East and North Herts
CCG
Business Case
Business Case
CCG Primary Care Workforce and Education Network
CCG Contact
Sheilagh Reavey, Director of Nursing and Quality
Dr Robin Christie
Date
9th July 2015
1.0
Introduction
The original proposal which set out the benefits of a primary care workforce and
education network and board, was presented to the Governing body in April 2015.
Following discussion, there was support in principle for the model but with a request
that it was tested with GP members through locality meetings. A series of
presentations were made in all six localities to explain the model and benefits, which
received overwhelming support.
1.1
In addition, a number of exploratory meetings and discussions have taken
place with key prospective stakeholders. These have included the Postgraduate GP
Dean at Health Education England (HEE) & East of England (EoE); the Head of the
Beds and Herts Workforce Partnership; the Chair of the Royal College of GP’s (RCGP)
National Nursing Group; the Chief Executive of Hertfordshire Partnership Foundation
Trust (HPFT) who is chair of the Workforce Partnership and Integrated Care Board;
Deanery representatives from the Universities of Hertfordshire and Bedfordshire as
well as others working on and influencing workforce planning and education in
primary care across Beds and Herts and the East of England. They have been
uniformly encouraging and supportive of the proposals so far and are keen to
engage with further development of the plan.
This paper now sets out the national and local context, the case for change, benefits
and cost. It articulates how the CCG can support the vision for primary care in the
future NHS.
2.0
Context
The National Perspective
In 2012, the RCGP published the “ 2022 GP “ – a vision for Primary Care in the future
NHS, which stated that the health service must be built on a foundation of
integrated, community-shaped, generalist healthcare services.
This will require a greater number and diversity of skilled, generalist-trained
professionals. Practice teams will require the skills and expertise of nursing staff,
physician’s assistants and other professionals, who have undergone specific
vocational training in community-based settings and are trained for their generalist
roles, which will compliment that of the expert generalist physician. These key
professionals will bring a range of unique skills and competencies including, with
additional training, prescribing and advanced nursing skills.
In 2013, the national “Call to Action” challenged CCGs to ensure that their strategies
for primary care maximised the practice nurse contribution to high quality
compassionate care and excellent health and wellbeing for people in local
communities.
In 2014, Simon Stevens published the “Five Year Forward View” which highlighted
the pressures in Primary Care and emphasised the need for a “new deal” for GPs
with more investment in Primary Care and the development of new care models
such as Multi-speciality Community Providers to provide integrated out-of-hospital
care.
In May 2015, the RCGP published “A blueprint for building the new deal for general
practice in England”.
In June 2015, The Secretary of State, Jeremy Hunt MP outlined the first steps of the
new deal. He acknowledged that “successive governments had undervalued,
underinvested and undermined the vital role that general practice plays”. He
highlighted the challenges around the primary care workforce and workload. He
stated the need to focus on recruitment, retention and returning to practice and to
promote the attractiveness of general practice. He backed the recent RCGP “Ten
Point Plan” to tackle the workforce crisis. However, he also re-iterated the
government pledge on seven day working which will require considerably more
investment in staff and infrastructure in primary care if it is going to be
implemented.
In June 2015 the District Nursing and General Practice Nursing Service Education and
Career Framework was also published. This supports educational standardisation of
both of these roles to ensure that staff can work effectively by being trained, safe,
confident and competent practitioners in order to meet the increasingly complex
emotional and physical conditions that patients cared for in the community now
have.
2.1
Local Context
We know there are particular difficulties locally with recruitment and retention of
GPs and practice nurses.
Health Education England (HEE) reports that the current service model for primary
care is unsustainable and that the estimated shortfall of GPs for East of England by
2020 will be around 200 FTE.
A RCGP survey in February 2015 estimates the figure for East and North Herts may
be as high as 126 FTE.
We know that 25% of established GPNs are due to retire over the next 5 years
We know that 35% of GPs are planning to retire in the next five years
We know that GP Training Scheme recruitment has been difficult again this year
We know that some 20% Trainees are considering working abroad.
We know that most Trainees do not stay and settle in this area at completion of
training whereas historically this was the case. There are a number of reasons for
this but it is clear we must be marketing the attractiveness of settling in this area and
ensuring that the quality of the training experience encourages an attachment and
loyalty to our local health care system.
We know that only 40% of Foundation Year 2 doctors have a GP attachment as part
of their training and also that the foundation programme is oversubscribed with over
200 applicants still waiting for places this year. (BMJ June 20 th 2015).
We know there is a lack of pre-registration nurse attachments in primary care
We know there is a lack of a coherent and co-ordinated approach to postregistration nurse training and development in primary care
We know that approximately 30% of practice managers are planning to retire in the
next five years and 20% are currently considering a career change.
