North Norfolk Primary Care Quality Account 2022/23
“Putting the patient central to the delivery of quality healthcare for the local community and beyond.”
CARE
INTEGRITY
COLLABORATION
CORE VALUES
LEADERSHIP
ACCESSIBILITY
TEAMWORK
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CONTENTS
Section One: An Introduction ........................................................................................................................3
1.1 Forward from Dr Peter Lawson, Chair & James Leeming, CEO..............................................................4
1.2 Our Values .............................................................................................................................................5
Section Two: The Organisation - NNPC .......................................................................................................6
2.1 Our Services...........................................................................................................................................6
2.1.1 Core .................................................................................................................................................6
2.1.2 Elective Recovery, Innovation, & Community Services.....................................................................7
2.1.3 Urgent and Emergency Care..........................................................................................................15
2.2 CQC Statement of Purpose ..................................................................................................................21
Section Three: Clinical Quality & Safety .....................................................................................................21
3.1 Review of Key Achievements 22/23 ..................................................................................................21
3.1.1 Clinical Supervision implementation ...............................................................................................21
3.1.2 Patient & Staff Experience – Bespoke Questionnaires ...................................................................22
3.1.3 Performance Scorecard .................................................................................................................22
3.1.4 Quality & Safety Meetings at Service Level ....................................................................................22
3.1.5 Development of the Quality & Safety Committee Agenda...............................................................22
3.1.6 Clinical Education and Training ......................................................................................................22
3.1.7 Development of Investigation into Incident Reporting .....................................................................23
3.1.8 Safeguarding..................................................................................................................................23
3.1.9 Complaint Handling ........................................................................................................................23
3.1.10 Communications ..........................................................................................................................23
3.2 Our Key Priorities in 23/24 ....................................................................................................................23
3.2.1 Primary Care Dashboard................................................................................................................23
3.2.2 Monday.com ..................................................................................................................................24
3.2.3 Staff Experience Survey – Core staff and clinicians .......................................................................24
3.2.4 Agilio TeamNet...............................................................................................................................24
3.2.5 Audit Schedule – Clinical Audits ..................................................................................................... 24
3.3 Patient Safety & Quality ........................................................................................................................24
3.4 Patient and Staff Feedback...................................................................................................................29
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Section One: An Introduction North Norfolk Primary Care Ltd (NNPC) is an alliance of 19 GP Practices in North Norfolk. The organisation’s aim is to sustain the delivery of primary care at scale, while supporting workforce development and improving access to primary care.
Our objectives are:
➢ To work in partnership with our service users towards a positive experience and understanding, involving them and their parents/carers/guardians in decision making about their treatment and care. ➢ To be a learning organisation that continually improves what we are able to offer patients. ➢ To treat service users as individuals and with the same respect we would want for ourselves or a member of our families, listening and supporting people to express their needs and wants and enabling people to maintain the maximum possible level of independence, choice and control. ➢ To ensure that we take close account of feedback about the services that we offer and, ideally, that it is externally evaluated. ➢ To ensure that all staff have the competency and motivation to deliver the required standards of care ensuring that all members of the team have the right skills and training to carry out their duties competently. ➢ To operate with a wide range of policies that ensure the ongoing safety of patients, as well as delivering an effective and responsive service. ➢ To operate on a financially sound basis. ➢ To improve the service through feedback from patients and staff. ➢ To ensure confidentiality and data protection for each patient and staff member.
The organisation offers a range of high quality, safe services that improve patient experience.
Our services are delivered in GP Practices and other clinical environments, such as acute Emergency Departments, or community settings. Our services are delivered by a combination of health care professionals including GPs, Advanced Nurse Practitioners, Paramedics, Physiotherapists and Pharmacists.
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1.1 Forward from Dr Peter Lawson, Chair & James Leeming, CEO Now in its 6th year of operating, NNPC has continued to provide support to the 19 North Norfolk GP practices. We have supported and co-ordinated the delivery of core services by providing a PCN Support Team, in addition to co-ordinating and supporting the employment of Additional Reimbursed Role (ARRS) Staff for the PCN’s. These challenges have required our workforce to adapt and change the way they work to respond to rapidly transforming demands in Primary Care. We have continued to work in collaboration with the local Community Trust, Ambulance Trust, Local Council, and other partners to improve patient care and to bring healthcare delivery to the heart of the community. This has been demonstrated by the implementation of the Rapid Access Integrated Support (RAIS) Team, which has delivered an enhanced home visiting service to assess patients to prevent any unnecessary hospital admissions, or if recently discharged, a re-admission. We have also worked to support Secondary Care in their post-pandemic recovery in areas such as elective care and waiting lists – in specialities such as dermatology, gynaecology and cardiology, which has brought the patient ’s care closer to home. The Dermatology Service was initially commissioned as a pilot in January to June 2021 by NHS Norfolk and Waveney CCG, in which NNPC facilitated the clinical delivery between practices and an external dermatology service provider. We have seen the continuation of the Dermatology Service providing remote advice and treatment services, which has now been re-commissioned until April 2024. We have continued to provide the GP Front Door Streaming Service at the James Paget University Hospitals NHS Foundation Trust and The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust. Working in collaboration with the Trusts has made an impactful, demonstrable, and positive difference to the patient experience and is reducing the flow of activity through the ED departments. In June 2021, we successfully developed and implemented one of the first Primary Care Led Rapid Diagnostic Service in North Norfolk, which was rolled out to other areas in September and December 2021. This service has brought together the Cancer Alliance and NNPC to deliver a vital service for the benefit of patients who do not meet the 2 week wait cancer referral criteria but have suspicious symptoms. The patient feedback remains positive and has provided much a valued and needed support to the Acute Trusts and General Practice. We strive to ‘ keep up ’ with the ever-changing horizon of Primary Care for the benefit of high-quality service provision for patients. In doing so, we continue to remain fully committed to our values, mission, vision, and strategy; whilst also supporting our resolute staff in achieving these goals.
