OneNorwich Practices Annual Report 2022 Leading integrated health and care

We are delighted to present to you, the OneNorwich Practices (ONP) Annual Report 2022. We have made significant progress in the last 12 months and are pleased to share our achievements with you as well as our aspirations for the future.

The pandemic has continued to cast a shadow over the entire health and care sector but, despite these difficult times, ONP has maintained its focus and continued to deliver high standards of care and services throughout.

We have worked hard to develop and implement our strategy, as detailed in this report. We continue to seek new opportunities to ensure that all the residents of Norwich have equity of access to the services they need, where and when they need them, delivered by individuals or teams with the skills, knowledge and experience required.

We have continued to support our practices in a number of ways, for example enhancing workforce through the PCN Additional Roles Reimbursement Scheme, delivery of the large-scale vaccination programme, Protected Learning Time sessions and a dedicated PCN role to assist practices with bespoke quality improvement plans. In addition, we have provided services that support both practices and the wider health and care system, such as the Home Visiting Service, Asthma in Schools and the Care Homes at Scale Service. Further information about these and other projects can be found within this annual report.

Of course, there have been many challenges, which have affected us all in some way. The demands on the acute trust and emergency services are overwhelming, so the ONP priorities of sustainable primary and community services, improving population health and proactive care have never been more important.

Workforce also continues to be an issue, with recruitment and retention of valued, highly skilled staff being fundamental to the future of health and care services. We are supporting system initiatives to address these, for example the Large-Scale Vaccination retention project, GP and Nurse Fellowships, portfolio careers and sharing resources.

At the AGM in 2021, we received unanimous shareholder approval of our newly formed board, with each director having a specific role to fulfil, with clearly defined responsibilities. The last 12 months have seen us develop both individually and collectively and we have emerged as a highly functional and focused unit supporting the leadership team to deliver our strategic goals. We have worked hard to develop a robust governance framework and an open and honest culture, underpinned by our core values and behaviours, which we have developed in collaboration with our staff members.

Our Primary Care Network team has evolved and grown in the past year. Our ARRS are much more embedded in our practices, working hard alongside surgery colleagues to provide direct patient care. The team has

delivered some incredible projects which are highlighted in these pages. We are proud to see that our Living Well team, the Impact Team and The Asthma in Schools Programme have been short-listed for both HSJ and General Practice Awards. Norwich PCN is a finalist for the PCN of the Year category. The Norfolk & Waveney Vaccination Programme is a finalist in the vaccination category with Norwich PCN playing a very vital part in its success. Many congratulations all round for all this well-deserved National recognitionand best of luck!

We have been very active in research and recognised by the NIHR Clinical Research Network East of England as a Winner for our Panoramic Trial and are actively working with Greener NHS and our regional colleagues to reduce the impact of asthma inhalers on the environment. We believe in collaborating, learning and the sharing of best practice widely.

There is great focus in seeking out and addressing Health Inequalities across our PCN work plans. We know that the pandemic has exacerbated this and that the predicted worsening austerity and poverty will hit our communities hard. We will reach out with offers of support. Our greater links with our VSCE and social care colleagues is key to developing our ambition of compassionate and resilient communities.

We are very proud of how the organisation has not only navigated though the pandemic but adapted and grown stronger, leaving us well positioned for the future.

Much of this is due to our staff and senior leadership team, for whom there is no praise high enough. They have worked tirelessly throughout the most challenging period and we are extremely grateful for their hard work and dedication.

We must also pay tribute to you - our member practices, your staff and other key partners who have supported us over the last 12 months by positive engagement, healthy challenge and unwavering support. We owe a debt of gratitude to you all.

Our vision is to lead integrated, sustainable and clinically excellent community health care services for the residents of Norwich and beyond. As we look to the future, we are confident that we can build on our successes and continue to provide quality improvement and innovation, supporting patients, practices and partners as we become embedded within the evolving Integrated Care System.

Sarah AmbroseChair Dr Jeanine SmirlPCN Clinical Director

Executive summary

OneNorwich Practices (ONP) has come a long way since its inception in December 2019 and has achieved many things of which to be proud. Primary among these is where we have effectively delivered support to the 22 GP Practices within the Norwich Primary Care Network (PCN) who selected us as their PCN delivery vehicle. We are thrilled that the Norwich PCN has been shortlisted for PCN of the Year at the GP Awards, and that the amazing collaboration of Norwich practices is being recognised in this way. ONP has had five teams/programmes shortlisted for National Awards this year, an achievement by these teams of which we are immensely proud.

This annual report provides an overview of our progression towards our goals and a summary of our future aspirations.

Our mission continues to be focused on three areas: Extended Primary Care (EPC), Integrated Population Model of Care (IP) and Primary Care Transformation (PCT). You will find definitions of these themes further down in the report. To make our report easier for you to navigate to areas of interest we have themed our work by the three aforementioned mission areas and also in alphabetical order. In addition we have included an acronym buster at the back of the report for your reference.

A summary of progress towards our goals is below:

Over the past three years we have focused on key commitments such as recruiting to the Additional Role Reimbursement Scheme (ARRS), the budget for this year was £3.8m and is growing annually and next year it will be £5.2m.

We now employ more than 100 staff in ARRS related roles all contributing to excellent patient care across the Norwich Practices.

ONP has made significant progress in Addressing Inequalities, partly through partnership working and projects such as INTERACT (Integrated Anticipatory Care Team) the team includes care coordinators, social prescribers, volunteer coordinators and housing support officers. Lead by Queen’s Nurse Tracy Williams we have worked closely with the ICB to develop a health inequalities strategy.

Addressing inequalities is embedded in everything we do, some of the services we provide are listed below:

Age Healthy Norwich who this year, thanks to Captain Tom funding are working with two practices to support more than 50 patients with comorbid hypertension and diabetes.

The Asthma in Schools Project is going from strength to strength and is receiving national recognition for its innovative and integrated approach. Now working with 10 schools across Norwich this service was shortlisted for two national awards in 2022.

The Asylum Seeker Service is a relatively new initiative and consists of a growing team who provide health screening, general support and access to mental health services for those in need across Norwich.

Our Care Coordinators who are split roughly 50/50 between practices and ONP coordinate support for patients who require health checks/recalls for QOF, IIF, DES and CQC reports.

The Care Homes at Scale service continues to grow and evolve to support the needs of the many Care Homes aligned to our practices across Norwich and includes the delivery of Covid-19 Autumn boosters to those with Learning Disabilities (LD) or Severe Mental Illness (SMI).

Our Inclusion Hub which was previously known as the Vulnerable Adult Service (VAS) and was changed following feedback from users. There are 12 Inclusion Health practices who refer patients into the service. A holistic and integrated approach has ensured improved outcomes for patients and positive feedback.

One of our biggest break throughs this year has been with the Living Well Team, shortlisted for an HSJ Award the Living Well Team is a multi-agency partnership which draws on the expertise of its members to ensure the best possible support is provided for patients. Members of the Living Well Team are embedded in roughly half our practices.

More than 100k Norwich residents vaccinated against Covid-19 by a dedicated team of more than 500 people

Good communications and engagement are key to the success of many organisations and this includes OneNorwich Practices. Communicating with practices, patients, staff and the media effectively is often the glue that holds all our hard work together.

Progress this year has included the development of a successful newsletter and social media along with shooting, editing and publishing 23 videos and working with the CEO and HR Team to launch the ONP Values.

Covid-19 is unfortunately still with us and our teams have gone above and beyond expectations, their efforts have ensured that as of May 2022 more than 100k Norwich residents had received their Covid 19 Vaccination. In total 543 people worked long hours to make this possible. We thank them all and will continue to support them as we move into the next phases.

The Dietician Service has delivered a comprehensive service across all 22 practices for more than a year now and has resulted in optimised medicine usage, more efficient use of GPs’ time and an improved service and outcomes for patients.

Having undergone tremendous change in the last 12 months, much of this would not have been possible without the support and proactive approach of the ONP IT Team and as part of their Digital Innovation strategy they have introduced a fully ticketed

support system which works well, along with IT Forums which are run for the Practices. They are also in the process of developing a comprehensive Intranet to improve communications within the organisation.

