Clinical Commissioning
Forum – Stakeholder
Engagement
Summary of Discussions
Tuesday 3rd September 2013
5.30 – 8.30 pm, Education Centre, Mile End Hospital
Long Term Conditions
What are the main challenges?
Hospitals telling
patients to get
oxygen cylinders
from GP for oxygen
prescriptions
Lack of education
of patient
population is a big
barrier in Tower
Hamlets
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. )
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.
Need holistic
personalised approach
to care planning. This
isn’t always happening
at the moment.
There is duplication between QOF and NIS
payments
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’
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.
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
Hospitals telling
patients to get
oxygen cylinders
from GP for
oxygen
prescriptions
Need a strategic
approach to
diabetes education
Need more children
friendly public spaces
Need to focus on
developing health
literacy projects as
level of health
literacy is poor in the
community
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,
Care packages too complicated
rationalise the payment structure, criteria
for the NISs. Providers to provide data
and evidence
Self care in GP
practices
Retinopathy walk in service at the diabetes
centre
Close Fried Chicken
Shops
Communicate what
is going on in this
work stream
Need more
coordination across
medical specialisms
so that patients are
not ‘passed around’
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.
Achieving Excellence in General
Practice
What does excellence in general practice mean to you?
Excellence should be a reflection of
the whole system – or at least this is
what is seen by the patient
(incorporated community and
secondary care services)
Polite and welcoming
reception staff
Good access to services
Supportive colleagues
Equality of access,
equity of service
Getting the right
appointment with the
right professional at the
right time
Trusted relationship with
Doctor
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
Patient education and self-management
• We can sometimes assume patients know more than
they do
• Many patients are not ready to take on a selfmanagement approach – they expect to be told what to
do by their Healthcare professional
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.
Population growth
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
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
Continuity of Care
• Noted as very important
to patients for some
conditions
Time with the Practice Team
• Need time for clinicians to
discuss their clinical practice
to ensure consistency and
continuity amongst them
Demand for services
Old fashioned and poor
business processes e.g.
the level of use of printing
and faxing
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
What are the potential solutions to addressing these barriers?
•
•
•
•
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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
•
Urgent Care
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
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.
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
Develop and implement marketing
campaigns with a positive message –
‘Your health is your responsibility’
Children and Young People
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’
Maternity
How can we address the challenges facing Maternity services in
Tower Hamlets?
Deskilling of community midwives in dealing with
mental health problems / high risk patients
Concerns about Gateway communication with
primary care, big gaps in care, high risk patients
being ‘lost’
Also MSLC should be promoted within practices –
one way for patient feedback
Possible use of KPIs / CQUIN for continuity of
community midwifery care
Possible use of dashboards for community
midwifery
Need for antenatal pathways to be reviewed – who
does what e.g. vitamins, injections were mentioned
here
Role for MSLC in promoting Barkantine?
Last Years of Life
What are the challenges in delivering good patient care?
Lack of awareness and promotion
of services for bereavement – is it
a gap in the services, esp.
Bangladeshi community / use of
voluntary sector is a hugely
untapped source
Inverse care law is very
stark here
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.
It’s hard to get information as a
patient that is non-medical. Current
approaches almost actively
discourage people who want to get
involved.
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)
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.
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.
WHFS – they have good links with the Somali and Bengali
communities. Helping to access and capture the family
stories and patient engagement opportunities
Is there any connection
between the services that
support people in later
years e.g. Link age plus.
Emotional support for
families and people
surrounding the dying.
Clear case approach
needed – frail and elderly
NIS will help with this
Need to build on the GSF
successes. Link in to leadership in
practices.
Professionals need help in
terms of homecare outreach
advocacy in people’s homes if
they want to die at home.
Supporting people to make
their own decisions and take
some control
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.
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.
Palliative care group MDT
that meets in general
practice is critical to
underpinning and
coordinating care.
Complex frail NIS sight
actively manage patients.
Empowering patients,
families and carers to
deal with the
uncertainty
surrounding last
months and days of
life
May benefit in getting
feedback from carers at
different times post
bereavement. Their views
and perspectives may be
different as they go through
their journey but all views
are valid.
Planned Care
What are the main challenges and how can they be addressed?
Referral 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
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.
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.
Patient journey
Separate services under CAG are an issuefeels 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
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)
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.