Integrated Report 2013/14. Positive action. for Greenwich

Transcription

1 Integrated Report 2013/14 Positive action for Greenwich

2 Introduction Who we are NHS Greenwich Clinical Commissioning Group is made up of all the GP practices across the borough. We are responsible for commissioning hospital, community, and mental health services for the local population of Greenwich. Our aim is to secure the best possible healthcare services for people in Greenwich, specifically in community settings and in hospitals as necessary. For more information visit: About this report Integrated reporting We are the first NHS organisation to publish an Integrated Report. You will see throughout our report the details of how we developed our strategy and agreed our clinical priorities. The report also describes our governance structures, performance and prospects, in the context of our external environment, which leads to the creation of value in the short, medium and long term. Understanding our external environment helps us as an organisation to make the best commissioning decisions and improvements in the quality and performance of service provision for our local community. PILOT PROGRAMME For more information visit:

3 In this report 1. Improving Care Long Term Conditions See p10 6. Improving Engagement See p20 See p12 2. Improving Patient Care Stroke services Positive action As part of our programme to improve the provision of care in the borough we have identified six key action areas: 5. Improving Health Outcomes Diabetes See p18 3. Improving Patient Care See p14 See p16 4. Improving Patient Care Improving Access Contents 2 Clinical Chair s introduction 3 Governance 4 Introduction to services 5 How we set our priorities 8 Business model 10 Action areas 22 Looking to the future 24 Map of GP practices NHS Greenwich Integrated report 2013/14 1

4 Introduction from the Clinical Chair of NHS Greenwich CCG How our GPs are leading changes in healthcare Our first year as commissioners has been exciting and challenging, as we bring about real change in the delivery of healthcare in Greenwich. GPs are now at the heart of local healthcare decisions. We believe this is a good thing for our patients. As local clinicians we know our patients, have heard their views, and understand their needs and expectations. This insight enables us to commission services best suited to meet those needs and expectations. As a membership organisation, we are able to draw on the knowledge and expertise of GPs and other staff across the practices that constitute Greenwich CCG. The Governing Body, which includes six elected local general practitioners, was established to represent the 45 Greenwich GP practices and act on their behalf. Each practice belongs to a syndicate or grouping of GP practices in close proximity to each other geographically. The syndicate leads are elected NHS Greenwich CCG Governing Body by the practices and represent their syndicates at regular meetings with the senior management team and clinical executive leads. This ensures the members have an opportunity to be involved in decision-making and can raise any issues on behalf of their membership. We work with the Royal Borough of Greenwich (RBG), our partners, patients, stakeholders and the wider public to develop and improve the services that we offer, reduce health inequalities and improve health outcomes. I have been a GP in Greenwich for nearly 30 years. The important part of my job has always been giving my patients the best possible care. My commitment to my patients remains the same, but being a commissioner has given me and my fellow GPs the opportunity to make important decisions and help shape services that our patients need. Dr Rebecca Rosen Clinical Commissioner Dr Nayan Patel Clinical Commissioner Jim Wintour Lay Member Vice Chair/Audit Dr Hany Wahba Chair Annabel Burn Chief Officer Chris Costa Chief Financial Officer Dr Junaid Bajwa Clinical Commissioner Yemi Osho Registered Nurse Dr Ellen Wright Clinical Commissioner Dr Eugenia Lee Clinical Commissioner Dr Greg Ussher Lay Member (Patient Engagement) Mr M T Vandal FRCS Secondary Care Doctor (until 09/09/2013)* Iyngaran Vanniasegaram MSc, FRCS, MBA (WBS), FRCP Secondary Care Doctor (from 08/01/2014) Simon Hall Director of Integrated Commissioning Nicola Moore (Havutcu) Director of Integrated Governance Councillor John Fahy Cabinet Member for Health, Adults and Older Peoples Services Steve Whiteman Director of Public Health * Iyngaran Vanniasegaram took over from Mr M T Vandal as Secondary Care Doctor on the Governing Body from 08/01/ NHS Greenwich Integrated report 2013/14

