Agenda item

Investment and Evolution - Primary Care and Developing Rotherham Community Health Centre

Jacqui Tuffnell, Head of Commissioning
NHS Rotherham CCG


Jacqui Tuffnell, Head of Commissioning NHS Rotherham CCG, gave presentations on Primary Care and Developing Rotherham Community Health Centre as follows:-


Investment and Evolution – Primary Care


NHS Long Term Plan:  Overview

Published in January 2019

Sets out the key ambitions for the NHS over the next 10 years

Produced in response to a new five- year funding settlement


1 New Service Model

2 Prevention and Health Equality

3 Care Quality and Outcome Improvement

4 Workforce Pressures

5 Technology

6 Sustainable Financial Plan

7 Next Steps


A New Service Model for the 21st Century

Five major changes to the NHS service model:

        Boosting ‘out-of-hospital’ care and finally dissolving the historic divide between Primary and Community Health Services

        Redesigning and reducing pressure on emergency Hospital Services

        People will get more control over their own health, and more personalised care when they need it

        Digitally-enabled primary and outpatient care will go mainstream across the NHS

        Local NHS organisations will increasingly focus on population health and local partnerships with local authority-funded services, through new Integrated Care Systems (ICSs) everywhere - in relation to concerns about health inequality population it was about making sure the population's health would be managed appropriately.


What this means

        Urgent Community Response and Recovery Services – integrated rapid response and care home liaison

        Primary Care Networks of Primary and Community Teams – localities now in place renamed PCNs and strengthened

        Guaranteed NHS support for care homes - already had care home alignment with GP practices so one GP practice tended to look after a care home instead of everybody being assigned to different care homes, getting different levels of care and it being reactive instead of proactive

        Supporting people to age well – right support services when needed

        Increasing patient choice

        Same day emergency care – ensuring people were in and out of hospital on the same day by increasing the kind of conditions managed within a 24 hour period so people went back home

        Personalised care when needed

        Reducing delays in patients going home

        Digitalisation of Primary and Outpatient care

        Integrated Care systems everywhere by 2021 – focussing on population health


Rotherham already had some of these Services, therefore, the long-term plan did not bring any big surprises in relation to the direction of travel already taken. 


Investment and Evolution: A Five Year Framework for GP Contract Reform to implement to NHS Long Term Plan

- Introduces automatic entitlement to a new Primary Care Network Contract

- Gives five-year funding clarity and certainty for practices


This was quite significant in relation to how GP practice currently operated.  It had not been expected to be so clear on the expectations in relation to how Primary Care would change.


The Vision for Primary Care Networks (PCNs)

        The key building block of the NHS long-term plan

        All GP practices in geographical based PCNs with populations of around 30,000–50,000 patients - < 30,000 probably too small to be able to provide shared services across the network and ensure you could almost share staff/back-office staff as well between practices. > 50,000 would start to get a little too big

        Intended to dissolve the historic divide between Primary and Community Medical Services – latter ultimately provided from PCNs with leadership arrangements changed not necessarily contractual

        Proposals from practices submitted and agreed in May 2019 by CCG

        Small enough to provide valued personal care;

        Large enough to work with other practices and organisations

        General practices working at scale together, to

        recruit and retain staff;

        manage financial and estates pressures;

        provide a wider range of services to patients

        integrate with the wider health and care system.


What will PCNs do?

They would be more flexible in relation to how they would operate in terms of providing care for generally healthy people.  Some practices had only a 1,400 population and were starting to struggle in terms of resource for the wider remit of care expected from general practice.  As part of that Network somebody else might provide the more complex care on their behalf for a particular patient.   Some practices did not have any female GPs or male GPs and some people only wanted to see a female GP or a male GP, so it was to provide that support to ensure the population got the appropriate care and also enabling patients.


        Provide care in different ways to meet different needs, e.g.

          flexible access to advice and support for generally healthy people

          joined up care for those with complex conditions


        focus on prevention and personalised care,

          supporting patients to make informed decisions

          to look after their own health

          connecting patients with statutory and voluntary services


        provide a wider range of services through a wider set of five funded staff roles i.e.

          First Contact Physiotherapy, Associate Physician, Paramedic

          extended access

          Social Prescribing (100% funding, others 70%)


        deliver 7 national Service specifications.