We know that future practice nurse requirements and skill mix are unknown and
that detailed current workforce data is not yet available from Health Education
England. Given that the national response rate has been 25% for the minimum data
set, it is clear that we urgently need comprehensive local primary care data.
In summary both the national and local context highlight the burning platform of
primary care workforce issues and action is needed urgently to manage this crisis.
3.
Proposal
3.1
To create a Primary Care Workforce and Education Infrastructure (Network)
overseen and supported by a CCG Primary Care Workforce and Education Board,
which will link into the work of the CCG Integrated Care Board, the Beds and Herts
Workforce Partnership and the Co commissioning Board. This will create a coherent
and stable platform which will support both workforce and education issues and the
implementation of integrated care.
3.2
To create a Primary Care Workforce and Education Board chaired by the Director of
Nursing and Quality/ CCG Governing Body Workforce and Education Lead (with the
Network team as core members) which will bring together all key stakeholders from
across the CCG to ensure a more rational and joined up approach to primary care
workforce and education developments as well as place the CCG in an ideal position
to access additional transformation and training monies from external partners.
3.3
To appoint the CCG Primary Care Workforce and Education Clinical Lead, who will be
a member of the Workforce and Education Board and who will link into external
organisations, secure external funding opportunities, support the leads and drive
innovation in relation to the three Rs.
3.4
To appoint a Primary Care Workforce and Education Locality Lead in each locality.
This post has emerged from discussions with localities. It will support local
ownership, engagement and locality initiatives in conjunction with the overall Lead.
3.5
To appoint Primary Care Nurse Tutors in each locality, one of whom as the senior
tutor would be a member of the Board. These posts would be focused on skills,
competencies and training developments as well as revalidation, needs assessments
and supporting integration.
3.6
The medium term vision is for an integrated model of workforce and educational
delivery based around federations as educational and employing organisations with
board level ownership and focus on workforce development, that recruits and
retains the skill mix necessary to provide the best quality care for our local
population and that can access the funding required to ensure long term
sustainability.
4.0
The case for change (rationale)
4.1
The delivery of the CCG Primary Care Strategy and its nine ambitions are
underpinned by the need for a competent, continuously improving and flexible
workforce in order to provide the high quality integrated physical and mental health
services required to meet our patient’s needs in the most appropriate settings.
4.2
In order to meet the above challenges, the “three R’s” of recruitment, retention and
returning need to be addressed urgently. Education and training support play a
crucial role in all three areas particularly in helping making general practice an
‘employment of choice’
4.3
We know that there is a need for greater diversity and expertise, with the next
generation of health care professionals needing to have a broader range of skills and
competencies as we move from a GP-provided to a GP- led service.
4.4
The development of the skills of the General Practice Nurse (GPN) and their support
staff is imperative. However, most of these skills are not part of pre-registration
nurse training, nor are they found in nurses working in other settings. There was no
mandatory education for GPNs or Health Care Assistants (HCA) and no national
career framework for GPNs until now. It is envisaged that the network team will
work with HEE, the local university and other key stakeholders to put into place the
required supporting education and development in line with local needs and
national requirements.
4.5
Increasing the number of pre-registration nurse placements in primary care is crucial
if we are to attract the required number of newly qualified nurses into general
practice nursing. It is important to note that there is an issue with the ‘image’ of
general practice from nurse graduates which an increase in practice placements
should go some way to ameliorate. A key performance indicator for the network
team will be to facilitate a step change in the number of pre-registration placements
available within the next academic year.
4.6
As yet there is no infrastructure in primary care to support Nursing and Midwifery
Council (NMC) revalidation requirements for the practice nurse workforce. The first
tranche of nurses requiring NMC revalidation will come on stream in the spring of
2016. This is a high risk situation as those nurses who are unable to meet NMC
requirements will be removed from the register and will be unable to practice.
4.7
The CCG requires a more structured approach to training needs analysis. This would
ensure that there is prioritisation and alignment of educational opportunities with
improved coordination and consistency to what is an expensive resource giving
better value for money.
4.8
Without a dedicated practice improvement infrastructure the CCG and Federations
will struggle to make available to their practices the necessary tools and support to
deliver the step changes in care needed. For example, when a CCG practice recently
needed an experienced GPN to undertake a root and branch review of its practice
nursing service NHS England and the CCG struggled to find suitable support. It was
only with the goodwill of an ex GPN Tutor employed by one of the Governing Body
practices that the struggling practice was able to access the support it needed.
Individual practices will also struggle to implement the recommendations in the
District nursing & General Practice Nursing Education and Career framework.
