Clinical Commissioning Forum – Stakeholder Engagement Summary of Discussions Tuesday 3 rd September 2013

1. Clinical Commissioning Forum – Stakeholder Engagement Summary of Discussions Tuesday 3rd September 2013 5.30 – 8.30 pm, Education Centre, Mile End Hospital

2. Long Term Conditions

3. What are the main challenges? Hospitals telling patients to get oxygen cylinders from GP for oxygen prescriptions Diabetes care package does not cover Type 1 Diabetes Access into appropriate services for BME patients is an issue. GPs are gatekeepers of this but are often ‘holding on to’ patients by not referring them to specialists. (NB: Upon further discussion – it transpired that patients see the GP multiple times for the same ailments and are given the same treatment or a different medication without any explanation. This is frustrating for the patients as it’s viewed as lack of interest and understanding by the GP. The issue underlining this is the lack of communication by GP with patients on why they are prescribing some treatment and not others e.g. referral to specialist services. ) Need holistic personalised approach to care planning. This isn’t always happening at the moment. Lack of education of patient population is a big barrier in Tower Hamlets There is duplication between QOF and NIS payments What about patients who don’t fall into the integrated care cohort? Lack of coordination for these patients. These are the majority of the patients.

4. Preventing and Managing LTC Need to adopt the German model of universal vaccination for those with Hepatitis B. This can be done at the new patient check Need to focus on self care – encouraging patients to self manage. Use care plans more effectively and more frequent progress meetings between annual reviews to check progress. This should be part of the payment indicator for diabetes care package. ‘Greater incentive in care package for follow up goals’ Need more children friendly public spaces Close Fried Chicken Shops Increasing specialist input by Barts Health diabetic nurses into GP practices to reduce strain on practice. Network 2 have the largest diabetic population – skilling up existing nurses isn't going to provide adequate capacity. NHS health checks now also identifying new patients. The demand is increasing but the resource is decreasing, Improve the uptake of flu vaccination to manage COPD. Flu vaccination for staff is a must as they can potentially infect others they come into contact with through work. Incentivised staff target for this. Incentivise early vaccination for vulnerable groups such as frail and those in nursing homes. Ideally – we need universal flu vaccination for all. Need to focus on developing health literacy projects as level of health literacy is poor in the community Hospitals telling patients to get oxygen cylinders from GP for oxygen prescriptions Communicate what is going on in this work stream Care packages too complicated rationalise the payment structure, criteria for the NISs. Providers to provide data and evidence Need a strategic approach to diabetes education Care planning – can reviews with patients be done remotely to encourage patients to turn up to reviews and increase the number of reviews per patient Need more coordination across medical specialisms so that patients are not ‘passed around’ Self care in GP practices Retinopathy walk in service at the diabetes centre

5. Some local examples Social Action for Health – good moves Project with diabetes centre on healthy eating After school clubs for children where GP visits to provide education on healthy lifestyle – Network 2. Blithehale Practice has more data on this.

6. Achieving Excellence in General Practice

7. What does excellence in general practice mean to you? Excellence should be a reflection of the whole system – or at least this is what is seen by the patient (incorporated community and secondary care services) Good access to services Getting the right appointment with the right professional at the right time Polite and welcoming reception staff Supportive colleagues Equality of access, equity of service Trusted relationship with Doctor

8. What are the challenges and barriers in achieving excellence? • Coordinating care for patients with complex conditions: • We should be able to offer one appointment that will address all the conditions a patient has • IT systems need to support this coordination of care – particularly across agencies • Continuity of Care • Noted as very important to patients for some conditions Population growth • Patient education and self-management • We can sometimes assume patients know more than they do • Many patients are not ready to take on a self-management approach – they expect to be told what to do by their Healthcare professional • Workforce mix in the practice • It is not always clear to patients who is doing what in the practice team – this could be better communicated so patients know who they can book an appointment with • Time with the Practice Team • Need time for clinicians to discuss their clinical practice to ensure consistency and continuity amongst them • Access • Older people in particular reporting challenges in access • Concerns over the use of 0845 numbers – people think this will cost them a lot of money • Impacts on practices in terms of changes to access funding. Was felt that this has impacted practices offering good levels of access and therefore has had an impact on morale. Demand for services • Wasted appointment in General Practice • People could have used the pharmacist or self-care but default to a GP appointment • Patients are blocking primary care appointments with their secondary care issues Old fashioned and poor business processes e.g. the level of use of printing and faxing

