Transcript Improving the management of LTCs in children

City and Hackney Clinical
Commissioning Group
Draft Commissioning Intentions 2014/15
Maternity Programme Board
Programme Board Objectives
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Ensure our maternity services are affordable, of high
quality and improve patient experience
Increase the numbers of women who book early
Improve the quality of the community midwifery
Early identification and provision co-ordinated care for
vulnerable and at risk women
Ensuring user views drive the service model and
improve quality
Commissioning Intentions
Ensure our maternity services are affordable, of high quality and improve patient experience
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On-going review and monitoring of Homerton staffing levels;
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Roll out of friends and family.
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On-going review and monitoring of the levels of care offered to pregnant women
Improving the care of socially vulnerable women:
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Improving the services offered to vulnerable women
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Agreeing the enhanced offer for vulnerable women
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Roll out joint antenatal visits, midwifes and health visitors, for vulnerable women.
Review of community midwifery:
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Improved patient experience;
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Ensuring low risk births receive their care in the community rather than in a hospital setting;
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Ensuring maternity services are provided in high quality, patient friendly compliant sites;
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Improved access to community provision;
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Improved communication between GPs and midwifes.
Review of antenatal classes
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Review of the full spectrum of Parentcraft provision to see where improvements can be made
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Input from the Maternity Services Liaison Committee parent reps
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Review of settings and times of classes to increase accessibility
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Training for midwifes
Urgent Care Programme Board
Commissioning Intentions
Accident and Emergency (A&E) performance
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Review of senior staff (decision makers) presence in A&E and compare against other London A&Es
Frequent attenders group
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To develop improved relationships with our practices, providing data and improved collaboration with other
teams;
Improved winter planning
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Preparation and provision of additional funds to cope with recognised capacity challenges.
Observational Medical Unit (OMU) and associated pathways
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New pricing to be agreed to avoid duplication of costs;
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Increased utilisation and encourage direct referrals from GPs;
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Additional pathway development and implementation – Cellulitis is ready for implementation, Chest pain,
Tonsillitis/Quinsy and sudden onset headache are under development.
Primary Urgent Care Centre (PUCC)
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Development of new service specification taking into account changing needs and the local environment.
Commissioning Intentions
Out of Hours (OOH)
•Embed new provider (City and Hackney Urgent Healthcare Social Enterprise (CHUHSE) into the system;
•Strategic marketing of service;
•Review likely implementation of additional sites to deliver base services closer to City and the rest of Hackney;
•Improved collaboration with local providers, delivering integration where possible.
Access in primary care
•Increase access and support for same day urgent appointments for practices;
•Development of the duty doctor responsibilities and activities;
•Increased interaction with Trust A&E and OMU regarding admission and discharge;
•Increased capacity for patient visits referred via community services;
•Extension of practice hours;
•To consider evening and weekend coverage;
•To consider individual and collaborative working for practice provision.
London Ambulance Service (LAS)
•Collaborative review and assessment of existing pathways and the current impact in order to agree necessary
changes;
•Development of GP support to LAS paramedics in a car service. Pilot to be developed for January
to provide support to emergency calls where GP intervention may help avoid conveyance
and increased interaction with patients GP and community services.
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to hospital
Planned Care Programme Board
Programme Board Objectives
City and Hackney CCG aims to:
• Improve the equality of healthcare for our registered patients
• Ensure our health care system is affordable, of high quality and
improves patient experience
• Work with our partners to reduce health inequalities and improve
outcomes
The Planned Care Board is responsible for commissioning services
from hospitals that are arranged by your GP – for example outpatient
appointments, planned operations as a day patient or inpatient.
Our approach:
• Agreed pathways for patients with GPs and hospital doctors working
together
• Providing training to keep GPs informed
• Hospital consultants providing support and advice
• Services in the community
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Commissioning Intentions
Commissioning an integrated multidisciplinary community based pain management
service
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Educating and supporting patients to improve quality of life whilst continuing to live with
persistent pain.
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Reduced uptake of interventional therapies (injections), promoting a psychosocial
approach
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An increase in self-management strategies and tools
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Increased peer support for service users with persistent pain
Total Knee Replacement Pathway
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Improved health gain for people who have a Total Knee Replacement procedure
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A simplified pathway reducing number of ‘steps’ in the process
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Shared Decision Making with patients from all clinicians involved in the new pathway
Ophthalmology
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Working with Optometrists to provide more testing for glaucoma in the community and to
increase numbers of people referred for a cataract operation direct from the optometrist
after being supported to make an informed decision about the procedure
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Commissioning Intentions
Dressings care
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Dressings care will be provided by the right person in the right place through a
coordinated service model.
