Download Minutes - Upton Group Practice

Minutes of the Patient Participation Group Meeting
Monday 16 November 2015
Present
Patients:- Mr Peter Hunt, Mr John Coleman, Mr Peter Daniel, Mrs Eileen Hume, Mr Alan Jones, Mrs
Elaine McBride, Mrs Diann Pollock, Mrs Joan Stanley
Mr Mike Coupe - Director of Strategy Wirral University Trust Hospitals, Jo Goodfellow – Programme
Director Healthy Wirral, Dr Helen Kini – GP Partner, Mrs Peta Murphy – Practice Manager and Mrs
Christine Pengelly – Office Manager
1. Apologies
Apologies were noted from Jean Dunn and Keith Lindsay
Everyone introduced themselves.
2. The Primary Care Quality Scheme
Peta explained that the CCG had now changed the way it offered services to the practice and rather
than offer specific Enhanced Services to work on issues such as Contraception, Prostate Specific
Antigen testing or Diabetes they were offering us the opportunity to identify what we felt would benefit
our patients under the three areas of



Prescribing
Unplanned Care and
Planned Care
The paper at Annex A had been circulated to the Patient Group members and they were invited to
make any comments on it. Peta highlighted a couple of queries that had been noted by Keith Lindsay
from our Virtual Patient Group. He had asked how many housebound Diabetic patients we have and
how often they are visited by our Nurses. Peta explained that we have about 48 patients who are
visited every six months by our Practice Nurses to manage their Diabetes. We feel that this is
important for the reasons outlined in the Proposals.
Keith had also enquired about Planned Care and referrals being discussed before being made. Peta
explained that the reason for this is so that the GP Partners can ensure that all avenues have been
explored appropriately in primary care before a referral is sent on to secondary care.
Peta highlighted one other aspect of the Primary care Quality Scheme proposals – which is the
adoption by the practice of the Wirral Hospital sick day rules to prevent Acute Kidney Injury – and a
copy of their leaflet, which we will use, is attached to the proposals at Annex A. There were no further
questions on the scheme.
3. The Vanguard Initiative – now known as Healthy Wirral
Jo explained that she is now employed by all the Trusts who are Partners to this initiative as the
Programme Director for Healthy Wirral. The initiative is about providing joined up care (so patients
only need to tell their story once) and doing things differently as we are all living longer and patients
are developing co-morbidities and needing more care. Jo ran through a presentation – copy at
Annex B – and explained that our greatest strength on Wirral is developing the use of IT so that
patient records, currently held separately by the different organisations, are linked to support the
provision of better care. She emphasised her understanding that the sharing of patient data is of great
concern to patients and explained that the initiative is working through the Information Governance
processes to prevent record sharing being open to risk. An Information Sharing Agreement has been
drawn up to be signed off and details will also be notified to patients before records are shared. In the
future this could also link in to sharing with Social Care.
Jo explained that this year the Healthy Wirral project has £3.5 million to invest in IT, project managers
and initiatives on chronic diseases such as Diabetes to make changes to the way care is managed.
Chris Ham at the Kings Fund is involved in supporting the Vanguard initiatives across the country.
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Jo highlighted the 10 years (for men ) and 12 years (for women) difference in life expectancy just
within areas of the Wirral and explained that Healthy Wirral is about helping patients to stay well and
empowering people to work together and to stay well and stay fit. It asks the question “What matters
most to you?”
The aims of the initiative are for everyone to live well and stay well for longer and to have access to
high quality and cost effective care. Jo mentioned that at a national level Wirral is known to have a
very high number of foot and lower limb amputations amongst Diabetic patients and we need to
address such issues by helping people to prevent illness and supporting them to look after
themselves. Jo also made reference to risk stratification whereby data can give us a pyramid of those
who are most at risk of hospital admission at the top of the pyramid, scaling down the pyramid to those
who are not at risk at the base of the pyramid. For example a person who has a history of repeat
hospital admissions due to falls can be identified as at highest risk of further admissions and the
healthcare team can arrange for an Occupational Therapist to see the patient to help put measures in
place to minimise their risk of falling.
Jo explained that integration is key and in the future Community Nurses will work closely with
Community Social workers and the Integrated Care Co-ordination Teams will work with higher risk
patients to support them. Pathways of care will be developed and health inequalities will be
measured.
Jo mentioned that another area where Wirral scores poorly is for people living independently and in
the North West Wirral has the highest number of people going into care homes.
Jo highlighted the fact that we need to pay attention to avoidable admissions and another important
aspect of the initiative is enabling children to have a good start in life, as by the time they grow up the
healthcare system will look very different. Jo explained that cultural change is key to the success of
the Healthy Wirral initiative and that the healthcare workforce will change to support people to look
after themselves. Outcome-based commissioning of services will be important and social prescribing
is to be developed – whereby a resource of local voluntary groups and support services will be
