Primary Care Networks Update January 2020 · 2020-04-15 · Hastings and Rother CCG | High Weald Lewes Havens CCG | Horsham and Mid Sussex CCG Now continuing support through NHS Long

Brighton and Hove CCG | Coastal West Sussex CCG | Crawley CCG | Eastbourne, Hailsham and Seaford CCG

Hastings and Rother CCG | High Weald Lewes Havens CCG | Horsham and Mid Sussex CCG

SussexClinical Commissioning Groups

Primary Care Networks Update

January 2020



Contents

1. The Journey so far in Sussex

2. Year 1 delivery

3. Year 2 onwards delivery (national service specifications)

4. Primary Care Governance

5. PCN Programme development plan

6. Integration and Partnerships

7. PCN engagement and GP voice

8. Next Steps



GP Five Year Forward View laid foundation for change in

General Practice …

GP5YFV published 2016:

• Represented a turning point in investment in General Practice – committing an additional

£2.4bn a year to support general practice services until 2020/21

• Ambition to strengthen and redesign general practice

• Vision built on the potential for transformation in general practice

– Enabling self care and direct access to other services

– Better use of the talents of the wider workforce

– Better use of digital technology

– Working at scale across practices to shape capacity

– Extended access to general practice including evening and weekend appointments



Now continuing support through NHS Long Term

Plan (LTP)

LTP Aims:

• Everyone gets the best start in life

• World class care for major health problems

• Supporting people to age well

How:

• Primary Care Networks as the foundation of Integrated Care

Partnerships

• Preventing ill health and tackling health inequalities

• Supporting the workforce

• Maximising the opportunities presented by data and technology

• Continued focus on efficiency



Future landscape – integrated commissioning & provision

Sussex Integrated Care System

East Sussex CCGs /

councils

Voluntary care

Mental health care

Brighton and Hove

CCG / councils

West Sussex CCGs / councils

Acute care

Primary care

Community care

N CP N

P

C N

P

Locality and

Borough

Place

System

Neighbourhood

and Primary Care

Networks

C

Underpinned by citizen

engagement

Strategic partnerships

Collaborative & integrated

commissioning for improved

population health outcomes

Integrated care partnership

Delivery of integrated health and

social care across primary,

community and secondary care

Primary care networks

Local needs analysis and proactive

population health and prevention.

Integrated delivery / MDTs

Key planning, commissioning

and delivery Units

Primary Care General practice Community

pharmacy

DentistryPrimary Care

Independent providers meeting the

needs of list base local population



Purpose of PCNs

• Bring practices together to deliver the collective DES and form the foundation for practices to come together with other providers to develop and deliver integrated services

• Provide the building block for developing services with partners more widely than GP practices e.g. pharmacy, opticians, dentistry, community and voluntary care

• Put in place seamless care across primary care and community services for physical and mental health and remove the historic separation of these parts of the NHS

• Focus on the local population and address the inequalities at a local level

• Deliver care as close to home as possible in neighbourhoods rather than around organisational boundaries

• Integrate primary, community and acute care in PCN neighbourhoods with more clinically appropriate secondary care in primary care settings

• Assess population health – focusing on prevention and anticipatory health – and maximise the difference we can make operating in partnership with other agencies

• Promote and support people to care for themselves wherever possible

• Build from what people know about their patients and population

• Make a tangible difference for patients and staff:

– Improve outcomes for patients and provide an integrated care experience

– Development of sustainable and satisfying roles for staff & multi-professional teams



The Network DES

The Network Contract will be a Directed Enhanced Service (DES).

As a DES, it is an extension of the core GP contract. It is established in

accordance with Directions given to NHS England. This compels CCGs or

NHS England to offer the Network Contract DES to all practices.

The Network Contract DES has three main parts:

1. the national Network Service Specifications. These sections set out what all

networks have to deliver. National investment and services grow in tandem.

