Annual Report 2020/21 Underpinning the resilience of General Practice throughout the Pandemic
Contents Page No A welcome from our Chairman, Dr Nigel Fraser .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
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An overview of the year from our MD, Dr Mike Hearne .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
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Taurus Healthcare Vision, Values and Purpose .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. How We Deliver .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Who’s Who on the Taurus Healthcare Board .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
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Working with Local Health and Social Care Organisations
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Herefordshire General Practice Leadership Team .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
The Importance of Strong Primary Care Leadership : A View from the CCG .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Supporting Local Practices
Supporting Practices to be Safe, Effective and Resilient .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Human Resources and Organisational Development .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Flexible GP pool - a New Service to Support General Practice .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. COVID Workforce Recruitment Drive is a Big Success .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Herefordshire and Worcestershire Primary Care Training Hub .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Business Intelligence and Communications .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. GP Teamnet .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Herefordshire Primary Care Networks .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
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10-11 12 13 14 15 16 17 18-19 20-21 22-23 25-42
Contents Page No Providing Clinical Services Expanding and Improving our Clinical Services .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Business as Usual for Taurus’ Clinical Services Team .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Weekend Care Home Service - Providing Welcome Support for Residents and Staff .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . COVID Management Service - Reassuring Patients Through Worrying Times .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Virtual GPs Evolve From Success of COVID Management Service .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. New Post-COVID Care Service Introduced in 2021 .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
43 44 45 46 47 48 49
Quality and Improvement
51-52
Financial Summary
53-55
The Year Ahead
57-58
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A Welcome From Our Chairman, Dr Nigel Fraser The past year has once again been headlined by COVID, where the emphasis has moved away from the disease itself and more on to the roll-out of the new vaccination programme and the whole restoration process. The vaccination programme has been hugely successful, limited only by the volume of vaccine available to us. This success underlined the importance of taking a collaborative approach, whereby Herefordshire General Practice worked closely with its partners and communities to achieve fantastic results. Indeed, the ethos of the Federation to support its member practices and networks was emphasised with the approach of ‘Practice First’. The heroic efforts of General Practice to deliver this programme on the back of the pandemic, supported by the federative team, the acute trust, local authority and local volunteers, has laid the foundation to continue the vaccine programme. This year we have also seen the voice of General Practice become unified through the development of the Herefordshire General Practice Leadership Team. This brings together Primary Care Network Clinical Directors, Taurus Federation leaders, the Secretary of the Local Medical Committee (LMC) and the Director of Primary Care from the local Clinical Commissioning Group to provide the decision making forum for Herefordshire General Practice. This transforms the landscape for General Practice, where such an arrangement is seen as a national exemplar in ensuring the voice of General Practice is co-ordinated into the system. Both operational and strategic decisions are taken. The LMC provides oversight and acts as ‘critical friend’. This is a key development that strengthens the position of General Practice as we move into a transition year of the ICS. It builds on current relationships and ensures that General Practice is welcomed as a peer in the transformation of services and - equally important - is well placed to advocate on behalf of its patients. Page | 4
An Overview of the Year From Our MD, Dr Mike Hearne Since the last Taurus Annual Report was published, we have been building on our successes and acting on the feedback we have received from practices. As a Federation, we continually aim to underpin the resilience of Herefordshire General Practice, whilst always looking to improve the experience of patients and access to our services 24/7. Strategically, distributed co-ordinated leadership has improved our collective representation, whilst developing an approach that enables the voice of our practices to be heard. We have been pleased this year to respond to feedback received at last year’s Annual General Meeting by providing weekly video updates. These outline the key actions we have taken on behalf of Herefordshire General Practice as well as pointers to strategic items of national, regional and local interest. The clinical services delivered by Taurus Healthcare on behalf of our practices, have evolved into Herefordshire’s ‘Sixth PCN’. This approach recognises the need to provide a continuum of care for our patients and to ‘make every contact count’. Indeed, we have attracted national interest in the way we work as the only GP Out of Hours service to use the same system as practices and community services EMIS. The resilience of our services has allowed for new ways of working, including remotely delivered COVID Management and Virtual GP Services. We will be looking at how we can further adapt the service to best support our practices. Federative support to practices continues to grow, where workforce and management support are the greatest areas of need. Taurus has employed Practice Managers to provide direct support for practices and back office support, where required. The Primary Care Networks have grown hugely in terms of additional roles, overseen by the PCN management team. I would like to thank all my General Practice colleagues and all those in the growing Federation workforce. It’s been a year where we have all worked long hours whilst retaining flexibility and collaboration at the core, in order to deliver good quality patient care. Collectively, I think we should be proud of everything we’ve achieved.
Picture courtesy of Simon Hylton Page | 5
Our Vision, Values and Purpose
Our vision
Our Values
Our Purpose
To be recognised as trusted experts, delivering high quality General Practice for the people of Herefordshire
Collaborative working
Aiming for 24/7 ‘joined up’ General Practice across Herefordshire
We always aim To work with partner organisations to provide coordinated prevention and early intervention To provide expert advice or support, when required, as close to home and as ‘joined up’ as possible Page | 6
To always care and be compassionate to our patients and teams
Supporting the sustainability and resilience of Herefordshire General Practice Providing a single strategic voice on behalf of Herefordshire General Practice
We want To support and empower our patients and communities to live independent, healthy, fulfilled lives
Photo: Nikki Marriott
How we deliver
1
2
3
By working with local health and social care organisations
By supporting local practices
By providing clinical services
We represent the views of General Practice at local health and care meetings to ensure care is shaped around the needs of our local population.
For example, by helping with recruitment, managing staff and providing management support, so that practices can focus on caring for their patients.
On behalf of local practices. For example, when surgeries are closed or when it makes sense to deliver a single service across the county.
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Who’s Who on the Taurus Healthcare Board?
Dr Nigel Fraser
Dr Mike Hearne
Mr Andrew Lee
Mrs Nikki Marriott
Dr Lauren Parry
Mrs Nisha Sankey
Chairman
Managing Director
Director of Finance
Director of Nursing and Quality
Associate Medical Director
Director of Strategy and PCNs
Dr Ritesh Dua
Dr Paul Harris
Dr Cath Laird
Dr Louise Mottram
Mrs Alex Price
Mr Graeme Walker
North and West PCN
Wargrave, Belmont and Cantilupe (WBC) PCN
Hereford Medical Group (HMG) PCN
East PCN
South and West PCN
Chair of Finance Committee
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Working With Local Health and Social Care Organisations
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Herefordshire General Practice Leadership Team Bringing together General Practice leadership in order to unify the voice of General Practice. Also, to act as the conduit to bring together the voice of our practices and those of the wider system, across operational and strategic initiatives. Who are we?
PCN Clinical Directors - representing each of Herefordshire’s five Primary Care Networks
GP Federation (Taurus Healthcare) Leaders
Local Medical Committee (LMC) Secretary
Herefordshire and Worcestershire Clinical Commissioning Group (CCG) Director of Primary Care
What is our role?