The Enhanced Access Service replaced the Improved Access Service in October 2022 and endeavours to ensure that through a Multi Disciplinary Team (MDT) approach which is rolled out across the Neighbourhoods, patients have access to NHS Health Checks, phlebotomy services, wound dressing, LTC and chronic disease treatment, as well as access to mental health services, smear tests and a physiotherapy service.

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 our GP 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 patients. The service is currently being piloted across six of our practices.

The Integrated Motivational Proactive Anticipatory Care Team (IMPACT) who since June 2021 have formulated more than 580 personalised care and support plans, have successfully decreased A&E attendances, reduced hospital admissions and a significant reduction in the number of patients who need to see a GP. The service was shortlisted for an award in the 2022 GP Awards.

As with so many primary care services our lymphoedema service has had to adapt to respond to Covid-19. The lymphoedema team work collaboratively with community services in Norwich which enables any onward referrals to be managed and co-ordinated in a timely manner, holding over 1000 patients on its list the service has booked over 3300 appointments for patients this year.

Across Norfolk and Waveney we now have 37 mental health practitioners, as well as our enhanced recovery workers recruited through MIND to be first contact practitioners working with our primary care teams.

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 10,987 which is served by a multidisciplinary team of clinicians. The practice has recently increased the number of GP appointments to about 489 per week. Last inspected by the CQC in Feb 22 the practice was rated as ‘Good’.

The pharmacy team has experienced a rapid growth and transformation over the last 21/2 years and is producing some fantastic outcomes. Through utilisation of the ARRS funding the team has been able to recruit a total of 12 pharmacists and 8 pharmacy technicians.

We currently have a team of four Physician Associates also partly funded through the ARRS. Carrying out Quality and Outcomes Framework (QOF) reviews for chronic diseases such as chronic obstructive pulmonary disease (COPD), asthma and diabetes has provided further support for practices and patients with these conditions.

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, subsequently this technique has been used by the GP High Intensity Service, the Age Health Norwich

programme and the INTERACT project. This has proved extremely effective has been 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 12 external PLT events since 2018 with over 2,350 staff attending.

Pure Physiotherapy continues to provide the First Contact Practitioner (FCP) service across OneNorwich Practices (ONP) and now provides over 14 face to face services, consistently seeing over 1500 patients per month.

The Quality Improvement Team was established in early 2022 and began with the successful implementation of the care coordinator role in practices. The primary focus of the quality improvement team has been to support practices and services to prepare for CQC inspections and to develop monitoring of quality improvement plans.

OneNorwich Practices remains committed to working with the NIHR Clinical Research Network (CRN) East of England, the local ICS, and wider strategic stakeholders, to develop, promote, and facilitate high quality research that is integral to delivering health and care for the population’s benefit. To this effect, the PCN has continued to strengthen its research network and activities throughout the year, leading to many successes.

In 2022, we launched a Respiratory Diagnostic Hub that will run on Saturdays 09:00 – 17:00 with respiratory trained nurses/clinical pharmacist. This service will also support the Enhanced Access Service (see p. 42), with it’s weekend offer.

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.

Our Weight Intervention Service (WIN) (Tier 3) is delivered across Norfolk and Waveney using a blended model which incorporates physical 1:1 appointments. Supported by our lead provider Oviva we have booked over 2700 appointments in the past year.

ONP has gradually and consistently invested in its workforce and now employs over 200 staff. Each one of them is focused on supporting general practice and ensuring better outcomes for patients. We recently launched our ‘Values’ and together with feedback from the staff survey we hope to further strengthen staff resilience, motivation and retention.

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

Who we are

OneNorwich Practices Values

In 2022 OneNorwich Practices reviewed our core values in order to identify the organisation we wish to be as a newly formed merged organisation.

Our new values are: While these values are primarily internally focused, they will also positively impact on our care of patients and our work with external partners. The values review process began with a Board consultation with staff in 2021, has resulted of the launch of these values in 2022 and the start of working with our staffing to make them lived values within our organisation. While this work is ongoing with our staff, as CEO these values mean the following to me:

Open and honest Committed to excellence

• We are open and honest with ourselves, each other and in our external relationships.

• We value honesty and demonstrate this in our interactions with each other and partner organisations and colleagues.

• We are committed to being a learning environment. We voice opinions, successes, disappointments, difficulties, frustrations, and general ideas.

• We each leave judgement at the door, so that we create an environment where everyone can be honest about mistakes, where we don’t penalise creativity where it has good patient care at heart. We use successes and mistakes to learn as an individual, a service or as an organisation.

Kind and respectful

• We are committed to excellent care for patients and creating an excellent working environment.

• We are committed to having excellent relationships with, and understanding of practices in Norwich and being a desirable partner with which they want to collaborate.

• We recognise that excellence requires constant adaptation, innovation and vigilance, and that it will involve errors along the way.

• We are committed to continuously improving, valuing each other, valuing external colleagues and the skills and expertise we can each bring to creating excellence.

Courageous

• We act with respect and kindness to each other, our patients and our external colleagues.

• We acknowledge that everyone is doing their best, and we respect and value each other by giving them the attention they need, listening to their opinions and speaking with kindness.

• We recognise that all our partner organisations and colleagues are working under extreme stress and pressure, and believe that being kind and respectful is an assistance to reducing stress.

• Through this we create a positive work culture that reduces stress, encourages the sharing of ideas, creativity and collaboration.

• We are courageous in our goal to lead in integrated health and care.

• We develop and deliver courageous ideas for transformation, resilience and sustainability in primary care.

• We are courageous in listening to open and honest feedback and taking responsibility for improving and creating excellence.

• We are courageous in seeking to excel in the most challenging areas of primary care delivery.

We hope these values represent an organisation with which our partners and collaborators are proud to work.

Governance

OneNorwich Practices Board of Directors

The Directors of OneNorwich Board are:

• Sarah Ambrose (Chair)

• Dr Jeanine Smirl (PCN Clinical Director)

• Dr Kelly Markham (Medical Director)

Norwich Primary Care Network (PCN)

The Norwich Primary Care Network (PCN) is collaboration of all Norwich GP practices. OneNorwich Practices is extremely proud to have been chosen by these practices to be their delivery vehicle, employing staff and delivering management support for the PCN.

The PCN is led by an executive committee and clinical strategy group. Our clinical directors are:

• Dr Jeanine Smirl (Clinical Director)

• Dr Emily Raine (Clinical Governance Director)

• Dr Martin Falkingham (Norwich North Neighbourhood Clinical Director)

• Michael Stonard (Finance Director)

• James Foster (Business Director)

• Colleen Humphrey (Independent Director for Patient Engagement and Experience)

At the 2022 AGM, assuming successful scrutiny by the Integrated Governance Committee, Dan Mobbs will be proposed to shareholders for appointment as the independent director for the voluntary sector.

• Dr Saffana Rasul (Norwich East Neighbourhood Clinical Director)

• Dr Jo Walsh (Norwich Central Neighbourhood Clinical Director)

• Dr Ed Turnham (Norwich West Neighbourhood Clinical Director)

OneNorwich Practices Senior Leadership Team

There have been some changes in the Senior Leadership Team of OneNorwich Practices across 2021/22, as we have said a fond farewell to team members Tracey Bullard (Head of Transformation), Lisa Townshend (Head of Nursing and Clinical Governance), Jo Watts (HR Manager) and Chris Wright (Finance Manager) who have gone on to other opportunities. A review of the structure of OneNorwich Practices Senior Leadership Team is underway at the time of production of this Annual Report. This is with the goal of ensuring a structure that best supports delivery of OneNorwich Practices. This may result in a changes to the current Senior Leadership Team roles and responsibilities:

• Janka Rodziewicz (Chief Executive Officer)

• Duncan Anderson-Brown (Temporary Head of Operations)

• Zena Aldridge (Acting Head of Nursing)

• Jan Hardinge (Currently Finance Manager but transitioning to Head of Services)

• Dr Sabeena Foster (Clinical Lead for Training and Development)

Norwich Practices

The practices of Norwich are the shareholders of OneNorwich Practices and the members of the PCN.

