Download THCCG Prospectus - Tower Hamlets CCG

NHS Tower Hamlets
Clinical Commissioning
Group prospectus
Our plans for 2013/16
Contents
Foreword
3
About us
4
Patient and public involvement
11
The health needs of Tower Hamlets
13
Quality, performance and financial challenges in Tower Hamlets 15
Our plans
17
Being born and growing up in Tower Hamlets
— Maternity
— Children and young people
Being adult and growing older in Tower Hamlets
— Urgent and emergency care
— Planned care
— Integrated care
— Long-term conditions
— Mental health
— Last years of life
18
19
22
24
25
28
30
34
39
43
Supporting our plans
— Information and technology
— Prescribing
— Achieving excellence in general practice
— Delivering our plans
47
48
51
53
54
Contact us
56
If you would like help understanding this document, or require it
in another format or language, please contact us by:
Telephone 020 3688 2500
2
Email info@towerhamletsccg.nhs.uk
Foreword
We are deeply committed to Tower Hamlets — it is unique in London
and England with a rich historical and cultural identity. The borough
now has the fastest growing population in London with an expected
339,000 residents by 2026.
Dr. Sam Everington
Chair
Tower Hamlets has historically been home to a mix of communities;
nearly half of the borough’s population comprises of black and
minority ethnic groups. In recent times the borough has experienced
rapid growth and has been the focal point of regeneration in London.
We are also blessed with physical and cultural assets, including
extensive waterways, Victoria and Mile End Park, museums and
markets, and the UNESCO World Heritage Site of the Tower of
London from which the borough derives its name.
Unfortunately, too many people in Tower Hamlets have poorer
health than people in many parts of England. They die younger from
diseases that can be avoided and are exposed to social factors, like
overcrowded housing and poverty. People in Tower Hamlets are more
likely to die from heart disease, lung disease and cancer, and are more
likely to have diabetes, than other areas of England.
Jane Milligan
Chief Officer
Clinical commissioning gives us an exciting opportunity to improve this
situation. By working alongside our residents and local health and care
partners, we will commission services that create positive health and
wellbeing for the population.
The priorities set out in this document have been identified using local
knowledge and with a clear understanding of the performance and
quality of the services we commission.
We have used the personal insight of patients and the professional
experience of our GPs, nurses and other staff to help us identify those
areas that most need improvement.
We want everyone to receive consistent, high quality care. The recent
inquiry into the failings at Mid Staffordshire Foundation Trust has
implications and lessons for the whole NHS. We are working to ensure
that we support the provision of high quality care, while reinforcing
the way we monitor quality and patient feedback.
We will also make sure we get the best value from our budget and
meet our financial obligations to you, the taxpayer. Unless we make
improvements to the healthcare system, we will need to find an extra
£30 million to continue to fund the services that we need. It is our
intention to live within our means.
We want our plans to be meaningful, achievable and make a difference
to patients, carers and the public. This is the first plan the CCG will be
fully responsible for and we are keen that we grasp this opportunity
to improve your services.
We look forward to sharing this journey with you.
Dr. Sam Everington
Chair
Jane Milligan
Chief Officer
3
About us
Primary care
Primary care is the local healthcare
that we receive from GPs,
NHS walk-in centres, dentists,
pharmacists and optometrists.
These are the services that most
often bring people into contact
with the NHS.
Secondary care
Secondary (or ‘acute’) care is the
healthcare that people generally
receive in hospital. It may be
unplanned emergency care or
surgery, or planned specialist
medical care or surgery. If you go
to hospital for planned medical
care or surgery, this will usually
be because your GP, or another
primary care health professional,
has referred you to a specialist.
Community care
Many types of care are delivered
outside of health facilities.
Community care includes services
such as home care, rehabilitation
services to help with mobility
and independence, treatment
for substance use disorders and
other types of health and social
care services.
Care pathways
A step-by-step process to help
a patient with a specific condition
or diagnosis move progressively to
the services they need. While each
individual is unique, care pathways
help healthcare professionals
deliver consistently good care
and helps patients understand
how they can access services.
NHS Tower Hamlets Clinical Commissioning Group (CCG) is a clinically-led
organisation that was established in April 2013. Made up of all 36 general
practices in Tower Hamlets, we are committed to bringing about better
health for the local population, constantly improving services and ensuring
that we make the best use of the NHS resources allocated to us.
Following the introduction of the Health and Social Care Act in 2012,
CCGs are now responsible for planning, buying and monitoring (a process
known as commissioning) most hospital, community-based and mental
health services. A new central body, NHS England, is responsible for
commissioning GP and specialist services and the local authority (the London
Borough of Tower Hamlets) looks after public health services.
CCGs bring a unique insight into commissioning services. Doctors understand
the health service and are responsible for guiding patients through the
healthcare system. Most of all, GPs understand what their local population
needs most.
Our work is overseen by a Governing Body, which includes a formally
elected representative from each of our eight local GP networks, local health
professionals (including a nurse and a Practice Manager), lay members
and the local authority. It is chaired by Dr Sam Everington, a local GP. This
means local doctors, health and social care partners, patients and the public
are working together to ensure health services are up to standard and are
designed to best suit the people of Tower Hamlets.
Membership of the Governing Body
8
2
4
3
1
1
1
Elected GP representatives
Local authority representatives
Lay members
NHS senior managers
Practice manager
Practice nurse
Allied health professional
This prospectus sets out the health needs of Tower Hamlets and our plans
to meet these needs. Patients and the public have been vital in helping us
develop our priorities and we will continue to put the voices of local people
at the heart of everything we do.
Successes to date
1 Launched innovative bursary scheme and funded five projects across a range of local voluntary
sector organisations.
2 Led development of the east London Maternity Services Liaison Committee.
3 Improved referral rates through our ’Commissioning Facilitators’ programme.
4 Improved outcomes for diabetics on our diabetes care package including better blood pressure
control, reduced cholesterol and 10 per cent fewer unplanned hospital admissions.
5 Improved inpatient assessment services for people with dementia.
6 Reduction in the prescribing of ‘Specials’.
4
Network 1. Weavers, Bethnal
Green North, Mile End
and Globe Town
1
Strouts Place
2
Bethnal Green
3
Pollard Row
5
Mission
6
Globe Town
The 36 Tower Hamlets practices and the 8 GP networks
23
5
3
2
1
4
8
20
6
19
22
21
26 7b
27
24
7a
10
25
14
9
12
11
13
15 16
30
32
29
31
28
17
18
33
Network 2. Spitalfields and
Banglatown, Bethnal
Green South
4
36
* XX Place and
Bromley by Bow
are counted as one
practice in two
separate locations.
35
Blithehale
34
7a XX Place*
8
Health E1
9
Spitalfields
10 Albion
Network 3. Whitechapel, St.
Duncan’s and Stepney Green
Network 5.
Bow West, Bow East
19 Grove Road
Network 7. Limehouse,
East India Lansbury
20 Tredegar
28 Limehouse
11 Whitechapel Health
21 Harley Grove
29 Gough Walk
12 City Wellbeing
22 St. Stephen’s
30 Chrisp Street
13 Brayford Square
23 Ruston Street
31 All Saints
14 Harford Health
Network 4. St. Katharine’s
and Wapping, Shadwell
Network 6. Mile End East,
Bromley by Bow
24 Merchant Street
32 Aberfeldy
Network 8. Millwall,
Blackwall and Cubitt town
15 East One
25 St. Paul’s Way
33 Barkantine
16 Jubilee Street
26 Stroudley Walk
34 Docklands
17 St. Katherine’s Dock
27 St. Andrews
35 Island Health
18 Wapping
7b Bromley by Bow*
36 Island Medical Centre
5
Our Vision
We want to use the opportunities in the Health and Social Care Act to bring
real improvements to the health of people in Tower Hamlets. We are doing
this by talking with our patients, partners and providers to shape our ambitions
and using the solid foundations built up over recent years. It is well-known
that engagement with clinicians is essential for a healthcare system to work
effectively. As a clinically-led organisation, we are keen to work together and
make the best use of staff across primary, community and secondary care.
Our vision is of high quality services, within a vibrant and stable healthcare
economy, that focuses on integration around individual people’s needs:
High quality health and social care services
We are overwhelmingly concerned with obtaining the highest quality services
for our population. We will:
• Constantly look at areas to change services so that they meet patient’s
needs and that they respond quickly to feedback when they don’t.
• Demand that organisations providing care to Tower Hamlets strive to
provide the highest standards, in terms of clinical quality, safety and
experience.
Foundation trusts*
NHS foundation trusts have a
greater degree of managerial and
financial freedom, which helps
them to adapt services to meet
the needs of their patients and
the local community. NHS trusts
can only become foundation trusts
once they demonstrate
they are providing high quality
care and are financially stable.
• Work with our member GPs and NHS England to make sure that primary
care is of high quality.
• Support research and development to improve existing services and develop
new ones.
A vibrant and stable health and social care system
We recognise that as stewards of a large NHS budget, we must act responsibly.
We will:
• Ensure that all our plans are developed within our budget.
• Only decide whether or not to invest where we believe it will improve
services.
• Work closely with the London Borough of Tower Hamlets, in particular in
public health and integrated care.
• Support Barts Health NHS Trust in their application for foundation trust*
status, and we will work with neighbouring commissioners to ensure that
our plans for this are aligned.
Integration
For us, working in an integrated way means:
• Commissioning services that are arranged around individual people,
with the flexibility to be personalised as much as possible. Services will
also consider the wider needs of people, such as social care, employment
or bereavement support.
• Commissioning services that act together seamlessly. Approaching
commissioning as a joint effort, with different commissioners and providers
collaborating through partnership working.
6
What we commission
NHS Tower
Hamlets CCG
NHS England
London Borough
of Tower Hamlets
Responsible for
commissioning:
Responsible for
the performance
of CCGs and for
commissioning:
Responsible
for public health
commissioning:
• Planned hospital
care.
• Maternity
services.
• Community
services and
rehabilitation.
• Urgent and
emergency care.
Primary Care Trusts (PCTs) used
to commission all health and
public health services for Tower
Hamlets residents. Following the
introduction of the Health and
Social Care Act, CCGs are one
of a number of organisations
who will buy and plan services
for the borough.
• Continuing
healthcare.
• Cancer services.
• Fertility services.
• Children’s
services (except
health visiting).
• GP services.
• Specialist
commissioning
(e.g.
neurosurgery).
• Prison
healthcare.
• Immunisation
and screening.
• Health visiting
(until April
2014).
• Health
promotion and
prevention.
• Sexual health
services and
treatment
(except HIV).
• Drugs and
alcohol.
• NHS Health
Checks.
• Health visiting
(from April
2014).
• Mental health
and learning
disabilities.
• Treatment
of infectious
diseases.
7
Who we work with
NHS Tower Hamlets CCG works
with a range of providers and
partners to plan, commission and
deliver local health services.
Providers
We use the term provider or service provider to include anyone who is
commissioned to supply a health or care-based service. For example,
GPs are primary care providers. Social care providers include social workers
and home support workers. Hospital trusts are also providers.
In the last year Barts Health NHS Trust has been formed out of a merger of
three former trusts (Barts and the London, Newham Hospital and Whipps
Cross) to create one of the largest healthcare organisations in Europe. Its
largest site, and the main provider of care in Tower Hamlets, the Royal
London Hospital, has recently moved into a new state-of-the-art building.
