Wandle Locality Commissioning Group Wandsworth CCG Board Update October 2013 1) INTRODUCTION Wandle is the largest of the three Wandsworth localities, and comprises the geographical areas of Balham, Tooting, Wandsworth Town, Southfields and Furzedown. Wandle Locality has 22 member practices, listed below, which serve a population of 194,677 residents (as of April 13) and is represented on the CCG board by clinical leads Dr Michael Lane and Dr Seth Rankin. Balham Health Centre Bedford Hill Chatfield Elborough St Surgery Grafton Medical Partners Greyswood Practice Nightingale Southfields Practice Streatham Park Tooting South Practice Trinity Medical Centre Wandle Locality Practices Balham Park Surgery Brocklebank Group Practice Earlsfield Practice Furzedown Granville Road The Haider Practice Open Door Surgery St Pauls Cottage Tooting Bec Surgery Triangle Surgery Wandsworth Medical Centre The Wandle Locality practice representatives meet to make decisions at a monthly Members Forum, and patient involvement is embedded at all levels throughout decision making, with our active and enthusiastic Patient Consultative Group (PCG) meeting every 6 weeks. The Wandle Management Team meets fortnightly, with representation from the PCG, Public Health, Wandsworth Council and practice nursing. Regular Practice Managers Forum and Practice Nurse Forum meetings ensure active engagement with constituent practices. 2) LOCALITY DEMOGRAPHICS AND HEALTH NEEDS The Wandle resident population is bound by the electoral wards of Bedford, Earlsfield, Fairfield, Graveney, Nightingale, Southfields, Tooting and Wandsworth Common represents just over 45% of the entire population of Wandsworth with marginally more men than women. It currently stands at 142,000 which is anticipated to increase by about 5,000 in the next 3 years. The majority of the residents are aged between 20 and 44, or 55% of the population, with approximately 2,300 births a year. The Wandle area represents a diverse demography, for example from Wandsworth Common with a high level of overcrowding, pensioners living alone and older people in deprivation to Tooting with a much broader age spectrum of the population in deprived conditions, higher levels of BME groups, and higher levels of childhood obesity, and emergency admissions for long term conditions or alcohol related harm. Wandle October Board Paper 2013 Version 1 1
While sharing many of the same health priorities as the rest of Wandsworth, a public health analysis shows that Wandle does have specific issues to the locality that could be addressed. A few examples are: there are high rates of obesity in year 6 in Bedford and Earlsfield, people with ethnicities categorised as Asian or Black have an increased risk of developing diabetes and the highest proportions are in Balham, Tooting and Furzedown there are low rates of immunisations in Tooting and Graveney. Wandle also has the highest rate of outpatient attendances, A+E attendances and emergency hospital admissions. These issues have helped us to inform both our chosen priority areas and GP Engagement Scheme focus. A&E admissions, diabetes, obesity and interventions to increase the uptake of childhood immunisation have been included among the key activities in Wandle during the last 12 months. 3) CLINICAL LEADERSHIP Wandle practices, both small and large, have supported their GP members to fill many of the CCG leadership positions; several CCG board members, are from Wandle and the locality is actively promoting CCG succession planning within their GP complement. Many of the Clinical Reference Groups are chaired by Wandle GPs who are clinical leads for: Cardiovascular Disease (CVD) Chronic Obstructive Pulmonary Disease Mental Health Dementia Diabetes Falls & Bone Health Maternity Community Services Redesign Children Primary Care Education The St Georges Clinical Quality Review Group and Commissioning Groups are chaired by Wandle GPs, and the Planning All Care Together (PACT) LES has been clinically sponsored and developed by Dr Seth Rankin. 4) COMMISSIONING Wandle Locality recognises that its population s health needs may vary from that of Wandsworth s and its member practices are keen to realise the potential added value that localisation can offer. Public Health presented the members with a health needs assessment and Locality commissioning priorities were decided by consensus in a dedicated workshop that was attended by Wandle GPs, patient representatives, public health and Wandsworth Council. The five key areas that were identified for particular Wandle focus all fitted strategically with the JSNA and CCG commissioning strategy plan, and were COPD, Obesity, Diabetes, health promotion for Seldom Heard Groups and reducing inappropriate A&E attendances. Working groups were established with named GP, management and patient leads; these groups developed action plans for each initiative area and they report back on progress to the management team. 4.1) COPD Although Wandle has a relatively low recorded prevalence of COPD, there are a large number of people living in the area who smoke. This suggests that there may be a high number of people living with undiagnosed COPD or who are at significant risk of developing the condition. Wandle October Board Paper 2013 Version 1 2
