Here are the slides from the PCN development event on 2nd April 2019

1. Accelerated Solution Event
The PCN development support
offer
Supporting PCNs to
#primarycarenetworks

2. MaryWardHouse
8d0da34dfe

3. 3
Our mission
#primarycarenetworks
• Hold an accelerated solutions event (with regions/ICS/STPs, key
stakeholders, national teams) on 2nd April 2019
• Hold a Lead Provider Framework virtual engagement meeting on
10th April 2019
This accelerated solutions event will focus on:
• Co-producing a specification that meets the needs of local
systems (in preparation for the LPF engagement event)
• Co-creating a ‘development community’ that connects those
working in this area, builds relationships, shares learning and
provides a platform for the future to work collectively on
specific issues

4. 4
“They did not know
it was impossible so
they (just) did it”
Mark Twain
#primarycarenetworks

5. 10.00 Registration and coffee
10.30 Welcome and aims for the day
10.35 Who is in the room?
10.45 The story so far
11.15 What makes a healthy PCN?
12.30 Themes for the development
specification
13.00 Lunch
13.45 An “unconference” to
develop the key themes
15.30 Putting our plans in to
action
16.00 Bringing the plans
together
16.30 Close

6. Before lunch: Making this real
Who can help us to
achieve our purpose?
How do we use all the resources
and support systems that already
exist in the system?
Use the pink post-its to suggest
groups within the system and the
resources and support they bring
What are the themes for
the specification?
What are the topics and
themes that the specification
of support needs to cover?
#primarycarenetworks

7. Capturing our work today
We are keeping a record of our
discussions in “real time”
We will use this to prepare a
written report and pull together
the specification ready for the
virtual provider engagement
event
#primarycarenetworks

8. The Fundamental Law for today
“Thesum of the
expertise of the
people in the
audience is greater
than the sumof
expertise of the
people on stage”
DaveWiner
Sourceof image:www.citynet.com

9. First conversations: what unites us
•Introduce yourself to others on your table
•Find five things that everyone on your table has in
common and be prepared to share them with the wider
group
#primarycarenetworks

10. What unites us
Table:
1
2
3
4
5

11. Our starting point
• The PCN opportunity - Alex Morton
• A primary care perspective - Peter Tinson

12. Primary Care Networks
Development Support
2nd April 2019

13. 13
The changing health needs of the population are
putting pressure on the health and social care
system in England.
Ageing
population
Between 2017 and 2027, there will be 2
million more people aged over 75.
Chronic
conditions
The main task has changed from treating
individual episodes of illness, to helping
people manage long-term conditions.
The steady expansion of new treatments
gives rise to demand for an increasing range
of services.
New Treatments
And our expectations are changing too.
Things are changing…

14. General Practice Forward View lay
foundations for change in general practice…
GPFV published in 2016:
• Represented a turning point in investment in
general practice – committing an extra £2.4 billion
a year to support general practice services by
2020/21
• Ambition to strengthen and redesign general
practice
• Vision built on the potential for transformation in
general practice:
• Enabling self care and direct access to other
services
• Better use of the talents of the wider
workforce
• Greater use of digital technology
• Working at scale across practices to shape
capacity
• Extended access to general practice
including evening and weekend
appointments.

15. Now continuing support through the NHS
Long Term Plan…
15
Aims:
• Everyone gets the best start in life
• World class care for major health problems
• Supporting people to age well
How:
• Primary care networks as the foundation for Integrated
Care Systems
• Preventing ill health and tackling health inequalities
• Supporting the workforce
• Maximising opportunities presented by data and
technology
• Continued focus on efficiency

16. • Put in place seamless care (for both physical and mental health) across primary care and NHS
community services, and remove the historic separation of these parts of the NHS.
• Deliver care as close to home as possible, with networks and services based on natural geographies,
population distribution and need rather than organisational boundaries.
• Integrate across primary care networks and secondary care/place-based care with more clinically-
appropriate secondary care in primary care settings.
• Assess population health - focusing on prevention and anticipatory care - and maximise the difference we
can make operating in partnership with other agencies
• Promote and support people to care for themselves wherever appropriate
• Build from what people know about their patients and their population
• Because we want to make a tangible difference for patients and staff alike, with:
• improved outcomes for patients and an integrated care experience for patients;
• more sustainable & satisfying roles for staff, & development of multi-professional teams.
• a more balanced workload
PCNs - What are we trying to do?

