North Norfolk Primary Care Quality Account 1 st April 2023 to 31 st March 2024
“ Putting the patient central to the delivery of quality healthcare for the local community and beyond”
Patient Centred
Supporting the needs of
Effective
General practice
Quality of Care
Improvement
Safe
Equitable
INTEGRITY COLLABORATION
CARE
CORE VALUES
TEAMWORK
ACCESSIBILITY
LEADERSHIP
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CONTENTS Part 1: Introduction – Quality Account April 2023 to March 2024 ...........................................................3 1.1 Who we are............................................................................................................................................3 1.2 Our Values ............................................................................................................................................4 1.3 Forward from NNPC Chair & CEO .......................................................................................................6 1.4 Care Quality Commission (CQC) Registration ...................................................................................7 Part 2: Our Services ...................................................................................................................................8 2.1 ‘Core’ Services......................................................................................................................................8 2.2 Elective Recovery & Innovation.........................................................................................................12 2.3 Urgent & Emergency Care .................................................................................................................16 2.4 Research, Education, and Training ...................................................................................................22 Part 3: Clinical Quality and Safety Assurances......................................................................................25 3.1 Information Governance & Data Protection - Data Security & Protection Toolkit (DSPT).............27 3.2 Infection Prevention and Control (IPAC)...........................................................................................28 3.3 Audit - Clinical and Administrative....................................................................................................29 3.4 Safeguarding.......................................................................................................................................29 3.5 Incident reporting and investigations ...............................................................................................30 3.2 Complaint reporting and investigations ...........................................................................................31 Part 4: Our Key Priorities .........................................................................................................................32 4.1 Review of Key Priorities for quality improvements for 2023/24 ......................................................32 4.2 Key Priorities 2024/25.........................................................................................................................33 Part 5: Patient and Staff Feedback ..........................................................................................................35 5.1 Service Feedback – Patient Survey and Compliments ....................................................................35 5.2 Staff Experience Surveys – Clinical & Non-Clinical staff & General Practice Staff Survey 2023 ..38 Part 6: Overview of NNPC in the 2023/24 period and Into The Future ..................................................45
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Part 1: Introduction – Quality Account April 2023 to March 2024 It is with great pleasure that we introduce you to our Quality Account for the 2023-24 period. This covers from 1 st April 2023 up to 31 st March 2024. As you read this Quality Account, it demonstrates that we have made significant progress within the Norfolk and Waveney Healthcare System to support improvement in the delivery of clinical services in Primary Care, with the ethos that the patient is central to what we do. The patient experience of healthcare is wholly our motivator for the work we carry out. This quality account will share our achievements over the past year, as well as our goals moving into the 2024-25 period. We have continued to work together with our North Norfolk Practice Care Network (PCN) teams and extended to other PCN’s in the Norfolk and Waveney region to develop a clear strategy to support sustainability for general practice, and have strived to represent Primary Care in an ever demanding healthcare system both locally and nationally. This Quality Account is testament to the dedication, drive, innovation, and outstanding commitment of the team of staff at North Norfolk Primary Care who plan and then deliver the clinical services from inception to reality. 1.1 Who we are North Norfolk Primary Care Ltd is a provider of Primary Care services and was established in 2017 with a vision to support local Primary Care. The organisation is wholly owned by the 19 GP Practices in North Norfolk, and has a Board which is representative of the shareholder membership. Our shareholder practices are:
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We have successfully grown at a steady pace with a mission to deliver and develop strategies to support general practice with the provision of healthcare to the local communities on an ‘at scale’ footprint. We have continued to work independently, and in collaboration with or in partnership with other healthcare provider organisations to further facilitate and support better care for patients. The organisations future into 2024/25, and beyond, will bring wider opportunities and possibilities as we work together within the Integrated Care System (ICS) to deliver innovative and improved ways to deliver healthcare in the community, all for the benefit of patients. With the growth and planned development of the organisation in 2024/25, it will see a change in our name to Norfolk Primary Care (NPC) and we will become a Community Interest Company (CIC). A CIC is a type of social enterprise designed specifically to serve the community, ensuring that any profits are reinvested back into the organisation to further its objectives for the benefit of the communities it serves. The decision to convert Norfolk Primary Care into a Community Interest Company is driven by a mission to enhance healthcare services while ensuring that the community's needs remain at the forefront of the organisational goals. This model aligns perfectly with the ethos of NPC, as it allows the organisation to focus on improving how care is delivered to the communities in Norfolk and Waveney, without the pressure of generating profits. The transition is aimed at achieving greater transparency, accountability, and community engagement, all of which are crucial for delivering high-quality primary care services in the future. This transformation is set to bring a host of benefits to primary care services, General Practitioners (GPs), the Norfolk and Waveney Integrated Care Board (ICB), and most importantly, patients and services users in the region. With this, it is hoped that it will bring new ways of working and exciting opportunities with our organisation members to support general practice and the wider community, in a collaborative approach for the delivery of patient care in the Norfolk and Waveney healthcare system. 1.2 Our Values Our organisational values remain the same and are embedded in our work on 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.
