OneNorwich Practices Annual Report 2021

OneNorwich Practices

Annual Report 2021

Leading integrated health and care

01

Foreword

Executive summary

Who we are

Our achievements

02

Contents Foreword

03-04

Executive summary

05-08

Who we are

09-12

Our achievements and how we’ve supported practices 2020/21

13-40

Where are we going?

41-42

How will we deliver our strategy?

43-48

Acronym buster

49

Norwich location photography credit: Graeme Taplin Primary care photography credit: Ian Wakefield

Where are we going?

Our vision and strategy

Acronym buster

03

Foreword We are delighted to present to you the OneNorwich Practices Annual Report for 2021 and to update you on the progress we have made, so far, in implementing our strategy.

It is without doubt that the last year and a half has been unprecedented as the spread of Covid-19 has thrown the world into disarray. It is testament to our wonderful NHS and all who work within it, that we have been able to continue to deliver high standards of care throughout.

Of course, we have all had to adapt and it is our ability to be agile and flexible that has meant that the residents of Norwich have had their primary care needs met. Yes, we have all had to work differently and, in doing so, we have discovered that different is sometimes better and there are some practices that we have adopted over the last 18 months that will become embedded as the new norm.

Notwithstanding the challenges, we have made good progress in a number of key areas within the organisation. The independent governance review, conducted by Xytal and VWV, made a number of recommendations and we have begun a structured programme of improvement and outputs.

Part of this has been to undertake a robust Board skills review to ensure that we have a functioning Board that is fit for purpose and that we have people with the right skills, knowledge and experience to drive

Foreword

Executive summary

the organisation forwards. In doing so, we identified some key gaps and have developed new roles, with clearly defined responsibilities.

We are in the process of recruiting for these new roles and will be seeking shareholder input in the appointment process.

In November, we will sadly be saying farewell to four directors: Dr David Ling, Dr Alison Dow, Ian Wilson and Tracey Bullard.

We extend our sincere thanks and gratitude to each one for their contribution to the Board and commitment to OneNorwich Practices. David, being one of the original NPL Board members, is currently the longest serving director of the organisation and remains a local GP; Alison, one of the founder members of OneNorwich and vice-Chair, has recently retired after a total of 30 years’ service as a GP; Ian having previously worked as a practice manager in Norwich, and now working in Swaffham; and Tracey, who will continue to contribute to the development of the organisation in her role as head of transformation.

We wish all of them the very best for the future.

Our CEO, Janka Rodziewicz, who joined us late 2020, has worked tirelessly over the last 12 months, together with the senior leadership team, to affect positive change in many parts of the organisation, further detail to be found in this report.

Who we are

Our achievements

04

Our Primary Care Network (PCN) team has worked extremely hard to support all our member practices. Daily reporting and regular communications provided much needed resilience at the start of Covid-19.

The Yellow Clinics and Home Visiting Service enabled us to continue seeing our patients and the very successful vaccination sites, run by the PCN, enabled us to forge ahead with Covid-19 vaccinations 6 days a week, including to all our care homes and housebound patients. We have meanwhile continued with regular PCN meetings, our PLT educational events and our long-term conditions and health checks. The launch of the IMPACT team has also been a particular highlight. Our amazing pharmacy team has been applauded nationally and short-listed in the Primary Care awards. We continue to successfully recruit more ARRs into our growing team with OneNorwich Practices support. We have worked closely with our CCG colleagues to tackle health inequalities, improve Learning Disability (LD) checks and early cancer diagnosis.

Underpinning these various initiatives, work has begun on updating our HR practices and streamlining our business processes. These are key elements in meeting our goals of creating an agile organisation with a culture that supports quality improvement and innovation.

Where are we going?

We must pay tribute and acknowledge the extraordinary efforts made by all our staff members, particularly over the last 12 months. Our services and support for our member practices and the wider health care system, have depended on their resourcefulness, flexibility and engagement.

Finally, and by no means least, we would like to extend our thanks and appreciation to all our shareholders, member practices, together with their staff and other key stakeholders who have worked with us and risen to the challenges of the last year with fortitude and vigour. It is without doubt that it has been difficult but together we have built the foundations for a balanced recovery to enable us all to be ready for the next chapter in transforming the delivery of primary care in Norwich.

Sarah Ambrose Dr Jeanine Smirl Chair PCN Clinical Director OneNorwich Practices Board Director from the PCN Executive Committee

Our vision and strategy

Acronym buster

05

Executive summary As we approach two years since the formation of OneNorwich Practices (ONP) in December 2019 now feels like the right time to record our achievements and set out our aspirations for the future.

The report includes an overview of how we came into being, along with a summary of the areas we work in and the governance of our organisation.

There are three very clear areas to our work, with these being, Extended Primary Care, Integrated Population Model of Care and Primary Care Transformation, you will find definitions of these themes further down in the report. To make our report easy to read and so you can find things easily that are of interest to you we have themed our achievements by the three aforementioned themes and also in alphabetical order. In addition we have included an acronym buster at the back of the report for your reference.

Our achievements include not only those for ONP but also in supporting the 22 GP Practices within the Norwich Primary Care Network (PCN).

Foreword

Executive summary

A summary of our achievements is below: Over the past two years we have focused on key commitments such as recruiting to the Additional Role Reimbursement scheme (ARR), the budget for this is growing annually and next year will be £3.8m, we are proud of our achievements in this area and will continue to keep this high in our priorities.

ONP has made significant progress in Addressing Inequalities, partly through partnership working and projects such as the Vulnerable Adult Service and through the innovative work of the primary care community officer (PCCO) who we commissioned recently.

Our Admiral Nurse Service which supports the carers of people with dementia has gone from strength to strength having worked with more than 1,400 families in the last two years. ONP has also recently recruited a children’s asthma nurse specialist to perform respiratory clinics in schools, the benefits of this promise to be significant.

In October 2021 our contract to provide services to the Bowthorpe Care Village ended. The clinicians and care team worked in partnership with other disciplines and agencies to build up an effective

Who we are

Our achievements

06

multidisciplinary team allowing the provision of on-site integrated care to all residents, this model of care has provided learning for the future delivery of primary care services to care homes in Norwich.

Good communications and engagement are key to the success of many organisations and this includes the NHS. Communicating with practices, patients, staff and the media effectively is often the glue that holds all our hard work together. Recognising this, ONP recruited a communications and engagement manager in August 2021 who has already made great strides towards more effective communications.

Covid-19 are words I’m sure many of us wish we’d never heard, but our teams across the PCN embraced the challenge and having vaccinated more than 200,000 patients to date have been shortlisted for a national award.

Some of the many adaptations we had to make during Covid-19 were on the digital side and in early 2021 ONP commissioned a digital report which was shared with practices in July, many of the recommendations have already been implemented and we are optimistic that we will find many more ways to streamline processes and improve the experience of our patients and our staff.

Where are we going?

GP Front Door has been a tremendous success. This service was set up to reduce the footfall to our emergency departments and since December 2019 our team has seen over 14,000 patients. Overall feedback has been extremely positive. We are continuing to develop this service so that it has maximum impact for patients and the wider healthcare system.

Our Home Visiting Service was set up to support practices and to improve urgent care responses for on the day visit requests.

The service has provided visits for over 20k patients since April 2018 and continues to go from strength to strength.

With the time of clinical staff at a premium within our practices our High Intensity User programme recognises that not everyone has the same needs and that some people need a different approach when it comes to maintaining a good general health. Supporting those patients who visit our GP practices most often, this programme has been very successful in reducing the number of visits and has achieved good health outcomes for the patients.

Our vision and strategy

Acronym buster

07

Utilising population intelligence to tackle health inequalities by using personalised care and support has also worked extremely well. The team are referred to as the Integrated Motivational Proactive Anticipatory Care Team (IMPACT) who since June 2021 have formulated more than 500 personalised care and support plans.

The Improved Access Service (IAS) has been designed to provide additional access to primary care services. The service which is run by experienced GPs, ANPs and an HCA has provided more than 93,000 telephone or face-to-face appointments and has significantly reduced the pressure on our GP Practices.

