Clinical Commissioning Forum – Stakeholder

Engagement Summary of Discussions

Tuesday 3rd September 20135.30 – 8.30 pm, Education Centre, Mile End Hospital

Long Term Conditions

Hospitals telling patients to get

oxygen cylinders from GP for oxygen

prescriptions

What are the main challenges?

There is duplication between QOF and NIS payments

Access into appropriate services for BME patients is an issue. GPs are gatekeepers of this but are often ‘holding on to’ patients by not referring them to specialists. (NB: Upon further discussion – it transpired that patients see

the GP multiple times for the same ailments and are given the same treatment or a different medication without any explanation. This is frustrating for the

patients as it’s viewed as lack of interest and understanding by the GP. The issue underlining this is the

lack of communication by GP with patients on why they are prescribing some treatment and not others e.g.

referral to specialist services. )

What about patients who don’t fall into the integrated care cohort? Lack of coordination for these patients. These are the majority of

the patients.

Diabetes care package does not cover Type 1 Diabetes

Need holistic personalised approach to care planning. This isn’t always happening

at the moment.

Lack of education of patient

population is a big barrier in Tower

Hamlets

Preventing and Managing LTC

Hospitals telling patients to get

oxygen cylinders from GP for

oxygen prescriptions

Need to focus on self care – encouraging patients to self manage. Use care plans

more effectively and more frequent progress meetings between annual

reviews to check progress. This should be part of the payment indicator for

diabetes care package. ‘Greater incentive in care package for follow up

goals’

Improve the uptake of flu vaccination to manage COPD. Flu vaccination for staff is a must as they can potentially infect

others they come into contact with through work. Incentivised staff target

for this. Incentivise early vaccination for vulnerable groups such as frail and

those in nursing homes. Ideally – we need universal flu vaccination for all.

Need to adopt the German model of

universal vaccination for those with Hepatitis B.

This can be done at the new patient check

Increasing specialist input by Barts Health diabetic nurses into GP practices to reduce strain on practice. Network 2 have the largest diabetic population –

skilling up existing nurses isn't going to provide adequate capacity. NHS health

checks now also identifying new patients. The demand is increasing but

the resource is decreasing,

Need to focus on developing health literacy projects as

level of health literacy is poor in the

community

Need more children friendly public spaces

Close Fried Chicken Shops

Communicate what is going on in this

work stream

Need a strategic approach to

diabetes education

Care planning – can reviews with patients be done remotely to encourage patients to turn up to reviews and increase the

number of reviews per patient

Care packages too complicated rationalise the payment structure, criteria

for the NISs. Providers to provide data and evidence Need more

coordination across medical specialisms so that patients are not ‘passed around’

Self care in GP practices

Retinopathy walk in service at the diabetes centre

Some local examples

Social Action for Health – good moves

After school clubs for children where GP visits to provide education on

healthy lifestyle – Network 2. Blithehale Practice has more data on this.

Project with diabetes centre on healthy eating

Achieving Excellence in General Practice

What does excellence in general practice mean to you?

Excellence should be a reflection of the whole system – or at least this is

what is seen by the patient (incorporated community and

secondary care services)

Trusted relationship with Doctor

Polite and welcoming reception staff Supportive colleagues Equality of access,

equity of service

Getting the right appointment with the

right professional at the right time

Good access to services

What are the challenges and barriers in achieving excellence?

Population growth

Wasted appointment in General Practice• People could have used the pharmacist or

self-care but default to a GP appointment• Patients are blocking primary care

appointments with their secondary care issues

Workforce mix in the practice• It is not always clear to patients

who is doing what in the practice team – this could be better communicated so patients know who they can book an appointment with

Old fashioned and poor business processes e.g. the level of use of printing and faxing

Demand for services

Time with the Practice Team• Need time for clinicians to

discuss their clinical practice to ensure consistency and continuity amongst them

Continuity of Care• Noted as very important

to patients for some conditions

Access• Older people in particular reporting challenges in

access• Concerns over the use of 0845 numbers – people think

this will cost them a lot of money• Impacts on practices in terms of changes to access

funding. Was felt that this has impacted practices offering good levels of access and therefore has had an impact on morale.