We are enormously proud of the persistent hard work displayed by our staff who are all dedicated to ensuring high quality, patient-focused care.
We aim to provide quality assurances to our patients, staff, Board, and stakeholders via this Quality Account, and to use this as a platform to demonstrate plans for continuous care quality improvements as we head into 2023/24.
Dr Peter Lawson, Chair & James Leeming, CEO
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1.2 Our Values
Our organisational values always remain the same when approaching existing and new opportunities:
Care – Quality patient focussed, holistic health care in the local community and beyond.
Integrity – Acting ethically and remaining accountable.
Collaboration – Partnering to work together to deliver quality health care services.
Leadership – Leading the way, building relationships & trust and being efficient.
Accessibility – Inclusive and open to all
Teamwork - We aim to ensure that our shared values are adopted and incorporated into our team. We aim to appreciate and value each other to enable us to undertake our work in a safe, happy environment. “ Our organisational core values are to provide high quality care that is accessible by all, is driven by good teamwork and collaboration , all of which is supported by good leadership and carried out with integrity ”
CARE
INTEGRITY
COLLABORATION
CORE VALUES
LEADERSHIP
ACCESSIBILITY
TEAMWORK
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Section Two: The Organisation - NNPC
2.1 Our Services 2.1.1 Core Enhanced Access (EA) Service
With the event of the Network Contract DES having evolved from Improved Access & Extended Access to Enhanced Access (EA) in October 2022, NNPC has continued to deliver Enhanced Access Services across the 19 North Norfolk Practices, with the increase from 5 to 11 practice hubs over 2022/23. A key challenge to this has been the variation in requirements from each Primary Care Network (PCN). NNPC has provided the EA service workforce needs and clinical system support during this time. In the future, it is anticipated that variations in PCN requirements and individual Enhanced Access Plans will continue with the provision of the EA service. NNPC remains committed to providing EA Services based on each PCN’s requirements moving into 2023/24. Primary Care Network (PCN) Support Team & Additional Roles Reimbursement Scheme (ARRS) The PCN Support Team consists of a PCN Programme Lead, a PCN Clinical Support Facilitator, and a PCN Service Manager. Together, they continue to support a variety of elements of our practices service delivery. The team has worked with the four North Norfolk PCN’s to develop shared vision, support the communications of National and local policy affecting General Practice, and has provided ongoing support in the recruitment, retention, and employment of Additional Roles Reimbursement Scheme (ARRS) staff. By the end of March 2023, NNPC directly employed 22 member of ARRS staff on behalf of the members practices. NNPC has also facilitated the employment of other ARRS staff who are directly employed by the Practices. The NNPC PCN Clinical Support Manager role, in particular, aids as a facilitator for the induction and clinical supervision for the ARRS staff employed by NNPC in practices. They also provide day- to-day human resources support for the NNPC employed ARRS staff, with support from an external human resources consultant, where required.
NNPC Health & Safety (H&S) / Infection Prevention & Control (IP&C) Service
Since the appointment of a H&S Officer in February 2020, NNPC has offered support to our Practices in the provision of up-to-date H&S compliance in risk assessments and auditing in all aspects of health and safety. Over the course of the 2022/23 period, the H&S Officer has undertaken further education, acquiring formal qualifications in Infection Prevention &Control (IP&C), in order to provide audits and risk assessments in the area of IP&C. The Practices have accessed this provision in order to comply with legal and statutory obligations, as well as being compliant with Care Quality Commission (CQC) regulations. The H&S / IP&C Officer also undertakes quality assurance audits on all premises used by NNPC for the delivery of clinical
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services in order to ensure that the organisation is providing a safe clinical area for our patients and staff.
