The Leeds Plan

The Leeds Plan

Page 1 Delivering the GP Forward View in Leeds DRAFT v0.22 7 December 2016 NHS Leeds North Clinical Commissioning Group NHS Leeds South and East Clinical Commissioning Group NHS Leeds West Clinical Commissioning Group Page 2 Draft. Version 0.22| 7/12/16 Delivering the GP Forward View Contents: 1. 2. 3. 4. 5. Introduction 3 Vision for general practice 2 What will be different when we achieve our vision 5 Collaborative working across general practice in Leeds Ambitions for delivery 1. Ambition 1 - Supporting and growing the workforce 7 2. Ambition 2 - Improving access to general practice 12 3. Ambition 3 - Transforming estates and technology use 15 4. Ambition 4 - Better workload management 21 5. Ambition 5 Redesigning care delivery 25 4 6. Ambition 6 - Investment and resourcing general practice and primary care 33 6. Engagement37 7. Risks and mitigation 39 8. Governance 41 Delivering the GP Forward View in Leeds Page 3 Draft. Version 0.22| 7/12/16 1. Introduction Welcome to our General Practice Forward View (GPFV) delivery plan for Leeds. Our starting point is a recognition that a good standard of primary care is already being delivered across large parts of the city. We recognise the unique strength of general practice in providing continuity of care for patients through the registered list and that the public relies on primary care services for the health and wellbeing of themselves and their family. We recognise this as one of the great strengths of the NHS if general practice fails, the NHS fails. In the current environment of increased demand and finite resources, patients and professionals need to think creatively about how and why services are delivered and used in order to sustain and transform high quality general practice. Our plan is set in the context of the West Yorkshire and Harrogate Sustainability and Transformation Plan (STP) and the Leeds Plan (figures 1 and 2) both of which set out the vital role that general practice will play in achieving sustainability across the whole health and social care system. Put bluntly unless we are able to transform the way in which primary and community services are commissioned and provided, we will not deliver the STP or Leeds Plan. This GPFV delivery plan describes the steps we will take, in partnership, with the 105 general practices across Leeds, to build on the many existing approaches to collaboration and service integration - using the GP registered list as the cornerstone to ensure: Figure 1 Tests and cross-cutting programmes within the Leeds Plan Patients will have an increasingly improved experience of using GP services; Patients will be increasingly involved in managing their own care and experience better health and wellbeing outcomes; The Leeds pound invested in general practice will be used to better effect for maximum impact and gain; The overarching aim of system change to support people to stay in their own homes, families or community and that people will only spend time in hospital or residential care when needed; The move to a system-wide population health management approach that secures collaborative and integrated ways of working though new models of care based around general practice; Staff working within general practice will feel supported and confident with the vision of where general practice is going and how it will feel in the future. We have recognised the challenges and risks in responding to this ambitious agenda and have committed to work collectively in Leeds to bring about the transformation of general practice through workforce development; reducing the workload; environmental and technological improvements in infrastructure; redesigning care including population health accountability; using available investment and aligning system incentives. We have articulated the work required to achieve our ambition through six ambitions for general practice described in detail in the following slide. The primary care transformation initiatives and models of care described within the GPFV

delivery plan underpin the delivery of the Leeds Plan. Figure 2 Annotated Leeds Plan on Page to demonstrate links to GPFV Delivery Plan Page 4 Draft. Version 0.22| 7/12/16 2. Vision for general practice Our Six Ambitions for general practice by 2020/2021 across Leeds are to: 1. Ensure there is a motivated, engaged, integrated and healthy workforce with the right skills, behaviours and training, available in the right numbers. 2. Ensure all patients registered with a GP in Leeds: - understand how, when and are able, to access routine and urgent primary medical care when needed; and - are empowered to manage their own conditions to live fulfilling lives in their community. 3. Fully use and prioritise our collective estates and technology resources we have available to improve the quality of primary medical care and New Models of Care experienced and delivered by patients and professionals. 4. Free up more time in general practice to plan and deliver better care for patients and professionals by streamlining workload in primary care and between different care providers. 5. Redesign the way care is delivered by progressing a whole system model which focusses on a place-based approach where everybody has a part to play, both citizens and services together. 6. Increase the investment and resourcing into general practice and primary care through maximising funding opportunities Underpinning principles The three Leeds CCGs will work, with one commissioning voice, to achieve these ambitions by: Working with patients, practices and partners to be a constant listener and to ensure implementing our ambitions responds to local needs. Working with commissioning partners and key local providers to align local contracts and incentives to deliver the priority health and wellbeing outcomes for populations in Leeds. Improving the quality and efficiency of general practice through greater working at scale. Supporting general practice to establish their Provider Voice across the city as a key provider of New Models of Care. Fully using our delegated commissioning responsibilities to align system incentives and use new contract forms to commission for improved health outcomes for patients registered with a Leeds GP. Ensuring commissioning intentions and decisions support the wider shift to a population health management approach . Delivering the GP Forward View in Leeds Page 5 Draft. Version 0.22 | 7/12/16 3. What will be different when we achieve the ambitions set out in the GP Forward View (GPFV) Delivery Plan? In the context of increased demand and finite resources, patients and professionals need to think creatively about how and why services are delivered and used in order to sustain and transform high quality general practice. We have described what will be different from the perspectives of patients (in blue) and practices (in purple) when we deliver the full ambition described in the plan. This summary should be read in conjunction with the detail of the GPFV delivery plan itself which outlines how these ambitions and key objectives will be achieved. Ambition 3

Fully use and prioritise our collective estates and technology resources to improve the quality of primary medical care and New Models of Care experienced and delivered by patients and professionals. By 2020/21 patients will: Be aided to use a range of different digital skills and solutions to meet their needs Receive care from primary and community premises which support their wellbeing, relieves stress and aids recovery Be able to have more choice of locations from which to access care depending on their need By 2020/21 practices will: Be able to use effective and efficient technology and digital working which supports clinician to clinician and patient to clinician interfaces Be able to use premises in a more flexible way Have premises which are utilised more effectively and are fit for purpose Ambition 1 Ensure there is a motivated, engaged, integrated and healthy workforce with the right skills, behaviours and training, available in the right numbers. Ambition 2 Ensure all patients registered with a GP in Leeds: - understand how, when and are able to access routine and urgent primary medical care when needed; and - are empowered to manage their own conditions to live fulfilling lives in their community. By 2020/21 patients will: Be supported to see the most appropriate professional to meet their needs See a greater range of health and care professionals within the practice Take an active part in managing their health and wellbeing through collaborative care planning By 2020/21 patients will: Have access to routine and urgent appointments 7 days a week Be confident to know when and where to access care Be supported to access a greater range of services and wider support through other routes such as digitally and virtually By 2020/21, practices will: Have access to trained staff to support patients to navigate the health and care system more effectively Be part of a wider team of professionals including mental health workers and clinical pharmacists working across groups of practices Be confident in the ability to recruit, retain and train new members of the team Ambition 4 Free up more time within general practice to plan and deliver better care for patients and professionals by streamlining workload within practices and between By 2020, practices will different care providers. By 2020/21, patients will: Be confident in being able to manage minor self limiting illnesses themselves, obtaining advice from other health professionals such as

pharmacists or through other initiatives such as NHS111 Avoid the morning on the day rush for appointments through effective appointment capacity Have an improved overall experience of general practice By 2020/21 practices will: Have been supported to review workload and will see a reduction in bureaucracy and reporting Experience improved communication between providers, preventing the need for re-referrals and chasing up tasks etc. See better managed demand and will experience a better work/life balance By 2020/21 practices will: See a reduction in demand for care that could be more appropriately delivered by other providers such as community pharmacy Deliver a higher proportion of care through digitally enabled solutions Be working at-scale and collaboratively with other providers to deliver extended access to routine and urgent appointments 7 days a week Ambition 5 Redesign the way care is delivered, by progressing a whole system model which focusses on a place-based approach where everybody has a part to play, both citizens and services together. By 2020/21 patients will: Access a broader range of health and wellbeing services out of hospital in their community Be empowered to make decisions to stay well and improve their physical and mental health Be confident that the professionals caring for them have the right information to support them, reducing the need for repeat assessment By 2020/21 practices will: Have more time for GPs to provide expert medical advice to support patients with the most complex needs Working more collaboratively to share resources , increase resilience and provide patients with access to a wider range of options Part of a wider team of health and care professionals working together to meet the needs of the local population Engagement with patients, member practices and wider stakeholders on how we what will be different will be undertaken to ensure that priorities are appropriately reflected and the language is consistent with other plans in the city. Draft. Version 0.22| 7/12/16 4. Collaborative working between general practices in Leeds In Leeds, 105 individual general practices provide primary medical care services and wider primary care for the population of Leeds. These 105 general practices are diverse in size, shape and form. The list size of general practices in Leeds varies between 1,040 and 37,000 with a (median) average list size of 6,844. As individual businesses with an individual contract, there is significant variation in the way in which services are delivered to registered populations of patients. The population of Leeds is also extremely diverse and so the ability of general practice to respond and deliver care in relation to the specific needs of different population groups is a key strength of general practice. As demonstrated by the outcomes of the recent Care Quality Commission (CQC) visits , the vast majority of the 105 general practices in Leeds are providing good, and in some cases outstanding, care to patients registered with general practices in Leeds benchmarking above average in relation to the domains assessed by CQC. However, the range and quality of services, patient experience and sustainability of care delivered to patients across general practices in Leeds can vary significantly. The ambitions described in this GPFV delivery plan aim to reduce this variation through quality improvement support and through greater collaboration between general practices. Another key strength, unique to general practice, is to continuity of care provided to patients through the registered list. Going forward we recognise that that this unique strength of general practice must be retained within the context of greater collaboration and care redesign. General practices in Leeds are increasingly working together in collaboration to design and deliver services which respond to the needs of their populations. The drivers, structure and form of these collaborations vary between the formal federation across 30 GP practices across NHS Leeds South and East CCG, the provider network in NHS Leeds West CCG and Memorandum of Understanding (MOUs) between locality grouping of GPs in NHS Leeds North CCG. The commonality across these different structural arrangements is that they enable general practices to: work together to identify, plan and respond to a specific need e.g. providing extended hours through hub working in NHS Leeds West CCG work collaboratively and with other providers to design and deliver innovative, bottom-up models of care to the needs of a defined population, such as delivering multi-provider diabetes and mental health wrap-around services for patients living in the Chapeltown locality of NHS Leeds North CCG share core functions to increase the efficiency and effectiveness of back-office functions and care provided to improve the sustainability and resilience of general practice and improve care for patients, for example the work undertaken by the GP federation in NHS Leeds South and East CCG to support quality improvement with local GPs. Alongside commissioning general practices to deliver primary medical care at individual practice level, going forward the Leeds CCGs will increasingly: work with GPs and other providers to commission services at scale for populations of 30-80,000 patients commission services through hub and spoke models of delivery which are aligned to general practice consider the future sustainability of practices required to meet the need of patient populations when making decisions around the provision of general practices services across the city. Strong collaborative working is essential for the future sustainability of general practice as the key provider of care in its own right, as well as being the foundation to develop New Models of Care (NMoC). The role of general practice in supporting and enabling emerging models of accountable care, and a wider move towards a population health management approach across the city, is described in greater detail in Section 5 Care Redesign. Page 6

Draft. Version 0.22| 7/12/16 Page 7 Section 5. Ambition 1: Supporting and growing the workforce Ensure there is a motivated, engaged, integrated and healthy workforce with the right skills, behaviours and training, available in the right number Introduction and overview Leeds will be a vibrant and attractive place to work, offering flexibility and innovative employment opportunities within an integrated workforce which supports a transformed primary care service. Our members are passionate about general practice and its place within the health care system and wish to promote it with health care professionals, emphasising the importance of the role of general practitioner (GP) in the community. Leeds has a lot to offer our future GPs and we plan to expedite and target the recruitment of additional GPs, focussing on areas where recruitment is currently proving a challenge. It is well documented that there is a need to look at alternative workforce models to support the sustainability of general practice given the recruitment and retention challenge that is facing us. We have several sites across Leeds testing new workforce models and we are working with our Local Medical Committee (LMC) colleagues to highlight positive case studies and identify practices who are keen to develop further. We are committed to working together as a city on workforce to ensure a collective review and equity across the whole Leeds system so that workforce models reflect population need and support a reduction in health inequalities. A primary care workforce sub-group has already been established as part of the Leeds Plan programme structure to ensure an appropriate focus on primary care workforce which is not isolated from the wider health and social care workforce. The group will be accountable for delivering the immediate milestones of: 1) establishing an accurate baseline of general practice workforce including gaps : 2) supporting an increase in the number of (additional) clinical pharmacists in practice (30% = 10) through engaging in the clinical pharmacist scheme: 3) implementing new care navigator / medical assistant roles in general practice following 1 st cohort of training. At a recent engagement event 71% of practice representatives (lead clinicians and managers) surveyed said that they were considering alternative workforce models, with 43% looking at working across a groups of general practices demonstrating the current transformational appetite within general practice. Leeds has made significant progress with regard to workforce models and currently has learning to share in the following areas: NHS England clinical pharmacist pilot Practice employed pharmacists Direct employment of mental health workers Physio First and other models Clinical care co-ordinators Practice nursing preceptorship HCA apprenticeships Physician associate placements (Y1) Role emerging placements for occupational therapists (REPOT) Learning disability nurses providing routine health checks in GP Supporting and growing the Hub and cross-site working in the evenings and at weekends primary care workforce underpins Inclusion health inc paediatric asthma programme and Gypsy and Traveller health the delivery of the Leeds Plan and Introduction of the Collaborative Care and Support Planning (previously known as Year of Care) GP team approach to managing long term conditions forms part of the wider Care home nurses and enhanced care home teams of AHPs, incorporating the Calderdale Framework to Leeds workforce strategy. risk assess role merging and role blending) Page 8 Draft. Version 0.22| 7/12/16 Ambition 1: Supporting and growing the workforce Figure 3 - Combined Leeds CCGs - Job Type Summary Source - NHS Health Education Male Full Time Equivilant (FTE) GP Practice Nurses Direct Patient Care Pharmacist Practice Management Apprentices 45 to 54 GP 93.60 58.11 Practice Nurses 1.00 4.00 Direct Pati ent Care 0

