Download Maternity Programme Board

NHS City and Hackney CCG Programme
Board Commissioning Intentions for
2016/17
City and Hackney CCG and
City of London Corporation
Commissioning Intentions Event
2016/17 Wednesday 24th of February 2016
12pm-2.30pm
The Bishopsgate Institute
Content
Children …………………….....
Maternity ………………………..
Long Term Conditions…………..
Integrated Care and Urgent Care
Primary Care Quality……………
Prescribing……………………….
Mental Health…………………….
Planned Care……………………..
Sustainability and Equality ……..
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9-15
16-19
20-25
26-31
32-39
40-47
48-53
54-58
Children’s Board Commissioning
Intentions 2016-2017
Children’s Services we commission
:
Homerton
Acute (hospital
based) services
Homerton Community Health
Services
Voluntary Sector
Community Paediatrics
Richard House Hospice
Occupational Therapy
(respite for Continuing Care and End of
Life)
Physiotherapy
KIDS Sunday club
Speech and Language Therapy
Audiology
Children’s Community Nursing: Generic
Children’s Community Nursing:
Complex Care
Hackney Ark – services for disabled
children
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Other Acute Hospital services
e.g Royal London and UCLH
(1:1 respite for disabled Children)
Huddleston Centre
(escort to and facilitation at leisure centre
for disabled children)
Tertiary / Specialist care
e.g Great Ormond Street
In addition the CCG Funds:
1) The HUHT ‘Hit Squad’, a team of
therapists who support disabled
children to access universal settings
2) The Designated Nurse Looked After
Children; this post sits within the
Looked After Children service
commissioned by Public Health
Hackney from the Whittington
Children’s Mental Health Services are commissioned by
the Mental Health Programme Board
Our plans for 2016/17
Service
Plan
What difference will this make
Early Years
Our plan is to identify families with medical, psychological and
social risk factors early and ensure they have high quality joined up
care, pre-conceptually through to school age and beyond.
• A consistent service offer, with improved quality of care for
our registered patients
• Vulnerable women and families’ needs are identified at an
earlier point, improving life expectancy and health outcomes
• Professionals have clear communication pathways to support
women and families, so their experience is of one care
pathway across different organisations
Our activities with providers will be:
•
Opportunistic preconception care
•
Targeted preconception care
•
Pregnancy presentation – structured appointment
•
16 week antenatal appointment
•
Pregnancy communication and liaison
•
6 week postnatal maternal appointment
•
6-7 week baby check appointment
•
Multi-agency meetings for 0-5 year olds
•
Safeguarding responsibilities for 0-18 year olds
•
Vulnerable children register and action plans for
0-5 year olds
•
Carers register for 0-18 year olds
•
16th Birthday information pack
We want to extend the scope of our Early Years work to:
1) Improve the links between GPs and children’s centres
2) Include the transition to school, and continued communication
with the family and relevant key professionals
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Our plans for 2016/17 continued
Service
Plan
What difference will this
make
Long Term Conditions
• Continue our primary care focus on asthma and diabetes
• Ensure all our children and young people with epilepsy have an agreed
care plan and access to local clinical support and advice
• Extend our offer of Personal Health Budgets to children with long
term conditions – make clear and transparent those who are eligible
for the pilot
• GPs and Homerton Consultants to work on delivering and reviewing
new guidelines / pathways for asthma and rheumatology, transition
from acute children’s to acute adults services
• Review of children and young people with LTCs attending A&E and
the provision available to them
• Children receive a service that meets their
need in the local community, with reduced
need to go to hospital
• Families know how to access advice and
support when they need it
• Care is personalised to the individual
• Children and their families are supported
to make the often big change from
children’s to adults’ services
Community Health
Services
• Review services to reflect new responsibilities / focus on integrated
care:
- Community Paediatrics
- Hackney Ark
- Occupational Therapy
• Continue to maximise the joint delivery of care though Hackney Ark
• Explore what community provision we need to reduce unnecessary
hospital activity
• Review the access all City and Hackney children have to community
services
• Improved health outcomes achieved
through:
- Care being delivered closer to home
- The scope and accessibility of services
being clear
- Early intervention based on identified need
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Our plans for 2016/17
Service
Plan
What difference will this make
SEND
• Work with education and social care to deliver Education and
Health Care Plans (EHCPs) that meet the needs of children and
young people and are co-produced with the child / young person
and family
• Review what is working well and what needs improvement,
leading to an action plan with the City
• Contribute to the City’s focus on transition preparation and
support
• Ensure all relevant health information is on the City Local Offer
website
• Bring the EHCP and Personal Health Budget (PHB) processes
together into one where best for families
• Children, young people and their families have joined up care,
and have a single process for accessing support and
information about local services
• The health pathways are clear for all children and young
people from 0-25; including for post 16s whether or not they
are eligible for adults’ services
Engagement
• Strengthen the engagement we have with existing young people’s
and parent / carer forums
• Agree an engagement strategy that applies to all children’s
services but does not marginalise children with disabilities
• The development and commissioning of services are informed
by the views of children, young people, and their families
• Families have confidence in our approach to engagement
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Patient and Public Involvement
What forms of engagement make most sense in the City?
We want to agree an engagement strategy with our Children’s Board PPI Representatives, informed by our
recent engagement work:
•
Children’s Disability Forum - current plans include:

Themed forum sessions – proposals include ADHD/learning difficulties/ Epilepsy/Autism and
Asperger's/Mental and Physical Health of Parents and Siblings; sessions are expected to be supported
by parent testimonies and professional advice

