Item 7 - Primary Care Improvement Plan Update
North Lanarkshire Council · 16 November 2022
Back to IJB Performance, Finance and Audit Committee — 16 November 2022 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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REPORT Item No: 7 SUBJECT: New General Medical Services 2018/ Primary Care Improvement Plan (PCIP) Update TO: North Lanarkshire Integration Joint Board Lead Officer for Report: Ross McGuffie, Chief Officer North HSCP Lucy Munro, Medical Director Author(s) of Report Linda Findlay, Medical Director, South Lanarkshire HSCP DATE: 16th November 2022 1. PURPOSE OF REPORT This paper is coming to the IJB for: update members on the progress of Primary Care Improvement Plan implementation For approval For endorsement To note 2. ROUTE TO THE BOARD This paper has been: Prepared and approved by the South Lanarkshire IJB. This paper has been: Prepared Reviewed Endorsed 3. RECOMMENDATIONS The Integration Joint Board is asked to approve the following recommendation(s): - 1) That the report and progress is noted; and 2) That the proposed revitalised reporting regime be approved. 4. VARIATIONS TO DIRECTIONS? 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 The purpose of general practice is to provide continuing, comprehensive, coordinated and person-centred health care to patients in their communities. Since the inception of the NHS, general practice has developed as an independent contractor model. Most general practices are run as independent businesses and provide services for NHS boards. On behalf of IJBs, NHS boards specify what healthcare services they need and then fund the GPs to do this work through an arrangement called the General Medical Services (GMS) contract. Yes No N/A
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5.2 The 2018 GMS Contract was developed by the Scottish General Practitioners Committee (SGPC) of the British Medical Committee (BMA) and the Scottish Government. The 2018 GMS Contract recognised the reality of projected general practitioner numbers; and the value of a greater emphasis on care being provided by multi-disciplinary teams. A Memorandum of Understanding (MOU) between the Scottish Government, the BMA, IJBs and NHS Boards for the 2018 GMS contract was agreed in April 2018. This MOU set out the principles by which primary care redesign would be delivered. 5.3 As a result of the 2018 Contract, all IJBs and Health Boards developed locally- agreed Primary Care Improvement Plans (PCIPs). PCIPs were designed to support the delivery of the national GMS contract aim of refocusing the role of GPs as expert medical generalists, working with a wider team to provide more healthcare in the community. 5.4 The initial Lanarkshire PCIP was agreed by NHS Lanarkshire, North and South Lanarkshire IJBs and the NHS Lanarkshire GP Sub-Committee by the end of July 2018. South Lanarkshire Health and Social Care Partnership (HSCP) oversees the implementation of the PCIP as part of its hosting arrangements. It was initially agreed that PCIP progress would be formally reported on locally at six monthly intervals, national reporting was annually. However, with the demands of the Covid- 19 pandemic, it was accepted that both the delivery of PCIPs would inevitably be disrupted and delayed; and that reporting periods would be elongated. With the move of the NHS into a remobilisation phase, this report is being brought forward to revitalise more regularised and proportionate reporting. 5.5 A revised MoU for the period 2021-2023 was published by Scottish Government in July 2021. This MOU 2 reaffirmed the direction of travel, revised delivery time scales and brought in Transitionary Arrangements (payments) where Health Boards failed to deliver the contract within the revised timescales. The focus of the MoU 2 remains the delivery of the transfer of provision of service from general practice to HSCPs and Health Boards, with a focus on the following three services for 2021-22: Vaccine Transformation Programme (VTP) Community Treatment and Care (CTAC) Pharmacotherapy 6. PCIP Progress Pre-Pandemic 6.1 Pre-pandemic Lanarkshire’s position was a strong one. This was achieved by a programme underpinned by a clear governance structure; that utilised project management and quality improvement, with an evaluation framework in place from the commencement; and a dedicated improvement and general management resource. 6.2 Progress During the Pandemic Whilst the first wave of the pandemic saw the standing down of the PCIP, the structure that was in place allowed for the stepping back up in May 2021 (as resources allowed) enabling the reviewing and revision of project plans. The resulting planning and preparatory work undertaken enabled continued progress to be made on delivery as soon as system pressures allowed.