4.46 Pharmacist 0.21 0 Practice28.72 Management 15.02 Apprenti2.60 ces 0 400.93 192.96 113.79 3.41 756.35 21.92 Total Under 45 1,489.36 130.59 Apprentic es 1% 77.53 Female Over 55 Under 45 45 to 54 Over 55 Under 45 45 to 54 44.84 1.00 0 0 8.65 0 128.38 67.86 40.85 3.20 234.46 18.15 52.78 74.00 43.66 0 242.10 1.17 23.22 45.10 24.42 0 227.40 0 GP 221.98 Practice Nurses68.86 Direct Patient Care 45.31 Pharmacist 3.41 Practice Management 263.18 Apprentices 20.75 54.49 492.90 413.71 320.14 80 of 105 Practice Reporting Age Range Breakdown

Split by Job type Practic e Management 51% Practic e Nurses 13% GP 250 Practic e Nurses 200 Direct Patie nt Care 150 Pharmacist 100 Practic e Management Apprentices Over 55 50 0 Apprentices Practic e Management Pharmacist Direct Patie nt Care Practic e Nurses Direct Patient Care 8% 68.06 46.10 24.42 0.00 236.05 0.00 45 to 54 GP Pharmacist 0% 110.89 78.00 44.06 0.00 257.12 1.17 Under 45 300 GP 27% Over 55 Delivering the GP Forward View in Leeds Page 9 Draft. Version 0.22| 7/12/16 Ambition 1: Supporting and growing the workforce City wide position One of the key priorities for Leeds as a system is establishing an accurate baseline of the primary care workforce so that we can identify gaps and priorities at individual practice level and across localities. The data we currently hold only represents 75% of general practices in the city. In order to offer further help and support we need a complete picture of the current challenge, gaps and risks facing practices. As CCGs we have worked closely with Health Education England (HEE) and LMC colleagues to raise awareness on the importance of submitting workforce data so that it enables proactive planning in terms of recruitment and identifying hot spots as well as commissioning future training places. The information provided from practices (figure 3 ) identifies a number of key risks several practices are already highlighting problems recruiting new GPs with a number also highlighting multiple leavers over the next three years leading to concerns

regarding sustainability. One of the key actions is to manage these risks and use available resources and programmes, such as the general practice resilience programme, to look at alternative recruitment options or innovative solutions. By 2020/21 patients will: Be supported to see the most appropriate professional to meet their needs See a greater range of health and care professionals within the practice Take an active part in managing their health and wellbeing through collaborative care planning The average list size per GP FTE for Leeds is currently at 2004. Whilst we recognise this is a traditional way of measuring demand, looking at this at a practice level highlights variation in practices, particularly where recruitment difficulties are already starting to have an impact. Current workforce information (figure 3 ) shows that we have a current workforce gap of 50 GPs which represents a 12% gap in overall GP numbers. This would represent what is needed to fulfil some of the unmet needs but fails to address what is required for general practice to perform at its highest level. We would need to exceed this amount to truly bring general practice into the 21st century. The Leeds fair share of the 5,000 additional doctors (committed to in the GPFV) equates to 74 doctors, however we know the population is expected to rise over the next five years due to the number of new housing developments. Leeds also continues to thrive as a city and other external factors such as Leeds University being awarded University of the Year may further attract additional students to Leeds. We need to attract new doctors to general practice by showcasing the good work undertaken in primary care by encouraging additional practices to become training practices. By 2020/21, practices will: Have access to trained staff to support patients to navigate the health and care system more effectively Be part of a wider team of professionals including mental health workers and clinical pharmacists working across groups of practices Be confident in the ability to recruit, retain and train new members of the team The Leeds fair share of the additional 1,000 physician associates committed in the GPFV is 15. We need to continue to model workforce numbers based on the availability of other staffing groups and use tools such as the HEEYH WRaPT tool (a planning tool to enable us to help model workforce for population groups). Delivering the GP Forward View in Leeds Page 10 Draft. Version 0.22| 7/12/16 Ambition 1: Supporting and growing the workforce City wide position continued As a city we already have some experience of clinical pharmacists in practice. Initial feedback from practices is that this is already having a positive effect on workload. We are committed to taking the opportunity of being an early adopter site for the clinical pharmacist scheme where we estimate having an additional 25 pharmacists across the city. There is a growing appetite amongst primary care to embrace new roles and we have some positive examples across the city of mental health workers working in an integrated way with general practice to reflect the population needs. A number of practices have already expressed an interest in being early implementers for this role as we prioritise its expansion across Leeds, working collaboratively with our mental health commissioning colleagues to ensure alignment with the overall strategy. We have identified that we have a moderate risk regarding GPs aged 55 and over who may be looking to retire in the next few years and to some degree a greater risk of practice nurses and practice management (which includes our administrative and clerical colleagues). A number of initiatives are in development to help support greater resilience in our workforce, including: Career seminars for those close to retirement, with a view to looking at options for supporting colleagues to stay in practice Developing alternative workforce models including employing physician associates and pharmacists Greater collaboration with other independent contractors such as community pharmacy with the Pharmacy First scheme which helps support patients to self-manage and a possible alternative to general practice Application to HEE on behalf of Leeds re: nursing associate role test site lead partner LTHT (successful application to start in Dec 2016 - trainee nurse associates to be placed in primary care as part of the programme which includes placements across secondary care, community, mental and care homes Implementing the general practice nurse scheme, delivered in partnership with HEE, across 16 practices in Leeds. A key element of supporting and growing the workforce is adopting an integrated approach to staff training and developing clinical and non-clinical groups. Over the next few months we will work as a city, and with partners, to understand key issues and gaps relating to training provision particularly how we use our collective resources to maximise training opportunities across organisational boundaries. This is particularly relevant in areas of training where there has been a reduction in nationally funded training places, such as practice nurse training. Going forward, a key enabler is the cross-organisational development of a business case to establish a Leeds Health and Care Academy which would provide a system wide resource for health and social care staff. Delivering the GP Forward View in Leeds Page 11 Draft. Version 0.22| 7/12/16 Ambition 1: Supporting and growing the workforce

City wide approach Current position 2016-17 2017-18 2018-19/ 2020-21 Pilots established within specific localities: clinical pharmacists : Physio First and mental health therapists Joint LMC / CCG workshop to take place in January 2017 to discuss workforce sustainability. Pilots within specific localities: evaluated and rolled out: Physio First; mental health therapists. Actively promote healthcare careers, including recruitment days established to support practices and groups of practices in recruiting All Leeds CCGs have pre-registration pharmacists doing part of their years training in CCGs. Citywide workforce group established with key stakeholders with a specific focus on primary care workforce. Harmonising pan-Leeds workforce underway (redeployment and mandatory training). Developing a core workforce offer for practices taking into account the needs of the population Testing locality developments for shared staff, back office functions, urgent and routine access, home visits. Joint CCG / LMC communication to encourage accurate recording of workforce data to truly understand baseline position. Promote leadership at every level including LIQH and induction training packages delivered through TARGET. Development of the Leeds Workforce Plan, incorporating values based recruitment at every level. Implement GPN Ready scheme and support new to role GPNs. Underpin training with RCGP competence assurance framework at practice level. Leeds Institute for Quality Healthcare LIQH) development proposal being implemented across the Leeds CCGs. Including patient leaders as part of our extended team to ensure patient experience is embedded into everything we do. Working with HEIs & FEIs to inform curriculum redesign / refreshment, promoting community inclusivity and parity of esteem (physical and mental health). Scoping opportunity to work more closely with providers (esp LCH including WE hubs, shared training opportunities). Participating in citywide collaborative recruitment events / careers fairs. Primary Care Workforce Development Group set up. Leeds Workforce Transformation Group set up. CCG support for the successful nursing associate pilot Increase number of apprenticeships at business admin and health care assistant levels including vocational qualifications for progression into nursing - general practice to support placements for the nursing associate roles. Scaling up locality developments for shared staff, back office functions, urgent and routine access, home visits across all practices. Staff roles including health care assistants, practice nurses and advanced nurse practitioners improve consistency and benchmarking for learning beyond registration as well as induction, preceptorship and refresher/update training. Wider integration of health and social care. Also promote parity of esteem between mental and physical health Advanced Training Practices Network support LSMP, expand number of spoke practices, increase placement capacity to 20% of practices offering undergraduate nursing placements. by 2017 Develop new mentors and sign-off mentors n localities to support preregistration nurses and GP mentors to support non-medical prescribing and the development of the clinical pharmacist role Develop recruitment and retention initiatives to support growth in the workforce. Include recruitment days, develop career portfolios Evaluate the outcomes of the pilots established within localities: with CCG based teams: clinical pharmacists; community and practice nurse

collaborations Expand and integrate the pilots established in localities with CCG based teams - clinical pharmacists , including advanced level pharmacists , community and practice nurses collaborations Further roll out of the ANPs and ACPs including pharmacists roles in CCGs to develop the skills required for working in primary care and GP practices, including post graduate diplomas and non-medical prescribing. Develop foundation AHP and pharmacists roles in CCGs to develop the skills required for working in primary care and GP practices. Improve IT literacy across all teams so technology can underpin improvements in administrative and consulting behaviour - best use of data; include single care record and online services (e.g. non-complex LTC review). Support development of business case for proposed Leeds Health and Care Academy Ensure Cavendish Care Certificate obtained by all non-registered patient-facing clinicians. Leavers destination surveys analysed and action plan to address. Include support for those to stay in or return to work Continued roll out of schemes such as Physio First, mental health workers, ACPs and clinical pharmacists Continued development of apprenticeship schemes, Develop AHPs / ACPs including pharmacist roles in CCGs to develop the skills required for working in primary care and GP practices, including post graduate diplomas and non-medical prescribing. Continued increase in Advanced Training Practices Network, with an aspiration of 30% of practices offering undergraduate placements by 2019 Reduce dependence on temporary staffing Shift administrative burden from clinicians to administrative staff to free-up direct contact time; train and support care navigators at front desk Develop skill mixing in practice nursing and advanced nurse practitioners. Develop collaborative working between general practice and community nursing. Additional support requirements: Local NHSE Transformation Team to provide dedicated Leeds-level capacity to lead project management and coordination of current schemes and support the Leeds PC workforce group. Support to include bid development for accessing additional monies. National support to address gap in access to practice nurse training. Page 12 Draft. Version 0.22| 7/12/16 Ambition 2: Improving access to general practice Ensure all patients registered with a GP in Leeds understand how, and are able to, access routine and urgent primary medical care services when needed, are empowered to manage their own conditions and live fulfilling lives in their community Introduction and context We know, from what patients have told us, that the majority of patients in Leeds find getting an appointment with a general practice in Leeds fairly or very easy. Headlines from the GP Patient Survey in July 2016 demonstrate that 72% of patients find it very easy or fairly easy to access the GP practice via telephone and 74% of patients have a very good or fairly good experience of making an appointment. We want to build on these results to provide even better access to routine and urgent primary care from general practice and wider primary care services alongside a greater focus on supporting and empowering patients to better manage their own conditions. While figures suggest that the majority of patients registered with a general practice in Leeds are able to easily access their general practice, we know that for other patients, this is not the case. Our patients have told us that improving access to general practice services during routine hours and for some population groups (such as those with complex needs), and continuity of seeing the same health professional, are key priorities. We know from GPs that the demand for routine in-hours appointments is increasing and placing significant pressures on general practice. At the same time, the GP Patient Survey highlights that the majority of patients surveyed want additional extended hours appointments;71% of patients would like additional appointments after 6.30pm and 74% of patients would like additional appointments on Saturdays. The challenge and opportunity for the Leeds CGGs is how we balance these local priorities alongside a national directive and increasing patient expectations to establish seven day access to primary care by 2020/21. In 2014, NHS Leeds West CCG was successfully appointed as a GP Access Fund site to test a new model of extended seven day access to GP for registered patients. This opportunity has enabled improved access to general practice for the 350,000 patients registered with a Leeds West CCG GP, and has also generated key learning and insight to be applied across the city as the CCGs work together to improve access to routine and urgent primary medical care services for the whole population of Leeds. The CCGs have three, interrelated opportunities as we work together to improve access to routine and urgent primary medical care services for the whole population of Leeds: 1) Providing greater support to empower patients to better manage their own conditions 2) The Leeds urgent care system redesign, currently being developed as part of the Leeds Urgent Care Strategy 3) The huge opportunity to increase the role of technology in providing Developing digital capacity and and infrastructure underpins the supporting digital access to GP for patients delivery of the Leeds Plan and forms part of the wider Leeds

