Primary care transformation is occurring in the Frimley Integrated Care System (ICS) through developing networks of general practices and integrating services. The summary is: 1) General practices in the Frimley ICS are forming networks to strengthen primary care, integrate services across different levels of the health system, and improve care quality through new models of coordinated, proactive care. 2) Networks aim to standardize systems, share workforces and facilities, reduce unwarranted variations, and give general practices influence over system decisions. 3) Clinical leaders are encouraged to engage with the ICS transformation, which seeks to empower primary care through partnership working, co-design of new models, and leadership skills that transfer

1. Primary Care Transformation in the Frimley ICS
Dr Andy Brooks
GP Park Road Group Practice
Chief Officer Surrey Heath & East Berkshire CCGs
Frimley ICS Board member, lead for General Practice

2. Contents
• What is an ICS? (& why should I care?)
• Practice view (what have we done?)
• Network view (what is the reality?)
• Clinical Leadership (How get the most out of
General Practice, your CCG and ICS)

3. Level Pop. Size Purpose
Each level performs specific functions under the following common headings
• Leadership and workforce
• Strategy and planning
• Population health management & care redesign
Neighbourhood ~50k
• Strengthen primary care
• Network practices and other
out of hospital services
• Proactive & integrated models
for defined population
Place ~250-500k
• Typically borough/council level
• Integrate hospital, council &
primary care teams/services
• Develop new provider models for
‘anticipatory’ care
System 1+m
• System strategy & planning
• Develop accountability
arrangements across system
• Implement strategic change and
transformation at scale
• Manage performance and £
Region 5-10m
• Agree system ‘mandate’
• Hold systems to account
• System development
• Intervention and improvement
• Performance and improvement
• Managing collective resources
What is an integrated care system?
ICSs do different things at three different levels

4. Population of 800,000
people in East
Berkshire, North East
Hampshire and
Farnham and Surrey
Heath CCG’s.
Involves 30 statutory
bodies. Includes Local
Authorities, CCGs,
provider Foundation
Trusts and others

6. Practice view
(what have we done?)

8. A Brief History …..
2000 – 6 Partners
2003 – 7 Partners
2004 – 7 Partners

9. Mergers
2015 – 5 Partners merged Old Dean
Surgery 1 Partner (now retired)
Formed Park Road and Old Dean
Surgeries
2018 – 3 Partners merged
Heatherside 1 Partner (now retired)
Formed Park Road Group Practice

10. Now
21 000 patients
3 sites – 1. NHS property 2. Private
ownership 3. Partnership owned
2016 PRODs Outstanding CQC
Research Ready / PCRN
Training Practice

11. Primary Care Team
2 (inc. 3) Paramedics
2 (inc. 3) Triage Nurses
Pharmacists – did trial direct employ, now
Pharmacy Team in Surrey Heath
Nursing Team (nurses/ HCA / phlebotomist) 11
10 Salaried Doctors

12. Future
Clinical Triage Team
Document management
Online consultations

13. Network view
(what is the reality?)

14. Aims:- Improved care quality * Sustainable general practice * Strong voice within system
Frimley ICS GP Maturity Grid: Plan on a Page
Right Scale
Integrated
Working
Targeting
Care
Managing
resources
Plan
There is a plan in place to
achieve full geographical
coverage articulating a clear
end state vision and steps to
getting there, including
actions required at practice,
network and system level.
System responsibilities to
include:
• Articulation of system
wide network benefits
• Development needs
identification
• Resources to support:
money, people,
technology, estate
• Agreeing levels of
ambition and baseline and
pace of change with
general practice
Engagement: GPs, local
primary care leaders and
other stakeholders believe in
the vision and the plan to get
there.
Foundations for
transformation
End State Step 1 End State Step 2 End State Step 3
Empowered
primary care
NHSE Pillars
Practices identify partners for
network-level working. Full
geographical coverage across the
ICS. Year 1 plans agreed.
End state business, relationship
between network partners is
discussed and stepped plans
developed.
Agreed business model at network
level fully operational.
Interoperable systems. Shared
workforce and optimum estate
usage.
Opportunities and benefits for
integrated care delivery are
identified. Form part of year 1
plans
New care delivery models are
agreed, designed and tested. Fully
functioning integrated care teams
covering all networks.
New care delivery models
embedded and benefits evidenced.
Person level data is linked and
shared between service delivery
partners
Outline plans to reduce
unwarranted variation in care &
outcomes identified . Inform year 1
plans. Development /educational
needs are identified.
Process to analyse & discuss
variation between practices have
been agreed and acted upon.
Required data and analysis support
is available.
Networks can track population
resource usage using real time data
and information.
Opportunities for shared skills,
workforce planning and delivery
discussed and agreed. Clinical and
back office. Form part of year 1
plans
Plans implemented. Career
opportunities across the network
described.
Networks have the opportunity to
take collective responsibility for
funding.
Relationship between the
networks and the provider voice
on the ICS Board described.
General Practice as a provider has
a seat at the table for all system-
level decision making
Single voice from general practice
represents the views of networks
(internal relationships) and
influences system decision making
(external relationships).

16. Federation vs network?

17. • Networks agreed and plans being worked on.
Engagement with practices underway.
• Demand and capacity modelling approach agreed
to support workforce actions
• All areas will have improved access in place by 1st
October – ICS comms being developed
• Online consultation provider contract awarded –
same provider across whole ICS geography. Roll
out complete in NEHF CCG – rest by end of year
• Time for Care Actions – nearly all completed in all
CCGs

18. Clinical Leadership
(How to get the most out of General
Practice, your CCG and your ICS)

19. • Don’t be put off by management speak
• You have the skills
• Consultation skills are transferable
• Timescales are slightly longer
• You have the trump card – direct care
• Leadership courses, coaching, read stuff

20. • Co-design
• Bring people along with you
• Genuine big scale transformation is rare
• You can achieve a lot by partnership working

21. Questions?