Taurus Healthcare Ltd Annual Report - 2019/20

Annual Report 2019/20 Connecting and collaborating throughout the year

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Contents Page No

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Welcome from Taurus Healthcare Chairman and Managing Director

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Taurus Healthcare's Purpose

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Who's who on the Taurus Healthcare Board

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Progress towards this year’s set objectives – We said. We did.

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Review of the year

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Herefordshire Primary Care Networks (PCNs)

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Quality and safety

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Financial Summary 2019 - 2020

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The year ahead

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A welcome from our Chairman, Dr Nigel Fraser Twelve months seems a long time in the current climate - the hard work, the pace of change, the video calls in fancy dress, but most of all a feeling of being proud to be part of Herefordshire General Practice.

The year has, of course, been dominated by the events of recent months of the pandemic, which built on the rapidly evolving role the Federation plays to support General Practice.

Significant foundations were already in place to ensure practices had systems and leadership to work collaboratively across a network, whilst the services that the Federation provides as the ‘6th PCN’ offered opportunities for at scale working and support.

The COVID pandemic accelerated the need for practices to work together, strengthening the leadership provided by clinical directors in unison with the Taurus team.

The role of Taurus to support Herefordshire General Practice is to provide three things: • •

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Leadership and representation: a role that has been aligned and developed with clinical directors Clinical services that support General Practice, where 24/7 patient centred care is at the core Federated services, back office support and PCN management functions

A welcome from our Chairman, Dr Nigel Fraser (2) Much of the work the Federation does is to strengthen the role of General Practice, providing support where we can, with a vehicle to deliver at scale where it makes sense, but to fundamentally ensure each practice remains viable.

Practically this has involved running a practice directly, providing management and leadership support at others, setting up dispensing support and training, as well as the recruitment service evolving into a full HR programme.

The role that Taurus plays to support General Practice is underpinned by our workforce where the whole team play a significant part.

Indeed the work delivered by the Federation is highlighted in our new logo, where the ethos is centred on

'We are Herefordshire General Practice’ Everything we do looks to uphold the key elements of our agreement with member practices. Taurus has grown during this time and now employs over 100 people who work across contracted services, corporate, PCNs and practices, with a larger base at the Berrows Building in Hereford that is used by Herefordshire General Practice and One Herefordshire colleagues.

General Practice is now in a stronger position to develop even closer mutually respectful relationships with our colleagues as we move towards an integrated care system. I would like to thank colleagues at the Clinical Commissioning Group, Wye Valley NHS Trust, Herefordshire & Worcester HCT and Herefordshire Council for recognising the strength of working collaboratively with General Practice, with clinical leadership playing a stronger role in the transformation of our health and care system for the people of Herefordshire.

Thank you.

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An overview of the year from our MD, Dr Mike Hearne My passion for General Practice and federated working has become further embedded during this memorable year. Whilst the headlines around primary care networks are the most visible to the system and practices, there are teams that deserve special mention for their work, much of which has allowed a more dynamic response to COVID.

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The Operations team has aligned Improved Access with OOH services, where we are the first Out Of Hours provider to deliver the service on EMIS, a key step for a patient centred service that delivers 24/7 care. The flexibility of the team during COVID allowed the adaptation of the hub model to rapidly support the needs of each network and will continue to evolve. The team have also successfully been approved by the Medicines and Healthcare products Regulatory Agency (MHRA), a huge accolade, that allows us to hold medicines that can be used in our services and therefore improve the care delivered to patients.

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The Business Intelligence team has co-produced endless graphs and reports on workforce and activity, helping to lead the One Herefordshire Population health informatics, and influencing the national picture on General Practice activity reporting.

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The Quality and Assurance team has cemented performance and quality developments into the services, whilst ensuring that the COVID matrix management response was supported with infection control and Care Quality Commission (CQC) approved assurance processes.

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The HR team has delivered a successful recruitment service for General Practice, playing a key role in the new Primary Care Network (PCN) roles, as they now look to embark on an expanded HR service that supports practices.

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The PCN team has worked tirelessly to support PCN development, the new roles, and the COVID response, where networks are now the currency of health and social care within a developing integrated care system.

Taurus Healthcare purpose We believe that we can best support the people of Herefordshire to live healthy and satisfying lives by providing joined up, 24/7 General Practice.

We do this in three ways …......

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01 The Federation: to support practices to ensure General Practice sustainability and resilience • Recruitment • PCN management and new roles • Holding liabilities

Provider of Clinical Services: to deliver contracts on As a

behalf of General Practice, which support resilience and drives high quality joined up General Practice – ‘GP 24/7’ with patient centred care at the core​

03 Through Strategic leadership: representing General Practice across Herefordshire and Worcestershire STP and One Herefordshire integrated care programmes A role that has been aligned and developed with clinical directors

Who’s who on the Taurus Healthcare Board?

Taurus Healthcare Board Members

Progress towards delivering this year’s objectives We said …. We did 9

We will implement a new Board committee structure, recruit to senior leadership posts and set individual, clear objectives for the delivery of corporate objectives

What we’ve done:  A new committee structure has been implemented: Finance Led by: Graeme Walker and Andrew Lee

People Led by: Dr Louise Mottram and Andrew Lee

Quality Led by: Dr Ritesh Dua and Nikki Marriott

Strategy Led by: Dr Nigel Fraser and Nisha Sankey

 Non-executive Directors have been appointed as Chairs of the sub-committees  New non-executive Directors have been appointed: Graeme Walker and Dr Cath Laird  Senior leadership appointments have been made: Andrew Lee

Assoc Director Nursing and Quality Louise Parker

Primary Care Training Hub Head of Service Caroline Hatton

Head of Business intelligence and Information Conor Price

February 2020

January 2020

March 2020

November 2019

Director of Finance

 Objectives have been set for all Board Members for cascade throughout the organisation.

