spring engagement event 14 march 2019 care closer to home · 14/03/2019 · 49 phgh doctors 10941...

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Spring engagement event

14 March 2019

Working together with the Barnet population to improve health and wellbeing

Care Closer to Home


Welcome

Dr Charlotte Benjamin, Chair, Barnet CCG


Housekeeping

• There is a hearing loop. This is switched on and available

• No fire alarm is planned today. If you hear the alarm,

please make your way outside

• Please turn your mobile phones off or put them on silent

• Please speak to a member of Community Barnet staff if you

have any questions


Focus for today’s event • Arrivals and registration

• Introduction

• Jargon Bingo

• Scene setting

• Scenario exercise Paediatric Hot Clinics

• Scenario exercise Social Prescribing

• Break

• Scenario exercise Frailty and Palliative Care

• Q&A

• Close

About the CCG


We are a membership organisation, made up of 54

GP practices, responsible for planning and buying

most of the local healthcare services for Barnet

residents

Dr Charlotte Benjamin is the new Chair of

Barnet CCG

Kay Matthews, is the CCG’s

Chief Operating Officer

What we do


CCGs are responsible for planning, buying and monitoring:

• The care and treatment you receive in hospital

and community health services, including district nurses,

physiotherapy and other therapies

• The care that you receive in an urgent or emergency

situation (including out-of-hours services)

• Maternity and newborn baby services

• The medicines you are prescribed by your GP

• Mental health and learning disability services

In April 2017, the CCG also took over the commissioning of

GP services from NHS England

What does a CCG not do?

CCGs are not responsible for other out of hospital services,

which include:

• Dentistry

• Optometry

• Screening programmes, e.g. cancer screening

• Immunisations

• Stop smoking services

• Sexual health services

• Health visiting services

These are commissioned by teams in NHS England, the Local

Authority or Public HealthWorking together with the Barnet population to improve health and wellbeing

Who we work with

Amongst others, we work closely with:

• London Borough of Barnet (Barnet Council)

• Barnet HealthWatch

• NHS England

• Central London Community Healthcare Trust

• Royal Free London Hospitals NHS Trust

• Barnet, Enfield and Haringey Mental Health Trust

• London Ambulance Service

• London Central and West Unscheduled Care Collaborative


Enfield CCG / Enfield Council

GP registered population: 320,000

GP practices: 48

Barnet CCG / Barnet Council


GP practices: 54

Camden CCG / Camden Council


GP practices: 35

Haringey CCG / Haringey Council


GP practices: 45

Islington CCG / Islington Council


GP practices: 34

UniversityCollegeHospital

BarnetGeneralHospital

ChaseFarmHospital

NorthMiddlesex

Hospital

RoyalFreeHospital

StAnn’sHospital

TheWhittingtonHospital

EdgwareCommunityHospital

FinchleyMemorialHospital

StMichael’s

PrimaryCare

Centre

LondonAmbulanceService

EastofEnglandAmbulanceService

Moorfields EyeHospital

GreatOrmondStreetHospital

CentralMiddlesex

Hospital

Highgate Hospital

StPancras Hospital

StanmoreHospital

Tavistock Clinic,PortmanClinic,

GloucesterHouseDayUnit

Our place in North Central London

Primary Care Networks

We would like to play you an animation produced by NHS England that

describes what Primary Care Networks (PCN) are:


