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1 Executive Summary ....................................................................................................................................................... 6 1.0 Introduction.......................................................................................................................................................... 7 2.0 Context and drivers ............................................................................................................................................ 8 2.1 National context .............................................................................................................................................. 8 2.1.1 Five Year Forward View ........................................................................................................................ 8 2.1.2 General Practice Forward View ........................................................................................................... 8 2.1.3 Health Education England Workforce Plan ........................................................................................ 9 2.1.4 ‘The Future of Primary Care – Creating Teams for Tomorrow’..................................................... 10 2.2 Regional context ........................................................................................................................................... 11 2.2.1 Greater Manchester Health and Social Care Partnership ............................................................. 11 2.2.2 Health Education England (North West) Primary Care Workforce Transformation ................... 12 2.3 Local context ................................................................................................................................................. 13 2.3.1 Salford Locality Plan – Start Well, Live Well, Age Well .................................................................. 13 2.3.2 NHS Salford Clinical Commissioning Group .................................................................................... 14 2.3.3 Salford Together ................................................................................................................................... 15 2.3.4 Salford Primary Care Together .......................................................................................................... 16 2.3.5 Salford Standard................................................................................................................................... 17 3.0 Vision for primary care workforce .................................................................................................................. 18 4.0 Principles ........................................................................................................................................................... 19 4.1 Building the workforce around the local population ................................................................................ 19 Figure 1: The Population Centric™ Workforce Planning Model ................................................................... 20 4.2 A competency-based approach to workforce redesign .......................................................................... 20 4.3 Primary care as a learning organisation ................................................................................................... 21 4.4 Widening participation ................................................................................................................................. 21 Strengthening foundations for primary care workforce development....................................................... 23 5.0 5.1 General practice workforce data ................................................................................................................ 23 5.1.1 Primary care workforce data collection ............................................................................................. 23 5.1.2 Locality workforce data ........................................................................................................................ 24 Figure 2: Summary of general practice workforce (March 2016) ................................................................. 26 5.2 Skills review................................................................................................................................................... 26 Figure 3: Clinical skills of nursing staff (March 2016) ..................................................................................... 28 5.3 Future staffing models ................................................................................................................................. 29 Figure 4: Emerging primary care staffing model ............................................................................................. 29 6.0 Enabling workforce transformation ................................................................................................................ 30 2 6.1 Developing future supply............................................................................................................................. 30 6.1.1 General Practitioners ........................................................................................................................... 30 6.1.2 General Practice Nurses ..................................................................................................................... 32 6.1.3 Enhanced training practices ............................................................................................................... 33 6.1.4 Pre-employment programmes ............................................................................................................ 34 6.2 Upskilling the current workforce ................................................................................................................. 35 6.2.1 Primary care learning and development programme ..................................................................... 35 6.2.2 Enabling career progression ............................................................................................................... 35 6.2.3 Advanced Practitioners........................................................................................................................ 36 6.2.4 Talent for Care and Care Certificate ................................................................................................. 37 6.2.5 Developing the non-clinical workforce............................................................................................... 38 6.2.6 Developing wider skills ........................................................................................................................ 39 6.3 Developing new roles .................................................................................................................................. 40 6.3.1 Clinical Pharmacists............................................................................................................................. 40 6.3.2 Physician Associates ........................................................................................................................... 41 6.3.3 Paramedics ........................................................................................................................................... 41 6.3.4 Mental health workers.......................................................................................................................... 42 6.3.5 Physiotherapists ................................................................................................................................... 43 6.3.6 Medical Assistants................................................................................................................................ 44 6.4 New ways of working ................................................................................................................................... 44 6.4.1 Productive General Practice ............................................................................................................... 45 6.4.2 Asset-based care and care navigation.............................................................................................. 45 6.4.3 Empowering patients and the public ................................................................................................. 46 Implementation of strategy.............................................................................................................................. 47 7.0 7.1 Delivery plan ................................................................................................................................................. 47 7.1.1 Year 1 ..................................................................................................................................................... 47 Table 1: Year 1 delivery plan .............................................................................................................................. 48 7.1.2 Year 2-3 ................................................................................................................................................. 48 Table 2: Year 2-3 delivery plan .......................................................................................................................... 48 7.2 Risks ............................................................................................................................................................... 49 Table 3: Risks ....................................................................................................................................................... 49 Appendix 1: General Practice Workforce Headlines .......................................................................................... 51 Appendix 2: Feedback from patient and public engagement ............................................................................ 53 3 Foreword With its highly skilled workforce, effective multi-disciplinary teams and welldeveloped IT systems, the NHS is in an unparalleled position to develop a modern primary care system that is truly world class. ‘The Future of Primary Care: Creating Teams for Tomorrow’, Primary Care Workforce Commission We are pleased to introduce this Primary Care Workforce Strategy for Salford. Primary Care is at the heart of the NHS and the public has high levels of trust in their GP and practice team. However, we know that Primary Care is under increasing pressure due to a growing number of patients with complex health needs and rising public expectations. Salford CCG has a clear vision for primary care to enable it to transform in a way that is sustainable and fit for the future. Our Primary Care Strategy, published earlier this year, recognises that workforce development is a key enabler for primary care transformation. Our locality plan ‘Start Well, Live Well, Age Well’ sets out our approach to improve health and wellbeing across the city and remove health inequalities in Salford. We are committed to working with our partners to develop a highly skilled, flexible workforce which can deliver the ambitious objectives detailed in the plan to provide more integrated services, closer to home. This means that we must support the primary care workforce to train, learn and work differently. We know that practices are finding it increasingly difficult to recruit GPs and Practice Nurses, so we will work collaboratively with our partners to make Primary Care in Salford an attractive place to learn and work. Our goal is that practices can recruit and retain the best primary care professionals in the right numbers to meet local needs. At the same time, our aspiration is to expand the skills within primary care by developing new roles and new ways of working to complement the traditional general practice team. Salford has a strong history of innovating and collaborating to improve the quality of services delivered in primary care. A number of activities and local projects have already been initiated to support the development of the primary care workforce, including the introduction of advanced practitioner and physician associate roles into primary care and the development of an Enhanced Training Practice, operating across a number of practices across the City. By March 2017 we will have mobilised our new practice pharmacy service, commenced a pilot to explore the role of paramedics in primary care, increased the number of apprenticeships within primary care and established consistent workforce data across all practices. 