4.9
CCG links to the work of HEE and the Workforce Partnership need to be
strengthened and the Primary Care Workforce Board will provide a formal conduit to
the work of HEE. This work includes development of Associate Physicians, GPN
mentoring programmes, implementation of a GPN regional framework, Foundation
degrees for bands 1-4 and GP return to practice scheme. The CCG will not be in a
position to make the most of these opportunities without the necessary supporting
infrastructure proposed in this paper.
4.10
The proposed investment to create the Primary Care Workforce and Education
Infrastructure (Network) would enable the delivery of a number of key work streams
(in partnership with key stakeholders) that would not be possible to deliver without
such an investment.
4.11
Workforce planning systems are currently fragmented. We need to articulate what
we want to deliver and negotiate with HEE and HEIs for a system that meets our
needs. We need to encourage a cultural shift and with key stakeholders promote
primary care as a career pathway of choice
5.0
Benefits
As described in the original proposal there will be a number of benefits. These
include:
5.1
Practice Nursing
There are many benefits, which are listed below but most importantly it will enable a
coherent approach to training and development that will result in better informed,
skilled and supported primary care nurses, to meet the challenges outlined above.
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5.2
Training and Development packages for HCAs.
Increase in pre-registration students’ placements in general practice, in order
to introduce primary care as a career to a larger number of student nurses.
There is an opportunity to develop 3rd year attachments for 6 – 12 weeks
whereby students can be assisting in practical HCA level work as well as
observing. The uplift to the Tariff to support this development is noted
below. At present, less than 20 practices across Beds and Herts accept prereg student nurse attachments. It is proposed that we fund ten placements
that have students four times a year, for a twelve week period.
In collaboration with HEE and Herts University, development of bespoke post
registration GPN training for newly qualified nurses. This will ensure high
quality consistent training opportunities for core areas across the CCG.
Introduction of GPN mentorship opportunities, to ensure the above training
is embedded, competencies are developed and new nurses are supported.
Introduction of structured Clinical Supervision programme(s).
Work with NHS England to ensure that general practice is ‘ready’ to
implement NMC revalidation, and support it ongoing development.
Scope the feasibility of nurse rotational posts as part of the integrated care
delivery agenda.
Help support the implementation of the District Nursing and General Practice
Nursing Service Education and Career framework.
General Practitioners
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Development of supported placements (fellowship schemes) for newly
qualified GPs to aid recruitment and retention in this area and facilitate the
development of new skills and competencies. This would include
opportunities to develop organisational and leadership skills as well as
consolidate clinical expertise and to work across different provider
organisations including the CCG, HUC, HCT, HPFT, the acute Trust as well as a
variety of GP Practices. These posts will be innovative and flexible to allow
for a menu of opportunities as well as help to secure increased GP capacity in
practices. These schemes are already being advertised and appointed to in
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nearby CCGs. The CCG would need to be clear about contracts and
employment arrangements with these schemes but by putting in place the
infrastructure described above, the CCG will be able to pilot and test such
arrangements in conjunction with HEE first.
Increase the percentage of Foundation Year doctors having a four month
placement in general practice from 40% towards 100% with the aim of
promoting general practice as a positive career choice.
Development of training practices and federations as ‘learning organisations’
with the introduction of Community Education Provider Networks (CEPN’s) in
localities which would link primary care providers. CEPNs would provide
placements for workforce training in the community covering a number of
disciplines, initially GP trainees and nurses. They would hold an SLA with the
GP School which would specify the standards and educational requirements.
Work with HEE to promote and support the re-launched GP Retainer Scheme
and the Induction and Returner Scheme. Three new practices have already
been approved so far this year with interest being expressed by three more.
Work with federations to develop options for retaining GPs, GPNs and
practice managers who are nearing retirement.
Work with practice managers and their teams to scope the requirement and
source options for any necessary non-clinical training and development such
as leadership skills (this will include all practice staff)
These changes would be structured around localities/federations and their local
circumstances, ambitions and priorities with a Workforce and Education Lead at
locality/federation board level.
Further development of both training and non-training practices would be
encouraged with the key appointment of Primary Care Nurse Tutors in localities as a
priority. They would link together as a wider network to enable opportunities for
nurses including training rotations, shadowing, mentorship and leadership
development.
5.3
Vision
Federations as employing and educational organisations with a local board level
focus on workforce and education that recruit and retain the integrated skill mix
necessary to provide the best quality care for our local population.
