Milton Keynes Place based Care

Milton Keynes Place based Care

NHS Milton Keynes CCG GP PLT Thursday 13th July 2017 Protected Learning Time The Future Model of Milton Keynes Primary Care Dr Nicola Smith CCG Chair Milton Keynes PLT: Case for Collaboration 3 Agenda 13:00-14:00 Introduction Nicola Smith The future of General Practice in MK Nicola Smith STP update Maria Wogan How collaboration is currently working Martin Mcshane Federation update Thao Nguyen

Introduction to Workshop - Jill Wilkinson/Hopeson Alifoe 14:00-15:00 Group Working 15:00-15:15 - Break 15:15-16:00 Panel Discussion/Q&A Hospital CNWL MK Council CCG Federation Summary 4 The future of General Practice in MK Nicola Smith Aims for today Update on progress so far Share our ideas for the future configuration of General Practice in MK

Listen to your feedback about possible options and listen to any concerns Start the process of taking steps towards developing a new model of acre for MK General practice. Compelling need for change Change is difficult Under no illusions about how difficult this is Now is the time to start the process But.. Some of those who have made changes have been able to improve care for patients, improve their working lives and have had success in recruiting good quality, motivated staff. Collaborative working -at scale STP Place-based MK wide / Federation level MK Locality ( 30-50,000 patients)

Why cant we go on as we are now? What problems are we trying to fix? Workload Funding Quality of patient care (and variations in quality) Workforce Morale Population growth Premature mortality Health inequalities Case for Collaboration Changes in demographics, disease patterns, new treatments and technology mean that the historical ways of working can no longer cope with the needs and demands, standards and expectations that have to be met. There are 454 FTE GPs across BLMK (259 FTE Nurses in GPs) GP Consultation rates, nationally, have increased by 14% (2007-2014) There are 6000 Care and Nursing Home beds across BLMK (cf 1500 hospital beds). The population is getting older with more complex care requirements. 10 Case for Collaboration - GPFV 5 year forward view triple aim

Health Gap better health Quality better care Financial sustainability better sustainability Future resilience and sustainability for General Practice Workforce and recruitment challenges Practice sizes tend to be biggest in Milton Keynes and Bedfordshire (excluding Bedford). Both areas have more than half of their practices having more than 10,000 patients: for Milton Keynes it is 60%. 11

Case for Collaboration Population Growth MK wide Milton Keynes was the 20th fastest growing local authority in England between 2005 and 2015 with a growth of 17.1 per cent. All age groups are projected to grow with the fastest growth in the older age groups. The population of Milton Keynes is projected to grow from 261,750 in 2015 to 308,500 in 2026. This is an increase of 46,750 people and a growth rate of 18 per cent. Over the next 11 years it is forecast to grow by an average of 4,200 people per year. 20,800 dwellings are anticipated to be built in Milton Keynes between 2015 and 2026. 12 Expansion areas map 13 Case for change Population Growth GP Neighbourhood specific North East

South West Northern Expansion Area (Redhouse Park) 600 dwellings 1380 people 2015-2018 Eastern Expansion area 4,031 dwellings 9271 people 2015-2022 South West MK (Salden Chase) 1855 dwellings 4267 people 2017-2026 Western Expansion area 6,570 dwellings

15,111 people 2015-2025 Strategic Land Allocation 2590 dwellings 5957 people 2015-2020 Oakgrove 1000 dwellings 2300 people 2015-2019 CMK/Campbell Park 6600 dwellings 15180 people 2015-2025 Totals 600 dwellings 1380 people By 2018 Totals 14221 dwellings

32708 people By 2025 Newton Leys 2000 dwellings 4600 people 2015-2020 Eaton Leys 1800 dwellings 4140 people 2018-2027 Totals 5655 dwellings 13007 people By 2027 Oxley Park 3080 dwellings 7087 people 2015-2025 Totals 9650 dwellings