Commence April 2020 onwards

2. National schedule of Network Financial Entitlements, akin to the existing

Statement of Financial Entitlements for the practice contract. National entitlement

increases financial certainty for everyone. Alongside these entitlements come

clear transparency requirements, including for subcontracting arrangements

3. The Additional Roles Reimbursement Scheme (ARRS)

• From 2019 Clinical Pharmacists and Social Prescribing Link Workers

• From 2020 Physician Associates and First contact Physiotherapists

• From 2021 First Contact Community Paramedics



The journey so far across Sussex

What has been achieved in Sussex:

• 38 Primary Care Networks (PCNs) across Sussex covering 100% of population:

• All PCNs have signed their Network Agreement and appointed a Clinical Director

• All practices are delivering Extended Hours DES from July 2019

• PCNs have begun recruiting to additional roles (Clinical Pharmacists and Social Prescribers). Preparations

underway to support recruitment to further additional roles from 20/21 (Physicians Associates and First Contact

Physiotherapists).

• Some PCNs are working with local provider partners to provide joined up responsive care

• Sussex wide Clinical Directors Network Events established and development programme being designed

• Primary Care Programme Board established to provide a structure for governance of primary care strategy and

oversight of plans

• Development of Primary Care Strategy as part of the wider STP strategy

• Deployment of PCN development and accelerator monies to support organisation, leadership and infrastructure

maturity.

• Successful bid to NHSE/I for Sussex STP to become a part of Population Health Management Programme to

deliver on this ambition for the Sussex system.



What is expected of PCNs by March 2020

The Network Contract DES began on 1 July 2019

01 July 2019 Network Contract DES goes live across 100% of the country

July 2019 – Mar 2020 National entitlements under the 2019/20 Network Contract start:

• PCNs deliver Extended Hours Access appointments to all patients within their

PCN

• Year 1 of the Additional Roles Reimbursement Scheme (ARRS) –

Employment of a Clinical Pharmacist and Social Prescribing Link Worker

• Ongoing support funding for the Clinical Director

• Ongoing £1.50/head from CCG allocations

Apr 2020 onwards National Networks Services start under the 2020/21

Network Contract DES

Year 1 Timeline



Service Specifications

• The first five draft service specifications to be delivered by PCNs (from April 2020) under the GP

contract framework (in collaboration with community services and other providers) were recently

published and NHSE/I are currently seeking feedback on these.

• The GP contract framework set out seven national service specifications that will be added to the

Network Contract DES: five starting from April 2020, and a further two from April 2021. The five

services are:

• Structured Medication Reviews and Optimisation

• Enhanced Health in Care Homes (jointly with community services providers)

• Anticipatory Care (jointly with community services providers)

• Personalised Care; and

• Supporting Early Cancer Diagnosis.

• A Sussex wide response to the consultation on service specifications will be coordinated via the

primary care board as well as detailed proposals on how PCNs will be supported to deliver each of

the new service specificaitons.



Metric description

1 The number of individual SMR episodes undertaken, including:

• The number of SMR processes undertaken (number of individual patients given

one or more SMR appointment)

• The number of SMR follow-up appointments

2 Outcome measurement to monitor impact of SMR

3Prescribing rate of nationally identified medicines of low value that should not be

routinely prescribed

4 Prescribing rate of low carbon inhalers

5 Prescribing rate of medicines that can cause dependency

6 Prescribing rate of anti-microbial medication

PCN members will support direct tackling of the over-medication of patients, including inappropriate use of

antibiotics, withdrawing medicines no longer needed and support medicines optimisation more widely

Structured Medication Review and Optimisation



Enhanced Health in Care Homes

Metric description

1 The rate of emergency admissions for people living in care homes.

2 The rate of urgent care attendances for people living in care homes.

3The proportion of people living in a care home who have a personalised care and support plan

in place.

4The number of people living in a care home who receive an appointment as part of the weekly

care home round

5The number and proportion of people living in a care home who receive a structured

medication review.