Wandle GP Dr Penny Osborne and the Locality Manager led the redevelopment and refinement of the COPD missing millions project. This project aims to reduce the proportion of undiagnosed COPD through offering Spirometry testing to smokers over the age of 35 who have a risk factor (generally smoking) and who present with exertional breathlessness, chronic cough, regular sputum production, frequent winter bronchitis or wheeze. The project started in Wandle and ran for two months across Wandsworth from 1 st February to 31 st March 2013. Thirteen practices signed up and completed the programme of which eleven practices were from Wandle. The results of the initiative showed that over the course of 2 months: 784 patients were screened using the questionnaire 218 patients were referred to smoking cessation 114 extra spirometry tests were performed 23 additional patients were diagnosed with COPD After results were evaluated, the decision was taken to re-run this project in 2013/14. Wandle is again leading on it and the format has been changed to reflect new NICE guidance. Brocklebank and Greyswood Practices are currently piloting the amended scheme with roll out to other practices expected later this year. 4.2) Diabetes Wandle residents are at higher risk, compared to the Wandsworth average, of developing diabetes. Wandle GP Dr Neil Bamford is leading an audit of undiagnosed patients as it is believed there are around approx 1,500 people in Wandsworth who have diabetes that is either not diagnosed or incorrectly coded and the aim of this exercise is to close the gap between actual prevalence and the estimated prevalence. Dr Bamford and Dr Shobi Sreetharan have led the development of a diabetic foot QP pathway in conjunction with St George s Hospital to be used for QP 2013/14. This pathway, subject to approval, will be implemented as one of the QP pathways for the next 6 months. Wandle led, over the past year, the production of a booklet and DVD as guides for people living with diabetes, titled Diabetes day to day putting you in control. Wandle is also leading the evaluation of this project; practices were asked to identify 20 patients to whom this booklet had been given to complete a survey around their experience of the booklet. 4.3) Obesity Wandle has the highest prevalence of obesity of the Wandsworth localities. The Obesity work stream aims to raise the awareness of the health issues associated with obesity, promote healthier lifestyles and encourage obese patients to access weight management service at a local level. Working together over the last year with Public Health and the Wandsworth Council, the group has sought to realise the benefits of working in partnership with the school nursing team. Each year, the team measures the weight and height of every child in Wandsworth schools reception and year 6. Wandle arranged for all Wandsworth GPs to receive a letter from the team informing them if one of their registered children is identified through the National Child Measurement Programme as having severe obesity (>99.6 th centile). Parents are also sent a letter outlining the results of their child s measurement, including the weight category their child is in (underweight/healthy weight/overweight/very overweight). Wandle member practices have received specific advice about recommended actions upon receipt of a notification, and can refer the child to a specialised child and adolescent community weight management programme. Wandle October Board Paper 2013 Version 1 3
An obesity referral pathway was developed in association with Public Health and sent out to all practices for use. Practices have printed this and made it available in consulting rooms to use as a prompt when discussing weight with their patients. Public Health have recently presented the new obesity services to the Wandle members forum, and have provided advice to practices with unspent FURs about appropriate equipment they could purchase to increase measurement and recording of weight and BMI. 4.4) Health Promotion for Seldom Heard Groups As part of last year s GP Engagement Scheme, practice leads visited Seldom Heard Groups within the Wandsworth community. The management team received reports from 16 practices confirming that they had visited groups such as Thrive, Thomas Pocklington Trust, Asian Community Centre and Word Up. These visits helped GPs to understand the health and social care needs of the group, explored how health promotion messages could be better spread and ensured that a wider patient voice was heard. We received very positive feedback from the groups and the GPs who carried out the visits, and the scheme is continuing this year under the auspices of the Members Development Programme. Wandle also supported in the distribution of 10,000 Getting the most from your visit to the surgery cards to practices across Wandle. The cards were produced in conjunction with Wandsworth Carers Centre and aim to encourage patients to think about what they wanted to get out of the visit to the surgery and to help identify carers in order to be able to direct them towards available support. Wandsworth Carers Centre attended and spoke at a Wandle Members Forum, in order to raise awareness of their resource. 