2.1.2 Elective Recovery, Innovation, & Community Services Elective Recovery
i)
North Central London (NCL) Integrated Care System (ICS)
Referral Validation & Triage
From April 2022 until March 2023, NNPC was commissioned to engage with, review, risk-stratify and prioritise patients who have been ‘referred but not seen’ as part of the Elective Recovery Program within the North Central London (NCL) ICS. PSL and the Eclipse Live system were included as part of the approach. The intended outcomes were to reduce the numbers waiting to be seen and to enable hidden clinical risks to be identified by bringing together patient derived feedback with current clinical insight. NCL includes the Royal Free London Hospital, University College London, and Whittington Health. ENT was selected by NCL as the initial specialty to work with, followed by Dermatology and Ophthalmology. Patients were engaged via an on-line questionnaire which was agreed with the clinical team at the Royal Free Hospital (including risk assessment scores). Patients were asked to complete the questionnaire which provided insight into their view of their health status, and this was aligned with their current medical information to risk assess and prioritise the patient. Patients were supported in their use of the on-line system (Eclipse) by nursing and administrative staff where necessary, plus escalation to doctors for review. The system was monitored so that patients who did not complete the questionnaire could be followed up with phone calls, which were made during the day, evenings, and weekends.
The main points and outcomes from the service were as follows:
687 ENT patients were reviewed:
• 27% of patients were removed from th e waiting list in line with the Royal Free Hospital’s access policy. • 7% patients were identified as meeting the Core20 (high deprivation) criteria for health inequalities. • 8% patients were identified as higher priority (>50%) using the locally defined risk calculator.
838 Dermatology patients were reviewed:
• 30% of patients were removed from the waiting list in line with the access policy. • A further 228 patients have been selected by the Royal Free for the process.
926 Ophthalmology patients were reviewed:
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• 28.8% of patients were removed from the waiting list in line with the Royal Free Hospital’s access policy.
ii) Norfolk & Waveney Integrated Care System (ICS) - Norfolk & Norwich University Hospitals NHS Foundation Trust (NNUH), James Paget University Hospital NHS Foundation Trust (JPUH) & Queen Elizabeth Kings Lynn Hospital NHS Foundation Trust (QEH)
Community Ambulatory Echocardiogram (ECG) Service
As part of the National Elective Care Recovery (ECR) programme, Norfolk and Waveney CCG (NWCCG) commissioned NNPC to provide a Community Diagnostic Ambulatory ECG Service. The primary aim was to support the James Paget University Hospital NHS Foundation Trust (JPUH) and Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust (QEH) by providing a high-quality ambulatory diagnostic cardiology service that enabled patients to have a package of care delivered at home instead of attending the acute provider for the supply, fitting & recording of ECG monitors across the Norfolk & Waveney system. The service provided a capacity solution to reduce the current pressures in cardiology for access to ECG services by using digital technology combined with the use of virtual review of the results and the delivery of a management plan to the referrer. Patients currently on the waiting list for an ECG test at the JPUH & QEH were diverted to the new community service, which reduced waiting times experienced by patients and freed up capacity for the acute hospitals.
The service was delivered in partnership with Neo Health Tech and Capitol Medicare.
The service started with JPUH on the 8 th March 2022 and closed on the 2 nd September 2022. The majority of the patients (83%) of patients were seen in the first 3 months of the service.
In total 833 patients were referred to the service from the JPUH.
Of the 833 patients that were processed by the service:
629 patients completed tests.
•
• 5 patients had urgent findings identified and were escalated to the Cardiology Department at the JPUH • 204 were discharged back to the JPUH. The service started with QEH on 20 th May 2022 and closed on 8 th September 2022. The majority of the patients (99%) of patients were seen in the first 3 months of the service.
In total 303 patients were referred to the service from the QEH.
Of the 303 patients that were processed by the service:
194 patients completed tests.
•
• 0 patients had urgent findings identified and were escalated. • 109 were discharged back to the QEH.
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Community Gynaecology Service (CGS)
NNPC, as part of the National Elective Care Recovery (ECR) programme, were commissioned by Norfolk and Waveney ICB (NWICB) to provide a Pilot Community Gynaecology Service (CGS), having already completed the same support for the Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH) from the 1 st to 15 th March 2022. The primary aim of both services was to support the Trusts in recovering compliance with Referral to Treatment (RTT) times by giving the longest waiting patients the choice to be in the CGS. Appropriate patients were identified from the gynaecology list for Heavy Menstrual Bleeding and general gynaecology. The key value for the services was that patients attending the CGS would not be disadvantaged should their care need to be returned to the Acute Trust and they would revert to the correct place on any other waiting list (e.g., for a procedure/surgery). The service for JPUH was Consultant-delivered and based at the Shrublands Health Centre in Gorleston. It ran for 18 days between 24th August and 29th September 2022 and was staffed with a Locum Consultant in Obstetrics and Gynaecology, supported by a Nurse with experience in gynaecology. The service saw a total 293 patient referrals being provided to NNPC. Of those, 246 patients had appointments booked, 191 patients attended, and 55 appointment slots were lost due to patients not attending (DNA & CNA). 47 patients confirmed they no longer needed an appointment. A limited variety of procedures were available in clinic, e.g., biopsies, smear tests, Mirena coil fittings, with more specialist diagnostics or procedures being available at JPUH. Of the 191 patients attending the clinic: • 86 patients were discharged back to the GP (some with treatment or prescription or treatment recommendations) • 57 patients had their care returned to JPUH for further acute care. • 47 patients were awaiting test results. • 1 patient was upgraded to a cancer pathway 2 week wait for biopsy and ultrasound.