5 Introduction to Governance and how our organisation is managed How you can have confidence in what we are doing As a responsible NHS organisation we must make sure we have good governance in place. Governance determines who has power, who makes certain decisions, how others make their voices heard and how people are held to account. Good governance is important To patients and the public because they depend on the quality of judgements that clinical commissioning groups make; it will give them confidence that the best decisions are being taken for the right reasons, that the quality of healthcare services is protected and that public money is being spent wisely; and To clinicians because it supports them to make the best possible decisions, reduces the likelihood of things going wrong and protects them in the event that things do go wrong. Greenwich CCG ensures that the right arrangements are in place with providers of services, that they are in the best interests of the people that use those services, and that they represent value for money. Considering the complexity and range of services offered, it is vital that we have a governance structure with sufficient delegation to ensure that decisions can be made, but also with sufficient oversight to adhere to what is set out in the constitution. Greenwich CCG is accountable for exercising its statutory functions. It may delegate authority to act on its behalf to: any of its members the Governing Body employees any of the committees or sub-committees established. The extent of the authority of the respective bodies and individuals depends on the powers delegated to them by Greenwich CCG as expressed through: its Scheme of Reservation and Delegation; and for committees, their terms of reference. The Scheme of Reservation and Delegation sets out: those decisions that are reserved for the membership as a whole those decisions that are the responsibility of the Governing Body (and its committees), and sub-committees, individual members and employees. However, Greenwich CCG remains accountable for all of its functions, including those that it has delegated. There is a robust corporate governance structure with the roles and responsibilities of the members of the Governing Body and supporting committees clearly set out. A number of committees provide challenge and assurance over specific areas, for example Quality Innovation Productivity Prevention (QIPP) delivery through the Finance, Performance and QIPP Committee. All committees have been formed with a membership that provides a sufficient range of skills, including clinical expertise and lay membership, to provide effective management and oversight. Our committee structure is set out below Bexley and Greenwich Remuneration Committee NHS Greenwich CCG Governing Body Charitable Trust Fund Committee ASSURANCE EXECUTIVE Finance, Performance and QIPP Committee Quality Committee Audit Committee GP Executive Group Greenwich Executive Group (considering Strategy and Commissioning quarterly) Market Management and Procurement Committee Health, Safety and Wellbeing at Work Group Patient Reference Group Syndicates Clinical Project Leads QIPP Group QIPP Gateway Greenwich Wide Forum NHS Greenwich Integrated report 2013/14 3

6 Introduction to services What we spend and how we spend it Greenwich CCG commissions a range of services, community and hospital-based, including mental health services, community health services and continuing care services. Net Operating Expenditure for the year to 31 March 2014 ( 000s) 30,310 35,638 4,817 4,686 15,858 47,194 Acute Services Mental Health Services Primary Care Services Community Services 6, ,462 Continuing Care Services Other Programme Services Other Corporate Costs Running Costs Residents have a large choice of NHS services they can access across Greenwich. Lewisham & Greenwich Healthcare NHS Trust (LGT) is the main provider of hospital services to Greenwich residents, and also to the residents of Lewisham and Bexley. Our main local hospital is the Queen Elizabeth in Woolwich, which is one of two hospitals run by the Trust. It has an Accident & Emergency (A&E) department that operates 24 hours a day. There is also an Urgent Care Centre (UCC) based there, which is open from 8am to 11pm, seven days a week. It also provides a wide range of out-patient services, diagnostics and in-patient beds. Greenwich residents are also served by other acute trusts across south east London. Guys and St. Thomas NHS Foundation Trust (GST) serves the whole of south east London and it provides specialist services for patients from much further afield. King s College Hospital NHS Foundation Trust (KCH) provides a full range of general hospital services for over 700,000 people in the boroughs of Lambeth, Bromley and Southwark and specialised services that are available to patients across a wider area. Oxleas NHS Foundation Trust provides a wide range of health and social care services and specialises in caring for people with mental health needs and learning disabilities. It is the main provider of mental health and adult learning disabilities services for Greenwich as well as forensic mental health services. It is also the provider of community health services for Greenwich patients. Additionally, Greenwich residents are served by South London and Maudsley NHS Foundation Trust (SLaM) which provides the most extensive portfolio of specialist mental health and substance misuse services in the UK. In south east London we have one of only five Academic Health Sciences Centres (AHSC) in England. King s Health Partners (KHP) is a partnership between King s College London, Guys and St. Thomas NHS Foundation Trust, King s College Hospital NHS Foundation Trust and South London and Maudsley NHS Foundation Trust. Specialised hospital services, and most primary care services, including GP services and dentistry, are commissioned directly by NHS England. Our expenditure for 2013/14 was just over 317 million and allocated as illustrated. In our first year of operation as a CCG we have achieved our statutory financial duties and have stayed on track to deliver an agreed surplus. Robust financial plans are in place for the coming five years. 4 NHS Greenwich Integrated report 2013/14