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Commissioning specialist dressings care for venous leg ulcers from community
nursing service and commissioning for post-operative and ‘other’ wound care
from a community provider(s)
Diagnostics
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Re-commissioning diagnostic tests directly accessed by GPs
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Increasing direct access booking for Colonoscopy as part of the
implementation of Cancer Best Practice Pathways
Community Health Services
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Review of current service specifications for ‘Locomotor’ (physiotherapy) Foot
Health, Dermatology GPSI and Community Gynaecology services
Cancer - Early diagnosis
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Working with primary care to improve early detection and treatment of cancer,
supported by the Planned Care Board cancer lead in partnership with
Macmillan.
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Children’s Services Programme Board
Programme Board Objectives
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Improve the equality of healthcare for our registered patients
Improving the health and wellbeing of vulnerable children
and families in the longer term
Improve working arrangements between practices and
community practitioners;
To improve the management of long term conditions
including asthma, diabetes & epilepsy
Ensuring child mental health is a higher priority and that
assessment of a child’s mental wellbeing becomes routine
across primary care
Ensure we are commissioning child friendly services
Safeguarding children and young people
Commissioning Intentions
Improving the management of LTCs in children:
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Standardised care plans for children with a long term condition
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Annual reviews for all children with a long term condition
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GP Practices following up children & families who frequently attend A&E.
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Patient education programmes to help children and families manage their long term
condition
Early identification and enhanced support for vulnerable children and families:
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Early identification of vulnerable children and families and enable practitioners to
recognise, assess, plan and provide for children as well as parents who need extra support
in bringing up their children.
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To ensure more pro-active care to address inequalities for those families who may not seek
help.
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GP Practices to follow up children & families who frequently attend A&E.
Improving children’s mental wellbeing
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Every family which completes a treatment with CAMHS/First Steps to be offered a follow
up appointment in primary care within 3 months of discharge
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Every child who presents with self-harm/OD at A&E to be proactively followed up
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Commissioning Intentions
Delivering child friendly services
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GP Practices will be required to develop policies that ensure their services are accessible
and child friendly following a Department of Health Framework.
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Developing child friendly leaflets
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Ensure practices have knowledge of the range children’s services available locally and how
to refer
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Ensure the service provision, environment and atmosphere are young people friendly
Implementing the changes in special education needs (SEN) code of practice:
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Rolling out personal budgets for children with complex health needs;
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Working with the Local Authority and Education to roll out joint education, health and care
plans for children with special educational needs and disabilities.
Long Term Conditions Programme Board
Programme Board Objectives
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Improve the equality of healthcare for our registered
patients
Ensure our health care system is affordable, of high
quality and improves patient experience
Work with our partners to reduce health inequalities and
improve outcomes
Develop integrated out of hospital services to mitigate
the increasing cost of hospital based unscheduled care
Reduce the early death rates from cardiovascular and
respiratory disease
Commissioning Intentions
Invest in an expanded integrated care programme
• GPs proactively identifying people who would benefit from care planning, based on their risk of
being admitted to hospital
• Multi-disciplinary care planning, including comprehensive geriatric assessment, regular review
of care plans and help for patients from “care coordinators” to manage their care plans
• Pro-active home visiting for housebound patients who have a care plan
Additional investment in primary care to better identify and manage cardiovascular and
respiratory disease, and other leading causes of illness and death in City and Hackney
• Building on work to date which has meant that C&H GPs now deliver some of the highest
standards of care in London
• Extra focus on chronic kidney disease
• Making better use of existing data and systems to identify new cases
• Extra support for patient on diagnosis with extra long nurse appointments
Invest in a new fast track service to diagnose and treat people with atrial fibrillation
• Atrial fibrillation is a leading cause of stroke
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Primary Care Quality Board
Programme Board Objectives– shared with LTC board
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Improve the equality of healthcare for our registered
patients
Ensure our health care system is affordable, of high
quality and improves patient experience
Work with our partners to reduce health inequalities and
improve outcomes
Develop integrated out of hospital services to mitigate
the increasing cost of hospital based unscheduled care
Reduce the early death rates from cardiovascular and
respiratory disease
Commissioning Intentions
Educational support to practices to deliver our plans for long term conditions
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Education and training re cardiovascular disease, respiratory disease, diabetes,
hypertension, chronic kidney disease, all specifically tailored to meet the needs of GP,
practices nurses, health care assistants and other members of the practice team
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Training in care planning to support integrated care with protected learning time to share