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6.3 Progress on the three Prioritised Areas 6.3.1 Vaccination Transformation Programme (VTP) - was fully achieved and service provision transferred over (April 2022). 6.3.2 Community Treatment and Care (CTAC) – all aspects of agreed Treatment Room Services were implemented, albeit operating at the levels effected by Covid. There has been progress with the initiation of a test of change for Chronic Disease Monitoring (CDM) put in place from May 2022 to date (as at 22 August 2022) with discussions underway to progress a Lanarkshire-wide roll out programme between September 2022 and March 2023. A learning report from the test of change is being prepared to enable and inform systems and processes that are required for the successful transfer of CDM from April 2023. 6.3.3 Pharmacotherapy – there has been steady progress of the Lanarkshire model, which (as with the national picture) has been adversely affected by available funding and workforce. The model allows 1 whole time equivalent (WTE) Pharmacist per 15,000 patient list size (some larger practices also benefit from technician resource), plus the development of a Pharmacotherapy HUB model. The latter utilises a staffing mix of Technicians and Pharmacy Support Workers to support with the delivery of a Level One Pharmacotherapy Service. A project plan is in place for the continuation of the implementation of this model in 2022-23, and this will be informed and revised by a Pharmacotherapy Quality Improvement Group. This group was established following an audit during 2022 that determined current levels of delivery, and has the remit to develop optimised process. 6.4 PCIP Reporting Status A RAG report is maintained against the three priority workstreams. The position as of 22 August 2022 is detailed in Appendix 1. 6.5 Progress on Other Areas Additional Professional Services: 6.5.1 The GP Community Link Worker programme is now fully implemented across Lanarkshire. Every practice has access to both generic and financial and welfare link workers. 6.5.2 The redesign of the Challenging Patients Service - now the Challenging Behaviour Service (CBS) - has seen a more sustainable model developed and become operational. This Service provides General Medical Services to patients who for a variety of reasons cannot have services delivered in mainstream general practice. 6.5.3 A small cohort of Advance Practice Physiotherapists (APPs) is in place, with learning being captured to inform future model should funding allow. 6.5.4 The growth and development of our Advance Practice Nurse (APN) workforce, testing relating to the urgent care model are being undertaken. 6.6 Urgent Care (delivery due 2023/24): 6.6.1 The Urgent Care in Hours Workstream was stepped back up in February 2022 with an initial remit of reviewing the appropriateness of the agreed pre-pandemic model: i.e. to recruit, train and deploy an ANP team to deliver on patients’ requests for urgent GP home visiting.
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6.6.2 The pandemic saw the redeployment of ANPs to support the Covid Assessment Service; and then on stepping this down, redeployment of those staff to practices in two geographic areas - Cumbernauld and East Kilbride. This redeployment gave the opportunity for a Test of Change in respect of ANP delivery across a number of practices. 6.6.3 In March 2022 the Workstream group commissioned a number of pieces of work to review the context of urgent care delivery and inform the GMS Oversight Executive Group regarding a future plan for sustainable GP Urgent Care-in-Hours delivery. The findings of this significant scoping exercise was as follows: Delivery definition remains “Initial Clinical Assessment and the Primary Care Management of unscheduled medical, surgical and mental health urgent issues ' The biggest challenge to service delivery is public behaviour, confusion and perception as to where to present in an increasingly complex and disconnected array of choices with “go to your GP” often perceived as the default Current PCIP ANPs and general practice staff are spread too thinly to deliver or collaborate effectively on changes to service delivery. There is no anticipated immediate solution to this workforce challenge and there is an acknowledgement that this is likely to persist into the next three-to-five-year planning period Requests for GP input to patients recently discharged from hospital and those with multiple complexity have increased exponentially largely as a result of changes in systems external to GP practices themselves. Co-location, adequate workspace and IT are essential to be in place prior to service go live to reduce journey times and inefficiencies 6.6.4 The following recommendations are now being linked with the wider urgent care redesign and will be progressed to realise delivery by the revised MoU date of 2023- 24: Consolidation of the current, available GMS urgent care provision. Criteria for this is to be clarified but must include sufficient space, infrastructure, and appropriate IT for the service to deliver its roles Progressing an exit strategy from the current model; and, based on review of evidence and outcomes of commissioned work to-date, that a revised Urgent Care in-Hours Service is progressed That the service should not be solely dependent on the PCIP ANP workforce but is seen as a whole system model with dedicated input from the wider Partnerships and NHSL secondary care (including the Flow Navigation Centre), administrative and quality improvement support plus protected professional leadership. This would be required to ensure the project achieves its aims of reducing GP workload to allow them to more safely provide existing service against a background of ever-increasing demand The development of services should be underpinned by quality improvement and co- produced, which will ensure engagement with GPs and all partners (including patients) to allow them to influence development That it is recognised that significant public and system engagement is required to challenge unrealistic expectations of ‘go see your GP’, as such that any changes will be accompanied by a communications plan which includes key messages to help the public understand the most appropriate healthcare service for them to attend. Key messages are already being shared with stakeholders to maximise the audience reached.
