Launched at the NAPC’s annual conference in October 2015 by Simon Stevens, the Primary Care Home offers an innovative approach to strengthening and redesigning primary care to support the delivery of the NHS Five Year Forward View.
Following the receipt of 110 requests for further information on the PCH model, almost 70 networks of GPs, health and social care staff submitted expressions of interest to be the first PCH ‘Rapid Test Sites’ (RTS), reflecting how much health professionals across primary care are committed to change and working in partnership.
15 RTS were chosen in December 2015 following a rigorous evaluation process, involving key health and social care experts, patient representatives and an evaluation workshop attended by all shortlisted applicants.
Driven by the triple aims and timescales of the Five Year Forward View, the sites are now making rapid progress in developing their plans to transform healthcare delivery for their local population, raising the profile of the PCH model right across the health system.
"This programme offers an innovative approach to strengthening and redesigning primary care, centred around the needs of local communities, and tapping into the expertise of a wide array of health professionals.
The programme shows health professionals across primary care are committed to change and working in partnership. This will be another step towards greater integration between primary and secondary care and to providing personal population-orientated primary care where physical, mental and social care is integrated around the needs of communities, particularly older frail people with long term conditions.
This will complement the delivery of the vanguards."
Simon Stevens Chief Executive NHS England
North - Cumbria & North East
1st Care Cumbria are working in partnership with Patients (via Patient Participation Groups), Success Regime , Cumbria CCG, Cumbria Partnership Foundation Trust, providers of Mental Health and Community Services, Cumbria County Council, North Cumbria University Hospitals NHS Trust, Cumbria CVS, Bishop of Carlisle – Bishop for Health for England sitting in House of Lords, Local MPs.
The health economy is in significant deficit – hence Success Regime
We recognise the need to move from sickness-led silo working to prevention-led seamless, integrated care, through truly transformational clinical change
Build on previous successes of Integrated Care Organisation Pilot
Investment in the physical, emotional and psychological wellbeing of patients, tailoring advice, care and support to individual needs/circumstances, ensuring the best outcomes, within available resources
A whole system approach delivered through the Success Regime
General Practice fully integrating with community, social care, and voluntary services to deliver 7-day a week services and reduce reliance on secondary care
Building multi-disciplinary primary/community care teams
Working actively to create mobilised communities for health and wellbeing
Implementing innovative technology at scale to both patient and NHS advantage with an integrated clinical record
Changing drivers and incentives, while taking responsibility for a capitated budget
Primary Care Home provides an unrivalled opportunity for General Practice to lead the development of agreed high quality and consistent standards, ensuring as much care as possible is provided locally, and only care which cannot be developed and/or delivered locally will be purchased from out with the Primary Care Home.
We will ensure the right care, delivered in the right place, at the right time, by a single team, which has the right skills to provide that care.
South - South West
New Devon CCG – Western Locality, Plymouth Hospitals Trust, Plymouth Community Healthcare (integrated health and social care provider), Plymouth City Council – as lead commissioner for Public Health and Social Care services, Devon LMC, Devon Local Pharmaceutical Committee and South West Local Professional Network for Pharmacy, Healthwatch and Patient Groups. Beacon Medical Group is a single merged partnership serving 32,500 a patient list.
Our vision is to make general practice better practice, to be a sustainable practice that thrives on innovation and to work with our patients, staff, partners and communities as one team.
We provide services from 4 sites, with plans to redevelop our two larger sites to create health and community hubs. We already host a range of healthcare professionals and want more space for greater multi-disciplinary and community usage.
Operating at scale has changed our interactions within our local health and care system. We haven’t waited for permission to lead in this area and have deliberately left finance and organisational boundaries outside the discussion. We’ve already shown that with collaboration primary care can offer more specialised care and offer quicker access at lower cost to the system.
Our vision is to actively promote this culture and through Primary Care Home give confidence to other practices and our partners that excellent healthcare; excellent relationships and innovation can and should start in communities.