SUPPORTING General Practice resilience and sustainability
Providing COORDINATED LEADERSHIP and being the VOICE OF GENERAL PRACTICE at PLACE and ICS LEVEL
SUPPORTING PCN DEVELOPMENT and DELIVERY via a ‘Network of Networks’
Overseeing DELIVERY OF CLINICAL SERVICES via Federation ‘GP 24/7’
Developing LOCAL SOLUTIONS to local problems
Providing a POINT OF ACCESS through which our partners can link to General Practice
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Pictured Top row: Dr Nigel Fraser, Dr Mike Hearne, Nisha Sankey, Dr Lauren Parry Middle row: Dr Sarah Newey, Dr Verity Wilkins, Dr Dominic Horne (replaced Dr Simon Lennane from 1.6.21), Dr Andy Watts Third row: Dr John Stevenson, Dr Paul Harris, Dr Silvana McCaffrey, Lynda Dando, (Herefordshire and Worcestershire Clinical Commissioning Group)
Working together with Taurus has improved communication with other providers across One Herefordshire and with the CCG/ICS. Our voice is not always heard, but generally I feel Primary Care has become more empowered over the last 12 months. The PCN Project Managers have, under Taurus support, helped us to embed our ambitions as a PCN Dr Sarah Newey, Joint CD, East Herefordshire PCN
Herefordshire General Practice Leadership Team How we work
We are committed to:
ENGAGING and COMMUNICATING with GP practices and system partners
Ensuring what is RIGHT FOR PATIENTS is at the heart of decision making
BEING THE VOICE of Herefordshire General Practice
Providing CLINICAL LEADERSHIP
Collaborating and CHAMPIONING THE ROLE OF PLACE #OneHerefordshire
COLLABORATING with GP colleagues across the ICS via the ICS GP Provider Forum
RESPECTING LMC responsibilities with LMC being our critical friend
CO-PRODUCING local GP CONTRACTUAL REQUIREMENTS with ICS colleagues
Weekly meetings: Tuesdays 9-11 am Dedicated time for system partners to join us every other week Key decisions and actions are captured and cascaded, eg to PCN Team Managers, Practice Managers, Communications team Transparent about any conflicts of interest
It’s fair to say that all of us CDs would have felt more overwhelmed with the expectations of the system and NHSE if the leadership team hadn’t been with us in Herefordshire. Very much value the lightening of the workload that is achieved by other team members regularly and reliably attending meetings on CDs behalf and giving a whole Herefordshire PCN/CD view. Dr Verity Wilkins, Joint CD, East Herefordshire PCN
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The Importance of Strong Primary Care Leadership : A View From The CCG The role and significance of PCNs in an integrated care setting is well documented in the Long Term Plan. The recently published Integrated Care Systems Design Framework confirms the importance of strong Primary Care leadership and involvement at System (ie Herefordshire and Worcestershire) and Place (ie Herefordshire county) level. A single, unified voice for Primary Care at system level, which is representative of all its parts, is essential for the ICS to deliver its objectives and PCNS to fulfil their potential especially in ensuring that the knowledge which practices have of their local community is harnessed. The steps being taken in Herefordshire in the last 18 months to gain a mandate from all practices and to establish a strong GP Leadership team to not only support PCNs and individual practices but to take on the strategic leadership role and voice at place and ICS level is to be commended. Lynda Dando, Director (Primary Care) Herefordshire and Worcestershire Clinical Commissioning Group
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Supporting Local Practices
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Supporting Practices to be Safe, Effective and Resilient Supporting practices can take many forms, particularly in a pandemic year. We aim to deliver activities that underpin practices, where it makes sense to do so. The support provided to practices has centred around three headlines. Direct Practice Support This has involved directly running a practice in the past, with more recent and ongoing provision of practice management related activities. This can be anything from providing an interim Practice Manager, to supporting and mentoring the existing practice management team around activities such as policy development, Information Governance support and estates. This also extends support to avoid ‘last man standing’ situations, where Taurus can join a partnership that ensures the GMS contract delivery, whilst retaining the practice level autonomy. Workforce The Herefordshire and Worcestershire Training Hub, educational meeting and podcasts and direct workforce provision all play a huge role in maintaining effective, resilient general practice. Primary Care Networks (PCNs) Employing the PCN Managers on behalf of the majority of networks, and employing the majority of Additional Roles (ARRS) PCN workforce, ensures there is coordinated delivery, whilst aiming to ensure that networks retain flexibility and autonomy in delivering their priorities. Taurus retains the employment workload and protects the surgeries from managing underspends.
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Human Resources and Organisational Development Taurus Healthcare’s Human Resources and Organisational Development team provides a valuable service to GP practices, offering professional advice and support, as required. Here’s how the team has helped to support practice resilience over the past 12 months.
Supported GP practices with recruitment to 36 vacancies, including Practice Nurses, Healthcare Assistants, Receptionists and Advanced Nurse Practitioners
Supported GP practices with recruitment to 15 PCN/ARRS (additional) roles, including Senior Social Prescribers, Care Coordinators, Pharmacy Technicians and Physician Associates.
Recruitment for PCN Vaccination Hubs: Undertook a successful recruitment campaign and set pre-employment and administrative systems in place to ensure PCNS had the staff they needed for delivery of the PCN Hub Vaccination Programme (see full story on page 17).
Development of a new Flexible GP Pool: As part of an NHS England initiative, they have established a new GP pool that provides flexible options to both GPs and practices (see full story on page 16).
Additional HR related services for GPs to be rolled out by the end of 2021. For example HR casework advice; support with Terms and Conditions of Employment and Job Descriptions; recruitment support; and reviews of HR files and report to show what HR support the practice may need from the team. Left to right: Aimee Miles, Tracy Gates, Jocelyn Hughes, Ella Jones and Laura Mansfield Not pictured: Sheila Thompson, who retired from her role as HR Manager for Taurus Healthcare in March 2021 Page | 15
Flexible GP Pool - A New Service To Support General Practice Recruiting, retaining, training, developing and supporting our workforce is key to General Practice resilience. In response to an ask from practices, and in line with NHS England initiatives, Taurus Healthcare, on behalf of Herefordshire General Practice, is creating three General Practice workforce pools. This supports those who want to work flexibly, those who work in one service and would be happy to occasionally and additionally support another and those who want to build portfolio roles. It will provide a long-term sustainable infrastructure that offers benefits to all six PCNs (20 practices and Taurus). Three options will be available, as detailed below. Initially the Pool will be for GPs but will expand to include nurses, additional and administrative roles. The Pool offers a ‘Herefordshire HR passport’ and local training, support and the tools to be an effective member of the Herefordshire workforce.
Option 1
Option 2
Option 3
Locum
Flexible
Salaried Portfolio
Offering a salaried role with no sessional commitment
Offering fixed hours / sessions across a number of in– and out–of hours environments
Enabling you to continue as a GP independent contractor
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COVID Workforce Recruitment Drive is a Big Success Late last year, once it became clear that a COVID vaccination was coming down the tracks, Taurus started work to recruit additional staff to support the PCN hubs across the county. An initial communications campaign saw a fantastic response from healthcare professionals wanting ‘to do their bit’. Some were retired doctors and nurses, others were practising healthcare professionals offering a few hours each week in addition to their normal shifts. The team at Herefordshire and Worcestershire Training Hub initially took charge of logging offers of help. They also made sure that volunteers received the necessary, nationally determined training as appropriate to their role and recent experience. A Taurus PCN Service Improvement Manager was deployed to work with the Training Hub and HR team to match volunteers with PCN staffing requirements. A key part of the logistical puzzle was the contribution of the Taurus HR team (supported by colleagues from the CCG). They made sure that all preemployment checks were undertaken before volunteers were deployed. From the beginning of 2021, they also took responsibility for managing the volunteer database.
