1. Summary 1.1 The Long Term Conditions programme has continued to generate

improvements in care. This report summarises the progress Tower Hamlets is making in meeting key targets, driving up quality standards, delivering new services to meet patient needs and providing support, information and education to patients and their carers. The report also sets out priority areas for investment in 2008/09.

2. Recommendations

It is recommended that the Health Scrutiny Panel: 2.1 Consider and note the report. 2.2 Comment on the priority areas for investment in 2008/09.

LOCAL GOVERNMENT ACT, 1972 SECTION 100D (AS AMENDED)

LIST OF "BACKGROUND PAPERS" USED IN PREPARATION OF THIS REPORT

Brief description of "background paper Name and telephone number of holder and address where open to inspection

Committee(s) Date: Classification: Report No: Agenda Item No:

Health Scrutiny Panel

18th December 2007 Unclassified

Originating Officer(s)

Sally Herne Associate Director, Service Improvement Tower Hamlets Primary Care Trust

Title: Tower Hamlets Long Term Conditions Annual Report September 2006 – September 2007 Ward(s) affected: All

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TOWER HAMLETS LONG TERM CONDITIONS ANNUAL REPORT

SEPTEMBER 2006 – SEPTEMBER 2007

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CONTENTS Page Executive Summary 3 1. Introduction 6 2. Overall Progress 9 2.1 Reducing Unplanned Hospital Care 9 2.2 Community Matrons 15 2.3 Case Management of High Intensity 15

Users 2.4 Uptake of Self Care 15 2.5 Improving Management of Long Term 15 Conditions in Primary Care 3. Workstreams 20 3.1 Diabetes 20 3.2 Heart Failure 26 3.3 Respiratory 30 3.4 Chronic Pain 36 3.5 Children 40 3.6 End of Life Care 46 3.7 Self Care 51 3.8 Older People 55 3.9 Urgent Care 61 3.10 Workforce 64 4. Conclusions and Recommendations 67

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Executive Summary Successes The Long Term Conditions programme has continued to generate improvements in care. This report summarises the progress Tower Hamlets is making in meeting key targets, driving up quality standards, delivering new services to meet patient needs and providing support, information and education to patients and their carers. • The health economy met the requirement to reduce emergency bed days by 5% two years early and the downward trend appears to be being maintained. We also exceeded the target to ensure 525 people obtained self care support and are on target to meet our stretch target for next year. Progress on meeting our two other Public Sector Agreement targets has been slower, but they should be achieved by March 2008. • The numbers of unplanned admissions, lengths of stay and readmission rates have decreased for many of our key conditions – particularly Heart Failure, Stroke and less complex respiratory cases. • New community services are in place to support people with Chronic Pain and Respiratory Diseases such as Asthma and COPD. Services created for Heart Failure and people at high risk of Heart Attack and Stroke have been expanded. • The coverage of Local Enhanced Services is improving and we have also improved Quality and Outcomes Framework scores • Tower Hamlets has also been recognised in a number of national schemes, bringing support and recognition for work in Heart Failure, Coronary Heart Disease and Diabetes • Important steps forward have also been made in improving access to key diagnostic and screening services – particularly echocardiograms, spirometry and retinal screening. Challenges Some of the most challenging areas of redesigning Long Term Conditions are reflected in the ‘Improving Health and Wellbeing’ strategy objectives Reducing Inequalities – a small core of conditions are still responsible for driving demand for primary, community and secondary care services. The National Support Team Health Inequalities review underlines the need for a comprehensive strategy for primary prevention, early and accurate diagnosis, effective treatment and on-going care. In addition, although a great deal of overall progress has been made, there are still significant gaps between the best and worst performing providers and between provision and need. Commissioning mechanisms will need to address these areas of inequality through mechanisms such as inter-practice referral or targeted specialist outreach. Improving Integration and Achieving Cultural Changes in Practice –the workforce project initiated as part of the programme has grown in scope over the last 12

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months. It is now a major organisational development initiative, which illustrates many of the practical challenges of achieving seamless care – difficulties in embedding effective common assessment and review, developing and sharing databases which describe patients’ needs and moving to a system of holistic, anticipatory care. Supporting Self Care – some services have made a demonstrable commitment to supporting patients to self care, with referral into education or rehabilitation being a core part of the care pathway. However, this is certainly not a universally adopted approach. In addition, whilst there is an expectation that staff will encourage patients and carers to adopt health promoting behaviours, many lack the necessary skills or confidence. Providing Care Closer to Home – the PCT has achieved a number of successes in moving specific parts of the patient pathway from hospital into the community. Achieving more fundamental change will necessitate more detailed mapping demand across the patient pathway, a comprehensive rapid redesign process and commissioning plans based on analysis of the capacity needed in primary, community and secondary care

Investing for the Future Tower Hamlets faces three key challenges in maintaining progress on Long Term Conditions

• Growth in the overall population

• Growth in the numbers of people with most complex needs, particularly the older elderly

• Predicted growth in the prevalence of key long term conditions such as Diabetes

The Long Term Conditions programme would therefore benefit from the PCT allocating £1.844m for 08/09. The themes and activities identified as priorities are listed below Promoting Clinical Engagement

Enabling primary and secondary care clinicians to spend dedicated time designing models of care for Heart Disease, Respiratory Disease and Diabetes

Developing Community Capacity

Creating a new Community Children’s Epilepsy service Commissioning additional specialist palliative care support for people with non-malignant conditions, particularly Heart and Respiratory Disease Extending capacity in the Community Children’s Nursing Team to provide respite at home and support for siblings of ill children Mainstreaming funding for the Macmillan Occupational Therapy Service

Improving Coordination and Quality of Care

Expanding case management capacity for complex patients Funding dedicated leadership in rolling out the Liverpool

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Care Pathway for the Dying Commissioning additional Clinical Psychology support for people with end of life care needs and the staff who care for them

Improving Information and Choice

Creating an end of life care directory of services and lay led support networks for vulnerable elderly people and parents of children with end of life care needs Commissioning training to develop staff skills in discussing preferred place of care with end of life patients Roll out of Marie Curie’s “Delivering Choice” programme

Supporting Patients to Self Care

Commissioning additional Expert Patient Programme Courses Developing an in-house service to develop staff skills in supporting behavioural change Mainstreaming the pilot Community Pulmonary Rehabilitation Service and extending it to offer support to people with Heart Failure and Intermittent Claudication

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1. Introduction 1.1 In last year’s report we had laid out a description of the needs in Tower Hamlets and the strategy we had to address them. Our second report is more focused on sharing with staff, partners, patients and the public more detailed information on need and reporting the outcomes we have achieved in the last twelve months. As a guide, the report is structured in 3 main sections

- Overall progress against the main targets for Long Term Conditions (LTCs) and trends in indicators of the quality of care given in community settings.

- Reports on our work streams : how we have implemented our commitments from last year and how we perform against a set of core quality standards.

- A summary of our priorities, investment needs and risks. These will be reflected in the Commissioning Plans for 2008/9.

1.2 The last 12 months have seen some important changes in relation to the context we are working in. These are already shaping how the PCT and its partner organisations set priorities and the direction of travel. 1.2.1 ‘Health for London : A Framework for Action’, published this summer, aimed to prompt a debate about the shape of health services in the capital and act as a trigger for some fundamental reforms. The document makes a case for change based on the fact that London has some of the greatest health needs in the country, stark areas of inequality and indications that resources could be used to better effect. A full copy of the report can be viewed at www.healthcareforlondon.nhs.uk. The detail of the report was produced by a series of working groups, focused on different aspects of care. This included a Long Term Conditions Review Group which had a remit to identify the key issues for services and make specific recommendations on the changes needed. The review highlighted a number of key problems, which tend to fit with evidence gathered here in Tower Hamlets.

� Services are too hospital centric – much of what happens in Outpatients could be safely and effectively provided in other settings. The major limiting factor in shifting activity is the availability of high quality buildings in the community to act as hosts for alternative services.

� Lack of robust, proactive, coordinated care planning also results in many people utilizing urgent routes such as Accident & Emergency (A&E) to access care.

� Access to diagnostics is too often embedded in an outpatient appointment. In order to get diagnostic information, General Practitioners (GPs) have to make a secondary care referral. Equally, a large proportion of first Outpatient appointments are conducted without the benefit of diagnostic information to guide treatment decisions.

� Patients and carers are given insufficient information on their treatment options or the steps they should take to self-care.

� Coordination of care is often compromised by lack of communication between primary and secondary care.

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� There is significant variation in the approach to LTC management, driven by a combination of factors such as lack of incentives, monitoring tools or decision support systems.

The proposals are currently out to consultation and, therefore, it is not yet clear how much of the suggested change will be adopted. The Borough Improving Health and Wellbeing strategy has also begun to address many of the issues raised by Health for London. We have also made progress against many of the specific recommendations put forward by the London-wide group. However, the Long Term Conditions Board has agreed that there are some additional actions we need to take to maximise the effectiveness of our local strategy. 1. At present we still commission separate pieces of care for patients from a range of different organisations. This does not necessarily support good integrated care for patients. We need to move towards commissioning a more coherent ‘pathway’ of care. 2. Developing a systematic process to support the shift of specific services from hospital to community settings. 3. Supporting patients to self care needs to gain more momentum and profile. This includes being clear what responsibilities acute and mental health providers have in relation to enabling people to adopt healthy lifestyles and take steps to reduce the effects of long term conditions on their quality of life. There is also a gap between the expectations we have of staff to be effective catalysts for change and their confidence in working with patients who may find changing behaviour difficult. 4. Pump priming clinical engagement to enable lead clinicians to have dedicated time to undertake detailed mapping and redesign work.

Implementing these recommendations will require making some investments. These are described in the work stream sections and summarised in Section 4. 1.2.2 In February, the Department of Health National Support Team for Health Inequalities carried out a detailed review, aimed at pinpointing areas where the partnership would most benefit from focusing its attentions. The review quantified the drivers at the heart of the gap in life expectancy between people in Tower Hamlets and the rest of the country. The table below highlights what percentage of the gap is made up by particular conditions. It also underlines just how important long term conditions are as contributors. Disease % contribution to life

expectancy gap for men % contribution to life expectancy gap for women

Lung Cancer 19.5 10.5 All Cancers 4.8 12.4

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Endocrine, nutritional and metabolic disease

6 4.7

Cardiovascular Disease (CVD)

40.1 24.7

Chronic Obstructive Pulmonary Disease (COPD)

6.4 11.6

In response the PCT, in collaboration with the London Borough of Tower Hamlets (LBTH), Barts and the London NHS Trust (BLT) and East London and City Mental Health Trust (ELCMHT), has launched a 2 year programme called ‘Making the Breakthrough’, focused on four of the conditions featured in the table Coronary Heart Disease (CHD) and Diabetes Stroke Cancer especially Lung Cancer And Vulnerable Older People with multiple health problems. The programme will make maximum use of the system reforms introduced over the last few years (Patient Choice, Practice Based Commissioning, Payment by Results, Direct Payments for example) in order to test new approaches. Where these are successful, we will embed them in our mainstream commissioning plans. Because CHD features so prominently in health inequalities, it was agreed that it should be formally added to the Long Term Conditions programme.

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2. Overall Progress At a national level, the health economy is monitored on 3 Public Sector Agreement (PSA) targets, all to be delivered by the end of March next year. They are used as a general diagnostic for progress made in shifting care from hospital out into the community

- reducing the numbers of unplanned days in hospital by 5% from our 2003/4 baseline (‘Emergency Bed Days’ or EBDs)

- implementing 14 community matrons within the community nursing workforce

- having 1088 high intensity users (HIUs) case managed 2.1 Reducing Unplanned Hospital Care Overall progress against this target is solid, with the health economy achieving its March 2008 target two years early (See Figure 1 on page 8). This has also been achieved against a backdrop of an increase of nearly 30,000 in the numbers of people registered with local GP practices. The fundamental problem highlighted in last year’s report still exists –

a) It is not clear whether this level of reduction can be maintained, particularly as the overall local population continues to grow

b) Some of the areas where we are seeing rises in EBDs are for older people with complex, multiple health problems. As this proportion of the population grows we may see rises in admissions and lengths of stay.

c) There are multiple initiatives in place to prevent unplanned admissions and reduce lengths of stay in hospital and therefore it is not possible disentangle cause and effect

2.1.1 Key Conditions Around one third of all emergency bed days can be tracked back to either a Respiratory or Cardiovascular cause. However, much of our analysis this year has been at Healthcare Resource Group (HRG) level. HRGs are units used to denote a type of care / care group and its associated cost. A single disease such as COPD can be split across 4 different HRGs. Despite being a small unit of currency, just 10 HRGs account for nearly 20% of all our EBDs. The biggest individual contributors also reflect the priorities of Making the Breakthrough (Figure 1). Respiratory Conditions – COPD, Bronchitis & lower respiratory tract infections such a Pneumonia – code D40 in the table Cardiovascular Disease – particularly Heart Failure (E18), Ischaemic Heart Disease and Percutaneous Coronary Intervention Stroke – A22 Lung Cancer – D25 Complex elderly people, particularly those with a respiratory illness (D99) and urinary tract infections – L09. The issue of urinary tract infections is now being picked up in the older people’s workstream (see Section 3.7).