Patient education and self-management• We can sometimes assume patients know more than

they do• Many patients are not ready to take on a self-

management approach – they expect to be told what to do by their Healthcare professional

Coordinating care for patients with complex conditions:• We should be able to offer one appointment that will

address all the conditions a patient has• IT systems need to support this coordination of care –

particularly across agencies

What are the potential solutions to addressing these barriers?

Quality improvement• There should be greater opportunities

for the sharing of best practice across the Networks

Self-management• There needs to be a separate service that patients can be referred to that will support this – Doctors will not have the

capacity to support patients in self-management• Provide more information to help patients navigate the practice system

• Details of which professional to see• Notices for patients e.g. ‘put your repeat prescription requests in this box’

• National campaigns are needed to support patients in making the right choice about where they access their care – with the level of population churn in TH this cannot be driven locally.

• This should be targeted and children and their parents – GPs reporting young people attending appointments with minor problems

• Noted that this needs to be balanced with messages for patients to see their GP if they have symptoms that might be something more serious.

Access• Telephone triaging to manage access and continuity of care – there is not

going to be additional funding put in through the primary care commissioning route

• Focus needs to be therefore on developments that might attract funding from the integrated care funds or to maximise existing resources e.g. delivering flu vaccination in nursing homes, and getting staff vaccinated.

Demand and capacity management• More staff are needed so that teams can deliver care better

• This project should define the optimum levels of staff in general practice• Need to identify where the inefficiencies are in the system at the moment• Need to streamline our approach to managing long term conditions

• Move away from disease specific clinics and specific long term condition pathways• Operate chronic disease clinics instead• Use IT to support this model – patient rather than a disease template (not available on EMIS web but could be advocated by practices)

• Reduce levels of measurement and audit – move away from a prescribed model of what should happen to a local tailored model that supports local priorities e.g. make changes to the new patient health check

• Exploit further use of IT for modernising and managing demand in General Practice• Skype consultations• Run some marketing events to encourage GPs to invest in new technology• Use peer support to learn about how best to use the new technology – learn and pass the knowledge on•

What are the potential solutions to addressing these barriers?

Urgent Care

How can we encourage patients to stop using A&E services inappropriately?

Develop and implement marketing campaigns with a positive message – ‘Your health is your responsibility’

Support patients to self-care / manage minor ailments e.g. encourage them to have flu jabs, keep first aid kit at home, etc.

Understand the top 3 reasons that mothers of <5s inappropriately attend A&E and develop a targeted education and training programme that is aligned to these. WHFS can support with this piece of work – sharon.hanooman@whfs.org.uk

Enhance education, training and support for parents, particularly through the children’s centres

Practices should call every patient that attends A&E inappropriately – this has proved effective for St Katherine’s Dock, with patients responding well to the call/advice to visit primary care first in the future

Explore decommissioning of the walk-in centres, with a view to re-investing some of the funds in:• Improving primary care access• Developing a network / locality based same day

appointment system

Children and Young People

Children and Young People

Continuing CareIn terms of personal health budgets:• Use the learning from local authorities as they have

been implementing personal budgets for some time• It will be important to strike a balance between patient

choice and provider stability

Community EngagementFurther Outreach Work is required to engage with children and families, particularly through collaborative working with the children’s centres and local schools. There are many examples of good practice across the borough:• Bromley by Bow minor ailment scheme• Blithehale after school club• St Paul’s Way School ‘Teach the Teachers’

Public Health• Concerns raised regarding capacity and quality of

health visiting services in the borough• Further communication and engagement with practices

is required around what they can do to increase Vitamin D uptake.

Maternity

How can we address the challenges facing Maternity services in Tower Hamlets?