          5 would start by April 2020: Structured medication reviews, enhanced health in care homes, anticipatory care, personalised care & supporting earlier cancer diagnosis

          2 would start by 2021: Tackling local health inequalities,  CVD case finding


        join up the delivery of urgent care in the community


        Be responsible for providing enhanced access services and extended hours requirements


        Publication of GP activity and waiting times data alongside hospital data

          New measure of patient-reported experience of access


        Will be the base for:

          integrated community-based teams

          Community and Mental Health Services


        will consider population health,

          from 2020/21, will identify people who would benefit from targeted, proactive support. 


        will represent Primary Care in integrated care systems, through the Accountable Clinical Directors from each Network


How will the funding work

Practices have to be part of the network to receive payments, which will include:


        Separate national funding for digital-first support from April 2021

        Funding for additional roles to support general practice: Clinical Pharmacists and Social Prescribing Link Workers in 2019/20,

        funding for physiotherapists, physician associates and paramedics to follow (worked through in terms of the numbers being trained and supported)


PCN Accountability

        Practices were accountable to commissioners for the delivery of Network services.

        A legally binding agreement 

        An accountable clinical director for each Network

        Publication of GP activity and waiting times data alongside Hospital data

        New measure of patient-reported experience of access


Benefits for Patients

        More co-ordinated services; where patients do not have to repeat information many times (Rotherham Health Record)

        Access to a wider range of professionals in the community – patient education needed to explain for example how physiotherapists had greater experience on musculo-skeletal (MSK) issues than GPs)

        Appointments that work around patients’ lives; shorter waits & treatment and advice delivered through digital, telephone and face to face

        More influence when people want it, with more power over how Health and Care Services were planned and managed  

        Personalisation and a focus on prevention and living healthily


Benefits for Practices and the Wider Health System

        Greater resilience; using shared staff, buildings and other resources to balance capacity and demand

        Better work life balance

        More satisfying work; each professional able to do what they do best

        Improved care and treatment for patients,

        Greater influence on the wider health system

        Better co-operation and co-ordination across services

        Wider range of services in community settings, meaning patients do not default to Acute Services – for example DVT this year

        Using the expertise in Primary Care on local populations to inform system-wide decisions and how resources were allocated – Housing and Social Care involvement expected in understanding health impacts for our population and what we can do better together


Rotherham Primary care Networks

6 Primary Care Networks all over 30,000 population:

       Health Village/Dearne Valley PCN - Clifton Medical Centre, Crown Street Surgery, Market Surgery, St. Ann’s Medical Centre

       MaltbyWickersley PCN - Morthern Road Group Practice, Wickersley Health Centre, Manor Field Surgery, Blyth Road Medical Centre, Braithwell Road Surgery, Queen’s Medical Centre

       Raven PCN -Gateway Primary Care, Treeton Medical Centre, Stag Medical Centre and Rose Court Surgery, Brinsworth and Whiston Medical Centre, Thorpe Hesley Surgery

       Rother Valley South PCN - Dinnington Group Practice, Village Surgery, Swallownest Health Centre, Kiveton Park Medical Centre

       Rotherham Central North PCN - Greenside Surgery, Woodstock Bower Group Practice, Greasbrough Medical Centre, Broom Lane Medical Centre, Broom Valley Surgery

       Wentworth 1 PCN - Magna Group Practice, High Street – Rawmarsh, Parkgate Medical Centre, Shakespeare Road, York Road Surgery, Rawmarsh Health Centre


A number of the Clinical Directors had been in this system and supported either CCG projects or were Deputy Chairs of Committees.  However, others were new to undertaking this type of work so there would be development programmes, both national and local, as this was a big ask for Primary Care in what they were being asked to do in terms of change.


·           We would all welcome people being treated in the community rather than being in a hospital, but how confident were you that the out of hospital services could cope as in some areas a lack of trained staff has been reported for example.

-      It was about being cleverer in terms of utilising and bringing resources together and losing the divide that currently existed because of employment, although a lot was already happening.  Staff would do things such as take bloods because they were already with the patient or this could be done in general practice rather than patients returning to the hospital as before.  Work currently happening included understanding the Home First model and ensuring the right resources were in place for this.


·           On communications, an officer attended a Ward event to talk about the Rotherham App and people were very impressed.  Had it been rolled out well enough and did people know about it?  Surgeries did not seem to offer appointments at the hubs and previously the Select Commission had suggested that surgeries could play a recorded message when people were holding on the phone alerting them to the option to go elsewhere, so could that be considered. 