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Figure 1

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Figure 2

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The upward trend for all these HRGs suggests that the core of conditions contributing to use of unplanned care is becoming increasingly concentrated. It confirms our approach of focusing on a few key areas and getting them right.

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Table 2 overleaf shows trends from 2002-2007 in the number of spells i.e. the numbers of people being admitted and the median length of stay. A reduction in spells broadly suggests community services are exercising more effective care and control whereas a reducing length of stay is a general indicator of increasing hospital efficiency. Admissions for a number of respiratory conditions appear to peak around 2005. However, in the year to the end of March 2007 there appears to have been a marked downturn in admissions for COPD without complications and respiratory infections. This suggests that more straightforward cases are being contained in the community. As the data for older people with respiratory diagnoses fluctuates from year to year it is too early to say whether there is a downward trend in admissions. Preventing admissions in this group will be inherently more difficult because their respiratory illness is one of a number of health (and possibly social care) problems they may have. This may also explain why their lengths of stay have remained similar for the last 5 years. A proportion of this group may also be end of life patients. The number of patient with lung cancers being admitted also seems to be decreasing and, at the same time, the length of time they tend to spend in hospital is also reducing. The picture for Heart Failure and stroke is very positive – with both a sustained reduction in admissions and lengths of stay. The same trend also seems to be appearing for urinary tract infections.

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Table 2 - Trends in Admissions and Lengths of Stay for Key Long Term Conditions 2002/3-2006/7 HRG Spells 2002/3 Spells 2003/4 Spells 2004/5 Spells 2005/6 Spells 2006/7

Complex elderly with a respiratory diagnosis 95 142 197 172 150

COPD or bronchitis without complications 371 357 381 408 312

Acute unspecified lower respiratory infection 197 198 250 234 179

Respiratory neoplasms 128 117 103 92 94 Heart Failure / shock over 69 or with complications 144 125 95 94 Non transient stroke or cerebrovascular accident 156 167 131 109 101

Kidney or urinary tract infection 208 254 198 193 196

Median LoS 2002/3

Median LoS 2003/4

Median Los 2004/5

Median LoS 2005/6

Median Los 2006/7

Complex elderly with a respiratory diagnosis 10 10 8 9 10

COPD or bronchitis without complications 6 6 5 5 6

Acute unspecified lower respiratory infection 5 4 5 4 5

Respiratory neoplasms 10 10 11 10 7.5 Heart Failure / shock over 69 or with complications 8 8 9 6.5 Non transient stroke or cerebrovascular accident 11 11 9 8 8

Kidney or urinary tract infection 8 7 7 7 6

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2.1.2 Speciality Level Analysis at specialty level also supports the information reported in the previous section – with a marked reduction in the number of unplanned days spent in hospital for Cardiology and General Medicine. Achieving reductions in Care of the Elderly appears to be a slower process. Interestingly, although HRGs affecting children do not appear in the top ten drivers, unplanned admissions for children do have a substantial effect on overall emergency bed days. This is discussed further in the Children’s Section (3.5)

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2.2 Community Matrons The PCT took a decision to place the development community matrons within a broader redesign of community nursing. The complexity of the workforce project (see Section 3.10) means that progress against this particular target has moved at a slower pace. However, a plan has been agreed which should mean that the target will be met. 2.3 Case Management of High Intensity Users Achieving this particular indicator will be a challenge as the target number rises sharply from 469 last March to 1088 next March. Agreement has been reached on a strategy to significantly boost the numbers benefiting from case management. This will be backed by a programme of mentoring, training and support to help embed the case management ethos into the wider community nursing workforce 2.4 Uptake of Self Care In addition to the national targets, the Local Area Agreement sets out a requirement for 795 local people to pass through some form of self care support by the end of March next year. The interim target for 06/07 was 525 completers. The health economy actually achieved 684, with the bulk being delivered by the Diabetes Team (particularly self care support for people with type 2 Diabetes) and the Expert Patient Programme (EPP). Plans to sustain this achievement are described in the sections on Diabetes (3.1) Respiratory (3.3) and Self Care (3.8).

Number of local residents who completed self-care

courses in 2006/07EPP

Cardiac Rehabilitation

Heart Failure Exercise and

Education (pilot course)

Pulmonary Rehabilitation

Diabetes: DIANA (type 1)

Diabetes HAMLET (type 2)

2.5 Improving Management of Long Term Conditions in Primary Care The Health for London report and Improving Health and Wellbeing both set health economies the challenge of creating a shift of care into the community whilst maintaining the quality and safety of patient care. Making sustainable progress in this area relies on a few fundamental elements being in place

- Effective identification of those at risk and those with undiagnosed disease

- Creation of accurate disease registers, backed by effective call and re-call systems to enable patients to be monitored effectively

- Implementation of known best practice e.g. in prescribing, management of risk factors, referral to rehabilitation etc

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- A skilled generalist workforce, with appropriate specialist back up for more complex cases.

2.5.1 Identifying People at Risk The Quality and Outcomes Framework (QoF) is the main vehicle for encouraging general practice to create and maintain disease registers. Data for the last 3 years shows some marginal changes in numbers of patients recorded on registers for Stroke, CHD, COPD, Asthma and Diabetes. The numbers of people recorded with Heart Failure and Hypertension have seen a marked increase. Both changes may be the effect of better diagnosis – for example, better access to echocardiograms will support more accurate diagnosis of whether a patient has Heart Failure.

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There are two key areas where data on deprivation, ethnicity and risk factors suggest there is a gap between the numbers of people we would expect to have a condition and the numbers actually recorded on the registers – Diabetes (with some marked variation in the gap between expected and observed prevalence at practice level) and Heart Failure. These issues are discussed further in Sections 3.1 and 3.2. 2.5.2 Implementing Best Practice There are currently 3 ways in which to assess the quality of care being delivered in the community

- number of QOF points attained by local practices and the gap between the best and the poorest performers

- the uptake of Local Enhanced Services (LES), where GP practices and Pharmacists are commissioned to provide additional elements of service. These are in place for Heart Failure, Diabetes, COPD, People at High Risk of Heart Attack and Stroke and Palliative Care

- Clinical Effectiveness Group (CEG) reports, which monitor specific indicators of care

QoF % of points

scored by TH practices of those available 2005/6

% of points scored by TH practices of those available 2006/7

Percentage points gap between best and poorest performing practices 05/06

Percentage points gap between best and poorest performing practices 06/07

CHD 96.5 97 48.5 26 Heart Failure No data

available 93 No data

available 80

Diabetes 91.5 94 53.8 26 Hypertension 94.5 97 72.7 31

Asthma 97 93 45.6 75.5 Epilepsy 85 87 87.5 63.7 COPD 93 95 46.5 65.2 Stroke 95 95 34.7 57.8 The table above shows that for the majority of key Long Term Conditions Clinical Indicators, Tower Hamlets practices are tending to achieve a greater percentage of available points. The exception is Asthma where there has been a slight drop. Stroke performance is also more static. Of greater concern is the data showing the gaps between our best and worst performing practices. Not only does this underline the difference in quality of care many patients may experience, but the gap also appears to be widening for COPD, Asthma and Stroke. On a more positive note, there have been significant steps forward in Diabetes, Hypertension and CHD. This would tend to suggest that the process of targeted visits and specialist support to practices with lower scores may be beneficial for other clinical areas.

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Enhanced Services Number of

practices commissioned 06/07

Number of practices commissioned 07/08

% of population covered 06/07

% population covered 07/08

Diabetes – Insulin Initiation

22 31 69 91

Diabetes – Annual Reviews

27 29 84 86

COPD 27 32 84 95

Heart Failure 26 29 80 86 High Risk Heart Attack and Stroke

26 29 80 88

Palliative Care

20 28 64 79

The table above shows that the PCT is making good progress overall in rolling out higher standards of care to a wider group of practices. However, there are a number of issues which warrant action if the overall level of care is to be improved. At present 12% of known Heart Failure patients are not covered by the Enhanced Service. The figure for Diabetes is more difficult to establish as not all practices were able to submit data to CEG. However it is at least 7% for the Insulin Initiation LES and 6% for the Diabetic Annual Review LES. Some of the specific implications of non-coverage are discussed in Sections 3.1, 3.2 and 3.3. Data collected by CEG also highlights that there are specific standards within Enhanced Service Specifications which are not being delivered effectively : Ethnicity recording – Practices have been supported to improve their ethnicity recording and the majority are now achieving in excess of 60%. However, the range is significant – from 32.7% at the lowest end to 99.5%. Recording ethnicity is obviously important in providing an accessible service (for example, knowing when a patient will require interpreting support during a consultation) but it is also a key risk for a number of conditions – particularly Heart Disease and Diabetes. Data from Heart Disease registers suggests that overall practices are performing well – with ethnicity recorded in an average of 94% of cases. However, some practices can have no ethnicity recorded in over a fifth of their CHD patients. Promotion of self care – Data on some of our priority diseases shows clearly that there is significant variation in the degree to which clinicians incorporate self care management support into their practice. The data for COPD is given below :

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Indicator Range of scores for TH practices

Patients are referred to pulmonary rehabilitation 0-75% Patients are given a self management plan 0-100% Patients who are known to be smokers are given advice on how to stop

25-100%

Inhaler technique is checked 55-100% Control of risk factors – Concerns were expressed in last year’s report on the degree to which risk factors for Heart Disease, Stroke and Diabetes were being recorded. The latest CEG data suggests this is also room for improvement, both in management of risk factors and also in data recording. % of patients on Heart Failure registers with Blood Pressure of 150 or above

% of patients on Heart Failure registers with no Blood Pressure recorded

% of patients on Heart Failure registers with Cholesterol of 6.5 or above

% of patients on Heart Failure registers with no Cholesterol recorded

13 6 3 20

% of patients on CHD registers with Blood Pressure of 160 or above

% of patients on CHD registers with no Blood Pressure recorded

% of patients on CHD registers with Cholesterol of 6.5 or above

% of patients on CHD registers with no Cholesterol recorded

7 3 2.6 10

% of patients on Diabetes registers with Blood Pressure of 145 or above

% of patients on Diabetes registers with no Blood Pressure recorded

% of patients on Diabetes registers with HBA1c above 10%

% of patients on Diabetes registers with no HBA1c recorded

% of patients on Diabetes registers with Cholesterol of 6.5 or above

% of patients on Diabetes registers with no Cholesterol recorded

17 4 9 12 3 8

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3.1 Diabetes 3.1.1. There are an estimated 12, 000 Diabetics in Tower Hamlets currently, but less than 11,000 of these have been identified and placed on a Diabetes register. Based on current obesity trends, these numbers are expected to increase by 3,000 by the year 2010. The focus of the Diabetes work stream is therefore developing an effective strategy for prevention, early diagnosis and intervention. Our commitment from 2005/06

Our progress / outcomes in 2006/07

1. Developing a robust patient pathway for Diabetic patients and strengthening links with those services with high proportions of Diabetic patients such as Renal and Stroke.

A high level pathway has been agreed by the Diabetes National Service Framework Group. Attention has been focused on the more immediate issue of addressing underperformance in a cluster of practices.

2. Ratifying the Tower Hamlets Diabetes Strategy and producing a costed and prioritised implementation plan

The Tower Hamlets Diabetes Strategy 2006-2010 was agreed by the National Service Framework (NSF) group and PCT Professional Executive Committee and is in the process of implementation. The main aim is to support the implementation of the Diabetes NSF, and enable the shift of most care for type 2 Diabetes in to the community by investing in multidisciplinary locality teams.

3. Offering targeted support through the Diabetes team, including Diabetes lead nurse, Diabetes centre staff, and PCT Medical Director, consultant and primary care managers to the ten practices with the lowest QOF scores.

There has been a significant improvement in Diabetes Nurse Specialists (DSN’s) ability to access G.P practices and to improve care for patients with Diabetes. One of the key objectives has been to encourage more systematic application of best practice. If services are not appropriate, robust mechanisms are in place to decommission a practice. Of the ten original red rated practices, only five are still rated at this level. In addition, the key markers of disease control (gylcaemic control, blood pressure and cholesterol levels) have universally improved in the bottom ten practices between 05/06 and 06/07. The criteria for grading practices are also reviewed each year in order to keep raising the bar for performance.

4. From December 2006 the Diabetes Nurse Educator will roll out the Warwick Certificate in

A second Warwick Certificate course will commence at the end of September, with 19 people enrolled on it. Over 200 people, including care home staff, have attended

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Diabetes Care and support the Roehampton University Masters in Diabetes.

study days aimed at improving the quality of consultations and addressing risk factors such as obesity. Nine staff also attended specific training on managing Diabetes in hospital clinical areas.

5. Working in partnership with Ophthalmology at BLT to provide a second choice for screening in accordance with patient choice.

Patients now have two choices for place of treatment for their Diabetic retinopathy - BLT and Moorfields Eye Hospital. Referrals to Moorfields and the Royal London are all seen within the required times i.e. within two weeks for any urgent referral and thirteen weeks for non urgent. Initial uptake of the retinal screening was poor. However there are signs this is improving – with a rise from 63-69% attendance between August 2006 and August 2007. Over 4,000 people had been screened by the end of March 2007, enabling the PCT to meet it’s target.