This has been a real success story for the Taurus team working closely with partners from the CCG.
More then 1,400 sessions (lasting four hours each) were supported
Approximately 180 volunteers went through the process and became available for deployment Page | 17
Herefordshire & Worcestershire Primary Care Training Hub Herefordshire and Worcestershire Primary Care Training Hub is an ambitious service, commissioned by Health Education England and hosted by Taurus Healthcare. A comprehensive suite of quality assured, professional clinical and non-clinical training courses and updates are provided via the dedicated website and its associated Learning Management System. But that’s only part of our role. In addition, we support practices and professionals with placement opportunities and workforce planning. As our understanding of the needs of Herefordshire and Worcestershire’s Primary Care workforce grows, so too will the services we are able to offer.
What we’ve achieved in 2020/21
Four Trailblazer Fellows in post with a bid for a further cohort having recently been successful. Proactive projects undertaken include cervical cytology, QOF and Chronic Pain Exploration within areas of deprivation
Launch of Cohort 2 of the New to Practice Fellowship for GPs and General Practice Nurses
Supporting Nurse Associate and Trainee Nurse Associate training programme
Development and appointment of five Multi-professional Educators
Expansion of the Learning Management System (see opposite)
Paramedic Roadmap scoping and support
Population Health Management programmes and webinars
ARRS Induction sessions, in conjunction with Primary Care Commissioning
Successful in bid for cross-sector pharmacy technicians. We are one of only four areas of the country to be successful in such a bid.
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Our Core Objectives
Herefordshire & Worcestershire Primary Care Training Hub: Learning Management System Development - Outputs August 2020 - May 2021
59 Courses delivered Including: Video Consultations Care Navigation, Wound Care Leadership
14 bespoke group areas Including GPN HCAs Pharmacy Technicians
17 Live Events (some with multiple dates) Including Interactive COVID19 vaccination training sessions
Hosting Regional Trailblazers Events and Information Repository
714 people registered since
346 people registered on courses, excluding live
platform launch
events and forums
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Business Intelligence: Helping Practices to Understand Their Populations One of the key priorities of the Business Intelligence (BI) team is to ensure practices have knowledge and insight of their population. This enables future planning and strategy development to be carried out in order to meet future needs. The team also works to provide ways that enable effective and efficient working to make best use of available resources. Since the last Taurus AGM, the BI team has been working with practices and the Clinical Commissioning Group to reduce the burden, where possible, of local and national reporting. The team has ensured oversight and understanding of the pandemic and vaccination programme, as well as providing leadership in the data and analytics agenda where General Practice is at the heart of representation and decision making
Delivery CCG contractual reporting to reduce workload
Transformational analysis to better understand the population
EMIS Training to additional (ARRS) roles, thereby relieving capacity
COVID and vaccination reporting, to allow prioritisation and oversight
PCN profiles to support priority setting and inequalities
Support Developing an analytical approach to allow PCNs to become self-sustainable and resilient
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Providing QOF (Quality and Outcomes Framework) expertise and advising practice teams Supporting vaccination digital requirements and providing additional resource, where required Supporting understanding of population health management and working up examples of good practice Supporting development of organisational Business Intelligence dashboards
Representation Ensuring representation at Herefordshire and ICS (Integrated Care System) boards and groups to reduce practice workload and ensure appropriate knowledge and experience:
Primary Care Digital First
ICS Digital Board
PHM Steering Group
Intelligence Cell
ICS Integrated Information, Intelligence and Insight Workstream
Communications : Raising Awareness and Joined up Messaging Engagement with partners through the One Herefordshire Communications Group and STP Communications
Informed, coordinated and agreed approach to key messages, especially important for national and regional campaigns.
Leads to greater understanding and support between the communications leads from key partners across the health and care system.
Supporting General Practice and PCNs by communicating key messages via Taurus channels
Key messages identified via weekly GP Leadership Team meetings
Other materials developed in conjunction with PCN Managers / Taurus Executive Team eg: case studies, press stories
National and regional campaigns shared, as well as messaging from partners and individual GP practices
Will prove invaluable as we move towards Integrated Care Systems Platforms utilised: Facebook, Twitter, Linked In
Internal Communications
New weekly (later fortnightly) newsletter for all Taurus staff, ‘In Touch’ Also circulated to GP practices
In response to feedback from 2020 AGM, the development of weekly video updates. These feature Taurus activities carried out in the previous week to support General Practice, together with important updates for General Practice.
More podcasts and interactive resources planned for the future
Outputs / Outcomes Measurements
NEW Herefordshire General Practice website delivered June 2021 2,214 Followers on Facebook
Growth in number of Twitter Followers. From 187 in Sept 2020 to 290 in May 2021 Steady increase in number of Linked In followers: 84 new followers in the past 12 months Page | 21
GP Teamnet - A Major Focus This Year on Clinical Support Information GP Teamnet provides an indispensable, single resource store to support a local model of clinical effectiveness. During the COVID19 pandemic it became the go-to, reliable port of call for the latest updates and advice. That momentum has been carried forward throughout the past year, whereby we’ve focused on the development of a Clinical Support Information (CSI) section for General Practitioners. The objective in developing the CSI is to make it easier for frontline workers to ‘do the right thing locally’. All information follows a stereotypical format that is easily searchable and specific to local pathways. This is more important than ever as we restore services and tackle significant postpandemic waiting lists. The CSI enables General Practice to manage care in the community more effectively, to find the advice and guidance when and where it’s needed and, wherever possible, to ensure outpatient attendances are one-stop shops. It’s easy to navigate, but training videos were created to support full usage of the platform - both for those accessing and those providing information.