22198 people By 2025 14 GPs per 1000/PLS age ranges 15 Case for Collaboration - Workforce BCCG Primary care workforce GPs and practice nurses /1,000 pop 0.67 LCCG 0.53 MK CCG 0.52

STP average 0.59 England average 0.67 Comments BCCG at England average 16 17 Budget for health and social care What we are NOT trying to do We are NOT trying to impose a new model of care on General Practice-but suggest a new structure for General Practice that will enable a new way of working to benefit both patients and clinicians We do NOT want to stifle innovation but develop a framework in

which innovation can flourish supported by commissioners We are NOT advocating a change in your contract just a new way of working We are NOT suggesting that individual practices merge-unless that is something practices want to do themselves We are NOT going to make a decision today but take your feedback into account to design a model that best fits MK The status quo is NOT acceptable -change will happen We have made a start . General Practice Resilience Programme MK have 2 practices MK has the General Practice Access Fund (formerly Prime Ministers Challenge Fund) 4 practices employ paramedics 4 practices employ clinical pharmacists 1 practice employs a physician associate Many practices employ nurse prescribers and advanced nurse practitioners Commencing a pilot in 4 practices using Mental Health Practitioners Federation currently forming across MK GP resilience and sustainability working at scale 1st April delegated commissioning. Next Steps

Look at comments and reflect on todays event Feed back to GPs PLT event September for further feedback and discussion (note new arrangements:2-6.30pm) Begin process of organising community services and alignment of commissioning processes around the MK Locality model Bedfordshire, Luton & Milton Keynes Sustainability and Transformation Partnership (STP Update) Matthew Webb, Chief Officer, MK CCG Sustainability & Transformation Partnership (STP) Update Next Steps on the NHS Five Year Forward View our aim is to use the next several years to make the biggest national move to integrated care of any major western country The NHS stands on a burning platform the model of acute care that worked well when the NHS was established is no longer capable of delivering the care that todays population needs.transformational change is possible, even in the most challenging of circumstances

Sustainability and Transformation Partnerships (STPs) Are a way of bringing together GPs, hospitals, mental health services and social care to keep people healthier for longer and integrate services around the patients who need it most. Accountable Care System (ACS) Bedfordshire, Luton & Milton Keynes one of 8 lead ACS in the first wave During 2017/18 Shadow ACS Lead ACS Offer: Greater control over primary care delegation Access to capital funds and transformation funding One stop shop with NHSE/NHSi Support from national teams Lead ACS Ask: Evidence of hospital alignment Financial and operational system wide performance agreement System control total for managing our finances Evidence of vertical integration and development of locality provision at 30-50,000 population What are our citizens saying they want? I only go to hospital when

I really need to I want to be able to ring one number that leads to the right person/ service and the right outcome, 7 days a week I ts about more than j ust my health I can raise other issues too, like housing and financial concerns I dont always see someone f ace to f ace sometimes I speak to them on the phone or email, but I still f eel in saf e hands I f I call the emergency services, they are able to access my inf ormation to see whether my team could help instead I f I do need to go and see someone, their offices are easy to get to and

are easy to find your way around The service is really simple to access I know exactly what to do I want the best available treatment if I have a lif e threatening condition I want to know my doctor and also know that he/ she is there f or me, irrespective of where in the system I might turn up I no longer have to be sent to all different services to get things sorted the GP is part of the same team as my physio and home carers All of the inf ormation about me and my care is together in one place and I have access to it and ownership of it What accountable care is and what it isnt!