7 How we set our priorities Greenwich CCG has some guiding principles at the heart of what we do when commissioning all these services and determining our priorities: Improving health outcomes Reducing health inequalities Simplifying clinical care pathways Encouraging self-management Improving collaboration Connecting services to primary care Right services, right place, right time Judicious use of integration and competition. These are underpinned by seven NHS principles: A free, responsive, high quality service, available to all, delivered in partnership, with accountability and value for money. In addition, patients have rights under the NHS Constitution that cover how patients access services, the quality of care they receive, the treatments and programmes available to them, confidentiality, information and the right to complain if things go wrong. We must also adhere to a number of statutory regulations laid down in The Health and Social Care Act 2012, and further recommendations from the Francis, Berwick, Keogh and Winterbourne View reports shape how we work. All of these, and many other factors, influence how we set our priorities: Population: Greenwich is recognised as having an increasingly diverse population and is amongst the most deprived in the country. Deprivation is strongly associated with poor health. Significant population growth is projected and we have a relatively high proportion of children and young people under the age of 19. Life expectancy is substantially shorter than the national average and many people live with illness and disability. Health behaviours: Nationally, current lifestyles present a serious threat to population health, particularly for more disadvantaged groups. Despite successes in reducing the prevalence of smoking, other health behaviours in Greenwich are translating into an increasing burden on health services. The effects of physical inactivity, poor diet, obesity and alcohol consumption are already significant and are worsening, which means we need to do more to support people to be healthy. Disease and disability: People are living longer, as medical interventions are successful, but with age comes the increased likelihood of people experiencing many different long term conditions. The main health challenges in Greenwich are: cardiovascular disease cancer respiratory disorders such as chronic obstructive pulmonary disease (COPD) mental illnesses such as depression, anxiety and dementia falls and fractures in older adults alcohol related harm diabetes. Health is determined by a complex interaction between individual characteristics, lifestyle and the physical, social and economic environment, and all of this has informed the development, with the Royal Borough of Greenwich, of the joint Health and Wellbeing Strategy, which is overseen by the Health and Wellbeing Board. The Health and Wellbeing Strategy aims to: 1. Secure the best health and wellbeing for children and young people including vulnerable children 2. Secure the best health and wellbeing for adults and older people including vulnerable adults 3. Improve the health and wellbeing of the most disadvantaged 4. Increase life expectancy for men in Greenwich 5. Promote the health and wellbeing of new populations in Greenwich 6. Ensure public policy supports good health 7. Make healthy choices easier 8. Invest resources wisely and in partnership (commissioning and joint commissioning) 9. Communicate with the public 10. Develop the full potential of our workforce This in turn has directly influenced local priorities. We have ambitious plans to improve health outcomes for local people but there are risks to our ability to achieve these. The dissolution of South London Healthcare Trust, leading to the Lewisham and Greenwich Healthcare NHS Trust (a new organisation bringing together Queen Elizabeth Hospital and Lewisham Healthcare NHS Trust), has meant a significant period of change to how healthcare is delivered locally. This has to be managed alongside continuing to improve quality. We have made 9.9 million of savings this year, but current funding prospects for health and social care suggest we will need to continue to keep a tight grip on finance, whilst addressing the future challenges of service delivery. NHS Greenwich Integrated report 2013/14 5

8 How we set our priorities An illustration of what drives our decision-making NHS Greenwich principles Drivers Improving health outcomes Reducing health inequalities Simplifying clinical care pathways Encouraging self-management Improving collaboration Connecting services to primary care Population Deprivation and poor health High proportion of young people under 19 Increasingly diverse population Shorter life expectancy than national average Right services, right place, right time Judicious use of integration and competition Patients have rights Statutory regulations Health behaviours Smoking Significant alcohol consumption Poor diet Inactivity; obesity NHS principles A free: responsive; high quality service; available to all; delivered in partnership; with accountability and; value for money Disease and disability Cardiovascular disease Cancer Respiratory disorders Mental illnesses Diabetes Fractures in older adults Alcohol related harm 6 NHS Greenwich Integrated report 2013/14

9 Heath and wellbeing strategy Secure the best health and wellbeing for children and young people including vulnerable children Secure the best health and wellbeing for adults and older people including vulnerable adults Improve the health and wellbeing of the most disadvantaged Increase life expectancy for men in Greenwich Promote the health and wellbeing of new populations in Greenwich Ensure public policy supports good health Make healthy choices easier Invest resources wisely and in partnership (commissioning and joint commissioning) Communicate with the public Develop the full potential of our workforce Local priorities Driven by patients Staying healthy and health promotion A whole system approach for children and young people Improving mental health care Improving long term conditions care Coordinating the provision of urgent and out of hours care Increasing capacity in quality cost effective alternatives to hospital planned care Enhancing end of life care Risks Lack of funding Local health economy Changing provider landscape NHS Greenwich Integrated report 2013/14 7