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6.7 Evaluation The PCIP in Lanarkshire is an ambitious transformational programme. Evidence is needed to demonstrate how effectively the agreed outcomes are being achieved. As previously agreed, a contribution analysis approach to this evaluation as recommended in the National Monitoring and Evaluation Strategy is being applied. The national outcome frameworks - for people using Primary Care, the workforce, and the system as a whole - will be used to collate evidence of their achievement. 6.8 Communication and Engagement A Communication and Engagement Strategy is in place for PCIP, specifically to focus on ensuring that there are: Engaged and knowledgeable GPs and general practice teams Engaged and knowledgeable wider health and social care system Engaged and knowledgeable public 6.9 Conclusion 6.9.1 While it is evident that progress continues to be made - with plans in place, including where necessary mitigation in response to challenges - there remains clear risks to the overall delivery of the PCIP. The unprecedented scale of change resulting from managing the response to the pandemic has created new opportunities and challenges in delivering on-going reform of Primary Care and the PCIP. As such, across the PCIP, consistent review and appropriate revision is being made along with mitigation specifically focused on addressing these areas. 6.9.2 Given this, a twice-yearly reporting regime is proposed with an annual overview presented to the IJB in the autumn (to correspond with annual reporting submissions to Scottish Government) and an interim report presented to the Performance and Audit Sub-Committee in-year. These reports will also be shared with the Population Health & Primary Care and Community Care Governance Sub-Committee of the NHS Lanarkshire Board. 7.1 NATIONAL OUTCOMES The PCIP workstream impact on all nine national outcomes. 7.2 ASSOCIATED MEASURE(S) The activity described within this report contributes to mitigation of a number of identified risks within the NHS Lanarkshire risk register, notably ability to maintain existing GMS across NHS Lanarkshire. There are emerging risks associated with the overall Plan as well as individual workstreams. Each PCIP work stream has an individual Risk Register which feed to an overarching risk register for the programme, the highest rated risks remain around workforce, funding and infrastructure. An agreed project plan underpins the ongoing delivery of the PCIP and the mitigation of these risks. 7.3 CLIMATE CHANGE, SUSTAINABILITY AND ENVIRONMENTAL IMPLICATIONS Where clinically appropriate tele-health is being used across models. Where resource allows, there is a mix of CTAC delivery across treatment rooms; and a peripatetic approach to reduce patient travel.
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7.4 FINANCIAL Financially, implementation of the PCIP is complex. It requires a balance in expenditure between different workstreams, recycling of existing expenditure and efficiency of “back office” functions. Despite review and skill mixing the PCIP is not fully deliverable within the financial envelope indicated and this has been highlighted to Scottish Government. This paper has been reviewed by Finance: Yes No N/A 7.5 RISK ASSESSMENT/RISK MANAGEMENT GP sustainability sits on the IJB and NHSL Risk Registers. 7.6 PEOPLE This report contributes to the performance measurement approach committed within the current IJB Strategic Commissioning Plan. The areas of performance described within this report contribute to the delivery of a number of strategic priorities within the current IJB Strategic Commissioning Plan, notably: Sustaining statutory social care and core health care functions Improving unscheduled care and increasing intermediate care The intention of the GMS contract, the MoU and the local PCIP taken together is to allow clinicians to work at a high level in expanded and integrated teams. This will have implications for many employees over the coming years and should be broadly welcomed by all involved. There are implications for those in changing roles, the development of new roles and the need to explore Transfer of Undertakings (Protection of Employment) (TUPE) for a number of, but not all staff currently employed by GPs. For example, the contract is explicit about the development of Practice Nursing and Practice Manager roles, both of which will remain practice employees. 7.7 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed: Yes No N/A There is no requirement to carry out an Equality Impact Assessment in terms of the proposals contained within this report. However, consultation will continue to be extensive. The EQIA for the programme is being refreshed. 7.7.1 Consultation and engagement across a wide range of stakeholders is pivotal to the successful implementation of the PCIP. 8. BACKGROUND PAPERS List of Background Papers Audit Scotland (2019) General Medical Services contract in Scotland: A short guide https://www.audit- scotland.gov.uk/uploads/docs/report/2019/briefing_190516_general_medical_services. pdf