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“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 ” Our organisational values supports the ethos of how we operate on a day to day basis to achieve our performance goal of providing safe, high-quality, effective healthcare within our services and support we deliver to Primary Care. Our organisational structure for Quality Performance ensures that this is monitored closely. Organisational Structure for Quality & Safety Performance Monitoring 2023/24
North Norfolk Primary Care Board of Directors
Senior Management Team
Quality & Safety Committee
Policy Committee
Information Governance Steering Group
Colour Key – Lines of Reporting Assurance Reporting to: Board Delegation, Accountability, Reporting to: Management Delegation, Responsibility, Reporting to: Responsibility delegation, Reporting to:
Services Operational and Clinical Management Team
Service & Clinical Lead MDT
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1.3 Forward from NNPC Chair & CEO NNPC has now been in existence and operational for 7 years. Over the span of time, we have developed from a small organisation supporting local practices into a provider that is now working across Norfolk in General Practice, in all three Acute hospitals, and is working within Place footprints in Norfolk and Waveney for both Elective and Urgent Care. During this time, we have built a wealth of knowledge and networks across the Norfolk and Waveney area with the ICB and other service providers. We have experience of delivering services at scale across Norfolk and Waveney and have developed the relevant expertise, infrastructure and capabilities to support general practice, PCN’s, hospital Trusts, the ICB, and other service providers. We have delivered vital services to our practices and acute Trusts to enhance the delivery of Primary Care services to the heart of communities, and to support general practice in meeting the ever- increasing demands in the healthcare system. We continue to remain true to our organisational values in the delivery of high-quality patient centred care, working with our shareholder practices, and stakeholders to ensure the continuation of our pursuit of working with Practices to enable more of a voice in how healthcare is delivered in the Norfolk and Waveney ICS. We are hugely proud of and grateful to our workforce who demonstrate dedication, commitment, and vision to continuously work together towards our common goals of delivering excellent care, compassion and quality in our clinical service delivery. This is the organisation’s fourth quality account, and is an opportunity for us to be able to share the details about the high-quality service delivery we strive for and deliver on a daily basis. Alongside demonstrating evidence of our achievements, it highlights our priorities and commitment to work on quality improvement over the past year. It represents the stringent governance processes which we have in place to provide continuous improvement and evidence-based 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 the 2024/25 period. This quality account has been prepared by the Director of Clinical Services & Quality, and has been
endorsed by the Board. Dr Peter Lawson, Chair James Leeming, Chief Executive Officer
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1.4 Care Quality Commission (CQC) Registration NNPC is registered with the CQC to provide the following regulated services:
• Treatment of disease, disorder, and injury • Diagnostic and Screening procedures • Maternity and Midwifery Services • Family Planning • Surgical Procedures
The CQC Registered Manager is James Leeming, CEO. The nominated individual for regulated activities is Emma Smith, Director of Clinical Services & Quality.
Our previous inspection in September 2019 resulted in an overall rating of ‘Requires Improvement’, which then led to a targeted inspection on 17 th June 2021. This resulted in us being rated as ‘Good’ in the areas of safe, effective, and well-led. Therefore, NNPC has an overall CQC rating of ‘Good’.
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Part 2: Our Services 2.1 ‘Core’ Services Additional Roles Reimbursement Scheme (ARRS) & the Practice Care Network (PCN) Support Team Introduced in 2019, the NHS England’s Additional Roles Reimbursement Scheme (ARRS) has been supporting the expansion of the workforce in general practice. The range of roles and integration into the Primary Care teams has been crucial to support new ways of working in the longer term – for the benefit of the patient and the staff who deliver their care. Each PCN has its own approach to integrating ARRS employed staff into their workforce. NNPC has supported the PCN’s by directly employing ARRS staff in between 1 st April 2023 and 31 st March 2024. The ARRS roles include Clinical Pharmacists, Pharmacy Technicians, Care Coordinators, Physiotherapists, and Advanced Care Practitioners. The PCN support team continue to work with the practices to provide access to advice and information utilising decision aids and tools to best support the delivery of patient care. The team has given support to recruit, retain, and employ the ARRS staff across the PCN’s. They also facilitate the delivery of clinical supervision and provide day-to-day human resources support for the NNPC employed ARRS staff, with support from an external human resources consultant, where required. They support and work with practices to build strategies and implement National Directives such as premises strategies, extended access plans and Capacity & Access Improvement Plans. This is done through a series of regular meetings set up and serviced by our dedicated PCN team to: • Disseminate summarised, complex, national information – developing options and building consensus between the practices leading to action • Provide momentum, bringing people together, setting of agendas, servicing meetings – ensuring that practices are fully engaged and prepared for whatever the Network Contract evolves into next year • Facilitate strategic planning, financial planning, and inter-practice agreements • Data & analytics – for the Investment & Impact Fund (IIF), capacity & demand, or business case development. Synthesising changing patterns of demand and money, benchmarking practices in a non-confrontational way, and presenting back to practices to prompt decision- making • Work on behalf of practices in service improvement work with other system providers (for example NCH&C, NSFT, MIND etc), frequently needing to lead on behalf of the system • Being the “engine room” behind Clinical Directors (CD’s) and other clinical leaders: facilitating peer networking, giving CDs succinct “what you need to know” information, ensuring important system decisions are presented to CDs for clinical input, and making best use of limited CD time • Ensure that PCNs and general practice have a loud voice at Place Board and Health & Wellbeing Partnerships