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GP Teamnet Clinical Support Information - How Does It Work? There has been good engagement from other providers and the Clinical Commissioning Group to provide information for the platform. Governance has been provided by a ‘Clinical Cell’, comprising GP and nurse colleagues from Herefordshire and Worcestershire at provider and commissioner level. For each specialty area, we are aiming to provide access to:
Training
We commenced lunchtime training sessions via MS teams every Thursday
Local management guidelines
Attendance: up to 80 people per session from General Practice
Who to refer (referral criteria), How to refer (including referral forms to smart EMIS templates)
How to access advice and guidance
Useful forum for up to date COVID19 advice and building a team across primary, secondary, community care and the local authority
Getting the most out of a referral (for example: what to do before referral so the specialist has access to the necessary bloods, imaging, etc to determine the patient’s management plan
Later developing into wider topics
Review currently underway – likely mixed model in the future with podcasts, interactive live sessions and pre-recorded training for multi-professionals
Building on a model of clinical effectiveness where data, system priorities, training, templates and contractual incentives align to maximise impact of interventions
Patient Information leaflets (aiming for all local providers to use the same ones - easily attachable to a text or email and printable)
Covid Vaccination Page
COVID19 Teamnet topic page (now moved to CSI)
48,565 hits
All the latest information as it arrived to support the vaccination hubs
4,776 hits
Next steps Clinical cell team resourced Aligning information on Teamnet with training sessions Ensure all areas populated - starting with the priority areas for restoration General Practice and Consultant pairings to review current pathways and resources Page | 23
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The PCNs
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Herefordshire Primary Care Networks (PCNs) The NHS Long Term Plan set out new and exciting ways of meeting the challenge of our growing population and helping them to live healthy, happy lives – the development of Primary Care Networks in 2019 formed part of that plan. Little did we know then what part the PCNs would play in protecting their communities against Coronavirus! Practices across Herefordshire have always worked closely with community, mental health, social care, pharmacy, hospital and voluntary services in their local areas, and the Primary Care Networks have brought local practices together more formally into groups to support their local population in receiving fully integrated care closer to home. Herefordshire has five PCNs covering its entire population. Each PCN is different with their populations having different needs to respond to – a summary of the features and progress of each PCN is included in the next few pages. It continues to be a privilege to lead the PCN Development Team and to support the Clinical Directors and their teams – their collective leadership, energy and good humour in what has been the most difficult of circumstances has delivered more than any of us believed possible. Well done, all Nisha Sankey Director of Strategy and PCNs
2020/21 has been a unique and challenging year for all parts of the health and care system, with PCNs playing a critical role in continuing to support their population during the pandemic, all whilst delivering the largest vaccination programme in history. With challenge comes opportunity though, and the PCNs have all responded in a way that galvanised working between GP practices and their health and care partners and provided an expanded specialist workforce to support rising patient demand. Increased system working has been welcomed, with continued progress in building relationships and working in partnership, including increased strategic input from General Practice into our Integrated Care System. Spurred on by COVID and the vaccination programme, Herefordshire PCNs have turned their attention to tackling health inequalities, and this will form a significant part of their priorities in coming months. The PCNs should rightly be proud of what has been achieved in the last year and excited about the potential to further improve the health of their local communities. In partnership with:
0
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South and West Primary Care Network Practices in the PCN: Alton Street, Pendeen, Fownhope, Much Birch, Kingstone, Golden Valley ….. of whom 21%
Population: 40,937
are over 70
Key People Care Homes 19 homes
Practice staff: 183
Covers: 348 sq miles
365 beds
Key People
The role of PCN Clinical Director transferred from Dr Simon Lennane to Dr Dominic Horne with effect from 1 June 2021. We would like to thank Simon for all his work as CD, particularly in leading the delivery of the COVID vaccination programme across the PCN.
Major Achievements during 2020/21 Developed closer relationships with our care homes through our Care Home Care Coordinator, working hard to
Enhance Health in Care Homes and provide an efficient and effective multi-disciplinary approach.
Dr Dominic Horne PCN Clinical Director
We have worked together as a PCN to successfully deliver the COVID Vaccination Programme at the Larruperz Centre in
Ross-on-Wye. We have developed close relationships with our voluntary and community sectors, including the Ross Community Development Trust, Ross Lions and the Rotary Club, who have been instrumental to the programme’s success. The six practices within the PCN are supporting one another in what remains a challenging time for General Practice.
Key Focus for the Forthcoming Year To align PCN priorities to the strategic outcomes of the Integrated Care System.
Sharon Waldis PCN Development Manager
Expand Social Prescribing with a focus on areas of health inequalities and personalised care. Adopt and develop a Distributed Leadership Approach. Continue to expand ARRS (Additional Roles) Workforce to reflect the needs of Anticipatory Care. Service improvement training across PCN. Explore and develop spirometry services in collaboration with community services. Engage with our population through a network of PPGs.
Alex Price Taurus Healthcare NED Page | 27
North and West Primary Care Network Practices in the PCN: Kington, Weobley and Staunton, Mortimer, The Marches, Tenbury Wells, Westfield ….. of whom
Care Homes 18 homes
22%
Key People
Population: 41,320
are over 70
Practice staff: 188 Covers: 430 sq miles
435 beds
Major Achievements during 2020/21 Worked with colleagues from Wye Valley Trust to pilot a new multi-disciplinary team, providing advice and specialist
guidance to one another to best support our diabetic patients. Dr Silvana McCaffrey PCN Clinical Director
Established a Wellbeing Team, which is currently focusing on proactive support for our frail patients. Our social prescribers have supported voluntary and community organisations to make closer links with practices. We’ve built strong relationships with our partner organisations which are supporting the development of our PCN to
have a collaborative approach to support our population’s needs and target inequalities. All practices have worked together with the amazing support of volunteers to vaccinate 46,403 people.
Key focus for the forthcoming year Gillian Pearson PCN Development Manager
Further development and expansion of our wellbeing team to deliver group consultations and lifestyle behaviour
change within the community. Working closely with Healthwatch to ensure that the patient voice shapes development of the PCN priority areas. Decreasing obesity in adults and children – increasing access to services to support patients to be more active, promote
healthy eating and weight loss. Dr Ritesh Dua Taurus Healthcare NED Page | 28
Improve access to emotional wellbeing support. Proactive support and management of frail elderly. Increasing health checks to support early identification and proactive support for patients.
East Primary Care Network
Key People
Practices in the PCN: Cradley, Colwall, Nunwell, Ledbury Health Partnership ….. of whom
Care Homes 17 homes
22%
Population: 29,013
are over 70
Practice staff: 124
Covers: 188 sq miles
336 beds
Key People
Major Achievements during 2020/21 Established our Frailty Team who are now working to keep our patients well at home for longer. With the input of
social prescribing in this service, we are able to support the whole household. We have been working hard together to vaccinate our patients from Ledbury Community Hall. We have had some wonderful volunteers without whom we couldn’t have achieved all that we have. Our practice teams are all working together closer than ever providing peer support to one another over what has
Dr Sarah Newey and Dr Verity Wilkins Joint PCN Clinical Directors
been a challenging 12 months due to the pandemic.
Key focus for the forthcoming year Looking forward to further strengthening the relationships between our partner organisations so that we can deliver care
jointly to our population. We will be working hard to tackle health inequalities and are looking to build stronger links with organisations such as
Turning Point so that we can build on expert support for patients in the PCN.
Gillian Pearson PCN Development Manager
We will further develop our Frailty Team and make links with teams within community services so that we can seam-
lessly support patients across organisations. We are hoping for greater integration in the next six months across all community teams. We will be focussing on early interventions to increase health checks and to improve health by reducing obesity. We will be improving our links with Turning Point to work jointly to tackle alcohol use in adults.
Dr Louise Mottram Taurus Healthcare NED Page | 29
Hereford Medical Group Primary Care Network
Practices in the PCN: Hereford Medical Group ….. of whom
Care Homes
14%
Key People
are over 70
Population: 49,057 Major Achievements during 2020/21
16 homes
Practice staff: 173 Covers: 135 sq miles
510 beds
Set up dedicated COVID19 vaccination service. Provision of this service to over 26,000 patients. Working in partnership
with Herefordshire PCNs to respond to the challenges of delivering this unprecedented vaccination programme. Dr Andy Watts PCN Clinical Director
Successful recruitment to multiple Additional Roles Reimbursement Scheme posts, eg Care Coordinators, Pharmacy
Technician, Social Prescriber and an Advanced Practitioner to lead our Enhancing Health in Care Homes work. New ways of working more collaboratively with PCN partners to provide a more joined-up service for our patients,
including in areas of mental health, First Contact Physiotherapy and Community Pharmacy. Closer working with the 16 care homes within HMG. Worked closely with WBC PCN and Herefordshire Council and Venture to reach homeless and extremely vulnerable city
residents (see case study on page 37). Rebecca Semple PCN Development Manager
Moved into new purpose-built premises during a global pandemic, and using the space in creative and unplanned ways
to ensure our patients continue to receive the highest level of care that we are able to provide.