Our board members represent our constituent practices which are represented on the map below and are comprised of:

Adelaide St. Health Centre

Bacon Road Medical Centre

Bates Green Health Centre

Beechcroft Surgery

Bowthorpe Health Centre

• Ashlyn Byrne (Head of People)

Hellesdon Medical Practice

National and Local Context

OneNorwich Practices operates in a challenging local and national context for healthcare that continuously influences our strategy for achieving our goals. Both locally and nationally, there is a high level of political interest and rhetoric around healthcare and access, not all of it helpful to delivery on the ground. Political pressure has also grown for greater integration with the goal of improving the patient journey while also maximising available resources in a constrained economic environment. This has contributed to the transition of Clinical Commissioning Groups into Integrated Care Boards. Secondary care continues to hold significant sway within this new structure, with the Fuller report proposing further secondary care ownership of primary care.

The economic picture has put yet more pressure on the workforce challenges in primary care, as the growing cost of living for our staff needs to be met without a growth in funding. The energy rises also increase the cost of running our premises. Most concerningly, social determinants of health can be expected to be negatively impacted for many patients, increasing need and demand on primary care.

Political pressure has grown for greater integration with the goal of improving the patient journey

The social context we operate in is also evolving, as patient demand grows, abuse of primary care staff grows and mental health difficulties are on the rise. Litigiousness among patients is also expected to rise in response to the political and economic environment.

The technical environment has rapidly changed during the Covid pandemic, with the swift adoption of technology. There is still more that can be done with technology in primary care, but we battle with time and funding to trial and implement these among the many demands on practices. Many companies are developing offers for primary care, but are doing so in a complex balance of risk and reward that is already finely held in practices.

Just as we continually strive to adapt our OneNorwich Practice strategy to match this evolving context, we seek to continuous evolve our support to practices so they can also best meet the current and coming challenges.

Our vision

OneNorwich Practices vision is to:

Lead 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.

Practices

We will:

• Collaborate openly and transparently with Norwich practices to deliver integrated, sustainable and clinicallyexcellent healthcare services for practices

• 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.

• Support the Primary Care Network to be a strong network and to deliver its goals and vision.

• Develop and deliver services with Norwich practices, and with them in mind, to create services that contribute to the sustainability of Norwich general practice.

• Support practices to make general practice in Norwich is an attractive and enjoyable place to work.

Patients

We will:

• Keep patients at our heart and deliver excellent care in our services.

• Support practices, so that they can continue to deliver excellent care to patients.

• Meaningfully engage with patients in regular reviews of our services and in our service development.

• Measure the quality of our care and outcomes to ensure the delivery of the best quality care.

Integrated

We will:

Care System

• Influence to place general practice is at the heart of the Integrated Care System.

• Be a leader in delivering improved patient outcomes and journey with and within the Integrated Care System.

• Engage in and promote data analysis collaboration with system partners to support improved patient outcomes and care journeys.

• Be an innovator in integration and collaboration with the voluntary sector.

OneNorwich Practices vision for future care

Misson

OneNorwich Practices’ mission has three overarching elements:

• Primary Care Transformation

• Extended Primary Care

• Integrated Population Health Management (Integrated population-based model of care)

These also form the foundation of the PCN strategy, as our contracted agreement with practices as their delivery vehicle includes to ensure that Norwich continue to deliver the agreed strategy focusing on these areas.

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.

• Provide the Network with the staff, expertise, core services and governance they need to thrive.

• 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.

• Create improved ways of working and improved patient care, through working with partners across general practice, community health, mental health social care, local authorities and voluntary sector to integrate services.

• 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.

Extended Primary Care

We will:

• Continue to capitalise on opportunities to deliver clinical services at hub, locality and larger level.

• Create collaborative at scale services, seeking to provide more care in the community, shifting care from the acute hospital setting.

• Produce value for practices in workload support, diverse income streams, services delivered in primary care and with primary care knowledge and needs in mind.

• 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.

• 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.

Integrated Population Health Management (Integrated population-based model of care)

We will:

• Utilise data and information to better understand people’s health and care needs and how they are likely to change in the future.

• Identify the people who are most likely to benefit from integrated care to improve physical and mental health outcomes, reduce health inequalities and help patients live extra years in better health.

• Support practices to work effectively and have a strong voice in the Integrated Care System.

• Integrate and collaborate with partners across the NHS, social care, local authorities and the voluntary sector

• Design and deliver new integrated services.

• Work with partners to collectively tackle system wide issues, such as health inequalities.

Strategic Goals

Following a business analysis, OneNorwich Practices has reviewed and revised its strategic goals. This has been to ensure that we are best placed to succeed in the current political, economic, social, technological, environmental and legal landscape, and that we build on our strengths and opportunities while tackling our weaknesses and threats.

OneNorwich Practices has strategic goals for:

• Patients

• Practices

• Staff

• Business Development

• Influencing

These goals are:

Staff

Be an excellent place to work

Business Development

Be a significant regional contractor and provider of:

• Primary care at-scale services

• Health inequalities services

• Non-practice based services

Patients

Improve clinical outcomes for diverse communities

Practices

Support practices by delivering functions that are best delivered at a city-wide level

Top-level operational goals have also been set, which are forming the foundation of the OneNorwich Practices strategic plan and business plan.

Deliver meaningful and useful patient engagement

Patient-led design embedded in service development

Deliver a positive patient experience in all our services

Offer a menu of support to practices

For patients:

Measure quality of care and outcomes across our services

Have excellent understanding of and relationships with practices

For Practices:

Influencing

Be a strong voice for patients and practices at local, regional and national level

Support practices to effectively deliver national contract requirements

Obtain contracts for practice delivery

Embed meaningful and useful staff engagement in organisational review cycle

For staff:

Embed a values-based culture throughout the organisation

Influence through excellent qualitative knowledge and information

Embed a learning and development culture throughout the organisation

Develop the internal infrastructure and skills to deliver our goals

For business development:

Provide excellent wellbeing support to staff

Develop capabilities and relationships for wider geographic delivery

Influence through inspirational leadership

For influencing:

Be an active participant in influential forums

Deliver highly effective and influential communications

The OneNorwich Practices Senior Leadership Team is revising our Strategic Plan and Business Plan for delivery of these new Strategic and Operational Goals.

Develop the financial capability and capacity to deliver our goals

Listen to practices and patients in plan development

(A-Z)

Each achievement will be themed according to the three definitions below:

Theme Definitions:

EPC

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.

IP PCT

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.

What have we achieved and how have we supported practices

Additional Role Reimbursement Scheme (ARRS) Addressing Inequalities PCT IP

The Additional Roles Reimbursement Scheme (ARRs) is now fully embedded within Norwich Primary Care Network (PCN) and accounts for in excess of 100 staff supporting practices in the PCN. We have successfully recruited to nine distinct roles within the programme and have plans to increase this to include additional roles not previously utilised by the PCN.

Key successes this year have included rolling out the quality improvement team (see p. 57) which is made up of care coordinators who support practices in a number of ways, including contacting patients to arrange long term condition reviews.

The PCN has also been piloting a GP High Intensity User Service (see p. 45) and a health coaching programme delivered in partnership with local providers. Both of these projects have been successfully funded through ARRS.

With the anticipated increase in the ARRS budget in 2023/24, we hope not only to introduce further programmes of work to facilitate improved health outcomes for our population, but to also bolster existing, successful and effective programmes within the PCN.

Practices and Clinical Directors will be consulted on all future plans to ensure that they support the PCN in a way that offers value for money and provides excellence in patient care.

Norwich remains the only PCN in Norfolk and Waveney to have successfully utilised its maximum allocated ARRS budget at £3.8m in 22/23. We are confident this will be replicated in 23/24 with an increased budget of £5.2m.

Following last year’s successful bid for community transformation funding, OneNorwich Practices (ONP) became a key partner in delivering the INTERACT (Integrated Anticipatory Care Team) project. This will be funded until 2024, with additional funding coming from the Better Care Fund allowing us to further expand the project.

INTERACT works both proactively and reactively to support anyone living with frailty in inappropriate housing.

The team includes care coordinators, social prescribers, volunteer coordinators and housing support officers in a multi-agency approach and has supported people with house moves, hoarding, decluttering and housing adaptations.