4 This strategy sets out how we will support and enable our member GP practices to build upon the innovative work to date and develop a highly skilled multi-disciplinary workforce. The development of Salford Primary Care Together provides additional opportunities for practices to work together to enable workforce development and innovation. Over the next two years, the CCG will work collaboratively with our member practices and Salford Primary Care Together to support the development of a city wide education hub with a bespoke learning and development programme, support more practices to become training practices and enable the development of new clinical and non-clinical roles. The Primary Care Workforce Strategy provides a framework to achieve our vision of a multi-disciplinary workforce, built around the needs of a defined population, which has the right knowledge, skills, values and behaviours to enable primary care transformation at scale and pace and ensure high quality care for the residents of Salford. Dr Tom Tasker Chair Anthony Hassall Chief Accountable Officer 5 Executive Summary Primary care has been described as the foundation of the NHS and general practice is at the heart of our communities. However, the demands on general practice are increasing, particularly for people with multiple, complex problems. The Five Year Forward View describes a vision for developing new models of care, with primary care working more closely with community services and hospitals to integrate services around the person and deliver more care closer to home. Following this, the recent General Practice Forward View defines a plan to stabilise and transform general practice to enable it to deliver high quality services as part of these new models of care. Alongside national drivers, the Salford locality plan ‘Start Well, Live Well, Age Well. Our Salford’ sets out a strategy to improve the health and well-being of the citizens of Salford with a key focus on delivery of integrated services. The development of an integrated care system across Salford provides both opportunities and challenges for primary care. One of these challenges is a chronic shortage within the general practice workforce, specifically for General Practitioners and practice nurses. It is recognised that the transformation of primary care at scale and pace will not happen without workforce transformation. This Primary Care Workforce Development Strategy (for the purposes of this strategy primary care refers to General Practice) describes how Salford CCG will enable the development of a multi-disciplinary workforce, built around the needs of a defined population, with the right knowledge, skills, values and behaviours to deliver high quality care within general practice, leading to increased choice, improved access and better outcomes for patients. The Strategy provides a comprehensive outline of how Salford CCG will work with partners within primary care and across the locality to: Strengthen the foundations for primary care workforce development Develop primary care as a learning organisation Ensure the future supply of GPs, primary care nurses and the wider workforce Up-skill the current primary care workforce, including both clinical and nonclinical roles Develop new roles and new ways of working within the general practice team The development of Salford Primary Care Together, a federated entity for general practice within Salford, offers many opportunities to transform the primary care workforce and this Strategy sets out how the CCG will support providers to develop their workforce, to ensure that there is sufficient capacity, with an effective skill mix, to deliver emerging new models of care. 6 1.0 Introduction Salford is a growing, vibrant city with an ambition to become a place where people live happy and healthy lives. More people than ever before are choosing Salford as a place to live, work, invest and visit. But Salford is a city of inequalities with some of the poorest health outcomes in England. 70% of the local population are living in highly deprived areas and people living in poorer areas live up to 14 years less than those living in the richer neighbourhoods. The Salford locality plan, ‘Start well, live well, age well’ aims to “improve health and wellbeing across the city and remove health inequalities”. However, the plan recognises that the availability of a suitably skilled workforce across all areas, including primary care, is a key enabler for achieving service transformation across health and social care. Primary care has been described as the foundation of the NHS and general practice is at the heart of our communities. National and local strategies are driving more out of hospital care, meaning that primary care will need to collaborate with partners to develop new models of care as part of an integrated health and social care system. However, the demands on general practice are increasing, particularly for people with multiple, complex problems. Workload projections suggest that older people with long term conditions, including people with frailty, will be the major source of increasing work for primary care in coming years. In addition to this, patients and the public have rising expectations in relation to access and treatment. The situation is amplified by chronic shortfalls in the general practice workforce, specifically in terms of numbers of general practitioners (GPs) and practice nurses. Salford Clinical Commissioning Group’s (CCG) Primary Care Strategy recognises the need to support and develop primary care to deliver a service that addresses its population needs and to ensure a primary care that is sustainable and fit for the future. The strategy highlights that workforce development is a key enabler for primary care transformation. This Primary Care Workforce Strategy sets out how Salford CCG will support and enable primary care providers to develop a multi-disciplinary workforce, in the right numbers with the appropriate knowledge, skills and values, to provide high quality primary care for the residents of Salford. 7 2.0 Context and drivers 2.1 National context 2.1.1 Five Year Forward View The Five Year Forward View, published by NHS England in 2014, sets out a new shared vision for the future of the NHS based around new models of care. It sets out how the NHS needs to adapt and evolve to meet new challenges, of people living longer with more complex health needs, and to take advantage of the opportunities that science and technology offer patients, carers and those who serve them. It specifically seeks to address gaps in three areas: The health and well-being gap The care and quality gap The funding and efficiency gap The Five Year Forward View emphasises that primary care will remain the foundation for the NHS, but recognises that a ‘new deal’ is needed to expand and strengthen general practice. The strategy also sets out the need to reduce the divide between primary care, community services and hospitals to integrate services around the person and highlights how primary care is a key element within new models of care, whether these are multi-speciality community providers or primary and acute care systems. The Forward View acknowledges the need for a suitably skilled workforce to deliver these new models of care. It highlights that whilst there has been a growth in the overall healthcare workforce since 2000, this growth hasn’t been equitable across all parts of the system, with hospital consultants having increased around three times faster than GPs. The ‘new deal’ for general practice includes a commitment to expand as fast as possible the number of GPs in training while training more practice nurses and other primary care staff. 2.1.2 General Practice Forward View Building on the Five Year Forward View, the General Practice Forward View, published by NHS England in 2016, sets out a plan to stabilise and transform general practice through additional investment and support in relation to workload, workforce, infrastructure and care redesign. 8 The document sets out how NHS England, in partnership with Health Education England (HEE), Royal Colleges and other stakeholders, will grow the GP workforce whilst accelerating use of the wider, multi-disciplinary workforce. It sets out a bold ambition to create an extra 5,000 doctors in general practice and a further 5,000 nonmedical staff over the next 5 years. In relation to the GP workforce, the Forward View describes plans to increase recruitment and retention of GPs by: Increasing training capacity Promoting general practice as a career choice Offering flexibility of career paths Supporting post CCT (Certificates of Completion of Training) fellowships Developing a new portfolio route for GPs with previous UK experience Addressing workload concerns to support GPs to stay in practice Investing in leadership development, coaching and mentoring skills Offering targeted financial incentives to GPs to work in areas of greatest need The plan recognises that the success of general practice in the future will also rely on the expansion of the wider non-medical workforce, including investment in nurses, pharmacists, practice managers and administrative staff and the introduction of new roles, such as physician associates and medical assistants. The plan describes how NHS England and HEE will: Invest in general practice nurse development, including support for return to work schemes, improving training capacity in general practice and increasing the number of pre-registration nurse placements Extend the clinical pharmacist programme to enable every practice to access a clinical pharmacist Invest in additional mental health therapists to work in primary care Provide funding to support reception and clerical staff to play a greater role in care navigation Invest in practice manager development. 2.1.3 Health Education England Workforce Plan The role of Health Education England (HEE) is to provide system wide leadership and oversight of workforce planning, education, and training. The overarching aim of HEE is to support the delivery of excellent healthcare and health improvement to the patients and public of England by ensuring that the workforce of today and tomorrow has the right numbers, skills, values and behaviours, at the right time and in the right place. 9 Each year, HEE publishes a workforce plan to set out its investment in education and training across the system. The 2016/17 plan ‘Investing in People’ sets out three key challenges for the healthcare workforce in England: Future workforce supply Service and workforce transformation - designing sustainable services and the teams that deliver them to deliver on the aims set out in the Five Year Forward view Current workforce capacity and supply - establishing the mix and numbers of funded workforce posts capable of delivering the volume of services to standards required The Workforce Plan for 16/17 recognises that investment into the primary care workforce is essential to ensure that primary care remains as the foundation for the NHS. It sets out a vision to ‘ensure that we will provide challenging and fulfilling careers as part of a modern, innovative primary care system’. HEE’s workforce plan defines the additional investment into GP training to support the GP ten point action plan, published by NHS England in 2015, which aims to: Increase recruitment into general practice Retain more doctors within general practice, and Support more doctors to return to general practice In addition to investment into GP training, HEE acknowledges that a wider, multiprofessional workforce is required in primary care. The Workforce Plan highlights that new clinical roles such as Physicians Associates, Clinical Pharmacists and Paramedics and the creation of the new administrative support roles will ensure an integrated, diverse workforce for the emerging service models. 2.1.4 ‘The Future of Primary Care – Creating Teams for Tomorrow’ In 2015, HEE commissioned an independent review of the primary care workforce, led by Dr Martin Roland. The Primary Care Workforce Commission was asked to identify workforce solutions that would meet present and future needs of the NHS primary care workforce. Through the submission of evidence, site visits and conversations with local and national organisations, the commission found that many areas had created new and innovative ways of working and recommended that these examples of good practice be rolled out more widely. The report ‘The future of primary care – creating teams for tomorrow’ includes three key recommendations: 10 1. A multi-disciplinary workforce. The report sets out how new clinical and support roles can enhance the skill mix in primary care. It specifically highlights the contribution that clinical pharmacists, physician associates, physiotherapists, paramedics and medical assistants can make to patient care within general practice 2. Better use of technology. With advances in technology, the report emphasises that education and training will need to reflect the different skillsets required for alternative forms of consultation 3. Organisational changes to the NHS primary care system. The commission recommended that networks or federations of practices will enable primary care to offer a wider range of services, as well as better opportunities for staff development and training and the creation of new roles. It also highlighted that the primary care workforce has historically been relatively unengaged in NHS opportunities for leadership development and that this must be redressed. 2.2 Regional context 2.2.1 Greater Manchester Health and Social Care Partnership In 2015 an historic devolution agreement was signed to give direct, local control to public sector organisations in Greater Manchester. As part of this agreement, a strategic Health and Social Care Partnership has been established across 37 NHS and local authority organisations within Greater Manchester to manage the £6 billion spend on health and social care. ‘Taking Charge of our Health and Social Care in Greater Manchester’ sets out a five year plan to reform health and care across the region, through the development of an integrated system. A key focus within the ‘Taking Charge’ plan is the transformation of community based care and support, with the aim of enabling more people to be cared for at home or in a community setting and to drive up the prevention agenda. The vision is for primary care to be part of an integrated system, including general practice, community based services, social care and third sector organisations. This will require multi-disciplinary neighbourhood integrated care teams, coordinating the care for a defined group of people using evidence-based pathways. The plan recognises that the workforce required to work within the transformed system will need to be supported to develop new skills and new ways of working and that this will impact on education programmes and workforce development activities. From 2016, a Greater Manchester Health and Social Care Strategic Workforce Board will be established to: 11 Provide assurance on the workforce transformation programme for Greater Manchester Oversee the development and implementation of the Greater Manchester Workforce Strategy Develop new accountability arrangements to recognise that different ways of working will be required to deliver the transformational ambition of Greater Manchester Deliver the workforce transformation programme To support the transformation of community and primary care services, a Greater Manchester primary care workforce strategy is currently being developed. Additionally, there is an expectation that each locality across Greater Manchester will develop a local workforce transformation plan, overseen by a locality workforce transformation group (see section 2.3.1). These locality workforce groups will report to the Greater Manchester Health and Social Care Strategic Workforce Board. As the Greater Manchester and locality workforce plans evolve, Salford CCG will review its approach to primary care workforce development to ensure alignment with the wider health economy workforce strategy. 