17. • Practices continue to provide core services
• Network Contract DES provides practices opportunity to work collaboratively
with other practices health, social care and voluntary partners to deliver
services
• Practices and other health, social care and voluntary partners collaborate as
primary care networks, providing additional services that can’t be delivered on
a smaller scale
Place
c.250-
500k
• Primary care interacts with hospitals, mental health trusts, local
authorities and community providers to plan and deliver integrated care
• In some systems, federations support efficiencies of scale and provide a
voice for primary care
• Primary care participates as an equal partner in decision making on
strategy and resource allocation
• Action is taken to ensure collaboration across hospitals, community services,
social care and other partners, helping to join up and improve care
• Data is used to deploy resources where they can have the maximum impact
• Each person can access joined up, proactive and personalised care, based on ‘what matters’
to them and their individual strengths, needs and preferences
Neighbour
hood
c.30k~50k
System
c.1+m
Individual
And primary care will play a key role in each level of the system

18. Anticipated benefits of integrated care systems and primary care networks
For patients For general practice and other
providers of care
For the whole health and care system
More coordinated services where they do not
have to repeat their story multiple times
Access to a wider range of services and
professionals
• in the community
• In a single coordinated appointment
Access to appointments that work around their
life
• shorter waiting times
• different ways of accessing appointments
using technology and face-to-face options
More influence when they want it, giving more
involvement and decision making opportunities
over how their health and care are planned and
managed
Access to personalised care and with a focus on
self care and prevention, living healthily,
recognising what matters to the person and how
their individual strengths, needs and preferences
can support better outcomes
Greater resilience across primary care by making
the best use of shared staff, buildings and other
resources, they can help to balance demand and
capacity over time
Better work/ life balance with more tasks routed
directly to appropriate professionals, such as
clinical pharmacists, social prescribers,
physiotherapists
More satisfying work with each professional able
to focus on what they do best
Improved care and treatment for patients, by
expanding access to specialist and local support
services including social care and the voluntary
sector
Greater influence on the wider health system,
leading to more informed decisions about where
resources are spent
More coordinated care through collaboration and
cooperation across organisational boundaries and
teams
Wider range of services in a community setting,
so patients don’t have to default to the acute
sector
A more population-focused approach to
systemwide decision-making and resource
allocation, drawing on primary care expertise as
central partners
Greater resilience across the health and care
system

19. DRAFT
Plan: Plan in place
articulating clear vision and
steps to getting there,
including actions at network,
place and system level.
Engagement: GPs, local
primary care leaders,
patients’ representatives,
and other stakeholders
believe in the vision and the
plan to get there.
Time: Primary care, in
particular general practice,
has the headroom to make
change.
Transformation resource:
There are people available
with the right skills to make
change happen, and a clear
financial commitment to
primary care transformation.
The network is taking the
opportunities that GP
network contract affords
There is a clinical director
for the network. The clinical
director may serve multiple
networks where that is
agreed locally.
Practices identify PCN partners and
develop shared plan for realisation. There is
joint planning underway to improve
integration with community services as
networks mature. There are arrangements
for PCNs to collaborate for services
delivered optimally above the 50k footprint
Analysis on variation in outcomes and
resource use between practices is readily
available and acted upon.
Basic population segmentation is in
place, with understanding of needs of key
groups, their needs and their resource use
Integrated teams which may include social
care are working in parts of the system.
Plans are in place to develop MDT ways
of working, including integrated rapid
response community teams.
Standardised end state models of care
defined for all population groups, with clear
gap analysis and workforce plan
Steps taken to ensure operational
efficiency of primary care delivery and
support struggling practices.
Primary care has a seat at the table for
system strategic decision-making.
PCNs are engaging directly with
population groups, and with the wider
community
Providers within the PCN are embedding
shared population health models
identified at Step 1 that supports a
significant maturity for integrated care.
Functioning interoperability within
networks, including read/write access to
records, sharing of some staff and estate.
All primary care clinicians can access
information to guide decision making,
including risk stratification to identify
patients for proactive interventions, IT-
enabled access to shared protocols, and
real-time information on patient
interactions with the system.
Early elements of new models of care in
place for most population segments, with
integrated teams throughout system,
including social care, mental health, the
voluntary sector and ready access to
secondary care expertise. Routine peer
review.
Networks have sight of resource use
and impact on system performance,
and can pilot new incentive schemes.
Primary care plays an active role in
system tactical and operational
decision-making, for example on Urgent
and Emergency Care
Networks are developing an extensive
culture of authentic patient partnerships
PCN population health model fully functioning
for all patient cohorts, working with other PCNs
and local agencies in a provider alliance or similar
collaborative working approaches.
Fully interoperable IT, workforce and estates
across networks, with sharing between networks
as needed.
Systematic population health analysis allowing
PCNs to understand in depth their populations’
needs and design interventions to meet them,
acting as early as possible to keep people well.
Fully integrated teams throughout the system,
comprising of the appropriate clinical and non-
clinical skill mix. MDT working is high functioning
and supported by technology. The MDT holds a
single view of the patient. Care plans and
coordination in place for all high risk patients.
New models of care in place for all population
segments, across system. Evaluation of impact of
early-implementers used to guide roll out.
PCNs take collective responsibility for
available funding. Data is used in clinical
interactions to make best use of resources.
Primary care providers full decision making
member of ICS leadership, working in tandem
with other partners to allocate resources and
deliver care.
The PCN has built on existing community assets
to connect with the whole community.
Foundation Step 1 Step 2 Step 3
The journey of development for primary care networks in a health system – maturity matrix
Primary care networks
08
Our learning to date tells us that primary care networks will develop and mature at different rates. Laying the foundations for transformation is
crucial before taking the steps towards a fully functioning primary care network. This journey might follow the maturity matrix below.
The Network Contract DES, when published, will provide important support for this new way of working