mapped to be accessed to provide help to keep people healthy. The Single Front door to Care will
also be important so that people can be signposted appropriately at the point at which they access
services to ensure that they are directed to the most relevant and appropriate service.
Jo advised that the Healthy Wirral Initiative is to be launched at the Floral Pavilion on 25 and 26
November with the programme being a half day programme that is repeated on each morning and
afternoon. Everyone is welcome and Jo will send us some leaflets about this.
Eileen asked about the funding of £3.5 million over 3 years and what the exit strategy was. She asked
if the initiative is meant to be self-sustaining as clearly it is not possible to employ staff without
recurrent funding. Jo explained that the funding of £3.5 million is for the first year but there is no
information yet on what the funding is to be for years 2 and 3. Jo added that the aim of the initiative is
to change the way patients are treated so that acute care is fast and effective when needed and the
patient is returned home. She said she is due to meet the Prime Minister in the next week and will be
highlighting to him the good work done so far on smoking and asking if similar cannot be achieved
with both alcohol and obesity, which could make a huge difference to healthcare.
Peta picked up what Jo had highlighted on risk stratification, explaining that one of our Primary Care
Quality Scheme proposals is to review risk stratified data that has been anonymised and combined
across primary and secondary care activity to return to us the NHS numbers of patients most at risk of
hospital admissions. She explained that the practice had risk stratified patients a couple of years
previously – focusing on our 131 patients in 14 care homes and on patients over the age of 75 – which
was a perfectly sound basis to use for risk stratification. However the new IT tool has flagged up
some patients in younger age groups - for example a girl of 14 and a lady of 35, as well as confirming
the older patients we have already stratified. Peta explained that the Partners had had an initial
meeting recently to discuss the new risk patients flagged up by the tool, had been aware of all of these
patients and had been able to consider other supportive pathways such as referral for counselling to
try to prevent further unplanned admissions for these patients. Dr Kini added that finding the time to
carry out this work is a challenge and it is not simply a case of meeting and discussing the patients but
also then taking the follow-up action, engaging with them and the support services that can make a
difference.
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At this point Jo left the meeting.
4. Infection control and C-Difficile infection
Elaine asked Mike how many cases of C-Difficile the Hospital had had in the past year. Mike advised
that he was not the best person to answer this question as he had been appointed to post just two
months previously and had not been briefed to respond to these points today. He advised that it
would be better to get someone from Infection Control at Arrowe Park to talk to us on the issues.
However he could advise that the hospital is likely to breach its defined ceiling for C-difficile infections
which is a target of 29 for the year and currently the total stands at 27. Elaine explained that her
husband had been in hospital for a short stay and had contracted C-Difficile. She had been very
pleased at our meeting with the Trust last November to report on the excellent care she had received
during her own three week stay in the hospital and had been disappointed that her husband had
suffered this infection from a stay of about a day. Mike said he was sorry to hear of Mr McBride’s
experience and explained that any such case is a regrettable incident. Mike explained that the annual
targets for such infections had reduced over time across the whole of the North West yet it is
noteworthy that right across the NHS there seems to be an increase in C-Difficile. He advised that
local actions include the putting in place of a full ward HPV programme, introduction of a 48 hour step
down target, ring fencing of the C-Difficile unit and weekly reports to, and review by, Senior Managers.
Alan Jones commented that a lot of infection control responsibility rests with visitors to the hospital
and in his recent experience he had seen a number of visitors going onto the Wards without applying
the hand gel that is available outside each ward. He suggested that the hospital monitor this. Mike
expressed the view that people must take responsibility for their actions.
Diann asked if Mike had heard of the new version of C-Difficile that was so virulent it was likely to
cause 50% morbidity. Mike advised that he had not heard of this and again recommended that we
invite an Infection Control team member to a future meeting.
5. Update from the Hospital on their recent Care Quality Commission Inspection
Mike explained that he was actually here to talk about the Vanguard initiative from the Hospital Trust’s
perspective. He advised that the Trust had recently had their CQC inspection but the report on this
was not due for another two weeks. He advised that the Inspectors had reported that they were struck
by a number of good things at the Trust – including the culture of the organisation. However they
were tight-lipped on any “Buts” and he could not add anything further at present
6. Healthy Wirral and the Hospital Trust
Dr Kini asked Mike how he thought Healthy Wirral would change things at the Trust Hospitals. Mike
explained that he had just joined the Trust and was giving his comments based on experience of
integrating health and social care in a west Midlands health economy. His initial impression of the
Healthy Wirral initiative is three key things:
it will tighten up the system and ensure that patients who are fit for discharge are discharged
home.