6.0
Project Costs
Phase 1 - Direct costs
Lead GP sessions - 4 sessions weekly
Senior Primary Care Nurse Tutor - 4 sessions weekly
(Inc. 2 locality sessions)
£ 48,000 max PA
£17,056 Inc. 20%
On costs
Total = £65,056
Indirect costs
It is difficult to quantify this in relation to this proposal as yet, other than support to the
Board, and lead posts but it is clear that more widely, co commissioning in relation to joint
working on primary care quality and workforce issues are new areas of work that are not
currently resourced and will have an impact.
Phase 2 - Direct costs
Primary Care Nurse Tutors across 5 localities (2 sessions/week)
Locality GP workforce and education Lead (1-2 sessions monthly)
Pre reg nurse placements (top up national tariff from £15.00 to £30.00)
X 10 @ 300 per month per practice
£42,640 Inc. 20%
On costs max pa
£43,200
Max pa
£36,000
£121,840
Total for both phases =
£186,896 PA
(GP fellowship schemes - £75,000 p.a x 12 = £ 900,000. CCG to host contracts with full
contributions from participating practices and organisations.)
(Nurse rotations schemes x 6 = £154,641. CCG to host contracts with full contributions from
participating practices and organisations)
External Funding Opportunities.
In 2013/14, the Beds and Herts Workforce Partnership funded a number of varied projects
from the CCGs which are now being evaluated. The strategy for 2015/16 is to agree shared
aims and priorities across the four CCG areas and to focus funding support only on these
(2015/16 Transformation funds approx. £1m – was £1.5m in 2014/15). The final
collaborative approach is to be agreed by August at which time investment priorities should
be known. Primary care is a priority for the workforce partnership particularly in relation to
the supply of GPNs and our local CCG proposals have been made known to them. There is
therefore the possibility that HEE/Workforce Partnership funding may be provided in future
for the Primary Care Nurse Tutor roles and the tariff supplement for pre-registration nurse
placements.
In addition, there is approximately £45k allocated to this CCG for primary care nurse
development which currently supports the free courses available for nurses at the
University of Hertfordshire.
It is proposed that the CCG meets the above costs for a 2 year period, on a pump priming
basis. Following evaluation, discussions will be held with the Federations about their
support for all or part of the ongoing costs, (which may be supported by HEE funding as
outlined above) in order to ensure local ownership and future sustainability.
Outcomes
OUTCOMES
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A successful transformation of primary care by supporting workforce planning
underpinned by education and training for all staff in primary care.
 Continually improving quality of care for our patients in the community through the
right staff and skill mix working more effectively together with shared learning.
 Achieving the strategic aims of the CCG and the “Five Year Forward” plans.
 Improved shared understanding of the work of others working within the community
team.
Outcomes Measures and Evaluation
 Measurable increase in pre-reg nurse training opportunities in the community.
 The development of nurse rotations across acute and community.
 Measurable increase in Foundation Year training posts in the community.
 Measurable increase in number of Training practices and Trainers/Associate Trainers
(GP and Nurse).
 Measurable number of Fellowship posts introduced, and retention of those
practitioners.
 The development of Federations as “learning organisations”.
 Measurable increase in recruitment and retention of GP and Nursing staff in the
community.
 Better support and career development for nursing staff supported by the new
Nurse Tutors.
 Introduction of new roles such as Physicians Associates and Community pharmacists
working in practices.
 Co-ordinated network with key local stakeholders involved in workforce planning
and education.
 Accurate and up to date workforce planning data.
If funding is agreed these will be developed further in relation to:
Success criteria, Proposed measure and associated KPIs for evaluation purposes
7.0 PESTLE
Politics
Economic
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Social
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Technical
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Legal
Environmental
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Five Year Forward Plan
Vanguard programme
Building the workforce – the New Deal for General Practice
Nurse revalidation
A blueprint for building The New Deal RCGP
Federation Development
Influence use of new resources
Integration agenda
Best use of resources by supporting new models of
integrated care
Access to funding streams from HEE/WP
Better use of resources through co-ordinated training
programmes
Improved productivity and less reliance on agency staff
Reduced staff stress and absenteeism.
Enhancing the image of primary care in E&N Herts as a place
to work
Establishing development of new skills
Opportunity to support further qualifications
Leadership development
Links to Primary Care Strategy and implementation of single
platform across primary care and other key providers.
Revalidation
8.0
SWOT Analysis
Strengths
(internal)
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Weaknesses
(internal)
Opportunities
(external)
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Threats
(external)
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Will support the work of the CCG Strategy and the Primary Care
Strategy
Will support the work of the CCG Integrated Care Board
Will support practices becoming NMC re-validation ready
Ensures that clinical staff have the necessary skills and competencies to
deliver high quality integrated services
Will improve clinical recruitment and aid retention across all
professional groups
Will promote new models of care and primary care leadership.
