East and North Herts CCG · Please call back tomorrow. “ ” Comein and see nurse Come in and see preferred GP Calls are allocated to GPs (allowing patients to choose which GP they

East and North Herts CCGNorth Herts

Stevenage

Welwyn &Hatfield

Upper Lea Valley

StortValley and Villages

Lower Lea Valley

12 practices

9 practices

9 practices

16 practices

6 practices

8 practices

Health and Wellbeing Board priorities

Healthy Living• Reducing the harm caused by alcohol• Reducing the harm from tobacco• Promoting healthy weight and increasing physical activity

Promoting Independence• Fulfilling lives for people with learning disabilities• Living well with dementia• Enhancing quality of life for people with long term conditions

Flourishing Communities• Supporting carers to care• Helping all families to thrive• Improving mental health and emotional wellbeing

111,384 patients

£123.9m budgetFiona Sinclair Rob Graham Robin Christie

Russell Hall Prag Moodley

90,281 patients

£98.7m budget

111,067patients

£117m budgetHari Pathmanathan John Constable

124,635 patients

£121.1m budget Nicky Williams Steve Kite Mark Andrews

51,835 patients

£58.4m budget Nabeil Shukur Deborah Kearns

73,152 patients

£83.4m budget Alison Jackson Ed Bosonnet

Main acute trust: E&N Herts NHS Trust



Main acute trusts:E&N Herts

NHS Trust, PAH, Addenbrookes

Main acute trust: PAH

Main acute trusts: Barnet & Chase

Farm, PAH

Home First is now successfully implemented!

• Proactive and improved case management• Integrated health and social care• 1,121 patients seen

What do patients say about HomeFirst?

• 89% respondents felt they were actively involved in the decision about their care

• All HomeFirst clients who responded to the patient experience questionnaire felt they were treated with dignity and respect

• 99% respondents had confidence in HomeFirst team

The way forward…. HomeFirst Plus• HomeFirst Pharmacy• End of Life

Target GroupTackling childhood obesity by inviting those children (4‐5 year olds and 10‐11 year olds) who have been identified as being overweight through the National Child Measurement Programme to attend healthy lifestyle review clinics at their GP Practice.

Engagement:8 Lower Lea Valley practices in partnership with Upper Lea Valley

All practices have obesity leads

Childhood obesity project

Partnership working: Children’s Centres, Public Health, School Nurses, Primary Care, Upper Lea Valley, Broxbourne Council and MEND (Mind, Exercise, Nutrition and Do‐it!).

The teamChairs: Dr Alison Jackson and Dr Ed BosonnetLeads: LTCs – Dr Alison Jackson and Dr Chika UduchukwuMental Health – Dr Suboshini KugaprasadPrescribing – Dr Mo DabbaghPatient Group – Dr Angela GoodwinPatient Group User – John Skitt

Key Health Priorities1. Tackling childhood obesity (and obesity in general)2. End of life care3. HomeFirst (integrated health and social care)

Key Aims• Reduce health inequalities• Improve health outcomes• Enhance partnership working

Local Challenges• Diverse population (cultural and socio‐economic)• Geography (urban fringe north London)

Lower Lea Valley

Happy birthday HomeFirst!

Carers project

Partnership between CCG, Crossroads and named carer leads from all practices. Project aims to 1) identify and engage with local carers ; 2) improve their awareness of, and access to, local health and social care information and support; 3) improve the overall health and wellbeing of local carers.

Pat satisfaction in bottom 10% in country

Stort Valley and Villages

Improved access to GP services; long term conditions and end of life care; cancer and dementia

• 1 session a week in each practice

• Improved repeat prescribing and dispensing processes

• Advised on medicine interactions

• Reduced wastage on appliance prescribing

• Role paid for itself in 4 months

GP sees patient (10 min slot)

Problem solved

Reception takes call

70% “routine”

30% “urgent”

Patient pressure

Long waits for appointments lead to high rates of non‐attendance

Seeing any GP/locum = poor continuity, repeat booking

Sorry, all today’s appointments are full.