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We will revise the Quality Strategy to reflect best practice and the scale and scope of our services

What we’ve done:  Revised our approach addressing our quality goals for corporate services and our Chambers model  The strategy is to be redesigned to reflect Herefordshire PCN quality requirements and to support General Practice quality improvement with local stakeholders  Significant progress has been made against previous years’ quality goals including:  Set up Herefordshire Integrated Care Quality Committee (HICQC) with Wye Valley NHS Trust including system stakeholders to support work of Herefordshire Integrated Care Alliance Board. Prioritised three areas: end of life care, pressure ulcers/moisture associated skin damage and advanced care planning.

HICQC paused during COVID, working up revised approach to fit with Transition Board  Worked with Directors of Nursing across STP to develop primary care quality approach to align with STP and place-based quality forums  Set up PCN quality group to provide forum for reviewing shared General Practice incidents and developing strategy to support PCN quality requirements 11

We will develop a Quality Assurance Framework for Taurus provider services and practices  The Quality Assurance Committee has matured to oversee a wide range of service provision:  Joint clinical governance for Out-of-hours service provision with Malling Healthcare and Commissioners  Service quality and safety reports which are used to support commissioner meetings  MHRA and Home Office compliance (Good Distribution Practice)  General Practice/PCN quality developments  During COVID pandemic, oversight of Herefordshire and PCN quality activity  Configured incident management system - Datix to reflect General Practice and PCN requirements. GP Practices and PCNs can now share incidents for issues in common that would benefit from system discussion to resolve.  Published first practice incident feedback, sharing lessons learnt from raised incidents

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We will work towards integrated 24/7 Herefordshire General Practice by integrating Herefordshire OOH and 7 day services and recruiting more staff in order to reduce reliance on locums What we’ve done:  EMIS is now the clinical record for the Out of Hours Service, enabling a continuum across 24-hour patient care  Making every contact matter – aspiring to resolve issues for patients without unnecessary referral to other services

 EMIS is now integrated with overnight district nurse service  We’re working with 111 and CAS to improve patient access across providers  Aligning Improved Access service to deliver PCN based hubs  OOH hub moved location to align with General Practice COVID response, having just completed a move to the Station Medical Centre with Hereford Medical Group.

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We will develop a comprehensive support package for Herefordshire PCNs What we’ve done:

• We’ve built crucial local relationships and a strong, multi-skilled team • We’ve supported the development of five strong PCNs in Herefordshire, supporting delivery of their plans • We’ve supported Clinical Directors to lead their PCN and work together at scale, to improve General Practice resilience • We’ve assisted PCNS with: • Recruitment and retention of staff • Providing an enhanced range of services, and • Better integration with wider health and care services • We’ve supported PCNs to deliver their ambitions and contractual requirements during their critical initial year These relationships proved critical during the Coronavirus pandemic. Our single focus was on keeping patients and staff safe. By working together, we achieved a co-ordinated and cohesive approach to the challenges being faced.

Through our actions in the past year, we believe the PCNs have developed a clear understanding as to the role Taurus Healthcare can play in supporting the resilience of General Practice, including its vision to:

Deliver outstanding, quality General Practice 7 days a week, 24 hours a day for the people of Herefordshire 14

We will be the voice of primary care in all primary care settings across the STP

What we’ve done:  We have a mandate from practices to be the first ‘port of contact’ for primary care matters in Herefordshire  We've integrated the leadership of General Practice with PCN Clinical Directors (CDs) that ensures networks and practices have a co-ordinated voice at all levels of the system  We have GP representation at all levels of the Herefordshire and Worcestershire System Transformation Partnership (STP) and One Herefordshire  We have worked with system partners to set up the Herefordshire Transition Board with an influential clinical voice through the CPF (Clinical and Practitioner Forum)  Weekly attendance at Consultant and Herefordshire Council Forum to discuss, inform and problem solve together  We co-Chair the STP GP Provider Board

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We will define a formalised chambers proposal and present to Shareholders and the CCG

What we’ve done: A proposal was defined and presented to Taurus Shareholders and the CCG in March 2019. This showed how we will protect GMS contracts at practice level, enabling them to work autonomously and continue to make their own decisions.

We also demonstrated how the proposal would reduce the liability of GP Partners, thereby reducing the risks arising from ‘the last man standing’.

At the same time, the proposal sought to show how the practice’s relationship with its own local community and registered patients would be preserved.

What this looks like: Our first Chambers partnership was with Ledbury Market St and St Katherine’s surgeries, as we co-produced the creation of the Ledbury Health Partnership, with plans to formalise the partnership arrangement in the new year. A process that involved due diligence analysis to understand the financial, legal and quality elements of each practice to preserve the best and build a new merged team. This involved significant work for everyone, ably led by the St Katherine’s team, with Taurus supporting where required.

Further information discussions are currently being undertaken with other Herefordshire practices.