2.2.2 Health Education England (North West) Primary Care Workforce Transformation Within the North West, HEE has established a workforce transformation team to work with care providers to support whole system service transformation, by developing a workforce responsive to changes in care, now and in the future. This is delivered through a framework which encompasses four pillars of workforce transformation: Developing a sufficient supply of highly skilled staff Enabling up-skilling of the current workforce Developing and promoting new roles Developing and promoting new ways of working HEE (North West) has developed a number of initiatives and funded activities to support primary care providers to transform their workforce to support service transformation. This includes, but is not limited to: A continuing professional development (CPD) cash allocation to CCGs to support non-medical staff development in general practice Ring fenced places for primary care applications to Assistant and Advanced Practitioner programmes Expanded commissioned places for the Community Specialist Practitioner (General Practice Nursing) Programme 12 Commissioning a Core Foundation Programme in Practice Nursing Funding the education of a cohort of physician associate trainees Funding the development of the enhanced training practice model Expanded non-medical prescribing places for primary care Salford CCG has supported the implementation of a number of these initiatives across practices in Salford. These are described in later sections of this strategy. 2.3 Local context 2.3.1 Salford Locality Plan – Start Well, Live Well, Age Well The locality plan – ‘Start Well, Live Well, Age Well’ - details the strategic approach to improving the health outcomes of residents of the City, while also moving towards financial and clinical sustainability of health and social care services. It is the blueprint for the health and social care system in Salford for the next 5 years and supports the development and delivery of the Greater Manchester Health and Social Care Partnership plan. The overarching aim of the plan is to “improve health and wellbeing across the city and remove health inequalities” in Salford. One of the limiting factors for achieving the key objectives within the plan is the availability of a suitably skilled workforce. The development of seven day services, transforming primary care at scale and pace and the integration of health and social care is likely to need new roles as well as a regular supply of existing roles. All health and social care partners across Salford, along with wider public sector organisations, are engaged in the development of a locality workforce plan. Whilst the development of this plan is in its infancy, it is envisaged that the key strands of the plan will include: Leadership and management: Develop leadership capability and connect primary and secondary care leaders together at all levels to help them think differently and be open to new ideas and test concepts without the fear of failure Culture: Develop a shared culture that promotes asset based thinking, supports innovative ways of working, enables employees to work differently and supports staff to engage with citizens in a positive way Employee engagement: Develop appropriate employee engagement strategies that will enable the transition and transformation of services whilst maintaining an engaged and motivated workforce 13 Learning and development: Provide support to all employees, enabling them to develop the skills, knowledge and behaviours to operate in different operating models and across organisational and professional boundaries Employment conditions: Achieve the best possible working conditions for the workforce across the city, in order to improve health and well-being Early thinking around the workforce transformation priorities to enable delivery of the locality plan focuses on: An expansion of the workforce delivering primary medical services Increased numbers of staff delivering care in a community setting Staff with a broader range of skills that span health and social care Exploring opportunities for integrated training and education Exploring opportunities for staff to gain skills in working across all areas of care delivery (hospital, community and primary care) Exploring opportunities for the creation of new roles that will reduce duplication and improve the experience of people using health and social care services To oversee development of the locality workforce plan and to drive delivery of the ambitions set out within this plan, a Salford locality workforce transformation group has been established. As a key partner within the locality, Salford CCG has contributed to the draft locality workforce plan and will continue to inform the development of this through membership of the locality workforce transformation group. The CCG recognises that the development of the primary care workforce must be considered in the context of the wider workforce plan to enable integrated working across organisations and sectors to ensure a sustainable workforce, fit for the future. 2.3.2 NHS Salford Clinical Commissioning Group Salford CCG’s vision is to ‘commission and ensure delivery of high quality health services and enable our population to live longer healthier lives’. The Strategic Commissioning Plan 2014/15 to 2018/19 describes how the CCG will strive to improve health outcomes and improve the quality of the health services commissioned over the next five years, whilst doing so within a balanced budget. Community Based Care is a strategic programme for the CCG. This programme aims to support and invest in primary and community based care services to increase integration and the scope and scale of care provided outside a hospital setting. To enable this to happen, the CCG has developed a three stage approach to improving the scope, capability and quality of general practice: 14 General Practice Development Plan. This was developed in 2014 to support practices to manage their existing workloads more effectively and help to remove barriers to any future planning and service development Primary Care Strategy. This provides a comprehensive plan on the commissioning intentions of Salford CCG to transform primary care. The strategy sets out how the CCG will: o Commission high quality primary care which improves patient outcomes; reduce variation in quality and improving the patient experience o Improve access to general practice o Improve the management of long-term conditions and help patients to become empowered to self-manage. o Support integration of primary care and its health and social care partners to deliver seamless, fully integrated care o Enable federated working across practices to share expertise, service improvements and resource Community Based Care Strategy. The final vision is that general practice operates on a larger scale and works in a more integrated way with other services with general practice being at the hub of local communities and networks of services The development of the primary care workforce is seen as a key enabler for the delivery of the Community Based Care programme. 2.3.3 Salford Together Salford Together is a partnership of Salford City Council, Salford Clinical Commissioning Group, Salford Royal NHS Foundation Trust and Greater Manchester West Mental Health NHS Foundation Trust. This partnership was established to integrate health and social care for older people in Salford, bringing together services and workforces from across the partner organisations into a more aligned system and provide older people with the support they need to manage their own care. This is being enabled through: The development of neighbourhood multi-disciplinary groups, to review and problem solve complex cases, provide plans and anticipate care needs for those using health and social care services The development of a care home and supported living group, focussing on those who require a high level of support from health and social care services The creation of a centre of contact, to deliver a joined-up approach to health information, advice and support for health and social care 15 The establishment of a community assets group to strengthen the support networks and groups already in place and also to help communities work together to enable older people to remain active and independent members of the community In 2015, Salford Together was awarded PACS (Primary and Acute Care Service) vanguard status by NHS England to build on the success of its partnership work. This will enable further development of the integrated care system to encompass all vulnerable adults across Salford. A key step in the future development of the integrated care system is the establishment of an integrated care organisation (ICO) to bring staff working in health and social care services together into one organisation. The roll out of the integrated care system and the establishment of an ICO will require a skilled and motivated workforce, who can work differently to deliver more integrated care. An integrated workforce planning process across all providers, including primary care, will be required to identify future workforce requirements to deliver new models of care. As part of this process, it will be essential to identify the baseline workforce across all parts of the system and consider new modes of education and training across all parts of the workforce. 2.3.4 Salford Primary Care Together Primary care currently sits outside of the ICO, but general practice is a key component of the integrated care system. The CCG has been working with member practices, through the General Practice Design Group, to develop a ‘blueprint’ of how general practice might work more collaboratively to deliver primary care at scale and pace within the integrated care system. Following a successful proposal to all member practices regarding the creation of an out of hospital federated entity that will support the delivery of the neighbourhood model, a business case is currently being developed to progress the establishment of Salford Primary Care Together as the out of hospital entity. A federated, collaborative general practice model would enable many opportunities for education, training and workforce development. These include: A city wide education hub A learning and development programme for all general practice staff Stronger links with education partners, including HEE and universities Improved recruitment and retention of the workforce, specifically for GPs and practice nurses Broadening the skill mix within primary care through workforce innovation and the establishment of new roles 16 2.3.5 Salford Standard Salford CCG has recently launched the ‘Salford Standard’ for general practice to reduce unwarranted variation in the quality of care across Salford and improve the health outcomes for the people of Salford. There are 32 standards, across 10 domains, with a focus on long term conditions, medicines optimisation, public health, children and young people, vulnerable groups, safeguarding, access, proactive care, safety and experience and business management. To support delivery of the Salford Standard, the CCG has committed to providing a programme of education and training sessions to meet training needs identified by practices. This will include programmes for GPs, practice nurses, practice managers and the wider practice staff. 17 3.0 Vision for primary care workforce In response to the national and local drivers outlined above and taking consideration of the local challenges faced by primary care in Salford, Salford CCG’s vision for the primary care workforce is: To develop and sustain a multi-professional workforce, built around the needs of a defined population, which has the right knowledge, skills, values and behaviours to enable primary care transformation at scale and pace and ensure high quality care for the This will beofenabled residents Salford. through the four pillars of workforce transformation: Developing a sufficient supply of highly skilled staff This will be enabled through the four pillars of workforce transformation: Developing a sufficient supply of highly skilled staff Enabling up-skilling of the current workforce Developing and promoting new roles Developing and promoting new ways of working Later sections of this strategy set out how Salford CCG will work with primary care providers and other partners to enable this vision to be achieved. The development of Salford Primary Care Together, a federated entity for general practice within Salford, offers many opportunities to realise this vision and to ensure the development of a primary care workforce fit for the future. 