https://www.youtube.com/watch?v=W19DtEsc8Ys#action=share


Jargon Bingo

Nicholas Ince,

Senior Primary Care Transformation Manager, Barnet CCG

Colette Wood,

Director, Care Closer to Home, Barnet CCG

Care closer to home in Barnet

Dr Charlotte Benjamin,

Chair, Barnet CCG

Progress to Date


99% of the Barnet population are now covered by a Primary care network

April 2018

3 Networks

October 2018

6 NetworksJune 2019

Integrated Networks

Benefits


Benefits to patients Benefits to Staff System-wide benefits

• Equitable access to

new services and

pathways

• Patient centred care

tailored around

communities

• Integrated services

with wider system

partners to deliver

Care Closer to Home

• Easy to navigate

system

• Releasing capacity

within General Practice

by developing

innovative service

models and pathways

• Opportunities for cross

and multi

organisational working

and upskilling of staff

• Being part of an

innovation hub and

improving quality for

patients and carers

• New models of care to

support Care Closer to

Home

• More patients being

managed within a

primary and community

care setting

• Opportunity to bridge

health and social care

closer together through

project delivery

• Scale what is working

well to support current

and future system

pressures

Primary Care Networks in Barnet


Barnet CCG - Primary Care

Networks

Key Practice List size

(Jan 19)

Primary Care

Networks

1 Deans Lane Medical Centre 4257 Network One

2 Parkview Surgery 6556 Network One

3 Oak Lodge Medical Centre 18472 Network One

4 Watling Medical Centre 16207 Network One

5 The Everglade Medical Practice 8267 Network One

6 Dr Lamba (Colindeep Lane) 8835 Network One

7 Wakeman’s Hill Surgery 4675 Network One

8 Jai Medical Centre 8303 Network One

9 Hendon Way Surgery 8493 Network One

10 The Village Surgery 5201 Network Two

11 East Barnet HC (Dr Weston & Dr Helbtitz) 3609 Network Two

12 East Barnet HC (Dr Peskin/Syed/Hussain) 4507 Network Two

13 East Barnet HC (Monkman) 3074 Network Two

14 St Andrews Medical Practice 10885 Network Two

15 Brunswick Park Medical Practice 8548 Network Two

16 The Clinic (Oakleigh Rd North) 8934 Network Two

17 Friern Barnet Medical Centre 9046 Network Two

18 Doctors Lane - Colney Hatch Lane 5425 Network Two

19 Longrove Surgery 11327 Network Three(a)

20 The Old Courthouse Surgery 8323 Network Three(a)

21 Addington Medical Centre 9061 Network Three(a)

22 Vale Drive Medical Practice 5555 Network Three(a)

23 Gloucester Road Surgery 1802 Network Three(a)

24 Derwent Medical Centre 5581 Network Three(b)

25 Torrington Park Group Practice 12569 Network Three(b)

26 The Speedwell Practice 11440 Network Three(b)

27 Wentworth Medical Practice (Ballard Lane Merging with Wentworth on 1/4/2018)11404 Network Three(b)

28 Cornwall House Surgery 6411 Network Three(b)

29 Squires Lane Medical Practice 5796 Network Three(b)

30 Lichfield Grove Surgery 6235 Network Three(b)

31 Rosemary Surgery 5286 Network Three(b)

32 Woodlands Medical Practice 4395 Network Three(b)

33 East Finchley Medical Practice 7806 Network Three(b)

34 Penshurst Gardens 6639 Network Four

35 Millway Medical Practice 18483 Network Four

36 Lane End Medical Group 13136 Network Four

37 Mulberry Medical Practice 9946 Network Four

38 Langstone Way Surgery 7997 Network Four

39 St George’s Medical Centre 11116 Network Five

40 Hillview Surgery 1876 Network Five

41 The Phoenix Practice (Boyne Ave (E83656) has now merged with this practice)9987 Network Five

42 Dr Azim & Partners 9147 Network Five

43 Ravenscroft Medical Centre 7378 Network Five

44 Pennine Drive Surgery 8991 Network Five

45 Greenfield Medical Centre 6857 Network Five

46 Supreme Medical Centre 4357 Network Six

47 Mountfield Surgery 5006 Network Six

48 Heathfielde 8135 Network Six

49 PHGH Doctors 10941 Network Six

50 Temple Fortune Health Centre 7264 Network Six

51 The Practice @ 188 7588 Network Six

52 Adler & Rosenberg (682 Finchley Road) 5846 Network Six

53 Hodford Road Surgery 3663 Network Six

54 Cricklewood Health Centre(Barndoc Healthcare Ltd)4739 Unallocated

Network One


Clinical lead: Dr Aashish Bansal

Focus: Diabetes and Paediatrics

Population: 84,065

Involving: 9 practices

Current Project: Paediatric Hot Clinics

The objectives of the proposal are:

• To deliver a paediatric hot clinic across the network, which runs Monday to Friday

• To provides additional same day access to primary care GPs and Nurses

• The clinics can be accessed through your GP practice, NHS 111 and the Emergency

Department

• There are plans to integrate further services into the clinics over the coming months and then

assess and evaluate the impact

Network Two


Clinical Lead: Dr Anita Patel

Focus: Frailty

Population: 59,229


Road map: All system partners by April 19

Current Project: Frailty Multi Disciplinary

Team

The objectives of this proposal are:

• To enable patients to benefit from a range of integrated services across health and social care

• To introduce models of care that will reduce avoidable non-elective admissions for the frail and

elderly population of Barnet, focused on pneumonia and UTIs

• To promote the use of end of life care plans to enable a greater number of Barnet residents to

die in their place of choice

• To support GP Practices to work together effectively

Networks Three (a) & Three (b)


The Diagnostics in Primary Care service aims to provide patients with timely and clinically effective access to

investigative tests in a setting where they receive other aspects of their care. This would initially include the

following tests:

• 12 lead ECG

• Ambulatory ECG monitoring

• 24 hour blood pressure monitoring

• Spirometry / Feno Testing

• Phlebotomy

Clinical Lead: Dr Alexis Ingram

Focus: Diagnostics

Population: 3a – 36,068

3b – 76,941


Road map: All system partners by Apr 19

Current Project: Diagnostics

Networks Four, Five and Six


Network Four

Clinical Lead: Dr Daniella Amasanti

De-Bono

Focus: Digital

Population: 56,201


Road map: All system partners by Jun

19

Network Five

Clinical Lead: Dr Tonia Briffa

Focus: Dementia

Population: 55,352


Road map: All system partners by Jun 19

Network Six

Clinical Lead: Dr Leora Herverd

Focus: TBC

Population: 52,800


Road map: All system partners by Jun 19

The focus for this network is on

digital innovations to support patient

care through the use of apps and

moving to new appointment types

such as online consultations and

SKYPE

This network is exploring innovative

ways to deliver enhanced and

integrated care for patients suffering

with Dementia. This will include our

current mental health provider and

potentially be expanded to VCSE

providers.

This network is currently in the

discovery phase, analysing data and

looking at areas that would benefit

their patient population.

London Borough of Barnet and

Integrating Services


The “LBB offer to Networks” which is comprised of services that are provided, funded and/or supported by the

Council, include:

• Adult social care

• Children’s Service – support for children, young people and families

• Prevention Support Services and Prevention & Wellbeing Coordination

• Self-care and social prescribing services

• Housing and employment support services

• Sport and Physical Activity

• Culture and Learning


Paediatric Hot Clinics

Network One

Dr Aashish Bansal, Primary Care Network One Clinical Lead

Network One


• Parkview Surgery

• Deans Lane Medical Centre

• Oak Lodge Medical Centre

• The Everglade Medical Practice

• Jai Medical Centre

• Colindale Medical Centre

• Watling Medical Centre

• Wakemans Hill Surgery

• Hendon Way Surgery

Paediatric Hot Clinics


• 5 Hot Clinics per week (occurring daily in hours)

• The service is led by GPs from within the Network with resource

provided by Barnet Federated GPs.

