healthy london partnership children & young people’s programme · tackle the overall...

Healthy London Partnership Children & Young People’s Programme

Transforming care for children and young people in primary care

April 25, 2017

Transforming London’s health and care together

Overview

Russell Viner, Clinical Director, Children and Young People’s Programme

Tracy Parr, Head of Childre and Young People’s Programme

Healthy London Partnership’sChildren and Young People’s Programme

Welcome and communications

www.menti.com

Question 1 code 98 83 38

Question 2 code 98 83 38

#LdnCYPPC

@HealthyLDN

Who is in the room today?

Expectations

Healthy London Partnership –Children and Young People’s programmeKey facts

8.2 millionpeople live in London

of which

2,049,576are children aged 0-19

134,186live births in

London in 2012

600,000of London’s children

live in poverty

Mental Health conditions affect

1 in 8Children

Emotional andbehavioural

problems affect

1 in 5Children

20% of4-year-oldsareoverweightorobese

25%of15-year-oldsFirstsmoked

AGED13oryounger

40%of15-year-oldsdrinkalcoholonceaweek

LESSTHANHALFof11-15

yearoldsdoanhourof

exerciseeachday

20%of13-year-oldsdrinkalcoholonceaweek

What do children, young people and families think?

I need rapid access to

someone I can talk to when I

feel depressed

We need easier

access to healthcare

Services are not joined

up

I want to know that my GP is experiencedin caring for

children

Make sure the school can look

after my son when he has an asthma

attack

I am worried about what will happen next year when I am too old for the children’s clinic

London Health Commission

Healthy London Partnership –The delivery arm of the London Health Commission

Goal – London to be world’s healthiest global city

10 programme aims from London Health Commission

Delivering value and sustainability across the whole system

Preventing ill health and making Londoners healthier

Giving London’s children and young people

the best start in life

Transforming care for

Londoners experiencing mental illness

All Londoners to be able to

access the best cancer care in

the world

Joining up to transform the lives of the homeless

Transforming London’s urgent and emergency

care system

Creating world class specialised care

services

Transforming London’s primary care

Connecting Londoners and health and care

providers to allow for real

time access to records and information

Transforming London’s estate to deliver high quality care(scoping)

Developing London’s

workforce to enable

transformation of care

(scoping)

Aligning funding and incentives

to promote transformation

of care(scoping)

Ensuring Londoners are engaged and

involved in their own health and

the health of their city

A radical upgrade in prevention and public health

Designing care around Londoners’ needs

Transforming how care is delivered to every Londoner

Making change happen

Workforce

CDOPBaseline audit

Suicide preventionBereavement

Sharing data and learningCluster level working

Urgent and emergency careAcute care standardsPeer reviewPAU standardsL1 and 2 PCC standards and education

Commissioning development programme

Place-based care and planning (data packs, support for networks)

Mental healthLTP refresh support

Guidance for mental health crisisModels of liaison psychiatry

Benchmarking/KPIsEating disorders CoP

Thrive (Mayor)Learning disability (theatres)

SchoolsModels of school nursing

Guidance for management CYP asthma and diabetes

System Leadership (CYP Board and clinical leadership group)

Primary careGP federation pilot model care CYP

Population based dataToolkit for GP federations

Prevention and self careNHSGo

Marketing campaignCommunity Pharmacies Audit of CYP with asthma

Online learning hub for MURsAudit CYP with dental pain

Role of pharmacists CYP health

Out of hospital careCompendium models of careStandards for OOH careModelling impact different models

System-wide

enablers

Long Term ConditionsAsthma standards

Asthma toolkitAsthma baseline audit

Epilepsy standards

Improved integration of care across the system for children and young people

January 2017

Whole system approach to transformation for children and young people’s health

Healthy London Partnership Children and Young People Programme Governance

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HLP C&YP Transformation Board

London Transformation Group (London’s CCGs and NHS England)London Health

Board

CYP Clinical Leadership

Group

CYP Commissioning Advisory Group

KEYAccountableInformation sharing/ endorsementProgramme alignment

Critical Care Education

Programme Steering Group

Surgery Clinical

Leadership Group

Asthma Clinical

Leadership Group

Out of Hospital Care Clinical Leadership

Group

CYP MHW Clinical

Leadership Group

• CCG SRO & SEL SPG (Martin Wilkinson)

• NHSE SRO (Will Huxter)• CYP Clinical Director (Russell Viner)• CCG Clinical Lead (Nicola Burbidge)• SPG rep SWL (Chris Elliott)• SPG rep BHR (Louise Mitchell)• SPG rep WELC (Satbinder Sanghera)• SPG rep NCL (tbc)• SPG rep NWL (Nicola Burbidge)• DPH (Dagmar Zeuner)• PHE (Marilena Korkodolis)• DCSS (tbc)• CYP/family rep (Emma Rigby)• Programme Manager (Tracy Parr)• GP lead (Eugenia Lee)• NHSE asthma lead (Dave Finch)

CYP & Families Engagement throughout

Prevention BoardPrimary Care BoardU and EC BoardMental Health BoardSpecialised Services Board

Young People’s Steering Group

v0.12 April 2017

Primary Care Clinical

Leadership Group

Peer Review of Acute

Care Services Steering Group

Asthma Implementation

Group

CYP Mental Health and Wellbeing

Implementation Group

London & SEC Diabetes

Partnership Board

Parent and Carer Group

CDOPImplementation

Group

Epilepsy Task and

Finish Group

Publications

NHSGo – designed by young people for young people

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• NHS Choices content• Chosen by young

people – survey/focus groups

• IoS and Android• Social media and you

tuber marketing campaign

• 40,000 downloads• 400,000 page views• Sexual health and

mental health top visited pages

• Now linking into 111 DoS

Children and young people in primary care

• Children and young people make up over 40% of the primary care workload

• Lack of well developed models of care for children and young people in the primary care setting

• HLP has launched new project working with GP hubs/federations to develop a toolkit to support them in addressing the health needs of children and young people in their population

• HLP GP leads group made up of each CCG’s children and young people GP lead with a workplan looking at primary care issues

Please speak to the team if you are interested in joining the group or working up another pilot

01


Making primary care work for young peopleEmma Rigby, Chief Executive, Association for Young People’s Health

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Makingprimarycareworkforyoungpeople

EmmaRigby,ChiefExecutive,AssociationforYoungPeople’sHealth

AboutAYPH

• Bridgestheworldofpolicy,practiceandevidencetopromotebetterunderstandingofyoungpeople’shealthneeds.

• Supportsyoungpeople’sparticipationinhealthandwellbeing

• Supportsthedevelopmentofyouthfriendlyhealthservicesandimprovedpractice

• Collatesanddisseminatesusefulinformationinreader-friendlyformatsforpractitionerandpolicyaudiences(KeyDataonAdolescence)

• Workswithourmemberstoshareinnovativeexamplesofworkinthefield(events,twitter,publications)

Weareamembershiporganisationforindividualsandorganisationsworkingintheyoungpeople’shealthfield.

www.ayph.org.uk

Whyfocusonyoungpeople?

• Importanttothinkaboutchildrenandyoungpeople

• 0-25yearsisahugeagerangeandtherearesignificantdifferencesinhowyoungpeopleneedtoaccessprimarycare

• Howmanyyoungpeopleareinourpopulation?

• Whyisitimportantthatwegetprimarycarerightforthem?

KeyDataonAdolescence2015 |Demographics

http://www.youngpeopleshealth.org.uk/our-work/practice/gp-champions

• GPstellustheysee‘veryfewyoungpeople’

• Yetyoungpeoplearefrequentusersofprimarycare– youngwomenvisittheirGPfourtimesayearandyoungmentwotimesayearonaverage.

• AgegroupleastsatisfiedwithGPwithshortestconsultationtimes

• TwiceaslikelytoattendA&EorWalk-In

Somekeyissuesforyoungpeopleandprimarycare

“Itdoesn’tfeelliketheylisten,justfobyouoffwithmedication,andtheDrsdon’tcommunicatebetweeneachother.”