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Enhanced Access (EA) Service The Enhanced Access Service was a development from the Improved Access and Extended Access Service in October 2022. NNPC continued to fully deliver EA services to 3 of our 4 North Norfolk PCN’s, within a total of 10 hub sites from April 2023. In November 2023, we also commenced delivery of the EA service in 1 hub site in the Breckland PCN. It is anticipated that Norfolk Primary Care (NPC) will further deliver EA services to other PCN’s from April 2024. We worked with the practices to develop a shared vision of service delivery which met the requirements of the patients in the community. This has meant that the service design is bespoke to the PCN’s and has been developed with them to ensure that a multidisciplinary approach to the clinics is met. The EA service provides patients with access to general practice from 18:30 hours until 20:30 hours Monday to Friday, and 09:00 hours on a Saturday delivering face-to-face appointments, and remote appointment where required. The clinics offer a wide range of appointments, for example, general consultations, long term condition management, same day / acute problems, and health checks. In the 2022/23 period, we have offered a total of 24,023 appointments. Health & Safety (H&S) / Infection Prevention & Control (IPAC) Support Service Since February 2020, NNPC has employed a H&S manager whose role has developed to provide a much-valued support service to the practices. In 2022/23, the H&S Manager undertook further education in IPAC to widen the scope of support being offered to the practices. This service has been delivered to North Norfolk practices, and beyond. The areas of work which the H&S manager undertake are: • Audit with action plan – RAG priority rating covering the following areas: Management of H&S Staff consultation, information and training Risk Assessments likely to be required in General Practice First Aid Accident reporting and investigation Visitors, locums and contractors Building maintenance The workplace DSE Work Equipment First aid Safety and Emergency management Personal Safety/Violence and Aggression COSHH/Clinical Waste Electrical Safety Gas Safety External pedestrians & car parking Welfare Storage/Manual handling
• Follow up visits for re-auditing or further advice or support • Infection Prevention and Control Advice • Quality assurance audits to all hubs where NNPC services are delivered
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Norwich Health Centre (NHC)
NNPC took over the delivery of the services based at Norwich Health Centre, Rouen Road, on 11 th December 2023 under a ‘care taker’ contract until 31 st March 2025. This was to ensure that the Practice continued to deliver care to the communities in the circumstance of the previous provider no longer being able to deliver this established service.
NHC cares for a wide demographic of patients in the Norwich area, with approximately 10,948 patients on their list. We continue to deliver high-quality care to those patients who are registered at the Practice, and have already made an impact on the improvement plans to positively impact the quality of service delivery into the 2024/25 period. Our priorities were as follows: • To ensure safety of patients, through staff working to clear processes and policies • To recruit to a full establishment of staff for both the Practice. For this, we needed a clear financial budget to work towards • To clarify our position within the Norwich PCN’s and planning for how this will look in 2024/25 Since joining NNPC, we are pleased to report that all remaining members of the Practice Team and the newly appointed staff have been and continue to be motivated to work towards excellence in patient care. Those who work in the Practice are committed to improving service delivery, and it will be rewarding to work with them to reach our quality improvement goals. In the period since 11 th December 2023 and 31 st March 2024, there were 11,301 patient appointments delivered at the Norwich Health Centre. This accounts for patient contacts across the whole clinical team which includes the Phlebotomist, Physiotherapist, GP’s, Health Care Assistants, Practice Nurses, Clinical Pharmacists, and Advanced Nurse Practitioners. The Norwich Health Centre was visited by Health Watch in February 2024, which reported that patients are mostly happy with their care and that staff were kind and polite to them. They also highlighted some aspects where things could be improved, which the team will incorporate into the quality improvement goals moving forward. The last CQC inspection of the Norwich Health Centre and the Walk-In Centre was in February 2022, and both were rated overall as ‘Good’. The Vulnerable Adults Service (VAS) and Asylum Seeker Service Like the Norwich Health Centre, NNPC took over the delivery of this Norwich based service on the 11 th December 2023 under a ‘care taker’ contract until 31 st March 2025. Like the Norwich Health Centre, this was to ensure that the services continued to deliver care to the communities in the circumstance of the previous provider no longer being able to deliver the services.