18 4.0 Principles A number of principles underpin the vision set out above. These are: Building a workforce around the local population Taking a competency based approach to workforce redesign Developing primary care as a learning organisation Supporting widening participation 4.1 Building the workforce around the local population Long term planning for the primary care workforce requires a patient centred and population based approach if it is to be effective. Traditional methods for workforce planning, based simply on increasing numbers of the current workforce, reinforce traditional ways of working and out dated service delivery models. Salford CCG advocates a whole-system approach to the development of a future workforce model, whereby partners from across the health economy work together to build a workforce responsive to the needs of a particular population. This population could be based on a geographical footprint e.g. a neighbourhood, a subset of the whole population e.g. frequent A & E attendees or a cohort of patients within a defined clinical pathway e.g. Chronic Obstructive Pulmonary Disease (COPD). The Population Centric™ Workforce Planning Model (Gold Business Consulting Ltd), shown in figure 1, provides a framework to identify the needs of the local population and the services required to meet these needs and then to consider the skills and competences required within the workforce to deliver these services. From this, roles can be described and a gap analysis undertaken to allow workforce planning to be completed for that defined population. The CCG, along with partners from Salford City Council, Salford Royal NHS Foundation Trust and Greater Manchester West Mental Health NHS Foundation Trust, is at the early stages of testing this approach to workforce planning. The CCG is clear that primary care must be a key partner within this methodology to develop an integrated workforce plan which meets the needs of the local population and is aligned to the Salford locality plan. 19 Figure 1: The Population Centric™ Workforce Planning Model 4.2 A competency-based approach to workforce redesign Role redesign within general practice teams is a way of increasing efficiency and effectiveness in primary care, through the development of new and amended roles, which can address workload issues, improve patient experience and sometimes deliver savings. By taking a competency based approach to workforce redesign, teams can consider where changes in skill mix and working practices or new roles can streamline patient care without compromising on quality and safety. Without the development of a wider multi-professional workforce, the risk is that highly skilled professionals, such as GPs and practice nurses, undertake tasks that could be completed by other parts of the workforce, working to a competency framework. Salford CCG supports a competency based approach to workforce redesign, underpinned by the ethos of ‘only do what only you can do’. This approach means that where GPs, practice nurses or others are performing tasks or duties that other roles could competently undertake, then consideration should be given to how these activities can be passed on safely and effectively. In many instances, existing members of staff can be trained to develop new competencies, but where this is not possible new roles may be required. However, the CCG recognises that the very nature of general practice requires the workforce to work in a holistic way and patients 20 should not have to ‘tell their story’ several times. Therefore when considering new roles and skill mix changes, the underpinning approach must be to improve, not compromise, patient care. Salford CCG will encourage primary care providers to review the skill mix within their local teams, and across the wider integrated care system, and identify where new roles or new ways of working can be introduced to ensure that the skills and competencies of the whole primary care workforce are being utilised effectively, whilst maintaining a high quality service for patients. 4.3 Primary care as a learning organisation With some exceptions, for example medical student teaching and GP training, little priority has been given to training and professional development for staff working in primary care. In addition to this, pressures of both capacity and capability in general practice have historically hindered systematic engagement with healthcare training, resulting in limited exposure of healthcare students to primary care. The Primary Care Workforce Commission recommended that structured training opportunities should be available for all primary care staff to develop extended clinical, academic or leadership roles and that there should be more opportunities for joint training of health and social care staff. The report also highlights that there should be increased primary care exposure at pre and post-registration level through additional placements in primary care. Salford CCG believes that developing primary care as a learning organisation will lead to improved recruitment and retention of the primary care workforce. The CCG endorses the development of ‘Enhanced Training Practices’ (see section 6.1.3) which are accredited to provide undergraduate and postgraduate training placements through a hub and spoke model, whilst creating a multi-professional learning organisation ethos. In addition to this, the CCG is committed to developing a primary care learning and development programme for the whole primary care workforce to support delivery of the Salford Standard. The CCG will identify priorities for training and utilise its CPD allocation in the most effective way to deliver these. 4.4 Widening participation Widening participation remains a continuing workforce priority to ensure that the healthcare workforce represents the communities it seeks to serve. It is acknowledged that within healthcare, a diverse workforce can ensure a better understanding of patients' needs and lead to the delivery of joined up, personalised care. 21 Unemployment rates in Salford are higher than the North West and national averages and worklessness is recognised as one of the wider determinants of ill health. Salford CCG is committed to maximising Social Value for the City’s residents. Salford’s locality plan ‘Start Well, Live Well, Age Well’ sets out how partners will work together to improve the economic prosperity of families to reduce the harmful impact that worklessness and unemployment have on health and well-being. The health sector is one of the largest employers in Salford, so supporting local people into employment through widening participation activities is important for all healthcare employers. Salford CCG is committed to working with partners across the City to enable Salford citizens to become part of the local workforce across all health and social care settings, including primary care. 22 5.0 Strengthening foundations for primary care workforce development To achieve the vision of a multi-professional workforce, based around the needs of a local population, and to enable workforce transformation to take place, a number of foundations need to be in place as a basis for further workforce development. These foundations enable practices or neighbourhoods to consider where they are now and where they would like to be in terms of their workforce. In summary, it is important to: Understand the current workforce – roles and numbers Identify skills and skills gaps within the current workforce Consider the desired staffing model for a defined population 5.1 General practice workforce data In order to fully understand the current workforce within primary care and to effectively plan the workforce required to deliver care now and in the future, comprehensive workforce information is required across all practices in Salford. Workforce data needs to be collected in a way that information can be analysed over a neighbourhood or locality footprint, providing an inclusive representation of the numbers of different roles that constitute the current workforce. 5.1.1 Primary care workforce data collection The Health and Social Care Act 2012 places a duty on all organisations that deliver care funded by the NHS to provide data on their current workforce and to share their anticipated future workforce needs. NHS England has developed a workforce census module within the Primary Care Web Tool (PCWT) which practices can use to fulfil the requirements of the workforce minimum data set and provide details of their current workforce. In the North West, HEE has also developed a General Practice Workforce Data Collection tool, which feeds directly in to the WRaPT tool (see section 5.1.2). This collects workforce information which meets the requirement of the minimum data set (as above), but also collects additional data around roles, skill sets and vacancies. The HEE GP Workforce Tool therefore provides a richer level of information and for this reason practices within Salford have been encouraged to submit their workforce data through this method. Practices are currently asked to refresh their workforce data every six months. In March 2016, 63% of practices submitted workforce data through the HEE GP Workforce Tool, which was an increase from 41% the previous year. In comparison to other CCGs, analysis of this data showed that NHS Salford CCG is broadly similar to 23 both the regional (Greater Manchester) and North West average position; however, the age profile across the CCG is slightly younger, as is observed across all staff types. Part-time working increases with age and a smaller proportion of staff work parttime hours across the CCG, including GPs. Despite this, the number of GPs is average for the region (Greater Manchester), but low compared to the North West and England averages. However, this is offset by a higher percentage of other direct patient contact roles (e.g. advanced practitioners, Allied Health professionals). A high level summary of analysis of this data is shown in Figure 2. The CGG will work with primary care providers to identify the most effective way to collect workforce data in a consistent way and to utilise this data to provide information which is useful to the CCG, primary care providers and other partners. The CCG will also continue to monitor which practices have submitted workforce data and explore options for including workforce data as a key performance indicator within the Salford Standard to encourage all practices to submit to the HEE GP Workforce Tool, aiming for 100% completion. Further information on the Salford general practice workforce is provided in Appendix 1. 5.1.2 Locality workforce data As part of the evolving integrated care system, the CCG will work with its partner organisations to develop an integrated workforce plan. HEE (North West) has commissioned the development of a strategic workforce tool, WRaPT (Workforce Repository and Planning Tool), which enables organisations to plan their workforce based on anticipated changes in the delivery of care. WRaPT enables the collection, analysis and modelling of workforce information across the whole health and social care economy. Salford Together partners are working with the WRaPT team to identify the baseline workforce data across all parts of the system, including primary care, as a foundation for workforce modelling to support delivery of new models of care. The work is at an early stage, but having comprehensive primary care workforce data is a prerequisite for the next phase of work, which will focus on a defined sub-population to establish anticipated changes in services and activity and how the workforce may need to change to reflect this. 24 25 Figure 2: Summary of general practice workforce (March 2016) DPC = other direct patient contact roles GPs (R&R) = Registrars and GPs on the retainer scheme 5.2 Skills review ‘The future of primary care – creating teams for tomorrow’ report highlights that there is currently a lack of systematic data on who does what in primary care or data on whether the primary care workforce has the appropriate training and skills to deliver the necessary services. Salford CCG recognises that a key enabler for delivery of the Salford Standard is a suitably skilled workforce and is therefore committed to developing a primary care learning and development programme for the whole primary care workforce aligned to the domains and standards within the Standard. Little information currently exists on the current skills within the primary care workforce across Salford. Where practices submitted workforce data into the HEE (WRaPT) tool some analysis of skills within the workforce is available. A summary of this for the nursing workforce is shown in Figure 3. This highlights that, when compared to other CCG areas, a higher number of nurses across Salford report that they have skills in cervical cytology and family planning, but there are lower numbers of nurses who report they are non-medical prescribers. It should, however, be noted that this data is incomplete and has not been validated for these practices who did submit to WRaPT. To identify where there are gaps in the knowledge and skills of the current workforce, the CCG has recently carried out a training needs analysis across all practices by job role, based on the Salford Standard. This highlighted that all parts of the workforce, including GPs, nurses, practice managers and reception staff, feel that they require training in a diverse range of topics. The results of this exercise will be used to inform 26 the development of a primary care learning and development programme, which will be made available to the whole workforce. Competency or capability frameworks, which describe the knowledge, skills and expertise required to competently carry out a role, have been developed for a number of roles within primary care, including GPs, General Practice Nurses, Advanced Practitioners, Physician Associates and Health Care Support Workers. These can be used as a basis for employers or individuals to assess a person’s current level of competency and identify where training or development may be required, as part of a personal development plan. These competency frameworks can also be used to establish a baseline of current skills across a whole section of the workforce to inform a standardised approach to training and development. The CCG supports this approach to assessing and reviewing current skills and skills gaps to enable suitable workforce and education programmes to be developed for the primary care workforce. 27 0% 28 Suture removal Wound Care Phlebotomy New Patient Check Health Promotion GTT ECG 50% BP Check 50% Diabetic foot check 50% Antipsychotic Drug… Ambulatory check Treatment room Telephone triage Non-medical prescribing Minor surgery Minor illness Family Planning Cervical Cytology LTC: Spirometry LTC: Respiratory… LTC: Insulin initiation LTC: Hypertension LTC: Heart Failure LTC: Diabetes LTC: CVD LTC: COPD LTC: CKD LTC: Asthma Figure 3: Clinical skills of nursing staff (March 2016) Clinical Skills (nursing staff) North West 25% 0% The analysis is based on WRAPT data. The data does not specify what proportion of time is spent within a clinical area, only whether or not an individual has expertise in one or more specific areas. Greater Manchester 25% 0% NHS Salford CCG 25% 5.3 Future staffing models In order to enable them to move towards the vision of a multi-professional workforce, practices need to be able to make informed decisions about their desired staffing model, based on current activity and longer term planning assumptions. Whilst it is recognised that there is not one ‘ideal’ staffing model – for example, based on ratios of GPs or nurses per head of population - practices need support to consider how their workforce should be configured to reflect the needs of their local population. The Primary Care Workforce Commission recommended that ‘practices should analyse their workload and clinical case-mix when deciding what skills they need to employ. They then need to agree clear criteria for what each healthcare professional will do and ensure that staff are fully competent in the roles they undertake’. Salford CCG is keen to support practices to identify their desired staffing model and, working in partnership with HEE (North West), has commissioned a piece of work to develop, test and embed a model which can be used on a practice or neighbourhood level to determine future staffing requirements. The emerging model, depicted in figure 4, enables practices to review current activity, consider future ways of working and make informed decisions on how their workforce should be shaped to deliver local services. Following development with key stakeholders from the CCG and primary care providers, the model and approach is being tested in 4 practices in Little Hulton. Early feedback from these practices is extremely positive, but a more formal evaluation will be undertaken. Figure 4: Emerging primary care staffing model 29 This model reflects the principle of building a primary care workforce around the needs of the population and therefore the CCG endorses the wider roll out of this approach. 