It is anticipated that there will be further work in this area looking into the 2023/24 period.
Dermatology Referral Triage
The NNUH provided NNPC with 140 suitable patients for dermatology referral triage, as part of referral management for those patients waiting for more than 72 weeks. NNPC carried out referral triage by patient consultation with an aim to assess the patients skin lesions or rash, then treat, discharge or refer back to NNUH, where required.
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The outcomes were:
• Discharged back to primary care = 51% o Patients seen and d/c after 1st appointment – 46.
o Patients no longer requiring appts – 19.
Patients DNA – 6
o
• Follow Up in Secondary care = 41% o Patients seen and upgraded to 2ww – 4. o Patients seen and upgraded to urgent – 13.
o Patients seen, given interim care and requiring further monitoring/surveillance/medication only prescribed in secondary care – 40. • Other = 8% o Patient requiring biopsies to be done at Lionwood Medical Practice (still under Community Dermatology Care) – 4 o Patients not able to make appts at Community Dermatology Care – so returned back to NNUH at their request – 8.
Spirometry Service Pilot
The Spirometry Pilots aim was to support the practices in carrying out the work required and directed by the Spirometry Locally Commissioned Service (LCS), commissioned by Norfolk and Waveney ICB (NWICB). NNPC worked collaboratively with Neo Health Care to undertake diagnostic spirometry, as per published quality services described in the Norfolk and Waveney LCS. The pilot commenced in February 2022, and will continue to roll into the 23/24 LCS spirometry service delivery plan. The delivery of the spirometry service is based on a local hub basis, with the patients attending their own Practice and having virtually assisted spirometry carried out. The innovative technology behind the testing uses remote analysis, which is then reported back to the patient’s G P. The pilot will deliver a service evaluation and could lead to a wider scale provision in North Norfolk, or beyond.
Cancer Services - Rapid Diagnostic Service
i)
Serious Non-Specific Symptoms (SNSS) Pathway
Since April 2021, NNPC was awarded a contract to provide a Rapid Diagnostic Service (RDS) across Norfolk & Waveney which supported the National Cancer Plan. The service is open to all patients that are not acutely unwell; are over the age of 18; and who have serious signs/symptoms that may indicate cancer, but do not meet the cancer 2 week wait pathway criteria (symptoms include for example, unexplained weight loss, fatigue, abdominal pain or GP “gut feeling” of cancer). It supports both Primary and Secondary Care in the assessment of patients who may otherwise be inappropriately referred on a 2 week wait cancer pathway which contributes to a delay in the diagnostic process. It operates from clinical sites in Norwich, Great Yarmouth, and Kings Lynn and can also fac ilitate virtual appointments where clinically appropriate.
The dedicated RDS team consists of four experienced part-time GP’s and a patient pathway coordinator. They all are able to be contacted by patients or referring clinicians throughout the
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patient journey. They have the benefit of time and are able to offer longer appointment times than are generally available in Primary Care. They co-ordinate the organisation of investigations and the timely reporting of those with integration with diagnostics, hospital specialties and the cancer of unknown primary multi-disciplinary team. The RDS aim is to diagnose and, where appropriate, refer onwards within 28 days of initial referral.
Year of Service
Year 1
Year 2
Total Numbers of Referrals Received into RDS
257
965
Total Number of Accepted Referrals into the service
245
705
Total Number of Rejected Referrals from the service
12
5%
260
27%
Patients discharged from service with cancer diagnosis
18
7%
65
9.21%
Patients discharged from service with other non-cancer diagnosis
203
83%
498
71%
Patients discharged from service back to GP with no diagnosis
24
10%
135
19%
Patients requiring CT as part of Diagnostic Testing (by RDS)
164
67%
514
73%
ii) Lower Gastrointestinal Support Service (LGISS) - supporting the Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH)
A large proportion of patients referred into the colorectal 2 week wait cancer pathway by primary care do not have bowel cancer. One aspect of the triaging of lower risk patients is by initiating a screening test called a FIT (faecal immunochemical test). Commencing in May 2022, NNPC worked with the NNUH Lower GI team to stream suitable FIT negative patients into a primary care-led rapid diagnostic service where symptomatic patients can receive expert review and relevant diagnostic tests through specialist primary care centres whilst increasing capacity within secondary care for managing those higher risk patients on a 2 week wait cancer pathway.