Please call back tomorrow.“

”

Come in and see nurse

Come in and see preferred GP

Calls are allocated to GPs (allowing patients to choose which GP they

would like to talk to)

Problem solved

GP phones patient

Admin question

Reception takes call

10%

20%

10%

70%

30%

60%

The new way….The old way….Access and patient

satisfaction problems

Average wait to see a GP down from 5‐7 days to same day

Dedicated in‐practice pharmacist

From £1.8m overspend in

2011/12 to £300k underspend in 2012/13

How did we do it?Dedicated patient access projectAsk us

about our winter bids and Productive General

Practice model

Locality priorities:

Reduced locality prescribing costs by £77,400 (ytd)

Financial success +hardworking locality team

= better patient care

Upper Lea ValleyMeet the locality team…

Patient representatives from Upper Lea Valley are involved in:

• Patient Network (Quality)• Unscheduled Care Programme Board• NHS 111 visits• Acting as patient ambassadors for other

practices who wish to set up a PPG

Practice nurse developmentLucy Eldon has been co‐ordinating practice nurse development and covered the following topics:

• Smoking cessation and brief intervention training on chlamydia • Needs of the young person ‐ Youth Connexions • Clinical supervision meetings • Holistic and wound assessment • Pulmonary rehab • Inhaler devices workshop• Training on the ‘Desmond’ and ‘Dafne’ diabetic courses • Heart failure diagnosis and treatment with Clare Young, cardiac specialist nurse. • Antibiotic update from prescribing team

• Steve Kite (The Maltings, Ware) – Chairman• Nicky Williams (Church Street, Ware) – Co‐Chair• Mark Andrews (The Limes, Hoddesdon) – Co‐Chair• Martyn Davies (Dolphin House, Ware) – Locality long

term conditions lead and CCG COPD lead• Jay Kuruvatti (Wallace House, Hertford) – Mental

Health lead• Nick Condon (Park Lane, Broxbourne) – Prescribing lead• Funmi Subair (Hanscombe House, Hertford) – Patient

participation lead• Gerry McCabe (Wallace House, Hertford) – CCG

diabetes lead• Jawad Shahzad (Ware Road, Hertford) – Leg ulcer lead• Lucy Eldon (Church Street, Ware) – Practice nurse lead• Jill O’Brien (Dolphin House, Ware) – Practice manager

representative• Tracey Waterfall – CCG locality manager

• Healthier Communities – Carer leads and training from Carers in Herts• Challenge Fund ‐ Transforming primary care GP services (extended opening hours,

8am‐8pm, seven days a week).• Enhanced Residential Nursing Home Management• Developing leg ulcer service Need help

setting up a PPG?If your practice would like help to get a patient participation

group (PPG) off the ground, please let your locality manager know

and they will put you in touch with the

patient ambassador

Weighted rate per 1000 population

Rank1 = lowest

Upper Lea Valley 238.6 1Lower Lea Valley 242.2 2Stort Valley & Villages 242.6 3North Herts 249.6 4Welwyn Hatfield 286.9 5Stevenage 318.3 6CCG total 264.3

A&E rate per 1000 weighted population

Upper Lea Valley has best A&E rate in CCG area, but elective referrals still present a challenge

Future projects

Welwyn & Hatfield

Strong Practice Manager network

New QEII Hospital: On schedule to open in spring 2015

Welwyn Hatfield locality GPs are key members of the QEII development group, ensuring clinical leadership in the commissioning of the urgent care and elective services at the new hospital.

Collaborative working with Public Health to improve patient outcomes. At Q3, Welwynand Hatfield smoking quit rates were top of the CCG area, including referrals from GPs and pharmacies. Q3 quitter rates for GP referral alone were at 244, which has Welwyn and Hatfield positioned 2ndacross the localities behind Upper Lea Valley at 334.

Spring House Medical CentreThe ‘Federated Model’ in action: Spring House offers GP and walk‐in services from 8am – 8pm. Organised by 8 GP practices in Welwyn and Hatfield, Spring House is helping to improve patient access and reducing A&E admissions.