Robust evaluation will be required in the near future
Success is dependent on the ability to recruit
Not all practices may be committed to the ethos of training and
development
Internal capacity to manage and support the team
Will support East and North Herts and primary care being seen as
‘employment of choice’
Opportunity to showcase innovation
If the network is successful, it builds CCG credibility
CCG will be in a better ‘position’ to access external funding streams and
be a key player in any external innovative recruitment and retention
schemes
Transformation of inter - professional working and learning.
Builds a solid foundation on which to move in the medium term to an
Integrated Primary and Community Care Network
Potential delay in recruiting to posts due to lack of interest or suitable
candidates
Resilience of the model ( predicated on local ownership)
Poor engagement form key stakeholders
May not meet practice’s or external stakeholders expectations
9.0
Recommendations
Given the strong rationale for change, and the positive number of internal and
external strengths identified for this Business Case, it is proposed that recruitment
proceeds with immediate effect. A clear set of outcome objectives with success
criteria, proposed measures and KPIs, will be drawn up based on the key work
streams highlighted within this paper. An update paper will be brought back to the
Governing Body no later than December 2015.
Activity
Next steps
1) Take final version to CCG Board for agreement and sign off – 30th July 2015
2) Finalise job specs for key roles – 1st week Aug 2015
3) Seek agreement from Execs regarding these roles and go out to advert/interview and
appoint – Aug/Sep 2015
4) Plan interactive workshop for core membership and stakeholders (with facilitator)
late Sep 2015
5) Prepare Primary Care strategic workforce Plan and Education, Training and
Development Plan for LETB. Summer 2015
6) Workforce and Education Board established - October 2015
7) Develop and promote first Fellowship posts – Autumn 2015
8) Develop and promote expansion of pre-reg nursing posts – Autumn 2015
9) Advertise and appoint to new posts December 2015
Appendix 1
Primary Care Workforce Board Composition
The Board would consist of a CCG core membership that would initially meet monthly with
administrative support from the CCG. This group would design, promote and monitor the
strategic developments and their work would be augmented by representatives from other
organisations on a quarterly/ad hoc basis.
CORE MEMBERSHIP Director of Nursing and Quality (Deputy - AD Nursing and Quality)
Director of Commissioning
CCG Primary Care Workforce and Education Clinical Lead (new post)
CCG Senior Primary Care Nurse Tutor (new post)
AD Primary Care
NON CORE MEMBERSHIP –
CCG Clinical Lead/AD Integrated Care Board
Associate Dean HEE EoE
University of Hertfordshire
Locality Primary Care Nurse Tutors (new posts).
GP Tutors
Training Programme Directors for GPST (Lister and QE2).
RCGP Faculty Educational Lead
Beds and Herts Workforce Partnership
HEE EoE Primary Care Programme Board
Beds and Herts LMC Ltd
Long Term Conditions Senior Nurse
HEE EoE Lead Nurse – Jenny Aston
Medical Director/Nursing Directors HPFT/HUC/ENHT/HCT
Appendix 2
Primary and Community Care Education Training and Development Network
Dates shown below where applicable otherwise timeline shown as a visual representation of project delivery
2015/16
2014/15
Qtr 3
Project Steps:
Start Date
End Date
01-03-2015
01-04-2015
01-04-2015
01-05-2015
Discussion and feedback Clinicians Meetng
01-04-2015
01-05-2015
Discussion and feedback at Executive Committee
01-04-2015
01-05-2015
Presentation to Localities and invite feedback
01-05-2015
01-07-2015
Preparation of final draft
01-05-2015
01-07-2015
Share with stakeholders and invite feedback
01-05-2015
01-07-2015
Update at Clinical Development Bussiness Meeting
01-06-2015
01-07-2015
Board Agreement and sign off
01-07-2015
30-07-2015
Interactive workshop for core members and stakeholders
01-07-2015
01-09-2015
Primary Care Workforce Plan for HEE
01-07-2015
01-08-2015
Prepare job specification Lead and Tutors
01-06-2015
31-07-2015
Seek executive agreement to recruitment
01-06-2015
15-08-2015
Establish workforce and education board
01-07-2015
01-10-2015
First Fellowships in post
01-09-2015
01-12-2015
Expansion of pre registration posts
01-06-2016
01-12-2015
Engagement ( March 2015 - December 2015)
Present presentation and discussion of draft plan to CCG
CEO
Circulate draft to CCG Board Clinicians and Executive
Team
Oct
Nov
Dev
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Qtr 4
Qtr 3
Qtr 2
Qtr 1
Qtr 4
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Appendix 3