Improving Primary Care for People with Learning Disabilities: The Greenwich Picture

1. Primary Care, Vision, People with Learning Disabilities and facing the Challenges ahead… The Greenwich Picture… Mark Bradley – Health Facilitation Coordinator - Greenwich Emma Brezan – Health Informatics Specialist

2. Note: • This is an ongoing project. • Presentation more a ‘Trailer’ than a ‘Premier Launch’. • Feedback useful. • Currently communicating with North East to align systems as closely as possible. • End product will be freely available.

3. The NHS London Project • NHS London invested in small project to improve systems in primary care services re: • Identification of people with learning disabilities and • appropriate cross referencing of chronic disease registers with learning disability registers.

4. We’ve got new tools for GPs… making it easier to do more health checks, gather more information, refer to the right services, highlight people’s needs and improve outcomes with better plans! Main Aims of Project: • ‘To develop a practical resource/ guide to raise awareness on how and why to embed these systems within primary care settings’. • ‘To strengthen the present Strategic Health Facilitation Network and have a London-wide conference to disseminate best practice and ensure that Health Facilitators are equipped with information to support primary care in developing systems to address health inequalities’.

5. Greenwich Picture… • Didn’t do well in the SAF – last year • No. of people known to Local Authority on LD Register = 806 • No. on QOF registers = 795 • Total Greenwich population 267,000+ • Estimated LD population = 4,000+ • Confusion still exists in some practices re: eligibility for DES (QOF Vs DES register) – GP Commissioning… future?? • Capacity for GP Contracting to performance manage DES very limited!

6. VISION Greenwich Picture/Challenges… • 44 Practice Groups. 4 Practices use EMIS LV, 40 use Vision. • 66 GP Practice sites in Greenwich. • 59 sites use Vision, 7 use EMIS LV. • EMIS LV practices currently converting to EMIS Web. • Main focus on Vision Practices. • 41 of 44 Practice Groups currently offering health checks.

7. Added Greenwich challenges… • % of practices engaged does not = lots of quality health checks completed? • Attendance rates poor – high DNAs. • Service user, carer and practice feedback conflicting in some cases (use of HAPs/books etc) • Tools that assist health checks not always valued by everyone (easy read Vs practice systems). • I.T. and system literacy in practices an issue. • Wider carer (paid/unpaid) support networks sceptical of new system etc… so many initiatives out there… • NHS Architecture – a mess!

8. What is this mess??? Key national priority to set up new health and social care architecture: Who ensures people with learning disability are included? Funding Accountability Other Parliament Version 0.5 DH Public Health England National NHS Commissioning Board NHS Trust Development Authority Monitor (economic regulator) CQC Health Education England NHS CB London Sector NHS TDA London Sector LETBs PHE London Sector Sector Joint licensing between Monitor and CQC Health & Wellbeing Boards (HWBs) Clinical Senates NHS CB Patch Teams Work together to ensure commissioner support for aspirant FTs contract Providers Commissioning Support Services Local Authorities (incl. Public Health) Clinical Commissioning Groups (CCGs) NHS Trusts FTs ‘Footprint’ / Local contract contract contract Accountability for results Local HealthWatch Patients and Public

9. Recent steps in the right direction • Refreshed Health Sub Group of LDPB • New TOR with advocacy input • Public Health support with detailed JSNA data from 28 of the 44 practices • Agreement with GP Contracting for Health Facilitation to Quality Check DES before payments are made • NHS London Project – getting the tools right for the job…

10. So….. • What’s this Vision tool like? • What does it do? • What is needed to get it up and running properly? • When can we start using it?

11. Step 1: Identification of People with learning disabilities • Relates to SAF Standard 1 (A1 & A4) = ‘LD and Downs QOF registers reflect local prevalence data (A1)’ and registers are annually validated (A4). • The tools being developed, like any tool, are only as good as those who use them! • Health Facilitation Role to regularly visit practices, develop a supportive rapport with clinical and administrative staff. • View on ‘bigger picture’ or ‘whole systems’ approach. – What’s the health check for? – The Person & their relationship to the population i.e. their needs are counted!

12. View from Informatics: Ensure patients are read coded with Severity code: Eu816 Mild learning disability Eu814 Moderate learning disability Eu815 Severe learning disability Eu817 Profound learning disability On LD register - 918e = On learning disability register. Question – Codes for DES registers?? Actual diagnosis – most do not have thorough psychometric testing. Coding Consistency/Challenge –Preparation is Key!