As with so many primary care services our lymphoedema service has had to adapt to respond to Covid-19. It has however gone from strength-to-strength with a new lymphoedema practitioner joining us this year and recruitment for an assistant practitioner underway.

Norwich PCN has been at the forefront of mental health community transformation and through a combination of working closely with partners and recruitment of key roles have had extremely positive results both within primary care and within the PCN staff.

Foreword

Executive summary

ONP has four PCN neighbourhoods, GPs, practice managers and other key staff meet regularly to discuss strategy, progress and issues on a monthly basis. This is proving to be effective.

ONP operate the Norwich Practices Health Centre in Rouen Road, Norwich.

The practice has a list size of 10,302 which is served by a multidisciplinary team of clinicians. The practice has recently increased the number of face-to-face appointments which are almost back to pre-covid-19 levels.

In May 2021 we initiated an Opioid Project to address the increasing dependence on prescribed opioids. Trialled in several of Norwich’s practices the project is showing early signs of success and has received positive feedback from patients. It is hoped to roll out the project further.

The pharmacy team has experienced a rapid growth and transformation over the last 18 months and is producing some fantastic outcomes. Future plans include doubling up our technician workforce and allocating two technicians per neighbourhood and specialist care home pharmacy teams.

Who we are

Our achievements

08

ONP has made significant progress in developing its Population Health strategy, the IMPACT team first trialled using this data to contact patients with long term conditions at the start of 2021. This has proved extremely effective and will be further advanced by the appointment of a data analyst.

Hands-on training has always been an important aspect of maintaining a highly skilled, motivated and professional workforce.

ONP manages a programme of training for primary care called Protected Time for Learning (PLT). We have held 9 external PLT events since 2018 with over 1,500 staff attending. To support this ONP is also rolling out a training programme known as Productive General Practice, this is designed to improve efficiency within the practices.

ONP has recently been recognised for leading the way locally for encouraging patients to participate in research. We have a dedicated research officer who continues to drive this agenda forward to encourage learning which will ultimately result in improved patient outcomes.

ONP has gradually and consistently invested in its workforce and now employs almost 200 staff. Each one of them is focused on supporting general practice and ensuring better outcomes for patients.

With many of our vulnerable patients shielding through Covid-19 our Weight Intervention Service (WIN) have had many challenges but have adapted by using video calls and rather than face-to-face visits and we have asked patients to weigh themselves for weigh-ins. The team is consistently evolving and has high aspirations for the future.

Having reviewed our achievements our report ends by setting out where we are going (Our Vision) and how we are going to deliver it (Our Strategy).

It is clear that our future direction will not only be led by data but also by patients. Our vision is to ‘Lead integrated, sustainable and clinically-excellent community healthcare services for Norwich practices’.

Janka Rodziewicz Chief Executive Officer

The Walk-in Centre in Rouen Road has proved to be invaluable in serving the local population who have minor injuries and illnesses, with extended hours at weekends and in the evenings it consistently helps to reduce unnecessary visits to the Emergency Departments at the local hospitals.

Where are we going?

Our vision and strategy

Acronym buster

09

Who we are Creation of OneNorwich Practices In December 2019 OneNorwich and Norwich Practices Limited merged to form OneNorwich Practices. We continue to deliver the goals of these original organisations for primary care transformation and by delivering primary care services. The Companies House name of OneNorwich Practices remains Norwich Practices Ltd (Company number 06059636), with OneNorwich Practices the company’s trading name.

OneNorwich Practices has also become the delivery vehicle of the Norwich Primary Care Network (PCN), supporting the PCN to deliver its aims and objectives. The PCN and OneNorwich Practices have common goals for primary care transformation, delivering extended primary care and integrated population-based models of care. The members of the PCN also align closely with owners of OneNorwich Practices, as the shareholders of OneNorwich Practices are 21 of the 22 practices that form the members of the Norwich PCN. Thus the interests of OneNorwich Practices and the Norwich PCN are closely shared.

OneNorwich Practices is funded via varied sources including contracts, non-recurrent funding and PMS, all with different end points.

Foreword

Executive summary

OneNorwich Practices Governance OneNorwich Practices is a company and the delivery vehicle of the Norwich PCN. We manage our governance to ensure appropriate separation of this provision while maximising opportunities to create value for the practices of Norwich by delivering through the shared OneNorwich Practices. In our capacity as the PCN delivery vehicle our role includes providing staffing for PCN management and delivery, providing financial and HR management and governance.

The Norwich PCN is a partnership of the 22 Norwich GP practices collaborating under a formal agreement to: • deliver the NHS long-term plan • Support delivery of the Specifications within the Primary Care Network Agreement • recruit and utilise diverse clinical roles • work at scale • improve ability to recruit and retain staff • manage financial and estates pressures • integrate with wider health and care systems.

Who we are

Our achievements

10

Following our 2021 governance review, we have further developed our governance structures. In addition to the ONP Board, and the PCN Executive Committee (also referred to as the Clinical Strategy Group), we have introduced a number of sub-committees and panels that include further representation from our members

in our governance: Integrated Governance Committee, Remuneration Panel, Appointment Panel, Finance Committee.

We will continue to work on developing this governance through 2021/22.

The governance created in 2021 takes the following form:

Company

PCN

Shareholders

PCN members PCN Neighbourhoods PCN Executive Committee/ Clinical Strategy Group

Board

Appointment Panel

Remuneration Panel

Integrated Governance Committee

Finance Committee

Senior Leadership Team/Executive Team Organisation

Key

Where are we going?

Owners

PCN and Company shared bodies

PCN-Specific bodies

Operational delivery

Our vision and strategy

Acronym buster

11

OneNorwich Practices Board of Directors

• Emma Miller (Senior Services Manager)

There have been some changes in our Board of Directors across 2020/21. During the 2020/21 period our directors have included: Sarah Ambrose (current Chair), James Foster, Dr David Ling, Dr Jeanine Smirl, Dr Alison Dow, Tracey Bullard, Ian Wilson, Dr Hitesh Patel, Stephen Roy and Donna Laws-Chapman.

• Jo Watts (HR Manager)

At the 2021 AGM a new Board of Directors will be proposed to shareholders for appointment.

Norwich PCN Executive Committee/ Clinical Strategy Group The PCN is lead by the Clinical Directors: • Dr Jeanine Smirl

• Francesca Bullman (Contracts Manager) • Chris Wright (Finance Manager)

Norwich Practices The practices of Norwich that are the shareholders of OneNorwich Practices and the members of the PCN. 01 Adelaide St. Health Centre 02 Bacon Road Medical Centre 03 Bates Green Health Centre 04 Beechcroft Surgery 05 Bowthorpe Health Centre 06 Dussindale Surgery 07 Gurney Surgery 08 Hellesdon Medical Practice

• Dr Nick Morton

09 Lakenham Surgery

• Dr Saffana Rasul

10 Lionwood Medical Practice

• Dr Jo Walsh

11 Magdalen Medical Practice

• Dr Raija Blenk

12 Mile End Road Surgery

OneNorwich Practices Senior Leadership Team

13 Newmarket Road Surgery

The Senior Leadership Team of OneNorwich Practices is comprised of:

15 Norwich Walk-In Centre

• Janka Rodziewicz (Chief Executive Officer) • Tracey Bullard (Head of Transformation) • Lisa Townshend (Head of Nursing and Clinical Governance)

Foreword

Executive summary

14 Norwich Practices Health Centre 16 Oak Street Medical Practice 17 Old Catton Medical Practice 18 Old Palace Medical Practice 19 Prospect Medical Practice 20 Roundwell Medical Centre

Who we are

Our achievements

12

32

21 Sprowston Primary Care Centre

28 West Earlham Health Centre

22 St Stephen’s Gate Medical Practice

29 West Pottergate Health Centre

23 Taverham Partnership

30 Woodcock Road Surgery

24 Thorpe Health Centre

31 UEA Medical Services*

25 Thorpewood Surgery

32 Lawson Road Surgery

26 Trinity Street Surgery 27 Tuckswood Surgery

Where are we going?

