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Transforming Primary Care in London: A Strategic Commissioning Framework

Acknowledgement

Acknowledgement

2

This Strategic Commissioning Framework ispresented by the London Primary CareTransformation Board and Primary CareTransformation Clinical Board. It has beendeveloped by clinicians, commissioners, patientsand other partners across London.

Members of the team and the governanceboards are listed in Appendix 2; however it is not possible to name everyone individually. Theteam would like to thank everyone who hascontributed to drafting, testing and refining thisFramework, as without these contributions,production of this Framework would not havebeen possible. In particular, we would like toextend our appreciation to the members of:

• The Clinical Expert Panels which carriedout the early innovative thinking andprovided some of the underpinning evidenceand case studies which shaped thedevelopment of the specification within this Framework.

• The Primary Care Transformation Boardwhich provided strategic oversight andtesting from across the health and socialcare system.

• The Primary Care Transformation PatientBoard which provided insight and direction.

• The Primary Care Transformation ClinicalBoard which provided clinical leadership;tested the rigour and practicality of thespecification; and ensured that thespecification was ambitious enough to meetthe needs of patients in London.

• The Primary Care TransformationDelivery Group which supported andtested the development and detail of the keyenabler work areas.

• The Primary Care Transformation Teamwho have worked with all the stakeholdersand supported development and delivery ofthis Framework.

NHSE brochure 2015 FINAL_Layout 1 18/03/2015 16:20

Acknowledgement

Acknowledgement

2

This Strategic Commissioning Framework ispresented by the London Primary CareTransformation Board and Primary CareTransformation Clinical Board. It has beendeveloped by clinicians, commissioners, patientsand other partners across London.

Members of the team and the governanceboards are listed in Appendix 2; however it is not possible to name everyone individually. Theteam would like to thank everyone who hascontributed to drafting, testing and refining thisFramework, as without these contributions,production of this Framework would not havebeen possible. In particular, we would like toextend our appreciation to the members of:

• The Clinical Expert Panels which carriedout the early innovative thinking andprovided some of the underpinning evidenceand case studies which shaped thedevelopment of the specification within this Framework.

• The Primary Care Transformation Boardwhich provided strategic oversight andtesting from across the health and socialcare system.

• The Primary Care Transformation PatientBoard which provided insight and direction.

• The Primary Care Transformation ClinicalBoard which provided clinical leadership;tested the rigour and practicality of thespecification; and ensured that thespecification was ambitious enough to meetthe needs of patients in London.

• The Primary Care TransformationDelivery Group which supported andtested the development and detail of the keyenabler work areas.

• The Primary Care Transformation Teamwho have worked with all the stakeholdersand supported development and delivery ofthis Framework.

NHSE brochure 2015 FINAL_Layout 1 18/03/2015 16:20 Page 2

Contents

Contents

3

Introduction 4

Foreword 5

Context 7

Executive summary 11

Future general practice 17

What will Londoners notice? 18

Models of care 19

The service specification 21

Evidence supplement and case studies 21

Service specification development process 22

Further engagement 22

1. Proactive care specification 23

2. Accessible care specification 27

3. Coordinated care specification 31

The enablers 36

Local plans to deliver the changes 36

Co-commissioning 36

Financial implications 38

Contracting approach to delivering the service specification 40

Workforce implications 42

Technology implications 49

Estates 52

Provider development requirements 53

Monitoring and evaluation 54

Innovation and improvement 56

Implementation of the Strategic Commissioning Framework 57

Appendix 1: Financial modelling methodology 58

Appendix 2: Team and governance board members 59

Appendix 3: Glossary 63


Introduction

Introduction

4

The NHS is unique because of its system ofgeneral practice – a medical home for thepatient – underpinned by a life-long medicalrecord. General practice is the first point ofaccess for many people, where a high proportionof care is delivered close to people’s homes withthe potential for a continuous relationship withthe same clinical team from birth through to theend of life.

General practice has served patients, the publicand the NHS well for over 60 years. It hasdelivered accessible, high quality, value formoney care. However our patients are changing,both in the complexity of their conditions and in their expectations. This means that if the NHSis going to continue to provide the excellentstandard of care to which we all aspire, we willhave to be more innovative.

Tweaking at the edges is not an option. Londonneeds solutions that will sustain primary care for the next 60 years. We must maintain theintegrity and core purpose of general practice (to provide holistic, patient-centred continuouscare to patients and their families). But at the

same time we must address the need to improvecoordination of care, access to services and take a more proactive approach to our patients’health and wellbeing.

I believe that this Strategic CommissioningFramework for Primary Care Transformation inLondon represents a platform where clinicians,commissioners, and other stakeholders can buildon the work done to date and find solutions tothe challenges for general practice; supportingthe healthcare community to make care betterfor all Londoners.

Building on the scale of support we have seenfor this work, and the additional focus onprimary care provided by the NHS Five YearForward View and Better Health for Londonfrom the London Health Commission, now is the time to make these changes together.

Dr Clare Gerada, Chair of the Primary CareClinical Board

Dr Clare Gerada: Clinical Chair for London’s Primary Care Transformation Programme

Dr Clare Gerada is a London based GP. She is the immediate past Chair of Council of the Royal College ofGeneral Practitioners (RCGP) – the first female Chair for over half a century – and was previously Chair of theEthics Committee. She established the RCGP’s groundbreaking Substance Misuse Unit and also led on thestrategic and logistical delivery of the RCGP Annual National Conference. She has held a number of local andnational leadership positions including Senior Medical Adviser to the Department of Health. She is MedicalDirector of the largest practitioner health programme in the country and she has published a number ofacademic papers, articles, books and chapters. Prior to general practice, she worked in psychiatry at theMaudsley Hospital in South London, specialising in substance misuse. She was awarded an MBE for services tomedicine and substance misuse and was presented with the National Order of Merit award in Malta fordistinguishing herself in the field of health.


Foreword

Foreword

5

We are pleased to present the TransformingPrimary Care in London: A StrategicCommissioning Framework on behalf of theLondon Primary Care Transformation ClinicalBoard and Transformation Board. This documentprovides both a new vision for general practice,and an overview of the considerations required toachieve it. Following drafting of this Frameworkthroughout 2014, London’s ClinicalCommissioning Groups (CCGs) and NHS England,working with partners (such as the Care QualityCommission (CQC), Health Education England(HEE) and Academic Health Science Networks(AHSNs)) have been engaging locally to fully

understand the implications of this Frameworkand how it fits into the context of wider localplans. NHS England and CCGs are now workingclosely together to develop implementation plansfor each local area clarifying what they will bedelivering in 2015/16 and beyond.

Transforming primary care is a concept that israpidly gaining momentum as a key priority in the NHS – both nationally and in London. Twoimportant pieces of work were published in thelatter part of 2014, which set the platform forbuilding on this energy and achieving theambitions that are developing.

1. NHS Five Year Forward View

In October 2014, the NHS published the NHS Five Year Forward View, developed in collaboration withPublic Health England (PHE), Monitor, HEE, CQC, and the NHS Trust Development Authority (TDA).

The Forward View sets out 'a new deal for general practice' recognising the central importance of theregistered list and everyone having access to a family doctor. It also confirms the need for greaterinvestment.

In 2015/16, London will host a number of national ‘Vanguard’ sites – areas that will be prototypingthe new models of service delivery set out in the Five Year Forward View. The vanguard sites willdemonstrate new ways of organising general practice services and support the delivery of thisFramework in London.

2. Better Health for London, The London Health Commission

Also in October 2014, the London Health Commission published Better Health for London. TheFramework closely aligns to, and is supportive of this report, which contained a number ofrecommendations specific to general practice.


Foreword

6

This Framework provides a response fromcommissioners across London to these importantpieces of work. Between April and November2014, over 1,500 key stakeholders were engagedas part of a pre-engagement. Since then, manymore stakeholders have commented from Londonboroughs as part of a local engagement. Theseactivities have strengthened our ambitions fordelivering a new patient offer for all of London.

Throughout the co-development of thisFramework it has been excellent to see the levelof clinical leadership, public and patientcontribution and the commitment ofcommissioners across London, together with theirpartners. Strategic Planning Groups (SPGs) havebeen working across CCGs to ensure all areas ofLondon have had an opportunity to discuss,debate and develop the key tenets of thisStrategic Commissioning Framework. There isnow consensus that this Framework appropriatelyrepresents the foundations for transformingprimary care, and the intentions described in thefollowing pages will be represented in local plansthroughout the capital.

There has also been positive support from theLondonwide Local Medical Committees, a ClinicalChallenge Panel (an independent panel set up by

the London Clinical Senate to review thespecification) and the CQC, for the aspirations wewish to achieve. Additionally, the NHS Five YearForward View and Better Health for London haveprovided further impetus to seize the momentand bring about sustainable transformation of thebedrock of healthcare in London.

There will always be challenges withimplementation, but 2015/16 provides anopportunity – with half of London CCGs receivingin excess of 5% increase in funding; underfundedCCGs receiving an extra £148 million; andadditional funding being announced forinfrastructure changes, Prime Minister’s Challengeand Vanguard sites.

Clinical programme leaders have also launched anInnovation Group for primary care leaders inLondon to help identify best practice forimplementing these changes, and propagatethem throughout the health care system in thecapital. There are no easy solutions to thechallenges we all face in the transformation ofprimary care but there is a strong belief that byworking together and building on the focus andcommitment to date, success can be achieved andwe can develop services that Londoners deserve.

Dr Marc Rowland

Co-Chair of the Primary CareTransformation Board

Dr Anne Rainsberry


Dr Clare Gerada

Chair of the Primary CareClinical Board


Foreword

6

This Framework provides a response fromcommissioners across London to these importantpieces of work. Between April and November2014, over 1,500 key stakeholders were engagedas part of a pre-engagement. Since then, manymore stakeholders have commented from Londonboroughs as part of a local engagement. Theseactivities have strengthened our ambitions fordelivering a new patient offer for all of London.

Throughout the co-development of thisFramework it has been excellent to see the levelof clinical leadership, public and patientcontribution and the commitment ofcommissioners across London, together with theirpartners. Strategic Planning Groups (SPGs) havebeen working across CCGs to ensure all areas ofLondon have had an opportunity to discuss,debate and develop the key tenets of thisStrategic Commissioning Framework. There isnow consensus that this Framework appropriatelyrepresents the foundations for transformingprimary care, and the intentions described in thefollowing pages will be represented in local plansthroughout the capital.

There has also been positive support from theLondonwide Local Medical Committees, a ClinicalChallenge Panel (an independent panel set up by

the London Clinical Senate to review thespecification) and the CQC, for the aspirations wewish to achieve. Additionally, the NHS Five YearForward View and Better Health for London haveprovided further impetus to seize the momentand bring about sustainable transformation of thebedrock of healthcare in London.

There will always be challenges withimplementation, but 2015/16 provides anopportunity – with half of London CCGs receivingin excess of 5% increase in funding; underfundedCCGs receiving an extra £148 million; andadditional funding being announced forinfrastructure changes, Prime Minister’s Challengeand Vanguard sites.

Clinical programme leaders have also launched anInnovation Group for primary care leaders inLondon to help identify best practice forimplementing these changes, and propagatethem throughout the health care system in thecapital. There are no easy solutions to thechallenges we all face in the transformation ofprimary care but there is a strong belief that byworking together and building on the focus andcommitment to date, success can be achieved andwe can develop services that Londoners deserve.

Dr Marc Rowland


Dr Anne Rainsberry


Dr Clare Gerada

Chair of the Primary CareClinical Board


Context

Context

7

This document, developed by commissionersacross London, is both a new vision, and in effecta response to the NHS Five Year Forward View andLondon Health Commission publications. It detailsa specification for Londoners in the future, andbegins to articulate how these changes fit withinthe wider out-of-hospital context. The documentalso considers how this specification might bedelivered with regard to cost, workforce,contracts, and other key enablers.

Background: responding to A Call to Action

In November 2013, NHS England (London)published Transforming Primary Care in London:General Practice A Call to Action1, which examinesthe challenges facing general practice in Londontoday. It has been used by NHS England (London)and London organisations to obtain a consensusview on the need for changes to the way generalpractice is provided.

A Call to Action showed that London containsworld-class examples of general practice but thaturgent action is needed to tackle significantvariations in quality. The report identifiedchallenges including an increasing workload; anexpanding population; people living longer andwith increased care needs; all of which haveoccurred whilst investment in general practice hasfallen significantly as a proportion of total healthspend. The pending workforce crisis was alsohighlighted, as a large swathe of GPs in the capitalare near retirement and practice nurses arebecoming increasingly difficult to recruit. Thereport was a call for bold action to developsolutions that will better meet the future needs ofLondoners and provide a sustainable model ofgeneral practice for the next 50 years.

Since the publication of this report clinicians,patients and commissioners from across the capitalhave been developing an ambitious strategy forservice improvement in three key areas of generalpractice – proactive care, accessible care, andcoordinated care.

In March 2014, NHS England (London) released anengagement document entitled The London GPDevelopment Standards: A Framework for ServiceImprovement. The document was developed by aclinical board and three expert panels working inpartnership with CCG leads and patients.

London CCGs and NHS England (London) havebeen working in partnership with others to ensurethat the service changes proposed in the initialdraft would meet the needs of Londoners, addresscurrent and future challenges and develop a strongmandate for the overall direction of generalpractice development across London. In addition,there has been further development on answering‘how’ this specification could be delivered. It isclear that changes are needed to support primarycare in delivering a new vision.

The initial view on the enabling work required isincluded in this document. This includes, forexample, the changes to the numbers, skills androles in the workforce that are needed. There isalso reference to the importance of suitableestates, and the investment needed to underpinthe changes.

Towards the end of 2014, two new importantpieces of work were published – one from theNHS, and one the result of work commissioned bythe Mayor of London.

These publications provide added momentum forthe ideas developed in the Framework and create aplatform for building on these proposals, ensuringthat London gets the investment required in orderto drive these commitments forward.

1 www.england.nhs.uk/london/ldn-call-to-action/gp-cta/


ContextContext

8

The NHS Five Year Forward View

In October 2014, the NHS published the FiveYear Forward View, which was developed incollaboration with PHE, Monitor, HEE, CQC andTDA. This laid out a new deal for generalpractice and also referred to funding in generalpractice – mentioning both “stabilising” and“new” funding. The commitments included:

A new deal for general practice

• Stabilise core funding for general practicenationally over the next two years while anindependent review is undertaken of howresources are fairly made available to primarycare in different areas.

• Give GP-led clinical commissioning groups(CCGs) more influence over the wider NHSbudget, enabling a shift in investment fromacute to primary and community services.

• Provide new funding through schemes suchas the Challenge Fund to support new waysof working and improved access to services.

• Expand as fast as possible the number ofGPs in training while training morecommunity nurses and other primary carestaff. Increase investment in new roles, andin returner and retention schemes andensure that current rules are not inflexiblyputting off potential returners.

• Expand funding to upgrade primary careinfrastructure and scope of services.

• Work with CCGs and others to design newincentives to encourage new GPs andpractices to provide care in under-doctoredareas to tackle health inequalities.

• Build the public’s understanding thatpharmacies and on-line resources can helpthem deal with coughs, colds and otherminor ailments without the need for a GPappointment or A&E visit.

In addition to emerging GP federations,networks and super partnerships across London, the NHS Five Year Forward Viewidentifies four further models which may beapplied. The most directly relevant to thisFramework have been described asMultispecialty Community Providers (MCPs) andPrimary and Acute Care Systems (PACs). Thedetails of these are still emerging, and a numberof areas will be developing prototype MCPs andPACs in 2015/16, but some of the featuresexpected from these models are below.

Multispecialty Community Providers(MCPs)

• Larger GP practices that could bring in awider range of skills – including hospitalconsultants, nurses and therapists,employed or as partners

• Shifting outpatient consultations andambulatory care out of hospital

• Potential to own or run local communityhospitals

• Delegated capitated budgets – includingfor health and social care

• Addressing the barriers to change toenable access to funding and maximisinguse of technology.


Context

9

The London Health Commission

In October 2014, the London Health Commissionlaunched its report Better Health for London.This report makes several recommendations forgeneral practice, and the Framework aligns verywell with these recommendations which include:

• increase the proportion of NHS spending onprimary and community services.

• invest £1billion in developing GP premises.

• set ambitious service and quality standardsfor general practice.

• promote and support general practices towork in networks.

• allow patients to access services from otherpractices in the same network.

• allow existing or new providers to set upservices in areas of persistent poor provision.

Additionally, the vision of this Frameworksupports several of the broader recommendations,such as to:

• engage with Londoners on their health andcare. Share as much information as possibleand involve people in the future of services.

• commission holistic services with clearlydefined outcomes developed by listening topeople who use services.

Primary and Acute Care Systems (PACs)

• A new way of ‘vertically’ integrating services

• Increased flexibility for Foundation Trusts to utilise their surpluses and investment tokick-start the expansion of primary care

• Contractual changes to enable hospitals to provide primary care services in somecircumstances

• At their most radical PACs could takeaccountability for all health needs for aregistered list – similar to Accountable Care Organisations.

It is also worth noting prototype delivery models will be developed in 2015/16 for‘smaller viable hospitals’ and for ‘enhancedhealth in care homes’. These are likely toinfluence the way general practice might goabout delivering this Framework.