6. Increasing throughput of patients into DIANA and HAMLET courses and signposting patients into generic Expert Patient Programme courses and support groups. Evaluation of the impact of self management courses will also be undertaken.

The team have delivered both increased numbers of patients accessing courses and tangible benefits in terms of their health outcomes. DIANA (Type 1 Diabetes) 8 courses were delivered, with 89% completion rate HAMLETS (type 2) - 23 courses in English and Bengali with 91% completion rates across both. Six months after the courses improvement in health outcomes for both courses were seen. DIANA participants have resulted in better blood sugar control and reduction ion weight. HAMLETS participants showed a reduction overall reduction in with cholesterol HA1cA and blood pressure. The challenge remains to scale up patient education so that all patients with Diabetes are able to access self management support as part of routine care.

7. Implementing Clinical Psychology-led motivational interviewing training for staff managing people with

As an initial pilot a clinical health psychologist worked with the Diabetic nursing team at Mile End to enhance their skills in achieving behavioural change in service users. The pilot was well received by staff and a formal

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Diabetes. evaluation will be produced by the end of November. A full time psychologist, currently working with the Diabetes Service at the Royal Free, will be in post by 1st January.

8. Diabetes Nurse Educator will implement structured obesity and weight management training and a stop smoking programme specifically for patients with Diabetes.

The Diabetes Nurse Educator has recently left post. This has provided an opportunity to look at what has gone well in training for professionals and what can be discontinued. An audit of practice training needs has been undertaken and attracted a high response rate. The new nurse educator will spend time supervising DSNs and practice nurses who are delivering education to ensure that the high standard remains in place. She/ he will also develop new packages of education for professionals incorporating district nurses and community staff. The dieticians are now moving more into the community and will do group sessions looking as weight management. A third dietician is currently being recruited to support this. it Also looking

3.1.2 The PCT has successfully bid to become one of three pilot sites for the Diabetes Year of Care initiative. This is a joint project with the Department of Health and Diabetes UK. The Year of Care is about people with Diabetes taking charge of their condition in partnership with healthcare professionals. A second aim is to shift the commissioning of services away from a service centred model to a patient centred one. As part of this work the annual review will become a discussion where the person with Diabetes is on an equal footing with their health care professional. Together they will discuss and decide the appropriate treatment options from a commissioned ‘menu’ of choices. This will form the individual tailored ‘year of care’ plan. The planning phase is has already underway and will be completed by March 2008. The implementation period will be from April 2008 for 18 months. Ongoing analysis and evaluation will assess the impact of the initiative. 3.1.3 Key Data Demand for Care As highlighted in the Overall Progress section, one of the greatest challenges is identifying people with or at risk from a Long Term Condition. Figure 2 on the following page shows that there are many local practices which appear to have a gap between the number of patients recorded as Diabetic and those we would expect based on the characteristics of the local population. It is anticipated that the successful model of targeted practice visits will be continued to address this. Additional data facilitation support in primary care will also help to improve the quality of recording. In terms of diverting care away from hospital, the Diabetes Team has continued to be successful. Community based coaching and training has led

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to a reduction in hospital referrals from over 20 a week to between 4 and 6 a week. Anecdotal evidence suggests that those who are referred are also being referred in a more timely fashion in that their HbA1c is lower. This type of earlier intervention helps to prevent Diabetic complications and improve quality of life. Equity and Access PCT data shows that the degree to which our locality populations are covered by the Enhanced Services can vary considerably. Locality Population % coverage by Insulin

Initiation LES % Coverage by Diabetic Annual Review LES

NE – 57,106 95 95 NW – 60,034 72 94 SE – 59,612 88 89

SW – 55,963 96 100 When data for the practices not accredited to deliver the Annual Review LES is analysed, this shows a very mixed picture in terms of the quality of disease control and also in the completeness of data recording. Between 8 and 21% of patients on these practices’ registers have high blood pressure and as many as 13% of patients have no blood pressure recorded. Glycaemic control is generally better managed, although one practice has nearly 1 in 5 patients with Hba1c of more than 10%. The same practice had no measure recorded for 26% of people on the register. Small proportions of patients (2-3%) have high cholesterol, but much high proportions (6-23%) have no cholesterol level recorded. For the Insulin Initiation LES, between 9 and 21% of known Diabetics registered to non accredited practices are insulin dependent. As part of the drive to improve uptake, retinal screening satellite clinics have been set up in a number of GP practices. Uptake has been variable despite some of the sessions running in conjunction with practice nurse Diabetes clinics. Some patients considered they received a ‘better’ service in a hospital based setting, despite the same screeners and equipment being used ; others felt uncomfortable attending an appointment in a GP practice other than their own. As a result there are proposals for retinal screening provision in the localities to be re-designed. A bid has been submitted to purchase a mobile unit which, if successful, would enable clinics to be held in the Local Area Partnerships on a rolling fortnightly basis with some sessions continuing to be held within the Diabetes Centre. Plans are also underway for a clinic to be held at the Royal London Hospital for patients who are under the continuing care of an ophthalmologist or Diabetologist or for women attending the ante-natal clinics. Appointments will be offered at the same time as secondary care appointments thereby offering more of a ‘one stop shop.’ An open session is to be held in November in partnership with the City and Hackney and Newham programmes at the East London Mosque where we will carry out opportunistic screening and provide information. Public Health are also currently commissioning some social marketing for retinal screening looking specifically at why people do not take up the

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invitation and we shall use the findings from this to influence future service developments.

Quality Data has been presented in Section 2.5 which suggests that many clinical indicators of care are improving. However, there remain areas of concern where improvement is a priority. In terms of clinical indicators, last year’s report highlighted a large proportion of people (40%) who did not have an annual review recorded. This has reduced to 34% in the last 12 months but this still represents a large number of people either not having a review or not having it written into their notes. In a similar vein, the PCT has a target to offer all eligible diabetics an annual screen. At present, we are only achieving this for 70% of patients. Qualitative information collected by the Picker Institute suggests that patients themselves feel there are a number of areas for improvement. These tended to be focused on 3 main themes – access, information and education. For example more than 50% of people responding to the survey said they

- did not get the results of key tests such as urine, blood sugar or cholesterol tests in writing

- were unable to get a GP or practice nurse appointment within 24 or 48 hours. Those having in-patient stays also reported problems in accessing advice from the specialist Diabetes team.

- had not had the opportunity to discuss medication use, diet and physical activity. This also included not being referred to training courses designed to support self-management.

The Year of Care initiative, with its focus on joint care planning between clinicians and patients will play a particularly important part in addressing these concerns. The PCT also has a major initiative underway to tackle barriers to accessing primary care services. 3.1.4 Priorities for the coming year � Complete and start to implement the commissioning plan for Diabetes for

2007/08 and develop a system of priorities for 08/09 which address the concerns raised by patients.

� Define the Diabetes Service ‘core offer’ to practices at different stages of development and measure performance against a traffic light system which ranks care from red (poor) to gold (best practice). The team aim to have no red practices in 12 months time.

� Complete the initial preparation work and plans for Diabetes Year of Care project by March 2008 with an implementation plan ready for April 2008.

� Identify local residents who are at risk of developing Diabetes and to validate local Diabetes disease registers by assessing register size against expected numbers and the mechanisms used by practices to maintain registers

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� The use of a local patient survey and the national Picker Survey to understand patient views and needs around Diabetes and deliver care that meets this using a culturally sensitive approach.

� Deliver education and training to 150 staff and 600 patients over the next 12 months

� Boost commissioning capacity by funding a new Diabetes Commissioning Lead.

� Examine how network level commissioning and inter-practice referrals may contribute to addressing inequalities in Local Enhanced Service provision

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3.2 Heart Failure 3.2.1 The Heart Failure workstream has achieved a number of successes in relation to admissions avoidance, streamlining care, reducing lengths of stay and improving access to essential diagnostic tests. However, there is still a need to improve certain aspects of primary care management, including looking at ways to assess the gap between the numbers of diagnosed patients and the total Heart Failure population in Tower Hamlets. Our commitment from 2005/06 Our progress / outcomes in 2006/07 1. Finalising and publicising a whole system patient pathway.

The draft pathway been completed. This has been approved by the LTC board and National Service Framework implementation group. The next step is to complete a more detailed pathway and launch this in the autumn.

2. Roll out of the enhanced service, including improving the numbers of referrals from practices to the community Heart Failure nurses.

The number of practices registered from the Heart Failure LES has increased from 20 to 26. The current number of referrals from practices to the community Heart Failure nurses remains low. The Heart Failure nurses are currently working to address this and to support practices to run their own clinics. Difficulties with roll out were also exacerbated by technical difficulties with coding. This is now being addressed.

3. Maintaining reductions in the number of admissions and readmission for Heart Failure and length of stay across sites.

Data on spells and lengths of stay has been reported in Section 2. Rates of unplanned readmission within 28 days of being discharged from hospital appear to be stable. There are no real significant differences between lengths of stay by site, however the Trust is looking into the details of admissions for people described as having a primary diagnosis of Heart Failure to review the appropriateness of their admission

4. Ensuring equity of access for echocardiogram across the 3 BLT sites.

Progress is reported in more detail overleaf. This is in line with the targets set to ensure all patients have first treatment initiated within 18 weeks of referral. Additional echocardiography has also been purchased from the independent

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sector, enabling GPs to refer direct. Local guidelines have been produced to support the process.

5. Development of a “One Stop Diagnostic Heart Failure Clinic” with an individual management plan for each patient, shared with the key professional responsible for their care.

A pilot clinic was launched, with 14 patients seen in first 5 months. Fifty percent had a diagnosis of Heart Failure confirmed, 4 were referred back to community based Heart Failure nurse specialists and GPs for management, 3 were referred to Outpatient Heart Failure service at London Chest Hospital. More throughput is needed to be able to evaluate the service more fully.

6. Opening up referral from the community into the “Education and Exercise Programme” to benefit all patients with a diagnosis of Heart Failure.

The initial pilot was successful, though the numbers completing the programme have remained small. Work is now ongoing with the Cardiac Rehabilitation team in the Trust along with the Community Rehabilitation and Pulmonary Rehabilitation groups to look at the most effective way in which to deliver this service. Discussions currently include extending the service provided by the Community Pulmonary Rehabilitation to include this group of patients (see next section)

7. Working with the Princess Royal Trust for Carers Tower Hamlets to pilot enhanced support services for carers of people with end stage Heart Failure

Please see the End of Life Care chapter.

3.2.2 The Heart Failure service was awarded joint second place in the 2006 Annual Cardiac Nursing Awards. The service was also successful in applying for a BHF grant. The award will support two nurses for a 3 year period to work in Tower Hamlets. The nurses will spend 60% of their time seeing patients and 40% will be dedicated to understand and addressing the impact of ethnicity issues in Heart Failure.

The Heart Failure team made a successful bid to launch the "Diversity in Heart Failure and its management at end of life" project. This is a piece of work looking at specific palliative care issues for the Bengali and Somali population. The majority of the work will be carried out by Social Action for Health. The objective then is to devise a pathway which incorporates the issues identified.

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3.2.3 Key Data Demand for Care The Health Care Commission has recently published the 2006/07 Heart Failure Service Review. The review data suggests that there may be 14,000 people nationally with currently undiagnosed disease. In the last two years local practices appear to be getting better in capturing this data with number on disease registers rising from 654 to 1252. QOF data for 2006/07 suggests a borough wide prevalence of 0.5% compared to a national prevalence of 0.7%. However, establishing whether there is a gap between actual versus recorded prevalence is complex because the case mix of patients with Heart Failure is very different in Tower Hamlets. The numbers of individuals at a practice level can also be very small and therefore if a practice is just a few patients away from the ‘norm’ this can appear as a large percentage variation. Equity and Access Data on enhanced service coverage also shows a similar picture of variation for Heart Failure.

As noted earlier in the report, 12% of those known to have Heart Failure are not covered by an enhanced

service. Data from CEG shows that between 11 and 33% of patients on these practices’ registers have high blood pressure and up to 25% have no blood pressure recorded. In the same cluster of practices up to 37% of Heart Failure patients have high cholesterol and as many as 50% have no cholesterol level recorded. Echocardiogram (echo) remains central to diagnosing Heart Failure. Waits for echo as an inpatient and outpatient have significantly improved over the last year. In August 2007 echo waits are:

BLT Site Inpatient March 06

Inpatient August 07

Outpatient March 06

Outpatient August 07

London chest

Same Day

Same day 0-10 days 0-2 weeks

RLH 1 day Within 24 hours

2 weeks 2 weeks

Barts 3 days 2 days 2 months 1 week

The number of local residents covered by the Heart Failure LES remains limited. 28 practice are signed up to deliver the Heart Failure LES. However the LES data indicates that only 50% of practices signed up to providing the Heart Failure LES have a disease register. Referrals to the community based

Locality Population % coverage by Heart Failure LES

NE – 57,106 75 NW – 60,034 91 SE – 59,612 77 SW – 55,963 100

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Heart Failure nurses remains low, with 90 referrals (25% of their total activity) in the first year of this service. Quality The model of care being pursued in Tower Hamlets was praised as excellent by the Heathcare Commission review. However, there are indications that some of the clinical criteria embedded in the enhanced service are not being applied universally. These issues are described in section 2.5. 3.2.4 Priorities for the coming year

� Agree a valid mechanism for estimating actual prevalence of Heart Failure and the potential under-recording at practice level.