20.  We are looking to all those in local systems and beyond, CCGs, ICS and NHS England,
NHS Improvement, HEE, other ALBs, professional representatives and other stakeholders,
to fully support the development of primary care networks – your role is crucial
 This work will be key to local systems as they develop plans to deliver better care for
patients and communities
 How we support development will be key - supporting the development of PCNs isn’t about
mechanics, we need to keep the vision in mind and focus on fostering a different type of
culture in organisations and relationships between people
 Responsibility for this ultimately resides locally, but we need to do all we can together to
support it – tell us what you need to make it work
20
Our roles in supporting PCNs

21. Getting this right together
• Likely to be a marathon not a sprint – an evolution
• Owned and led by primary care
• Needs to be meaningful to local communities and partners
• Should be the platform to build wider integration
• Must dock into the wider ICS to get system benefits
• We must ensure we remain focused on the end point and the spirit of
intent

22. We need to remember
We know what we’re aiming to achieve
We have a shared endeavour
The spirit of intent is crucial

23. Primary Care Network and Neighbourhood
Development Support
experience, learning and future work

24. • 5 Integrated Care Partnerships
• 2 former Vanguards (Fylde Coast and Morecambe Bay)
• 41 Primary Care Networks/Neighbourhoods (but reducing)
• Different development journeys and maturity
Lancashire and South Cumbria Integrated Care System
Primary Care Network and Neighbourhood ‘Organisations’
• Locally some are…
o less than 6 months old and others over 4 years old
o ‘provider’ driven and others ‘commissioner’ driven
o focused on building relationships between practices and others on their broader local
authority and voluntary sector partnerships
o focused on developing their ‘organisational’ governance arrangements and others on
developing their integrated care teams
• …and consequently some similar but some differing development support requirements and lots of
learning to share

25. Primary Care Network and Neighbourhood Leaders
• A Primary Care Network must appoint a Clinical Director as its named,
accountable leader, responsible for delivery
• Clinical Directors will play a critical role in shaping and supporting their
Integrated Care System to implement the NHS Long Term Plan
• They will provide strategic and clinical leadership to help support change
across primary and community health services
• A new and challenging leadership role
• Locally some have…
o existing ‘commissioning’ leadership experience from CCG roles
o existing ‘provision’ leadership experience from federation or similar roles
o existing ‘provision’ leadership experience from practice roles
o no previous leadership experience
• …and consequently some similar but some differing development support requirements
• Plus clarity of where they fit in the broader ICS and ICP clinical leadership arrangements

26. Learning 1 (chronologically)
Leadership
• Provided funding for Neighbourhood Chair and other leadership roles, standard
role outline, payment, process to secure and service contract – offer to develop
support products and don’t wait to be asked
Priority
• Asked each Neighbourhood to identify a local priority, develop a ‘light’ business
case, provided funding , secured evaluation support, agree to implement
learning, chose care home, house bound and same day access priorities – rapid
development of new care models and crucially built relationships/trust between
practices
Places
• Local GP Quality contract included funding and ask for Neighbourhoods to meet
monthly individually and also all together quarterly – share learning and co-
produce support products
Support
• Aligned an executive and commissioner to each Neighbourhood to provide
support, ‘system navigation’, occasionally remind of governance and leverage
support from elsewhere – now ‘leaning in’ more commissioning staff