YoungPerson

• Technologyisn’talwaysgood

• Waitingroom=stress

• Takeconcernsseriously

• Allowtimetobuilduptrust

• Won’t‘disclose’onfirstvisit

WhatGPslearntfromyoungpeople

“Workingwiththevoluntarysectorencouragesyoutobemoreflexibletowardsyoungpeopleandmoretolerantiftheyrunlate,areloud,orturnuptoanappointmentwithagangoffriends”

GP

www.ayph.org.uk/reaching-marginalised-young-people

Reachingmarginalisedyoungpeople

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Six principles to shape our thinking about young people’s health

The evidence tells us that treating different, specific health issues separately will not tackle the overall wellbeing of this generation of young people.2 Young people’s mental and physical health are intertwined, and at the heart of health and wellbeing3 are their relationships with others. Young people think about their health holistically. They want an integrated, youth friendly approach that recognises their particular needs, makes them feel supported, emphasises the positives and helps them to cope.4 Building on the research of what works for this age group, we have identified six core principles that cut across health topics to develop holistic approaches to meet needs. These build on concepts of resilience5 and are presented in a way that commissioners and service providers can use.

1

Improving young people’s health and wellbeing A framework for public health

1

Improving young people’s health and wellbeing A framework for public health

https://www.gov.uk/government/publications/improving-young-peoples-health-and-wellbeing-a-framework-for-public-health

Importanceofanholisticapproach

MakingapracticeYPfriendly1.Appointa'champion'inthepracticeforyoungpeople'shealth

2.LetyoungpeopleregisterwithaGP

3.Accessibleandflexibleappointments

4.Makethewaitingroommorewelcomingforyoungpeople

5.Listentoyoungpeopleandgivethemtime

6.Seeyoungpeopleontheirown,withnoloweragelimit

MakingapracticeYPfriendly7.Bookafollowupappointment

8.Feelcomfortablearoundconfidentiality(patientrecords)

9.Recordyourdataaccurately

10.Usedatatoseewhereimprovementscanbemade

11.Gatherfeedbackandcomplaints

12.Involveyoungpeopleinpatientparticipationgroups

www.ayph.org.uk/yourewelcome

[email protected]@AYPHcharity

“Veryoftenthere’snohelpavailableuntiltheproblemhasbecometotallyunmanageable”YoungPerson

“YoungPeopledon’twanttobesenttoadifferentserviceforeverydifferentproblemtheyaredealingwith.Theywantsomeonetohelpthemthroughavarietyofdifferentissues,recognisingthatthey’reoftenconnected.”

BeHealthyAdvocates

02


Child Health General Practice HubsDr Mando Watson, General Paediatrican, St Mary’s Imperialconnecting care for children (C4CC)

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ChildHealthGeneralPracticeHubs

Supportedby:LondonBoroughsofH&F,K&CandWestminsterCityCouncil

PaddingtonDevelopmentTrust&CLCHNHSTrust

Investedinby:

Starting with patients and citizens…

• “Myhealthvisitortoldmetodoonethingandthehospitaltoldmesomethingelse.It’sconfusing”

• “Ionlyfoundouthowtousemyson’sinhalerproperlywhenhehadanasthmaattackandwasonthechildren’sward”

• “Nooneseemstoknowwho’sdoingwhat.My[severelydisabled]sonhas3-4appointmentsaweekandIdon’tthinkanyofthese[professionals]talktoeachother!”

• “Ithinkyoungpeopleneedhelp”– apracticechampionwhosupportedmindfulnesstrainingforherlocalcommunity

• “IprefertoseemyGP– Iknowhimandhe’slookedafterallmyfamilyforyears”

Connecting Care for Children; 3 core elements focused on Primary Care, coming together as a ‘Child Health GP Hub’

Parent:‘Ihopeitwillcontinuelikethis– it’smucheasierandmorecomfortablebecauseIknowallthepeopleattheGPpractice,itissoquicktogetanappointment.WhatIlikethemostisthattheGPandIheartheplantogethersoIdon’thavetogobackandtellthem.ThegameofChineseWhispersisfinallyover.Iamsopleasedmypracticehasthisservice.’

GP:‘IhavemuchmoreconfidenceintalkingtothePaediatriciansbecauseInowknowthem,Idon’tfeelscaredtoemail,writeor telephoneandIknowtheywillanswermyqueries.Theclinicsarephenomenal,theyarethebestthreehoursofmymonth,Ifeelthepatientsgetexactlywhattheyneed,IlearnagreatdealwhichIcanthenuseinallmygeneralpracticeconsultations.Thankyouforempoweringmeandhelpingmedeliverthebestservicetoourpatients.’

Paediatrician:‘Theabilitytoworkintruepartnership,andtoco-createcareplanswithfamiliesandGPshasbeenenormouslyenhancedbymyseeingpatientsinprimarycare.’

GPChildHealthHubsaretypically:3-4GPpracticeswithinanexistingnetwork/village/locality~20,000practicepopulation~4,000registeredchildrenBuiltaroundamonthlyMDTandclinic

Child Health GP Hubs – a model of integrated child health

ChildHealthGPHubs

SecondaryCareGeneral

Paediatrics

TertiaryCareSub-specialtyPaediatrics

VerticalintegrationbetweenGPsandpaediatricservices

HealthVisitorsDieticians

CommunityNursesPracticeNurses

CAMHSVoluntarysector

SchoolsSocialCare

Children’sCentres

Horizontalintegrationacrossmultipleagencies

Child Health GP Hubs – MDT Professionals

GeneralPaediatrician

GeneralPractitioners

HealthVisitors

MDTaretypically:• 4-6weekly• 60-90minuteslong• Centredondiscussingclinicalcases• Anopportunityforsharedlearning

Child Health GP Hubs – MDT Professionals

GeneralPaediatrician

GeneralPractitioners

HealthVisitors

MDTaretypically:• 4-6weekly• 60-90minuteslong• Centredondiscussingclinicalcases• Anopportunityforsharedlearning

PaediatricDietician

MentalHealthWorker

PracticeNurses

SchoolNurses

SocialCareManager

MedicalStudents

StudentHVs&Dieticians

GP/PaediatricTrainees

VoluntarySector

Dentaltrainees

Case Hunting

37

Cases for discussion at the MDT may be identified through case hunting criteria.

Examples include:Midwives: pregnant ladies with drug use, medical problems, domestic violence

Health visitors: failure to thrive, maternal low mood, speech & language problems, developmental concerns, crossing centiles, unusual volume/ content of questions

School nurse: pupils with frequent absence, medical concerns, signs of safeguarding issues, mental health problems

Dietician: those on special formulas, obesity, failure to thrive

Social services: safeguarding, housing problems / entire caseload.

Practice nurse: those that have missed immunisations, unusual interactions between parents & children

GPs: frequent A&E attendances, those with medical problems, maternal anxiety etc., frequent GP attendance, high anxiety parents

Paediatrician:, patterns of referral, children and young people with long term conditions for transition e.g. severe disability, children and young people with long term conditions for discussion with specialist nurse (diabetes, epilepsy, ISW, sickle)

AWholePopulationApproach:PatientSegmentsinChildHealth

•Advice&preventioneg:Breastfeeding/Immunisation/Mentalwell-being/Healthyeating/Exercise/DentalhealthHealthyChild

•eg:Safeguardingissues/Self-harm/Substancemisuse/Complexfamily&schoolingissues/Lookedafterchildren

Vulnerablechildwithsocialneeds

•eg:Depression/Constipation/Type2diabetes/CoeliacDisease/Asthma/Eczema/Nephrotic syndrome

Childwithsinglelong-termcondition

•eg:Severeneurodisability/Down’ssyndrome/Multiplefoodallergies/Childonlong-termventilation/Type1diabetes

Childwithcomplexhealthneeds

• eg:Croup/Otitismedia/Tonsillitis/Uncomplicatedpneumonia/Prolongedneonataljaundice

Acutelymild-to-moderatelyunwellchild

•eg:Trauma/Headinjury/Surgicalemergency/Meningitis/Sepsis/Drugoverdose/Extremepretermbirth

Acutelyseverelyunwellchild

Integratedcareisoftenbuiltaroundpatientpathways.Instratifyingchildrenandyoungpeoplewestronglyadvocatea‘wholepopulation’approach,wherebroadpatient‘segments’canbeidentified:

Dr Bob Klaber & Dr Mando Watson Imperial College Healthcare NHS Trust


HealthyChild






Thereareanumberofcross-cuttingthemesthatcanbefoundwithinmanyorallofthesegments.Examplesincludesafeguarding,mentalhealth,educationalissuesaroundschoolandtransition.