10 Business model Improving our performance and facing the challenges All of these factors have informed the development of our integrated business model To become authorised as a CCG, we had to provide strong evidence to NHS England of our capability to discharge safely our statutory responsibilities for commissioning healthcare services. We needed to demonstrate a strong clinical and multi-professional focus, meaningful engagement, clear and credible plans, proper constitutional and governance arrangements, collaborative arrangements for commissioning, and great leadership. NHS England was satisfied that we met all these criteria and we also had a clean audit of the accounts. We measure our performance in many different ways in the NHS to ensure that patients receive the best care. There are key indicators that we pay particular attention to, which are those in the NHS Constitution. Below is a list of these showing how we did. Our plans are set against a backdrop of significant change in the NHS, both nationally and locally. The challenge of population growth, and the transient nature of that population, in addition to the large redevelopment of the area, means we must always think ahead. We have continued to introduce new services and make improvements to existing services, and have delivered against NHS Constitution standards for a number of key standards in relation to cancer waits, ambulance waiting times and mental health care. We recognise, however, that there is still a lot of work to do. Our patients are still waiting too long to be seen and treated in A&E at the Queen Elizabeth Hospital, too long to see a specialist following referral, and too long for their cancer diagnosis and treatment. We also still need to do more to reduce health inequalities, help local people stay healthy and narrow the gap still further in male life expectancy. Too many men are dying at a younger age than they should in Greenwich. We are determined to face these challenges and improve the experience of our patients. How are we doing this? Maximum 18 week wait from referral to treatment (RTT). The majority of patients were treated within the waiting time standard, but a small number of patients needed to wait longer than this. We are working with our hospitals to make service changes to improve this, and we are confident that those changes are working. Accident & Emergency waiting times failure to meet the four hour target. Greenwich CCG has worked with all providers in Greenwich (Lewisham & Greenwich NHS Healthcare Trust, Oxleas NHS Foundation Trust, Greenwich & Bexley Hospice, London Ambulance Service, NHS 111, nursing homes and others) to increase services in hospital and in the community, and has provided funding in addition to national winter monies. We are also reviewing all urgent care provision and improving access to services to reduce the number of people having to attend A&E. By working together we aim to improve the pathway of care for patients, so that they receive the right care, in the right place, first time and can be supported at home wherever possible. This improves the overall patient experience of services, but there is a lot more to do to achieve the target. Cancer waits failure to meet the 62 day standard, accompanied by slippage against breast two week waits and the 31 day surgery standard. All hospital trusts are committed to improving performance and the experience of our patients and have developed action plans that will form part of contracts for 2014/15. Progress will be reviewed through existing monthly performance meetings with each trust. These actions include providing education and training to GPs to help them with referrals and supporting trusts to adopt a one-stopshop approach, where appropriate, for prompt diagnosis and treatment. Additionally, we are working with NHS England, which commissions specialist services, to improve access to prompt treatment for some of the key cancer tumour groups. Quality and safety We continue to strive to secure improvements in quality, focusing on clinical effectiveness, patient safety and patient experience. Some key improvements and achievements in 2013/14 were: A reduction in Grade 4 pressure ulcers (the most severe type) through improved reporting, collaborative working and sharing best practice Working with RBG Public Health on reducing variation in outcomes across general practice An improved quality alert system allowing us to identify areas where improvement may be needed and enabling urgent issues to be raised and resolved Improved safeguarding arrangements for both adults and children, including the appointment of a Designated Nurse for Safeguarding Adults Joint working with the Metropolitan Police and the Public Safety Team at RBG on gangs and serious youth violence to build a better understanding of the issues, to learn from each other and help the young people whose lives are affected The Amber Project Run by Barnado s, this pilot service is based in three GP surgeries and is an early intervention short-term, family-orientated programme to help women at risk of abuse. In the next section of the report you will see many further examples of how we are improving healthcare for local people. 8 NHS Greenwich Integrated report 2013/14

11 Financial Intellectual Natural Human Social Inputs Public and patient opinions Financial Allocation (DH) Contract Management Staff Experience Organisational Partnerships Public health needs Commissioning Financial Management Medicines Management Quality & Governance needs Reviewing Assessing service provisions Seeking public and patient views Deciding profiles Strategic planning Monitoring Procuring services and evaluation Managing performance Designing services of supply Supporting structure Planning patient choice Shaping capacity and managing demand Contracting Comms & Engagement Continuing Care Service Redesign Outcomes Longer, healthier lives Better quality of life for people with long term conditions Recovery following illness Positive experience of care Patient safety Social Human Natural Intellectual Financial NHS Greenwich Integrated report 2013/14 9

12 Page Title It used to feel like we were banging our head against a brick wall. Now, for the first time in years, we are optimistic that our dad can have at least some quality of life and some meaning to his remaining years. And as a family, we feel we re being listened to about his cultural needs and what he used to be like as a person after all, we are the ones who have known him through thick and thin. This is what care services should be all about for other people like our dad. Mr S s family Coordinated Care patient, Eltham 10 NHS Greenwich Integrated report 2013/14

13 Positive action 1. Improving Care Long Term Conditions Working with our partners the Royal Borough of Greenwich, Oxleas NHS Foundation Trust and Greenwich Action for Voluntary Service, we have developed a new integrated approach, known as Greenwich Coordinated Care (GCC). Greenwich Coordinated Care aims to provide proactive, efficient, effective, and personally tailored care to patients with complex needs identified as being at risk of ill health and hospitalisation. A new model has been developed of a team around a person where a care navigator will act as the main point of contact for the patient. The Care Navigator spends time with the patient to understand what is important to them and helps them prepare a personal statement, called an I statement. The Care Navigator then coordinates a team of multidisciplinary professionals to design a care plan specific to the needs of the patient. This model has been tested in the ward of Eltham prior to a full roll out across the borough. Greenwich Coordinated Care is one of 14 schemes named as pioneers by the Government in the development of integrated health and social care, helping to share best practice among health and social care colleagues nationally. We have won recognition and praise within the care and health sectors, from Government ministers and from healthcare experts. This has included winning Gold in the Transformation in Health and Social Care category at the Improvement and Efficiency Awards 2014 hosted by the Improvement and Efficiency Social Enterprise (iese), which promotes innovation and efficiency in the public sector, and the top award for innovation in social care at the Municipal Journal Achievement Awards Experience in Greenwich since 2011 suggests that our integrated approach helps the elderly population maintain their independence longer, with fewer people requiring services after the completion of their pathway, fewer delayed discharges and reduced length of stay in intermediate care, as well as preventing A&E attendances and emergency admissions. The new approach aims to give people time and support to regain their independence wherever possible. According to his family, this has certainly been the case for Mr S six weeks after discharge from his latest hospital admission. Ever since the Greenwich Coordinated Care team have been involved, we ve felt that our dad s needs are considered in the round. We are relieved that we are involved in his care planning, and that GCC have put his needs first. They understand what is important for us and our dad, such as dad having family nearby. It s unbelievable how much dad s health has improved. A year ago, he was stuck in his flat and being repeatedly admitted to hospital with nowhere safe to be discharged to. Now, with GCC in the picture, our dad is truly back with us. It is really heartening to have dad join family birthday meals and then go to the park with all three of his grandchildren. Dad was also genuinely glued to the tennis and the World Cup he liked this stuff in the past and he s renewed his interest in them. This is the kind of recovery of his mental state that we always hoped was possible but that we feared was unlikely. A recent independent review, carried out by Healthwatch Greenwich, showed that the Care Navigator model has already improved patient experience, and further regular reviews will be undertaken to check on progress. A second pilot is now being rolled out in the Woolwich/ Thamesmead area. NHS Greenwich Integrated report 2013/14 11