workforce strategy. Urgent care forms one of the four redesign programmes in the Leeds Plan. Draft. Version 0.22| 7/12/16 Page 13 Ambition 2: Improving access to general practice City wide approach Supporting and empowering patients to manage their own conditions and live fulfilling lives in their community We recognise that supporting and empowering patients to better manage their health, wellbeing and conditions is central to improved access to general practice as well as the wider transformation of health and care services. To enable this we are working as a city on the Leeds Conversation a consistent approach across all health and care providers to frame all interactions between patients and services in the context of the contribution, assets and responsibilities of the patient (see Figure 8). In general practice, this is being supported through health coaching and self-management programmes such as Collaborative Care and Support Planning (previously known as Year of Care) approaches, and self-care campaigns. We want patients to feel confident to directly identify and access a range of services, including community pharmacy and services provided through the third sector, to meet their care and support needs. We have developed information points such as Mindwell and Mindmate to enable patients to directly access self-help and services to support their mental health and wellbeing and commissioned social prescribing to further enable and empower patients to directly access the support and services they need. This programme of behaviour change will be further strengthened by rolling out the Leeds Medicine Communication Charter, a unique approach coproduced with patients, to support patients to get the most of their medicines through different conversations with health professionals resulting in better clinical outcomes and experience, improved patient empowerment and reduced demand for services. Supporting patients to be more activated in the management of their own health, wellbeing and care is a key component of population health management described further in Section 5 Ambition 5. Leeds Urgent Care Strategy and The Leeds Plan Our approach to improving access to routine and urgent primary medical care forms a key component part of Leeds Urgent Care Strategy, (which in itself forms one of the four work programmes in the Leeds Plan). The Leeds Urgent Care Strategy provides an opportunity for commissioners and providers to work together to take a whole-system approach to redesigning urgent care services, including general practice to address the key challenges across the Leeds system. These include: 1) Variation in access for patients registered with different general practices within different CCGs; 2) Given the finite capacity of the GP workforce across Leeds - already under significant pressure to meet levels of demand for routine appointments - the need to develop alternative workforce models to deliver urgent and routine primary care; 3) The need to simplify what is currently a very complex urgent care system ; 4) High levels of A&E use in early evening by families with young children and from patients living within deprived Leeds 5) High rates of elderly admissions. In redesigning services to address these challenges, we will better understand and respond to the unmet needs of specific population groups in Leeds. These include 1) new migrant populations with low understanding of local services; 2) young families with social and emotional support needs 3) additional language needs within some migrant groups which require more face to face translation and care navigation 4) Growing elderly and multiple LTC population with limited assessment / near patient testing in the community 5) Limited digital literacy across a number of population groups with limited uptake of virtual access in working adult population. Increase the role of technology in providing and supporting digital access to GP for patients Technology, such as patient online services, provides a huge opportunity to support self care, provide direct digital access to GP and free up capacity in general practice for face-face care for groups who need this most. The opportunity for improvement is demonstrated in the most recent GP Survey results below: 35% of patients have awareness of online appointment booking 30% of patients have awareness of online repeat prescription ordering 6% of patients have awareness of online access to medical records 49% have no awareness of online services A focus on increasing technology, digital access and digital literacy will be a key focus for the CCGs in Leeds over the next five years (see Section 5 Ambition 3 for wider context re technology development By 2020/21 patients will: Have access to routine and urgent appointments 7 days a week. Be confident to know when and where to access care Be supported to access a greater range of services and wider support through other. routes ,such as digital and virtual By 2020/21 practices will: See a reduction in demand for care that could be more appropriately delivered by other providers such as community pharmacy. Deliver a higher proportion of care through digitally enabled solutions Be working at scale and collaboratively with other providers to deliver extended access to routine and urgent appointments 7 days a week Page 14 Draft. Version 0.22| 7/12/16 Ambition 2: Improving access to general practice Current position NHS Leeds North CCG Practice Reference Group + 3 Things feedback: Improve in-hours access, continuity of care for key population groups and provide some

extended hours pm and Saturday am; Successful system resilience scheme delivered between 8 practices and Local Care Direct since 2014. Provides enhanced access to GP appointments for all Leeds patients during system pressure. Ability and agility to flex capacity to meet demand; 84% of population have access to extended hours via national enhanced service. Member engagement feedback: future models should be hub-based, technology driven, multidisciplinary and flex to population need. NHS Leeds West CCG Successful 2nd Wave GP Access Fund site delivering 7 day access to services since Oct. 14 (local and national investment); Hubs established in a number of localities with high patient satisfaction and attendance; Locality groups established to provide infrastructure for population based approaches; 12 hour enhanced access Mon-Fri in 34/37 practices. Weekend access hubs serve approx. 50% of population; 83% satisfaction with opening hours. NHS Leeds South and East CCG Clinical pharmacy pilot providing direct patient care; Establish 4 collaborative hubs 37/42 practices (10,000 patients not covered); Improved access through additional roles within PC team provide in hours capacity, 1 hub providing additional extended opening; NMoC pilots established in Beeston and Cross Gates creating multidisciplinary teams Discussions with members regarding OOH/UC provision to inform commissioning intentions; 84% of the population have access to extended hours. 2016-17 Continue to support initiatives that improve access to GP and primary care whilst planning a citywide future model of care for extended primary care access as part of the developing Leeds Urgent Care Strategy. Future care model to reflect local and national learning, patient insight and member feedback. 2017-18 Further improve the quality of in-hours access, initial roll-out of extended access hub and spoke working and scope the integrated pathways across GP and Dentists, Optometrists and Pharmacists . A strong focus on signposting and communication WITH Leeds citizens will be a priority. In-year initiatives to improve access Implement clear (digital) communication resources to support patients to self care and navigate wider health and care system for routine and urgent care needs; Training and roll-out Leeds Conversation approach with patients and providers; CCG investment to enable partial delivery of extended access at-scale (LNCCG & LSECCG to utilise minimum of 1.50 p/h of GPFV baseline requirement, LWCCG investing 6p/h as a Challenge Fund site); Develop hub and spoke working to provide a form of extended access for 50% of the Leeds GP registered population; Spread learning from ETTF projects to increase digital literacy of patients (achieve GP online target of 30%); Test paediatric hot clinic to respond to primary urgent care for a priority population; Development and investment in future model Locally develop core in-hours standards to further improve quality of in-hours access to GP (explore 15m appointment); Develop and test local delivery of extended access in and OOHs through hub working across the city via West Yorks Roll-out stage 2 navigator training to other staff groups Vangurd (WYV) Accelerator funding; Further support collaborative working between practices to support even more efficiency service delivery; Test direct booking of in-hours GP-appointments from 111 through WYV to support quality triage process; Support development of non-GP workforce to support delivery of extended access. Analysis of existing capacity, population and activity flow data to inform design of wider model for extended PC access as part of UC strategy; Development and investment in future model Finalise primary care estates strategy to support future hub Confirm and agree model for GP extended access in the working including evening and weekend access; context of urgent care and OOHs review including the West Yorkshire Accelerator funding. Will reflect needs of different Design models of extended access that better meet

specific populations needs (families with young children; population groups. Understand re-procurement working age adults, elderly / those living with multiple requirements in the context of wider potential MCP LTCs; and deprived localities with lower uptake of planned developments timeframe; and preventative services); Scope requirement for wrap around and support services e.g. diagnostics, transport and near patient testing; Establish and support new technologies via (ETTF cohort 1) GP mobile devices, telephony hub and Increasing digital Engage with dentists, optometrists and pharmacists and their literacy for patients; associated local committees around wider integrated working; Seek national support to address liability issues associated with delivering extended hours. Work with NHSE/ WYCP re pharmacy contracting to include minor ailments, Pharmacy First and developing community pharmacy as part of a future PC access model. In-year initiatives to improve access: Ongoing provision of CCG access schemes; Ongoing support to practices to achieve online service target of 15-20% by 16/17; To look at peer review and ways to address variation in quality link to Right Care; Capacity and demand audits aligned to Primary Care Web Tool extended access data + newly developed tool; Continued local commissioning of community pharmacy to deliver Pharmacy First, and Prescriptions Urgent Request Medicines service (PURM); Deliver Phase 1 care navigator training to support signposting to effective services; Finalise citywide approach to Leeds Conversation; Launch of Leeds Medicines Communication Charter. 2018-19 / 2020-21 Deliver extended access by working across the city at-scale through an integrated hub and spoke delivery model. Improved access will be designed to meet specific populations needs. Key in year work areas 18/19 Use 3.34 p/h to increase population coverage of extended access in LNCCG & LSECCG via hub and spoke working; 19/20 Use 6 p/h to deliver extended access to 100% of Leeds population as per national specification through hub and spoke working and in partnership with other urgent care providers including GP OOHs. Transparently describe procurement approach as part of future urgent care procurement process. Working at scale will enable different access offers to meet specific populations needs. Digital literacy online services use, 40% in 18/19, 50% in 19/20); Early implementation of test models of urgent care responses for different population groups e.g. same day assessment / diagnostics for frail elderly / LTCs populations and community aligned support solutions to address language and system navigation needs within migrated populations; Leeds Conversation is fully embedded across all patient groups and service providers. Additional support requirements: Local NHSE Transformation Team to provide dedicated Leeds-level capacity to lead project management and coordination of Leeds approach to extended access ( Business Intelligence, population need modelling and service-redesign capacity and capability). Page 15 Draft. Version 0.22| 7/12/16 Ambition 3: Transforming estates and technology Develop and fully use our collective estate and technology resources to improve the quality of care delivered and the experiences of patients and professionals Introduction and context In June 2015, CCGs were asked to lead the development of local estates strategies supported by advisors from NHS Property Services. A Framework for Commissioners was produced which outlined the process required and the timescales for the work to be undertaken. This process included the formation of Strategic Estates Forums (SEF). Within Leeds this is the Strategic Estates Group which includes representation from key commissioner and provider organisations across the city. Estates strategies were to be completed initially by December 2015. In September 2015, local health and care systems were asked to produce Local Digital Roadmaps (LDRs) by 30 June 2016, setting out how they will achieve the ambition of paper-free at the point of care by 2020. In October 2015, CCGs were invited to put forward proposals to the Estates and Technology Transformation Fund (ETTF) for future estates and

technology investment, in line with their local estates and digital plans. 26 proposals were received, reviewed, prioritised and submitted as part of the national Stage One process by 30 June 2016. A draft Primary Care Estates Strategy for Leeds has recently been completed. This strategy highlights the current location and condition of general practice premises across Leeds as well as the outcomes of a number of building surveys undertaken within practices. There is enormous variation across Leeds in the quality of premises from which general practices operate and we are aware that this has a direct relationship on the quality and range of care received by patients and on the working lives of professionals. The result of surveys undertaken as part of the primary dare estates strategy along with local practice knowledge and intelligence, regarding future housing and local infrastructure developments, provides the rationale within the estates strategy for recommendations relating to the future investment and development of general practice estate. It underpins a strategic aim to develop a built environment fit for the future in delivering our ambition of sustainable and transformed primary care as a key aspect of whole system change. Developing improved estates, digital capacity and infrastructure underpins the delivery of the Leeds Plan and forms part of the wider Leeds workforce strategy. Page 16 Draft. Version 0.22| 7/12/16 Ambition 3: Transforming estates and technology Develop and fully use our collective estate and technology resources to improve the quality of care delivered and the experiences of patients and professionals The vision for the primary care estate is that it should move towards even more purpose-built, flexible, multi use, premises which are adaptable to changes in services, capacity or demand. Premises should continue to support a culture of teaching and learning both for healthcare professionals and patients. Estate is one of the biggest financial risks both from an investment, funding and ongoing maintenance perspective. Consolidating estates and sweating the assets creates opportunities through developing integrated, multi-occupancy premises which include a range of providers and services, but with sufficient room for future growth/expansion. Premises development should be planned on a hub and spoke model to allow for additional services to be delivered across a whole neighbourhood. Through the Leeds primary care estates strategy, proactive estate and infrastructure plans will be drawn up so that premises should be well managed and link whole health and social care systems. This approach will include greater partnership working with strategic landlords and others to ensure the total estate is considered. Consistent policies will be developed in relation to rent reviews, including premises reimbursements, as well as agreeing strategic decisions relating to ownership, leases and agreeing any future disposal options for estate. Infrastructure and technology should support patients to be involved in managing their own health and wellbeing and decisions about their care through information, advice and engagement. We know that new technologies provide huge opportunities to enable patients to access services, advice and their own records digitally but that different levels of digital literacy and appetite exist across different population groups. Promoting and supporting digital access across receptive population groups will free up face to face access for patients who most need this. We also recognise the importance and value of digital technologies in enabling greater integration and more flexible delivery of care across different service providers. This includes greater access to shared digital records, the development of near patient testing, the use of mobile devices as well as telephone and digital based solutions that enable improve real time communication between professional to deliver better and more efficient care for patients. The role of technology in delivering more efficient and effective care between patients and professionals is a key component of our wider approach to population health management Investment in estate and technology is needed, not just to improve existing facilities and the quality of primary medical care received by patients, but to increase the sustainability and transformation of general practice. The investment and development of flexible primary care estates and technology solutions underpin the delivery of the GP Forward View, New Models of Care and the aspiration of the city to establish a population health management approach. By 2020/21 practices will: Be able to use effective and efficient technology and digital working which supports clinician to clinician and patient to clinician interfaces. Be able to use premises in a more flexible way Have premises which are used more effectively and are fit for purpose By 2020 /21patients will: Be aided to use a range of different digital skills and solutions to meet their needs Receive care from primary and community premises which support their wellbeing, relieve stress and aids recovery Be able to have more choice of locations from which to access care depending on their need Page 17 Draft. Version 0.22| 7/12/16 Primary care estates - Citywide approach Current position