� Validation of current disease registers to ensure all patients have confirmed diagnosis of Heart Failure.

� Intelligent use of data to identify ‘red flag ‘ practices and target initial resources and intervention at these practices, using the Diabetes outreach model to support this development.

� Set locally agreed targets for the number of patients seen by community staff

� Examine how network level commissioning and inter-practice referrals may contribute to addressing inequalities in Local Enhanced Service provision

� Completion and launch of the agreed Heart Failure pathway. � Ensure all inpatients seen at the Royal London Hospital have review by

a Cardiologist. This is part of the Heart Failure chapter of the CHD National Service Framework and is an indicator used in the recent Healthcare Commission Review.

� Audit medical management of Heart Failure, using QOF data / LES template data.

� Evaluate the impact of the one stop clinic and consider its’ applicability to a community setting.

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3.3 Respiratory 3.3.1 The last two years have seen significant progress in re-designing the whole pathway of care for local residents with COPD. This workstream has also started to review the needs of local residents with asthma (adults and children.) As discussed in the general progress section respiratory disease is still the major contributor to unscheduled care and while progress has been made this still needs to remain a focus for the coming year Our commitment from 2005/06

Our progress / outcomes in 2006/07

1. Fleshing out the detail of the care pathway to take on board potential changes in the role of community teams, better use of intermediate care and more proactive end of life care.

The borough-wide Tower Hamlets Respiratory Group is working to reach consensus on the care pathway and the shift of services out into the community. The new model outside hospital will be delivered by creation of the new Community Respiratory Team (CRT). In parallel, Barts and the London have re-worked the Inpatient Pathway and it is in the process of being signed off by the relevant teams. As many respiratory patients present as repeat users of intermediate care services, the CRT has been placed within the Intermediate Care Service, to boost specialist support and reduce readmissions. Responsibilities for improving end of life care have been written into the job descriptions of the team and we envisage that they will work with St Joseph’s to establish a model of joint provision similar to that in place for Heart Failure.

2. Audit mechanisms also need to be established to monitor the implementation of the pathway and its impact on patients and carers.

Data on how we are performing in terms of reducing unplanned admissions, accurately diagnosing patients and meeting primary care based quality standards is included in section 2 and the section on Quality in this chapter. The CRT has been set a target to reduce the number of GP referrals to secondary care by 30% at the end of its second year. Specific targets will be included in the Service Level Agreement for 2008/9 to track the impact on use of both planned and unplanned secondary care. BLT readmission rates and lengths of stay tend to be around the national average but it should be possible to set targets for reduced length of stay when the CRT is more fully developed. Focus groups have taken place with some of the most at risk groups. These suggested that there is still much to do in terms of educating people in the causes of COPD and the triggers for

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exacerbations. Greater access to community based support and information, including smoking cessation support, was also cited as a need.

3. Completing the business case and securing funding for the Community Respiratory Team (CRT).

Funding has been secured for the CRT and the lead clinician will be in post in January. Key to improving the health and outcomes for people living with long term respiratory disease is developing care close to where they live. The team will build on the systems and infrastructures currently in place and develop a service which will support current initiatives and provide a specialist and highly skilled service to patients at risk of exacerbation, those who remain symptomatic despite optimal therapy and those who are unfamiliar how to access to primary care effectively. A formal evaluation will be commissioned after the first full year of the CRT being in place.

4. Continued support for the enhanced service and ensure as many non-accredited practices as possible are delivering it by September 2007.

30 practices commissioned for 2007-2008. Developmental plans have been offered to support non-commissioned practices to improve quality of care. The specification for the enhanced service is also being reviewed to set ‘stretch’ targets for practices who are already meeting the core standards, in order to encourage continuous improvement.

5. Piloting Asthma Action Plans in 8 practices by July 2007 and roll out to the remainder by August 2008.

Asthma Action Plans will be launched in 10 practices in August 2007. A commissioned evaluation has been awarded to the Department of General Practice at QMUL and will report by July 2008. Using these picture based plans it is hoped that self care capacity will be increased for those who have difficulty reading or for whom English is not a first language

6. Designing and piloting a community based pulmonary rehabilitation programme with the aim of reducing waiting times and increasing throughput

The community programme is now up and running in all 8 localities. At the end of June, 87 patient contacts had been made, 67 new patients had been assessed and 22 had completed a programme. In the same period 12 new patients were assessed for the maintenance programme and 7 completed the course. These figures represent a significant improvement compared to the hospital based programme.

In an effort to reach communities who tend to be under-represented, the first BME group is

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underway in the local mosque and a home-based programme is providing a service to people who are housebound. The waiting time has been significantly decreased in all areas from 10 months to 8 weeks. There has been a steady and significant increase in referrals to this service since it commenced and attendance figures are steadily improving. The maintenance programme has been very popular and work is ongoing to move patients post rehabilitation into local community exercise and activity groups. Further data analysis and evaluation of the project will help inform future service provision.

The current structure offers the opportunity to extend the model of exercise and education to patients with other long term conditions such as Diabetes, Hypertension, Heart Failure and Intermittent Claudication.

3.3.2. Prior to February 2007 the prescribing of oxygen did not adhere to national clinical guidance on the assessment and follow up for people given oxygen as part of their disease management. From February 2007 there was a national implementation of new guidance for assessment and follow up. A partnership of local clinical leads has developed a new pathway and agreed new contractual arrangements for the provision of oxygen. This means there is also now a facility to organise delivery of oxygen for domiciliary use within 4 hours. 3.3.3 Tower Hamlets staff have also contributed to development of the forthcoming COPD National Service Framework (due 2009). This included gathering patient feedback via focus groups at the East London Mosque. 3.3.4 Key Data Demand for Care Whilst COPD in Tower Hamlets currently tends to be a disease of the white working class, smoking rates amongst Bangladeshi men (50-60%) in particular mean that not only will overall prevalence rise, but the roles required for management and partnership working with patients will need to change. In order to prepare for this, focus group work with Bangladeshi men has been carried out this year and patient information literature is being adjusted which is culturally and linguistically appropriate. Case finding via spirometric assessment of symptomatic smokers is likely to yield an increase in overall prevalence. Earlier diagnosis will, in theory, at least allow time for smoking cessation (and health gain) as well as optimising functional and self care capacity. The other key risk for older adults is the tendency for COPD to be part of a broader range of health problems. Teams working in the community in particular will therefore need to be skilled in managing these more complex patients.

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Asthma rate continue to rise within the UK and it is anticipated that this will be reflected in the borough. Whilst there are demonstrable improvements in management, self care remains poorly developed particularly for those caring for children, hence the commissioning a specific post within the CRT to address this. The role Respiratory conditions play in driving demand for urgent care has already been described in section 2. On the elective care side, current data suggests that for respiratory outpatients only 39% of referrals to secondary care come from GPs. It is unclear at present what is driving the high proportion of consultant to consultant referrals. Equity & Access Data on enhanced services shows that roll out of the COPD LES has been one of the most successful areas of development, with only small pockets of patients not covered by the service. In the past one of the greatest difficulties of levelling up care was lack of specialist support. With the advent of a larger Community Respiratory Team, it should be possible to provide adequate support to all practices, irrespective of whether they are accredited to deliver the LES. Locality Population % coverage by COPD

LES NE – 57,106 95 NW – 60,034 94 SE – 59,612 94 SW – 55,963 100

In the small core of practices not currently covered by the LES, with the exception of one practice in the North East locality, between one third and one half of patients have very poor measures of lung function. Part of the rationale for developing the Community Pulmonary Rehabilitation programme was an awareness of poor throughput of particular communities for the hospital-based programme. Recruitment of local bi/tri lingual staff to the community pulmonary rehabilitation team has enabled the team to offer a full service to non English speaking patients.

LCH 2006-7 Community programmes

Bengali language

No of BME patients

3 9 +4 home programme

12

There has been an increase in these people accessing the standard community programmes as well as an opportunity to attend the Bengali specific programme run at a local mosque.

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The use of a range of community locations with good public transport links has improved access to people across the borough to rehab programmes and the home programme for house bound patients is proving popular with better than expected patient compliance for independent exercise. The home programme has so far assessed 15 people, patients are benefiting from individualised programmes, doing their exercises daily, doing outside functional work/ stairs. Equipment has been loaned out for the duration of the programme. The Occupational Therapy input into the programme has also been beneficial, with the OT seeing 9 patients on an individual basis within the home programme, and also identifying individual needs within the community programmes and issuing small aids for energy conservation. The planned women-only group has not yet been run due to a lack of demand for this service; however patients within this group will be offered alternative programmes. Quality Spirometry is required to confirm diagnosis and monitor disease progression annually. The percentage of patients with COPD who have had spirometry has increased over the last three years from 74% to 94 %. Primary care staff now carry out more than 50% of these tests. Thirty practices now have their own spirometers, of which 25 have been funded by the PCT. The spirometry technician is undertaking a series of quality assurance standards to ensure diagnostic standards are maintained. CEG data on the implementation of the enhanced service also shows steady improvement across all 9 parameters. Referral to pulmonary rehabilitation was added as an indicator for 2007-2008 ; however, the data presented in Section 2.5.2 shows clearly that there is much to be done to embed support for self care into routine treatment and monitoring of patients. Figure 3 overleaf shows that the number of patients readmitted to hospital as an emergency within a month of discharge also seems to be dipping for most respiratory conditions, suggesting community services and possibly liaison at the point of discharge may be improving. 3.3.4 Priorities for the coming year

� To embed the Community Respiratory Team within the Intermediate Care Service and define its’ relationship to the specialist service at BLT.

� To target initial efforts of the Team at housebound patients and those patients covered by practices not accredited to deliver the Local Enhanced Service. This includes targeting staff working in these practices to improve core Respiratory skills.

� Through the dedicated Children’s post, to extend the scope of the programme to include support for children with asthma, their parents and staff who work with them e.g. children’s centre workers.

� To extend the domiciliary spirometry service through training and support, introducing annual quality assurance visits and offering GPs and practice staff an on line interpretation service

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� Explore the potential for the CRT to extend its scope to cover Obstructive Sleep Apnoea and Interstitial Lung Disease.

� Secure mainstream funding for community based pulmonary rehabilitation and scope the potential to expand the model to cover Heart Failure patients requiring maintenance programmes and people with Intermittent Claudication

� To strengthen the end of life care part of the COPD pathway, in collaboration with St Joseph’s

� To drive improvement in the self care aspects of managing Respiratory Disease, including ensuring all patients with an MRC score of 3-5 are referred to Pulmonary Rehab.

Figure 3 – Readmissions 2003/4-2006/7 for Key Respiratory HRGs

0

20

40

60

80

100

120

140

2003/4 2004/5 2005/6 2006/7

Year

Sp

ells

CHRONIC OBSTRUCTIVE

PULMONARY DISEASE OR

BRONCHITIS W/O CC D40

ASTHMA W/O CC D22

COMPLEX ELDERLY WITH A

RESPIRATORY SYSTEM PRIMARY

DIAGNOSIS D99

CHRONIC OBSTRUCTIVE

PULMONARY DISEASE OR

BRONCHITIS W CC D39

RESPIRATORY NEOPLASMS D25

OTHER RESPIRATORY

DIAGNOSES <70 W/O CC D34

OTHER RESPIRATORY DIAGNOSES >69 OR W

CC D33

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3.4 Chronic Pain 3.4. 1 Last year’s report highlighted patients wish to have both better quality of care and better outcomes, particularly easier access to specialists and a more holistic approach to their needs. A considerable amount of analytical work has taken place to understand the demand for pain services more fully and come up with a service and pathway which represents good care for patients, support for non-specialist staff and best use of resources. The team working on the project has made excellent progress establishing a truly innovative approach which should provide a sustainable way to meet needs, both now and in the future. Our commitment from 2005/06 Our progress / outcomes in 2006/07 Establish a bio-psychosocial model of care centred on a community Pain Assessment and Triage Team (PATT), attached to the musculoskeletal Clinical Assessment Service, with clear care pathways, referral and prescribing guidelines and in-built screening for co-existing mental health problems.

The model of care has been completed and agreed by the project steering group and will focus on referral into a multidisciplinary team of an outreach hospital consultant & clinical nurse specialist, alongside psychology and physiotherapy. Space for the team has been allocated close to the main CAS at Mile End hospital (MEH). As pain patients often have other non-clinical needs, there will also be access to welfare advice such as help with housing or benefits. Tower Hamlets clinicians and patients have been consulted on and agreed the pathway. Funding was secured from the PCT and Practice Based Commissioners, enabling a launch of the service in January 2008. Formal referral criteria and a pathway have been agreed and will be supplemented by prescribing advice later this year. A specific Psychology-led piece of work has also identified gold standards for screening patients, enabling them to develop coping mechanisms and supporting behavioural change.