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We will deliver ‘Chambers Style’ services for sustainable General Practice

What we’ve done:  We have developed a professional recruitment service for practices to use for their clinical and non-clinical staffing needs  We have a full HR services proposal to present to practices in the new year for their wider HR needs  We have shared workforce across GP practices and Taurus services, with an evolving medical services contract where we look to attract workforce as a central employer on behalf of General Practice where sharing roles makes sense. This can promote career progression and encourage workforce retention across Herefordshire General Practice.  Dispensing business and training support has been provided and is ongoing, facilitated by a partnership with DDS (Dispensing Doctor Solutions), to enable dispensing practices to share and develop together in recognition of the key role dispensing plays for rural practices.  Direct practice support has been provided at local surgeries: • Kington: Leadership input, HR and dispensing support to the practice which now has a stable future, ably led by the local leadership team • Wargrave House: Practice manager provision with plans for a business management function that aligns with evolving chambers services • Westfields: Practice manager provision with view to working closely with existing partners and the neighbouring practice to support the long-term delivery of care for the patients of Leominster.

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Review of the year The past year will inevitably always be associated with the COVID19 pandemic. We are proud of Taurus Healthcare and Herefordshire General Practice’s response to the pandemic.

In the following pages, we highlight some of these achievements as well as presenting an overview – and celebration – of some of the other major achievements in the year.

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Joining up care ……Leading the way with innovative IT solutions Much of our work this year has focussed on joining up care across Herefordshire General Practice. This includes joining up daytime General Practice with the care we offer overnight and at weekends. It also includes using technology to help doctors and nurses working across different services quickly arrange for the right person to provide care without the need for extra steps or for patients to make repeated calls.

Taurus Healthcare received national recognition during the year for our pioneering use of cutting-edge IT – in particular, seamless patient care through the EMIS Web platform. All GP practices in Herefordshire use the EMIS system. This year, we have extended using EMIS for the services that Taurus Healthcare provides on behalf of the practices: GP OOHs service, the Overnight Nursing Service, the COVID Management Service and the Weekend Care Home Service. This development is unique to Herefordshire and ensures our doctors and nurses have access to up-to-date information recorded by any member of the team, day or night.

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It also included an electronic prescription service - Herefordshire was the first location outside of London to be given access to this service in this module of EMIS, and the use of softphone technology, which enables health practitioners to transfer seamlessly to video calls from within EMIS.

Joining up care ……to benefit our patients Doctors and nurses from the GP Out of hours service and the Weekend Care Home Service (CHS) are working together too. This means we can support patients in care homes who require a home visit at weekends following a telephone consultation - without them having to make another call or repeat their story.

When patients call NHS111, and where appropriate, some calls are diverted so that doctors and nurses working for Taurus can respond. The process that supports this has been a little 'clunky'. This year we have worked with colleagues at NHS111 to enable direct booking into our services. This reduces the need for telephone transfer and saves time for our busy clinical teams, ensuring they have maximum time with patients.

Finally, Taurus delivers Improved Access to GP and nurse appointments for people in Herefordshire. We offer appointments for routine care in the evenings and at weekends. This is often more convenient for people locally and supports practices to meet the demand for urgent appointments. Like many services this year, many of the consultations take place on the phone or via video. Sometimes though, patients will need to be seen face-to-face, and working closely with colleagues in the GP out of hours service ensures this can happen seamlessly and in a timely way.

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We are really pleased to have welcomed two new Advanced Nurse Practitioners and six additional GPs to our team this year

AWARD WINNING support for shielded patients Early on in the pandemic, Taurus Healthcare, working in conjunction with the Herefordshire PCN Clinical Directors, recognised that those patients who were especially at risk from the pandemic (otherwise known as ‘shielded patients’) would still need routine medical care. For example, help with dressings, medical checks, routine injections or other interventions.

With that in mind, a ‘Super Green Clinic’ was established to run from Sarum House Surgery in Hereford, where Taurus and the city practices collaborated in a rapid deployment.

The service was nurse-led, staffed by practice nurses and healthcare assistants from across the county. A Super Green service was also made available in housebound shielded patients’ homes, in collaboration with the WVT District Nursing team.

The ‘Super Green’ nursing service was recently nominated – and won - a prestigious Nursing Times Award (Infection Prevention and Control category) and the NHS Hero Award in the Sunshine Radio Pride Awards.

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We are SUPER PROUD of the SUPER GREEN Team!

Supporting patients with Covid-19 symptoms Early in the pandemic, Taurus was commissioned by Herefordshire and Worcestershire CCG to deliver a COVID Management Service (CMS). A dedicated telephone line was set up from mid-April 2020 to take referrals of COVID positive patients from GP practices, NHS111, care homes, Wye Valley NHS Trust and other health practitioners.

Once referred to the CMS, patients were contacted daily by the Taurus clinical team members who checked on their progress and recovery, offered advice and reassurance and discharged them once they were better. Patients were given the service telephone number in case they needed to ring for further reassurance or if their condition deteriorated.

Feedback has been universally positive. One patient said: “I feel reassured that someone is there who understands what I’m going through.”

Another said: “You are all heroes!”

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Providing Nursing Care in people’s homes throughout the night Working closely with the District Nursing Team at Wye Valley Trust, Taurus Healthcare has extended its services and has successfully established the Overnight Nursing Service.

The service is available seven days a week and offers nursing care through the night to patients cared for by the District Nursing team during the day.