14 Positive action 2. Improving Patient Care Stroke services Really good work has been done this year to improve the experience of local people who have suffered a stroke and to raise awareness of stroke and the risk factors. The Stroke Association also ran a number of well attended awareness raising events with the public on behalf of the CCG. The CCG commissions an Early Supported Discharge (ESD) service, which is provided by Oxleas NHS Foundation Trust. Early supported discharge enables medically suitable stroke patients to leave hospital early through the provision of intense rehabilitation in the community at a similar level to stroke unit care. For the time period that they would otherwise have been receiving in-patient rehabilitation (usually up to two weeks), stroke survivors receive at least five sessions per week of occupational therapy, physiotherapy and speech and language therapy as required. Following the initial intensive rehabilitation period the therapy regime reverts to a level of normal community rehabilitation as required. One person who has benefited from all this recent work is Mike Evans from Kidbrooke. He told us about his experience: In addition, the Stroke Association provides four services for the people of Greenwich: A Communication Support service, which is designed to maximise, as much as possible, the communication skills lost as a result of suffering a stroke and to develop new strategies for communicating A Life after Stroke service, which delivers information, advice and emotional support and helps survivors adjust to the changes caused by the stroke, as soon after their stroke as possible A six-month review for all survivors of a stroke A Prevention service which identifies residents of Greenwich with undiagnosed risk factors. The nurses, therapists and doctors were very understanding and sympathetic to my frustrations and how I was feeling after my stroke. I saw how each nurse, regardless of how busy he or she is, treats each patient with kindness, care and attention. One therapist told me about Stroke Insight, which changed the way I feel about my condition. I now feel lucky to be able to live in the moment without the constant chatter going on in my mind and I worry about things a lot less. The ongoing support and motivation from the stroke team has helped me rediscover my passion for writing poetry and gardening. It helps keep me focused and gives me a reason to get up in the morning. For more information on stroke, visit:

15 This is how I felt when I first experienced my stroke. From above looking down You can see all around But the puzzle doesn t fit anymore The pieces, need to be changed Also re-arranged To suit you! But not like before New adventures Phase me, as exciting as it is Simple tasks confuse me Just like a talk show quiz Slowly slowly climbing Up that steep hill Looking towards, the future With faith, courage, and will. This is how I feel currently. You have to lose to win Sometimes you have to lose to win But the prize is hard to see It s often like the wind that blows There but, where could it be Could it be the sun that shines Or the rain that falls at night Maybe the birds singing in the trees As they take flight Could it be so close to you That with your eyes, you cannot see Could it be, you take for granted The air that you breathe Could it be? You have to lose to win Mike Evans Stroke patient, Kidbrooke NHS Greenwich Integrated report 2013/14 13

16 Offering patients a variety of options of where they can go to have blood taken, in addition to the hospital, means they can fit it in around their work and home commitments at a time suited to them. Patients have already told us they really value the flexibility these new clinics offer and the opportunity to get their test done straight away. Paula Butler Phlebotomist, Clover Health Centre, Woolwich

17 Positive action 3. Improving Patient Care Phlebotomy and anti-coagulation services Local people told us that they wanted us to improve access to phlebotomy and anti-coagulation services. Before making any changes, we talked to patients and to patient groups, such as Healthwatch Greenwich, to understand what they were looking for in any new services we developed. Patients told us that they did not want to go to hospital unless they really needed to, and that they wanted better, faster access to blood-testing and blood-clotting services closer to where they lived or worked. We acted on this vital feedback by looking at making services available across the entire borough. We decided it was important to retain the existing phlebotomy and anti-coagulation service at Queen Elizabeth Hospital, for patients who either need a hospital-based service or choose to attend hospital for their blood tests. The service at QEH is now going to be complemented by 33 new community-based clinics that offer a range of clinic locations and opening times across the borough, ensuring patients have both shorter travelling times and shorter waiting times when they need to have blood tests done. In June 2014, we started the roll out of the new clinics to introduce these improvements to blood-testing and anti-coagulation services. This is to ensure Greenwich patients have better-quality services and more choice over where and when they access the services. Whether it is routine blood tests or more serious tests for blood-clotting, the new clinics and the existing service at QEH are a real boost for patient choice and convenience. As NHS commissioners, our aim is to ensure that key services are designed around the needs of our patients and feedback from patients is already showing that they are pleased with the options that are now available. Recovery College Working with Oxleas NHS Foundation Trust, RBG and local voluntary sector partners, this year we have developed the Recovery College. This aims to support people who have been discharged from hospital services to be cared for by their GP and closer to home. The courses on offer are for people with a lived experience of mental health or substance misuse, their friends, families, carers or practitioners from across the Royal Borough of Greenwich. GPs or other healthcare professionals can refer people to the service or people can self-refer. The courses are designed to support the individual s recovery and give them the skills they need to carry on with their lives. Enrolment is very easy: people call and arrange to meet with a helper. The helper takes them through the process over a cup of tea. An increasing number of courses and workshops are available and these are set out in five course programmes. The courses vary in content, length and types of activities. These may be linked to their condition, such as how to recognise issues and cope with them, or management of their medication, or may be totally unrelated to help them gain skills, such as IT or desktop publishing. These could give them the help they need to get back into work. The courses are free of charge and, as the programme is rolled out more widely, it is hoped that expert patients will be running some of the future courses. How to access the Recovery College NHS Greenwich Integrated report 2013/14 15

