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The Adventures of General Practice in Primary Care Land
David WingfieldGeneral Practitioner
Chairman of Hammersmith and Fulham GP FederationHon Senior Lecturer Imperial College
Or ……. A Hammersmith and Fulham response to a national challenge
Primary care as a speciality
• All of medicine in one professional discipline – Updating knowledge
• Whole population• Urgent care and long term condition
managementBut also …• Personal holistic care
Organisational dilemmas
• GP Business realities– independent contractor status
– Regulation
– Working in and running it
– Crises through lack of business skill
– HR and skillmix
– Gp accounts and business models
• NHS costs- Commissioner pressures to contain cost, increase access and maintain quality
Some good news:-
• Teaching and quality
• Audit and quality
• Research and quality
• Patient focus to all we do
Further education
Collaborative research
• WelReN funding for a research nurse agreed
• IT available to connect to all clinical records and to conduct patient level searches
• Potential for NIHR and other research across the 200,000 registered patients in Hammersmith and Fulham
Today's adventures
• Clinical Commissioning Group strategy and the Primary care home
• GP Federations as change management organisations
• The new business model and Super Practices
• Accountable care
Hammersmith and Fulham Clinical Commissioning Group strategy and
the Primary care home
This document explains the what, why, and how of primary care will improve in Hammersmith and Fulham
1 2 3 4 5
What happens now
Our ambition is to harness the energy and ideas of people who deliver
and receive care in Hammersmith and Fulham to create a system that
works seamlessly for everyone in the borough.
This document explains in very practical terms how the changes will
benefit patients as well as GPs and other practitioners.
The new approach to providing care in Hammersmith and Fulham will
particularly benefit people, including many older people, who rely on a wide
range of services
1 ‘Does the Primary Care Home make a difference? Understanding its impact’ (NAPC, 2017)
Our headline objective is for accountable – that is end-to-end - care for
Hammersmith and Fulham in 2019.
Within the limited resources we have, we are aiming for steady but
material improvement over coming years. These will be based on
sustainable changes in how local GPs and other primary care
practitioners work with each other and other services provided across the
borough.
The end result will be a local care system that uses the collected
expertise and compassion of all of our local care organisations to deliver
the health and wellbeing outcomes we and our residents want.
Dr Tim Spicer
Chair, Hammersmith and
Fulham CCG
Dr David Wingfield
Chair, Hammersmith and Fulham
GP federation
Our approach is based upon what local people have told us they expect from their services
1 2 3 4 5
A range of people provide my care but
they all work together, communicate
effectively, and have clear roles that I
understand. Together, they provide
me with seamless care
My GP and his or her colleagues
are linked in closely to all the
other people and organisations
who provide care for me and
support me in other ways
I can access care easily and in the way most
convenient for me, either in person or by using
technology. If continuity of care is important to me,
I have this too
If I have a care plan, it is developed with me and
then used right across all the relevant people
who provide me with care
My practice works with other organisations to
support me to maintain my physical and mental
wellbeing – as well as to support me when I am ill
My practice is my first point of
contact with the local health and
care system and provides the
network of support for the majority
of my care needs
More of my
care needs
can be
delivered
within
primary care,
without the
need to visit
hospital
I am supported to understand my
condition and to manage more of
my own care – but I know where
to get support when I need it
I have a clear say in how my
care is delivered and can access
different services by using my
personal budget
Through my practice’s Patient
Participation Group, I can continue to
shape how care is provided in my
community
I am cared for as a
whole person
rather than a series
of conditions
I can access the right skills from GPs across my local area –
meaning I get the specialist primary care that I need
People in Hammersmith and Fulham have been clear about their expectations from local health and care services. The statements below reflect these
ambitions and what the CCG and GP federation intend all people in the borough to be able to say about the care they receive.
These are based on Wsic and reflect the specifics of the
primary care home. What local nuances do we need to work in?
The local approach to primary care will be based around the needs of the different population groups in Hammersmith and Fulham (1)
The CCG and GP federation will respond to local
health needs with a population-based approach.
This means that they will look at the combined
needs of whole groups of people, based on age
(such as older people or working-age adults) or
health and wellbeing status (such as mostly healthy
people or people with complex conditions).
This approach helps providers to ensure that
services that people need are wrapped around them
in a co-ordinated way.
As the chart opposite shows, the North West
London CCGs are already thinking of their Local
Services transformation in terms of how they meet
the needs of different groups of people, for example:
Self-care support, based on different age groups’
needs
Improving intermediate care and expanding
common discharge arrangements
People have different wants and needs depending
on age and health status. The chart on the page
next shows how some of these needs will be met.