“We have excellent handovers from the Overnight Service Nurses....the nurses are not just going in to ‘do the job’ – they are providing holistic care, doing care plans and following up on the care.” District Nurse, Ross “The service has really taken off. The service itself proves that there is a need for the nurses at night and the nurses and doctors...worked together to create solutions to issues that they have both faced. The nurses are already a valuable part of the Out of Hours team. It has been a pleasure settling in together.” Team Leader “Good teamwork, good communication - makes it an enjoyable experience and boosts morale.” Out of Hours GP “With Taurus successfully delivering the ONS, this has improved recruitment and retention for WVT nurse teams as it has removed the need for District Nurses to be on call overnight.” WVT Associate Director of Integrated Community Services 24

Human Resources and Organisational Development Highlights of the year Our collective ambition to provide the best care and support that we can for the people of Herefordshire is dependent on being able to recruit, retain, support and motivate our staff.

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Our HR team have supported the recruitment of staff on behalf of both Taurus and wider General Practice, in particular with regard to the new additional roles reimbursement scheme (ARRS) roles

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An offer of a menu of other HR support services will be made to Practices in the new year

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We are working hard to develop and update our HR polices, all of which are available for our practices to use or adapt to their specific needs, and we have commissioned specialist occupational health and legal advice to support our local team as needed

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As our PCNs mature we are jointly developing our collective ambitions for Herefordshire General Practice and the values and behaviours we believe are important. Our newly established staff council and annual staff survey are key to ensuring we understand what matters to our whole team.

Herefordshire & Worcestershire Primary Care Training Hub Herefordshire and Worcestershire Training Hub provides a central portal to a wide range of training and personal development opportunities targeted at the healthcare sector. The Hub includes details of new initiatives for the Primary Care workforce, alongside a wide selection of face-to-face and online training programmes for clinical and health-based administration staff.

Herefordshire and Worcestershire Training Hub is commissioned by Health Education England and is hosted by Taurus Healthcare.

Despite the restrictions and complexities arising from the Covid-19 pandemic, the Training Hub has developed at pace to meet infrastructure and governance requirements.

Highlights from the year include: • Recruitment of 18 GPs to cohort 1 of the ‘new to practice’ GP fellowship programme (GPs employed by practices) • Recruitment and placement of 10 qualified nurses to cohort 1 of the GPN fellowship (GPN trainees employed by the Training Hub) • Successful appointment of an ACP Educator for the Training Hub • Procured and launched a Learning Management System (LMS) for enhanced learning opportunities for all professionals within primary care across the STP (see: https://www.hwth-lms.co.uk/) 26

Herefordshire & Worcestershire Primary Care Training Hub (2) • Continued mentoring services for training practices via specialist GP trainer mentors • Increase in GPN mentors to support placements for pre-registration students and also support GPN fellows • Continued Physician Associate Ambassador role with increasing development to meet ARRS requirements • Development of new Pharmacy Ambassador roles • Successful bid for GP Trailblazers scheme – currently in recruitment • Facilitation of national CPD scheme for nurses and AHPs • Additional funding streams that have enabled 15 funded ACP MSc and 9 GPN fundamentals BSc/post grad diploma places to be secured.

• In addition, a suite of leadership modules has been secured for the LMS and further long-term conditions modules are being developed in partnership with the University of Worcester.

• Further details can be found on its dedicated website: https://www.primarycaretraininghub.co.uk/

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Business intelligence From operational reporting to strategizing across the counties the BI team is beginning to really embed itself in the Herefordshire and Worcestershire Health and Social Care system and supporting a real joint up approach to information integration, analysis and usage • • • • • • • • •

Corporate Template Development Corporate Performance Dashboard Appointment development and support General Corporate BI requirements EMIS Template and Protocol maintenance OOH EMIS Integration NHS Health check reporting IA KPI Reporting EH KPI Reporting

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Herefordshire General Practice DES Reporting PCN Dashboards IIF Dashboard Health Inequalities profiling EMIS Cross-organisational working Practice support Clinical Template development Document Template development 2WW Referral Improvement project MRI Protocol and Pathway development project

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PLACE Lead on the Integrated Intelligence Cell Aligning GP EMIS and Community EMIS Secondary Use Data sharing agreement across Herefordshire System information reporting for the 7 priority programmes and intelligence support Early discharge support team – EMIS facilitation and technical support Joined up Information strategy

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ICS / STP Representing General Practice at the Performance Forum EMIS Innovation Group Population Health Management Co-leading the Analyst Network Developing EHCH Dashboard COVID Workforce modelling Leading on PCN Analytics EMIS standardisation Advising Nationally regarding Demand and Capacity

Communications In the past year, significant time has been invested in developing close working relationships with communications partners from across One Herefordshire and the STP. Relationships built prior to the pandemic provided a solid foundation on which to build an effective cross-county COVID communications strategy. At the height of the pandemic, weekly comms meetings were held with One Herefordshire partners and STP Comms Leads. These helped us to understand, develop and implement joined up messaging to all stakeholders including the general public and all county healthcare practitioners.

The relationships will continue to be developed both during the pandemic and long into the future. They will help to ensure that Herefordshire General Practice’s voice is heard and communicated and that partners can develop a coordinated and agreed approach to communications campaigns.

Throughout the pandemic, the Comms team has grown our social media channels – particularly Twitter (new feed set up), Facebook and Linked in

Facebook: 186 new followers Twitter: grown from 0 to 187 followers Mar – Sept 2020 from Jan – Sept 2020

Linked In: 48% growth in number of followers since the start of the year

New Corporate logo In 2020, Taurus Healthcare developed a new corporate logo. The logo was developed in conjunction with Clinical Directors and we believe it better reflects Taurus Healthcare's role in supporting and working with Herefordshire General Practice.