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A three-month pilot was run from 1 st April 2022 to 30 th June 2022, and was funded by the Cancer Alliance. To differentiate from the RDS pathway, it was renamed the Lower GI support service (LGISS). The pilot was delayed due to procedural issues so only started receiving referrals from 17 th May 2022, the service had the following outcomes: • 136 patients were transferred from the 2 week wait LGI cancer pathway to the LGISS during the pilot in May and June 2022. An audit of 50 patients assessed the quality of referrals, patient management, and the diagnosis. • From 15 th August 2022 until 25 th January 2023 a further 301 patients had been transferred to the LGISS. An audit of 150 of these referrals concentrated on the management and diagnosis. The positive outcomes of the service included a reduction in pressure on Lower GI 2 week wait cancer pathways, which resulted in reduced waiting times and increased colon cancer detection rates. Patients on the NNUH waiting list fell from over 1000 in August 2022 to circa 600 in November 2022. As the work continued, these figures further improved. This service demonstrated improved patient care, avoiding unnecessary investigations and reduced waiting times (86.6-94.6% patients seen and discharged within 6-weeks), with patient satisfaction of the service being rated highly. GPs also benefited from the service as the patient pathway was completed with onward referral if necessary, alongside the provision of advice and guidance (A&G) to improve learning.
It is suggested that other pathways for specific other lower GI conditions would benefit from similar support.
The work which NNPC has undertaken was nominated for an award from The British Society of Gastroenterologist Awards and came 2 nd out of 19 entries. The pilot stopped on the 30 th June 2022. Both the NNUH and NNPC hoped to continue the service because of the positive impact on patients and the improved performance in the Trust. Further funding was secured from the Norfolk & Waveney ICB, so the service resumed on the 15 th August 2022 with funding until the 31 st March 2023. It is hoped that this service will run beyond this time and will be rolled out across all 3 Acute Trusts in the region.
Home Visiting Service – Great Yarmouth & Waveney
In October 2022, NNPC was contracted by Great Yarmouth & Waveney ICB to deliver a home visiting service for 7 practices in the Great Yarmouth, Northern villages, and Gorleston area. This service was initially contracted until 31 st March 2023, but has since been extended until 30 th June 2023. The home visiting team are based at Shrublands Health Centre in Great Yarmouth, which provides good links with the local community nursing team, who also uses this as their base.
The home visiting service has provided and carried out a total of 1,212 home visits between the start of the service in October 2002 up to the end of March 2023. These visits have supported the
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housebound population in accessing healthcare, prevented admissions, and supported the Practices with providing community-based care services.
Collaborative Community and Primary Care Leg Ulcer Pilot
NNPC worked jointly with Norwich Community Health & Care (NCHC) to implement a pilot programme to bring leg ulcer management into Practices and the neighbouring communities – bringing the delivery of care closer to the patient. The pilot was funded by the North Norfolk Community Transformation Fund and was due to run for 12 weeks. The outcomes of the pilot were evaluated in relation to the impact of the changes implemented on training, waiting lists for clinics, and benefits for patient outcomes.
The first pilot clinics were commenced June 2022, which had the following outcomes:
• All staff involved felt the joint clinics were a positive experience. The sessions were informative, and the patients told the clinical team that their treatment was explained clearly, and it was a good experience. • The Practice nurses reported that the shadow shifts hosted by NCHC specialist nurses were beneficial, and they gained learning and a greater understanding of patient management. • Patients being managed in Practice, where appropriate, allowed urgent and more complex patients to be seen by NCHC in the community hospital setting. • NCHC to continue to support practices by offering joint Leg Ulcer Clinics. Patients who cause concern in the Practice setting can be seen jointly, which utilised the expertise of the specialist nursing team from NCHC. These can be tailored to the Practice requirements. • The joint clinics in Practices are continuing to run indefinitely beyond the pilot timeframe.
Prehabilitation – Knee Replacement Pathway Pilot
From October 2022, NNPC worked jointly with the Norfolk & Norwich University Hospitals NHS Foundation Trust (NNUH) and Pure Physiotherapy ’ s First Contact Physiotherapy (FCP) Services on a prehabilitation knee replacement pathway. This was a 12-month pilot for patients who were on a waiting list for knee replacement surgery for more than 78 weeks and supported the COVID-19 waiting list recovery plans, as the halt of elective surgery saw an increase in waiting times. The pilot was designed to work with the patient to provide them with the best possible support in achieving improvement or prevention of deterioration of function, pain, and confidence to optimise preparation for surgery. It was contract by the Norfolk & Waveney ICB with Community Transformation Funding for 12 months and will have outcome measures taken at 3-, 6- and 12- month intervals. The aim of the service was that patients currently on a waiting list for more than 78 weeks for a total knee replacement from the NNUH are reviewed in Primary Care for an assessment of current function and pain. From this, the goal was that a management plan will be created based on the patient’s presenting condition .
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The FCP Physiotherapist aimed to:
• Perform a thorough assessment of the presenting patient’s strength, movement, function, well-being and pain. Documenting this and any reviews within the clinical system. • Formulate an evidence-based exercise plan for each individual patient based on the assessment. • Address any issues with exercise compliance. • Discuss the extent of knee replacement surgery with the patient to encourage adherence of self-management for improved post operative outcomes. • Support weight loss programmes, smoking cessation and healthy living, referring onto the in- house dietician or social prescribers as necessary. • Provide a holistic approach for self-management of the patient and referring into secondary care as necessary. • Communicate with patients that it is essential they discuss any changes with the FCP and attend their 6 weeks, 3-, 6- and 12-month reviews. • Work alongside the in-house pharmacist to review pain medication as required. • Communicate with the patient’s named GP as required.