13. Step 2: Data Tidy for Recall Process (SAF A5 & A6) • Annual Health Checks and Health Action Plans need to be systematically linked (DES guidance). • Need to be mindful of local GP Vision system and guidance for it. • The toolkit will offer guidance on how to set up a recall protocol. Again, tool only as good as those who use it. Who gets ‘cleaned’?

14. Standard Recall ProtocolInformatics… As this is an annual Health Check, we must set up a standard recall protocol which should run as follows; • A recall must first be added into the patient record to include them into the recall protocol. (Screen shot on next slide) • Each time the patient is seen this recall date is updated to a new future date. • This is imperative as it is always the latest recall which is searched for. If the recall is not updated they will become overdue and start receiving letters when they have in fact been seen. • Each patient will get three invitation letters; after the third letter if they have not come in they will be removed from the recall protocol for that year. • This means that a recall date for the following year will be added to their records and they will then start to receive letters again the following year. • Those patients who have not come in despite your very best efforts will be exception reported using read code 9HL

15. Recall Protocol Flagging!

16. Recall Due Search DES Year Recall after Yr end

17. Step 3: Invitation Letters & Pre-Health Check • Need to agree local invitation letter – issue re: Easy Read Vs Practice desire to limit changes to established protocols. • Pre Health Check being adjusted to match flow of Vision & System One Guideline.

18. Not considered popular in GP practices

19. IT System generated letter.. Sent to Patient..

20. Step 4 – The Vision Guideline/Template • Usual Vision appearance: • Click to expand each section • E.g. ‘Measurements’ • Complete free text and ‘Advice’ Section for HAP HAP

21. Click to add BMI etc Look out for Action – ‘Advice about Weight’ etc.

22. Standard Format • Guideline follows same format that practice staff will be familiar with i.e. similar to QOF guidelines Expand each section to see last piece of information and allow adding Uses QOF codes where possible Follows Cardiff HC but will be aligned to system one. Guideline acts as an ‘Aide Memoir’ – fill all sections in

23. Each line expands…

24. HAP HAP

26. Discussions taking place about content and whether this should be completely or partially aligned to Cardiff 2?

27. Expanded

29. SAF A2 = Primary care ‘communication of LD status’ to other healthcare providers. System for Primary Care to communicate LD status to other services. This Vision Guideline produces referral forms for mainstream and specialist services. SAF A8 looks at wider primary care reasonable adjustments – this system helps identify those with learning disability being referred. – See Screen Shots… Step 5 – Referral Forms(Reasonably Adjusted) - SAF (A2 & A8)

32. Automatically populated form…

33. Health Action Planning

34. Step 7 – Other Health Care Professionals - report • In Greenwich we use Personal Health Profiles, issued by GP practices. • Any OHCP can look in the black book to find out past information. • Vision system will enable a print out of the health check info. • This can be ‘stuck in’, supplementing/replacing need for handwritten parts.

35. OHCP report Other health care professionals OHCP are often involved in the care of a patient with LD and will require up to date information. This report details findings from the annual health check.

36. Step 8 – Activity Searches / Reporting (SAF – A3, A5 & A7) • A3 = QOF disease areas (Obesity, Diabetes, CardioVascular Disease & Epilepsy), How are these managed in the LD population compared to the general population? • A5 = Reporting on No.s of health checks. • A7 = reporting on cervical, breast and bowel screening with exception reporting • Toolkit will give instructions on how to set up searches to meet these reporting standards

37. Step 9: Probity – (SAF A6)Checking the quality of AHCs including HAPs…

38. Probity • Example of a probity checklist for illustration….. • Points awarded for admin function and clinical quality of the HC. • Practice can then be scored; • Allows comparison between staff members delivering the HC to enable training requirements to be pin pointed • Can compare practice scores across patch • Payment awards/non payment easier to justify • This practice has been adopted by Greenwich PH for the Free NHS HC programme and has been received well by practices who see it as helpful.

39. Step 10: PilotIn Greenwich Practice(s) • Currently piloting solution in large Greenwich Practice with significant LD population with full administrative, IT and LD specialty Health Check support to enable us to ‘fine tune’ the approach.

40. Step 11: Training, Support, Installation and Sharing etc… • Quickest installation is via .exe file • Virus checker issues make web downloads on NHS servers difficult. • Can make freely available regionally via posted CD / Key Stick with loading instructions.

41. Further information - Finish • See Oxleas website: www.oxleas.nhs.uk • IHAL web pages – will request! (look at uploading .exe file there for practices to use)? • Guideline .pdfs can be made available. Can post on Oxleas website and NHFN web pages (need to be a member of NHFN!). • Any Questions????