2016-17 2017-18 2018-21 105 general practices occupying 127 premises ranging from rural branch surgeries, to large single practices in fully maintained buildings. Primary care estates property appraisals to be completed, analysed and action planned. Project workstream implemented for estates transformation , business cases from development and investment plan to be drafted. Leeds LIFT building space use improved to 65% and above. 5,506 new homes each year for next 5 years focussed around city centre and inner area = 27,530 x 2.3 new patients per dwelling = 63,319 new patients in the next 5 years. Established Leeds Strategic Estates Plan covering all local health, social care and local authority stakeholders. 10 x LIFT buildings developed from 2004-2010. Space utilisation surveys show many buildings under used, and some such as LIFT significantly so. 54% of primary care buildings fail to meet minimum NHS standards for physical condition, 15% for functional suitability and space utilisation and 58% for statutory compliance status. Significant issues with backlog maintenance on a large number of practices. (1.5m 2016 6 facet surveys). Numerous opportunities to consolidate primary care estate and co-location with other health and social care partners. Estates workshops with representatives of key stakeholder groups. Workshops review the current collective stakeholder estate in each neighbourhood and identify any initial opportunities for collaborative estates development. Complete primary care estate strategy as part of wider health and social care estates strategy. Agreed NHS provider estates strategies updated and factored in to the citywide Estates Transformational Plan. Draft development and investment pipeline of potential estates schemes based on strategy and list of issues identified. Implement successful schemes from the Estates and Technology Transformation Fund. Improvements in the primary care estates through the One Public Estate programme. Centralised shared training facility to be established estates solution provided. Scope utilities technology to reduce estate costs Centralised CCG/LCC back office and head office accommodation estates solution agreed and delivered for health and social care partners. Agreed future citywide transformational Primary Care Estates Development, Investment and Divestment Plan. Integrated strategic estates and development lan developed including redesign for Leeds general Infirmary. Map citywide training capacity and other multifunctional space such as meeting rooms etc. Submission of Phase 4 One public estate bid to include primary care. Leeds LIFT contract: implement recommendations for actions to realise financial savings opportunities. Leeds LIFT/PFI contract review to be completed.

Leeds PFI contract: implement recommendations for actions to realise financial savings opportunities. Citywide policy on approach to rent reviews, decision making around premises reimbursements agreed. Citywide approach to estates ownership, lease agreements and future disposal of primary care estate. Partnership working arrangements with key organisations establish to support a cohesive approach to estates of the future Additional support requirements developing primary care estate is currently dependent on the successful funding of applications submitted through the ETTF from the Leeds CCGs. Specialist support required around estates development and support for practices to look a estates issues across their neighbourhoods. Delivering the GP Forward View in Leeds Page 18 Draft. Version 0.22| 7/12/16 Primary care estates CCG specific actions Current position 2016-17 2017-18 2018-21 NHS Leeds North CCG 34 buildings ranging from small converted premises to large multipurpose sites. ETTF: CCG supported submission for 11 bids, 7 premises schemes and 4 IT schemes including one citywide IT scheme. ETTF: Project initiation of remaining premises schemes to be completed by 2019. Establish integrated community hubs aligned with the urgent care strategy and MCP models of working. 53% of primary care buildings fail to meet minimum NHS standards for physical condition, 18% for functional suitability and space utilisation and 56% for statutory compliance status. Project initiation of St Martins House development in in Chapeltown. Implementation of ETTF scheme for extension of Westgate Surgery to be completed by 2016-17. Scope potential hub locations to align with proposed extended access schemes and urgent care strategy. Develop and implement action plan to address priorities identified in Primary Care Estates Strategy Implement successful Phase 2 ETTF schemes. 5 practices flagged as high risk. NHS Leeds South and East CCG 45 buildings ranging from small converted premises to large multipurpose sites. 52% of primary care buildings fail to meet minimum NHS standards for physical condition, 18% for functional suitability and space utilisation and 58% for statutory compliance status. ETTF: CCG supported submission for 11 bids, 10 practice bids (2 IT) , one IT CCG bid. Implementation of successful ETTF schemes and develop evaluation plan for ETTF Review of primary care estates within defined areasLS8/9 and Garforth will be completed by 2016/17inform future estates needs and support sustainability of PC. Continue phased assessment of primary care across

geographical areas within CCG/ shared boundaries with other CCGs- to aid understanding of estates and IT, to support development of collaboration and integration, and primary care working at scale to deliver extended access Potential resubmission to ETTF portal based on review/ in line with estates strategy. 11 practices flagged as high risk. NHS Leeds West CCG 48 buildings ranging from small converted premises to large multipurpose sites. 56% of primary care buildings fail to meet minimum NHS standards for physical condition, 9% for functional suitability and space utilisation and 58% for statutory compliance status. 2 practices flagged as high risk. Ongoing evaluation of premises development in 2017/18 to understand further need and possible further submission to ETTF. Development and implementation of action plan to address priorities identified in Primary Care Estates Strategy ETTF: Progression of 5 successful premises development schemes supported through first stage Development of action plan to address priorities identified in Primary Care Estates Strategy . Management of locality workshops to explore potential estate for future planning/community hubs. Action plan to include assurance that minimum standards for practice premises attained. Completion of 6 facet surveys and Leeds West Primary Care Estates Strategy . Implementation of successful ETTF schemes and develop evaluation plan for ETTF. Evaluation of premises development in 2017/18 to identify further need. Coordinate future planning of estate needs working with locality hubs. Delivering the GP Forward View in Leeds Page 19 Draft. Version 0.22| 7/12/16 Primary care technology - Citywide approach Current position 2016-17 2017-18 Leeds Digital Roadmap (LDR) and the Leeds Plan outlines the case for improving and maximising technology. Scope further development and opportunity with the Leeds Care Record (LCR); develop clinical specialist advice and increased use particularly in community pharmacy and A&E. Roll out further use of the LCR focussed on care navigation and patient records which can be accessed on the move . Linked to new Health Information Exchange. Leeds Care Record in use across multiple providers e.g. secondary care, mental health, community and social care includes medications, allergies and adverse reactions. All GP practices signed up. Evaluate patients currently using patient online, who, where and how used. Increase uptake to 20% (national target 10%). Increased uptake of Patient Online from 20% to 25% (national target 20%). Enable availability of clinical correspondence. 20% of patients registered for online services to be actively using them. Currently 15% of patients have signed up to access online services. Less than 1% has access to detailed coded record (DCRA). Only 54 practices enabled

DCRA. Current use of Electronic-Referral Systems across Leeds average 60% (national QP target 80% by Sept 2017). Current use of electronic discharge advice notices from secondary to primary care 84%. 90% of GP practices EPS2 compliant. Only 6% using repeat dispensing. All practices using common Electronic Palliative Care Coordination System (EPaCCS) template. All practices have at least 3 PCs capable of supporting Skype-like consultations. Support digital literacy skills for patients and staff increasing percentage who have all five basic digital skills. 10% of patients registered for online services to be actively using them. DCRA to be offered to all patients on 2% high risk group. Add flag for other providers. Provide tools to supported self-care e.g. telehealth, online questionnaires. Public Wi-Fi access in all GP practices. Consistent approach to practice website design and links to other services. Implement technology to support hub and spoke and collaborative working to support delivery of extended hours and seven day working eg shared records and call handling. Implement e-consultation - email, instant chat and video consultations with patients. 90% digital referrals. 95% of GP practices EPS2 compliant. 80% of repeat scripts to be done via EPS2. 10% via repeat dispensing. Increase uptake of EPACCS across GP practices with more patients having palliative care plans in place. Roll-out electronic out-patient letters from secondary care to primary care. Undertake benefits analysis of the practice PODs and measure the impact on practice workload. Test and further develop the e-consultation offer to patients. Scope impact of digital Lloyd-George notes (e-LGS) to free up space from paper records. Move towards one infrastructure footprint and service for the city including voice, data, email, collaboration tools etc. Scoping utilities technology to reduce costs of estates. 100% of practices using EPS2. 80% of all scripts via EPS2 incl acute. Increase repeat dispensing to 15%. Introduce SNOMED DM+D - a universal identifying coding system which is used by the Dictionary of Medicines and Devices (dm+d). Implement unified communication systems such as instant messaging, voice and video in primary care. Scope digital support for care homes through remote access to clinical records or shared education and training opportunities. Additional support requirements accelerating digital capability is dependent on the successful funding of applications submitted through the ETTF from the Leeds CCGs. Accelerating digital literacy across Leeds will be underpinned by the Leeds CCCGs receiving national monies to further support uptake of GP online as committed in the GPFV. Additional support from NHS Digital on maximising and implementing new technology. Delivering the GP Forward View in Leeds Page 20 Draft. Version 0.22| 7/12/16 Primary care technology CCG specific actions Current position 2016-17 2017-18 2018-21 NHS Leeds North CCG Investment in introduction of Surgery PODs via PCIF . Implement the Digital Literacy Programme. Evaluate Digital Literacy programme to share best practice and commission citywide. Implementation of hub and spoke working around back office, call handling and urgent care across all localities. Develop the Health Information Exchange to link with the GP clinical system and Leeds Care Record. Pilot for integrated nurse triage unit and call handling across multiple practices. Roll-out Wi-Fi to facilitate use of new technologies in Practices. NHS Leeds South and East CCG 2015/16 Direct investment by CCG to support roll out of Wi-Fi in

practices supported by PCTF monies. Direct investment by CCG to support roll out of mobile working. NHS Leeds West CCG Establish baseline assessment of all current estate and technology requirements within the CCG. 39/42 practices have access to Wi-Fi. By end of 2016/17 39 practices (52 sites ) will have the ability to support mobile technology to support safe high quality care. ETTF: CCG supported submission for 2 IT practice bids, one IT CCG bid. LCR: encourage practice use through shared messages and development of case studies. Linked Health Information Exchange with wider developments on Leeds Care Record to support population health management. Additional locality triage units linked to urgent care and new models of care strategy. Support the implementation of city wide IT ( tokens) bid during 2017-2019- facilitated learning/ standards of approach. Share learning from health pods and impact on access and workload to PC services. Explore opportunities from Vanguard sites and the evaluation to understand impact for PC. Other clinical system and tools (EPACCS) to enhance pt care and clinical practice. Continue phased assessment of primary care across geographical areas within CCG/ shared boundaries with other CCGs to aid understanding of estates and IT, to support collaboration and integration, and primary care working at scale to deliver extended access. Progress successful technology scheme to enable mobile working supported through first stage of ETTF. Implement successful ETTF schemes. Wi-Fi Installation in all practices to facilitate use of new technologies. Skype Telehealth Kit installed in all practices to support virtual means of access and multi-disciplinary working Develop a standard practice website to include appropriate signposting to services Continued support to practices for access to Leeds Care Record. Explore options for patient held technology and integration with clinical records Develop evaluation plan for ETTF schemes. Evaluate premises development in 2017/18 to identify further need Work to support practices and localities through the network to: test and increase use of video kit to improve patient care maximise the potential of practice websites in signposting patients to self-care, obtain advice from pharmacy first and connecting to voluntary sector through social prescribing. Expand the Leeds Care Record. Delivering the GP Forward View in Leeds Page 21 Draft. Version 0.22 | 7/12/16 Ambition 4: Better workload management Reduce practice burdens and help release time with the management of demand, diversion of unnecessary work and an overall reduction in bureaucracy Introduction and context The three Leeds CCGs have successfully supported member practices in managing their workload through significant historic investment in quality improvement programmes such as the General Practice Improvement Programme (GPIP), Productive General Practice, in addition to establishing and supporting the bespoke Leeds Institute for Quality Improvement. A key component of quality improvement is the ability to accurately assess capacity and demand and support practices to make small changes to manage appointment systems. As a national GP Access Fund site, NHS Leeds West CCG is an early implementer of a systematic approach to capacity and demand. The understanding and learning from this will be shared across the city as we launch the approach in 2017, providing dedicated support to practices. The plan will be to initially work with those practices that have currently identified specific capacity issues. We will also look at a structured approach to reducing missed appointments, focused on those practices that are indicating this is a particular issue for them and their patient population.