6The number and proportion of people living in a care home who receive a delirium risk

assessment.

The aim of this service will be to enable all care homes to be supported by a consistent multi-disciplinary team of

healthcare professionals, delivering proactive and reactive care. This team will be led by a named GP and nurse

practitioners, organised by PCNs.



Metric description

1 Number of individuals in receipt of the Anticipatory Care model

2Number of needs assessment carried out for individuals in receipt of the Anticipatory Care

model.

3Number of individuals in the active cohort of the anticipatory care model with a

personalised care and support plan.

4Number of individuals in the active cohort of the anticipatory care model receiving a falls

risk assessment.

5Number of individuals in the active cohort of the anticipatory care model receiving a

delirium risk assessment

6 Number of SMRs for the active cohort on the anticipatory care model

7 Number of SMR follow-ups in the active cohort on the anticipatory care model

8Number of individuals in the active cohort on the anticipatory care model given a referral to

social prescribing service or where social prescribing is declined

Anticipatory Care

PCN GP practices and other member providers will work collaboratively to introduce more proactive and intense

care for patients assessed at being high risk of unwarranted health outcomes, including patients receiving

palliative care



Personalised Care

The Comprehensive Model of Personalised Care has six main evidenced based components:

• Shared decision making

• Enabling choice (including legal rights to choice)

• Personalised care and support planning

• Social ‘prescribing’ and community-based support

• Supported self-management

• Personalised health budgets and integrated personal budgets

This model will be developed in full by PCNs under the Network Contract DES by 2023/24. the minimum national

activity levels for all elements of the model will increase gradually over time in line with increases in capacity. As

part of the national requirements, PCNs will need to contribute to the ICS plan and the ICS will also need to set out

what it is doing locally, given some of the services are best delivered within a framework of wider local coordination

and support.



Metric description

1The number of personalised care and support plans delivered (including measure of

delivery rate for required cohorts)

2 The quality of personalised care and support plans

3The number of shared decision making conversations completed (including measure of

delivery rate for required cohorts)

4 The quality of shared decision making conversations

5 The number of social prescribing referrals made

6The number of patient activation measurement assessments undertaken (including

measure of delivery rate for required cohorts)

7 The number of Personal Health Budgets



Supporting Early Cancer Diagnosis

PCNs will have a key role in helping to ensure that all their GPs are using the latest evidenced-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.

Metric description

1The proportion of cancers diagnosed at early stage (stage 1 and 2) – progress towards local

Cancer Alliance target

2 PCN-level participation in breast, bowel and cervical screening programmes

3 Proportion of urgent cancer referrals that were safety netted

4The number of new cancer cases treated that have resulted from a two week wait referral

(the ‘detection’ rate)

5 The number of two week referrals resulting in a diagnosis of cancer (the ‘conversion’ rate)

6 Number of cancers diagnosed via emergency presentation



Primary Care Governance

Primary Care Programme Board

• The Primary Care Programme Board has been established across Sussex CCGs to provide oversight and consistency of primary care development across

Sussex and successfully deliver the primary care strategy.

• A PCN programme plan has been developed to provide oversight and governance around PCN work streams. This has been aligned to PMO methodology

from digital and estates primary care programmes.

Primary Care Programme

BoardReporting to :

7 CCGs Governing Bodies

Primary Care Co Commissioning

Committees

NHSEPCN Development Group

Primary Care Estates

Primary Care Digital

Primary Care Workforce

Primary Care Development Group

• The Primary Care Development Group reports to the Primary Care Programme Board, and supports the development and delivery of Primary Care

initiatives, including Primary Care Networks, General Practice Forward View (GPFV) and Long Term Plan (LTP), across Sussex. Its core purpose is to

facilitate the delivery of the local primary care strategy and underpinning plans.

