SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
SW New Forest BLC
Dr Nigel Watson, GP Arnewood Practice – Chair
Team Members/Leads:
Dr Sally Johnston, GP Chawton House Surgery – Vice Chair
Laura Rothery, Locality General Manager
Dr Will Howard, GP New Milton Health Centre
Dr Matt Davies, GP Central New Forest Practice
Version History:
V7 – 19 Apr 16
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SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
Contents
Executive Summary ............................................................................................................................. 3
Introduction............................................................................................................................................ 5
The Practice – at Lymington New Forest Hospital .......................................................................... 9
Transformation Fund ......................................................................................................................... 12
Extended Primary Care Team (One Team) ................................................................................... 13
End of Life Care.................................................................................................................................. 20
Frailty.................................................................................................................................................... 22
Mental Health ...................................................................................................................................... 24
Management of Long Term Conditions and De-layering Specialist Services........................... 26
Patient and Public Engagement....................................................................................................... 29
Creating a Common Health Record ................................................................................................ 31
Teaching and Training ....................................................................................................................... 34
Challenges .......................................................................................................................................... 34
The Future ........................................................................................................................................... 35
Conclusion ........................................................................................................................................... 36
Members .............................................................................................................................................. 37
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SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
Executive Summary
The NHS is about to enter one of the most significant periods of change since its introduction
in the 1940s. This transformation was laid out in the document published by NHS England
in October 2014 called “The Five Year Forward View”.
Locally there was general support for the roadmap that was laid out which indicated that
there needed to be greater investment in Community Services and General Practice to
provide out of hospital care delivered at scale.
Commissioning that was determined by activity based contracts would be replaced by
budgets based on natural communities of care (i.e. populations) and there would be an
incentive to develop integrated services that created better outcomes for patients.
Competition was replace would collaboration and partnership working.
In March 2015, Southern Hampshire became one of the 29 Vanguard sites and within this
groups was working as one of the 14 Multi-Speciality Community Providers (MCP). Within
Southern Hampshire there are three localities; SW New Forest, Gosport and East
Hampshire.
The MCP was established as a partnership between individual Practices, Southern Health
FT as our Community Provider and the various GP provider companies (New Forest
Healthcare Ltd, the Alliance).
By working closer together we have been able to secure funding for a Primary Care Access
Centre, part of the Prime Minister’s Challenge Fund. Offering 8am to 8pm services seven
days a week, working as a branch surgery of 7 local practices. Associated investment in
telephony and developing a common health record has help to develop integrated services.
The greatest achievement in Year One has been the clinical engagement. The seven
practices are working together far more closely than ever before. The programme of
developing an Extended Primary Care Team (the One Programme) has meant Practices and
Community staff have be co-designing a new way of delivering integrated service.
Lymington Hospital is valuable asset to our community. The GPs are working closely with
the Consultants to develop and improve services and create a sense of one community, all
working for the patients and population without the historic barriers that have traditionally
existed between primary and secondary care.
The workforce is critical to the effective delivery of care. We know we do not have enough
GPs now and we are losing more GPs than we are training. So we need to make General
Practice a better place to work in addition to training and working with other healthcare
professionals who could undertake work traditionally carried out by GPs.
3
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
We have completed a pilot using an MSK extended scope practitioner working as the first
point of contact in a practice. This has been shown to have high patient satisfaction and
reduce referrals to Orthopaedic Choice and Physiotherapy.
We are about to introduce Pharmacists working in every Practice, link them together and
with the Community and the Hospital based Pharmacists. This should help with hospital
discharge as well as poly pharmacy, compliance and the management of long-term
conditions.
Gosport has successfully introduced Mental Health workers in some practices and we are
looking to replicate this.
Frailty is the new long-term condition and with more than 5% of the local population being
aged 85 or more it is important that we develop services to meet the needs of this group of
patients.
Patients are important not only in terms of they are the reason that we are here trying to
deliver service to them but also to contribute to the development and introduction of new
service.
Finally technology is critical to the delivery of an efficient and effective healthcare system
that shares information appropriately and communicates well with patients and others who
are contributing to the care of that individual.
4
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
Introduction
We are now approaching the completion of our first year of working together to form an
effective Multi Speciality Community Provider (MCP). It is worth reflecting on what we have
achieved, what have been the barriers to change and what the opportunities are looking
forward.
This is not intended as to be an annual report but a position statement of where we are now
and to give some clarity about the opportunities and challenges that lie ahead. When you
have been heavily involved in something, it is easy to assume that everyone else
understands what you are trying to achieve. I am often asked to present at meetings and to
describe the work and developments that we are undertaking in our MCP. I am always
surprised as to how interested people are in what we are doing and once I start describing
the various streams of work we are undertaking, I begin to realise how much has been
achieved in a relatively short period of time. This document tries to articulate those
achievements and hopefully inform a wider group than those who have been involved so far.
The Five Year Forward View (5YFV)i was published in October 2014 and was clear that
much had been achieve by the NHS in the past, in terms of improving the populations
health, proving better outcomes for diseases such as cancer and heart disease but to meet
the growing needs of an aging population and the increasing number of people with long
term conditions (LTCs) a change is required in the way care is delivered with a greater focus
on the provision of out of hospital care.
The proposals in the 5YFV were that to enable the providers to deliver “New Models of Care”
should move from commissioning activity using Payment by Results (PBR), which provides
perverse incentives to change, to a system where by the NHS commissions on a population
basis and looks for well-defined outcomes. To achieve this, contracting would need to
change and providers would need to work together in a very different way from how care is
delivered currently. The proposal was that there would be new types of organisation that
should be tested, the most significant being:
1. Multi-Speciality Community Provider (MCP)
2. Primary and Acute Care System (PACS)
The Vanguard programme is the name given to the pilots of MCPs and PACS – in March
2015 it was announced that there would be 29 Vanguard sites, of these there 9 PACS and
14 MCPs. There were originally over 60 areas that bid to become Vanguard pilot sites. We
were chosen as one of the MCP pilot areas.
The Southern Hampshire MCPii (known as Better, Local, Care) included 3 localities, namely
South West New Forest, Gosport and East Hampshire. The intention was that more
5
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
localities would join the programme with the ultimate aim of providing coverage of the whole
of Hampshire within 2 years.
Each locality is seen as being semi-autonomous with a clinical lead, a locality manager,
project manager and administrative support with resources to establish a working group of
clinicians and managers who are expected to work together to transform local services.
The Clinical Commissioning Groups (CCG) are critical in terms of their support and
contribution to the development of new and better services. During the course of the year
the CCG has undertaken some internal restructuring to ensure that they are aligned to the
established MCP and emerging localities.
Southern Health Foundation Trust (SHFT) have been an important partner in the
establishment of our MCP and without the total support of the Chief Executive, Katrina Percy
and the Trust Board we would not have made the significant progress that we have achieved
so far.
For more information click here - https://vimeo.com/161042528
Background Information
The SW New Forest has a population of 70,000, served by 7 practices. All the practices are
actively involved in GP training, and some are involved with undergraduate nurse training
and the teaching of medical students.
Lymington New Forest Hospital moved into a newly built facility in 2007 and offers medical
in-patients, medical assessment unit, elective surgery, out patients, a wide range of
diagnostics (X-ray, Ultrasound, CT and MRI scan) and a minor injury unit. The community
staff largely work within two localities.
In the SW New Forest 31% of the population are aged 65 or over (nationally 17.1%)iii and
5.1% of the population are aged 85 or more (nationally 2.3%)iii . This has a significant impact
on the demand for health and social care. Older people are more likely to have a long-term
condition (LTC) or multiple long-term conditions. People aged 65 or more make up over
60% of all hospital admissions.
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SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
The implications of social determinants of health as define for the SW New Forest by
Hampshire County Council are:






Predominantly white population
Relatively affluent
Lower proportions in education/work
Relative deprivation
Lower levels of deprivation affecting older people but the burden of disease falls
disproportionately resulting in greater need
Variable pockets of social isolation – the aging population and rurality may be
contributory.
The prevalence of Hypertension, Diabetes, Coronary Health Disease, Stroke, Cancer,
Chronic Obstructive Airways Disease (COPD), Asthma, and Dementia is significantly higher
in our area compared to the CCG or England average.
The male life expectancy is 81.5 (England 78.9) and female is 85 (nationally 82.8)iii in West
Hampshire.
Our natural community of care (population 70,000) has an aging population with a lower
proportion of younger people, meaning there are fewer younger people to provide support
for the increasing numbers of elderly people.
The conclusion from Public Health in terms of what needs addressing was:

Aging demographics – promote healthy aging, help retain independence for longer
working with social care.

Higher prevalence of chronic disease – focus on prevention, support active
management of ill health, self-care.

Promoting healthy lifestyle across all ages ensures people have, and continue to
have, good health outcomes and remain independent.

Areas that have high surgical activity – better focus on shared decision-making.

Rural geography – consider alternative community, domiciliary or peripatetic
innovative service delivery, partnership working with New Forest District Council,
involving people and communities designing services.

Whilst this is an aging population with high healthcare needs, need to focus equality
on children and young people.
With these factors it was clear that the Practices, Community staff and the hospital should
work in a far more integrated way and gain engagement from the patients and general
public, Social Care, Public Health and the Voluntary Sector.
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SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
Clinical Engagement
We recognised that we would not achieve much unless we had the clinicians on board. We
therefore established Local Delivery Group (LDG) the full list of members are detailed at the
end of this document. This group is the decision making group locally and has the
responsibility for co-ordinating the transformation and includes GPs, Consultants, Nurses,
Managers and has representatives from the patients, Voluntary Sector and Local Authority.
Meetings have been held with local GPs, Consultants, Nurses and Community Staff. The
overwhelming response has been one of interest and support.
To make a significant difference we needed the support of local GPs and Practices. Effective
change will not be able to be delivered without the engagement and support of the
Community Team, who include Consultants in Care of the Elderly, District Nurses,
Therapists and the Community Mental Health and Older Peoples Mental Health Team. To
deliver out of hospital care at scale, General Practice needs to be central to this. In the past
it has proved difficult for Community Services to integrate effectively at Practice level and
deliver care at scale. New Forest Healthcare Ltd as a provider company whose members
are made up of the 17 local Practices in the New Forest is able to deliver General Practice at
scale. The SW New Forest is very fortunate to have an excellent local hospital in Lymington
and the clinicians have always been an important part of MCP.
The MCP established a Clinical Development Group (CDG) that has a membership drawn
from each of the local Practices, the Community staff, Mental Health, Older Peoples Mental
Health, Lymington Hospital and New Forest Healthcare Ltd, The list of member of the CDG
are detailed at the end of this document.
There have been a number of meetings held over the past year with local clinicians. These
occurred during the development and establishment phase, over the last few months wider
engagement has been achieved through the LDG and CDG and in the various work streams
(see below).
I believe one of the greatest achievements over the last year is how the clinicians (doctors,
nurses and allied health professionals) have either become involved with the MCP or have
expressed their support for the plans for transformation.
This engagement can only be transformed into positive action if supported by the managers
of the commissioners and providers locally. We are very lucky to have excellent managers
in Practices, the Hospital and Community strongly supported by Managers and Clinicians
within the CCG who share and have helped develop the same vision for the future that is
held by the local providers.
Our challenge is now to deliver the vision as we recognise that we have gained the trust of
the clinicians on the basis of delivering a better future for patients and providers alike.
8
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
We recognise that the clinicians are not the only important factor in having an effective MCP
it also requires the active involvement of patients and public, the local authority, the
Voluntary Sector and Public Health.
The Practice – at Lymington New Forest Hospital
The Prime Minister’s GP Access Fund (PMAF)
was originally launched in October 2013 with
£50m being made available to deliver improved
access to general practice 7 days a week
between 8am and 8pm.
New Forest Healthcare Ltd bid for funding from
the PMAF but were unsuccessful.
There were 20 Wave One pilots. The work that was undertaken by New Forest Healthcare
Ltd was not wasted because it was used to develop services that became part of the
Transformation Fund (see later).
In September 2014 the second wave of the PMAF fund was announced and the available
funding was increased to £100m. In the second wave there were 57 successful pilots
covering about 25000 practices and a population of about 18m (approximately 1/3 of the
country).
There are now 7 practices involved in the SW New Forest MCPiv and 6 of the 7 practices
joined together with Southern Health (our Community Provider) and New Forest Healthcare
to bid for funding for the Wave Two Pilot.
We were successful in the bid and the announcement came at about the same time as it
was announced that our bid to become an MCP as part of the Vanguard programme
implementing the New Models of Care was announced.
The Government’s plans for the PMAF were a way to deliver the Prime Minister’s
commitment to provide better access to routine General Practice and for this to be available
over a 7 days period. It is clear that this service cannot be delivered at Practice level and
cannot be delivered without additional funding. It can be delivered at a larger population
level, if adequately resourced. It is believed that by providing better access the demand on
A/E and other hospital-based services will be reduced.
Our final bid locally focused on developing a freestanding service based in Lymington
Hospital. This would be seen as a “branch surgery” of the local Practices and be open 7
9
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
days a week from 8am to 8pm and would be staffed by GPs, Nurses and other Allied Health
Professionals. There would be a mixture of same day and pre-booked appointments.
The critical part of this service is that it remains a branch surgery of the seven local
Practices. This means that there is a feeling of ownership amoungst the Practices. The
technology has allowed the clinician who sees the patient at the Practice to access the full
GP record held by the patient’s own practice and not only view the complete record but also
to write their notes and findings in this record.
The development of this important building block of our MCP was achieved with a huge
amount of unfunded work from all the Practice Managers locally and staff from New Forest
Healthcare Ltd and Lymington Hospital. This service is an important “delivery unit” where
General Practice is required to offer services at scale.
As part of the PMAF all 7 local Practices have moved to the same telephone system. The
VOIP system is an Internet based system and allows calls to be transferred between the 7
Practices and the Practice at Lymington Hospital. This helps facilitate the working together
as a larger unit and means that if for example a Practice is unable to deliver services from
their site this can easily be transferred to another.
Another important aspect of the technology bid for the PMAF was to fund WebGPv. This is a
now called e-Consultation and allows patients to explore self-help, particularly focused on
common illnesses seen in general practice. It also allows patients to explore their symptoms
and sign posts them to the appropriate place to seek help. This may be the Pharmacist or
even online services. In addition it facilitates e-Consultations, patients complete online
information which is then transferred electronically to the there Practice who will respond
within 1 working day. The response may be advice, could be a prescription or could be
offering a face-to-face appointment. Studies have shown that WebGP can reduce practice
workload by up to 10%.
The Practice opened in September 2015, and faced some difficulty in gaining CGC
registration caused largely by this service being new and innovative and CQC not being able
to fit this service into their existing structures. The service has received excellent feedback
from patients as demonstrated via the family and friends test.
In the early days it took some time to establish a workforce of GPs and nurses. There are
now a mixture of GPs undertaking sessions ranging from partners in local Practices,
partners from practices outside the MCP, sessional GPs, younger GPs who have recently
qualified and older GPs who have left their Practices but are not ready to fully retire. For
some there is an attraction to undertake a set 4 or 8 hour session with a well-defined start
and end point, focused on delivering clinical care, with access to the complete clinical record
with no responsibility to manage blood test results, letters, repeat prescribing etc.
10
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
One of the major challenges has been the lack of security in terms of recurrent funding. This
has meant that it has been impossible to establish a permanent workforce.
The Practice currently only has one GP working at a time and therefore can offer
approximately 250 appointments per week. There is no established link with NHS 111, the
Out of Hours Service or the Minor Injury Unit at Lymington Hospital.
The potential for the future
If we are going to deliver out of hospital care at scale then this facility provides the vehicle for
delivering this to our natural community of 70,000 patients. The Practice is an essential
building block for the future for the MCP.
Recurrent funding is required to employ a clinical lead whose responsibility will be to provide
leadership and clinical governance to the service. This will then allow more permanent staff
to be employed. Having one GP working in isolation is far from ideal. The service needs to
be expanded so there are a minimum of 2 GPs working at any one time and this will the
allow for the service to develop into a training practices and attract GP Trainees – which will
add capacity and also enhance the potential of the service.
The original bid included additional clinical staff to add capacity to the service and included
MSK, a Pharmacist and potentially a mental health worker. The MSK service is expected to
start shortly with the Pharmacist being considered later in the year.
The Out of Hours service (OOHs) is under enormous pressure and to gain the maximum
benefit of the OOHs and the service that is delivered by the Practice, there needs to be
greater integration with the services. Currently both services are competing to employ the
same GPs and both see patients at Lymington Hospital in rooms that are in the same
corridor. The Practice having full access to the patient’s practice records and the OOHs
service having no access.
With other localities developing their own MCP there is the potential to establish Lymington
as the central Hub for Saturday and Sunday services.
Lymington Hospital has a well-established, Nurse Led, Minor Injury Unit (MIU). This is open
from 8am – 9pm seven days a week and is located next to the Practice. There is a lot of
commonality between the Practice and MIU. The proposal over the next 6 months is to
integrate the Practice and MIU into a single service using the same clinical record system.
This will allow patients to be managed by the appropriate clinician and also provide greater
flexibility in service delivery.
11
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
There is the potential to develop other services for the local population working on behalf of
all local practices including:
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