* UEA Medical Services is a PCN practice, but not a ONP shareholder

Our vision and strategy

Acronym buster

13

“ We work to support our member practices to develop a sustainable, resilient and strong foundation of core general practice” Foreword

Executive summary

Who we are

Our achievements

14

What have we achieved and how have we supported practices (A-Z) Each achievement will be themed according to the three definitions below: Theme Definitions:

EPC

IP

PCT

Extended Primary Care (EPC) We deliver primary care clinical services at hub, locality and larger scale.

Our goal is to move more care into the community, connect care services effectively with primary, shift care from acute hospital settings, and to add value to patients and practices.

Integrated Population Model of Care (IP) We work collaboratively with diverse partners, drawing on best practice, to design and deliver multispecialty community provision in Norwich as a bedrock of a future integrated care system in Norfolk and Waveney.

Primary Care Transformation (PCT) We work to support our member practices to develop a sustainable, resilient and strong foundation of core general practice. Our transformational work will capture and share best practice approaches to improving the efficiency and effectiveness of working at individual practice and locality level.

Where are we going?

Our vision and strategy

Acronym buster

15

Additional Role Reimbursement scheme (ARR) A PCN is entitled to funding as part of the Network Contract DES to support the recruitment of new additional staff to deliver health services. Norwich PCN tasked OneNorwich Practices to host the roles.

Additional roles must: • Be embedded within the PCN’s Core Network Practices and be fully integrated within the multi-disciplinary team delivering healthcare services to patients

PCT

To date Norwich PCN is the only PCN within Norfolk and Waveney to fully utilise the available funding following an extremely successful recruitment plan.

Practices and patients of Norwich are benefiting from receiving the support and care from the following roles: • Social prescribing link workers • Clinical pharmacists

• Have access to other healthcare professionals, electronic ‘live’ and paperbased record systems of the PCN’s Core Network Practices, as well as access to admin/office support and training and development as appropriate

• Pharmacy technicians

• Have access to appropriate clinical supervision and administrative support

• Mental health practitioners

The ARRs are a regular agenda item at clinical director and neighbourhood meetings to review and ensure the roles being recruited will meet the needs of our practices and population.

• Occupational therapist

The budget set available is: 2021/22 2022/23 2023/24 £2,766,381 £3,811,208 £5,239,947 5M 4M 3M 2M 1M 0

2021/22 2022/23 2023/24 £2,766,381 £3,811,208 £5,239,947

Foreword

Executive summary

• Dietitian • Physician associates • FCPs (physiotherapists) • Covid care coordinators • IMPACT care coordinators • Care homes at scale care coordinator • Patient representative care coordinator.

The workforce plan was completed and returned to the commissioner using the agreed national workforce planning template, providing details of its plans for 2021/22 ahead of the 31 August 2021 deadline. Engagement with the PCN formed indicative intentions through to 2023/24 for the 31 October 2021 submission deadline.

Who we are

Our achievements

16

Addressing inequalities

IP

Working in collaboration with Norwich City Council, OneNorwich Practices is making a concerted effort to reduce unwarranted variation in primary health outcomes.

Work undertaken by Norwich City Council on the Reducing Inequalities Target Areas (RITA) has influenced how we deliver services at scale. The newly developed primary care high intensity user service pilot will initially support practices situated in the 7 RITA areas.

The primary care community officer (PCCO), commissioned by ONP is working with voluntary and community providers to understand how primary care can be better accessed by those who might ordinarily decline help. We are seeking ways to deliver a health outreach service in community spaces with a particular focus on patients with learning disabilities and serious mental illness as well as those in the most deprived areas of the PCN.

We are working with system partners on a joint community transformation funding bid to support people with frailty in over or under-occupied housing in an anticipatory approach to care. This will bolster the already substantial work the IMPACT team is undertaking in proactively contacting and supporting those not currently engaging with health and care, thus reducing the need for them to rely on general practice in future.

In Q1 2021/22 the Living Well team (social prescribing) was fully migrated to ownership of the PCN following the cessation of local authority funding.

Subsequent to offering support to practices during lockdown, the team is now operating as usual. Social prescribers are starting to work from practices to support those less able to attend appointments elsewhere.

Where are we going?

Our vision and strategy

Acronym buster

17

Admiral Nurse Service

IP

Our admiral nurse team work across central Norfolk with family and carers of people with dementia to improve the quality of life for people with dementia and their carers. They use a range of biopsychosocial interventions that help people with dementia and their families to live well with the condition and develop skills to improve communication and maintain relationships. The admiral nurses also offer specialist support and education to other professionals working with families and people with dementia.

We work closely with Dementia UK and the Alzheimers’ Society in the delivery of this service.

Over the last two years, the team have worked with 1,436 family carers and 1,420 persons living with dementia during this period. 74% of referrals come form GP practices, with the next largest referral route being self-referral. 81% of the people living with dementia had at least one comorbidity recorded, highlighting the prevalence of co-morbidities amongst this population of people living with dementia.

Foreword

Executive summary

81%

of dementia patients have comorbidities

Carers have reported the largest improvements in their lives as a result of this service in the areas of ‘Support for caring’ and ‘Caring Choice’, which measure the extent of support carers perceive that they receive and the extent to which carers feel that they have control over their own lives.

Alongside working directly with families, admiral nurses work with others to promote best practice in dementia care.

We have recorded 603 supporting best practice activities from June 2019 to June 2021. 43% of these activities were CPD for clinicians. Other activities included speaking to promote and inform audiences about admiral nurses and dementia, providing professional advice to other health and social care professionals and training for tier 1 provision.

Who we are

Our achievements

18

Asthma in Schools

EPC

This one year project commenced on 6th September 2021. We have employed a full time children’s asthma nurse specialist to perform respiratory clinics in schools in Norwich to address issues in diagnosing and managing symptoms of asthma in children through improved technique and adherence support. The aims of the service are to: • improve the overall wellbeing of the child and reduce risks of morbidity and even mortality • to reduce unplanned GP / OOH and A&E attendances/admissions as a result of poorly managed asthma • to reduce absence from school due to ill health • to optimise efficient prescribing for asthma and related co-morbidities • to reduce prescribing of antibiotics and oral steroids by up to 45% in asthmatic and non-asthmatic children alike by improving medication adherence and challenging diagnosis

The scope of the project includes any children prescribed a minimum of a Salbutamol (reliever inhaler) between the ages of 5-16 who attend school, with or without a diagnosis of asthma.

The children’s asthma nurse specialist has so far engaged with head teachers from 2 schools in Earlham where there are known pockets of deprivation to try and capture those children and families with historically poor compliance. The schools have been very positive about the project and are keen to be involved.

The first clinics will be held in November where the annual asthma reviews will be carried out for these children. The children’s asthma nurse specialist will provide education to these children and their families around the importance of attending annual reviews. She will also provide education to the staff in the schools on the management of children with asthma.

• to reduce side effects associated with inhaled corticosteroid • to review comorbidities, e.g. rhinitis, eczema and any allergies.

Where are we going?

Our vision and strategy

Acronym buster

19

Bowthorpe Care Village

EPC

This was a unique model of care set up to provide holistic care on site to residents of Bowthorpe Care Village. The site comprises of 92 housing with care flats and an 80 bedded dementia unit. The onsite care was provided by one advanced nurse practitioner (ANP) and one health care assistant (HCA) between the hours of 9-5 Monday to Friday with GP support provided

by Castle GPs twice weekly.

Oakwood House Nursing home and St Johns House Care home also came under this model of care.

The clinicians worked closely with the Norse care team providing them with education and support.

The clinicians and care team worked in partnership with other disciplines and agencies to build up an effective multidisciplinary team allowing the provision of integrated care to all residents.

The clinicians and care team worked in partnership with other disciplines and agencies to build up an effective multidisciplinary team

Foreword

Executive summary

This model of care came to an end on the 1st October 2021 to align the care provided to residents in care homes across Norwich.

This has shown us different ways of working and allowed us to trial models of care using resources available. For example, the MDT has built up over time allowing for effective communication and joined up working with other healthcare providers resulting in improved patient outcomes.