good practice across City and Hackney
Helping practices improve quality through intra-practice working
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Enable practices to find the time to work together to share what works well, e.g.,
appointment systems, or to provide services for patients from neighbouring practices in
order to improve equity of access to additional services
Additional support for those practices who need it the most
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Practices who have been identified by NHS England (who commission general practice)
as outliers on measures of performance, e.g., GP Outcome Standards – practical support
to these practices on reviewing systems and procedures
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Mental Health Programme Board
Mental Health Need
Children/adolescents
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1 in 10 children & young
people aged 5 - 16 have
a diagnosable mental
health disorder - around 3
in every class
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Only 25% access
effective care
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Between 1 in every 12
and 1 in 15 children &
young people deliberately
self-harm – admissions
have increased by 68% in
10 years
Adults
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1 in 6 at any time
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50% of all women & 25% of
all men are affected by
depression at some time in
their life
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0.4% adults have a psychotic
illness
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5.4% of men & 3.4% of
women have a diagnosable
personality disorder
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Suicide is the greatest cause
of male deaths < 35 years
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People with schizophrenia
are likely to die 15-25 years
earlier than others
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30-50% of people with mental
health problems are not
acknowledged as having a
mental health problem at
consultation with GP
Seniors
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1 in 6 over 65 have
depression due to social
isolation or physical illhealth
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Dementia effects 5% over
65s, 10-20% over 80
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30% of over 65s in acute
trust beds have dementia
In physical care services
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Up to 50% of people in
outpatient clinics have
medically unexplained
symptoms
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25% of all people with
long term physical
conditions have
depression & die earlier
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Alcohol-related injury is
approx. 24% of A&E
presentations
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Stroke patients have
anxiety rates of 30-49%
up to 12 years post stroke
Groups at risk
Children and young people
Adults
Children with parents who have mental health
• 4-5 fold increase in onset of mental disorder
Children with parents who have substance use problems
Children experiencing personal abuse or witnessing parental
domestic violence
• 2 fold increase of all mental disorder (child abuse)
‘Looked after’ children’
• 5 fold increased risk of mental disorder
Children with learning disabilities
• 6.5 fold increased risk of mental illness
Children excluded from school
Teen parents
Young offenders
• 18 fold increased risk of suicide for men (15-17yrs)
Young lesbian, gay, bisexual & transgender people
Young Black & minority ethnic groups
Children in families living in socioeconomic disadvantage
• 3 fold increased risk of mental health problems
(children from lowest quintile of household income)
Black & minority ethnic groups (7.9% of UK pop)
Rates of schizophrenia:
• 5.6 times higher in the black Caribbean group
• 4.7 times higher in black African group
• 2.4 times higher in Asian groups
Homeless people
• 11.3 fold increased risk in psychosis
• 5.5 fold increase alcohol dependence
Unemployment
• 2.7 fold increase in Common Mental Disorder
In debt
• 3 fold increase in Common Mental Disorder
Adults with a history of violence or abuse
Adults with alcohol or substance misuse
Offenders & ex-offenders
• 20 fold increase in psychosis among prisoners
Lesbian, gay, bisexual & transgender adults
Travelers, asylum seekers and refugees
People with a history of being looked after/adopted
People with intellectual disabilities
• 3 fold increased risk in schizophrenia
Isolated older people
Our Target Groups
Target Groups
Headline Interventions
Children and young people
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Improved waiting times, access to psychological therapies, DNA and user choice
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Improved training for school nursing to identify early prodromal signs
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Every child aged 14 upwards thought to meet the EIP criteria will be assessed within 2 days
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All children and families social workers, residential staff and foster carers will receive basic mental
health training to be repeated every 2 years
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Rapid assessment interface and discharge working within A&E and inpatient settings
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Wider skills and competencies for community based staff to recognise the signs of psychosis in order to
enable swifter referrals
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Every patient to have a recovery plan and introduction to benefits and employment support
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Reduce waiting times from referral to assessment and treatment
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Expand the range of interventions available through IAPT to include IPT and brief interventions
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Review of Community Mental Health Teams and the role of EIT, AOT etc
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Improved inpatient standards including medication reviews, and a Patients Charter which reflects a
minimum set of standards
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Improved access to MH support across LTC pathways and within acute care
Improved screening and coding
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Improved support for patients and carers in the community
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Alcohol and substance misuse screening
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Improved referral pathways for eating disorders
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Integrated psychological therapies improving access at the right time for complex presentations
(including Child Tavi?)