Smaller viable hospitals

• Testing options to sustain local hospitalservices where they provide the best clinical solution, are affordable and havecommunity and commissioner support.

Enhanced health in care homes

• Developing in-reach support and servicesthrough partnerships with social care and care homes.


Context

10


This document builds on work alreadyundertaken and aims to support localtransformation plans and other responses thatLondon is making to the challenges currentlyfaced in general practice as well as the two keypublications referenced above. The Frameworkaims to complement and enhance other servicerequirements and standards, such as thosepublished by the Care Quality Commission(CQC) in the Provider Handbook for PrimaryMedical Services (October 2014). Goingforward, London’s primary care transformationprogramme and the CQC will collaborate closelyto ensure that there is true alignment betweenthe vision set out in this Framework andstandards articulated by the CQC. This alsoaligns with the National Institute for Health andCare Excellence (NICE) in their regularly updatedguidelines. In summary, the specificationoutlines a new service design, but this must alsobe delivered to, for example, the level of safetyand quality described by these other standards.

When I was asked to establish the CQC’s new approach to the inspection andregulation of primary medical services I madethe following statement: “I passionatelybelieve that everyone in our society deserveshigh quality, accessible primary care whetheryou’re a rich person or someone who is poor and homeless, you should have thesame access to the same high quality care no matter what your circumstances are orwhere you live”. Nowhere is this truer than in London.

I welcome this publication, TransformingPrimary Care in London: A StrategicCommissioning Framework. This documentidentifies three aspects of care that mattermost to patients; proactive care, accessiblecare and coordinated care, all areas that CQCcurrently considers as it undertakes theinspection of the more than 1500 generalpractices in London.

The CQC is pleased to have been involved in working with the production of thisFramework and looks forward to be one ofthe organisations working towards the deliveryand implementation of the vision that hasbeen set out.

Prof. Steve Field, Chief Inspector ofGeneral Practice, Care Quality Commission


Context

10


This document builds on work alreadyundertaken and aims to support localtransformation plans and other responses thatLondon is making to the challenges currentlyfaced in general practice as well as the two keypublications referenced above. The Frameworkaims to complement and enhance other servicerequirements and standards, such as thosepublished by the Care Quality Commission(CQC) in the Provider Handbook for PrimaryMedical Services (October 2014). Goingforward, London’s primary care transformationprogramme and the CQC will collaborate closelyto ensure that there is true alignment betweenthe vision set out in this Framework andstandards articulated by the CQC. This alsoaligns with the National Institute for Health andCare Excellence (NICE) in their regularly updatedguidelines. In summary, the specificationoutlines a new service design, but this must alsobe delivered to, for example, the level of safetyand quality described by these other standards.

When I was asked to establish the CQC’s new approach to the inspection andregulation of primary medical services I madethe following statement: “I passionatelybelieve that everyone in our society deserveshigh quality, accessible primary care whetheryou’re a rich person or someone who is poor and homeless, you should have thesame access to the same high quality care no matter what your circumstances are orwhere you live”. Nowhere is this truer than in London.

I welcome this publication, TransformingPrimary Care in London: A StrategicCommissioning Framework. This documentidentifies three aspects of care that mattermost to patients; proactive care, accessiblecare and coordinated care, all areas that CQCcurrently considers as it undertakes theinspection of the more than 1500 generalpractices in London.

The CQC is pleased to have been involved in working with the production of thisFramework and looks forward to be one ofthe organisations working towards the deliveryand implementation of the vision that hasbeen set out.

Prof. Steve Field, Chief Inspector ofGeneral Practice, Care Quality Commission


Executive summary

Executive summary

11

The Strategic Commissioning Framework aims tosupport primary care transformation across thecapital. A high-level overview of the content ofthe Framework is included below, however moredetail may be found in the document.

Future of general practice

General practices in London are under strain and are bearing the brunt of pressures to meetincreasing and changing health needs.

This Framework sets out an ambitious andattractive vision of general practice that operateswithout borders, and in partnership with thewider health and care system. A patient andtheir GP should be at the heart of amultidisciplinary effort to deliver patient-centredcoordinated care. This should occur in generalpractices which are recognised as centres in eachneighbourhood, developing communityresilience and supporting Londoners to stay aswell and as healthy as possible.

The Framework focuses on ‘function’ not ‘form’ and sets out a new patient offer for allLondoners that can only be delivered by primarycare teams working in new ways and bypractices forming larger primary careorganisations. These organisations will need tobe aligned to a shared geography in support of apopulation health model with other health,social, mental health, community and voluntaryorganisations. How this looks will differ fromarea to area and will be designed and ownedlocally. It will require an environment whichsupports innovation; shares best practices andnew technologies; and is an attractive place towork for a variety of healthcare professionals.

The service specification (patient offer)

At the core of the Framework is a specification forgeneral practice that sets out a new patient offer.This specification is arranged around the threeaspects of care that matter most to patients:

• Proactive care – supporting and improvingthe health and wellbeing of the population,self-care, health literacy, and keeping peoplehealthy

• Accessible care – providing a personalised,responsive, timely and accessible service

• Coordinated care – providing patient-centred, coordinated care and GP/patientcontinuity

Some elements of the specification have alreadybeen achieved and implemented in some parts ofLondon. General practice will be transformedwhen all patients in London are able to access thecare described in this document and when thatcare is of a sufficiently consistent high quality.


Executive summary

12

Local planning

Since November 2014, London CCGs and NHSEngland have been engaging with stakeholders in each local area to get feedback on thisFramework and better understand local contextand implications for its delivery. Work is nowunderway to finalise delivery plans for 2015/16. It is anticipated that different areas will deliver thispatient offer in different ways and at differentpaces depending on their starting point, and thatlocal populations will be involved in developingdelivery plans and deciding what will work bestfor their local communities.

Co-commissioning

NHS England (London), CCGs and localauthorities recognise that the vision in thisFramework will require significant collaborationacross all parts of the commissioning system andthat co-commissioning will be a key enabler. TheNHS Five Year Forward View set out the aim toallow CCGs more control over NHS budgets, withthe objective of supporting more investment inprimary care. All CCGs in London will becomemore involved in the commissioning of primarycare services in 2015/16.

Co-commissioning will allow for a varying level of increased involvement. The options andconsiderations are described in detail in NextSteps Towards Primary Care Co-commissioning,published in November 2014. The optionsavailable include three levels:

1. allow CCGs greater involvement incommissioning decisions, including activelyparticipating in discussions about all areas ofprimary care

2. joint commissioning model that enablesone or more CCGs to assume responsibilityfor jointly commissioning primary medicalservices with their area team, either through ajoint committee or “committees in common”

3. delegated commissioning offers anopportunity for CCGs to assume fullresponsibility for commissioning someaspects of general practice services. Theexact models for delegated commissioningwill need to be worked up in local areas.

All CCGs in London have expressed an interest inmoving to arrangements at level two or threewithin the 2015/16 financial year.

Financial implications

The new patient offer and the changes to, forexample, the workforce and estates required todeliver it, cannot be made without significantinvestment.

Further work is required to understand thefinancial impact of this Framework in each localarea, as it will be dependent on financial startingpoints and type and pace of change. High levelanalysis has been undertaken to assess the overallcost of the new service, and shift of moneytowards primary care in the next five years.


Executive summary

12

Local planning

Since November 2014, London CCGs and NHSEngland have been engaging with stakeholders in each local area to get feedback on thisFramework and better understand local contextand implications for its delivery. Work is nowunderway to finalise delivery plans for 2015/16. It is anticipated that different areas will deliver thispatient offer in different ways and at differentpaces depending on their starting point, and thatlocal populations will be involved in developingdelivery plans and deciding what will work bestfor their local communities.

Co-commissioning

NHS England (London), CCGs and localauthorities recognise that the vision in thisFramework will require significant collaborationacross all parts of the commissioning system andthat co-commissioning will be a key enabler. TheNHS Five Year Forward View set out the aim toallow CCGs more control over NHS budgets, withthe objective of supporting more investment inprimary care. All CCGs in London will becomemore involved in the commissioning of primarycare services in 2015/16.

Co-commissioning will allow for a varying level of increased involvement. The options andconsiderations are described in detail in NextSteps Towards Primary Care Co-commissioning,published in November 2014. The optionsavailable include three levels:


2. joint commissioning model that enablesone or more CCGs to assume responsibilityfor jointly commissioning primary medicalservices with their area team, either through ajoint committee or “committees in common”

3. delegated commissioning offers anopportunity for CCGs to assume fullresponsibility for commissioning someaspects of general practice services. Theexact models for delegated commissioningwill need to be worked up in local areas.

All CCGs in London have expressed an interest inmoving to arrangements at level two or threewithin the 2015/16 financial year.


The new patient offer and the changes to, forexample, the workforce and estates required todeliver it, cannot be made without significantinvestment.

Further work is required to understand thefinancial impact of this Framework in each localarea, as it will be dependent on financial startingpoints and type and pace of change. High levelanalysis has been undertaken to assess the overallcost of the new service, and shift of moneytowards primary care in the next five years.


Executive summary

13

The required additional investment is estimated tobe in the region of £310 – £810 million per year,which represents a 2.00% – 5.36% shift in theoverall health care budget. This will need to bephased, and can be achieved, for example, overfive years with an average shift of 0.40% –1.07% per year. This funding requirement ispartially supported by additional fundingannounced for CCGs in 2015/16; and moreinformation can be found on this in the FinancialImplications section.

Contracting approach

The specification described here can only bedelivered in full by general practice workingtogether at scale and with other parts of thehealth and care system. The Framework proposesnew funding, not at an individual practice levelbut delivered through wider population-basedcontracts. The exact nature of thesearrangements will vary depending on theprovider landscape, but the principle of at-scaleproviders increasingly sharing pooled incentiveswith shared responsibility and risk for deliverywill be a key marker against which investmentwill be made. Local approaches will bedetermined within each CCG area, supported by co-commissioning.

It is likely that the contracting vehicle will needto ‘wrap around’ existing national contracts(unless constituent practices are opting for a fullmerger/super partnerships and therefore mayvoluntarily relinquish their current contract). Thecontracting vehicle may also need to be flexibleto wider collaborations and partnerships withother types of providers, for example where thestrategic intent locally is for accountable careorganisations that can hold capitated budgets

and shared risk for whole populations. Althoughcurrent legislation does not allow it, co-commissioners may also want to consider afuture in which the accountability for constituentGeneral Medical Services, Personal MedicalServices and Alternative Provider MedicalServices might sit with the lead provider/at-scaleprimary care organisation.

The full contracting approach section outlinesexample contractual forms and potential initial changes. Many areas already have a strong ambition towards bringing generalpractice and community services together overthe next two years. It is however anticipated that most areas will be looking to move tonetworks or federations of general practice as a starting point.

Workforce

A workforce of appropriate number, skills androles is imperative for transforming care.Bolstering the primary care workforce has beenidentified as a core objective of Health EducationEngland and its Local Education and TrainingBoards (LETBs).

In January 2015, a £10million ten point plan was released, developed by NHS England, HEE, British Medical Association (BMA) GPCommittee and the RCGP to tackle the GPworkforce crisis, dubbed the ‘new deal’ forgeneral practice. This plan is focused onrecruitment, retention and supporting those who wish to return to general practice. HEE hasalso established an independent workforcecommission to identify models of primary care to meet the needs of the future NHS. Thiscommission will report at the end of June 2015.


Executive summary

14

This document describes a future of more person-centred systems of care and less division betweenprimary, secondary, community, voluntary andsocial care organisations. Although the way thatroles and teams fit together will evolve in localareas, it is anticipated that the roles required willbe as shown in the table above.

The full workforce section outlines these in more detail, as well as some of the programmesbeing taken forward to support workforcedevelopment, however it also highlights thatthere is a great opportunity for partnersassociated with workforce development inLondon to collaborate. Ensuring the workforce isappropriate to deliver the specification will becrucial in improving outcomes across the capital.

Technology

This Framework does not aim to provide atechnology blueprint for London, however itrecognises that technology is a key enabler fordelivering the specification. This is complementedby the 2014 publication by the NationalInformation Board, Personalised Health and Care2020 which describes the need to better usetechnology to improve health, transform qualityand reduce the cost of health and care services.

Technology usage should support organisationsworking together – allowing less focus on co-location, and a smoother patient journey throughthe healthcare system. People should also beempowered with information about their care inorder to participate in their care planning, sethealth goals, and better manage their health.

The technology section of this Frameworkidentifies ways in which technology can support:

• proactive care, for example through onlinewellbeing assessments, health improvementresources or support communities

• better access, for example with onlineservice portals, telephone triage and emailappointment systems

• better coordination, with interoperablesystems allowing clinicians to share agreedinformation across organisational boundaries

• modern care, for example, remotemonitoring and diagnostic devices.

Aligned to each practice but working across a widergeography / at-scale primary care organisations

Prescribing advisors, GPs with a special interest (GPSIs), carecoordinators, wellbeing teams, and ‘super practice managers/directors’ with sufficient skills to lead the development andoperational management of at-scale primary care organisations

As part of, for example, a wider Multispeciality Community Provider(MCP): secondary care specialists, social care, mental health andcommunity services teams, community pharmacy.

Within each practice

GPs, practice nurses, GP nurse practitioners /nurse prescribers, volunteers, receptionists,managers, health careassistants and may alsoinclude physician associates.


Executive summary

15

Estates

The recent London Health Commission (LHC)report, Better Health for London presented evidencethat the quality of general practice estate in Londonis highly variable. This results in poor patientexperiences, poor working conditions in someLondon practices and lost opportunities to improvehealth and healthcare. The specification in thisFramework does not rely on estate changes, butthere are a number of practices in London for whichpremises solutions are now urgently needed. Theestates section of this document echoes therecommendation of the LHC report, that theconsistency and quality of the primary care estateneeds to change. With £1 billion of infrastructurefunding over four years being made available byNHS England (nationally), there is a definiteopportunity to start to make these changes.

Provider development

None of the changes set out in this Framework willbe delivered unless there is significant investment inorganisational development and capability building.The real change cannot be delivered bycommissioning levers alone but will requireproviders to grab the development challenge andfind successful ways to adapt it in their local area.The provider development section outlines somerequirements for example, leadership for change,strategic planning, business development, legalguidance. It also identifies the need for a strategicand comprehensive approach to building systemcapacity and capability for delivering change; anapproach that is mapped to a development journeyfor emerging organisations which can respond totheir evolving needs. An 'Innovation group forprimary care leaders in London' is being set up bythe Primary Care Transformation programme as aforum for London’s emerging providers and systemleaders to share innovation and learning.

Monitoring and evaluation

The purpose of this Framework is to improveoutcomes, patient experience and working lives.Monitoring and evaluation will be designed tosupport practice teams working together on qualityimprovement at a population level. This Frameworkoutlines the principles that monitoring andevaluation should build on systems already in place,and should also focus on supporting providerdevelopment (through best practice sharing andpeer learning), as well as commissioner assurance.

Next steps

This Strategic Commissioning Framework aims tocapture some of the core aims of primary caretransformation, and the fundamental tenets ofwhat would need to be done to deliver this acrossthe capital. The next step is for this to bedeveloped into CCG delivery plans, building inlocal demographics, funding, and otherconsiderations to make it appropriate to thediverse needs of Londoners. This process will besupported by NHS England (London) and otherdelivery partners such as LETBs and the CQC.

Implementation is expected to start from April2015, and will take over five years to make this areality in all areas of London.


Executive summary

16

Commissioners (CCGs and NHS England) ofgeneral practice are required to give specificconsideration to addressing health inequalitiesas stated in the Health and Social Care Act2012 and requirements relating to people withprotected characteristics as outlined in theEquality Act 2010 (e.g. the nine protectedcharacteristics of the Equality Act 2010: age;disability; ethnicity; gender reassignment;marriage and civil partnership; religion;pregnancy and maternity; sex (gender) andsexual orientation). An equalities impactassessment has been completed to accompanythis Framework, and is available as a separatesupplement.

The equalities impact assessment concludes thatthe Framework provides a structure withinwhich a consistent general practice patient offercan be delivered to all Londoners.

The delivery and implementation of thespecification outlined in the Framework has the

potential to address health inequalities inLondon as commissioners work with generalpractices to secure services that are responsiveto different needs and appropriate to all.

The Framework particularly notes therequirement for commissioners to give dueregard to the reduction of health inequalitiesand to the statutory requirements of theEquality Act 2010 to consider the impact forpeople with protected characteristics. It istherefore recommended that local equalityimpact assessments are conducted to reflectlocal plans when these are sufficientlyadvanced. The proactive care specification alsooutlines the need to give consideration toadditional vulnerable groups that have beenidentified such as travellers, sex workers, peoplerecently released from custody, homelesspeople, vulnerable migrants or people withlearning disabilities.