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The national GMS Memorandum of Understanding 2: https://www.sehd.scot.nhs.uk/publications/Memorandum_of_Understanding%202- GMS_Contract_Implementation_for_PC_Improvement%2030_July_2021.pdf 9. APPENDICES Appendix 1 South Lanarkshire IJB Report Appendix 2 RAG Status Appendix 3 GMS Oversight Exec CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following; Lucy Munro on telephone number 01698 752 751 Lucy.munro@lanarkshire.scot.nhs.net
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Report Report to: South Lanarkshire Integration Joint Board Date of Meeting: 20 September 2022 Report by: Director, Health and Social Care Subject: Primary Care Improvement Plan - Update 1. Purpose of Report 1.1. The purpose of the report is to: - [purpose] update members on the progress of Primary Care Improvement Plan implementation [1purpose] 2. Recommendation(s) 2.1. The Integration Joint Board is asked to approve the following recommendation(s):- [recs] (1) that the report and progress is noted; and (2) that the proposed revitalised reporting regime be approved. [1recs] 3. Background 3.1. The purpose of general practice is to provide continuing, comprehensive, coordinated and person-centred health care to patients in their communities. Since the inception of the NHS, general practice has developed as an independent contractor model. Most general practices are run as independent businesses and provide services for NHS boards. On behalf of IJBs, NHS boards specify what healthcare services they need and then fund the GPs to do this work through an arrangement called the General Medical Services (GMS) contract. 3.2 The 2018 GMS Contract was developed by the Scottish General Practitioners Committee (SGPC) of the British Medical Committee (BMA) and the Scottish Government. The 2018 GMS Contract recognised the reality of projected general practitioner numbers; and the value of a greater emphasis on care being provided by multi-disciplinary teams. A Memorandum of Understanding (MOU) between the Scottish Government, the BMA, IJBs and NHS Boards for the 2018 GMS contract was agreed in April 2018. This MOU set out the principles by which primary care redesign would be delivered. 3.3 As a result of the 2018 Contract, all IJBs and Health Boards developed locally- agreed Primary Care Improvement Plans (PCIPs). PCIPs were designed to support the delivery of the national GMS contract aim of refocusing the role of GPs as expert medical generalists, working with a wider team to provide more healthcare in the community. Appendix 1
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3.4 The initial Lanarkshire PCIP was agreed by NHS Lanarkshire, North and South Lanarkshire IJBs and the NHS Lanarkshire GP Sub-Committee by the end of July 2018. South Lanarkshire Health and Social Care Partnership (HSCP) oversees the implementation of the PCIP as part of its hosting arrangements. It was initially agreed that PCIP progress would be formally reported on locally at six monthly intervals, national reporting was annually. However, with the demands of the Covid- 19 pandemic, it was accepted that both the delivery of PCIPs would inevitably be disrupted and delayed; and that reporting periods would be elongated. With the move of the NHS into a remobilisation phase, this report is being brought forward to revitalise more regularised and proportionate reporting. 3.5 A revised MoU for the period 2021-2023 was published by Scottish Government in July 2021. This MOU 2 reaffirmed the direction of travel, revised delivery time scales and brought in Transitionary Arrangements (payments) where Health Boards failed to deliver the contract within the revised timescales. The focus of the MoU 2 remains the delivery of the transfer of provision of service from general practice to HSCPs and Health Boards, with a focus on the following three services for 2021-22: Vaccine Transformation Programme (VTP) Community Treatment and Care (CTAC) Pharmacotherapy 4. PCIP Progress Pre-Pandemic 4.1 Pre-pandemic Lanarkshire’s position was a strong one. This was achieved by a programme underpinned by a clear governance structure; that utilised project management and quality improvement, with an evaluation framework in place from the commencement; and a dedicated improvement and general management resource. Progress During the Pandemic 4.2 Whilst the first wave of the pandemic saw the standing down of the PCIP, the structure that was in place allowed for the stepping back up in May 2021 (as resources allowed) enabling the reviewing and revision of project plans. The resulting planning and preparatory work undertaken enabled continued progress to be made on delivery as soon as system pressures allowed. Progress on the three Prioritised Areas 6.9 VTP - was fully achieved and service provision transferred over (April 2022). 6.10 CTAC – all aspects of agreed Treatment Room Services were implemented, albeit operating at the levels effected by Covid. There has been progress with the initiation of a test of change for Chronic Disease Monitoring (CDM) put in place from May 2022 to date (as at 22 August 2022) with discussions underway to progress a Lanarkshire-wide roll out programme between September 2022 and March 2023. A learning report from the test of change is being prepared to enable and inform systems and processes that are required for the successful transfer of CDM from April 2023.