6.0 Enabling workforce transformation Workforce transformation is about developing a workforce responsive to changes in care, now and in the future, taking account of national, regional and local drivers. The Five Year Forward View, The GP Forward View, the Greater Manchester Health and Social Care Partnership and Salford CCG’s Primary Care Strategy all highlight that primary care workforce transformation is required to enable reform and change to happen at scale and pace, in a sustainable way. There are four key ways to transform the workforce: Developing future supply Upskilling the workforce Developing new roles Promoting new ways of working 6.1 Developing future supply Salford CCG has an ambition to develop primary care as a career of choice and to work with partners to ensure that Salford is as an attractive place to train and work. It is essential that a wide range of professionals are exposed to primary care as part of their pre- and post-registration training and that primary care is seen as a desirable option for a post-registration career. 6.1.1 General Practitioners GPs are the bedrock of general practice. Salford CCG recognises that the GP role is core to the wider practice team and must be valued as the provider of holistic, patientcentred care for undifferentiated illness, across time within a continuous relationship. For this reason the CCG wishes to promote and support GP training, recruitment and retention within Salford. The latest NHS England workforce figures (September 2015) show that there are 135.2 FTE GPs in Salford (excluding registrars, retainers and locums), with a fairly even split by gender (54% of GPs in Salford are female). Information collected by HEE, highlights that 11% of GPs are over the age of 55 and that 66% are under the age of 45, with the CCG having a slightly younger GP workforce than the regional (Greater Manchester) and North West profiles.. 30 There is currently no consistent way of collecting GP vacancy data, but anecdotally many practices across Salford report difficulties in filling GP posts. Practices also report that where posts are filled, these are more likely to be salaried or locum GPs rather than partners. Salford CCG is committed to working with primary care providers and other partners, including the Post-graduate Medical School and the Local Medical Committee, to ensure there are sufficient numbers of GPs in Salford. This will be achieved through a number of approaches: Increasing training capacity. There are currently 20 GP trainers in Salford. Previously, the number of trainers has not been the limiting factor in GP training, due to a national shortfall in the number of filled GP training places. However, NHS England has made a commitment in the General Practice Forward View to increase GP training recruitment through national and international campaigns. HEE has increased GP training capacity and in the most recent recruitment drive, 70% of posts were filled in the first round, an increase from previous years. Therefore, as the numbers of GP trainees increase, more trainers will be required. Salford CCG will identify ways to support GPs who wish to develop their practice as a training practice. This may include encouraging more GPs to become trainers for the FY2 programme, to enable them to start their journey as a trainer. There are opportunities to align with the development of enhanced training practices (see below), which provide a firm foundation for multi-professional learning placements Promoting general practice in Salford as a career choice. The CCG will explore options to work with partners to develop campaigns which promote primary care in Salford as an appealing place to train and work. This supports broader strategies across the City to make Salford an attractive place to work and live Exploring flexibility of employment routes. With the development of the integrated care system and closer working relationships between primary care and other parts of the health and social care system, there are opportunities to explore alternative methods of employment for GPs. Anecdotally, many GP trainees do not wish to become a partner, but would prefer a more flexible career path, which will allow them to work in other parts of the integrated system, as well as in general practice, and access wider opportunities for personal and professional development. The CCG would support the further consideration of this approach Induction and refresher scheme. GP Induction and Refresher Schemes provide an opportunity for qualified GPs to be inducted into or return to general practice in the UK. The scheme offers a bursary to an individual, whilst they are working on a supervised placement in general practice. Whilst these schemes are operated centrally by Post-graduate Medical Schools, the CCG will explore options to support the scheme locally. 31 Targeting areas of greatest need. NHS England is offering bursaries to GP trainees to work in areas that have been traditionally hard to recruit. The CCG will work with practices to identify where there are high levels of unfilled vacancies and consider how it may support future recruitment into these areas 6.1.2 General Practice Nurses The nurse is a core part of the general practice team and, as care shifts from the acute sector into community settings, will have an increasingly important role in the care of patients, especially those with long term conditions. Development as a General Practice Nurse is undertaken at a post-registration level, although increasing numbers of nurses are undertaking supervised placements in primary care as part of their preregistration education (see enhanced training practices, below). As with GPs, there are local reports of difficulties in recruiting to some practice nurse posts and low retention levels. The reasons for this are multi-factorial and include: Secondary care nurses not having had relevant experience in primary care, therefore unable to work independently without further development Primary care not seen as a preferred career path, due to a perceived lack of support and personal and professional development Previous absence of an agreed career development framework for primary care nurses No standardised approach to induction, supervision and training A variation in pay and conditions across practices Within the North West, there are two established education routes, funded by HEE, to drive the supply of practice nurses. These are: Core foundation modules, aimed at new practice nurses, whether newly qualified or working in a different speciality Community Specialist Practitioner (general practice nursing) programme, enabling study at a post-graduate or degree level Salford CCG recognises that these education programmes offer a standard approach for practice nurse development and, as such, recommends that all new practice nurses attend the foundation modules. In addition to these, the CCG supports practice nurse development through its CPD cash allocation by funding additional training which is felt to be essential to meet service needs e.g. vaccination and cytology training. The CCG is committed to continue to support practice nurse training, to ensure a sufficient future supply, and will agree priority areas for funding. 32 To increase and sustain the numbers of nurses within the primary care workforce, Salford CCG is committed to working with primary care providers, partners across the health economy and HEE to explore options to attract nurses to move into general practice and to improve retention. This may include: Supporting the development of a standard induction and preceptorship programme Supporting the development of a core local training programme Enabling the local implementation of the nationally defined career pathway for the primary care nursing workforce Supporting a return to nursing scheme for primary care Enabling the further development of the enhanced training practice approach Facilitating opportunities for new models of employment for nurses Recently, HEE has announced the creation of a Nursing Associate role. This new role would support registered nurses in providing high quality person-centred care and would be trained in a higher skill set than a traditional healthcare support worker. The proposed education route for this role would be via an apprenticeship framework, with a high level of work based learning, leading to a foundation degree. As well as bringing direct benefits to patient care, the associate role is seen as enhancing the overarching career framework for nursing, enabling progression for healthcare support workers and providing an additional route into pre-registration training, thus increasing the supply of registered nurses. The CCG is keen to participate in further discussions about this new role and will work with HEE and primary care providers to test, embed and evaluate the contribution of the Nursing Associate role to the primary care workforce. 6.1.3 Enhanced training practices Enhanced training practices are a practice or group of practices accredited to provide undergraduate and postgraduate multi-professional training placements, operating through a hub and spoke model. Hubs take the lead role in developing both sufficient capacity and quality of learning environments, whilst also creating a multi-professional learning organisation ethos as part of core business. The purpose of an enhanced training practice is to increase exposure of healthcare students to primary care and therefore provide an opportunity to harness and assure future workforce supply. They are multi-professional, offering placements to support a variety of pre-registration programmes, including nursing, medical and Allied Health Professions students. 33 To support the establishment of enhanced training practices, HEE (North West) recently invested in the development of a number of hubs across the region. Within Salford, Salford Health Matters has developed as a hub and is working with other practices to successfully deliver high quality learning placements to healthcare students. Salford CCG endorses this innovative approach to increasing the future supply of the primary care workforce. As further opportunities arise, the CCG will work with higher education partners and others to develop additional capacity for learning environments in primary care, at both a pre-registration and postgraduate level. 6.1.4 Pre-employment programmes To support the widening participation agenda and ensure a primary care workforce which reflects the diversity in the local population, the CCG is keen to explore options to promote pre-employment programmes such as cadets and internships. By facilitating opportunities for local citizens to work in the local health and social care sector, this reflects the ambitions set out within Salford’s locality plan of improving the economic prosperity of families, whilst also assisting with the future supply of the primary care workforce. In the North West, career engagement hubs have been established to bring together local employers, schools and training providers and coordinate a number of activities aimed at promoting healthcare careers to a range of people, including children, school leavers and those not in employment. Salford CCG is part of the Greater Manchester hub and through this is considering how it can work with primary care providers and others to provide opportunities for the local population to become part of the local workforce. The Skills for Health Academy in the North West runs a 14 week pre-employment programme. This aims to help unemployed adults, often from disadvantaged backgrounds, to attain the skills, values and capacity required in order to secure employment. Participants complete a four week study period in college, followed by a 10 week placement with a local healthcare employer. Traditionally these placements have been in secondary care in NHS Trusts, but the CCG is considering how primary care may be able to engage with this programme. Internships are a relatively new approach to providing work experience within the health and social care sector. A number of providers and charities are now working with employers to develop internship programmes, often as part of a wider career development programme, to enable individuals to be exposed to work and to develop essential skills for career success. Salford CCG is keen to consider how these internships may be useful in primary care as an approach to widening participation, but also to enable future recruitment into roles within general practice. 34 6.2 Upskilling the current workforce With national and local strategies driving more community based care, alongside the launch of the Salford Standard to improve the quality of care offered by primary care in Salford, the CCG recognises that the whole general practice team needs to be highly skilled to deliver high quality care in an effective way. This includes up skilling both clinical and non-clinical staff, to ensure the most effective skill mix is available to meet patients needs. 6.2.1 Primary care learning and development programme Following a recent exercise to identify training needs across the primary care workforce, the CCG is committed to developing a primary care learning and development programme for the whole workforce. This builds upon established training programmes for the primary care workforce in several areas, including end of life care, safeguarding and diabetes management. This programme will focus on supporting delivery of the Salford Standard, with specific educational events linked to individual standards e.g. respiratory care, dementia, kidney disease and learning disabilities. A calendar of training events will be published and promoted to all practices with targeted audiences where appropriate and sessions will be evaluated to ensure that they are meeting the needs of the workforce. Salford CCG receives a CPD cash allocation from HEE (North West), as well as access to modules at North West universities through the CPD-Apply system. These funding streams support the development of all non-medical clinical staff. Following the recent Comprehensive Spending Review, there has been a significant reduction in the CPD funding which has been made available to the CCG. Therefore the CCG will identify priorities for education and development and will ensure that there is a transparent process for allocation of the funding across the primary care workforce. 