Tracy Williams was appointed as health inequalities lead for the Norwich Primary Care Network (PCN) in February of 2022 and has been working closely with ONP and Integrated Care Board (ICB) colleagues to develop the PCN’s health inequalities strategy that will be published in due course. In addition to this, Tracy has also supported the inclusion health Locally Commissioned Service (LCS), to which 12 practices have signed up to support health inclusion groups in accessing general practice and healthcare more widely.

Norwich City Council work on Reducing Inequalities Target Areas (RITAs) continues to influence strategic thinking, with some projects being piloted in those areas. ONP now also has a seat on the place-based Equality, Diversity and Inclusion Partnership Group led by Norwich City Council. With this in mind, a number of proposals are currently being worked up to further support health inclusion groups within the PCN, with a particular focus on the national Core20Plus5 approach as well as the Impact and Investment Fund indicators.

Age Healthy Norwich Asthma in Schools Project IP EPC

Building on an existing programme funded by a successful bid by Age UK Norwich to NHS Charities Together (Captain Tom funding), OneNorwich Practices (ONP) has funded a one-year pilot with two practices to support patients over the age of 50 with comorbid hypertension and diabetes.

The service provides a 6-month physical activity intervention of weekly sessions, in-person, virtually or class based. The sessions are run by Health Coaches who as a minimum are level 3 Personal Trainer Qualified. This is then followed by a 6-month self-care period where the patients will be able to use their skills and newly developed habits to continue their health journey. During this time, the patients are asked to complete questionnaires that look at the level of activity, flourishing and quality of life.

A full evaluation is forthcoming; however, initial results show that blood pressure has been successfully reduced to (or below) the target. Patients have reported increased confidence and satisfaction with their health and wellbeing.

The full evaluation will seek to understand the impact of this service on patient contacts with their practices as well as other clinical outcomes.

The Asthma in Schools Project was developed to make it easier for children and young people to attend their annual asthma reviews. The project specifically aims to challenge health inequalities, by holding clinics in schools in deprived areas. Children from poorer backgrounds are more than twice as likely to attend hospitals due to asthma attacks and yet least likely to attend preventative reviews. Evidence suggests most asthma attacks are preventable if children and young people are given the correct diagnosis, receive the correct preventative medicines, understand how they work and why they need to take their preventer inhalers regularly, but also have the correct inhaler technique, and know how to respond if their asthma symptoms get worse.

The project has covered 10 schools in Norwich and the feedback has been very positive. Families advised that due to the pandemic holding clinics in schools is far more accessible. Two thirds of the families reviewed had either never had an annual review or had never had one recently. This reflected in only half the children having their asthma under control. School staff have also been trained, allowing children to feel supported during the day. Confidence and knowledge have increased within families and staff significantly. Each family receives a personal asthma action plan which is shared with the school.

The project is now receiving national attention and has been shortlisted for the Health Service Journal awards as well as the GP Practice Awards. Funding has been approved to extend the project across Norfolk and Waveney schools.

Asylum Seeker Service EPC

The Asylum Seeker Healthcare Team is a team of registered healthcare professionals and support staff who provide a multidimensional specialist role offering an integrated approach to health and social care for asylum seekers, refugees and migrants (planned and unplanned dispersal and refused immigration status), in Norwich. The health team are co-located within Norfolk County Council’s People from Abroad Team and are part of the Vulnerable Adult Service model (see p. 60).

The team has grown over the last 12 months to meet the increased population of this client group within dispersal housing and contingency hotels in Norwich. The team prides themselves on developing new services to meet the complex needs of this vulnerable community. The team has developed a specialist mental health service alongside the Norfolk and Suffolk Foundation Trust located at the REST.

The team provides support for clients to register with a local GP Practice, enabling them to access mainstream health care services. The service aims to provide any asylum seeker, refugee, or migrant ,no matter their country of origin, with fair and equal access to General Medical and support services by:

• Providing an in-depth and comprehensive initial healthcare screening to identify any health and social care needs. This information is shared with the registered GP to provide a history and baseline assessment for the medical practitioner.

• Provide support and learning for inclusion practices to assist with the clinical management of this client group

• Integrated working with other agencies who are part of the Inclusion Health model to ensure a joined-up approach, such as Voluntary Sector groups

• Promoting the use of translation services and assisting practices with any support they may require with this.

Care Coordinators EPC

We currently have a mixture of practice employed care coordinators and OneNorwich Practices (ONP) employed care coordinators, with roughly a 50/50 split. Care coordinators support practice patient cohorts who require health checks/recalls for QOF, IIF, DES and CQC reports, the focus is to invite patients by using a month of birth recall system with a particular drive on mental health and learning disability engagement.

The role is quite varied practice to practice, depending on the practice/patient needs and current workforce. Here are some examples of some the work which is currently taking place at some of the sites:

• Following-up with patients who recently discharged from hospital or have a change in medical circumstances, supporting the patients’ journey/needs, conducting welfare checks and/or arranging follow up appointments.

• Conducting home visits with the GP to care homes, supporting patient, GP, PCP and gaining information from the care home staff.

• Coordination and navigation for people and their carers across health and care services, working closely with social prescribing link workers, health and wellbeing coaches, and other primary care professionals. Raising awareness of how to identify patients who may benefit from shared decision-making. Supporting Norwich Primary Care Network (PCN) staff and patients to be more prepared to have shared decision-making conversations.

• Utilising population health intelligence to proactively identify and work with a cohort of patients to deliver personalised care. Helping people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.

• Coordinating multi-disciplinary working within the practice and facilitating onward referrals to external services.

• Facilitate shared decision making with patients, their carers and clinicians.

Care Homes at Scale (CHAS) EPC

The Care Homes at Scale (CHAS) service has various strands and is growing and evolving as we try to find new and innovative ways to improve our services for people living in care homes.

This year has seen a continuation of an enhanced GP led multi-disciplinary approach for residents with complex needs in participating care homes which provides an enhanced service to GP practices and improved coordination of patient care across partner organisations.

CHAS has also delivered weekly GP and Advanced Nurse Practitioner (ANP) led ward rounds to three care homes where demand exceeds capacity. This service enables patients who are medically stable to leave the Norfolk and Norwich Hospital, continue their recovery and receive reablement support in a more homely care home environment.

We have also commenced a year-long pilot that has seen an ANP work with practices and care homes in the East Norwich Neighbourhood to support staff and residents with end-of-life care planning and long-term condition reviews. The ANP has also been able to attend to other urgent reviews and offer advice and guidance in other cases, which has diverted requests away from GP practices. We are already evaluating the outcomes of this pilot and exploring how this service could be expanded in the coming year.

Preparations are also underway currently to deliver Covid autumn boosters to the Learning Disability (LD) and Severe Mental Illness (SMI) care homes within CHAS by the same team who have attended previously. We hope this will go some way to providing familiarity and reassurances to staff and service users alike.

Communications and Engagement PCT

Having been in position now for over a year the communications and engagement manager has made significant progress toward providing a high-quality communications service to the organisation and its key stakeholders including staff, public, the media, patients, and partner organisations.

Over the last year significant achievements have included:

• Development and delivery of a dynamic newsletter which goes out monthly to ONP staff, practice managers, GPs, practice nurses and stakeholders. On average the newsletter is opened more than 1000 times a month.

• Planning, commissioning and delivery of the ONP Annual Report 20/21 and 21/22

• Rebranding signage to the Walk-in Centre entrance

• Planning, shooting, editing and promoting 23 videos hosted on the ONP YouTube Channel designed to improve understanding of different services and raise awareness of primary care related issues

• Planning, commissioning and promotion of a Norwich Primary Care image library to be used in promoting primary care across the PCN

• Planning, coordinating and submitting entries for the HSJ and GP Awards, currently two projects have been shortlisted for the HSJ Awards and three for the GP Awards

• Working with HR and the CEO to launch the ONP Values

• Planning and implementation of the Norwich PCN Primary Care Enhanced Access Survey (635 responses) then producing a comprehensive report to enable effective decision making

• Planning and implementation of the ONP Staff Survey and subsequently producing a report for management to inform the development of an action plan going forwards

Covid-19 vaccinations IP

Following the great success of the COVID vaccination programme since its launch in December 2020, the Norwich Primary Care Network (PCN) signed up to deliver Phase 5 of the programme, which aims to deliver booster vaccinations of the enhanced bivalent vaccines to eligible cohorts including over 50s and younger patients at risk. OneNorwich Practices (ONP) now has a dedicated team that offers this service to the most vulnerable in Care Homes as well as housebound patients. Furthermore, larger clinics continue to be held in two locations across Norwich operating at the weekend to offer patients out-of-hours appointments making it more convenient to book.