27. Learning 2 (chronologically)
Community
• Provided small amount of funding for Neighbourhoods to invest in community
owned and driven self care and wellbeing initiatives – see Healthier Fleetwood
Innovation test beds
• Encouraged and supported Neighbourhoods to develop and test new care
models, pathways and technologies - see innovation map plus CCG risk appetite
issue
Incentive scheme
• Responded to Neighbourhood request to design gain share scheme – more
challenging with new payment approaches based on cost reduction
Leadership peer support
• Neighbourhood chairs meet every 6 weeks – their agenda with CCG attendance
System leadership
• Neighbourhood chairs participating in Healthier Fylde Coast 100 System Leaders
and Systems Integrators programme - work across the partnership effectively,
connect people to each other and create communities for action

28. • Statistics showed residents in Fleetwood could expect to
live shorter lives and experience more life-changing
illnesses than people elsewhere
• Healthier Fleetwood began as an idea in the Spring of
2016. Perhaps it wasn’t even an idea then, just a
question: Is there a better way to improve the health and
wellbeing of people living and working in the Town than
just prescribing more medicines and making
appointments to see the GP?
• Residents, voluntary, faith and community groups, health
professionals, the emergency services, local authority
representatives and businesses leaders met and found
there was a shared desire that something should be and
could be done
• Into 2017 and Heathier Fleetwood launched its own
projects such Garden Buddies, volunteers helping isolated
residents with some TLC for their gardens and the Young
Chef of the Year Challenge which supported the benefits
of nutrition and learning to cook among Year 5 pupils

29. Innovation map

30. • Initially Vanguards started using matrix over 12
months ago
• Provided a valuable framework to engage
Networks about future direction of travel and
assess their maturity
• Through engagement began to explore and
expand maturity steps and theme
• Began in Fylde Coast Vanguard and then
expanded across Lancashire and South Cumbria
ICS
• Over a period of 3 months co-produced
development and support tool and supporting
annual plan template
• Involved clinical and managerial colleagues from
primary, community, LMC, NHSE and local
authority partners (plus subject matter experts)
Maturity matrix to development and support tool

31. • Six themes…
Planning and support tool
Leadership and
corporate
governance
Population health
management and
care models
Care team and
clinical governance
Resource
management
Empowering
people and
communities
Provider
collaboration

32. • Each theme based on practical steps up a
ladder (may jump some)
• Aligned with NHSE maturity matrix and NAPC
grid
• Launched before five year framework for GP
contract reform
• Tried to keep it simple!
• Also identifies support products (about which
more later)
• Consistently assess maturity
• But more importantly develop a plan for
2019/20
Planning and support tool

33. • Builds on tool themes, not prescriptive and live!
• Which steps aiming to deliver by when and what support required
• Expect initial focus on leadership and corporate governance and care team and clinical
governance themes (setting up)
Annual plans by 31 March 2019

34. • When developing tool identified what support products made
sense to develop at ICP/ICS place involving Networks (overleaf)
• Task and finish groups established, led by ICP colleagues (bottom
up approach)
• In response to five year framework reviewing what…
o Not expected nationally and continue to develop locally
o Expected nationally and not continue to develop locally
o Expected nationally but continue to develop locally (timing)
• Notably Networks also receiving multiple support product offers
Support products

35. Support products for each theme
A. Chair/lead
recruitment
package
B. Terms of
reference for
leadership
groups
C. MoU
between
practices
D. Annual
plan template
A. Population
health
profiles
B. Real time
patient
tracking tool
C. Risk
stratification
&
segmentation
tool
D. Care
model
effectiveness
report
A.
Stakeholder
mapping tool
A. Care team
operating
model
B. Care
package co-
ordination
tool
A. Resource
utilisation
report
B. Workforce
Tool
C. Incentive
framework
D. KPI &
Outcome
framework
A. Business
continuity
plan template
B. Data
sharing
agreements