DrBobKlaber&DrMandoWatsonImperialCollegeHealthcareNHSTrust

SafeguardIng

Mental

Health

TransitIon

School

Issues

Inequalities


HealthyChild






Thissegmentationmodelalsoallowstheactivityandspendonapopulationofchildrenandyoungpeoplewithinadefinedlocality,andsplitintoagegroups,tobeassessedandanalysed.Thispresents

theopportunityforutilisingdifferentpaymentandcontractingmechanismsforchildhealth.


perinatal

0to5

years

5to10

years

10to15

years

15to20

years

20to25

years

PracticeChampions

41

Demonstrating Value, Outcomes and Benefits

ConnectingCareforChildrenEthos

Patientswillbeseenbytherightperson,intherightplace,firsttime

Betteruseofhospitalservices

Inthe3-practiceChildHealthGPHubatHRHC(WestLondonCCG)39%ofnewpatientappointmentswereavoidedaltogetherthroughMDTdiscussionandimprovedcarecoordination.Afurther42%ofappointmentswereshiftedfromhospitaltoGPpractice.

Inaddition,therewasa19%decreaseinsub-specialtynewpatientappointments,a17%reductioninpaediatricadmissionsanda22%decreaseinA&Eattendees.

PositivePatientReportedExperience

90%ofpatientsandcarerssaidthathavingbeenseenintheoutreachclinicwithintheirregisteredpracticetheywouldnowbemorelikelythanbeforetoseetheGPforfuturemedicalissuesintheirchildren

HealthEconomists…

…calculateabreakevenpointbytheendofyear2:basedonassumedreductionsinhospitalactivity(thatarebeingsurpassedinthepilotwork)andarolloutof6newhubsperyear

ReducedBureaucracy

TheHubusesfewerreferralletters,appointmentlettersandresponses

Moreaccessibleforpatients

TheHubsmeanthatfewerworkinghoursarelostbyparents,andanxietyisreduced

EvidenceforPracticeChampions.…

Nationalevidence(AltogetherBetter)indicatesthatPracticeChampionswilldeliverapositivereturnoninvestmentofupto£12forevery£1investedintrainingandsupport

Workforcedevelopment

‘ThisisthebestCPDI’veeverhad’HubGP

Impact of CC4C Child Health GP Hubs on Outpatient Activity

Demonstrating Value, Outcomes and BenefitsPuttingaconservativeestimateofactivitychanges…Modelled reductioninactivity:• Outpatient 30%• A&E 8%• Admissions 2%Intoaneconomicevaluation…

WhatwesawhappeninginourHubs…Observed reductioninactivity:• Outpatient 39%• A&E 22%• Admissions 17%

Year Number of Hubs

Child Population Covered

Total costs of the CC4C Child Health GP Hubs

Total savings fromreduced hospital activity

Net Economic Benefit

1 2 8672 £153,220 £319,822 £166,602

2 8 34690 £332,803 £1,236,029 £903,226

3 16 69379 £500,894 £2,388,462 £1,887,567

4 24 104069 £644,832 £3,461,539 £2,816,706

5 28 121414 £794,896 £3,901,895 £3,107,000

CumulativeFinancialImpact(over5years): £8,881,102

Child Health GP Hubs in North West London

ImperialandWestLondonCCG:3multi-practiceHubs

ImperialandCentralLondonCCG:4multi-practicehubs

Evelina(GSTT)andCentralLondonCCG:One4multi-practiceHub

ImperialandHammersmith&FulhamCCG:ParkviewHealth&WellbeingCentre

WestMiddlesexandHounslowCCG:1GPpracticepilot

ChelseaandWest.&WestLondonCCG:Two3GPpracticehubs

ImperialandEalingCCG:CloisterRoadSurgery

Howdoesitwork?

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BetterQuality Services• Safe• Timely• Efficient• Equitable• Patient-centred

ImprovedOutcomes• Health• Vulnerable• SingleLTC• Complexneeds• Acute

Sharedknowledgeabouthowservicesworkandhowtoaccessthem

Socialcapitalandtrust–howpractitionersandcommunitysupporteachotherinpromotingchildhealth

Parentsandprofessionalscapability– knowledge,skills,confidenceinchildhealthissues

Professionalsupport–MDTcasereview,emailandtelephone

Professionaleducationpackages–sharedguidelines,jointstudydays

Patientsupportandeducation–PracticeChampions,FixFreddie,PatientAcademy

NewCareModelsinchildren– DesignPrinciplesWhatisthelearningfromlocal&nationalworkonnewcaremodels?

1. Focusonconnectionsandrelationships;NHSservicescanbeminimallychanged,whiletheircapabilityandcapacityaremaximised

2. PutGPpracticesattheheartofnewcaremodels- specialistservicesaredrawnoutofthehospitaltoprovidesupport& tohelpconnectservicesacrossallofhealth,socialcareandeducation

3. Awholepopulationapproachfacilitatesmorefocusonprevention4. Healthseekingbehavioursimprovethroughpeer-to-peersupport

5. Co-designnewapproachestocarewithchildren,youngpeople,parents,carersandcommunities

6. Focusonoutcomesthatreallymattertopatients7. Learninganddevelopment,forthewholemulti-professionalteam,isa

keywaytobuildingrelationshipsandfindingnewwaystoworktogether

49

[email protected]@imperial.nhs.uk

@CC4CLondon

www.cc4c.imperial.nhs.uk

Extras…• http://www.cleanvideosearch.com/media/action/yt/watch?v=2MbJcM6T

X48&feature=youtu.be• https://vimeo.com/117572439• https://www.cc4c.imperial.nhs.uk/• http://datasyrup.net/examples/cc4c-program/• https://www.dropbox.com/s/zfav9x0hn2wxh96/Mapping%20services%20f

ramework%20v06.xlsx?dl=0

51

UtilisingWholePopulationSegmentationinChildHealth

HealthyChild






Thisfigureillustrates5importantstagesofworkthatneedtobeundertakentoutilisethesegments.Thiswillhelpustomovetowardsmodelsofcarecommissionedforpatient-centredoutcomes:


(1)Coding,activity&finance–Wheredopatientsgo?

(2)Attitudinalsurveys–Wherewould patientsgo?

(3)Mapexistingindicatorsandoutcomemeasurestoeachsegment

(4)DevelopPatientCentredOutcomeMeasures(PCOMs)foreachsegment

(5)Outcomes-basedcommissioningforeachsegment

Impact of CC4C Child Health GP Hubs – Patient Feedback

Patients/parentsfelt

• reallylistenedto(99%)• involvedindecisions(88%)• veryconfidentinthecaretheywerereceiving(99%)• satisfiedconcernswereaddressed&thattheyhadreceivedclearexplanations(96%)

Most(70%)hadinitiallypresentedtotheirGPthinkingahospitalreferralwouldbeneeded.AftertheHubclinic,nonehadapreferencetobeseeninhospital

Asaresultoftheappointment,88%feltmorecomfortabletakingtheirchildtoseetheirGP

100%wouldrecommendtheservicetofriendsandfamily

Impact of CC4C Child Health GP Hubs – Professionals Feedback

Participants‘agreed’or‘stronglyagreed’thatthehubshadhelpedthemto:

• gainknowledgeoflocalservices(28/28)• improvecollaborationandprofessionalrelationships(28/28)• increaseprofessionalcapability(25/28 withthreeneutralresponses)

Thebenefitmoststronglyidentifiedbyprofessionalswasthedevelopmentoftrust,reciprocityandcollaboration

03


Bexley Asthma Assessment Project in PharmaciesDr Karen Upton – Bexley CCG Clinical Lead for Children and Young People

55

0

50

100

150

200

250

300

350

400

No.ofAdmissions

NumberofAsthmaEmergencyAdmissionsbyCCGsinLondon2013/14and2014/15(Sourcedata:HES)

1314 1415

• InBexleypatientsasthmaadmissionsinchildrenundertheageof18years

• 2015/16therewere88

• 2016/17firsttwoquarters61

• Anestimated75%ofhospitaladmissionsforasthmaarethoughttobeavoidable.

• Asmanyas90%ofdeathsfromasthmathoughttobepreventable.

WhyisasthmaimportantinBexley?

WhyBexleyAsthmaAssessmentintheCommunityPharmacy

58

• Co-ordinatingcarewiththeGP:• Non-attendanceforasthmareviewsatGPPractice• PatientsoftenattendasthmareviewsatGPPracticewithouttheir

inhalers• Largepatientcohorts– helpGPpracticetostratifythepatients• Partgatherdatainthepharmacywhichwillsupportpatient

recordsintheGPPractice– QOFandinasthmareviews• WhatthepharmacistseesandGPdoesnot:

• Requestsforinhalersinanemergencyscenario• Non-collectionofprescriptionsforinhalers(patientonlywantsthe

relieverinhaler)• Inappropriateselfcarebyasthmapatientse.g.cough&cold

symptoms

Aims&ObjectivesBexleyAsthmaAssessmentProjectinPharmacies

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1. EnhancecommunicationbetweenpharmacistsandGPs.Thiswouldbeviaanasthmatemplatewhichallwoulduseandbecomefamiliarwith.Thiswillbedevelopedandtrialledduringtheprojectwithinputfromallstakeholders.