We will be offering the two bivalent vaccines from Moderna and Pfizer to ensure the appropriate level of protection and will ensure all staff are trained up to deliver these new vaccines.

There have been new challenges this year in offering this service, with a reduced service fee and the expectation of returning to business as usual. However, we have a great group of vaccinators, pre-screeners, clinical supervisors, administrators and volunteers who have made these clinics possible by working collaboratively.

Over 10,000 slots were booked within a few days of the launch of Phase 5, and we continue to work on adding even more dates to meet the local demand.

Dietician Service PCT

The role of a primary care dietitian is a new role within the NHS which is partly as a result of NHS Long-Term Plan. The dietician role has been active in Norwich Primary Care Network (PCN) for over a year now and has included work as expert generalist dietitian seeing a wide variety of clinical conditions such as: frailty and malnutrition, diabetes, overweight and obesity, gastroenterology, and paediatrics.

The Dietetic Service delivers a comprehensive nutrition service to all 22 GP Practices within the PCN.

Referrals are received from all health care professionals working in the PCN, patients are seen either face-to-face at the individual GP practices or remotely via telephone appointments. The dietitian works closely with the clinical pharmacists to help with medicines optimisation of oral nutritional supplements and to achieve nutrition related targets for PQS.

Having recently completed the non-medical prescribing course as a supplementary prescriber, this enables the dietician to prescribe medications and oral nutritional supplements/formulas, using a care management plan as agreed with the GP and the patient. Thereby reducing the demand for GP time, optimising medicine usage and helping improve the patient’s safety.

The dietician is currently in the process of completing the HEE Roadmap to Practice pathway, to become a First Contact

Practitioner (FCP) Dietitian. A FCP Dietitian works in primary care to assess, diagnose, formulate, and implement management plans for conditions relating to nutrition and dietetics.

Digital innovation PCT

Enhanced Access Service (EA) EPC

OneNorwich Practices (ONP) IT have introduced the ONP IT support policy, using a fully ticketed support system we ensure we can continue to provide a high-quality support system to our staff.

We continually innovate and introduce and support new systems to benefit ONP. This year we are excited to debut the ONP Launchpad, a one-stop-shop for ONP staff old and new; based on the SharePoint platform the site will offer news, knowledge and support to all those who need it.

We aim to involve all departments and services and produce a comprehensive corporate intranet style site. We are continuing to build alliances with the member practices via our ONP IT support forums. Running monthly the forums promote collaborative working and best practice, we aim to learn and succeed together.

ONP IT liaises closely with all services on improving existing administrative processes and ensuring teams are equipped with the skills and resources to run in the most efficient ways possible, our experienced and knowledgeable team assess and recommend improvements where needed in support of line management and staff. We are currently in discussion with the Integrated Care Board (ICB) on the future on the ONP IT team and are seeking ITIL accreditation in order to support a more comprehensive in-house IT service, our ambition is to support more in house IT work and defer as little as possible to AGEM, we understand the consistent and continuing functionality of IT is core to the delivery of services across Norwich Primary Care Network.

The Enhanced Access Service was established in October 2022 to replace the Improved Access Service (IAS), which has been running since September 2018, and the Extended Access service. The EA Service has been designed in collaboration with practices and Norwich Primary Care Network (PCN) neighbourhoods. This has resulted in a diverse service design, with an MDT approach rotating across each neighbourhood offering NHS Health Checks, phlebotomy, wound dressing, LTC and chronic disease, mental health appointments, smears and physio to name just a few.

The EA service takes a neighbourhood approach and is run across four neighbourhoods, East Hub (Lionwood Medical Practice), West Hub (Roundwell Medical Practice), Central Hub (St Stephens Gate Medical Practice and Gurney Road Medical Practice on a rotating model) and North Hub (Magdalen Medical Practice and Woodcock Road Medical Practice rotating model).

The service runs across all four neighbourhoods Monday to Friday with two clinicians in each hub 18:30 – 20:00 offering remote appointments. On a Saturday there are three clinicians running across each neighbourhood hub 09:00 –13:00 delivering face-to-face appointments.

Front Door (GPFD) IP

Home Visiting Service (HVS) EPC

The GP Front Door Service was established in December 2019, and is a service that works in collaboration with the Norfolk and Norwich University Hospital (NNUH) The service’s main objective is to work with the Emergency Department (ED) to reduce the overall footfall of patients coming through to the ED. This is achieved by the GPFD service treating all patients presenting with conditions that could be managed within a Primary Care setting, such as minor injury and minor illness.

The Service is staffed by General Practitioners (GP) or/and Advanced Nurse Practitioners (ANP).

The Service operates from 09:00-21:00, Monday to Sunday, including all bank holidays.

In the last 12 months the GPFD Service has seen 12,752 patients. On average the service sees 23% of patients walking into the NNUH ED front door. This has been rising, and in October 2022 the service saw up-to 36% a day.

The Service was adapted in January 2022 to allow the GPFD service to see patients outside of the Norfolk and Waveney catchment area, further relieving the demand on the ED.

The team are currently working with the NNUH looking at the joint clinical pathways and processes, which will allow us to see a greater number of patients within the service and increase the level of care we can offer to patients.

The service has developed a regular team of locum clinicians that work within the service, along with a new reception team and GP Clinical Lead. This has allowed professional relationships to form and further collaborative working.

The primary focus of the Home Visiting Service (HVS) is to support practices and to improve the urgent care response for on-the-day home visit requests.

We were thrilled that Norwich GP Practices voted in 2022 to continue the HVS through Proactive Health Care funding when the previous PMS funding ceased to be available.

The service runs Monday to Friday 9 am-5 pm. Following the change of funding it was decided to cease the previous weekend service, in order to align with practice delivery hours.

We now have 6 experienced nurses, 1 paramedic, and 2 GPs working within the team. This is an increase in the number of GPs from the original service. We have also expanded the service to include visits for long-term condition management and LD checks. The Home Visiting Team is also currently doing their RESPECT Training, another great addition to what the Home Visiting Services offers.

The HVS team works collaboratively with the Norwich Escalation Avoidance Team (NEAT), which enables any onward referrals to be managed and coordinated promptly. The team has expanded since inception and now has two full-time Integrated Care Coordinators (ICCs) working across both services. We are also looking at referral pathways to be able to work more collaboratively with Community Matrons moving forward.

The service has provided 9636 nurse visits and 3213 GP visits over the last 12 months.

GP

GP High Intensity User (GPHIU) IP

The GP High Intensity User (HIU) Service is currently being piloted across six practices in the Norwich Primary Care Network’s (PCN’s) reducing inequalities target areas to provide intensive support to patients who frequently and inappropriately contact their GP practice.

Although there are many similar services in and across the country supporting frequent attenders of A&E, this is the first of its kind in the country working with general practice. As such, it has garnered significant interest from partners across the ICS, including the University of East Anglia (UEA) multi-morbidity research group who successfully applied for research funding to evaluate this new service. The results of this initial evaluation will be available in 2023/24

To date, approximately 25 patients and families have been supported through the service, with the second cohort of referrals currently due. Following the pilot period, a full-service evaluation will be made available to PCN practices to make a decision about continuing, decommissioning or expanding the service.

Integrated Motivational Proactive Anticipatory Care Team (IMPACT) PCT

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.

A team of care coordinators employ personcentred 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.

Utilising their enhanced knowledge of system wide services, IMPACT care coordinators navigate patients to the most appropriate interventions to support more efficacious self-management.

Currently, IMPACT has proactive contact with patients who have a specific unmanaged long-term condition and are not engaged with services. Following the success of its first cohort, IMPACT is now working with its second cohort: Type II diabetes in East and North Neighbourhoods, hypertension in Central Neighbourhood and asthma in West Neighbourhood.