7 CCGs

Executive meetings

Clinical Director meetings



Overview – PCN programme

There is a need to ensure there are sufficient primary care and community services to meet the needs of an ageing population with increasingly complex health and care needs. This national

Primary Care Networks programme has bought together general practices to work at scale around a combined patient population to improve each practices ability to recruit and retain staff,

to manage financial and estate pressures, to provide a wider range of services to patients and to more easily integrate with community services and the wider health care system.

ObjectivesTo ensure governance and oversight of the PCN

development programme covering:

• Implementation of the Network DES service

specifications

• PCN maturity, development and planning

• Developing adequate and appropriate PCN

workforce.

• System working and alignment to the ICS

priorities;

• Integration and partnerships

• Primary Care estates;

• Digital transformation and client records

across providers

Highest risks1. Insufficient workforce / not

developed to provide new

specifications.

2. Non alignment of community

nursing teams to PCNs reduces

the ability to deliver integrated

services

3. No single PMO process leads to a

lack PCN programme oversight.

4. Insufficient Clinical director

support leads to PCN lacking vison

and leadership

5. Lack of clinical system integration

is a risk to effective collaboration

and patient care

Milestones

• July 2019 –PCNs signed off

• August 2019 – PMO process agreed

• Sept/Oct 2019 – PCN self assessment

completed and development plans

agreed

• March 2020 – PCNs ready to deliver new

specifications network DES Key details

1. There are 38 PCNs in Sussex; all with

Clinical Directors; across 7 CCGs. Nationally

the PCN programme has been implemented

at pace with a national prospectus

2. Integration relies on community services

aligned to each network

Planned Outputs

1. Single process to have oversight of PCN

development

2. PCNs delivering the services outlined in

the network DES specifications

3. Primary and community care teams

delivering integrated patient care.

Resources

• £1.50pp to PCN for development

• Legal advice

• PCN Clinical Director funding

• PCN Workforce funds to provide

new staff

• PCN Development fund

• PCN Accelerator funds

Interdependencies

• Community services integration

• PCN and Clinical Director Development

plan

• GP Forward View Programme

• NHS Long Term Plan

• Primary Care Strategy



PCN Development

• £1.3million allocated for PCN and Clinical Director development across Sussex for 19/20 (recurrent)

• NHSE have launched the following support documents:

• Maturity matrix for PCNs - outlines core components that underpin the successful development of

networks.

• Prospectus - sets out key components that should be used as the basis of any support offer

• PCNs will use the matrix to self-assess their development and prospectus to formulate a development plan

• PCNs will be supported by CCG primary care leads and network events to self-assess and develop plans to

deliver their PCN and ICP ambitions for their neighbourhoods



PCN Development – indicative timeline



PCN Development - update

• All Sussex PCNs (38) have completed self-assessments against the NHSE/I maturity matrix and begun to

formulate development plans. Monies were allocated to PCNs at end of Q3.

• PCN development funding is overseen by the Sussex CCGs Primary Care Programme Board with approach

to allocation agreed by PCCCs. PCN development monies have been top sliced 10% and allocated equally

between the 38 PCNs to earmark a specific fund for PCNs to use on leadership development. The

remaining has been allocated according to PCN population size.

• Self-assessment of the developmental domains outlined in the matrix indicate similar levels of maturity

across Sussex PCNs.Below

foundation

Foundation Step 1

Leadership, planning and partnerships 2 28 7

Use of data and population health management 2 32 4

Integrating care 1 34 3

Managing resources 3 35

Working with people and communities. 6 29 3



• The top 3 themes for development identified from our 38 Sussex PCN self-assessments were:

• Organisational Development

• Team development and Support to set up new teams/services

• Leadership and change management

• Other areas identified include:

• Using Public Health population data

• Wider engagement including councils, community, PPGs, patients etc.

• Data analyst support (CCG performance data)

• Vision and strategy setting

• Scaling and connectivity will be overseen by the primary care board. A further update on PCN maturity and

use of resources against development plans will be requested in Q4.