We hope to replicate this MDT model across other care homes in Norwich.

Who we are

Our achievements

20

Care Homes at Scale (CHAS)

EPC

Service commenced on 19/08/2021.

We currently have 37 LD, MH, dementia and older people’s care homes under this model.

The team has received very positive feedback from care homes, patients, relatives and other healthcare professionals for the work carried out within this service.

The service runs with a GP clinical lead and an ANP lead supported by two integrated care coordinators (ICCs). There are structured multi disciplinary team meetings (MDTs) each week covering 4 neighbourhoods, each neighbourhood is covered once per month.

We are looking to expand this service to other care homes across Norwich and for the team to work alongside the HVS and GPHVS.

The MDTs are tailored for each patient cohort and include representation from NSFT, adult social services, specialist OT and PT services, pharmacy support as well as the ONP GP, ANP and ICCs. Structured medication reviews are carried out by the clinical pharmacist when required. The GP carries out a thorough review of the full records of all patients referred to the service. Part of this review is to ensure relevant annual checks have been completed and to identify any issues or concerns that should be raised within the MDT meeting. This can include any safeguarding concerns or behavioural changes in the patient which may indicate an underlying problem. The MDT acts as an advocate for these patients in vulnerable groups by raising and discussing concerns to mitigate risk to the patient.

Where are we going?

Our vision and strategy

Acronym buster

21

Communications and Engagement Recognising the need for better communication and engagement OneNorwich Practices recruited a communications and engagement manager in August 2021.

The communications and engagement manager is responsible for supporting the team in providing a high quality communications service to the organisation and its key stakeholders this includes the Norwich PCN GP Practices.

Good progress has been made since this appointment with the following work having been undertaken: • An audit of current branding, digital presences and communication processes.

• Creation of OneNorwich Practices social media platforms for Twitter, Facebook, YouTube and LinkedIn. • Claiming ownership of OneNorwich Practices digital presence on Google.

• Auditing the Facebook and Google presence of the 22 GP Practices and presenting a report to practice managers, along with the offer of supporting the practices on a one to one basis to improve engagement on these platforms.

Foreword

Executive summary

PCT • A review and make-over for the current OneNorwich Practices website.

• Implementation of a OneNorwich Practices Style Guide and Media Protocol.

• Issuing several press releases and working more closely with the CCG to ensure joined up messaging.

• Review of current emailing protocols resulting in trialling a new procedure to reduce duplication and streamline messaging.

• Development of a new Newsletter for all practices and OneNorwich Practices staff • A revision of the signage for the Walk-in Centre to ensure messaging is clear, on-brand and consistent with current guidance.

• Work is in progress to support the OneNorwich Practices PPG Officer to further develop the Patient Participation Groups.

In addition, the communications and engagement manager initiated a digital meeting to progress all things digital and produces a monthly report on digital engagement.

Who we are

Our achievements

22

Covid-19 vaccinations

IP

OneNorwich Practices Ltd. PCN team took on the challenge to become a key player in keeping the UK population safe during the coronavirus pandemic through offering an unprecedented vaccination service in three different locations across Norwich as well as providing practice workforce resilience and allowing surgeries to focus on direct patient care.

The service launched in December 2020 and has since vaccinated in excess of 200,000 patients to date. During this time, a great number of housebound patients, care home residents and staff have been vaccinated off-site. To ensure every person had access to the programme, out-of-hour clinics were set up at a number hostels, mosques and homeless settings.

More than 200,000 Norwich patients vaccinated

Where are we going?

Now, we continue to vaccinate patients for their first and second doses for those who have not yet received the full course and we have also started phase 3 of the programme with booster doses being delivered across multiple GP surgeries across Norwich. This success has benefited both patients and practices involved.

The service has been delivered primarily

by ONP staff, especially those employed through the ARR scheme such as pharmacists, pharmacy technicians, physician associates, occupational therapists, dietitians, care coordinators, etc.

Furthermore, it has been a collaborative piece of work, working alongside staff from the practices in Norwich as well as a wide range of volunteers who have all contributed to running a smooth service.

From police and fire brigade members to retired healthcare professionals, all have been a great support in rolling out the programme.

Our vision and strategy

Acronym buster

23

Digital innovation

PCT

OneNorwich Practices is extending the Clarity TeamNet license for a further two years from December 2021. This will become an increasingly important tool in the way information is shared across the PCN and to act as a repository as the workforce and work streams continue to diversify. More and more communications will continue to be migrated onto the intranet for staff to view.

ONP procured the services of a digital consultant who engaged with practices and the commissioners over a number of months. The final report was shared with practices in July 2021. A GP IT lead has been appointed at ONP to start to operationalise PCN wide elements of the strategy and to support practices to evaluate their own needs and deliver local solutions.

A GP IT lead has been appointed at OneNorwich Practices to operationalise the PCN elements of the digital strategy.

Foreword

Executive summary

ONP meets regularly with the CCG digital team to stay apprised of CCG wide and national developments to ensure the PCNs’ digital assets continue to improve in line with national guidance. The team has been instrumental in supporting the CCG in rolling out the new additional roles reimbursement scheme (ARRS) registration authority process, meaning a significant reduction administrative burden on individual practices. In addition to this, non-ARRS staff will soon be able to benefit from a similar system with support from ONP. OneNorwich Practices continues to work closely with the CCG and Silicone Practice to embed further improvements in the functionality of FootFall. Version six of the software began rollout at the start of October following extensive testing and more updates are inbound to support smoother triage and a wider array of options for patients.

ONP postponed the Digital Forum during Covid-19 but is looking to reinstate these, offering practice staff support and training.

Who we are

Our achievements

24

GP Front Door

IP

The GP Front Door Service was set up in collaboration with North Norfolk Primary Care and South Norfolk HealthCare in December 2019. The main objective of the service was to reduce the footfall through the Emergency Department (ED) and offer patients an alternative appointment, with a GP or ANP, if ED was not the correct pathway for their presentation. Since the start of the pilot we have seen over 14,000 patients, reducing the pressure on ED by taking away those patients who are presenting with more minor problems.

The service is currently run 7 days a week from 09.00 – 21.00 and is usually staffed by a GP and an ANP. We have recently introduced a third clinician to the service to increase capacity and are working with the ED to ensure patients are appropriately streamed.

Feedback from patients include:

‘Excellent, very helpful and kind staff’ Score: Very Good

‘Very good service’ Score: Very Good

‘Perfect service’ Score: Very Good

We are currently in the process of planning a rotation model for the clinical and administrative teams to work within the different clinical services across OneNorwich Practices.

The service is still currently running as a pilot, however we are recruiting a clinical lead to help with our collaborative governance framework and to evolve the service in collaboration with system partners as part of the emergency and urgent care agenda.

Where are we going?

Our vision and strategy

‘Brilliant, all been great’ Score: Very Good

‘The receptionist was fantastic, brilliant thank you’ Score: Very Good

Acronym buster

25

Home Visiting Service (HVS)

EPC

The primary focus for the Home Visiting Service is to support practices and to improve the urgent care response for on the day home visit requests. The Nurse HVS Service runs Monday to Friday 9am-5pm and GP HVS Monday to Sunday 10-4pm The HVS team works collaboratively with the Norwich Escalation Avoidance Team (NEAT) which enables any onward referrals to be managed and coordinated in a timely manner. The team has expanded since inception and now has two full time Integrated Care Coordinators (ICCs) working across both services.

The service has provided visits for

20,653 patients since April 2018

We have recently recruited and now have 6 experienced nurses working within the team. We have also expanded the service to include visits for long term condition management and LD checks.

In April 2020, we were successful in gaining Covid Response funding to expand the service to include GPs. The aim was to support the early discharge of clinically stable patients, mainly into care homes, and provide additional capacity for practices, during the early days of Covid-19. This element of the service has continued and the GPs will visit any appropriate patients who have been triaged and referred by their own practice.

The service has provided visits for 20,653 patients since April 2018, with 7,195 visits over the last 12 months.

To date, the GP HVS has provided 5,280 visits with 2,314 of these being in the last 12 months.