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c 4,500 users of Taurus website every month

TeamNet • Well established use in Herefordshire practices for various back office functions • COVID19 Topic Page established in March 2020 • Clinical cell established by Herefordshire and Worcestershire Primary care clinicians and developed with CCG • Met daily to review, synthesise and upload information – currently meeting weekly • Fantastic buy in from Wye Valley NHS Trust and the local authority to provide information to the cell • Provided the timeliness needed. Simple, practical, one page wherever possible • Herefordshire page, Amber hub, EOL, Care home pages…….

“Making it easier for front line staff to do the day job whilst keeping up to date with the tsunami of information coming”

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“Helping primary care to stand together and offer care to patients and staff in a uniform way”

c 42,850 hits to the main TeamNet COVID page

TeamNet: next steps

(endorsed by Transition Board, Clinical Practitioner Forum, STP Clinical Leadership Forum, CCG)

To have all clinical and service provision information at the fingertips of the frontline work force – making it "easier to follow the right path locally" • Widen TeamNet for clinical care beyond COVID improving the primary and secondary care interface • Single place for all clinical information (provider and commissioner) • Simple standarised format so information is easy to find • Robust governance to keep accurate and up to date

• Enable WVT community teams to access • Clinical Support Information (CSI) modules will store local guidelines, pathways, referral forms, what to do before referral, advice and guidance, patient leaflets, self- management • Making every contact count – maximising opportunity for one stop OPA (better for patients, reduces waiting lists, cost saving) 31

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Herefordshire Primary Care Networks

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Herefordshire Primary Care Networks Primary care networks (PCNs) form one of the key building blocks of the National Health Service’s Long-Term plan. They bring GP practices together to work at scale in order to: • Improve their resilience • Improve their ability to recruit and retain staff • Improve their ability to manage financial and estates pressures • Enable a larger range of services to be provided to patients • Integrate more easily with the wider health and care system.

From 1 July 2019, five PCNs have been established in Herefordshire.

In the following pages, we feature each of these. We look at the challenges they have faced in the past 12 months and the hopes they are harbouring for the future.

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The Battenberg Analogy One of the Herefordshire PCN Clinical Directors suggested that Herefordshire General Practice is like a Battenberg cake …

GP Practices are the SPONGE The PCN team is the JAM, and Taurus Healthcare is the MARZIPAN A truly inter-dependent relationship of equally important parts!

In this section of the Annual Review, we focus on the PCNs and some of the challenges and fantastic achievements they’ve had in the past year.

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Common challenges in 2020 No-one would have predicted at the start of 2020 that we were about to be faced with a pandemic, the like of which hasn’t been seen since the Spanish flu back in the early 20th Century.

But face it General Practice did. Like the rest of the country, Herefordshire GPs had to make unprecedented changes to their mode of operation. Some were common to all practices and PCNs: • Everyone had to work differently. Practically all meetings moved from face-to-face to remote. At the beginning of the pandemic, online meetings between key partners were held daily, later changing to weekly as the situation eased. As Herefordshire General Practice and Taurus Healthcare worked with our system partners* to resolve issues and problems, teams were strengthened, and levels of trust increased. These relationships will have significant

benefits for future healthcare provision in the county.

"There is no doubt that the response to the Covid pandemic has accelerated our partnership working. Our senior clinical and managerial staff across primary, secondary, social and community care have worked closely together to provide safe care to our patients. There has been a lot of innovation and enthusiasm for a new way for working that feels like a positive to come out of the crisis."

Jane Ives, Managing Director, Wye Valley NHS Trust

• Decisions had to be made quickly. Primary Care Networks had to decide how to resolve problems right here and now. These were always made with an eye to national guidance but more importantly on what was right for Herefordshire.

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Common challenges in 2020 • Effective communication became critical to our ability to meet the challenges of the pandemic. Together we established robust communication channels, including a dedicated online portal on TeamNet, where partners could receive up-to-the minute and accurate information about all aspects of the pandemic. This helped clinicians to make sense of the tsunami of information they were receiving from a multitude of different sources.

The support of system partners continues to be invaluable. Their regular attendance at the PCN Clinical Directors meetings enables us to share information and work together to solve problems quickly – Thank you!

"We have laid firm foundations for health and care partners to further explore opportunities for integration across a range of commissioning, operational and community service areas all aimed at improving the health and well-being of Herefordshire residents” Stephen Vickers, Director for Adults and Communities, Herefordshire Council

• Clinicians faced a steep learning curve as they got to grips with online technology. Patient consultations moved primarily from face-to-face to remote (telephone or video) and meetings were held via Microsoft Teams. This required everyone to learn new skills, which will be beneficial in the future (although most clinicians still would prefer to see their patients face-to-face).

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• Levels of stress and pressure increased exponentially, especially in the early days of the pandemic as we all had to change our ways of working and cope with an unknown enemy – COVID19. Team working and collaboration were the way that we got through these challenges to develop a truly collaborative and interdependent approach to the pandemic.

North and West Primary Care Network

Key People

Practices in the PCN: Kington, Weobley and Staunton, Mortimer, The Marches, Westfield

Population: 41,320

...of whom 22% are over 70

Practice Staff: 188

Covers: 430 sq miles

Care Homes 18 homes 435 beds

Major achievements during COVID19 • • • •

Working together and effective collaboration to quickly set up a safe ‘Amber hub’ and home visiting service for COVID symptomatic and non-COVID patients to safely receive face-to-face clinical support Great team working resulting in the intelligent deployment of our staff resources and all clinicians being able to access patient records for any Network patient in any location. A WhatsApp group for the N&W was also started and continues today so that any member of the Network Practices can post information or request guidance or action Successful recruitment to additional roles to provide resilience - we have welcomed a social prescriber, a clinical pharmacist and a First Contact Physio to the PCN team this year Established a strong leadership team, with support from key managers in partner organisations - allowed us to solve problems and find solutions quickly.