Key Focus for the Forthcoming Year Proactive identification of further vulnerable groups of patients and working with partners to care for them with a
personalised care approach. Dr Cath Laird Taurus Healthcare NED Page | 30
Restoring services following the pandemic and vaccination programme delivery. Improving continuity of care. Building on our use of IT systems and data to improve patient pathways and professional communication.
Wargrave, Belmont & Cantilupe Primary Care Network
Key People
Practices in the PCN: Wargrave House, Belmont, Cantilupe and Hampton Dene Surgeries ….. of whom
Care Homes 16 homes
16%
Population: 29,580
are over 70
Practice staff: 86
Covers: 61 sq miles
367 beds
Key People
Major Achievements during 2020/21 Successfully delivered our Vaccination Programme from Saxon Hall Community Centre, working collaboratively to
ensure our population is protected. Continued to focus on the development of a Medicines Management team which releases GP time, making patient
appointments more accessible. We have successfully recruited a Nurse Coordinator Lead to develop our focus on tackling health inequalities and long term condition management, as well as improving quality within the nursing workforce.
Dr Paul Harris Joint PCN Clinical Director Taurus Healthcare NED
We continue to support one another as a team in this challenging time for general practice.
Key Focus for the Forthcoming Year To align PCN priorities to the strategic outcomes of the Integrated Care System. Develop a standardised approach to chronic disease management.
Dr John Stevenson Joint PCN Clinical Director
New role of Nurse Coordinator Lead to embed Personalised Care and health inequality focus. Expand Medicines Management Team. Service Improvement training across Primary Care Network. To incorporate a Primary Care Network Patient Participation Group into long term condition planning – ‘How does it
feel to be a patient in Herefordshire?’ Embed an informed and standardised approach to Safeguarding administration and improve learning in this area.
Anna Straker PCN Development Manager Page | 31
PCNs Working With Partners to Roll Out COVID19 Vaccinations In the first months of 2021, PCNs and their GP practices were faced with the challenge of managing a third wave of COVID19 alongside their on-going ‘business as usual’ requirements and in the face of increasing demand from patients. Although in a better place to do so because of systems and processes set up during the first and second waves of the pandemic, the PCNs were also given the responsibility for the roll-out of the new COVID vaccination programme. This placed PCNs under significant additional pressure. However, PCNs were considered to be the most suitable delivery partners for the vaccine roll-out because of:
EXISTING COLLABORATIVE RELATIONSHIPS already in place with partners
Their ability to ACCESS GP RECORDS and to PROVIDE CLINICAL OVERSIGHT. This was vital to the rollout because patients were being called according to particular risk factors
Their EXPERTISE and EXPERIENCE of delivering previous mass vaccination programmes, notably thousands of annual flu jabs each year.
Without the cooperation and involvement of the PCNs, the COVID vaccination programme would not have been possible until many months after was the case
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Setting up COVID Vaccination Hubs - The Very Best of Herefordshire The national roll-out of the COVID vaccination has been a huge success story for the NHS. This success has been mirrored locally in Herefordshire where more than 167,000 first and second doses have been administered since December 2020. In some cohorts, almost 100% of those eligible have taken up the opportunity to be vaccinated. Five vaccination sites run by Primary Care Networks and a local vaccination centre run by Wye Valley Trust have been operating in various locations throughout the county since December 2020. These have been responsible for the delivery of a large proportion of the vaccinations. However, this didn’t all happen by chance. It was achieved thanks to painstaking and extensive planning and collaboration between many different partners: Herefordshire General Practice (including Taurus Healthcare), Wye Valley NHS Trust, Herefordshire Council and local volunteers - including friends, family and the local community. Planning started back in September 2020 when it became clear that local health and care providers would be responsible for the delivery of the largest vaccination programme ever seen in the UK. Good local knowledge was key to the roll-out, as were strong relationships that were already in place before the pandemic. What was achieved was a truly magnificent joint effort between all partners. There was - and continues to be - a real sense of team working. If there’s a problem, it’s a problem for all of us and together we get it sorted.
We began planning back in September 2020. Relationships were absolutely key. We are a small county. We know who to talk to, who can put you in touch with whom. Our approach was very ‘Herefordshire’. But that’s what was needed and which proved so invaluable to the successful roll-out of the vaccination programme. Erica Hermon, Associate Director, Wye Valley NHS Trust
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COVID Vaccination Heroes at the Larruperz Centre, Ross-on-Wye
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Recognising our COVID Vaccination Heroes Local schoolgirl, Bethan Pearson, designed a Thank You badge to give to all volunteers who helped out at the Herefordshire General Practice Vaccination Hubs. Bethan is the daughter of Taurus Primary Care Network Manager, Gillian Pearson. A student at Whitecross High School in Hereford, she hopes eventually to go to an Oxbridge college. The badges and an accompanying thank you postcard were presented to hundreds of COVID ‘vaccination heroes’ across the county. Many were hugely touched to be recognised in this way. We wrote to the Prime Minister, the Government’s Vaccination ‘Tsar’ Kate Bingham, and several other senior officials to tell them about what we had done to recognise the volunteers. We were delighted to receive replies from many of them - including from No 10!
Some volunteers turn out every weekend. Whether they’re members of the clinical teams, helping out with administration or acting as car park marshalls, we couldn’t have achieved what we have without them. We wanted to thank them with some small token of thanks to show how grateful we are for their help. Gillian Pearson, Primary Care Network Manager
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Herefordshire Social Prescribers - Achievements This Year and Plans for the Future
Seven Social Prescribers are currently employed by Taurus Healthcare with plans to recruit an additional two in the near future
1,038 referrals had been made to the Social Prescriber service in the past 12 months
7,122 patient contacts have been made
701 patients have been supported by telephone consultation
Simple referral via one EMIS form to the PCN’s Social Prescriber
Data reporting directly from EMIS
In 2021, the Taurus Social Prescribers will be focusing on ……
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Receiving appropriate referrals from healthcare practitioners, leading to better patient outcomes
Developing awareness of the services available to PCNs via the Social Prescribing service
Social Prescribers to become fully embedded members of their Practice and PCN teams
Social Prescribers will help to ensure the increased resilience of General Practice and the wider PCN teams
Social Prescribers to be greater empowered to work within their communities
Social Prescribers to support PCN priorities by proactively identifying and supporting patients linked to areas of health inequality specific to each PCN
Social Prescribers Supporting ‘Project Brave’ Throughout the pandemic, Taurus Healthcare’s Social Prescribers have continued to support Herefordshire patients in many ways. One of these was a joint endeavour between Herefordshire General Practice, Herefordshire Council and the CCG working within the Project Brave initiative which supports Herefordshire’s homeless and rough sleepers to identify and maintain housing solutions. Although many of these people are younger than those identified in the Government’s top nine priority groups, their ability to maintain their health can be hindered by their circumstances. This can lead to poor health and the development of long term chronic ill health, placing them into the vulnerable cohorts. Also, as many do not register with a GP, there is a high chance that they could be missed out of any vaccination programme. Herefordshire General Practice, Herefordshire Council and the CCG worked together to ensure this cohort were offered access to the COVID Vaccination Programme. With the help of Herefordshire Council’s Outreach Workers, several special vaccination clinics for the homeless were set up, supported by Herefordshire General Practice and the Social Prescribers. Although there was a disappointing turnout at some of these, nevertheless they provided an opportunity for a significant proportion of this cohort to receive vital protection against the virus. Crista Gaunt, Social Prescriber for Wargrave, Belmont and Cantilupe PCN, says that the clinics have also been valuable for identifying other important issues. For example, one man arrived who had stopped taking essential medication, with obvious imSome homeless people are not registered with a plications for his health. Another, communiGP, some don’t care at all about their health. But cating through a translator, managed to open we felt it was important to reach out to them and up to the healthcare team in a way that he let them know what’s available. hadn’t previously been able to with his outreach worker. The clinics also identified the I’m really pleased that we have been involved in difficulties many homeless men were experienc- this important initiative and it’s been great to ing when trying to find a safe and warm place work together to provide vital healthcare to the to meet with their children. homeless. Crista Gaunt, Social Prescriber, WBC PCN Page | 37