Outcome based Accountable care is about Accountable care is not about Collaborative Statutory bodies losing control User centered Removal of public scrutiny or accountability

Lack of community involvement Right first time Salaried general practice Profiteerin g from NHS Risk where best managed Efficient delivery Changing services by stealth Cutting staff

Capitation risk managed either at ACS or Borough level; H&WB outcomes are set at Borough level; ACS system integration function operates at scale, across BLMK, and supports all four Borough care collaboratives Tier 2 - Functions @ Place Tier 1 - Functions @ locality Tier 2 - Functions @ Place Support e.g. supply chain assembly & management Tier 1 - Functions @ locality

Tier 3 Functions @ scale Support e.g. population health analysis and risk stratification Tier 1 - Functions @ locality Support e.g. integrated case management and care coordination S upport e.g. clinical decision support platf orm Accountability for performance can happen at multiple levels: At ACS level for overall quality, meeting national targets and ACS overall financial performance At Borough level for achievement of required place H&WB

outcomes, contract obligations and for community involvement and empowerment At locality level for service delivery, operating effectiveness and supply chain performance Tier 1 - Functions @ locality 27 BLMK:STP Triple Tier model in development Locality GP practices working together with health and care teams Approach will be tailored to local needs and context

Population size of 30-50,000 Place Borough level Milton Keynes Population of 270,000 Scale BLMK level Population size circa 1M Defining population health and well-being outcomes for local populations, strategic commissioning, accountability to our communities e.g. via H&WB Specialised commissioning Population health analysis and data sharing How Collaboration is

currently working Dr Martin McShane Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. People overestimate what can be achieved in a year and underestimate what can be achieved in a decade. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 30 An unnecessary malaise? The most obvious cause of doctors' unhappiness is that they feel overworked and under-supported. They hear politicians make extravagant promises but then must explain to patients why the health service cannot deliver what is promised. Endless initiatives are announced, but on the ground doctors find that operating lists are cancelled, they cannot admit or discharge patients, and community services are

disappearing. They struggle to respond, but they feel as though they are battling the system rather than being supported by it. BMJ. Why are doctors so unhappy? bmj.com/content/322/7294/1073?sso. Published May. 5, 2001. Accessed Jun 22, 2017. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 31 Primary care challenges Rising demand Declining collaboration Staff retention Unactionable

data Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 32 Key statistics illustrate the growing challenge There are 454 FTE GPs and 259 Nurses across BLMK for 1 million population. GP consultation rates, nationally, have increased by 14% (20072014). There are 6000 care and nursing home beds across BLMK (cf 1500 hospital beds). The population is getting older with more complex care requirements. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 33 Clinical workforce Community 13% Mental health

14% GP 9% Hospital based 4,867 Community 1,021 Mental health 1,024 General practice (GP) 669 Hospital 64% Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

34 Workflow analysis Two week time motion study for single practice Task allocation by role (GP, ANP, admin, etc.) Tasks divided into whether they could be reallocated to another role or not Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 35 Planning assumption Significant variation across and within practices Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

36 Potential for reallocation by role For ANPs, practice managers, practice nurses and GPs, over 50% of tasks could be potentially reassigned to a lower cost resource ANP HCA Practice manager Practice nurse Receptionist GP

Tasks by role ANP HCA Practice nurse Nearly 30% of GP time spent on clinical administration GP Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 37 System gearing2000/per person Primary care Community care 200

500 Pop7.5k Pop 300k Specialised care 300 1000 Acute care Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 38 Current model of care Frank Smith 69 year old male Parkinsons and COPD prone to depression married

Develops the flu and a secondary chest infection. GP starts with steroids and antibiotics. He and his wife have a hard time coping with the conditions severity; Franks condition worsens. Frank falls and the out of hours service admits him to the hospital. During his stay he becomes increasingly immobile and after many weeks, is placed into a nursing home, miles from home. He dies, alone in the nursing home, two months later. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 39 In practice: Proactive care for patients with LTCs Known care management 1 Patients are able to access primary care through a range of channels (including the SPA, NHS 111, practice call centre or practice reception)

Condition management EPC care management Practice reception Complex care management** Acute issue 111 2 GP/ANP assessment Care navigator identifies patient need to access EPC Care navigation Community psychiatric nurse assessment