6.2.2 Enabling career progression In 2015, HEE published ‘Transforming Nursing for Community and Primary Care’. This education and career framework sets out the specialist knowledge and skills needed to deliver and advance in district nursing and general practice nursing. This Framework is part of a workforce transformation work programme for community and primary care nurses to enable care to be delivered in out of hospital settings, improving patient outcomes and the experience of patients, carers and staff. The Framework also supports standardisation of roles by outlining core and specific competencies, enabling practitioners to identify learning needs, plan and develop careers. 35 The Framework clearly establishes the careers escalator for a general practice nurse, from level 1 (pre-employment) to level 8 (advanced nurse practitioner) and as such embraces the unregistered and registered nursing workforce. For each level, the framework provides a clear role description, minimum professional and education requirements and the scope of clinical practice, with a link to competency frameworks where appropriate. Across Salford practices, there are a number of different roles within the practice nursing workforce, namely healthcare assistant, assistant practitioner, practice nurse and advanced nurse practitioner. However for the majority of these roles, with the exception of advanced practice, there is currently no standardised approach to role definition and no agreed method to enable individuals to progress up the careers escalator, although many practices have used in-house learning and external development opportunities to support the development of their nursing workforce. Salford CCG wishes to promote the local implementation of the HEE education and career framework for general practice nursing to enable a consistent approach to role definition, education and training requirements, competency levels and scope of practice. As well as bringing clear benefits to service delivery and patient care at a practice level, this would provide opportunities for the nursing workforce across Salford to work in a more collaborative way across neighbourhoods, through pooling resources and sharing skills. This could initially be across practice teams, but, with the further development of the integrated care system, could also provide opportunities to work more collaboratively with the wider community nursing teams. The CCG will continue to explore options for promoting the further development of the general practice nursing career framework to enable progression of individuals through the various roles. 6.2.3 Advanced Practitioners Over recent years, the Advanced (Clinical) Practitioner has become more important in primary care and both the Primary Care Workforce Commission and the General Practice Forward View highlight the contribution that non-medical clinicians with advanced level skills can make to the general practice team. An Advanced Practitioner is an experienced, non-medical, registered professional who has developed their theoretical knowledge and clinical skills to a high standard. Advanced Practitioners bring a unique skill mix to general practice teams, provide patients with a broader range of choice and add capacity to service delivery to better meet demand. They work in addition to, and together with, GPs and the wider practice team. 36 In the North West, the recognised education route for Advanced Practice is a two year MSc programme, with a significant amount of work based learning. This enables individuals to develop high level knowledge, clinical skills and competencies as well as critical analytical skills to risk manage and make safe, evidence-based decisions at a high level. On completion of the programme, Advanced Practitioners are able to independently assess patients with a wide range of clinical presentations, request and review diagnostic tests, undertake differential diagnosis and treat patients, including referral to other services where appropriate. Many Advanced Practitioners are also independent prescribers. Salford CCG supports the development of Advanced Practitioners and views them as an essential part of the primary care workforce. HEE (North West) currently supports the development of Advanced Practitioners through funding the education programme plus salary costs while the individual is studying at university. To supplement this funding, the CCG has invested £1,763,388, over three years, in a cohort of 14 primary care trainee Advanced Practitioners, who are currently half way through their two year programme. This training programme is hosted by Salford Health Matters with several other practices providing placements. The multi-professional cohort consists of nurses, physiotherapists and paramedics and anecdotal feedback from practices about the value of the role is extremely positive. The CCG is committed to continuing to work with partners to evaluate the role of Advanced Practitioners in primary care and to support the further development of this role. 6.2.4 Talent for Care and Care Certificate HEE has recently published Talent for Care, a strategy produced to recognise, support and further develop the development of the healthcare support workforce. Talent for Care was developed following wide consultation with national bodies, education institutions, health and social care employers and healthcare staff and represents a significant development, as it is the first ever national strategy for the development of healthcare support staff. One of the key pledges included in the Talent for Care strategy is the implementation of the Care Certificate. The aim of the Care Certificate is to ensure that all new support staff are taught and can demonstrate the right skills, knowledge, values and behaviours to provide high quality and compassionate care. From April 2015 all new NHS and social care staff providing direct support to patients and clients need to complete the Care Certificate. However, the implementation of the Care Certificate within primary care requires some consideration to ensure it can be integrated into the support workforce and to enable providers to utilise it in a way that is meaningful to individuals and practices. 37 The CCG is currently facilitating some work to identify where a standardised approach to the development and training of healthcare assistants would add value to patient care and the wider system. This includes consideration of how the Care Certificate can be used and applied to best effect within primary care. The initial phase will review the baseline competencies within the current healthcare assistant workforce, to enable an informed decision to be made regarding future development of the role. 6.2.5 Developing the non-clinical workforce The success of general practice in the future will rely on the development of the wider, non-clinical workforce and Salford CCG recognises the contribution that practice managers, receptionists and other non-clinical roles make to the practice team. The administrative burden on primary care clinicians is well documented and it is estimated that GPs spend 11% of their time on administration. ‘The future of primary care – creating teams for tomorrow’ suggested that new support roles have the potential to reduce the administrative workload of GPs and other clinicians. Historically, the development of this part of the workforce has been overlooked and practice managers have found it difficult to identify appropriate education and training programmes to develop this part of their workforce. Salford CCG’s vision for the primary care workforce is inclusive of non-clinical roles and therefore the CCG is committed to supporting the development of this part of the workforce. Practice managers provide a crucial senior administrative function within general practice and, although the role can vary from practice to practice, they are usually responsible for a number of key activities including business planning, handling financial systems including payroll, selecting, training and supervising non-clinical staff and the effective use of data and information. Practice managers can gain relevant qualifications through external accredited providers, such as AMSPAR (Association of Medical Secretaries, Practice Managers, Administrators and Receptionists ) which offers a Certificate/Diploma in Primary Care and Health Management or the ILM (Institute of Healthcare Management) which provides the Vocational Training Scheme for General Practice Managers. However, a scoping study of the non-clinical workforce across Salford in 2015 revealed that 42% of managers were not qualified to level 3, highlighting that there are significant opportunities to up skill practice managers within Salford practices. The recent General Practice Forward View committed new investment to support practice manager development, although the detail of this is not yet known. Administrative roles within general practice are often used as an entry point into the primary care workforce and can be used as a foundation for career development into other roles. Practices cite that they are keen to develop their administration and reception staff into healthcare assistants or into more senior administration roles. 38 Apprenticeship programmes can be a cost-effective means of creating a skilled, flexible and motivated workforce. These programmes can also help improve the diversity of the workforce and provide employment opportunities for the local community to enter the healthcare sector. Apprenticeships are work-based training programmes available to anyone over the age of 16. They enable learners to demonstrate their competence while gaining a recognised qualification, which span a range of levels from level 1 (GCSE equivalent) to level 7 (Masters level), achieved through a mix of on the job training and study, whilst at the same time being in employment. The government is committed to increasing the growth of apprenticeships and there is a commitment to achieve 3 million apprenticeship starts in the UK economy by 2020. To facilitate this there are major changes in apprenticeship national policy and the introduction of some significant reforms. All public sector organisations will have a legal duty to support apprenticeship starts and will be set a target of 2.3% of their workforce. It is estimated that to meet the target of 2.3% over 4000 apprenticeship starts will need to be achieved by North West NHS organisations. In addition to this, in April 2017 an annual Apprenticeship Levy will be introduced and applied to all organisations with a pay bill of £3m or more. Whilst apprenticeships are well established in NHS Trusts, there has been less use of these programmes in primary care, so a targeted approach is currently being deployed by HEE to increase the numbers of apprenticeships within this sector. Salford CCG recognises the opportunity to utilise apprenticeships to develop the skill mix within primary care and to specifically develop the non-clinical workforce, including practice managers. The CCG will work with primary care providers, HEE and education providers to enable an increased usage of apprenticeships within primary care and to support the government’s ambition and targets. 6.2.6 Developing wider skills Salford CCG recognises that the primary care workforce needs to develop a wider skill set than those related directly to the delivery of patient care. This may include, but is not limited to, training and development in: Quality improvement Research and innovation Leadership Enhanced use of technology Risk management Clinical system training Coding 39 The recent training needs analysis provided an initial overview of where this training is required, which demonstrated a need for both the clinical and non-clinical workforce to develop a wider knowledge base and skill set in relation to the areas listed above. The CCG will review this information and, through discussions with providers, will establish the most effective way to meet these needs. 6.3 Developing new roles The General Practice Forward View highlighted that the success of general practice in the future will rely on the expansion of the non-medical workforce and the introduction of new roles. This reflects the findings of the Primary Care Workforce Commission which emphasised where new roles can bring benefits to patient care, through enhanced models of service delivery. Salford CCG has an innovative approach to the development of new roles within primary care and has committed significant investment, through innovation funding and the commissioning of new services, to the testing, evaluation and embedding of several new roles. The CCG is committed to exploring additional opportunities for role development in primary care. 6.3.1 Clinical Pharmacists There has been considerable interest over the last few years in the role of clinical pharmacists within the general practice team. Pharmacists are able to support patients to self-manage their well-being and long term conditions, through optimising medicines, and enabling improved medicine related communication between general practice, hospital and community pharmacy e.g. on admission and discharge and at other interfaces of care. This therefore means that GPs can focus their skills where they are most needed and frees up GP time. The Primary Care Workforce Commission recommended that ‘there should be greater involvement of clinical pharmacists, including prescribing pharmacists, in the management of people on long-term medication and people in care homes. This role is best carried out in the GP practice in order to allow full access to the patient record and to maximise interaction between the pharmacist and other clinical staff in the practice.’ NHS England is testing a general practice clinical pharmacist programme and, through the General Practice Forward View, has committed to a further roll out of this scheme. In 2014, Salford CCG funded an innovation scheme which provided clinical pharmacists to three neighbourhoods. These posts evaluated favourably and were shown to improve medicines safety, long term condition reviews and medicines reconciliation at transfer of care as well as a reduction in waste and financial savings. 40 Following this successful pilot, the Salford CCG has approved a business case to the value of £1,077,425 to commission a clinical pharmacy service to ensure every practice has clinical pharmacist input on a regular basis. The key outcome of this new service will be improved care and health outcomes for patients. In addition to this, it is expected that this new service will release savings in the primary care prescribing budget as well as reduce the number of medicine related non-elective admissions. A lead provider has been appointed for the clinical pharmacists and the service is currently being mobilised. The pharmacists will be based within general practice and seen as a member of the primary care team. It is proposed that the teams are formulated on a neighbourhood basis with a team leader supporting several pharmacists. 6.3.2 Physician Associates A physician associate is a new healthcare professional who, while not a doctor, works to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and treatment within the general practice team under defined levels of supervision. Physician associates provide generalist clinical care in general practice, typically seeing people with acute minor illness. They have two years post-graduate training, following a minimum of a 2:1 science degree. This training follows the model of a medical qualification. Working under the supervision of a GP, physician associates can make a significant contribution to practice workload. Across the North West, HEE is leading the delivery of a pilot physician associate education and training programme to develop these roles in secondary and primary care. Salford CCG recognised this pilot as an opportunity to test and evaluate the contribution of this new worker to the general practice team and has provided £100,000 additional funding over two years to sponsor 10 trainee physician associates to work in practices across Salford, coordinated by Salix Health Ltd. The trainees commenced their education programme in January 2016 with their first primary care placement starting in June 2016. The CCG recognises that more studies are needed to assess how effective and cost effective these roles are in the long term and will work closely with HEE to undertake a robust evaluation of the contribution and impact of these roles in general practice. 6.3.3 Paramedics Paramedics are autonomous practitioners who are registered with and regulated by the Health and Care Professions Council. The Paramedic Career Framework (2015) recognises that many paramedics are now moving away from traditional ambulance 41 service roles to work in primary and critical care, including out of hours services, general practice, walk in centres and emergency departments. Paramedics are experienced in pre-hospital care and are able to assess, diagnose, treat or signpost patients. Paramedics have many clinical skills which are transferable into primary care and have well developed communication skills including supporting patients to selfmanage their condition, where appropriate. A number of community and primary care paramedic services have developed across the United Kingdom. Within general practice, there are a number of options for utilising paramedics as part of the primary care team. This may include running clinical sessions, including pre-booked and urgent appointments, telephone triage and home visits. The Primary Care Workforce Commission highlighted that ‘the potential for paramedics to substitute for GPs in the assessment of urgent requests for home visits merits further evaluation’. Salford CCG is currently exploring options to utilise advanced practice paramedics in one neighbourhood, as part of an acute home visiting service, to evaluate how this role may improve access and patient care. This builds upon the success of utilising trainee advanced practitioner paramedics within general practice, as part of the advanced practice programme described above. The CCG recognises that an agreed competency framework would need to be in place when introducing this role and that defined protocols and supervision arrangements would also be required to ensure that patient safety, quality and effectiveness are not compromised. Through the innovation process, the CCG would carry out a robust evaluation of this role to determine impact and benefit, prior to further roll out of the role. 6.3.4 Mental health workers Mental health problems are widespread and mental health and physical health are often linked. Many people presenting to general practice have primary mental health needs or secondary mental health problems associated with their physical conditions. As well as impacting on physical health outcomes, individuals with mental health problems are less likely to engage in school or employment, leading to an impact on wider public health services and resources. Nine out of ten adults with mental health problems are treated in primary care, although the primary care workforce may not always feel it has the appropriate level of knowledge and skills to care for these people effectively. Resources for primary care practitioners have increased through the development of IAPT (Improving Access to Psychological Therapies) services, and in some areas nationally, the attachment of primary care mental health workers to practices. 42 The General Practice Forward View has set an ambitious target to ensure there are an extra 3,000 mental health workers in primary care by 2020, providing an average of a full-time therapist for every 2-3 typical sized practices. In addition to this new resource, the primary care workforce needs to be trained to ensure they are fully supported to lead the delivery of multi-disciplinary mental health support in primary care. General practices need links to mental health advice for the wide range of psychological problems seen in both adults and children in primary care. In Salford, there are established pathways of care for people requiring IAPT services and for those with higher level mental health needs. The development of the integrated care system in Salford provides opportunities to join up general practice, community services and mental health services to provide new models of care delivery for patients with low level mental health needs, through an integrated approach to physical and mental health. Salford CCG will work with partners to explore where new roles, new ways of working and learning and development within the primary care workforce could improve care pathways and quality of care for all individuals with mental health needs. 6.3.5 Physiotherapists Musculoskeletal (MSK) conditions make up to 30 per cent of a GP’s caseload, rising to 50 per cent for patients over 75. There is increasing evidence of the role that physiotherapists can take as part of primary care teams to support the management of MSK problems. Physiotherapists are autonomous practitioners able to assess, diagnose, manage and discharge patients. Increasing numbers of physiotherapists are independent prescribers and are able to administer injections or prescribe drugs as part of a treatment plan. However, rapid referral to physiotherapy reduces levels of medication and therefore having access to physiotherapy as part of the primary care team can help to reduce levels of unnecessary prescribing. As autonomous practitioners, physiotherapists can be accessed through self-referral schemes, reducing the demand on GPs. This streamlines pathways of care and saves time and money. Self-referral schemes in physiotherapy have been well evaluated and have been shown to reduce DNAs, increase access, reduce administration costs and increase patient satisfaction. One evaluation found that 85% of MSK patients seen by a physiotherapist in primary care did not need to see a GP. Salford CCG is keen to identify approaches to enabling patients with MSK problems to access physiotherapy in a more timely and effective way at a location which is easily accessible to them. Self-referral to physiotherapy is one area which is currently being 43 explored and as part of this, the CCG will consider where these services may be located. Increased collaboration across primary care providers, as part of the development of Salford Primary Care Together, may offer opportunities to co-locate physiotherapists in practices or for primary care providers to employ them directly. In addition to this, the integrated care system brings opportunities to develop new pathways of care for patients with MSK problems and the CCG will work collaboratively with secondary care providers to identify where the development of physiotherapy roles may enhance primary care MSK provision. 6.3.6 Medical Assistants Excessive administration in general practice is a major problem and many GPs cite that non-clinical workload is a major factor in them leaving primary care roles. It has been estimated that GPs spend 11% of their time on administrative duties, which could be delegated to other parts of the workforce to enable GPs, and other clinical staff, to focus more time on direct patient care. The Medical Assistant role has been used in American and Australian primary care to provide appropriate skill mix solutions to the demands on GPs. Medical Assistants are trained to perform both clinical and non-clinical duties to support GPs. ‘The future of primary care – creating teams for tomorrow’ report identified Medical Assistants as a key area to pilot and evaluate its impact in primary care. A recent workshop facilitated by HEE to discuss the role of Medical Assistants in primary care across the North West revealed that some practices are already developing roles which have a clinical and non-clinical element e.g. reception and phlebotomy, and that many healthcare assistants undertake a variety of tasks which cut across both areas. However, it was recognised that education and training to support these roles, within a defined career framework, was not standardised and this should be explored further, specifically to understand the core competencies needed for this type of worker. Salford CCG will continue to work with HEE and primary care providers explore opportunities which this type of role could bring to primary care. 6.4 New ways of working Introducing new roles into the general practice team will provide additional capacity in primary care. In addition to this, there are several options which will reduce demands on GPs and other clinical staff through new ways of working. Salford CCG would wish to identify and explore options for new ways of working with primary care providers and other stakeholders. 44 6.4.1 Productive General Practice One of the key recommendations of the General Practice Development Plan was the development of a framework to help and support practices to identify and implement quality improvements. The Productive General Practice (PGP) programme, developed by the NHS Institute for Innovation and Improvement, provides a systematic approach to support practices in their drive to improve productivity, by creating improvement capability. The programme enables the whole practice team to review their current working practices, identify where improvements could be made and agree a plan for improvement. Salford CCG has commissioned Shaping Health International to deliver PGP across practices in Salford. There are currently 22 practices, within 3 cohorts, engaged in the PGP programme. The CCG recognises that the PGP programme will provide practices with information relating to how they are currently utilising their workforce and will support these practices to consider how new ways of working may lead to improvement and increased productivity. There is a particular alignment between the PGP programme and the approach being developed to identify future staffing models, as described in an earlier section and therefore early links have been established across the two programmes of work. 6.4.2 Asset-based care and care navigation Socio-economic factors account for 50% of the determinants of health and social isolation is one of the biggest health risks. It is known that GPs spend a fifth of their consultation time on non-health problems. As demand on general practice continues to grow, more interest is being taken in an asset based approach to health and wellbeing. The aim of asset-based practice is to promote and strengthen the factors that support good health and wellbeing, protect against poor health and foster communities and networks that sustain health. An asset based approach identifies the skills and capabilities within local residents and communities and connects these assets into more formal groups to build strong relationships and reciprocal social networks. The ultimate aim is to mobilise local people to act on the things they care about and want to change. Salford has a strong sense of community cohesion and a well-developed voluntary, community and social enterprise sector, ‘Salford Community and Voluntary Services’. Salford City Council has mapped over 7,000 community assets available to individuals and has developed a ‘Way2Well-being’ portal. However, general practice is not yet sufficiently linked into these community assets to take full effect of them. Salford CCG is currently supporting an innovation pilot in one neighbourhood to develop a ‘Health to Wellbeing’ GP Network. The aim of this Network is to improve the health and well- 45 being of the local population and reduce pressures on the primary care system by signposting the population to more appropriate services across the city. ‘Care navigators’ or ‘community champions’ are people who are trained to assist patients and member of the public to identify appropriate support services without needing to see a GP. There are different approaches to developing care navigators within general practice. One option is to recruit additional people to work in the practice to specifically undertake a care navigator role. Another option is to up skill the current workforce e.g. reception staff to develop a wider care navigation function across the team. For those individuals with higher needs, a shared point of access can streamline the process to connect people with the services they need. HEE (North West) is currently developing a training package to support an asset based approach within primary care. This will offer different levels of development for the primary care workforce to support asset based care, care navigation, social prescribing and well-being coaching. Salford CCG will explore how this development may be of value to the primary care workforce across Salford. 