The maps below show the locations of some of the main hospitals and
health care centres in Tower Hamlets and surrounding areas.
8
Partners
We work closely with our partners on commissioning certain services.
London Borough of Tower Hamlets
Local councils are now in charge of public health services such as sexual
health, stopping smoking, promoting health eating and many more.
We work together to:
• Jointly fund the mental health voluntary sector and reablement services
(services to help a person restore their independence, for example
following a period of illness or due to a disability).
Find out more about some of
our providers and partners by
visiting their websites.
Barts Health NHS Trust
www.bartshealth.nhs.uk
East London Foundation Trust
www.eastlondon.nhs.uk
The London Borough
of Tower Hamlets
www.towerhamlets.gov.uk
Newham CCG
• Manage third sector contracts to the value of around £3.7 million
(combined NHS and local authority spending).
• Improve health services that have overlapping public and social
care elements, such as dementia, mental health, primary care and
integrated care.
Newham and Waltham Forest CCGs
Tower Hamlets is currently the lead commissioner for Barts Health NHS Trust.
Collaborating with neighbouring CCGs when dealing with the trust allows us
greater financial leverage and more influence to make improvements for our
patients. It is also easier for Barts Health to talk to one commissioner rather
than three. This makes it more likely that we can secure changes and achieve
greater equality of services for people in east London.
www.newhamccg.nhs.uk
We also lead on the major integrated care programme, which is focused on
Barts Health NHS Trust and its partner services.
Waltham Forest CCG
NHS England
www.walthamforestccg.nhs.uk
Formerly known as the National Commissioning Board, NHS England has
taken over much of the work of the old PCTs. They commission GP services,
as well as pharmacy and optometry services (primary care), and some
specialist services. They work on behalf of, but independently from, the
Department of Health. NHS England also handles patient complaints about
GP practices.
NHS England
www.england.nhs.uk
Healthwatch Tower Hamlets
www.healthwatchtowerhamlets.co.uk
North and East London
Commissioning Support Unit
www.nelondoncsu.nhs.uk
Health and Wellbeing Board
Health and Wellbeing Boards are a way in which leaders from the health and
care system work. The board members collaborate to understand their local
community’s needs, agree priorities and encourage commissioners to work
in a more joined-up way. Members include a councillor, CCG representatives,
a local Healthwatch member, representatives from the volunteering and
community sector and council directors for both adults and children’s
services, as well as the public health director.
Healthwatch
Healthwatch is the independent consumer champion for health and social
care in England. Locally Healthwatch replaces Local Involvement Networks
(LiNKs) and work with CCGs to make sure they hear what patients say and
take it into account.
Commissioning Support Unit
Commissioning Support Units (CSUs) have been set up across the country to
support CCGs with services that are better delivered at scale. Our CSU helps
us with business intelligence, health and clinical procurement services, as well
as back-office administrative functions, including contract management.
9
How we spend our budget
We have a commissioning budget of around £340 million, which is allocated
as shown in this chart. Our spending includes:
34.6
8.4
• £164 million for hospital care, 83 per cent of which is spent
at the Royal
London Hospital (now part of Barts Health NHS Trust). 10
• £51 million spent on community health services, 92 per30cent of which is
spent on Tower Hamlets Community Health Services, now provided by
Barts Health NHS Trust.
42
• £42 million spent on mental health services provided by East London
Foundation Trust.
• £8.4 million spent on ambulance services.
• £10 million on continuing healthcare.
• £30 million on prescribing.
Hospital Care
Community Services
Mental Health
Prescribing
Continuing Healthcare
Ambulance Services
Other
10
51
164
Patient and public involvement
“ Involving patients and the wider public is central to service planning,
development and provision. Not only is it vital for service improvement,
it also leads to a more positive patient experience of care. We want to
commission services that are based on the needs and priorities of our
community and ensure that our providers deliver patient centred care.
To do this, we will work with the community to ensure the patient and
public voice can play an active role in shaping, planning and improving
our local NHS services.”
Catherine Boyle
CCG Governing Body
Vice Chair and Lay Member
for Patient and Public
Involvement (PPI)
How will this improve health
in Tower Hamlets?
• Services based on local need
and focused on the priority
health issues of the community.
• Improved patient experience
with a focus on better
self-management.
• Involvement in decisionmaking, giving patients greater
ownership over health services
and managing their health.
Financial impact
Additional investment of
£222,000.
Current situation
There is a long history of good patient and public involvement
(PPI) in Tower Hamlets, which we will build on and learn from.
In 2012/13, we began this approach by:
• Commissioning a pilot project to gather community knowledge about
local health and social care services. Over 300 comments were gathered
from more than 200 local people.
• Setting up a forum to share information and provide feedback on patient
involvement activities across the borough. It involved a wide range of
organisations including community and voluntary sector partners, the
Local Involvement Network (LINk), patients, local providers, the local
authority and the Health and Wellbeing Forum.
• Developing an initial Patient and Public Involvement strategy.
• Undertaking research to understand how local people use urgent care
services and using this to develop services.
• Setting up a bursary scheme, which funded five innovative health and
wellbeing projects across a range of local voluntary sector organisations.
Our approach reflects the current policy for patient and public
involvement across the NHS and social care, and has been
developed based on:
• The Francis Report into Mid Staffordshire Foundation Trust (2013) —
this report stresses the importance of listening to patients and carers,
and using their experience as an early warning sign that there may be
problems with the system or that poor quality services are being provided.
• The NHS Operating Framework Everyone Counts: Planning
for Patients — this clearly identifies greater patient participation in
commissioning and planning health services. It is supported by the
introduction of the new ‘friends and family’ test, which asks people
whether they would recommend health services based on their
experience.
• The NHS Outcomes Framework (2013/14) domain four of ensuring
that people have a positive experience of care.
• The NHS Constitution (Department of Health, 2012).
• Essential Standards of Quality and Safety (Care Quality Commission,
2010b).
From April 2013 Tower Hamlets LINk has become Healthwatch. This change
means we will need to build new working relationships and develop new
ways to involve patients and the public in our work from 2013.
11
Our approach in 2013/14
We will achieve our vision
of patient-centred services by
helping the community to work
with us to identify the services
they need; to plan new or
redesign existing services; and to
monitor and feedback on services.
We want to commission high
quality services that are clinically
effective and give patients a
good experience. We will work
with our providers to ensure
they put patient experience
and involvement at the heart
of everything they do.
To do this we need to:
Interest and engage the local community so they actively
choose to be involved. We will achieve this by:
• Developing our website so it is a useful way to access information and
allows people to easily provide feedback on services.
• Ensuring all planning and development work involves the public, patients
and/or carers. Specifically, we will work with patients to monitor and
evaluate the patient experience of integrated care.
• Funding innovative proposals from the community and voluntary sector
to support health service improvements and involvement in our 2013/14
priority areas.
Build capacity and capability for involvement by working
with the voluntary and community sector, and ensure that all
sections of the community have a voice. We will achieve this by:
• Making patient experience a vital measure of quality for commissioning,
evaluation and innovation.
• Working with providers to ensure they deliver patient-centred services and
can demonstrate they have a workforce that values patient and public
involvement.
• Working with our local partners to share patient experience information.
We will work to ensure we have the right information to monitor the
experience of services we commission and hold our providers to account.
Embed patient and public involvement across our organisation
by supporting the PPI lay member to provide strategic
leadership and scrutiny of how patient and public involvement
is being applied in commissioning. We will achieve this by:
• Ensuring the Governing Body can understand patient experience in the
context of the broader quality data. This is vital if we are to be able to
objectively assess the overall quality of the services we commission.
• Seeking to review methods and outcomes from across the country to
adopt best practice and innovative approaches.
• Developing a collaborative approach to commissioning with our providers,
partners and members of the public and piloting this in 2014/15.
12
The health needs of Tower Hamlets
Being born in Tower Hamlets
Over 4,500 children were born in Tower Hamlets in 2010.
Given the connection between high deprivation and low birth weight, it is
not surprising that a higher percentage of babies in the borough are born
with low birth weight (9 per cent), compared with London as a whole
(7.5 per cent). However, there are other things that impact the health of
a new born baby that are prevalent in Tower Hamlets, such as substance
misuse, problem drinking, poor diet and smoking. Around three per cent
of expectant mothers in Tower Hamlets smoke during pregnancy, however
within this group 16 per cent are white mothers. For white women this is
higher than the national average.
There has been a steady reduction in the teenage pregnancies since 1998
and it is now similar to the rest of London.
What is a Joint
Strategic Needs
Assessment?
Growing up in Tower Hamlets
A Joint Strategic Needs
Assessment (JSNA) aims to
understand the health and social
care needs of the local population.
Led by the London Borough of
Tower Hamlets and overseen by
the Health and Wellbeing Board,
it informs developments in health
services and other areas such
as social care.
Some of the key findings
from the JSNA are summarised
below and throughout the
chapters of this document.
Visit www.towerhamlets.gov.uk/
lgsl/701-750/732_jsna.aspx to read
the complete JSNA.
More than half of the children in Tower Hamlets live in poverty. By the age
of five, only 46 per cent of infants in Tower Hamlets have achieved a good
level of cognitive development compared with 56 per cent nationally.
However, our pupils are performing at or above the national average
at Key Stages 1, 2 and 4.
There are around 18,700 children aged under-five in Tower Hamlets. There
are also around 28,700 children and adolescents aged five to 14 and 14,600
aged 16–19. Overall, around 60 per cent of under–20s are Bangladeshi.
Over 12 per cent of children in Reception year are obese — the sixth
highest rate in the country. By Year 6 (10–11 year olds) this increases to
around 25 per cent and is the fourth highest rate in the country.
It is encouraging that around 89 per cent of mothers in Tower Hamlets
start breast feeding at birth (compared with 74 per cent across England),
and 74 per cent are still breast feeding at six to eight weeks (compared with
45 per cent across England). In addition, immunisation uptake in under–fives
is amongst the highest in the country with 94 per cent of children receiving
the second dose of the measles, mumps and rubella (MMR) vaccine.
Being an adult in Tower Hamlets
There are around 125,500 people aged 20–39, 45,000 aged 40–59 and
21,400 over 60 living in Tower Hamlets.
Tower Hamlets has some of the highest premature death rates from the
major killers in London — long-term illness, cancer, heart disease and
respiratory disease. The borough has a 34 per cent higher level of long-term
illness or disability than the national average and in London, it has:
• The fourth highest cancer premature mortality rate.
• The second highest heart disease premature mortality rate.
• The fifth highest mortality rate for chronic obstructive pulmonary disease
(COPD — the name for a collection of lung diseases including chronic
bronchitis, emphysema and chronic obstructive airways disease).
• Among the highest rates of HIV, Tuberculosis (TB) and sexually
transmitted infections.
13
While 27 per cent of people in Tower Hamlets smoke, compared with 21
per cent nationally, recent smoking cessation programmes have delivered
the best performance in London. Of the 50 per cent of the adult population
who drink alcohol, 43 per cent have consumption patterns that are either
hazardous or harmful to their health; around twice the national average.
Although levels of physical activity are around the national average, fewer
people in Tower Hamlets consume the recommended level of fruit and
vegetables (12 per cent) compared with the rest of the country (30 per cent).
In addition, the rate of problem drug users (2.3 per cent) is almost double
that of the London rate (1.2 per cent).
Growing old in Tower Hamlets
There are around 15,500 people who are 65 or over living in Tower Hamlets.