We are in the process of developing and aligning the GP and Nurse Home Visiting Service with the Care Homes at Scale (CHAS) team.

Foreword

Executive summary

Who we are

Our achievements

26

High Intensity User (HIU)

IP

Building on the expertise NCH&C has built with the high intensity user services supporting NNUH A&E, 111 and the East of England Ambulance Service, ONP has commissioned them to deliver a general practice high intensity user service to 7 practices in Reducing Inequalities Target Areas (RITA).

Running for an initial 12 month term from Q3 21/22, the programme will minimally support 50 frequent users of general practice. The service will offer intensive support to patients who have consented to take part. This will include understanding their health concerns and addressing the wider determinants of health, such as housing, finance, employment and relationships.

Historically, the service has significantly exceeded its minimum target of a 40% reduction in attendance at A&E and other services. It is widely anticipated that this success will be replicated in general practice. Assistance from ONPs’ business intelligence analyst will determine the level of success seen in this project and will help build a business case for an extended programme after the initial pilot term.

High Intensity Users: the service has more than 40% reduction in attendance at A&E and other services

40%

Patients will be supported by a health improvement practitioner who will take time to develop a deep understanding of that patients’ needs and support them to engage with the support they need to reduce their attendance in general practice. This might mean accompanying them to appointments of referring them to voluntary sector providers.

Where are we going?

Our vision and strategy

Acronym buster

27

Integrated Motivational Proactive Anticipatory Care Team (IMPACT) IMPACT is supporting the development of sustainable general practice by utilising population health intelligence to tackle neighbourhood health inequalities through proactive personalised care and support planning.

PCT

Currently, IMPACT makes proactive contact with patients who have a specific unmanaged long-term condition, dependent on the neighbourhood. Type II diabetes patients in central and west Norwich, asthma patients in north Norwich and COPD patients in east Norwich.

A team of care coordinators employ person-centred and motivational approaches to support patient-led identification of biopsychosocial needs, before collaboratively formulating a personalised care and support plan to address patients’ current challenges.

Since June 2021, over 500 Personalised Care and Support Plans have been formulated, resulting in over 350 referrals to system-wide services. Only 9 percent of these referrals were for input by a General Practitioner.

Utilising their enhanced knowledge of system-wide services, IMPACT care coordinators navigate patients to the most appropriate intervention(s) which will support more efficacious self-management.

Three-month reviews are currently underway and following the completion of these (anticipated end of December 2021), the team will conduct a thorough evaluation of outcomes which will direct future work.

Composition of IMPACT onward referrals Weight Management Services (1%) PCN Dietician (1%) Community Dietetics (3%)

Social Prescribing

(7%)

(20%)

Community Occupational Therapy

(14%) (12%)

NSFT (via GP) (3%)

(9%) Signposting

(13%)

(16%)

Wellbeing Service

Foreword

Community Physiotherapy

Continence Nursing (1%) CFICS General Practice

Executive summary

Who we are

Our achievements

28

Improved Access Service

EPC

The Improved Access Service (IAS) was established in September 2018, initially as a single hub model, providing additional access Monday to Friday 14.00 – 20.00, Saturday 08.00 – 14.00 and Sunday 08.00 – 12.00. The second hub opened in 2019, to ensure equity of access to patients across the city.

The service is run by experienced GPs and ANPs. We have also employed an HCA for a day a week for wound checks, dressings etc. There is scope in the future to expand the clinical team to provide access to other health care professionals

Before and during Covid-19 we have continuously monitored the service to ensure it meets the needs of practices and patients and are dedicated to provide the most comprehensive service for our practices.

In response to being outliers for cervical screening, we have recently provided dedicated clinics on Saturdays for cervical smears. Utilisation of these appointments has been good suggesting that access to cervical screening outside of normal surgery hours is popular.

In total, the IAS has provided over 93,000 telephone or face-to-face appointments, supporting Norwich practices in the delivery of primary care. In the last year, we have provided over 17,000 face to face and telephone consultations.

In total the Improved Access Service has provided over

93,000 telephone or face-to-face appointments for Norwich patients

Where are we going?

Our vision and strategy

Acronym buster

29

Lymphoedema Service

EPC

The Lymphoedema Service provides patients with lymphoedema with a co-ordinated package of care, at a level of intervention appropriate to their needs.

It aims to: • Stabilise and ideally reduce the limb volume and address any skin changes • Liaise with community services to ensure a smooth transition of care from acute to primary care and have in place a fast track referral back to acute care or site specific consultant in case of recurrence of disease or escalation of lymphoedema or infection.

• Improve quality of life for patients living with lymphoedema • Ensure patients are supported to self-manage where appropriate and have a self-management plan and an understanding of the disease

We have adapted our services throughout Covid-19 to ensure our patients have remained safe and their health outcomes optimised.

Foreword

Executive summary

• Increase prevention of lymphoedema in those at risk of developing the disease The service has been working at full capacity offering a mixture of telephone and face to face appointments. The service worked with many patients classed as shielding during Covid-19, adapting the service to respond.

We are looking at the possibility of relocating the service to a bigger location to be able to offer more as the service grows.

Who we are

Our achievements

30

Mental Health in General Practice

IP

Norwich PCN has been at the vanguard of mental health community transformation.

Working closely with Norfolk & Suffolk Foundation Trust (NSFT) we have successfully piloted the primary care mental health practitioner role in the central neighbourhood.

This has been extended through the Additional Roles Reimbursement Scheme (ARRS) to include funding for one mental health practitioner in each neighbourhood for 21/22 with an additional 0.4FTE in Central. Two posts have been filled since Q1 21/22 with recruitment ongoing for the remaining posts.

Due to the high mental health demand across the PCN, we have also been working closely with the Wellbeing Service and social prescribing to improve mental health triage processes. The first Wellbeing service pilot in West neighbourhood had extremely positive results with 100% of staff surveyed saying they felt more confident about signposting patients to the Wellbeing Service.

West and central neighbourhoods were chosen as pilot sites for the new NSFT Advice and Guidance Service. ONP continues to engage regularly with NSFT to continually improve all PCN facing services.

All practices in the PCN are now able to use the service, which, following feedback from ONP at the review stage, will become increasingly proactive in offering more detailed information about our patients.

Through open dialogue with NSFT, we have been able to help shape community transformation plans as they develop, meaning that the PCN will see additional value in services as they are operationalised. We also maintain good relationships with voluntary sector mental health providers as their offer develops in parallel to that of NSFT.

100% Wellbeing Service

100%

of staff surveyed said they felt more confident about signposting patients to the Wellbeing Service

Where are we going?

Our vision and strategy

Acronym buster

31

Norwich PCN Neighbourhoods

PCT

ONP meets with practice managers and lead GPs from each neighbourhood on a monthly basis. The purpose of the meetings is to share and discuss PCN and strategy, updates about PCN services and the impact they are having on practices and patients.

Within each meeting is the opportunity for PCN colleagues to benchmark the contractual position, raise concerns, make suggestions and ask questions of colleagues. The meeting also provides an opportunity for guest speakers from across the local system to keep colleagues informed of new services.

The core themes of the PCN neighbourhood meetings are aligned to the guidance in the NHS Long Term Plan and the Network DES. This means that the content of the meetings, as well as being open to suggestions from attendees, focusses on development of the PCN and the core requirements for service delivery.

Foreword

Executive summary

The structure of the meetings was redesigned in Q2 21/22 based on the feedback of PCN colleagues so that the agenda items are more clearly linked to the aims and goals of the PCN. This has the added benefit that development can be more closely interrogated and shared understanding can be better achieved. All neighbourhoods now additionally have access to minutes from each of the other neighbourhoods’ meetings on TeamNet to promote equity and transparency.

The Health Centre has recently increased its face-to-face appointments, ratios are nearly back to pre-Covid-19 levels.

Who we are

Our achievements

32

Norwich Practices Health Centre

PCT

We have a variety of different clinicians Norwich Practices Health Centre is our City Centre GP practice located at Rouen Road. We provide an 8am - 8pm service, 7 days/week, 365 days per year.