Equality impact assessment


Future general practice


17

Dr Clare Gerada, Chair of the Primary Care Clinical Board

Patients tell us that they want better continuity ofcare (“my doctor, my nurse”). They also wantbetter access to services when they need them; tocontact a health professional when they need to; tohave care closer to home; to stay healthier andmore independent for longer; have fewer trips tohospital and more support to enable them tomanage their own health more effectively. Thislatter point is particularly important. As demand forhealth services grow, patients will need a goodunderstanding of the services and resourcesavailable to help them to stay well and look afterthemselves through minor illness. General practiceswill be recognised as centres within eachneighbourhood that are supporting Londoners tostay as healthy and as well as they can be. Localcommunities, voluntary groups, faith organisations,patients and volunteers are part of a network ofsupport for wellbeing that can work both insideand outside general practice, supporting generalpractice to connect people to wider resourcesavailable in the community and extending its scopeto deliver proactive health and wellbeing resources.Partnership working with these groups and withlocal authorities and health and wellbeing boardswill be essential.

At the moment (and for a number of reasons)general practice is not able to deliver this level ofcare consistently across London. Probably the mainreason for this is that funding for general practicehas been declining in real terms over the lastdecade, now receiving just over 7% of the NHSEngland budget, compared with over 10% adecade ago. Yet primary care continues to deliverthe majority of care to patients in the NHS.Increasing funding alone will not solve theproblem, general practice still needs to change.

Our patients’ needs are different now, and keepchanging. The systems that are in place to care forthem have to evolve to keep pace with this change.

If London is going to meet the challenges we allface there will need to be additional resource, butwe will also need to achieve significant economiesof scale and be more innovative in the way wedeliver primary care. There is no one-size-fits-allsolution. One of the great strengths of generalpractice is its variety – reflecting the great diversityof the population we serve in London. How weachieve excellence will be largely dependent oneach local area, supported by providers,commissioners and patients. But there are tencommon building blocks that we need to addressto reach the desired state, which are set out below.

1. The way we deliver care: Inside andoutside of the practice; how we best useskill-mix; how we work in and out of hours;how we work with others – not confined byour individual consulting rooms, practicesand organisations; and how we work bestwith the primary, secondary, community,voluntary and charity sectors.

2. The way we organise ourselves: Thisapplies to normal working hours and out ofhours; how we deliver unscheduled care andhow we organise our physical environment –the buildings we work from. Individualpractices may want to form part ofsomething bigger. Across London, practicesare already starting to work together.

3. How we work together to deliverpersonalised care for certain groups ofpatients across a wider population forexample:



18

a. finding creative ways of connecting withthe vulnerable, isolated and sociallymarginalized who are at highest risk ofbecoming ill and least likely to seek outsupport to stay well.

b. developing services across groups ofpractices where the complexity of care andrange of professionals involved is such that itrequires a central focus for higher intensitycare coordination and frequent specialistinput (e.g. complex frail elderly, people livingwith learning disabilities, people in carehomes and prisons).

c. creating alternative access points for highvolume, low complexity care services forminor ailments in order to free-up additionalcapacity in each GP surgery for the patientswho need us most.

d. developing expert generalists andarrangements for working with secondarycare practitioners such that they become aresource for groups of practices, enhancingthe level of care and support offered andproviding additional training anddevelopment activities for GPs locally.

4. How we meet the different access needs:By allowing patients to choose from a rangeof service options (length of appointment,rapid access, booking ahead, GP of choice);enabling choice in the way patients accessgeneral practice (in person, online, by phone,email or video conference); and looking athow we meet any personal accessibilityrequirements (e.g. physical or sensorydisability, language, chaperone/advocacy).

5. How we use data. Not simply to identifydifferent patient needs but also to inform us;to provide intelligence that will improve thequality of clinical care; to provide earlywarning for system failure; to enable us to

see patients on different sites; and to help usdeliver care in different ways, for examplethrough remote care (e-health and telecare).

6. How we improve ourselves and become alearning environment.

7. How we disseminate innovation.

8. How we develop a vibrant, attractiveworkplace with career prospects for clinicaland non-clinical staff (recruitment andretention).

9. How general practice can support patients,families and communities to stay well andcope with minor illness.

10. How we create an organisation thatempowers health and wellbeing in ourpopulation.

What will Londoners notice?

People living in London will be able to have theright length of consultation, provided by the mostappropriate health professional, in better premises,using up-to-date technology. There will be moreresponsive care which will be delivered in a rangeof ways, for example online, email and telephonerather than just face-to-face consultations. Peoplewill only need to make one call or click to booktheir appointment and won’t be told to call backthe next day. There will be no need to take a dayoff work to see a GP as there will be the choice ofearly or late appointments or telephoneconsultations. Those who need to, will be able tobook appointments up to several weeks ahead ata time to suit them. Care will be centred aroundeach person so they won’t need to have multipleappointments about different long term



18

a. finding creative ways of connecting withthe vulnerable, isolated and sociallymarginalized who are at highest risk ofbecoming ill and least likely to seek outsupport to stay well.

b. developing services across groups ofpractices where the complexity of care andrange of professionals involved is such that itrequires a central focus for higher intensitycare coordination and frequent specialistinput (e.g. complex frail elderly, people livingwith learning disabilities, people in carehomes and prisons).

c. creating alternative access points for highvolume, low complexity care services forminor ailments in order to free-up additionalcapacity in each GP surgery for the patientswho need us most.

d. developing expert generalists andarrangements for working with secondarycare practitioners such that they become aresource for groups of practices, enhancingthe level of care and support offered andproviding additional training anddevelopment activities for GPs locally.

4. How we meet the different access needs:By allowing patients to choose from a rangeof service options (length of appointment,rapid access, booking ahead, GP of choice);enabling choice in the way patients accessgeneral practice (in person, online, by phone,email or video conference); and looking athow we meet any personal accessibilityrequirements (e.g. physical or sensorydisability, language, chaperone/advocacy).

5. How we use data. Not simply to identifydifferent patient needs but also to inform us;to provide intelligence that will improve thequality of clinical care; to provide earlywarning for system failure; to enable us to

see patients on different sites; and to help usdeliver care in different ways, for examplethrough remote care (e-health and telecare).

6. How we improve ourselves and become alearning environment.

7. How we disseminate innovation.

8. How we develop a vibrant, attractiveworkplace with career prospects for clinicaland non-clinical staff (recruitment andretention).

9. How general practice can support patients,families and communities to stay well andcope with minor illness.

10. How we create an organisation thatempowers health and wellbeing in ourpopulation.

What will Londoners notice?

People living in London will be able to have theright length of consultation, provided by the mostappropriate health professional, in better premises,using up-to-date technology. There will be moreresponsive care which will be delivered in a rangeof ways, for example online, email and telephonerather than just face-to-face consultations. Peoplewill only need to make one call or click to booktheir appointment and won’t be told to call backthe next day. There will be no need to take a dayoff work to see a GP as there will be the choice ofearly or late appointments or telephoneconsultations. Those who need to, will be able tobook appointments up to several weeks ahead ata time to suit them. Care will be centred aroundeach person so they won’t need to have multipleappointments about different long term



19

conditions; they will be arranged around them.Patients will experience better management andcare of long-term diseases; when they are frailand elderly; and at the end of life. Generalpractices will be encouraged to organisethemselves so that all patients have a named GPaccountable for their care. The need forcontinuity of care should be defined by thepatient and has the potential to be regarded asimportant irrespective of age. This care might bedelegated to other GPs or healthcareprofessionals in the practice team as appropriate.Continuity of the personal care relationship isespecially important for those patients withcomplex and chronic health care needs. Thefuture practice will provide improved continuityof care for these patients and for those thatrequire more coordinated care.

Multidisciplinary teams will work together todeliver care in- and out-of-hours, and in- andout-of-hospital.

There will be safer, less (unwarranted) variabilityand better quality care delivered closer to homeby highly trained GPs, nurses and otherprofessionals. Patients will not necessarily see'their' healthcare professional for all care at 'theirpractice'. They may choose to access anextended range of services at convenientopening times either in their own practices or inthose practices linked to it. There will be no gapsfor patients who are unregistered to fall through.

Models of care

The health system needs to be primary careorientated so that it is focused on improvingpopulation health and wellbeing. In order toensure that patients receive the maximum benefit

from this, general practice needs to have acollaborative approach involving, for example,voluntary and community organisations;community health services; communitypharmacies; mental health services; social care andother partners. Some elements of the specificationcan only be delivered by working with patients andother partners to deliver high quality care.

It is likely that general practice will need to worktogether to form larger primary careorganisations if it is to improve sufficiently. Thiswill give groups of practices the opportunity tofocus on population health and provide extendedopening hours whilst protecting the offer of local,personal continuity of care. What begins as aconversation about greater collaboration willmove towards formation of practice networksthat increase joint working and will then gofurther towards shared teams and infrastructurerequiring a single primary care organisation. TheNHS Five Year Forward View describes this as thedevelopment of a Multispecialty CommunityProvider (MCP) which could offer increasedefficiencies through wider collaboration andintegration. These organisations are likely to align to a single population catchment or localitywith other health, social, community andvoluntary organisations. The shared organisationwill enable provision of a wider range of servicesincluding diagnostics; shared infrastructure,expertise and specialists e.g. for mental health orchildren; create new career paths; training andlearning together.

Shared systems for peer review, developmentaland supportive learning should improve patientsafety, clinical quality and outcomes for allpractices involved. The organisations will containteams that support care coordination and willhave arrangements in place for closerpartnerships with a wider range of practitionersand specialists beyond general practice.


Supra-Borough

DiseaseSpecialist

CommunityMatron/Snr

AHP

Social CareTeams

PracticeManager

Dentists‘Hub’

practices

ManagementFunction

PhysiciansAssociate

AHPs

GPs

HCAGeneral Practice

Nurses

Health andWellbeing

Coordinator

CareCoordinators

Receptionists

RehabService

AcuteSpecialist

Communitybased specialist

practitioners

CommunityMental Health

Mental HealthSpecialist

Health CareScientist

Citizens/Carers/

VoluntaryServices

CommunityPharmacists

Optometrists

District Nurses

Locality/Neighbourhood

Network/Federation

The Practice

The Patient


20

How this all looks will vary from area to area – localcommunities and patients will need to be involvedin developing and agreeing these changes. In someboroughs there may be a review of the numberand type of practices and other buildings. In areasof poor provision, existing and new providers mayemerge and the opportunity described in the NHSFive Year Forward View, for acute, mental healthand community services to also provide generalpractice services, may be taken.

The needs of an area will be met perhaps withfewer, smaller practices and some larger healthand education hubs with diagnostics, day bedsand leisure and exercise facilities for patients and the public. GPs will work together in a single system continuing to deliver first contact

care but also providing continuity of care to those that wish to see the doctor of their choice.GPs will be linked together via a single electronicrecord with other practitioners such as elderlycare doctors, paediatricians, palliative care anddistrict nurses helping to deliver 24/7 care tothose who most need it.

Patients will benefit through receiving care from agreater range of generalists, more specialist careand improved access to services in a betterenvironment.

We need to work together to achieve thisambitious specification to ensure we can deliverthe future requirements of our population.

All teams come together around thepatient. The patient is empowered to selfcare, and be involved in decisions andplanning for their care

The Practice is responsible for main careplanning and coordinating care betweendifferent levels and types of care services

Management, administrative and otherresources put in place to support practicesin care coordination

Integrated teams of providers supportongoing patient care needs

Specialist and expert input to local teams

Illustrative model of care


Supra-Borough

DiseaseSpecialist

CommunityMatron/Snr

AHP

Social CareTeams

PracticeManager

Dentists‘Hub’

practices

ManagementFunction

PhysiciansAssociate

AHPs

GPs

HCAGeneral Practice

Nurses

Health andWellbeing

Coordinator

CareCoordinators

Receptionists

RehabService

AcuteSpecialist

Communitybased specialist

practitioners

CommunityMental Health

Mental HealthSpecialist

Health CareScientist

Citizens/Carers/

VoluntaryServices

CommunityPharmacists

Optometrists

District Nurses

Locality/Neighbourhood

Network/Federation

The Practice

The Patient


20

How this all looks will vary from area to area – localcommunities and patients will need to be involvedin developing and agreeing these changes. In someboroughs there may be a review of the numberand type of practices and other buildings. In areasof poor provision, existing and new providers mayemerge and the opportunity described in the NHSFive Year Forward View, for acute, mental healthand community services to also provide generalpractice services, may be taken.

The needs of an area will be met perhaps withfewer, smaller practices and some larger healthand education hubs with diagnostics, day bedsand leisure and exercise facilities for patients and the public. GPs will work together in a single system continuing to deliver first contact

care but also providing continuity of care to those that wish to see the doctor of their choice.GPs will be linked together via a single electronicrecord with other practitioners such as elderlycare doctors, paediatricians, palliative care anddistrict nurses helping to deliver 24/7 care tothose who most need it.

Patients will benefit through receiving care from agreater range of generalists, more specialist careand improved access to services in a betterenvironment.

We need to work together to achieve thisambitious specification to ensure we can deliverthe future requirements of our population.

All teams come together around thepatient. The patient is empowered to selfcare, and be involved in decisions andplanning for their care

The Practice is responsible for main careplanning and coordinating care betweendifferent levels and types of care services

Management, administrative and otherresources put in place to support practicesin care coordination

Integrated teams of providers supportongoing patient care needs

Specialist and expert input to local teams

Illustrative model of care


The service specification


21

At the heart of this Transforming Primary Care inLondon: A Strategic Commissioning Framework isa new service specification for general practice.This supports the need to define and commission amore consistent service for all Londoners e.g.adults, children, young people, carers and families;reducing variations in access, patient experienceand clinical outcomes. The specification provides asingle definition of high quality care.

Three characteristics are needed for generalpractice to thrive and deliver the care that patientsneed and value.

1. Proactive care – supporting and improvingthe health and wellbeing of the population,self-care, health literacy, and keeping people healthy.

2. Accessible care – providing a personalised,responsive, timely and accessible service.

3. Coordinated care – providing patient-centred,coordinated care and GP-patient continuity.

The Framework covers these three aspects of careand contains a specification of the future patientoffer covering 17 aspects of care. The document isinformed by the London GP Innovation Challenge(2012) and Prime Minister's Challenge Fund(2013). Some elements have already beenachieved and implemented in parts of London.Whilst the Framework describes a common patientoffer, it is sufficiently flexible and adaptable forgroups of practices to design how the servicespecification might be delivered consistently for allpatients. Delivering the specification described inthis document will require local planning andcustomisation in order to ensure that these areprovided in the best possible way for the wholepopulation, for example the particular differencesneeded to deliver this for children as well as adults.

London’s general practice will be transformedwhen all patients are able to fully access the caredescribed in this document and when it is of asufficiently consistent high quality.

This Framework is about what is delivered andhow it is delivered. From the moment a patientbegins their interaction with general practice, theyshould feel they are treated with dignity andcompassion. The Care Quality Commissionassessment and inspection of general practicesplaces great emphasis on whether patients areexperiencing caring and empathetic services.

Evidence supplement and case studies

A supplement to this document is available on request ([email protected]) and provides acompendium of the supporting evidence. This includes:

• detailed insight obtained through theengagement activities and a record of thechanges made as a result

• research and evidence gathered from analysisand piloting activities

• a case studies supplement, first published aspart of the draft of this Framework in April2014, which has been reissued and madeavailable through the London Primary CareTransformation online portal. This supplementdemonstrates what is possible by capturingexamples of where general practices arealready innovating their service model todeliver aspects of this service specification.



22

Service specificationdevelopment process

NHS England has worked with London’s clinicalcommissioning groups to lead an open,transparent and collaborative process to engagekey stakeholders to provide feedback on its draftTransforming Primary Care in London: A StrategicCommissioning Framework, and identify theprimary care services which patients value, whatpatients need to remain healthy, and the servicesthat will positively impact on the wider healtheconomy. The service specification has beendefined by patient voices, clinical leaders, currentbest practice, innovation and best evidence.

Throughout the development of the patient offerand the Framework, this programme has putcollaboration and engagement at its core; it hasbeen developed by engaging with clinicians,patients and other stakeholders in order tounderstand the needs and perspectives ofdifferent groups. Over the development and pre-engagement phase (i.e. up to November 2014)the programme engaged with over 1,500stakeholders in order to develop, test and refinethe specification (see diagram below).

Further engagement

Following on from this development and testingphase, there has been a further period ofengagement in local areas. This has been ledmostly by the CCGs at a Strategic Planning Group(SPG) level. The feedback echoes the findings ofNHS England, which is that there is a strongappetite to now move forward withimplementation. Feedback has focused around‘how’ to make this happen, and ‘when will I seethese changes’, so it has been agreed that thefocus should now be making the vision a reality.

This will not be the end of engagement. It isessential that meaningful engagement continueswith all the appropriate stakeholders includingthe public and patients, the primary careworkforce, and other impacted groups. Thisengagement will provide a further opportunity toaffect how the specification is delivered in localareas, and help shape how primary care will workwith other groups, such as patient and publicgroups, charities and the voluntary sector. It isalso key to note that from April 2015, it will be acontractual requirement for all practices to have apatient participation group and to make reasonableefforts for this to be representative of the practicepopulation. This is expected to have a positiveimpact on ensuring that there is a good level ofpublic and patient engagement at all levels.

