Transforming Primary Care Networks for Improved Healthcare Collaboration

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Thinking big about collaboration in primary care, key speakers highlighted strategies for enhancing outcomes, access, and workforce satisfaction. Modality, a leading GP super-partnership, is pioneering innovative models to serve over 1 million patients nationwide. Expectations are high for Primary Care Networks (PCNs) to drive transformation, with a focus on better outcomes, convenient access, and a productive workforce. The first 100 days of PCN establishment revealed significant progress in clinical leadership and network development, signaling a positive shift in healthcare delivery.

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An ideal world: thinking big about collaboration with primary care Chair: Speakers:Andrew Ridley, Chief Executive, Central London Community Healthcare NHS Trust Dr Mina Gupta, Group Clinical Chair, Modality Partnership Thea Stein, Chief Executive, Leeds Community Healthcare NHS Trust Vincent Sai, Chief Executive Officer, Modality Partnership

Speaker: Vincent Sai, Chief Executive Officer, Modality Partnership

Introducing Modality Largest National GP Super-Partnership in the UK serving over 450K patients across 8 regions and growing AWC 8 Sites - 88K Hull 6 Sites - 61K Walsall 10 Sites - 71K Wokingham 2 Sites - 26K Nationally recognised innovator and leader in transforming primary care Birmingham & Sandwell 15 Sites - 97K Lewisham 3 Sites - 36K East Surrey 3 Sites - 36K Mid Sussex 4 Sites 33K 4

In PCN Terms A Super-PCN covering more than 1m patients across the country Modality AWC 88K Walsall West 1 32K South 1 34K North 1 51K South 2 39K East 1 33K East 2 42K West 2 45K Hull 70K Working in Partnership with Non- Modality Practices, Acute Trusts, and Other Stakeholders Wokingham 47K Modality Birmingham & Sandwell 72K Kingstanding 30K Citrus 30K Small Heath 30K Modality Lewisham 36K East Surrey North Tandridge 36K Horley 37K Mid Sussex East Grinstead 48K Burgess Hill 40K 5

Expectations Are High What transformational role should PCNs play? Improved outcomes for all More convenient (and appropriate) access (Even) more productive and happy workforce Source: NHS England and Improvement September 2019

The First 100 Days Primary Care Networks established 1250 Practices taking up PCN DES 99% 1250 PCN Clinical Directors identified Average size of a PCN 40k Source: NHS England and Improvement September 2019

Evolution (not Revolution) Opening Game Mid Game End Game Forces are in action; however, historical industry structure and market predominate Leading players experience virtuous cycle of growth and strengthening capabilities Growth slows Last move mergers happen with winners establishing themselves and losers exiting Winners and losers begin to emerge as competitors grow share rapidly organically and through mergers Initiatives by leaders to build capabilities and experiment with new business models Maturity Stable and concentrated industry structure emerges New competitors emerge with powerful new business models 2021-23 2019-20 2024+ Time 8

Speaker: Andrew Ridley, Chief Executive, Central London Community Healthcare NHS Trust

Andrew Ridley CEO Your healthcare closer to home

Some key facts about CLCH Some Key Facts about CLCH We work in 11 London Boroughs and Hertfordshire We provide 74 services including 255 rehab and palliative care beds Segment 1 Trust NHS Improvement Single Oversight Framework (Top 15% of 238 Trusts) We operate in 4 STP/ICS areas and 12 ICPs We care for Over 2 million patients with 10 million patient contacts each year. Kate Granger Award for Compassionate Care 2017 Special Recognition Award We have Over 4,200 staff working from 500+ sites And we are part of 86 Primary Care Networks

Why collaborate with primary care? To work towards greater integration of out of hospital services as a means to: Deliver person-centred coordinated and more joined up care Build local place-based care and support systems for local communities Create system leadership for integrated care Challenges and opportunities Maturity and readiness of PCNs Trust and relationships Shift from competition to collaboration Availability and sharing of data Wider system change

Integrated Community Teams in West London Patient cohort: Aged 65+ Under 65 with complex needs