Key focus areas for the forthcoming year •

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Working with our system partners to support patients with diabetes to self-manage their condition. Currently there are 2,549 patients registered as living with Diabetes in our PCN. We hope to bring together the physical and psychological aspects of their care, providing an holistic approach to our care. We look forward to working in a more integrated way with our hospital colleagues This includes recruiting a Dietician, Care Co-ordinator and Health and Wellbeing Coach, increasing our skills and the support we can offer patients.

South and West Primary Care Network

Key People

Practices in the PCN: Alton Street, Pendeen, Much Birch, Kingstone, Golden Valley and Fownhope

Population: 40,937

...of whom 21% are over 70

Practice Staff: 183

Covers: 348 sq miles

Care Homes 19 homes 365 beds

Major achievements during COVID19 • • • •

Working together and supporting each other to adapt to new ways of working and in order to overcome challenges. For example, how the PCN came together to set up and staff an ‘Amber’ clinic Huge shift towards PCNs being recognised as the main drivers of change within the NHS locally A strong and functioning CDs group, with much better collaboration with other partners Successful recruitment of additional roles to meet challenges of wide geographical area and to reduce the workload for existing staff – we have welcomed a Social Prescriber, two Clinical Pharmacists, a First Contact Physiotherapist and two Care Coordinators to the PCN team – we intend to recruit further with the addition of a PCN Dietician, two First Contact Physiotherapists and a Physician Associate able to support patients across all practices.

Key focus areas for the forthcoming year

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Building on relationships that have developed during the pandemic and to collaborate more over time To build on the additional roles scheme to ensure equity of access to all PCN patients ‘Breaking down barriers’ to enable staff to work at any practice within the PCN

East Primary Care Network

Key People

Practices in the PCN: Cradley, Colwall, Nunwell, Ledbury Health Partnership

Population: 29,013

...of whom 22% are over 70

Care Homes 17 homes 336 beds Practice Staff: 124

Covers: 188 sq miles

Major achievements during COVID19 • • • •

Initially one Amber hub was set up in Ledbury to serve all the surgeries of the PCN. This required successful management of logistics around vacating Market Street surgery to provide the premises In the second wave, each surgery has set up its own amber rooms with which to provide care for patients closer to their home Successful recruitment of additional roles to meet challenges of wide geographical area and to reduce the workload for existing staff – we have welcomed a social prescriber, another Clinical Pharmacist, a First Contact Physiotherapist, two Physicians Associates and the advert is out for an Occupational Therapist to join the PCN team Market Street and St Katherine’s have merged into one to create Ledbury Health Partnership, securing the future of General Practice for the local population despite the very difficult circumstances of the COVID pandemic

Key focus areas for the forthcoming year • • • • 40

Creation of PCN Frailty Team as PCN 'additional roles' are added year by year, supporting some of the most vulnerable in our population.

Aim to reduce workloads in General Practice to aid staff retention and job satisfaction Improving organisational planning so that we can be more proactive rather than reactive Over the last year the PCN has increased cohesion despite the challenges that have been faced due to Covid19. As a PCN we have worked to find solutions together. Due to this, we are leaving the year much stronger and ready to embrace 2021

Joint PCN Clinical Directors

Wargrave House, Belmont and Cantilupe PCN Practices in the WBC PCN: Wargrave House, Belmont, Cantilupe and Hampton Dene Surgeries

Population: 29,580

...of whom 16% are over 70

Practice Staff: 86

Covers: 61 sq miles

Care Homes 16 homes 367 beds

Major achievements during COVID19 • • • • •

Despite all the challenges that COVID has brought, feeling positive that primary care is ‘getting its act together’ Realisation that the PCN team is essential and that there is a huge net positive to being in a PCN Safeguarding role introduced providing standardised approaches and extra support for practice staff Developed a PCN medicines management approach with the introduction of two Clinical Pharmacists and a Pharmacy Technician, working as a team across the PCN to provide an improved service to patients and reducing waste and associated cost to the NHS Continuing to work closely with our PCN neighbours at HMG PCN to uphold our shared vision of 'working together to ensure the people of Hereford achieve their best health and well-being‘.

Key focus areas for the forthcoming year

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• • •

Getting the Practice Manager’s role right, getting 'Additional Roles' right and embedding the team Fulfil roles recruitment through ARRS and truly functioning as a PCN We have come along way - we need to continue the momentum and develop full plans for the next four years.