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The VAS and Asylum Seeker Services are based at Westwick Street, in Norwich, and supports access to Primary Care Services by registering with the VAS service or a local GP Practice, enabling access to vital healthcare and mainstream health services to those adults who have complex needs and severe multiple disadvantages. The VAS and Asylum Seeker Service staff has established a high-quality service since it was initiated in April 2020. The services have carried out a combined 795 appointments over the period of 11 th December 2023 to 31 st March 2024. i. The Vulnerable Adults Service (VAS) The service aims are to: • Provide an intensive collaborative approach to deliver health care • Reduce health inequalities to provide fair and equal access to healthcare services • Provide supportive and comprehensive assessments and screening services in a wide range of health and social care needs • Integrate access to other services and organisations such as Norwich County Council, voluntary sector groups, and Inclusion Health teams The clinical improvement measures undertaken in 2023/24 included: • The further development and delivery of monthly multidisciplinary clinical meetings to incorporate prescribing audits, death reviews, complex patient case reviews, updated policies, learning from significant events, and patient feedback • Clinical meeting educational sessions delivery from external speakers – planning included discussions on prescribing in mental health, alcohol pathway support, prescribing in liver disease and palliative care for complex patients, and safeguarding case discussions • VAS team contributions to ICS educational events and clinical pathway reviews
In December 2023, the VAS team won an award at the General Practice Awards in the ‘Clinical Improvement: Public Health and Prevention’ category. The service, on average, had 88 patients on their register each month over the period of 11th December 2023 to 31 st March 2024. In addition to the patients registered at the service, the team
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supported Inclusion Health Practices in Norwich with patient care and advice. This equated to a further 7 patients for the Vulnerable Adult Service Team. ii. The Asylum Seeker Service The Asylum Seeker Service team works closely with Norfolk County Council to support asylum seekers to access healthcare services in the Norwich asylum dispersal area of the Norfolk and Waveney region. The asylum seeker team supports and delivers new arrival health checks / screening services, GP practice registration, specialist support to those with complex needs, and reducing unnecessary attendances by ambulance to ED departments, for examples. The service aims are: • To provide an integrated approach with healthcare and social care professionals to work together to improve access and overcome obstacles • To support access and promoting the use translation services to provide support to service users to receive quality health and social care • Provide specialist knowledge and skills to support asylum seekers and refugees while living in the Norwich area, with the aim to encourage independence and improving outcomes • To reduce health and social care inequalities through a single-point delivery model offering specialist expertise in the field to promote good practice • Improve cultural competence of multi-sector organisations across Norfolk The NNPC Asylum Seeker team are embedded in the wider ‘People from Abroad’ Team (PFAT) which covers the Norfolk and Waveney region. The PFAT has a broad range of skills and expertise to support the Asylum Seeker team to deliver safe, effective healthcare to the migrant community. The team had a caseload of a total of 317 adult asylum seekers from 11 th December to 31 st March 2024, this breaks down to 231 patients in contingency hotels and 86 patients in dispersal accommodation. In addition to the patients seen in service, the team supported Inclusion Health Practices in Norwich with patient care and advice for an additional 26 patients. 2.2 Elective Recovery & Innovation Community Gynae Service NNPC supported James Paget University Hospital NHS Foundation Trust (JPUH) in outpatient waiting list validation from February 2023 to May 2023 for gynaecology and uro-gynaecology specialities. This was to identify those patients who had been referred to the gynaecology speciality at the JPUH by their GP for a gynaecological or uro-gynaecological problem, and had waited 12+ weeks for their appointment, with no planned appointment having been made. The patients were contacted to complete a questionnaire to confirm the status of their problem, and either remove them from the waiting list in the case if the referring problem had been resolved, or directed to the most appropriate next step to address their presenting complaint. This service resulted in the validation of 1,412 patients, who went on to receive the most appropriate care for their healthcare
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needs. The equates to almost 30% of patients being contacted and given appropriate care, so could be removed from the waiting list. On the back of the referral validation work, NNPC delivered a face-to-face service to further support the hospital. So far, 518 patients have been seen in face-to-face clinics which have been held locally to the James Paget University Hospital, out of the hospital base and treated patients between January and 31 st March 2024, with the work beyond this date is still continuing. This has supported patients accessing the healthcare which they require in a shorter time frame than they would have experienced had they waited for the hospital-based care. Dermatology – Teledermatology and Community Dermatology Clinics Over 2023/24 NNPC delivered a tele dermatology service in collaboration with Xyla Healthcare to enhance the referral pathways for patients in Primary Care. This enabled Primary Care access to consultant based expertise via a practice embedded digital platform. This supported GP’s in receiving expert opinion on dermatological conditions which may have otherwise been sent to hospital, having been on a waiting list for several weeks / months. The tele dermatology service reviewed 4,975 cases from 1 st April 2023 – 31 st March 2024 across the Norfolk and Waveney region, with a total of 73 practices being onboarded to use this digital platform service which supported 786 users of the referral pathway. The cases referred included 3,859 skin lesions, 860 rashes, and 256 of other dermatological conditions. Of those patients referred to the service, 3193 received a treatment plan in 0-24 hours, 1,155 between 24-48 hours 579 between 48-72 hours and 48 in excess of 72 hours but sooner than 5 days. Of those, NNPC arranged and saw 451 patients in face-to-face clinics for assessment, treatment or onward referral and 662 patients seen in lesion photography clinics between 1 st April 2023 – 31 st March 2024. This resulted in 71% of patients being retained in Primary Care. Alongside the tele dermatology referral pathway within general practice, NNPC supported the JPUH & the Queen Elizabeth Hospital (QEH) to reduce waiting times for patient who were awaiting a dermatology outpatient appointment. Throughout December 2023 and March 2024, there were 126 patients managed by the tele dermatology service, resulting in 21 of those being seen and treated in NNPC face to face clinics, and a further 30 patients being managed in Primary Care. The remaining patients were placed on the most appropriate pathway to address their healthcare needs in a timely manner via the hospital specialists. This service was decommissioned by the Norfolk and Waveney ICB on 31 st March 2024, with the plan to revert to a general practice hospital-based referral pathway.