• Use of the EMIS Community to book appointments and allow access

to the full patient record

• Replication of the existing referral routes from practices into the

Paediatric Hot Clinics (Redirection from ED, NHS 111, Practices and

self-referral)

• Mobilised early January 2019

Case for Change


• Data

– On average, in the last 12 months 17% of the population attended A&E

– 0-4s attend the Emergency Department in higher proportions than other Children’s age bands, with 34% of this patient cohort having had an attendance

– 8,940 pre-school children registered to a Barnet GP attended A&E in 2017/18

– 5 practices in CHIN 1 were within the lowest performing 8 practices for attendances to Barnet A&E for 0-5 year olds

• Network undertook service redesign to support:

– Patients

– Practices

– Federation

– CCG

– Secondary Care

Expected Outcomes


• Patients will be seen within a primary care setting where

waiting times are far shorter than the Emergency

Department

• Support the delivery of the Care Closer to Home

programme with patients being seen and treated within

their network

• Continuity of care and availability of their patient record to

support enhanced clinical decision making

• Number of redirections from A&E

• Where would you have gone? (for direct bookings from

practices)

Next Steps


• Evaluation of the project (June 2019)

• Work closely with Health Visitors (CLCH) to provide health

education

• Exploring extending into ‘Wheezy Children’

Scenario 1


A four-year old child with a one-week history of persisting

cough and cold symptoms and intermittent temperatures.

Appetite is reduced but is taking fluids. No rash or diarrhoea,

but occasionally vomits after coughing persistently. Previous

history of eczema. Parents are concerned due to the

persisting nature of the symptoms.

Scenario 2


A nine-month-old child with persisting diarrhoea (noticed

every time mum changes the nappy) and vomiting (six times)

for the past 24 hours – not taking her bottle as parents find

that she is difficult to keep awake. No significant previous

medical history and all her immunisations are up to date.

Feels warm to touch and has a little bit of nappy rash.

An introduction to Social

Prescribing

29

Seher KayikciLondon Borough of Barnet – Public Health

14th March 2019

What is Social Prescribing?

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Social Prescribing

• Recognises that social, economic and emotional needs have an impact on people’s health.

• Aims to empower individuals to find solutions which will improve their health and wellbeing.

• Reduces pressure on the NHS by directing people to more appropriate services and groups.

• Play video

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https://www.youtube.com/watch?v=O9azfXNcqD8

01

Transforming London’s health and care together

• National Activity

32

“Social Prescribing - “Social prescribing is a new way of helping people get better

and stay healthy…” Simon Stevens, CEO, NHS England”

Prevention is better than cure

Prevention will be at the heart

of the NHS long-term plan, and

will use new approaches like

predictive prevention, which will

explore how digital technology

can be used to offer individuals

precise and targeted health

advice.

Next Step on the NHS Five Year

Forward View (2017)

‘We will work collaboratively with

the voluntary sector and primary

care to design a common

approach to self-care and social

prescribing, including how to

make it systematic and equitable

NHS LONG TERM PLAN

33

• Page 6: 'Within five years over 2.5 million more people will benefit from

SP, a personal health budget, and new support for managing their own

health in partnership with patients' groups and the voluntary sector.‘

• Page 15: Primary Care Networks will result in 'fully integrated

community-based health care...supported through ongoing...development

of multidisciplinary teams in primary care & community hubs..& community

pharmacies who promote patient self-care and self-management.’

• Page 25: 'Over 1,000 trained social prescribing link workers will be in

place by the end of 2020/21 rising further by 2023/24, with the aim that

over 900,000 people are able to be referred to social prescribing schemes

by then.’

• Page 43: 'The NHS will roll out ‘top tips’ for general practice which have

been developed by Young Carers, which include access to preventive

health and social prescribing, and timely referral to local support services.

Link: https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/

https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/

Funding

NHS England will provide funding to Primary Care Networks for a new additional Social Prescribing link worker

The Social Prescribing Link Workers will be embedded within every Primary Care Network as part of a multi-disciplinary team.

This will be available from July 2019.