36. Future work
Development
Support Offer
– accelerated
solutions
Additional
Roles – fit and
options to
secure from
2019/20
onwards
People
Support –
including CCG
in kind
ICS and ICP –
engagement
Local
Supplementary
Network
Services –
integration into
DES from April
2020
Personalised
Care –
leadership
arrangements
Network
Service
Specifications
– fit and
options to
deliver from
2020/21
onwards
Network
Agreement –
sign up of
other
community
partners
Network
Delivery
Model –
options
Combined
Access Offer –
fit and options
to deliver
from April
2021Extended
Access DES –
options to
deliver from
July 2019
NHSE
development
and testing
programme –
volunteer for
test bed sites

38. 38
‘En este muno traidor
No hay verdad ni mentira,
Que todo esta en el color
Del cristal con que se mira.’
(In this world of many mazes
There is nothing false or true:
All depends upon the hue
Of the glass through which one gazes.)
(Sixteenth-century Spanish quatrain)
#primarycarenetworks

39. Seeing PCN development within the wider system
Complex systems are driven by the quality of the interactions
between the parts, not the quality of the parts. Working on
discrete parts or processes can properly bugger up the
performance at a system level. Never fiddle with a part unless it
also improves the system
@ComplexWales
#primarycarenetworks

40. Anatomy of change Physiology of change
Definition The shape and processes of the system;
detailed analysis; how the functional
components fit together.
The vitality and life-giving forces that enable the
system and its people to develop, grow and change.
Focus
Processes, systems and structures
to deliver population health and
healthcare
Energy/fuel for change
Leadership
activities
 defining functionality
 measurement and evidence
 governance systems
 reducing unwaranted variation in the
system
 redesigning pathways
 creating a higher purpose and deeper meaning
 creating organisational health
 building community
 connecting with values
 creating hope and optimism about the future
 calling to action
Source: Crump and Bevan

41. Anatomy of change Physiology of change
Definition The shape and processes of the system;
detailed analysis; how the functional
components fit together.
The vitality and life-giving forces that enable the
system and its people to develop, grow and change.
Focus
Processes and structures
to deliver population health and
healthcare
Energy/fuel for change
Leadership
activities
 defining functionality
 measurement and evidence
 governance systems
 reducing waste and variation in
health and care processes
 redesigning pathways
 creating a higher purpose and deeper meaning
 creating organisational health
 building community
 connecting with values
 creating hope and optimism about the future
 calling to action
Source: Crump and Bevan

42. Healthy PCNs as well as high-performing PCNs
“Organisational health is a state of being whole and
sound. Healthy organisations use the talents of
everyone in the organisation. They function
effectively, continuously improve and grow from
within.”
from the NHS Leadership Forum,
18 December 2018
#primarycarenetworks

44. Inter-dependence Who are the key people and groups that the PCN needs to
build relationships with in order to flourish and achieve its goals? How do we build strong
trusting relationships, both within the PCN and for the PCN in its wider context?
Shared purpose Why does the PCN exist? What unites the PCN with the
wider health system? How do we build a profound sense of shared purpose,
anchored in values?
Autonomy How do we build the adaptability, innovativeness and problem
solving capability of the PCN; the ability to respond to change without compromising
core values?
Resilience What capacity does the PCN need to impact upon its environment
and make a difference? What structures and systems does it need to enable
effective action?
Table:

45. Plot the dots
• Put a green dot on attributes you need that you have in
place or are confident you know how to fix
• Put a red dot on attributes you need that you are
certain you don’t know how to fix
• Put a yellow dot on attributes that need more
discussion to be clear about next steps
#primarycarenetworks

46. Making this real
Who can help us to achieve
this purpose?
How do we use all the resources
and support systems that
already exist in the system?
Use the pink post-its to suggest
groups within the system and
the resources and support they
bring
What are the themes for
the specification?
What are the topics and
themes that the specification
of support needs to cover
(enabling PCNs to work
inter-dependently)?

47. Who can help us to achieve this purpose? What are the themes for the specification?

50. 50
Specification
themes
Creating the
environment and
relationships
2 poster
types
depending
on your
challenge

51. Review the gallery of outputs
• One person from each group to stay with their poster
• Everyone else has the opportunity to review three
other posters; add additional ideas in a different
colour pen
• Three rounds, ten minutes each
#primarycarenetworks

52. Review the gallery of outputs
• Pull out three headlines from your poster on how to
bring the ideas to action and write them on a sheet of
flipchart paper
• Be ready to share this with the wider group
#primarycarenetworks

53. Reflection time
Think about the implications of today for your own
system/area of work
Plan what you might do as a result of today
#primarycarenetworks