Who are we?Chairs: Dr John Constable and Dr Hari Pathmanathan

Long Term Conditions lead – Dr Sarah HooleMental Health lead – Barbara HannockPrescribing lead – Dr John ConstablePatient Group lead – Dr Peter WilsonCouncil liaison – Dr Richard Lavelle

Cancer lead – Dr Sachin GuptaPatient group – Dr Sachin Gupta

The Delivering Quality Healthcare for Hertfordshire strategy outlines the vision to provide more healthcare in a primary care setting in local hospitals (the new QEII)

supported by a centralised acute hospital (the Lister).

Key health priorities

1. Supporting the frail elderly2. Pre‐operative healthy weight / healthy lifestyles3. End of life care in heart failure

Key aims

1. Reduce health inequalities2. Improve health outcomes3. Enhance partnership working

StevenageOur winter pressures project started on 3rd February. Two additional GPs provided by

Canterbury Way Surgery support all GP surgeries in Stevenage, seeing patients who ring for an emergency appointment. This frees up more time for practice GPs to focus on managing their patients with long term conditions. GPs are also doing rounds in some local care homes on a daily basis. We believe that this will help to pick up winter‐related illnesses early and prevent patients with chronic conditions getting suddenly worse and being admitted to hospital.

The Canterbury Way Surgery is responsible for clinical and information governance, administration, finance, clinical quality and other statutory and mandatory requirements related to this service.

We are keeping a close eye on any HCT issues you raise with us and agreeing actions to solve problems

We are working with East and North Herts

NHS Trust on the changes to the Emergency

Department at the Lister, which will be complete

in October 2014

Acute In‐Hours Home Visiting ServiceFrees up GP time to manage their practice populations in a more innovative way.

Patient phones surgery and asks for

a home visit

Telephone clinical triage by practice

GP within 30 minutes

If GP decides a home visit is needed,

he/she refers the case to AIHVS

AIHVS visits patient at home or in care home

GP practice sends patient’s clinical

summary to AIHVS

Very urgent (seen within 2 hours)

Less urgent (seen within 6 hours)

• GP time for root cause analysis where patientsfrequently access secondary care

• GP appointments to undertake proactive careplanning

• GP appointments to support themanagement of long term conditionsincluding self‐management plans

• Enabling GP time to review patients in nursingand residential homes

• Work collaboratively with key stakeholders,including A&E, secondary care and communityproviders

• GP appointments to review patients redirectedfrom A&E

• GP time to work collaboratively with localauthority staff

Winter pressures project

Summary of visit sent electronically to the practice within 2 hours

Stevenage has the highest A&E admissions for minor issues that could easily have been treated in primary care. More GP availability could lead to a reduction in unnecessary A&E attendance.

We’re working with partners to make

Stevenage the county’s first carer‐friendly

community

12 GP practices; one each in AshwellBaldock, Knebworth, Whitwell and four each in Hitchin and Letchworth.

The Knebworth practice has a branch surgery in Stevenage, and Ashwell Surgery has a branch surgery in Bassingbourne(Cambridgeshire). Two Letchworth practices also have some patients who live in Bedfordshire.

Our locality priorities are: • GP surgeries• End of life care• Mortality/morbidity figures

Discharge audit Ensuring that people are

discharged from hospital with the right notes and medication, and the correct treatments coded, to

ensure continuity of care with their GP practice and accurate charging.

North Herts consistently sends more reports to the hotline than other localities. Practices are encouraged to report contract and quality issues this way.

For patients with COPD – members of one practice’spatient participation group have installed equipment in patients’ homes as part of the project.

Good use of contracts hotline

North HertsComing soon! HomeFirstpilot to be extended to North Herts

Telehealth pilot scheme

Winter pressures projectThe CCG is paying for additional weekend clinics provided by Herts Urgent Care (HUC) in practices to prevent people having to travel to the Lister site.