-      Regarding the app, the CCG were working with practices in relation to the release of the appointments.  This had held them up as they did not want large scale communication when practices had not actually enabled the appointments yet.  The marketing plan included going to big companies in Rotherham and the Council to make sure they knew about it and would hopefully send messages in turn so that everyone knew about the app.  The CCG wished to ensure that every single practice released that 25% capacity so people could see there was an appointment, see extended access and see that you could have a Physio First appointment.  These would all be bookable but needed to be up on the app so no-one would be disappointed.

-      The phone message suggestion could be taken back and as practices tended to use one company across Rotherham it should be quite easy to do.


·           What had been the geographic rationale for the grouping of practices into Primary Care Networks as they did not seem to follow natural communities.

-        A lot did and they were predominantly based on how the district nursing structure.   Thorpe Hesley did not really fit with Raven but as it would soon become part of the Gateway Primary Care grouping that had been done immediately thinking ahead. 


·           The idea of amalgamating Primary Care into bigger entities made perfect sense, so why not just merge the practices.

-      For GMS practices a lifetime guarantee existed in essence that there would be no change to how they operated so the CCG had to negotiate to make any changes and a merger could not be enforced on a practice. 


·           First Contact Physiotherapy - what would that service look like.

-      First contact physios were not physiotherapists providing actual physiotherapy; they were doing the diagnosis/assessment that would have been done by a GP if a patient had gone to them with a MSK issue.  They would sort immediate pain relief and determine whether additional physiotherapy was required or referral to the hospital.  They could also provide physiotherapy leaflets.


·           The Primary Care Network names seemed rather odd, for example having Rother Valley South but not having Rother Valley North and also Rotherham Central North but not Rotherham Central or Rotherham Central South, so did these need another look.

-      The Networks determined the names, some of which were just historical but all were recognisable other than Raven.


·           What were the advantages of links with other Services, particularly between Primary Care and Adult Social Care, for the older person? 

-      Social Workers would not be seen out in PCNs but staff in RDaSH and the Council had been digitally enabled to be able to link in with MDT discussions without all being in the same room unless they really needed to be. 


·           Tackling health inequalities - how would links be made with other departments such as Housing.

-      This was probably one of the most significant changes in General Practice in 70 years, so the first thing they needed to do was work together as GPs.   They all knew each other but had never had to share resources or how they operated and it probably meant changing their operating models to align together.  One joint bank account had been set up for the monies coming in for Primary Care Networks.  So without wishing to push too quickly in relation to developing these, the expectation was that it would bring all that care together having those conversations rather than it just being one individual GP trying to resolve things.


·           Would there be consistency of care for older people who might go into residential care and have to change their General Practice because they no longer lived in the area covered by the Practice, and would that reduce their choice and control. 

-   When care homes were aligned people were not told that they would have to change Practice but they started to see that people who were all connected to that Practice were getting a different service to them.  No significant change in relation to care homes was anticipated from the PCNs as they had already aligned.  As new people went into care homes they could still choose to remain with their current GP but most of them chose to move.


·           We needed to build more engagement into this model, with patients and people in the community.  Are we taking choice away from people about where they go for care?  Other concerns were early intervention picking up cancers early and how waiting times for GPs would be measured. 


·           What about holistic care rather than treating individual things? Could medication reviews be done over the telephone rather than taking up an appointment, unless bloods were needed, and then people who wanted to see a GP might be more able to see one?  How would this model enable Practices to recruit GPs who were holistic and had often known families for years and had more background knowledge? There were reports that Practices were unable to recruit GPs and if that became a growing issue could it destabilise the model or would it exist with the other provision.

-        In terms of holistic care the concerns were recognised but there were not enough GPs, which meant supplementing the workforce.  Pharmacists would not detract from holistic care as they would be working within the Practices not remote from them and for some PCNs it would be almost one per Practice.  Next year’s funding was for 36 additional posts for Rotherham and by year 5 there would be about 100 extra people working in General Practice in those new types of role.  As a number of pharmacists already worked in Practices, the benefits for patients and the Practice were known, including freeing up GPs to spend longer with patients who needed more time.  Physio First had been in place for a year and freed up significant time for the GPs and the numbers referred into secondary care had levelled off after a huge hike nationally in terms of the numbers going to physio. 