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6.11 Pharmacotherapy – there has been steady progress of the Lanarkshire model, which (as with the national picture) has been adversely affected by available funding and workforce. The model allows 1 whole time equivalent (WTE) Pharmacist per 15,000 patient list size (some larger practices also benefit from technician resource), plus the development of a Pharmacotherapy HUB model. The latter utilises a staffing mix of Technicians and Pharmacy Support Workers to support with the delivery of a Level One Pharmacotherapy Service. A project plan is in place for the continuation of the implementation of this model in 2022-23, and this will be informed and revised by a Pharmacotherapy Quality Improvement Group. This group was established following an audit during 2022 that determined current levels of delivery, and has the remit to develop optimised process. PCIP Reporting Status 6.12 A RAG report is maintained against the three priority workstreams. The position as of 22 August 2022 is detailed in Appendix 1. Progress on Other Areas 6.13 Additional Professional Services: 6.13.1 The GP Community Link Worker programme is now fully implemented across Lanarkshire. Every practice has access to both generic and financial and welfare link workers. 6.13.2 The redesign of the Challenging Patients Service - now the Challenging Behaviour Service (CBS) - has seen a more sustainable model developed and become operational. This Service provides General Medical Services to patients who for a variety of reasons cannot have services delivered in mainstream general practice. 6.13.3 A small cohort of Advance Practice Physiotherapists (APPs) is in place, with learning being captured to inform future model should funding allow. 6.13.4 The growth and development of our Advance Practice Nurse (APN) workforce, testing relating to the urgent care model are being undertaken. 6.14 Urgent Care (delivery due 2023/24): 6.14.1 The Urgent Care in Hours Workstream was stepped back up in February 2022 with an initial remit of reviewing the appropriateness of the agreed pre-pandemic model: i.e. to recruit, train and deploy an ANP team to deliver on patients’ requests for urgent GP home visiting. 6.14.2 The pandemic saw the redeployment of ANPs to support the Covid Assessment Service; and then on stepping this down, redeployment of those staff to practices in two geographic areas - Cumbernauld and East Kilbride. This redeployment gave the opportunity for a Test of Change in respect of ANP delivery across a number of practices. 6.14.3 In March 2022 the Workstream group commissioned a number of pieces of work to review the context of urgent care delivery and inform the GMS Oversight Executive Group regarding a future plan for sustainable GP Urgent Care-in-Hours delivery. The findings of this significant scoping exercise was as follows:
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Delivery definition remains “Initial Clinical Assessment and the Primary Care Management of unscheduled medical, surgical and mental health urgent issues ' The biggest challenge to service delivery is public behaviour, confusion and perception as to where to present in an increasingly complex and disconnected array of choices with “go to your GP” often perceived as the default Current PCIP ANPs and general practice staff are spread too thinly to deliver or collaborate effectively on changes to service delivery. There is no anticipated immediate solution to this workforce challenge and there is an acknowledgement that this is likely to persist into the next three-to-five-year planning period Requests for GP input to patients recently discharged from hospital and those with multiple complexity have increased exponentially largely as a result of changes in systems external to GP practices themselves. Co-location, adequate workspace and IT are essential to be in place prior to service go live to reduce journey times and inefficiencies 6.14.4 The following recommendations are now being linked with the wider urgent care redesign and will be progressed to realise delivery by the revised MoU date of 2023- 24: Consolidation of the current, available GMS urgent care provision. Criteria for this is to be clarified but must include sufficient space, infrastructure, and appropriate IT for the service to deliver its roles Progressing an exit strategy from the current model; and, based on review of evidence and outcomes of commissioned work to-date, that a revised Urgent Care in-Hours Service is progressed That the service should not be solely dependent on the PCIP ANP workforce but is seen as a whole system model with dedicated input from the wider Partnerships and NHSL secondary care (including the Flow Navigation Centre), administrative and quality improvement support plus protected professional leadership. This would be required to ensure the project achieves its aims of reducing GP workload to allow them to more safely provide existing service against a background of ever-increasing demand The development of services should be underpinned by quality improvement and co- produced, which will ensure engagement with GPs and all partners (including patients) to allow them to influence development That it is recognised that significant public and system engagement is required to challenge unrealistic expectations of ‘go see your GP’, as such that any changes will be accompanied by a communications plan which includes key messages to help the public understand the most appropriate healthcare service for them to attend. Key messages are already being shared with stakeholders to maximise the audience reached. Evaluation 4.9 The PCIP in Lanarkshire is an ambitious transformational programme. Evidence is needed to demonstrate how effectively the agreed outcomes are being achieved. As previously agreed, a contribution analysis approach to this evaluation as recommended in the National Monitoring and Evaluation Strategy is being applied. The national outcome frameworks - for people using Primary Care, the workforce, and the system as a whole - will be used to collate evidence of their achievement.