Social Prescribing Models and Initiatives in Barnet

35

Social Prescribing Models

Referral to a ‘one-stop connector’

Referers

GPs, nurses, muliti-

disciplinary teams, social

care and self referral

Connectors

Social Prescribing Link

Worker, Community

Navigator, Community

Connector

Prescription

Community Groups -gardening,

singing, dance, peer support –

funded/non-funded

Social Prescribing Local Picture

37

Over 1,200 charities operating in Barnet

(JSNA 2015)

A wide-range of Care Navigation, Link

Working, Community Access, Coaching and

Peer Support roles

Directory of Community Services

(LBB)

Barnet Wellbeing Hub (Barnet CCG)

Practice Health Champions (Public

Health)

Prevention and Wellbeing Co-

ordinators (Adult Social Care)

For further information

38

https://www.youtube.com/watch?v=O9azfXNcqD8

Discussion

39

We want to:

• Gain a greater understanding of your experiences and expectations when looking for support and information about different issues that can affect health

• Gain a greater understanding of your experience using current ‘social prescribing’ services

Why?

• This will help us improve current services and help to shape future services

Sabina

40

Sabina is 36 years old, has a full-time job as a nurse and has many friends and social engagements.

She lives in a bungalow with her 3 children who are all in primary school. Her main mode of transport is driving and she doesn’t get involved in any exercise.

She is technically overweight. Her older sister was recently diagnosed with diabetes and this has prompted Sabina to think more about her own weight and diet.

Marie

41

Marie is 54 years old. She lost her job about a year ago and shortly afterwards her relationship broke down.

Since then she has been struggling to keep up with payments for her rent and her car.

She has tried to find information online but it is quite confusing and she doesn’t know which websites to trust. She also goes to the Jobcentre Plus but doesn’t find them very helpful, and isn’t sure what to do next.

Derek

Derek is in his 60s, and was recently diagnosed with coronary heart disease. He lives with his partner and is due to retire from his job as a tube driver in the next 2 years.

He takes medication prescribed by his GP but isn’t really sure what the pills are and what they do.

He has not been able to quit smoking completely but has reduced from smoking 30 cigarettes to 5 cigarettes a day.

He recently joined a running group but they are mostly faster than him and he worries slightly about his heart.


Break

44

Network Two

Frailty & Palliative Care Multidisciplinary Team (MDT)

Dr Anita Patel, St Andrews Medical Centre

Co-Chair Network Two


Network Two membership

GP Practices

Brunswick Park Medical Centre

Colney Hatch Lane Surgery

East Barnet Health Centre (Dr Monkman)

East Barnet Health Centre (Dr Helbitz)

East Barnet Health Centre (Dr Peskin and Dr Hussain)

Friern Barnet Medical Centre

St Andrews Medical Centre

The Clinic – Oakleigh Road North

The Village Surgery

Covering east Barnet wards: Brunswick Park; Coppetts; East Barnet; Oakleigh; Totteridge


Area of focus

In 2011, population over 65 -13.3%- the sixth-highest of London's boroughs.

Number of people aged 65 and over is predicted to increase by 33% between 2018

and 2030, compared with a 2% decrease in young people (Barnet Joint Strategic

Needs Assessment)

We know that elderly people are dying in Accident & Emergency or soon after

admission

Quality Improvement project carried out for patients from Oakleigh Road HC looking

at over 65s admitted with pneumonia or UTI.

Would they have been better served by caring for them in the community?


https://www.barnet.gov.uk/jsna-home/

GPs

MDT

Administrator

Social Care

Community Nurse

Consultant Geriatrician

Frailty

Nurse

Consultant Old Age

Psychiatrist

London Ambulance

Service

Palliative Care Consultant

Voluntary & Charity Sector

Providers

Multi-Disciplinary Team (MDT) Membership

NowPast

Voluntary &

Charity

Sector

GPs

Social Care

Community

Nurse

Consultant

Old Age

Psychiatrist

London

Ambulance

Service

Palliative

Care

Consultant

Consultant

Geriatrician

Scenario 1


Mr. S is 82 yrs. old and lives in sheltered accommodation and does

not have any family. He chooses not to engage socially.