People new to services
People with short term problems
People with ongoing problems
People withdementia
People with complex needs
Our plans to improve performance
Initiative
What will be different/what will be the impact
By end of March 2015
Each practice to have access to an SMI management bursary to
fund additional training and upskilling of staff.
- Increased levels of patients receiving care closer to home
- Parity of esteem
Integration of voluntary sector reporting systems to support
stepped care for common mental health problems
- Increased access points to MH services
Inclusion of Cluster 18 (mild/moderate dementia) patients in SMI
LES
- Additional annual health checks for this cohort of patients
- Reduced secondary care service costs
Development of Single Point of Entry for Psychological Therapies
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Develop a primary care oriented CAMHS Tier 1 approach which
supports identification and case management within Primary Care
(Hackney Healthcheck)
- A targeted mental health approach which identifies problems early and supports good
emotional health within schools
Finalise a CAMHS development curriculum which will actively
address concepts of recovery and community involvement within
it, identifying people currently missing services
- A map local mental health services available to under 18s
- A combined CAMHS and First Steps referral form
- A family model of CAMHS provision within primary care offering a service to children and
families not engaging with CAMHS services
Identify who is being missed completely (ie no depression or
anxiety diagnosis) - working with public health to look closely at
suicide figures, self harm, people on long term sick notes, MUS
and repeat analgesics and anxiolytics etc.
- Increased numbers of patients receiving psychological support to help manage pain and
medically unexplained symptoms
- Provide a service for those patients repeatedly presenting in crisis but not then engaging
Develop a depression & anxiety element to the SMI LES which
will actively address concepts of recovery and community
involvement within it, identifying people currently missing services.
- Improved voluntary sector interfacing with IAPT and primary care based services for
common mental health, increasing the options of support for SMI LES patients.
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Revised Outcomes Framework across CAMHS services to an
integrated model with sessional reporting
Improved care pathways across psychological therapies with
Reduced DNA and drop out..
Increase in need being meet moving from 15% to 17% for common MH
Increase in concurrent employment support services
- All providers delivering high quality care to the same standards across statutory and nonstatutory
Our plans to address user concerns
Initiative
What will be different/what will be the impact
By end of March 2015
Discharge Counselling for medication
- 100% of patients to receive discharge counselling improving compliance
and reducing readmission
Social marketing of emotional wellbeing resources
- Improved self-care amongst MH patients with a refocus on community and
personal assets
Recovery planning
- All patients to hold a user-defined recovery plan
- 100% of patients to be given or offered a printed copy of their care plan
Advocacy
- All patients to receive an easy to read version of the Care Review process to
include information on advocacy.
Alcohol
- 100% of patients to be asked about their alcohol intake and brief
interventions/treatment initiated where relevant
Carers
- All carers to receive an assessment and signposting to support
Crisis
- Timely access to crisis which uses inpatient resources effectively and at the
right time
User voice
- Pan borough User Advisory Group to influence and inform commissioning
decisions.
Employment support
- Employment support services coterminus across service provision. This
will involve coordinated work with Job Centre Plus.