Discussion based open group Facebook page

Youth forum, working with creative arts organisations

Listening posts and feedback from other forums
•
“NHS Community Voices” meetings, including the “Education and Health Care Plan” meeting held in
January 2016; plans to hold a session for young people in the spring
•
Need to review SEND / EHCP pathways, to include transition to adults services
•
Early years - engagement via Children’s Centres –intended to support cross health and social care
engagement
•
Work with City Gateway- joining up our consultation and engagement work with established
forums well used by young people
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Maternity Programme Board
Commissioning Intentions 2016/17
City of London: Maternity Context
•
Approximately 110 women registered with a City GP (Neaman Practice) give birth
each year.
•
Approximately 60 women residing in the City of London give birth each year.
•
The vast majority of these women receive their maternity care from University
College London Hospitals (UCLH) – based in the London Borough of Camden /
Camden CCG.
•
UCLH Maternity service as at January 2014 was rated by CQC as overall safe,
caring, effective, responsive and well–led.
•
The main conclusions of the CQC inspection of maternity section showed that:
•
•
•
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Staff were caring, attentive and professional in their roles. The women felt confident with the care
provided. The wards were clean and safe and had good security measures in place to protect women
and their babies. Most of the women that we spoke to told us they had positive experiences with the
maternity care and felt confidence in the staff that cared for them.
Maternity services were being planned to meet the increasing demand by extending the number of
beds and recruiting more staff.
There was insufficient evidence that all staff learned from incidents and complaints. There was a
maternal death in the last year and it was unclear that the lessons learned from the incident had been
shared.
Midwives were well supported. The ratio of supervisors of midwives to midwives was 1:16.
Maternity patient surveys
•
CQC use national surveys to find out about the experiences of people who
receive care and treatment.
•
During the summer of 2015, a questionnaire was sent to all women who gave
birth in February 2015 (and January 2015 at smaller trusts).
•
Responses were received from 184 patients at University College London
Hospitals NHS Foundation Trust and 145 from Homerton.
•
The results from both Trusts are largely comparable to one another, including;
•
•
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labour and birth results were worse for both Trusts compared to most other Trusts,
Staffing and care results were about the same as most other Trusts.
More detailed information can be found at: http://www.cqc.org.uk/content/maternityservices-survey-2015
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Area of care
UCLH scores
Homerton scores
Labour & birth
8 / 10
8.3 / 10
Staff during labour & birth
8.4 / 10
8.3 / 10
Care in hospital after the birth
7.3 / 10
7.3 / 10
Local patient and public involvement
Maternity Service Liaison Committee (MSLC)
•
We have used short term funding to buy in voluntary sector support (Social Action for Health) to deliver
our maternity patient forum. The emphasis of their work has been on engaging new parents to hear their
view on services and helping parents to influence change. This work started in June and has so far
reached over 230 parents.
Walk the Patch
•
Our MSLC delivered a patient survey with over 70 brand new mothers and fathers on the Homerton
postnatal ward. The report recommendations are being taken forward in our commissioning intentions for
16/17 e.g.
•
Reviewing waits, triage and the environment for women in labour
•
Developing projects on advocacy and language support and on compassionate care
Involvement in tenders
•
Our PPI reps have been involved in the development and approval of various short term funded projects.
•
In addition the reps were panels members for the appraisal of expressions of interests received for the
MSLC and targeted antenatal class projects.
Maternity Programme Board
•
We continue to have MSLC patient representatives contributing at our board and now also have
feedback from Social Action for health on emerging patient feedback themes at every meeting.
•
We have also reviewed a thematic report on complaints at the Homerton and will be doing this annually
from now on.
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C&H Maternity plans for 2016/17
•
Improve pre-conception care for all women but particularly those with long term
conditions and those with several relevant health issues (co-morbidities).
•
Identify medical, mental health and social risks earlier in pregnancy - by GPs
delivering a new Early Years service that includes a dedicated appointment for
women to confirm their pregnancy and discuss their needs as early as possible.
•
Promote and monitor early booking with maternity services (by 10 weeks) to
improve outcomes of pregnancy, including timely screening.
•
Extend continuity of care (seeing the same midwife) into both the antenatal and
postnatal periods, to ensure women can develop and maintain a relationship with
their midwife.
•
Ensure we have high quality and safe maternity services; with the aim of
reducing neonatal and maternal mortality and severe ill health in light of maternal
deaths at the Homerton and the subsequent CQC inspections. This will be
achieved by monitoring performance, clinical audits, external review and
comparing outcomes to other hospitals.
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Our plans continued
•
Ensure women have a good experience of care throughout the pregnancy,
during labour and birth and after they’ve had their baby.
•
Ensure parents can help to shape and influence maternity services in City
and Hackney, by listening to patient’s feedback and having a strong patient
forum in place (Maternity Service Liaison Committee).
•
Improve the uptake of the flu and pertussis vaccinations in pregnant women
to help stop preventable maternal and infant deaths and severe ill health.
•
Increase the number of normal births through promoting use of the Homerton
birth centre (and home birth teams); emphasising that midwifery led settings are
the safest options for women with low risk pregnancies.
•
Identify vulnerable families earlier and ensure they experience a smooth
transition from maternity to early years services, with adequate support in place
where needed and input from primary care.
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Our plans continued
Joint Hackney Public Health & CCG Maternity Priorities
•Improve joint working between Midwives, GPs and Health Visitors
•Improve the uptake of healthy start vitamins in pregnant women and children.
•Reduce smoking in pregnancy and improve referral rates for women who smoke and want
support to stop.
City Priorities
Provide high quality services in the City to support maternal health, specifically:
•Provide high quality perinatal care in the City of London
•Assess and identify early maternal mental health concerns and offer subsequent support
•Ensure that services are available for any teenage pregnancies in the City of London
•All new births in the City are contacted by the Health Visitor
•Targeted support for women from low income households to promote good maternal health
•An annual birth characteristics report for the City of London
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Long Term Conditions Programme
Board Commissioning Intentions
2016/17
Last year you Said – We Did
Peer Support
Extra time
with GPs
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You Said
We did
“Support the supporters”
with training and
supervision
We have commissioned Hackney Centre for Voluntary
Services to provide central training, quality monitoring and
support to organisations delivering peer support groups
Provide condition specific
as well as generic peer
support
We are starting with diabetes peer support and focussing on
“hard to reach” communities, delivered by community
organisations. If successful we hope to roll the programme
out more widely
Use a range of community
venues
Groups will be delivered from a range of different
community venues
We need a longer
consultation when
diagnosed with a long
term condition