Number of people and groups engaged to develop the service specification

Primary CareLeadership Group

(30 people)

3 x Expert panels(20-50 membersinc. patient reps)

Patient review panel (10 people)

3 x virtualgroups (60-80 people)

Clinical board (35-50

people)

Borough based health & social

care – CCGs & localauthorities (100

people)

Senate strategiccommissioning

networks (800+ people)

Clinicalchallenge

panel (≈20people)

Transformationboard and

delivery group(≈60 people)

Patient publicfocus groupsand patientboard (≈200

people)

Over 50Charities



23

Primary care is at the heart of every community,putting it in a unique position to empowerpatients to keep safe and well, and to leadhealthier lives – the essence of proactive care.This includes activities and interventions whichcontribute to improving health and wellbeing byincreasing self-reliance; building greater capacityfor health and health resilience in patients, thepeople who support their care (for instancefriends and families), and through partnershipwith local communities.

By supporting people to live well we avoidunnecessary care interventions, improve qualityof life and reduce the overall cost for taxpayers.

Proactive care can reduce health inequalities byproviding a targeted response to those who arehighly reliant on additional support to stay well.People who are at higher risk of deterioratinghealth due to social isolation, or a lack ofpersonal capacity e.g. homeless people, ‘lookedafter children’ and isolated elderly people requirea different level of support to achieve positivehealth outcomes. This care might be deliveredacross a group of practices by a team comprisingroles such as care navigators, peer advocates,

health coaches, wellbeing support workers andcommunity volunteers. Reducing healthinequalities is not just about focusing on illness,but providing a holistic response to social issueslike debt, housing, employment and substancemisuse to improve health and wellbeing.

Proactive care requires moving assets acrossmultiple agencies and community organisationsto re-focus our efforts onto illness and a clinicalagenda aimed at enabling people to live well.

General practice is well placed to improvepopulation health because:

• it is the most accessed part of the health system

• it holds a registered list for a definedpopulation in an immediate locality

• generalists deliver care to people with a full understanding of their social context.

Proactive Care Expert Panel Chair: Dr Nav Chana

Dr Nav Chana is a GP and senior partner at the Cricket Green Medical Practice where he has been a GP for22 years. He was previously the Postgraduate Dean for General Practice and Community Based Education atthe London Deanery. He is now Chairman of the National Association of Primary Care (NAPC) where he hasestablished collaborative networks to support primary care innovation. Nav’s interests include improving thevalue of primary care through an enhanced focus on population-based healthcare.

1. Proactive care specification



24

Delivering the proactive care specification willrequire practices to co-design new approachesto improving health with individuals, families,other health agencies and local communitypartners. Londoners will recognise generalpractice as caring about their wellbeing andproviding holistic support to enable them to staywell. But delivering proactive primary care willgo beyond general practice and will draw on thewhole family of primary care services andprofessionals including those within thevoluntary and third sectors.

The nature of consultations will change, tobetter combine clinical expertise with patients'aspirations for wellbeing. Patients will noticethat they are being asked more frequently abouttheir wellbeing, capacity for improving their ownhealth and their health improvement goals. Theymay be reminded of signs of early disease suchas cancer, or be offered support to manageconditions themselves (e.g. health information,advice and equipment) or social prescribing (e.g.debt advice).

Patients will be offered additional services suchas coaching, mentoring and buddying fromprofessionals or peers offering support to helpbuild patient knowledge, skills and confidencefor self care.

These types of services are already offered bysome London practices. Practices in Lewishamhave been piloting a service to support patientsreach their care plan targets including regularmotivational callers (people who phone patients– helping and encouraging them to meet theirhealth goals), self-management demonstrationsand role play; and the Well Centre in Streathamhas helped 650 young people with complexneeds to manage their conditions better,reducing the need for further referrals.

The service specification covering proactive careidentifies opportunities for general practice totake a population based approach to improvinghealth and wellness in partnership with localcommunities. This creates the required socialcapacity and resources in communities, improveshealth literacy, and increases the capacity andresilience of individuals for maintaining theirhealth and wellbeing.

Dr Nav Chana

proactive care



25

P1: Co-design

Primary care teams will work withcommunities, patients, their families,charities and voluntary sector organisationsto co-design approaches to improve thehealth and wellbeing of the local population.

Involving individuals and communities indesigning services will ensure that approachesare relevant locally; that they do not duplicate(and are integrated with) existing services in the community; and that they are more likely tobe successful.

The process of co-design in itself will supportimproved understanding of health and wellbeingfor those involved, support the identification ofcommunity advocates and volunteers and furtherbuild community resilience.

An example would be engaging local youngpeople, schools and youth workers in designingnew ways of communicating with young peopleliving with a long term condition.

P2: Developing assets and resources for improving health and wellbeing

Primary care teams will work with others to develop and map the local social capitaland resources that could empower people to remain healthy; and to feel connected to others and to support in their localcommunity.

Practices will work with local voluntary andcommunity, health, third sector and otherorganisations; and with local authorities to:

• provide additional capacity for improvinghealth and wellbeing (e.g. Citizen's Advice,community pharmacy services and theprobation services)

• protect community resources for futuregenerations (e.g. with the EnvironmentAgency)

• test new ways to build and improverelationships with local communities

• build a map of local community assets thatcan be harnessed for health and wellbeing

• identify and develop local community healthand wellbeing champions, advocates andvolunteers.

Establishing and maintaining an up-to-date mapof community assets will assist a range oforganisations involved in an individual’s care. Themap will support other ‘first contact’ providerssuch as NHS 111 and community pharmacies tooffer patients a range of options.

P3: Personal conversations focused onan individual’s health goals

Where appropriate, people will be askedabout their wellbeing, capacity for improvingtheir own health and their healthimprovement goals.

Practices will coordinate plans of care, particularlyfor people who regularly visit the practice andwhose health is at risk of deteriorating. If relevant,patients will be offered self-management supportand/or social prescribing – directing them ontoother information, resources and services availablein their local communities e.g. debt advice.

proactive care



26

P4: Health and wellbeing liaison andinformation

Primary care teams will enable and assistpeople to access information, advice andconnections that will allow them to achievebetter health and wellbeing. This health and wellbeing liaison function will extendinto schools, workplaces and othercommunity settings.

These services would offer a range of interventionsfrom brief focused information to more extensiveadvice and support. Interventions could includegroup support, 1:1 coaching, signposting andimproving health literacy. The service would alsobuild partnerships to build on the contribution tohealth and wellbeing already made by leisurecentres, gyms and voluntary groups.

P5: Patients not currently accessingprimary care services

Primary care teams will design ways to reachpeople who do not routinely access servicesand who may be at higher risk of ill health.

This specification focuses on two key areas:

1. People on the registered list (but notattending the practice).

• Practices will design ways to reach vulnerable patients who may live in circumstances which make it harder for them to access general practice. This includes patients whose language and culture form barriers to receiving care, forinstance gypsies, travellers, sex workers, homeless people, vulnerable migrants, people in care homes, and people with learning disabilities or severe mental illness.

Practices will identify the patients on theirregistered list who have not been attending and are therefore at higher risk of ill health. These may be people who have declined invitations for services, are reaching crisis, suffering social isolation or stigma.

These patients will require a more personalised service offer, care coordination and care planning. Using peer advocates who have direct personal experience and can empathise with patients has been shown to be an effective way of engaging with these groups of patients.

• Primary care teams will also design approaches to follow up those patients who might be attending the practices from time to time but are not taking up invitations for services such as screening and vaccinations. Understanding the root causes for non-attendance will be crucial to ensuring maximum take-up of these services in the future; for example, understanding religious or cultural reasons for non-attendance.

2. The unregistered population.

• Working collaboratively across a population and across multiple agencies, primary care teams will also design (with the support of their CCG) ways to reach and care for the unregistered population, for example homeless patients and people released from custody or places ofdetention.

proactive care



27

Good access to general practice is important toeveryone. It’s important to patients who may bedistressed or who may suffer if diagnosis andtreatment is delayed; those who value acontinuous relationship with their clinician inorder to remain healthy and independent; andpeople who find it hard to see a GP withincurrent opening times. It's important to practiceswhose workloads can become inefficient ifaccess is not managed systematically. It'simportant to the NHS as good access to primarycare has the potential to reduce unnecessaryemergency admissions and reduce the numberof patients attending A&E.

Although there are examples of excellent servicesat some practices, many London patients reportthat access to general practice does not alwaysmeet their needs. On average, patients inLondon are less satisfied than those in otherparts of England with contacting the practice;seeing a GP quickly; their ability to book ahead;opening hours; and seeing a GP of choice whenthey want.

Patients who cannot access their practice becauseit is closed or they are unable to get anappointment are more likely to attend A&E with

issues that their GP could have resolved. Lessthan half of patients wanting an appointment inLondon are seen by the next working day. Phonelines are busy first thing in the morning and sameday appointments run out quickly. Many patientsare asked to call back the following day. Formany patients, access to weekend and eveningappointments is limited and many practices stillclose on a Wednesday or Thursday afternoon.

More London patients report that it is hard tosee a preferred GP in London than anywhere elsein England. Consequently patients who needregular contact and a continuous relationshipwith a clinician may not receive the best supportto manage their health effectively in thecommunity.

Our proposals

Good access means different things to differentpeople. In developing this specification we havetried to consider the various needs of differentpatient groups – whether that is accessingcontinuity of care, rapid access, out of hours careor online services.

Accessible Care Expert Panel Chair: Dr Tom Coffey OBE

Tom has been working as a GP in Wandsworth since 1994. He started as a chemical engineer then transferredto medicine at Charing Cross and Westminster medical school. He is a GP partner at Brocklebank GroupPractice; a medical advisor to Tooting Walk-in Centre; Clinical Assistant in A&E at Charing Cross Hospital and atutor at St George’s, University of London. Dr Coffey was awarded an OBE for services to healthcare in southwest London in June 2009.

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Often patients concerned about a new healthproblem want to be seen as quickly as possiblebut are less concerned about who they see. Thereis also evidence that some patients go to A&Ewith minor issues because they can’t get a sameday appointment with a GP – especially atweekends when many practices are closed. Sowe’ve proposed that all patients should be able toaccess a consultation with a GP or senior nursefrom their own practice on the same day duringroutine opening hours and on Saturday mornings.We’ve also suggested that patients should be ableto access a primary care health professional sevendays a week, 12 hours a day in their local area.

Commuters with occasional health needs wantadvice and care quickly, conveniently and in avariety of ways. Patients should be required toonly make one call or click to make anappointment, and practices should promoteonline services including appointment booking,prescription ordering, viewing medical recordsand email. Many systems make telephoneconsultations the normal starting point for mostpatients – linking the two people who need totalk, in the shortest possible time.

Other patients, such as those with long termconditions, tend to need more frequentconsultations and value continuity and familiarity– but are willing to wait a little longer to be ableto do so. So this specification outlines thatpatients should be able to book at least fourweeks ahead if they wish and see their GP ofchoice in an appointment with a flexible duration.

We know that patients will have different needsat different times. So we’ve suggested aspecification that patients should be given achoice of access options to select the service thatbest meets their needs.

We also need patients to use the mostappropriate service for their needs. For medicalhelp or advice in a situation that is not life-threatening, patients can call 111 free from anyphone. NHS advisers are on the line 24 hours aday, seven days a week and can give healthcareadvice or signpost patients to local services.Patients are often unaware of the range ofservices that their pharmacy can offer, so manypeople simply don’t consider visiting. Butpharmacies can provide medical advice on arange of conditions and can even provideprescription drugs under minor ailment schemes,without an appointment.

The fact that different dimensions of access arevalued differently by different people (and by thesame people at different times and in differentcircumstances) presents a real task to theformulation of concrete measures of good-qualityaccess. Our challenge is to design and deliver atruly personalised service that responds to allpatients, irrespective of their particularcircumstances. We hope that this specificationoutlines a service which does just that.

Dr Tom Coffey OBE

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A1: Patient choice

Patients will be given a choice of accessoptions and should be able to decide on theconsultation most appropriate to their needs.

Different patients, in different situations, havedifferent access needs. Some patients valuecontinuity of care over rapid access. Some peopleplace more value on seeing a particular clinician.Others want a more convenient appointmenttime, or to book an appointment four or moreweeks in advance.

General practice should make all these optionsavailable to the patient at the point of contactand allow the patient to select the service theywant. Practices should also include reasonableadjustments to remove access barriers forpatients, such as considerations for the homelessor non-English speakers, as well as adhering tothe Equality Act (2010) for physical access needs(ramps, hearing loops etc).

A2: Contacting the practice

Patients will be required to only make onecall, click or contact in order to make anappointment. Primary care teams willmaximise the use of technology and activelypromote online services to patients includingappointment booking, prescription ordering,viewing medical records and emailconsultations.

Currently appointments are often allocated basedon who gets through to the practice rather thanby clinical need. Many practices hold backappointments so that a patient getting throughmay be told that there are no appointments leftbut that they should call back later or the

following day when more are released. Thisincreases the number of calls coming into thepractice as patients have to call several timesbefore securing an appointment and patientswho do call back join the back of the queue.

In future patients would have multiple options formaking an appointment, and would only need tomake contact once in order to have a discussionwith a clinician.

A3: Routine opening hours

Patients will be able to access pre-bookableroutine appointments with a primary healthcare professional (see ‘workforce implications’for the proposed primary care team) at allpractices 8am – 6.30pm Monday to Friday and8am to 12 noon on Saturdays. An alternativeequivalent patient offer may be providedwhere there is a clear, evidenced local need.

There is significant variation in opening hoursacross London. This specification will create anequitable offer to patients across the capital.During the specified hours, all practices will beopen to allow patients to access all services,including attending an appointment, speaking to a receptionist, and collecting or ordering aprescription.

A4: Extended opening hours

Patients will be able to access a GP or otherprimary care health professional seven daysper week, 12 hours per day (8am to 8pm oran alternative equivalent offer based on localneed) in their local area, for pre-bookableand unscheduled care appointments.

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This service will be delivered by networks ofpractices working together at scale. In most casesa larger practice in the local community will takethe lead to provide this service on behalf of otherpractices. A suggested offer of 8am to 8pm isdescribed here, however there could be a suitablealternative equivalent offer based on localpopulation needs, for which the totality of theoffer (seven days, 12 hours) is not reduced.

A5: Same day access

Patients who want to be seen the same daywill be able to have a consultation with a GPor appropriately skilled nurse on the sameday within routine surgery hours at thepractice at which they are registered (seeSpecification A3: Routine opening hours).

Patients with new health conditions often want to see or speak to a GP as soon as possible. It’simportant for patients who may be distressed orsuffer if diagnosis and treatment is delayed.Consultations could be face-to-face or on thephone (or video phone) but will be provided by a GP or an appropriately skilled nurse on the same day.

Practices would be encouraged to use a demand-led telephone triage system. These approachesprovide a phone conversation with an appropriateclinician throughout the day, often within 30minutes of the patient contacting the practice.The patient can then discuss their needs with the clinician and between them they can decidethe most appropriate course of action (e.g. face-to-face consultation of appropriate lengthaccording to need; referral to communitypharmacist, nurse, healthcare assistant or other service; booking for diagnostic tests; andself care).

A6: Urgent and emergency care

Patients with urgent or emergency needswill need to be clinically assessed rapidly.Practices should have systems in place and skilled staff to ensure these patients are effectively identified and responded to appropriately.

In the event that a patient accesses generalpractice with emergency care needs, thereshould be sufficient processes and procedures inplace to enable all members of the practice torespond to that patient’s needs appropriately.

A7: Continuity of care

All patients will be registered with a namedGP who is responsible for providing anongoing relationship for care coordinationand care continuity. Practices will provideflexible appointment lengths as appropriate.

All patients should have a named GP for carecontinuity and coordination. Other GPs orhealthcare professionals within the practice team may provide care as appropriate but thenamed GP will effectively still oversee delivery of the care plan.

General practice will routinely improve continuityof care through a range of mechanisms such asbuddying; job sharing; forming ‘teams withinteams’; developing organised handover systems;enhanced use of communication and record-keeping technology; and increased involvementof patients and carers in care planning. Thesemeasures are of particular importance wherepersonal continuity is not possible.

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For people with complex health and social careneeds, coordinated care is essential to supporttheir health and wellbeing.

One in five Londoners are living with one or morecomplex conditions. Other people go throughperiods of severe, complicated, health problemswhich may last months or years before they areresolved. Changes to the GP contract focus onthe over-75s, but in London it is often youngerpeople who live with complex health problemswhich may be harder to manage because of drugor alcohol dependence, mental health problemsor financial and social pressures. ManyLondoners, young and old, will be receiving carefrom several different services, which can becomeconfusing and frustrating if the services don'twork in close collaboration.

The National Voices report Integrated care: whatdo patients, service users and carers want?provides a powerful narrative which highlightsclearly and effectively the kind of relationshippeople want with their health professionals. Itstresses that coordination and care are the two'top lines' in what people expect and need.

The statement “My care is planned with peoplewho work together to understand me and my

carer(s), put me in control, coordinate and deliver services to achieve my best outcomes”summarises the service we want to outline in thisspecification. We know this type of service wouldresult in significantly improved health outcomesand patient experience.

In the National Voices document, patients tell usthey want a service where their needs as a personare taken into account; they are involved indiscussions and decisions about their care; theyhave regular reviews of their care, treatment andcare plan; and they have the information andsupport they need in order to remain asindependent as possible. We also know patientswant a first point of contact from someone whounderstands them and their condition and whothey contact to ask questions at any time.