Hotline number: 07786 625043

Making Patient Partnership a Reality in East and North Herts

Making patient partnership a reality

Dr Nicky WilliamsGP, Church Street Surgery, Ware

To meet our needs,our NHS wants to listen and care for us as patients. Now is the time to get involved, don’t be fringe patients, it’s rewarding and will

make a difference.

Martin Connolly, Patient member, Potterells Surgery, Brookman’s Park

We have some excellent patient members involved in the

day to day monitoring of services as well as influencing new projects. Working together, patients and

clinicians can make positive changes towards improving the quality of local services.

“”

“

”

More than 70 patients and carers have joined Locality Patient Commissioning Groups and a patient network for quality, using their experiences to improve all aspects of health services for everyone in the area.

• Sit round the table with GPs andmanagers, being listened to andworking together as equal partners;

• Provide information from their ownsurgeries to promote good practice intheir locality;

• Comment on reports, care pathwaysand information leaflets;

• Visit hospitals and community services, talking topatients, carers and visitors to monitor quality andassess the patient experience;

• Put time and effort into contributing theirperspectives in committee meetings andworkshops.

All give their time for free

60% of GP practices have Patient Participation Groups which send representatives to attend Locality Patient Commissioning Group meetings.

If you are one of the 40% not yet signed up to give your support, please encourage your surgery to become involved

How do these groups help GPs?

Quality

Quality

• Incidents and serious incidents• Mortality data e.g. Hospital Standardised

Mortality Ratios• Quality assurance visits to all main providers• Falls• Pressure ulcers• Infection Control• Safeguarding Safety

Effectiveness

Experience

Key achievements

• Establishment of C diff task and finish group led by newly appointed Head of Infection Control, also hasinput from a GP clinical lead

• Critique approximately 24 serious incident investigation reports from provider organisationsper month; ongoing management of approximately 50 cases per month

• NICE guidance• Clinical Audit• Patient Reported Outcome Measures

(PROMs)

Key achievements

• Development of contract particulars – CQUIN, quality and reporting requirements, for all main providers

• Hold regular contract quality meetings withall main providers – NHS and independent

• Patient surveys• Complaints• MP enquiries• Soft intelligence e.g. GP Hotline• Ensuring patient voice is clearly heard in quality

monitoring and helps inform decision making

Key achievements

• The inclusion of patient representatives in our quality assurance visitshas been identified by NHS England as exemplar of excellent practice • The GP hotline continues to be reviewed and further refinedto ensure that all issues raised translate into better quality care

for patients where possible • Case manage on average 33 complaints (mainly Individual

Funding Requests and Continuing Healthcare) per month and respond to 30 PALS enquiries

Sheilagh ReaveyDirector of Nursing

Jessica LinskillLead Nurse ‐

Quality

Dr Rachel JoyceMedical Advisor

James GleedAD, Quality & Patient Safety

Rosie ConnollyQuality lead: NHS providers

Julie BallardQuality lead: independent Providers

Claire JacksonQuality manager

Emma HollingsworthRebecca Cornish

Patient safety & experience leads

Deborah Brice: Designated Nurse for Safeguarding Children

Tracey Cooper: Head of Adult Safeguarding

Fiona Simpson: Head of Infection

Control

Julie’s is a key new role. Her focus is on improving care in the independent sector, including care homes and primary care. The wider team now also benefits from a medical advisor and a designated adult safeguarding lead.

Sheilagh ReaveyDirector of Nursing

Enablers Outcomes Benefits Strategic ObjectivesProjects

Urgent Care Programme Board: Benefits map

Consistent high quality patient experience

Right care, right time, irrespective of place

Controlled costs

Co‐ordinated and personalised service linked to planned care

Accessibility: equal and appropriate for all users

Improving health and social care outcomes (NHS Outcomes

framework)