1 2 3 4 5
Source: NWL Local Services team. The cost, spend, and activity information at the bottom of the chart
is based on data from a group of Hammersmith and Fulham practices in 2013/14.
Primary Care Medical HomeWorking at scale we can provide all the long term or acute services for our patients
napc.co.uk/primary-care-home
• A cluster of GP practices working to common systems and goals rapid learning and up-scaling of activity
– GP and community trust contracts not altered
– 30-50k Registered population- to allow consistent personalised
experience of care
• Integrated diverse workforce
• Aligned financial drivers. Unified capitated NHS budget- Risk management
• Extended range of services- particular risk groups
DRAFT 26 Jan 2017 David Wingfield
The CCG and GP federation are now planning for the optimum configuration of primary care homes in Hammersmith and Fulham
1 2 3 4 5
The CCG and GP federation will now begin to work with practices to develop the current network system into the best configuration of primary care
homes. This will be completed by October 2017 and will be based on a series of considerations, including existing collaborative relationships, common
challenges, and an appropriate mix of practices’ readiness to lead the development process.
The maps below show, on the left, the current three primary care homes and practices not part of a primary care home and, on the right, an illustrative
future configuration. The practices names for each number are in the appendix.
May
20
17
Illu
stra
tive
co
nfi
gura
tio
n
for
Oct
ob
er 2
01
7
Intermediate care
GP Practices
Mental health
Community nursing and
therapiesU
rgen
t ca
re
CEPN
All CLCH, GP, Community mental health and urgent care services. C£40-50m OOHS
R&D HEECCG NHS Services
funding
Integrating primary care into a single organisation
Aligning GP andCommunity Services
16
Traditional General Practice, dispersed, but loosely arranged in networks
Primary Care Home 30-50k joint projects partial NHS budget holders/shadow
GP Partnership merger or functional alignment, providing organisational capability to deliver
GP Federation facilitating coherent GP integration across a borough
Federation Plus- integrated primary and community care
+
+
=
+
Primary care development roadmap
Hammersmith and Fulham GP Federation as a change management
organisation
4 strategic priorities………..
Out of Hospitals Clinical Service
Delivery
Accountable Care
Development
Primary Care Transformation
Workforce DevelopmentCeommunity education
Provider Network (CEPN)
Hammersmith & Fulham GP Federation Work Streams Summary Apr17-Mar18
Funded By……
Trading Income 10% of c.£2.5m
contract
Whole Systems£50k
T&T £250k PMCF £500kHENWL Grants
c. £500k
Practice Delivery
Population Coverage
OOHS
Clinical staffing (hosted and bank)
Governance & Safety
Capacity & Configuration
Funding Source
Trading Income
CIS, UCC, Practices Rep
ort
ing
and
Co
ntr
act
Mo
nit
ori
ng
Hammersmith & Fulham GP Federation Work Streams Summary Apr17-Mar18
Quality Improvement
Expand Portfolio
Federation Board
Research NIHR Hub [new]
Federation Board Transformation
PMCF
Funding Stream
PMCF
Programme ManagerDave Sellers (part time)
Shared Services Phase 1Rollout Workflow
Rollout Patient Care Plan toolExtend MESH to C&W
More MJOG campaigns
On-line engagement
Hammersmith & Fulham GP Federation Work Streams Summary Apr17-Mar18
T&T
Merger Support Services
Clinical Governance
Caroline DurackProgramme Manager
Funding Stream
Federation BoardAccountable Care System
DevelopmentAlliance Contract
MCP development with CLCH and WLMHT
Implement Models of CarePaediatrics
Ambulatory careFrail Elderly
Develop Informatics Function
Hammersmith & Fulham GP Federation Work Streams Summary Apr17-Mar18
WSIC
Primary Care Home roll out
Funding Stream
HENWL
HENWL annual allocations
Nursing
Workforce modelling & redesign
Run all clinical training including OOHS
H&F Community Education
Provider Network Practice manager and reception training
Workforce developmentApprenticeshipsCare Certificate
GPN ProgrammePhysician Associates
Fellows
Training for all staff groups
Hammersmith & Fulham GP Federation Work Streams Summary Apr17-Mar18
H&F CEPN Steering Group
Education Hubs 8 Hubs (+3 in 17/18)
Pharmacy, AHPs, & OtherGP upskilling
Federation Board
Care management and navigation
The new business model and Super Practices
H&F PartnershipPrimary care for the 21st Century
HFP is a new GP super-practice