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Home Visiting Service – Gorleston Primary Care Network (PCN) From the 1 st July 2023 until 30 th November 2023, NNPC supported home visiting to 3 practices in the Gorleston PCN by delivering 2,121 visits to patients homes. This was a service which was commissioned by the practices directly with NNPC to support those patients who required a home visit. The service provided valuable support to deliver: • Urgent home visiting service to housebound patients • Routine housebound patient review • Chronic illness reviews and management plans • Acute illness exacerbation reviews and management plans Lower Gastrointestinal Support Service (LGISS) – Supporting the Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH) and the James Paget University Hospital NHS Foundation Trust (JPUH) NNPC continued to be commissioned until February 2024 by the Norfolk and Waveney ICB to provide the LGISS which has the aim of assisting the NNUH, and in addition from May 2023, the JPUH. This remote service supported the pathway for inappropriate / low risk 2 week wait (2WW) referrals that the Trusts received from Primary Care that fulfil the below criteria: 2WW GP referrals with negative FIT PLUS one or more of below symptoms: • Change of bowel habit • Abdominal pain • Weight loss • A raised platelet count Exclusion criteria: • Iron-deficiency Anaemia • Anal ulceration and/or mass • A palpable rectal or abdominal mass • Rectal bleeding The primary aim of the service is to exclude colorectal cancer. Secondary aims include: • Onward referral to Community Services as required. • Phlebotomy and other diagnostic investigation requesting • To give additional advice on likely diagnosis, further investigation and management option • To diagnose serious pathology in patients and to ensure that they are put on the correct cancer pathway • To give guidance on the management of symptoms of non- serious pathologies through a clinical history and a diagnostic process • To work with colleagues in general practice and secondary care to achieve the best possible care and outcome for the patient
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The service has supported 550 referrals from the NNUH and JPUH over this period, with an average of 83% of those patients being managed and discharged back into the care of their GP with 36% of those patients having had further diagnostic investigations (such as a CT scan, repeat FIT testing). The LGISS was temporarily halted in March 2024 due to the recommissioning process, but it has since been reinstated by the Norfolk and Waveney ICB. The service has now been expanded to include all three acute hospital Trusts in the Norfolk and Waveney ICB area. Primary Care Support to New Hospital Programme and James Paget University Hospital NHS Foundation Trust NNPC provided a Primary Care Project Manager to support the new hospital programme team, working closely with hospital speciality teams to develop links, ideas, and support on where workload can be reduced from the hospital footprint. This focussed on where services could be relocated to Primary Care via developing alternative referral pathways which meant that patients could be treated nearer to home and receive a more community-based approach to their health needs. Collaborative specialty approaches and strategic insights into patient care across many specialities has been explored, and will continue into the coming years. The end goal of the new JPUH build will enhance the flexibility and adaptability of the hospital facilities to improve the patient experience, whilst supporting the delivery of healthcare services to people nearer to home, wherever possible. Rapid Diagnostic Service (RDS) NNPC continued to be commissioned by the Norfolk and Waveney ICB to deliver the RDS. This service is for people with serious symptoms that could indicate cancer, but which do not fit the criteria for urgent cancer referrals on a site-specific pathway. Symptoms might include unexplained weight loss, fatigue, or abdominal pain, or if the GP just has a strong feeling something is not right. Without this service, these patients might have to visit their GP multiple times before getting referred to a specialist, causing delays in diagnosis. To refer a patient, clinicians need to fill out a form online, which triggers various tests based on the patient's gender