It will make us focus on prediction and prevention. A small percentage of the patients
consume a lot of the cost. We need to look at what is avoidable and undesirable.

The definition of health can be described as a job and good friends and this is what the
Healthy Wirral initiative focusses on.
Mike said that there are high levels of hospital admission of between 2 hours and 2 days and we need
to sort those out. He felt that there was a particular challenge in maximising the use of communitybased resources which raised a number of questions about how primary and community services
could work together to manage any shift in care away from hospitals. As the care shifts so the finance
also needs to move but Mike feels that Healthy Wirral/Vanguard is not necessarily the solution to all
the financial problems of the NHS.
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Mike highlighted the need to think about and plan for hospital services not just on a Wirral basis but on
a Wirral and West Cheshire basis. The Trust is looking to work with Chester to strengthen local
services where otherwise the inability to recruit staff or new quality standards might result in a move to
Liverpool. Alan highlighted that this type of joint working is already the case with Vascular Services
which are now provided at Chester. Mike gave the example of there being 16 Paediatric units across
the North West yet there are only enough junior doctors to actually support four. The issue is not
localness but the need to reduce the clinical risk and improve patient outcomes.
Eileen explained that she has been appointed as a Public Governor for the Hospital Trust and as such
she is happy to take feedback to Hospital meetings. Mike advised that in the future the clinical teams
will come out and talk to the GPs. Dr Kini thanked Mike for sharing his views. At this point Mike left
the meeting.
7. Urine specimen containers
Peta explained that the hospital have introduced a new type of urine specimen container with a
collection pot and showed the Group the current version and the new one. As a practice we had
raised concerns about this and Genevieve Christian, Clinical Biochemistry Manager from Wirral
University Hospital Trust, had come out to meet with us on 20 October to discuss the new system.
Genevieve had explained that the new system had been piloted in January 2015 in several practices
in Wirral and was now being rolled out to all. Genevieve had advised that the rationale was that the
new tube fits directly onto lab instruments unlike the current one and the idea of having a collection
cup was because patients have been using other non-sterile containers to collect specimens to put
into the current bottles and by having a cup they aim to reduce contamination of the sample. There is
also a leaflet for patients about the new system and copies were passed round.
Peta explained that at home patients can dispose of cups in the household waste whereas here
because of the volume and being commercial premises we have to have clinical waste bins in the
patient toilets for these cups to be disposed of. Diann Pollock commented that the new smaller tube
would still be difficult to pour a sample into if the patent had any dexterity problems. Joan Stanley
agreed that the new system would be more complicated for some patients, particularly those with
learning disabilities.
Peter Hunt asked what was the importance of a mid-stream sample of urine and Dr Kini explained that
the initial stream of urine clears the genital area and the best sample is then obtained from the midstream urine.
8. Any Other Business
Alan Jones enquired about our check-in screen and whether the use of hand gel by patients using the
system was monitored. It was noted again that people need to take responsibility for infection control
measures and we will invite someone from infection control to the next meeting.
As there was no other business to discuss the meeting was closed at 1345hrs and everyone was
thanked for attending.
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ANNEX A
Upton Group Practice - Primary Care Quality Scheme Proposals
1. PRESCRIBING
Our CCG Pharmacist highlighted wound care and the use of dressings as an area for work on
prescribing. The Practice Nurses are currently having a series of training sessions on the use of
dressings and wound care and they will arrange to share the outcomes of this learning with the GPs
once the training is complete.
2. UNPLANNED CARE
a. Post discharge checks on patients who have had emergency admissions
In the past is has proven helpful to patients to have a Phonecall from the Practice Nurse within 3
working days of discharge from Hospital after an emergency admission. This applies to patients
discharged home and not those discharged to Care Homes. The Nurses check if the patients need
anything and can flag any problems or concerned raised back within the practice for action. Patients
themselves comment that it is reassuring to have a phonecall and we feel that this system contributes
to ensuring that patients are not swiftly re-admitted to hospital.
b. Employment of a Care Home GP
We have 131 patients in 14 Care Homes and we plan to employ a locum GP to do a session a week
to:
Carry out Dementia Shared Care reviews for all Nursing Home patients on the Shared Care
scheme. These patients require 6 monthly review.