SPA 3 Patients access the EPC team based on need: Known patient in a care management programme Acute illness requiring review Routine requests Pharmacist management & medication review Practice call centre PT/OT/AHP assessment Routine care PT/OT/AHP assessment Administrative (sick notes) Requests for tests/interventions 40

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. Applying the new care model Frank Smith 69 year old male Parkinsons and COPD Prone to depression Married to Sarah for 49 years GP team Anna Langley, health coach Developed Franks care plan and is familiar with his medical history Franks assigned health coach building a relationship over the last two years and helping Frank manage his care plan Anna, Franks health coach, has helped him manage self-administration of his COPD medicine and keeps him updated on his annual flu jab. Recently, he has been less willing to try changes in his Parkinsons medication

He has an exacerbation of his COPD. He starts using his rescue medications which his local pharmacist has issued in accordance with his agreed upon treatment in his care plan, created by his GP team. His mobility however, is deteriorating. Sarah is getting tired and Frank is concerned about the impact it's having on her health. Franks GP and Anna organise a weeks respite in a step-up bed in a local nursing home to give his wife a break, decreasing his anxiety. He also agrees to a trial of medications which his GP prescribes through a virtual consultation with a neurologist. This is coordinated through Anna, supervised by the nursing home staff and tracked using his electronic health record. Frank returns home more mobile and is stabilised on his medications. Frank and Sarah plan how to celebrate their 50th wedding anniversary in four months time. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 41 Primary Care Home model Place-based care model Focus on collaboration amongst practices for to provide care for populations of 30-50k. Alongside community, social and mental health services , the model supports population health management for a defined, registered population of between 30,000 and 50,000 An integrated workforce, with a strong focus on partnerships spanning primary, secondary and social care inclusive of patients and the voluntary sector with multidisciplinary teams that enable individuals to practice to the top of their licence A combined focus on personalisation of care with improvements in population health

outcomes Aligned clinical and financial drivers rewards through a unified, whole population budget with appropriate shared risks Similar features to multispecialty community provider (MCP) but focused on a smaller population enabling primary care transformation to happen at a fast pace, either on its own or as a foundation for larger models. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. Early indications from PCH pilots are promising Staff Satisfaction Utilisation Staff Retention Patient Experience GP Referrals Prescribing GP Waiting time

67% of staff surveyed felt that PCH had improved their job satisfaction across the three sites 78% of staff felt PCH had decreased or not added to their workload across the three sites 86% of staff regarded Beacon Medical Group as a good employer 82% of staff felt that PCH had improved patient experience across the three sites 330 GP referrals to hospital avoided, a slowdown in the growth rate, demonstrated by Beacon Medical Group 220k of prescribing savings demonstrated by Larwood and Bawtry 6 day reduction in the average time patients wait to see their GP at Beacon Medical Group Population Health 13% increase in flu vaccinations for patients with COPD registered with Beacon Medical Group A&E Attendances 27k of savings each year enabled by providing extended primary care access in Thanet

A&E Admissions 295k of savings from reductions in A&E admissions driven by Thanet Health Length of Stay 8 day reduction for admitted care home residents registered with Beacon Medical Group Beacon Medical Group (Devon) Larwood Surgery (Bassetlaw) 33k Patients Recruited 3 new partners as it is the type of practice I want to be in Be the people we want to work with Be the GP you want to be

Increased staff satisfaction Integrated working (community/MH and voluntary sector community facilitator service). Provider Board Decreased emergency admits, assessment referrals and prescribing costs (estimated savings 1m in one year). Luton Polypharmacy Interventions: Clinical Pharmacist met patients (home or in surgery) to review medication, follow-up conducted 12 weeks later