9. What are the potential solutions to addressing these barriers? • Self-management • There needs to be a separate service that patients can be referred to that will support this – Doctors will not have the capacity to support patients in self-management • Provide more information to help patients navigate the practice system • Details of which professional to see • Notices for patients e.g. ‘put your repeat prescription requests in this box’ • National campaigns are needed to support patients in making the right choice about where they access their care – with the level of population churn in TH this cannot be driven locally. • This should be targeted and children and their parents – GPs reporting young people attending appointments with minor problems • Noted that this needs to be balanced with messages for patients to see their GP if they have symptoms that might be something more serious. • Access • Telephone triaging to manage access and continuity of care – there is not going to be additional funding put in through the primary care commissioning route • Focus needs to be therefore on developments that might attract funding from the integrated care funds or to maximise existing resources e.g. delivering flu vaccination in nursing homes, and getting staff vaccinated. • Quality improvement • There should be greater opportunities for the sharing of best practice across the Networks

10. What are the potential solutions to addressing these barriers? • Demand and capacity management • More staff are needed so that teams can deliver care better • This project should define the optimum levels of staff in general practice • Need to identify where the inefficiencies are in the system at the moment • Need to streamline our approach to managing long term conditions • Move away from disease specific clinics and specific long term condition pathways • Operate chronic disease clinics instead • Use IT to support this model – patient rather than a disease template (not available on EMIS web but could be advocated by practices) • Reduce levels of measurement and audit – move away from a prescribed model of what should happen to a local tailored model that supports local priorities e.g. make changes to the new patient health check • Exploit further use of IT for modernising and managing demand in General Practice • Skype consultations • Run some marketing events to encourage GPs to invest in new technology • Use peer support to learn about how best to use the new technology – learn and pass the knowledge on

11. Urgent Care

12. How can we encourage patients to stop using A&E services inappropriately? Practices should call every patient that attends A&E inappropriately – this has proved effective for St Katherine’s Dock, with patients responding well to the call/advice to visit primary care first in the future • Explore decommissioning of the walk-in centres, with a view to re-investing some of the funds in: • Improving primary care access • Developing a network / locality based same day appointment system Understand the top 3 reasons that mothers of <5s inappropriately attend A&E and develop a targeted education and training programme that is aligned to these. WHFS can support with this piece of work – sharon.hanooman@whfs.org.uk Enhance education, training and support for parents, particularly through the children’s centres Support patients to self-care / manage minor ailments e.g. encourage them to have flu jabs, keep first aid kit at home, etc. Develop and implement marketing campaigns with a positive message – ‘Your health is your responsibility’

13. Children and Young People

14. Children and Young People • Continuing Care • In terms of personal health budgets: • Use the learning from local authorities as they have been implementing personal budgets for some time • It will be important to strike a balance between patient choice and provider stability • Public Health • Concerns raised regarding capacity and quality of health visiting services in the borough • Further communication and engagement with practices is required around what they can do to increase Vitamin D uptake. • Community Engagement • Further Outreach Work is required to engage with children and families, particularly through collaborative working with the children’s centres and local schools. There are many examples of good practice across the borough: • Bromley by Bow minor ailment scheme • Blithehale after school club • St Paul’s Way School ‘Teach the Teachers’

15. Maternity

16. How can we address the challenges facing Maternity services in Tower Hamlets? Possible use of KPIs / CQUIN for continuity of community midwifery care Deskilling of community midwives in dealing with mental health problems / high risk patients Possible use of dashboards for community midwifery Concerns about Gateway communication with primary care, big gaps in care, high risk patients being ‘lost’ Need for antenatal pathways to be reviewed – who does what e.g. vitamins, injections were mentioned here Also MSLC should be promoted within practices – one way for patient feedback Role for MSLC in promoting Barkantine?