As of March 2023, the pilot is still ongoing and has had the following outcomes, so far:
✓ On average pain scales have reduced. ✓ Some improvement on patient’s BMI but where there is no improvement or an increase , an onward referral to Slimming World has been made. ✓ On average Oxford Knee scores have improved. Some patients have seen a dramatic change – with one patient progressing from 12 to 35 in 6 weeks. This resulted in an improvement in the impact of the severity of the patient’s pain, mobility, and general wellbeing.
Enhanced Discharge Support Service – Primary Care
NNPC secured funds from both the 2022/23 ‘Community Transformation Fund’ and additional ‘Winter Resilience’ monies to develop and mobilise an Enhanced Discharge Support Service. Working together with a project manager team from within Practices, this service was implemented from June 2022 until March 2023. This service targeted patients being discharged from the Norfolk & Norwich Hospitals NHS Foundation Trust (NNUH) who required additional services when returning to their home (both social and health related).
The project aimed to ensure:
• Timely notification to Practice of all relevant patient discharges • Training and support for local care-coordinators to make welfare calls to patients discharged. • Escalation of problems or needs requiring support from health, social-care or VCSE partners.
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This programme was designed with Norfolk & Waveney ICB colleagues to meet the requirements of the Proactive Healthcare LCS and as such ensured resources were directed to Practices to support this initiative. This service will continue to be funded into the 23/24 period.
2.1.3 Urgent and Emergency Care GP Front Door (GPFD) Service
The purpose of the GP Front Door (GPFD) Service is to offer suitable patients access to a GP appointment instead of being seen and treated in the emergency department (ED).
The GPFD service operates from 9am until 9pm, 7 days a week, it aims to support patient flow away from ED and to provide the patients with a more appropriate avenue for their healthcare needs to be addressed.
i)
James Paget University Hospital NHS Trust (JPUH)
Commencing in September 2021, the GPFD Service at JPUH has continued to support a ‘see and treat’ service for patients who present themselves to ED. The success of the service, saw the opening of a dedicated ‘GP Streaming Unit’ on site at the JPUH in May 2022.
Over the course of the year to the 31 st March 2023, there were 44,464 patients streamed at the front door, with 15,299 of those seen in the service. This is an annual average of 34% of those patient who walked in to be seen in ED who were seen at the GPFD service instead.
Patient outcomes for those seen at GPFD JPUH in 2023, so far:
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• 82% of GPFD patients return home with either a treatment given, no treatment, no follow up or discharged from the service. • 8% are referred back to their registered GP practice. • 5% are referred back to ED. • 3% are referred for an outpatient appointment. • 2% are referred for an inpatient appointment. During 2022/23, there has been two periods of an initiative to support non-conveyance of ambulance patients to ED. This involved NNPC GPFD service clinicians working with East of England Ambulance Service NHS Trust (EEAST) with the provision of an advice line directly to the ambulance crew on scene with a patient. The aim of this pilot was to provide the ambulance clinicians with advice which might enable them to not convey a patient to hospital, unless necessary. The links with the GPFD service provided the crews with valuable advice via clinician-to-clinician dialogue with full access to the medical record for safe and improved patient care and management. From the Winter pilot, which ran from the 27 th December 2022 until the 17 th April 2023, the outcomes of the GPFD / EEAST advice line were:
ii) Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust (QEH)
NNPC commenced the GPFD Service at QEH in early January 2022, with the same clinical model as that of JPUH. It is based on a simple streaming model, with a narrow inclusion and exclusion criteria of clinical presentation which accounts for patient safety, which enables the safe and effective delivery of Primary Care services. The clinician who sees the patient has full access to the clinical record, and functions as a ‘satellite’ GP hub, working on behalf of the patients registered Practice.
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Over the course of the year to the 31 st March 2023, there were 37,299 patients streamed at the front door, with 11,663 of those seen in the GPFD service. This was an annual average of 31% of all walk-in patients being seen at the GPFD service. Patient outcomes for those seen at GPFD QEH in 2023 so far: • 69% of GPFD patients return home with either a treatment given, no treatment, no follow up or discharged from the service. • 6% are referred back to their registered GP practice. • 9% are referred back to ED. • 8% are referred for an outpatient appointment. • 8% are referred for an inpatient appointment.