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Prescribing Programme Board
Introduction
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Medicines are the most frequent intervention and cost the NHS over £12 Billion in
2011
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If used appropriately, medicines can make significant impact on reducing
morbidity, mortality and demand on other health resource
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Research has shown that at least 6% of emergency admissions are due to
adverse drug reactions and that up to 50% of prescribed medicines are not taken
as intended
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City & Hackney CCG will spend approximately £27M on medicines in 13/14 - this
medicines expenditure is likely to grow annually
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Effective management medicines activities will enable City &Hackney CCG to:
– secure efficiency and value for money through cost effective prescribing
choices
– improve patient outcomes
– ensure quality of medicines used in commissioned services
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Our plans to improve clinical outcomes
Initiative
What will be different/what will be the impact
By end of March 2015
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Adherence and improvements in
Clinical Outcomes
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Adherence - Increase patient
engagement
http://www.nice.org.uk/CG76
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Medication review of prioritised
patients in key clinical areas
Cardiovascular
Respiratory
Mental Health
Improved use of medicines to
prevent morbidity and hospital
admissions in the prioritised areas
Identify through patient groups –
gaps in medication reviews/ use
reviews
Improved provision of information for
patients on appropriate ordering of
repeat prescriptions
By end of March 2016
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Subject to level of funding make available to each C&H practice,
medication review for all prioritised clinical areas
Improve adherence & clinical outcomes of patients with
cardiovascular, respiratory and mental health
Reduce medication waste
Increased access to medication related counselling for patients
Improving patients awareness and uptake of medication review /
Medicines use review schemes
Improvements in patients’ knowledge about the medicines that
they take
Our plans to address members concerns
Initiative
What will be different/what will be the impact
At the June 2013 – CCG Prescribing Forum, practices identified
areas of concern - clinical areas to be addressed as follows:
By end of March 2015
By end of March 2016
Prioritising clinical outcomes over cost savings
Reviewing how we align cost
effectiveness of prescribing with clinical
outcomes
Measuring the impact of medicines
related interventions on morbidity and
hospitalisations
Clarification about recommendations from the Pain Clinic
Pain guidelines – development and
practice implementation
Measuring impact of Pain pathway and
prescribing guideline on prescribing and
hospital services
Review of combined drug inhaler use
Respiratory Medication reviews
Improved implementation of NICE/BTS
guidelines on Asthma and COPD
Continuation of Pharmacist support at individual Practice level
Each practice to be offered support from
dedicated Pharmacists (pending
funding) to support quality improvement
of prescribing
Each practice to be offered support from
dedicated Pharmacists (pending funding)
to support quality improvement of
prescribing
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An overview of the relationship between our future
plans and our strategic objectives
Area
Strategic Objective
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Medicines Optimisation
Strategy
Effective Formulary,
prompt implementation of
NICE guidance
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Effective local decision
making arrangements
Cost effective use of
medicines and budget
management
Continued development
of relationship with
community pharmacy
Advice available for safe
handling of medicines
provided or commissioned
by CCG
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Work with our partners to reduce
health inequalities and improve
outcomes
Reduce the early death rates
from cardiovascular and
respiratory disease
Improve the equality of
healthcare for our registered
patients
Improve the equality of
healthcare for our registered
patients
Activity
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Patients supported with
medicines taking
Safe use of medicines in all
settings
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Robust process for entry of
new medicines, safe/effective
systems in place for
considering individual funding
requests
Ensure our health care system
is affordable, of high quality and
improves patient experience
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Develop integrated out of
hospital services to mitigate the
increasing cost of hospital
based unscheduled care
Expenditure data, future
strategic plans, management
of payment by results
excluded drugs
Work with our partners to reduce
health inequalities and improve
outcomes
Effective methods of
communication established
with community pharmacy
Work with our partners to reduce
health inequalities and improve
outcomes
Ensuring access to medicines
out of hours, development use
and monitoring of patient
group directions (PGDs),
medications governance and
policy
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NHS constitution and NICE
funding direction are met
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Future plans
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Respiratory pharmacist to extend medication review pilot which has ↑ QoL,
adherence to therapy, ↓ unnecessary prescribing
Medication reviews in care homes
Use of "NHS Informatics" tool to relate outcomes/ prevalence data to prescribing,
use of ScriptSwitch
Continued use of sessional pharmacists to identify opportunities for medicines to
be optimised within practices
Continued management of the eBNF following launch in 2013. This joint project
between CHCCG and HUHT will support DoH requirements for Innovation,
Health and Wealth.
Future NEL wide formulary to improve quality and cost planning
Continued collaboration with NEL Medicines Management Network, impact of
new drugs being identified
Strengthened management of Individual Funding Request process
Sessional pharmacists will continue to deliver QIPP plan and generated savings
to enable CCG to stay within prescribing allocation and reduced inappropriate
prescribing
Budget updates and forecasts provided regularly, improved processes in the
management of HCD to reduce variation for C&H patients
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Future plans to train community pharmacists to provide CVD and respiratory
interventions and motivational interviewing for patients on long term medication
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Development of audits to encourage reflection on current practice and to support
implementation of procedures where deviations from safe and effective practice
had been identified
Monitoring of Serious Incidents and effective use of PGDs
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