Empowering self‐management

Activity levels and costs match predictions

Effective strategic and operational clinical leadership

Consistent and standardised process eliminating duplications

Integrated pathways in place

Rapid access diagnostics and treatment

Rapid appropriate access to specialist opinion across health

and social care

Redesigned job roles to meet 7 day working

Urgent Care Centre developed with pathways

Reduced emergency admissions for over 75s

Reduce length of stay

Pathway – discharge to assess

Reduce 30 day re‐admissions

Urgent Care centre, Lister Emergency department

Re‐procurement of CheshuntMinor Injuries Unit

Ambulatory Care pathways for emergency presentations

New QEII local A&ERapid assessment unit /

Ambulatory emergency care

Clearer navigation and signposting

Patients accessing right care in right place

Re‐procuring Out of Hours and NHS 111

Improved patient experience

Fewer inappropriate presentations

Improved clinical outcomes

Financial sustainability

Improved staff satisfaction through integrated working

Ambulatory Care pathways for emergency presentations

Ambulance expertise in CCG

Secondment from acute trust supporting winter pressures &

patient pathways

Acute medicine pathways (non‐elective)

Telephone triage for GPs

System wide urgent care network

System wide urgent care network

Unscheduled Care strategy

Urgent Care dashboard

Cross working with Planned Care Board, Partnership & Out

of Hospital Board

Competent, compassionate workforce

makes it easy for Hertfordshire patients to

access urgent healthcare services. By calling one free, memorable number, patients get straight through to highly trained call handlers who assess their symptoms and direct them to the right service for their needs, or give self‐care advice where that’s the best thing to do.

Unlike some areas of the country, the 111 service in Hertfordshire has been particularly successful because of the strong clinical and managerial leadership since the pilot began in October 2012.

The service continues to work well – including reducing pressure on A&E services during these colder months –and is providing vital information to the CCG about how urgent care services are being used.

NHS 111CCG Associate

Director: Denise

Boardman

Chair:Mark Andrews

Clinical Champion:Vishen Ramkisson


Better Care Fund

NHS improving quality programme

Joint posts

Prevention of falls strategy

Care homes business case

Integrated care project board

Home First steering group

Integrated Point of Care negotiations

Community IT

Quality, Innovation, Productivity and Prevention

Primary care access projects

Falls Liaison service

Support for care homes

Integrated services

Home First

Integrated points of access

Primary care access

Medicines Management

Reduction in variation (eg by locality, by GP practice)

Clearer navigation and points of access (for patients, carers

and clinicians)

Integrated health and social care community services

Jointly commissioned enablement and intermediate

care, better aligned to secondary care

Improved information on activity, cost and outcomes in

non‐hospital settings

Reduction in non‐elective admissions for over 75s

Increased number of care plans for over 75s

Improved patient satisfaction

Reduced non‐elective admissions cost

Reduction in staff absence rates in community services

Reduction in incidence of adverse effects for patients on

multiple medications

Out of Hospital Care Programme Board: Benefits map

Consistent, high‐quality patient experience


Controlled costs




Framework)



Competent and compassionate workforce

CCG Associate Director:

Jacqui Bunce

Chair: Deborah Kearns

All localities have reported an increased workload from care homes over and above the standard GP contract.

Often, care homes are looked after by more than one GP practice, all with their different ways of doing things, leading to difficulties for the home and potential continuity of care issues. We are also seeing a rise in the number of emergency short stay hospital admissions from care homes. In 2012/13 there were 2,300+.

The Programme Board has supported the development of a new model, with locality devolved budgets, to match care homes with just one practice. Proposals have been welcomed by the Herts Care Homes Providers Association.

From Spring 2013, this aims to improve the way that care homes, GPs and pharmacists work together and to reduce the number of unnecessary admissions to hospital through better, more targeted falls prevention work.