Patients and communities have significant untapped assets and energy. We want to unlock these by working from the ground up; bringing new collaborations and renewing passion in existing partnerships to make a sustainable difference. This can come from any sector or any size organization.
By operating a Primary Care Home at our scale we have the flexibility to innovate and move faster, and the relationships to make it work.
Midlands & East - East
South Norfolk Clinical Commissioning Group (SNCCG), local Mental Health Trust (Norfolk & Suffolk NHS Foundation Trust), the local acute hospitals (Norfolk & Norwich University Hospital NHS Foundation Trust and West Suffolk Hospitals NHS Foundation Trust), West Suffolk CCG, Norfolk Community Health and Care Trust, other local community providers and Social Services.
The Breckland Alliance is a group of four Practices in South Norfolk working together in partnership to develop a collaborative care organisation which delivers safe, effective, caring and sustainable health and social care for the population of our geographical area. We are working to align all four Practices into one cohesive Primary Care Organisation: one workforce, one team, one service delivered by the right people in the right place at the right time. We aim to contribute to the triple aims of the NHS Five Year Forward View in the following areas:
The care and quality gap: improving quality of care through developing inter-practice care and management of long-term conditions and disease prevention alongside integrated community care services.
The health and wellbeing gap: identification of health needs locally and the establishment of services directed at our high population of frail older people including commencement of a nursing, care home and frailty service including a locality based social care advice service.
The finance and efficiency gap: improving organisational capability through implementation of a fully integrated clinical, admin & management workforce across three practices utilising efficient IT and systems support and procurement. In addition plans for better use of resources through workforce development including skills analysis, training & development and recruitment and retention planning.
The Breckland Alliance also owns Thetford Healthcare CIC, a not for profit organisation that manages the local community hospital, on behalf of the NHS. This facility currently incorporates 21 organisations offering 50 NHS services and is an ideal base for our planned integrated hub of healthcare provision.
Horsham & Mid Sussex CCG, 4 GP practices of East Grinstead, Queen Victoria Hospital NHS Foundation Trust, Sussex Community Trust, Sussex Partnership Foundation Trust, Age UK East Grinstead and District, St Catherine’s Hospice, East Grinstead Town Council, Brighton and Sussex University Hospitals Trust and West Sussex County Council, South East Coast Ambulance NHS Trust, our local population.
We are a collaborative of 4 GP practices, an acute Foundation Trust, a community trust, a mental health trust, hospice and local authority. Our ambition is to improve the health and wellbeing of the 40,000 population of East Grinstead.
Objective 1: Identify and commit to improving a set of population outcomes across segments of our population who share certain similar needs
Objective 2: Create a community of practice, with purposeful leadership, which staff will recognise is a multidisciplinary-based approach around the needs of our town.
Objective 3: Create a culture of practice in which people using our services and the staff providing front line services are in control of the design and delivery of care
Objective 4: Co-design the care with the individual empowering them to make informed choices and are clear about how and where to access advice and care
Objective 5: Create a single system infrastructure and transformation that supports the town based community of practice.
In seeking to achieve these objectives we will:
- explore initially shared and then delegated budget functions from our CCG with effective learning on how to risk manage this process;
- develop our data capability and informatics systems so we are better able to understand how local people are behaving in real time so we can tailor our approach accordingly;
- build on established pilots including proactive care, tailored health coaching and patient activation and links with our community and 3rd sector to build a foundation for improving community health and wellbeing.
North - Yorkshire & the Humber
CCG, local hospital, county council including the Health and Wellbeing Board Chair, Community and Mental Health Services and the Integrated Care Partnership Board which includes all health stakeholders locally.
The Primary Care Home model will allow the surgeries to take the next step towards truly integrated care built around patient need. We have worked hard to develop close working relationships with community services, nursing homes, the voluntary sector, mental health colleagues and local secondary care services and this model will enable us to demonstrate the benefits of developing an integrated team.
We have support from all local stakeholders including our patient group, and believe working together across two practices will demonstrate the advantages of collaboration and building capacity across a larger population base.
