Report improving quality in general practice engagement April 2017
Improving quality in general practice NHS Southwark Clinical Commissioning Group held a workshop for local people on the evening of 4 April 2017 to discuss general practice and improving quality. The workshop was attended by approximately 40 local people, plus seven CCG members of staff, two GP clinical leads, the CCG lay member for patient and public engagement, one GP federation member of staff and one assistant practice manager. A clear text typist also attended. 36 people filled in equal opportunities forms: Ethnicity: 74% identified as White British 15% identified as Black British 6% identified as Black African 3% identified as Black Caribbean 3% identified as Chinese Gender 67% identified as female 33% identified as male Sexual orientation 6% identified as gay Religion 64% identified as Christian 3% identified as Muslim 6% identified as other including humanist Age 15% were aged 35 44 32% were aged 45 54 6% were aged 55 64 33% were aged 65 74 15% were aged 75-84 Disability / long term condition (LTC) 23% identified as deaf / hard of hearing 23% identified as mental ill health 40% identified as having a long term illness 23% identified as having a physical disability 7% identified as having another disability
Purpose Caroline Gilmartin, Director of Integrated Commissioning, introduced the event and explained the purpose of the meeting: to discuss the current pressure general practice is facing and how local GP practices are changing to address these pressures to discuss the CCG s plans and role in improving general practice now that the CCG has fully delegated commissioning from 1 April 2017 She explained that this is one of a series of engagement events on general practice with others having taken place in February 2016 and October 2016.
Southwark s population Dr Emily Gibbs, clinical lead for primary care, outlined some key points about Southwark s population: 319,270 registered patients High ethnic diversity. Over 300 languages spoken High population turnover and densely populated Southwark population turnover rate is 8th highest among London boroughs Young population, median age in Southwark is 32.7 years Resident population expected to increase by 12% over 10 years* Almost 40% of Southwark residents live in areas considered most deprived nationally Continued improvements in overall health, but health inequalities still remain Despite an overall increase in life expectancy a significant deprivation and gender gap remains
General practice in Southwark Emily continued to highlight some key points about general practice in Southwark and the pressures it is under. 41 GP practice contracts over 42 sites 3 sites with multiple practices: Borough Medical Centre Lister Primary Care Centre, Peckham St Giles Surgery, Camberwell The average Southwark practice size is 8,000 registered patients, the smallest is 2,300 In Southwark there is 1 GP per 1000 registered patients Practices are changing to meet pressures: Groups of GP practices have formed 2 GP federations to provide services together like the Extended Primary care Service (8-8, 7 days/week: North Southwark Quay Health Solutions (QHS) - 21 member practices South Southwark Improving Health Limited (IHL) - 20 member practices Pressures include: Workload Recruitment and retention of staff Premises and systems e.g. IT CQC inspections Impact of pressures on quality that patients have highlighted include: Access to appointments Length and type of appointments Sustainability Variation in range and quality of services offered Practices are merging so they can offer better use of shared resources to deliver services e.g. Nexus, in the north has 7 branch sites and has 58,000 registered patients and is the largest local practice.