Initiatives planned to improve the efficiency and effectiveness of the interface between within primary care and general practice will support this strand of the Leeds Plan. A standardised quality dashboard has been produced across the city which will further support how we transparently work with practices to identify and share good examples of quality improvement as well as where additional support may be required in relation to specific citywide quality themes or at specific practice level. The One Voice work has emphasised the importance of primary care development support and commitment to use our collective resource to support practices on the basis of need as required. Leeds has made significant progress in implementing a number of the national expectations relating to the NHS Standard Contract. A full review of the recommendations arising from the GPC Urgent Prescription for General Practice has been undertaken with our LMC colleagues which aims to reduce the impact on general practice. A system is established, through Leeds Provider Query to allow practices to flag where there are compliance issues and these will continue to be monitored and fed back to our local providers to continue to support the appropriate workload management in general practice. Delivering the GP Forward View in Leeds Page 22 Draft. Version 0.22 | 7/12/16 Ambition 4: Better workload management Reduce practice burdens and help release time with the management of demand, diversion of unnecessary work and an overall reduction in bureaucracy We are working with NHS England colleagues in identifying those practices that may benefit from the GP resilience programme. 13 practices (and one locality) have been identified by CCGs and practices to date, in addition to at least 11 practices (or localities) receiving vulnerable practices funding. This demonstrates some of the challenges being faced by our practices and our focus will be on sustaining services for the population. Recognising the importance of the general practice registered list in providing continuity of care, we also know that by supporting increasing collaboration between practices, we will continue to identify schemes which may allow the resources to be managed at scale across a wider footprint. The CCGs and the LMC have agreed to work together to continue to identify areas of good practice and share case studies to ensure continuous improvement and spread of initiatives across the city, particularly encouraging practices to share initiatives that have impacted upon their workload. All three CCGs have successful social prescribing models in place which is already starting to show an impact on supporting GP workload. A high level review against the 10 high impact changes has been undertaken (see figure 4) and a commitment has been made to share good practice, learning and ideas for development, particularly regarding productive work flows, in a coordinated way across the city. An identified lead for each high impact area has been identified who will help to monitor and push for progress through the citywide collaborative. Effective workload management also sits alongside the workforce chapter in identifying opportunities for other health and care professionals to work as part of an integrated team to help support a more appropriate workload depending on the needs of the population and the skills available within the practice team. A positive example of this is the integration of mental health workers in primary care reflecting the key role of general practice is holistically supporting the mental and physical health and wellbeing needs of patients. By 2020/21, patients will: Be confident in being able to manage minor self limiting illnesses themselves, obtaining advice from other health professionals such as pharmacists or through other initiatives such as NHS111 Avoid the morning on the day rush for appointments through effective appointment capacity Have an improved overall experience of general practice By 2020/21 practices will: Have been supported to review workload and will see a reduction in bureaucracy and reporting Experience improved communication between providers, preventing the need for re-referrals and chasing up tasks etc. See better managed demand and will experience a better work/life balance A GP wellbeing action plan for 2016-18 has been developed across the city which aims to focus on a number of initiatives to support GP resilience including coaching and mindfulness . Feedback from GPs who have participated in the initial Mindfulness course has been extremely positive. Delivering the GP Forward View in Leeds Page 23 Draft. Version 0.22| 7/12/16 Ambition 4: Better workload management Figure 4 - City wide assessment of progress against delivery of 10 high impact changes and links to the ambitions outlined in the GPFV delivery plan. Active signposting

Personal productivity Coaching support for GPs Review of TARGET session to support personal productivity Mindfulness sessions New consultation types All CCGs testing new consultation types need to consolidate efforts to reduce duplication of testing, share good practice Evaluation of e-consultations underway in Leeds West as part of GPAF funding in 2017/18 for online consultations Various models underway need to share learning Partnership working Good links with CPWY Pharmacy First All CCGs progressing primary care, provided at scale either through networks, federation, MOUs or scoping options Prototypes established in each CCG for New Models of Care Reduce missed appointments Support for MJOG Forgotten Something campaign Structured approach to DNAs to be launched in 2017 Develop the team LSECCG & LNCCG part of clinical pharmacist scheme learning to be shared Citywide approach to workforce pilot new roles, PA, physio /MSK in house services LNCCG in-house diabetes led nursing management and recruitment & retention for new GPs (Chapeltown HATCH Initiative Productive work flows All CCGs funded support packages through either Productive General Practice or General Practice Improvement Programme. Focus on capacity and demand processes systematic approach planned for 2017 Social prescribing All CCGs have social prescribing initiatives in place Leeds Directory to help signpost to other services in the community Support self care Leeds part of National Diabetes Prevention Programme, established collaborative care and support Planning (YOC) approach, health coaching Procure Healthy Living Services Pharmacy First Develop Quality Improvement (QI) Expertise Review TARGET proposal to include LIQH within TARGET to develop QI expertise locally Productive General Practice and general practice improvement programme offered to all Leeds practices Focus on information for improvement standardised quality dashboard Increase in use of online services Procure new website to actively signpost Leeds Directory Commitment to work across the city to commission training for admin and clerical staff Workforce Access Estates & Technology Workload Redesign

Delivering the GP Forward View in Leeds Page 24 Draft. Version 0.22 | 7/12/16 Ambition 4: Better workload management City-wide approach Current position 2016-17 2017-18 2018-21 Baseline assessment against the 10 high impact areas undertaken. Leeds identified and will continue to monitor and share good practice through the citywide primary care collaborative. Leeds Institute for Quality Healthcare to offer quality improvement course to GP staff teams. Scope a web solution for a common front end access point to deliver: active signposting, self-management and triage (as per West Wakefield and Leeds West model). Further offer care navigation training with a focus on supporting patients to access new posts and functions within the general practice team and wider multidisciplinary team. NHS Leeds West CCG trialling new software to measure demand through GP Access Fund. Expression of Interest submitted to the releasing time to care programme submitted assessing scope of programme and benefits in light of previous investment. Local training and support offered to receptionists to encourage uptake of online services to support workload management (further sessions to be arranged). Support roll out of electronic repeat prescribing. 56% practices participated in either GPIP or PGP. Use Leeds Provider Query email to understand non-compliance of acute providers against the NHS Standard

Contract. Identify 1st wave priorities for GP resilience . Review 3 CCG engagement schemes and align where possible Collaborative Care and Support Planning consultations (previously known as Year of Care) scaling and targets Develop a quality strategy for general practice, capturing the positive work already in place across Leeds. Promote a culture of quality improvement amongst practices. Develop a standard quality dashboard to support workload management and identify areas of support for practices. Practice manager representation from CCGs to scope an active signposting and correspondence training offer for GP reception staff with health coaching and social prescribing models to roll out training across the city by Jan / February 2017. Systematic approach to demand and capacity to be offered across the city. Embedding quality improvement methodologies. Continued to audit DNAs and utilise the Forgot Something campaign. Development and testing of Mindwell citywide information portal to improve mental health information access, self-help and direct referral to IAPT will divert a proportion of patients from GP direct to MH services. Continue sharing case studies and best practice across Leeds through practice manager sessions, TARGET, CCG bulletins and using the LMC Viewpoint. Engage the sessional GP workforce. CCGs continuing to support the delivery of 10 high impact changes across GP at scale over 17/18 and 18/19. Engagement with community pharmacy colleagues to scope joint approaches to support workload management. Scope citywide social prescribing service based on pilot evaluations. Continue sharing case studies and best practice across Leeds. Continue to increase online services through active promotion. Continue to increase online services through active promotion. Evaluate impact of Collaborative Care and Support Planning (previously known as Year of Care) Programme. City wide approach to communications and engagement to support self care through Pharmacy First and 111. Roll out Mindwell and increase awareness of the portal. Wave 2 investment (Dec 17) in more psychological therapy linked employment advisors to support those with LTCs. Develop standard templates and processes to support practices management of housing / PLP forms etc. Share standardised protocols for reception staff to manage clinical correspondences. Further offer care navigation training with a focus on asset mapping local community resources /self-care options / pharmacy first as a route for helping navigate patients. Continue sharing of case studies and best practice across Leeds. Work with communication and engagement colleagues to undertake campaign for supported self management (Pharmacy First etc.) Additional support requirements support to be provided by the transformation Team to secure funding for bespoke resources to support quality improvement methodologies in Leeds in recognition of the significant local investment in general practice quality programmes; support to align national and local enhanced services and local schemes to reduce bureaucracy and share best practice case studies from across the Region Page 25 Draft. Version 0.22 07/12/16 Ambition 5: Redesign care delivery Progress to a whole system model which focusses on a place-based approach where everybody has a part to play, both citizens and services together Introduction and background The ambition to redesign the way primary care is delivered is at the heart of ensuring the sustainability and transformation of both general practice and the wider health and care system. We know that general practices understanding of local population needs alongside the continuity of care enabled through the registered list are strengths that we will value and retain going forward. Building from the general practice registered list provides a firm foundation for care to be delivered differently in a more collaborative and integrated way - bringing together different providers of health and social care across the city. This chapter outlines the central role of general practice and general practitioners in driving forward change that will support and enable the wider system transformation described within the West Yorkshire and Harrogate Sustainability and Transformation Plan (WYSTP) and the underpinning Leeds Plan. Leeds is recognised nationally as being ahead of the curve in relation to current levels of integration between service providers within the city. Over the last two years the Leeds CCGs have guided and supported general practices to develop new ways of working in line with the New Models of Care (NMoC) approach described in the Five Year Forward View. Across Leeds, general practices are working with community, acute and third sector providers to develop and deliver NMoC which respond to the needs of priority populations within a given locality. Joint leadership teams are being developed and supported to enable provider joint working. The aim of this approach is to support the consideration of the use of collective resources and expertise, including the social assets of patients and communities, to deliver increasingly better outcomes for local populations. The benefits of working in a more collaborative way includes the better use of finite system resources such as workforce and estates. We believe this will lead to improved outcomes and increased satisfaction for patients and in improvements to the working lives of front line staff through better working relationships. Supported through facilitation and resource from CCGs, the following examples illustrate how general practices are working collaboratively and with other providers to develop NMoC.

Armley Test Bed A Community Wellbeing Leadership Team has been established in the Armley locality. Membership is local leaders drawn from general practice,(representing five practices in the area) LCH, LYPFT, adult social care, the Armley One Stop Centre and the local voluntary sector. The key aims are to improve relationships, develop local leadership and promote integration. The overall aim of the group is to improve the aspirations of people in Armley. The group have identified priorities around mental health, self care and delivery of care using coaching approaches. Self-led projects are underway including setting up a self-care whole system MDT to support the Adult Social Care Strengths Based Social Care innovation site in partnership with New Wortley Community Centre. The group also want to roll out coaching training to all front line clinical and non clinical staff so that all people in the area will receive a consistent response when accessing all services. Beeston & Crossgates Test Bed Chapeltown Test Bed In the Beeston and Cross Gates localities of LSECCG a new model of care project is developing that aims to provide proactive, integrated, patient centred care for people with multiple LTCs including CVD or COPD. A new multidisciplinary team in in place in both localities comprising of GP, geriatrician, matron, therapist and health advisors, with provision for mental health and pharmacist input once the level of need has been identified. The model will focus on developing wellbeing plans in partnership with participants along with resilience plans that support better self-management of conditions, coordinate resources more effectively and use community assets to better effect. The team are working with small groups(approx. 600/locality) from the identified cohort to develop the model in line with participant needs, ensuring citizen feedback is integral to the service design and development. In the Chapeltown locality of LNCCG, practices have established a Memorandum of Understanding (MOU) to strengthen their ability to work together, to develop and deliver services and approaches for one of the most deprived populations in Leeds. Working alongside community providers, GPs in the locality have established a new local diabetes service. With a jointly appointed nurse specialist, the service is seeing more complex patients in the practices and upskilling the practice workforce. With mental health and third sector providers and alongside the social prescribing service Connect-well the locality has also established a mental health wraparound service for local patients as an early implementer of the citywide MH Framework for Leeds. In addition, the locality has established HATCH (Health and Social Care Talent In Chapeltown and Harehills), which aims to strengthen and make more resilient the workforce in Chapeltown and make the locality a national go-to destination for primary care workforce . Working with providers, the CCGs in Leeds have described an ambition to move to a population health management (PHM) approach to commissioning for improved outcomes for the population of Leeds. The establishment and learning from the NMoC described are one of a number of key steps towards a PHM approach which include the move towards more strategic commissioning, providers working together in a more accountable care way, and the alignment of contracts and incentives to support this way of working. Another step is to understand and explore the appetite and benefits of testing Multi Specialty Care Provider (MCP) contract within the city. Figure 5 outlines and describes a roadmap to PHM and some of the key steps on this journey. Delivering the GP Forward View in Leeds Page 26 Draft. Version 0.22 07/12/16 Figure 5 Approach to population Health Management (PHM) Delivering the GP Forward View in Leeds Page 27 Draft. Version 0.22 | 7/12/16 Ambition 5:Redesign care delivery The role of general practice in supporting delivery of the Leeds Plan and Sustainability and Transformation Plan The Leeds Plan (Figure 6) describes the system changes required to achieve a sustainable and transformed health and care system and supports the delivery of the West Yorkshire and Harrogate Sustainability and Transformation Plan (STP). The Leeds Plan describes four work programmes which will achieve the three overarching tests of the plan; 1) People will be supported to stay in their own homes, family or community 2) People requiring hospital and residential nursing care will spend the minimum time possible there 3) The health and social care system in Leeds will be financially sustainable. GP redesign is at the heart of supporting and enabling this change. There are three areas of focus within the care redesign of general practice that contribute towards the wider system change to support delivery of the STP and the Leeds Plan. 1. 2. Redesign general practice to be sustainable - As outlined in the preceding sections of this GPFV delivery plan, this