Key People

Hereford Medical Group PCN

Key People

Practices in the PCN: Hereford Medical Group

Population: 48,422

...of whom 14% are over 70

Practice Staff: 168

Covers: 135 sq miles

Care Homes 16 homes 510 beds

Major achievements during COVID19 • • • • •

Provision and support in setting up the site for the award winning ‘Super Green’ clinic and home visiting service for Herefordshire, a nurse-led service for those who were most vulnerable, working closely with WBC PCN to manage the bookings Demonstrated ability to be flexible, work together and be proactive – keeping our staff and our patients safe The new ways of working developed due to COVID have really helped to cohere the PCN team and help them to come together, including successfully moving into purpose-built premises in November 2020 Successful recruitment to additional roles to alleviate pressure on existing staff and to develop multi-disciplinary team that benefits patients – we have welcomed a Social Prescriber, a First Contact Physiotherapist, a Pharmacy Technician and two PCN Care Coordinators to the PCN team this year Proud of work and new initiatives introduced for GP registrars, including a more robust induction and support programme

Key focus areas for the forthcoming year 42

• • •

Settling into new premises, whilst continuing to provide high quality services and address unmet needs Managing patients’ expectations and making best of the new roles in the PCN Improving continuity of care

Herefordshire PCN Social Prescribers During the last year, Taurus Healthcare has delivered a Social Prescribing service on behalf of the Herefordshire PCNs. This service enables health professionals to link patients with all sorts of non-medical support in their local community. Working closely with colleagues in Herefordshire Council, it recognises that our health and well-being can be affected by a wide range of factors – including social, environmental and economic ones.

Each Social Prescriber is responsible for supporting people in a different Primary Care Network.

Before COVID19 they were meeting face-to-face with patients to understand ‘what matters to them’.

Although this has not been possible since the pandemic, the Social Prescribers have played an important role in contacting and reassuring the most vulnerable, or ‘shielded’ patients in the county.

Since implementation a year ago ….  846 referrals have been received by the service  4,100 contacts have been made  The Social Prescribers have connected patients to more than 42 community groups and services  New leaflets and resources have been developed, aimed at both general public and clinicians

“I thought you'd really like to know … that my patient thinks you are an absolute star and have helped him SO much :o) big up Crista Gaunt!

Virtual cuppa made for you.” From a Herefordshire GP 43

“You made me see myself again and I haven't done that for years. I was just a mum now I am me again.” Patient feedback

PCNs supporting patients with their medicines Each of the PCNs in Herefordshire recognises the value pharmacy professionals including pharmacists and pharmacy technicians, can add to their teams and to their patients. As a result, they have all taken the opportunity to expand their teams this year, improving patient care and safety around medicines use.

Pharmacy professionals support patients to optimise the use of medicines via structured medication review and multi-disciplinary team (MDT) working across Health and Social Care teams. This MDT approach provides holistic patient care focusing on those patients at higher risk, including residents of Care Homes, people living with frailty who are isolated or housebound, have had recent hospital admissions, falls, need high risk medicines and those prescribed multiple medicines.

Working as part of the multi-disciplinary PCN and GP practice teams, they support a joined-up approach to medicines use and ensure that patients receive the best outcomes from their medicines.

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"Having joined the PCN team two weeks ago, I have never felt more supported and empowered to work hard and achieve great things in a new job than now. I am grateful for all the time and effort put in by the management team and all the pharmacists who have made me feel warm, welcomed and appreciated.

I can't wait to work hard and help our patients make the most out of their life!"

Mohamed Elattar East Herefordshire PCN Clinical Pharmacist Pictured with Damsel Kuriakose, WBC PCN Clinical Pharmacist

Lead Pharmacist and Lead Pharmacy Technician roles Working together, Taurus Healthcare including the Training Hub and Wye Valley Trust, have appointed a Lead Pharmacist. Part of her work covers the Pharmacy Ambassador role in the Training Hub to enable Herefordshire PCNs to develop pharmacy roles and provide professional support to this growing team.

In addition, Taurus Healthcare and Wye Valley NHS Trust have appointed a Lead Pharmacy Technician to work in collaboration with the Lead Pharmacist. She will also support the Training Hub with the delivery of the Pharmacy Technician Apprenticeship Programme in order to create a pipeline system for future ARRS workforce planning.

A PCN Pharmacy Network has been established to share good practice and facilitate close links with pharmacy colleagues, such as the Specialist Care Home Pharmacist and pharmacy professionals in hospital, mental health and community pharmacy.

“Expansion of the pharmacy teams into primary care networks not only improves patient care but also supports attracting pharmacy professionals into Herefordshire as part of the integrated team and improves issues with recruiting and retaining our valuable staff” Tony McConkey, Clinical Director of Pharmacy, Wye Valley NHS Trust 45

PCNs supporting patients with musculoskeletal problems Nationally, a high proportion of people consult their GP about musculoskeletal problems and concerns. This is no different in Herefordshire. This increases the workload on General Practice, has also led to an increasing number of referrals onto specialist, hospital-based colleagues and can result in long waiting times for key services such as physiotherapy.

Working collaboratively with colleagues at Wye Valley Trust, a new role has been piloted – First Contact Practitioners (FCPs) working as part of the General Practice team. The pilot demonstrated improved patient satisfaction, including the right people getting access to the right care at the right time.

As a result, every Primary Care Network now has a First Contact Practitioner working as part of their General Practice team, with plans to extend that further in the coming year.

“The importance of FCP's supporting practices in this way provides an excellent service for the patients of Herefordshire and ensures that the right patients are seen by specialist colleagues at the right time" 46

Dr Judith Johnson, GP, The Marches Surgery, North & West Herefordshire PCN

PCNs delivering Enhanced Health in Care Homes This year has seen an unprecedented challenge for care homes, their workforce and their residents and families. Working with colleagues from across health and social care, Primary Care Networks have been well placed to provide support at this critical time.

By working together, General Practice, Wye Valley NHS Trust, Hereford and Worcester Clinical Commissioning Group and Herefordshire Council have joined up their approach to supporting care home providers in an Integrated Care Home Support Programme.