North Norfolk Provider Alliance – Integrated working
A key part of the local working of the Integrated Care System ICS) is operating at ‘ Place ’ , which for North Norfolk covers the four Primary Care Networks NN1, NN2, NN3 and NN4. Place-based partnerships are collaborative arrangements formed by the organisations responsible for arranging and delivering health and care services in a locality or community. The aims of the North Norfolk Provider Alliance are reflective of the NHS Engl and document ‘Working together at scale: guidance on provider collaboratives and are: • Partnership building: Agree a common purpose aligned to the triple aim and agreed with ICSs and system partners to ensure alignment with system priorities. • Programme delivery: Agree a set of programmes that are delivered on behalf of collaborative members and their system(s) and are well informed by people and communities where they will result in service changes. • Shared governance: Work within proportionate shared governance arrangements that enable providers to come together and efficiently take decisions that speed up mutual aid, service improvements and transformation. • Peer support and mutual accountability: Challenge and hold each other to account to ensure delivery of agreed objectives and mandated standards, through agreed systems, processes and ways of working; for example, open-book approaches to finance and performance. • Joined up working: Work with clinical networks, clinical support networks, Cancer Alliances and clinical leaders to develop strategies, agree proposals and implement resulting changes. • Quality improvement: Drive shared definitions of best practice and the application of a common quality improvement methodology.
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Rapid Access Integrated Support (RAIS) Service
In July 2022, NNPC co-ordinated the formation of a provider alliance for the purpose of improvements in three key aspects of NHS England guidance for the Winter pressures. These were:
• Reducing crowding in emergency departments (ED). • Reduce hospital occupancy. • Better support for people at home.
This led to the development of a formal collaboration with Primary and Community Care focussed organisations with the aim of supporting better care for patients in their own homes, which also supported reducing attendances to ED and hospital occupancy. The initial membership of the alliance included:
• The 19 general practices in North Norfolk • Norfolk Community Health & Care (NCHC) / Norfolk County Council (NCC) • Norfolk & Suffolk Foundation Trust (NSFT) • East of England Ambulance Service (EEAST) • Integrated Care 24 (IC24)
This then led to the formation of plans in the development of the Rapid Access Integrated Support (RAIS) service. The service delivery pathway was designed to support the system to cope with the daily demand on urgent and emergency care for the frail, housebound patient. This would change unplanned to planned care which would provide the patient with the best possible outcomes in dealing with their healthcare needs.
The initial key expected outcomes of the service were:
• Reduction in conveyance to ED (in conjunction with EEAST) • Reduction in the walk ins/conveyances from North Norfolk patients to ED • Increased capacity for urgent Primary and Community care • Better management of the frail and elderly in the community – development of a cross provider model to support people in the Community. • Development of an integrated service across the Alliance with provider commitment to improve healthcare delivery. • Sharing of resources across organisations i.e.: o Paramedics, o Community clinical teams, o Supporting complex discharges to avoid readmission. The RAIS service was operationally launched on the 1 st February 2023, and was contracted by the Norfolk & Waveney ICB until 30 th April 2023. It was modelled on the management of the housebound patient, which encompassed an integrated approach to urgent and emergency care which created more responsive capacity for Primary and Community Care for other demands.
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The clinical delivery model simple illustration :
RAIS Team Support
Call to EEAST 999, IC24 111 or own GP Practice triage: Unwell
Housebound Patient with same day / urgent healthcare needs
NCHC NEAT Team
GP Triage
Social care support
Conveyance to ED
EEAST Ambulance/ paramedic visit
Stay at home
Where possible – To admit direct to specialty if via RAIS Service
ED attendance & assessment
Feedback to GP, follow up plan where required
Emergency Admission
Discharge home
The work from 1 st February up until 31 st March 2023 has had the following impact:
887 patients were seen by the clinicians in the RAIS Team, of which
• 770 patients were either discharged (54%) or referred to their GP (38.3%) • 23 (2.8%) referred to NEAT • 18 (2.7%) were sent to hospital, of which 10 (1.2%) went directly for admission and 8 (1%) went to ED. • 90% were over 70 years of age, suggesting the frail elderly were the majority targeted patient group. These figures suggest that 92.3% of patients were effectively managed in Primary Care. Only a small number of patients required support from NCHC NEAT team, and an even smaller number required EEAST conveyance to ED. During this time EEAST data suggests that overall, 61% of urgent ambulance call outs were converted to an unscheduled conveyance, which is comparable to just 4.9% of the North Norfolk RAIS service patients. NNPC are working with the Norfolk & Waveney ICB in the continuation of the RAIS service beyond the 30 th of April 2023 to further build on the collaborative and inter-organisational working for the benefit of the System, and above all, the patients.
Acute Respiratory Infection (ARI) Community Service
The purpose of the ARI Community Services was to drive a model of support which helped to reduce pressure on systems by providing timely and appropriate care for patients with respiratory symptoms. It was initiated on a National scale NHS England in October 2022.
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In December 2022 NNPC was contracted by Norfolk and Waveney ICB to provide ARI Community Hubs to the North, West, and East Norfolk areas. The aim of the initiative was to reduce the pressures of acute respiratory illness on Primary Care and provide more time for Practices to support patients in other aspects of their healthcare needs. ARI East was commenced on the 16 th January 2023 to run until the 31 st March 2023, and was operated out of Kirkley Mill, Tudor Unit. Over the time of the service delivery, it achieved 1907 appointments for patients. ARI North was commenced on the 31 st January 2023 and was planned to run until 31 st March 2023. This was delivered at multiple hubs across North Norfolk, with the majority of the 19 Practices being used as bases. Over this time, it supported the North Norfolk Practices with 1,573 appointments for patients who would have otherwise been attending their GP Practice. It is hoped that this service will be funded for an extended period which may provide further support for the Practices going forward. ARI West also commenced on the 31 st January 2023 and was planned to run until 31 st March 2023. This was based at the Queen Elizabeth Hospital in Kings Lynn. Over this period, it supported 1,561 patients being seen and assessed. It is hoped that this service will be funded for an extended period from 31 st March 2023, which may provide further support for the Practices going forward.