Of these:
• 4,200 are 80 or over
• 65 per cent are white
• 22 per cent Bangladeshi
• 60 per cent are female (because women live longer).
While growth in the older population is expected to be lower than
elsewhere, the numbers of people over 80 in the borough is projected to
increase by 23 per cent over the next 10 years.
Within the Tower Hamlets population who are 65 or older:
• 80 per cent have at least one chronic (long-term, incurable) condition,
and 35 per cent of these people have at least three other conditions.
• There are indications that dementia is significantly under-diagnosed.
• There is the second highest stroke mortality rate in London.
In addition, most people in Tower Hamlets do not die in their place of
choice — 64 per cent die in hospitals while national surveys suggest that
most people would like to die at home.
In line with the general deprivation in the borough, half of older people
live below the poverty line and a higher proportion live alone (47 per cent)
when compared nationally (33 per cent). In addition, only 10 per cent of
older people consume the recommended level of fruit and vegetable and
only 20 per cent meet recommended physical activity levels.
14
Quality, performance and financial challenges in Tower Hamlets
Our first objective is to ensure
high quality health and social care
services. We are implementing a
number of measures to ensure
that quality will be at the heart of
the local NHS, and everything
we do as commissioners.
Hospital services
We will build on the findings
of the Francis Report and take
into account the Department of
Health’s response Patients First
and Foremost.
Four hour wait for A&E
We currently:
Barts Health NHS Trust is aiming to be a Foundation Trust, which means
it will have greater freedom from the Department of Health. We support
this application but expect Barts Health NHS Trust to focus on a number of
performance concerns, namely the A&E waiting times, referral times and
cancer waiting times.
Currently Barts Health NHS Trust is not achieving the standard of seeing 95
per cent of people at A&E within four hours, only seeing 84.5 per cent in
that time. This has been a persistent issue throughout the last year and we
now have weekly discussions on how to improve the situation, as well as
additional support from the Department of Health.
• Attend Quality Surveillance
Groups, along with our partners
across the north east of London to
share learning, improve processes
and challenge our providers to
deliver high quality care as the
norm.
18 weeks
• Work with our CSU to ensure a
continued delivery of quality care,
in light of provider organisations’
cost improvement programmes.
Cancer waiting times
• Hold monthly clinical quality
review meetings with providers to
monitor quality indicators, such
as serious incidents, complaints,
the friends and family test and
infection control.
• Operate a ‘Service Alerts’ system
by which GPs can raise quality
concerns with providers. This
allows local knowledge to be used
effectively to hold providers to
account.
Patients have the right to start their NHS consultant-led treatment within
a maximum of 18 weeks from referral, unless they choose to wait longer
or it is medically appropriate that they wait longer. This 18 week target is
particularly challenging to deliver in care specialties under the most pressure,
such as trauma and orthopaedics.
Patients referred by their GP with suspected cancer should have
their first appointment within a maximum two weeks. If a decision is
made to treat the patient then this treatment must start within 31 days
of that decision being made. This standard applies to all cancers. For some
patients the decision to have treatment may take more time, for example
their needs are very complex. However even in these cases the maximum
time anyone should have to wait for treatment to begin is 62 days.
Barts Health NHS Trust perform well against the target of waiting
no longer than two weeks for the first appointment and treating patients
within 31 days once the decision to treat them has been made. However,
more than 15 per cent of people do not receive their treatment within 62
days of their referral from their GP. This was raised formally by NHS Tower
Hamlets CCG in November 2012 and we have agreed an action plan.
Patient feedback
An engagement exercise done by Tower Hamlets Involvement Network
(THINk) with patients in August 2012 found that:
• Those with a sick child had a good experience at the new Royal London
Hospital A&E.
• There were complaints about the maternity ward at the Royal London,
including a perception that there were not enough nurses and midwives
to care for patients or to give adequate support; lack of staffing on
reception; and a perception that staff are rude to people who speak
English as a second language.
Cancer treatment
More information about waiting
times for cancer treatment can
be found here:
http://www.nhs.uk/conditions/
Cancer/Pages/Introduction.aspx
15
Community health services
Tower Hamlets Community Health Services were incorporated into Barts
Health NHS Trust in 2011. During the last year we have worked to understand
how community health services link with other parts of the care system, and
how this has changed since services became part of Barts Health NHS Trust.
Our biggest challenge has been to improve the quality of information that is
provided to commissioners. This has improved steadily over the last year and
we are continuing to work on developing these systems in 2013/14.
Specific areas of improvement are physiotherapy waiting times and the
work of the clinical assessment service (a group of services which seek to
bridge the gap between primary and secondary care). These continue to
be addressed with Barts Health NHS Trust through action plans to improve
service performance and delivery.
Patient feedback
The engagement exercise done by THINk (Tower Hamlets Local Involvement
Network) in August 2012 found that:
• There were positive comments about the health information and support
provided by children’s centres. These centres also provided parents with
opportunities to meet and share information and give breastfeeding
support to women.
• There were good experiences with the breastfeeding support team and
diabetes support from Jubilee Street.
• Several positive experiences were shared at Barkantine Birthing Centre in
terms of staff being supportive and helpful, and the environment being
clean and tidy.
Finance
One of our objectives is to maintain a vibrant and stable health and
social care system, recognising that as stewards of a large budget for
commissioning services, we must act responsibly. In this period of
unprecedented change we must achieve stability and overcome the
challenges of transferring commissioning responsibilities and dividing NHS
funding. Part of our commitment to supporting Barts Health NHS Trust’s
application for Foundation Trust status includes financial support, to ensure
the full benefits of the new organisation are realised.
As seen on pages 13 and 14, we have a growing and aging population who
have high health needs which means we have to find ways to pay for more
care for more complex issues. To do this the CCG undertakes programmes
of work as outlined in this prospectus that aim to achieve this by improving
the quality of services, improving peoples’ health and saving money. Each
chapter gives an overview of the financial impact of the programmes.
16
Our Plans
Health outcomes
A change in the health of an
individual, group or population
that can be attributed to a
planned intervention or series of
interventions.
Care packages
A care package is a combination
of services put together to meet
a person’s assessed needs. It
defines exactly what that person
needs in the way of care, services
or equipment to live their life in a
dignified and comfortable manner.
Our plans for the coming years seek to address the health challenges in
Tower Hamlets. We will focus on the following key areas:
Chapter
Being born
and growing up
Programme
area
CCG Governing Body
Lead
Maternity
Dr Judith Littlejohns
Children and
young people
Dr Hannah Falvey
Urgent care
Virginia Patania
Planned care
Dr Victoria
Tzortziou-Brown
Some of the services included in
a Care Package might be:
Dr Nicola Hagdrup
(Integrated Care)
• Education and support to help
take their medications correctly.
• Disability equipment and
adaptations to the home.
Being an adult
and growing old
• Daily assistance with personal care
and cooking.
Integrated
care and
long-term
conditions
Dr Isabel Hodkinson
(IT and Informatics)
Katherine Gerrans
(Long Term Conditions)
• Day centres to give the person
or the person who cares for them
a rest from care.
Supporting
work
Mental health
Dr Judith Littlejohns
Last years
of life
Dr Isabel Hodkinson
Prescribing
Dr Stuart Bingham
Achieving
excellence
in general
practice
Maggie Buckell
IT
Dr Isabel Hodkinson
In developing these plans we are mindful of our responsibility to deliver on
the NHS Outcomes Framework, the NHS Constitution and national policy.
We also need to respond to the new strategic priorities laid down by the
Tower Hamlets Health and Wellbeing Board.
17
Being born and growing up
in Tower Hamlets
18
Maternity
“Our vision is to commission maternity services that are safe and
convenient to use, with friendly staff that inspire confidence in
the families using them.”
Dr Judith Littlejohns
CCG Governing Body
Member and Lead for
Maternity
How will this improve health
in Tower Hamlets?
• Women feeling more
supported during their
pregnancy.
• More responsive services with
effective patient engagement.
Current situation and health needs
Many of our population are disadvantaged. Vulnerable and disadvantaged
women are 20 times more likely to die from pregnancy-related complications.
In 2010, for example, 11 per cent of pregnancies were complicated by
diabetes.
Around 16 per cent of white women in the borough smoke during
pregnancy creating problems during pregnancy and for the child after
birth. We also have a high incidence of female genital mutilation within
our population, which can lead to complications during childbirth.
The CCG commissions maternity services from Barts Health NHS Trust,
which includes:
• community midwifery in children’s centres and general practice
• Reduced use of A&E and
Maternity Assessment Unit.
• hospital services
• Improved quality despite
increased pressure.
• a midwifery unit at the Royal London Hospital
Financial impact
Additional investment of
£437,000.
• deliveries in an obstetric-led unit
• the standalone Barkantine Birth Centre.
In the five years between 2009/10 and 2014/15, the birth rate is expected
to increase by 5.3 per cent or an extra 235 births a year. It is expected to
increase again by 2.2 per cent, or 100 extra births a year, between 2014/15
and 2019/20. This rising birth rate across north east London is increasing
demand for maternity services. The newly-built maternity unit at the Royal
London Hospital is already proving popular.
In the past, there has been a lack of consistency in patient experience across
our maternity services. Patients have told us we need greater compassion
in the postnatal ward, better signposting around the new maternity unit at
the Royal London, better information about maternity services, and better
communication between health professionals.
19
Our approach in 2013/14 and beyond
During 2012, the CCG has delivered a number of improvements
to local services. We will build on the work below over the next year
and beyond:
• East London Maternity Services Liaison Committee: a new commissionerled network that responds to patient feedback and manages performance
across Tower Hamlets, City and Hackney, Newham and Waltham Forest.
• Tower Hamlets Maternity Quality Board: who will oversee the delivery
of maternity services.
• Barts Health NHS Trust Maternity Strategy Group: this group brings
together commissioning leads across east London to identify and address
gaps in maternity service provision.
Triage*
The process of deciding how best
to treat a patient based on the
severity of their condition. This
may include changing who sees
a patient based on their needs.
• A ‘maternity mates’ pilot project: a team of volunteers providing
one-to-one emotional and practical support for mothers with
complex social factors, such as those who do not speak English.
• Piloting consultant triage* of all antenatal outpatient referrals: ensuring
women get to see the right person first time, with fewer visits to hospital.
• A maternity dashboard: to compare information about the quality of
maternity services across east London and inform our commissioning plans.
• Tongue tie service (breastfeeding): ensuring the tongue tie service is
provided at St Bartholomew’s Hospital rather than Kings Hospital, which
is inconvenient and leads to a number of patients paying for private care.
Patient and public involvement
We have set up a patient feedback process through the Maternity Service
Liaison Committee. The committee advises the CCG on maternity services
and has patient representation. Since its launch a year ago, a number of
improvements have been made to maternity services, including:
• Strengthening midwife management and leadership and improving
patient experience.
• A triage system that ensures women are seen by the right clinician
at the right place and time.
Public health
We will continue to work with the local authority’s public health team
to improve the health and wellbeing of mothers and babies, including
the provision of supplements for those who are Vitamin D deficient, flu
vaccinations, education on female genital mutilation for clinicians, stop
smoking initiatives and increasing breastfeeding rates.
20
Long-term strategy
In three years we want our maternity services to be of the highest standards,
with midwife-led care for women with low-risk pregnancies and rapid access
to specialist care if problems arise. All women and their families will be
treated with respect and courtesy and will be supported by community and
hospital staff, and if needed, by volunteer maternity mates.