17. Last Years of Life

18. What are the challenges in delivering good patient care? Lack of awareness and promotion of services for bereavement – is it a gap in the services, esp. Bangladeshi community / use of voluntary sector is a hugely untapped source Can the role of primary care within the multi disciplinary care team be described and the coordinator role be clearly identified. Case management support to approach. Inverse care law is very stark here It’s hard to get information as a patient that is non-medical. Current approaches almost actively discourage people who want to get involved.

19. How can we address these challenges? A piece of work that needs to underpin this is to looking at professionals / behaviours and how they shape the system and therefore what the levers and incentives might be (financial, professional) WHFS – they have good links with the Somali and Bengali communities. Helping to access and capture the family stories and patient engagement opportunities Need to build on the GSF successes. Link in to leadership in practices. Is there any connection between the services that support people in later years e.g. Link age plus. Professionals need help in terms of homecare outreach advocacy in people’s homes if they want to die at home. Palliative care group MDT that meets in general practice is critical to underpinning and coordinating care. Complex frail NIS sight actively manage patients. Need an approach that cares holistically for the family as well as the frail or dying person. Support and information for carers. Better information for practices to support them to de-medicalise. Emotional support for families and people surrounding the dying. Clear case approach needed – frail and elderly NIS will help with this Supporting people to make their own decisions and take some control Empowering patients, families and carers to deal with the uncertainty surrounding last months and days of life Need to ensure use of churches as well as mosques and other places of worship for spreading and sharing of messages and information. Multi faith forum. Doctors can find it very difficult to talk about some of these issues, there is a generational issue. To do this work well is very rewarding but extremely time consuming. This needs to be recognised and resourced. Capabilities and competencies need to be high across all the groups that see the patient and family. May benefit in getting feedback from carers at different times post bereavement. Their views and perspectives may be different as they go through their journey but all views are valid. Need to ensure that vulnerable carers are identified earlier in the journey so they’re already linked to services that will be needed to support them after they’re bereaved. Some risk assessment is needed of those that might require the most intensive support and interventions.

20. Planned Care

21. What are the main challenges and how can they be addressed? Referral Process It was felt that the referral process to Barts Health outpatient services could be improved. Concerns were raised about the accuracy of referrals/ if they were being sent to the right department. It was agreed that Choose and Book(C&B) needs to be pushed (i.e. increasing the number of referrals via the C&B process). It was noted that not all services were on the C&B system. This could be improved by marketing and raising the profile of C&B with GPs , improving the ease of navigating the system and flagging the issue with Barts Health. The Planned Care Board will link in with the IT work stream and supported the introduction of Clinical Assessment services on C&B Patient Experience Patient experience was raised and the need for patients to understand the referral process. GPs also need to be clear of the referral process. We are working with GPs and Barts Health clinicians to improve some patient pathways (e.g. back pain pathway) and providing training and support for GPs. • Quality of Data • Improvements in data quality and cleaning of data required • Waiting times • Some improvements to the 18 week RTT (referral to treatment standards) • Patient journey • Separate services under CAG are an issue- feels like services are fragmented and less organisational responsibility. The work for the back pain pathway is involving different clinicians from different service areas/ speciality areas to agree the new pathway • Communication • Some improvement needed in letters/ discharge letters from Barts Health. GP needs to be clear/ understand what they need to do (i.e. simplify the process). For the re-procurement for direct access MRI we are looking at ensuring reporting imaging and quality is improved. IT Improvements needed on cerna system to improve accuracy of data/ completeness There was a general feeling that we needed to support Barts Health as it could not be allowed to fail.