Deskilling of community midwives in dealing with mental health problems / high risk patients

Concerns about Gateway communication with primary care, big gaps in care, high risk patients being ‘lost’

Also MSLC should be promoted within practices – one way for patient feedback

Role for MSLC in promoting Barkantine?

Need for antenatal pathways to be reviewed – who does what e.g. vitamins, injections were mentioned here

Possible use of dashboards for community midwifery

Possible use of KPIs / CQUIN for continuity of community midwifery care

Last Years of Life

What are the challenges in delivering good patient care?

Lack of awareness and promotion of services for bereavement – is it a gap in the services, esp. Bangladeshi community / use of voluntary sector is a hugely untapped source

Inverse care law is very stark here

It’s hard to get information as a patient that is non-medical. Current approaches almost actively discourage people who want to get involved.

Can the role of primary care within the multi disciplinary care team be described and the coordinator role be clearly identified. Case management support to approach.

How can we address these challenges?

A piece of work that needs to underpin this is to looking at professionals / behaviours and how they shape the system and therefore what the levers and incentives might be (financial, professional)

Palliative care group MDT that meets in general practice is critical to underpinning and coordinating care. Complex frail NIS sight actively manage patients.

Is there any connection between the services that support people in later years e.g. Link age plus.

Professionals need help in terms of homecare outreach advocacy in people’s homes if they want to die at home.

Need to build on the GSF successes. Link in to leadership in practices.

WHFS – they have good links with the Somali and Bengali communities. Helping to access and capture the family stories and patient engagement opportunities

Need an approach that cares holistically for the family as well as the frail or dying person. Support and information for carers. Better information for practices to support them to de-medicalise.

Emotional support for families and people surrounding the dying. Clear case approach needed – frail and elderly NIS will help with this

Supporting people to make their own decisions and take some control

Empowering patients, families and carers to deal with the uncertainty surrounding last months and days of life

Need to ensure use of churches as well as mosques and other places of worship for spreading and sharing of messages and information. Multi faith forum. Doctors can find it very difficult to talk about some of these issues, there is a generational issue.

To do this work well is very rewarding but extremely time consuming. This needs to be recognised and resourced. Capabilities and competencies need to be high across all the groups that see the patient and family.

Need to ensure that vulnerable carers are identified earlier in the journey so they’re already linked to services that will be needed to support them after they’re bereaved. Some risk assessment is needed of those that might require the most intensive support and interventions.

May benefit in getting feedback from carers at different times post bereavement. Their views and perspectives may be different as they go through their journey but all views are valid.

Planned Care

What are the main challenges and how can they be addressed?

Referral ProcessIt was felt that the referral process to Barts Health outpatient services could be improved. Concerns were raised about the accuracy of referrals/ if they were being sent to the right department. It was agreed that Choose and Book(C&B) needs to be pushed (i.e. increasing the number of referrals via the C&B process). It was noted that not all services were on the C&B system. This could be improved by marketing and raising the profile of C&B with GPs , improving the ease of navigating the system and flagging the issue with Barts Health. The Planned Care Board will link in with the IT work stream and supported the introduction of Clinical Assessment services on C&B

Patient ExperiencePatient experience was raised and the need for patients to understand the referral process. GPs also need to be clear of the referral process. We are working with GPs and Barts Health clinicians to improve some patient pathways (e.g. back pain pathway) and providing training and support for GPs.

Quality of Data Improvements in data quality and cleaning of data required

Patient journey Separate services under CAG are an issue- feels like services are fragmented and less organisational responsibility. The work for the back pain pathway is involving different clinicians from different service areas/ speciality areas to agree the new pathway

Waiting times Some improvements to the 18 week RTT (referral to treatment standards)

Communication Some improvement needed in letters/ discharge letters from Barts Health. GP needs to be clear/ understand what they need to do (i.e. simplify the process). For the re-procurement for direct access MRI we are looking at ensuring reporting imaging and quality is improved.

ITImprovements needed on cerna system to improve accuracy of data/ completeness  There was a general feeling that we needed to support Barts Health as it could not be allowed to fail.