FOREST HILL ST JAMES DR RS FALMOUTH DMC QUEENS ROAD SIR JOHN KIRK OLD KENT PENROSE THE THREE MANOR PLACE DR KK MISRA'S STERNHALL MELBOURNE ALBION STREET THE VILLA THE GARDENS THE LORDSHIP SURREY DR R KADHIM'S DR AT ST GILES Quality and patient experience / satisfaction Dr Noel Baxter, clinical lead for quality, outlined some key points about quality and patient experience: Most people in Southwark report a good experience of their GP surgery (national GP survey), however: in Southwark the % of patients reporting very good or fairly good experience has declined in recent years There is variation in experience across practices, with patient experience falling below the CCG and national average for a number of Southwark practices There is significant variation across practices when comparing National Quality and Outcomes Framework (QoF) data There has been an improvement in quality as a result of the CCG commissioning services on a population basis through GP federations (Population Health Management Contract) Patients who attend the Extended Primary Care Service (8am-8pm, 7 day per week) consistently report high levels of patient experience; however, general awareness of the service and how to access it could be improved 580.00 560.00 540.00 520.00 500.00 480.00 460.00 440.00 420.00 400.00 QoF 2015/16 Achievement Score (max. 559)
Where we want to be Noel went on to explain where we want general practice to be in Southwark and that we are already working on this. General practice services that deliver high quality, equitable and sustainable health and care services for all A varied general practice workforce able to respond to patient needs Joint working across practices to improve quality and access for patients Joint working with other partners like social care, community health services, hospital services and the voluntary and community sector as members of the north and south local care networks to better joined up care for local people General practice contracts that allow practices to focus more time and resources on delivering fewer but more important priorities which enable local people to experience less variation and higher quality care, such as: Improved access Improved prevention Improved care coordination Consistent system and processes across practices that free uptime and resources in practices to devote to improving care for patients
Questions and answers How many GPs are there in total in Southwark? There are approximately 340 GPs working in Southwark and this includes locums and part time GPs The majority of CCG funding is spent on hospital services, but now that we are responsible with NHS England for GP services we have more local control over how the money for GPs services is spent to meet local need. Is the CCG happy with the level of funding? How does the Extended Primary Care Service (EPCS) work? How many people fill in satisfaction surveys? EPCS: you contact your GP practice in the normal way and, after being telephone triaged, you will be offered an appointment at one of the EPCS sites if you need to see a GP and your practice has no appointments left. Mental health is very important and needs to be seen on the same level as physical health. This could be a focus on another event. People have long waits for hospital appointments and so continue to see their GP. Looking at physical health and mental health together is very important and GPs need to know eligibility criteria for social care services People should normally have their treatment finished within 18 weeks of being referred. There are more pressure in south Southwark to achieve this. For July 2016 national GP survey 15,305 questionnaires were sent out and 4,336 were returned, which is a response rate of 28%.
What the CCG is doing to improve quality and experience Caroline Gilmartin spoke about what else the CCG is doing to improve quality. From 1 April 2017 the CCG took on a greater role in managing and planning GP services. This is called delegated commissioning and includes: Local contract & budget management Design of local incentive schemes that focus on local equality issues Design of enhanced services Approval of practice changes e.g. mergers Benefits include: Greater control over local decisions informed by local people and local clinicians Helps join up services across hospital, community, GP and other services such as pharmacy to benefit local people Ensures the budget for GP services in Southwark stays in Southwark Improving resilience and sustainability through supporting: Quality improvement programmes Royal College of GPs support for practices in special measures Practice mergers GP federations supporting practices to deliver services Improving GP estates and premises: Dulwich health centre New developments at Elephant & Castle, Old Kent Road and Canada Water Each practice will have an agreed access model based on their practice population Review GP contracts to support: improved access Improved patient experience Keeping people well Better continuity of care for patients that need more support CCG will look at: Friends & Family Test results Childhood immunisations and flu vaccinations rates Health checks for at risk groups Management and care coordination people with long term conditions & frail older people
Questions and answers How does the proposed Dulwich health centre relate to being a new model of care? Where can we get more information on public health information and rates of disease like cancer in Southwark? The Dulwich health centre will be a building that enables services to work together and having a GP practice there is central to this so that the needs of the population are more effectively met, but not as a formal new model of care with an alliance contract. The NHS is confusing and complex and uses complex language such as Extended Primary Care Service and Urgent Care Centre. People do not where to go for what. You can get more information including looking at the Southwark Health Profile and the Annual Public Health Report by following this link http://www.southwark.gov.uk /health-and-wellbeing/publichealth/health-in-southwark The NHS can be complicated and that is why we developed the Extended Primary Care Service to be available via your GP practice so you contact your GP practice as normal. There are issues around pain management for children in sickle cell crisis when they are discharged from hospital with medication and told to go to their GP for more, but GPs do not want to prescribe it. The CCG will be organising an internal quality seminar to look at some of the issues around sickle cell services.