• Review of PCN development monies allocation approach will be undertaken in Q4 by the primary care

board with a view to taking forward proposals through PCCCs in 20/21.

PCN Development - update



PCN development : accelerator sites

To support PCNs to move at pace, ahead of the national minimum requirements, an accelerator programme will be established to

drive progress, support the desired integration of services, and reduce clinical variation across the Sussex STP foot print. The

aims of the programme are as follows.

Progress

faster

• To support PCNs across Sussex STP who want to develop faster in 2019/20, and deliver more than the national PCN specification requirements.

Integration

• Test out how PCNs and local health, care or voluntary sector providers can come together to better integrate and transform care and services for their local population with PCNs as a key part of the local transformation approach.

Clinical variation

• Identify and demonstrate how practices in the PCN can come together to enable local transformation and delivery of elements of the Sussex STP clinical variation programme and or LTP ambitions in their PCN to improve population health.

Four specific areas of focus have been identified, for PCNs to accelerated and respond to the challenges and focus on:

1. Development and acceleration of the PCN through the maturity matrix

2. Delivery / test the Sussex STP Clinical Variation Programme ambitions and requirements (Musculoskeletal falls, Diabetes, and Cardiovascular disease)

3. Delivering the requirements of the LTP (including anticipatory care, personalised care and early diagnosis for cancer)

4. Integrated joint working of the PCN with other providers to better support integrated care, MDTs and improve the PCN population health; and better

integrate urgent or planned care pathways to improve system flow, avoid admission and improve value for money).



PCN development - accelerator sites - update

• £20K per PCN across Sussex has been made available to support accelerator sites. The deadline for

submission of bids aligning with the areas of focus outlined is end Q4 19/20.

• As of end December 2019 – 21 PCNs submitted bids for this funding. Bids were evaluated by the Primary

Care Development Group, which has representatives from NHSE, the LMC, primary care clinical and

commissioning; and approved through the primary care board.

• The bids can be broadly categorised into three areas;

a. Bids that support PCN and community provider integration and plans to redesign some services to meet the

PCN population health needs

b. Bids that support the MSK clinical variation programme and the introduction of First Contact Practitioner

roles

c. Bids that support PCN governance and maturity and bids that support the early diagnosis of cancer.

• Deployment of funding will be monitored and outcomes reported through the Primary Care Board.



PCN development – additional accelerator sites - update

• An additional £20K accelerator opportunity has been made available for up to 10 PCNs only who can

demonstrate that they will use the additional fund to progress initiatives and plans either at a faster pace, or

greater scale. The criteria for the additional PCN funding includes:

• Readiness to share the learning

• Fast tracking the project

• Patient outcome focused

• Focused on integrated teams addressing a PCN population need

• 24 PCNs have bid for the additional accelerator funding across Sussex.

• Bids are being reviewed through the primary care development group for decision on the 10 sites that will

receive monies, for final approval via the Primary Care Board in February 2020.



PCN and provider engagement, integration & partnerships

• All PCNs are at a different place in their maturity, ambition and aspiration. There are many local examples of integration of primary and

community services in PCN neighbourhoods and places across Sussex.

• A PCN development and engagement programme is being developed to provide the forum to build on and share the learning from these

examples of joined up care, supporting PCN CDs to engage with local voluntary, acute and community care providers, stakeholders and the

public.

The purpose of these PCN provider forums are for PCN CDs and local providers to :

• Review the PCN population health data and agree priority areas for focus to improve PCN population health

• Develop population based commissioning and delivery and further develop plans to join up care

• Formation of integrated multidisciplinary care configured around PCNs neighbourhoods

• Development of Integrated Care Partnerships

• Gain consensus on how to get PCN CD provider voice and representation at system / place / local forums

• Share examples of best practice and learning and feedback from wider meetings

• Support PCNs to identify how to best engage with and listen to the public and patients



• We have established PCN Network Events across Sussex PCNs to support partnership working, PCN

development and integration throughout 20/21.