We expect to show significant benefits in patient outcomes, and improve organisational efficiency. We will provide better holistic, targeted care for those patients who need to use primary and secondary care most, by working with patients to identify their needs, address any gaps in their care and deliver a team-based approach to meet their needs. This may include community or secondary care input, and we will provide dedicated staff to work with the voluntary sector to meet their wider needs.
Our future Primary Care Home model will bring together a range of healthcare professionals to improve choice, integration and better outcomes for our patients. We want to remove the barriers to care, find innovative funding models and develop a workforce model that is high quality, diverse and sustainable for the future. The model will be co-created with partners and patients. Supported by robust administrative and governance processes, we want to free clinicians to have time to care, and deliver truly coordinated person-centred healthcare.
Midlands & East - East
Luton Primary Care Cluster together with Cambridgeshire Community service NHS Trust
Luton is a challenging health and care economy:
- high proportion of black/minority/ethnic residents
- rapidly growing population of children
- an over-reliance on hospital delivered emergency care
- high proportion of primary care operating from small GP practices
However, we are developing energetic and ambitious leaders who believe the Primary Care Home model offers an exciting way to tackle many of these challenges. General Practice and community health services have a vision to create truly integrated working in each locality. This involves improving the lives of the local (GP) registered population; delivering care close to home that is responsive and flexible and is value for money.
Recent initiatives focussed on the following mean that our relationships are strong and ready to develop into an innovative primary care/community health model.
Care co-ordination in palliative care
Multi Disciplinary Team co-ordinators for the frail elderly
Introduction of social prescribing
A rapid response team for the children’s urgent care pathway
An Integrated personalised commissioning pilot site for dementia.
Our first year will focus on:
- Testing the model with two Luton GP Clusters focusing initially on poly-pharmacy and diabetes.
- Developing the scope of the capitated sum and agreeing clear accountability/delegation with the Clinical Commissioning Group.
- Developing a shadow budget.
- Agreement, informed by public input, of outcome measures to judge success.
- Embedding the multi-disciplinary ways of working to give confidence that they. can be recurrently funded without double paying via acute tariffs.
Midlands & East - East
Nottingham North & East Community Alliance (NECA) is a group of like-minded practices with one aim - to improve the care of our population. We will foster strong team-based care accountable for quality and the cost of care for this population.
Fuelled by determination, commitment and enthusiasm, we are clear our vision will reduce health inequalities through harnessing practices to shape the sustainability of the wider health and care system. Priorities include clinical variation, improving mental health, reducing emergency admissions, facilitating discharge, enhancing access, maximising technology around integrated care delivery and supporting self-care. Our health promotion activities will ensure a focus on longer-term health and wellbeing impacts. Citizen engagement, endorsing our patients and care givers as active participants in care processes and using performance outcome measures that matter to our citizens will be central to success.
We feel the true value of the Primary Care Home rests on the people who are part of it, making a daily effort and enjoying the confidence of being part of a commitment environment. This pioneering commitment drives us to design, build, operate and continuously improve the new care model for serving our population. It is underpinned by our focus on training, education, workforce development and shared learning. Developing on existing areas of good practice, we will look to replicate across the wider CCG area.
Seeking to overcome existing structural and cultural barriers we will prioritise primary care within integral seamless management of medical and socio-medical services actively involving patients, caregivers, voluntary sector, pharmacists, opticians, community services, homecare and social workers.
Richmond CCG, RGPA and the Richmond CEPN are working together: Richmond CCG is the health commissioning organisation for the London Borough of Richmond upon Thames. Richmond GPA is a federation of all 28 GP practices in the London Borough of Richmond. Its role is to improve care to our patients and to protect Primary Care. The practices have joined together to develop innovative ways of improving patient access to primary medical care across the Borough. Richmond CEPN is a Community Interest Company with the aim of supporting workforce development through training and education, by developing multi-professional training opportunities, increasing community base placements and introducing new roles to general practice working closely with Health Education South London, other CEPNs and our Higher Education Institution to enable all staff in its 28 member practices to access CPPD funded development.