North and West PCN Wellbeing Team - Helping Patients to Stay Well At Home This is a new service, offered to patients in the North and West Primary Care Network (following referral from a health professional) who need help to improve their physical and mental wellbeing within the home. The team, which includes a dedicated Occupational Therapist and Care Coordinator, works with patients to provide an holistic assessment of their needs. Using a practical, problem solving, patient centred approach, treatment programmes are developed that enhance patients’ health and wellbeing. For example, the Wellbeing team helps patients:
Who are becoming more frail within their home environment
Whose health is deteriorating and there is a need for clear preventative input to enable them to remain safely and independently at home
Whose main carer/family needs help to optimise their own health and wellbeing so they can continue to support the patient
By signposting or referring onto additional services, as appropriate
Sometimes the team’s involvement will be brief, but for other service users there will be more prolonged contact whatever is most appropriate for the patient. The team will be expanding over the coming months and years. Its focus at the moment is to look at factors which can improve patients’ health and resilience and to find services to help or that can provide direct input. Page | 38
The North and West PCN Wellbeing Team Pictured (L to R): Casey Ord (Social Prescriber); Sara Hathaway (Occupational Therapist); Bryony Reed (Care Coordinator)
New East PCN Team Aims To Provide Holistic Care For Frail Patients An advanced Occupational Therapist Specialist, Sian Nunn, has been recruited to the East PCN to head up a new Frailty Team. Sian has been joined by a Care Coordinator. Physicians Associates are being integrated into the team, with additional input from the PCN’s Social Prescriber. The aim of the Frailty Team is to provide a local community service which integrates with the existing community services to provide holistic care to the frail within the PCN. As at June 2021, the Team has started running a small caseload as a pilot to the service.
Frailty Team’s vision for the next six months Through proactive involvement, the team aims to INCREASE the number of patients who can stay at home well, for longer, REDUCE carer strain, SUPPORT those patients most at need of regular practice contact. Provide ADVICE and EDUCATION for care homes in line with the Enhanced Health in Care Homes framework. INCREASE forward planning/ReSPECT forms within the community. BUILD close working relationships with the Community Advanced Care Practitioners and other community services. WORK WITH ICT to enable the Frailty Team to record on EMIS, providing the secure and flexible access to records, care management tools and data that the Long Term Plan’s new model of care requires. Our team will use a PERSONALISED CARE APPROACH to ensure ‘WHAT MATTERS TO THE PATIENT’ is at the heart of everything we do. We will ensure PROACTIVE IDENTIFICATION OF PATIENTS ensures interventions are made as EARLY AS POSSIBLE to keep patients WELL AT HOME FOR LONGER. We will do this by using a MULTI-DISCIPLINARY APPROACH with our team, practice colleagues and wider system partners, looking at people as a whole as well as household members who may also need support. Page | 39
Pharmacy Teams Supporting Herefordshire General Practice In January 2021, three experienced Pharmacy Technicians were recruited in General Practice to work in the North and West and City PCNs. Yvonne Coates, Taurus Healthcare’s Lead Pharmacy Technician has supported this emerging role with a structured induction programme and regular support meetings. A local training accreditation has been created for Medicines Reconciliation which includes theory, practice and competencies. Alongside the PCN Clinical Network there is a Pharmacy Technician Network. This is a monthly meeting which covers news and hot topics, a clinical session and information to support the role. The meetings have included meeting Social Prescribers, learning about clinical audit and how to support care homes. A Pharmacy Technician led audit has been completed on the new hospital Electronic Discharge Summaries. This powerfully demonstrated the benefits of joined up working and brought about improvement. Working with Health Education England there is a pilot training Cross-sector Pharmacy Technicians. We have four posts across Herefordshire. This is an exciting and innovative project and will help trainees see the role that they can play in patient care in General Practice. It will also help create the workforce for the future. All of these posts have been pivotal in supporting integration of pharmacy teams, increasing communication across community, hospital and General Practice. Without a doubt they will help to improve patient outcomes. Page | 40
Pharmacy Team WBC PCN
I am so proud of the way the pharmacy teams across Herefordshire practices have risen to the challenge of the COVID vaccination programme, ensuring safe systems of vaccine storage, supply and administration with many involved in clinics delivering vaccinations. For others they have been managing more medicines issues at the practice than ever before, taking on duties previously undertaken by nurses and doctors to enable those staff to be freed up for vaccination clinics. The whole team should be super proud of everything they have achieved. Yvonne Coats, Lead Pharmacist Herefordshire PCNs
Pharmacy Technician Network Herefordshire, Training Workshop May 2021
South and West PCN Care Coordinator Supports Care Home Residents’ Needs Care Coordinators work with patients to understand and support their specific needs. These needs can be very complex. For example patients can be living with five or more diagnosed conditions that affect their health, which means they could be under the care of several different teams. Care Coordinators act as a single point of contact for all these services to encourage and facilitate a multi-disciplinary approach to patient care. Care Coordinator roles can be flexible, according to individual PCN and practice needs. In the South and West PCN, the focus is on care home residents, including helping the PCN to promote Enhanced Health in Care Homes. It’s a fledgling service, having only begun in December 2020, but Shannon Meaney (the PCN Care Coordinator) is now actively monitoring and supporting the care of those living within nursing homes, residential learning disability homes and residential care homes within the PCN. Shannon’s role is vital for us, especially during the period of COVID. It gives us a single point of contact, who is available and ready to offer any assistance needed in caring for our residents….. All the senior staff find that any issues with residents are much better resolved when having Shannon as a point of contact. Ross Court Care Home
Shannon is developing a close relationship with the care homes and helps to coordinate which residents will need a review within the multi-disciplinary ward round each week. Shannon has developed a template for annual reviews which usually take place in the birth month, ensuring clinicians have all the information they need when the reviews take place. This also facilitates an opportunity to ensure individual care plans are updated to reflect the ongoing needs of care home residents. As her role becomes more established and well-known, Shannon is hoping for increased contact from other services, leading to more referrals to the multi-disciplinary team meetings. As a result of this more proactive approach, and due to the more regular contact with patients, Shannon is anticipating that the health and well-being of care home residents is improved and that the health professionals involved in their care can ensure care is delivered in the right place for everyone, at the right time in their life journey.