Appoint clinical and lay tutors to teach on the ‘Persistent Pain Programme’ (PPP) self management course. The course will consist of seven modules over seven weeks, with advice on pacing, relaxation, use of medicines and setting baselines. It will be hosted by Social Action for Health (SAfH) and aimed initially at patients from Black and

Social Action for Health organised and delivered the PPP taster course and education day designed for clinicians who had a specialist interest in pain. They took place took place on the 22nd and 29th January 2007 respectively. Two Bengali PPP course have been delivered by SAfH, with 21 people attending with a 52% completion rate. The 2 courses have been fully evaluated and the findings will be collated with a

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Ethnic Minority backgrounds. We anticipate that the first course will commence before the end of 2006

further 2 PPP courses held in 2007/08. The Mile End Physiotherapy department will be providing additional support to the programme and have developed a specific “Back To Fitness” course which began in November. This will connect the clinical and non clinical elements of the care pathway. As chronic pain often affects someone’s ability to get or remain in work, a link has been established with Job Centre Plus to enable people on Incapacity Benefit to be offered the opportunity to attend a Self Care Management course

Agree core competencies for assessing and managing pain and mapping current formal education provision. The education group will produce recommendations for commissioned and locally delivered training and pilot at least one protected learning time session for primary and secondary care professionals. It will also explore the potential mentoring and training remit of the PATT and mechanisms to spread specialist skills more widely through in-service programmes.

The project has agreed draft core competencies that will cover referral criteria, the medication requirements of people living with pain. Educational material will be accessible through a PCT intranet learning site that is being developed. The intranet site will go live in January 2008 when the Formulary has been approved. Teach and treat sessions have taken place in 7 practices, with a further 2 arranged before Christmas. Over 40 staff have taken part, including health care practice clinical and support staff. The feedback about the project has been positive; the topic under discussion was the types of medication available for GP’s to use with patients who had long term pain generated internal discussions within the practices.

3.4.2 In parallel, researchers at Queen Mary College have submitted a research proposal to the national Best Research for Best Health scheme. The project would establish East London as a centre of excellence in pain research and also include provision to follow up patients accessing self care support to evaluate the long term impact on health outcomes, confidence and use of health services. The proposal has been short listed and a final decision is due next year.

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3.4.3 Key Data Demand for Care Chronic pain is a widespread problem and therefore assessing the demand for a new model of care has been one of the major challenges for this workstream. Modelling was undertaken to assess how many patients could be diverted into the PATT from other services. This produced a figure of just under 1,000 patients in Year 1, drawn from Rheumatology, Orthopaedics, Neurology, Physiotherapy and Occupational Therapy. Evidence from City and Hackney suggests that on top of this the service can expect to find an additional 250 cases of previously un-met need. Many of these patients will be regular visits to their GP – data collected from people attending the PPP course reported visits of between 3 and 70 times a year, with an average of nearly 1 visit every two weeks. The project team has also linked into work which aims to clarify which underlying conditions are responsible for impacting on people’s ability to be economically independent. A snap shot survey showed that of the 11,120 people living on Incapacity Benefit in the Borough 1,760 or 16% had a musculoskeletal problem as their primary cause of disablement. Equity and Access Tower Hamlets PCT research has shown that the current pathway into the pain services is complex and does not enable people with chronic pain to access the correct service at the most appropriate time. This problem is exacerbated by the tendency for care to be structured around treatment for a particular problem or a specific joint – for example, someone presenting with back pain will be referred to a specialist Physiotherapist and the, if necessary onto a specialist Orthopaedic surgeon. People with generalised pain (often Bengali women) do not fit this model and therefore tend to have the most difficulty finding an explanation and appropriate care. The project has audited a sample of case notes and found that the mean time that a patient spent in the secondary sector was 5 years; with the mean average number of reviews completed by BLT consultants equalling 8. Coupled with the data on the frequency of attendance at the GP, it is clear patients build up multiple visits and assessments over a significant period of time, often without effective resolution. Quality In order to produce a set of meaningful indicators for the new model of care further work has been done to gather patients’ views of current problems. People attending a series of focus groups report feeling confused about their diagnosis and management; they felt they received conflicting messages, continue to seek a “cure” and become distrustful of the health service. They therefore tend not to feel empowered to take steps to self-care.

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The new service will only commence in mid January 2008 and therefore there are no outcomes being currently delivered. However, in next year’s report we will be able to produce more detailed activity and outcome data. 3.4.4 Priorities for the coming year

� PATT to see and assess 500 patients by September 2008. � To conduct an interim evaluation of the quality of care via a patient

survey. � To complete a PCT wide formulary which gives clear guidance to GPs

and other independent prescribers on the optimal way to treat pain by January 2008.

� To deliver and evaluate 8 PPP courses and successfully tender for a further 8 to be provided in 08/09.

� To use the team to provide education sessions to a wide variety of clinicians including GPs, community nurses and community pharmacists. The Pain Team will provide 2 sessions for Protected Learning Time (PLT) during 2007/08 and 2 PLT for 2008/09 with 2 sessions per year for the community nurses and pharmacists. In addition, there will be a minimum of eight education sessions undertaken in local practices.

� Produce an information pack for all PCT clinicians on to the web site and to have produced and published a translated service leaflet by December 2007

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3.5 Children 3.5.1 Long Term Conditions are often only thought of in terms of adults. However, there is considerable evidence that in deprived, inner city populations, Long Term Conditions affect all age groups. The data reported in Section 2.1.2 shows that children with long term conditions not only are not only frequent attenders at A&E and the Walk in Centre, but generate a large number of emergency bed days too. Two priority areas were identified in 2006 / 7 for improvement – epilepsy and asthma. In addition, children with Long Term Conditions and Disabilities often suffer from continence problems. Redesign of the Continence Service is therefore an important supporting project. 3.5.2 Asthma Our commitment from 2005/06 Our progress in 2006/07 1. Hold a children’s’ benefits

realisation planning event with stakeholders in November. This event to provide a project plan with defined outcomes, responsibilities and time scales.

An Asthma Project Plan for 2005/6 is in place. The pathway mapping event, held in November 2006, led to a care pathway being developed. This will be completed by December 2007.

2. Training and education for community staff to support the development and implementation of agreed care pathways.

A training programme for community nursing teams and school health service practitioners has been completed. Secondary care practitioners will provide training and updates for GP’s as part of protected learning time sessions planned for late 2007. A written toolkit, to support delivery of training by school health staff, has been developed and completed.

3. Strengthening work with schools/wrap around care to reduce the numbers of days lost in school for children attending A&E or admitted to hospital.

The School Health service is key in offering support for children, families and education staff in managing children’s asthma in school - a partnership project to improve attendance at school is due to start in October 2007 School health staff are now delivering asthma awareness and management sessions to staff, pupils and parents in schools. This is currently being rolled out to all schools, children’s centres and wrap around care facilities.

4. Applying for funding for a project from Asthma UK to increase self-care skills in children from BME groups and their parents. If successful, the project would use more innovative techniques such

Asthma UK funded the ‘Planet Asthma’ project (Bromley by Bow practice) which uses art to teach children about asthma and help them describe how it feels. The project also identified 6 previously undiagnosed children.

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as drama workshops and offer training in local venues such as children’s centres.

The team are also in discussion with Asthma UK to develop other projects

3.5.2.1 Discharge Follow-up During the pathway mapping process various gaps in care were identified – in particular following a child’s discharge from secondary care. A carefully selected group of asthmatic children are now being followed up, after discharge from hospital but before being referred back to their GP, either

o by the community children’s nursing team or o by a Clinical Nurse Specialist or Consultant ‘rapid referral’ process (for

children with complex asthma) Both ‘step-down’ approaches are being measured against effectiveness and outcome 3.5.3 Key Data Demand for Care Getting accurate data on the numbers of children with asthma in Tower Hamlets is difficult. QoF and Enhanced Services tend to be targeted at adults and therefore there is no disease register available. However Asthma UK estimate that one in ten children in the UK live with asthma. This prevalence is mirrored in Tower Hamlets but local research suggests that it is compounded by socioeconomic deprivation, ethnicity and poorly developed self management skills (Griffiths et al 2001). Equity and Access Without good data it is difficult to comment on equity. However, recent data analysis shows that alot of asthma care is accessed through urgent care routes. Respiratory conditions account for the greatest number of attendances at the Whitechapel Walk in Centre. Analysis of A & E attendances shows that the greatest proportion of under 15s who have attended with a ‘respiratory condition’ are under five years of age. Quality Analysis of admission data shows that 80% of children, admitted as an emergency are under 5, 22% of admissions are for less than 2 days and the number of children being readmitted as an emergency has doubled between the years 2004/5 and 2006/7 (although total numbers remain small). This suggests that by improving the management of children with Asthma in Primary Care there is significant potential to prevent admissions. 3.5.4 Priorities for the coming year Priority Timescale Project Plan for 2007/08 November 2007 Complete and implement the children’s asthma care pathway

December 2007 – March 2008

Monitor the use of, and impact of, the care pathway December 2007 –

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against key indicators – urgent care attendance, admission data, school attendance

December 2008

Implement self management plans for all children with Asthma

Ongoing

Standardised written information to be in use across primary, secondary and specialist services

Ongoing

Continue training of practitioners, across all services, to manage children’s asthma to British Thoracic Society guidelines

Ongoing

Application to Asthma UK to support self care skills for children and families in BME groups

November 2007

Involve parents and children in improvement and redesign work

From October 2007

Continue monitoring and analysis of hospital admissions and the use urgent care services (the Walk-in Centre, Out of Hours Services and A&E) by children with Asthma

Ongoing

Update data analysis to focus improvement work, training and support

October / November 2007

3.5.3 Epilepsy Our commitment from 2005/06 Our progress / outcomes in

2006/07 1. Implement a clear referral

pathway across community, primary and secondary care.

Analysis of children with Epilepsy who attended A & E in a two year period has been completed. This identified the ‘frequent fliers’ (>5 attendances) and ‘very frequent fliers’ (> 10 attendances) Pathway mapping and redesign work has commenced to develop a better model of care for these children

2. Improve the support network for children and families with epilepsy in the community. There is currently one meeting for families every 2-3 months, but it not well advertised or attended. This is an important factor in addressing the isolation that some families and children can experience.

The facilitator of the parents’ support group is a member of steering / working group. Parents will also be actively involved in shaping the new model of care.

3. Ensure literature is available to all families in appropriate languages and formats.

Patient information leaflets developed by Epilepsy Action and by Newham PCT have been identified and the group is now looking at how these could be used in Tower Hamlets.

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4. Continue training of core staff including school nurses, practice nurses, Community Children’s’ Nursing Team and health visitors in recognising the different types of seizures and administering the appropriate medication.

Training in use of Buccal Midazolam training was offered in September 06

5. Recruit an epilepsy nurse specialist, able to instigate nurse led clinics where parents and children can provide life style, medication and self care advice.

We will recommend investment of £200K in 2008 for a nurse-led Community Based Service

3.5.3.1 Key Data Demand for Care Like Asthma, it is difficult to get reliable data on the prevalence of childhood Epilepsy within the Borough. For the time being we are reliant on using national estimates. Approximately 1 in 20 children in the UK have some form of epilepsy (Royal College of Paediatrics and Child Health) which equates to over 300 children in Tower Hamlets living with epilepsy. Research shows that there is both an increased prevalence of epilepsy in areas of socioeconomic deprivation and that, therefore, this is a significant risk factor. Equity, Access and Quality Data on this area is also limited. Recent analysis of children with Epilepsy, who attended the A & E department of the Royal London Hospital over a two year period, identified a significant number of frequent attenders (>5 attendances) and very frequent attenders (> 10 attendances). Analysis of admission ‘spells’ and lengths of stay, during the same period, shows that a significant number of children with epilepsy are also being admitted frequently and / or staying in hospital for considerable periods (up to 18 days). The number of emergency readmissions for Epilepsy seems to have been relatively stable over the last 3 years. 3.5.3.2 Priorities for the coming year Priority Timescale Project Plan for 2007/08 November 2007 Reform steering group to include CAMHS October 2007

Carry out epilepsy tracking study on 25 cases - including tracking the ‘very frequent fliers’, admissions and school time lost

October 2007

Complete the specification for a specialist Community Based nurse led Paediatric Epilepsy Service

November 2007

Involve parents and children in mapping, improvement and redesign work

From October 2007

Map child’s journey / care pathway across Primary and Acute Care

November / December 2007

Improvement work on care pathway Commencing

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November 2007 Monitor the use of, and impact of, the care pathway against key indicators – patient experience, urgent care attendance, admission data, school attendance

Ongoing

Design measures based on patient experience, analysis of hospital admissions, use urgent care services (the Walk-in Centre, Out of Hours Services and A&E) and school attendance

December 2007

3.5.4 Children’s continence Our commitment from 2005/06 Our progress / outcomes in 2006/07

1. To establish a working group to lead on this work

A working group, comprising a range of Primary Care clinicians, has been formed to steer the next phase of the improvement / redesign work

2. To map out the current service provision and highlight the gaps to be addressed

A thorough mapping of the use of the current community based service has been carried out, issues identified and the findings shared both with the group and also the operational managers

3.5.4.1 Key Data Demand for Care Incontinence affects a wide ranging group of children. This includes children who have not as yet become continent (delayed toilet training), children who have complex health needs which include incontinence and children who have psychological needs resulting in incontinence. Currently there are approximately 300 children in Tower Hamlets who are prescribed continence products at an estimated cost of £80,688 per year. Access, Equity and Quality Data analysis has shown that in a nine month period thirty six children were referred to the Royal London Hospital Paediatric Urology service - approximately 70 % from GPs and mainly for daytime incontinence. A recent survey of parents, carried out in 6 local schools, showed that 55% of Primary School children suffer from urinary incontinence / bed wetting. This underlines the need to look at how the Community Continence Service, working with Physiotherapy and Child and Adolescent Mental Health Services (CAMHS), can provide a more effective integrated model of care. 3.5.4.2 Priorities for the coming year Priority Timescale Project Plan for 2007/08 November 2007 Include CAMHS and Physiotherapy in working group October 2007 Review continence training sessions for health professionals – health visitors, school nurses,

November 2007

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practice nurses and Community Children’s Nursing Team and implement revised training schedule Work with health visitors, family support workers and school health teams to establish consistent approaches, guidelines and information leaflets on promoting continence and toilet training

October / November 2007

Work with education staff to establish consistent approaches, guidelines and information leaflets on promoting continence and managing incontinence

October / November 2007

Involve parents and children in mapping, improvement and redesign work

November / December 2007

Map child’s journey / care pathway across Primary and Acute Care

November / December 2007

Improvement work on care pathway Commencing November 2007

Monitor the use of, and impact of, the care pathway against key indicators – patient experience, number of children receiving incontinence products, school attendance

Ongoing

Measure the effect of proactive support for parents in the promotion of continence, and the reduction of nocturnal enuresis

Ongoing

Measure the effect of increasing the specialist support for children with complex continence issues in the community (numbers seen, treated and discharged)

Ongoing

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3.6 End of Life Care 3.6.1 In the 2006 Annual Report, work on improving end of life care was in its infancy and the emphasis was on reporting what the group was intending to do. In the last 12 months a significant amount of both information gathering and action has taken place. Feedback from external partners suggests that Tower Hamlets is now leading the field in North East London.