We are available for registrations by any resident of Norwich, up to and including NR7.

We have a current list size of c. 10,302 patients.

We have a CQC rating of Good.

The Norwich Practices Health Centre is committed to primary care transformation and being and active participant in the initiatives of the Norwich PCN. Like all practices, we have had to rapidly change services to respond to Covid-19, introducing more telephone call appointments, introducing Footfall messaging services, triaging, new distancing and safety measures. Although challenging, this has given us opportunities for new ways of working and to progress our implementation of the GP Forward View.

We have a dedicated multi-disciplinary team who have risen to these challenges and delivered excellent care through Covid-19.

Feedback from patients on our Health Centre in 2020/21 included: “ During these tough times I have found this surgery to be extremely helpful and supportive” “ superb attention to detail and very patient and pleasant manner”

Where are we going?

Our vision and strategy

Acronym buster

33

Opioid Project

EPC

This 1 year pilot commenced on the 17th May 2021. OneNorwich Practices are working in partnership with the Drug and Alcohol Liaison Team at NNUH to address the increasing dependence on prescribed opioids. Norwich has been identified as a national outlier in terms of opioid prescribing according to national data. The project commenced Initially in the west neighbourhood at Wensum and Bacon Road Practices as they were identified as being in the highest percentiles. This has now been extended to Lakenham Surgery in the central neighbourhood.

Suitable patients have been identified using the following eligibility criteria; • Patients prescribed opioids for CNCP (chronic non-cancer pain) at 120mg morphine equivalent or above.

• Elderly patients prescribed opioids and have had a fall.

• A dditional nurse led service with specialist input on an as ‘required basis’ for those patients with pain issues using opioids that need further expert advice/ assessment to prevent escalation.

Foreword

Executive summary

The specialist drug and alcohol nurse has also commenced joint clinics with one of the clinical pharmacists which is working really effectively.

Baseline data has been collated for each Practice on an individual patient basis including demographics, medications, medication doses, medical history, pain and wellbeing scores. This data will be reviewed on a quarterly basis to measure progress.

The nurse will also write up some case studies to present along with this data.

This project has so far generated positive feedback from Practices and patients.

Baseline data has been collated for each Practice on an individual patient basis which will enable us to manage patient needs more efficiently.

Who we are

Our achievements

34

Pharmacy

PCT

The pharmacy team has experienced a rapid growth and transformation over the last 18 months.

It started off with two clinical pharmacists for the whole PCN. We soon saw the value in these roles and developed a structure to have one clinical pharmacist in each neighbourhood and an overarching senior clinical pharmacist leading the team.

With further funding coming through the ARR scheme, we grew our workforce and recruited one pharmacy technician per neighbourhood.

We were the first PCN to introduce these roles into primary care and practices welcomed these new roles into their practices.

Given the success in embedding these roles into the PCN, we conducted a further recruitment campaign and doubled our clinical pharmacist workforce to deploy two full time pharmacists per neighbourhood.

Where are we going?

These roles have been involved in multiple tasks such as: supporting practice workforce resilience, conducting audits, completing several indicators of the Prescribing Quality Scheme, reducing the burden of medicines’ related tasks, reconciling discharge medications and developing the Structured Medication Review Service – amongst many other things. They have also played a key part in the Covid vaccination programme.

Our future plans include doubling up our technician workforce to have two technicians per neighbourhood as well as creating a dedicated care home specialist pharmacy group formed by a clinical pharmacist and a pharmacy technician who will support Care Homes visits.

We aim to have this workforce fully trained in primary care as soon as possible to further support practices with the delivery of the DES contract.

Our vision and strategy

Acronym buster

35

Population Health

IP

Norwich PCN is developing its population health approach through a number of projects and programmes. The IMPACT team first trialled this at the start of 2021 by looking at the population health data of each neighbourhood and identifying specific cohorts of patients with long term conditions using UCLP risk stratification techniques.

To continue to develop our population health management approach, ONP has appointed a BI analyst whose role is to systematically review the at scale services ONP delivers. The data produced with these services can be overlaid with wider datasets shared by local authorities, the CCG and others, to give a fuller picture of our local population.

The IMPACT team proactive contact patients identified as having a long term condition, but who are not currently engaging with health and care. Each patient is given the opportunity to complete a personalised care and support plan with the care coordinator. Following completion, the care coordinator make referrals to appropriate services and teams.

The first cohort for each neighbourhood is expected to be completed by Q4 21/22 with a full evaluation to follow. At the time of writing, tasks sent to practices represent only 9% of total onward referrals made by the team.

The PCN is now part of wave 3 of an NHS England population health programme that will deliver two projects: one at neighbourhood scale and one at ‘place’ level. This process will last approximately five months from November 2021 and will include working with system partners from the voluntary sector, community health, local authority and others to develop a comprehensive approach to population health that can be replicated and scaled up as needed by the PCN.

Foreword

Executive summary

Who we are

Our achievements

36

Protected Time for Learning (PLT)

PCT

Protected Learning Time (PLT) was introduced in May 2018, allowing practices to close for a half day at the same time.

There have been 9 external PLT events since May 2018 with over 1,500 practice staff attending and four internal events.

OneNorwich Practices delivers 6 PLT half day sessions a year, 3 for external education and 3 for internal practice level training and education. Integrated Care 24 (IC24) were commissioned by OneNorwich Practices to provide cover across the city for the 6 events. OneNorwich Practices has a dedicated project coordinator who assists in the development of new learning and development opportunities ensuring effective communication networks are established and maintained with key stakeholders, and the external environment.

Previous sessions have included Microsoft Teams training, medical terminology, excel training, active signposting, conflict resolution, wellbeing in the workplace, leadership and management along with more clinical training such as BLS (basic life support), safeguarding, tissue viability, wound care, cancer supporting early diagnosis and more.

Where are we going?

The Productive General Practice (PGP) programme is an on-site, hands-on, short term support package for practices that forms part of a local Time for Care programme. The programme focuses on using process mapping techniques to help practices identify, manage and mitigate barriers to systems and processes in the following areas: Well organised practice; e-mails; meetings and interruptions; team planning; frequent attenders; common approach; appropriate appointments; clear job standards; efficient processes.

These improved skills help to create headspace for practices working their way through current and future pressures by working with clinicians and staff to identify and strip out wasteful activities.

In total, 19 out of 21 practices have participated in one or more module of Productive General Practice and/or a Learning in Action module.

Our vision and strategy

Acronym buster

37

Research

PCT

OneNorwich Practices is committed to working alongside the CRN Eastern Primary Care Locality Team on its Research Strategy 2019-2023, which aims to achieve health benefits for patients who participate in medical research by enabling them to live more independent and healthier lives.

33%

A dedicated Norwich PCN research administrator was recruited to act as a champion and advocate, supporting practices to take part and increase study uptake.

In 2020/21 Norwich Primary Care Network’s research active practices compared well against those across England with 55% of our practices being active against 42% nationally, thus keeping the PCN ahead of the national trend in research carried out in community settings. In addition, OneNorwich Practices recruited 33% of the total number of patients recruited into medical trials in Norfolk and Waveney CCG in 2020/21. This is a magnificent achievement when one takes into account the very difficult circumstances in which general practices have been operating due to Covid-19.

Foreword

Executive summary

OneNorwich Practices recruited 33% of the total number of patients recruited into medical trials in the Norfolk and Waveney CCG area in 2020/21

There have been several high performing practices within the PCN during 2020/21, one of whom recruited 768 patients into seven healthcare studies. Two further important COVID-19 studies were carried out which had national importance and resulted in Norwich being the second highest recruiter in the country to recruit into the Psychological Impact of COVID-19 Study.

In addition a Norwich Primary Care Research Forum was established and is now an important part of the PCN research activities as it enables experts from a wide range of research organisations to attend and is open to all staff from interested practices to gain further information first hand from the trial managers.