2. EnhancethevalueofMURstoincludeevaluationandeducationofpatientsininhalertechnique,inawaythatthereisconsistencyinthemessagebetweenallhealthcareproviders.

3. Educationandupskilling ofallclinicians(GPs,Practicenursingstaffandpharmacists)

a. Concerningissuesspecifictochildrenandyoungpeopletoincludecommunicationanddevelopment.

b. Inasthmamanagementgenerally

OverridingPrincipleInclusionofpharmaciesinBexleyasthmamanagementpathway

60

“Takewhatcurrentlyexistsandworkwithwhatyouhavegot…inmanycasessystemsofcarejustneedtojoinupmoreeffectivelyasopposedtooverlayingawholenewinterventionorpathway”

Mando WatsonConsultantPaediatrian ,ImperialCollegeHealthcareNHSTrust

1%

44%

55%

BexleyQ1- AsthmaActionPlan- %Contacts(0-18yrs)

Don'tknow

No

Yes

1%

30%

69%

BexleyQ2- Asthma- InhalerTechniqueAssessment%Contacts(0-18yrs)

Don'tknow

No

Yes

AsthmaAssessmentinthePharmacyWhatweARE askingpharmaciestodo

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• Competentin– understandingthemanagementofasthma– promotinggoodinhalertechniqueinchildren&adults– promotingeffectiveuseofappropriatespacersdevices– providingMURs,NMS– performinginhalersurveillance(qualitypayment)

• Learnhowtouseane-templatetorecordinformationandsendittotheGP

• TalktoyourlocalGPsandPracticeNursesaboutyourreferrals

• Followupwithpatients• Participateinevaluationoftheservice• Servicecontinuityandremainengaged

AsthmaassessmentinthePharmacyWhatweareNOT askingpharmaciestodo

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• DiagnoseAsthma• Specialistsinasthmamanagementinchildren&adults

• Retrainasspecialistpharmacists

• BeaPrescribers• Readlongandcomplicatedservicespecifications

• Spendexcessiveamountsoftimestudyingandpreparingforaservice

On-lineAsthmaToolkit•Supportacrossthesystemtoimproveasthmacare•https://www.healthylondon.org/children-and-young-people/london-asthma-toolkit

Timelines,NextSteps,Evaluation12monthproject

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• Timelines• Startdate02.05.17(worldAsthmaDay)• Quarterlyreviews• Darsi Fellowtosupportthereview– academicpublicationsetc

• SupportwithinHealthyLondonPartnerships• NextStep• Feedbackfrompharmacists• MDTmeetinginAprilwithLocalGPPractices

EvaluationCo-designing– needlocalinputtoidentifymeasurableoutcomes

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GPPractice• Impactonpatientcare&localpractice• QualityandrelevanceoftheinformationPharmacy• Easeofadministration• UseoftheeTemplate• ServicemodelbasedonPi,MUR,NMs&qualitypayments• Training&competencePatients• Satisfactionwiththeservice• Access• Benefitstohealthandwellbeing

EvaluationofeffectivenessCCGstatistics

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• Considertrendsandadmissionsforasthmaoverthecomingyearandonwards.

Filmstodemonstratewhatwearedoing

• Overarchingasthmatoolkitfilm:https://www.youtube.com/watch?v=ikdAB9qyk9U

• Hospitalcare:https://www.youtube.com/watch?v=UK8wHN0sdJ0

• Schools:https://www.youtube.com/watch?v=bIb80lOjoO8

• Pharmacy:https://www.youtube.com/watch?v=kCAzCmI-R_k

• Primaryandcommunitycare:https://www.youtube.com/watch?v=A2iNQE7utRE

• Parentsandcarers:https://www.youtube.com/watch?v=iNPSFal0OIM

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04


Making Child Health a Local Priority: The Role of GP FederationsDr Chad Hockey, Hammersmith and Fulham GP Federation

70

Children in H&F

42%

32%

26%

North H&F- up to 45% child poverty

Child Wellbeing Index (2009)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Health

Education

Crime

Environment

Material Wellbeing

Children in need

Housing

OVERALL

Overall, H&F ranked as 23rd worst borough in Englandhttp://webarchive.nationalarchives.gov.uk/20100410180038/http:/communities.gov.uk/publications/communities/childwellbeing2009

Who coordinates strategy?

H & F GP Networks Jan 2015

6/17

3

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12 13

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27

28

29

30

/2

30

Network 1

Network 2

Network 3 - South Fulham Group

Network 4 - Small Practice Collaborative

Network 5

20

5 / 31 21/26

15. Richford Gate Medical Centre 10,315

20. The New Surgery 4,956

23. Park Medical Centre 7,981

24. The Bush Doctors 11,377

28. Ashchurch Surgery 5,817

11. Hammersmith Bridge 9,329

13. Dr Jefferies, 139 Lillie Road 3,124

14. Dr Jefferies, 292 Munster Road 12,786

25. Brook Green Surgery 4,012

29. Brook Green Medical Centre 11,580

2. Ashville Surgery 8,956

6. Bridge House (Dr Das & Partner) 2,245

8. Cassidy Road Medical Centre 3,931

10. Lillyville Surgery 7,394

17. Sands End Clinic 7,512

19. Fulham Medical Centre 6,716

1. Old Oak Surgery 3,821

3. Shepherd's Bush Medical Centre 3,547

5. Parkview Practice (Dr Hasan & Canisius) 3,587

7. Westway Surgery (Dr Dasgupta & Partner) 3,519

12. Fulham Cross Medical Centre 1,915

16. The Medical Centre (Dr Kukar) 5,309

18. Palace Surgery 4,169

21. White City Medical Centre (Dr Kukar & Dr Mirza) 1,616

22. Salisbury Surgery 1,453

26. White City Medical Centre (Dr Uppal) - Second site in Southall, Ealing7,051

30. Hammersmith & Fulham Centres for Health - split over 2 sites 5,889

4. The Lillie Road Surgery 7,875

9. Sterndale Surgery 4,461

27. North End Medical Centre 14,838

31. Canberra Medical Centre 2,961

190,042Total

Co

na

nJo

eJo

eC

on

an

Joe

40

,44

64

0,8

31

36

,75

44

1,8

76

30

,13

5

H&F Locality Area Arrangement H&F GP Network Arrangement

Who Translates Strategy in the Community?

GP Practice

Health Visitors

Early Years Centre

Milson Road

Flora Gardens

Old Oak

Parkview

Natural Neighbourhood Model

All H&F GP Practices H&F Practices where GP has Diploma Child Health

GP List Size0-4,0004-6,0006-8,0008-10,000

10-15,000>15,000

GP Skill-mix and Practice Size in H&F (2016)

H&F GP Federation Represents Every GP Practice in the Borough

42%

32%

26%GP List Size

0-4,0004-6,0006-8,0008-10,000

10-15,000>15,000

Developing GP Leads for Child Health…

Clinical Skills36 unplanned care sessions

18 outpatient sessionsIn-house teaching

Leadership Skills18 Community project sessions

Supported leadership developmentQSIR practitioner

Service TransformationCollaboration and coordinationClinical support and education

Network formation

HEE Funded Initiative, run via local CEPN program

Application: same day access…


Network formation

Get Seen

Need an Appointment

Walk-in and wait

UCC CAUED

Need a Connection

SpecialistTherapists

HV, SN

GPsNurses

Get Advice Telephone

Online

Informal

Face to face

Children’s centreGP receptionPharmacistFriends

Champions

111GP, HV

Specialists

ExperienceEducation

Culture

Housing Deprivation

Support networksParental health

FamilyHealth Beliefs

Coping Ability

Self Care

Resources

Confidence

TimeFinances

Expectations

UnderstandingServiceUse

Un-targetedSupport

TargetedSupport

IFSSMaternity

Champions

DevelopingServiceDelivery

ActivePromotionofSelfCare

DIY HealthConsistent adviceCoordinating initiatives

GP accessRole developmentLinking unscheduled care

Service user interviewsPublic health study


Network formation

Get Seen

Need an Appointment

Walk-in and wait

UCC CAUED

Need a Connection

SpecialistTherapists

HV, SN

GPsNurses

Get Advice Telephone

Online

Informal

Face to face

Children’s centreGP receptionPharmacistFriends

Champions

111GP, HV

Specialists

ExperienceEducation

Culture

Housing Deprivation

Support networksParental health

FamilyHealth Beliefs

Coping Ability

Self Care

Resources

Confidence

TimeFinances

Expectations

UnderstandingServiceUse

Un-targetedSupport

TargetedSupport

IFSSSchools

DevelopingServiceDelivery

ActivePromotionofSelfCare

Application: asthma…

Prevalence finderAsthma annual reviewLearning needs assessment

Asthma plansGroup sessionsSchool initiatives

Across ages and settingsAsthma dashboard

Model Summary

• Hub as touch-point between networks

• GPs as conduits for strategy across sectors

• Single model applicable to multiple scenarios

• Future-proofed for MCP structure

• Investment in staff resources

05


Islington Paediatric Integrated NetworksCatherine Lad, CYP Commissioner and Dr Sabin Khan, GP lead Islington CCG