We commissioned “time to talk” extended GP consultations
for people with multiple conditions and extra time for
consultation for those newly diagnosed. In the Neaman
practice, there are 8860 registered patients, 401 patients
with 2 or more long term conditions and 80 “time to talk”
consultations have taken place so far (to Jan 2016).
Our plans for 2016/17
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•
Continue to commission GPs to deliver extra high quality care for people with long term conditions
including extra support and treatment targets such as blood pressure control
•
Continue work on our “virtual clinic” in conjunction with the renal team at Barts hospital for people with
renal disease to help identify them early and prevent progression to dialysis or transplant
•
Provide peer support for people with long term conditions including those with diabetes and the
orthodox Jewish community
•
Roll out the social prescribing service to all GP practices in City and Hackney to help tackle social
isolation
•
Move any patient with a learning disability or autism who is in a long stay hospital out into the
community, where it is safe to do so
•
Provide specialist rehabilitation programmes for those with specific conditions such as heart and lung
problems
•
Support people with sickle cell disease to live full lives with input from psychologists and social care
professionals
Patient and Public Involvement
Over the last year we have consulted with patients and the public in the following ways:
-
Patient representatives sit on our main Long Term Conditions programme board and many of
our condition specific sub boards
-
Engagement with the public at events including the CCG’s Annual General Meeting, Winter
Warmers and Self Care events on our plans and achievements and views on exercise
groups at GP practices
-
Discussions on specific areas such as heart failure services with healthwatch and the Older
People’s reference Group
-
Consultation with the CCG’s patient and public involvement on our plans and service
developments
-
Attendance at community voice events to discuss specific topic areas, such as sickle cell
disease
-
Review of patient experience surveys submitted by many of our services such as “time to
talk”; heart failure and sickle cell.
We plan to continue discussion via all these mechanisms in the year ahead
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Integrated Care and Urgent Care
Commissioning Intentions 2016/2017
What you asked for and what we have put in place for Urgent Care?
1.
You wanted - Better access for patients to see their GP for urgent care.
Our response.
1.
Duty Doctor service ( dedicated GP that takes urgent calls from patients and health care professionals during
working hours) are now open earlier and later during the weekdays and also some are open on Saturdays and
Sundays)
2.
Enhanced access service – most practices
3.
Non-clinical Navigators – based at the Homerton accident and emergency department give advice and signpost patients to register with their GP practices and also offer advice around other community based services
that patients can self-refer to rather than going to A&E or the Urgent Care Centre
4.
Primary urgent care centre – situated at A&E and is a GP led service for urgent illnesses that can be treated by
GP’s and nurses.
5.
Out of Hours services
2. You Wanted - Better response to patients suffering from crisis at home
Our response.
1.
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ParaDoc service – a GP will go to the patients home when they are in a crisis and help them so that they don’t
need to go to A&E.
What you asked for and what we have put in place for Urgent Care?
3. You wanted – Improved pathways of care to enable services to work together
better in the community – better coordinated care
Our response.
1.
2.
3.
4.
5.
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One Hackney & City – lots of different health care professionals working together to help
patients receive better care that is joined up
Integrated Independent team – A range of services, including rapid response,
intermediate care rehabilitation and home-care reablement.
Frail Home visiting service run by your GP practices for patients that are housebound and
need more coordinated care.
More GP’s in the emergency department
Social care workers in hospital departments to help patients over 75 that have been
admitted to hospital to get back home as soon as possible and prevent delays in
discharge.
What we want to do in 2016/2017 for Urgent Care
Better Access to GP’s
Monitor and develop: Duty doctor, Enhanced access, Out of hours services
To communicate more with community pharmacists so they can help shape the Urgent Care
Strategy and are fully informed on what services are available so patients can be given the right
information whilst in the pharmacy.
Continue to explore more opportunities for working across the new urgent and emergency care
networks that have evolved from NHS England, to ensure patient are seen in the right place at the
right time by the right clinician.
Maintain the Primary Urgent Care Centre as a service for patients with urgent care needs so they
can be treated by primary care clinicians
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What we want to do in 2016/2017 for Urgent Care
Better response for patients suffering a crisis at home.
•Support the delivery of the newly developed ParaDoc pathway to ensure complex, frail and elderly patients are treated at home
when appropriate to do so .
•Work with other borough commissioners to ensure the Local Ambulance Service (LAS) performance continues to improve for its
urgent and emergency/Red1 cases
•Engage LAS with continued work to refer into City and Hackney’s community crisis response pathways
•Ensure on-going referrals to the newly developed ParaDoc pathway, to improve experience for patients with complex health needs
•Continue to support the delivery of the Integrated Independence team and its links with urgent care access points, ensuring patients
are treated by the right clinician when in crisis
•Monitor the delivery of the action plan to engage care homes and housing with care schemes with the overall crisis response
pathway
•Continue to work with our patient groups and patient representatives to raise awareness around the right care at the right time
every time including self care, primary care and urgent and emergency care when in crisis
In addition we also want to improve Secondary Care by;
•Continuing to work with the local hospital to ensure the A&E department continues to meet the 4hr performance target
•Explore opportunities to develop outpatient services in the emergency department and look at new models that will improve the
patient journey, experience and outcomes
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What we want to do in 2016/2017 for Integrated Care
Pathways of care to enable services to work together better in the community coordinated care.
We will continue to develop and support ;
• Patient wishes captured in their care plan – care plan shared across all services electronically (if patient consents)
• One access number to co-ordinate crisis services across health and social care
• Practice MDTs co-ordinate care, supported by a new co-ordinator role
• Quadrant working to ensure quality
In addition we want to be able to offer better access to end of life services for patients so that:
•Patients will be identified as approaching end of life where appropriate
•Patients will be supported to express their wishes about care at end of life (these shared where appropriate) and supported
to die in the place of their choice
•There will be better communication between secondary and primary care about prognosis and conversations about this
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Primary Care Quality Programme Board
Commissioning Intentions 2016/17
Commissioning Primary Care Services
 In City & Hackney, NHS England is responsible for the commissioning of
core Primary Care services
 The CCG can fund GP practices to improve the quality of existing primary
care services provided that:
 the improvement can be expected to improve wider outcomes for
the CCG’s population; and
 the area team agrees it is over and above what it would expect a
GP practice to provide under its existing GP contract.
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Improving Quality in Primary Care
Clinical Commissioning & Engagement Contract