Key features Improved communication between primary care/community provider and patients Overlap of roles reduces duplication and improves continuity - case managers with a district nursing background will pick up some district nursing tasks for their patients, likewise, district nurses will use their training to provide case management No matter who (DN/CM/SCM) same offer agreed / aligned approach to the patient / practice Daily huddle with 1 or 2 Lead(s) per PCN who have visibility of the clinical system and E-roster to manage demand and capacity within the PCN Huddle leads provide the interface / point of contact for practices, with a helicopter view of the PCN, managing inputs from specialist services, District Nursing, Case Managers and the impact of staff absences A clearer distribution of specialist roles within the PCN especially case managers with a Mental Health or Social Work background Staff employed by the Trust and voluntary sector

Delivery of QI for PCNs With the aim of building capability across the system, includes: Access to CLCH QI training programmes Introduction to quality improvement ( day) Foundations of improvement (3x 1 day modules) Quality Coach programme*(in development) Access to QI masterclasses (various topics) Access to QI facilitators Support improvement planning Support systems/local QI projects Coach/mentor local QI leads Development of bespoke QI programmes

Current areas of focus Building and strengthening relationships with the PCN Clinical Directors and GP Feds Aligning our planned services around the new PCN geographies Creating local integrated community teams with case management, District Nursing/ Night Nursing, and Health & Social Care Assistants Developing the CLCH Academy offer for PCNs, access to training for practice nurses, facilitation and QI Providing pharmacy expertise and support, potential for joint roles/rotational posts across primary, community and secondary care

Speaker: Dr Mina Gupta, Group Clinical Chair, Modality Partnership

Personalised Journey De-Medicalisation Recruit (Day Zero) 1 It was a pleasant surprise that I could keep the pain under control without a knee replacement Eve s living life more fully and receives semi-annual calls to help her stay on the path to her optimal health. Eve is identified for the service through health analytics 8 1 Biannually One-time How can we reverse the chronic pattern of over-diagnosis and over-treatment? Health Review (Month 1) 2 She is invited to the service by her GP and decides to enroll. Feeling more confident in her ability to self-care, Eve graduates from the service. Behavioural Change (Months 2-6) 7 Patient Preferences 3 I didn t need this new hip. All I needed was a bannister so I could get down to see the postman! She continues to receive support but is consistently making healthy choices on her own. Transform (Months 7-8) Care Management Nurse contacts her to conduct an initial health assessment. 4 6 2 Quarterly Weekly How do we ensure patient preferences matter? Case Review (Month 9) 5 Her nurse sets up regular calls and sends Eve info about her health conditions. Eve s is reassessed as she starts to adopt healthier behaviours. 5 Maintain (Months 12-15) Social Determinants 6 3 Eve s Care Management Nurse supports her to make healthy lifestyle choices and achieve her health goals. Fortnightly You forgot to ask about the dog. It died. That s why she doesn t get out or take care of herself as much 4 Using motivational interviewing, Eve s health coach helps her identify health goals. Monthly Graduate (Month 18) 7 Outreach (On-going) How do we account for patients life circumstances as context for decision? 8 * Illustrative - each patient s journey will vary as the care plan will be tailored to their unique needs

Embracing Digital Real-time consumer friendly appointments system improving access and convenience Enhanced Risk Stratification and Predictive Analytics, and Telemonitoring Systems Real-time Access to Personalised and Actionable Information promoting Health Literacy and Engagement Wellness, Prevention & Community Resilience Enhanced Primary Care Care Management Acute Interface Hospital at Home Self-Care Enablement 24/7 Single Point of Access Nursing Home / Advanced Illness Residential Care Acute Inpatient Complex Case Management Management Condition Intermediate Bed Front Door A&E Sub-acute Care Healthy Communities Enhanced Primary Care (Physical & Virtual) Interim Bed Specialist Services (Outpatients) Bed Management (Discharge Planning) Referral Facilitation 24/7 Single Point of Access Artificial Intelligence triage and signposting driving operational efficiency and effectiveness Advanced care and monitoring systems Social media and Community Support Development (Crowdsourcing, blogs, etc)

Primary-Secondary Collaboration Pathway s Finance Analytics Workforce Simplified to Deliver Right Care, First Time, Every Time Actionable Insights Drawn from Single Source of Truth Re-balanced to Create Long Term Ownership & Sustainability Collaboration Takes Us Further Than Competition 20