81

IslingtonPaediatric Integrated Networks

• The‘IslingtonChildrenandYoungPeople’sHealthStrategy’underpinsallourworkforchildrenandyoungpeopleinIslington,withaprioritytoimproveintegrationforCYParoundprimarycare

• In2013Islingtonbecameanintegratedpioneer

• Adultandchildren’sMDTTeleconferencingwascommenced,whichbringstogetheracoreteamofprofessionalsinaweekly– monthlyteleconference

• Adultshavegoneontodevelop12integratednetworkswithfacetofacemeetings,withgroupingsof2– 4GPpracticescoveringtotalpopulationsofbetween7000– 30,000

• Therewere4localities,butthisisbeginningtoevolveinto3localitiescoveringtotalpopulationsofapproximately90,000(CHINs:CareClosertoHomeNetworks)

• CHINswillbesupportedbyQualityandIntelligenceSupportTeams(QISTs)

ISLINGTON BACKGROUND

17,287

Central1

Central2

Central4

North1

Central3

North3

CentralSouthEast

17,4040-18–2,917

97650-18–1,535

12,9240-18–2,262

15,1710-18–3,392

15,5160-18–2,608

83110-18–1,420

75150-18–1,372

21,2010-18–4,608

24,0820-18–4,028

28,6800-18–4,879

24,7890-18–4,310

30,955

0-18–4,651

SouthEast1

North2

SouthEast2

SouthWest2

SouthWest1

Nonetwork

CURRENTINTEGRATEDCARENETWORKMAP

WiderMDTClinicalNurseSpecialistsDischargeNurseSocialWorkerPharmacistsDieticianSENCOSHINEPhysioSLTOT

PROPOSED INTEGRATED NETWORK TEAM

JOINTCLINICS• Paediatricianprovidesanoutreachclinicinprimary

care,attendedbyGPs.• Childrenreferredtotheclinicarethoseusually

referredtoOP,thoseseeninsecondarycareandanychildthataGPwouldliketorefertotheclinic.

VOLUNTARYSECTOR• Releasingcommunityassetsthroughpublicandpatient

participation• Peertopeersupport• Practicechampions• Parentchampions• Socialprescribing

JOINTCLINICSANDTHEVOLUNTARYSECTOR

06


What kind of health economy do you want to leave our children? The role of primary care in making it happenProf Albert Mulley, Dartmouth Institute for Health Policy and Clinical Practice

87

HealthyLondonPartnership:ChildrenandYoungPeople25April2017,London

ProfessorAlbertMulley,MD,MPPDartmouthInstituteforHealthPolicyandClinicalPractice

WHATKINDOFHEALTHECONOMYDOYOUWANTTOLEAVEOURCHILDRENWITH?

THEROLEOFPRIMARYCAREINMAKINGITHAPPEN

TheRoleofthePrimaryCareinRealisingtheFiveYearForwardViewDesigningNewCareModelsfromTopDownand fromBottomUp

The Goals of the Forward View• A radical upgrade in prevention and public

health through ‘full engagement’• People and patients with far greater control

over their health care and health• New options for the workforce with skills

leveraged by innovation and technology• Better care experiences, better health for

people and populations, and lower costThe Way Forward• A triple integration of primary and acute

care; physical and mental health services; and health and social care

• A joining up of provision and funding• New care models that integrate service

delivery around people’s needs and wants

Copyright Trustees of Dartmouth College

The Leadership• National leadership showing respect for

diversity and local context and knowledge• Place-based local leadership engaging with

and learning from the people served

LEARNINGFROMVARIATIONTODELIVERWHATISVALUED

Higher levels of health care produce higher levels of health & wellbeing for people and populations;

Prevailing Assumptions Evidence to the Contrary

Health care contributes less to health than social circumstances, including education and behaviour;

ChallengingAssumptionstoThinkandDoThingsDifferently

Health care is delivery of services by professionals to people unable to understand or do for themselves

Clinical evidence tells us what is the right thing to do for people in need of health care;

Evidence is insufficient; patients’ preferences matter in decisions to deliver services that produce value;

Much of health care is exchange of information about achieving what is possible and most valued.


LEARNINGFROMVARIATIONTODELIVERWHATISVALUED

Bias toward biomedical vs social science; specialism vs general knowledge; most proximate cause;

Resistance to Thinking Differently New Models to Do Differently

Integrate services around patients’ needs and wants addressing more broadly the determinants of health;

ChallengingAssumptionstoThinkandDoThingsDifferently

Bias toward expertise, capabilities, and agency of professionals with neglect of that of patients / people.

Bias toward the objective and generalizable; neglect of context at the level of the individual patient;

Engage, inform, and support patients in identifying and acting upon their needs and wants;

Leverage joint assets of people and professionals to co-produce better health and wellbeing at lower cost.


With higher intensity and cost:• No better outcomes in

mortality & function• More difficulty for patients

seeing doctors, longer waits• More difficulty for doctors

admitting to hospitals and obtaining referrals

• Poorer patient relationships, ability to provide quality care

LearningfromVariationintheUnitedStatesandtheUnitedKingdom

$10,250 to 17,1849,500 to < 10,2508,750 to < 9,5008,000 to < 8,7506,039 to < 8,000Not Populated

UnitedStates,1996- 2012

UnitedKingdom,2010

Vermont,197310-foldVariationinSurgeryRates

• 3-fold variation among 152 PCTs in per capita costs for cancer and heart disease care

• 8-fold variation in stents for stable heart disease after NHS Plan capacity building

Sources of waste and harm:• Failure to deliver effective

health care safely (outcome variation)

• Overuse and underuse of preference-sensitive care(uninformed clinical decisions)

• Overuse of supply-sensitive care (uninformed investments in health system capacity)


93

When Linda was diagnosed with breast cancer, she was devastated. She was 58. She quickly found support from others who had dealt with the disease. Nonetheless, her anxieties as she awaited surgery nearly overwhelmed her. Linda’s operation went well. However… .

When Susan was diagnosed with breast cancer, she was more stoical than Linda. She was 78, other members of her family had had breast cancer, and she had already been treated for a serious illness –heart failure. She dreaded having surgery, but her surgeon was insistent. Susan’s mastectomy was routine….

Learning from Variation in Patients’ PreferencesEvidence is Necessary but Not Sufficient – Patients’ Preferences Matter


94

Treatment of early-stage disease

Treatment of metastatic disease

Learning from Variation in Patients’ Preferences Evidence is Necessary but Not Sufficient – Patients’ Preferences Matter


DeliverWhatisValued

ProcessesCosts

OutcomesPreferences

LearnfromVariation

TheStrategicIntent:LearningfromVariationtoDeliverWhatisValued


Policy Makers

Patients and Family

HealthProfessionals

Preference:WhatisValued

Evidence:WhatisPossible

Accountability for Engagem

ent

Feedback

Pref

eren

ces

for C

omm

issi

onin

g an

d Sy

stem

Des

ign

Feed

back

LearningfromPatients’PreferencesforSystemReformGivingSystemLeaders theDatatheyNeedtoHoldThemselvesAccountable

Decision AidCopyright Trustees of Dartmouth College

LearnfromVariation

DeliverWhatisValued

ProcessesCosts

OutcomesPreferences

BringtheDisciplineofScience

BeGuidedbySimpleRulesDeliverwithTeams

DedicatedTeam

SharedStaff

OrganizeforInnovation

Summary

LearningfromVariationtoDeliverWhatisValuedOvercomingConceptualandOperationalBarriers


Level of training & Skills

Diff

icul

ty o

f the

task

High

High

Low

Low

Inefficient care

Ineffective or unsafe care

RedefiningRolesforaKnowledge-IntensiveServiceModelSupportingandMeasuringtheTeamworkNeededtoAchieveValue

• SharedGoals• SharedKnowledge• MutualRespect• MutualTrust

98Copyright Trustees of Dartmouth College

PrimaryCareServiceModelsDesignedAroundTeamsCo-CreatingValueinaKnowledgeIntensiveServiceDeliveryModel

99 99©Socios En Salud 2007

Socios En Salud in Lima Norte

South à NorthService Innovation


TheBMJ-DartmouthInitiativeChallengingAssumptionsandTestingHypothesesonaGlobalScale

Children and Adolescents with

Mental and Behavioral Health

Needs

The Care They Need and Want – No Less But No More


iTHRIVE:UnderstandingaPriorityPopulation’sNeedsandWants

• ANationalInnovationAcceleratorbringingtogetherthemodelofcareforchildren&youngpeople’smentalhealthcalledTHRIVEwithtoolstosupportSDM;CollaboRATE,InteGRATE andOptionGrids.