Group work We discussed in our tables the following questions: How will our plans support practices to improve their services for patients? What else could the CCG and local practices be doing to improve the quality of services for patients? What role can patients play in supporting quality improvement?
How will CCG plans support practices to improve their services for patients? Communication The Local Care Record has been a good development and helps for better communication between hospitals and GPs Strong information systems to link people to relevant specialists Support for navigation/signposting Patient referral appointment cards are a good idea Ensure GP practice databases and hospital systems are up-to-date and talk to each other more coherently More information for local people and GPs about Local Care Networks: what they are, what they do and how to get involved Working together Very supportive of collaboration between practices/mergers Supportive of work with community/voluntary sector Practices working together is a good idea as they can learn from each other Greater practice resilience (fewer single hander practices) Access to specialist nurses i.e. diabetes etc. and sharing of resource between practices Quality Some anxiety that mergers will cause a reduction in quality Need to be clear on the issues of the worst performing practices and how we address them together GP federations, CCG and patients Not useful to use the patient satisfaction survey as numbers of respondents so small
How will CCG plans support practices to improve their services for patients? Information Technology Use of technology to get better efficiencies e.g. online, remote testing, email etc Create capacity in GPs through the development of better systems e.g. projects in primary care (e.g time to care) IT use More local decision making / delegated commissioning of GP services Delegated commissioning build on local relationships and knowing what is going on Having local decision making around general practice is a good idea Premises Fit for purpose premises is important GPs Will the plans results in enough GPs for the Southwark population? Concern raised that plans don t go far enough given the mass exodus of GPs
What else could the CCG and local practices be doing to improve the quality of services for patients? Communication Use easy to understand language when talking or describing health services and avoid management speak Practices and CCG could use social media more We need to reach out more to people from minority communities to help them have their voice and access services Patients still telling their story over and over Local Care Record needs to be rolled out to mental health services and community teams We need better and simpler communication around the Extended Primary Care Service so people understand and know how it works, especially for receptionists Improved relationships with primary and secondary care particularly in updating contact information e.g. when sending results/letters make sure they go to the right GP address Make more patient friendly information available for pharmacy services The CCG needs to take account of languages and people with other communication needs e.g. people who may be deaf Appointments Practices need help with their systems around telephone triage to support the take up of the Extended Primary Care Service Market the Extended Primary Care Service (EPCS) so that people understand it more and how to ask for it Extend opening hours and let patients call the EPCS directly if their practice is closed Provide consistency with GP, practice to advertise GP schedule in advance and EPCS to guarantee appointment with usual GP where possible
What else could the CCG and local practices be doing to improve the quality of services for patients? Working together Invest in more projects where there is collaboration with community/voluntary sector - buddying/befriending projects Need to raise more awareness of the links between health and social care Create patient navigators and ensure that they are supported to make things work more effectively and consistently navigate to self help groups Involve the voluntary sector and invest in prevention and public health interventions Invest in young people GP to follow up/hold hospitals to account on patient pathways so we provide a responsive local service to local residents rather than prioritising specialist patients from further afield When services are taken out of hospital in to the community / primary care they need to be accessible to all by public transport Patient engagement and experience Support patient led forums/ppgs as they are still led too much by practice managers Practices should be encouraged to send newsletters to patients Practices should communicate to patients in different ways, not just meetings The CCG needs to monitor what practices are doing and that they are providing quality services - the CCG needs to listen to patients to support this Looking into complaints raised, following them up and ensuring that they are effectively resolved Promote the GP-patient relationship as a partnership of equals