The objective of this contract is to improve the quality of primary care and to ensure that
effective and high quality services are consistent throughout City and Hackney.

This is done by giving GP Practices clear standards and quality requirements as well as
supporting them through sharing good practice and evidence about what care works best
for patients.

There are 20 domains in which practices are required to adopt certain best practice
behaviours and carry out pieces of work, including:

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In-house discussions of non-urgent referrals
Attendance to education sessions
Recording of duty of candour issues
Reviews of referral activity
Audits of care pathways

Historically, this contract has contributed to lower than London average referral rates to
secondary care which means that more investment has been able to be made in primary
care/community services – this directly impacts patients in that they are able to benefit
from services closer to home and in community settings.

The contract has been in operation over the past 5 year. We plan to recommission this
contract in 2016/17.
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What else do we plan to do in 2016/17?

GP IT - support practices to run efficiently through effective IT support. We will
commission services from NELCSU for:

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IT support staff costs (NELCSU)
Helpdesk and engineers (IT support)
GP Systems of Choice (EMIS, Vision)
Project management (National IT programmes)
Management and reporting on IT service
Strategic management support
Asset management, IT procurement, software licensing
Overheads (e.g. hardware upgrades, servers, printers, network security)

Commission support from the Clinical Effectiveness Group - support clinical
improvements in primary care through working with CEG to translate new
initiatives and research on quality and clinical excellence into general practice in
City & Hackney

Quality dashboard – continue to develop and update the primary care quality
dashboard to allow identification of areas where practices may need additional
support
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Primary Care Strategy
This year, the Primary Care Quality Board has worked to develop a strategy for
Primary Care in City & Hackney for the next 1-3 years. Following extensive
consultation with our patients and the public, our members, and local stakeholder
organisations, the strategy sets out that these are the aims we want to achieve for
City and Hackney:
 Be in the top 5 CCGs in London in terms of quality
 Be an attractive place to work for existing and new primary care staff
 Delivery of safe services
 Services that are resilient by being productive, efficient, safe and value for money
 Services that are the first port of call for highly quality, comprehensive patient support
 Services that are accessible
 Reduce health inequalities
In 2016/17 we plan to work in partnership with local stakeholders towards
delivering the outcomes in line with the Primary Care Strategy.
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Key Questions

How can patients contribute towards the quality and sustainability of primary
care?

How can we communicate to the public that primary care in C&H is (generally)
good?
What are your thoughts on:

Saturday morning opening / 7 day opening

Booking appointments online

Electronic consultations

Ordering prescriptions online

Are there other priorities
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Prescribing Programme Board
Commissioning Intentions 2016/17
You Said – We Did
You Said
Medicines review should be provided e.g. through lunch clubs, Older
Peoples Reference groups
Dr’s should explain the side effects of drugs.
Some patients feel they get given meds they don’t take as they should
Patients should be able to ask their Pharmacists what they can expect
from their drugs – 10 minutes with the Dr is not enough to find out about
their meds
Need more information on- drugs that must NOT be stopped suddenly
and need to gradual tapering off and also more info on drugs that need
step wise loading
Medication R/v dates- Patients don’t understand this very well;
Those on many drugs – have problems with having to request various
medicines at different times – as they all run out at different times –
need system to try and ensure patient doesn’t have to make repeated
trips to order different meds
Patients want to have warfarin testing done at their GP surgery or their
community pharmacy. They do not want to test their own blood or
change warfarin dose. There are unacceptable waiting times at HUHFT of
typically 2-3hrs but up to 4hours
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We did
Much of the feedback we received points to need to help support patients
in how to take their medicines
From January 2016, we have started to pilot a Domiciliary Medication
Review Service. We plan to expand this pilot from the SW Quadrant of the
CCG
Working with practices to encourage medication review
We have also continued to provide a respiratory pharmacist specialist
medication review to support those with asthma and COPD (Chronic
Obstructive Pulmonary Disease) to make better use of their inhalers and
other medicines
We plan to work with practices regarding training for non-clinical practice
staff on the management of repeat prescriptions. We hope if agreed, the
Training Programme will include how non-clinical staff can support patients
with advice on repeat prescribing systems.
NHS City and Hackney CCG is undertaking a tendering exercise to identify a
provider for a new Consultant led Community Warfarin Service in 2016. The
new Community Warfarin Service will be a comprehensive, community
based, consultant led service for patients on warfarin and will aim to
provide a more convenient service, as close to patients’ homes as is
appropriate, with reduced patient waiting times.
Reducing Antimicrobial Resistance
Why
• Antibiotic resistance is driven by over-using antibiotics and prescribing them inappropriately. Keeping levels of
antibacterial prescribing low, by only prescribing antibiotics when appropriate, will help reduce the spread of the
antibacterial resistance that can be a serious threat to patients who have infections that do not respond to
antimicrobial drugs.
Why?
• Broad spectrum antibiotics need to be reserved to treat resistant disease and should generally be used only when
standard antibiotics are ineffective.
• In 2015/16, NHS England set targets for CCGs to improve their antibiotic prescribing in primary care by:
• Reducing the number of antibiotics prescribed in primary care
• Reducing the proportion of broad spectrum antibiotics prescribed in primary care by 10%, or to be below
11.3%
• Identified as a clinical priority in NHS Planning Guidance for Delivering the 5year Forward View
Proposed Service Change
The Prescribing Programme Board will lead on this crucial Public Health issue through
• Development of patient posters & leaflets promoting antimicrobial awareness in those languages most commonly
spoken & read across C&H
• Requirement for Practices to undertake 2 sets of Audits to show appropriateness/ prudence of antimicrobial
prescribing
• Supporting GP antimicrobial awareness education events & provision of training tools
• Encouraging practices to reduce range & volume of antibiotic prescribing in line with national requirements
• Recruiting a GP Antimicrobial lead to champion this workstream
• Developing with Homerton Hospital, local antimicrobial guidelines
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Prescribing for Learning & Disabilities
Why