• Thiswillenabletheimplementation(i)ofTHRIVEusingtheSDMtools.

ConceptualFramework

ToolsSupportingSDMImplementation

CombinedInnovation– newmodel

care


TheBMJ-DartmouthInitiativeChallengingAssumptionsandTestingHypothesesonaGlobalScale

Children and Adolescents with

Mental and Behavioral Health

Needs

People who Need Care and

Compassion due to Frailty or when Death is Near

People who Need Support to be Productively

Employed in their Middle Years

The Care They Need and Want – No Less But No More


It was not the pleurisy that caused the screaming but loneliness. It was a wonderful education about the care of the dying.

I felt desperate. I knew very little Russian then and there was no one in the ward who did. I finally instinctively sat down on the bed and took him in my arms, and the screaming stopped almost at once. He died peacefully in my arms a few hours later.

"Another event at Elsterhorst had a marked effect on me. The Germans dumped a young Soviet prisoner in my ward late one night. The ward was full, so I put him in my room as he was moribund and screaming and I did not want to wake the ward.

I was ashamed of my misdiagnosis and kept the story secret."

I examined him. He had obvious gross bilateral cavitation and a severe pleural rub. I thought the latter was the cause of the pain and the screaming. I had no morphia, just aspirin, which had no effect.

Archie Cochrane’s Education at Elsterhorst: A Silent Misdiagnosis


SomeClosingQuestionsforDiscussion

1. WhichoftheseideasaremostrelevanttoprimarycareatscaleintheHealthyLondonPartnership?

2. Whicharemostrelevanttotransformingcareforchildrenandyoungpeopleinprimarycare?

3. Whatwouldprimarycareteamslooklikeiftheyweredesignedtolearnthewantsandneedsofchildrenandyoungpeople?

4. Whatsupportwouldyouneedtodesignandimplementsuchteamstodeliverdeliver primarycareatscaleintheHealthyLondonPartnership?

5. Whatarethe‘socialcaresensitiveconditions’youwouldwanttoidentifytotestthe‘sustainabilityhypothesis’amongchildrenandadolescents?


Thefollowingareback-upslidesforresponsestoquestionsanddiscussion.


LearningObjectivesMeasures&ToolsforMutualAccountability

Theory of Change Logic Models

coope

PREMs for Engagement &Measures & Tools for Teamwork

• Confirm vanguards’ intended impact logic including any revisions

• Identify metrics and tools needed to drive change

• Identify priorities for learning and evaluation

• Assess relevance of experience sourced from UK, US, other countries

WORKSHOP 1Using Logic for Learning

• In process & outcome to improve quality/safety

• In practice & preferences to improve co-production

• In needs & wants of patients to improve value and health

• In local area contexts to implement innovation & adapt to achieve scale

WORKSHOP 2Learning from Variation

• Focus on vanguards’ front line learning priorities for quality/safety & value

• Examine logic for local context and beneficiaries

• Identify opportunities for high value co-production

• Assess relevance of experience sourced from UK, US, other countries

• Focus on patient-reported measures including needs and preferences

• Measure decision quality as well as process quality

• Measure engagement and co-production of care

• Achieve real-time data & feedback to learn & adapt while innovating for value

WORKSHOP 3Delivering What is Valued

• Design microsystem teams for learning and meeting patients' needs & wants

• Fill each role with people working at highest & best use of skills and training

• Leverage skills with IT to support co-production

• Measure & reward care coordination by providers

• Distinguish innovation from improvement

• Hold dedicated innovation team leaders responsible for learning & adapting

• Ensure innovation leaders flexibility to define new roles within care models

• Identify and learn from similar efforts elsewhere

• Agree design principles for organizations & systems

• Focus on outcomes with improvement in quality & total cost of care

• Support patient choice & accommodate diversity

• Measure competencies & capabilities for risk based payment models

• Build IT for continued learning & improvement

• Govern with accountability for stewardship goals

• Lead with integrity of purpose and transparency in reporting to stakeholders

• Sustain system impact & value through reallocation of resources as needed

WORKSHOP 5Delivering with Teams

WORKSHOP 4Measuring What Matters

WORKSHOP 6Organizing for Innovation

WORKSHOP 7Leading for Accountability

WORKSHOP 8Governing for Stewardship

RightCare Commissioning for Value

Learning from Process Variation

Learning from Preference Variation

PREMs for Integration & Coordination

Value Compass for Population Health

Person Centred Learning Network

New Care Model Canvas for Connections

Strat Organisational Readiness Tool

ReThink Health & Wellbeing ROIs

Recognising Complementary Assets

Organising Teams for Innovation

Understanding Delivery Innovation ROI

Innovators’ Accountability for Learning

ConfidentialDraftforDiscussion

Learning What is Valued


107

Measures&ManagementToolsforMutualAccountabilityAcrossHealthandCareSystems

Frontlines of Delivery System Leadership

#of

sta

keho

lder

s w

ith ro

le in

terd

epen

denc

es

Patient & Clinician Reported Measures of Engagement to

Agree Goals, Needs & Wants

Patient & Clinician Reported Measures of Care Coordination

& Teamwork

Value Compasses : Measures of Quality &

Cost with Focus on What Matters to People Served

Tools to Guide Implementation of

Innovation, Learning from Success &

Failure

Measures and Tools for Quality &

Efficiency Improvement in

Clinical Microsystems

Measures to Learn from Variation in

Outcomes & Costs ; in Preferences & Personal Value

System Dynamics Models to Test Impact and ROI Assumptions

about Cross-Sector Investments

Tools to Partner for New Care Models

Across Health Services with Needed

Capabilities

Tools to Partner for New Care Models Across Health &

Other Sectors with Needed Capabilities

Measures to Assess Health Organisations’Readiness to

Deliver Accountable Care

Tools to Assess Health & Care Organisations’Readiness to

Deliver Accountable Care

Tools:CollaboRATEIntegRATE

Tools:• RightCare• NHSAtlas• 3-Box

thinking

Tool:ReThinkHealth

Tools:• ValueCompass• Microsystem

Tools

Tool:ReThinkHealth

Tools:• STRAT:Readiness

AssessmentforHealthCareOrganisations

• NewCareModelCanvasforHealthCareOrganisations

ConfidentialDraftforDiscussion Copyright Trustees of Dartmouth College

LearnfromVariation

DeliverWhatisValued

ProcessesCosts

OutcomesPreferences

BringtheDisciplineofScience

BeGuidedbySimpleRulesDeliverwithTeams

DedicatedTeam

SharedStaff

OrganizeforInnovation

Summary

LearningfromVariationtoDeliverWhatisValuedOvercomingConceptualandOperationalBarriers


IntegratingAcutewithPrimaryCareAcrossthePatientJourneyFromthePerspectivesofPatientsExperiencingaHeartAttack

Livingwithheartdisease–planningforthefuture

Recovery

WholePersonLTCsCarePlanning&Management

CommunityHealthCenter

AtRisk

PopulationatRisk

10Prevention(NoknownLTCs)

20 Prevention(KnownLTCs)

Gettingbetter–learningself-care

PostAcuteRehabilitation&Support

PostAcute

Long-TermCareCenter

Chestpaindiagnosedasaheartattack

AcuteIllnessAssociatedwithLTCs

Acute

AcuteCareHospital

CommunityHealthCenter

PatientswithKnownLTCsAndComplex

Needs

© Trustees of Dartmouth CollegeCopyright Trustees of Dartmouth College

HospitalAdmissions

SpecialistDiabetesVisits

EmergencyRoomVisits

OutpatientProcedures

90% 41%

HospitalReadmissions

*72%23%

48% HospitalLength-of-Stay

*10%

*ImprovementsinPatientSatisfactionDiabetesControlSmokingCessation12.3%reductionincostsperperson