These are significant challenges for all health andcare professionals, including GPs, which willrequire a fundamental change in the culture ofgeneral practice and communications betweenservice users and professionals. New approachesto delivering care are needed, informing patientsand their carers about their condition(s) andenabling them to participate effectively indecisions about their health and care.

Coordinated Care Expert Panel Chair: Dr Rebecca Rosen

Rebecca is a Senior Fellow in Health Policy at the Nuffield Trust, a GP in Greenwich and an accredited publichealth specialist. Her current policy interests include integrated care, primary care, new organisationalmodels for general practice and NHS commissioning. Rebecca is a clinical commissioner with GreenwichCCG – where she leads on long-term conditions and quality. At her GP practice, Rebecca leads work toimprove continuity and quality of care for people with chronic complex ill health. In the past, Rebecca hasworked as a Medical Director of Humana Europe; as a Senior Fellow at the King’s Fund; and in NHSacademic public health departments. Past research interests include the diffusion of new medicaltechnologies, patient choice and primary care policy.

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Our proposals

We want to move away from a reactive systemwhich treats people when they become ill, to onewhich coordinates care and supports people tostay well.

Firstly we need to identify the patients who wouldbenefit from this approach. Many will be elderlyand suffer from multiple chronic conditions whileothers may suffer from mental health issues orhave a set of social circumstances and lifestyleissues which are best addressed thoughcoordinated care.

Secondly patients need a named clinician who willroutinely provide the patient’s care or act as anadvocate, guide and contact for the extendedpractice team and to the wider multidisciplinaryteam in line with their needs.

Thirdly we want all such patients to have apersonalised care plan and to have played anactive role in determining its aims and content –agreeing goals and the support they need toachieve them.

Fourthly we want to create an environment inwhich patients can maximise the potential of theirself-care, lifestyle changes and knowledge tocontribute to their own health and wellbeing.

Finally, patients who require coordinated care willneed frequent reviews and input from a range ofmembers of a wider team ranging from a micro-team of practice staff, pharmacy and communitynursing to a macro-team of health and social careproviders. The provider network needs to be well-connected and patient services seamless.

While these challenges sound daunting, a greatdeal of work has been done on how to deliverhigh quality services tailored to individual and

population health needs and examples continue tobe developed across London. The chronic caremodel introduced the idea of ‘informed, activatedpatients’ and a ‘prepared, proactive’ clinical team.The recently launched Delivering Better Servicesfor People with Long Term Conditions – Buildingthe House of Care adapts this model for the NHS,highlighting the four key components ofcoordinated care: informed, engaged individualsand carers; organisational and clinical processes;health and care professionals committed topartnership working; and effective commissioning.

The ambitions of National Voices’ patient-centredcoordinated care and the organisational model ofthe House of Care feature heavily in the followingspecification. They create a framework aroundwhich practices can organise themselves to deliverhigh quality care with a relational continuity(seamless care), focused on the goals andpreferences of individual patients and tailored tomeet individual needs.

The specification is rightly ambitious and will notbe achieved overnight. It requires a new culturefor general practice in which the co-creation ofhealth by patients, doctors, nurses and othersbecomes the norm. The specification addresseswhat individuals can do to keep themselves well;the ways in which professionals consult withpatients; the ways in which practices are organisedto support coordinated care; and the ways inwhich GPs work with other providers to delivercoordinated care. Practices may need additionalresources to deliver the specification and these willhave to be negotiated and put in place, but webelieve achievement of the specification will resultin better care for people with long term, complexhealth and care needs.

Dr Rebecca Rosen

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C1: Case finding and review

Practices will identify patients who wouldbenefit from coordinated care and continuity with a named clinician, and willproactively review those that are identifiedon a regular basis.

Patients with complex conditions who need carefrom more than one professional or team will beadded to a coordinated care register and will beprovided with an enhanced level of service.

These patients may have long term conditions butmay also be patients with a range of other healthconditions and social support needs such aschildren and families with complex problems;people with mental health conditions; people innursing homes; people at the end of life; orvulnerable people who find it hard to accessservices (for example homeless patients; thosewith learning difficulties or members of thetraveller community).

Patients will be identified using a combination ofclinical alerts, risk profiling and clinical judgment.Every practice, or network of practices whereappropriate, will run a regular risk profiling/riskstratification process in order to identify patientswho should be on their care coordination register.

The intensity of care, frequency and duration ofcontact with patients should be scaled up orstepped down as a result of reviews and patientprogress. This should enable practices to identifythose who may be, or are at risk of, experiencingan exacerbation of their condition but who havenot reached a crisis point to seek treatment.

C2: Named professional

Patients identified as needing coordinatedcare will have a named professional whooversees their care and ensures continuity.

All patients identified as needing coordinatedcare should have a named professional fromwhom they routinely receive their care. The leadGP will provide continuity of care, eitherpersonally or in collaboration with a 'micro team'of clinicians and professionals in and around thepractice, for example members of the wellbeingteam or community pharmacists.

Patients may also be allocated an additionalmember of the practice team or an additionalhealth or social care professional as a carecoordinator to act as their first point of contact if they have questions, concerns or problems.

The person who coordinates their care shouldwork with the patient to achieve their goals. Forsome patients this will require extendedconsultations, for others it will mean regularcontact with an extended primary care team.Patients with more complex needs would ideallybe able to contact their care coordinator 24/7 forcertain periods of very acute clinical risk ortowards the end of their life.

The intensity of contact and amount of timespent with the named GP and extended team willfluctuate in accordance with need, as assessed byrisk profiling and regular communication withpatients and their family and carers.

The GP should act as an advocate and guide andshould coordinate care with the extendedpractice team and a wider multidisciplinary teamas appropriate. If patients go into hospital ortransition to other services, general practiceshould continue to be proactively informed aboutthe patient as they move between services,continuing to coordinate their care if appropriate.

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C3: Care planning

Each individual identified for coordinatedcare will be invited to participate in a holistic care planning process in order todevelop a single care plan that can beshared with teams and professionalsinvolved in their care.

Development of the care plan should follow theapproach described in Delivering Better Servicesfor People with Long Term Conditions – Buildingthe House of Care. This represents a departurefrom the current focus on individual diseasestowards a generic approach in which patients’goals drive care delivery and greater attention ispaid to the contribution that people maketowards managing their own health.

Care planning should be based on a philosophyof co-created goals for maintaining andimproving health. It should be an iterativeprocess that continues for as long as anindividual has complex needs.

Patients identified for coordinated care, and theircarers, should be encouraged to play an activepart in determining their own care and supportneeds as part of a collaborative care planningprocess. This should involve discussing care andsupport options, agreeing goals the patient canachieve themselves, and co-producing a singleholistic care plan that includes the needs offamily and carers.

C4: Patients supported to manage theirhealth and wellbeing

Primary care teams will create anenvironment in which patients have thetools, motivation and confidence to takeresponsibility for their health and wellbeing.

A culture of self-management support willunderpin care coordination, recognising that thepersonal information that patients, their carersand families bring to the development of careplans can be as important as the clinicalinformation in medical records.

Practices will develop an infrastructure to provide self-management support for patientswith ongoing complex problems and support fortheir carers.

Following a new diagnosis of a long termcondition (or identification of a need forcoordinated care such as recovery from cancer) all patients will have at least one encounterdedicated to enhancing their ability to self-care,and then frequently according to need thereafter.

Support for patients could be provided byindividual practices or across a number ofpractices and could for example include internetresources; advice from staff skilled in lifestyletraining and/or motivational support; informationpacks; services provided by volunteers orvoluntary organisations and access to patientgroups in which patients support each other.

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C3: Care planning

Each individual identified for coordinatedcare will be invited to participate in a holistic care planning process in order todevelop a single care plan that can beshared with teams and professionalsinvolved in their care.

Development of the care plan should follow theapproach described in Delivering Better Servicesfor People with Long Term Conditions – Buildingthe House of Care. This represents a departurefrom the current focus on individual diseasestowards a generic approach in which patients’goals drive care delivery and greater attention ispaid to the contribution that people maketowards managing their own health.

Care planning should be based on a philosophyof co-created goals for maintaining andimproving health. It should be an iterativeprocess that continues for as long as anindividual has complex needs.

Patients identified for coordinated care, and theircarers, should be encouraged to play an activepart in determining their own care and supportneeds as part of a collaborative care planningprocess. This should involve discussing care andsupport options, agreeing goals the patient canachieve themselves, and co-producing a singleholistic care plan that includes the needs offamily and carers.

C4: Patients supported to manage theirhealth and wellbeing

Primary care teams will create anenvironment in which patients have thetools, motivation and confidence to takeresponsibility for their health and wellbeing.

A culture of self-management support willunderpin care coordination, recognising that thepersonal information that patients, their carersand families bring to the development of careplans can be as important as the clinicalinformation in medical records.

Practices will develop an infrastructure to provide self-management support for patientswith ongoing complex problems and support fortheir carers.

Following a new diagnosis of a long termcondition (or identification of a need forcoordinated care such as recovery from cancer) all patients will have at least one encounterdedicated to enhancing their ability to self-care,and then frequently according to need thereafter.

Support for patients could be provided byindividual practices or across a number ofpractices and could for example include internetresources; advice from staff skilled in lifestyletraining and/or motivational support; informationpacks; services provided by volunteers orvoluntary organisations and access to patientgroups in which patients support each other.

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C5: Multidisciplinary working

Patients identified for coordinated care willreceive regular multidisciplinary reviews by ateam involving health and care professionalswith the necessary skills to address theirneeds. The frequency and range ofdisciplines involved will vary according tothe complexity and stability of the patientand as agreed with the patient/carer.

Patients on the coordinated care register willhave a review by a multidisciplinary teaminvolving clinicians from within the practice andfrom linked services. GPs should be regular,active participants in multidisciplinary reviews of their registered patients who have beenidentified for coordinated care. The frequency ofmultidisciplinary reviews will vary according tochanging needs.

Multidisciplinary reviews should ideally includeprofessionals from both health and social care.This might include acute care specialists, socialservices, housing and finance advisors,community matrons, mental health specialistsand district nurses depending on the needs ofthe patient.

General practice should fully participate inmultidisciplinary work across the health and caresystem and use reflective learning to improvepatient care and for system enhancement.

coordinated care


The enablers

The enablers

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This Strategic Commissioning Framework forPrimary Care Transformation represents asignificant ambition for service improvement.Delivering this ambition will require strongcollaboration from all parts of the NHS, the CQC, LETBs, academic health science networks(AHSNs), local authorities, charities and voluntaryorganisations and health and wellbeing boards(HWBs) in London. This section of theFramework provides a strategic London-widecase of the underpinning enablers that will need to be utilised in order to meet the scale of that challenge.

Local plans to deliver the changes

CCGs across the capital will continue to develop(in partnership with NHS England (London)) andrefine local plans for delivering these changes.These plans will focus on how to improve generalpractice and the wider primary care system fromApril 2015 onwards. The changes required to thesystem will take a long time to fully achieve,however some changes and some practices maybe quicker to implement than others. In order forlocal populations to be able to take part indiscussions to decide what is best for their localcommunity, it is essential that plans are locallydesigned, based on different starting points.

The Framework is not intended to be used as astand-alone static document but will form aplatform for developing strategic plans totransform primary care in each local area. There isan expectation that different areas will work atdifferent paces and NHS England (London) willwork closely with those areas that are ready, and

will share the learning across London.Commissioners across London aim to ensure thatin the future, all Londoners will receive theprimary care services described in this document.

Co-commissioning

NHS England (London), CCGs and localauthorities recognise that achieving the vision in this Framework will require significantcollaboration across all parts of thecommissioning system, and co-commissioningwill be a key enabler. The NHS Five Year ForwardView set out the aim to provide CCGs morecontrol over NHS budgets, with the objective of supporting greater investment in primary care. There are three different levels of co-commissioning available:


2. joint commissioning model that enablesone or more CCGs to assume responsibilityfor jointly commissioning primary medicalservices with their NHS England area team,either through a single joint committee, or“joint committees in common”

3. delegated commissioning offers anopportunity for CCGs to assume fullresponsibility for commissioning someaspects of general practice services.


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The picture in London

January 2015 saw the first set of applications forco-commissioning submitted. In London, allCCGs applied for co-commissioning, althoughsome of the CCGs and SPGs which applied forJoint Commissioning will be moving to thesearrangements later in the year (e.g. October).

• Four SPGs covering 25 CCGs applied forjoint commissioning

• Two SPGs covering 6 CCGs applied fordelegated commissioning

• One CCG submitted an individualapplication for delegated commissioning

CCGs are able to move from joint commissioningto delegated commissioning at the end of eachfinancial year; and some CCGs have alreadyexpressed an interest in moving to delegatedcommissioning in 2015/16.

Benefits of co-commissioning

There have been several anticipated benefitsidentified as a result of co-commissioning:

• improved access to primary care and widerout-of-hospital services, with more servicesavailable closer to home

• high quality out-of-hospital care

• improved health outcomes, equity of accessand reduced inequalities

• a better patient experience through morejoined up services.

In addition to these benefits, the applicationshave referenced several further benefits such as:

• more joined up services by working withother providers and other CCGs. All of theCCGs describe a method or intention ofworking with other CCGs in the local area.This is expected to support a beneficialbalance between local decision making andworking at scale

• more optimal decision making processregarding Primary Care resources. ProvidingCCGs with greater decision making powerwill support local decisions, facilitate greatercollaboration with other local areas andpotentially make the decision makingprocess more efficient

• better ability to deliver the NHS Five YearForward View and this StrategicCommissioning Framework. CCGs have citedthat further involvement in primary caredecision making will make them better ableto deliver key strategic priorities. This includestheir five year strategic plans, the NHS FiveYear Forward View, and this Framework.

Commissioning and the future ofprimary care transformation

It is important to note that all co-commissioningapplications reference a commitment to deliverthe intentions of the Strategic CommissioningFramework, and it is believed that co-commissioning will be a key enabler to deliveringthis patient offer.


The enablers

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Expenditure on general practice services hasfallen in real terms between 2010/11 and2011/12 in comparison to an increased spend in acute and community services.

The new service specification needs to beaffordable within current NHS financialconstraints, and NHS England (London) and CCG budgets. There is a £2.4 billion savingrequirement for London by 2020/21, whichmeans that finding ways to use existing resourcesmore effectively is urgently needed.

Within this context there is a strong rationale for re-balancing the NHS investment profiletowards primary care. Some key elements of this rationale are:

• improving services for patients and creating asustainable general practice service

• supporting sustainability across the widerhealth system. For example there have beenestimates that 10-30% of A&E attendanceshave the potential to be managed as part ofa primary care offer

• securing better value for money.

Investing in general practice capacity andcapability to deliver a higher proportion of activitycloser to home is a prime driver of servicereconfiguration in CCG five year strategic plans.

Costing the changes

The level of investment required to transformprimary care will be analysed at a local level as partof wider out-of-hospital strategies. The analysiswill take into account key factors about localhealth economies including pace of change,

available funding etc. However some analysis hasbeen undertaken to estimate the cost of providingthe new patient offer.

High level modelling suggests that in order todeliver a modern, high quality service for all, £310– £810 million (representing 2.00% – 5.36% oftotal health spend today) will need to be investedannually. This is expected to begin with a gradualshift in total health spend of 0.40% – 1.07% eachyear over five years. This shift in total healthspend has the potential to deliver a significantincrease in general practice capacity in the mediumterm. This will require changes at a local andregional level, both in terms of redirecting fundingand supporting the process for doing this (e.g.with co-commissioning).

Caution: This estimate is a very high levelcalculation for the purpose of assessing thefeasibility of the service changes.

The high level financial modelling work hasfocused on the recurrent revenue investmentrequired to provide the service specification forwhole populations with differing degrees of carecomplexity. The modelling has focused on twomain areas.

1. Delivering a new service modelSupporting clinicians to deliver more person-centred care by analysing the cost of new activities and the potential increaseand diversification of the primary care team needed.

2. Increasing patient access to primary careCreating additional appointment slots,allowing extended practice opening hours in each area including evening and weekend working.

The methodology used to create this analysis canbe seen in Appendix 1.


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Why is now the time?

The availability of funding for transformationalchange is a key requirement to enactTransforming Primary Care in London: AStrategic Commissioning Framework. There areseveral factors which mean that 2015/16 is anopportune time to start implementing thesechanges in London:

• London has received £446m recurrent growthin 2015/16 CCG allocations. This is just under£200m more than in planned 2015/16allocations announced in December 2013

• London as a whole is now approximately0.5% over target allocations

• underfunded2 CCGs, mainly in outer Londonhave received approximately £148madditional growth

• nearly half of London CCGs have received inexcess of 5% growth.

Although not all of this funding will flow directlyinto primary care, this position gives anindication of what may be possible, particularlyconsidering that:

• CCGs have committed to including deliveryof the intentions of this Framework in theirlocal plans

• co-commissioning is seen as an enabler tosupport additional funding moving intoprimary care

• additional funding is being providednationally in the form of:

– an increase of the primary care budget from 1.7% to 2.3%

– Prime Minister's Challenge funding (a further £100m nationally for 2015/16)

– primary/community care infrastructure funding of £250m recurrent for four years

– an additional transformation budget of £200m; likely to be badged for developing ‘vanguard’ sites.