and symptoms. The RDS makes the process a quicker pathway to diagnosis for the patient by organising tests, reviewing results, and coordinating with specialists, leading to faster diagnosis and an enhanced patient experience. The team includes four experienced GPs and patient pathway navigators, who are available to help patients and clinicians throughout the process. They have more time for appointments than the usual allocation in general practice and work closely with hospitals and specialists to ensure prompt testing and diagnosis. Their goal is to diagnose and refer patients to the most appropriate specialism (where required) within 28 days of referral. The service operates from three locations; Norwich, Great Yarmouth and Kings Lynn. It also offers remote appointments when suitable. Over the course of 1 st April 2023 to 31 st March 2024, there has been a total of 828 patients referred into the service. This resulted in an average of:
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• 70% of patients being discharged with a non-cancer diagnosis • 9% of patients being diagnosed with cancer • 21% of patients being discharged with an alternative or no diagnosis Referral validation – Ear, Nose, and Throat (ENT) Speciality - James Paget University Hospital NHS Foundation Trust (JPUH) In June 2023, NNPC supported the JPUH with referral validation for patients on the ENT waiting list, having already waited 46+ weeks to be seen. We contacted with a total of 573 patients to validate their referral, with the results that: • 4% no longer required the appointment, as they had been treated elsewhere, so removed from the waiting list • 9% no longer required the appointment, as the symptoms had resolved, so removed from the waiting list • 29% of patients were uncontactable, or had been referred to the service more than once during their waiting list period • 58% still required the appointment 2.3 Urgent & Emergency Care Acute Respiratory Infection (ARI) Services
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 acute respiratory symptoms. It was initiated on a National scale NHS England as part of the Winter planning in 2022, and 2023 alike. As part of the 2023 Winter planning, the ARI service was commissioned by the Norfolk and Waveney ICB and delivered by NNPC in the North, West, and Gorleston & Mid-South Norfolk areas.
The patients were seen in the ARI same day service with specific respiratory symptoms in clinics, which were in addition to the usual general practice clinics held on a daily basis. The additional capacity is also intended to reduce the burden of acute respiratory illness on primary care releasing time for primary care to support patients where continuity of care is most important (such as those with existing long-term conditions and co-morbidity). i. North Norfolk The North Norfolk area ARI service was delivered across the majority of the 19 Practices on a hub based model. Commencing on the 8 th January 2024 until 29 th February 2024, the service delivered 1,882 appointments, with the outcomes of:
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Count of Clinical Intervention
Outcome
Discharged from service - treatment given. No further action required
1,086
Discharged from service - no treatment. Advice only Follow up with own GP Cancelled by Other Service
474
98 62 61 44
Did Not Attend
Cancelled by Patient
Referred to ED - urgent assessment requested
31
Admission to hospital
9
Cancelled by GP Practice
17
Grand Total
1,882
These appointments are in addition to the end of the ARI North service from 2022/23, where a further 2,119 patients were seen. ii. Gorleston & Mid-South Norfolk The Gorleston & Mid-South Norfolk area ARI service was delivered between 10 th January to 31 st March 2024 with bases at JPUH, and the Orchard Surgery in Dereham, Norfolk. The service delivered 831 appointments, with the outcomes of:
Count of Clinical Intervention
Outcome
Discharged from service - treatment given. No further action required Discharged from service - no treatment. Advice only
482
183
Did Not Attend
65 46 24 13
Follow up with own GP Cancelled by Patient Cancelled by GP Practice
Cancelled by Service Admission to hospital
1 6
Referred to ED - urgent assessment requested
11
Grand Total
831
These appointments are in addition to the end of the ARI service at Kirkley Mill, Lowestoft from 22/23, where a further 1,907 patients were seen.
