Primary and Community Care

1

• Primary and Community Care
• Services Strategy
• Stakeholder Event
• 14 May 2009

2
Agenda

• 6.30 - Welcome and Introductions Jackie Forshaw
• 6.50 Thoughts and Pointers on Primary and
  Community Services Jeff Anderson and Pat
  Gartside
• 7.10 Questions
• 7.15 Working Groups
• 8.15 Next steps and future events
• 8.30 Close

3
Welcome and Introduction

• Setting the Context and Outlining the scope of
  the Strategy
• Where are we now?
• Engagement - How we will develop the Strategy
• World Class Commissioning and Transforming
  Community Services
• Timescales for developing the Strategy
• Challenges

4
Context

• High Quality Care for all NHS NSR June 08
• Vision for NHS Clear national vision to make
  quality the organising principle of the NHS
• DH Our Vision for Primary and Community Care
  July 08 sets vision for how services will
  continue to grow in next 10 years
• Key messages
• Access at times which are convenient make
  appointments easily booking in advance
• Choice - ability to make more choices including
  ability to choose their GP practice
• More services delivered in community settings and
  in patients own homes
• Support in taking greater control over how they
  manage their care, particularly for those with
  LTCs.
• Fairer Payment change to current payment system
  to one based on needs of the population served by
  practices
• Quality development of QOF to reflect
  objectives of promoting healthy lives and
  accreditation of practices to include peer
  validation
• Development further development of PBC

5
Context

• World Class Commissioning
• Adding Life to Years and Years to Life
• Key Messages from Mark Britnell, NHS Director
  General
• Will be excellence
• Will address poor performance through failure
  regime organisations will be held to account
• Primary Medical Care continue with improving
  access, GP led health centres etc..
• NHS Dentistry make sure people get access
  needs to be off the agenda by 2011
• Transforming Community Services
• Community Services pivotal to the delivery of
  high quality closer to home, helping people stay
  healthy, supporting patients with LTCs at home to
  prevent hospital admission, providing end of life
  care in community setting.
• Work programme focuses on level of reform and
  innovation required to transform community
  services.

6
Context

• Vision achieving continuous improvements in the
  quality of services
• Delivered through whole system re-design and
  spanning primary, community and secondary care
• Final Product A Strategy which describes the
  vision of primary and community healthcare in ALW
  in next 5 years which will also identify the
  development programmes needed to deliver the
  vision

7
Scope of Strategy

• Includes
• Primary medical
• Dental
• Pharmaceutical
• Optometry
• Community Services
• Closely linked/aligned to the TCS work
  programme

8
Where are we now?

• ALW still one of most under-doctored PCTs in
  England (PCT in lowest quarter on GPs per 100,000
  population) 50.36 p. 100,000 recently
  published by DH (ALW record 53.31 p 100,000
• National average 57.89 Have increased actual
  numbers of GPs by 7 since Oct 06 would still
  need 14 to meet national average
• 62 GP practices
• 39 dental practices (including 3 ortho only)
• Access to NHS dentistry to be off governments
  agenda by 2011
• Procurement of 2 new dental practices in
  Pemberton and Atherton to open in next few
  months

9
Where are we now?

• Optometrists
• 33 practices plus 8 domiciliary only contracts
• Average waiting time for optometrist 1 x day
• Most offer Saturday service
• Potential for utilising this resource
• Pharmaceutical Services
• 67 pharmacies
• Community Pharmacy Strategy developed in
  September 2008 in response to Pharmacy White
  Paper (April 08)
• Vision builds on core competencies of
  pharmacists

10
Where are we now?

• Community Services
• pivotal to the delivery of high quality closer to
  home, helping people stay healthy, supporting
  patients with LTCs at home to prevent hospital
  admission, providing end of life care in
  community setting.
• Work programme focuses on level of reform and
  innovation required to transform community
  services