Financial conclusion

Funding is undoubtedly one of the biggestchallenges to delivering the specification, andeven with the additional funding describedabove there are areas of London which havesignificant deficits or other challenges whichmake increasing funding into primary careparticularly difficult. However there is widespreadagreement that without investing in primarycare, many of the other issues cannot besustainably fixed. Therefore this investment isnecessary, and although the pace of investmentand delivery may be different in different areas ofLondon, the commitment to change must bedemonstrated with a shift in funding by allcommissioners.

2 By more than 2%


The enablers

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Contracting approach todelivering the servicespecification

The service specification for general practice canonly be delivered by general practices workingtogether at scale and with other parts of thehealth and care system. With that in mind theproposal in this Framework is that thespecification will not be funded at individualpractice level but will be delivered through a newcontract at a wider population level, offered togroupings of geographically aligned generalpractices or Multispecialty Community Providers(MCPs) (alternative options might be consideredfor individual practices that have a significantgeographical footprint and alignment with otherhealth and social care providers).

The exact contracting approach used in each place will be determined through co-commissioning arrangements, decided locally by CCGs or jointly with NHS England. This willenhance the ability of commissioners to developa tailored approach that reflects localarrangements for services. In both instances NHSEngland will assure itself that decisions, madethrough co-commissioning, support the strategicintentions in this Framework as outlined in theparagraph above.

Potential contractual forms

Contracts will be developed that incorporate theservice specification from this Framework as adistinct, scheduled and incentivised serviceinnovation and general practice collaboration.Broadly speaking, the following contractualforms are likely to be reviewed and consideredfor use in commissioning the new servicespecification for general practice:

• Alternative Provider Medical Services (APMS)

• NHS standard contract

• hybrid of the APMS and NHS StandardContract (note – this would represent a newform of contracting that would requirelegislative change).

Whatever contract form is used, it will typicallyinclude a phased transition for the primary careorganisation/provider. For example, this couldinclude a year-on-year increase to the contractvalue as well as a greater degree of risk shareand pooling of current incentives fromconstituent practices that might include:

i) complete or phased incentive sharing acrossconstituent practices with regards to Qualityand Outcomes Framework (QOF), LocalEnhanced Service (LES) and other enhancedpayments

ii) increasing the level of shared decision-making across constituent practices withregards to the specification for how currentPersonal Medical Services (PMS) investmentcontributes to delivery of the new servicespecification and specific local needs

iii) increasing the level of pooled funding acrossconstituent practices with regards to APMS,PMS and General Medical Services (GMS) forexample £x per patient is pooled torepresent the efficiencies that will be gainedfrom working collaboratively or by deliveringcurrent services in different ways.

The contracting vehicle will need to ‘wraparound’ the existing national contracts unlessconstituent practices are opting for a fullmerger/super partnership in which case they mayvoluntarily relinquish their current contract.


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Whatever the approach, it will need to providesufficient new financial incentive to increase thelevel of collaboration and joint ownership. Theexact nature of these arrangements will vary bynature of the provider landscape but theprinciple of at-scale providers increasingly sharingpooled incentives with shared responsibility andrisk for delivery will be a key marker againstwhich additional investment will be made.

Consideration will be given as to whether theaccountability for delivering the constituent GMS,PMS and APMS can be attributed to a leadprovider within an at-scale primary careorganisation. That type of change would requirenew permissions and a shift in national policy. Itcould only be undertaken on the basis thatsystems for assuring quality and patient safetycontinue to have sufficient probity and it wouldrequire changes in the approach to regulation.There is however some evidence, from TowerHamlets networks for example, that clinicalgovernance systems that are owned and reviewedacross a number of general practices by peers andlocal training leaders have greater potential tosecure improved quality and patient safety.

The contractual form chosen will need to beflexible, to allow for wider collaborations andpartnerships with other types of providers, forexample community services and the voluntarysector. This may be in the form of governancearrangements that reflect the wider partnership.In some local areas, elements of the specificationcould be commissioned alongside other servicesas a single tender. For example, one CCG hassuggested putting together the accessspecification with out of hours, 111 and otherrelated services as a single tender exercise. Inother local areas the strategic intent may be totake a single step towards a merged contractbetween general practices and the wider system

to form an accountable care organisation thatcan hold capitated budgets and shared risk for awhole population.

Many areas already have a strong ambition tobring general practice and community servicestogether over the next two years. It is howeveranticipated that most areas will be looking tocontract networks/federations of generalpractices as a starting point.

It is clear that there is not a one-size-fits-allapproach to commissioning this servicespecification and it needs to be locally developedand tailored. Any commissioning approach willfail if the provider landscape is not ready torespond and providers will need to be preparedto deliver new ‘population health’ models ofgeneral practice well ahead of thecommissioners' planning process. With that inmind, some areas of focus in this area aresuggested to be:

1. creation of a provider readiness/self-assessment tool that describes the elementscommissioners might reasonably assess inany tender exercise for at-scale generalpractice services

2. work with local commissioners to navigatethrough the options by sharing learning andcase studies. A workshop was held inDecember 2015 to examine legal advice tocommissioners on provider models andcontract forms.

3. co-develop wording/KPIs relevant to theFramework that might be adapted andembedded into future contracts.


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Workforce implications

Implementation of the service specification inthis Framework is set in the context of growingdemand for primary and community care,increasing expectations, and the changingpatterns of needs of patients with more complexand long term conditions. These demands,coupled with technological advances and theadoption of best practice across care settings,have important implications for how to developand train primary and community clinicians andthe wider workforce of the future.

General practices have historically been smallorganisations, working in relative isolation fromone another, with the exception of somenetworking for the purposes of out of hourscover and involvement in clinical commissioning.Increasingly however this is changing with therapid formation of at-scale general practiceorganisations involving closer working and insome areas changes to legal structures to enablepractices to come together. However the generalpractice workforce (including GPs and GP nurses)is under significant workload pressure with manystaff considering early retirement3. The numberof mid-career doctors (under the age of 50 years)considering leaving the profession is also rapidlyrising4. Nationally the growth in GP numbers hasnot kept pace with that of hospital consultantnumbers (per WTE)5 and boosting numbersentering GP training is proving difficult.

GPs in London are a lower proportion of thetotal workforce compared to national figures.

Ongoing planning of the future workforcerequirements will be at the heart of transformingcare. Bolstering the primary care workforce hasbeen identified as a core objective in the HealthEducation England mandate and is alsorecognised as a key priority for HEE and its LocalEducation and Training Boards. Implementing thegeneral practice specification and planning thefuture workforce requirements will requirealignment of resources to:

• manage immediate and forecastedworkforce supply shortages

• reshape existing roles through ongoingtraining, education and development

• modify core training programmes to alignwith new service needs

• develop and pilot new roles

• evaluate and research the effectiveness ofnew roles and workforce configurations

• manage expectations around the pace ofworkforce change

• develop new primary care learningenvironments that build on multidisciplinaryapproaches such as Community EducationProvider Networks (CEPNs6).

It is also key to note that a ten point plan hasbeen developed by NHS England, HEE, RCGP andthe BMA GPs committee (GPC). This plan aims toaddress immediate issues, and to take the initialsteps in building the workforce for the future andnew models of care.

3 BMA quarterly tracker survey: Current views from across the medical profession. Health Policy and Economic Research Unit, 20144 Securing the Future GP Workforce. Delivering the Mandate on GP Expansion. GP taskforce final report. March 20145 Centre for Workforce Intelligence; In-depth review of general practitioner workforce. June 20146 CEPNs: collectives or networks of primary and community organisations working collaboratively to enhance educational delivery in local geographical contexts


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There are three key strands to this work:

• improving recruitment into general practice

• retaining doctors within general practice

• supporting those who wish to return togeneral practice.

The ten point plan is summarised below:

1. A marketing campaign including a letter toall newly qualified doctors setting outpositive aspects and future careers in generalpractice

2. Offering GP trainees an additional ‘flexible’year of training where they can train in aspecial interest, get an MBA in leadershipskills or another academic pursuit

3. Setting up ‘training hubs’ for GP practicestaff to extend their skills

4. A time-limited incentive scheme for GPtrainees committing to work in an under-doctored area for at least three years,including financial support

5. Reviewing current retainer schemes andinvesting in a new national scheme

6. Offer premises funding to training practicesfocused on the agenda of transferring careinto community settings

7. Reviewing how to incentivise experiencedGPs to remain in practice, for example via a funded mentorship scheme or offerportfolio careers

8. Piloting new general practice support staff totake workload off GPs, such as physicianassociates, medical assistants, clinicalpharmacists and advanced practitioners(including nursing staff)

9. Making it easier to return to practice after working overseas or taking a careerbreak, via a new clearer induction andreturner scheme

10. Offering financial incentives to returnersopting to work in under-doctored areas andreviewing the value of the performers' list inits current form.

It is expected that implementation of this planwill be a useful support to delivering the ambitionoutlined in this chapter.

Addressing the workforce challenges

Implementation of the service specification in thisFramework will require practices to offer anextended scope of services; more convenientopening times; personalised care; and anongoing development of access options to matchthe needs of the population. Practices of all sizeswill be faced with the challenge of how to:

• configure the workforce to ensure safepractice, ongoing training and developmentwhilst maintaining continuity of care; andharness the potential of temporary andlocum staffing

• expand flexible working arrangements

• prevent professional isolation

• ensure staff are up to date on evidence-based practices, treatment developments,changes in medicines use, technologicaladvances etc

• efficiently manage workforce demands while ensuring the team has time fororganisational development, service redesignand quality improvement.


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The future health service will see more person-centredsystems of care and less division between primary,secondary, community, voluntary and social careorganisations. The developments to commission thefuture workforce for general practice will beundertaken in the context of overall professionalclinical training and increasing multidisciplinaryworking across organisational boundaries.

Governance arrangements will need to be developedto support the increasing numbers of staff that will bein training, on placement and working independentlyoutside hospital, and in community settings.Delivering integrated primary care usingmultidisciplinary models of working in communitysettings will require new approaches to safeguarding;to support safe clinical practice whilst ensuring staffare supported to continually learn and develop.

How roles and teams fit together in deliveringfuture care still needs to be determined anddifferent roles and responsibilities are likely to evolvein each local area as the specification is implemented.Broadly it is anticipated that the roles detailedbelow will be required:

• within each practice: GPs, practice nurses, GPnurse practitioners/nurse prescribers, volunteers,receptionists, managers, health care assistants and may also include physician associates

• aligned to each practice but working across a wider geography/at-scale primary careorganisations: prescribing advisors, GPs with aspecial interest (GPSIs), care coordinators,wellbeing teams, and ‘super practicemanagers/directors’ with sufficient skill to lead the development and operational management of at-scale primary care organisations

• as part of, for example, a widerMultispeciality Community Provider (MCP):secondary care specialists, social care, mentalhealth and community services teams, community pharmacy.

A number of extended roles are appearing in the general practice setting enabling the delivery of high quality care, improved patient experience andimproved clinical outcomes. These are additional to what is now considered a core team of GPs, practice nurses and GP nurse practitioners,managers and reception staff. A few examples areprovided below to illustrate the functions these new roles are performing and how they aresupporting new ways of working both withingeneral practice and across a wider care team.

• Healthcare assistants (HCA)/clinicalassistants: provide clinical support for GPs to enable them to allocate more time forpatients with complex problems.

• Health and wellbeing coordinators:enable patients to maintain their health andwellbeing and improve self-management oftheir condition.

• Physician associates: work to the medicalmodel in the diagnosis and management ofconditions in general practice and hospitalsettings, with the supervision of medicalpractitioners.

• Care coordinators/navigators: provide acentral coordination role on behalf of thepatient, working with their wider care teamcovering health, social care, voluntary and other local services.

For example, the National Association of PrimaryCare has joined forces with HEE to create a trainingprogramme for new Primary Care Navigators (PCN)to support patients with dementia, their carers andfamilies. It is intended that this training willeventually be adapted and used for other long term conditions.


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Basic clinical checks and tests inclupdating clinical records

Input to diagnosis and treatment planning

Refer to secondary care (incl A&E)

Focuses on acute conditions

Supports patients with long termconditions

Broader assessment of patients’ ownhealth goals

Care plan facilitation

Self-management support

Health coaching

Establishing referral pathways topreventative and wellbeing services andactivities

Multi-agency working

Directs patients to additional sources ofsupport and care – health, social care,voluntary sector

Reports primarily to the named GP –largely practice employed

Reports to the named GP and a wider MDT– largely non practice-based / employed

HCA/clinicalassistant

4

4

4

4

4

4

4

4

4

Health andwellbeingCoordinator

4

4

4

4

4

4

4

4

Physicianassociates

4

4

4

4

4

4

4

4

4

4

Carecoordinator/navigator

4

4

4

4

4

4

4

4

The table below examines some of these roles and the functions they perform.

Function Role


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7 Skills for care. Principles for Workforce Integration. 20138 Health Education England: Consultation on the role of bands 1-4. March – April 20149 The Cavendish Report. An Independent Review into Healthcare Assistants and Support Workers in the NHS and Social Care Settings. 201310 Greenaway, D., Shape of Training: Securing the future of excellent patient care. An independent review of the way we educate and train our doctors. 2013

Planning the future workforce requirement isalways challenging and many organisations,institutions and professional bodies areattempting to do this as they develop their long-term plans. Especially important are HEE and theLETBs which are working with patients, carers andother key stakeholders to explore the workforcechallenges and find ways of meeting thesechallenges7,8,9,10. Sharing and utilising existinglearning will be pivotal as prototype delivery andeducation models are being developed andtested across the capital as part of:

• integration pioneer sites

• Prime Minister's Challenge Fund sites

• LETB development programmes

• Academic Health Science Network (AHSN)primary care development work streams

• Community Education Provider Networks(CEPNs).

In addition, specific LETBs are taking forwardprogrammes to support and enable the workforce.

Health Education North West London(HENWL)

Health Education North West London hasinvested funds to support all staff working ingeneral practice to access continuousprofessional development courses which areblock commissioned from Higher EducationInstitutes (HEI). £100,000 has been invested sofar for 2014/15 and further funds will be addedif demand exceeds this figure. The HENWL boardhas also funded £1.1 million workforce

development activity for primary care for2014/15, distributed via the CCGs to support theworkforce transformation and developmentactivity required to enable GP teams to cope withgreater levels of demand and complexity as partof the wider system reconfiguration.

A further £1 million has been invested throughthe Shaping A Healthier Future programme tosupport the development of community learningnetworks which will be aligned to the wholesystems programme in north west London(beginning with initiatives relating to the over75s population).

As part of the planning work to inform theShaping a Healthier Future service transformationprogramme, north west London’s CCGscommissioned a piece of work called From Goodto Great, a workforce strategy to support out-of-hospital care in north west London which waspublished in January 2013. The documentexplores the need for innovative new roles andhas been used to shape some of the thinkingabout demand for new roles in the future northwest London health system.

Following the 2014 workforce and educationplanning activity, it has been recognised thatwhilst overall demand for staff groups isreflective of the overall transformationprogramme, the detailed analysis of specific newroles and changes to skill mix are not clear.

HENWL has initiated a series of task and finishgroups in 2014 to focus on the requirement fornew and different roles to inform workforcedevelopment, investment, and future educationcommissioning decisions. Primary care will be akey focus within this.


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Health Education South London (HESL)

Health Education South London’s approach tothe ongoing development of the primary careworkforce is twofold, encompassing a short- andlong-term view. In the short term, HESL hasmade a direct Continuing Personal andProfessional Development (CPPD) allocation of£1.2 million available for staff working in primarycare in both 2013/14 and 2014/15 (a total of£2.4 million over two years). This money hasbeen distributed to CCGs based on weightedcapitation. HESL’s Primary Care Forum (PCF)which acts as the advisory group to the HESLBoard on matters relating to primary care,recommended that CCGs focus the CPPD moneyon bands 1-4, practice reception staff, healthcareassistants working in primary care, practicemanagers and practice nurses. The PCF alsonoted that the funding could be used for clinicalstaff where no other allocation was available. Inaddition to the direct allocation made to CCGs,an indirect allocation of £400,000 was lodgedwith south London HEIs for practice staff toaccess. In 2014/15 this indirect allocation wasoverspent for the first time. In the future, theintention is for the CPPD budget for primary carestaff to be allocated to the CEPNs rather thanthe CCGs and for the CEPNs to coordinate theongoing development needs of their localworkforce. The above funding allocations weremade in addition to funding for general practicenurse training and mentorship training for nursesworking in primary care.

Health Education North Central and EastLondon (HE NCEL)

A key priority for Health Education North Centraland East London is to support the development ofintegrated care, especially across organisational

boundaries. Local health economies have beeninvited to bid for up to £250,000 per borough to support education and training interventionsthat support integrated care based education. This has resulted in significant conversations and partnership arrangements that havepreviously not been possible. HE NCEL hasengaged primary, community, secondary andsocial care providers in working together onworkforce development opportunities. By the end of 2014, there will be a multi professionaleducator-led CEPN with cross- boundaryengagement in every borough across HE NCEL. It is anticipated that as these CEPNs mature theywill support local workforce planning, programmecoordination, faculty development, localworkforce continuing professional development,and achievement of relevant HEE mandates. It ishoped CEPNs they will be able to support bothfuture and current workforce development.

