Rural Locality Network Meeting 2-5pm on Tuesday 8 March 2016 at Cheshire View, Chester Chair Louise Davies (Vice Chair) APPROVED MINUTES

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1 Rural Locality Network Meeting 2-5pm on Tuesday 8 March 2016 at Cheshire View, Chester Chair Louise Davies (Vice Chair) APPROVED MINUTES Attendants: (see the embedded attendance list at the end of this document) In attendance: Lee Hawksworth Sarah Murray Tanya Jefcoate-Malam Diane Taska Brian Green Janet Durrans Nick Thompson Emma Lea Helen Cunningham Sue Pratt Pauline Roberts Simon Hill Director of Operations (WCCCG) Programme Lead Primary Care (WCCCG) Primary Care Manager (WCCCG) Locality Support Manager (WCCCG) Head of Quality and Safety (WCCCG) Clinical Services Manager for Aging Well (CWP) Membership Support Officer (Minutes), (WCCCG) Team Manager (Broxton) Team Manager (Princeway) Team Manager (Tarporley) Pharmacy Advisor, North West Commissioning Unit Community Geriatrician Present: Helen Black Andrew Campbell Jonathan Gregson Louise Davies Kylie Daniels Alistair Adey Simon Hall Sue Dewhirst Sam Jeffery Lynn Suckley Brian Yorke Debbie Bailey Neil Symonds Practices not represented by a GP: The Village Surgeries Minutes of Rural GP Network by 1 Date: 08/12/2015

2 Agenda No Action 1. Welcome & Introductions Steve Pomfret was on leave for this meeting and so Vice Chair Louise Davies welcomed a number of guests to the meeting: Emma Lea, Helen Cunningham, and Sue Pratt are the Community Team Managers for the three Networks clusters and were in attendance again to aid in the discussion about Ageing Well projects, as was Karen Townsend from the Countess of Chester Hospital. The meeting was also being attended by Lee Hawksworth and Diane Taska from the CCG, Community Geriatrician Simon Hill, and Simon Hall representing the Knoll Surgery and Frodsham Medical Practice. 2. Previous Minutes Nil Apologies Melissa Siddorn, Trevor Ferrigno, Paul Smith, Steve Pomfret Declarations of Interests Nil Actions n/a 3. Primary Care Update The Network heard updates on the various Prime Minister s Challenge Fund projects. It was noted that funding has been agreed and papers sent to FPCC for sign off for a further six months of Physio First and 12 months of the Wellbeing Co-ordinators. The Network heard that the required hardware for EMIS Anywhere/Mobile has been ordered and is expected to arrive at the CCG within the next week or so. From there, all items will have the requisite security installed and then be distributed to practices for commencement of EMIS Mobile/Anywhere. With regards to e-consult, arrangements are being made for a GP from the Halton/Runcorn area who has a lot of experience using the system to present at a session and provide practices with his experience and suggestion on how to make the most of the system. This session is planned to take place on 24 th March. There was discussion about the switch to out of hours calls being handled by 11 which is due to begin at the end of March. It was noted that a number of Rural patients live across the Welsh border and the network was interested to know the impact for those patients, as well as the interaction with Shrop Doc. It was also discussed whether calls to 111 would result in a third workstream on EMIS; the suspicion being that it would. It was agreed that a more complete update would be provided on the next agenda, and these topics would be discussed at the Practice Manager s Forum in the meantime. Minutes of Rural GP Network by 2