11
Where are we now?

• ALW Community Healthcare

12
Challenges

• Economic downturn impact on NHS
• Variations in Quality of primary care
• QOF only 16 achieve scores of lt950 but changes
  in 2009/10 in prevalence may have impact
• Significant variations in non elective admissions
• Significant variations in actual v expected
  prevalence of chronic diseases
• Managing the market
• Secondary care services review
• Public expectations increasing
• Reducing Health Inequalities
• Increasing Life expectancy
• How we will measure and demonstrate success

13
Making it fit together

• Steering Board Meets fortnightly
• Engaging with stakeholders events in May and
  June
• Communicating progress
• Patient Engagement
• Governance
• Next Steps

14
Governance
Provider Boards
-
Wrightington
,
Wigan
and Leigh
Ashton Leigh and Wigan PCT Board
Ashton Leigh and
NHS Trust
Wigan
PCT Board
-
Ashton Leigh and
Wigan
Community Healthcare
PCT SMT
Transforming Commissioning

Saving Lives
Programme
Board
Primary and Community Care Strategy Steering
Board Hilary Heywood, Programme Director
Transforming Commissioning, Transforming Lives,
PCT Jackie Forshaw, AD Primary Care Julie
Southworth, Transforming Community Services,
PCT Kate Fallon, Director ALW Community
Healthcare PBC Clinical Lead GP
Representation David Valentine, Medical Director,
PCT
Acute Services Review Project
Steering Boards for
Steering Board
other workstreams
Service
-
specific
Working Groups
Steering Board Composition
-
Mick Dolan (Sponsor and Executive Lead within
Ashton Leigh and
Wigan
PCT)
-
Tony Chambers (Sponsor and Executive Lead within
Wrightington
,
Wigan
and Leigh NHS Trust)
-
Hilary Heywood (
Programme
Director)
-
Representatives from PCT and WWL Directorates
-
PEC Representative
Task and Finish Groups
-
PBC Commissioners
-
Ashton Leigh and
Wigan
Community Healthcare
-
Representative from
Wigan
MBC.
.
15
International perspectives Developing Roles in
Primary Care
Care Coordination
Expanded Provision
Gatekeeper
Integration
Case Management
Curative and Preventative
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Key features for the future

• ? Variation
• ? Quality in everything we do
• Patient choices and more in control
• A customer focus
• Individualised care AND population care
• Clinicians leading the change
• Competition for patients funding following
  patient
• New and expanding providers
• Primary care commissioners AND Primary care
  providers
• Financial environment

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What will success look like in 5 years?

• Culture shift - better relationships, highly
  valued
• Patients empowered, expectations managed
• Fair and equitable system of care
• Evidence based, preventative and
• outcome focused
• Integrated clinical teams with leaders,
• with earned autonomy
• Maximised and controlled resources
• Highest quality (100 QOF performance, optimal
  patient experience, KPIs aligned to needs of
  local people)
• Quality incentives as a lever for change

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Where are the opportunities?

• Workforce
• Integration
• Contracts
• Provider market
• Investment and Incentives
• Facilities
• Information
• Technologies
• Local people

19
Initial Thoughts on Community Services

• International picture
• National practice
• Policy

20
International Picture

• Most research and academic papers relate to
  primary care, which may include aspects of
  community provision, but rarely relates directly
  to what we consider as community services
• Keleher et al 2008 conducted a systematic review
  covering Australia, the UK, the US, the
  Netherlands, Canada, Sweden, New Zealand and Hong
  Kong.
• Modest international evidence that nurses in
  primary care settings
• Can provide effective care and achieve positive
  health outcomes for patients similar to that
  provided by doctors.
• Nurses are effective in care management and
  achieve good patient compliance.
• Nurses are also effective in a more diverse range
  of roles including chronic disease management,
  illness prevention and health promotion.
• Nevertheless, there is insufficient evidence
  about primary care nurses roles and impact on
  patient health outcomes.

