of primary care networks (PCNs). The core functions of the board are:

To shape and influence the design and delivery of system-wide enablers to cluster (PCN)

development (‘do it once’ approach), liaising with other HIOW programmes as appropriate.

To facilitate collaborative problem solving and issuer resolution which impact multiple

PCNs/local systems.

To provide a forum for all systems partners to liaise on matters than affect the development of

primary care networks and models of integrated primary and community care; and to facilitate

shared learning between local systems and national best practice.

To develop proposals for the deployment of HIOW-wide transformation/non-recurrent funding

and resources Where relevant/necessary, this will include securing formal sign-off/ratification

through the relevant HIOW board e.g. EDG.

To track progress in both the development and impact of PCNs and models of integrated

primary and community care across HIOW, using the maturity matrix and PCN dashboard as

tools for system-wide benchmarking.

Future ICS performance and accountability framework

Moving forward, we are developing an ICS accountability and performance framework that reduces

complexity, duplication and the bureaucratic burden whilst providing a consistent and comparable

set of performance measures.

The framework will set out the performance and assurance responsibilities of ICS, ICP, Care System,

PCN and organisations and incorporate the new national expectations of an ‘integration index’

developed jointly with patients’ groups and the voluntary sector. This index will measure

from patient, carer and the public point of view, the extent to which the local health service and its

partners are genuinely providing joined-up, personalised and anticipatory care.

The existing HIOW primary care and models of care programme boards will evolve and align to these

arrangements.

The arrangements will be co-produced with SE Region to ensure consistency with the new SE Region

Operating Model.

13.2. ICS governance and decision making

Our ICS will have a board, drawn from and representing commissioners, trusts, PCNs, local

authorities, the voluntary and community sector and other partners. Our intention is to create a

working environment and method of collective decision-making that enables health and care

partners to reach a single set of decisions about how to deploy resources and plan services where

this is required. The board arrangements will also ensure we have arrangements in place to involve

non-executive members of boards / governing bodies.

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In developing the board we will co-develop the governance map for the ICS (reviewing the role,

membership and terms of reference of all constituent groups) and confirm the relationships to

Health & Wellbeing Boards (H&WB), ICP, Care Systems (around local authority footprints) and PCNs.

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Next steps: Planning for successful delivery 14.

14.1. Development of plans with other primary care contractors

We recognise that this iteration is largely focused on general practice and work is ongoing to engage

the other primary care contractors and reflect their ambition and plans in future iterations of this

document.

An initial workshop was held on June 21st with further engagement sessions planned over the next

couple of months.

14.2. Wider stakeholder engagement

This outline strategy has been produced through a synthesis of existing strategic planning documents describing plans at CCG, STP and national level; all of which have had extensive stakeholder engagement with health and care professionals and the public to inform their development. This document will now be shared and presented to key stakeholder groups to check strength of messaging and alignment to local ambition, and get additional input as required. The following engagement activities are scheduled over the next 8 weeks to facilitate this:

July 3rd

HIOW STP Executive Delivery Group

July 10th

HIOW LMC Committee Meeting

July 12th

(tbc) NHS England (South East)

July 17th

HIOW Primary Care Programme Board

July 17th

HIOW Models of Care Programme Board

July 25th

HIOW STP Clinical Executive Group

August PCN Clinical Directors

August Workshop: Primary care contractors

August CCG Primary Care Commissioning Committees

In parallel to this, we will now bring together the further iteration of this strategy with the

development of the HIOW Long Term Strategic Delivery Plan, to include any associated engagement

and communication activities. This will ensure that we have a single, cohesive plan for all partners in

the system; and that the role and requirements of primary care are clearly articulated as part of this.

14.3. Alignment to development of Hampshire and Isle of Wight Long Term Strategic

Delivery Plan

The HIOW STP has determined a requirement for an updated strategic delivery plan as the centre-piece in our ‘reset’ as HIOW health and care system and as a key component of our evolution from STP to ICS status. We are refreshing our shared vision, purpose and objectives, reflecting on the latest position and assessing the future requirements of the HIOW health and care system. The plan will set out how we will implement the commitments set out in the NHS Long Term Plan as well as address the constraints of our current clinical services. We intend to publish our plan in autumn 2019. At the time of writing, we have commenced a review of existing strategies and data, and are beginning work with partners across the HIOW footprint to devise a refreshed strategic delivery plan for aspects that merit strategic whole system transformation at a scale of HIOW.

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As described elsewhere within this document, it is for this reason that this primary care strategy is iterative. It will both inform the development of, and evolve in response to, the ambition, objectives and plans that will be described for the whole system over the coming months.

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