The development of CEPNs is being supportedthrough infrastructure funds and peer groupsupport and is linked to a broader movementtaking place across all three LETBs in London andKent, Surrey and Sussex11.

• Additional funding is likely to be provided tosupport apprenticeships in primary care(including both general practice andcommunity pharmacy).

• A number of projects cross organisationalboundaries and have a general practiceelement. For example, the mental healthprogramme, which has included a successfulproject to train practice nurses in thefoundations of mental health; and thedementia project, which trained over 13,000staff last year in dementia awareness(including many in primary care) and willachieve the same in 2014/15.

11 www.radcliffehealth.com/community-based-education-providers-network-opportunity-unleash-potential-innovation-primary-care


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• Leadership development programmes havebeen commissioned for the broad primarycare workforce from the London LeadershipDelivery Partnership as well as the FlorenceNightingale Nursing Programme. Theprogrammes have been offered to thenetwork of general practice nurses andnurses sitting on governing bodies in northcentral London.

A number of initiatives are already in place todeliver prototype education and delivery models;for example CEPNs, which are being developedand tested as collectives or networks of primaryand community organisations workingcollaboratively to enhance educational delivery inlocal geographical contexts. The LETBs believethat the CEPNs offer an unprecedentedopportunity for the development of the primarycare workforce including the development of newroles where appropriate. By understanding boththe local population and the existing workforcewithin their geographic areas CEPNs will be ableto ascertain the development needs of existingstaff and be able to identify the future workforcerequired to deliver on CCG commissioningintentions. This may include new roles such ascare navigators or the use of physician associatesin general practice depending on local need.

CEPNs are being used as the mechanism to bringworkstreams together within a definedgeography. Their work currently includes:

• developing, testing and evaluating new roles– with higher education provider involvement

• drawing together feedback from localstakeholders. Understanding futurerequirements in relation to preparation,supply and development of the primary care workforce

• exploring how to increase undergraduateand foundation placements for doctors topromote positive experiences of primary careand encourage choice of general practice asa career

• exploring ways to provide inter-professionallearning opportunities in community settings.

CEPN development must include the fostering oflearning organisations in primary and communitycare. Currently LETBs accredit GP practices fortraining, and HEIs accredit practices andcommunity providers for nurse andundergraduate medical teaching. Other AHPs aretrained in a variety of community placements.However the transformation of primary careservice delivery requires a transformation inprimary care education and training facilities.

In the same way that hospitals educatemultidisciplinary teams, all primary care andcommunity care providers could becomeeducation providers. CEPNs will be well placed todrive this necessary development as botheducation managers and education providers totheir local professionals, commissioned by LETBs.

It is now important for partners associated with workforce development in London tocollaborate to ensure a coordinated approach.This will include:

• working together to analyse futureworkforce requirements in London

• working to improve the recruitment andretention of clinical staff

• developing working practices to support thedelivery of person-centred integrated care

• representing London’s priorities on nationalworkforce initiatives.


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Technology implications

Technology and digital health care provision willplay an increasingly significant role in generalpractice service delivery, and will be a key enabler indelivering the service specification for proactive,accessible and coordinated care. There is already a considerable spectrum of useful technologiesimplemented or being implemented across thecapital such as those outlined in the NationalInformation Board publication Personalised Healthand Care 2020, as well as being referred to inBetter Health for London and the Five Year ForwardView. Currently, the uptake of the availabletechnology is varied and existing arrangements forinformation sharing are limited.

In order to best address the needs described in thisdocument, there should be a focus on maximisingthe use of the technology available; empoweringthe patient, and ensuring that there isinteroperability between systems and acrossproviders. This is being addressed as part of the response to Better Health for London (see‘Technology strategies’ section below). Primary careteams in the future will need to rely less on co-location, but instead will be able to come togethervirtually around a patient to design services. Thisdoes not need to be using the same type oftechnology, but ensuring that communication canoccur seamlessly across systems will improveteamwork and the patient experience.

People should be empowered with informationabout their care that supports them to participatein care planning; helps set personal health goals;and enables them to better manage their ownhealth independently.

New advances in digital healthcare will providepatients with more choice about how they access services and what they access. This willrequire active promotion of the new accessapproaches available.

Technology to enable proactive care

Proactive care services will be best enabled by theintegration of general practice systems with othersystems and applications sitting outside ofgeneral practice:

• online wellbeing assessments that identifylifestyle risks and enable people to establishpersonal goals for staying healthy

• online resources to support healthimprovement e.g. apps and informationservices

• online communities that enable people tolearn and care for each other based on similarexperiences of living with, and managingphysical, social and psychological challenges.

Existing systems can be used to identify peoplenot making best use of healthcare resources and to reach out to those people not accessingcare. Systems can also be enhanced to trackpatient reported symptoms and investigations,highlighting those at greater risk of, for example, cancer.


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Technology to enable access

Providing improved access will require allpractices in London to make use of the systemsin place for online appointment booking,ordering of repeat prescriptions and givingpeople access to their care records. These will beprovided through a single place for all Londonersvia ‘Patients Online’. The evidence on theeffectiveness of phone and email appointmentsis still relatively limited; however in this digitalage they are expected to become the norm andare already provided in many practices inLondon. Video conferencing may also becomemore commonplace. Other new systems alreadyin operation in some parts of London, that arelikely to become more widespread include:

• telephone triage and email appointmentsystems

• summary care records.

Technology to modernise care

In addition to the technologies that will enabledelivery of the service specification, there aremany other examples of new technologies thatare modernising care in general practice settings.Just a few examples include:

• online communities of practitioners, buildingrelationships and sharing knowledge todeliver improved care

• remote monitoring and diagnostic devices,enabling patients to be cared for in thecomfort of their own home; and new devicesbringing hospital-based diagnostics into thegeneral practitioner’s consulting room

• hand-held care record devices that allowpractitioners to bring care away from thecomputer and alongside the patient andother practitioners

• electronic prescribing service

• e-referral service.

Technology to enable care coordination

Coordinating care requires timely informationexchange, across a multidisciplinary team, withpatients and their carers. This will require generalpractice to have interoperable systems with otherproviders to enable shared management ofpatient information through an integratedpatient-held care record.

Technology strategies

The importance of technology across the wholeNHS has been supported by several nationalpublications (such as Personalised Health andCare 2020).

Additionally, as part of the response to BetterHealth for London, one of the programmes whichis being mobilised is about ‘business intelligenceand interoperability’. This programme aims to:

• support digitalisation of primary care e.g.with electronic referrals and enhancedinformation exchange

• establish standards for interoperability toexchange information across all healthcareservice providers (such as GPs and health andsocial care providers). This is expected toenhance the patient experience throughoutthe London healthcare system


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51

• support delivery of a paperless NHS

• facilitate the extraction and analysis of datato support and build on ‘businessintelligence’ of CCGs

• support efforts for sharing learning and best practice.

The programme will be used as a delivery enginefor many of the technology elements required forthis Framework, alongside local technologystrategies and other programmes such as theambitious plans of the National Information Boarddescribed in Personalised Health and Care 2020,which lays out a timeline of technologyimprovements from now to 2020 (see below).

Additionally, proliferation of best practice intechnologies will also be encouraged through theInnovation Group for Primary Care Leaders inLondon (see ‘Innovation and Improvement’section), and the CQC.

Technology will be critical in ensuring that primarycare in London is modern and fit for purpose. It isimportant to consider how technology can helpwith each element of the patient interaction withprimary care; from having sufficient phone lines toreceive calls to book an appointment, to havingsystems which are interoperable with secondarycare and specialists to ensure patients cansmoothly transition out, and back into, primarycare. It will therefore remain a key area of focusthroughout implementation.

By March 2015proposals willhave been setout to extendand enhance theMyNHS serviceon NHS Choices.

By June 2015the HSCIC will developproposals withindustry forpersonal datausage reporting.

By April 2016HEE will introducea new knowledgeand skillsframework for all levels of thehealth, care andsocial careworkforce.

By 2018clinicians in primarycare and other keytransitions will beoperating withoutthe use of paperrecords.

From March 2018all individuals will beable to record theirown comments andpreferences on theircare record.

By 2020all carerecords willbe digitalreal-time andinteroperable.

From March 2015all citizens to haveaccess to their GPrecords online.

From April 2015mandatory use ofNHS number asprimary identifier in clinicalcorrespondence andfor identifying allpatient activity.

By September2015 proposalsto be publishedfor linking 111with NHSChoices.

By October 2015HSCIC, CQC,Monitor and NHSTDA to publish data qualitystandards for allNHS care providers.

Overview Timeline of NIB Framework Milestones


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Estates

The quality of the general practice estate is highlyvariable and there is a real challenge to improve it.A poor estate means poorer patient experiences,poor working conditions for London GPs and lostopportunities to improve health and healthcare. Inorder to deliver the Framework, it is expected thatmodern, state of the art facilities will be required.It is likely that general practice will need totransition out of the existing estate gradually asinvestment is made in more modern buildings.

London’s GP practices are largely found inconverted residential buildings – many are in poorcondition. Many parts of the estate are not fit forthe purpose and are underutilised. Better Healthfor London reported that 34% of premises need tobe rebuilt and 44% are in need of repair. Often,even the most basic disabled access requirementsare not in place. There are two main causes for thisstate of affairs: insufficient investment andfragmented decision making on primary and out-of-hospital estate; and a lack of incentives for GPsto move from existing residential conversions tomodern purpose-built facilities.

Investment in estates

Better Health for London set out thatapproximately £1 billion needs to be invested inthe GP estate in London. Spread over severalyears, this scale of investment would representaround 4% of the national NHS capital budget.

In January 2015, the first phase of infrastructurefunding from the Five Year Forward View wasannounced; £250 million of available funding forestates changes. The expectation is that the £1billion will be made available over the next fouryears. London will continue to work with thenational team to influence the way that thisfunding is bid for and distributed.

Supporting primary care estateimprovements

As part of the response to Better Health forLondon, London CCGs and NHS England(London) are discussing estates transformation,with the aim of:

• supporting robust estates planning acrossLondon to ensure high quality NHS estatethat meets agreed standards and disabilityaccess requirements

• developing a system that incentivises efficientand effective use of capital assets

• delivering general practice in modernpurpose-built/designed facilities

• consolidating unused and underutilisedestates and developing a planned programmeof disposal/transfer of properties to build aninvestment fund for local priorities

• aligning both the core NHS capitalprogramme/funding/process and the newnational transformation fund for disposal,transfer and flexing of existing estate.

Some of the key objectives are to both simplifyestates processes, and enable further strategicestates planning to be carried out locally.Working across CCGs, with the Greater LondonAuthority (GLA), NHS Property Services and otherpartners, it is expected that the process fordecisions and actions will be simplified which willimprove the quality of general practice estatesthroughout London.


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Provider developmentrequirements

GP provider development is fundamental to thesuccess of primary care transformation in Londonand the implementation of the Framework. Thestrategic direction is ambitious, and theoperational changes, working routines andlearning needs are significant.

General practice teams and their health and carepartners need to be supported in owning the newvision for primary care and be clear about thebenefits it will deliver. This will require focusedsupport and interventions so that general practiceteams can co-develop solutions to the newoperational requirements. There will be manyattributes and behaviours to nurture in generalpractice, but the roles of effective leadership andcollaboration are fundamental. Development andsupport programmes and activities should beflexible, tailored and provide practical support to arange of professionals across general practices.

The intra- and inter-organisational developmentneeds should not be underestimated, to ensurechange happens.

The following diagram, provided by South WestLondon Collaborative Commissioning, identifies GPprovider development requirements.

There is not a natural forum in London to bringtogether and support system change leaders totransform primary care. London would benefitgreatly from an agreed forum for commissioners,providers and lead partners such as local authoritiesand the voluntary sector to share innovation andlearning about transforming primary care.

London’s NHS should set out a strategic andcomprehensive approach to building systemcapacity and capability for change, in partnershipwith London and national partners. This shouldinclude a phased plan mapped to a developmentjourney of emerging organisations which canrespond to their evolving development needsover time.

Potential GP provider development requirements

Individuals• Leadership for change• Project management• Peer support and buddying• Supporting portfolio careers• Secondments• Mentoring and coaching• Integrated working – care planning and case management• Academia and research• Undergraduate teaching and GP training

Inter-organisational Intra-organisational

• Intra-organisational development• IT training and informatics• Fostering innovation• Commercial awareness and development• Collaborative working• Decision support

• Workforce capacity development and management• Strategic planning• Legal support / contracting• Quality improvement methodology• Consultancy support• Developing commissioning / procurement / commercial acumen• Governance• Inter-organisational development for networked leadership

• Workforce planning• Modelling, forecasting and evidence-based decision making• Overarching governance and accountability framework• Building relationships with secondary care, mental health

services, voluntary sector• Health promotion and prevention service / role development• Inter-organisational development across the full range of

health and social care organisations

System support

GP practice provider

development


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Monitoring and evaluation

Providers and commissioners will be able to demonstrate progress across the capital at a pan-Londonlevel through an approach that encompasses:

Evaluationand learning

QualityImprovement

HeadlineIndicators

• An evaluation and learning partner will becommissioned for London

• Reporting key findings and supporting systemwidelearning and transforming primary care

• Collaboration with CQC to identify learning needs

• Identifying case study examples of effective QI andhow to spread learning

• Establish development opportunities to improve QI capability

• Small number of measures similar to those used toevaluate the Prime Minister’s Challenge Fund

• Patient/staff satisfaction, system impact, clinicaloutcomes, registered change in the service offer,investment profile

The information gathered for use as headlineindicators will have a dual use for both providersand commissioners and will form the basis of aself-assessment.

The approach will encourage progression towardsat-scale primary care organisations (in theirvarious forms). The Framework will monitorimprovements at both individual practice and atgrouped practice/wider population levels. Thisapproach to monitoring and evaluation worksupports integrated care and practices workingtogether on quality improvement at a populationlevel. The direct impact that general practicedevelopments have on population health andwider system activity are difficult to isolate from

wider system changes. It is therefore important,in developing co-commissioning arrangements,to look towards monitoring the impact of wholesystems on population health outcomes (this willbe complemented by the work of the CQC in thisarea) as well as patient enablement and person-centred care and changes in overall activity.

Sources of information

General practices in London are already subjectto considerable monitoring and assurancecontrols. The approach taken will use existingdatasets and collection processes in order tominimise additional administrative burden on


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practices. Information will be drawn from CQCassessments, GP outcome standards, high levelindicators, QOF and the national GP patientexperience survey; forming a picture of progressto deliver the new service specification. Inaddition the following will be considered:

• An extension of the annual self-declaration used by practices to provideassurance of contractual delivery. This would include an appraisal of progress todeliver the new service specification (unlessa suitable alternative approach is availablethrough CQC).

• A small number of ‘proxy markers’ identified from existing data sets thatprovide additional assurance thatimprovements are having an impact. Theseact as a signal to undertake further enquiryand evaluation where measures areinconsistent with information providedthrough self-declarations.

• Refreshed national GP Patient ExperienceSurvey to reflect changes in the patient offer(the national team is considering ways inwhich the survey can reflect different modelsof care across the country).

• A new survey of working lives to monitor theimpact of these changes on staff.

The self-assessment tool

As described above, the annual self-declarationcould be extended to include an online self-assessment tool. This would form the basis of aself-appraisal that could be undertaken bygeneral practice teams, assured by people

working with each practice and shared as a toolfor enhanced development. The self-assessmenttool will be designed in collaboration withvarious stakeholders in order to ensure thisprovides an appropriate reflection of progressand outcomes. The business intelligence team atNHS England (London) will establish amonitoring and evaluation working group inorder to ensure this work continues to alignwith, and not duplicate, the approach beingundertaken by the CQC. An updated CQCassessment framework was published in October2014. The design group will review this and mayconclude that the CQC evaluation is sufficientlycomprehensive and that a new self-assessmenttool is not required. The working group isfinalising this approach and will have headlineindicators in place for quarter 1 of 2015/16. Anevaluation partner will be appointed and qualityimprovement work will be ready for a showcaseevent in May 2015.

Keeping Londoners informed of service changes

NHS Choices provides patients with a singleonline portal through which they can accessinformation about services provided throughgeneral practice. Patients will be keen to knowwhether services are improving in their local areaand what service changes are being planned,including any changes to access arrangements.NHS England (London) and CCGs working withlocal providers will need to ensure any servicechanges are well communicated and explainedthrough both NHS Choices and other methods.


The enablers

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Innovation and improvement

Members of the Clinical Board for Primary CareTransformation in London have considered deeplyhow the general practice change effort can beled and sustained by providers.

It is important that systems and processes are inplace to deliver the enabling changes e.g.contracts, incentives, technology. However, thereis widespread recognition that there must beprovider driven change as well, and that this willnot come from a top-down managed process orthrough a hierarchical leadership model. It isessential to ensure that there is focus on thedevelopment of transformational leadershipcapacity and capability supported by building achange platform for innovation and improvementto proliferate learning in a more dynamic way.