The ARI Service proved to be highly regarded by the System in giving support during the Winter months and had multiple positive feedback communicated from Practices and patients.
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2.2 CQC Statement of Purpose
The CQC Registered Manager is James Leeming, CEO.
The nominated individual for regulated activities is Emma Smith, Director of Clinical Services & Quality
The CQC regulated activities for NNPC are:
• Treatment of disease, disorder, and injury • Diagnostic and Screening procedures • Maternity and Midwifery Services • Family Planning • Surgical Procedures
Section Three: Clinical Quality & Safety 3.1 Review of Key Achievements 22/23 3.1.1 Clinical Supervision implementation
We have successfully achieved all areas of the implementation of a clinical supervision programme for our ARRS clinicians. The development of a staged plan to improve has been developed by the PCN Support team and has resulted in an effective clinical supervision programme across all the ARRS clinicians.
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3.1.2 Patient & Staff Experience – Bespoke Questionnaires
The development of staff and patient experience questionnaires were developed and has provided NNPC with invaluable feedback across the organisation and clinical services, in areas of achievement and where improvement measures may be required.
3.1.3 Performance Scorecard
The Performance Scorecard was implemented in April 2022, and has been a valuable tool in the demonstration of the growth and development of services in relation to the organisational strategy, growth, and development. It provided the Board with a clear overview of the organisation’s monthly performance in relation to quality, clinical and information governance, and service delivery key performance indicators.
3.1.4 Quality & Safety Meetings at Service Level
Weekly service level Quality and Safety Meetings, alongside the monthly Quality and Safety Committee meetings, has enhanced the early identification of areas requiring improvement or development to enhance the patient experience and service performance. The outcome of the implementation of these meetings further embeds the quality and patient safety focus in the delivery of our services.
3.1.5 Development of the Quality & Safety Committee Agenda
The Quality & Safety Committee agenda was restructured in April 2022 to maximise the value of the outputs of the meeting. This agenda provides assurance to the Board that there are robust processes in place for the effective management of Quality and Safety Governance across the organisation and that it supports the delivery of the strategic objectives relating to the provision of high-quality care, which also meets regulatory requirements and standards. This supports the demonstration of the organisational governance of patient safety and quality to operate effectively, and that appropriate action is taken to address areas of concern.
3.1.6 Clinical Education and Training
This objective was achieved by seeing further delivery of Dermatology Teaching Events, the continuation of the ‘Nice to see you……to see you NICE’ Podcasts, and has added further Journal Publications to NNPC’s profile – see:
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❖ Testing for SARS-CoV-2 Infection in Care Home Residents and Staff in English Care Homes: A Service Evaluation - Journal of Long-Term Care (ilpnetwork.org) ❖ Feasibility and evaluation of an emergency department-based GP streaming and treatment service (medrxiv.org)
3.1.7 Development of Investigation into Incident Reporting
This has been achieved with the linking of the significant event and incidents investigations with the corporate performance scorecard report. This includes having a clear root cause analysis / patient harm RAG assessment, to provide a clearer picture of demonstrating the organisation’s identification of, responding to, and outcomes of events and incidents.
3.1.8 Safeguarding
The implementation of the annual safeguarding regulatory compliance auditing tool highlighted areas required for improvement in the development of policy. These were followed up and resulted in improvements in recruitment standards, updating the complaints policy, and ensuring that ‘ safeguarding ’ forms the agenda for all services’ weekly quality and safety meetings.
3.1.9 Complaint Handling
Jointly agreed policies and procedures in relation to complaint handling has been developed and implemented where NNPC has worked with other organisations in the delivery of clinical services. This has provided a standardised approach to complaint handling and has provided clarity to both stakeholders, staff, and patients.
3.1.10 Communications
NNPC’s new, updated website was launched in Summer 2022. It provides the public, stakeholders, and staff with information on the services which NNPC delivers. The aim was to develop a ‘members only’ area, which would be for sole use of our 19 Practices. This, however, is still under development with the aim of the completion of this by the end of 2023. It is hoped that this will enable access to data, reports, and fiscal updates easily and quickly.
3.2 Our Key Priorities in 23/24 3.2.1 Primary Care Dashboard
The Primary Care dashboard project seeks to provide an accessible data tool for GP practices in North Norfolk to use. It is hoped the dashboard will provide Practices, PCNs and North Norfolk with the quantitative evidence to support the ‘Primary Care narrative’ ultimately demonstrating why
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