3 4. IRIS Action: Update from 111 to be on next agenda Action: Questions regarding 111 s interaction with Shrop Doc, the access of Welsh patients, and the presentation of 111 episodes on EMIS to be discussed at Practice Manager s Forum. Jackie Holland, who is employed between the CCG and CWP, attended the meeting to discuss the IRIS (Identification and Referral to Improve Safety) programme. Full details of the IRIS programme are attached to these minutes but Jackie explained the principle reason for her visit was to offer training to GPs and practice staff around identifying possible victims of domestic violence and the most appropriate and effective ways to provide these possible victims with avenues to seek help. The Network heard that referrals from the practice (made by clinical and non-clinical staff) go directly to Jackie and she takes over, managing the patient through a network of support bodies. 5. Being Well - The Buurtzorg Model The Network received a presentation from Brian Green and Janet Durrans about a model of community care currently in place in The Netherlands referred to as The Buurtzorg Model. The model focuses on a holistic approach to health and social care, providing continuity of care by working to ensure that all elements of a patient s care plan are delivered by the same people. The presentation slides accompany these minutes. The Network was enthusiastic about the model, stating that it provides true outcomes-based care. There was concern however that it would be difficult in an NHS health economy as the absence of KPIs would make it difficult to justify the use of public money in managing increasing demand for services. It was discussed that the overarching theme of the model is relevant as it takes the kind of borderless approach to health and social care the West Cheshire Way has been designed to work towards, and it was suggested that as money has been set aside within Vanguard to pilot projects that have an emphasis on aligning health and social care, it might be possible to identify the most relevant areas of the Buurtzorg Model for potential application in West Cheshire. Brian Green explained that he is due to take some time off from work due to a knee replacement operation, but on his return he would be happy to take such discussions forward. - Community Geriatricians The Network also heard a brief update from Simon Hill around the use of community geriatricians. He was asked whether community geriatricians are currently being used as well as they could be and he feels that this is not the case. He explained that it has been a frsutrtatubng second year with a lot of pressure from secondary to firefight as opoosed to managing patiens. The Network heard that some patients are now being admitted to Ward 51 at Minutes of Rural GP Network by 3

4 the Countess to be managed by consultant geriatricians, but community geriatricians do not have admitting rights to the ward and all patients requiring admission from the community still have to go via A&E or be moved there from other specialties wards. - Community Phramacist The Network also heard a brief update from Pauline Roberts regarding a pilot to introducing community pharmacists as part of the intergrated teams and to ask for feedback and input from the Rural Network as to how to develop the project. She agreed to distribute information electronically and receive input in the same way.this information is now attached to these minutes. Action: Pauline Roberts to circulate information via CQUIN 2016 The Network received a presentation containing specific information around the 2016 CQUIN. Full presentation is attached. There is a focus on care plans, and the Network commented that it is crucial that care plan related information goes both ways. TJM confirmed that aligning tools and encouraging an increase in the use of universal read codes is a focus and work is already underway with CWP in relation to contracts. There was also concern amongst the Network that so much of the CQUIN relates to admissions and admission of avoidance of frail and elderly patients while practices do not necessarily feel that they have a strong control over that during out of hours, particularly cases of patients in care and nursing homes where staff my call an ambulance at the slightest concern despite a GPs best efforts to build a robust and ongoing care plan to keep this patient out of hospital. It was agreed that Jim Ramsdale would be invited to attend the next meeting to discuss how best to align GP s ideas about the long term management of a patient and nursing staff s actions during out of hours. Action: Jim Ramsdale to be invited to next meeting. 8. Future Agenda Items The Network would like to discuss how to go about establishing a common care plan, accessible and referenced by all parties involved in a patients care. 9. Any Other Business The Network voted unanimously in favour of Steve Pomfret continuing as Chair of the Network. The Chair noted that this is Nick Thompson s last meeting. Next Meeting: 08 March 2016: 2.00 Cheshire View, Christleton City & E Port Network Minutes February 2015 EP&N APPROVED Minutes pdf City Minutes APPROVED p Minutes of Rural GP Network by 4

5 Key: Outstanding Actions NB: Actions will be taken off the table upon completion Current Overdue Ongoing Date Initiated Action By Whom Due Date March 2016 Update from 111 to be on next agenda DT April 2016 COMPLETE March 2016 Questions regarding 111 s interaction with Shrop Doc, the access of Welsh patients, and the presentation of 111 episodes on EMIS to be discussed at Practice Manager s Forum. DT April COMPLETE March 2016 Pauline Roberts to circulate information via . NT April COMPLETE March 2016 Jim Ramsdale to be invited to next meeting. DT April Minutes of Rural GP Network by 5