Created 3 April 2017 by a three way merger
Overview
Mission & Values
Patient Driven
Lifelong Learning
The underpinning professional values that the organisation works to
A clinical model with patients at the centre
A commitment to continuing professional and organisational enrichment and support
Specialisation
Generalism The principle of holistic care and continuity of care, and the maintenance of those principles over time
Allowing primary care to engage with complex community care and every clinician being able to follow their interests
42,000 patients
3 sites in H&F
88 staff
17 Partners
Clinical Model
UNIVERSAL PRIMARY CARE
Complex Children
and Families
Complex Medicine
EOLC, Care Homes,
Frail Elderly
Complex Mental
Health, PD, Substance
Dependency
Specialisation
Clinical decision support
Teaching & Research
Michele Davison
Exec Board
All Partners Overall business
leadershipCulture, values & ethos
Sarah Douglas Exec Board
Corporate Lead: HR and peopleSite Lead: North End
David Wingfiel
dJo Huddy
Exec BoardCorporate Lead: FinanceSite Lead: Bush
AnnaWilson
Exec BoardCorporate Lead: Business
Development
Pamini Ledchumykant
hanExec BoardCorporate Lead: Clinical
Governance & Quality
Exec BoardCorporate Lead: NHS StrategySite Lead: Brook Green
Partner responsibilities and Executive Board
Finance Lead Finance &
accountingSupply chainPropertyInsurancesLegalBankCompany secretarial
Operations Lead
Service availability and
deliveryHR operationsTrainingIT & TelephonyBCPRecruitmentPatient ExperienceProcesses & proceduresOccupational Health
Quality Lead
Contracts Lead
Clinical qualitySafety and auditClinical governanceCQCInformation governanceSafeguardingHR infrastructureOrganisational
developmentMarketing & PRHealth & Safety
Contract managementRevenue maximisationExternal relationsData analysisProject managementBids
Marta Cabrera
Daniella Rubio
Stephen Weller
Sena Shah
Integrated senior management team
Pamini Ledchumykantha
n
Clinical quality & governanceClinical performance and safetyAppraisal & revalidation oversightClinical education frameworkComplaints, incidents and auditBest practiceQuality improvement
Clinical Leads
DiabetesMental HealthTBC
Pharmacy Lead
Nursing, HCA & Therapy
Lead
Clinical quality and governanceWorkforce planning & developmentService developmentMentoringPolicies and procedures
Quality Lead Clinical quality
Safety and auditClinical governanceCQCInformation governanceSafeguardingHR infrastructureOrganisational
developmentMarketing & PRHealth & Safety
Sena Shah
Clinical quality and governanceWorkforce planning & developmentService developmentMentoringPolicies and procedures
Comprehensive clinical governance infrastructure
Accountable care
33
Hammersmith & Fulham:
working in partnership and
contributing to NWL’s
Sustainability and
Transformation Plans
34
Accountable care – let’s simplify…
Patient experience
Commissioner and
provider interface
35
Accountable care – H&F is an ideal size
36
Our ambition
• The Hammersmith and Fulham Integrated Care
Programme is a formal partnership launched in
January 2016
• We will provide:
– high quality care to defined outcomes, for the whole
population.
– Good patient experience of health care
– cost effective care within a budget,
– This is the “triple aim” (Institute for health improvement)
• This is what an ACP means to us and today is about
further engagement with commissioners
37
Hammersmith and Fulham
Health and Care Partnership
Board
Steering Group
Outcome measures
Governance development
Programmes & Projects
Finance/Contracting
What we have done so farPatients at all levels of our Governance
CEOs/Directors/GPsLay board member:Janis Cammell OBE
Directors/Senior managers/GPsPatients and lay reps:Maria ConnollyTrish LongdonOlivia FreemanIan Lawry (SOBUS)Lydia Hodges (Carers Network)
Led by lay members
38
Primary and Community Care alignment
Jan 2017 April 2017 April 2018Jan 2018Oct 2017 April 2019
Alignment complete
ACP goes live- 5y+ contract
basis
Agreement to form aligned Primary Care
services
Our next stepsTimeframe
ACP whole budget accountability
Agreement with CCG to develop ACP
ACP shadow
year
Primary Care Home integrated provision
Data gathering
Service co-design
Run new service elements with continuous evaluation
Roll-out to other PCHs
Primary Care home established
Culture and strategy,
• patients first,
• care for our workforce,
• Education and training
• robust business model with diversification beyond core nhs commissioned budgets