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Care Coordinators at Hereford Medical Group (HMG) HMG has taken an innovative and exciting approach to the use of the new Care Coordinator role, specifically to address and support the Multi-disciplinary Team (MDT) aspect of PCN patient care. Two full-time PCN Care Coordinators have been in post since October 2020. Their role currently includes:
Being the main point of contact for care home managers and lead staff
Coordinating weekly ward rounds for the 16 care homes in the PCN
MDT meeting coordination and administration (eg palliative care, care homes)
Coordination of the cancer patient pathway
Being the main point of contact for Wye Valley Trust Community Advanced Clinical Practitioner Service, and playing a central role in a pilot of cross-organisational EMIS working within this service (with plans to extend to other areas of WVT Community team in future)
Supporting the COVID Vaccination Team in providing a vaccination programme for care home and homeless patients (in coordination with Social Prescriber/Project BRAVE).
We’re increasingly identifying creative uses for this role across the PCN and beyond. Patient feedback on the work undertaken so far has been really positive
Rebecca Semple, HMG has also recently employed a Business Intelligence Care Coordinator who will lead on data PCN Development Manager, HMG collection and analysis. This will support and inform current and future clinical and operational work at Practice and PCN level, using a Population Health Management approach. The post-holder will work with other PCN data leads across Herefordshire and aim to improve the patient journey across the MDT to increase the efficiency of patient services. Future PCN Care Coordinator planned role development includes:
Extending the role to include diabetes, cardiac, mental health and other conditions
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Post long-term condition review and audit administration. Long-term condition specific patient contact for priority cohorts.
Coordination of Group Consultations
Become the main point of contact for Community Advanced Clinical Practitioner service
Supporting Enhanced Health in Care Homes (EHCH)
Providing Clinical Services
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Expanding and Improving our Clinical Services In our last Annual Report (November 2020), we spoke about the huge impact that the Coronavirus had had on our clinical services and highlighted some examples of excellent work carried out by the Taurus Healthcare Team and Herefordshire General Practice. In particular, we focused on the efforts made by teams across the county to respond to the demands of the pandemic whilst protecting our patients, our staff and the wider general public. As we moved into December and then a brand new year, sadly (but expectedly) we were faced with another spike of COVID cases. However, thanks to our experiences earlier in the year, we were well-prepared to face up to demands. There was hope on the horizon, in the shape of a Coronavirus vaccination. This became available in late December 2020, since which time literally thousands of doses have been administered to Herefordshire residents, the majority through PCN-run vaccination hubs. At the same time, Practice and Taurus staff have been and are continuing to meet day-to-day patient demands. It’s been very pressurised and sometimes disheartening for healthcare teams not to have been recognised by the general public for their incredible hard work and the dedication they have shown. But we are only too aware of the lengths Herefordshire General Practice has gone to and are extremely thankful for all of their work. As well as taking a central role in the management of the pandemic and rollout of the vaccination programme, the Taurus Healthcare team has continued delivery of its clinical services on behalf of Herefordshire General Practice, for example Improved Access, Out of Hours and Overnight Nursing. This has required immense agility and flexibility from team members in order to step up to new roles. In the following pages we focus on some of the highlights and achievements of the past year as a means of paying tribute to the continued professionalism and dedication shown by Taurus Healthcare and Herefordshire General Practice staff in the face of ongoing significant challenges.
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Business As Usual for Taurus’ Clinical Services Team Despite the significant additional challenges placed upon them by the Coronavirus Pandemic, the Taurus Healthcare Clinical Services Team has worked hard to continue – and even expand - existing services provided on behalf of Herefordshire General Practice. Team members have maintained a positive, professional and flexible attitude throughout. They’ve been receptive and responsive to change, happy to embed and drive forward new working practices.
Improved Access Service
Number of Improved Access Hubs available increased from three to six, meaning there are now one or two sites in each PCN. Hubs now operating in Hereford, Ross, Ledbury, Kington, Bromyard and Leominster So improving the accessibility of services for all Herefordshire patients
Overnight Nursing
Now comprises three Overnight Nurses supported by Associate Director of Nursing and Quality
Available seven nights per week, 365 days of the year
The service consistently delivers high quality, holistic care to patients
Out of Hours
Increased flexibility through adoption of new technology, in particular the extension of EMIS into OOH environment - the only OOH provider to use EMIS.
Seamless access to the whole patient record reduces risk, enables healthcare practitioners to provide better quality care, consistent with care plans, reducing duplication and making every contact count.
I regularly work in the Improved Access Service ... I can see everyone’s notes ... I’ve never felt more secure in my job. It means that we don’t have to spend time ferreting around for information – it’s easy to see. Advanced Nurse Practitioner
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Weekend Care Home Service - Providing Welcome Support for Residents and Staff During the COVID19 pandemic, care home staff have been able to access Taurus Healthcare’s weekend Care Home Support Service via one direct dial telephone number, instead of having to contact NHS 111. The service was staffed by experienced clinicians who were familiar to the care homes, who understood how they ran and the importance of person-centred care. Advice was provided by telephone, video link or by visits to patients in their care home, as required. The team was proactive in their support for the care homes. If no calls were being received, they would telephone the homes to make sure that everything was going well or if there was anything with which they needed any help. In this way, problems or issues were resolved quickly, reducing the risk of residents having to be hospitalised. Over the last year, Health and Social Care Partners have worked closely together to enhance support to our Care Providers in HerefordCare homes are busy. By shire. In the initial lockdown period where many care homes being proactive and faced the reality of caring for residents with COVID19, we offering an enhanced developed a network of support that included colleagues from service, we are helping them to save Taurus Healthcare, Herefordshire Council, Hereford and time. We are also helping to reduce Worcester CCG, and Wye Valley NHS Trust. We are committed the number of hospital admissions, to continuing to work together through the Integrated Care with obvious benefits for the whole Home Support Programme to provide a truly integrated healthcare system. approach to supporting the care home market in Herefordshire centred on the needs of individual Caroline Mansell, Advanced Nurse Practitioner residents, their families and care home staff. Sharon Waldis, S &W PCN Development Manager
Between May 2020 and May 2021
57 Herefordshire care homes used this service. In the same period, 566 calls in total were received. Page | 46
COVID Management Service - Reassuring Patients Through Worrying Times A dedicated COVID Management Service (CMS) was commissioned from Taurus Healthcare by Herefordshire and Worcestershire CCG in April 2020. Its continued presence throughout the third wave of the pandemic, which hit in December 2020 and January 2021, was invaluable to unwell or vulnerable COVID positive patients. The CMS was a telephone and video support service that GPs, hospitals, care homes and public health could utilise. From one hotline number, calls were distributed to Taurus GPs or Advanced Nursing Practitioners (ANPs) and managed effectively and simply through the EMIS platform. GPs and ANPs offered advice and support, oxygen monitoring and medical management to patients. If face-to-face assessment was needed, they could book the patient in at an appropriate Herefordshire GP-run clinic or send a prescription. Complex cases were discussed with the acute medicine or respiratory team at Wye Valley NHS Trust. Between April 2020 and May 2021, the CMS supported more than 1,500 COVID symptomatic patients. The service was invaluable not only in reassuring patients through what was potentially one of the most worrying times of their lives, but also to help alleviate increased pressure on GPs and the emergency department. I would like to thank you all for looking after me when I had COVID. I was self isolating but your team rang every day to make sure I was safe. I'm now fully recovered with you help. CMS User I felt reassured that someone is there who understands what I’m going through. CMS User Between April 2020 and May 2021 the CMS supported more than 1,500 COVID symptomatic patients
Proactive follow up of vulnerable people with COVID was possible seven days a week. Close links were formed with acute physicians, care homes, ‘hot hubs’, out of hours clinicians, Public Health and the local authority so that care was integrated across the system and learning took place at pace. Ben Hall, GP
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Virtual GPs Evolve From Success of COVID Management Service The success of the COVID Management Service (see previous page) has resulted in a new Virtual GP service being established. Available seven days each week, the Virtual GPs offer proactive, senior clinician input to support unwell people in the community or to escalate to other services, as appropriate. The service was developed with the Community Integrated Response Hub to provide two main functions:
To provide medical support for the two hour response requirement, including a single point of access for West Midlands Ambulance Service
To offer a more intensive support service than is usual from General Practice for unwell patients or those with a long term condition.
