NHS City and Hackney CCG Programme Board Commissioning Intentions for 2016/17

Transcription

1 NHS City and Hackney CCG Programme Board Commissioning Intentions for 2016/17 City and Hackney CCG and Hackney Council Commissioning Intentions Event 2016/17 Tuesday 2 nd of February pm-8.30pm The Tomlinson Centre

2 Content Long Term Conditions...slides 3-7 Primary Care Quality...slides 8-12 Planned Care.slides Children slides Maternity..slides Urgent Care and Integrated Care...slides Mental Health.slides Prescribing..slides Sustainab

3 Long Term Conditions Programme Board

4 Long Term Conditions You Said We Did Peer Support Extra time with GPs You Said Support the supporters with training and supervision Provide condition specific as well as generic peer support Use a range of community venues We need a longer consultation when diagnosed with a long term condition We did We have commissioned Hackney Centre for Voluntary Services to provide central training, quality monitoring and support to organisations delivering peer support groups 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 Groups will be delivered from a range of different community venues We commissioned time to talk extended GP consultations for people with multiple conditions and extra time for consultation for those newly diagnosed

5 Long Term Conditions Our plans for 2016/17 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 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 (Please also see joint commissioning intentions with the London Borough of Hackney) Provide specialist rehabilitation programmes for those with specific conditions such as heart and lung problems Provide expert care and support for those with severe asthma, learning disabilities and diabetic foot complications across hospital and community services Support people with sickle cell disease to live full lives with input from psychologists, social care professionals and 24 hour support

6 Long Term Conditions Key Questions How can we help you feel supported to manage your Long Term Condition? How can we improve on things to save your time? Do you have a care plan and is it useful?

7 Long Term Conditions 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

8 Primary Care Quality Programme Board

9 Primary Care Quality You Said We Did At last years commissioning intentions event the discussion took place around a quality dashboard under development and selected indicators the CCG looks at in terms of the quality of primary care. Dialogue focused around markers of quality in general practice, how the quality of care provided across City & Hackney practices can be maintained/improved, and what could be achieved if the CCG were to be given more control over the commissioning of primary care. The completed Primary Care Quality dashboard comprised of 21 indicators and has been shared with practices to promote sharing of best practice and identification of areas in which practices may need additional support. The dashboard will be updated and shared annually. This year, the Primary Care Quality Board has also 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

10 Primary Care Quality Our plans for 2016/17 Work in partnership with local stakeholders towards delivering outcomes in line with the Primary Care Strategy Continue developing quality of patient care and supporting clinicians commissioning behaviours through the Clinical Commissioning and Engagement Contract Commission IT support service from CSU to maximise the efficiency by which practices can run their IT systems Commission support from the Clinical Effectiveness Group Continue to develop and update the primary care quality dashboard to allow identification of areas where practices may need additional support Delivering the Forward View: NHS Planning guidance 2016/ /21 National must dos for 2016/17 Develop and implement a local plan to address the sustainability and quality of general practice, including workforce and workload issues.

11 Primary Care Quality Patient and Public Involvement Throughout the last year we have consulted with patients and the public in the following ways: - We have a Patient Representative position on our main Primary Care Quality programme board where work plans, strategies and areas for development are discussed - We have engaged with the public at events including the CCG s Annual General Meeting - We have consulted with the CCG s Patient and Public Involvement Committee on our plans, including those for the CCE contract and the Primary Care Strategy We plan to continue discussion via all these mechanisms in the year ahead.

12 Primary Care Quality Key Questions What are your thoughts on: Saturday morning opening / 7 day opening Booking appointments online Electronic consultations Ordering prescriptions online Are there other priorities 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?

13 Planned Care Programme Board HOSPITAL & COMMUNITY SERVICES Inc. CANCER

14 Planned Care 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 We commissioned improved blood collection services which will be available to every patient either from their own practice or one nearby. 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 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

15 Planned Care 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 provided by the Homerton 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* 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/ /21)

16 Planned Care Our plans for 2016/17 Cancer: Improve access to investigations for GPs (MRI/Ultrasound/Endoscopy etc) Improve follow up pathways and patient experience build on time to talk Misc: 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 Improve the services for patient interpretation services (deaf and non- English speakers)

17 Planned Care 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?

18 Planned Care 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 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. Ophthalmology: Engaged Healthwatch s (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.