$2,100peryearnetaftersubtracting$600forthecostofSCCservicesincludingmedicinesprovided

12%

*against benchmarks

WhatCanBeAchievedByDeliveringHighValueCaretoPatients


T

TheBMJ-DartmouthInitiativeChallengingAssumptionsandTesttheSustainabilityHypothesis


T

TheBMJ-DartmouthInitiativeChallengingAssumptionsandTestingtheSustainabilityHypothesis


PrimaryCareResidencyTraining

ContinuingClinicalEducation

HealthCareManagementTraining

TertiaryAcuteCareHospital

SystemsBalancingAcuteCarewithCommunityHealthCare

CommunityHealthCenters

HealthCareDeliveryScienceResearch

113

TertiaryAcuteCareHospital


07


Q&A / Panel discussion

114

Q&A / PANEL DISCUSSION

TEA & COFFEE

08


Using data to support changeDr Dagmar Zeuner, Director of Public Health, Merton

117

ImprovinghealthoutcomesforCYP throughPrimaryCare

Usingdata tosupportchangeHowcanlocalPublicHealth help?

DrDagmarZeunerDirectorofPublicHealth,LondonBoroughofMerton

HLPCYPevent,April2017

118

Purpose&format• Purpose – Exchanginglearning,perspective,resources

• Part1– Settingthescene– Context,concepts→Keypoints– Referencematerial(illustrativeonly)

• Part2– Examplesofusingdatatosupportchange– Jointcommissioning(HealthyChildProgramme)– Leadershipandadvocacy(Childhoodobesity)– Surveillance(Immunisation)– Sharedlearning(childdeathsoverviewpanel)→Improvedoutcome/orproxy

• Conclusions

119

PrimaryCare- StrategicContext• Publicsectorfunding↓,demand/need↑=health&caresystemunsustainable

• NHSresponse:FYFV(incl GPFYFV,FYFVnextsteps)– Practicesworkingtogether(30-50,000population)

• GPfederations,hubs,networks– Newcaremodels,experiencefromvanguards(MCP,PACTetc)– STPs/accountablecaresystems

→ Focusonpopulationhealth,prevention&integration

120

HowcanPHhelp – PHdutiesinLAAim:protecting&improvingpopulationhealthandreducinginequalitiesthroughconcertedeffortsofsociety

• Strategic/systemleadershipforhealth– Health&wellbeingboard;JSNA;APHR

• Commissioningdefinedrangeofservices– Healthvisitors;schoolnurses;sexualhealthservices;drugs&alcoholservices;healthylifestyleservices

• CommissioningsupportforlocalCCG– Needsassessment;strategydevelopment;service&pathwayredesign;evaluation

• Oversightoflocalhealthprotectionarrangements– Screening;immunisations;infectioncontrol;emergency

planning→DataareessentialPHtoolsbutthereismorethatPHoffers;

Useitall!

121

CYPhealth&wellbeingoutcomes• OverallsignificanthealthimprovementBUT

– Persistentinequalities(childpoverty;seeRCPCHreport)– Preventionopportunities++(earlyyrs,obesity,immunisations,risktaking,injuries)

– Disability– Emotional&mentalwellbeing– Safeguarding/maltreatment

→PreventionstartswithCYP→CYP20-25%ofcurrentpopulation,100%future→Theyneedyourexplicitleadership&advocacy

122

NavigatingservicesforCYP→itisamaze!Service type Provider CommissionerMaternity services NHShospitaltrust CCG

Primary Care GPpractices CCG/NHSE

0-19HCP;FNP Communityhealthcaretrust LAPH/CS

CHIS;imms;screening Community/acutetrust NHSE

Children’sacutehealthcare NHShospitaltrust CCG/NHSEforspecialist services

Communitypaediatrics Hospital/communitytrust CCG

CAMHs Mentalhealthtrust CCG(NHSEfortier4)

Dental;oralhealthpromotion

NHS/privatedentists;communitydentalservices

NHSE/PHE(on behalfofLA)

Drugsandalcoholservices Mentalhealthtrust, vol sector LAPH

Children’scentres/earlyyrs/childrensocialcare

LA,schools, vol sector LA CS

Sexualhealthservices Acute/communitytrusts LAPH 123

Data• Oxforddictionary:

– ‘Knownfactsusedininferenceorforreckoning’• Datatypes(forneedsassessment/servicereviews)

– Populations(registered,resident,schoolchildren)– Demography(age,ethnicity,projections)– Determinantsofhealth;distributionofrisk&resiliencefactors&

diseases;serviceutilisation/performance/cost– Assets(notjustdeficitfocus)– ‘Voice’(Patient/public/communityviews&experience)– ‘Whatworks’(NICEguidance,evidencereviewsetc)

• Importanceofcomparators(whatdoesitmean?)– Trends,benchmarks(variation),standards;controls

• Whatisyourquestion?– Whydoyouwanttoknow/whatdifferencewillitmake?

→Dataneedstobeturnedintointelligence→ Dataisessentialbutnotamagicbulletfordifficultdecisions→Keepamind-setoftriangulation,checking,myth-busting

Goodread:BGoldacer Badscience;MSyedBlackboxthinking 124

Datasources• PHEfingertipstools– Child&maternalhealth

fingertips.phe.org.uk/profile-group/child-health

– Lifecoursestage(pregnancy&birth;earlyyrs;school-age;youngpeople)

– Themes(breastfeeding;mentalhealth;healthbehaviours;mortality;LTC&complexhealthneeds;obesity;injuries;immunisation;vulnerablechildren;PH&NHSoutcomesframeworks;healthcareuse)

– Overview;maps;trends;profiles• PHEfinger-tipstool– Generalpracticeprofiles(update17/18)

fingertips.phe.org.uk/profile/general-practice

• NHSErightcare– CCGdatapacks(incl maternity&earlyyrspathway)www.england.nhs.uk/rightcare/intel/cfv/data-packs/london

• HLP– STPCYPdatapackwww.healthylondon.org/children-and-young-people/resources• LA– JSNA;APHRwww.merton.gov.uk

125

Childhealthprofile

126

Maternity&earlyyrs pathway

127

HLPSTPdatapacks

128

MertonJSNA&APHR

129

Localexample(1)

• 0-19healthychildprogramme(HV,SN,FNP)–datauseforeffectivejointcommissioning– Jointcommissioning(withotherhealthservicessuchascommunitytherapies)- informedbyNA

– Clinicalinputfromprimarycare– Clearservicespecsfocussedonhighimpactareas– Disciplinedcontractmanagement– Co-productionrelationshipwithcommunityprovider,primarycare&LACS(shared‘thinkfamilyapproach)

→ImprovedKPIs→Improvedhealthoutcomes

130

0-19healthychildprogramme

131

Numerator

Denominator

Perf ormance

Numerator

Denominator

Perf ormance

Numerator

Denominator

Perf ormance

Numerator

Denominator

Perf ormance

Numerator

Denominator

Perf ormance

Numerator

Denominator

Perf ormance

Numerator

Denominator

Perf ormance

228233

97.9%219229

95.6%219229

95.6%169229

73.8%234268

87.3%218292

74.7%146233

62.7%

263276

65.2%147267

55.1%

95.3%209276

75.7%209292

71.6%178273

265271

97.8%263276

95.3%

94.7%193263

73.4%181293

61.8%168264

53 9461.8% 61.6%

279

54.4%183279

65.6%158268

59.0%

270 296 256

63.6%162274

59.1%

61.7%

248258

96.1%249263

94.7%249263

65.5%187

28196.4%206281

73.3%171261

53.7% 56.1% 58.2%

237 258 277 232

162 145 166

277 232

254 252

147 180

96.4%271

266 284

14948.5% 52.3% 53.1% 69.0%

282

237 258 277 232

115 135 147 16062.0% 69.8% 74.7% 92.2%

237 258

273280

97.5%271281

3.1% 10.7% 21.3% 37.3%259 252 249 252

144 172 164

248 253 246

207

17457.4%

233

270 267

147 180 207 21462.0% 69.8% 74.7% 92.7%

21595.2% 92.9% 99.6% 97.6%

257

112

1.8%2775

275189

49.2%264130

46.5%241

68.7%

241

83.0%137241

191230

HVs:breasfeedingstatusrecordedat6-to8-weekreview

95%

56.8%133

55.2%

HVs:6-to8-weekreviewsby8weeks

95%

CM07 HVs:NBVwithin14days 90%

26391.3%

277284

97.5%242

92.0%240

29763.0%161266

60.5%

CM33

69.96%148272

263

CM53HVs:totallyorpartiallybreastfedat6-to8-weekreview

70%

CM25HVs:12-monthreviewsby12months

75%

CM26

184263

HVs:12-monthreviewsby15months

80%

CM37

61.3%

CM27aHVs:2.5-yearreviewsby2.5years

80%8 27

239242

98.8%249261

95.4%249261

95.4%179261

68.6%204267

76.4%193262

73.7%167292

57.2%

Localexample(2)