A travel clinic
Wound care services
A respiratory Nurse led service to review patients with an exacerbation of COPD.
A childhood immunisation service
To view a short video about the practice please click here - https://vimeo.com/159778092
Transformation Fund
In December 2013 NHS England published its Planning Guidance for 2014 to 2018vi. The
document talked about integrated services and primary care provided at scale and to a great
extent laid the foundation for the 5YFV. Within this document was a commitment to
investing additional funding to support general practice to deliver care to the patients aged
75 and over.
The document states:
“CCGs will be expected to support practices in transforming the care of patients aged 75 or
older and reducing avoidable admissions by providing funding for practice plans to do so.
They will be expected to provide additional funding to commission additional services which
practices, individually or collectively, have identified will further support the accountable GP
in improving quality of care for older people. This funding should be at around £5 per head of
population for each practice, which broadly equates to £50 for patients aged 75 and over.”
West Hampshire CCG has a greater than average % of population aged 65 or more and far
higher % aged 85 or morevii. The SW New Forest has the highest % of the population in
Hampshire aged >65, > 75 and > 85. In England 17.1% of the population are aged 65 or
moreviii in the SW New Forest about 30% of the population are aged 65 or more (close to
twice the national average). It therefore is essential that there are robust services to meet
the needs of this population.
The current funding has been focused on Care Navigators based in each Practice and GPs
are focused delivering enhanced care to the housebound and those who are resident in
Care Homes.
The impact of these services is yet to be evaluated. There has been some difficulty in
recruiting GPs to these roles and some sessions remain unfilled.
12
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
The provision of care to the older persons remains an important part of the MCP. It is also
important to provide services that support general practice to meet the needs of this age
group and ensure its sustainability.
The commissioning of these services was initially CCG wide. With the development of the
natural communities of care there is now a needs to be an alignment of this funding with the
agreed plans of the MCP.
Extended Primary Care Team (One Team)
Many GPs have seen close working relationship with District Nurses disappear as
community services became more geographically rather than Practice based.
Over the last 2 - 3 years there has been a move to create Integrated Community Teams
(ICTs), which include Community Nurses, Therapists, Mental Health and Older Peoples
Mental Health and Social Care.
Yet we know 90% of patient activity occurs in General Practice. To create effective teams
the ICT must involve General Practice.
Some studies have shown that at least 10%
of work undertaken by Community Teams
and General Practice are duplicated and 20 –
30% of visits are undertaken by the wrong
health care professional when there is a lack
of integration between General Practice and
Community Services.
The SW New Forest has a population of
about 70,000 and divides into two natural
localities.
There are two Community Teams who are based in each of the localities supported by a
Single Point of Access.
The challenges and perceived barriers that currently include GPs and Community Teams
working from different sites, lack of face to face communications, increasing communication
using electronic proformas, recruitment and retention of community staff, lack of integration
13
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
of clinical records, Practice and Community Nurses working in isolation, rising workload, lack
of integration with Social Services.
Our aim is to provide services focused on a patient's needs.
We believe this can be achieved by putting the patient at the centre of the provision of care
and removing the artificial barriers that exist between General Practice and Community
Teams.
The basis of this programme is to develop a single team based in a locality that has clinical
and management leadership.
Over a 6 month period, General Practice and the Community Teams have been working
together to create a new structure that is based in a locality and has GP and Community
Leadership and has been empowered to co-design a better service.
What could be different?
•
A common electronic patient record.
•
Stronger clinical leadership – each locality has a lead GP, Community Matron and
Manager.
•
Improved efficiencies – reduced home visiting by Community Staff.
•
Wound Care Clinics – based in the community for mobile and the less mobile
patients.
•
Continence Clinics.
•
Long-term conditions – greater focus on delivering an appropriate service to the
housebound.
•
Creation of a core team that is practice based but also the team is part of a wider
locality based team.
•
Better care for frail elderly at home and in residential care.
•
More confident Community Team including Practice Nurse expertise visiting the
elderly - undertaking chronic disease assessments if needed and linking in to needs
as they arise - not firefighting in crisis
•
Locality based Well Leg Clinics – shown to improve the healing rates and help
address social isolation.
•
Links in with the Wellbeing Cafes run by Age UK with voluntary sector transport and
social signposting.
14
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
Conclusion:
Out of hospital care provided at scale has to start with the registered list but to work
effectively there needs to be critical mass to be able to undertake the work that is needed at
scale.
The extended primary care team needs to be embedded in the practices but will need to be
able to meet the needs of a wider population.
Working as a single team does not mean a single employer but will require a share patient
health record.
Workforce and Skill mix
To provide more care out of hospital we need to maximise the use of the existing workforce
and develop a new workforce that is able to meet the demand of an emerging out of hospital
model. Currently there are more GPs leaving the profession than there are joining. To
make General Practice sustainable we need to address the issue of workload and make
General Practice a better place to work. This can be achieved through the MCP but it is
also essential to look at other healthcare professionals who could play and important role in
providing care in a General Practice setting.
Over the past 20 years the role of the Nurse Practitioner working as an independent
healthcare professional has been well established. Other healthcare professionals who
could play an important role include Pharmacists, Mental Health workers, Physiotherapists
and Paramedics.
Many of these healthcare professionals with suitable training can be a valuable asset
working within General Practice. What has become clear is that they will add some capacity
but their greatest benefit is to the wider system.
15
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
Musculoskeletal Care
An experienced practitioner is providing an MSK service based
in a practice. Patients are offered the option of an appointment
with a GP or with the MSK practitioner.
The aim is to increase the capacity within general practice and
evaluate whether this is a cost effective model that can be
replicated. The practitioner is trained to take a history, examine
patients and make a diagnosis.
They are also able to request and interpret X-rays, MRI and CT scans.
Many physiotherapists reduce their scope of practice as they become more experienced.
They will then focus on the management of a single joint. Some choose to leave the NHS
and move into private practice in order to be able to extend their scope of practice.
The project was seen as a way of developing career opportunities for experience
physiotherapists.
The early outcomes
The data below is a summary of the first 183 patients seen by this service.
OC = referral to orthopaedic dept
GP = returned to GP
16
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
Conditions seen
25
20
15
10
5
0
MSK Data entry – enhanced with the aid of a bespoke template
The templates are designed specifically for the MSK practitioner. This allows easy data entry
into the patient’s GP record.
In addition, the template links to referral forms for investigations and links to self help advice
leaflets.
Patient satisfaction
As part of the pilot it was important to evaluate patient satisfaction.
All patients who were seen were asked to complete a satisfaction survey. There was a 100%
patient satisfaction with the service.
17
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
Patients were satisfied with the outcome; none expressed a view that they would have
preferred to be seen by a GP.
Conclusion:
•
•
•
•
The service was had strong patient support.
Potential improvement in quality was seen
An MSK practitioner can replace some GP appointments therefore adds
capacity.
There are wider benefits to the NHS:
• Reduced physiotherapy referrals
• Reduced referrals to orthopaedic service
• Potential reduction in imaging
• Improvement in self management strategies
Action taken:
The service is going to be reduced at the single practice to one session a week rather than 2
but this will be for 3 hours rather than 2. There will be 4 new sessions introduce at the
Practice in Lymington Hospital to expand the service so that it becomes available to all local
practices.
Potential next stage:
Within out natural community of care there are two localities. We know that MSK services
are under significant pressure both in terms of physiotherapy and orthopaedics. Our
proposal is two consider each of the localities to develop an MSK service lead by and
Extended Scope Practitioner and to include a physiotherapy service. This would be
integrated with the practices and using the same clinical record as the practices.
This would need to be evaluated to establish the benefit for patients and the outcome in
terms of demand on orthopaedic OPD and conversion rates for operation.
For more information please click here https://vimeo.com/159778562
Pharmacists
It is well recognised that Pharmacists have an important role to play in Primary Care ix.
There is significant use of prescribed medicines that is inappropriate, costly, wasted or
causes harm – estimates of 17% of hospital admissions in the >65s have a medicines
related component. Introducing the Clinical Pharmacist role into Primary Care will improve
quality of prescribing, reduce prescribing spend, improve drug monitoring, reduce medicine
related hospital admission amongst >65s, improve prescribing habits within a GP Practice
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Date: April 2016
The costs of the Clinical Pharmacist will be covered by the reduction in prescribing costs
directly – wider savings i.e. hospital admissions will be made however not evaluated by this
project.
Currently we have Pharmacists working in the Hospital, in Community Pharmacies and
working within the Medicines Management Team of the CCG.
The impact a clinical Pharmacist could have working as part of a practice include:

Review of poly-pharmacy and advise on prescription changes – perhaps invite
patients to a review and explain changes to ensure compliance.

Review of prescribing and ensure in line with best practice / local formulary.

Clinics for monitoring medication regimes.

Clinics for patients with long term conditions requiring medication reviews and
compliance checks

Liaison with local pharmacies

Review of nutritional; stoma products etc.

Improve repeat prescribing processes

Care home medication reviews

Opportunities are missed during admission/discharge for integrated medication reviews.

Pharmacists are capable of providing minor illness advice (1 in 5 GP consultations
are for minor illnesses), and potentially capable of independent prescribing with
training
The proposal is to redeploy the CCG Medicines Management Team to become part of the
Practice Team rather than be seen as a CCG visitor who looks at the prescribing of a
Practice and departs leaving the GPs with a list of actions to undertake.
Additional employed Pharmacists who should be prescribers will supplement this resource.
They would initially be hosted by the CCG.
The Pharmacists based in Practices would work closely with the other Practice based
Pharmacists and with the Community and Hospital Based Pharmacists.
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Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
The short term outcome that are expected include:





Reduce prescribing costs
Reduce number of medicines being prescribed
Provide alternative capacity to GP for medication reviews, the management of LTCs,
drug monitoring
Reduce number of medication errors
Increase compliance with formulary
The medium term outcomes would include:


Release sufficient costs from prescribing budget to increase provision of clinical
pharmacist across locality
Increase number of clinical pharmacists that prescribe through training associated
with this work
The Practice based Pharmacists would provide some much needed capacity within General
Practice but the will not replace a GP, they could release valuable time. Their wider benefit
is in terms of reducing prescribing costs, reduction in poly-pharmacy, reduced Hospital
admission; it is therefore the local health system that benefits – hence why this is an
important component of our MCP.
It is estimated that there would need to be an annual saving of £200,000 to fund these
proposals. This is less than 2% of the total prescribing budget for the MCP.
End of Life Care
One of the factors that define a civilised society is how we care for those in our community
who are reaching the end of their life.
In the South West New Forest community, we have high quality general practice that put a
high priority on the provision of end of life care. The community nurses also provide
valuable help and support to those who require this. This is supported by our local hospice,
Oakhaven. It is however it is often the case that the Practice, the Community Teams and
the specialist Palliative Care services from Oakhaven are all involved in the care of
patients. But all too often these services are provided in isolation are not integrated; each
provider developing their own care plans and co-ordination of care can be inconsistent.
The key step change is that the 3 separate and independent providers contributing to care
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Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
are looking at ways to develop methods of co-ordination, communication and redefine
responsibilities; to improve EoLC in the SWNF. Essential working as a single team.
A significant step forward will be the creation of a common health record between the 3 TPP
SystmnOne Practices in New Milton, the Community Team in New Milton who have moved
to the Community version of TPP and Oakhaven who are about to move to the Palliative
Care version of TPP.
The MCP has established a “Task and Finish Group” to include the hospice, the Community
Team, General Practice and the Commissioner. The aim is to improve end of life care by
evaluating what is already in place and to develop better ways to co-ordinate care through
collaborative and more integrated working between teams offering end of life care services
(enhancing specialists skills). Expanding the service.
Provision and accessibility of end of life care staff to all with end of life care needs (improving
twilight hours provision and management of ‘just in case medication’; prescribing and
administering).
In late 2015 a new Guidelinesx were published by NICE for End of Life Care, the main
recommendations include:
•
•
•
Recognising when someone is in the last days of their life
Patient discussing and planning care
Help to stay comfortable and managing
o pain
o breathlessness
o nausea and vomiting
o anxiety, delirium and agitation
To manage current medication.
Adequate provision of “Just in Case Medication”.
For this national policy to have any impact it has to gain local ownership. This can be
achieved through the MCP.
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Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
Frailty
With one of the greatest concentrations of older people not only in the UK, but also in
Europe this is a very important area for the MCP. The UK has 17.5% of the population aged
65 or more the SW New Forest has close to 30% of the population who are aged 65 or
more. Of the 50 practices within West Hampshire CCG the 7 SW New Forest practice all
come in the top 8 in terms of the % of the practice population who are aged 85 or more.
It is well known that older patients will consult their GP more often the average being 5.6
times a year rising to > 12 times a year for people aged 85 or more. There are about 1.5m
people in the UK who are aged 85 or more (about 2.2% of the total population). The local
practices have between 4-6% of their registered population who are aged 85 or more.
A higher % will be housebound and be reliant on social care. In addition the rate of
admission to hospital will be higher and if an in-patient for more than 48 hours then the
length of stay increased significantly.
Older people are the main users of health and social care services; approximately 10 per
cent of people aged over 65, and 25 to 50 per cent of those aged over 85, are living with
frailty. Research suggests that only half of older people with frailty syndromes receive
effective health care interventions.
Too often, long-term conditions strategies have tended to focus on single conditions,
whereas most people over 75 have a number of conditions and want to be treated as an
individual who needs coordinated, person-centred care rather than as a collection of
diseases. These strategies frequently ignore common conditions associated with ageing
and, in particular, fail to mention the unique challenge of frailty. Older people who are frail
often require a different level and type of support to those who are younger and fitter.
It is estimated that 9% of patients aged 75 or more have frailty and this increases to between
25-50% in those aged 85 or more . People with frailty have a substantially increased risk of
falls, disability, long-term care and death. We also know that frailty is a graded abnormal
health state which ranges from the majority who are mildly frail and need supported selfmanagement, through those who are moderately frail and would benefit from interventions
such as case finding/case management, to those who have advanced frailty where
anticipatory care planning and end-of-life care may be appropriate interventions.
We know that in the SW New Forest, we have a high elderly population with a far higher
than average % of the population who are aged > 75 and > 85, it is therefore reasonable to
conclude that we have a higher % of the population with mild, moderate and severe frailty.
The MCP has been developing work streams for frailty in several themes, which together will
provide a whole service.
With regards to proactive care we need to consider different strategies for mild, moderate
and advanced frailty. For mild frailty – the MCP is working closely with the Local Authority
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SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
and the Voluntary Sector to create a database of services and self help tools to maintain a
good general state of health by remaining active and preventing the decline towards
moderate or severe frailty. It is hoped this web-based resource will include a selfassessment tool for the general population with a signposting advice tailored to the individual
assessment results.
For moderate frailty, work is ongoing looking at how care planning and case management
will fit into our everyday work, although we expect that the proposed acute frailty intervention
team (AFIT) -see detail below - will capture some people and start the process off.
Many people with advanced frailty reside in care homes – several streams of work are being
initiated- looking at detailed escalation planning and examining the role of regular visiting in
care homes.
Proposed new frailty service- the Acute Frailty Intervention Team (AFIT).
It is common for GPs to be asked to visit elderly patients who have “gone off their legs”, had
a fall, aren’t coping well or are confused – so-called ‘decompensated frailty
syndromes’. Sometimes these issues are addressed using an incomplete medical model
and sometimes the person may be admitted to hospital often because an alternative
pathway is too difficult to access.
The unique nature of our proposed frailty team for patients with decompensated frailty is
developing local expertise drawing on existing knowledge from a variety of backgrounds (
i.e. not just geriatricians but all the other professions who already deal with a lot of older
people in their day to day work) in the expectation that the result will demonstrate a synergy
which is far in excess of the sum of the parts. For this reason we are also seeking support
from Health Education England (Wessex) for workforce development. The aim is to set up a
dedicated Frailty Team for the locality that will include Geriatricians, GPs, Frailty
Practitioners, doctors in training, Community Nurses, Therapists and Ambulance staff and
would involve social workers.
The service will take referrals from practices or other appropriate sources. Patients will be
triaged using the relevant expertise( i.e. not just using doctors but the specialist skills of the
ambulance service for example). This could then result in a package of care being delivered
at home, could result in some time spent at the local Ambulatory Care Unit for further
assessment or if required the person could be admitted to hospital.
The person if required on going input from the Frailty team would be added to the AFIT
“Virtual Ward” for a period of up to two weeks after which a comprehensive geriatric
assessment will ensure appropriate ongoing support.
The Frailty team will have full, access to the GP records and make their notes in these
records.
The Acute Frailty Intervention Team brings together health (primary and secondary care);
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SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
social and emergency services functions in a unique combination to deliver more appropriate
and timely care without denuding existing services. Working as a single virtual team with
shared aims is expected to break down traditional barriers. This will provide opportunities for
learning and the development of new pathways to support older people with frailty at home.
This approach provides a much needed third option for clinicians and emergency services to
call upon when they encounter patients with decompensated frailty - no longer a decision
between EITHER continue in primary care OR refer to secondary care, but the option of
coordinated, enhanced out of hospital care.
Some people with frailty will still need hospital admission; therefore another work stream
involves our local hospital, where we are also reorganising the in hospital management
of frailty to ensure that it properly reflects the priorities of care and recognises the role the
hospital plays in the whole pathway.
Mental Health
Mental health problems are widespread, at times disabling, yet often hidden. People who
would go to their GP with chest pains will suffer depression or anxiety in silence. One in four
adults experiences at least one diagnosable mental health problem in any given year.
People in all walks of life can be affected and at any point in their lives, including new
mothers, children, teenagers, adults and older people. Mental health problems represent the
largest single cause of disability in the UK. The cost to the economy is estimated at £105
billion a year – roughly the cost of the entire NHS.
There is now a need to re-energise and improve mental health care across the NHS to meet
increased demand and improve outcomes.
Mental health accounts for 23 per cent of NHS activity but NHS spending on secondary
mental health services is equivalent to just half of this.
People facing a crisis should have access to mental health care 7 days a week and 24 hours
a day in the same way that they are able to get access to urgent physical health care.
Getting the right care in the right place at the right time is vital.
People want care in the least restrictive setting that is appropriate to meet their individual
needs, at any age, and is close to home
“Making physical and mental health care equally important means that someone with a
disability or health problem won’t just have that treated, they will also be offered advice and
help to ensure their recovery is as smooth as possible, or in the case of physical illness a
person cannot recover from, more should be done for their mental wellbeing as this is a
huge part of learning to cope or manage a physical illness.”
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SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
We recommend eight principles to underpin reform:
• Decisions must be locally led
• Care must be based on the best available evidence
• Services must be designed in partnership with people who have mental health problems
and with carers
• Inequalities must be reduced to ensure all needs are met, across all ages
• Care must be integrated – spanning people’s physical, mental and social needs
• Prevention and early intervention must be prioritised
• Care must be safe, effective and personal, and delivered in the least restrictive setting
• The right data must be collected and used to drive and evaluate progress
In January 2016 the Prime Minister announced £1bn investment in mental healthxi. This
included the following commitments:




£290 million to provide specialist care to mums before and after having their babies
First ever waiting time targets to be introduced for teenagers with eating disorders and
people experiencing psychosis
Nearly £250 million for mental health services in hospital emergency departments
Over £400 million to enable 24/7 treatment in communities as safe and effective
alternative to hospital
Over £400 million for crisis home resolution teams to deliver 24/7 treatment in
communities and homes as a safe and effective alternative to hospitals
Crisis resolution and home treatment teams have been introduced throughout England as
part of a transformation of the community mental healthcare system. They aim to assess all
patients being considered for acute hospital admission, to offer intensive home treatment
rather than hospital admission if feasible, and to facilitate early discharge from hospital. Key
features include 24-hour availability and intensive contact in the community, with visits twice
daily if needed.
As Southern Health not only provides community services they are the provider of mental
health services.
We are looking primarily at enhancing care, treatment and the development of crisis plans in
a primary care setting:
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SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
Model 1: Imbedding and Integrated Mental Health Team:
Patients with emotional instability, who present with recurrent episodes of crisis, with social
issues that do not meet the criteria for CMHT or have been discharged from CMHT (due to
non- engagement or after completing an episode of treatment with CMHT and further
involvement at this point with CMHT deemed not beneficial).
a. This group of patients takes up considerable amount of GP time as well as
emergency services involvement.
b. Currently there are no readily available therapeutic interventions/support in the
community that are able to consistently meet this need
Model 2: Vulnerable High-intensity users – with no current access to services:
Patients with a psychotic illness who are stable on depot medication and whose physical
health needs are greater than their mental health needs. From a patient care perspective,
their needs are not being met in the current system:
They do not overtly take up GP time like the other group, but they do not attend reviews for
their physical health (nor do they consistently look after their physical health) and therefore
in the longer term, this has an impact on the GP time required to address their physical
health as a result of their lifestyle, medication, illness etc. (smoking, diet, sedentary lifestyle,
obesity, diabetes…).
The T&F group will look at increasing the time mental health specialists can spend in the
community, by arranging for depot injections, annual health checks (bloods, feet, blood
pressure, smears, cholesterol, med review) for people whose mental health is stable to take
place within primary care.
Management of Long Term Conditions and De-layering Specialist
Services
Over 15 million people currently live with one or more LTCsxii and this is expected to
increase to 18 million by 2018. The most common of these are Diabetes Mellitus,
Hypertension, Chronic Obstructive Pulmonary Disease and Arthritis.
The number of people with three or more LTCs is predicted to rise from 1.9 million in 2008 to
2.9 million in 2018xiii.
It is estimated that 70% of the NHS budget is spent on managing LTCsxiv and much of this
work is carried out by general practice that receive less than 8% of the total NHS budget.
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SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
A new approach is therefore required to managing LTCs with greater emphasis on self-care
and self-management, critically looking at how individual conditions are best monitored and
managed, developing greater capacity with an appropriate skill mix.
Diabetes Mellitus
In 1996 there were 1.4 million diabetic patients in the UK, this has now increased to over 4
million.
The current spend on diabetes in UK is £10bn or 10% of the NHS budget which equates to
£2800 per diabetic patient. The vast majority of this spend is Hospital based and treated the
avoidable complications of diabetes. Diabetic patients are 35% more likely to die at a
younger age than their peers.
A programme in Tower Hamlets focused on producing better outcomes for patients and
invested in General Practice, particularly focusing care on attaining blood pressure, HBa1c
and cholesterol targetsxiv. This has made a significant impact on reducing complications,
esp. the incidence of stroke.
With the increasing prevalence of Diabetes, the aging population, the retirement of Practice
Nurses with a special interest in Diabetes, the lack of investment in General Practice
Diabetic services all mean the current model is not sustainable.
The Quality and Outcome Framework was a useful tool when introduced to reduce variation
and improve quality. It has now reached the end of its useful existence and needs to be
reformed.
We believe we should divide our population into the needs of the individual. They would
naturally fall into three groups. (Children excluded, as they are a special group).
Group 1: Patients who have complex needs or complications (higher % of Type 1 Diabetics).
Group 2: Patient where the aim is to control symptoms rather than achieve strict control as
this will not improve the outcomes (e.g. elderly)
Group 3: The largest group where active management esp. of BP, Cholesterol and HBa1c
will improve life expectancy and reduce complications.
The proposals is that the population is risk satisfied into one of these groups and their
monitoring and management is tailored accordingly.
Our proposal is to recruit addition Health Care Assistants who can perform much of the
monitoring and which will assist in terms of the active management of patients.
The current Diabetic service delivery is fragmented between the hospital based care,
community care and general practice based. There is duplication in the provision of service
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SW New Forest Multi Specialist Community Provider:
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Progress Report
Date: April 2016
between the hospital and general practice. In addition housebound patients often receive
sub-optimal care.
Our proposal is to work with local Practices and the Community Diabetic Service to produce
a new service that is either based in a practice or within a locality. The team would include a
Consultant, GPs, Specialist Nurses, Practice Nurses and HCAs and could include
Pharmacists. To improve community training and adding capacity to this service it could
include GP trainees and also Specialist Trainees.
Practices have largely moved from a GP delivered monitoring and management service to
one that is largely delivered by Diabetic trained Practice Nurses. Many of these Nurses will
be impossible to replace. It is therefore essential that we develop a workforce that consists
of HCAs, Diabetic trained Nurses and Specialist Nurses.
There should be a common management plan that is owned by the patients and is produced
once and shared across all healthcare professionals. There should be data entered on one
system and this should be the patient’s GP record. (The whole team would have access to
these records).
Patient empowerment is often talked about but rarely delivered. We need to help patients
take more responsibility for the LTC and improve the knowledge by education. The use of
Apps is actively being explored.
Respiratory Services
There is above average prevalence of respiratory disease in the New Forest. The largest
component of this being asthma and COPD but interstitial lung disease and cancer of lung
are also relatively common.
There are 4 Consultants based in Lymington providing general respiratory services who also
provide specialist care in airways disease, interstitial lung disease and cancer. The CCG
has also commissioned a community based respiratory rehabilitation service. Many
practices have nurses who have an interest in respiratory disease and some also have GPs
with an interest.
A study carried out by the local Academic Health Science Network (AHSN) has shown that
there are a number of patients with undiagnosed respiratory disease and some who have
the wrong diagnosis, which may be related to the quality of respiratory function tests and the
interpretation of these tests.
The MCP is keen to build on the work that has been carried out in this study.
The NHS has traditionally measured care by counting activity and funding has followed this
model. This provides a perverse incentive to change the model.
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SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
If we look at our natural community of care there will be a well-defined prevalence of
respiratory disease, the resources to manage these patients include the hospital, community
staff and general practice. Could we use these resources more effectively? What about
patient self-management and the use of other resources such as the Voluntary Sector or
technology?
Pilot about to commence
Patients are referred to a Respiratory Consultants for an opinion in terms of on-going
management. Often the GP needs advice rather than the patient needing to be seen. In
addition, Choose and Book patients frequently end up not being booked to see the most
appropriate respiratory consultant.
There will be a template created initially in TPP SystmnOne (if successful it will be replicated
for the EMIS practices) that will allow the GP to construct a referral to the Respiratory team –
this will extract from the GP records, demographic details, relevant past medical history,
medications, measurement (height, weight, BMI, blood pressure, blood tests, X-rays,
specialist investigations and respiratory function tests). The GP indicates whether they are
seeking an OPD appointment, advice (which can be emailed back) or a telephone or Skype
conversation about the patient.
The document is emailed to a specific email address managed by the Respiratory team. It is
hoped that this will reduce the number of patients that need to be referred, improve the
quality of the service and ensure the patient is seen in the correct clinic.
Ultimately within the MCP we would like to explore community based respiratory teams
based in each of the two localities, using the patient’s GP record and the primary clinical
record.
Patient and Public Engagement
An important part of developing services to meet the needs of patients within the natural
communities of care is the engagement with patients and the wider engagement with the
public.
Each practice has a Patient Participation Group (PPG). Lymington New Forest Hospital and
the Community have a League of Friends. The public and patients also contribute to the
commissioning of services in the area.
There are two representatives from the PPGs who contribute to the work of the LDG and the
CDG.
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SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
The PPGs are proving to be a powerful voice of the patients and are helping to shape local
services. They PPGs helped with the production of the submission for transformation
funding and played a critical part by expressing the patient voice.
Each Practice has a Patients Charter and although these are similar in contents, the PPGs
have identified that there are some differences. The PPGs from each Practice are committed
to work together to produce a single Charter to cover all local Practices.
For a view of a Chair of the PPGs – click here - https://vimeo.com/157456412
The Community Engagement Group has been established to help with the engagement with
the public and patients. This group is chaired by one of the PPG members and plays an
important role in working with the voluntary sector and critically encouraging the population
to take responsibility for their own health and well as engaging effectively with local
healthcare system.
Patient activation
Patient activation is a measure of a person’s skills, confidence and knowledge to manage
their own health. It’s simple to find out, like measuring blood pressure, and is scored from
one to four.
Patient activation can be used to reduce health inequalities and deliver improved outcomes,
better quality care and lower costs.
Social Prescribing
In 2015 the Secretary of State said:
'We need to empower general practice by breaking down the barriers with other sectors,
whether social care, community care or mental health providers, so that social prescribing
becomes as normal a part of your job as medical prescribing is today.’
There are some excellent examples around the country of Social Prescribing such as in
Bromley-by-Bow Centre in Tower Hamlets, where by the Clinicians can access over 1,000
voluntary sector organisations. With the workload issue that faces General Practice we are
keen to embrace Social Prescribing but are also keen to explore ways that patients can be
signposted to services without having to see a GP.
The MCP is working with Hampshire County Council to procure a new database that will
enable Social Prescribing to be achieved and to signpost people to local service.
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SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
The conclusions of a recent King’s Fund Report concluded:

Patient activation is a better predictor of health outcomes than known sociodemographic factors such as ethnicity and age.

People who are more activated are significantly more likely to attend screenings, checkups and immunisations, to adopt positive behaviours (eg, diet and exercise), and have
clinical indicators in the normal range (body mass index, blood sugar levels (A1c),
blood pressure and cholesterol).

Patients who are less activated are significantly less likely to prepare questions for a
medical visit, know about treatment guidelines or be persistent in clarifying advice.

Patient activation scores and cost correlations show less-activated patients have costs
approximately 8 per cent higher than more-activated patients in the baseline year, and
21 per cent higher in the subsequent year.

Studies of interventions to improve activation show that patients who start with the
lowest activation scores tend to increase their scores the most, suggesting that
effective interventions can help engage even the most disengaged.
Creating a Common Health Record
Over the last 25 years records in General Practice have been transformed with the
introduction and development of the electronic patient record. The GP record is generally
the most comprehensive and detailed of all clinical records. Hospitals and Community
Providers generally have less detailed records and all to frequently even within a single trust
the records are fragmented.
For some patients there may be several healthcare professionals who are involved in the
provision of care, each having their own unique records. This can lead to duplication and
ineffective use of our most valuable resource, namely people. One of the core principles of
the Multi-Speciality Community Provider is to create a common health record to enable
primary care (GPs and Community Staff) to work as a single team with a shared record –
better for patients and better for staff.
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SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
What are the problems?
Currently the are 4 practices that use TPP SystmnOne, and 3 that use EMIS Web. When
Avon Valley join this will increase to 7 TTP SystmnOne and 4 EMIS web. The Practice at
Lymington Hospital is using the Community version of TPP SystmnOne and because of the
difficulty with interoperability with EMIS web there is a version of EMIS in the Practice to
allow full read write access to all practice clinic al records.
Oakhaven Hospice are about to move from paper records to the Palliative Care version of
TPP SystmnOne and will therefore be able to create a single record with the TPP practices
and enable internal messaging between Oakhaven and the practices. The Community staff
use a software system called Rio. This was a free system provided to all Community and
Mental Health Trusts. This has been developed into a second version, which Southern
Health are currently using. Currently Rio does not have the functionality to create a common
health record.
In New Milton the Community Team have started a pilot whereby they have moved to the
Community version of SystmnOne and are therefore able to create a common health record
with the 3 local practices (all using TPP) and Oakhaven.
In 2013 TPP launched an Electronic Patient Record Corexv (EPR), which allows hospital
trusts to access patient records from across the country. The solution will allow trusts to
become paper-lite and securely share patient data – irrespective of where that data is
held. This solution is currently being evaluated with the intention of installing this at
Lymington Hospital.
Arden’s Templates
The MCP has secured funding for to install Arden’sxvi templates, which is currently being
used by over 100 practices and population of 1,000,000 patients. This will allow a consistent
approach to data entry and provide support and tools to clinicians and for example:
•
•
•
•
•
•
•
•
•
•
•
Consultations and care plans
Patient diaries, scores and screening tools,
Diagnostic and referral criteria
Procedures and consent forms
General formularies and drug monitoring
Local enhanced service templates
Local lifestyle referral forms
Local referral safety net letters
Local address book
Local referral forms and 2WW
Development of a local reporting feature
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SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
The MCP is exploring the potential for interoperability and enhanced functionality with EMIS
Web whilst trying to show proof of concept with TPP.
Data sharing to create a common health record
It is important when sharing patient information it is done with the law and the appropriate
consent is gained. Under the Caldicott principles – “the appropriate sharing of data for the
provision of direct care for patients should be the rule not the exception.” It has been
difficult to gain clear advice from the Information Commissioners Office about how this might
work practically. This advice received recently from the Information Commissioner’s Office
has been very helpful and this has allowed us to develop this line of work.
The solutions
To write to every patient to explain how patient records will be shared would be a time
consuming and costly process. Money would need to be diverted from patient care to fund
this.
Our plan is to provide information for patients:
•
•
•
•
•
•
•
•
On the Practice website
In practice booklets
As posters in practices
Leaflets available in practices
Clear instructions on how to opt out
Engagement with local media
Messages on prescriptions
New consent process when patients register with the practice
All providers involved in the sharing of patient information have signed a Data Sharing
Agreement
There is a common set of leaflets, posters etc. that have been shared across all practices.
33
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
Providing the best possible care for our patients will inevitably mean that the sharing of
clinical information is important.
The creation of a common record has to be the best way to provide the safest and most cost
effective care – it is better for the patients and better for the clinicians.
It is also important that patients have the choice not to share this information for those who
do not want this to happen.
Teaching and Training
As we are developing services in the community and try to reduce the dependence on
hospital-based service, we need to ensure the sustainability of General Practice by retaining
the workforce and recruiting a new workforce by offering a variety of roles.
We now have 4 GP trainees who as part of their training have been offered a post that
includes some general practice and the ability to work alongside community-based
specialists in diabetes, respiratory care, musculoskeletal, frailty and pain services. This has
the advantage of adding capacity in the community and evolves the thinking in terms of
managing urgent care and long-term conditions.
The Primary Care Access Centre needs to expand the number of GPs who provide sessions
in the service and then this will allow the development of training. With the difficulty of
obtaining time for GP Registrars to complete their Out of Hours requirement the PCAC could
be used for this purposed.
Challenges
Over the last 12 months there has been considerable progress. The most striking
achievement has been the clinical engagement with GPs, Community Consultants and
Clinicians based at Lymington Hospital sharing a common vision for the future. This will
mean building on the current strength of our local healthcare system but recognising the
need for change.
The funding that has received through the New Models of Care has helped fund clinical and