•
In December 2012, the Department of Health (DH) publication “Transforming Care: A national response to
Winterbourne View Hospital” highlighted concerns on the over-use of antipsychotic and antidepressant medicines and
subsequently commissioned 3 pieces of work to be undertaken by Care Quality Commission (CQC) , Public Health
England (PHE) and NHS Improving Quality (NHSIQ)
Why?
Following the publishing of these 3 reports, NHS England issued a letter in July 2015 to healthcare professionals calling
for rapid & sustained action to be taken in order to tackle the over-prescribing of psychotropic drugs to people with
learning disabilities after three separate reports highlighted the need for change.
In response to these findings, NHS England recommended that:
o Healthcare professionals caring for people with learning disabilities assess and keep under review the medicines
requirements for each individual to determine the best course of action for that patient, taking into account the
views of the person wherever possible and their family and/or carer(s).
o Services should have systems and policies in place for that patient to ensure that this is done safely and in a
timely manner and should carry out regular audits of medication prescribing and management, involving
pharmacists, doctors and nurses.
This is In line with the National Must-Do’s for 2016-17 in the Planning Guidance for Delivering the Forward View
Proposed Service Change
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A learning and disability audit would be undertaken by Practices to assess whether information relating to patient’s level
of challenging behaviour, capacity to make decisions about their psychotropic medication and medication review have
been recorded.
•
The learning and disability audit will:
o
Identify areas in which record keeping needs to be improved in order to determine the best course of
action for that patient, taking into account the views of the person family and/or carer(s).
o
Identify how to improve the management of prescribing medications in this group of patients.
o
strengthen integrated pathways of care.
Domiciliary Medication Reviews
Why
•
•
•
•
Patients/public have given feedback that more time is required to discuss their medicines and also medicines
wastage needs to be reduced.
A recent medicines review survey found that 83% of patients said that there was a need for more support to help
manage their medicines better.
GPs have highlighted problems with medication use (including oversupply of medicines).
Findings from other areas in London who provide domiciliary medication reviews have shown positive results such
as reduced acute hospital admissions and subsequent potential cost savings
Proposed Service Change
• To provide a City and Hackney wide Domiciliary Medication Review (DMR) service by clinical pharmacists, ensuring
there is an extensive medication review using patient records, evidence based guidelines and assessments of how
medicines are used. This service will help vulnerable patients get the best out of their medicines
• To extend this to practice based clinics for patients who are able to come to practices
• To work with Practice Support Pharmacists in increasing the number of medication reviews
Proposed Implementation
The pilot DMR service started in January 2016 and will finish in March 2016. Two DMR pharmacists work closely with
GPs, Community Matrons and PSPs to identify and provide support to the following high risk vulnerable patients:
•
•
•
Patients who have frequent hospital admissions
Patients on complicated medication regimens
Patients on ‘high risk’ medicines (e.g. warfarin, digoxin, antipsychotics, opioids, antihypertensives, injectable or
medicines via feeding tubes, medicines requiring extensive monitoring)
Post review recommendations are discussed with patients and their GP. To ensure integrated care, other healthcare
professionals are contacted if needed (e.g. social care, specialist nurses, community pharmacists) with the patients
3consent.
6
Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
Why
• Disease-Modifying Anti-Rheumatic Drugs (DMARDs) are a group of medicines that are used to treat rheumatoid
arthritis. They are also used to treat other conditions such as chronic inflammatory skin or bowel disease.
Why?monitoring as they can cause side-effects which can be serious therefore patients are
• DMARDs require regular
required to have regular blood tests.
• DMARDs have now been around for a number of years and there are an increasing number of patients being
prescribed DMARDs. Currently, many patients continue to receive routine monitoring in the hospital which may
be inconvenient for patients as prescribing is carried out by their GPs.
• By enabling GP’s to carry out both prescribing and monitoring in the community, this would reduce the need for
patients to have one set of appointments with GPs for their prescriptions and another set of appointments at a
hospital for the monitoring of the drugs prescribed.
Proposed Service Change
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7
• The aim is to review the options for a community based DMARD monitoring service for clinically appropriate
patients prescribed a DMARD who have been stabilised in secondary care
• The review will involve working collaboratively with secondary care and primary care colleagues and aims to look
at the following:
• improved patient access offering a more convenient service, with care offered closer to home and with
reduced waiting times
• strengthened integrated pathway of care
• This review will be used to inform the CCG and determine a business model for 2017/18
Consultant Led Community Warfarin Service
Why
• Currently, patients continue to receive routine care in the hospital and do not have equitable access to
community based warfarin services
• The current mechanism for warfarin service provision could be more cost effective
Proposed Service Change
• The new Community Warfarin Service will be a comprehensive, community based, consultant led service for
patients on warfarin
• The new Community Warfarin Service will be delivered to all appropriate patients registered with GP
practices in NHS City and Hackney CCG and will ensure equitable access and quality of service to the entire
population group
• The overall aims of the service are to improve patient access to safe and effective warfarin initiation and
monitoring by providing a more convenient service, as close to patients’ homes as is appropriate, with
reduced patient waiting times
Proposed Implementation
• NHS City and Hackney CCG is undertaking a tendering exercise to identify a provider for a new Consultant
led Community Warfarin Service
• The new service is anticipated to start in autumn 2016
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8
Patient and Public Involvement
The topic of medication reviews was presented & discussed at July 2015 Patient & Public
Involvement Committee & also at the Older People's Reference Group (OPRG) in August
2015. The representatives of both groups were supportive of the concept of medication
reviews and a patient & public engagement plan on the proposed service has been
developed which includes:
Articles for newsletters for Healthwatch City and Healthwatch Hackney.
Patient survey using paper forms and Survey Monkey.
Presentations to local groups to obtain feedback, e.g. 50+; Community Voice and Barbican
Tuesday Club
Stalls at the annual conferences for Healthwatch City, OPRG and Hackney Homes winter event.
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Mental Health Programme Board
Commissioning Intentions 2016/17
Mental Health - Life in City &Hackney…Starting off well
MHPB Commissioning Intentions 16/17 We will…