18 Positive action 4. Improving Patient Care Improving Access There are a number of different ways in which Greenwich residents can access urgent care. They may choose to call NHS 111, see their GP, visit an Urgent Care Centre or call at their local pharmacy for advice. With so many options, local people have told us that services can be hard to navigate and some people are left not knowing where to go for the right care. From November 2013 to January 2014 we ran a public consultation called Right Care, First Time. We received responses from over 1,300 Greenwich residents from all walks of life and over 80 per cent of people who responded told us they support putting GPs at the heart of urgent care provision in Greenwich. Local people want to be able to access GPs and primary care services more easily, and would like to have increased telephone support. At the moment, too many people go to A&E departments in hospitals for conditions that are not caused by accidents, or are not emergencies, because they feel unable to access primary care. We have worked hard this year to understand the reasons why a sizeable number of local people are not registered with a GP and to promote GP registration as the most effective way to reduce health inequalities and improve access to health services for Greenwich residents. Encouraging everyone who lives in the borough to register with a GP has real benefits. By registering they would have access to health screening, enabling them to receive prompt treatment, and the relationship that can be built with their GP gives better continuity of care. So if you are not registered with a GP, please make it a priority to visit your local GP and add your name to the GP s register. We also decided to test with some GP practices new ways of providing routine and urgent appointments, so that we improve access for patients this is our telephone triage pilot. The telephone triage pilot involves GPs providing an initial consultation to patients over the phone and conducting an initial telephone triage of all requests for appointments, telephone consultations or visits. GPs start taking calls from patients from 8am as soon as surgery phone lines are open. During the phone call, patients are able to talk through their symptoms and concerns, and benefit from the GP s clinical expertise, just as they would in an appointment at the surgery, but without needing to physically attend surgery if this is not convenient. On the whole, patients especially parents of young children or people who have work or other commitments say they are glad of clinical advice from a GP at their regular surgery. If, after the doctor has spoken with the patient, they decide he or she needs to attend the surgery, the doctor is better prepared for the patient s appointment, as they will already be familiar with the patient s condition. For every 30 telephone consultations with patients, roughly four to five of those patients find there is a need to attend the surgery. By and large, patients say they are happy with being able to speak to a GP and have their health concerns dealt with by phone in the first instance. For their part, GPs cite several benefits of telephone triage they report being less stressed and more in control of their workload. Dr Lee, GP Commissioner, says: Telephone triage works well in our surgery. It appeals to a range of patients, from those patients with work or personal responsibilities that make it difficult to attend surgery, to those patients who need that extra bit of reassurance. Many patients do choose not to attend the practice after they have spoken to a GP and feel their health needs have been met. Some of the positive comments from patients include: Better as do not have to wait for an appointment. Saves having to take time off work. Better as do not need to come in for things that can be sorted out over the telephone. Better as appointment may be in seven days and you may forget or not need the appointment then. Easier to contact a GP than before. Keep the appointment system like this.

19 My GP colleagues and I have worked hard to make telephone triage fit the needs of our patients and telephone triage is as patientfocused as the rest of the care provided by the surgery. Dr Eugenia Lee Clinical Commissioner, Thamesmead NHS Greenwich Integrated report 2013/14 17