includes the redesign of workforce, access, workload and estates and technology to increase the sustainability and transformation of general practice as the key provider of primary care for the population of Leeds . The 10 high impact actions to release GP capacity is the key starting block for sustainability and GPs being able to work at the top of their license within integrated services. Redesign the delivery of general practice services through collaborative working at-scale By working collaboratively to share some workforce, back-office, estates and service delivery models, general practice will be more efficient, sustainable and resilient. Working together at-scale across population groups of approximately 30-80,000 will shape the formation of hub and spoke working to deliver a range of GP services and enable wider alignment to support provider integration. By 2020/21 patients will: Access a broader range of health and wellbeing services out of hospital in their community Be empowered to make decisions to stay well and improve their physical and mental health Be confident that the professionals caring for them have the right information to support them, reducing the need for repeat assessment By 2020 /21 practices will: Have more time for GPs to provide expert medical advice to support patients with the most complex needs. 3. Redesign and integrate the wider health and care system, of which the general practice registered list is the Working more collaboratively to cornerstone - This is the focus of the Leeds Plan, which consolidates four work programmes . Aligning this plan to share resources , increase resilience other strategies around urgent care, pharmacy, mental health, children and families and carers is key. and provide patients with access to a wider range of options. Delivering redesign across the three levels outlined above is predicated on fully accessing the funding and resources committed in the GPFV as well as realigning Part of a wider team of health and existing resources, including finance and workforce, between existing provider boundaries. care professionals working together to meet the needs of the local population Figure 6 The Leeds Plan -Page DRAFT 28 Ensuring flow across whole system for all ages Rebalancing the conversation working with staff, service users and the public Test1: People are supported to stay in their own home, families or community Test2: People requiring hospital and residential nursing care will spend the minimum time possible there Self-Management, Proactive & Planned Care Prevention Optimising the use of Secondary Care Resources & Facilities Test3: The Health & Social care system in Leeds will be financially sustainable Urgent Care / Rapid Response in times of Crisis Links to West Yorkshire Priorities (& beyond): Urgent & Emergency Care; Specialised Commissioning; Mental Health; Prevention at Scale; Stroke; Cancer; Primary & Community Care; Acute Sustainability; Standardisation & Variation 1. Integrate the delivery of primary and 1. Re-commission Integrated Health Living Services: community based care services: One You Adult Healthy Living activities and including acute services that could be interventions delivered in community, using a Family Healthy Living activities & Child & Family commissioning 'lever' and framework such as weight management services MCP 2. Re-commission Locality Community Health taking account of plans to improve the quality Development & Improvement Services of care for people with learning disabilities, 3. Re-commission Community Mental Health dementia and those at the end of life Development & Improvement Services taking account of plans to improve the quality 4. Re-commission the Cancer Awareness Community of care for more general cohorts such as long Service as a contribution to Leeds Cancer Strategy

term conditions 5. Develop a system wide approach to increasing physical 2. Targeted Prevention programme including: activity National Diabetes Prevention Programme 6. Share learning and build on the evaluation of the Social high risk of CVD Prescribing Schemes high risk of COPD 7. Implementation of health & care elements of the Leeds falls prevention Suicide Prevention Delivery Plan Cancer screening to be an integral part of 8. Refresh and implement the Self-Harm Reduction Plan this programme. 9. Utilising the workplace to promote healthier lifestyles, 3. Systematic implementation House of Care as particularly focusing on larger workforce employers the integrated approach to embed supportive 10. Progress the Leeds contribution to the West Yorkshire self-management (inc Long Term Conditions, STP Prevention at Scale workstream on workforce dementia & Mental Health) (Making Every Contact Count & Health Promoting pool and re-commission Third Sector those Trusts) services that specifically support self11. Pool and re-commission the Third Sector for those management and proactive care ambitions services that support the programme ambitions third sector provision to other aspects of care 12. Ensure delivery of the prevention projects including sit elsewhere West Yorks STP Prevention at Scale along with integrate information and advice / selfprevention projects within the other three management tools (such as Mindmate and Programmes: (including targeted prevention, falls Mindwell) into the specifications; review of prevention, A and E alcohol related admissions , Leeds Directory smoking cessation in secondary care) 4. Recommissioning enhanced care homes support 1. Improving Secondary Care Functions LTHT Response to Carter Review LTHT/West Yorkshire Cancer Strategy Increase Use of e Referrals at LTHT LTHT Elective Care Improvements 2. Transforming Secondary Care Services Elective Care Redesign Maternity Strategy Mental Health System Flow 3. Secondary Care support & advice for healthcare workers Pre Referral Optimisation LTHT to work with CCG med directors re efficiencies re referrals Decision support tools. Potential for use of software such as Arezzo. Consistent Referral Data Consideration of consultant connect Understand pathology use variation 4. Commissioning of secondary care to deliver high value services Right Care Review and implementation of commissioning criteria for procurement of LCV Healthy Futures work plan Review Spend in Independent Sector Medicines Optimisation Review Value of AQP Procured and all Non Procured Services 5. Improving Acute Flow and Demand: Increase in Ambulatory Care Sensitive Condition Pathways 6. Releasing non simple discharges: Integrated Discharge Service 1. Urgent and Emergency Care Delivery Model Review the current landscape of urgent and emergency care services across Leeds Determine the future functions Communications and engagement programme Link into Estates Strategy to facilitate the changing landscape Assess the financial impact of the channel shift Explore alternative commissioning and contracting processes to enable the required change Develop an agile and empowering approach to change, including project management Develop an escalation process for the new system 2. Influencing self-care Influence the Self-Management Steering Group informing them of system wide pathways development Ensure consistent links with Public Health colleagues and initiatives/campaigns maximising opportunities Influence NHS111 self-care algorithms to reflect a self-management approach Influence to ensure care-planning approach is embedded into core business across all health and social care services Improve self-care in Care Homes

3. Delivering community urgent care Scope ways to maximise telecare systems to ensure the delivery of Leeds business requirements (Vanguard) Co-develop multi-disciplinary Urgent Care services, including enhanced diagnostics across the city 24/7 Conduct service review of PTS and potentially re-procure Leeds specific transport services to deliver the STP Pilot co-location of primary care within LTHT across both sites to provide an evidence-base for co-location and supporting the development of 24/7 urgent care services Influence NHSE in the development of their primary care services commissioning to ensure alignment with the proposed changes 4. Reshape rapid response Support the development of the Clinical Advisory Service and 1 11 in West Yorkshire ensuring integration with Leeds Develop robust processes to implement and continuously update 111 algorithms to include all service developments Undertake a strategic review of all the current single points of access (Health & Social Care) and explore options of establishing a multi-disciplinary point of contact including a bed bureau and other assessment tools Support YAS in the development of the Vanguard Hear, See & Treat model Ensure all patients have up to date care plans to inform the plan with me pathway approach Review High Volume Service Users work 5. Admission avoidance/Review of ambulatory care pathways and assessment functions Work with the effective secondary care programme Review all admission avoidance pathways Review current assessment functions at LTHTs front door Maximise the Integrated Discharge Service at the front and back door All plans will consider cross cutting themes : Third Sector; Maternity; Childrens & Young People; Mental Health; New Models of Care; Transform General Practice 5. TGP: Delivery of the GP Forward View 13. CYP/MAT: Best Start Plan & Maternity Strategy: Commission services to deliver to new Perinatal Mental Health Pathway 14. MAT: Activities aligned to the Leeds Maternity Strategy: Develop small community midwife teams with named obstetrician delivering continuity of carer and alignment to Early Start Service Deliver full choice offer by establishing a Leeds Midwifery Led Unit Develop maternity pathways for women with Learning Disabilities & teenage parents Deliver national Saving Babies Lives care bundle to continue to reduce numbers of stillbirths Activities targeted to reduce smoking, alcohol and substance misuse in pregnancy 15. CYP: Early identification and support for pregnant women who have had a previous baby placed into care 16. CYP: New Models of Care developed, targeted to support most vulnerable families and CYP 17. MH: increase the take up of annual health checks for people on the SMI register in line with national guidance 6. CYP: Further development of Mindmate: Develop emotional resilience resources & tools Expand role of the single point of access with advice/promotions of self-help resources 7. CYP SEMH service: Co-commission with school clusters a sustainable early intervention offer 8. MH: Increase access to IAPT for those people with LTC and link to the GP FYFV priority of integration of MH therapists 9. MH: Deliver the IAPT Access and recovery standards in line with national targets 10. MH: Delivery of Early Intervention in Psychosis access and care standards in line with Planning guidance 11. MH: Maintain delivery of IPS based Employment model in line with national guidance 12. MH Dementia: to deliver expected diagnosis rate in line with planning guidance 7. 8. CYP: Commission Community Eating Disorder Service to national standards that meets national access targets (2017/18) MH: Improve access to Psychological Therapy for those with SMI 6. 7. 8. 9. 10. TGP: Delivery of Leeds Urgent Care Strategy including roll-out of extended GP access CYP: Commission a 24/7 rapid response service for CYP in mental health crisis according to NCCMH guidance (2017/18) MH: Develop effective liaison psychiatry service in line with Core 24 model as set out in MHFYFV.

MH: Develop plan for reduction of Out of Area Placements (OAP) in line with national guidance 17/19 MH: Assess Crisis Resolution and Home Treatment Service in line with national guidance 17/19 Enablers: Comms & Engagement; Digital; Education, Innovation & Research; Estates; Finance, Procurement; Workforce & Organisational Development STP/05. Master slides and docs/Latest slides/ 1 Draft Leeds Plan Element Programme Structure V16 30Nov16 Plus links to WY Enablers: Leadership & Organisational Development; Bestindividual Practice; Commissioning V16 | 30/11/16 Page 29 Draft. Version 0.22 | 7/12/16 Ambition 5: Redesign care delivery The layers of redesign 1. Redesign general practice to be sustainable The initial focus of redesign is to support GP sustainability. Building on the delivery of the previous four sections of this plan, general practice will be supported to work through and adopt the changes in the 10 high impact actions which will release capacity within general practice. The focus of the 10 high impact areas is likely to vary across the city depending upon local population and practice needs. For example, focussing on the high impact action on social prescribing may be a higher priority in areas of deprivation where there is a high need to support the wider social needs. The capacity created will support greater redesign and integration of the wider health and care system, notably this will free GPs time to work more at the top of their licence and support the management of complex patients who have multiple needs. This would see GPs having more dedicated capacity to support system flow, for example, supporting the discharge process by actively supporting patients out of secondary care and aligning the management of care home and housebound patients. This capacity will also support better in hours access to care. Figure 7 below demonstrates the future focus of GP capacity within the integrated health and care system and management of patients with complex and multiple needs. 2. Redesign the delivery of general practice services through collaborative working at-scale The second area of focus is to support GP collaboration, through this we can deliver a foot print for hub working on which the next layer of redesign can be based. The assumption here is that collaborative and hub working is used to support delivery of services and functions where this makes sense and that this builds on, as opposed to replaces, the registered list and care that is more appropriately delivered at individual practice level. We know there are existing high levels of public satisfaction with general practice, however, due to the workload pressure in general practice, some patients have reported difficulty accessing services. As described at Ambition 2, the GPFV has committed extra national money to extend access to core primary care medical services to be delivered through collaborative working in hubs. This will encourage and support general practices to work at scale. Working at scale supports the STP and Leeds Plan place based approach to care and the ability to integrate general practice and community services through hub working. It is envisaged that hubs in Leeds will cover localities consisting of population footprints of approximately 30-80,000. There will be two phases to developing hub working. The first will be to support general practice collaboration to work more collectively to deliver extended access, the second phase will be to align more community health, mental health and third sector services around hub working. We envisage future hubs will offer a skilled mixed team with some specialist services to meet local populations needs. As an example, we will explore how hub working could enable delivery of specialist paediatric care via hot clinics to meet existing needs for same day early evening access to care for unwell children. Figure 7 Future focus of GP capacity within integrated health and care system Draft. Version 0.22 | 7/12/16 Page 30 Ambition 5: Redesign care delivery The layers of redesign 3. Redesign and integrate the wider health and care system, of which the GP list is the cornerstone The third focus of redesign is to align and integrate primary care, including general practice, with pharmacy, community health, mental health, childrens and maternity services and third sector providers around geographical neighbourhoods, localities or hubs. Working together in this way helps to build relationships as providers come together to consider and plan the delivery of their services in response to local needs. This system redesign and renewed focus will support the achievement of the four key Leeds Plan work programmes as well as the Leeds Conversation each of which are described in further detail below. Prevention work programme Integrating health and social care including third sector providers will bring a renewed focus on promoting health and wellbeing and preventing ill-health across the city. General practices in Leeds are already commissioned by CCGs and Leeds City Council to deliver activities aimed at promoting health and wellbeing and preventing people from becoming ill e.g. delivery of NHS Health Checks, and commissioning screening champions within the most deprived practices in the city. The Leeds Plan prevention programme consolidates and builds on the work already being undertaken and places specific emphasis on targeting resources to support the citys most deprived populations addressing the inequalities gap and improving the health of the poorest fastest. A much stronger focus on prevention and the use of new technology to support this is a key component of a future population health management approach. Proactive care and self-management work programme For some time, general practice in Leeds, has been changing the way support is offered to patients to self-manage. A significant programme is already under way to roll out the collaborative care and support planning (previously know as Year of care). This approach enables patients to set their own goals, and skills staff to provide health coaching and will be adopted and used as a fundamental model of interaction with patients throughout the integrated teams . A self-management approach to care through the use of decision support, asset based approaches and common signposting will be fundamental in care redesign. Care redesign for general practice will also involve ensuring patients are informed and clear about their medications (through the launch of a Leeds Medicines Charter), receptionists are skilled and trained to signpost and ensure patients are seeing the right professional first time and patients expectations about this are managed well. Proactive ,rather than reactive, care will be delivered through more integrated care models, with proactive care and case management targeted at patients with more complex needs e.g. those living in care homes or with multiple long term conditions. Care delivered in a range of settings will be enabled by a greater use of technology and the increasing participation of patients as they take more control of their own health. These are both key features of a future population health management approach. Optimising the use of secondary care resources and facilities work programme GPs and secondary care consultants will be supported to maximise their clinical capacity in order to work more jointly to support patient care in the community. GPs will be freed to work at the top of their license and support the management of more clinically complex patients. The programme will explore ways of working that ensures patients are only in hospital for as long as clinically needed with GPs playing a role in proactively support their care back into primary care. The programme also aims to increase the capacity for diagnostic and rapid assessment of patients across primary and secondary care. Urgent Care /Rapid Response in times of crisis work programme It is well recognised that the majority of urgent care is delivered in general practice. The programme will explore how the primary care contribution has maximum

