in Northumberland
Stakeholder update
August 2016
One system, one team, one you
2
3
The story so far…
Building on very strong foundations of integrated working
in Northumberland, the aim of this work is to create a truly
Augus� 2015
GP capacity and
demand review
begins
June 2015
Northumbria Specialist
Emergency Care Hospital
opens (phase one
of vanguard)
joined-up system between GP and primary care services,
hospital-based care and with any ongoing health or social
care support that people might need. Our collective
vision is to create ‘one system’, with no organisational
boundaries. A system which allows patients to easily access
the highest possible quality of care, relevant to their own
individual needs and which empowers people to stay
healthy and well.
February 2016
April 2016
Launch of
northumberland.nhs.uk
and the vanguard
co-design panel
March 2015
Northumberland
announced as a
vanguard site
In March 2015, Northumberland was announced as
one of several areas across England, chosen by the
chief executive of the NHS, to take a national lead on
developing new ways of working to improve the
quality and experience of patient care.
Oc�ober 2015
Perceptions research with
all staff groups asking
how we can improve
integration
Public engagement
activity begins
July 2016
Roll out of ‘medical
interoperability gateway’
MIG (shared health
record) begins
North locality
co-design panel
June 2016
August 2016
Six new trainee primary
care pharmacists on
board (see page 23)
July 2016
ACO strategic
commissioning model
approved
All GP practices signed
up to sharing health
records (via the
MIG)
Strategic
commissioning model
begins in shadow
form
April 2017
Northumberland
ACO established
Blyth enhanced care
pilot begins (see
pages 12-13)
April 2016
All GP practices in
Northumberland signed
up to implementing new
access models
Central locality
co-design panel
May 2016
September 2016
July 2016
One year on
from new model of
emergency care
March 2016
February 2016
One system, one team, one you
June 2016
New Northumbria
nursing degree is
launched
June 2016
West locality
co-design panel
September 2016
July 2016
Over 30% of
population have easy
access to same day GP
consultation
Byth Valley locality
co-design panel
April 2017
Majority of GP practices
in Northumberland
with enhanced
access models
4
5
A new model of
emergency care
The opening of the Northumbria Specialist
Emergency Care Hospital (The Northumbria) in
June 2015 and redesigning of urgent care services
at general hospitals marked the first important
phase of the vanguard work.
Senior clinical
decision making from
consultants seven days
a week
One system, one team, one you
Patients who are seriously ill or injured now have
access to specialist emergency care, seven days a week,
which is centralised on one site. Early indications show
this new clinical model is working well. Senior clinical
decision making from consultants, which is now available
consistently seven days a week and access to dedicated
diagnostics 24/7, has resulted in fewer emergency
admissions, less time in hospital for patients and
improved clinical outcomes. The subsequent savings
for the local health economy equate to £6 million
within the first 11 months alone.
Urgent care centres which operate 24/7 at Hexham,
Wansbeck (and North Tyneside) general hospitals
have continued to see around half of all urgent and
emergency activity with over 70,000 attendances in
the first 11 months since The Northumbria opened.
Work is now taking place to see how these general
hospital ‘hubs’ can be developed to integrate urgent care
services even further through the co-location of GPs, out
of hours providers, community teams and other sources
of urgent specialist advice.
This builds on arrangements already in place within
urgent care centres whereby emergency care practitioners
are supported by GPs employed by Northumbria
Healthcare and have direct links with clinicians in the
emergency department at The Northumbria. Northern
Doctors Urgent Care, who are commissioned to provide
the GP out-of-hours service across Northumberland, are
also already based within urgent care centres, presenting
further opportunities to develop a future system which
is not only simple for the public to understand, but also
delivers much improved economies of scale and reduced
need for people to attend emergency care.
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7
Delivering primary care at scale
Like all parts of the NHS, GPs are under increasing
pressure with ever growing practice lists and more
complex, elderly patients to look after.
During 2015/16, GPs across Northumberland took part in
a ‘capacity and demand’ review, to help understand how
patients are accessing GP appointments across the county
and where improvements could be made. At the same time,
almost 3,000 members of the public gave their views as part
of a widespread public engagement exercise about accessing
GP services, with 85 per cent of people who took part in
the vanguard survey rating their most recent GP experience
as good or very good. The most recent Ipsos Mori poll shows
89 per cent of people in Northumberland highly rating
experiences at their GP surgery - the highest in the North East.