20 Positive action 5. Improving Health Outcomes Diabetes We are bringing care out of hospital and closer to where patients live, ensuring more GP practices offer high quality care for people with diabetes. To improve the experience of patients with Type 1 and Type 2 Diabetes, we set up a consultant-led Community Diabetes Service as an alternative to hospital. The service is a one-stop shop, which brings together a multi-disciplinary team (MDT) of specialist dietitians with advanced knowledge of weight management, such as the Very Low Calorie Diet and extensive carbohydrate counting skills including ethnic food variations. The MDT also includes specialist podiatrists, a specialist psychologist, acute consultants, diabetes specialist nurses with extensive experience in managing patients with complex needs, and clinicians based at the Diabetes Day Centre at Queen Elizabeth Hospital, as well as in community locations across Greenwich. Patients with Type 2 diabetes are encouraged to take part in the DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed) self-management course led by diabetes specialist nurses with support from clinical psychologists and specialist dietitians. Under the DESMOND programme, patients learn the skills and lifestyle changes they need to avoid the serious health problems that can result from poorly managed diabetes. We worked with GPs and community health providers to make improvements to the diabetes service and the service now regularly treats over 500 patients a month in community clinics throughout Greenwich. Patients say they find it more convenient to be treated in clinics that are close to where to they live or work. In turn, the hospitalbased clinics can look after more serious cases. As a result of the service changes, Greenwich now has one of the lowest admission rates for diabetes complications in London. Over 1600 patients were helped by the Diabetes service during Of this number, over 600 patients benefited from the dietetic service and over 600 patients took part in the DESMOND course Most importantly, the team has been able to consistently discharge patients back to their GP s care over 700 patients were discharged between 2013 and In addition, we work with our Royal Greenwich Public Health partners to improve local health outcomes in relation to diabetes through the early identification and management of people at risk of Type 2 diabetes. The roll-out of the National NHS Health Check Screening Programme continues to be highly successful in Greenwich; screening eligible patients for Type 2 diabetes (as well as heart disease, stroke, kidney disease, depression and dementia) in general practice and other community settings. This leads to faster and more effective treatment, including access to local healthy lifestyle support services. For example, patients identified as being at high risk of developing Type 2 diabetes are referred to Walking Away from Diabetes ; a structured self-management programme (part of DESMOND) to support patients to make lifestyle changes to reduce this risk. For more information on diabetes, visit:

21 I am embracing my days with happiness and ease because of the care and attention from the diabetes team. I thank them from the bottom of my heart for the respect they gave me. I wish the nurses and dietitians in the diabetes team the very best as they go on to treat and care for others. I know other people will benefit as I have from the team s dedication and fortitude. Linda Ellen Diabetes team patient, Eltham NHS Greenwich Integrated report 2013/14 19

22 When health services are being designed, there is no substitute for local knowledge and we have that in abundance. Judy Smith MBE South Greenwich Forum, Eltham

23 Positive action 6. Improving Engagement At NHS Greenwich Clinical Commissioning Group (CCG) patients, carers and the general public are central to commissioning the right services. Listening to what patients and local people tell us will help us to deliver a better standard of care and improve healthcare and health outcomes for our local population. We are passionate about capturing and listening to patient and public voices to ensure locally responsive healthcare commissioning and to drive up the quality of care. We have worked with our Patient Reference Group this year to develop our Patient and Public Engagement Strategy, which aims to engage patients and the public through the Commissioning Cycle. Engagement with our member GPs is extremely important and allows us to ensure their clinical expertise is informing our decisions. GPs have been involved in the commissioning of services, the monitoring of contracts and the assessment and assurance of the quality of services. They meet regularly at the Greenwich Wide Forum and have elected syndicate leads who are able to represent their views and feedback to them on a wide range of issues. We also survey their individual views regularly and GP Clinical Project Leads are involved in all our transformational work, to ensure that we are a clinically-led organisation. A major consultation took place this year called Right Care, First Time aimed at getting local people s views on how we could improve urgent care in terms of both access and quality. The consultation ran over four months and was wide ranging. The views of local people are now informing the development of the specification for the re-procurement of urgent care services to ensure they are fit for the future. In addition, we have been engaging on the redevelopment of Children and Adolescent Mental Health services and have been involving service users, carers and families to ensure their experience and views are informing any service redesigns. To ensure local people s views are informing the development of the community hospital in Eltham, Judy Smith, MBE, of South Greenwich Forum has been closely involved. I am a community representative on behalf of South Greenwich Forum, the information exchange network for community groups in the south of the borough; our members represent over 10,000 households. Much of my community work involves talking to and working with local residents associations, NHS Greenwich CCG, the Royal Borough and other groups to make sure that changes and improvements to the health service are achieved with input and support from local residents after all, we will be the ones using the services. I m proud of the changes I ve seen in 30 years as a community representative. I ve seen a real focus on preventative care, thanks to the NHS and the Royal Borough working closely together to make sure people receive help early, to stop little problems from turning into big problems. The best change of all is the new Eltham community hospital. We not only have better healthcare closer to home, but as a community we have helped ensure the hospital meets our local needs. NHS Greenwich CCG s Commissioning Engagement cycle Monitor and learn Working with patients & carers to monitor services Working with patients & the public to procure services Working with communities to identify needs & aspirations Engagement Strategy Culture & Systems Analyse and Plan Working with the public to plan and transform services Working with patients & carers to improve quality & safety Design and Improve NHS Greenwich Integrated report 2013/14 21