6.4.3 Empowering patients and the public New care models and the priorities of the Five Year Forward View are achievable only by fundamentally changing the relationship that the NHS and social care have with patients, people and communities. Patients and the public require empowering to enable them to self-care and to manage their healthcare needs, where appropriate. Salford’s locality plan ‘Start Well, Live Well, Age Well’ sets out a need to use behavioural approaches, including health coaching, to achieve its transformation priority to upgrade population health, prevention and self-care. Health coaching helps patients to acquire the knowledge, skills, tools and confidence to become active participants in their care, so they can reach their self-identified health goals. Rather than just an acknowledgment of the patient's ideas, concerns and expectations, coaching explores patients' personal health beliefs and empowers them to select health goals pertinent to their life. Health coaching can have positive impacts on outcomes for patients, especially those with long term conditions, as well as reducing demand on general practice. However, the primary care workforce needs training and development to enable them to work with their patients in this way to move from a directive approach to a more equal, patient-focused, collaborative one. Salford CCG will work with primary care providers to establish the most effective way to enable the workforce to feel confident in utilising health coaching. 46 7.0 Implementation of strategy Salford CCG recognises that workforce development is a responsibility for employers and, as such, the implementation of many strands of this strategy will fall within the remit of primary care providers and the emerging out of hospital entity, Salford Primary Care Together. However, through the Community Based Care programme, the CCG will continue to support and enable primary care workforce development through: Testing and evaluating new roles and new ways of working through access to innovation funding Non recurrent funding to pump prime workforce development projects and initiatives Commissioning new roles where evaluation demonstrates evidence of positive impact on primary care delivery Working with HEE to pilot new roles and new ways of working in primary care Building close relationships with other partners across the integrated care system and wider locality to ensure primary care workforce development is a key enabler for wider service transformation Supporting providers to consider alternative methods of employment to improve recruitment, retention, learning and development The development of a federated model for general practice within Salford offers many opportunities to realise the CCG’s vision outlined within this strategy and to ensure the development of a primary care workforce fit for the future. The CCG will support the development of federated working to enable providers to utilise their workforce differently and test and embed new roles. The Workforce Development Group as a sub-group of the Community Based Care Commissioning Group (CBCG) will be the forum for the development of proposals for non-recurrent resources to support primary care workforce development. Investment to date in workforce development initiatives totals just under £3 million over a three year period. The CBCG will continue to act as the sponsoring strategy group to progress any further proposals for funding though the CCG Governance structures. 7.1 Delivery plan 7.1.1 Year 1 NHS England has mandated that, in 2016/17, every local system must develop and implement a local plan to address the sustainability and quality of general practice, including workforce and workload issues (‘Delivering the Forward View: NHS Planning Guidance, 2016/17 – 2020/21). 47 ‘Development of the General Practice Workforce’ is one of the deliverables in Salford CCG’s 2016/17 business plan for the Community Based Care programme. As such, this sets out the delivery plan for the first year of the Primary Care Workforce Development Strategy. This is summarised in Table 1. Table 1: Year 1 delivery plan 1. 2. 3. 4. 5. 6. 7. 8. 9. Action Establish baseline workforce data across all practices Implement pilot for primary care staffing model across one neighbourhood Evaluate pilot of primary care staffing model and agree next steps Develop and implement primary care learning and development programme Evaluate year one of advanced practitioner programme Enable systematic utilisation of apprenticeship framework to increase the number of apprenticeships within primary care Commission and evaluate a primary care leadership development programme Implement a pilot within one neighbourhood to explore the role of paramedics in primary care Mobilisation of new practice pharmacy services Timescale March 2017 May 2016 September 2016 September 2016 October 2016 March 2017 March 2017 December 2016 December 2016 7.1.2 Year 2-3 A number of priority action areas for years 2 and 3 have been identified through discussion with the CCG Primary Care Workforce Development Group and the Medical Director of Salford Primary Care Together. These are outlined below. The detail of how these areas will be delivered from 2017/18 onwards will be subject to further discussion with practices and neighbourhoods as part of the implementation of the business plan for Salford Primary Care Together. Table 2: Year 2-3 delivery plan 1. Priority areas Roll out of primary care staffing model 2. Development of city wide education hub 48 3. 9. Creation of bespoke learning and development programme for all staff accessed via a variety of media Development of standardised competency framework for all staff groups commencing with healthcare assistants Profiling of skills within primary care administrative workforce to identify skills gaps and develop options and proposals for new roles or new ways of working Support more practices to become training practices for GP training and wider multi-professional students. Explore options for development of roles for Allied Health Professionals in primary care, commencing with physiotherapy roles. Work with Academic partners to explore whether the research capability building outlined within the Research & Innovation Strategy can support recruitment and retention of GP’s into Salford practices. Evaluation of practice pharmacist service 10. Evaluation of impact of advanced practice roles in primary care. 4. 5. 6. 7. 8. 7.2 Risks The following risks have been identified in relation to delivery of this strategy. Table 3: Risks Risk Lack of engagement of practices Limited capacity in primary care providers to deliver workforce development Public and patient resistance to workforce development Lack of funding for workforce innovation and development Mitigation GP Lead (Workforce development) Neighbourhood Leads (GP leads, practice manager leads, practice nurse leads) Salford Primary Care Together Financial investment Significant investment in Primary Care through Salford Standard to enable workforce development Patient and public engagement through PPGs Innovation funding Partnership working with HEE 49 Development of a primary care federated model that does not support workforce development Primary care workforce development seen in isolation from wider ICS and locality workforce Limited ability to recruit to substantive or new roles or training posts. Business case for federated working with early opportunities for workforce development identified ICO workforce group Locality workforce transformation strategy and delivery plan ETP to expose healthcare students to primary care Initiatives to promote Salford as a place to train and work 50 Appendix 1: General Practice Workforce Headlines The data source for the information below is based on practice submissions to the Health Education England (North West) GP data collection tool in March 2016. Only 63% of Salford practices submitted to this tool, so the data set is not complete. Therefore this analysis only provides an indicative picture. Age and gender profile of the Primary Care workforce all staff male headcount male staff North West Greater Manchester 50% female headcount 13% NHS Salford CCG 31% 30% 10% 2% 30% 24% 4% 27% 21% male FTEs 40% 87% female FTEs 15% 85% 30% female staff 20% 22% 4% 22% 30% 23% 22% 10% 0% 16-34 35-44 45-54 55-64 65+ Profile of workforce % FTEs of total General Practice workforce by role type NHS Salford CCG % FTEs by role type NHS Salford CCG Greater Manchester North West England (indicative as based on different data) North West Greater Manchester Admin DPC GPs GPs (R&R) Nurses 55% 57% 57% 52% 12% 7% 7% 7% 19% 23% 23% 24% 2% 1% 1% 4% 13% 11% 13% 13% 51 Staff ratios per head of population GPs per 100,000 weighted Population l l l l l NHS Salford CCG Greater Manchester North West England North West CCGs 40 45 50 55 65 GPs (excluding R&R) per 100,000 weighted Population The analysis is based on national data provided to HSCIC (General and Personal Medical Services in England 2005-2015, Provisional Experimental Statistics) 40 45 50 The data shows the spread and range in the rates for each role type across the North West, along with the respective regional and national averages. 55 60 Nurses per 100,000 weighted Population - Rates for NHS Salford CCG 60 5 10 15 20 25 30 35 40 FTEs per 100,000 weighted population GPs 48 GPs (exc Registrars and Retainers) 45 Nurses 24 Direct Patient Care 19 Admin 110 Direct Patient Care Staff per 100,000 weighted Population - 5 10 15 20 25 30 Admin (non-clinical) staff per 100,000 weighted Population 90 95 100 105 110 115 120 125 130 Note: Direct Patient Care includes all other staff (except GPs and nurses) with patient care responsibilities. This includes healthcare assistants, physiotherapists, pharmacists and others. 52 135 Appendix 2: Feedback from patient and public engagement To ascertain how patients and the general public would respond to plans to develop new roles and new ways of working within general practice, a survey was sent to the CCG Citizen and Patient Panel. 43 responses were received. These responses are summarised below. It appears that the public are generally supportive of the plans to extend the workforce within primary care. However, further assurances would be required around education, training, competencies and confidentiality before the introduction of some of these new roles. 1. Do you have any experience of seeing other clinical people in general practice, apart from GPs or practice nurses? Response Response Percent Total 1 Yes 44.19% 19 2 No 55.81% 24 Comments: Respondents reported that they had been seen by a number of other healthcare workers including a counsellor, phlebotomist, midwife and podiatrist. 2. Would you be happy to see a physiotherapist if you were suffering from a back or neck problem, without seeing the GP first? Response Response Percent Total 1 Yes 97.67% 42 2 No 2.33% 1 Comments: ‘But I would have to be confident in their skills and abilities to diagnose any problems’ ‘It is impossible for one person (i.e. the GP) to know everything about everything. So I think it is an excellent idea to have added roles such as a physiotherapist’ ‘Of course, this makes much sense as it saves time and money, as more than likely a GP will refer a patient to a physiotherapist in any case’ 53 3. Would you be happy speaking to a clinical pharmacist in the practice about any medication you are taking? Response Response Percent Total 1 Yes 100.00% 43 2 No 0.00% 0 Comments: ‘Pharmacists should be used more in my opinion!’ ‘There is a Pharmacist attached to practice whom is valuable’ ‘This is offered by the pharmacy that prescribes my medication so not sure there is a need for further unless it were co-ordinated’ 4. Would you be happy if a paramedic, working as part of a general practice team, carried out a home visit for you instead of a GP? Response Response Percent Total 1 Yes 72.09% 31 2 No 27.91% 12 Comments: ‘I put no because if it was an emergency I would be happy for a paramedic to come. It if I was ill and needed a diagnosis and treatment I would want to see a GP’ ‘Provided they had access to the GP in the practice should they need to refer. I think the only thing would be their access to my medical history in order to make a proper diagnosis’ ‘Though I have not been in need of one thus far I am sure they would be sufficiently skilled enough to carry out an assessment’ ‘This would depend who it was and who had access to my medical records?’ 5. Would you be happy speaking to someone other than your GP or nurse about any non-medical or social problems you have? Response Response Percent Total 1 Yes 88.37% 38 2 No 11.63% 5 Comments: ‘What sort of non-medical problems would I talk to a doctor or nurse about anyway? Would the "someone" be a professional person?’ 54 ‘I think non-medical and social problems should be referred elsewhere to keep GP surgeries focuses on health care’ 6. To what extent do you agree with the plan to develop new roles? Response Response Percent Total 1 Strongly agree 44.19% 19 2 Agree 53.49% 23 3 Disagree 2.33% 1 4 Strongly disagree 0.00% 0 Comments: ‘The changes should not be made in order to block the way to the GP, but I agree something has to be done to relieve GPs of some of their burden of work’ ‘I agree but you need the right people - qualified and credible people’ ‘Extending the services can only be good for patients, and help to focus the staff and skills in appropriate areas of need’ 7. Do you have any concerns regarding developing new roles within primary care? Response Response Percent Total 1 Yes 6.98% 3 2 Yes, to some extent 37.21% 16 3 No 55.81% 24 Comments: ‘Roles have to be clearly identified and training given’ ‘The focus should be on ensuring the correct skill mix not on saving money’ ‘Right person for the job, confidentiality must be assured, adequate qualifications and opportunities to remain as up to date within the role as possible. It should not create a watered down service but meet people's needs’ 55