managerial time and enable to establishment of a local structures to bring providers together
to improve care for patients.
There has not been a problem in terms of gaining clinical engagement or ideas on how care
can be improved. The biggest challenge has be the lack of recurrent funding for service
development.
34
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
The CCG faces a financial deficit because of an overspend in hospital based services. This
has meant that it has been very difficult to make any radical change in current service
provision, as the current system of payment by results proves too difficult to achieve change.
It has also been difficult in terms of aligning the CCG’s commissioning plans with the MCP’s
plans. This is a particular problem when working within a large CCG where the MCP only
covers a part of the CCG.
The NHS uses activity data as a measure of quality and performance, in many cases it is
neither. If the NHS is to become more efficient and effective we must use relevant
information and that which is collected for clinical purposes.
The Future
The greatest frustration of the last year has been the amount of time and the barriers that
exist in terms of implementing change. This has to be a focus for the next year.
Accountable Care Organisation
Over the last 12 months 7 practices in the SW New Forest has been working closely with
Southern Health FT and the GP provider company. This has achieve a significant amount
but we are reaching the point whereby we need to establish a joint venture that is a
recognised legal entity to enable the delivery of services. The ACO would be clinically led
and allow practices to remain independent but play a role within the ACO or to be within the
ACO in a new model of provision.
Employed model
GP colleagues in Gosport have found it difficult to recruit new GPs, this has led to practices
deciding that they cannot continue as a Partnership with the risks associated with premises,
employing staff and trying to provide a service with insufficient GPs to meet the clinical
demand. Southern Health have temporally taken responsibility for the premises, employ the
practice staff, have employed the GPs and as they now work for the Trust they get NHS
Trust Indemnity instead for having to pay for the level of medical defence that GPs working
in an independent practice have to. The Trust has also provided other clinicians to work in
the Practice including a physiotherapist, mental health worker and they are also considering
the use of a pharmacist. This has in a short time improved the conditions for the GPs
working in the Practice and they have now been able to recruit new GPs.
Three other Practices in Gosport are considering following the same model. There is a
possibility that the majority of Practices in Gosport will choose to work in an employed model
in the next year.
35
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
Southern Health FT is temporarily employing the GPs with the expectation that an ACO
covering this area could ultimately hold the practice contract and employ the GPs.
This model could be used in other areas and therefore all parts of the MCP are supporting
the development.
Commissioning for outcomes
Many would agree that the current system focuses too much on activity based in a single
organisation rather than delivering the best outcomes for an individual or a wider population.
Commissioning for outcomes will help the collaboration between providers and stop some of
the perverse incentives that exist in the current system.
Population based contracts
This will allow natural communities of care to work together in a more collaborative ways and
support the formation of joint ventures where this is seen as appropriate. This development
is essential to the changing mind-set moving away from some of the current measurements
of quality being based on activity to true improvements in the health of populations.
MCPs working together
Each natural community of care needs to have ownership and have the ability to make
decisions and have a sense of ownership and self-determination. The model that is evolving
in Hampshire is to have these 12-15 natural communities of care that share ideas and
enable joint working but have a larger supporting network that allows the elements of
delivery that is required to be done at scale to be undertaken.
Conclusion
There has been a significant amount of progress in a relatively short period of time. This has
been achieved by a significant amount of work by a wide range of people some who are
directly involved in the MCP but many who are not. Clinical engagement has been really
important but so has the support we have received from Practices, Southern Health
Foundation Trust, the local Patient Participation Groups, the Voluntary Sector, the Local
Authority and the national New Models of Care Team.
This year has given us the potential to achieve so much over the next year but to achieve
this we will require continued engagement, the willingness to do things differently and
additional resources.
36
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
Members
Locality Development Group
Members
Dr Nigel Watson, GP Arnewood Practice – Chair
Dr Sally Johnston, GP Chawton House Surgery – Vice Chair
Dr Peter Hockey, Clinical Director, Lymington Hospital
Dr Kate Fayers, Consultant Community Diabetologist
Julia Lake, Head of Nursing and Allied Health Professionals, Southern Health FT
Andy Lopez, Director New Forest Health Care Ltd
Sara Robinson, Practice Manager
Laura Rotheray, Locality Manager (Nurse by background)
Dr Tim Cotton, Vice Chair West Hants CCG
Rachael King, Assistant Director West Hants CCG
Ian Cross, Hampshire County Council
Co-opted
Dr Will Howard, GP New Milton health Centre
Dr Matt Davies, GP Central New Forest Practice
Other attending the open meeting
Michael Clowes, Voluntary Sector
Mike Hodges, Patient Participation Group
Roger Hills, Patient Participation Group
Clinical Development Group
Chaired by Dr Sally Johnston
Representative from each of the participating practice
CCG representative
Practice Manager
Consultants from Lymington Hospital
Mental Health Consultant
Representative from New Forest Healthcare Ltd
Locality MCP General Manager
37
SW New Forest Multi Specialist Community Provider:
Author: Dr Nigel Watson MBBS FRCGP
Progress Report
Date: April 2016
i
www.england.nhs.uk/ourwork/futurenhs/nhs-five-year-forward-view-web-version/5yfv-exec-sum/
ii
www.betterlocalcare.org.uk
iii
Health and Social Care Information Centre, National General Practice Profiles – PHE 2015
iv
Practices involved in the SW New Forest MCP:

The Arnewood Practice

Barton and Webb Peploe Surgery

Central New Forest Medical Group

Chawton House Surgery

Lyndhurst Surgery

New Milton Health Centre

Wisteria and Milford Surgery
v
www.webgp.com
vi
https://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf
vii
http://www.westhampshireccg.nhs.uk/downloads/1025-whccg15-026-b-revised-strategic-plan-2014-19-and-operating-plan2015-16/file
viii
http://webarchive.nationalarchives.gov.uk/20160105160709/http://www.ons.gov.uk/ons/dcp171776_377047.pdf
ix
www.england.nhs.uk/2015/07/pharm-supp-gp-surgeries/
x
www.nhs.uk/news/2015/12December/Pages/New-guidelines-on-end-of-life-care-published-by-NICE.aspx
xi
www.gov.uk/government/news/prime-minister-pledges-a-revolution-in-mental-health-treatment
xii
www.kingsfund.org.uk/time-to-think-differently/trends/disease-and-disability/long-term-conditions-multi-morbidity
xiii
Department of Health (2012). Report. Long-term conditions compendium of Information: 3rd edition
xiv
www.londonscn.nhs.uk/wp-content/uploads/2015/06/dia-moc-toolkit-062015.pdf
xv
https://www.tpp-uk.com/latest-news-stories/tpp-launch-epr-core
xvi
www.ardens.org.uk
38