24 South east London Commissioning Strategy Looking to the future We will continue to work with our partners and local people to improve healthcare services and are working to refresh the joint Health and Wellbeing Strategy. We have developed our five year strategy, linked to the south east London wide strategy, which sets out the longer-term vision. We are seeking improvements in key areas as follows: Wider primary care: We will develop a primary care strategy to improve GP services. We will pilot more new telephone and internet-based systems in GP surgeries to make it easier to see a doctor, and practices will be helped to come together as local care networks, so that they can offer a greater number of services in the community. A modern model of integrated care: We will build on the pioneering work that is being progressed in Eltham through the coordinated care model (detailed in the case study on page 11). A second pilot is now being run in the Woolwich/Thamesmead area prior to a wider rollout across the borough. Improving Health: We will work to address the major root causes of ill-health in Greenwich including negative behaviours such as smoking, physical inactivity, and substance misuse. We will also build on existing successful services which keep people healthy. We will work with public health, primary care, and NHS service providers to help diagnose long term conditions sooner and we will develop new services that will help patients diagnosed with long term conditions to stay healthy and prevent acute illness. Additionally, we will work with our partners in Public Health to improve access to health protection, such as immunisation, screening and sexual health services. Reducing Health Inequalities: We will provide help to high need families across the borough to increase resilience and ensure an integrated approach from health and social care. Inequalities for children and young people with respect to sickle cell anaemia, tuberculosis, and vitamin D deficiency will also be addressed. In order to track our performance, we will roll out improvements to the Equalities Delivery System. Parity of esteem: We will continue to seek improved outcomes from our main mental health services providers, including Oxleas NHS Foundation Trust, and integration with third sector providers, acute, and community services. In future a greater emphasis will be placed on physical health in order to improve the outcomes for patients with poor mental health who are far more likely to die prematurely of preventable illness. We will develop enhanced primary care mental health services to help patients manage better in the community. An early diagnosis of dementia project will increase capacity and awareness within acute, community and primary care to ensure that diagnosis rates improve. Urgent Care: Access to high quality urgent and emergency care: We will implement our model for unscheduled care which was consulted on with the public ( Right Care, First Time ) and will re-procure urgent and out of hours care as one coherent service. The urgent care centre at Queen Elizabeth Hospital will be expanded. We will work with our local providers to ensure that they meet national quality standards in Accident & Emergency. Improving the productivity of elective care: We will provide greater support for patients before they need an operation to keep them healthy and informed and, where possible, for them to receive care nearer to their home; to ensure when an operation is required, that patient outcomes improve dramatically; and that after an operation patients are supported within the community to ensure that they stay healthy. Patients are supported within the community: We will ensure that they stay healthy. We plan to reassess how services for musculoskeletal care, ophthalmology, cardiology and other long term conditions are provided. We will also review endoscopy, neurology, and urology services from 2014/15 with a view to providing more of this care in a community setting and reducing unnecessary procedures. Anti-coagulation and phlebotomy services will be provided in the community with added convenience for patients. We will also offer a wide variety of services, including surgical day cases, from the Eltham Community Hospital from 2015/16. Implementing Local & National Quality Priorities: Following the Francis Report and further recommendations from the Berwick Report, Keogh Report and Winterbourne View case, a programme of work including a Quality Action Plan has been implemented by the Quality Committee, working with Clinical Quality Review Groups from our local NHS Trust. We will also work with our local providers to ensure that they meet quality standards for maternity and paediatrics where specific issues have been identified (e.g. consultant cover). We will continue to improve systems for gathering information and intelligence on the quality of commissioned services, and we will support care providers to deliver the six action areas from the Compassion in Practice implementation plans. Reducing our carbon footprint: We have carried out a number of initiatives including promoting cycling to work, increasing the use of technology to complete management tasks rather than travelling to meetings, stopping using bottled water, sharing printing and moving to greener equipment, and building waste reduction targets into provider contracts. We will continue to build on this work for a more sustainable future. 22 NHS Greenwich Integrated report 2013/14

25 South east London Commissioning Strategy The six clinical commissioning groups (CCGs) in south east London (Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark) have agreed to work together with commissioning colleagues from NHS England London region on a five year strategy to improve health services across south east London. This is being developed to tackle particular issues which need collective action across south east London to be successful. This also meets the NHS England requirement that all CCGs produce a commissioning strategy. This work is being undertaken in partnership with local authorities, local clinicians, social care leads, hospitals, community health services, mental health services, patients, carers, Healthwatch representatives, patient and public voices and local people across south east London. The strategy focuses on seven key areas: Urgent and Emergency Care Primary and Community Care Maternity Children and Young People Long Term Conditions Physical and Mental Health Planned Care Cancer. The overall shaping of the strategy is done by the Partnership Group of senior leads from each of the partner organisations, local Healthwatch organisations and local patient and public voices, and is chaired by a CCG clinical chair. The programme board for the strategy is the Clinical Commissioning Board, the members of which are the clinical chairs of each of the CCGs, local authority leads, local Healthwatch organisations and local patient and public voices. It reports to the Clinical Strategy Committee of the six CCGs, which in turn reports to each of the CCGs Governing Bodies. The work is already underway and progressing well. Clinically-led commissioning leadership groups have already been set up for each of the seven key areas to determine the specific workstreams that need to be developed for the strategy to be successful. There will continue to be extensive engagement with the public in each borough and across south east London. Feedback from this engagement and involvement will continue to inform further development of the strategy. In our first year, we made great strides in improving healthcare in Greenwich, but we recognise that there is still a lot of work to be done. An artist s impression of the new Eltham Community Hospital NHS Greenwich Integrated report 2013/14 23