We want to see midwife-led antenatal clinics in GP surgeries and children’s
centres, each with a named lead and second midwife, and supported by GPs.
Women will have the choice of individual antenatal care with separate parent
education, or group antenatal care with integrated parent education and
peer support.
If a woman has a high-risk pregnancy or develops a complication she will be
seen by her GP, or a senior midwife or obstetrician in the hospital. She will
have 24/7 access to advice by telephone and will be invited to be seen in
the clinic as appropriate. The GP will also have access to obstetric advice by
telephone or email. If a woman needs to be seen in the obstetric clinic she
will be triaged by a consultant obstetrician so she is seen at the right time,
by the right person. Outpatient monitoring will allow most women to stay
at home and avoid having to be admitted to hospital unless in labour.
Women with low-risk pregnancies will be encouraged to deliver in their
local midwife-led birthing unit or at home. These units would be staffed
by community midwives and, where possible, an expectant mother will
be supported by a midwife she already knows. Women with high-risk
pregnancies will deliver in a state-of-the-art labour ward with access to
theatres, obstetricians and high-dependency nursing care.
Once a woman has had her baby, she will be helped to go home sooner
through efficient processes on labour and postnatal wards. At home
she will receive:
• home visits
• community midwife phone support
• breastfeeding advice
• a health visitor
• postnatal and baby clinics in GP surgeries and children’s centres
• and, where appropriate, a maternity mate.
21
Children and young people
“ Tower Hamlets CCG is committed to improving health outcomes for local
children and young people. We want to give confidence to our member GP
practices, patients and the public that valuable resources are being used
wisely. We have recently set up a Children and Young Peoples Programme
Board with the specific aim of enhancing the quality of CCG commissioned
children’s services.”
Dr Hannah Falvey
CCG Governing Body
Member and Lead for
Children and Young People
Current situation and health needs
We commission a range of services for children and young people including:
• children’s community nursing team
• speech and language therapy
How will this improve health
in Tower Hamlets?
• Better patient experience.
• Improvements in clinical
pathways and the quality
of service provision.
Financial impact
Additional investment of
£495,000.
• physiotherapy
• occupational therapy
• audiology
• school nursing for children with continuing care needs
• Richard House Children’s Hospice
• acute inpatient and outpatient services.
In 2012/13, the total cost of these services was in the region of £24 million.
However, this year the responsibility for commissioning some of these
services will go to other organisations (see the ‘what we commission’ on
page seven for more information).
There are significant health needs for children in Tower Hamlets:
Levels of childhood obesity in Tower Hamlets are higher than
the London and national average. In 2011 just under 13 per cent of
four to five year olds were obese — the sixth highest rate in London. While
childhood obesity in Year 6 has stabilised in the last three years, it is still the
second highest in London.
Vitamin D deficiency and insufficiency is a substantial issue for
the population, with 74 per cent of pregnant women not having enough
Vitamin D and 11 per cent having dangerously low levels. Children under five
tested in primary care also show low levels.
Levels of tooth decay remain higher than the London and
national average. In 2008, the proportion of five year old children
experiencing tooth decay was 39 per cent, the fifth highest in London.
In December 2010, the proportion of children accessing dental services
was 54 per cent compared with around 67 per cent for London and
70 per cent for England.
Compared with the national averages, Tower Hamlets has:
• Higher hospital admission rates for upper and/or gastro-intestinal
endoscopy.
• More children admitted to hospital who end up staying less than three
days, suggesting some of these patients could be better treated outside
of hospital.
• More deaths in hospital for those aged 0–17.
22
Our approach in 2013/14 and beyond
NHS Tower Hamlets CCG has three main priorities for children and young
people’s services over the next three years:
New investments
Continence services: We are committed to creating a specialist
community service to review and treat children and young people with
enuresis, constipation and long-term continence problems. The service
will develop best practice, a training programme for staff and resources
for children and parents. The service will be closely monitored to ensure
effectiveness and quality from the beginning.
Diabetes: The national best practice tariff* for children’s diabetes will
come into effect from 2013/14. This will result in an increase in funding
to Barts Health NHS Trust for their children’s diabetes service, based on
their continuing best practice in this area.
Best practice tariffs*
These are used to drive quality
of service and provide universal
best practice across the NHS.
Providers are incentivised to
provide care that is high
quality and cost-effective.
Research to inform future commissioning
During 2013/14, we will review the services we commission for children and
young people. As part of this, we will ensure that robust key performance
indicators (KPIs) measuring timeliness of service, activity levels, clinical quality
and patient experience are incorporated into all of our contracts for 2014/15,
together with strong systems for reporting and monitoring. We will also look
at how we can improve the whole system of care, with a particular focus on:
• Continuing care, gastroenterology and asthma.
• Exploring integrated working with the local authority on areas such as
speech and language therapy.
• Hospital admissions for children and young people with mental health
disorders.
• A&E attendances for children and young people.
• The transition from children’s to adult health services.
This work will help us better understand where problems exist and how we
can best address them. We will make sure that we work closely with other
relevant areas, such as mental health, last years of life and urgent care.
The findings of this research will be used to inform our plans for 2014/15
and beyond.
Continued commitment to public health-led initiatives
We will continue to support public heath-led initiatives related to obesity,
vitamin D and oral health over the next three years. This will include:
• Contributing to the refresh and implementation of the Healthy Weight,
Healthy Lives strategy.
• Endorsing any future plans to improve the uptake of the Healthy Start
Vitamin scheme among local women and children.
• Contributing to the refresh and implementation of the Oral Health
strategy.
23
Being adult and growing
older in Tower Hamlets
24
Urgent and emergency care
“ Our vision for urgent care is simple — we want all Tower Hamlets residents
with an urgent care need to receive high quality care from the right person,
in the right place and at the right time.”
Virginia Patania
CCG Governing Body
Member and Lead for
Urgent Care
How will this improve health
in Tower Hamlets?
• Shorter A&E waiting times.
• A clear, simple 24/7 model of
care so patients are seen by the
professional best able to meet
their needs.
• Primary care needs addressed
by an individual’s own practice,
whenever possible.
• A&E and ambulance services
concentrating their skills on
the more serious and lifethreatening conditions.
• Local people educated and
informed about the range of
services available to them,
and how to make the most
appropriate choices.
Financial impact
Savings of £2.3 million by:
• Reducing the numbers of
people who require A&E
services.
• Incentivising Barts Health NHS
Trust to operate an integrated
urgent and emergency care
system.
Additional investment of
£530,000 in NHS 111.
What do we mean by urgent
and emergency care?
Urgent and emergency care is the response that health and social care
services provide to people who need or think they need urgent advice,
care, treatment or diagnosis. Urgent care can take place in A&E for those
who are in a life-threatening condition. Most urgent care can be provided
by your family doctor, pharmacies, or through self-care, using services like
NHS Choices www.nhs.uk or NHS 111 (a free healthcare advice number
available 24 hours a day, 365 days a year).
Current situation and health needs
NHS Tower Hamlets CCG commissions a range of urgent care services,
including the A&E department and Urgent Care Centre at the Royal London
Hospital and the London Ambulance Service. There is also a GP out-of-hours
service commissioned by NHS England and walk-in centres at The Barkantine
and St Andrew’s Health Centre. In 2011/12, the cost of these services was
around £63 million. There are a number of reasons why we are looking to
improve the urgent care system:
There is high use of urgent and emergency services,
not all of which is necessary. Tower Hamlets has among the highest
emergency admission and lowest elective (care you receive following a
referral from your doctor) rates in London. The borough has a particularly
high rate of A&E attendances and emergency ambulatory admissions* that
did not require inpatient hospital treatment.
In addition, between April and June 2012, approximately one in four patients
presenting at A&E were discharged with no investigation and no treatment.
This suggests that it may have been better for them to be seen in primary
or community care. In 2011/12, approximately seven per cent of all the
people that went to A&E were Tower Hamlets residents who were not
registered with a GP. This is significantly greater than the London average
of four per cent.
Increasing costs across the system. There has been a 15 per cent
increase in the cost of A&E for Tower Hamlets patients between 2009/10
and 2011/12.
The system is complex and difficult to navigate. People have told
us that we need to do more to make services easier to understand, with
consistent messages given to patients. This has been reinforced by providers
who have highlighted the duplication between urgent care services.
25
A&E attendance per 100,000 population 2011/12
600
500
400
300
Emergency ambulatory
admissions*
Unplanned hospital admissions
that could be avoided by people
being cared for or helped to
manage their health outside
of hospital.
200
100
0
Tower Hamlets
Newham
City and Hackney
Admissions with emergency ambulatary care conditions
per 100,000 population 2011/12
80
70
60
50
40
30
20
10
0
Tower Hamlets
Newham
City and Hackney
Source: Atlas of Variation
Quality and patient experience could be improved. In this year
already, less than 95 per cent of Tower Hamlets patients have been seen and
treated within four hours of presenting at A&E.
National policy. Government has signalled that transforming the quality,
access and provision of urgent care remains a national priority. They have
made a commitment to developing a coherent 24/7 urgent care service in
every area of England that makes sense to patients when they have to make
choices about their care.
26
Our approach in 2013/14 and beyond
We have four priorities over the next three years for urgent and
emergency care:
1. Redesign of the front end of A&E
We want to make sure that A&E and ambulance services concentrate their
skills on emergencies. To help achieve this, we re-introduced GPs at the ‘front
door’ of A&E from April 2013. This will mean that all adults arriving on foot
will be reviewed by a GP who will refer them to the best service to meet their
needs. This may be in A&E or the Urgent Care Centre, or it could be their
local GP, pharmacy or back home with self-care advice. The impact of this
change will be closely monitored and evaluated during the first nine months
of 2013/14 to inform future decisions.
2. Implement the NHS 111 service
NHS 111 is a free healthcare advice number available 24 hours a day, 365
days a year. NHS 111 is designed to make it easier for patients to access
urgent care services. On calling, patients are directed to the service that is
best able to meet their needs, taking into account their location, the time
of day and the capacity of local services. NHS 111 will be piloted over a
two-year period between 2013/14 and 2014/15. If successful, we will
formally commission the service in 2014/15 and beyond.
3. Pilot project to support GP registration
NHS Tower Hamlets CCG will implement a project to help patients register
with a local GP so they are able to access a GP, rather than going to A&E.
The project will be piloted in the first six months of 2013/14. If successful,
we will formally commission the service in 2014/15 and beyond.
4. Public awareness and education
We want to support local residents to understand the urgent care system
and help them make informed choices about the services that can best meet
their needs. Our research has shown that young males under the age of 30
and mothers of young children make up a large amount of the people who
are not always using A&E appropriately. We will work with these groups
to understand how we can support them to access the right services in
the future. Their initial feedback has suggested that we need to do more
hard-hitting campaigns, outreach work and use technology.
27
Planned care
“ We want high quality, efficient and integrated planned care services that
meet the needs of the local population and are value for money. We are
working with clinicians from primary, community and secondary care to
re-design and develop services where there is scope for better patient care.
This approach is also being used to provide education and support to GPs
and we are actively supporting practices to improve the quality of GP referrals
to secondary care.”
Dr Victoria Tzortziou-Brown
CCG Governing Body
Member and Lead for
Planned Care
How will this improve health
in Tower Hamlets?
What do we mean by planned care?