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Communication and Engagement 4.10 A Communication and Engagement Strategy is in place for PCIP, specifically to focus on ensuring that there are: Engaged and knowledgeable GPs and general practice teams Engaged and knowledgeable wider health and social care system Engaged and knowledgeable public Conclusion 4.11 While it is evident that progress continues to be made - with plans in place, including where necessary mitigation in response to challenges - there remains clear risks to the overall delivery of the PCIP. The unprecedented scale of change resulting from managing the response to the pandemic has created new opportunities and challenges in delivering on-going reform of Primary Care and the PCIP. As such, across the PCIP, consistent review and appropriate revision is being made along with mitigation specifically focused on addressing these areas. 4.12 Given this, a twice-yearly reporting regime is proposed with an annual overview presented to the IJB in the autumn (to correspond with annual reporting submissions to Scottish Government) and an interim report presented to the Performance and Audit Sub-Committee in-year. These reports will also be shared with the Population Health & Primary Care and Community Care Governance Sub-Committee of the NHS Lanarkshire Board. 5. Employee Implications 5.1. The intention of the GMS contract, the MoU and the local PCIP taken together is to allow clinicians to work at a high level in expanded and integrated teams. This will have implications for many employees over the coming years and should be broadly welcomed by all involved. There are implications for those in changing roles, the development of new roles and the need to explore Transfer of Undertakings (Protection of Employment) (TUPE) for a number of, but not all staff currently employed by GPs. For example, the contract is explicit about the development of Practice Nursing and Practice Manager roles, both of which will remain practice employees. 6. Financial Implications 6.1. Financially, implementation of the PCIP is complex. It requires a balance in expenditure between different workstreams, recycling of existing expenditure and efficiency of “back office” functions. Despite review and skill mixing the PCIP is not fully deliverable within the financial envelope indicated and this has been highlighted to Scottish Government. 7. Climate Change, Sustainability and Environmental Implications 7.1. Where clinically appropriate tele-health is being used across models. Where resource allows, there is a mix of CTAC delivery across treatment rooms; and a peripatetic approach to reduce patient travel. 8. Other Implications 8.1. This report contributes to the performance measurement approach committed within the IJB Strategic Commissioning Plan 2022-25. The areas of performance described within this report contribute to the delivery of a number of strategic priorities within the IJB Strategic Commissioning Plan 2022-25, notably:
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Sustaining statutory social care and core health care functions Improving unscheduled care and increasing intermediate care 8.2 The activity described within this report contributes to mitigation of a number of identified risks within the NHS Lanarkshire risk register, notably ability to maintain existing GMS across NHS Lanarkshire. 8.3 There are emerging risks associated with the overall Plan as well as individual workstreams. Each PCIP work stream has an individual Risk Register which feed to an overarching risk register for the programme, the highest rated risks remain around workforce, funding and infrastructure. An agreed project plan underpins the ongoing delivery of the PCIP and the mitigation of these risks. 9. Equality Impact Assessment and Consultation Arrangements 9.1. There is no requirement to carry out an Equality Impact Assessment in terms of the proposals contained within this report. However, consultation will continue to be extensive. The EQIA for the programme is being refreshed. 9.2. Consultation and engagement across a wide range of stakeholders is pivotal to the successful implementation of the PCIP. 10. Directions 10.1. Direction to: 1. No Direction required 2. South Lanarkshire Council 3. NHS Lanarkshire 4. South Lanarkshire Council and NHS Lanarkshire Soumen Sengupta Director, Health and Social Care Date created: 1 September 2022 Link(s) to National Health and Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community People who use Health and Social Care Services have positive experiences of those services, and have their dignity respected Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services Health and Social Care Services contribute to reducing health inequalities
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People who provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative impact of their caring role on their own health and wellbeing People who use Health and Social Care Services are safe from harm People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide Resources are used effectively and efficiently in the provision of Health and Social Care Services Previous References none List of Background Papers Appendix 1 – Lanarkshire PCIP RAG status Audit Scotland (2019) General Medical Services contract in Scotland: A short guide https://www.audit- scotland.gov.uk/uploads/docs/report/2019/briefing_190516_general_medical_services. pdf The national GMS Memorandum of Understanding 2: https://www.sehd.scot.nhs.uk/publications/Memorandum_of_Understanding%202- GMS_Contract_Implementation_for_PC_Improvement%2030_July_2021.pdf Contact for Further Information If you would like to inspect the background papers or want further information, please contact:- Name: Linda Findlay, Medical Director Phone: 01698 453844 Email: Linda.Findlay@lanarkshire.scot.nhs.uk