Findings have been shared and discussed with the vanguard
co-design locality panels and show that:
Appointments
Urgent access
Travel / distance
27%
Most
77%
55%
People are willing to access an
urgent GP appointment at another
location than their usual practice
of people got an
appointment more than five days
after contacting the practice
42%
of people got an
appointment in two days or less after
contacting the practice
70%
Over
of people were
happy with the amount of time it took
to get an appointment
people said that seeing any
GP within their own practice as soon as
possible was most important for them
of people said they would
not want to access a GP at the weekend for a routine appointment
72%
of people said they would
want to access a GP at the weekend for
an urgent appointment, the majority
wanting those appointments on Friday
evenings or Saturday mornings
93%
would be willing to see a
different GP for an urgent appointment
and would expect to be seen the same day
One system, one team, one you
of people live within 5 miles
of their GP practice
70%
of people said that
transport would not be a problem
People highly
rate their experiences
of GP services in
Northumberland
8
9
Engaging with GPs
Engagement with GPs throughout the vanguard
programme has enabled a countywide picture, for
the first time ever, about how patients are
accessing GP services.
GP practices across
Northumberland are
committed to improving
timely access for
patients
One system, one team, one you
Important conversations are now taking place about
how primary care can work in a more integrated way
with the wider health system - the aim is to help improve
access for patients and free up time for GPs to look
after those with more complex needs. Widespread
discussions are also taking place in primary care amongst
GP practices to propose and agree how these new access
models will work in future.
All partners are working towards a collective
vision to ensure:
All GP practices are signed up to and working
towards improving timely access to GP advice
By April 2017, the majority of practices in
Northumberland will have implemented new
models of enhanced access
Practices are being encouraged to increase the percentage of their patient population seen each
week and are being supported to help balance
the numbers of ‘same day’ appointments with
appointments booked in advance
A consistent approach to extended GP practice
hours across Northumberland to help patients
understand where to get help and ease pressure
in emergency care.
10
11
Over 30% of people
in Northumberland will
have easy access to a same
day GP consultation
Improving primary
care access for patients
GPs are working in a number of different ways to
achieve the collection vision of improving access to
GP advice during the normal working week. They are
also exploring the potential for new networks of GP
practices to work together to offer extended access
in a uniform way across the county.
This work goes hand in hand with discussions around
creating a fully integrated system for urgent care,
which maximises GP clinical expertise, resources and
the physical infrastructure of the current NHS footprint
in Northumberland.
for same day consultations with a GP, the majority of
which take place over the phone. A number of practices
in Northumberland already use similar access systems
with evidence showing that only around 30 per cent
of people ringing their GP practice need a face to face
appointment, with many having the totality of their
clinical need met with a telephone consultation.
Over 100,000 people across Northumberland will soon
have access to a same day telephone or face to face
consultation from a GP. All other practices in the county
are similarly reviewing and enhancing their own access
systems.
Several practices in north Northumberland are now
improving access for patients by using telephone
triage to allow people to talk directly with a doctor –
improving access to same day consultation and reducing
the number of physical appointments taking place.
The system works on the ethos that there will be no
‘pre-booked’ appointments, instead freeing up time
Telephone consulting systems can be used for urgent and
non-urgent health problems and aims to make sure that
everyone is able to speak to their GP on the day they call,
or the day they choose. As it is the GP talking directly
with patients over the phone, they are much better
able to judge how much time may be needed to support
patients with their problems.
One system, one team, one you
one system, one team, one you
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13
Enhanced care for complex patients
People who have very complex needs require
compre-hensive support and intervention from the
health and social care system on a daily basis. They
use multiple services, have multiple interactions and
see multiple health and social care professionals.
In Northumberland, this accounts for around 2-5 per
cent of the overall general population and these complex
patients are often frail, elderly people who require
bespoke packages of care wrapped around them to keep
them well. It also includes those nearing the end of life,
regardless of age, who need palliative care and support,
as well as those with very complex needs such as mental
health problems or learning disabilities.