The current Clinical Board will therefore bedisbanded in April 2015 and in its place anetwork will emerge, supported by a central‘Innovation group for primary care leaders inLondon’ jointly led by Dr Clare Gerada and DrMarc Rowland. This Innovation Group will bemultidisciplinary, and will aim to:

• support the design and development of thenetwork, its workshops and learning events

• create strategic partnerships with others thatare supporting primary care leadershipdevelopment, improvement and innovatione.g. RCGP, Londonwide LMCs, NHS ImprovingQuality, and Improvement Science London

• enable closer working with AHSNs andprogrammes such as Collaboration forLeadership in Applied Health Research andCare (CLAHRC) to bring the rigor of academicresearch and evaluation alongside networksfor learning, development and improvement.

‘Champions for change’ from every part of Londonwill be brought together to identify the significantcommon challenges to delivering this Frameworkand share these across a wider network togenerate solutions across London. Champions willbe general practice provider innovators andentrepreneurs already implementing elements ofthis Framework and will be matched withchampions from a range of disciplines. Championswill receive development support as changeleaders and will be testing new ideas anddisseminating good practice in each locality.

The wider network will cut across traditionalorganisation boundaries and bring togetherprofessionals and individuals with a commoninterest such as practice nurses, communitypharmacists, people interested in improvingtraining together or proactive care. The networkwill build on established structures to connectemerging leaders e.g. Darzi fellows, managementtrainees, and academic fellows. Within thenetwork, events, learning sets and forums will beprovided for exchanging ideas.

The vision for this change platform isdemonstrated in the diagram below:

Onlinecommunity

Network (widervirtual network)

Champions for Change

InnovationGroup

Partners


Implementation of the Strategic Commissioning Framework

Implementation of the Strategic Commissioning Framework

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This Framework outlines a specification forgeneral practice which aims to transform primarycare. It also provides an analysis of thesupporting work required to do this.

It is by definition a framework, as its purpose isto provide guidance for commissioners whenmaking strategic plans and decisions on primarycare, and it outlines how the vision of atransformed service can be achieved. TheFramework represents a new consistent patientoffer for all Londoners. However this documentis not intended to provide the solution for howthese changes are delivered throughout London,as local plans are expected to be built on top ofthis foundation. Plans for 2015/16 are currentlybeing finalised, and there will be rolling updatesto strategies and plans which will build on whathas been delivered each year.

Investment and development of primary caretransformation as described in this document isexpected to start from April 2015. Althoughelements of the specification are already beingdelivered in some parts of London, in order torealise the vision of high quality general practicefor everyone, it will require a long termcommitment and a consensus of allcommissioners of health and care in London to work together.


Appendix 1: Financial modelling methodology

Appendix 1: Financial modelling methodology

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In developing the financial hypothesis for thefunding needed to deliver the envisaged primarycare, a methodology was used to estimate theadditional cost of delivery of the totalspecification as compared with current spend.

a) Calculating the additional cost ofdelivering the coordinated and proactivespecification. The methodology is based ona differentiation of patients at different levelsof need (i.e. some patients will require highfrequency and longer appointments becausethey have more complex care needs, somemay only require a quick consultation) andthe requirements for involvement of differentmembers of the practice team. Cliniciansthen provided estimates based on clinicalcomplexity categories and the complexitybandings associated with patients ondifferent disease registers of the frequency,amount of time, and the member of theclinical team who would be required to treateach type. These figures were then adjustedto account for their relative proportion of thepopulation (e.g. approximately 80.3% of thepopulation are ‘mostly healthy’ and not onthe disease registers). This allowed an overallcost to be estimated.

b) Calculating the additional cost ofincreasing patient access to generalpractice. There is a direct cost increaserelating to additional opening hours.Extending the opening hours will result inadditional workforce and non-pay costs. Twomethods of estimating this additional costare described below:

• Methodology A: calculating the cost ofincreased demand based on redirection ofexisting A&E minors

• Methodology B: The cost of increased accessbased on theoretical current estates capacity.

See below for high level costs calculated throughthese methodologies.

Cost Type

Cost of delivering a new patient offer(excluding access)

Cost of delivering betteraccess. (Methodology A,low end of range)

Cost of delivering betteraccess. (Methodology B,high end of range)

Total Cost Estimate

Annual Cost (£m)

250 – 300

607

510

310 – 810

Summing these methodologies demonstratesthat a range of between £310 – £810 millionpotential investment will be needed in primarycare in London depending on the approach.

In addition to this, transitional funding will be required in the first few years to invest in the infrastructure and transition oforganisations to these new ways of working.


Appendix 2: Team and governance board members


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Primary Care Transformation Team:

• Denise Bailey, Primary Care Transformation Programme Team, NHS England (London Region)• Keziah Bowers, Primary Care Transformation Programme Team, NHS England (London Region)• Denis Cremin, Deputy Head of Commissioning System Development, NHS England (London Region)• Heleno Ferraz, Primary Care Transformation Programme Manager, NHS England (London Region)• Jemma Gilbert, Head of Primary Care Transformation, NHS England (London Region)• David Groom, Primary Care Transformation Programme Manager, NHS England (London Region)• Georgie Herskovits, Primary Care Transformation Programme Manager, NHS England (London Region)• Lucy Laycock, Primary Care Transformation Programme Team, NHS England (London Region)• Paul Roche, Primary Care Transformation Programme Director, NHS England (London)• Christina Windle, Primary Care Transformation Programme Team, NHS England (London Region)

The below lists indicate the membership of the Primary Care Transformation Board, Patient Board, ClinicalBoard and Delivery Group as of February 2014.

Our thanks go out to all board members, past and present. Thank you also to the Primary CareTransformation team, NHS England for supporting these boards.

Primary Care Transformation Board:

• Dr Anne Rainsberry (Co-Chair), Regional Director, NHS England (London Region)• Dr Marc Rowland (Co-Chair), Chair of the London Clinical Commissioning Council; Chair, Lewisham Clinical

Commissioning Group

• Dr Sanjiv Ahluwalia, Primary Care Lead, Health Education North Central and East London• Shahed Ahmed, Director of Public Health, London Borough of Enfield• Ronke Akerele, Director of Programmes, Change and Performance Management, Imperial College Health Partners• Caroline Alexander, Chief Nurse, Nursing Directorate, NHS England (London Region)• Jane Barnacle, Director of Patients and Information, NHS England (London Region)• Paul Bennett, Area Director, North Central and East London, NHS England (London Region)• Alison Blair, Chief Officer, NHS Islington Clinical Commissioning Group• Andrew Bland, Chief Officer, NHS Southwark Clinical Commissioning Group• Eleanor Brown, Chief Officer, NHS Merton Clinical Commissioning Group• Dr Adrian Bull, Managing Director, Academic Health Science Network, Imperial College Health Partners• Helen Bullers, Director of HR and OD, NHS England (London Region)• Conor Burke, Chief Officer, Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups• Helen Cameron, Director of Transformation, NHS England (London Region)• Dr Nav Chana, Chair of the Proactive Care Expert Panel; Chairman NAPC; Joint Director of Education Quality for • Sir Cyril Chantler, Board Member, London Health Board• Jane Clegg, Director of Nursing, NHS England (London Region); Co-Chair, Primary Care Transformation Patient Board• Karen Clinton, Head of Primary Care Commissioning (NW London), NHS England (London Region)• Dr Tom Coffey, Chair of the Accessible Care Expert Panel; Co-Clinical Lead for Urgent and Emergency Care,

London Region

Special thanks go to the Primary Care Transformation Team for their significant contribution to thedevelopment of this Framework.



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• Ged Curran, Chief Executive Merton Council; London Chief Executive Lead on Adult Services• Dr Charlie Davie, Director, Academic Health Science Network, UCL Partners• Dr Michelle Drage, Chief Executive, Londonwide Local Medical Committee• Dr Clare Etherington, Head of Primary Care Education and Training, Health Education North West London• Sir Sam Everington, GP; Chair, NHS Tower Hamlets Clinical Commissioning Group• Andrew Eyres, Chair of London Chief Officers Group; Chief Officer, NHS Lambeth Clinical Commissioning Group• Professor Sir David Fish, Academic Health Science Network, UCL Partners• Professor Chris Fowler, Managing Director, Health Education North Central and East London• Dr Clare Gerada, Clinical Chair, Primary Care Transformation, NHS England (London Region)• Jemma Gilbert, Head of Primary Care Transformation, NHS England (London Region)• Steve Gilvin, Chief Officer, NHS Newham Clinical Commissioning Group• Claire Goodchild, Chief Officer, London Health Board• Professor Howard Freeman, Previous Chair, London Clinical Commissioning Council• Terry Huff, Chief Officer, NHS Waltham Forest Clinical Commissioning Group• Aurea Jones, Director of Workforce, Health Education South London• Zoe Lelliott, Director of Strategy and Performance, Health Innovation Network, South London• Paula Lloyd-Knight, Head of Patient and Public Voice, NHS England (London Region)• Dr Andy Mitchell, Medical Director, Medical Directorate, NHS England (London Region)• Dr Kanesh Rajani, London GP; Governing Body Member, NHS Harrow Clinical Commissioning Group

Health Education South London• Neil Roberts, Head of Primary Care Commissioning (North Central and East London) NHS England (London Region)• Paul Roche, Programme Director, Primary Care Transformation, NHS England (London Region)• Dr Rebecca Rosen, Chair of the Coordinated Care Expert Panel; GP Board Member, NHS Greenwich Clinical

Commissioning Group; Senior Fellow Nuffield Trust• Stuart Saw, Head of Financial Strategy, NHS England (London Region)• Thirza Sawtell, Director of Strategy and Transformation, NHS North West London Collaboration of Clinical • Grainne Siggins, Director, Adults Social Care, London Borough of Newham• Barry Silverman, Patient Representative• David Slegg, Director of Finance, NHS England (London Region)• Dr Chris Streather, Managing Director, Academic Health Science Network, South London• David Sturgeon, Head of Primary Care Commissioning (South London), NHS England (London Region)

Commissioning Groups• Michael Vidal, Co-Chair Primary Care Transformation Patient Board• Simon Weldon, Director of Operations and Delivery, NHS England (London Region)• Dawn Wakeling, Director, Adults and Community, London Borough of Barnet

Primary Care Transformation Patient Board:

Jane Clegg (Co-Chair), Director of Nursing, NHS England (London Region)Michael Vidal (Co-Chair), Patient Representative

• Helia Evans, Patient Representative• David Groom, Primary Care Transformation Team, NHS England (London Region)• Nida Hafiz, Patient Representative• Maurice Hoffman, Patient Representative• Norman Keen, Patient Representative• Bernadette Lee, Patient Representative



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• Normondary Quille, Patient Representative• Asmina Remtulla, Patient Representative• Barry Silverman, Patient Representative• Nanette Spain, Patient Representative• Natalie Teich, Patient Representative• Derek Thimbleby, Patient Representative

Please note: only the names of Patient Board members who wished to include their name have been listed here,others are not listed to protect their privacy.

Primary Care Transformation Clinical Board1

Members who also attend the Transformation Board are not listed here

• Dr Clare Gerada (Chair), Clinical Chair, Primary Care Transformation, NHS England (London)

• Sheila Adam, Chief Nurse and Director of Governance, Honorary Professor of Nursing Leadership, Homerton University Hospital NHS Foundation Trust

• Keziah Bowers, Project Officer, Primary Care Transformation, NHS England (London Region)• Eileen Bryant, Nursing Advisor, NHS England (London Region)• Tony Carson, Pharmacy Advisor, NHS England (London Region)• Jane Clegg, Director of Nursing, NHS England (London Region); Co-Chair, Primary Care Transformation Patient Board• Sarah Didymus, Independent Nurse Practitioner; Darzi Fellow in Community Nursing• Dr Murray Ellender, Liberty Bridge Road Practice, Newham• Dr Angelo Fernandes, Assistant Clinical Chair, NHS Croydon Clinical Commissioning Group• David Finch, Medical Director (NW), NHS England (London Region)• Dr Jane Fryer, Medical Director (South), NHS England (London Region)• Jemma Gilbert, Head of Primary Care Transformation, NHS England (London Region)• Dr Jonty Heaversedge, Clinical Chair, NHS Southwark Clinical Commissioning Group• Dr Isobel Hodkinson, Principal Clinical Lead, NHS Tower Hamlets Clinical Commissioning Group; RCGP Clinical

Champion for Person-centred Care and Support Planning• Dr Sian Howell, PM Challenge Pilot representative; NHS Southwark Clinical Commissioning Group;

Bermondsey and Landsdowne Medical Centre• Dr Jagan John, PM Challenge Pilot representative; NHS Barking and Dagenham Clinical Commissioning Group• Dr Nicola Jones, Clinical Chair, NHS Wandsworth Clinical Commissioning Group• Dr Alex Lewis, Medical Director and Director of Quality (Mental Health), Central and North West London NHS

Foundation Trust• Dr Steven Mowle, RCGP Vice Chair, NHS Lambeth Clinical Commissioning Group• Maria O’Brien, Divisional Director, Central and North West London NHS Foundation Trust• Dr Tony O’Sullivan, Community Paediatrician, Lewisham and Greenwich NHS Trust• Terry Parkin, Director of Children’s Services, London Borough of Bromley• Dr Mohini Parmar, PM Challenge Pilot representative; Clinical Chair, NHS Ealing Clinical Commissioning Group• Virginia Patania, Practice Manager, Jubilee Street Practice, East London• Dr Niraj Patel, GP partner, Thamesmead Medical Associates; Visiting Fellow in Health Policy, The Nuffield Trust;

Executive Member, NAPC• Dr Arup Paul, Locum GP, Medical Director, HCML



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• Dr Julian Redhead, Consultant in Emergency Medicine and Clinical Programme, Director for Medicine, Imperial College Healthcare NHS Trust

• Asmina Remtulla, Patient Representative• Dr Tina Sajjanhar, Consultant Paediatrician, Lewisham and Greenwich NHS Trust• Dr John Sanfey, Appraisal & Revalidation Lead, North West London Area Team, NHS England (London Region);

Freelance Chambers GP• Ashi Soni, NHS Lambeth Clinical Commissioning Group; Royal Pharmaceutical Society Board Member; Pharmacy

and Dentistry Board member for Health Education South London• Dr Mark Spencer, Deputy Regional Medical Director, NHS England (London Region)• Karen Stubbs, Project Director, First4Health Federation• Jane Wells, Adult Community Services Director, Oxleas NHS Foundation Trust• Fiona White, NHS Merton Clinical Commissioning Group

Primary Care Transformation Delivery Group

Members who also attend the Transformation Board are not listed here

• Paul Roche (Chair), Programme Director, Primary Care Transformation, NHS England (London Region)

• Denis Cremin, Primary Care Transformation Team, NHS England (London Region)• Carl Edmonds, Deputy Director of Delivery, NHS Waltham Forest Clinical Commissioning Group• Olivia Farnesy, Communications Manager, NHS England (London Region)• David Groom, Programme Manager, Primary Care Transformation, NHS England (London Region)• Georgie Herskovits, Primary Care Transformation Team, NHS England (London Region)• Delvir Mehet, Deputy Head of Commissioning and System Development – OD, NHS England (London Region)• Ginny Morley, Assistant Director, South West London Collaborative Commissioning• Andrew Parker, Director of Primary Care Development, NHS Southwark Clinical Commissioning Group• Mike Part, Head of Strategic Systems and Technology, NHS England (London Region)• Paul Price-Whelan, Senior Financial Strategy Accountant, NHS England (London Region)• Katie Robinson, Head of Analytical Services, NHS England (London Region)• Matthew Walker, Deputy Director Primary Care Transformation, NHS North West London Collaboration of

Clinical Commissioning Groups• Gary Williams, Senior Manager, Analytical Services, NHS England (London Region)


Appendix 3: Glossary

Appendix 3: Glossary

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A&E Accident & EmergencyAHP Allied Health ProfessionalAHSCs Academic Health Science CentresAHSNs Academic Health Science NetworksAPMS Alternative Provider Medical ServicesBCF Better Care FundCCGs Clinical Commissioning GroupsCCP Clinical Challenge PanelCEPNs Community Education Provider NetworksCQC Care Quality CommissionCSUs Commissioning Support UnitsDH Department of HealthGLA Greater London AuthorityGMS Contract General Medical Services ContractGP General PractitionerGPOS General Practice Outcome StandardsHCA Health Care AssistantHEE Health Education EnglandHEI Higher Education InstitutesHE NCEL Health Education North Central and East LondonHENWL Health Education North West LondonHESL Health Education South LondonHSCIC Health and Social Care Information CentreHWB Health and Wellbeing BoardIPC Integrated Personal CommissioningKSS Kent, Surrey and SussexLES Local Enhanced ServicesLETB Local Education and Training BoardLHC London Health CommissionLMC Local Medical CommitteeLondonwide LMC Londonwide Local Medical CommitteesLTCs Long term conditionsMCP Multispecialty Community ProviderMDT Multi-Disciplinary TeamMonitor NHS regulatorNAPC National Association of Primary CareNHS National Health ServiceNHS IQ NHS Improving QualityNHS TDA NHS Trust Development AuthorityNIB National Information BoardNICE National Institute for Health and Care ExcellenceNIHR National Institute of Health ResearchPACs Primary and Acute CarePCN Primary Care NavigatorPHE Public Health EnglandPMS Personal Medical Services QIPP Quality, Innovation, Productivity and Prevention SchemeQOF Quality and Outcomes FrameworkRCGP Royal College of General PractitionersSCN Strategic Clinical NetworkSPG Strategic Planning GroupWTE Whole Time Equivalent


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