Planned care (sometimes referred to as elective care) is any care you receive
following a referral from your doctor. You will have a choice about where
to be referred and will be involved in making an appointment. Planned care
is mostly provided in hospital outpatient departments but it is increasingly
available locally, for example in community health services or even in a
GP surgery.
• Care provided for patients in
the right setting.
Current situation and health needs
• Better patient experience (as
they are seen in the most
appropriate setting, in the
fastest possible time).
There have been a number of developments during 2012/13:
• Community health services have become part of Barts Health NHS Trust,
which has moved into new premises with modern facilities.
• Localised and integrated care
for users.
• Stronger links are being created between primary and secondary care, for
example work being undertaken to improve urology, ear, nose and throat
(ENT), dermatology, trauma and orthopaedics departments.
• Services that represent value
for money.
• Joining up of IT systems and development of Choose and Book, which
allows GPs and patients to directly book their first appointment.
Financial impact
Savings of £2.3 million by:
• Improving efficiency of hospital
services.
• Developing community services
to care for patients outside
of hospital.
28
• Appointment of GP Commissioning Facilitators to work with practices to
support better quality referrals.
• Successful completion of the Magnetic Resonance Imaging (MRI) pilot
project that allows GPs to directly book scans for lumbar spine patients.
However, there a number of areas that we can improve on:
• Due to increases in demand for particular specialities, we are actively
reviewing referrals to improve quality. We will continue to focus on
improving patient pathways and referral patterns by providing support
and education to GPs and getting the best value for money.
• Concerns have been raised about some community services, including
the Clinical Assessment Service. In 2013/14 we will specifically look
at strengthening the interface between primary, community and
secondary care.
• Meeting the 18 week target for referral to treatment for all conditions
continues to present a challenge to Barts Health NHS Trust.
Our approach in 2013/14 and beyond
Anticoagulation* services
To prevent a blood clot developing
or to help treat an existing clot,
patients are often prescribed
blood-thinning drugs. Patients
who need these drugs require
regular blood tests to ensure they
are receiving the correct dosage.
These tests are usually performed
in a hospital outpatient clinic.
This year we want to build on our work to date by focusing on:
Service improvement programme
In the coming year we will continue to improve:
• How patients access trauma and orthopaedics, musculo-skeletal and
physiotherapy services so pathways across primary, community and
secondary care are clearly defined.
• Urology services so more patients can be treated in primary care.
• Dermatology, Paediatrics and Ear, Nose and Throat (ENT) services,
by undertaking audits to identify structured care programmes and
ways to enhance patient care.
• The service pathway for ophthalmology to ensure value for money.
Continued development of the Commissioning Facilitator role
We will continue to review and develop the role of the Commissioning
Facilitator across all of our GP networks to support practices reduce variation
in referral patterns and provide peer review. The role will continue to focus
on where patients are being referred to understand what is driving the
choices patients make so we can deal with any real or perceived quality
problems.
Expansion of the MRI pilot
Following the successful completion of pilot project to allow GPs to directly
book scans for lumbar spine, we are reviewing the potential roll-out of this
project. Expanding direct access for GPs will increase patient choice and
improve patient experience and waiting times.
Review of anticoagulation* services
Significant progress has been made in implementing community clinics
for anticoagulation* services to effectively manage stable patients in the
community. During 2013 we will be reviewing how services are currently
provided to help inform future contract negotiations.
29
Integrated care
“ This year we will focus on those patients that have multiple conditions and
are the most frail and vulnerable. We are working with colleagues in social
care, community health services, primary care, secondary care and mental
health to provide a more seamless and co-ordinated approach and provide
care that reflects an individual’s and their carer’s specific needs.”
Dr Nicola Hagrup
CCG Governing Body
Member and Lead for
Integrated Care
How will this improve health
in Tower Hamlets?
• Better management of complex
health conditions.
• Easier to access services, with
fewer hand overs.
• Partnership working between
health and social care.
• Fewer emergency attendances
and admissions.
Financial impact
Additional investment of
£700,000.
What do we mean by integrated care?
We sign up to the National Voices definition of integrated care as
‘person-centred, coordinated care’ when: “My care is planned with people
who work together to understand me and my carer(s), put me in control,
co-ordinate and deliver services to achieve my best outcomes.”
National Voices www.nationalvoices.org.uk
Current situation and health needs
While people aged 65 and over make up a relatively small proportion of the
population in Tower Hamlets, this group has the most complex health needs,
often with long-term and multiple conditions.
Our analysis has shown that around 80 per cent of what we spend on
hospital care goes towards treating these patients. A significant amount
of this is due to emergency hospital admissions, which could have been
avoided. These patients also frequently use other services such as GPs,
community health services and social care.
In addition, Barts Health NHS Trust has undergone a period of change since
bringing together three previously separate trusts and taking over Tower
Hamlets Community Health Services. The trust needs to manage this change
while responding to pressures from our growing number of patients with
complex health needs.
We believe that we have an opportunity to radically improve the care
that we provide to these patients who need it most. To do this and to
more effectively commission integrated care, we have partnered with our
neighbouring CCGs in Waltham Forest and Newham, our main health
providers, and social services.
Tower Hamlets is already a nationally and internationally recognised leader
in integrated and coordinated care. GP networks were set up (mirroring the
London Borough of Tower Hamlet’s Local Area Partnerships) to develop care
packages for patients with long-term conditions, such as diabetes. With the
introduction of these two initiatives in 2009, there have been significant
improvements in the management of long-term conditions, for example:
• Diabetic control has improved.
• Confirmed diagnosis of COPD has increased by 10 per cent.
• We have achieved 95 per cent immunity through childhood vaccinations.
30
Our approach in 2013/14 and beyond
Disease
specific
specialist
Allied
community
health
teams
professional
Integrated
Acute
Community
specialist Health
Team
Network
coordinators
Healthcare
assistant
Network
Borough
Community
mental health
GP
Patient
Practice
nurse
Care navigators
(high/medium
risk patients)
Network
manager
Social care
specialist
Practice
Locality
Case managers
(very high risk
patients)
Hybrid health/social
support workers
Patient
Social
workers
District
nurses
Mental health
specialist
Patient
• Supported by integrated system to self-care.
Practice
• Accountable for care coordinaton of top 20% at risk registered patients.
• Care coordination includes assessments, care plans, reviews, and
navigation (supported by case managers and care navigators from
the network of Integrated Community Health Teams).
Network
• Management, administrative and clinical resource to support practices
in care coordination for patients.
• Multi-disciplinary team case conferences at network level to discuss
complex patients, bringing together the full team around the patient
(primary, community, secondary, social, mental health).
Locality (Integrated Community Health Team)
• Integrated (ideally co-located) teams of phsycial, mental, social care
providers wrapped around networks (one team to two networks).
Borough
• Specialist/expert input to local teams (e.g. through attendance at
network-level case conferences).
31
We will build upon our successes to date in moving towards a full integrated
system. Specifically in 2013/14 we will focus on:
Development of a multi-disciplinary
integrated community health team
From September 2013, local integrated community health teams will provide
patient-centred care to high risk patients. The team will be expanded to
include:
• community nursing
• palliative care
• community rehabilitation
• enablement and support team
• adult respiratory care and rehabilitation team
• access to specialist teams.
It will also include:
Community geriatrician
NHS Tower Hamlets CCG will include dedicated community geriatricians
in the community health team for a 12 month pilot. Their role will include
education, further development of the community and intermediate care
teams, looking at news ways of working with frail elderly patients, and
supporting care homes and patients in their last years of life.
Social workers
Social work has a clear role of advocacy and challenge within the health
system. It ensures that social circumstances are considered and that a holistic
approach is taken to problems in order to empower and protect individuals
and families. Working in partnership with patients, carers and others where
difficult issues exist, social workers will be able to ensure that patients’ views
are considered and individuals are helped to get involved in the planning of
their own care and support.
Rapid response
Changes to the integrated community health teams will mean they will be
available for longer opening (seven days a week, 8am-10pm). Proposals
are being considered to co-locate the local authority’s night time service in
Imperial College Healthcare Trust, making it easier for patients to access care
services.
Individuals in this group have health and social care needs. To ensure all their
needs are captured in one document, a joint assessment that both health
and social care staff can access is being designed. As a result, all agencies
involved in the individual’s care will have access to the right information
when making decisions.
32
Discharge support
An initiative is being launched from September 2013 to identify patients in
hospital who could be better managed by the integrated community health
teams. A senior member of the team, complemented by the community
geriatrician, would move appropriate patients from hospital and coordinate
their care at home, reducing the length of stay.
Frail and complex care package and care coordination
Targeted at those considered high and very high risk, this care package will
be delivered within primary care networks and will provide coordinated care.
By supporting patients with all their health and care needs, we aim to avoid
any unexpected deterioration in an individuals’ general health. This package
will look after between 1,500 and 6,000 individuals.
We are developing this care package alongside key partners and
stakeholders, and will incorporate dementia screening. It is expected that
the package will launch in September 2013.
Mental health
A number of patients within this group suffer with dementia or other mental
health conditions. These individuals are mainly managed by mental health
services, with primary care supporting those who are suitable for discharge.
We will investigate incorporating community psychiatric nurses into the local
integrated community health teams, with access to advice from a specialist.
Information sharing
Provider organisations use separate IT systems that are not linked, meaning
that health and social care professionals are not able to share information
easily. At best this can mean that things are done twice, for example, a GP
ordering a scan unaware that the hospital did one a day earlier. At worst,
it can mean that some vital information is not available when it is needed.
We are investing in an IT solution that links all the various computer systems
together, giving a patient record that can be seen by all professionals involved
in the person’s care. We believe this will reduce duplication and wastage and
improve the patient experience.
We intend to pilot this tool over three months, focusing first on patients who
have many complex issues across both health and social care. If successful,
we will expand the pilot to focus on other key areas and will also use the
system to try and bring in information from other sources, such as mental
health and social care providers.
33
Long-term conditions
“ An ever increasing proportion of people live with chronic, long-term
conditions. These conditions need a different approach that involves the
patient making their own decisions about their healthcare with the help
of skilled professionals, enabling people to live as healthy lives as possible
in their own homes. We need to find new ways of encouraging patients to
have more control over their own health, as well as working with our local
authority and public health colleagues in ways to stop our children and
grandchildren developing these conditions as they grow older.”
Katherine Gerrans
CCG Governing Body
Member and Lead for
Long Term Conditions
How will this improve health
in Tower Hamlets?
• Improved clinical outcomes for
those using oxygen.
• Fewer emergency admissions.
• Better disease control.
• Increased patient satisfaction.
• Improved clinical pathways.
Financial impact
Additional investment of £80,000.
What do we mean by
long-term conditions?
A long-term condition is an illness that cannot be cured but can be managed
through medication and/or therapy. Care for long-term conditions tends to
focus on improving symptoms and supporting people to live a full life.
Current situation and health needs
Within Tower Hamlets there is a high occurrence of diseases such as diabetes,
COPD and TB. We want to work with patients and colleagues to improve
the health outcomes of those suffering from long-term conditions or likely
to do so in the future. This includes supporting the London Borough of
Tower Hamlets to implement its carer’s plan, particularly by providing health
support for those in caring roles and developing their understanding of
health conditions.
Our work on long-term conditions focuses on the areas where we have the
biggest local challenges.
Neurological conditions
The JSNA identified 1,231 people with a long-term neurological condition
registered with a GP in Tower Hamlets or just 0.48 per cent of the local
population. However, long-term neurological conditions make up about
two per cent of all hospital care and cost £15.59 million in 2010/11.