Regular
pharmacist input is
helping to improve
understanding of
medicines use
One system, one team, one you
The town of Blyth on the Northumberland coast has
a population of around 38,000 people (12 per cent
of overall population). Local health and care services
are provided from four GP practices, two of which
are co-located at Blyth Community Hospital. The town
also has 13 care facilities offering services to around
460 people with nursing, residential and learning
disability needs. Work is taking place in Blyth amongst
community, primary care and hospital based teams,
to pilot new ways of working to proactively look after
those who are most vulnerable. This work will
influence the overall delivery of new ‘enhanced
care’ models across Northumberland and includes
three main elements.
1. Enhanced care for those living in care homes
GP practices in Blyth are already aligned to specific care homes and work closely with the community matron at
Blyth Community Hospital to care for patients. Our aim is to align the wider community nursing team in the same
way and introduce pharmacy expertise so that all those living in a care home have regular, proactive reviews, led by
the care home team, but supported by a GP, elderly care consultant and wider multi-disciplinary team. In particular,
pharmacist input will help improve understanding of medication, involve care home residents (and their families)
in decisions about medication and, ultimately, reduce the amount of unnecessary medication being prescribed and
wasted. Working in this proactive and joined up way, will help anticipate problems, manage people in their place
of choice and reduce unplanned contact with multiple services. Once established, the model will be extended
to other vulnerable people in Blyth who are in their own home and housebound.
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15
2. Acute home visiting service
A pilot is underway, involving practices in Blyth, to support GPs in managing daily telephone requests for GP home visits.
Whilst many patients requesting a home visit will require the advice of a GP, particularly those nearing the end of life and
receiving palliative care, the aim is to explore the extended role of skilled nurse practitioners and pharmacists as part of a
wider rapid response team. In the first week of the pilot at Station Medical Group alone, from a total of 24 GP home visit
requests – over 40 per cent did not require a GP to carry out the home visit, instead using the skills of community matron,
pharmacists and social care along with telephone advice from the GP, with further scope for nurse practitioner input.
After the first month, around 30 per cent of all home visit requests are now being carried out by pharmacists. The pilot
will soon be rolled out to cover all GP practices in Blyth using the ‘multi-disciplinary’ triage approach to manage home visit
requests and GP time. For those patients that do require a GP visit, the aim is for these to be arranged as early in the day as
possible so that any necessary onward care can be arranged. By offering more interventions in the community, by the right
healthcare professional, our aim is to ultimately reduce any unnecessary referrals to emergency care for complex patients.
3. Multi-disciplinary team (MDT) working in the community
Building on experience on joint working already in place, our vision is to develop MDT working ‘at scale’ across Blyth,
with a view to replicating the model across Northumberland. In conjunction with the acute home visiting service (outlined
above), our aim is to provide regular support and input from elderly care consultants, pharmacists, the wider community
nursing team and social care support, into multi-disciplinary meetings to discuss complex patients and those receiving
home care. This will help to proactively manage patients identified by GPs as ‘high risk’ or presenting as high users of
services. Our overall aim is to develop an effective model for complex patients, exploring the efficiencies of a whole
system approach in Blyth, whilst continuing to meet the needs of individual GP practices.
Initial steps will see the introduction of a regular MDT discussion, exploring the use of technology and booked case
discussions to help facilitate this collaborative working as part of everyday, routine business. The exact timing and
structure of how these MDT discussions will work, is being developed with stakeholders and involves a wide range
of professionals from across primary, community and hospital-based settings. To support this workstream, a new
‘enhanced care steering group’ has been established, bringing together key staff across partner organisation to drive
this agenda forward. This work is also being developed in the other three localities across Northumberland with each
area testing different elements of the model.
One system, one team, one you
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in Blyth are working
together to care for those
with complex needs
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18
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Ultimately,
our aim is to help
tackle the main causes
of ill health including
obesity and diet
Enabling care for patients
with long term conditions
Supporting people who live with long-term conditions
and who regularly use health and care services, is at
the heart of the vision for improving integration of care
across Northumberland. We want people to be able to
confidently manage their own condition, have full choice
and control over their lives and to stay active for as long
as possible.