To be available on a weekly basis to do an initial review and assessment of new patients
admitted to Care Homes. This review will include completion of DNAR paperwork and noting
Preferred Place of Death – both of which are instrumental in ensuring that terminally ill
patients do not suffer the distress of a hospital admission.

To carry out annual medication reviews on all Care Home patients
We will start work with The Manor and Woodheath as we have the greatest numbers of patients in
these care homes - 31 and 37 respectively.
c. Home care for Housebound Diabetic patients
We will allocate some of the funding to cover our Practice Nurses doing Home visits to diabetic
patients as we have a higher prevalence of diabetics and elderly housebound patients. We have 525
Diabetic patients on our practice list and of these 340 are over the age of 65. Of those 17 are in Care
Homes and 12 are Housebound. However not all our housebound patients are coded as such and
we know from management of the lists of housebound Warfarin patients that patients can be
housebound at times but able to attend the practice at other times. Our Nurses are visiting an
average of 8 Diabetic patients each month at home to monitor their Diabetes. We recognise that it is
important to manage the care of Diabetic patients as they get older:



to prevent hospital admissions for falls (due to neuropathy).
to prevent problems with hypertension possibly leading to strokes.
to check urine to monitor kidney function which may decline considerably necessitating
dialysis.
to monitor blood sugar levels as low levels can contribute to falls whilst high levels can cause
anxiety and possibly even Diabetic ketosis. Diabetics with high sugar levels are also more
likely to suffer Myocardial infarctions.
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d. Provision of supportive healthcare contact telephone numbers
Our Salaried GP has obtained copies of the Age Concern list of useful telephone numbers that can be
given to patients so they know how to contact them to access a range of information guides and
helpsheets.
e. Avoiding admissions of patients with Acute Kidney Injury.
We have drawn up a list of medications in conjunction with Arrowe Park, that patients who are diabetic
or have other chronic health conditions such as chronic kidney problems or heart failure, should be
advised by clinicians to stop taking immediately should they develop diarrhoea and vomiting. These
medications can cause Acute Kidney Injury if the patient continues to take them whilst severely
dehydrated. Acute Kidney Injury means admission to hospital and can be fatal.
The hospital have developed a leaflet – attached - regarding sick day rules when taking these
medications to prevent kidney injury which will be useful to flag up to patients in their medication and
chronic disease reviews and also when patients contact us regarding this.
f. Review of patients risk stratified by the CCG risk tool
When the Avoiding Unplanned Admissions Enhanced Services started a couple of years ago we drew
up our own list of high risk patients drawing these from patients over the age of 75 and those in Care
Homes and have reviewed and managed these since then. We will be reviewing the top three or four
highest risk Group patients as stratified by the CCG tool and will compare the Groups monthly as the
tool is flagging up some of our younger patients for attention. Many of those in Groups 1 to 4 are
already on our risk list but regular reviews of those who are not but are highlighted by the tool will give
us an opportunity to see if there is any additional care or support we can offer these patients.
3. PLANNED CARE
a.
All referrals to be cleared by a Partner
All locums to be asked to discuss referrals with a Partner before referring.
b. Practice discussion of options and referrals
We will produce a spreadsheet for the GPs to update daily at their lunchtime meetings to evidence
discussion of planned referrals.
c. Referral audit
The Partners will audit referrals over a period of a month now and then re-audit in 5 months’ time to
see if the regular review of referrals at 3b. above has made a difference.
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ANNEX B
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