What else could the CCG and local practices be doing to improve the quality of services for patients? Recruitment and roles Increase the number of GPs by recruiting more Increase nurse prescribers and advertise the availability of these better Free up GP time by having more nurse practitioners, practice pharmacists etc Receptionists need more training to understand different services better Continue to support projects such as GP pharmacists but there needs to be an element of patient choice when making an appointment Influence the development of community nurses/district nurses helping these develop will take pressure off general practice Do more to look after practice staff support and motivation Diversifying the workforce/use voluntary and community/ non medics and encourage task-shifting to non-medical staff Information technology Continue the push for online/digital feels this will help general practice (although wanted to emphasise that large parts of older population are not online) Home visits for housebound patients can t get to practices but also are not online Online services can t be solely relied on as not all patients have access to the internet Promote Use of Electronic Referral Service to enable patient choice and improve patient experience, including waiting times
What else could the CCG and local practices be doing to improve the quality of services for patients? Self-management Support carers more to look after their family member Have a local agreement ( contract ) between patient and practice to promote selfmanagement Focus on particular populations to improve health behaviours, outcomes and conditions e.g. development of welcome packs for new arrivals e.g. Lambeth CCG Portuguese populations project There needs to be more information for patients to support with self-management Mental Health More support for mental health issues - people are experiencing a lot of stress these days which affects their health Faster access to talking therapies so people get more timely help Stability of staffing is important especially for people with mental health needs More priority should be given to mental health. The best mental health care I have received is from my GP Premises Need to ensure that all practices are fully accessible
What role can patients play in supporting quality improvement? Role of PPGs and patient engagement What more can CCG do to support PPGs? Review the PPGs are they doing what they are supposed to do? Train PPG members as first aiders and let them be the first point of contact in the surgery Patient led PPG - practices to listen to patients, not run the PPGs themselves. Consider the practice role in PPGs? What can the CCG do to encourage practices to engage with PPGs? Using patients as volunteers to talk to other patients and help make improvements at practices Discuss patient satisfaction survey results and QOF outcomes at practice PPGs with clinicians and managers so we can understand the issues at our practice and help support ideas for improvement Use of Patient Participation Groups to create feedback and encourage innovation in practices Create Patient Charter produced with full participation of patients Feedback on the quality of services and what some of the issues / unintended consequences are Reporting on quality of services provided Peer support / self management Self-organised/patient led support groups i.e. for diabetes or asthma Patients need to take more responsibility for their own care self care/self-management There needs to be more information for patients to support with self-management Cardiac health support group signposting needed Use local pharmacies more (but to do this patients need more education and information) Patient need to take more responsibility for their own health - GPs and health professional can advise but ultimately it is their own responsibility Self-help support groups to identify what is important and whether any gaps
Next steps Practices to have discussions on quality and their PPGs Discussions to continue at locality PPGs Autumn engagement event: To continue discussions and ideas To feedback outcome of CCG s implementation plans
What people said about the event 34 people filled in evaluation forms: Event 21% rated the event as excellent, 61% as good, 12% as OK and 6% as poor 24% rated the structure of the event as excellent, 56% as good, 18% as OK and 3% as poor Information 56% stated that they understood all of the information, 29% most of the information, 15% some of the information 24% stated that they found the information excellent, 58% good, 18% OK Group work 24% found it excellent, 50% good and 26% OK Involvement in NHS 47% stated that they definitely felt more involved in the NHS after the event, 33% moderately more involved, 17% partially more involved and 3% not at all more involved 96% of respondents would come to another event like this and 1% would not
What people said about the event: is there anything that was not covered which could have been A further breakdown of organisations and how they relate to each other Improving practice regarding the 60+ non digital population Role of the practice manager An explanation of the CCG and what changes it has been involved in A further breakdown of organisations and how they relate to each other The role of the GP federations and how they involve patients How could we improve this kind of event? Allow more time for questions and ask people to keep their questions short No management speak Use the microphone better Ensure everyone feeds back to their practice and PPG Limit the number of attendees Coproduction Less PowerPoint and more interaction Tables too close together so difficult to hear during group work More time for feedback. Only one question per table How many whole time equivalent GPs working in Southwark Culture of receptionists and their role as gatekeepers More public health information Publicise better to open to more people Perhaps have a patient testimony on quality Hold more events like this
Live tweeting from event
Live tweeting from event