4.5) A+E Attendances Wandle has the highest per capita rate of A& E attendances in Wandsworth, and increasing access to out-of-hours GP services has had only limited effect on the attendance trajectory over the last two years. The Wandle working group undertook a comprehensive review of practices QP submissions from last year and produced a document detailing a summary of attendance-reduction initiatives for each practice, inter-practice comparisons and current access arrangements with a summary detailing common themes and innovative ideas. Common initiatives include reviewing frequent A&E attendees and offering them advice, increasing education about access for patients and staff, increased usage of the community ward and increase of telephone consultations and same day appointments. Other innovative approaches have included: walk-in clinics for under 5 s; spending the day in A&E to find out why patients presented there; leaflets produced in different languages; education of local schools to ensure they are not advising children attend A&E if they could be seen in primary care and increased promotion of expert patient programmes. Many practices have also chosen their use their money released by savings (Freed-up resources) for extended hours of GP consulting, to allow patients increased access to the practice and more appointments. Wandle had planned to use the QP peer review meeting this year to review the outcomes of our initiatives, but NHS England have not yet been able to provide us with the required data. 4.6) Ready for School Packs Wandle undertook a joint project with Wandsworth Council, aiming to communicate key health information to applicants for primary school places. The packs importantly included information on childhood immunisation as well as healthy eating. A number of films were produced which are now Wandle October Board Paper 2013 Version 1 4
available on the dedicated ready for school section of the Council website and printed information packs were developed and distributed to primary schools, health centres, GP practices, children s centres and libraries. A total of 12,680 packs were printed in English with a further 580 printed in Bengali, Somali, Urdu & Gujarati. These packs were distributed out in November 2012. Wandle is working with the local authority to evaluate the success of this project 5) PERFORMANCE AND FINANCE 5.1) Freed up Resources The Wandle locality and its Member Practices have made efficiency savings, termed Freed up Resources (FURs), over the year totalling 317,000. The locality agreed that a proportion of these FURS would be pooled for Wandsworth-wide projects but that the rest would be available for practices to spend on improving services for their patients. Sixteen Wandle Practices submitted bids to spend FURS to offer additional extended-hours clinics to their patients, over and above those funded by the access LES (Locally Enhanced Service). This resulted in over 2000 additional hours (equating to approximately 8044 extra appointments) of GP, nurse and health care assistant consulting time with many appointments provided at times where traditionally there has been little or no access. Other practices chose to run innovative services such as Citizen Advice Bureau sessions, counselling services or to further develop their patient group using their FURs budgets. Wandle members have chosen to invite bids from practices to spend any remaining FURs money for the year 13/14 on clinical equipment- bids are measured against strict criteria to ensure they directly enhance patient care and are subject to approval by the Wandle Management Team. Any remaining underspend will be pooled in January 2014 and decisions taken at locality level about how best to allocate funding to continue to enhance patient care. 5.2) GP Engagement Scheme 2012/13 All Wandle Practices joined the GP Engagement Scheme, which ran for its second year in 2012/13. Practices were asked at the start of the year to identify 3 key areas to focus on improving, and to develop action plans to address those areas. Three peer review meetings were held during the year to promote peer review, share good practice and review performance. All practices had to work on Child Immunisation rates, and were encouraged to select the other two key areas from those in which their performance was suboptimal. One key area was uptake of the seasonal flu vaccine, and Wandle was able to achieve the highest uptake for patients under 65 at risk and pregnant women, with an increase from 2011-12 across all patient categories. Wandle also delivered an increase in uptake rates of all childhood immunisations, including all doses of DTaP/IPV/HIB and MMR2 (year 5). 6) ENGAGEMENT 6.1) Members Forum The Wandle Members Forum meets on the first Thursday of every month. Each of the 22 practices sends at least one representative and practices are required to attend at least 80% of meetings. The forum format is interactive, and content determined following consultation to determine the preferences of member practices. The forum provides a conduit upwards from member practices and their patients via the Locality to the CCG Board as well as a regular opportunity to cascade information, policy and decisions back down to them. Decision making follows our locality terms of reference, and the CCG and Public Health regularly attend to consult on draft strategy. Wandle October Board Paper 2013 Version 1 5