19 Children s Programme Board

20 Children s Programme Board You Said We Did Engaging with children, young people (CYP) and parents Commissioned a Children s Disability Forum from the Huddleston Commissioned a Choices engagement project with YOH, a youth service in Hackney Early feed back from engagement tool rolled out by Homerton Hospital Want to support children with complex needs but very concerned about Personal Health Budgets Established a PHB service for children with a Continuing Health Care Package 8 of 15 eligible children sought referral to the service, 3 PHBs are live and others are in the care planning stage Excellent feedback from one family s 12 week review We want joined up services and want to protect Hackney Ark health and social care delivered together Social care team not based at the Learning Trust but operationally still integrated working Designated Medical Officer leading health s contribution to Education and Health Care planning Homerton delivered Integrated Epilepsy Service local support and coordination for all City and Hackney children

21 Children s Programme Board Our plans for 2016/17 Service Plan What difference will this make Early Years A new service building on the antenatal, postnatal and vulnerable children s provision currently provided by GPs GPs will deliver targeted support to women and families from pre-conception to school age GPs will deliver the service working closely with Midwifes and Health Visitors SEND Work with education and social care to deliver Education and Health Care Plans that meet the needs of children and young people and are co-produced with the child / young person and family Ensure all relevant health information is on both the Hackney and City Local Offer websites Bring the EHCP and Personal Health Budget (PHB) processes together into one where best for families 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 pathways across different organisations 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 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 PHBs 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

22 Children s Programme Board Our plans for 2016/17 continued Service Plan What difference will this make 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 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 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 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 Joint work with Hackney and the City Build on the learning from our planned self assessment of delivery of SEND reforms Hackney -Respond to the concerns raised by the Orthodox Jewish community (via Interlink) re: - Speech and Language therapy - Occupational Therapy Families have a positive experience of services and pathways that are commissioned / delivered / accessed across health and social care

23 Children s Programme Board Patient and Public Involvement We want to agree an engagement strategy with our Children s Board PPI Representatives, informed by our recent engagement work: Children s Disability Forum - learning from the CCG led meetings, tender process and early work plan being taken forward by the newly established steering group NHS Community Voices meetings, including the Education and Health Care Plan meeting held in January 2016 With London borough of Hackney, SEND reform engagement with HiP (Hackney Independent Forum for Parents/ Carers of Children with Disabilities) and Interlink Our current plans via the Children s Disability Forum 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 Early years - engagement via Children s Centres intended to support cross health and social care engagement Young Hackney and City Gateway- joining up our consultation and engagement work with established forums well used by young people

24 Maternity Programme Board

25 Maternity You Said We Did Continuity of care Having the same midwife through pregnancy, birth and after had baby continuity was probably key knowing your midwife makes all the difference Birth Choices Ensuring pregnant women have accurate and realistic information about what to expect of a maternity service and what options there are (e.g. birth centre, home births). Flagging up the options at early GP appointments. Ensuring pregnant women are aware of the choices available to them. Vulnerable Women Supporting vulnerable and at risk women - agreed we should focus on transition points and supporting very vulnerable women though shared information and management. Utilising community resources. Asset based approach. We have proposed a scheme for the Homerton so women see the same midwife through their pregnancy and after they have had their baby. This build on the scheme in 14/15 which saw 67% of women seeing the same midwife throughout their pregnancy. In 2015/16 we have supported the Homerton to increase the numbers of women choosing to have a midwifery led birth, at home or at the birth centre. We are aiming for 21% of women to be choosing these options and delivering in these settings. The MSLC plans to undertake more work in 16/17 with women to understand how they understand their options and how they can be better communicated to women. In 2015/16 the vulnerable women s maternity care pathway has been signed off and audited. In 2016/17 GPs will be commissioned to deliver more risk assessments for women right at the start of their pregnancy. Various local community organisations are delivering ante and postnatal projects with vulnerable women.