Richmond has plans to transform into four primary care home sites, each of around 50,000 people. The initial rapid test site will be focused in the locality of Twickenham and Whitton.
In our Primary Care Home, we are bringing together health and social care professionals from primary as well as community care to work together and with other health and social care providers in the borough to deliver integrated and timely health and social care services to the residents of Richmond.
The project is jointly led by the Community Education Provider Network, Richmond GP Alliance and Richmond CCG, in collaboration with community services, overseen by a joint steering group.
Our initial work is focusing on workforce analysis, population mapping, and mapping of current services in the localities.
Engagement events with all stakeholders in the test site area and organisational development workshops are planned for April.
We aim to develop the workforce to become multi-skilled and able to deliver high quality care to patients at the right time and in the right place. The primary care home will create the opportunity for multi-speciality professionals to work together to develop innovative ways of delivering more care to patients out of hospital in a community setting or at home.
Primary care cannot operate in isolation. Therefore, there will be strong partnership working with our other health and social care colleagues and the voluntary sector which has a strong and active presence in Richmond.
Midlands & East - North Midlands
The Practices and GP First Federation are working with the CCG, Douglas MacMillan and St Giles local hospices, South Staffordshire & Shropshire NHS Healthcare Foundation Trust, Alzheimer’s Society, Badger Out of Hours Service, Staffordshire Social Care and West Midlands Ambulance Service.
Rugeley is a discrete ex-mining community in South Staffordshire served by 4 Medical Practices who have a strong history of collaborative working. The vision is to create a “home” for multi-speciality working with a ‘one organisation’ approach for delivering bespoke population healthcare to the collective registered list of the constituent Practices whilst retaining the ability to provide personalised care to individuals.
In partnership with the CCG we will manage whole population health, linking clinical service development with financial accountability for the patient population of 31k patients.
The CCG and all health economy stakeholders support this bid and are prepared to engage in innovative service redesign. The bid is supported by GP First Federation who has a strong management team with a history of budget management, innovative service implementation and delivery together with robust governance and data analysis skills.
A capable workforce capacity will be developed with funding from health education budgets and support from a Community Education Provider Network. This will integrate with established community assets with collaborative working of pharmacy, nursing, local authority and 3rd sector services. We aim to make best use of existing resources including estate management.
The PCH will provide:
- A community response to long-term condition management delivering new models of out of hospital care.
- Modernisation of primary care delivery with increased patient access and promotion of personalised self-care.
- The use of technology to improve care co-ordination and communication.
- A social and cultural context to public health promotion.
- A Dementia friendly community.
South - South West
Bristol Clinical Commissioning Group (CCG), Bristol City Council (BCC), supporting Better Care Bristol’s vision for local health and social care integration around groups of practices and for the potential to link with one or more of our Integration Pilots which already have local multi-agency support. Aligned with the work of the One Care Consortium, which is delivering a Prime Ministers Challenge Fund across wider Bristol, and with Brisdoc, our GP Out of Hours service. In addition, South Bristol Primary Care Collaborative are working with our main acute Trust, University Hospitals Bristol (UHB) and South Bristol Community Hospital (SBCH).
South Bristol Primary Care Collaborative (SBPCC) is an innovative partnership between six south Bristol GP practices and Bristol Community Health, Bristol’s provider of Adult and Children’s community health services.
Our vision is: Reduction in health inequalities, promotion of independence and creation of social value in an area of high deprivation with high levels of disease prevalence and unmet needs.
We will deliver this through:
Clinicians striving to get the best possible care for our 45 000 strong population, forging new pathways to develop ‘out of hospital care’.
Delivering person-centred, holistic, patient care through a single point of access and locally led, integrated services.
A range of supported self-care options and education to promote good health and reduce healthcare utilisation.
An integrated and multi-disciplinary workforce, where patients are seen by the right health or social care professional with appropriate skills at the right time, closer to home.