Mr. S is living with:

• memory loss

• has difficulty remembering to take his medication

• difficulty in hearing which affects his ability to use the phone

• has numerous other long terms health conditions which are poorly

controlled affecting his ability to function

• often feels very unwell, dizzy resulting in falls or feels very anxious

and calls the GP in hours, NHS 111 or 999 out of hours and is

often taken to A&E

Mr. S is also anxious about his financial situation and is keen to get

his affairs in order.

Question: How could an MDT help Mr. S?

What actually happened?

•GP (with consent) refers to the Frailty Nurse

•Patient goals – ‘to get my mind and legs working and stop feeling

dizzy. Stop the pain in his mouth and also foot pains’. Wants to

know how much money he has and to make a will. Does not want

to attend groups.

•Carers goal - to help him get stronger and more steady on his

feet.

•Discussed at the MDT using information from GP, Frailty Nurse,

social services, community services, Age UK which helped define

the MDTs goal.


Scenario 1

MDTs goals (taking into consideration Mr S and his carer’s goals)

were:

• to stabilise his medical conditions & encourage him to attend OPD

• refer him to the memory clinic

• improve his compliance with medication

• to reduce his falls

• increase his care package

• improve his nutrition

• make his environment safer

• help sort out his financial uncertainties

• to create an advanced care plan.

ALL disciplines worked together to address all aspects holistically in an

integrated approach


Scenario 1


Actions

Consultant Geriatrician - organised a one-stop investigation assessment

appointment at TREAT clinic.

• drew together all the medical specialities involved and joined up his needs

• communicated results and medication changes to GP

• sent next due appts (=7!) to frailty nurse to support him to actually attend them

Frailty Nurse

• Installed key safe (with consent) informed the community pharmacist, warden,

care agency & hospital transport

• Arranged appointment letters (with consent) to go to Mr S, warden and carers

• Arranged for community dietician to do a joint home visit with the carer and

shopper to improve his weight loss, build up his energy and decrease falls and

stop pressure ulcers

• Organised a lock safe box for the medication which the carers encouraged him

to take

Scenario 1


Actions continued

Social services

• liaised with the care agency and increased his package of care.

Community physiotherapist

• to change height of furniture and showed him exercises to build up

strength and balance reduce falls

GP

• medication changes, liaised with community pharmacist

• completed an advance care plan which was loaded onto CMC

Scenario 1

Actions continued

Age UK Barnet

• Mr. S wanted to make a will and lasting power of attorney. He also wanted

to find out if he had enough money to continue paying for his care and his

food.

• The Age UK Barnet team worked closely with the CHIN Specialist Practice

Nurse. This joint working provided Mr. S with seamless support, with only

having to tell his story once.

• Visited by a retired solicitor and a retiree from working in social services.

Patient Feedback

• “relieved to now be able to put his affairs in order and was also provided

with information on social activities within his locality”.

Scenario 1


Results of the MDT intervention

• Happier as Age UK Barnet had supported him to put his affairs in order

• Now aware he has money for carers, nutritious meals, rent, able to pay to see

a dentist to sort out his tooth ache

• Social services helped organise carers x3 per day, who help with meal

preparation, encourage him to take his medications on time and also to do his

exercises

• Outpatient appointments are 100% attended ( warden and care agency

organise the transport and key safe enables entry)

• Mobilising more steadily and has not fallen again

• No longer calls 111 or 999 because medically he is stable and socially he is

less isolated

• CMC records completed

Scenario 1

Coordinate My Care (CMC)

What is CMC?

• an electronic personalised urgent care plan

What is in the plan?

The urgent care plan contains clinical information about

• patient’s diagnosis

• allergies

• medications and resuscitation status

• their wishes and preferences on where they would prefer to be

cared for and, if appropriate, where they would wish to die.

Who can see the plan?

The patient and all health and social care providers who have a

legitimate relationship with the patient, including doctors; nurses;

social care providers; and emergency services (ambulance service,

NHS 111 and the out of hours GP service)


Questions



Panel Q&A

Barnet CCG senior staff

spring engagement event 14 march 2019 care closer to home · 14/03/2019 · 49 phgh doctors 10941...

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