Epilepsy made up 55 per cent of all hospital care involving long-term
neurological conditions. Of these episodes, 78 per cent were emergency
attendances. Furthermore, only 68 per cent of epilepsy sufferers in Tower
Hamlets were seizure-free during 2009/10 compared with national figures
of 74 per cent. This suggests that better seizure control could reduce the
number of emergency admissions and inpatient stays.
Respiratory diseases
There is a high level of respiratory disease in Tower Hamlets. In 2011/12
the emergency admission rate for COPD among those registered with a
GP was nearly 16 per cent. This is higher than national (12.5 per cent) and
London (13.6 per cent) averages. Emergency readmission rates for 2011/12
were also high.
Despite there being less asthma sufferers in the borough when compared
with London average, Tower Hamlets has higher hospital admission rates for
asthma than the London average. Of these admissions, 75 per cent are likely
to be preventable through better disease control. Acute asthma admissions in
2009/10 cost £1.35 million. There are also significant inequalities in asthma
admission rates between ethnic groups and age groups.
34
Tuberculosis rates in Tower Hamlets have increased from 60.3 per 100,000
populations in 2008 to 60.5 per 100,000 populations in 2009. This is higher
than the London average rates of 44.2 per 100,000 and England’s rates of
15 per 100,000 in 2009.
Tower Hamlets currently has over 300 people on long-term oxygen treatment
for a range of conditions, including COPD, cluster headaches and obstructive
sleep apnoea. Oxygen is usually prescribed by specialist clinicians in a
hospital or outpatient setting. Respiratory patients, who fall under the care
of ARCARE, will have their oxygen needs monitored by the service. However,
it is unclear what the review and assessment pathways are for people with
non-respiratory conditions, particularly if they are housebound and cannot
attend outpatient appointments. There is also a lack of scrutiny of oxygen
prescribing, as well as if and how oxygen is used by patients in their homes.
Diabetes
Tower Hamlets has a high prevalence of diabetes, which is increasing on a
yearly basis. In March 2010, nearly eight per cent of Tower Hamlets residents
were diagnosed with diabetes. This is higher than the national and London
averages of around five per cent. It is estimated that prevalence will increase
to 10 per cent by 2030.
Diabetes Prevalence
11%
prevalence
10%
9%
8%
7%
2010
2015
2020
2010
2015
2025
2020
2030
2025
2030
Number
13,674
14,987
16,871
18, 968
21,314
Prevalence
7.8 %
8.1 %
8.7 %
9.3 %
10.1 %
Table: Diabetes Prevalence Projections in Tower Hamlets 2010–2030, APHO Diabetes
Prevalence Model, 2010 (Diabetes Factsheet, Tower Hamlets JSNA 2010–2011)
35
Statins*
A group of medicines that can
help lower rates of low-density
lipoprotein (LDL) cholesterol
(so called ‘bad cholesterol’)
in the blood.
They do this by reducing the
production of LDL cholesterol
inside the liver.
It is estimated that 16 per cent of deaths in adults in Tower Hamlets can be
attributed to diabetes, compared with 12 per cent nationally. Diabetes also
increases the risk of heart disease, eye problems and limb problems. These
risks can be reduced with early diagnosis, proper control of blood sugar in
the first 10 years after diagnosis, and healthy lifestyle choices.
The diabetes care package was introduced in 2009/10 and has helped
improve blood pressure and cholesterol control in people with diabetes.
This is critical to reducing the likelihood of developing heart diseases and
other complications. The NHS Health Checks programme also facilitates the
early identification of diabetes and those at risk of coronary vascular disease,
and directs them to services to improve their lifestyle. This work resulted in
a 10 per cent reduction in unplanned hospital admissions for diabetics in
2010/11 compared with the previous year, equating to cost savings of
around £837,000 (JSNA 2010–11).
Cardiovascular disease
Compared with London, Tower Hamlets has the third highest premature
death rate from circulatory diseases. These death rates vary across the
borough and, in general, are higher in areas of higher deprivation. They also
vary substantially by ethnicity with significantly higher death rates in the
white population.
Huge progress has been made in Tower Hamlets to improve the health
outcomes of people suffering from cardiovascular diseases, including the
implementation of care packages for coronary vascular disease, peripheral
vascular disease (secondary prevention) and hypertension. These are
underpinned by the NHS Health Check care package developed in 2010.
The NHS Health Check care package identifies people aged 40–74 at high
risk of cardiovascular disease. The package has increased the amount of
high-risk patients prescribed a statin* by 10 per cent between September
2010 and August 2011, and the increased the amount of high-risk patients
who quit smoking.
The full impact of the care package has yet to be evaluated.
36
Our approach in 2013/14 and beyond
We will build on our work so far in the following ways:
Neurology
In the coming year, we will review current services for epilepsy with a view
to reducing emergency admissions and managing more patients outside
the hospital. Progress in this area will inform how we treat other long-term
neurological conditions including Parkinson’s, Multiple Sclerosis and Motor
Neuron Disease.
Respiratory
Since 2009, Tower Hamlets PCT and now the CCG has invested over
£1 million in primary care, community and outreach services, and pulmonary
rehabilitation to address health inequalities for COPD patients. There has also
been significant investment in smoking cessation services.
Progress has been made to improve health outcomes for these patients with
the introduction of the COPD care package in April 2011. This care package
aims to improve the identification of COPD sufferers and provide them
with effective and consistently high-quality treatment, aiming to reduce the
number of times they are admitted to hospital and improving their quality
of life. We anticipate that these improvements will reduce COPD-related
hospital admissions in 2012/13, which would indicate better management
of COPD in the community.
We will be evaluating the COPD care package for its effectiveness in helping
people manage their condition outside hospital, improving their health and
extending their life expectancy. Findings of the evaluation will be used to
further develop the care package, ensuring it complements the frail and
complex care package under development as part of the integrated
care programme.
In 2013/14 we will appoint a home oxygen specialist to:
• Review the current service.
• Analyse how oxygen is currently prescribed to ensure it is used
appropriately.
• Analyse oxygen use by patients in their homes.
In 2014/15 we will also explore the feasibility of developing a sector-wide
Home Oxygen Service Assessment and Review (HOSAR) service.
For 2013/14, we will continue to commission the TB outreach service.
This service will include supporting patients with complex needs to take
their medication properly. The service will then undertake outreach work
to ensure those identified with TB complete their treatment. We will also
establish links with statutory and voluntary sector organisations who work
with disadvantaged and hard to reach communities in Tower Hamlets,
to raise awareness and develop joint working in the management of TB.
Findings from the JSNA and THINk research on patient perspectives on longterm conditions will help us carry out a review into the provision and needs
for asthma patients. The outcomes of this review will inform commissioning
plans for asthma services in 2014/15.
37
Diabetes
In 2013/14 we will be taking the following steps to reduce deaths and
hospital admissions from diabetes complications:
• Revise the diabetes care package to support individual general practices in
controlling diabetes in the first 10 years after diagnosis.
• Seek feedback from patients on their experience of their care-planning
consultation. This will be used to improve the process and ensure
newly-diagnosed diabetics are educated and supported to manage their
condition effectively.
• Review current training and education of diabetic patients and healthcare
professionals with a view to commissioning training at a local level. This
will ensure the skills and knowledge required to manage diabetes are
being met.
• Collaborate with Public Health England to identify prevalence of renal
diabetic disease; the impact of this on hospital admission and mortality
rates; and how it can be reduced. Findings from this will be used to
develop commissioning plans for 2014/15.
• Work with the prescribing team to reduce high cost insulin use.
Cardiovascular disease
NHS Tower Hamlets CCG will review the way that we commission:
• NHS Health Checks
• coronary heart disease and stroke
• heart failure
• hypertension.
38
Mental health
“ Our vision is to commission integrated mental health services that are safe
and effective, with friendly staff that inspire confidence in the people and
families using them, and which help people to take control of their own lives
and recovery.”
Dr Judith Littlejohn
CCG Governing Body
Member and Lead for
Mental Health
Current situation and health needs
Tower Hamlets has among the highest levels of mental health need in the
country. With a growing population, particularly of young people, we need
to ensure that we commission the very best mental health services.
How will this improve health
in Tower Hamlets?
We will deliver health
improvements for service users
in line with the No Health
Without Mental Health
national outcomes strategy:
• More people will have good
mental health.
• More people with mental
health problems will recover.
• More people with mental
health problems will have good
physical health.
• More people will have a
positive experience of care
and support.
• Fewer people will suffer
avoidable harm.
NHS Tower Hamlets CCG has set an ambitious agenda to
improve the quality, productivity and efficiency of mental
health services in the borough.
• Fewer people will experience
stigma and discrimination
Some of the key achievements during 2012/13 include:
Financial impact
Net investment of £480,000.
Additional investment of:
• £600,000 for mental health
services in hospitals.
• Introduction of a new primary care mental health service, consisting of
a new serious mental illness service, a primary care mental health liaison
nurse and improved links between GPs and secondary care mental
health services. It is anticipated that around 300 patients will move from
secondary care mental health services into the new primary care mental
health service. The service promotes recovery and a joined up approach
to mental and physical health.
• £180,000 in inpatient
psychiatric intensive care.
Savings of £300,000 by:
• Supporting people to transfer
from secondary into new
primary care mental health
services.
• Improved productivity in
psychological therapies.
39
• Working with East London NHS Foundation Trust, we have:
— Redesigned dual diagnosis services, personality disorder services
and clinical psychology to promote better care pathways and
generate significant savings.
— Improved the experience of inpatients at the Tower Hamlets Centre
for Mental Health by keeping occupancy low and continue to work
with the trust to consider the future design of inpatient services.
— Developed Improving Access to Psychological Therapies (IAPT) for
children and young people.
• Working with partners to deliver significant improvements in community
services for people with dementia. We achieved the most improved rate
of dementia diagnosis in primary care in the country.
• Working with partner CCGs across east London and with East London
NHS Foundation Trust, we have redesigned inpatient assessment services
for people with dementia. This included a new ward at Mile End Hospital
providing a specifically-designed therapeutic environment for people with
dementia and releasing £1.1 million of savings. Half of these savings were
reinvested into community services for people with dementia. In Tower
Hamlets, we invested our share in specific projects to:
— Promote integration with primary care and the community health
services.
— Improve person-centred care in care homes.
— Improve our understanding of the needs of people with alcoholrelated dementia.
• Working with the London Borough of Tower Hamlets to deliver our
strategy for improving supported accommodation for people with serious
mental illness.
NHS Tower Hamlets CCG is currently working with the London Borough of
Tower Hamlets and the Health and Wellbeing Board to develop a Tower
Hamlets Mental Health strategy. The strategy will drive plans for mental
health services. A JSNA looking specifically at mental health and a draft
strategy are currently in development prior to a public consultation in
summer 2013. Our plans reflect the strategy’s emerging priorities but
do not represent a full and complete set of the partnership priorities.
40
Our approach in 2013/14 and beyond
Integrated care
The integrated care project includes mental health services and is a key
priority for NHS Tower Hamlets CCG. This work is still in development but
priorities are likely to include:
• The integration of mental health into new community health teams and
support for patients with long-term conditions who are at very high and
high risk of emergency hospital admission.
• Developing new ways of working between medical and psychiatric
professionals in secondary care.
• Continued implementation of the new primary care mental health service.
• Continued work to promote more integrated approaches to physical and
mental health care.