Impact
Coordinate improvements to Perinatal Mental Health services
• Emphasising the importance of perinatal mental health in early years
development and establishing better links with parenting/children’s centre
• Introduce evidence-based Parent-Infant Psychotherapy work as part of early
years transformation.
• Support parents with premature babies to prevent future mental health
problems and deliver better pre-conceptual care through early identification of
women at risk through pre-conception clinics and Edinburgh screening
• Work with the Children’s programme board to promote Mental Health in
Antenatal classes and develop Homerton hospital as perinatal mental health
friendly.
Vulnerable parents are identified and supported early on
to ensure mental health and well-being of family is
considered.
Launch an Autism Assessment service in City and Hackney as part of the
borough wide Autism Strategy
with a focus on ensuring effective transition and support provision across schools
and the local authority.
Children with an ASD diagnosis and their families
will have recommendations from the assessment
service and formal link to SEND plans and school
pathways
Reducing potential developments of mental health
problems in children.
Principles of emotional well-being embedded early on
through ante-natal class.
Adults with an ASD diagnosis will have access to
support provision and a specialist assessment
service which can advocate for needs of this group
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Mental Health…Living healthy and Staying Well
MHPB Commissioning Intentions 16/17
We will…
Impact
Improve communication on physical health monitoring between primary and
secondary care
Promote the importance of prevention in supporting mental health and well-being
and embed these principles across all care pathways
for example:
- depression screening for diabetic template in Primary Care,
- MH component of young person’s health check offer in primary care,
- 5 To Thrive well-being reminder in Recovery Care Plans
- Antipsychotic drug monitoring
Use existing resources and universal public services to anticipate deteriorating
mental health and promote wellbeing to:
ensure that all local public services promote positive mental health, support those with
mental health needs
Greater recognition of importance of both physical
and mental health
Social resources and networks are in place and
recognised to support local people at transition
points in residents’ lives (for example, moving
house, having a child, losing work, bereavement)
Availability of transferable resources on promoting
City and Hackney 5 To Thrive – the five ways of
well-being for use across health services,
community groups, schools, Primary care
Work with Providers to consider community-based assets and provision that can
provide innovative and / or holistic support to local MH service users
Statutory sector services delivered from more
accessible, less stigmatised community based
locations eg libraries
Develop a coordinated and consistent approach to Peer Mentoring / support
programmes as early intervention
Improved mental health resilience in young
people
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Mental Health Getting help and support when you need it…
MHPB Commissioning Intentions 16/17
Impact
Establish coordinated employment support for with specific focus on recovering from ill-mental health
Through the IPS Model (Individual Placement Scheme) for residents with a severe and/or enduring mental illness
co-ordinated through Ways into Work. Lead the 8 borough European Social Fund initiative to procure
employment support for people with mental health needs in City & Hackney, as part of an East London-wide
project and ensure outcomes monitoring in supported living on access to education, training and employment
People recovering from ill-mental health have better access to a
more coordinated employment support offer
Ensure all local Mental health services are developed in a coordinated way whereby services understand
all components and models behind mental health service delivery
Alliance working across services with cross-cutting pathways
Single point of entry for ease of referral and access
Develop a system for Service User Involvement and participation
in local commissioning and service design
Community groups are adequately represented in participation
activities
This is across demographics, seldom heard groups, BME
communities
Ensure culturally sensitive, relevant and inclusive provision
Services are designed with local people in mind, therefore
increased likelihood of access and continued engagement
Support development of coordinated, recovery focused rehabilitation accommodation and implement
mental health accommodation review
Ensuring a recovery-based model of support, enabling Clients to take ownership of their lives and supporting
social recovery.
Commission a framework agreement for spot placements for mental health supported living
Clearer pathway into housing with support in City & Hackney,
avoiding the need to move into residential care. Review and
update the pathway to ensure access and throughput based on
assessed need: Customer journey pathway: improving
information (knowing what is available) and access, enabling
smooth discharge, links with home treatment and assertive
outreach, dual diagnosis, case tracking
The mental health supported living services are key preventative services enabling people to establish and
maintain independent living and prevent or delay the need for costlier care interventions e.g. directly contributing
to reduction in demand for residential care.
Improved preventative housing and advice service helping
people to maintain or achieve independence
Develop local support provision for people with personality disorders
Crisis café evening support open to all (i.e. no eligibility criteria), mainstream SUN group projects and integrate
PD pathways and have more primary care focus / education and in the longer term, in order to continue reducing
PD related admissions
Recommission crisis services across CH and include psychiatric liaison in HUH and develop a small pilot
in paediatric mental health liaison to assess need.
Residents receiving quick timely support for their needs.
Mental Health - Supporting the later years…
MHPB Commissioning Intentions 16/17
Ensure a sustainable, holistic approach to dementia support and care
The Dementia Alliance will ensure improved outcomes for people with dementia and their carers by ensuring an
holistic approach to assessment and effective co-ordination of care and support. The Alliance will continue to
promote awareness of dementia and to support the development of dementia friendly communities and
environments e.g. by piloting dementia friendly swimming and working with local businesses.
Improve hospital discharge processes and community based support
Priority will be given to improving hospital discharge processes by supporting GPs and providers to improve care
coordination through One City & Hackney and the Dementia Alliance, and by improving access to accommodation
Impact
The experience and outcomes
for people with dementia and
their families living in City &
Hackney will be positive and will
continue to improve.
The needs of people with
dementia and their carers and
families will be identified and
addressed in a person centred,
personalised way.
Develop effective systems for information sharing between practitioners
Short and medium term strategies will be agreed and implemented by commissioners and providers to ensure that
IT and other systems support appropriate and effective information sharing between practitioners.
Improve carer assessment and support