113 identified, 62 reviews, 43 accepted follow-up De-prescribing (71 medicines, 2 evidence based switches , 2 formulation changes) 2 medications started (inhalers) Simplified regime -30 patients did not understand why they were taking their medication Luton Polypharmacy Immediate Benefits: Reduced risk of Adverse Drug Reaction Application of the risk tool showed 40% of patients had a reduced risk of having a future medicines related problem at follow up review reported that their concerns had been understood Reduced drug cost Better adherence with regimen Improved quality of life (survey) for patients reported the review had helped them take control of their health

reported that their appointment helped them understand how to take their medications safely and correctly Moss Valley Medical Practice The practice had proactively provided clinics in the community to avoid patients needing to be referred to secondary care. For example; GPs with special interest and additional training provided additional services, such as dermatology and musculoskeletal clinics to be provided from the practice enabling treatment to be provided more promptly. This service provision had resulted in the practice having the lowest rate of dermatology referrals to secondary care in the CCG area. The CCG rate of referral was 17 per 1,000 patients and practice rate 7 per 1,000 patients. Weekly care home ward rounds and medicines reviews by a prescribing pharmacist employed by the practice, as well as robust joint working between practice and community staff had reduced emergency admissions. A&E admissions were particularly low for patients aged 65 and over and 75 and over at 230 per 1,000 patients and 350 per 1,000 patients. The local CCG average was 250 and 400 per 1,000 patients respectively. Thanet: Enhanced Frailty Pathway yields results First PCH pathway developed Former Over 75s Schemes Nursing Homes LES

End of Life LES Focus on personalisation of care, prevention and wellbeing for the Over 60s Integrated Workforce - Acute Response Team (ART) Live on 1st October 2016 6,983 mild, moderate or severe frail patients identified (30% of over 60s) 510 medication reviews (wastage and prescribing reduced) Geriatricians attached to each PCH MDTs taking place GP Managed Beds 64% of admissions resulted in admission avoidance 45% patients discharged back to own home Pharmacist Pilot with 2 care homes 71 patients reviewed 12,180 cost efficiencies (165.47 per resident) 282 interventions, 163 medicines stopped Released GP time

Acute Response Team (ART) 61% of admissions avoided over first 8 weeks (13.7 pts per week) The future Whole system view Value driven analysis Value driven interventions Align with the motivations of professionals Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 50 Milton Keynes General

Practice (MKGP) Ltd Federation of General Practices Leading the Transformation of Local Primary Care BY D R N E IL DO USE & D R T H AO N GUY E N IN T E RIM C H AIR & IN TE RIM L E AD GP M K GP F E D E RAT ION Federation update Federation membership: 23 of 26 Practice (88% - with one pending application) 266K of 288 K patient population (92%) Director election Practice Manager Lead Election Recruitment of permanent management team Future recruitment of other Federation leaders 2017/18 Priorities update 1. Reduce General Practice workload: Main priority for the new Practice Manager Lead 2. Improve General Practice efficiency: Main priority for the new Practice Manager lead

3. Enable General Practice sustainability: Improve, develop & deliver the General Practice Access Fund (GPAF) Service. Bid for Physiotherapy AQP, working towards RMS, Care homes and prescribing savings. 4. Enable high quality care: Develop a local clinical leadership programme 5. Support our local community: National self-care week 13th-19th November 2017 supporting charities. Working at scale MKGP Federation MKGP Fed Enhanced General Practice Hubs MKGP Fed Questions Introduction to Workshop

Jill Wilkinson & Hopeson Alifoe 56 Option development criteria and principles Options developed taking into consideration - Additional criteria to be considered as part of next steps Geography Patient view and general practice staff view Number of practices Cost of the options including provider change/cost of change High level population need Activity Demography

Workforce and efficiency MK communities/identity Detailed population need/unmet needs Travel time Estates/work bases Planned growth areas Fit with other plans in Milton Keynes system 57 Option 1 Community Provider led locality design 58 Option 1 design based on North, Central, South split used by CNWL and MK Council providers and so requires minimal change for existing community services in terms of configuration Provider knowledge of demand for services and how they manage their workforce and

services efficiently. Proximity of practices to each other which should enable better multi-disciplinary team (MDT) working working and improved access 30-50k patient list size as a group with allowances for expansion areas where possible However - Does not reflect all existing primary care relationships Does not take into account branch practices 59