Primary care mental health services
We will continue to work to improve how primary and secondary care
work together. This work will promote the clinically-appropriate discharge
of patients who have a serious mental illness, but who are stable, from
hospital mental health services into primary care mental health services. We
will consider how the experience of primary care of patients with a serious
mental illness could be improved, including how they can be supported to
access the same GP, if that is their preference.
Talking therapies
We will work with our new provider of primary care psychology to make sure
people have the right access to services. More broadly, we will consider how
people with mild to moderate mental health problems who currently receive
treatment, are assessed and treated within East London NHS Foundation
Trust. We will then review access and pathways into talking therapies.
Dementia
We will:
• Continue to improve the diagnosis rate of dementia and improve
community mental health services for older adults, including people with
dementia.
• Evaluate 2012/13 projects and invest in more mental health staff as part
of our integrated care work.
• Consider how we can work with the London Borough of Tower Hamlets
to improve the experience of people with dementia who live in care
homes in the borough.
41
Crisis House*
Provides clinical care and support
to individuals going through
a mental health crisis.
Child and Adolescent Mental
Health Services (CAMHS)*
Tier 1
Services provided by practitioners
who are not mental health
specialists working in universal
services; this includes GPs, health
visitors, school nurses, teachers,
social workers, youth justice
workers and voluntary agencies.
Practitioners are able to offer
general advice and treatment for
less severe problems, contribute
towards mental health promotion,
identify problems early in their
development, and refer to more
specialist services.
Tier 2
Practitioners at this level tend to
be CAMHS specialists working
in community and primary
care settings. For example, this
can include primary mental
health workers, psychologists
and counsellors working in GP
practices, paediatric clinics, schools
and youth services.
Practitioners offer consultation to
families, and other practitioners,
outreach to identify severe or
complex needs which require
more specialist interventions.
Inpatient services
With our main provider of acute mental health services, East London NHS
Foundation Trust, we will examine the effectiveness of crisis pathways.
This work will look at the separately commissioned Crisis House* and
promote better crisis care for women in the context of new additional
female psychiatric intensive care capacity. We will work with:
• East London NHS Foundation Trust to deliver the recommendations of
the recent independent investigation into a serious incident at the Tower
Hamlets Centre for Mental Health.
• Partner CCGs and East London NHS Foundation Trust to consider
opportunities for further improvements to the quality and productivity of
crisis pathways, and the number of inpatients in 2013/14 and beyond.
• Partner CCGs to consider improvements to community and inpatient
pathways for older adults with functional mental health problems.
Liaison mental health services
We will work with Barts Health NHS Trust and East London NHS Foundation
Trust to develop new mental health liaison services for people with mental
health problems who are admitted to the Royal London, Mile End or London
Chest Hospitals. This will improve the experience of people with mental
health problems in general hospital care, reducing their length of stay and
reducing readmissions.
Children and young people
As part of our developing mental health strategy, we will consider how
Tier 2 Child and Adolescent Mental Health Services (CAMHS)* work and
are delivered in partnership with the London Borough of Tower Hamlets.
Joint working with London Borough of Tower Hamlets
We will work with providers to develop mental health services that focus on
helping people recover by promoting personalised care and support; and
considering with the London Borough of Tower Hamlets, the effectiveness
of the recovery college model. We will work with the London Borough of
Tower Hamlets to redesign day opportunities for people with mental health
problems to ensure these services are responsive, meet the needs of patients,
and support the new financial flows of personal budgets. We will continue
to implement the Accommodation strategy for people with mental health
problems, and are considering further opportunities for tackling long-stay
and forensic patient occupancy.
Tackling stigma and discrimination
We will sign the Time to Change pledge and work with the London
Borough of Tower Hamlets and partners from the statutory and voluntary
sector to develop a plan of action across the borough to reduce stigma and
discrimination both within our organisations and across communities.
Better information
We will work collaboratively with providers to improve financial and
activity data in preparation for the introduction of Payment by Results
into mental health.
42
Last years of life
“ Our vision for last years of life care is integrated, population-based
and person-centred, taking into account where people are in their lives,
irrespective of age or diagnosis. Care will be delivered 24 hours a day seven
days a week, 365 days a year with investment predominantly in primary care
which will help patients receive the support and care that they need.”
Dr Liliana Risi
CCG GP and Clinical Lead for
Last Years of Life
How will this improve health
in Tower Hamlets?
• A clear, simple 24/7, 365 days
a year model.
• Patients are seen by those best
able to meet their needs.
• Primary care needs are
addressed by an individual’s
own GP/practice, whenever
possible.
• Local residents are educated
and informed about the range
of services available to them,
and how to make the most
appropriate choices.
• A cost-effective model, which
maximises benefits for people
in last years, months and days
of life.
Financial impact
Investment decisions to be made
in 2014/15.
Current situation and health needs
Of the estimated 1,200 people who die each year in Tower Hamlets,
approximately 75 per cent will have a long-term, irreversible condition that
allows time for advance care planning. Between 2005 and 2009, around
250 people per year were admitted to A&E who were expected to die and
went on to do so during their last admission. When asked, nearly 70 per cent
of local residents said they wish to die at home. However, at any one time
as many as 25 per cent of all hospital beds are occupied by Tower Hamlets
residents who are in their last year of life.
A review of Tower Hamlets residents who died at Barts and the London
(now Barts Health NHS Trust) in 2011 found that half had an identifiable
palliative care need (meaning their death was predictable in the last year
of life). Of these people, most spent between two and three weeks and
ultimately passed away, in hospital and most were more than 67 years old.
Individual case reviews from a large GP practice in Tower Hamlets showed
that:
• Cognitive assessments were not done or done but not documented.
• Palliative care templates were either partially completed or not completed
at all.
• Multiple GPs were involved in the care of each person but no key GP
or team of GPs was identified to oversee a care plan.
• DS1500 (a mechanism to fast track benefits) was either not done or done
but not documented.
NHS Tower Hamlets CCG currently commissions a range of services for
people in their last years of life, including St Joseph’s Hospice, Specialist
Palliative Care at Bart’s Health NHS Trust, Tower Hamlets Palliative Care
Centre, Age UK Lay Network, City and East London Bereavement Service
and GP Network Improved Services for Palliative Care. In 2011/12, the cost
of these services and all urgent and emergency activity for Tower Hamlets
patients was in the region of £4.5 million. Tower Hamlets has invested
substantially in last years of life services and has the second highest spend
per death in the UK. Despite this investment, significant numbers of people
die in hospital. Our priorities are to improve these services, and in particular
focus on gaining better health intelligence and systematic analysis of local
needs; and to promote the concept of healthy dying in the community or
within the health profession.
The best practice evidence for last years of life care identifies the following
considerations for Tower Hamlets.
43
Deprivation
Social deprivation increases the palliative care needs of terminally ill patients
with double the resources needed to achieve the same levels of care as in
non-deprived areas. There is also evidence that patients from deprived areas
with complex problems feel less supported and their doctors feel more
stressed after consultations. People from ethnic minorities and the elderly
tend to be excluded from palliative care and are more likely to die in hospital.
Integrating care between primary care
and partner organisations
Over half of the healthcare needs of people in their last years of life can be
delivered in primary care. However, lack of access and continuity can create
problems, for example elective admissions increase as being able to consult
a particular GP declines. Nationally, fewer generalists possess the skills to
manage patients within the last years of their life. Those that are left are not
making the most of potential partnerships with palliative care teams. There is
also a lack of partnership working between specialist and generalist palliative
care teams.
44
Our approach in 2013/14 and beyond
NHS Tower Hamlets CCG has
seven priorities over the next three
years to improve care in the last
years of life.
1. Identify patient priorities, local trends
and person-centred preferences
Although we have made a significant financial investment into last years of
life services, we need to get better at collecting data to help us understand
how best to manage patients in their last years, months and days of life.
We will produce a needs assessment, conduct effective patient and clinical
engagement and work closely with providers and the CSU to understand
local trends. The needs assessment will have a specific focus on the carers’
view of care in the last three months of life.
2. Develop a three year strategy for
last years, months, and days of life
We will ensure that this strategy takes into account the different needs of
patients, depending on each stage of the life course – for example, maternity
and young people’s strategies would focus on premature and neonatal
deaths, stillbirths, life-limiting childhood developmental and neurological
conditions and childhood cancers.
3. Focus on health promotion and roll out
of the ‘living and dying well’ agenda
People in the last years of life often receive care that is over-medicalised.
Our vision is to move towards care that is less focused on drugs and
medication and concentrates more on improved patient wellbeing,
experience and quality of life.
4. Review specialist palliative care expenditure and ensure
this is in line with proportionate investment in primary care
We will:
• Review current spend against the last years of life funding review results.
• Use national tools to benchmark our services and better understand
the appropriate levels of investment for our population.
• Analyse the balance between specialist and generalist care so that
we commission the right care in the right place.
• Commission more generalist care from our primary care providers.
45
5. Train GPs to provide last years of life care
We want clinicians to have the skills and confidence to manage more patients
in primary care, where it is clinically appropriate. As such, we will offer a
robust training programme for our primary care workforce.
A needs assessment has been produced to determine GPs confidence
in assessing the level of cognition and function in a person with multimorbidities, and acting on the findings.
6. Roll out ‘Coordinate my Care’
Coordinate my Care is an electronic record of a palliative care patient’s
wishes and preferences that can be shared with multiple providers.
We will work to ensure that the programme is rolled out in an integrated
and effective way across Tower Hamlets. This will include overseeing
the development of IT solutions to overcome any compatibility issues
and a comprehensive training programme for all users of this system
within the borough.
7. Review all services providing palliative care
to identify overlaps and gaps
We will check for any duplication within our last years of life services in order
to make best use of resources. To do this, we will:
• Review all contracts.
• Analyse data and use case studies collated by our priority projects to
highlight where duplication exists within bereavement, counselling and
specialist services.
• Investigate different ways of commissioning services that provide value
for money.
46
Supporting our plans
47
Information and technology
“ IT is a powerful tool. It is vital to help patients manage their own health,
clinicians provide effective care and to inform commissioners. We are at an
exciting point in Tower Hamlets; we have most of the technical pieces of the
jigsaw available to us and over the next year we expect to piece far more
of these together, in particular by sharing information between teams of
professionals, to enable fully integrated services.”
Isabel Hodkinson
CCG Governing Body
Member and Lead for
Informatics
How will this improve health
in Tower Hamlets?
• Make services easier to access.
• Better joint working and
information sharing.
• More effective care planning.
Financial impact
Supporting savings in other
programmes (especially
integrated care).
NHS Tower Hamlets CCG recognises the role that technology can play in
improving the quality of services for patients. Technology will be key to
the success of a number of our projects, and will also ensure that we keep
information safe and secure.
We have an ambitious information strategy and are looking to make a
number changes in 2013/14.
Integrated care pilot
Integrated care is one of the areas we are focusing on to help make peoples’
experience of care services as simple as possible. One of the main issues with
integrating care is the wide variety of computer systems used by different
services. NHS Tower Hamlets CCG will pilot software called Orion, which
links all various computer systems and allows them to ‘speak’ to each other
to create a single patient record. We believe this will improve the quality of
information that clinicians use to make decisions and therefore
the quality of care that patients receive.
We will pilot this tool on community virtual wards*, where patients have
many complex issues that span both health and social care. If successful,
we aim to widen the pilot to focus on other key areas and to use Orion
to bring in information from other key sources.