impact across the urgent care system by reshaping the crisis response including extending access to general practice across the city. Changing the way that same day urgent care need is responded to across the system will be a key part of the required transformation for future sustainability. See Ambition 2 for further information. Page 31 Draft. Version 0.22 | 7/12/16 Ambition 5: Redesign care delivery Enabler to redesign the Leeds Conversation The Leeds Conversation an enabler to system sustainability The Leeds Conversation will activate patients to be owners and partners in their own care and using this system is fundamental to supporting prevention and self-management. Leeds will create a one team approach to care delivery. This will support person centred care, empower staff to do the right things and remove duplication in care. Developing the Leeds Conversation between patients, the public and professionals and which all providers will support, will help us have transparent conversations WITH people about the services we are delivering and peoples role in their own care. This approach is crucial to support a culture change in both staff and the public and help with the shift towards scaled prevention, self-management and system sustainability and is central to the future approach of population health management. The Leeds Conversation features in a number of strategies and plans that set out the delivery of improved outcomes for populations and across care pathways. These include urgent care; mental health; children and maternity services; and Carers. Longer term system redesign A longer term, 10 year redesign of current approaches to commissioning and provision with a move towards population health management (Figure 5) will move the strategic commissioning of outcomes for defined populations within an agreed budget within an agreed timeframe for new ways of working to deliver accountable care, supported by aligned incentives and contractual levers across the system. Figure 8 The Leeds Conversation and its key component parts Page 32 Draft. Version 0.22 | 7/12/16 Ambition 5. Redesign care delivery Citywide delivery approach: Current position 2016-17 2017-18 2018-21 Core GP redesign and hub working CCG commissioned engagement schemes moving general practice towards more prevention, supported self-management, managing populations and working jointly together. GPs are at the heart of NMoC test projects for segments of the population or a via a placed based approach. General practice at scale through federations, networks or across local agreements to support hub working. CCGs taken on level 3 delegated commissioning of core GP contract in April 2016. The focus in 2016-17 is to understand where opportunities exist to support collaboration between practice and integration with other providers The focus in 2017-18 will be to align community providers to deliver joint population outcomes. To develop an MCP model for Leeds and scope where general practice sits within this model The focus between 2018-21 will be on full MCP model working and aligning contract outcomes to deliver integrated care Key in year work areas

Core GP redesign and hub working Continue to support and develop PPGs and virtual PPGs. Scope service changes that GP could deliver in the Leeds Plan (supported by expanded access to GP, community pathways, point of care testing). GP to continue to be part of NMoC test projects and develop more supported self-management. Implement a joined/ coordinated Leeds GP engagement scheme. To scale collaborative and care support planning. To further roll out extended access via hub working and scope alignment of other services Key in year work area Core GP redesign and hub working Scale NMoC learning. Support clinical leadership with better data sources. Develop improved GP access to specialist opinion (physical and mental health). Deliver extended access supported by skilled mixed teams as part of hub working. Wider system redesign 13 neighbourhood teams based around the GP registered list. Leeds Plan developed with identified work streams. Leeds Care Record supports sharing of appropriate health and social care information across providers. Quality improvement methodology across providers (LIQH courses) Developing the PHM approach. Developing a one team approach to service provision. Concept of a social contract signed up to. Key in year work areas Core GP redesign and hub working Scoping the opportunities and learning from elsewhere around GP contract changes with QOF/ES. Review CCG commissioned GP engagement schemes to support alignment of resources towards system wide priority populations in 2017-19. To focus care to be proactive and on secondary prevention. Support and develop patient participation groups (PPGs) to be active in their role as part of the whole system redesign and support development of the Leeds Conversation. Consolidate any core NMoC learning into commissioning planning for 2017-19. Continue to skill GP staff to deliver collaborative and care support planning towards supported selfmanagement. Continue to support and facilitate collaborative working through federation, networks or alignment to have a strong GP provider voice. Facilitate collaboration to hub working to support access. GP as part of wider system redesign The city is developing a population health management (PHM) approach as a framework for the future health and care system. Further develop and agree segmented priority populations. Deliver a further quality improvement programme to support joint working and learning to address variation in care. Facilitate providers to align in NMoC development to create the one team approach. Develop the Leeds Conversation through a social contract between providers and citizens for the city. GP as part of wider system redesign Ensure general practice is part of MCP model conversations, scoping and development. Continue developing and testing the PHM approach. Test population budgets. Build clear expectations around NMoC and PHM joint working into all CCG provider contracts. Support integrated nursing approach for practice and community nursing teams through empowering front line staff to make change. Embed the Leeds Conversation through a social contract between providers and citizens for the city Use the social contract as a tool to support culture change and shared vision for the workforce. Develop models / plans for community care hubs which

integrate urgent care, 111, rapid assessments, diagnostics and extended GP access. Scale health coaching skills roll out across health and care staff to support self-management. GP as part of wider system redesign To use the PHM approach for managing more priority populations / place based care. Roll out / go live on some population budgets. Review and further develop the Leeds Conversation through a social contract between providers and citizens for the city. Commission community care hubs which integrated urgent care, 111, rapid assessments, diagnostics and align to extended GP access. Alliance or integrated MCP contract in place. Additional support requirements transformation team to support the alignment of the STP and GPFV delivery plans and support the Leeds Conversation movement and provide regional and national support for local communications and engagement to manage patient expectations with any service changes Page 33 Draft. Version 0.22| 7/12/16 Ambition 6: Investment and resourcing of General Practice and Primary Care Delivering our ambition is predicated on fully accessing the funding and resources committed in the GPFV as well as realigning existing resources, including finance and workforce, between existing provider boundaries across Leeds. The table below outlines our investment plan incorporating local and national investments to deliver all aspects of the GP Forward View in 2016/17 Ambition NHS Leeds North CCG NHS Leeds South and East CCG NHS Leeds West CCG 1. Supporting and Growing the Workforce a) Clinical pharmacists (local investment) b) TARGET (60K city wide in S+E budget) c) Supporting and growing workforce clinical navigator training national allocation d) Health & wellbeing FD 2. Improving Access to General Practice a) Improving quality schemes (CCG engagement that supports patients through increased access & self care) b) Extended access enhanced service (1.90) Per patient c) Improving Access to general Practice 3. Transforming Estates and Technology a) WIFI b) Infection control audits c) Surgery pods d) GP IT (based on registered capitatio n split) 4. Better Workload Management a) Secondary care requested bloods b) Vulnerable practices 16.17 c) Fair share of national GP resilience funding d) CCG Social prescribing 5. Redesign of Care Delivery a) Enhanced provision to care homes b) Prevention and health inqualities c) New care models support 6. Core Contract a) Delegated Primary Medical Services b) Core Contract Uplift c) PMS Premium Total Primary Care Resource 305,000 22,500 224,000 60,000 38,000 18,000 24,000 32,000 2,667

2,667 2,667 1,872,000 5,183,344 5,760,840 326,147 522,200 701,488 2,215,223 126,000 2,833 144,000 543,086 3,750 4,000 695,150 934,107 34,000 32,000 59,106 666,667 45,000 40,200 76,269 460,000 60,000 15,000 102,246 278,833 229,000 200,000 710,000 446,000 489,000 800,000 475,000 24,813,853 768,000 128,000 31,002,859 35,107,800 1,043,000 227,000 45,449,380 40,728,512 1,089,842 387,158 53,253,916 429,000 Page 34 Draft. Version 0.22| 7/12/16 Ambition 6: Investment and resourcing of General Practice and Primary Care Delivering our ambition is predicated on fully accessing the funding and resources committed in the GPFV as well as realigning existing resources, including finance and workforce, between existing provider boundaries across Leeds. The table below outlines our investment plan incorporating local and national investments to deliver all aspects of the GP Forward View in 2017/18 is: Practice and Primary Care The local investment plan to deliver all aspects of the GP Forward View in 2017/18 is: NHS Leeds North CCG Ambition 1. Supporting and Growing the Workforce a)Clinical pharmacists

Fair Share of Clinical pharmacists National funding b)TARGET 60K city wide in S+E budget c)Supporting and growing workforce clinical navigator training d)Practice manager training 2. Improving Access to General Practice a)Improving quality schemes (CCG engagement that supports patients through increased access & self care) b)Extended access enhanced service (1.90) Per patient c) Improving Access to general Practice 3. Transforming Estates and Technology a)Infection control audits b)GP IT c)GP IT Transformation d)GP Software 4. Better Workload Management a)Secondary care requested bloods b)Fair share of GP resilience c)Social prescribing CCG d)Fair share Releasing time to care 5. Redesign of Care Delivery a)Enhanced provision to care homes b)Prevention and health inequalities c)New care models support d) Redesign of care delivery 1.50PP (CCG using this funding differently) Leeds North for access, Leeds S+E for Transformation and Leeds West for Leadership to support new models of care) 6. Core Contract a) Delegated Primary Medical Services b) Core Contract Uplift c) PMS Premium Total Primary Care Resource NHS Leeds South and East CCG NHS Leeds West CCG 321,000 (+National Funding) 414,101 532,718 713,618 22,500 60,000 38,000 36,692 47,579 63,836 22,176 28,546 38,300 1,872,000 4,769,626 1,856,802 329,408 525,887 705,585 2,228,162 2,833 543,086 250,000 55,443 3,750 695,150 320,000 71,368 4,000 934,107

430,000 95,755 34,000 29,625 333,333 110,883 45,000 38,134 460,000 142,731 60,000 51,165 488,500 191,503 to be confi rmed 100,000 446,000 125,000 800,000 475,000 322,536 413,718 555,423 25,581,853 418,739 192,000 30,671,208 35,624,913 1,568,200 341,000 47,059,320 * Future investment pending evaluation of Non Recurrent schemes 41,112,769 2,271,314 616,332 52,930,170 Page 35 Draft. Version 0.22| 7/12/16 Ambition 6: Investment and resourcing of General Practice and Primary Care Delivering our ambition is predicated on fully accessing the funding and resources committed in the GPFV as well as realigning existing resources, including finance and workforce, between existing provider boundaries across Leeds. The table below outlines our investment plan incorporating local and national investments to deliver all aspects of the GP Forward View in 2018/19. Practice and Primary Care The local investment plan to deliver all aspects of the GP Forward View in 2018/19 is: NHS Leeds North CCG Ambition 1. Supporting and Growing the Workforce a)Clinical pharmacists Clinical pharmacists National funding b)TARGET 60K city wide in S+E budget c)Supporting and growing workforce clinical navigator training d)Practic e manager training 2. Improving Access to General Practice a)Improving quality schemes (CCG engagement that supports patients through increased access & self care) b)Extended access enhanced service (1.90) Per patient c) Improving Access to general Practice 3. Transforming Estates and Technology a)Infection control audits b)GP IT c)GP IT Transformation d)GP Software 4. Bette r Workload Management a)Secondary care requested bloods b)GP resilience 16.17 17.18 and 18.19 c)Social prescribing CCG d)Releasing time to care

5. Redesign of Care Delivery a)Enhanced provision to care homes b)Prevention and health inequalities c)New care models support d) Redesign of care delivery 1.50PP (CCG using this funding differently) Leeds North for access, Leeds S+E for Transformation and Leeds West for Leadership to support new models of care) 6. Core Contract a) Delegated Primary Medical Services b) Core Contract Uplift c) PMS Premium Total Primary Care Resource NHS Leeds South and East CCG NHS Leeds West CCG 248,461 22,500 172,000 (+National Funding) 319,631 60,000 418,171 38,000 36,975 47,566 63,418 22,184 38,230 28,538 1,872,000 1,379,060 (additional investment to be advised*) 1,866,691 332,703 529,527 709,342 723,585 930,852 2,240,029 2,833 543,086 3,750 695,150 4,000 934,107 73,949 95,132 127,436 34,000 29,701 to be confirmed 110,920 45,000 38,208 To be advised* 143,269 60,000 51,183 506,500 191,148 446,000 125,000