• The next PCN Operational Event is on 21st January 2020 at the Amex, Brighton.

• The next Sussex Wide PCN Event is on 18th March at the Amex, Brighton.

• The focus of these sessions will be around the following areas

• Understanding and utilisation of population data

• Supporting implementation of the DES service specifications

• Citizen engagement

• Partnership working and integration

PCN network forums



Primary,

community &

acute, health and

care providers

delivering the

Long Term Plan

priority areas

Local

general

practice

resilience

needs

Primary Care

Strategy

GPFV priorities

PCN development

Practice resilience

Workforce plans

STP

Population

Health

Check

Integrated Care

Provider Partners

• PCNs

• Social care

• Physical and Mental

Health

• Voluntary sector

• Independent sector

Commissioners

• Local authority

council partners

(borough, district,

unitary & county)

• CCGs

• NHS England

(NHSE)

Local engagement

• Public

• Patients

• Patient

representative

groups, including

general practice

PPGs

Primary and community care - a landscape for integration


Hastings and Rother CCG | High Weald Lewes Havens CCG | Horsham and Mid Sussex CCG 29

Integrated care

model operates at

three levels, and is

underpinned by

three fundamental

building blocks.

29

You can access a wide

range of professionals

within primary care, who

will work together to

support your social,

physical and mental health

needs wherever you liveExtended access to

GP appointments and

improved access to online

resources

We will share best

practice and use our skills

and knowledge to deliver

safe and coordinated care

for you in your home,

local community, hospital

and beyond

Hospitals will work together to provide the

best quality, safety, value and equity of care

in a timely manner

Care will be based on the

best knowledge available

We will provide

health and social

care at or as close

to home as possible

All decisions about your

care will be inclusive:

made with you

EstatesWorkforceDigital

Services designed to address the

wider determinants of health

Enabling people to manage their own

health and care better, supported by

services

Preventionto improve population health and wellbeing

Seamless end to end care

across all services to

provide the best possible

outcome for you along a

coordinated pathway

You, your family and

carers will be supported to

have the knowledge, skills

and confidence to self-

manage your health and

wellbeing to start well, live

well, age well and die well

We will

harness

research and

innovation to

meet local

needs

In your local area

(~250-850k

population), primary,

community and local

hospital services will

provide joined-up

place-based care

through Integrated

Care Partnerships, at

or close to home.

In Sussex (1.8m

population), we will work

in partnership to deliver

high quality specialist and

complex services to

achieve the best

outcomes based upon

the best knowledge

available.

Each neighbourhood

(30-50k population) will

be supported by a

Primary Care Network

where a range of

professionals work with

you to manage your

social, physical and

mental health needs.



Next steps

Primary Care Strategy

• Finalise the Primary Care Strategy at Governing Bodies – November 2019

• Gain and incorporate stakeholder and membership views on Primary Care Strategy

PCN development

• Develop aggregated plan for PCN development and implement process for support funding

• Deployment of advanced accelerator monies

• Implement Sussex wide process for ARRS and support workforce expansion and retention

• Provision of data offer PCNs for segmentation and stratification to support specification delivery

• Support PCNs to prepare for the delivery of the new services specifications

Integration of primary, voluntary, community, acute, health and care services

• Establish Sussex wide PCN, place based and individual PCN and provider

• Support the Primary Care Networks in Sussex to work as part of an Integrated Care Partnership providing care to each neighbourhood

• Support PCNs to engage with the public, patients and stakeholders in the design and development of PCNs and Integrated Care

Partnerships

Documents

Primary Care Networks Update January 2020 · 2020-04-15 · Hastings and Rother CCG | High Weald Lewes Havens CCG | Horsham and Mid Sussex CCG Now continuing support through NHS Long