Following implementation of the Care Act, 2014, more work will be done to ensure that all carers are offered an
assessment of their needs, and that the help to which they are entitled is provided. Commissioners will work with
carers and provider partners to develop a workplan with targets and milestones. The carer’s information pack
provided when someone is admitted to hospital will be promoted.
Improve access to information, advice, signposting and guidance
A co-ordinated approach to providing information about dementia services to City & Hackney residents will be
developed across the dementia care system. All providers will be asked to provide up-to-date and accessible
information about their services. We will work to increase the % of older people using psychological therapies (incl.
digital services)
Ensure that services are fit for purpose in the future
Commissioners and the Dementia Alliance will refresh the City & Hackney Dementia Strategy working in partnership
with other providers and people with dementia and their carers in order to improve outcomes from care and support
and meet the needs of the increasing number of people with dementia in City & Hackney to be met
44
People with dementia will be
supported to live at home and to
be active members of their
families and communities for as
long as possible.
Treatment and support will be
well co-ordinated and
responsive.
Crises will be prevented
wherever possible; the
necessary support and care will
be available when they do occur
with emergency hospital
admissions minimised.
Best use will be made of
available resources.
Mental Health - You Said – We Did
CAMHS: Need wider access and support
for young people and extend CAMHS
threshold to 0 -25years
Ensuring a range of support options available
including online and face to face support.
Lack of autism specific services in the
borough. Need continuing support for high
threshold autism and information for parents
on autism
Formed a CAMHS Alliance,
focus on embedding use of
Outcome measures across all
CAMH services, reducing
waiting times across all
providers, Implementing a
Single assessment process for
children and families with no
wrong door
Local Autism Implementation
Plan now in place. Have a high
functioning ASD assessment
service for children aged 5-13yrs
and Adult Autism assessment
service piloting support groups
such the one for social skills.
4
5
Dementia : Early diagnosis ,
Aftercare, treatment and
support should be readily
available
Involve carers in the diagnosis
and ensure dementia suffers
have care, support and
communication of resources
available
One City & Hackney Dementia
alliance – focusing on improved
access and early intervention,
working towards a shared register.
Community based care packages and
dementia friendly communities and
Dementia Advisor service to reduce
waiting times .
Redesigning Dementia pathways to
improve access in primary care and
community teams.
Reminiscence Pods Piloted in 4
residential/inpatient settings.
Community action plans to make
public spaces dementia friendly.
Primary Care: Better integration
and use of voluntary sector
groups by primary care .
Incorporating /prescribing
complementary therapies such as
meditation and mindfulness and
promoting nutrition and prescribe
exercise to boost mental and
physical health
Commissioned ELFT, HUH and voluntary
sector providers to provide services that
support treatment and recovery of mental ill
health.
Examples include launch of City & Hackney
Wellbeing Network in collaboration with other
voluntary sector organisations to support
wellbeing and recovery of local residents.
Recovery focused Enhanced Primary Care
service fully embedded interface between
primary, secondary care & community,
supporting clearer pathways & linked to the
Mental Health Network.
Carers and other
Vulnerable groups: Extend
IAPT to include assessment
of substance misuse
patients by the CMHT.
There should be out of hours
support for IAPT with
possibility of at home
provision.
There should be peer
mentors and peer support
for carers
Commissioned with
HUH as part of the
IAPT programme to
provide a range of
services to patients.
Access via GP and
self-referral.
All boroughs have a
crisis resolution team
and we now have a
crisis line
Mental Health - Improvements our residents’ will experience by the end of
16/17
Primary Care
• More mental health care
in primary care by providing
more comprehensive
services at primary care level
more people to treat locally
in a familiar setting.
• Better links to other
services. Through working in
partnerships and alliances,
barriers between services will
be removed creating
smoother transitions for
patients and more
comprehensive care
packages
• Early Identification and
treatment: implementation of
mental health register and
use of primary care mental
health workers will support
the early intervention and
management of people with
MH problems
• Mental Health and
Physical health – the
identification and referral to
treatment for people with long
term conditions or medically
unexplained symptoms will
be improved
46
CAMHS
• No wrong door. Referrals
reviewed across organisations
with clearer transitions
between tiers and reduction in
inappropriate referrals
• Increasing Resilience.
Work with families and
communities to increase
resilience.
• Stronger community
services for eating disorders
and perinatal services
• Standardised outcome
measures across all
organisations regularly
reported.
• Youth justice and crisis
pathway better integrated and
coordinated .
• Autism - Have a high
functioning ASD assessment
service for children aged 513yrs
• Strong links with schools
and community groups
including informal parent
support for families with
children who have disabilities
Psych.
Therapies
•No wrong door. The alliance
organisations work together
and patients can enter through
any organisation.
•Closing gaps. The alliance
organisations are working
together to close gaps in
service provision e.g. BME
community based therapies.
•Better access. More
organisations will provide
therapies for common mental
health problems particularly for
hard to reach groups.
•Reduced waiting times.
Alliance organisations are
pooling resources and
supporting each other to
reduce waiting lists.
•More comprehensive care.
treatment that might combine
psychological interventions
with social interventions such
as employment work and
meaningful activity.
Dementia
• Pathway re-design to
reduce duplication and coordinate care across
organisations so patients
receive the right treatment in
the right place at the right time
• Early diagnosis and
treatment. Dementia Alliance
is piloting two forms of early
treatment - cognitive
impairment group programme
and cognitive stimulation
therapy
• Improved post
diagnostic support and sign
posting through the dementia
advisory service
• Dementia register. More
consistent information shared
across organisations.
• Dementia friendly
environments. Reminiscence
pods in residential settings
and public places made more
dementia friendly (DAA)
• Staff training in identifying
and supporting dementia
sufferers - LTwD training.
• More support for carers
of people with dementia
• Better community
resilience through awareness
raising
Mental Health - Improvements our residents’ will experience by the end of
16/17
Prevention
•
•
47
Promote importance of prevention in supporting
mental health and well-being and embed these
principles across all care pathways e.g. depression
screening for diabetic template in Primary Care, MH
component of young person’s health check offer in
primary care, 5 To Thrive well-being reminder in
Recovery Care Plans
Suicide prevention
Crisis
• Create a more integrated pathway across teams and
organisations that delivers clinically effective value for money