26 Maternity You Said We Did Continued Improving the environment at Homerton hospital Equitable breastfeeding support across the borough including effective use of volunteers The reception area has been refurbished, and more ideas are being considered about how best to improve the environment when space cannot be extended. Delivery of antenatal classes by communities to communities Better links to UCLH and Whittington what is their maternity service offer? The pilot of a 3 rd scan was welcomed as it seems very long between 20 weeks and birth not to have an update and it was reassuring to women, as well as picking up issues Information that goes to GPs from HUH maternity was seen as a nightmare as instead of receiving updates GPs got all previous notes so lots of repetition. It would be safer to provide a succinct summary at the beginning of the pregnancy (once booked for maternity care) then very short updates thereafter, as long notes means a GP may miss a critical fact in the reams of information. The CCG has funded the Breastfeeding peer support project and new volunteers have been recruited to deliver help in hospital, antenatally, at home and at more postnatal drop in clinics. Four different pilot programmes of antenatal classes have been run in 15/16 by different and for different communities. The 3 rd scans have not yet started but are being discussed more at the Programme Board. Links with UCLH and Whittington are being developed. Information sharing between GPs and midwives has been discussed at length and the new Health Information Service, which allows Homerton and Primary Care health professionals to view each others records (with patient consent) will help GPs and Midwives be able to see notes, updates, test results, etc.

27 Maternity Our 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 and subsequent CQC inspection. This will be achieved by monitoring performance, clinical audits, external review and comparing outcomes to other hospitals. Ensure women have a good experience of care throughout the pregnancy, during labour and birth and after they ve had their baby.

28 Maternity Our plans for 2016/17 Continued 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. Joint 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.

29 Maternity Patient and Public Involvement Maternity Service Liaison Committee 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 we expect to have some firm figures and feedback at the end of January. Walk the Patch Our MSLC delivered a patient survey with over 70 brand new mothers and fathers on the 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 The survey also started to be repeated in Autumn 2015 and is continuing now. We should be able to see what has changed, what new issues have arisen and what stubborn issues remain. 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. CQC / Picker survey workshop The Homerton are responding to the results of their national patient survey and will be sharing the findings and actions for 16/17 in the next few months. 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 feedback themes at every meeting. We have also reviewed a thematic report on complaints and will be doing this annually from now on.

30 Integrated Care and Urgent Care

31 3 1 Urgent Care You Said We Did 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) 2. Enhanced access service most practices are now open earlier and later during the weekdays and also some are open on Saturdays and Sundays) 3. Non-clinical Navigators based at the Homerton accident and emergency department give advice and sign-post 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. 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.

32 3 2 Urgent Care You Said We Did 3. You wanted Improved pathways of care to enable services to work together better in the community better coordinated care Our response. 1. One Hackney & City lots of different health care professionals working together to help patients receive better care that is joined up 2. Integrated Independent team A range of services, including rapid response, intermediate care rehabilitation and home-care reablement. 3. Frail Home visiting service run by your GP practices for patients that are housebound and need more coordinated care. 4. More GP s in the emergency department 5. 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.

33 3 3 Urgent Care What we want to do in 2016/2017 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

34 3 4 Urgent Care What we want to do in 2016/2017 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

35 3 5 Integrated Care What we want to do in 2016/2017 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

36 Mental Health Programme Board

37 Mental Health Life in Hackney Starting off well MHPB Commissioning Intentions 16/17 We will 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. 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. Impact Vulnerable parents are identified and supported early on to ensure mental health and well-being of family is considered. Reducing potential developments of mental health problems in children. Principles of emotional well-being embedded early on through ante-natal class. Children with an ASD diagnosis and their families will have recommendations from the assessment service and formal link to SEND plans and school pathways Adults with an ASD diagnosis will have access to support provision and a specialist assessment service which can advocate for needs of this group 37

38 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 38 Improved mental health resilience in young people

39 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 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 Ensure culturally sensitive, relevant and inclusive provision 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 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. Community groups are adequately represented in participation activities This is across demographics, seldom heard groups, BME communities Services are designed with local people in mind, therefore increased likelihood of access and continued engagement Clearer pathway into housing with support in 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 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.

40 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 Hackney and the Dementia Alliance, and by improving access to accommodation 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 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 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 Hackney to be met 40 Impact The experience and outcomes for people with dementia and their families living in 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. 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.

41 4 1 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. 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

42 42 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 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 5-13yrs Strong links with schools and community groups including informal parent support for families with children who have disabilities Psych. 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 Therapies 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

43 Mental Health Improvements our residents will experience by the end of 16/17 Prevention Crisis 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 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 43

44 Prescribing Programme Board

45 Prescribing You Said We Did You Said We did 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 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, across City & Hackney 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 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 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. 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 NHS City and Hackney CCG is undertaking a tendering exercise to identify a provider for a new Consultant led Community Warfarin Service in 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.