Our commitment last year Our Progress Completing an end of life strategy which would build in consultation with local people

The Department of Health has required all PCTs to undertake a baseline review of end of life services and set priorities based on the results. The baseline review was completed in October 2007 and sent to the National End of Life Care programme and Health Authority. The strategy and action plan for 2008-11 will be ready by the end of March next year. Consultations took place with a number of groups including older people, Bengalis, Somalis and parents of children with life limiting conditions. The key themes have been collated and used to set out our priorities for the next 2-3 years.

Continue roll out of the enhanced service and training for practices

There are now 28 practices accredited to deliver the enhanced service, compared to 20 last year. Discussions are under way with one or two key practices in the North West of the borough to see if we can boost this further. The new Alternative Provider Medical Service commissioned to provide services to patients currently registered with St Paul’s Way practice will also be required to provide the LES.

Use the enhanced service audit template and NICE benchmarking to gather more detailed information on numbers of palliative care patients, their needs and outcomes

The group is currently collecting a significant amount of data on end of life care as part of the baseline review. A summary of some of some of our findings is included in the data report.

Implement the Care Plus project for carers of people with Heart Failure

The project has started and 12 carers had received support by the end of June, with many benefiting from the coordinators role in securing financial and practical support. The specialist Heart Failure nursing team have provided an education session to carers on the symptoms of Heart Failure, how best to manage them and when to call for urgent help. A DVD version is also being prepared which should be completed in January 2008. A formal evaluation has been designed and will be undertaken by Health Psychologists at City

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University Re-model the Clinical Nurse Specialist post at St Joseph’s Hospice to improve support to generalists working in the community.

The job description for the post was re-written and it will now sit within the PCT Community Nursing Service, working closely with the hospice team and District Nurses. The new post holder started on 1st August 2007

Agree a core data set for specialist palliative care providers

The national end of life care strategy will identify key performance indicators for end of life care and we will therefore incorporate these into our commissioning arrangements for 08/09

Collaborate with other London PCTs and the local authority to implement recommendations of the London wide review of Children’s Palliative care

A London-wide Service Level Agreement has been established for children’s hospices such as Richard House, giving them a more secure financial footing. Locally, a Children’s Palliative Care Commissioning Group has been established and will take forward work to identify how we commission and provide the best end of life care for children and their families.

Begin implementation of the Liverpool Care Pathway (LCP) in the community

Baseline audit data has been collected from GP practices and community nursing teams assessing how patients were cared for in their last days has already been collected and submitted to the national End of Life Care programme. The second wave has been to repeat the exercise for patients in our inpatient facilities at Mile End. This was completed In October and a formal launch of LCP was held with over 50 community staff in November. Currently there are no care homes using LCP at the moment, but education on the principles of care has been started, led by St Josephs Hospice.

Develop the end of life care pathway elements for COPD and Heart Failure

Work on Heart Failure is described in the Heart Failure Chapter. A similar project would be launched when the new Community Respiratory Team is in place (see Respiratory Chapter 3.3)

3.6.2 In addition, three other key developments were initiated St Joseph’s Hospice provides specialist end of life care for adults in inner NE London. It is also a significant education and research resource. In autumn 2006, the hospice launched a strategic review, inviting the views of its staff, other provider partners, commissioners and local communities to shape its future direction. Full details of the review are available from the hospice, but the proposed change of direction fully supports the principles of the Tower Hamlets Long Term Conditions Strategy and the Borough Improving Health and Wellbeing Strategy.

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The PCT, Cancer Network and St Joseph’s have successfully bid to be part of the Cancer Services Collaborative Improvement Programme, piloting urgent direct access for GPs to specialist palliative care. This is in response to a project launched by BLT last year which identified problems of elderly people with known cancer diagnoses being admitted via A&E, some of whom died in the A&E department. The PCT and its partners have been invited to be an implementation site for Marie Curie’s ‘Delivering Choice’ programme, which aims to support people to exercise their choice to die in the community. Being part of the programme gives us access to the learning from the first wave of the programme, as well as Marie Curie’s service improvement methodologies for end of life care. 3.6.3 Key Data Demand for Care There were just fewer than 1200 deaths in Tower Hamlets in 2006, which reflects an average year. Just under ¾ were aged 65 and over. The main causes of death have also remained consistent in that the 3 principal causes are Cardiovascular Disease and Stroke, Respiratory Disease and Cancers. Ethnicity is not recorded in deaths data but we are able to identify which country someone was born in - 72% of people who died were born in the UK, with the next largest group (11.4%) being those born in Bangladesh. This obviously does not distinguish people born in the UK but who would describe themselves as British Asian, or Black British for example and therefore it is not currently possible to know whether some of our Black and Minority Ethnic (BME) groups are over / under-represented. Equity and Access The Local Enhanced Service based on the Gold Standards Framework (GSF) now covers nearly 80% of the borough’s population and undoubtedly represents positive progress. However an analysis of the characteristics of the populations covered by the LES, shows that we tend to have the greatest degree of coverage in localities where the population is younger, less deprived and where the concentration of BME groups is lower. This means some of the people who would benefit most from the structured care may not be offered it. Addressing this inequality is key over the next 12 months. Last year’s report also raised the issue of people from BME groups and people with conditions other than cancer not accessing specialist palliative care support equally. Data for 2006/7 shows that 162 people received 203 episodes of care. Of this, 75% described themselves as White British, 10% as Bangladeshi and 3% as Black Caribbean. This suggests that BME groups are still not accessing specialist palliative care services in proportion to the size of their respective populations. Outreach from the hospice to understand why and address barriers to access is now under way. Similarly inpatient care remains overwhelmingly driven by Cancer, with only 5 patients having confirmed non malignant diagnoses. The hospice strategic review recognises

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this imbalance and is looking to extend its services to other long term conditions particularly heart and respiratory disease. Quality There are currently a number of mechanisms for establishing whether end of life care is being delivered well

• The number of points local GP practices achieve from the Quality and Outcomes Framework. At the end of March 2007, practices had achieved 96 points out of a possible 111 for keeping a register of palliative care patients. However, they scored only 3 out of a possible 111 for the standard which requires practices to meet regularly to review patients on the register. This underlines the need for the enhanced service and the service improvement lead role to raise standards in implementing GSF much more comprehensively.

• Carers of people with life limiting conditions are being identified, involved and supported. CEG data shows only 34% of patients on the register have their carer details recorded

• People are enabled to receive their end of life care in the place of their choice. In the first year of the enhanced service only 16% of people on the register had their preferred place of care documented and 11% completion of the actual place of death. This means we currently have limited ability to determine the proportion of patients enabled to die in the place of their choice. An audit of 77 patients on the register showed that over half did not half their preferred place of care recorded. However of those who did, 58% were enabled to die where they chose to. In the vast majority of cases this was in a community setting. Only 30% died in hospital – half the norm.

• An audit of the use of the Out of Hours medication kit showed that it was accessed 6 times in 9 months. In each case the patient reported symptoms of pain and distress but no pain relieving medication was available in the patient’s home. Better proactive care planning should have ensured that patient’s medication was not allowed to run out. One patient had been discharged from hospital just the previous day, highlighting the role poor discharge planning may play in determining patient experience.

There is an explicit national objective to enable more people to die at home. Currently Tower Hamlets performs poorly against this criterion – only 18% of people achieved this in 2006, although this is a slight increase on the previous year (16%). The majority of people (just over 60%) die in a general hospital or geriatric hospital setting. Much of this may be driven by the tendency for older people in particular to have a series of unplanned admissions to hospital in their last year of life. In the last year we have seen an improvement in the number of days end of life care patients spent in hospital, however it is still too early to say whether this is part of a sustained downward trend.

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Year Total emergency bed days in last year of life

Total cost

2004/5 32,459 6,236,976 2005/6 30,305 6,247,727 2006/7 27,890 5,461,689

3.6.4 Priorities for the coming year

� Agree a Commissioning Plan for End of Life Care for 2008-2012, which addresses the weaknesses identified in the end of life care baseline review This will need to be backed by an investment fund.

� Participate in Marie Curie’s Delivering Choice Programme, to identify specific areas of redesign to support the shift of care from hospital to community.

� Roll out and sustain the Liverpool Care Pathway across community teams and inpatient areas at Mile End.

� To improve the quality and availability of information on local services to patients and their carers

� To address the inequalities in coverage of the Local Enhanced Service and implement a more robust data collection system to assess impact

� To support further education and training for generalist staff to build their competence and confidence to manage people at home and initiate ‘Preferred Place of Care’ discussions

� To support implementation of St Joseph’s Hospice Strategic Review, particularly extending support to people with non malignant conditions and people from BME communities.

� Develop the end of life care part of the COPD Pathway

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3.7 Self Care 3.7.1 The first priority for the self care programme was to establish a more effective system for commissioning self care support and making sure the systems were in place to attract and recruit participants. The success of this part of the programme is illustrated by the PCT exceeding its Local Area Agreement target. The priority has now shifted to looking at ways in which we can build on the recommendations of the Inequalities review and create more of a culture of support for self care. Our commitment from 2005/06 Our progress / outcomes in 2006/07 A PCT self care coordinator for LTC will be recruited by mid November. This role will act as a local champion for self care, as well as having operational responsibility for organising the tendering and contracting process, collating activity and evaluation data, quality assurance and ensuring there is active awareness raising and communication with the public and potential referrers

The Coordinator came into post as expected in November and played an important part in reviewing the tendering process for EPP, managing EPP providers and producing better quality information and publicity. The role has been changed to be more commissioning focused and the new post holder will be in place in January.

A specification for commissioned EPP courses will be completed by the end November and organisations will be invited to tender by January 2007, with service level agreements in place by March 2007.

A robust tendering process was developed with Procurement, which will be used again for the 08/09 process. Three local third sector providers were commissioned to deliver 35 courses – Social Action for Health will concentrate on delivering generic and chronic pain courses, with the main target group being BME communities ; The Expert Patient Programme Community Interest Company are providing a mix of generic courses and also launching a number of new, condition specific products for CHD, mental health, substance misuse and people with visual impairment. Positive Place will run sessions specifically aimed at people with AIDS and HIV. Contracting monitoring meetings are in place to monitor progress.

Exploring how new primary care mental health services and roles could improve self-management and patient support, especially in relation to managing the underlying anxiety experienced by a proportion of high intensity users

Three mental health courses have been commissioned, working closely with the community mental health team and local voluntary organisations such as MIND & BESIDE. The tutors will also make contact with practices to identify

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frequently attending patients who may benefit from this type of support. In addition, members of the Psychology service have provided mentoring support to the Diabetes service to develop skills such as motivational interviewing.

Strengthening engagement with the community link pharmacist, locality pharmacists and the Local Pharmaceutical Committee to raise awareness and increase referral to self care courses.

Some progress has been made and EPP providers have been urged to work with community and locality pharmacists to encourage referrals of patients known to have a long term conditions e.g. those attending for regular repeat medications. We will also invite Pharmacy representation onto a new Self Care and Healthy Lifestyles operational group.

Ensuring the core skills necessary for staff to support self care are identified and factored into education commissioning plans. At present e.g. smoking cessation, motivational interviewing and Cognitive Behaviour Therapy have all been highlighted as key as areas to target.

Suggestions for the key areas to target were fed into the education strategy. However, it is important that this is not just viewed in terms of commissioned education, but also includes work-based learning and mentoring. Developing this work further will be a major priority for next year.

Expanding the capacity for the voluntary sector to act as the main providers of self care by recruiting at least 6 further EPP tutors by the end of 2006.