Option 1 Information summary North West North Rural North Central Central East Central West South MK South Bletchley Number of practices 3

(Wolverton , Stony MC, Stonedean ) 3 (Newport Pagnell MC, Kingfisher, Cobbs Garden) 4 (Sovereign , Purbeck, Oakridge, Neath Hill) 5 (Ashfield, Fishermead The Grove, MK Village, Broughton Gate)

3 (Central MK, Hilltops, Watling Vale MC) 4, (Parkside, Whaddon, Walnut, Westcroft) 5 (Red House, Bedford st, Water Eaton, Westfield rd, Drayton rd) Total registered PLS

34,399 33,809 33,882 51,024 47,632 47,981 41,301 Total number of GPs (FTE) 17.6 16.5 10.2

25.5 22.7 19.6 21.4 Total Staff (FTE) inc. GPs/Admin 57 87 59 92 76 82

70 60 Option 1 Map Provider split 61 Option 2 Locality design based on local communities and established GP relationships 62 Option 2 design based on Alignment with parish council boundaries and natural communities in MK

Existing GP practice relationships and working Practices which already having over-lapping geographical coverage 30-50k patient list size as a group with allowances for expansion areas where possible Proximity of practices to each other However - Does not take into account current GP neighbourhoods or provider geographies 63

Option 2 Information summary West & West central South West East North Central Central South North Number of practices 6 (Wolverton,

Stony MC, Stonedean, Watling Vale, Hilltops, Drayton Road) 4 (Parkside, Whaddon House, Westcroft, Bedford St with Furzton) 4 (Kingfisher, Walnut Tree, MK Village, Broughton Gate)

5 (Newport Pagnell MC, Sovereign, Purbeck, Oakridge, Neath Hill) 4 (Ashfield, Fishermead , Central MK, The Grove) 3 (The Red House, Water Eaton, Westfield Rd) 1 (Cobbs Garden + Group 4

Beds. includes Harrold MC) Total registered patient list size 66,494 50,109 40,566 54,508 44,366 25,505 42,490

Total number of GPs (FTE) 32.2 21.3 20.5 19.2 21 15.1 4.3 (Cobbs only) Total Staff (FTE) inc. GPs/Admin 110

84 82 115 70 45 17 (Cobbs only) 64 Option 2 Map 65 Option 3 CCG Neighbourhood led locality design 66

Option 3 - design based on Current GP neighbourhoods Proximity of practices to each other which should enable better mulit-disciplinary team (MDT) working and improved access 30-50k patient list size as a group with allowances for expansion areas where possible option to split the South grouping (65k PLS) if appropriate However - Does not reflect all existing relationships

Does not take into account branch practices 67 Option 3 Information summary North Central North Rural Village East Central & East Bletchley West West

Central Number of practices 4 (Oakridge, Neath Hill, Purbeck, Sovereign) 3 (Newport Pagnell MC, Kingfisher, Cobbs Garden) 3 (Walnut Tree, MK village, Broughton Gate)

4 (Ashfield, Fishermead , Central MK, The Grove) 7 (Red House, Water Eaton, Westfield Rd, Drayton Rd, Parkside, Whaddon House, Bedford St) 3 (Wolverton , Stony MC, Stonedean )

3 (Hilltops, Watling Vale, Westcroft) Total registered PLS 33,882 33,809 35,863 44,366 64,914 34,399 42,795

Total number of GPs 10.2 16.5 17.2 21 32.2 17.6 18.9 Total Staff (FTE) inc. GPs/Admin 59

87 68 70 114 57 69 68 Option 3 Map 69 Now onto Workshop 70

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