Electronic referrals

Enhanced recovery

Joint posts

Map Of Medicine

Commissioning Framework

End of Life Strategy

Stroke Network

Long term conditions forum

Telehealth‐Flo

CCG Hotline

Quality, Innovation, Productivity and Prevention

Beds & Herts Priority Forum

Diabetes Care

Chronic obstructive pulmonary disease care

Stroke Pathway

Better End of Life Care

Heart Failure Pathway

Skin Health review/redesign

Cancer Variation

Maximising effective commissioned health care in primary / community setting

Evidence based pathways with clearer navigation and referral points for clinicians to reduce avoidable variation at practice /

locality level

Integrated health and social care services, e.g. for long term conditions and end of life care

Maximising patient and carer involvement in effectively

managing long term conditions

Improved information on activity, cost and outcomes for

entire care pathway

Reduction in non‐elective admissions for patients with

long term conditions

Increased patient use of Personal Health plans to

maximise long term conditions self‐management

Improved patient confidence to manage long term conditions

Reduced non‐elective admissions cost

Improving the health related quality of life for patients with

long term conditions

Cost effective care pathways

Planned Care Programme Board: Benefits map

Interface Geriatric Service

Musculoskeletal service review/redesign

Anticoagulation redesign

Tele‐health in Marymead

QEII: (4) x work streams

Achieve patients preferred place of death and carer experience

of end of life care

Increasing the number of people having a positive

experience of hospital care

Consistent, high quality patient experience


Controlled costs




framework)



Competent, compassionate workforce

Chair: Robin Christie

CCG Associate Director:

Nicky Poulain

The Welwyn Hatfield locality identified a need to review services for their heart failure patients. The locality spent 3 months working with multi‐disciplinary teams including acute consultants, specialist nurses and the palliative care team. The project is overseen by the Planned Care Programme Board.

They looked at the safety, quality and financial viability of a revised heart failure pathway. When the pathway is signed off it will form part of contract agreements with providers enabling us to make sure it is being implemented correctly. The locality and the programme board are looking forward to utilising the new pathway, once it has been agreed at the end of February.

Heart Failure

Clinical Champion for heart failure:Sachin Gupta


Joint posts

Map of Medicine

Commissioning Framework

Children’s strategic networks

Herts County Council strategic commissioning groups

Public Health Strategy

IT enablers

Maternity Services Liaison Committee

Children's continence review

Autistic spectrum disorder pathway review

Speech and language therapy service redesign

Single Point of Access

Improving access to psychological therapies

Rapid assessment, intervention and discharge

programme

Learning Disability – health checks

Children's centres review

Individual funding requests for children

Obesity project –Upper and Lower Lea Valley

Urgent care pathways

Patients and carers are equipped with the knowledge and confidence to manage and maximise their own health

Evidence based pathways with clearly identified referral

processes that are easy for the patient/service user to access

Defined joint commissioning strategy

Integrated health and social care assessments and services

Improved information on activity, cost and outcomes for

entire care pathway

Reduction in secondary care admissions.

Reduction in A&E attendances for children with the 7 “high

volume” conditions

Improved patient confidence to manage their own health

Increase in the number of children who achieve the

expected early learning goals.

Cost effective care pathways

Joint Commissioning & Partnership Programme Board: Benefits map

Child Zone – QEII

Special educational needs and disabilities – personal health

budgets

Home Start review

Autistic spectrum disorder and challenging behaviour review

Sufficient safe and accessible services for people with vulnerability indicators.

Safe and smooth transition between children's and

adults’ services.

Consistent, high quality patient experience


Controlled costs




framework)



Competent compassionate workforce

Chair: Prag Moodley

CCG Associate Director: Helen

Edmondson

To tackle this problem, obesity has been identified as a priority by Lower and Upper Lea Valley localities. A project to commission a service with Broxbourne Council was developed, with families of obese children initially offereda ‘healthy lifestyle review’ by GP practices.

Partnership working between the council, public health, midwives, health visitors, children’s centres and schools will enhance the support offered to residents to manage their weight. The programme board has helped to develop the project and will assess its efficacy.

Broxbourne has the highest prevalence of childhood obesity in the CCG area: 13.4% of four and five year olds are obese, where the regional average is 8.7%, and 17.4% of ten and eleven year olds, where the regional average is 17.2%.

Healthcare professionals are not always clear about what services to signpost overweight patients to, and a lack of services to support local families was reported.

Clinical Champion:Steve Kite

Documents

East and North Herts CCG · Please call back tomorrow. “ ” Comein and see nurse Come in and see preferred GP Calls are allocated to GPs (allowing patients to choose which GP they