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8 Identification of patients for integrated team pharmacist. Attendance at internal integrated team meetings As well as identifying suitable patients for a medication review, it also enables the pharmacist to offer advice and recommendations for other patients. Referral criteria from integrated team. (including GPs) Stock piling meds at home. Confusion with medication- struggling to cope with taking their medication. Non- compliance. Falls and taking the following meds: (information to be taken from prescqipp) Following discharge-?? how we identify these patients- (also include secondary caresee below) Patients thought to be suitable for de-prescribing. Definition of deprescribing: Cessation of long term therapy, supervised by a clinician, when potential benefits may be outweighed by a risk of harm. It is especially relevant as patients become older and/or frailer and are on multiple medication. (1) It needs to take into account patients/ carers wishes and will often involve titration of doses and stopping drugs over a period of time. INDIVIDUAL APPROACH IS KEY. o e.g. palliative care patients/ terminal illness- Shift in treatment goals. Symptom management, quality of life and reducing side-effects likely to be considered more important than reducing CV risk o Dementia, increasing frailty, delirium risk- reducing polypharmacy especially anticholinergic burden. o When an ADR is suspected- ADRs are not always easy to identify and can be mistaken for symptoms of disease e.g. falls or cognitive impairment. Drugs may need to be titrated over a period of time. o Either deliberate or non-deliberate non-compliance. o STOPP criteria- identify key areas to look at e.g. anticholinergics in the elderly Targeted Medication reviews- see attached list. Patients where benefit not seen from doing a medication review (identified from pilot): Chronic pain- often already referred to pain clinic. On multiple meds but reluctant to change To research further Social care referrals- define referral criteria for patients from social care and identify if this is something we could link to community pharmacists MUR- PR to contact gateway assessor. Community pharmacy- accept referrals and also work with pharmacy re: accepting referrals from the integrated care team, design proforma and discuss with local pharmacy. Secondary care- admission and discharge. Meeting planned. Minutes of Rural GP Network by 8

9 Raft of potential areas to target: Acute Kidney Injury (AKI)- o over 75 years, egfr <40 prescribed Diuretic, ACE/ARB, metformin, NSAID o over 75 years, no egfr in last 12 months, prescribed Diuretic, ACE/ARB, metformin, NSAID Over 65 years prescribed NSAID+ Diuretic+ Ace inhibitors- high drug combination known to cause ADRs to patients. Over 65 years Lithium and no lithium level in last 8 months. (6 monthly monitoring once stabilised) Over 65 years and last lithium level higher than (agree level for elderly population) Over 75 years NSAID + no PPI Over 65 years Warfarin and no INR in last 4 months (12 weekly monitoring once stabilised) NOAC and reduced renal function (Caroline to look at doses and renal functions etc and write search) Over 65 years allopurinol and egfr < 30- need to agree actions Over 65 years, fractured neck of femur and on listed drugs (drugs likely to call falls from prescqipp) Over 75 years and prescribed diabetic medication and HbA1c < (need to agree level) (? Exclude metformin) in the last 12 months Patients receiving long term LMWHs and no platelet count or potassium levels monitored or egfr in last 4 months (3 months recommended) Over 75 years and Hb <(need to agree level and actions- often non -compliance with fe preps due to side effects. Diagnosis of dementia and prescribed anticholinergic drugs Minutes of Rural GP Network by 9