Listening to our communities – and involving volunteers and the third sector in supporting patients in goal setting, care planning and accessing holistic support.
We have laid the foundations through:
- Active support from our CCG and local authority, underpinned by Better Care Bristol.
- A shared community and GP patient health record and information sharing with acute, social care and mental health providers through our local ‘Connecting Care’ informatics project.
- Pathways of care centred around our local community hospital, with access to diagnostics, in-patient and out-patient rehabilitation, urgent care and day assessment services.
North - Cumbria & North East
South Durham CIC are working with Durham Dales, Easington and Sedgefield CCG, Peaseway Medical Centre, Bewick Crescent Surgery, Jubilee Medical Group, Dr Baliga’s Surgery, Hallgarth Surgery (operated by IntraHealth), South Durham Health CIC, County Durham and Darlington NHS Foundation Trust, Durham County Council and local voluntary agencies.
“A Plan for Life” is a patient inspired vision for integrated care services for the communities of Newton Aycliffe and Shildon in County Durham. Patient representatives, five local practices across two federations and community services providers have been working together over the last eighteen months. Their joint aim is to organise care for each patient as a person around whom services revolve (irrespective of organisational boundaries) especially for those who have multiple health and care needs. Practices already work together to deliver nursing services for vulnerable adults, suicide prevention and Saturday opening. Building on this, “Plan for Life” is now working to wrap district nursing services around practices and put in place governance to support further integration.
Our Primary Care Home model will keep the GP practice at the heart of the patient’s care, coordinated with specialist nursing, hospital consultants, mental health services, pharmacy social care and voluntary and independent sector services. We will support patients with the information and care they need to take greater responsibility for their own health and to reduce reliance on hospital services though enhanced local options for treatment and diagnostics.
A highly effective local team will make best use of the clinical and care skills in the existing workforce and will help us develop roles which allow team members to see their direct contribution to improved outcomes for patients. Staff will work alongside patients to influence the planning and delivery of health care in Newton Aycliffe and Shildon so that is truly responsive to local need.
South - South West
Kernow CCG, Cornwall Health Out of Hours (OOH) Service, Kernow Health CIC - (Kernow Health, RCHT, CPfT consortium are the preferred provider for adult community health services from 1 April 2016), Cornwall Community Mental Health Team (CMHT) , Peninsula Community Health – current provider of community services, Cornwall Council, SAH Patient Participation Group (PPG), Pentreath, Connect and other third sector providers.
St Austell Healthcare was formed in May 2015 following the merger of three practices and acquisition of 9,000 patients from a neighbouring failed practice. We recognised the need to establish a sustainable model providing high-quality care. We aim to improve access, patient safety, collaborative working and have a proven record to innovate. Urgent care is provided through a central ‘Acute Hub’ whilst other sites concentrate on planned care for those who need it most.
Our key commitments are:
- Sustainable, bespoke and equitable care for all patients in line with the Five Year Forward View and strategic vision for Cornwall for health and social care
- Developing a highly skilled and varied workforce with strong clinical leadership supporting continued professional development for all staff and outcome driven work-force planning.
- New Premises Planning in partnership with other providers to promote well-being and reduce secondary care attendance.
- Collaborative working - maintaining excellent relationships with commissioners and local providers has been key to us exacting rapid change in our services.
- High-level clinical and financial governance in every-thing we do.
- Becoming part of the community we serve.
Our priorities are:
- Improved access to urgent and planned care services – responding to real-time data.
- Care co-ordination and case management – embracing technology and strategic planning responsive to the needs of our patient population.
- Integrated Care Delivery – from our sites and in our community
- Partnerships and collaborative working with other NHS/social care/third sector providers e.g. acute trust, mental health, Connect, Pentreath, neighbouring practices
- Workforce and education – leading in the establishment of the community education provider network
- Communication with patients – working with patients to improve what we do, embracing electronic platforms,
South - South East
The 18 practices that constitute Thanet CIC are working collaboratively with the CCG, the local Community Trust, Kent County Council Social Services, the Voluntary agencies and Acute and Mental Health Trusts. An Integrated Executive Partnership Board (IEPB) has been established. This group is overseen by the Health and Well Being Board (HWB) which has an overarching strategy of establishing an Integrated Care Organisation (ICO) by 2018.