services
• Improved communication, information sharing and
joint working with police and ambulance
• Better and more direct access to crisis services service
users and carers
• A responsive service which sees people in the most
appropriate setting and where possible, reduced use of A&E
Planned Care Programme Board
Commissioning Intentions 2016/17
PLANNED CARE
HOSPITAL & COMMUNITY SERVICES
Inc. CANCER
You Said – We Did
You wanted more access in the community to Specialist Services:
We are developing new multi-location specialist services such as Ear, Nose and Throat (ENT), Minor Surgery,
Gynaecology and Ophthalmology which should all be in place during 16/17.
You wanted to provide blood samples in your own practice:
From Jan 2016 - We commissioned improved blood collection services which will be available to every
patient either from their own practice or one nearby (Neaman practice is expected to start services from April).
You wanted improved post operation wound care:
We are in discussion with GPs around providing a bespoke service for post operation wound care so all non –
housebound patients will be able to attend their practice or another close by for this service. We aim to have
services up and running from April 2016.
You wanted longer GP Appointments:
We commissioned from April 2015 half hour appointments from GP practices so every patient diagnosed with
cancer could have extra time to talk about their cancer and related issues
4
9
Our plans for 2016/17
The pilot of the expanded Pain Management Service has been successful and it
will now be commissioned as a permanent part of the Locomotor service
Community services:
•Introduce a new gynaecology service model with the Homerton providing a
stepped approach across GP practices, community services and secondary care*
•New service (s) for urgent eye problems as an alternative to A & E, GP and
outpatient services* We have been working with City Healthwatch on how these
are developed
•With the Homerton plan and develop services to improve care and outcomes for
patients with Leg Ulcers
•Create a virtual service for dermatology allowing GPs to get specific patient
advice from specialists so they can diagnose and start some treatments in
practice rather than or before referral*
Note: *These support the 18 week pathway as part of the ‘must dos’ for 2016/17 as set out in the Delivering the Forward View: NHS planning guidance
2016/17 – 2020/21)
5
0
Our plans for 2016/17 (cont)
Cancer:
•Improve access to investigations for GPs (MRI/Ultrasound/Endoscopy etc)
•Improve follow up pathways and patient experience – build on time to talk
Misc:
•Improve the services for patient interpretation services (deaf and nonEnglish speakers)
•A new pathway/service for Tier 3 weight management service to ensure
appropriate patient access to bariatric surgery.
•A new service (on behalf of Public Health England) for latent TB testing in
GP practices
5
1
Response to 2016/17 Intentions
We are looking for your feedback specifically on the following:
1. Pre operation assessments although essential are time consuming for patients and
create an extra step in the pathway to surgery. How do you feel about generally
healthy patients being assessed virtually (online/telephone) for some kinds of
operation or patients with more complex conditions being assessed by their GP
instead of at the hospital?
2. One of our aims is to improve GP access to specialist/consultant advice so some
diagnosis and treatments can start before a referral to another service is needed. We
may introduce some special photography (dermatology) or video (skype?)
consultations. Would you be happy for new technology to be part of your GP service to
enable them to treat you for some conditions in practice rather than refer to the
hospital?
3. What other areas of outpatient or community services could be improved?
5
2
Patient and Public Involvement
The Planned Care board has done significant engagement with patients in
15/16 including the following:
All agreed community service developments have been discussed with the PPI
Committee and we will continue to work with City Healthwatch and City patient
representatives to develop improvements to planned care services.
Ophthalmology: Engaged Healthwatch’s (Both City and Hackney) to consult
patients who use current hospital services for their views on providing more
eye care in community services. A clinical workshop has involved local patients
on possible models for delivering services.
Gynaecology: Discussions with various community groups including the
Jewish community and travelling community. Community Voice raised the
menopause issues and our clinical lead has engaged Hands Inc about the
types of these issues that can be addressed in the service design.
5
3
City and Hackney CCG Eliminating Waste and Inequality
££Stability Reduce CO2 Eliminate Waste Economic Growth
Resilience Equality & Diversity Social Value
Adaptation
Companionship
Resilience
Fairness
Access to services Volunteering
Giving
Supporting communities
time
People’s time Creativity & Potential
Social
Diet & Exercise
Access to Green Spaces
Active Travel
Inclusion
Mobilisation
Training & Education
Well workforce
Health &
Wellbeing
Living Wage
Biodiversity
Environment
Economic
Responsible employer
Buying social, ethical
Growing Food
Innovation &
Improve Air Quality
Technology
Reduce congestion
55
Buying local
££C&H
Quality & Compliance
Efficient services /
operations
Equality & Sustainability
Why equality & sustainability
Significant
Equality
overlap between Equality Agenda and many aspects of social value / sustainability.
and Diversity is a work stream in Sustainable Development Management Plan.
Help
staff and stakeholders understand importance of workstream, help to widen the reach of the Equality
agenda and avoid duplication.
Promote
56
the Equality Delivery System with this SDMP.
Sustainability Commissioning Intentions 16/17
1. Develop & agree commissioning intentions with all providers
Input: All contracts develop and agree improvement targets against SC18 with providers to enhance
environment and social improvement.
Outcome: Sustainable development, and ‘reducing waste and inequality’, is understood and integrated into
service delivery of large providers as a priority improvement area with the CCG commissioning cycle.
Improvements will be measurable, and will meet Provider resource capacity.
2. All alliances with C&H sustainable objectives
Input: All alliances understand sustainable achievements and priorities, opportunities for providers to share
and learn from best practice, and identify support needs.
Outcome: Providers of small contracts / alliances agree to implement a sustainable development framework
that aligns to C&H CCG objectives (taking own business objectives as a priority).
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Sustainability Commissioning Intentions 16/17
3. Internal Training & Development
Input: Direct and bespoke support to the key leads within the CCG to support the delivery of their SDMP
activity, and support wider staff engagement.
Outcome: Staff are upskilled to improve delivery of sustainable healthcare; sustainable development and
the ‘reducing waste and inequality’ ethos is embedded into CCG operations.
4. Patient and Public Engagement Support
Input: Engage the public with C&H CCG SDMP with support from PPI
Outcome: Patients / the public engage with and contribute to C&H CCG sustainability plans.
5. Develop SDMP and Annual report
Input: Evaluation of the above work programmes to support and develop 2016/17 sustainability plans
Outcome: C&H CCG meets requirements of National Sustainability Strategy; Continuous improvement of
sustainable development integration in CCG operations.
58