-        The biggest benefit has been people getting an appointment within 24 hours if prepared to go anywhere in Rotherham to one of the hubs.  Patients could be seen the next day for Physio First when they could have waited 2 or 3 days to see their GP and are often getting earlier resolution.  It was a dilemma in relation to how you ensured holistic care, but by having those regular MDT discussions there was wider understanding of what was happening with that patient and with that family.


·           The other point was who would be screening patients, as currently this was done by non-medical receptionists in some Practices, and was it in the plan.

-        A number of receptionists from the Practices had been trained in relation to care navigation so the message already on the systems from the lead GP said that people would be asked a number of questions.  That was to ensure people went to the right services.  This had been supported by customer care training around how the questions were handled and people being treated courteously.  More care navigation was likely to happen.


·           Regarding the proposals that were submitted and agreed in May, would the Commission be able to have a summary of the content.

-        Yes, it was available publicly.


·                Would this create parity across the Borough.

-        A lot of work had taken place in relation to ensuring a consistency of offer around the population.  There were mandated local enhanced services so that wherever patients were they should get the same level of service and the same offer.  Minor surgery and Dermatology happened across the Borough but there was a view that some Practices, particularly the single-handed practices, would gain by being able to check out what they were actually delivering.   The big Practices held regular sessions where they review each other in relation to what they had done with patients so that was expected to happen more globally now in the Networks.  The data used would be the population health data which would pinpoint areas where more support might be needed and that was how achieving parity was expected.


·           Would extended hours and access go beyond what was currently in place through the hubs.

-        Currently 132 hours per week were available and work would take place in relation to the offer.  Very little use was made of Sunday appointments still yet the Hospital was under pressure on Sundays.  It was a case of bringing those offers together and might mean the hours available would not need to increase, although it centred on providing what was required in terms of access into the system and some would say in-hours provision required boosting up. 


Rotherham Community Health Centre

        Rotherham Community Health Centre – purpose built to house the walk-in centre, GP practice, Dental Services and Community/Outpatient facilities, already included quite a lot of therapy

        Services had changed resulting in 2/3rds of the Centre now being empty – clear feedback from our population that it needs to be better utilised


The Walk-in Centre had in essence been amalgamated within the Urgent and Emergency Care Centre although with a slightly different offer and diagnostics were difficult to provide from the Centre so were now provided on the main Hospital site. 


What will work best for the Centre and our population?

        5 options considered - CCG worked with its estates and advisers across our community and undertook a One Estate Review as well, including the Council, RDaSH and the Hospital. 

        Recommended option to relocate Ophthalmology outpatientsenabling:

-      amalgamation of the Service

-      to meet CQC requirements separating children from adults

-      ensuring the estate was fit for purpose to meet current and future capacity (double the floor space)

-      reducing the footfall substantially on the Hospital site (by approximately 48,000 visits per year), freeing up car parking and
increasing the footfall into Rotherham’s town centre, which should contribute to regeneration of the town centre

-      responding to the public’s request to utilise this central, good quality facility


       This was all subject to feasibility for the Hospital so had not been signed off but it was hoped that it would be achievable for the Trust and would go to their Board.  One issue raised already was that the pedestrian crossing from the bus station to the centre was a silent one.


Next Steps

       Engage current Service users:

-      surveys with patients and carers in the department

-      publicise in the Hospital main reception outlining the plans and asking for comments

 -     Utilising social media to undertake surveys

-      Identify relevant stakeholders and key audiences

    Incorporate comments into the case for change

    Work up a plan for changes required to accommodate Ophthalmology as there would be some estates work

    If finally agreed, facilitate relocation before the end of the financial year


Following the presentation Members sought clarification on the following points:-


·           In terms of the figures, what proportion of the total footfall were the 48,000 visits per year.

       The exact proportion was not known but with 15,000 going to the Hospital site for Diagnostics, more than triple that number would come off site for Ophthalmology. 


·           Would Pharmacy Services in the Centre be sorted out from the beginning to enable people to get any follow-up medications swiftly or would they have to go to the Hospital, or return to the Centre later, to collect them.

       Prescribing had been picked up as part of the proposal to move the service and people would not be expected to go to the Hospital. 


The Select Commission was supportive of making better use of Rotherham Community Health Centre and requested a follow up report with the outcomes from the public engagement.


Resolved:- (1) To note the information provided regarding the development of Primary Care Networks.


(2)          To note the plans for ophthalmology services at Rotherham Community Health Centre.


(3)           To receive a further report on the plans for Ophthalmology following the public engagement.

Supporting documents: