14 March 2019 Care Closer to Home 1 Working together with the - - PowerPoint PPT Presentation

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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

Working together with the Barnet population to improve health and wellbeing

Welcome

Dr Charlotte Benjamin, Chair, Barnet CCG

Working together with the Barnet population to improve health and wellbeing

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

Working together with the Barnet population to improve health and wellbeing

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

Working together with the Barnet population to improve health and wellbeing

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

Working together with the Barnet population to improve health and wellbeing

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 Health

Working 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

Working together with the Barnet population to improve health and wellbeing

Enfield CCG / Enfield Council GP registered population: 320,000 GP practices: 48 Barnet CCG / Barnet Council GP registered population: 420,000 GP practices: 54 Camden CCG / Camden Council GP registered population: 260,000 GP practices: 35 Haringey CCG / Haringey Council GP registered population: 296,000 GP practices: 45 Islington CCG / Islington Council GP registered population: 233,000 GP practices: 34 University College Hospital Barnet General Hospital ChaseFarm Hospital North Middlesex Hospital Royal Free Hospital St Ann’s Hospital The Whittington Hospital Edgware Community Hospital Finchley Memorial Hospital St Michael’s Primary Care Centre LondonAmbulanceService East

• f

England Ambulance Service Moorfields Eye Hospital Great Ormond Street Hospital Central Middlesex Hospital Highgate Hospital St Pancras Hospital Stanmore Hospital Tavistock Clinic,Portman Clinic, GloucesterHouse Day Unit

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:

Working together with the Barnet population to improve health and wellbeing

Working together with the Barnet population to improve health and wellbeing

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

Working together with the Barnet population to improve health and wellbeing

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

April 2018 3 Networks October 2018 6 Networks June 2019 Integrated Networks

Benefits

Working together with the Barnet population to improve health and wellbeing

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

• rganisational 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

Working together with the Barnet population to improve health and wellbeing

Barnet CCG - Primary Care Networks

Network One

Working together with the Barnet population to improve health and wellbeing

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

Working together with the Barnet population to improve health and wellbeing

Clinical Lead: Dr Anita Patel Focus: Frailty Population: 59,229 Involving: 9 practices 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)

Working together with the Barnet population to improve health and wellbeing

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 Involving: 15 practices Road map: All system partners by Apr 19 Current Project: Diagnostics

Networks Four, Five and Six

Working together with the Barnet population to improve health and wellbeing

Network Four Clinical Lead: Dr Daniella Amasanti De-Bono Focus: Digital Population: 56,201 Involving: 5 practices Road map: All system partners by Jun 19 Network Five Clinical Lead: Dr Tonia Briffa Focus: Dementia Population: 55,352 Involving: 7 practices Road map: All system partners by Jun 19 Network Six Clinical Lead: Dr Leora Herverd Focus: TBC Population: 52,800 Involving: 8 practices 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

Working together with the Barnet population to improve health and wellbeing

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

Working together with the Barnet population to improve health and wellbeing

Paediatric Hot Clinics

Network One

Dr Aashish Bansal, Primary Care Network One Clinical Lead

Network One

Working together with the Barnet population to improve health and wellbeing

• 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

Working together with the Barnet population to improve health and wellbeing

• 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

Working together with the Barnet population to improve health and wellbeing

• 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

• ther 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

Working together with the Barnet population to improve health and wellbeing

• 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

Working together with the Barnet population to improve health and wellbeing

• Evaluation of the project (June 2019)
• Work closely with Health Visitors (CLCH) to provide health

education

• Exploring extending into ‘Wheezy Children’

Scenario 1

Working together with the Barnet population to improve health and wellbeing

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

Working together with the Barnet population to improve health and wellbeing

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

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Seher Kayikci

London 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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01

Transforming London’s health and care together

• National Activity

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“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

• f 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

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• 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

• f 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

• ver 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/

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

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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

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Over 1,200 charities

• perating 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-

• rdinators (Adult

Social Care)

For further information

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Discussion

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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

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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

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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.

Working together with the Barnet population to improve health and wellbeing

Break

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Network Two Frailty & Palliative Care Multidisciplinary Team (MDT)

Dr Anita Patel, St Andrews Medical Centre Co-Chair Network Two

Working together with the Barnet population to improve health and wellbeing

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

Working together with the Barnet population to improve health and wellbeing

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?

Working together with the Barnet population to improve health and wellbeing

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

Now Past

Voluntary & Charity Sector GPs Social Care Community Nurse Consultant Old Age Psychiatrist London Ambulance Service Palliative Care Consultant Consultant Geriatrician

Scenario 1

Working together with the Barnet population to improve health and wellbeing

• 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

• ften 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

• ften 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.

Working together with the Barnet population to improve health and wellbeing

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

Working together with the Barnet population to improve health and wellbeing

Scenario 1

Working together with the Barnet population to improve health and wellbeing

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

Working together with the Barnet population to improve health and wellbeing

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

Working together with the Barnet population to improve health and wellbeing

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
• rganise 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)

Working together with the Barnet population to improve health and wellbeing

Questions

Working together with the Barnet population to improve health and wellbeing

Working together with the Barnet population to improve health and wellbeing

Panel Q&A

Barnet CCG senior staff