Much collaboration already takes place amongst clinical
teams and across several specialty areas to continuously
improve care for people living with long term conditions
in Northumberland. This ongoing work brings together
clinicians from primary care and secondary care to help
foster relationships, discuss the challenges faced in
delivering effective management of long term conditions,
as well as the areas where we can improve quality and
experience for patients.
The vanguard programme aims to accelerate some of this
work and will use the cardiology and respiratory clinical
pathways as a test bed for modelling a set of ‘five principles
for good long term condition management’ with a view to
rolling these out across all long term condition specialty areas.
These principles are currently being developed with cardiology
and respiratory clinical teams and will broadly aim to:
One system, one team, one you
1. Support a positive prevention agenda by raising
awareness of the causes of long term conditions
and importance of good self-care
2.Empower patients to manage their own condition,
through the use of technology and ready access to
clinical expertise
3.Identify relevant healthcare professionals and
new ways of working amongst primary care,
community teams and hospital colleagues, to proactively manage patients
4.Develop a leading quality assurance and governance
framework to support new models of care in long
term condition management
5.Establish best practice guidelines which support
bespoke care planning for individual patients
By developing and testing these principles with patients
who have long term heart problems or breathing
conditions, the aim is to create a system wide, consistent
approach to effective long term condition management
which can be applied in any speciality area. Ultimately,
our aim is to improve the health and wellbeing of local
people and tackle some of the main causes of ill health,
including obesity and diet, mental health and
alcohol misuse.
20
21
Building relationships and
new ways of working
Developing positive relationships, a collaborative culture
and strong leadership across all parts of the health and
care system in Northumberland is at the heart of the
vanguard programme. Our system already benefits from
very strong partnerships with colleagues from primary care
taking part in leadership development programmes run
by Northumbria Healthcare NHS Foundation Trust, helping
to foster positive working relationships and support the
sharing of ideas and continuous quality improvement.
Through the primary care leadership group, which involves
commissioners and GP providers, there is a growing energy
within primary care to think differently about the challenges
being faced by the entire spectrum of services and growing
recognition that the scale of the challenges must be met
collectively, with mutual understanding amongst all partners.
Through this group, colleagues are also discussing how
primary care can be represented, as a collective voice, at
ACO level as an equal provider of services.
only in terms of access, but also in the business models
and contract mechanisms used.
Understanding how our staff feel has underpinned much
of the work taking place to improve integration of services.
During 2015, in-depth qualitative research has taken place
to gather the views of healthcare professionals from all
parts of the health and care system. Staff gave multiple
examples of integrated care already in place, as well as
new ideas to improve multi-disciplinary working and more
efficient ways of seeing patients. In May 2016, over 86
per cent of senior clinical leaders said they were ready to
embrace further change and collaboration to deliver new
ways of working to improve patient care.
This research has also helped us understand some of the
key themes and concerns amongst employees, including:
Delivering new models of care and changing the way we
work to improve patient care, will impact on all aspects of
service delivery and our future ability to operate as a ‘whole
system’. Success will be dependent on ‘buy in’ of all parties
and a willingness to ‘recycle’ resource to increase capacity
and capability to deliver better outcomes for patient - not
One system, one team, one you
Professionals in all areas having high workloads and
making sure they are not stretched too thinly
Planning for early retirements and future-proofing
the workforce
Freeing up time for GPs to support more complex
elderly cases and building strong relationships
with consultants for informal advice
Understanding money and funding flow in the new
ACO system and as we change patient pathways and
ways of looking after people?
Our system
already benefits from
very strong partnership
working
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23
Developing the future
‘integrated’ workforce
Developing staff with flexible skills and who can work
across a range of care settings is pivotal to the success
of delivering new care models in Northumberland. Our
aim is to make sure patients experience the right care,
delivered by the right person and in the right place, with
a focus on community based specialist teams working
together to support patients outside of hospital.
First cohorts on
the Northumbria
nursing degree
One system, one team, one you
A new bespoke nursing degree, developed by Northumbria
Healthcare NHS Foundation Trust in partnership with
Northumbria University and approved by the Nursing and
Midwifery Council (NMC), took on board its first cohort
of ten students in April 2016. Believed to be the first of its
kind in the country, the new work-based programme leads
to an honours degree in nursing for people who already
have substantial experience and previous academic study in
the nursing and healthcare sector. The course lasts only 18
months, as opposed to three years and forms a key part of
the shared vision for of having one single workforce to cater
for patients’ needs, regardless of whether they are receiving
care at home, in the community or in hospital. A further
ten recruits will join the course in September 2016 and
once qualified the nurses will be able to work in a variety of
care settings, thinking holistically about a patient’s journey
to provide a seamless experience.