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iii. West Norfolk The West Norfolk area ARI service was delivered from 4 th December 2023 to 31 st March 2024 from with the based at the Queen Elizabeth Hospital NHS Foundation Trust (QEH) and delivered 3,128 appointments, with the outcomes of:
Count of Clinical Intervention
Outcome
Discharged from service - treatment given. No further action required Discharged from service - no treatment – Advice only
2,106
520 185
Did Not Attend
Follow up with own GP
96
Cancelled by Practice, Patient, or Service Referred to specialist service (Virtual Ward) Referred to ED - urgent assessment requested
148
27
46
Grand Total
3,128
The West Norfolk ARI Service continues to be operationally delivered into April 2024, which will further support practices to care for those patients with respiratory symptoms in a timely manner. The NNPC delivered ARI Services 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 which supported the management of a total of 9,867 patients over the Winter months. GP at the Front Door (GPFD) Service The purpose of the GPFD Service is to offer suitable patients access to a GP appointment instead of being seen and treated in the Emergency Department (ED). The service delivers care much like a ‘satellite GP hub’, with the provision of access to a Primary Care clinician who has full access to the medical records of all the patients who are streamed to the service. This promotes safe, effective primary care modelled healthcare to patients and supports a general practice service on behalf of the patients registered practice. The GPFD service operates from 09:00 hours until 21:00 hours, 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. However, it is not a patient-initiated referral service, but may be accessed via clinician streaming on a walk-in attendance to the ED front door. 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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i. James Paget University Hospital NHS Foundation Trust (JPUH)
The GPFD service continues to support the JPUH ED team to see, assess, and treat patients as an alternative to the ED care pathway. It streamed 44,741 patients at the front door, and saw 16,333 of those patients in the GPFD service from 1 st April 2023 to 31 st March 2024. This was an annual average of 37% of those patients who walked in to be seen in ED during the GPFD service hours, who were seen at the GPFD service instead. NNPC has worked closely with the ED management team at JPUH to further strengthen ED performance by providing an increase in GPFD Service workforce at certain times such as Bank holidays periods or staffing strikes over these periods. ii. Queen Elizabeth Hospital NHS Foundation Trust (QEH) Since its inception in early January 2022, the GPFD service at the QEH has had 35,792 patient contacts in the front door streaming, and has seen 13,058 patients in the service. This was an annual average of 37% of those patients who walked in to be seen in ED during the GPFD service hours, who were seen at the GPFD service instead. The QEH is delivered with the same clinical model as JPUH. It is based on a simple ‘pull’ streaming model, which is initiated at the front door at ED by an experienced Primary Care clinician with a narrow inclusion and exclusion criteria of clinical presentation which accounts for patient safety that facilitates the safe and effective delivery of Primary Care services. iii. Norfolk and Norwich Hospitals NHS Foundation Trust (NNUH)
Since July 2023, NNPC has delivered the GPFD service at the NNUH. It is co-located within the ED footprint, and operates on a ‘push’ clinical streaming model. This means that the ED clinical team selects walk-in patients who attended to be ‘streamed’ to the GPFD Service. This is in adherence to the inclusion and exclusion criteria of:
Inclusion Criteria • All patients who present to the ED, if they are registered with a GP Practice within the UK and are assessed by a clinician to be suitable for primary care • Children over three months may be seen by the service for minor illness complaints where appropriate as assessed by the clinician. All children 3-12 months will have a temperature recorded and documented by the streaming clinician within an aim of 15 minutes. • Patients with potential dental issues that require urgent medical treatment.
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Exclusion Criteria • Any patient requiring intervention or investigation within ED as an urgent measure (i.e. the same day) NOTE: Patients that may require onward referral to a specialty MAY be seen by GPFD and should be encouraged to support inappropriate ED attendances, depending on the nature of their symptoms and investigations should not delay this process – there is a separate Hospital specialty referral process) • Non-traumatic chest pain • Any patients with signs or symptoms of stroke • Children under 3 months
To this end, it has been vital that the ED and GPFD staff work together to communicate effectively in relation to appropriate patient management with consideration of patient safety and better outcomes for patients. In the period of 10 th July 2023 to 31 st March 2024, the GPFD service at the NNUH has seen, assessed, and discharged 13,495 patients in the service.
In November 2023, NNPC and NNUH teams undertook a ‘pull’ model of GPFD streaming pilot. This means that the GPFD clinical team selects walk-in patients who attended to be ‘streamed’ to the GPFD Service, which came with the provision of an extra experienced Primary Care clinician at the front door to be the first point of contact for the walk-in patient to the ED front door. This method of streaming is in comparison with the ‘push’ model of the ED team ‘streaming’ the patient to the GPFD Service. The pilot resulted in an average of a 55% increase in the patient numbers being seen when compared to the previous month, and a demonstratable positive increase in the qualitative data from the patient feedback surveys. Overall, the JPUH & QEH GPFD services has had 80,553 patient streaming contacts at the front door of ED. The combination of the three GPFD services has seen, assessed, treated and discharged a total of 42,886 patients over the course of 1 st April 2023 to 31 st March 2024 (Note: The NNUH GPFD Service commenced 10 th July 2023), with the following outcomes:
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Outcome
Outcome Number
Outcome of Specific Service %
JPUH
16,333 2,110
Discharged – no treatment – no further action
13%
Discharged - other
479
2.9%
Discharged - treatment given - no further action Referred into A&E for further investigation Referred on to speciality service (inpatient) Referred on to speciality service (outpatient) Referred to GP - further investigation required
