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28 July 2015

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The power to spend money based on your population’s health needs is now a reality. Here is what Harrogate intends to do

The power to spend money based on your population’s health needs is now a reality. Here is what Harrogate intends to do

On 1 April 2015, Harrogate and Rural District CCG became one of the first wave of CCGs to take on full delegated responsibility for primary medical care commissioning functions.
As set out by NHS England, the opportunity to take on primary care co-commissioning gave CCGs the chance to expand their role to help improve the quality of primary care, support integration of health and care services, reduce health inequalities and put the NHS on a sustainable path for the next five years and beyond.
Our CCG, with the support of our council of members, applied for full delegated responsibility for primary care commissioning from April this year, setting out our commitment to improving the quality and capacity of primary care to fulfil our vision of a sustainable health and social care system.  

The benefits
Our aim is to enable local clinicians and local communities, to have more influence over how primary care services are developed. Being able to shape primary care medical services through delegated commissioning arrangements will mean integration between all elements of health services becomes a reality in our area. It will give us more flexibility to tailor local services and will enable us to:  

  • Support our GP member practices to drive quality improvement within primary care, and reduce health inequalities.
  • Support the integration of health and social care services locally.
  • Increase public engagement and involvement in the development of primary care services.
  • Support the development of sustainable local services.
  • Ensure, as a membership organisation, the CCG has a greater positive influence on decisions affecting primary care locally.

Our CCG represents 17 GP practices and serves a population of around 161,000 people. Our ambition is that people in our locality can enjoy good health, have access to good services if and when they need them and that they can play an active role in making decisions about their own health and their own lives, as well as in influencing how health and social care services are delivered in the area.

The focus
Our most significant demographic issue is our increasing older population, with over a fifth of the population being aged over 65 years (20.6%) compared to 16.9% for England. This is reflected in the proportion of patients who are registered in nursing homes, which is double the England average (1.0% vs 0.5%). Some practices have more than four times the England average of older patients. This will have increased demands on primary care, which is already running over capacity. We know that in its current state it is not sustainable and we need to adapt to the demands on the service.
We have been working on an integrated agenda between primary care, social care, mental health and community services for a number of years to help solve these issues and were successful in our application to become a vanguard site as well.
Delegated commissioning will allow us to take a more holistic approach to commissioning end to end pathways that will lead to improved quality of care; integrated services, reduced duplication, and an engaged whole system approach including integrated personalised commissioning. Patients will experience a number of benefits including:

  • More opportunities for shared decision making, meaning patients are more informed and involved in their care including personal health budgets, allowing choice and flexibility of services.
  • A greater focus on prevention through care planning.
  • More care delivered closer to their homes as capacity within the community increases.
  • A more flexible integrated community service system to cope with the demographic changes within our population as it becomes older.
  • An even greater emphasis on primary care teams managing long-term conditions.

Our new models of care work, supported by the vanguard process, will allow us to redesign the space between traditional primary care and the hospital bed. This is a real opportunity for primary care to be in a more sustainable position, by being able to commission primary care as a single commissioner rather than a fragmented system involving multiple commissioners.  
We have established a primary care commissioning committee to make collective decisions on the review, planning and procurement of primary care services for Harrogate and Rural District under delegated authority from NHS England.
The functions of the committee are to increase quality, efficiency, productivity and value for money and to remove administrative barriers. In addition it will focus on ensuring the longer term development and sustainability of primary care services locally, considering issues such as workforce, training and changing models of care.
Our early priorities are to:

  • Determine personal medical services (PMS) premium reinvestment programme.
  • Review delivery of all the enhanced services that GP practices provide so that there is equity across all practices.
  • Review and evaluate quality and outcomes framework (QOF) and directed enhanced schemes (DES) activity to ensure effort is targeted appropriately for our population and determine and agree any re-specification.
  • Maximise the key role of primary care in our vision for integrated community services.
  • Work with our local GP alliance to develop workforce and sustainability plans for primary care.


What do we want our primary care system to look like in five years’ time?
We are working with our council of members, public and patients to develop a vision for primary care in the future. The following characteristics are emerging:

  • A more empowered workforce which:

–    Is happy and feels valued.
–    Is allowed to develop skills that are needed.
–    Is encouraged to be innovative.
–    Has a balance of specialist and generalist skills to meet the needs of the population.
–    Includes district nurses within the primary health care teams.

  • More engaged patients and carers who:

–    Are central in decision making about their health.
–    Are engaged in preventing and managing their illnesses.
–    Have realistic expectations

  • More sustainable provision of primary care that:

–    Is of high quality with equality of access to services.
–    Is responsive to the needs of the population – seeing patients quickly when needed and being able to spend the time needed to proactively manage long-term conditions.
–    Has the capacity to treat more patients in the community.
–    Values mental health equally with physical health.
–    Promotes continuity of care throughout.
–    Has ambition to change but protects and builds on what already works while not being afraid to do things differently.
–    Learns as it adapts.
–    Is joined up by IT systems.
There is still work to do on refining our vision but we see that the increased local engagement that co-commissioning gives us will help us realise that aspiration.  
While it is too early to show definitive improved health outcomes as a result of co-commissioning, early successes include the development of a ‘bundle’ of locally enhanced services to reduce variation and increase equality in provision of services by practices, and sign up to the new models of care work across all practices including extending the care planning to additional 2% of the population at risk of admission. l

Amanda Bloor, chief officer of Harrogate and Rural CCG.
Dr Bruce Willoughby, lead for planned care.

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