All local providers have reported progress in recruiting new tutors, with particular successes in recruiting more men. It is hoped this may help to improve recruitment of men onto courses. Tutors who are mental heath service users have also been recruited to deliver the mental health courses.

Ensuring that self care is built in to care pathways as they are developed i.e. COPD, childhood and adult asthma, Heart Failure and chronic pain.

Enhanced service specifications include clear requirements to refer for rehabilitation, address smoking status and other risk factors. Of those pathways which have been completed the opportunities to refer to self care are also highlighted. A separate Neighbourhood Renewal Funding project is piloting asthma action plans to be discussed with patients as part of their regular reviews.

3.7.2 The Clinical Effectiveness Group, Queen Mary College, successfully bid to the Health Foundation’s Engaging Clinicians in Quality initiative. The 3 year

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project will use data gathered from the EMIS system used by GP practices to highlight opportunities to improve standards of care, including establishing triggers for referral to self care. 3.7.3 The Department of Health Inequalities review underlined the importance of having an effective strategy in place for addressing primary prevention (encouraging healthy behaviours in order to reduce the risk of developing a long term condition) and secondary prevention – equipping people with the information and support to manage an existing condition and reduce its’ impact on quality of life. A decision has been taken to merge these two pieces of work and create an integrated Commissioning strategy and Commissioning group for self-care and healthy lifestyles. This group will develop our commissioning approach, evaluating information on best practice, current activity, uptake and impact. The group will be informed by two sub-groups :

An operational group which will bring together staff involved in front line provision of self care advice and support such as health trainers, physiotherapists, EPP providers and specialist nurses. Its’ remit is to share information on what is happening in the borough, highlight what works in terms of publicity and recruitment strategies and advise the commissioning group on gaps in provision, information or skills. A patients group, formed of people who have experience of self care and are committed to sharing their expertise, acting as advocates for self care & healthy lifestyles programmes and obtaining grass roots feedback on the quality and accessibility of services.

3.7.4 Priorities for the coming year

� Establish the new integrated infrastructure for self care and healthy lifestyles and complete a commissioning strategy by end of March 2008.

� Complete and publish a directory of self care and healthy lifestyles programmes and ensure this is widely available in health and other settings.

� Commission an extra 5 EPP courses and change the balance so that no more than 50% are generic.

� Ensure the Local Area Agreement target for 795 participants completing a self care support programme is met.

� Extend the number of third sector organisations commissioned to provide self care and healthy lifestyles courses.

� Develop an in-house behavioural change consultancy which will act as a hub of training and mentoring expertise. The service will provide intensive support for teams or services wanting to develop skills in using techniques such Cognitive Behavioural Therapy, goal setting, and Motivational Interviewing. They will also develop training for wider groups of staff which can also be marketed beyond the PCT to partner organisations.

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� Hold a clinicians’ workshop to define good practice in supporting self care and develop a clinical engagement approach which will also support roll out of the CEG project.

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3.8 Older People 3.8.1. National data tends to support a general trend between increasing age and prevalence of long term conditions and therefore many of the groups targeted by our initiatives will be people aged 50 and over. Unlike many of the other work streams, work on Older People has tended to focus on the large, system and infrastructure changes needed to coordinate assessment and care. In this year’s report, we are flagging the need to expand this and look at the needs of a very specific group of elderly. Our commitment from 05/06

Our progress / outcomes for 06/07

Extending the single point of access to provide more streamlined access and assessment

A single point of access to all PCT Community Intermediate Care, Case Management and Rehabilitation Teams has been set up, and Link Age Plus have started to use the Single Assessment Process Basic and Contact Assessment to direct referrals to external agencies where required.

Improving outreach, discharge processes and follow up procedures

A group is being set up to review the Joint Discharge Policy used across the Partner agencies. The introduction of a new Consultant Physician role with an interest in Older People has led to further joint working with BLT, aimed at improving discharge pathways and streaming referrals to community services where this is possible. Future introduction of the Community Matron for Nursing Homes aims to improve proactive care planning and management for people who need to live in the most supportive community setting.

Avoiding preventable admissions through joint working

The Making the Breakthrough initiative described in the Introduction will initiate a project specifically to look at a defined group of people aged 70 and over who have a regular, repeat pattern of admissions. This is described in more detail in 3.8.2 Respiratory conditions have been highlighted as a particular cause of unplanned admission and re-admissions ; hence the decision to site the new Community Respiratory Team within the intermediate care service. Older people reaching the end of life are particularly vulnerable to unplanned admissions and therefore the end of life workstream will have a direct effect. The Bancroft Unit will be conducting a baseline audit of End of Life Care, and plan to pilot the Liverpool Care Pathway for appropriate patients in the coming year. Mainstreaming of the Case Management Service within the PCT is also important in helping support

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primary care and community colleagues by working with individuals in their own homes to improve their self management of long term conditions, supporting them with problem solving across a range of health and social issues which affect their lifestyle. Additional community matron and GP support for care homes has also been funded by the PCT. Both should support more anticipatory care planning and implementation of ‘Essence of Care’ basic nursing standards. Introduction of the new Consultant Physician with interest in older people post is supporting the work developed in the Older People Service Review of last year, to take forward discussion and development of new pathways of care and referrals between teams, aimed at reducing avoidable hospital admissions

Reviewing the effectiveness of our older people’s services and exploring the options for better working with housing, the mental health trust and voluntary sector

A Review of Continuing Care provision for older people has been taking place over the last year. Continuing Care is provided on 2 wards at Mile End-Shadwell Ward for people with physical frailties and Robinson Ward for people with mental health conditions, in a Nursing Home (Hawthorne Green) and at home. The review has provided a very useful forum to bring together staff from each of the different provisions to look at current practices. A consultation of staff and patients from each of the different areas has highlighted that the patients highly regard the care received at both wards at Mile End. The final report is due to be finalised by the end of October. The local authority reported in June 2006 on the Best Value Review of Sheltered Housing, which identifies 11 recommendations to improve the service, and ensure it is fit for the future. Recommendations include the development of a monthly user forum, reconfiguration of the Supporting People funding provision, improvement of activities and involvement of service users, and actions to ensure development of sheltered housing provision in the borough best meets the requirements of future service users. The local authority has nominated older person’s champions in key areas of service provision, and there is an identified Housing Champion. There are plans to invite PCT representation to the local authority sheltered housing forum.

Agreeing a menu of services and advice

Expert Patient Programme providers have actively made contact with Link Age Plus to explore the

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which may be provided through Link Age Plus Centres

potential for the centres to act as hubs of self care activity. A number of courses have been agreed for autumn 2007 and Spring 2008.

The Falls Management Team (FMT) has set up a pilot project at the Sundial Centre, which includes screening by outreach workers, assessments by the FMT Physiotherapist, Occupational Therapist and Nurse and the provision of appropriate intervention. Those assessed are directed into one of three pathways - low intensity exercise group (includes education program), high intensity exercise group and 1:1 home review/rehabilitation. The exercise component is continuous and provided by an exercise instructor, employed by the centre and provided with appropriate information by the Physiotherapist. The FMT provides the education component. Further plans include evaluation of this pilot, including reassessments at 7 weeks, 6 months and 12 months after commencing the program. Over the next 6 months an extensive needs analysis will be completed for the Bangladeshi population and a pilot project plan will be devised, working with Sonali Gardens

Data from the Link Age Centres shows that between October 2006 and the end of August 2007 nearly 800 health promotion events took place.

Maintaining the roll out of the electronic Single Assessment Process, with training and support for staff

E-SAP was deployed to 228 users last summer. An evaluation earlier this year identified a number of issues relating to how much the tool was embedded in everyday practice, which groups are priorities for assessment and how assessments are shared. In response SAP leads launched a series of improvements aimed at - resolving technical difficulties in using the electronic version - maintaining training and support, particularly in those areas with greater staff turnover - launching a phased introduction of new, more user friendly documentation ‘FACE’ . Tower Hamlets was also awarded Community and Mental Health ICT Team of the Year by eHealth Insider magazine for its SAP project. The judges particularly mentioned the strength of the partnership and involvement of older people in the decision-making. They also noted the pioneering work undertaken in the provision of smart-cards to social care staff, and the way in which a health system (eSAP) has been made accessible to social care

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staff.

Review potential models of service integration in the community, with a decision on the preferred model by end October 2006

The Integration Project is seeking to bring together teams and approaches to practice in two areas – Commissioning and Service Provision. The Commissioning aspects are moving ahead, with lead arrangements now in place for services such as mental health and learning disabilities. The process of bring together services is more complex and is therefore proceeding more slowly. The PCT and Borough have held a number of joint seminars for staff across the partner agencies, which have introduced the concepts of joint working and shared the early work of the integration board. There will be further joint events held as the model of care and project plan are rolled out. Learning Disability Services and Occupational Therapy Services already operate an integrated service model, so the newly integrated services will be able to learn from these examples as they implement changes. The practical aspects of working towards integration are described more fully in Section 3.10 on Workforce.

Develop the enhanced home care service and enable home carers to dispense medication, undertake skills in basic foot and pressure area care

A Steering Group meets every 3 months to oversee development of the service. In terms of staffing a number of changes have taken place to boost nursing, occupational therapy and administrative support to the team. A Medicines Policy has now been agreed by the PCT Medicines Committee. Implementation is subject to the Council agreeing a Single Status Agreement with the Trade Unions. Home Carers are currently prompting service users to take their medicines and but will be in a position to directly administer once this is resolved.

Recruit a telecare project manager and complete an options appraisal for the provision of services. Services will be commissioned in time for the 2007/8 and an interim evaluation will inform how the service is mainstreamed.

The project manager has been recruited and is coordinating a multi-agency project board of health, social care and housing. An options appraisal was completed and an agreement reached on the core set of telecare equipment to be purchased. Training has been rolled out to all adult social work teams as the initial priority and a second wave of training is planned for September. Triggers for assessment for telecare have been built into the single assessment process and PCT teams will be able to make a direct referral for telecare support. Nineteen referrals have been made and 9 installations of equipment have taken place. Work is ongoing with local sheltered housing teams to identify further people who may benefit from the technology.

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3.8.2 Key Data Demand for Care Tower Hamlets is generally known for being a young borough, but changes to the demographic structure of our population will mean that in the future we have a greater proportion of older people to provide care for. We expect a 25.5% increase in middle-aged adults aged 45-64 years by 2012 – although this group are not classed as elderly, they will ‘graduate’ and create a bulge of demand over the following 20 years. More immediate pressure is likely to come from a 21% increase in the numbers of people aged 85 years, the group with the highest health and social care needs. In addition, Tower Hamlets tends to have high numbers of older people who live alone – particularly in Mile End and Globe Town, St Dunstans and Stepney Green. This may mean that they are more likely to be dependent on services, rather than informal carers, for support.

Ward Name All people 65+ Pensioners living alone

% pensioners living alone

Bethnal Green North 11,764 1,207 577 48

Bethnal Green South 13,675 999 472 47

Blackwall and Cubitt Town 11,941 840 393 47

Bow East 8,797 1,177 590 50

Bow West 10,422 1,102 531 48

Bromley-by-Bow 11,581 927 421 45

East India and Lansbury 11,495 1,313 585 45

Limehouse 12,484 1,316 584 44

Mile End and Globe Town 11,801 1,494 735 49

Mile End East 11,137 958 440 46

Millwall 12,890 675 362 54

Shadwell 12,078 973 443 46

Spitalfields and Banglatown 8,383 610 266 44

St Dunstan's and Stepney Green 12,678 1,656 749 45

St Katherine's and Wapping 11,244 765 377 49

Weavers 11,686 1,396 671 48

Whitechapel 12,046 947 477 50

Tower Hamlets 196,102 18,355 8,673

3.8.3 Equity, Access and Quality The Department of Health National Support Team Inequalities Review suggested that the health economy needed to develop a strategy to more proactively identify and manage the needs of vulnerable elderly people, particularly those with increased risk of mortality in the winter period. An initial analysis of deaths by quarter shows that pneumonia is the only condition which shows peaks in the winter period and the numbers involved are relatively small per quarter. One method for identifying elderly people vulnerable to admission to hospital or institutional care is suggested in report produced by the NHS Institute for Innovation in 2006 – unplanned admission with a urinary tract infection (UTI). Between April 2005 and end March 2006, 132 people aged 70 or over were admitted with UTI i.e. approximately 2-3 unplanned admissions per week. The mean length of stay in an acute and any

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rehabilitation facility (a ‘superspell’) was 18 days. Approximately 18% went into an intermediate care facility or another NHS organisation after their hospital stay. Approximately 7% died in hospital, with a further 2% dying within a month of leaving hospital. Seventy five percent of the original group were discharged back to their usual place of residence but over 20% of the total discharge group were admitted as an emergency again within 28 days. Analysis of who these patients are at an individual level, shows that a large proportion have a repeated pattern of emergency admission which may stretch back over several years. The total cost of the admissions for this group between 2002 and 2006 was over £2m. Urinary tract infection may be used as the marker condition but these patients tend to have multiple problems such as Heart Disease, falls, chest infections, dementias and stroke. The two practices with the highest number of unplanned admissions were Jubilee Street (12.4%) and XX Place-Bromley by Bow (11.8%) Only 9 (just under 7%) were from a BME group. Only 11 (8%) were recorded on SWIFT (the social services database of clients) as already being in receipt of social care support. It is therefore likely that the majority of this group are managing with the support of only informal carers or may have no support structure around them at all. Fifty six percent had not had a single assessment undertaken, which would normally act as a gateway into services. Further investigation is needed to identify the reasons behind these issues and design an appropriate intervention – this will be the focus of our Making the Breakthrough Older People’s project for 2008/2009. 3.8.4 Priorities for the coming year

� Undertake a series of Discovery Interviews with frequently admitted older people to identify what is happening from their point of view by end of December 2007.