11,220
68.7%
762
4.7%
282
1.7%
342
2%
1,016
6.3%
Returned to A&E - No GP
4
0.02% 0.68%
Not recorded
118
NNUH
13,495 1,511
Discharged – no treatment – no further action
11%
Discharged - other
712
5%
Discharged - treatment given - no further action Referred into A&E for further investigation Referred on to speciality service (inpatient) Referred on to speciality service (outpatient) Referred to GP - further investigation required
6,091
45%
624
4.5%
1,355
10%
873
6.5%
2,065
15%
Returned to A&E - No GP
5
0.04% 2.96%
Not recorded
259
QEH
13,058 1,961
Discharged – no treatment – no further action
15%
Discharged - other
444
3.5%
Discharged - treatment given - no further action Referred into A&E for further investigation Referred on to speciality service (inpatient) Referred on to speciality service (outpatient) Referred to GP - further investigation required
6,466
49.5%
927
7.1%
976
7.45%
1,206
9.2%
871
6.7%
Returned to A&E - No GP
7
0.05%
Not recorded Grand Total
200
1.5%
42,886
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Norwich Walk In Centre (WIC) Service
In conjunction with the previously mentioned Norwich based services, NNPC took over the delivery of the WIC service delivery on 11 th December 2023 under a ‘care taker’ contract until 31 st March 2025. The WIC service (located on Rouen Road in Norwich city centre) provides valuable same day and urgent access to primary care healthcare provision. The aims of the WIC is to provide support to patients who are unable to access their own registered practice, and to
provide system support for same day emergency pressures. The WIC is a face-to-face service and operates on a 7 days per week basis, from 07:00 hours to 21:00 hours, which includes Bank Holiday periods. The service is staffed by suitably experienced clinicians, which include GP’s, Advanced Nurse Practitioners, Nurse Practitioners, Nurse Prescribers, and Healthcare Assistants. Since 11 th December 2023 to 31 st March 2024, the WIC has seen, assessed, treated, and discharged 23,642 patients. In addition to the walk in ‘see and treat’ service, there is a WIC based phlebotomy service which has seen 2,268 patients come to the service within the same period. 2.4 Research, Education, and Training NNPC has a passionate approach to research, education, and training and is deeply committed to the creation of a positive learning environment for our workforce. Norfolk Research Hub NNPC commenced delivery of the Norfolk Research Hub on 11 th December 2023, which is located at Rouen Road, in Norwich and we are committed to delivering primary care clinical research at scale, benefiting Norfolk patients in a financially sustainable manner that provides an additional income stream to practices. Our team consists of a dedicated GP Research Lead, a Research Nurse, a Project Manager, and an administrator, supported by additional staff as needed. This includes research-experienced nurses, Advanced Nurse Practitioners, a Healthcare Assistant, and administrative support. We operate using a hub-and-spoke model, allowing us to deliver research across Norfolk and Waveney effectively. Our hub practices cover a total of 160,000 patients. This extensive reach is attractive to potential sponsors, significantly enhancing our chances of being selected for clinical studies. Our spoke practices work with us on an ad-hoc basis. When they agree to participate in a specific study, we work with them to present that opportunity to their patients. We can also support practice research activities using Hub resources.
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We are also establishing a Research Champions Delivery Group (RCDG) of patient representatives to help shape the future of research delivery in Norfolk and Waveney. We host bi-monthly forum meetings, open to anyone from Norfolk and Waveney Primary Care teams. These meetings showcase our research portfolio and provide a platform for receiving input from members and developing collaborative opportunities. We welcome interest from practices and PCNs, whether on an ad-hoc or more involved basis, and seek support to make the RCDG as successful as possible. The Hub offers support for grant funding bid applications and other funding opportunities, as well as activities supporting the creativity and innovation pathway. Teaching and Education Sessions Over the 2023/24 period, NNPC has developed and delivered teaching and educational sessions to benefit our workforce in the delivery of high-quality patient services. The focus of the sessions has been guided by the clinical workforce, or areas which have been identified as a learning need as a result of a significant event or complaint. We have had positive feedback from the participants of the educational sessions, which included various clinical topics which incorporated case-based discussions, evidence-based practice, and clinical pathway developments. Student Doctor Support at the GP at the Front Door and Rapid Diagnostic Services NNPC has supported the placements of medical students from the University of East Anglia (UEA) at the Rapid Diagnostic Service and GP at the Front Door services since 2022. We host medical students throughout the academic year, which has benefitted the medical students in their learning pathway and supports Primary Care workforce resilience into the future. Pharmacy Pilot – Rapid Diagnostic Service (RDS) Team Since February 2024, the RDS clinical team has been working on the delivery of “proof of concept” project exploring the efficacy of direct referrals from Community Pharmacy to the RDS. This is a nationally funded project, supported by the Integrated Care System and the Cancer Alliance. The sign-off the project went live during March 2024, with the original aim to run for 3 months. After a relatively smooth launch, it had been agreed in principle to carry on with the project until December 2024. Excitingly, the National Project Team and the Cancer Alliance has now negotiated an extension of the project to March 2025 with associated funding. The project hopes to test the hypothesis that ’community pharmacies can support the earlier diagnosis of cancer through direct referrals for suspected cancer symptoms. The aim of this project is to test the feasibility and acceptability of pharmacy referral routes into secondary care via the RDS. This involves the development of an adapted referral pathway, via a GP assessment provided by the local primary care-based RDS. The project includes participation in a national quantitative and qualitative evaluation.
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