21
International Picture

• The Australian Primary Health Care Research
  Institute at The Australian National University
  review of evidence in primary health care. This
  project reviews innovative models for
  comprehensive primary health care delivery
• It looks at primary health care in five
  countries, the UK, the US, Canada, New Zealand
  and the Netherlands.
• They identify commonalities in the aims of
  primary health care reform including
• Improving the cost-effectiveness and efficiency
  of services
• Improving service access and equity
• Improving the quality of services.

22
National Practice

• Recent Review by Kings Fund Shaping PCT
  Provider Services The future for community
  health, published in April 2009. Main findings
• Need to address performance issues
• The evidence suggests that community health
  services, particularly community nursing
  services, urgently need to address a number of
  performance issues. There are opportunities to
  enhance the quality of services if they
• clarify roles and responsibilities
• introduce more systematic approaches to caseload
  management
• move towards a service that is driven by needs
  not demand.
• If some community services are to provide a
  genuine alternative to hospital care they need to
  be able to provide 24/7 support, with close
  working between all those offering support in the
  out-of-hours period.

.
23
National Practice

• Recent Review by Kings Fund Shaping PCT
  Provider Services The future for community
  health, published in April 2009. Main findings
• Successful reconfiguration
• The report suggests possible reasons why
  previous attempts to locate community health
  service provision better within the health care
  system have failed
• each reorganisation has focused on structural
  change and not challenged the way in which
  services are delivered or staff work
• services have remained separate from primary care
  despite the importance of close working
  relationships
• aside from the attempts to reorganise, community
  health services have not been the focus of
  national or local attention and have struggled to
  attract investment effective leadership.

24
National Practice

• Recent Review by Kings Fund Shaping PCT
  Provider Services The future for community
  health, published in April 2009. Main findings
• .Better integrated care
• The experience of integrated care models
  reinforces a number of these messages and
  suggests that if primary care trusts wish to
  deliver more patient-focused and integrated care
  through their new community services structures,
  they need to
• focus on process as much as on structure
• take account of the dynamics of new ways of
  working
• focus on the patients
• actively engage GPs to ensure strong
  co-ordination of  primary and community services.

25
National Practice

• Tribals own exposure to provider service review
  is extensive, via the Partnerships UK Provider
  Development Programme.
• Key findings
• General intention to move away from describing
  services as individual service lines ( ie DN,
  HV, Sch Nursing, Physiotherapy) and towards
  Programmes of Care ( eg LTC, Urgent Care)
• Recognition that
• Performance monitoring is weak, due to data
  collection and lack of focus
• Quality measures are lacking
• Block contracts are mainly in situ, often without
  detailed SLAs/specs
• Community tariff offers opportunities to achieve
• Improved productivity
• Movement of services from acute setting

26
Policy

• Numerous national policy each building up a
  describe clear direction of travel for community
  services
• Our Health, Our Care, Our Say set out the
  original vision for community services
• The Next Stage Review built on this and presented
  an approach and some principles for the future of
  community services
• Transforming Community Services Programme
• Transforming Community Services provides a
  programme for the redevelopment of community
  services. it has been developed to improve
  service provision and drive up quality and
  overall performance in the services delivered to
  local communities

27
Policy

• Transforming Community Services Programme
• Work streams are developing which focus on
• Currencies
• Pricing
• Organisational form
• Clinical pathways or Programmes
• These are all underpinned by the new community
  services contract.

28
Policy

• Practice Based Commissioning (PBC)
• PBC provides the clinical leadership at the heart
  of World Class Commissioning - it is about
  engaging practices and other primary care
  professionals in the commissioning of services
• PBC enables primary care professionals, working
  across boundaries with secondary care clinicians
  and others, to redesign services that better meet
  the needs of their patients. 