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Appendix 2 Lanarkshire Primary Care Improvement Plan: RAG Reporting Status (March 2022) Service Lanarkshire Service Progress RAG Vaccine Transformation Programme (VTP) Pre-school programme NHS Lanarkshire had an established pre-school programme, pre 2018, delivered by managed services (health visiting). G School based programme Stat NHS Lanarkshire had an established school based programme, pre 2018, delivered by managed services (school immunisation team). A process for out of schedule has been confirmed. G Travel vaccination and travel health advice NHS Lanarkshire has procured a service provision via Community Pharmacy Lanarkshire. Since April 2022, there are 7 community pharmacists now offering a travel health vaccination and advise service to residents of and registered patients with a GP across Lanarkshire. There is continued engagement with additional community pharmacies to be contracted in across NHS Lanarkshire to offer this service. G Mass Vaccination Programme (MVP) The delivery of public (children and adults) and staff influenza vaccination programme in tandem with covid19 booster is now in place. Pneumococcal, and Shingles vaccinations are being progressed for delivery via the respective vaccination centres set up to deliver covid and influenza vaccines. Pneumococcal vaccine offer will be completed August 2022. Following this, there will be a pilot for people aged 79 and over whose eligibility is about to expire. People will receive a letter with details of their appointment and alternative arrangements if it is not suitable. Learning from this pilot will inform a wider roll-out of the shingles vaccine in early 2023, after the covid-19 booster and flu vaccination programmes have completed. The wider roll-out will include all other eligible people and those who have not had an opportunity to receive the shingles vaccine due to covid. There are a number of adhoc vaccinations which require to be delivered, mostly coming from secondary care (for example, patients who need further vaccination after a bone marrow transplant, or patients requiring pneumococcal vaccine outside of usual scheduled vaccinations due to commencing immunosuppressant’s). Referrals are being received and a process has been developed for these patients to receive their vaccination G
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in Ravenscraig vaccination centre. Once processes are mature, it would be intended to deliver this across all vaccination centres. Feedback was received from some GP practices that they were receiving requests from non-Lanarkshire secondary care departments for Lanarkshire residents. Discussions have taken place with colleagues in other WoS boards and an agreement reached to ensure information on all WoS referral pathways disseminated to relevant departments. Further contact between the Vaccination Service and specific departments (specifically haemato-oncology) has taken place. Community Treatment and Care (CTAC) NHS Lanarkshire benefited from an established Treatment Room Services (TRS) provision across all Localities, PCIP has invested additional resource to enhance board wide TRS to enable transfer of • Phlebotomy, • The management of minor injuries and dressings, • Ear syringing, and • Suture removal. There is a need to be cognisant that plans are being progressed in line with current Treatment Room Services provision which is affected by covid pandemic. There is an allocation of 49WTE Band 5 community nurses to support CTAC. In order to achieve the locality allocation levels, recruitment has been completed from Band 5 nursing staff previously deployed to the Mass Vaccination Programme returning, newly qualified nurses and external recruitment programmes underway in respective localities. G Chronic disease monitoring • Basic disease data collection and biometrics (such as blood pressure) A test of change is currently underway within the Hamilton Locality with 4 volunteer general practices involved currently to gather data and learning of the proposed CDM model to inform a future model for Board wide implementation by March 2023 using the Vision Anywhere system. There is the intention to recruit additional GP practices within this locality to further support the gathering of required intelligence. There has been positive feedback from staff, patients and general practice teams on the test of change to date. A Pharmacotherapy A clear model has been approved which will utilise a skill mix of Pharmacists, Pharmacy Technicians and Pharmacy Support Workers to provide a pharmacotherapy service delivered via practice based staff (1wte per 15,000 patients) and locality hubs. This model has been identified as the optimum delivery approach, within the available funding allocation, to progress towards achievement of what is outlined in the GMS contract as a full pharmacotherapy service. The contract offer details three levels of pharmacotherapy service and while there is an emphasis on implementing the level one element there are interdependencies between all three levels that require focus on the R
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delivery of the service as a whole, currently all practices receive a partial service. The quality improvement workgroup has been established and is progress recommendations identified in the June 2021 regarding variation and opportunities to ensure optimum service delivery. There are challenges relating to accommodation for hubs, with currently 5 Localities not having identified accommodation, this has been escalated via Board and HSCP structures.
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1 Oversight Executive Group ToR v0.1 Terms of Reference 1. Title NHS Lanarkshire GMS2018 Oversight Executive Group 2. Reporting and Accountability The group reports to and is accountable to The Primary Care Strategy Board 3. Purpose The objective of this work stream is to oversee and decide on matters relating to all the work streams for GMS2018 which require more senior agreement to progress in line with the mandate of the General Medical Services (GMS) 2018 contract. Decisions may be taken by the group or remitted to the Primary Care Strategy Board (PCSB). 4. Key Responsibilities and Objectives The roles and responsibilities of the NHS Lanarkshire GMS2018 Oversight Executive Group are as described below: Write and ensure adherence to the overarching Primary Care Improvement Plan (PCIP); Provide subject matter expertise plus links to other groups; Facilitate resolution of any disagreement or disputes between work stream leads and its members; Approve documentation and processes as appropriate to reflect the work stream plans; Provide advice and approve key decisions as required; Manage any project interdependencies and identify and recognise synergies with work ongoing at both a local and national level, including but not limited to, other GMS2018 work streams; Manage any risks and issues in relation to the implementation of GMS2018 services; Inform the risk register maintained by the Primary Care Improvement Team; Ensure members take responsibility for, and lead where appropriate on, relevant activities and report on progress to the group; Ensure members consult more broadly within their organisation / professional group on areas of particular interest to the group, and therefore create a feedback process. Appendix 3