Who we are

Our achievements

38

Vulnerable Adult Service

EPC

The Norwich Vulnerable Adult Service (VAS) model is a tiered, step up, step down integrated model of care for adults with complex needs and severe multiple disadvantages. The patients supported are often homeless, living in temporary accommodation or accommodation which may be at risk. Individuals are supported in the most appropriate tier, based on their acuity and complexity. The Inclusion Health Hub is for individuals experiencing acute chaos, extreme complexity and multiple co-morbidities. It is intended that individuals will only spend a short time (ideally less than 6 months) being supported by the Inclusion Health Hub before being ‘stepped down’ to the less intensive service.

The service commenced in April 2020 at the midst of a global pandemic, and despite the impact and challenges this posed, the service continued to grow. Key recruitment enabled the service to become robust and resilient and able to create a structured focus to strive to achieve the requirements of the new model and improve both the health outcomes for patients and address inequalities.

Where are we going?

The core team of a service lead, clinical lead, ICC and support workers adopted a collaborative working approach which created processes to follow by holding weekly Multi- Disciplinary Team (MDT) meetings with partners and stakeholders.

Communication networks with Inclusion Health Practices (IHPs) were established and regular meetings and discussions implemented to improve patient care.

A partnership approach was adopted to ensure that contributions from professionals within the IHPs and linking with their own ICCs was established to strive to continually improve the service and patient experience.

The service was subject to the Health Overview Scrutiny Committee (HOSC) in October to ensure it was deemed as safe and beneficial. The outcome from the HOSC was wholly supportive of the aim that services of this type will be rolled out across the county, which is fantastic.

Our vision and strategy

Acronym buster

39

Walk-in Centre (WIC)

EPC

The Walk-in Centre based in Norwich is delivered by OneNorwich Practices. The clinical care provided by the Walk-in Centre includes: • Minor cuts and wounds - dressings and care • Stomach ache, indigestion, constipation, vomiting and diarrhoea • Muscle and joint injuries - strains and sprains • Skin complaints - rashes and headlice • Blood pressure checks • Treatment of minor infections • Sexual Health The Walk-in Centre seeks to provide urgent, same-day-need primary care services, supporting pressures across the healthcare system. This service is provided by GPs and Nurses 7am-9pm, 7 days per week, 365 days per year. Services are offered predominantly face-to-face, but also via telephone and video call. The service is City Centre-based, on Rouen Road, with easy transport links and on-street parking.

The Walk-in Centre has overcome a number of challenges throughout Covid-19. Our staff have been committed to finding solutions to these challenges and continuing to provide excellent medical care. We have introduced a Yellow Zone

Foreword

Executive summary

to assess patients who have symptoms of Covid-19, and we have a respiratory room for consults with any patients attending with these symptoms. Covid-19 safety requirements have continued to place restrictions on numbers that could be seated in out waiting room, which has resulted in outside queues. We continually monitor safety requirements, and develop estate options, to improve the queue situation and patient experience. We have introduced clinical triage at the Walk-in Centre front door, to identify the needs of patients, ensure the Walk-in Centre is the right place for their treatment and support them to access the right care.

Over the next 12 months we are looking to develop the Walk-in Centre to ensure the Centre is providing maximum value to patients and the health care system.

The Walk-in Centre currently treats over 5,200 patients per month.

Who we are

5,200

Our achievements

40

Workforce

PCT

Weight Intervention Service (WIN)

Our staff in general practice are our greatest assets, and by supporting them we continue to offer resilience from a diverse workforce.

OneNorwich Practices have seen an exponential growth in workforce despite the challenges of Covid-19 with over 200 people on payroll proving Norwich is still an exciting and attractive place to work. Development has continued for our workforce with training offered in house and externally sourced allowing for new improved and innovative ways of working.

Collaboration has been key with system colleagues to gain the right skill mix to develop and shape future ways of working.

We have offered OneNorwich Practices clinical workforce within their individual practice as well as administrative workforce to deliver admin contractual requirements on their behalf.

We work closely with the Norfolk and Waveney Training Hub to capture any local or national opportunities and development for practices, whilst continuing to offer and host any newly introduced roles for general practice. OneNorwich Practices works alongside and outsources some contracts with other providers to maximise our resources for general practice and to gain the right expertise for the subject matter.

Where are we going?

EPC

The Weight Intervention Service (WIN) is a high quality, GP led, tier 3 weight management programme on behalf of Norwich practices. The service is for referred patients, to reduce weight, improve health outcomes and prevent further weight gain.

The programme is delivered by a multidisciplinary team comprising of a lead GP, specialist nurse, psychologist, dietitian, physical activity trainer, and a specialist healthcare assistant. Tier 2 elements are incorporated in this programme in association with partner organisations.

The service has had to make a number of adaptations to respond to Covid-19 safety requirements. The service was transferred to a video call offer while face-to-face sessions were not possible and continued to review patients through Covid-19 (including having patients weigh themselves at home to monitor weight through Covid-19).

We are recruiting for new roles to the team, which will enable the service to become more streamline and efficient.

Our vision and strategy

Acronym buster

41

Analysing data and turning it into meaningful information is a key to optimising patient care Foreword

Executive summary

Who we are

Our achievements

42

Where are we going?

Having reliable, accurate data and intelligence are vital in order to make the best decisions for patients and populations.

This is true whether addressing operational, financial or contractual challenges, or working across systems to deliver population health management and improve patient experience.

The most important part of data analysis is collecting high-quality data; this means it needs to be complete, accurate and relevant. We have been working with our services over the past 3 months to develop and implement an effective business intelligence function within OneNorwich Practices, with the aim of providing practices with evidence-based information about the various PCN services.

We are currently reviewing the services’ data collection methods and assessing data quality. We are also identifying where we have information gaps and how this data can be collected.

Where are we going?

Analysing data and turning it into meaningful information is a key process of Business Intelligence in order to help users interpret and understand how the services are being utilised. This is information that has not been previously available to practices and stakeholders and we have started to present it to them via the PCN Neighbourhood meetings, using visual interactive dashboards to show data in a user-friendly format.

We plan to roll these dashboards out for all the services. As our data gathering process becomes more robust, we will be able to provide additional intelligence to help develop future service models and linking data analytics to patient pathways and measuring outcomes.

We have also been supporting two new pilot schemes with data capture templates and will be able to provide further analysis at the end of each project.

Our vision and strategy

Acronym buster

43

Our vision Leading integrated, sustainable and clinically-excellent community healthcare services for Norwich practices We believe OneNorwich Practices makes a vital contribution to Norwich GP Practices, to patients and to the Integrated Care System. This is a contribution we will continue to grow and develop with practices and patients.

We will be a transformation leader of primary care redesign, designing services and ways of working to proactively care for people and the communicates they serve.

Our vision for OneNorwich Practices: To work collaboratively with practices and partners to lead integrated, sustainable and clinically-excellent healthcare services for Norwich practices. We will be a transformational leader of primary care redesign, embedding the voice of general practice in Norwich and its ambition for excellent clinical delivery in the heart of our organisation and all we do. We will support the Primary Care Network to deliver its goals and vision to enable greater provision of proactive, personalised, coordinated and more integrated health and social care for people close to home. We will develop and deliver services with Norwich practices, and with them in mind, to create services that contribute to the sustainability of Norwich general practice.

Foreword

Executive summary

Our vision for general practice in Norwich: For a strong network of practices working collaboratively for sustainable, clinical excellent general practice delivering core services to patients in Norwich. We see general practice at the heart of the Integrated Care System, collaboratively delivering extended services, improved capacity and efficiencies, supported by a more resilient workforce. Our vision is that general practice in Norwich is an attractive and enjoyable place to work.

Our vision for health and care in Norwich and wider Norfolk and Waveney: That the patients of Norwich receive the support they need through integrated, collaborative provision across local councils, the NHS, and other partners. That we deliver at scale through general practice and partner collaboration, keeping clinical excellence at the heart of all we do.

Who we are

Our achievements

44

OneNorwich Practices vision for future care

Where are we going?

Our vision and strategy

Acronym buster

45

Our strategy Janka Rodziewicz, Chief Executive Officer The OneNorwich Practices’ strategy for delivering its vision of Leading integrated, sustainable and clinically-excellent healthcare services for Norwich practices has three overarching elements: • Extended Primary Care

and the voluntary sector to integrate services, we will create improved ways of working and improved patient care. We will adopt best practice and utilise the data and research to create new ways of working and services for the benefit of Norwich practices and their patients.