10 THE HEADLINES Successfully working in two integrated teams to raise the profile of medicines optimisation. Efficiency Savings Potential saving for 12 months from changing or stopping medication Potential reduction in district nurse visits to administer tinzaparin over 12 months 536 visits. Potential reduction in district nurse/ assistant practitioner visits in one locality in 12 months for vitamin B12 admin 100 visits Reacting to findings. Focus on acute kidney injury in Ellesmere Port South Development of vitamin B12 admin procedure in Ellesmere Port south. Improving patient experience/ concordance. Support given to team to help patient receive an injection without distress. Dementia patient distressed receiving tinzaparin injection, changed to NOAC 7 patients were counselled about their medication- 6 in their own homes. Issues tackled include- the importance of taking magnesium and potassium supplements for a week following discharge, why amitriptyline would help with back spasm, explaining why a patient who had overflow diarrhoea in the past needed to take laxatives with morphine Liaising with Community Pharmacists for 7 patients. Supporting the integrated team to reduce hospital admissions. Work on acute kidney injury and education re: both stopping drugs when patient is at risk of dehydration and re-starting when patients are well. Other interventions included: stopping diclofenac in patient who wasn t eating and drinking- GP was worried about starting morphine until bloods taken for renal function, district nurse couldn t get blood. Reducing blood pressure medication in two patients, stopping duplicate meds. Accessible information source for the team 21 queries were answered- some of the interventions were identified from casual conversations in the office Limitations of pilot Problem solving rather than case finding. One day a week with each team gave limited availability to review patients in a timely manner. It also meant that patients couldn t be properly case managed and areas such as deprescribing further developed. Accepting all referrals was useful for pilot but now needs to streamline. Engaged with community geriatricians but need to further engage with secondary care. Initial meetings with community pharmacists and LPC but need to explore further. The Future For discussion Points already suggested- accept referrals from community pharmacists, focus on discharge issues, ensure social issues are taken into account when medication decisions are made in both primary and secondary care. Minutes of Rural GP Network by 10

11 Rural Locality GP Network Meeting, 2-5pm, Tuesday 12 April 2016, Cheshire View, Chester Chair Steve Pomfret (Chair) APPROVED MINUTES Present: Helen Black Andrew Campbell Jonathan Gregson Louise Davies Kylie Daniels Alistair Adey Sue Dewhirst Sam Jeffery Lynn Suckley Brian Yorke Debbie Bailey Neil Symonds Bunbury Medical Practice Tarporley (Campbell) Helsby & Elton Practices Malpas Surgery Kelsall Medical Centre Tarporley (Adey) Tarporley (Campbell) Tarporley (Adey) Malpas Surgery Helsby Practice Bunbury Medical Practice Kelsall Medical Centre In attendance: Sarah Murray Tanya Jefcoate-Malam Diane Taska Helen Cunningham Emma Lea Sue Pratt Zoe Fitzgerald Aidan McGrath Programme Lead Primary Care (WCCCG) Primary Care Manager (WCCCG) Primary Care Team (WCCCG) Integrated Care Team Manager (Princeway) Integrated Care Team Manager (Broxton) Integrated Care Team Manager (Broxton) Bunbury Registrar Ageing Well Programme Lead Agenda No Action 1. Welcome & Introductions Network members were welcomed to the meeting and noted Huw Charles- Jones, Chair West Cheshire CCG would update around the CCG s current financial situations and the implications of NHS England s interventions. Minutes of Rural GP Network by 1 Date: 12 April 2016

12 2. Previous Minutes The minutes of the previous meeting (March 2016) were approved as an accurate record of the meeting. Apologies Trevor Ferrigno / Debbie Bailey Declarations of Interests Nil Actions Update from 111 to be on next agenda - Complete Questions regarding 111 s interaction with Shrop Doc, the access of Welsh patients, and the presentation of 111 episodes on EMIS to be discussed at Practice Manager s Forum - Complete Pauline Roberts to circulate information via Complete The Impact of Special Measures on the CCG and General Practice Huw Charles-Jones, Chair West Cheshire CCG updated the Network around the CCG s current financial situations and the implications of NHS England s interventions. West Cheshire CCG financial deficit is in the region of 15m and because of this non delivery of financial plan NHS England propose to place the CCG in Special Measures. It was noted 4/5 CCGs across Cheshire and Merseyside area are in a similar Turnaround situation with pressures throughout the NHS and social services not allowing enough funding to support frail, elderly populations, the allocation of funding from central government is far greater in areas of high social deprivation. Three areas of work identified as having cost savings are detailed below: Outpatient referrals as a national outlier in this area the CCG needs to urgently look at its referrals, one suggestion being to revisit the Willaston Model. Prescribing stopping some of the over counter prescriptions such as paracetamol / gluten free. Managing Integrated Care Teams directly from within GP practice to improve services for the frail, elderly population. The Network asked what support they could offer and agreed to reimplement the Willaston Model for referral management. Action: Sarah Murray to circulate the Willaston Model Management documents to the Rural Network members. Action: Sarah Murray to liaise with the business intelligence team at the CCG around prescribing data reporting. Practices require a greater level of Minutes of Rural GP Network by 2 Date: 12 April 2016