46 Prescribing 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 Why? drugs. 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

47 Prescribing 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 in the Planning Guidance for Delivering the Forward View Proposed Service Change 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.

48 Prescribing 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 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 consent.

49 Prescribing 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. DMARDs require regular Why? monitoring as they can cause side-effects which can be serious therefore patients are 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 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

50 Prescribing Consultant Led Community Warfarin Service Why Currently, many patients in City and Hackney 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

51 Prescribing 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 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.

52 Eliminating Waste & Inequality

53 Stability Reduce CO 2 Resilience Equality & Diversity Eliminate Waste Adaptation Social Value Economic Growth Companionship Resilience Inclusion Fairness Mobilisation Giving time Access to services Supporting communities Volunteering Access to Green Spaces Active Travel Biodiversity Growing Food Diet & Exercise Improve Air Quality Reduce congestion Environment Buying local Social Health & Wellbeing Economic People s time Creativity & Potential Training & Education Well workforce Living Wage Responsible employer Buying social, ethical Innovation & Technology C&H Efficient services / operations Quality & Compliance

54 What do we mean by waste? Waste; anything that is squandered and not put to best use.. Clinical Environmental Social Financial What does this waste look like? Resources Medicines / Prescriptions Overbuying Travel Space or assets Error Potential Opportunity Unnecessary Care Redundancy Preventable conditions Low value procurement Poor sharing Duplication Underutilisation Time staff and patient Inefficiency

55 Equality & Sustainability Why equality & sustainability Significant overlap between Equality Agenda and many aspects of social value / sustainability. Equality 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 the Equality Delivery System with this SDMP.

56 Opportunities Influencing Procurement Influencing how large providers procure would be hugely beneficial to improving local areas. Improving resting spaces and amenities in busy environments and poorer communities was identified as a priority for Hackney. An example was given of Ridley Road Market, Dalston; a prime location for those on lower income to buy fruit and vegetables, however the area has nowhere to sit and rest for people visiting who may be elderly or of ill health and is also a hectic environment. Overall suggestions of local priorities that sustainable procurement should influence include: Quieter spaces in busy environments Improving and increasing green spaces Growing food / things, caring for things Access to libraries children s clubs, reading, access to computers. A requirement in CI could be for sustainable procurement plans to focus on key local priorities. If is required of the GP Confed, sustainable procurement could filter down to Practices too. Could the Confed provide guidance too?

57 Opportunities Communications between services Writing letters, faxing and other communications based inefficiencies still occur frequently between providers and partners especially related to appointment booking, referrals or transfer of records. This translates to: paper waste, printing waste, postage costs and time delays. It would be beneficial for organisations to undertake a mapping exercise of all routes of contact between different services to highlight hotspots and easy routes for improvement. There are, however some intrinsic difficulties in successfully getting different systems to talk to each other effectively, and this is an issue that is longstanding in the NHS. We do not want to join this band wagon, but instead look at practical local improvements. This should include communication between: Mental Health Providers Community Health Providers Acute Providers Social Services GP Practices Other?

58 Opportunities Prescriptions: When entering hospital If a patient enters hospital with current medication prescribed by their GP, it is taken from them on entry at the hospital but not returned. This results is a GP needing to re-prescribe when the patient is discharged. A better system could be devised where patient s medications are returned although this would need to ensure strict protocol to make sure the right medication is given back to the right patient. Prescriptions: End of life care If a patient is discharged during end of life care they are often overprescribed controlled medication to make the process easier for family and friends by reducing pressures such as a need to collect further prescriptions. While the sensitivity to the family should remain in this situation, other solutions could be trialled, for example: a weekly delivery service of prescriptions for such situations.

59 Opportunities Social Prescribing The social prescribing service is viewed positively, but there is a voiced need for more of a feedback loop to the GP. Sharing of resources and information would be beneficial to many situations where a full referral to the social prescribing service is not necessarily required, but some of the insight (e.g. a local group to support autistic children) could be widely beneficial to an individual consultation. A directory of support organisations could meet this need. Advice lines A number of specialist advice lines are used regularly among particular services that were spoken highly of, and deemed helpful to support general practice. The possibility of expanding this service into other areas should be explored.