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2 Oversight Executive Group ToR v0.1 5. Membership Organisation/Division Responsibilities Medical Director, South HSCP Chair of the GMS Oversight Executive Group Provide link to Urgent Care (in hours) Group Provide links and advice in regards to Lanarkshire Health & Social Care Partnerships Medical subject matter expert Medical Director, North HSCP Provide links and advice in regards to Lanarkshire Health & Social Care Partnerships Link to Community Treatment & Care Modelling & Planning Group Associate Medical Director, South HSCP Provide links and advice in regards to Lanarkshire Health & Social Care Partnerships Associate Medical Director, North HSCP Provide links and advice in regards to Lanarkshire Health & Social Care Partnerships Director of Nursing, North/South HSCP Provides nursing expertise and links to senior nursing management in NHSL & HSCPs 2x GP Sub Committee representatives Represent the interests of primary care doctors Provide communication & engagement links to Lanarkshire GP Sub committee Head of Health, South HSCP Provides operational links to South HSCP Head of Health, North HSCP Provides operational links to North HSCP Head of Commissioning & Planning, South HSPC/Interim Head of Commissioning & Planning, North HSCP Provide strategic commissioning and planning links to HSCPs Deputy Director of Finance Provides financial expertise Monitors PCIP finances Provides links to national finance groups Primary Care Services Manager Provides links to General Practices in Lanarkshire Service Manager, Primary Care Improvement Plan (PCIP) Provides links to PCIP work stream operational issues Senior Improvement Manager, Primary Care Improvement Team Provides improvement methodology expertise and links to the PCIP Support Team Project Support Officer, PCIP Schedules meetings Produces action & decision log
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3 Oversight Executive Group ToR v0.1 The Group shall have the right to invite representatives and expertise to any of its meetings when deemed appropriate. 6. Conduct of Business (Frequency, reporting, Quorum, Chair/deputy, agenda, minutes, actions, ToR review) Chair: The Medical Directors shall act as Co‐Chairs with a GP Sub representative as Vice Chair with the authority to nominate a deputy in their absence. Decision Making: The three‐year action plans for all work streams will be developed with the project leads and subject matter experts. Following an iterative development process, these will be collated into the Primary Care Improvement Plan (PCIP). Changes to the PCIP will be through the GMS Oversight Executive Group and identified lead author. Any such change shall only become operative after approval of the Chair of the Group in consultation with the Primary Care Strategy Board (PCSB). The GMS Oversight Executive Group will take decisions as often as possible within the Group to ensure progress of work streams in accordance with the established principles of implementation, as agreed by PCSB. Where sufficient clarity does not exist, decisions will be required by the PCSB. It is hoped that by including the key responsible officers within the meeting, there will be sufficient capacity to agree a way forward. Meeting Frequency: Meetings will take place 4 weekly with a review of the frequency taking place by the chair at an appropriate stage. Meetings will be two weeks after and two weeks before the PCSB. Meetings of this group will last approximately 2 hours and the appropriate quorum of membership is at the discretion of the Chair. Meeting Organisation: The Chair, in collaboration with the Project Support Officer will be responsible for arranging meetings, issuing and managing calendar invitations and associated tasks. All meetings should be arranged in line with the agreed frequency as set out within the group ToR and calendar invitations should be issued to group members up to 1 year in advance. Agenda/Papers: Agendas and relevant papers should be developed by the Project Support Officer; Decisions and actions from the meeting will be recorded within an action and decision log. It is the responsibility of each of the members to ensure actions assigned to them are completed and an update provided. The agenda will be managed by the Chair with input from Vice Chair and agenda items shall be given one week in advance of the meeting. A Highlight Report updating the progress of each of the work stream groups will be circulated prior to each meeting. Detailed minutes will not be produced; rather action points and timescales will be circulated within one week of the meeting. The LanGMS2018 mailbox (LanGMS2018@lanarkshire.scot.nhs.uk) should be included within all meeting invitations and relevant correspondence including meeting papers. A distribution list should be maintained by the Project Support Officer ensuring all invitees/ recipients are required and removing/adding those who no longer require to receive correspondence in regards to the group. Meeting Delivery: The Project Support Officer (PSO) will attend all group meetings to develop and maintain action and decision log. The PSO is responsible for version control and accuracy of the decision log and will be responsible for following up with action owners to provide updates on outstanding actions. The PSO will also be responsible for ensuring the most up to date action note document is provided prior to the next meeting for circulation alongside other relevant meeting papers to the members of the group. A nominated group member will capture actions and decisions in the PSOs absence. An up‐to‐date action log will be contained within the papers for the meeting. This should be
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4 Oversight Executive Group ToR v0.1 updated following the meeting and a new version dd‐mm‐yyyy draft v0.1 created for the date of the meeting. A final version dd‐mm‐yyyy v1.0 will be created following approval by the project lead(s) and circulated to group members no later than one week after the meeting. ToR Review: Changes to the ToR, functions or membership of the group may be proposed at any meeting of the group with due notice of the proposed change having been issued with the agenda of the meeting. Any such change shall only become operative after approval of the Chair of the Group in consultation with the Primary Care Strategy Board. Lifespan: This group will meet until April 2023 in line with the revised timescales set out within the GMS2018 contract. 7. Confidentiality Organisation confidentiality will be maintained. Any papers resulting from these meetings will be open to public scrutiny. 8. Review Date Date of review – 21/09/2022 Date of approval at GMS Oversight Executive Group ‐ Date of next review – 21/09/2023 or earlier as referenced in section 6 – ToR Review