Health and social care professionals across Thanet recognise the challenges associated with caring for a diverse population. And with this in mind, they’re working collaboratively to design the services of the future.
As part of the Primary Care Home project 3 logic models have been developed to realise the vision as well as contribute to the ‘gaps’ identified within the NHS Five Year forward View:
- The formation of a Primary Care Home within the Margate locality as the overarching vehicle to take forward the proposed new care models;
- Implementation of an integrated IT system and care record across the health economy;
- Development of integrated teams including an Acute Response Team (ART) serving the population of Thanet.
The outcomes for each of the above have been designed so as to have a direct impact on the triple aims of improving health and wellbeing, care and quality as well as efficiencies particularly around resources and funding.
By realising the outputs of the logic models it will enable services to be wrapped around the population with the ultimate aim of delivering one service, provided by one team, with one budget.
Areas for further development in conjunction with other primary, secondary, community and mental health colleagues are beginning to emerge. In the first instance these are likely to result in consultants and specialist teams working in primary care as part of a wider integrated care team.
The Integrated Executive Partnership is established and evolving to form an Integrated Accountable Care Organisation by 2018.
North - Cheshire & Merseyside
We have the right mix of challenges and opportunities to make our town of Winsford the ideal ‘test bed’ for a new model of organising and delivering local patient centred care.
Our five practices, working together, want to lead in developing a new approach to improving health and healthcare. We have a track record of success in our joint ventures so far, but we know we must continue to change and develop. Winsford is a deprived town set in an affluent county with considerable needs and health inequalities. We acknowledge that the current complex, piecemeal systems of providing services have not fully met the needs of our patients.
We will design our new way of working by really focussing on our patients, and will organise services around them. We will work collaboratively with our NHS, social care and third sector colleagues and already have a long list of new initiatives ready to go. We expect that our practices will stay separate but our patients will seamlessly access healthcare across the town from multiple providers.
We will be judged on our ability to:
- Dramatically improve access and patient satisfaction
- Address our priority health issues and improve outcomes
- Increase the range and effectiveness of locally based services
The right health and social care will be available and accessible locally and we will demonstrate that this is both better for the health and wellbeing of those we serve and that it is more cost effective.
Midlands & East - West Midlands
Wolverhampton Total Health Care (WTHC) comprises 26 General Practitioners providing Primary and Extended Primary Care to 47,000 patients through 8 Practices. We will become a not-for-profit Social Enterprise or Community Interest Company.
We’ll offer multispecialty working through our ‘Home’, creating a 'one organisation' approach to delivering bespoke population health to the registered lists of all 26 constituent GPs – whilst ensuring we retain personalised care for individuals, and continue to identify at risk patient groups.
We will do this through using existing resources and assets more efficiently and effectively (working with community services, and primary care contractors), and by taking budgetary responsibility for our 47,000 patients.
Wolverhampton Total Health Care (WTHC) will establish a leadership team to drive culture change, team-based working, and the willingness to participate in new ‘non-imposed’ ways of working. We will demonstrate innovative thinking by focussing on quality of care through a culture of continued service improvement combined with the use of latest technologies – all in line with national policies.
We will work collaboratively with our patients, co-coordinate care services with complementary community organisations, and build on our working relationships with pharmacies, the West Midlands Fire service, social care and secondary care teams, and the Clinical Commissioning Group.
WTHC will also partner with patients, carers, commissioning organisations, and local community/voluntary services, to ensure that our collaborative approach to the design, commissioning, and assessment of services makes a significant contribution to ensuring a successful outcome for the new Primary Care Home model - providing the right care, at the right time, at the right place.