Successes of IMPACT’s first cohort include:

• 93.57% of patients did not require additional GP care

• A&E attendances decreased by 23.42%

• Hospital admissions decreased by 44.11%

To date, over 580 Personalised Care and Support Plans have been formulated for cohort two. Three-month reviews are currently underway and following completion of these (anticipated October 2022) the team will conduct a thorough evaluation of outcomes which will direct future work.

The GPHIU Service is the first of its kind in the country

Living Well Team

EPC

The Living Well Team is a multi-agency partnership, commissioned by Norwich Primary Care Network (PCN), delivering an enhanced social prescribing service to patients and residents across the PCN.

The Living Well Team provides individualised and accredited advice, information and guidance on a wide range of issues, helping individuals and their families to identify what matters to them and offering solutions to the challenges that they face.

The partnership is led by Norfolk Citizens Advice working together with other local advice agencies - Age UK Norwich, Equal Lives, MAP (Mancroft Advice Project) and Shelter (Eastern Region).

The primary focus for the Lymphoedema Service is to support patients and to provide a comprehensive assessment and management plan as well as encouraging self-management of lymphoedema where appropriate.

Holding just over 1000 patients on its caseload we have booked over 3300 appointments for patients on our service this year.

Thank you for Living Well Team member

“We had found the form filling for a Blue Badge and Attendance Allowance far from straightforward and extremely daunting so had given up trying to seek help. Things had gotten really bad during the Covid lockdown with my wife, who I totally rely on.

Once the Covid rules started to be relaxed, I asked at the doctor’s surgery for help, and they contacted Age UK for me who are part of the Living Well Team. The team helped me to get a Blue Badge and a higher rate of Attendance Allowance for which I am extremely grateful”

Sid (Norwich Resident)

NB To protect privacy we have changed the patient’s real name to Sid.

The service acknowledges that mental and physical health can also be determined by a range of social, economic and environmental factors and recognises that not all ills can be cured with medicine or surgery alone. The team strives to support patients to identify and resolve practical issues that are having a negative impact on their health and well-being and manage their own health and well-being more independently, whilst connecting with local sources of support available in their local area.

Living Well Workers are embedded within half of the GP practices in the Norwich PCN with all practices actively referring to the project using a variety of ‘referral pathways’ whether it be via CFICS/ICC or using the community based NCAN (Norfolk Community Advice Network) system. Recent initiatives have involved the piloting of a new direct pathway from a GP practice and working in partnership with the INTERACT team (see p. 32).

The project has recently been recognised and shortlisted for the HSJ Awards in the category “Place-Based Partnership”.

The Service runs Monday to Friday 8-6pm.

The lymphoedema team work collaboratively with community services in Norwich which enables any onward referrals to be managed and co-ordinated in a timely manner. The team has expanded in the last year and we have recruited into the team and now have four lymphoedema nurses working on the service. The service is further developing with two of our four nurses taking on clinical courses, including community prescribing and Advanced Lymphoedema Management.

In the last year the service has expanded and is now offering appointments in Long Stratton and Thetford to support patient need on the service.

The service also offers a Physio/Exercise class which is held close to Bowthorpe Health Centre for patients on the service.

We are in the process of developing the service and looking at ways for expansion and links within other OneNorwich Practices services to deliver comprehensive clinical care to the Norwich Primary Care Network.

3300 appointments

Lymphoedema Service EPC

Mental Health Transformation EPC

Following the successful implementation of the Additional Roles Reimbursement Scheme (see p. 31) funded mental health practitioner role, Norwich Primary Care Network (PCN) recruited eight Whole Time Equivalent (WTE) band 6 and 7 mental health practitioners to support general practice. The roles have been successfully embedded throughout the PCN and development of the role is ongoing, through collaboration with NSFT.

The Wellbeing Service Triage pilot continues to be rolled out across the PCN, providing training to practice administrative staff about patient suitability for Improving Access to Psychological Therapies (IAPT) services and how to make referrals via clinical systems. Five practices have already received the training with plans in place to complete rolling this is out to the remaining practices in the next year.

To further support the mental health team across the PCN, Enhanced Recovery Workers (commissioned by the ICB and employed by Norfolk and Waveney Mind) will be deployed across the PCN. These first contact mental health workers can work with care navigator teams to be able to provide up to six sessions of contact with people with low level mental health conditions. They will provide additional, new capacity within the system and will seek to further bridge the service gap between IAPT services and secondary care.

Norwich is regularly chosen as an early implementer site for new mental health initiatives, this includes the new rehab team, SMI smoking cessation project, mental health deprescribing programme and others.

With this collaborative approach across Norwich PCN and the wider ICS, Norwich PCN is in a strong position to inform how mental health delivery is effectively developed as the roles mature.

Norwich PCN Meetings PCT

Norwich Primary Care Network (PCN) is split into four neighbourhoods to ensure that we meet the different needs of the communities across Norwich as efficiently as possible. The way these are set up is shown below:

Key staff from OneNorwich Practices (ONP) meet with practice managers and lead GPs from each neighbourhood on a monthly basis. The purpose of these meetings is to share and discuss current issues relating to primary care in and across Norwich, and also to share best practice, problem solve and to provide information on 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 as well as being an open forum to discuss local issues the meetings also focus on the development of the PCN and the core requirements of delivery.

Central Norwich North East Norwich West Norwich

Norwich Practices Health Centre (NPHC) PCT

Pharmacy PCT

The Norwich Primary Care Network (PCN) Pharmacy Team has continued to grow since its inception in 2019 and has now seen six of its pharmacists become independent prescribers as they come to the end of their educational pathway in primary care, which will further support practices with more complex tasks. We also have a number of pharmacy technicians who have completed their training pathway and have become a great asset to their practices.

Furthermore, the team contributes to reduce the burden of medicines’ related tasks, reconciling discharge medications and delivering the Structured Medication Review (SMR) service.

A dedicated Care Home specialist group was created to specifically support with the SMR service for the practices’ Care Homes as well as forming part of the MDT approach to the Care Homes At Scale project (see p. 37).

Norwich Practices Health Centre has recently undergone significant changes to the structure of the team and the services, which we hope will deliver an enhanced patient experience. Patient care is extremely important to us and we strive to positively reinforce this daily.

Not only does the Norwich Practice Health Centre (NPHC) provide healthcare for its registered patients, but it also coordinates the wider healthcare needs of Norfolk with the help of its managers. They oversee further individual services as well as support the team here at NPHC in the day-to-day treatment of patients.

Situated in the heart of Norwich we are well placed to provide primary care to those who need it most. This is delivered with an average of 489 GP appointments per week which is a large capacity of work carried out by the GPs and the supporting team.

Currently our clinician punctuality is at 96.81% meaning 96% of patients are seen within 30 minutes of arrival. When compared with the 9388 registered patients we currently have, it’s quite an achievement, but something we as a team are seeking to improve further still.

When last inspected by the Care Quality Commission (CQC) we were pleased to receive an overall ‘Good’ rating which we hope to improve on as we move into the future and recover from the pandemic.

The Health Centre is striving to further increase patient quality of care and increase the size of its workforce in order to achieve this.

With this in mind, our team have remained focused and tenaciously pursue the needs required to make our Practice better in every way possible.

The Additional Role Reimbursement Scheme has enabled OneNorwich Practices (ONP) to recruit a total of 12 pharmacists and 8 pharmacy technicians who are embedding well with practices’ teams and greatly supporting practice resilience. Although already a large team, we listen to practices, and we are in constant search to increase our capacity as a service. These roles have a key role in conducting audits, completing several indicators of the Prescribing Quality Scheme. They also support completion of indicators for the Impact and Investment Fund, focusing on supporting the PCN to deliver high quality care to their population, and the delivery of the priority objectives articulated in the NHS Long Term Plan.

The team continues to be involved in the Covid Vaccination Programme operating at the weekend.