A new pharmacy service has also been developed for
Northumberland. As part of this, six new trainee pharmacists
(band 6) began in post from August 2016 and are being
embedded as part of the practice-based multidisciplinary
team. Their training programme will involve ‘end-to-end’
pathways through primary, community and secondary
care, with the intention of exposing trainees to ‘whole
system’ working at the very start of their career. Trainee
pharmacists will be ‘paired’ with hospital-based trainees and
both will rotate into the GP practice as part of their training
programme – this innovative approach will allow pharmacists
to gain clinical skills in a hospital environment whilst practices
benefit from the input of a full time pharmacist. The trainees
will have seamless access to joined-up hospital and primary
care systems with significant benefits for streamlining
processes and effectively managing discharges.
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25
Delivering an
integrated health record
The first important steps towards a shared electronic
health record are now well underway thanks to strong
partnership working with GPs and informatics teams.
For the first time ever, with informed patient consent,
healthcare professionals working in a range of urgent
and emergency care settings can now view essential
information from a patient’s GP record to help inform
key clinical decisions about their care and treatment.
All GP practices have now signed up to the new ‘gateway’
technology – known as ‘Medical Interoperability Gateway’
(MIG) – which is already helping to deliver many key benefits
in the safety and quality of patient care, particularly in
urgent and emergency situations, with around 120 patients
a day now benefitting from the joined up system. Using
technology to share information electronically has very
clear benefits for providing safer and more joined-up care
for patients so that they get the right treatment, in the
timeliest way.
One system, one team, one you
By making the patient’s GP record available in different
settings, doctors and nurses will can now see:
current and past diagnosed conditions
current and past medications
any allergies and adverse reactions
test results
any recent encounters or visits to primary care
up-to-date contact details
Further work is also planned to align the IT systems
currently used by GPs across Northumberland, with
the same system used by community based teams.
By 2020, the ultimate ambition is for every patient across
Northumberland to have a fully interactive health care
record, with read / write capability for every healthcare
professional involved in their care.
Around 120 patients
a day now benefit from
a joined-up system and
shared health record
26
27
Developing an accountable
care organisation model (ACO)
Work is now well advanced to develop a single
Accountable Care Organisation for Northumberland
which will be one of the first of its kind in the NHS
and become operational from April 2017, with the
strategic commissioning model beginning in
shadow form from September 2016.
Our vision
for an ACO will
make it easier for staff to
work more effectively
together
One system, one team, one you
With the support of NHS Improvement and NHS England
this work is now moving at pace, with a draft memorandum
of understanding in place across all partner organisations
and a detailed due diligence process underway. A set of
population-based health outcomes is being developed in
partnership with the King’s Fund which will align the work
of all providers within the ACO, based on the following:
improving outcomes for the people
of Northumberland
improving the health status of the population
contributing to shaping sustainable services
for the future
moving care outside hospitals where appropriate
adopting the philosophy that an unplanned
hospital episode is potentially a missed opportunity
elsewhere in the system
reflecting mutual responsibility for system
management and integrating care.
The ACO will have a capitated budget for the population
of Northumberland and work towards shared quality
objectives, drawing on services that cross different
organisational boundaries to meet individual patient
needs. This will make it easier for staff to work more
effectively together in a joined up way and with the same
shared goals for delivering high quality patient care.
Partner organisations:
Northumbria Healthcare NHS Foundation Trust
NHS Northumberland Clinical Commissioning Group
Northumberland County Council
Healthwatch Northumberland
Northumberland Local Medical Committee
(representing GP practices)
Northumberland Tyne and Wear NHS Foundation Trust
North East Ambulance Service NHS Foundation Trust
Newcastle upon Tyne Hospitals NHS Foundation Trust
Follow us @N_LandNHS
www.northumberland.nhs.uk
One system, one team, one you