29
Key Messages

• Clinically led change
• The strength of integrated services
• Quality at the heart of good primary and
  community care

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List of delegates

• Jackie Forshaw (PCT)
• Rose Pealing (PCT)
• Clare Thomason (PCT)
• Deirdre OBrien (PCT)
• Chris Tunes (LOC)
• Derek Scholar (LCD)
• Paul Carrol (PCT)
• Sally Forshaw (PCT)
• Adil Khan (GP)
• Jo Culshaw (Practise Manager)

• Linda Woodgate (LDC)
• S. Mughal (GP)
• Kate Fallon (ALW CH)
• Sheila Shaw (GP)
• Umesh Patel (PCT)
• Linda Scott (PCT)
• Joe Chattin

31
Group Task and Delegate Feedback

• The delegates were split into 3
  multi-professional groups and were asked to
  consider 4 strategic questions which are relevant
  to developing a vision for Primary and Community
  Care Services in NHS ALW.
• The Questions were
• What are the key principles of good primary and
  community care services?
• How can we work together to assure high quality
  primary and community care improvements for the
  benefit of the people of NHS ALW?
• How do we ensure access and choice of services
  are delivered and maintained?
• What opportunities and innovations are available
  to NHS ALW?

32
Strategic Questions

• Key principles of good primary and community care
  services? The following list was generated by
  delegates

33
Strategic Questions

• Summary
• Primary and community care services in ALW should
  be consistently high quality and equitable and
  should meet the high expectations of patients and
  the public. To enable services to become
  integrated and seamless they need to also be
  innovative. Services should also be educational,
  allowing professionals to share knowledge and
  supporting patients to take responsibility for
  their health and well being. Services should be
  safe, responsive and be both accountable to, and
  supported by NHS ALW, patients and the community.

34
Strategic Questions

• How can we work together to assure high quality
  primary and community care improvements for the
  benefit of the people of NHS ALW?
• Clear benchmarking tools, agreed performance
  measures and disciplined contract monitoring that
  is consistent across all professions.
• Communication is key. NHS ALW needs to share the
  vision with stakeholders and with public.
• Need to understand what high quality means for
  ALW and communicate this to patients, so they
  expect high quality services.

35
Strategic Questions

• Need to ensure adequacy of supply do we have
  enough GPs, dentists, pharmacists, opticians,
  community staff to deliver the improvements in
  quality we need
• Need to ensure adequacy of funding and adequacy
  of our estates are buildings fit for purpose
  and being fully utilised.
• Integrated primary and community services is key,
  GPs should work in teams with community staff.
• Choice should not affect quality. Need to drive
  forward quality even where there is no
  competition by working in partnership.

36
Strategic Questions

• How do we ensure access and choice of services
  are delivered and maintained?
• Make sure access is as wide as possible and
  looking at alternative health promotion sites
  including hairdressers, leisure centres, schools.
• Better understand what people need to access 24/7
  and if there is a need and demand for that
  service.
• Commission a better range of availability from
  providers, including offering incentives to
  stimulate the market.
• Be clear about what must be commissioned, what
  should be commissioned and what can be
  commissioned.

37
Strategic Questions

• Patients need to be sign posted to facilitate
  choice and message needs to be consistent and
  high quality information.
• Ensuring teams are integrated and professional
  knowledge is shared across teams will facilitate
  choice.
• Ensuring patients take responsibility and
  reducing waste such as Did Not Attends.

38
Strategic Questions

• What opportunities and innovations are available
  to NHS ALW?

39
Strategic Questions

• Other key burning issues
• Need to find cost effective ways of doing things
• Need to shorten patient journey and reduce
  inappropriate visits
• Giving community services opportunities to expand
  and develop (shifting services from secondary
  care)
• Ensuring sing handed practises are not
  marginalised
• Risk averse culture needs to be addressed not
  just PCT but other providers/ contractors
• Federation

40
Next Steps in developing a Primary
Community Care Strategy

• How do you want be involved, own and drive
  forward primary and community care change?
• Feedback from event circulated swiftly
• We will be developing a clear understanding of
  the current service provision and reviewing best
  practice and opportunities
• We will be drafting the strategy and offering
  comment
• Date of next event 16th June 2009, Leigh Sports
  Village