Physician Associate (PA) PCT

Currently with a team of four Norwich Primary Care Network (PCN) physician associates (PAs), OneNorwich Practices has become one of the biggest primary care employers of PAs in the region. Originally taking on a team of two, the versatility of these clinicians was quickly evident resulting in a further two PAs being appointed through the Additional Role Reimbursement (ARR) Scheme (see p. 31) and a team lead being appointed. Feedback from practices has been very positive. By having a PA in each of the four neighbourhoods, working across a total of nine surgeries we are able to deal with a wide variety of clinical conditions across telephone and face to face appointments, increasing much needed appointment availability.

Carrying out Quality and Outcomes Framework (QOF) reviews for chronic diseases such as chronic obstructive pulmonary disease (COPD), asthma and diabetes has provided further support for practices and patients with these conditions.

Enrolment of our PAs into courses such as minor ops and the PA Foundation Programme have provided useful further experience and skills which can be implemented into practice.

OneNorwich Practices is committed to growing this role in primary care and have helped in examining for the physician associate national exams and aided with teaching for the local UEA course.

Our future aim will be to continue growing this team and to further develop skills with existing members, which will enable us to provide added support to surgeries within the PCN.

Population Health Management IP

The population health approach to health continues to grow throughout the Norwich Primary Care Network (PCN), not only with IMPACT, but also now including the GP high intensity user service, the Age Healthy Norwich programme (supporting over 50s with comorbid hypertension and diabetes) and the INTERACT project. In addition to this, the PCN has taken part in wave three of the national population health management development programme, facilitated by OPTUM, to identify new processes for supporting patients on the elective trauma and orthopaedics surgical waiting list.

The latter of these has involved working closely with the Integrated Care Board (ICB) and acute hospital colleagues, as well as physiotherapists, and other clinicians to establish a new pathway for patients. Aspects of this new pathway are currently being piloted in two practices within the PCN.

The PCN recently procured a two-year license with Ardens Manager, a software package that helps identify patients who would benefit from a range of interventions linked to the Investment and Impact Fund. Data produced by the software is accessible to both the ICB locality team and PCN team at OneNorwich Practices (ONP) to help identify areas where support can be offered.

ONP intends to develop the expertise within the business intelligence team to make better use of local health data.

This will ensure that future project development is more effectively targeted and implemented.

Protected Learning Time (PLT) PCT

Protected Learning Time (PLT) was introduced in May 2018, allowing practices to close at the same time for a half day of shared learning time. There have been 12 external and seven internal events PLT events since May 2018 with over 2,350 practice staff attending (850 in 2021/22).

OneNorwich Practices (ONP) delivers 6 PLT half day sessions a year, 3 for external education and 3 for internal practice level training and education.

IC24 were commissioned by ONP to provide cover across the city for these 6 events.

ONP 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.

We work with managers to assist in the identification of learning needs and coordinate the offer.

Previous sessions have included Microsoft Teams training, cancer supporting early diagnosis, medical terminology, sexual health promotion, excel training, active signposting, conflict resolution, wellbeing in the workplace, leadership and management along with more clinical training such as wound care training, chronic kidney disease updates, tissue viability, safeguarding, rapid diagnostic service training and more.

Fundamentally PLT is about improving patient care by providing a dedicated learning time for all members of General Practices across the Norwich PCN footprint away from their busy day-to-day primary care work.

‘These sessions have enabled colleagues to receive comprehensive training appropriate to their role, and integrate with their peers to share good practice and learn new skills.’

Christina Easter, Old Catton Medical Practice

The aim of this project is to create a regularly timetabled structured learning and engagement programme for all.

Physiotherapy First Contact Practitioner (FCP) service

Pure

PCT

Pure Physiotherapy continues to provide the First Contact Practitioner (FCP) service across OneNorwich Practices (ONP) and now provides over 14 face-to-face services, consistently seeing over 1500 patients per month.

We continue to support Protected Learning Time (PLT) events as well as training at individual practice level. In addition, we offer the opportunity to all Norwich Primary Care Network (PCN) staff to attend our monthly Musculoskeletal (MSK) evening lectures and to stay up to date with our MSK bulletins which are sent out weekly. Our experienced staff continue to support the neighbourhoods they are working in and are all now working on stage 2 of the Health Education England (HEE) Roadmap to Practice.

Over the next year we are keen to increase provision further across Norwich and continue our support for PLT events.

We are also starting to support patients on orthopaedic waiting lists across Norwich practices and hope to develop this further over the next few months.

Quality Improvement PCT

The Quality Improvement Team was established in early 2022 and began with the successful implementation of the care coordinator role in practices. The primary focus of the quality improvement team has been to support practices and services to prepare for CQC inspections and to develop monitoring of quality improvement plans.

The team have worked to streamline functions across the practices and services where possible to help support teams and identify areas for improved efficiencies.

Working with local and national teams we have used platforms to analyse data available to improve patient safety, data quality and maximise contractual achievements for the practices. These platforms have allowed the PCN and practices to monitor their own performance closely and have encouraged investigation of patient records to increase the accuracy and consistency of record keeping. The areas we have focused on have included QOF, IIF, CQC and DES requirements.

Supporting practices with quality improvement plans in their post inspection phase has been the team’s biggest development area in the first few months. This work has allowed for a better understanding of how the individual practices work and has enabled good integration with the local teams.

The aim in future will be to progress into more proactive work to support with readiness for planned inspection programmes. This will be done by using trends identified from inspections locally and nationally plus examples of best practice, the Quality Improvement team will strive to help practices and services evidence that they are Safe, Well-Led, Caring, Responsive & Effective.

Research PCT

OneNorwich Practices (ONP) remains committed to working with the NIHR Clinical Research Network (CRN) East of England, the local ICS, and wider strategic stakeholders, to develop, promote, and facilitate high quality research that is integral to delivering health and care, for the population’s benefit. To this effect, the Norwich Primary Care Network (PCN) has continued to strengthen its research network and activities throughout the year, leading to many successes.

For example, the Norwich PCN’s has been the highest recruiting single GP site nationally to the PANORAMIC trial, with over 800 participants enrolled so far. The Norwich PANORAMIC research team was the winner of the regional celebration award for this work and the research lead the RCGP/NIHR national research award. Many PCN colleagues were also given the opportunity to participate in research for the first time via joining the trial or joining the Associate Principal Investigator scheme that we support.

All practices (100%) in the PCN contributed to research this year thanks to patients volunteering for covid related studies. This is a great success when compared to the 61% participation across Norfolk and Waveney. ONP and individual PCN practices recruited a combined 3,392 participants to research this year which represents 44% of the Norfolk and Waveney recruitment.

Building on these attainments and in alignment with the NIHR CRN national research strategy, ONP has reinforced a Primary Care Research Hub, which allows improved coordination of the PCN’s research agenda. The Hub’s activities include running the bi-monthly research forum, facilitating clinician’s and practice’s participation in research, and delivering research studies at-scale.

In April 2022, the Hub received a Research Site Initiative contract from the NIHR CRN, which will allow the PCN and CRN to work more closely together and open the Hub to further NIHR support. We are looking forward to growing the Hub’s team and activity over the coming year.

Respiratory Clinic

Inclusion Health Hub (Vulnerable Adults Service) EPC PCT

In 2022, we launched a Respiratory Diagnostic Hub that will run on Saturdays 09:00 – 17:00 with respiratory trained nurses/clinical pharmacist. This service will also support the Enhanced Access Service (see p. 42), with it’s weekend offer.

The clinic will offer spirometry and FeNO testing to support the PCN in diagnosis of COPD and asthma. The Respiratory Hub will launch in Lionwood Medical Practice with the aim to rotate across the neighbourhoods in the future.

We will continuously monitor the services to ensure it meets the needs of practices and patients and provide the most comprehensive service for our practices.

The Norwich VA model is an integrated model of care for adults with complex needs and severe multiple disadvantages aiming to address health inequalities. The patients supported are often homeless, living in temporary accommodation, hostels or where their accommodation is at risk.

The Inclusion Health Hub is for individuals experiencing acute chaos, extreme complexity, and multiple comorbidities. It is intended that individuals will spend a short time (ideally less than 6 months) being supported by the Inclusion Health Hub.

Users are then integrated into primary care provision within the Norwich Primary Care Network (PCN) to one of the 12 Inclusion Health Practices to ensure a supported transition and to plan for ongoing needs.