13 prescribing activity and the current reports are too generic. It was recognised that the current financial issues cannot be solved by primary care or the CCG in isolation and it was discussed that both COCH and CWP are in discussion with the CCG about their roles in resolving the current situation. Coincidentally NHS England have also recently withdrawn the proposed Vanguard funding providing the following 3 reasons for the withdrawal: A poor return on investment although the CCG disputes NHSE s figures which differ from the CCG Value Proposition The pace of change with the GP Federation The CCG were not far enough ahead on a new MCP model contract The Network discussed the impact of not receiving the Vanguard funding and the possibility of bringing the Community Care Team and practices together to provide improved services for the frail/elderly population. It was noted the Rural Network retains full confidence in the CCG s Senior Management Team. The West Cheshire CCG Chair continued to update the Network around the Paediatric at Home service and it was noted the service was set up originally to reduce admissions and save money, with non-recurrent funding for a 3 year period. The service hasn t necessarily reduced admissions, cost savings have not been realised and therefore the service has now been stopped. Post meeting note: The Paediatric at Homes Service has been reinstated as from w/c 18/04/2016 negotiated by the WCCCG CEO and CoCH for a further 3 months whilst options to provide a safe, viable service going forwards are considered Questions (Welsh patients, Shrop Doc) The Network noted there is no specific commissioned service through 111 direct to Shropdoc. 4. CQUIN Frailty Assessment Tool The Network received a presentation from Dr Aidan McGrath, WCCCG Ageing Well Lead, on a frailty assessment tool which will assess a cohort of patients and their level of frailty: Frailty Assessment Tool.docx The assessment tool takes approximately 2.5hrs to complete and will enable Minutes of Rural GP Network by 3 Date: 12 April 2016

14 practices to identify patients who are frail and importantly identify their degree of frailty, providing an overall frailty score for the patient. The 16/17 CQUIN is focused around reducing frailty admission into acute care and it is hoped identifying the group of patients who are appropriate for the assessment tool will support this work. Firstly the criteria and the trigger need to be identified, patients coded and then the tool applied. It was noted Malpas Surgery are looking in to a proactive care plan currently used by an Oxfordshire CCG. 5. Integrated Team Pharmacisit Pilot & Future This item was discussed at the March Rural Network. 6. Future Agenda Items The following items were raised as future agenda items: Procurement of CWAC Sexual Health Contract and Public Health Checks Contract Frailty Assessment Tool update/workshop CCG Financial Situation 7. Any Other Business Sarah Murray, WCCCG Primary Care Lead, thanked Sam Jefferies and Lynne Suckley on behalf of the Network for all their hard work in bidding and winning the Sexual Health Contract and Public Health Checks Contract for East Cheshire. Next Meeting: 10 May 2016: 2.00 Cheshire View, Christleton E Port & City Network Minutes March 2016 EP&N APPROVED Minutes March 2016.d City Minutes APPROVED d Outstanding Actions Minutes of Rural GP Network by 4 Date: 12 April 2016

15 Key: NB: Actions will be taken off the table upon completion Current Overdue Ongoing Date Initiated Action By Whom Due Date April 2016 Sarah Murray to circulate the Willaston Model Management documents to the Rural Network members. SM May 2016 COMPLETE April 2016 Sarah Murray to Meds Management Team around reporting and practices receiving more appropriate, useful data. SM May 2016 Minutes of Rural GP Network by 5 Date: 12 April 2016

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