• Care homes aligned to a single PCN, with most registering residents with a single practice with a dedicated care home lead, promoting continuity of care • Weekly ward rounds – proactive interventions and care planning within a multidisciplinary approach • Recruitment of additional clinical pharmacists providing expertise in Structured Medication Reviews and reduction in polypharmacy /wastage • Access to GPs and Advanced Nurse Practitioners when needed via the countywide Weekend Care Home Service and the COVID Management Service • Development of a dedicated TeamNet page with resources, guidance and support for care home staff 47

86 Care homes across Herefordshire Home for up to 2,013 people

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Quality and safety

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Quality and safety • A successful CQC inspection of Ledbury Market Surgery on 8 October 2019 which resulted in a ‘good’ outcome

• During the COVID19 pandemic, Taurus Healthcare’s Quality team has supported our corporate services and Herefordshire General Practice with adapting to new ways of working, maintaining safety for patients and staff alike This work included support with the following areas:  Operational support, governance framework and PPE provision for ‘Amber’ and ‘Super-green’ services  Infection Prevention Control support (site visits/protocols) across 24/7 General Practice  TeamNet COVID pages to support collation and synthesis of national COVID information in conjunction with Worcestershire and CCG colleagues  Supporting General Practice in accessing PPE 50

Quality and safety • Embedded Lead Practice Nurse meeting with system partners    

Developed relationships and support system working to improve patient pathways Improved safety and patient experience Improved effectiveness Improved staff recruitment, retention and partnership working

 Oversee a weekly General Practice education programme that allows prompt communication, promotes collective decision making using electronic (‘sli.do polls’) and gives a platform for experts from across the system to present updates and educational material  Developed Herefordshire Wound Care Project looking to standardise care planning across primary and community care.  Built a rolling programme of education for nurses and health care assistants across General Practice to support education and development during COVID and beyond  Collaboration with CQC inspector to support General Practice registration/ regulated activity adjustment requirements during the pandemic 51

Quality and safety We have continued to work with our staff and wider stakeholders to ensure that services are safe, effective, responsive and well led:

 The Quality team has continued to ensure governance arrangements for our services through our quality and safety reporting, overseen by our Quality Assurance Committee.  During restoration we have re-established our governance meetings with Malling Health as part of our Out of Hours contract to increase collaboration and partnership working to develop and enhance services.  We have rapidly adapted to a new quality management system required for MHRA/Home office licence requirements.  We have worked to support General Practice with system resolution to incidents shared with Taurus and re-established the PCN Quality group.

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Ultimately this oversight aims to ensure that we continually learn and develop our services for patients, in keeping with the high-quality holistic care that is the foundation of General Practice.

Financial Summary 2019-20

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Financial summary : 2019-20 The past year has been a complex one for the Finance team, led by our experienced Director of Finance, Andree Lee.

Andrew joined Taurus Healthcare just prior to the pandemic, having previously held Director of Finance roles at provider trusts and commissioning.

The key challenge for this role is how to support Herefordshire General Practice, investing in (sometimes at risk) services whilst ensuring that the financial strategy underpinning Taurus provides a long term concrete financial platform.

This was particularly evident during the pandemic when practices and Taurus had to collaborate across the various financial pressures. The CCG have been extremely supportive of General Practice, working closely with Taurus to ensure the financial resilience and viability of General Practice.

During the year, additional income and expenditure in 2019/20 are largely a result of the full year impact of delivering the Out of Hours service across Herefordshire.

In line with our aim to deliver a small surplus from our contracted service each year to enable us to support our federative and strategic leadership functions, a summary of our financial performance is shown on the following page.

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Financial summary : 2019-20 £m

2018-19

2019-20

Budget 2020-21

Income for services provided

3.7

5.8

4.3

Cost of delivering federative, strategic and contracted services

3.6

5.9

4.5

0.1

(0.1)

(0.2)

Funds retained for future developments

An additional £200k from reserves is being used to support strategic and federative activities in 2020/21

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The year ahead At the time of writing (November 2020) it is challenging to look beyond the immediate weeks, as the situation continues to evolve on an almost daily basis. Inevitably COVID will provide the ongoing challenge, coupled with the need to restore services back to normal, working with partners to support the backlog of patients waiting for assessment and treatment created during the pandemic. Efforts and hopes are centred on the COVID vaccination, where General Practice will play a lead role in delivering the service, and our collective optimism is that this time next year, the pandemic may become a distant memory.

Integrated care systems will be a key development this year, and General Practice will need to work collaboratively to continue building on the relationships built with partners so that from April 2021, General Practice can play a leading role in the continuing development of services for our patients. Clear coordinated leadership will be a cornerstone of the role we aim to play, with PCNs at the heart.​ Photo:56 Crista Gaunt

The year ahead 24/7 General Practice will play its part, with our existing Out of Hours services supported by more ‘virtual’ General Practice, working alongside practices and urgent / community teams to facilitate a prompt response aimed at keeping patients in their own home.

Chambers will see a redefined offer, where practices may choose to consider the partnership resilience offer to support ‘last man standing’, as well as bespoke back office and clinical support, provided according to the needs of practices. As such the chambers work will dovetail with evolving PCNs, as we collaborate and support each other.

Finally, it is worth looking forward to a year where we will meet once again in person, building on the relationships so central to team working and so fundamental to good patient care.

Stay Safe.

57 Photo: Crista Gaunt

Suite 1, Berrows Business Centre, Bath Street, Hereford, HR1 2HE www.taurushealthcare.co.uk 01432 270636 enquiries@taurushealthcare.co.uk 58