60 Opportunities Reducing Clinical Waste Clinical waste was discussed as a problem area across the system with an opportunity for significant financial and CO 2 savings. It is also an opportunity that both large Providers, small providers and GP Practices can get behind and become a priority focus across the borough for 2016/17. This could include: Better management of clinical waste across organisations to ensure only clinical waste items go in the clinical waste bin. A campaign developed to run across all relevant sites with clear signage and a short briefing. Clear reduction targets for 2016/17

61 Opportunities Community Pharmacy There were several discussions around waste in prescribing that the CCG could influence: Electronic Prescriptions There was discussion around how well electronic prescriptions worked and appeared to be a lack of uniformity across different pharmacists with prescriptions not always being received and then a need to re-prescribe. Uncollected Prescriptions there a huge number of uncollected prescriptions at pharmacies this could possibly be related to errors in the electronic system buy more evidence of why they are uncollected is required. Photo / Video consultation for specific conditions While it was acknowledged the reason why specialists preferred to see a patient in person for a referral appointment, rather than a photo / video consultation, it was suggested that a trial could be undertaken where both routes are carried out for a trial period to help understand where a photo / video consultation would be appropriate, and where it would not.

62 Opportunities Engaging with the public The key to transforming services is engagement with the public to improve understanding, expectation, and reduce demand on some services (e.g. GP) by mobilising them to go directly to the right service (e.g. self referral and community pharmacy). The NHS needs to work with the public to sustain the NHS. The more the public understands about how it works the more Practitioner and Patient can work together to achieve better health & wellbeing.

63 Opportunities General Practice There were a number of areas of focus that specifically related to General Practice, but will be important to capture and develop within the 2016/17 sustainability plans for the CCG. Diagnostic Coding this is time consuming and often requires a GP to code and re-code medical information across different systems. Choose & Book some choose and book functions do not work properly for city & Hackney services (e.g. urgent appointments) and when printing appointments out for patients the system print is three pages long. Paper & Printing Different tests need to be printed out on different paper. A lot on unnecessary printing still occurs.

64 Questions Any general feedback/comments? Where is the Waste, how do we eliminate it? Where are the most detrimental E&D gaps, and solutions? Are we working in the right partnerships? How and where do we best influence providers? Are we using technology enough, or well enough? How do we best fit the sustainability lens into the everyday? Are there any other areas we should focus on?

65 Finally, 2016/17 Key Themes Partnership working expanded alliances/aco Membership Greater integration with physical health pathways Revision of MH payment systems 5 Year Strategy for MH services to ensure sustainability and stability Developing Public Mental Health services, not just specialist services Increased focus on access, outcomes and equity 65

66 Discussion Are we focusing on the right things? How can we make our resource go further? Where is there waste in the system? How can we ensure a system of shared outcomes across pathways and providers? How we can build a true model of prevention focused public mental health and move away from specialisms? If you had a magic wand, what are the things you would change? 66

67 2015 Commissioning Intentions Event Feedback on Reducing Waste Remove all admin burden for clinicians so they can devote their time to treating patients Outcomes clinicians and service users to be able to assess this together Integrated physical mental health Too much duplication, e.g. assessment Find things beyond one year to reduce cost of recruitment with fixed term contract ending Magic wand - Clarity regarding funding over minimum of three years Doing with less effective joined up pathways Coherence for continuity Needs analysis Joint commissioning intention Commissioning and contract management overheads could be streamlined through joint commissioning Magic wand issues. Five years funding ( three). Camden is doing baseline for nine years Allow enough time for changes in services to consolidate before making further changes/adjustments (as a general point) Keep reporting requirements and KPIs simple so no waste in staffing reporting Find a way to reduce admin/any unnecessary KPIs - Reduce time for clinicians focused on this.

68 2015 Commissioning Intentions Event Feedback Reducing Inequality Monitoring for peer support workers to increase their aspirations. Service users to take greater responsibility with their mental health Attracting bilingual young people into the work force Reducing inequalities Tackling stigma lots going on in schools but more focus on physical wellbeing rather than emotional nourishment People with no recourse to public fund at higher risk of poor mental health in the future Positive action to increase the proportion of mental health workers who are bilingual from a BME community More training opportunities for service users to work in mental health Bridging loans when service users benefits are late Lead provider model for contracts can be difficult if subcontractor does not see commissioner. Particularly if lead provider and subcontractor are in competition