Transcript Context: Key facts about Tower Hamlets

Improving outcomes for people
with musculoskeletal conditions
Dr Victoria Tzortziou Brown
NHS Tower Hamlets CCG Lead on Integrated Care and Research
Context: Key facts about Tower Hamlets
• Total population of 290,000, young
and growing
• Diversity, deprivation
• High burden of disease-cardiovascular,
diabetes, cancer, mental health,
musculoskeletal, obesity
• Barts Health
• GP federations
• Vanguard site
2
Improving MSK outcomes: The person
• Person-centred, holistic approach
• Taking into account multi-morbidity, person`s
family/social context, culture and priorities
• Empowerment
• Lifestyle factors
Improving MSK outcomes: The workforce
 Knowledge-Skills-Education
 Motivation
 Capacity
 Appropriate skill mix
Improving MSK outcomes: The system and processes
• Single point of access
• Clear pathways and processes
• Good communication, IT infrastructure, shared
records, patient access to records
• Common incentives and KPIs
At MSK provider level
• Single point of access: Education/upskilling vs triage/outpatient
service. Website, referral proformas, educational sessions, telephone
advice, GPs to observe clinics, structured discharge letters with
feedback and educational signposting.
• Shared records
• Multi-professional input: ESPs, GPwSIs, T&O consultants,
rheumatologists, radiologists.
• Close working with community providers, health trainers,
community psychology team, OT, social prescribing (weight loss,
dieticians, local gyms), voluntary sector.
• KPIs and key outcomes: conversion rates to surgery, waiting times,
condition-specific outcomes, EQ-5D, patient activation, service user
experience, patient/GP education.
At General Practice/Network level
• Network Incentive Scheme: holistic
approach for people with complex
needs and long-term conditions. Care
planning, patient activation, social
prescribing.
At Vanguard level
Common Incentives and KPIs
across providers
Level 1 metrics:
• quality of life
• patients fulfil their potentials
• safety from harm
• co-ordinated care
• population needs
Connecting up with what’s out there!
STATUTORY SERVICES
3rd SECTOR PARTNERS
Walking Groups
Specialist Nurses
Family Intervention Project
Creches
Health Visitors
Playgroups
Secondary Schools
Girls Clubs
Community Cafes
Employment Advice
Karate/ M Arts
GP Practices
Primary Schools
Welfare Advice
School Nurses
Drug Outreach Team
Children’s Centres
Person,
their carer
and family
Healthy eating classes
Cycling Groups
Elders Groups
Football Clubs
Seniors Shopping Trips
Senior Youth Service
Exercise on Referral Classes
Aerobics/Keep fit
Yoga
Home Helps
Health
Gardening Clubs
Sport
Junior Youth Clubs
Tai Chi trainers
Mental Health Groups
Singing groups
Job Centre +
Coffee Mornings
Churches & Mosques
Midwifery
Line Dancing
Parent & Toddler
Dance
Social Services
Cultural Groups