Wandle representatives on Clinical Reference Groups (CRGs) provide regular updates on the work of their CRG and ensure that pathway redesign is rooted in real practice experience. 6.2) Patient and Public Involvement (PPI) The Wandle Patient Consultative Group (PCG) is attended by representatives from most practice patient groups, usually around 20 25 patients. There are three Wandle practices that do not field a representative to attend, and we are working to continue to support recruitment of patients from these practices. The meetings take place once every six weeks, are chaired by elected patient chair Marion Endicott and are also attended by a Wandle Clinical Lead and the Locality Manager. The group is invited to contribute to commissioning needs assessments, strategies and CCG positions during early drafting, and CGG and Public Health staff frequently attend to present CCG work to this group. As a recent example, Public Health attended the PCG to consult on their draft Sexual Health Strategy; the needs-assessment workshop format was very well received by our patient group and provided Public Health with valuable feedback. Patient group representatives have over the past year volunteered to lead work on Wandle s five priority commissioning areas. A new reporting system has been developed to ensure that patients who sit on other health groups can feed relevant information back to the PCG. The PCG also invites the 2 Wandle representatives from the PPI Reference Group to attend the meetings on a regular basis to feedback on PPI across Wandsworth CCG. We try as patient group to ensure our cycle of business is relevant to what other Wandle/ CCG forums are discussing/implementing, and also make provision for anything which comes to attention as a matter of sudden importance or urgency, thus keeping our schedule flexible, accountable and relevant - Marion Endicott 6.3) Practice Managers Forum The Wandle Locality Manager attends the monthly Practice Managers Forum. This provides a good opportunity to brief Practice Managers on work in development and a forum to hear their issues and answer their questions about the CCG. 6.4) Practice Nurse Lead Wandle has appointed a nurse lead who attends the Members Forum and is also a member of the Wandle Management Team. She leads the well-attended monthly Practice Nurse Forum and provides a vital link in encouraging practice nurse involvement in Commissioning as well as ensuring that the practice nurse voice is communicated to both the localities and CCG. 6.5) Practice Visits The Wandle Clinical Leads and the Wandle Locality Manager have recently embarked on a series of visits to the practices. These visits provide an opportunity to listen to practices concerns and feedback about commissioning, and to help identify areas for potential CCG support where appropriate. In the past 3 months, 8 practices have been visited with 2 more scheduled, and we are continuing with this process over the rest of the year. 7) PRACTICE DEVELOPMENT 7.1) Training Wandle was able to secure funding in March 2013 to use for the training and development of GPs and practice staff via the Kings Fund. We plan to offer training sessions throughout the year and Wandle October Board Paper 2013 Version 1 6
practices are being consulted on what kinds of training they would find most beneficial for themselves and their teams. 7.2) Members Development Programme Following on from the GP Engagement Scheme, the Wandle locality manager has this year led implementation of the Members Development Programme. This program uses peer review and shared learning, with funded protected time for a multi-disciplinary team to develop and improve practice. Running in parallel with this is the Productive GP Programme, a structured approach designed to support practices in continuous improvement. All Wandle practices have joined the Members Development Programme, with 12 Wandle Practices choosing to participate in the Productive General Practice programme. 8) PLANS FOR THE NEXT 6 MONTHS COMMISSIONING - Engage and participate as a locality in the QIPP agenda - Continue to work on the 5 Locality Priorities with Service Redesign Managers and Public Health - Contribute as a locality to the 2013/14 programme of visit to seldom heard groups. - Continue to encourage more clinicians to be involved in ad hoc Locality Projects - Develop a priority list of practices to target around Obesity PERFORMANCE & FINANCE - Work with practices to review current spend of FURs and identify possible spend options tied to our locality priority areas - Investigate pooling underspent FURs money for investment in the Wandle locality - Support the 2013/14 QP schedule and work with practices to begin collation of evidence - When data becomes available, review against A&E action plans - Develop the Locality Investment Scheme for 2014/15 ENGAGEMENT - Continue to facilitate partnership working in the locality between GP practice staff at all levels, patient groups, local authority, public health etc, by engaging representatives in Locality Commissioning Group Members Forums, LCG Management Team and in project work - Work with Wandle PCG to promote effective PPI work - Work with Wandle Locality Representatives on Clinical Reference Groups to continue to ensure effective communication between groups - Continue with program of practice visits - Refresh of patient group skill sets and system in place for patients attending other meetings to feed back to the PCG PRACTICE DEVELOPMENT - Review progress of, and establish learning from, 2012/13 Members Development Program - Continue to support practices to put together and implement actions plans for 2012/13 Members Development Programme - Ensure that training sessions secured under the Kings Fund go ahead and are fully evaluated Wandle October Board Paper 2013 Version 1 7