To be advised* 475,000 100,000 322,536 413,718 555,423 26,192,592 421,705 256,000 31,345,730 37,193,113 1,055,360 454,000 42,633,506 * Future investment pending evaluation of Non Recurrent schemes 43,384,083 1,501,575 454,000 53,608,644 Page 36 Draft. Version 0.22| 7/12/16 Ambition 6: Investment and resourcing general practice and primary care The table below summarises the regional and national support required to deliver the Leeds GPFV delivery plan. Each support requirement links to the phased delivery plan for the ambitions outlined in section 5. Ambition Areas of regional and national support required 1. Supporting and growing the workforce 2. Improving access to general practice 3. Transforming estates and technology 4. Better workload management 5. Redesign care delivery Local NHSE transformation team to provide: Dedicated Leeds level capacity to lead project management and co-ordination of current schemes. Project management support to the Leeds primary care workforce group. Support in bid development for accessing local, regional and national monies. National support to address gap in access to practice nurse training. Explore GP resilience funds to support health and wellbeing plans for practice staff (across the region). Local NHSE transformation team to provide dedicated Leeds level capacity to lead project management and coordination of Leeds approach to extended access (business intelligence and service redesign capacity and capability). Assumes access to West Yorkshire Vanguard Accelerator funding in 16/17 to pump-prime additional enhanced access Assumes receipt of nationally available monies to support extended access in 18/19 (3 per head) and 19/20 (6 per head). Developing primary care estate and accelerating digital capability is dependent on the successful funding of applications submitted through the ETTF from the Leeds CCGs. Accelerating digital literacy across Leeds will be underpinned by the Leeds CCGs receiving national monies to further

support uptake of GP online as committed in the GPFV. Bespoke resources (over and above Releasing Time to Care Programme) to support quality improvement methodologies within Leeds in recognition of the significant local investment in general practice quality programmes. Support to align national and local enhanced services and local schemes to reduce bureaucracy. Sharing best practice case studies from across the region. Local NHSE transformation team to support the alignment of the STP and GPFV delivery plans and support the social contract movement and provide regional and national support to manage communications and engagement to manage patient expectations with any service changes. Page 37 Draft. Version 0.22| 7/12/16 6. Engagement Summary of engagement undertaken to date and plans for future engagement Introduction and context The initiatives, priorities and ambitions described within the GPFV delivery plan have been developed in response to engagement undertaken and feedback received by the three Leeds CCGs from a range of stakeholders. A summary of areas of engagement with key stakeholders undertaken to date and activities planned for the future is described in the summary table below. Going forward, a full engagement plan to support the design, delivery and evaluation of initiatives taken forward through the GPFV delivery plan will be developed and implemented. Stakeholder Group Engagement undertaken and insight gathered to inform content of GPFV Delivery Plan Principles of engagement in the future: Engagement should underpin activity at every stage, including feedback when changes have been implemented (You said, we did) Patients and public Engagement with patient reference groups or patient participation groups (PPGs) to inform scope and priorities within plan in particular in relation to emerging models of extended access 3 Things campaign has identified a range of local patient and public priorities relating to the workforce, access and technology sections of the GPFV delivery plan. National GP Patient Survey Update relating to the development of the citywide GPFV Delivery Plan presented to all 3 Leeds PCCC (public meetings) Feedback from Patient Assurance Groups. Ongoing and regular workshops with member practices around different elements of the plan as part of formal members meetings, operational working groups and locality meetings. Work with clinical leads for specific ambitions within the plan to scope and describe plans. CCG members We will undertake targeted specific engagement initiatives to inform the implementation of specific initiatives within the GPFV Delivery Plan. We know from feedback that a key focus of engagement will be on developing and communicating new workforce models such as the roles of pharmacists, physiotherapists and care navigators in general practices. Others areas include working with children and families to scope the development and test of paediatric hot clinics in the extended access initiative. Regular updates regarding the overall implementation of the plan through communications to patient reference/participation groups and the virtual patient reference groups and networks. Future conversations with public and patients regarding how best to positon the concept of the social contract as part of the wider Leeds conversation work.

Specific task and finish groups to progress specific elements of the GPFV delivery plan. Ongoing updates regarding implementation of GPFV delivery plan at members meetings. Page 38 Draft. Version 0.22| 7/12/16 6. Engagement Summary of engagement (continued) Stakeholder Group Engagement undertaken and insight gathered to inform content of GPFV Delivery Plan Principles of engagement in the future: Engagement should underpin activity at every stage, including feedback when changes have been implemented (You said, we did) Partners, including CCG workforce Work has been undertaken to engage with citywide commissioning teams i.e. teams leading on programmes and initiatives that interface with key elements of the plan, Examples include the citywide urgent care Team, primary care workforce group, citywide informatics team. LMC the three CCGs have worked closely with the LMC to understand the implications and commitments made within the GPFV and in relation to the content of the plan going forward. This has included specific LMC meetings and presenting the draft GPFV delivery plan at a recent LMC STP conference in Nov 16. Ongoing engagement with key internal partners in the implementation and more detailed scoping of initiatives within the plan. Commissioning primary medical care services across the three Leeds CCGs was a specific area of enquiry by the Adult Social Services, Public Health and NHS Scrutiny Committee in 2015/16. Key feedback was received in relation to adopting a citywide approach to commissioning and in particular in relation to extended access. This feedback has been reflected through the development of the citywide GPFV delivery plan. A draft copy of the GPFV has been shared with adult and children's social services, public health and local councillor health and wellbeing champions for review and feedback. Continue to engage with community committees on the GPFV delivery plan and its implementation Update and briefing provided to PCCCs outlining the proposed approach to the development of the GPFV delivery plan Final draft of the GPFV delivery plan to be presented to PCCC for approval in December 2016 in advance of final submission 23 December 2016. Regular updates and briefings relating to the implementation of the plan standing item at each meeting. Local authority and elected members CCG Primary Care Commissioning Committees Page 39 Draft. Version 0.22 07/12/16 7. Risks and mitigations

The three Leeds CCGs work together to identify, review and control collective risks relating to the sustainability and transformation of general practices . The level of differential risk and mitigating actions are reported to each of the three Primary Care Commissioning Committees. A summary of the current identified overall risk with specific reference to the implementation of the GP Forward View delivery plan is provided below. This should be read alongside each CCGs wider primary care risk register. Risk ID Risk Description Initial Risk Rating Controls and Measures in Place GPFV workforce There is a risk that general practices in Leeds are unable to recruit and retain workforce within general practice and within partner organisations . This is due to local and national workforce shortages resulting in the inability to provide high quality core primary care services and develop and deliver new models of care. Leeds CCGs working with members to support a wide variety of workforce development initiatives aimed at improving the recruitment, retention and resilience of general practice workforce. These include: recruitment programmes, development programmes, reviewing skills mix, new community pharmacy roles, trial of new physiotherapy roles and initiatives between primary care and community nursing. Workforce challenges and needs are being reviewed as part of the wider strategic workforce work and through the citywide primary care workforce working group. GPFV access There is a risk that CCGs are unable to deliver access to routine and urgent primary care appointments 7 days a week due to lack of available workforce and financial resource and resistance to change, resulting in reduced patient experience, potential pressure on the wider health and care system and non-delivery of a national directive. Leeds CCGs are working together to: support a variety of workforce initiatives (see mitigating actions above), engage with member practice to develop and test new models of care for extended primary care access, develop the model of extended access as part of the Leeds Urgent Care Strategy to maximise workforce and reduce service duplication fully utilise nationally available funds to commission new models of extended access monitor outcomes and impact of schemes on demand management and the wider Health and Social Care system GPFV estates and IT There is a risk that the Leeds CCGs are unable to support the transformation of primary care and new models of care due to the limitations of current primary care estate and technology; resulting in patients experiencing a poor quality of care and practices being unable to deliver improved models of care for patients. Practices encouraged to apply for capital funding via the National Estates and Technology Transformation Fund (ETTF) . Primary care estate is being reviewed as part of the wider citywide strategic estates work to understand the totality of available estate across all providers on a locality by locality basis. Draft Primary Care Estates Strategy completed for Leeds. GPFV workload There is a risk that the significant workload currently placed on general practice due to increasing demand and reducing capacity will result in the inability of general practices to deliver high quality care for patients, increased pressure of general practice workforce and the inability to transform and re-design general practice. CCG investment in quality improvement methodologies. Supported programme to roll out 10 high impact changes across general practice underway across Leeds positive feedback received already Work with LMC to improve workload at interface between general practice and other providers. Mitigated Risk Rating Delivering the GP Forward View in Leeds Page 40

7. Risks and mitigations (continued) Risk ID Risk Description GPFV redesign of care delivery There is a risk that engagement and relationships between the Leeds CCGs and member practices will deteriorate due to potentially unpopular decisions that may need to be made in relation to commissioning and contracting general practice services. This may affect the ability of the Leeds CCGs and member practices to work effectively to design and plan the delivery of the transformation of primary care and new models of care Proactive open and transparent discussions with members utilising existing infrastructure, ensuring clinical engagement is central in the development of all proposals relating to primary care GPFV investment There is a risk to the sustainability of general practice due to funding challenges resulting from the PMS equitable funding review; other contract changes; and non-recurrently funded schemes resulting in the inability of practices to deliver high quality services for their local populations . Systematic approach to the utilisation of PMS premium funding and wider investment in general practice. In year contract review meetings incorporating financial information and intelligence. Significant local CCG investment in general practice through the commissioning of local quality improvement schemes, subject to affordability. Application to maximise nationally available resources Strong relationships between the three CCG primary care and finance teams, supported through citywide Primary Care Collaborative group GPFV quality There is a risk that general practices are unable to deliver high quality services due to workforce, workload, estates and finance challenges; resulting patients experience poor quality and/or unsafe care. A citywide general practice quality dashboard has been produced to enable the Leeds CCGs to systematically identify and respond to quality issues and concerns at a CCG and individual practice level See mitigating actions described in relation to the workload, workforce, finance and estates mitigating actions above. GPFV CCG capacity There is a risk that the Leeds CCGs are unable to fully deliver responsibilities associated with primary care commissioning due to lack of capacity and capability within the primary care commissioning and locality teams resulting in the inability to implement the ambitions described in the GPFV delivery plan for Leeds. Through the One Voice work, CCG primary care commissioning and locality teams working together to maximise primary care commissioning capacity and capability across the city Citywide delivery of GPFV delivery plan and associated monitoring arrangements will identify risks to delivery and the implementation of mitigating actions. KEY Red = No effective plan to reduce risk - intervention required Amber = Plan in place to address risk - significant residual risk Green = Plan in place to mitigate risk to reasonable level Initial Risk Rating Controls and Measures in Place Mitigated Risk Rating Page 41 Draft. Version 0.22| 7/12/16 8. Governance The governance arrangements to assure each CCG and NHS England that the plan is being delivered fully and on time Figure 9 Governance of the GPFV Delivery Plan Health & Wellbeing

Board The GPFV delivery plan will be presented to the Primary Care Commissioning Committees of the three Leeds CCGs in December 2016 for sign off in advance of the plan being submitted on the 23 December 2016. Through the Leeds CCG Primary Care Commissioning Collaborative Group, the three Leeds CCGs will continue to work together to implement the GPFV delivery plan through a citywide approach. This will be further strengthened by wider One Commissioning Voice programme being undertaken to align the CCGs approach to commissioning across the city. Each CCG will formally report on the delivery of the GPFV delivery plan to its respective Primary Care Commissioning Committee. As part of the One Commissioning Voice programme, these three statutory committees will become increasingly aligned. The delivery of the component parts of the plan will be led by the three CCG primary care development teams, through the operational groups underpinning the PCCCs (see Figure 9 ) and working in partnership with appropriate stakeholders. Risks in relation to the sustainability of primary care in general and specifically in achieving the ambitions of the GPFV delivery plan, will be assessed, owned and reported through existing CCG governance structures. The GPFV delivery plan underpins the wider Leeds Plan. CCG primary care and New Models of Care leads will form part of the delivery teams for each of the four programmes for the Leeds Plan. Within this, there will be a requirement to report and provide assurance on the delivery of the GPFV delivery plan to the Leeds Sustainability and Transformation Plan delivery group. Each CCG will work closely with internal patient assurance groups to provide assurance to PCCCs and CCG Boards and Governing Body that the GPFV delivery plan is being implemented with full and appropriate levels of patient engagement and communication. Professional Executive Group Leeds Sustainability & Transformation Delivery Group Leeds North Primary Care Commissioning Committee Leeds Sth & East Primary Care Commissioning Committee Leeds West Primary Care Commissioning Committee Leeds CCG PC Commissioning Collaborative Central Delivery Unit (CDU) Proposed Primary Care Operational Group Primary Care Improvement Group Locality Teams Primary Care Engagement team Locality Development Sessions / Locality Teams

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