� Launch the Making the Breakthrough project by the end of December, with appropriate representation from the Older People’s Reference Group and define what a vulnerable elderly care pathway may look like.

� Define a set of criteria which could be used easily to identify people at greatest risk and pilot their use.

� Increase referrals for telecare support by NHS, social care and sheltered housing staff.

� Evaluate pilot of Falls Outreach provision to Link Age Plus sites, and identify resources required to continue and extend outreach services.

� Work with Acute trust and Primary Care to improve bone health and osteoporosis prevention in vulnerable groups after fractures.

� Roll out the new Community Matron role with specific responsibility for Care Homes and scope the potential for City University’s mobile training laboratory to provide ongoing support to care home staff.

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3.9 Urgent Care 3.9.1 The work stream has benefited from the support of the Urgent Care Network and has made considerable progress in understanding what drives demand for urgent care and designing a phased implementation for the new model of care. Our commitment from 2005/06

Our progress outcomes in 2006/07

Completion of urgent care strategy to support redesign of urgent care services

The Urgent Care Strategy has been completed and is awaiting final sign off at the January 2008 board. This strategy will develop a model of care that is easier to navigate by having fewer routes of entry. Patient needs will be assessed quickly, effectively and will be referred to the most appropriate service which could be in a hospital or increasingly, in the community. The four key aims are: 1. the patient will receive the right treatment, right place

and right time 2. costs will be met, financial risks identified and

reduced (value for money) 3. there will be less people using A&E (and hospital

based services) 4. there will be more self care and less reliance on

medical services Increased communication with the public on redesign of urgent care services

Dr Foster Intelligence was commissioned to analyse data on who uses our hospital A&E department and why. This information was used to produce a targeted campaign called Local Heroes. This campaign used 3 main communication methods to change the behaviour of those using A&E inappropriately. Two Urgent Care Events were held in 2006 to obtain local views on the experience of using urgent care services. The event informed us why some local residents choose A&E and some of the confusion regarding how a when to access urgent care services. This feedback was incorporated into the Urgent Care strategy. Six patient focus groups were organised to obtain local opinion on the proposed changes to urgent care in Tower Hamlets.

Patient groups in urgent care are difficult to sustain as users tend to be ad hoc, spontaneous and based all over the region. . One off events, focus groups and surveys are better methods to engage local people and users and this will be maintain at a continued high level of involvement through out the year.

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Developing Alternatives to A&E GP Appointments: Extended Hours

There are more appointments available to Tower Hamlets register patients at their local surgery with 28 out of 36 practices now offering extended hours beyond the tradition Monday-Friday day-time periods which creates an extra 654 appointments per week. Improving access to practices is a key target for the PCT. A scheme involving 10 practices was piloted in 2006 to make appointments available to A&E staff for patients who attend A&E but require primary care. A proposal to develop this scheme to all practices was supported by the Practice Based Commissioning Executive in May 2007.

Pharmacy First

More and more local people are using the Pharmacy First scheme for more conditions. At the start of 2007 24,000 people have registered (about 900 new people each month) and 3,500 are using the scheme each month. The scheme enables people to receive medical advice and medication from a pharmacist on conditions such as sore throat, diarrhoea, heartburn, back pain and cough.

Managing High Intensity Users

The purpose of the High Intensity User group (HIUG) is to identify people regularly using urgent care routes and coordinate the efforts of staff working with them. In November, the PCT is more than half way to meeting a target of 1088 people receiving 1-1 case management and care planning by April 2008.

3.9.2 Key Data Demand for Care The Local Heroes campaign resulted in a 6.4% decline in attendances at A&E at the Royal London Hospital between September and January 2006/07 compared with the same period in 2005/06. Also during the same period the two neighbouring hospitals reported an increase of 3.6% and 2.6%. At a more local level, the number of males aged 20-29 using two GP practices involved directly with the campaign by 8% and 16% respectively as a result of a direct mailing outlining alternatives to A&E. PCT data has also shown a steady increase in Pharmacy First consultations and the PCT is confident that the Local Heroes campaign contributed to this trend. Data indicates that over 60% of local residents using pharmacy first are Bengali. However in contrast only 11% of callers to NHS Direct (an over the phone medical advice service) are Bengali. This supports the need to review translating advocacy services in currently available in primary care. This may also impact on the development of an out of hours phone service. Equity and access

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The postcode of all attendance records were collated and mapped. The map below shows the by postcode sector

• Areas in red are those where the highest numbers of A&E attendees live. • Areas in white are those where average numbers of A&E attendees live. • Areas in blue are those where the lowest numbers of A&E attendees live.

It can be seen that there is a high concentration of attendees in the postcode sectors closest to the Royal London Hospital i.e Whitechapel, Mile End, Stepney and the southern edge of Bethnal Green (see map overleaf). Quality The PCT and BLT have met the 4 hour wait target in A&E in 2006/07. However, the challenge will be maintaining this level of performance, particularly in view of the large population growth forecast for the borough. The Out of Hours service is measured routinely against 13 National Quality Standards. These standards are being met although software is being developed to improve the measurement of all 13. The service receives a high regard from its users according to patient feedback, although many residents are unaware the service is available to them whenever their GP practice is closed. 3.9.3 Priorities for the coming year

� Continuation of urgent care service redesign. Phase 1 of the redesign is due to occur during 2007-2008. This work is now under way. The key deliverables are

o Establish Strategy Implementation group o Establish an Assessment Team in A&E. The first stage is an

audit planned for November looking at ‘front door’ streaming of patients in A&E. The data will help the PCT commission a new model for the new build in 2010

o Begin the process of developing Business Cases for four Urgent Care Centres which will provide a range of urgent care services at the Mile End site as well as referring patients on to the most appropriate alternative where necessary. The model being developed maximises integration with mental health, services and other community services.

o An Urgent Care Project Manager has been recruited and started in September 2007

� Tower Hamlets Urgent care strategy will be presented the urgent care

network board in January November 2008 for final sign off

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3.10 Workforce Development 3.10.1 Background One of the overall objectives of the Long Term Conditions strategy is to enable most routine care to be provided in the community. The workforce project was initiated as a joint provider-commissioner initiative to identify the changes which would need to be made in the community workforce in order to support this. Over the course of the last 12 months, it became clear that the original focus on role development and training would need to be broadened to include - developing a common understanding of case management across health and social care - embedding common assessment tools in practice and explicitly linking the assessment process to referral into health, local government or third sector services - creating live databases which map patients’ needs, update them regularly and share them appropriately - reaching agreement on the process for care planning and reviewing patients’ needs. The revised project is therefore now a major organisational development initiative, testing out approaches to integration, IT development and cultural change. 3.10.2 Developing a New Model of Care for People with Complex Needs Many patients with a long term condition will have stable conditions which can be managed through supported self care. In these instances, following a clear, evidence-based disease care pathway is the most appropriate model of management. However, at least 5% of our local Long Term Conditions population have more complex needs and would benefit from a system which proactively identifies them and allocates a case manager. The case manager is the patient’s first point of contact – they assess, care plan, make referrals and coordinate the input of a range of activities. The model of care for these patients is divided into 4 distinct stages (see page 66)

- Identifying Cases - Initiating Case Management - Care Assessment and Planning - Care Delivery and Review

In order to illustrate how the process might work in practice, we will use the example of an elderly patient with COPD, early-stage Dementia and a history of falls.

o The patient may be referred into the model either by a current care practitioner or by the hospital following an unplanned admission for a fall. Alternatively, a proactive search of GP practice disease registers and the social services ‘SWIFT’

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database identifies that the person has complex needs and would benefit from someone coordinating their care and triggers a referral – case finding.

o The referral information, which captures basic information on the

patient’s needs is used to determine the most appropriate case manager. This could be a community nurse, therapist, social worker or pharmacist for example. The name and contact details of the case manager is entered onto the patient’s record.

o The patient has a comprehensive assessment, which records

their social, clinical and psychological needs (see below). The information is captured on the EMIS-web system. Other professionals such as the person’s social worker, hospital consultant or falls clinic staff will be able to see important information about the patient’s history, circumstances, test results etc.

o The assessment leads to development of a care plan is produced which is also attached to the patient’s record. The case manager searches a central directory of services to identify any referrals which need to be made. Details of referrals or diagnostic tests ordered are entered into the patient record. For example a referral may be made to a ‘Healthy Moves’ physical activity session at a local Link Age Centre.

o The patient has an exacerbation of their COPD and is transferred to

hospital. The case manager activates the escalation protocol for the patient. A review identifies that the patient had been feeling unwell for a few days before the admission but wasn’t sure what to do. The case manager enlists the help of a locality pharmacist to talk the patient about the signs and symptoms which indicate their condition is worsening and the changes they need to make in their medication regime to alleviate them. The case manager then updates the care plan and checks the following week that the patient is now confident using their medicines and equipment. The case manager then liaises with the

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GP and district nursing team and meals on wheels to ensure that services are in place for when the patient returns home.

3.10.3 Priorities for the Coming Year 1. To spread awareness and understanding of the project amongst front line staff, managers and commissioners in order to achieve optimal engagement. 2. To agree and share the protocols which describe in detail how various elements of the project will work e.g. how to undertake case finding and clarify how these processes may differ from current practice. 3. Complete the service menu, building in other relevant work such as the directory of self care initiatives and end of life care directory. 4. Expand the capacity of the case management team in order to increase the number of patients benefiting from care coordination and to support general cultural changes in practices in the community workforce. 5. Hold consensus events to identify how bring together the generic model of case management with the development of disease specific care pathways. 6. Agree how information from individual patient needs assessments could be built up into detailed, locality-based profiles of need.

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4. Conclusions and Recommendations Overall, the programme is continuing to move ahead successfully and the core targets have either been met or are on track. In addition, the majority of the commitments made last year have been delivered. However, growth in our total population and in specific groups such as older elderly, will present further challenges. It is therefore important that the momentum we have created in the last 2 years is maintained - through robust performance management, redesign and investment. A list of key risks and our proposed actions to address then, plus a prioritised list of investment are given below. Key Risks Risk Actions to Mitigate Responsible Lead Failure to meet High Intensity Users target

Investment in case management functions within the community health and social care workforce Spreading learning from existing areas of strength through staff rotations, mentoring and training

Mabli Jones

Unquantified numbers of people with undiagnosed disease

Systematic use of Public Health tools designed to measure the gap between observed and expected prevalence Small area analysis of need e.g. through the LAP or locality structures Use of social marketing techniques to target people at risk and encourage them to present to services

Somen Banerjee

Significant gaps between the best and worst performing practices for QoF indicators

Maintenance of the targeted support visits to practices with poorest scores Robust use of prevalence and performance data to manage poorly performing practices

Douglas Russell Lucy Gittins

Lack of enhanced service coverage for some parts of the

Public health analysis of the implications of gaps in coverage Review how systems of inter-practice referral and enhanced service commissioning at network level may support more equitable

Somen Banerjee John Wardell

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population coverage Insufficient momentum behind the shift of services from hospital to community

Establish a systematic process for discussion of shifting care from hospital to the community Undertake more detailed analysis of demand and launch programme of rapid redesign events Implement Marie Curie methodology for End of Life Care

Andrew Ridley Sally Herne Sally Herne

Areas of Investment for 08/09 Priority Area Must Dos (recurrent unless indicated

otherwise) Second Level Priority (recurrent unless indicated otherwise)

CHD and Heart Failure Funding for dedicated BLT clinical sessions to develop the service model : 2 sessions a month for 1 year - £22k

Children’s Epilepsy Funding for community service £150-200k Funding for dedicated BLT clinical sessions to develop the service model : 1 session per month for 1 year - £11k

Respiratory Pick up of community pulmonary rehabilitation service (respiratory only) – approx £320k

Funding to support clinical engagement to help design the new model of care : 2 sessions a month for 1 year - £22k Expansion of Community Pulmonary Rehab to cover Heart Failure and intermittent claudication – additional £164k

End of Life Care Funding to support roll out of Marie Curie Delivering Choice methodology (18 months only)

Pilot lay networks for parents of children with life limiting conditions (2 year pilot) Develop capacity of community children’s

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Expansion of Clinical Psychology Support Expand specialist palliative care support for non cancer conditions Create Directory of End of Life Care Services (non recurrent) and ensure core literature is available for staff and families Commission training in use of ‘Preferred Place of Care’ (non-recurrent) Pick up Marie Curie funding for the specialist Palliative Care OT service Create a service level agreement with Great Ormond Street for symptom control support £500k

nursing team to provide respite at home Support roll out of Liverpool Care Pathway in the Community and at BLT (2 year funding) £200k

Self Care Develop in-house consultancy to enable staff to support behavioural change £180k

Commission an extra 5 Expert Patient Programme courses £20-25k

Workforce Commission additional case management capacity - £200k

TOTAL £1.4m £444k