Whitewater Loddon Primary Care Network Dr Tim Cooper GP Partner, - - PowerPoint PPT Presentation

Whitewater Loddon Primary Care Network

Dr Tim Cooper GP Partner, Chineham Medical Practice Clinical Director, WWL PCN

This evening ○ What are primary care networks (PCN)? ○ Who is part of the Whitewater Loddon PCN? ○ What things are happening already? ○ How will it affect me? ○ How you can help us shape the future?

What are Primary Care Networks?

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

What are Primary Care Networks going to do?

Provide more care out of hospital and closer to home Provide more comprehensive and integrated services - to match higher levels of demand and support higher levels of self care Provide services that can better meet demand at the time of access Provide different care models to different care groups

Community Care V

• l

u n t a r y O r g a n i s a t i

• n

s Hospital Specialists S

• c

i a l C a r e

Patient

G e n e r a l P r a c t i c e

Patient centred not diseased centred care

Who is part of the Whitewater Loddon primary care network?

Our GP Practices:

• Whitewater Health (Hook and Hartley

Wintney)

• Clift Surgery (Bramley)
• Chineham Medical Practice

(Chineham)

GP GP GP GP

Whitewater Health - 17523 Clift Surgery - 6965 Chineham Medical Practice - 13550

Network Size 38038 people

Who else could be part of our network?

Acute hospital trusts - Hampshire Hospitals Foundation Trust Community Hospital and Mental Health Trusts - Southern Health Local pharmacies and dentists Voluntary sector organisations e.g Citizens advice, MIND Local Community groups e.g running groups Social Care - Hampshire County Council Education - local schools

What are the benefits to being a primary care network?

Benefits

• Seeing the right person for the problem you face
• National support
• Sustainability
• Share good practice and training
• Improve patient experience and outcomes
• Prepare us for the future of integrated care

How will it affect me?

• New staff to help manage problems
• New ways of accessing health care and information
• Different ways of submitting your own health data and

reviewing your medication

• Support in the community
• Focus on keeping you well

New staff to support networks

• Clinical pharmacists - 2019
• Social prescribers - 2019
• First contact physiotherapists - 2021 onwards
• Physicians associates - 2021 onwards
• Paramedics - 2021 onwards

What things are happening already in Whitewater Loddon?

Whitewater Health Healthy Weight Project

Dr Charlotte Hutchings (Whitewater) and Annette Rushmere (Whitewater PPG)

Whitewater Health Healthy Weight Project

Project group :

• PPG members
• Public Health specialist
• Health Policy Manager
• Communications CCG
• Lead GP’s

Working with practice manager Developed action plan with timescales

Whitewater Health Healthy Weight Project

• Displays in both surgeries

Next steps

• PPG to visit local groups / nurseries playgroups/ schools

etc

• Texting messages from surgery
• Evaluation of project

Whitewater Health Healthy Weight Project

Let’s make Whitewater Loddon patients –and that’s all of us -healthier ! Thank You

Whitewater Loddon PCN Paediatric Clinics

Dr Roisin Ward (Clift Surgery)

Clinical Pharmacists

Dr Chiranthi Marston (Chineham) and Marta Radakowska (Chineham and Whitewater)

General Practice Forward View

• July 2015 NHS England announced a pilot to support the development of

clinical pharmacists in general practice 10 Year Forward View

• Grow and develop workforce-support practices to redesign their services

to patients

• Streamline workload
• Channel Investment and improve infrastructure
• Committed to over £100m of investment to support an extra 1500 clinical

pharmacists in general practice by 2020/21.

NHS England-role of the clinical pharmacist

“ Clinical pharmacists will work in GP as part of a multidisciplinary team in a patient facing role to clinically assess and treat patients using their expert knowledge of medicines for specific disease areas. The will work alongside the GP team, taking responsibility for patients with chronic diseases and undertaking clinical medication reviews to proactively manage patients with complex polypharmacy, especially for the elderly people in care homes and those with multiple comorbidities.”

Day to day in general practice

• Workload is increasing BUT we can be proactive and bring about change and

work in different ways

• Patient care is becoming more complicated (complex medical needs, ageing

population) BUT acknowledging we are not alone and there are resources and groups of people who are highly skilled and have the expertise to help the local primary care networks

• Signposting/education

At a practice level

• Recruitment of clinical pharmacist
• Supporting integration and facilitation of the training pathway via

Health Education England

• Working across 2 practice sites currently
• Chineham Medical Practice and Whitewater Health

Our hopes for what a clinical pharmacist would bring to the practice Clinical expertise working within the practice

• prescribing issues
• practical issues with medication

Reconciliation of hospital medication after discharge Outcomes

• Multidisciplinary approach to

working

• Liaising with patients regarding

medication

• Improved communication with

hospital

Our hopes for what a clinical pharmacist would bring to the practice

• Audit
• Care Home

Outcomes

• Looking at best practice to

continue to deliver high standards of care

• Complicated issues with

medication rationalised and changes made to benefit the patients

What will it mean in practice?

• Enabling a wider range of care options for patients and

enabling GPs to focus on patients with more complex needs

• Reinforce links and communication with community

pharmacies

• Signposting patients to appropriate services/information

Our aspiration for the future

• Clinics
• Medication review
• Optimisation of medication
• Involvement in improved access session /on the day duty sessions
• Recruit further pharmacist to work with us as we have seen the

benefits!

• Roll out across the PCN

Andover MIND Wellbeing workers in practice

Emma Hayhoe (Andover MIND) and Dr Tim Cooper (Chineham)

Why focus on Mental Health?

• 90% of adults with mental health problems are supported

in primary care.

• 1 in 4 appointments in primary care relate to mental

health

• Mental illness is a leading cause of disability in the UK
• Stress, anxiety and depression were the leading cause of

lost work days in 2017/18.

What did we do?

• The Wellbeing Worker was based at the surgery in

Chineham for 2 hours / week on a Tuesday afternoon

• Directly bookable 30 minute appointments
• The pilot ran for 3 months in total
• Patients aged 16+
• Basic mental health interventions, signposting and follow

up, as well as a comprehensive personalised care plan.

• Clinical information stored in GP records

How did it go?

“Listened, longer time to talk, good signposting to other agencies”

• 70 % would have recommended the service to other people.
• 67% of people felt comfortable seeing someone who wasn’t a GP about their

mental health

• After the appointment only 19% were seen by their GP within 2 weeks and
• nly 26% within 4 weeks about their MH

What next for Wellbeing workers?

• Plan to roll out across the whole of Whitewater Loddon

Network

• Funding jointly from the CCG and Hampshire County Council
• Aim to offer 8 hours per week + of bookable appointments
• Support closer working with our colleagues from Andover MIND

Community Link Nurses

Dr Kate McKenna (Whitewater Health)

Why Link Nurses?

• Public Health data shows elderly population in N.Hampshire

increasing faster than elsewhere in Hampshire

• There will be an associated increase in the number of frail, elderly,

housebound people with complex needs and co-morbidities

• Consequence of unmet needs and inequality in terms of health

service provision

• These patients are at higher risk of deterioration and admission

The Role of Link Nurses

• Whitewater Health establish the role of community Link Nurse in 2014
• Pilot 100% charity funded in association with the Odiham Cottage Hospital

trust

• 2 part time (1FTE) community link nurse for population of 17,000
• Last few years, Whitewater Health charity has taken over 50% of the funding
• Caseload of 740 patients in the 12 months to Nov 2017

Target group

○ Frail elderly with no healthcare contact for a prolonged period ○ Those identified as at risk of deterioration or developing a crisis ○ Those with chronic diseases unable to access GP services ○ Those recognised as having cognitive decline, living alone or not coping in their current home arrangement

What did the Link Nurses do?

Over a 12 month period

• 2,600 interventions
• 1,550 home visits
• 924 telephone appointments
• 38 referrals to other sector groups e.g. mental health, hospital services, OT,

Red Cross

• 16 orders for specialist equipment

Of the 740 frail patients on the caseload, only 26 GP home visits were needed due to the early interventions of the link nurses

What were the benefits?

• Proactive care, preventing unplanned admissions
• Diabetes: significant improvement in HbA1c levels which reduces the

chance of complications and reduces the demand on hospital services

• COPD: ensured early treatment for exacerbations
• Palliative care: support for patient and family
• Frail support needs. Ensuring other services accessed

Compared to control group: ❏ Less admissions, less readmissions (failed discharges) ❏ Less hospital days ❏ Less GP telephone calls and HVs ❏ Less calls to OOH

What’s the future for Link Nurses in WWL PCN?

• Business case submitted to North Hampshire CCG
• Successful in securing funding to end March 2020 for

1.75fte

• We will extend the role across the Whitewater Loddon

PCN

• Focuses on achieving more out of hospital care with

improved health outcomes and better utilisation of funds

Whitewater Loddon Improved Access Appointments

• Shared bookable appointments from 18:30 - 20:00 Monday - Friday
• Appointments on Saturday mornings
• Appointments available through Hantsdoc on a Sunday Morning
• Rotate across the network, can book into any practice for these

What does the network need to deliver next?

• Extended access appointments - July 2019
• Quality improvement activities - Focus on end of life care - 2019
• nwards
• Work with other non GP providers and community based
• rganisations - 2020/2021 onwards
• Structured Medication reviews and Optimisation - April 2020
• Enhanced Health in Care Homes - April 2020
• Improvements across primary care and for our communities

○ Visible dashboard coming in April 2020

By April 2021

First Contact Physiotherapists are available in PCNs and Primary Care training hubs are set up

By April 2022

Increased focus on heart and lung disease prevention, and Community Paramedics join PCNs

July 2019

Key appointments are made and additional funding starts. Extended hours begins to be delivered

By April 2020

Clinical pharmacists and social prescribers are appointed in PCNs

How can you help?

We’re still learning….

• Extended hours appointments survey
• Patient Participation Groups - directly linked to PCN
• Community groups and other organisations

Health starts in our Community

Our marketplace - many thanks to those that help us

Questions?

tim.cooper2@nhs.net @thtcoopernicus 07834995078

References:

• https://www.england.nhs.uk/gp/gpfv/redesign/primary-care-networks/
• https://www.who.int/about/who-we-are/frequently-asked-questions
• https://www.northhampshireccg.nhs.uk/wp-content/uploads/2019/04/PCN-Info-Handout-NHCCG.pdf