Inclusion health practices can refer patients registered with them to this service where they meet the identified needs for inclusion health hub. This enables these patients to benefit from the support of this specialist service.

Intensive collaborative working between the team has 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.

The core team of a service lead, clinical lead, integrated care coordinator (ICC), GPs, nurses and support workers adopted a collaborative working approach, holding weekly multi-disciplinary team (MDT) meetings with partners and stakeholders to provide holistic joined up care and support for patients.

We have had a positive media report from Norfolk Healthwatch this year about our service.

Norwich’s Vulnerable Adult Service (subtitled) - Please click here.

The Vulnerable Adult service ICC supports and coordinates potential onward referrals to other non-clinical services and interventions that will give patients greater support networks within the community.

This social prescribing approach enhances the ease of the transition to an inclusion health practice and addresses the wider determinants of health. The model ensures all patients have equitable access to health services within the PCN.

Weight Intervention Service (WIN) Walk-in Centre (WIC) EPC EPC

The Walk-in Centre (located on Rouen Road) provides same day and urgent access to primary care appointments, with the aim of reducing the pressures on the wider healthcare network, including practices and Norfolk and Waveney hospitals.

The Service operates Monday – Sunday 365 days per year, including bank holidays. The operating hours are 07:00-21:00. The Service is comprised of GPs, advanced nurse practitioners, nurse prescribers, nurse practitioners and health care assistants. The service predominately offers face-to-face appointments but also offers telephone and video consultations where appropriate. In 2022 the Walk-in Centre has also supported Norwich Escalation Avoidance Team (NEAT), providing access to clinical advice during operating hours.

The Walk-in Centre provides care for a multitude of conditions, these include but are not limited to:

• Treatment for minor illnesses including chest, ear, eye, skin and urinary tract infections.

• Treatment for minor injury including cuts, burns and sprains.

• Musculoskeletal complaints including joint injuries- strains and sprains.

• Neurological complaints such as dizziness, headaches and vertigo.

• Gastrointestinal complaints, including abdominal pain and diarrhoea.

2021 & 2022 have continued to be challenging for the Walk-in Centre. The clinical team have developed a designated process and pathway for those presenting with respiratory conditions. Clinical triaging at the front door continues to benefit patients and allows the clinical team to assess all presentations with greater efficiency and allows for the clinicians to identify prevalence amongst these patients.

Over the next 12 months the Walk-in Centre will be focused on ensuring we can provide the service to as many patients as possible, including focusing on patients that would usually struggle to access the service by increasing telephone appointments and developing specific specialty services.

The Walk-in Centre has provided 71,218 appointments over the last 12 months, with an average waiting time of 25 minutes. The majority of patients attend from Norwich and Norfolk, with the Norfolk market towns of Acle, Loddon, Wymondham, Long Stratton and Dereham most prevalent after Norwich. Patients have also utilised the Walk-in Centre when their registered practice is as far afield as the Isle of Man or Edinburgh.

The Tier 3 Weight Management Service is delivered across Norfolk and Waveney using a blended model which incorporates physical 1:1 appointments as well as the option for telephone and video consultation appointments run by our current partners and lead providers Oviva.

Face-to-Face clinics are provided across the Norfolk and Waveney area, offering a variety of locations where patients can attend for face to face appointments.

The service offers the opportunity for service users who meet the qualifying criteria to access a weight management programme tailored to their needs including reasonable adjustments and additional support where appropriate.

In the last year we have booked over 2700 appointments for our patients on this service.

The Tier 3 service aims to encourage long term behaviour change by offering a programme that promotes physical activity and reduces sedentary behaviour; promotes healthy eating and supports the psychological barriers to unhealthy relationships with food; supports and recognises the relationship between mental health and obesity and offers a system throughout the programme which will support the psychological needs of every patient.

The clinicians include a GP, an advanced nurse practitioner (ANP) and a dietitian. We are also working collaboratively with Broadly Active who run a range of activity-based group classes.

Patients may also need further onward referrals, including for Social Prescribing to tackle issues such as housing, cooking, income and benefits. We work closely with voluntary sector providers for this provision.

At the point of discharge from the service the patient will receive an offer for continued support to enable them to maintain the progress they have made during their engagement with the service. We follow-up once a year post discharge and re-engage with patients around their progress.

Workforce PCT

This year has been a year of growth for OneNorwich Practices. With an increase in our staff numbers it shows that Norwich is an exciting and attractive place to work. Our growth coupled with scarcity of labour, particularly within the healthcare sector, has encouraged us to focus on our recruitment practices and retention of our existing employees.

Our strategic goals and the launch of our values has given us an opportunity to review our People Management practices and ensure policies are aligned with our goals and that they foster behaviours that support our culture. This clarity has enabled us to direct our recruitment efforts in a way that attracts staff who share ONP’s vision of leading integrated health and care. We also recognise the challenges that our employees face with the increased pressures of general practice as a result of the pandemic plus societal and economic changes. To this end we launched an employee assistance programme which supports employees and their families in a variety of ways from supporting mental health, to providing guidance on healthy living and eating.

The next year will see the Human Resources team focused on supporting employee wellbeing and engagement to put our people in the best position to offer patients the excellent care they deserve.

Our finances

The financial activity and performance of the organisation remains very good.

At the time of going to press, the accounts for the year 2021-22 are currently with our accountants Lovewell Blake for finalisation. However, predicted turnover shows year-onyear growth in turnover:

Financial Year Predicted Turnover

2020-2021 £925,000,000 (actual) 2021-2022 £13,000,000 (conservative est.) 2022-2023 £12,391,372 (est. including PCN: £4,133,355)

This is accompanied by year-on-year growth in our number of employees:

Financial Year Employee Numbers

2020-2021 166 2021-2022 182 2022-2023 190 (September)

In order to manage this growth, and resulting demands, a series of changes have and are being made in 2022/23:

• Move to a new financial management Xero, which also automates some previously manual processes

• Introduction of new financial procedures, approval processes and schemes of delegation

• New HR and payroll system to automate some previously manual processes

OneNorwich Practices holds funding on behalf of the Norwich Primary Care Network (PCN). These monies are kept separate and accountable, with annual review by our accountants Lovewell Blake. We continue to maintain up-to-date advice to ensure that the PCN are within the law in accounting for PAYE. NI, Pensions and VAT. Transparency and reporting to member practices has been reviewed in 2023/24 with new reporting process implemented moving forward.

Our forecast for 2023/24 is for continued growth in turnover, with growth in PCN income plus intended development of new services.

Acronym buster

A&E Accident and Emergency

ANP Advanced Nurse Practitioner

ARRS Additional Role Reimbursement Scheme

BI Business Intelligence

CHAS Care Homes At Scale

CNCP Chronic Non Cancer Pain

COPD Chronic obstructive pulmonary disease

CPD Continuing Professional Development

CRN Clinical Research Network

CQC Care Quality Commission

DES Network Contract DES

EA Enhanced Access Service

ED Emergency Department

EPC Extended Primary Care

FCP First Contact Physiotherapy

FTE Full Time Equivalent

GMS General Medical Services

GP General Practitioner

GP IT GP Information Technology

GPFD GP Front Door

GPHVS GP Home Visiting Service

HCA Health Care Assistant

HEE Health Education England

HIU High Intensity Users

HOSC Health Overview Scrutiny Committee

HR Human Resources

HVS Home Visiting Service

IAS Improved Access Service

ICB Integrated Care Board

ICC Integrated Care Coordinator

ICS Integrated Care System

IHP Inclusion Health Practices

IFF Investment and Impact Fund

IMPACT Integrated Motivational Proactive Anticipatory Care Team

INTERACT Integrated Responsive Anticipatory Care Team

IP Integrated Population Model of Care

LD Learning Disability

LFT Lateral Flow Test

MDT Multi Disciplinary Teams

MH Mental Health

MSK Musculoskeletal

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

QOF Quality and Outcomes Framework

RCGP Royal College of General Practitioners

SMI Severe Mental Illness

RITA Reducing Inequalities Target Areas

UEA University of East Anglia

VA Vulnerable Adult

WIC Walk-in Centre

WIN Weight Intervention Service

WTE Whole Time Equivalent