We are currently exploring and testing two further elements:
General Practice support eg online consultations, Docman (electronic document management), Duty Doctor support, medical decision making into Advanced Clinical Practitioner home visiting
Virtual Ward: supporting hospital at home for step down care.
Virtual GPs work closely with Primary Care Networks, the Same Day Emergency Care Service, West Midlands Ambulance, the Community Integrated Response Hub and the Community Integrated Team.
Demonstrating the value GPs bring to an integrated system – decision making, risk management, community care, continuity in a period of crisis or deterioration Page | 48
We are currently balancing the needs of the urgent care response, step up care from General Practice and enhanced health in care homes. The virtual team have also tested online consultation support for practices. Modelling is now underway to understand the format that best serves General Practice and urgent care for the winter ahead.
New Post-COVID Care Service Introduced in 2021 In early 2021, Taurus Healthcare was commissioned by Herefordshire and Worcestershire Clinical Commissioning Group to provide a post-COVID care service. The service is available to patients from across Herefordshire, following referral from their GP. It is intended for those who have multiple ongoing significant symptoms more than 12 weeks after COVID infection and for whom all known medical causes for their symptoms have been excluded. The patient’s record is reviewed by a GP against a screening criteria to assess if the patient has Post-COVID Syndrome and to ensure other diagnoses are excluded. A multi-disciplinary team, comprising practitioners with expertise in mental health, chronic pain, social prescribing and rehabilitation consider each referred case weekly. The team makes recommendations for onward referral, further investigations or refers to the Ways to Wellbeing Programme. This new programme is about to launch and offers peer support and guided therapy at Tier 2 level to those whose needs are not met by current services. A more intensive rehabilitation programme has also been scoped and may be required for some patients.
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Quality And Improvement
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Quality and Improvement What have we done? COVID Vaccination Programme
Wider System Learning
Supporting and embedding governance arrangements for Herefordshire vaccination sites
Facilitating system escalation of incidents
Supporting dissemination of national and local clinical updates
Supporting Clinical Services
Widened links with partner organisations to support robust flow of communications surrounding learning from incidents
Established structured process for maintaining quality and safety reporting in line with newly established performance committee
Established clear Business Intelligence reporting requirements to support Performance, Quality and Safety reporting
Developing links with Mortality Lead in Wye Valley Trust and Herefordshire Coroner System engagement with partners to work on incidents together Building blocks in place with GPs to share incidents for system learning via Datix Support with Significant Event Analysis at PCN level
Investigation Principles training provided to service leads to further maximise opportunities for learning from our incidents
Medications Management
Building audit programme and assurance mechanisms to adhere to commissioning for medicines safety requirements
Embedded robust Data Protection processes to support appropriate safe distribution practice against Home Office Licence requirements
Focus for the Year Ahead Support the development of a Nurse Leadership Model across Herefordshire PCNs
Establish future Intentions and build federative quality offer for PCNs
Support Herefordshire PCNs with quality monitoring and reporting development.
PCN Quality Forum to establish monitoring/coordination function of system learning
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Financial Summary 2020 - 2021
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Financial Summary: 2020-2021 2020/21 has been a complex year from the finance perspective for a number of reasons, including:
The impact of responding to COVID and then the COVID vaccination process
The various streams of COVID related income and expenditure
Implementation of an upgraded financial system (SAGE50 to SAGE200), which in effect is a new financial system
Key finance personnel leaving or retiring, with new staff recruited sometimes at short notice
Ensuring all financial systems and governance worked effectively in a working from home scenario.
The 2020/21 Financial Plan agreed by the Taurus Board foresaw a deficit of almost £240,000, but actual performance has delivered a profit of almost £64,000 before tax. This is an excellent position, and is the result of strong financial management throughout Taurus, while providing high quality service delivery to all who use our services. Both income and expenditure have increased significantly during 2020/21, with the main factors being:
COVID Management Service income and expenditure
Significant increases to Primary Care Network income and expenditure, particularly as a result of the Additional Roles (ARRS) initiative
Significant increases to Training Hub income and expenditure
Showing Training Hub income and expenditure separately, rather than netting off as in the past. (This is a change of accounting policy, but in agreement with TCA Accountants we have not restated the 2019/20 income and expenditure figures on the basis of materiality and because there was no impact on the outturn position whatsoever).
A key and vital challenge for the Finance team, and Taurus as a whole, is always how best to support Herefordshire General Practice, investing in (sometimes at risk) services whilst ensuring that the financial strategy underpinning Taurus provides a solid underlying financial platform to continue to operate and support General Practice in the long term. This has been particularly evident during the pandemic when practices and Taurus had to collaborate effectively during a period of financial uncertainty. The 2020/21 accounts have been thoroughly reviewed by our accountants (TCA Accountants), and they have issued a letter confirming they are content. Although this review is not an audit and, therefore, TCA do not provide a formal opinion on the accounts, it is an independent review and provides significant assurance on the accuracy of our accounts. A summary of our 2020/21 financial performance is shown on the following page. Page | 54
Financial Summary: 2020-21 In line with our aim to deliver a small surplus from our contracted service each year to enable us to support our federative and strategic leadership functions, a summary of our financial functions is shown below:
£m
2019-20
2020-21
Budget 2021-22
Income for services provided
5.8
8.2
9.4
Cost of delivering federative, strategic and contracted services
5.9
8.1
9.7
(0.1)
0.1
(0.3)
Funds retained for future developments
An additional £300k from reserves is being used to support strategic and federative activities in 2021/22
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The Year Ahead
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The Year Ahead We look ahead to the future in the knowledge that there will be significant challenges and changes ahead. What does, however, seem to remain constant is the expectation and drive of the NHS, where restoration of services, coupled with the challenges of unmet demand and an ongoing vaccination programme, will inevitably dictate the forthcoming year. We believe that workforce will be central to this, so the Federation will look to expand its workforce pool, building on the flexible GP pool to expand into a wider workforce team and support General Practice to meet the rising demands it faces. We will also support Herefordshire’s Primary Care Networks to build on their success and continue recruiting additional specialist roles, supporting the delivery of an expanded range of services to their communities. Alongside this we have the opportunities presented by the Integrated Care System, as we move from a transition phase into the new collaborative way of working. General Practice is well placed to sit alongside our health and care partners in the system as we look to ensure change is clinically led, delivers maximum patient benefit and support for our workforce - and continues to focus on prevention at its core. Ultimately the Federation will continue to expand its offer to support practices, represent the general practice view, and provide clinical services that deliver 24/7 general practice.
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Photo: Lisa Bedford
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Taurus Healthcare / Herefordshire General Practice Suite 1, Berrows Business Centre, Bath Street, Hereford HR1 2HE 01432 270636 | www.herefordshiregeneralpractice.co.uk | enquiries@taurushealthcare.co.uk
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