Online access to primary care
According to recent research, the proportion of adults accessing the internet
has risen to 82 per cent with the top activities being:
• accessing email (72 per cent)
• browsing for information on hobbies (67 per cent)
• researching products or services (58 per cent)
• online shopping (54 per cent).
With more and more people preferring to do tasks online, primary care
services need to give their patients the option to access and interact with
services online.
Giving patients the ability to access and book primary care services online
will also reduce the pressures on practices’ reception areas and the strain
on reception staff, meaning patients get a better experience when they visit
their GP.
Most of this technology exists already but we need to ensure the processes
are in place to enable it to happen. Work is also needed to help change the
culture of patients and practices so we will be focusing on training
and marketing.
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Our approach in 2013/14 and beyond
Online patient engagement tools
Enabling patients to access their GP practice online and book appointments is
only a small part of the vision for online patient interaction in Tower Hamlets.
We are running a pilot with the Hurley Group and a number of local practices
to see what can be achieved by developing some existing software. This
should enhance the ability to access services for patients and help reduce
the pressures on primary care. We will focus on:
Self-care
Community virtual wards*
Provide multidisciplinary case
management services to people
who have been identified as being
at high risk of future emergency
hospitalisation.
Community virtual wards* use the
systems, staffing, and daily routine
of a hospital ward to coordinate
preventive care to these patients
in their own homes.
Before people consider going to the doctor, most care for themselves (for
example, by taking paracetamol for a headache). People often tell us that
they would like more information on how to self-care, where appropriate.
We will focus on ways to educate patients about self-care, teaching them
about their specific conditions with the aim of enabling them to help manage
their own treatment.
Virtual consultations
Some patients do not necessarily need to come into their practice in order
to consult with their GP. These patients may benefit from receiving a
virtual consultation using a web cam. In other areas of the country, virtual
consultations have improved access to GPs and have reduced consultation
times. Both of these factors should help to reduce the number of face-to-face
appointments in primary care, freeing up time for reception and clinicians
and improving access for patients.
Pre-appointment information
Often when visiting the doctor, patients are asked a lot of questions about
their condition to help the doctor diagnose and decide how best to treat
them. We will trial a system where patients answer some of these questions
online so that the doctor is better equipped to make a decision at the first
appointment. In some cases, the answer to the patient’s health issue may
be so straightforward that an appointment is no longer needed. This will
work especially well in areas where medicine is needed for minor conditions,
such as conjunctivitis, contraception, hay fever, aches and sprains, and
travel advice.
Clinical communities
Another area we are investigating is building relationships between
clinicians within primary care and secondary care. The aim is to build
clinical communities to help support and educate clinicians in their work
with patients. This should help share expertise and knowledge and make
sure people only go to hospital when they need to.
All of the above areas will be evaluated looking at the impact on different
groups of patients. Those ideas that are shown to work will be rolled out
gradually over the next few years.
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Data driven, evidence-based
improvements in quality
In Tower Hamlets we have a strong tradition within primary care of using
data, in conjunction with clinical engagement and guidelines, to improve
quality. We will support local GP teams to learn how to use tools that analyse
data and will use these to inform areas of work, like planned care. We also
plan to review and revisit the use of Choose and Book.
We intend to look at data from the patient perspective, to use data to learn
from and respond to changes, and to ensure that it can be used by clinicians,
as well as managers. We are seeking to develop platforms and processes to
maximise patient input and response. This approach will be tested as part of
the integrated care work between primary care and Barts Health NHS Trust.
Clinical record sharing
for the delivery of care
There has been a longstanding vision of making sure that the right
information is available at the right time to clinical (and ultimately social care)
teams. This year we believe that we will be beginning to really improve this
in the following ways:
• For urgent care, we are working closely with Barts Health NHS Trust to
create the ability to view a patient’s record between GP and hospital
systems. For example, with the right permissions, a doctor in A&E can
view the problems a patient has been to their GP for and any medications
their GP prescribed.
• For integrated care, we will work to provide a single patient record for
people with complex conditions, such as dementia. Using the Orion
software, we will link up computer systems from health and social care
services, so everyone involved in caring for a person is able to make
informed decisions.
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Prescribing
“ The Medicines Management Team support high quality, evidence-based, cost
effective prescribing within Tower Hamlets. This has been achieved in primary
care with good engagement from GPs, nurses, community pharmacists,
secondary care colleagues and others including the Clinical Effectiveness
Group. This is reflected by our excellent performance in comparison with
other areas.”
Stuart Bingham
CCG Governing Body
Member and Lead for
Prescribing
How will this improve health
in Tower Hamlets?
Current situation and health needs
Medication plays a key role in providing quality healthcare to patients
and helping patients to manage their care. Prescribing services use clinical
expertise together with practical knowledge to ensure the safe supply and
appropriate use of medicines by patients.
• Residents will have access to
the drugs they need, when
they need them.
• Better health through increased
provision of certain medicines,
such as vitamin D supplements
and oral nutritional
supplements.
Financial impact
Savings of nearly £1 million
by investments in medicines
management technology.
We need to help people get the drugs they need, while ensuring medication
is prescribed in the most cost-effective way.
NHS Tower Hamlets CCG supports GP practices in the borough to meet
certain targets in the way that they prescribe medication. In the last year
there have been the following successes:
Specials*
There has been a significant reduction in the prescribing of Specials* in the
last 12 months. This is due to the successful promotion of Scriptswitch (an
IT system that advises GPs on alternative medicines and potential savings),
which resulted in more doctors and community pharmacists using the system.
We will continue to raise awareness of Scriptswitch throughout 2013/14 to
reduce the prescribing rate of Specials.
Oral nutritional supplements
The prescribing of oral nutritional supplements grew 10 per cent in the
previous financial year, which stimulated the review of prescribing in this
area. In 2012/13 a team of dieticians provided training to all GP practices,
community pharmacists and community nurses on appropriate prescribing.
They also conducted reviews on adults in practices that spend higher
amounts on prescribing and care homes. The next phase of the project
in 2013/14 will build on these reviews and extend to include paediatrics.
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Management of acute and specialist medicines
The North East London Medicines Management Network supports consistent
provision of medicines across north east London. The group considers high
cost, low volume medicines which are excluded from Payment by Results tariff
and which have not received formal guidance from the National Institute for
Health and Care Excellence (NICE). We have rigorous processes in place to
assess individual requests for medicines not covered by the tariff.
Tower Hamlets is already performing well against a number of
best practice standards for prescribing but there is still room
for improvement. In the coming years, we are likely to face to the
following pressures:
New drugs, licenses and guidance
Specials*
Specials are special-order
unlicensed medicines that
are prepared to meet the
requirements for an individual
patient. They have varying costs.
Specials have not been assessed
by the Medicines and Healthcare
Products Regulatory Authority
for safety, quality and efficacy
in the same manner as licensed
medicines.
While the actual cost of all drugs that will be recommended for prescribing
in primary care during 2013/14 cannot be calculated, it is prudent to plan for
at least £1 million. There is a growing pressure on primary care prescribing
budgets and most new drugs are more expensive substitutions for (or additions
to) cheaper existing drugs. In 2012/13, the impact of new drugs in primary
care was not as significant as anticipated or as we are likely to have in 2013/14.
It is important to note that managing new treatments is different from
managing other service developments. The NHS Constitution gives patients
the right to expect local decisions about funding medicines and treatments
to be made rationally so there is a need for high quality, evidence-based and
systematic decision making. Other drivers include new guidance from NICE,
quality and outcome targets, national public health campaigns and tighter
treatment targets.
Vitamin D
There was a significant increase in prescribing Vitamin D specials last year. In
collaboration with GPs, community pharmacists and the London Borough of
Tower Hamlets, we have agreed guidance for health care professionals and
patients to ensure appropriate management of those at risk of Vitamin D
deficiency and insufficiency. Healthy Start is the free government programme
for specific high-risk groups and is managed by the local authority. We will
continue to support this work throughout 2013/14, as well as the Department
of Health’s campaign for all those at high-risk to receive appropriate
supplementation and help to adopt positive lifestyle changes.
Our approach in 2013/14 and beyond
In 2013/14 we will continue to drive quality improvements and lower costs,
in line with national and local priorities.
We will also continue to support patient engagement in medicines via
community pharmacy services, including the new medicines service and
targeted medicines use reviews, as well as raising awareness about medicines
waste.
The three initiatives highlighted started in 2012/13 and are part of a larger
programme to improve the use of medicines, improve patient outcomes and
increase productivity. These initiatives support evidence-based prescribing and
will deliver savings to resource other prescribing demands:
• Reduction in the cost and volume of Specials, including vitamin D, with a
target expenditure of no more than £75,000 per month on average across
all practices.
• Reduction in the cost of oral nutritional supplements to produce savings of
£50,000. This will be achieved by prescribing cost-effective, high dosage
products and implementing the paediatric allergy feed guidelines.
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• Maintain Scriptswitch’s profile and monitor to support savings achieved
to date.
Achieving excellence in general practice
“ Ensuring that our primary care system is constantly developing and delivering
high quality care is vital to maintaining an effective healthcare system. While
we do not contract or directly commission GP practices, we have a duty to
focus on development and quality improvement.”
Maggie Buckell
CCG Governing Body Lay
Member for Nursing and
Lead for Primary Care
NHS Tower Hamlets CCG is embarking on a programme to develop the
following in primary care:
Stocktake of primary care provision
(April to June 2013)
How will this improve health
in Tower Hamlets?
This will improve our understanding of the current state of primary care
provision to help us to focus our efforts. We will look at:
• Improve access to general
practice.
• Practice profiles, for example the number of patients, premises,
IT infrastructure.
• Improve patient experience.
• Our workforce and performance against clinical quality indicators.
• Ensure that primary care
workforce is of high quality.
• Patient experience, including access, continuing care and patient
engagement.
Financial impact
Additional investment of
£150,000.
Engagement with member practices
(July to December 2013)
Based on the results of the stocktake, we will engage with our GP members
to determine the implications for primary care quality and development and
agree on what work needs to be done.
Develop primary care quality
and improvement strategy
(January to April 2014)
This strategy will outline how we will improve primary care provision in
Tower Hamlets over a three year period, from April 2014 onwards.
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Delivering our plans
We will monitor the delivery of these improvements through our internal
management structures. Each programme will:
• Have a working group consisting of the CCG Governing Body Lead, their
clinical leader support and a member of the CCG management team. Most
of the time, these working groups will also include representatives from
local providers, partners and service users.
• Have a project plan with clear milestones, outcomes, risk logs, and
engagement plans.
• Produce regular monthly updates, which will be scrutinised by a subcommittee of the CCG Governing Body. Where appropriate, for example
due to poor performance, these updates will go direct to the CCG
Governing Body.
Other working groups will also have a role in tackling poor performance
throughout the year. For example, if a provider is struggling to maintain A&E
standards then our urgent care working group will be asked to use their clinical
relationships to influence and implement changes and improvements.
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Notes
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We would like to hear from you
To find out more about us, please contact us
using the details below:
Write to
NHS Tower Hamlets Clinical Commissioning Group
2nd Floor Alderney Building
Mile End Hospital
Bancroft Road
London E1 4DG
Telephone
020 3688 2500
Email
info@towerhamletsccg.nhs.uk
Or, visit our website
www.towerhamletsccg.nhs.uk
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© NHS Tower Hamlets Clinical Commissioning Group 2013