• Integrated population-based model of care

Extended Primary Care

Through these we support the Norwich Primary Care Network to deliver its goals, in addition to providing additional extended primary care services and integrated provision of value to Norwich general practice.

We will continue to capitalise on opportunities to deliver clinical services at hub, locality and larger level. We will create collaborative at scale services, seeking to provide more care in the community, shifting care from the acute hospital setting.

Our work will produce value for practices in workload support, diverse income streams, services delivered in primary care and with primary care knowledge and needs in mind.

• Primary Care Transformation

Primary Care Transformation We will work to support our member practices to deliver the transformational goals of their Primary Care Network (PCN) and the NHS long term plan. We will provide the Network with the staff, expertise, core services and governance they need to thrive. We will support the PCN to develop sustainable and resilient practices, working with them to adopt Additional Role Replacement posts and digital transformation in a manner that makes the biggest impact to the workload of staff and the benefit of patients, embedding new ways of working. Working with partners across general practice, community health, mental health social care, local authorities

Foreword

Executive summary

We will work with practices, commissioners and partners to scope opportunities, draw in clinical opportunities and use research and data sets to design new opportunities for services in the community delivered collaboratively by practices and partners.

We will work with other General Practice Provider Originations to deliver at scale opportunities that are commissioned county-wide, keeping local general practice connectivity at the heart of this delivery and providing value to practices.

Who we are

Our achievements

46

Integrated population-based model of care We see general practice at the heart of the Integrated Care System, and we will support practices to work effectively with this wider system. We will work with partners across the NHS, social care, local authorities and the voluntary sector to draw on best practice and design and deliver a new model of integrated services. We will work with partners to collectively tackle system wide issues such as health inequalities.

OneNorwich Practices has eight guiding principles for the delivery of this strategy: 1. Lead local Population Health and Care Management for all 2. Create effective collaborative partnerships 3. Be a preferred partner

Our OneNorwich Practices journey began in 2007 with a collaboration of Norwich practices to form Norwich Practices Limited and deliver the Norwich Walk-in Centre and Health Centre. In 2017 OneNorwich Practices was created to deliver primary care transformation. OneNorwich Practices and Norwich Practices Limited merged in 2019 to form OneNorwich Practices.

OneNorwich Practices is owned by 20 Norwich practices and has 21 Norwich practices as the members of the PCN (for which we are the delivery vehicle). The goals of our two foundation organisations are still at the heart of our strategy: to provide transformation, services, integration and through these value to the practices and patients of Norwich.

Delivering Primary Care Transformation

4. Lead and cultivate one strategy

We will:

5. Value people 6. Create value for members 7. Deliver considered and considerate communication 8. Deliver strong effective governance

Where are we going?

How will we deliver our strategy?

• Deliver primary care transformation through developing and maturing the Primary Care Network (PCN) and its Neighbourhoods. We will support Neighbourhoods and the PCN to collaborate and shape their vision, and work with them to turn this vision into highly effective delivery. We will support PCN leaders to fully participate in system decision-making, providing them with the data and research they need to make informed decisions.

Our vision and strategy

Acronym buster

47

• Support the PCN to deliver its evolving contractual requirements and goals, and provide transparent open governance to PCN. • Support practices to recruit, retain and diversify their roles in order to deliver excellent care and manage workload. We recognise that the staff of our practices are our greatest asset. We will work with the PCN practices, and our research and data experts, to support the PCN to utilise the Additional Role Replacements in a manner that most benefits the practices and neighbourhoods of the PCN. • Work with external partners, such as the voluntary sector to deliver this workforce transformation.

• Harness the opportunities of digital innovation to improve delivery of patient care and communication between clinicians and practices. We will work with practices to build on the opportunities of TeamNet and embed further improvements into the functionality of Footfall. We will deliver a Digital Forum, to offer support and training to practices.

• Continue to engage fully with practices through a variety of communication, and to support their communication needs.

• Continue to support practice learning, providing diverse protected learning time.

• Develop the interoperability of the practices of Norwich, including shared care records across providers.

• Continue to grow the work of the Integrated Motivational Proactive Anticipatory Care Team (IMPACT) to make anticipatory interventions, target patient groups and reduce health inequalities.

Delivering Extended Primary Care We will: • Continue to innovate, identify and deliver extended primary care services that bring value to the practices of Norwich.

• Utilise data and systematic analysis to design care and direct care interactions supporting proactive and personalised care.

• Support and develop sustainable primary care access provision.

• Continue and develop urgent care delivery in primary care.

• Continue to deliver services at scale and through hubs (following the model of our Care Homes at Scale and Improved Access Services), developing new opportunities and services on these models.

• Energetically promote the work of the PCN.

Foreword

Executive summary

Who we are

Our achievements

48

• Continue to work with multiple practices to deliver services that meet complex needs in Norwich, such as our Vulnerable Adults Service.

• Work with other Norfolk General Practice Provider Organisations to develop winning responses to Norfolkwide procurements and commissioning, keeping local general practice at the heart of healthcare services.

• Develop out research and data analysis capacity to ensure services are continually developing and improving to meet the needs of the patients and practices of Norwich.

• Seek new ways to support practices to deliver Quality Improvement.

• Explore new opportunities to design services that bring value to our member practices.

Delivering an Integrated PopulationBased Model of Care We will: • Work with system partners to develop a population health model and interventions that are grounded in data and population health analysis.

• Connect with partners and the community to codesign services, building on our experience of working with Norwich City Council and on the Community Transformation Fund.

• Embed integrated working with the voluntary sector and community representatives into the work of the PCN, planning and decision-making.

• Develop our partnership with voluntary and communicate providers, building the work of PCN Primary Care Community Officer.

• Work closely with hospital and acute care to provide same-day services, building on our GP Front Door service to provide urgent care services that integrate effectively with hospitals and primary care and bring value to the practices of Norwich.

• Support the PCN to develop its voice in strategic planning at place and system level.

Where are we going?

Our vision and strategy

Acronym buster

49

Acronym buster A&E

Accident and Emergency

ANP

Advanced Nurse Practitioner

IMPACT Integrated Motivational Proactive Anticipatory Care Team

ARRs Additional Role Reimbursement scheme

IP Integrated Population Model of Care

BI

Business Intelligence

LD

Learning Disability

CCG

Clinical Commissioning Group

LFT

Lateral Flow Test

CNCP

Chronic Non Cancer Pain

MDT

Multi Disciplinary Teams

MH

Mental Health

COPD Chronic obstructive pulmonary disease CPD Continuing Professional Development DES

Network Contract DES

ED

Emergency Department

EPC

Extended Primary Care

FTE

Full Time Equivalent

GP

General Practitioner

GP IT

GP Information Technology

GPFD

GP Front Door

GPHVS GP Home Visiting Service HCA

Health Care Assistant

HIU

High Impact Users

HOSC Health Overview Scrutiny Committee HR

Human Resources

HVS

Home Visiting Service

IAS

Improved Access Service

ICC

Integrated Care Coordinator

IHP

Inclusion Health Practices

Foreword

Executive summary

NCHC Norfolk Community Health and Care NEAT Norwich Escalation Avoidance Team NSFT Norfolk and Suffolk Foundation Trust ONP

OneNorwich Practices

OOH

Out of hours

OT

Occupational Therapist

PCCO

Primary Care Community Officer

PCN

Primary Care Network

PCT

Primary Care Transformation

PGP

Productive General Practice

PLT

Protected Time for Learning

PT

Physiotherapist

RITA Reducing Inequalities Target Areas VA

Vulnerable Adult

WIC

Walk-in Centre

WIN

Weight Intervention Service

Who we are

Our achievements

50

Where are we going?

Our vision and strategy

Acronym buster

To improve patient outcomes across Norwich, OneNorwich Practices aspires to lead integrated, sustainable and clinically-excellent community healthcare services for Norwich practices

For more information please contact comms. onenorwichpractices@nhs.net