• Childhoodobesity– datauseforleadership&advocacy(forcomprehensivepreventionapproach)– Greatweightdebate(politicalmandatefor

environmentalchangestopromotehealthychoicesatpopulationlevel,notjustservices)

– APHR(facts,figures,costs,evidencewhatworks)– Childhealthyweightactionplan(whattodo)→HWBBpriority(incl GPmembersandchair)→Reductioninobesityinequalityby2020

132

Childhoodobesity

133

Localexample(3)

• Childhoodimmunisation– datauseforsurveillance– NHSEiscommissioner,primarycareisprovider– PHEismonitoringinfectiousdiseasesie measles– LBMO&Scommitteereviewbecauseoflowcoverage→Strengthenedlocalactionplan(Immunisationsteeringgroupchairedbyprimarycarenurse,toptipsforGPs,immunisationpromotionbyHVsandhealthchampionsetc)→ Improvementofcoverage(fromlowbaseline)

134

Childhoodimmunisations

135

Localexample(4)• Childdeathoverviewpanel– datauseforsharedlearning– CDOPcurrentlystatutoryfunctionofLCSB– Allchilddeaths(unexpected=rapidreview)– Immediatesharingandannualreportwiththemes– Patternrecognitiondifficultwithsmallnumbers(in

responsechildren&socialworkbillwillchangearrangements)

– HLPpanLondonCDOPworkstream(SUDI,asthma,neonataldeaths,bereavement)

→ Preventionofavoidablechilddeaths

136

Childdeathoverviewpanel(CDOP)

ChildDeathOverviewPanelNewsletter(June2015)

Inthisissue:ButtonBatteryWarningsUncookedJellycubesChildCarSeats

137

ConclusionsImprovingCYPhealth&wellbeingoutcomesinprimarycareü Dataareessentialandpowerfultoolsbutneedtobe

turnedintointelligencethatmattersü Primarycareisattheheartoffuturenewcaremodelsas:

• Provider,commissioner&placeshaper

ü SharedbusinesswithPH/LA• Populationhealth,preventionandintegration• Helpwithdata/intelligence• Localinfluence(HWBB,DCS,CllrasCYPadvocate,community)

ü Investinrelationshipsandcapabilitynow

138

09


How can primary care support the mental health of children, young people and families?Alex Goforth, Programme Lead, London & South East CYP IAPT Learning Collaborative

139

Whataretheissues?• ReferralsarenotacceptbyCYPMentalHealthServices

– 60%referralsfromGPsdonotprogresstotreatment(Pulse,2016)

– Thirdarenotassessed(Pulse,2016)• Referralprotocolsandpathwaysneedimprovement

– GPreferrals3xmorelikelytoberejected(Hinrichs,etal.2012)

• Inadequatesignposting/lackofinformation(FutureinMind,2015)

• LackofknowledgeofCYPmentalhealthissues(Hinrichs,etal.2012)

• Additionalpressures…

Whatneedstobedone?• Increasecapacityandcapability

– Better,earlierspecialisttreatment(underway)– Betterandmorepreventativework,basedinGPsurgeries,schools,youthclubs,

• Buildresilienceamongstyoungpeoplefromanearlyage

• Getbetteratspottingpotentialissuesearlier,e.g.throughprimaryandsecondaryschools

• Findinnovativewaysofengagingyoungpeopleoutsideofthesystem,e.g.TIM

• IncreasedliaisonwithGPs• Increasedinterventionsinprimarycare,e.g.CWPs

ResearchbyEasternCheshireCCGgroup&STITCH

• RecommendationsbyEasternCheshireCCGgroup&STITCH:– Improvethereferralprocess– agreedprotocolbetweenCAMHS

andGPs– Createaninformationhubwithaccesstosupportand

information,foryoungpeople,parents,carers,schoolsandGP’scangotoaccessuptodate,relevantinformation,adviceandsignposting,whichdevelopsintoaplatformfordeliveringtreatment

Furtherrecommendationswere:1. Educationinschools2. Mentalhealthroadshows3. Parenthelpline&SMSservice4. Centralreferralhub

Whataretheopportunities?

WhatisCYPIAPT?!• FundedbyNHSEandHEE• Transformingexistingservicesthrough:

– highquality,fundedandsalarysupportedtraininginevidencebasedinterventions

– System-wideandwholeservicetransformationaloutreach– Pan-collaborativelearningevents

• Fiveprinciplesfortransformation:– Accountability– Evidencebasedpractice– Participation– Awareness– Accessibility

Therapist,supervisorandserviceleadershiptrainings

THERAPYTRAININGS

PGDipinCBTforanxietydisordersanddepression

PGDipinParentingtrainingforconductproblems(3to10yearolds)

PGDipinIPT-Aforadolescentswithdepression

PGDipinSystemFamilyPractice

fordepression,conductdisordersandselfharm//foreatingdisorders

PGCert inEvidenceBasedCounselling

PGDipin0-5s

PGCert CombinationsTherapies(prescribingandtalkingtherapies)

PGDipinEvidenceBasedPsychologicalTherapiesforChildrenandYoungPeoplewith

Autismand/orLearningDisability

HowcanCYPIAPThelp?

• IncreasecapacityandcapabilitythroughRecruittoTrainstaffbasedinGPssurgeries+implementationsupport

• IncreasecapacityandcapabilitythroughCWPsbasedinprimarycare(moreinamoment)

• Interventionsguidedbygoals,outcomesandyoungpeople’spreferences,aregenerallybriefer

• Supportimprovedreferralprotocolsandcommunication– Progressupdatesincludingfeedbackandoutcomes

Children&YoungPeople’sWellbeingPractitioners

• Nationalpilotofyoungpeople’sversionofadultPWP,throughCYPIAPTprogramme

• Foryoungpeoplewhootherwisewouldn’treachthresholdsforCYPMHservices

• Newservicemodel,linkedwithCYPMHservices• 15pilotsitesinLondon&SouthEastwith60(band4)CWPswith

highqualitysupervision• Offeringlowintensityguidedself-helpfor:

– Anxiety– Lowmood– Self-harm– Behaviouralissues

• BasedinVS,LA,schools,primarycare,etc• ApplicationsforsecondcohortfromSeptember2017

Afewexamplesofwhat’salreadyhappening…

https://www.mindmate.org.uk/

https://www.skylinesupport.org/

BromleyWellbeinghub• VoluntarySectorcounsellingorganisation• JoinedCYPIAPTin2012,andcontinuouslytrainedstaffin

evidencebasedinterventions+CWPs(2017)• SelectedbylocalCCGasSinglePointofAccessforallCYP

mentalhealthservices– YPupto18years,or25ifsubjecttoanEducation,Careand

HealthPlan– Assessmentwithin72hours– 2,206referralsin2015-16,ofwhich1491seenbyBromleyY– >80%casesareshowingreliableimprovementonSDQ&~80%

onRCADs• RecentlyaccreditedbyCORCfortheirfeedbackand

outcomesmeasurement

TheIntegrateMovement

TheIntegrateMovementseekstosupportservicesto:–Co-produce(doingwith,notfor)–Reachouttopeopleintheirplaceandattheirpace

–Deliverpsychologicallyinformedservices

SchoolsLinkPilot• 22pilotsitesledbyCCGstoimprove

linksbetweenschoolsandCYPMHservices.

• Quantifiableimprovementsin:– Frequencyofcontact– Satisfactionwithcommunicationsand

workingrelationships– Understandingofreferralroutes– Knowledgeandawarenessofissues

affectingYP• Somesitesfoundincreaseddirect

referralsfromschoolstoCYPMHservices,ratherthanindirectreferralsfromGPs

• Phase2hasbeencommissionedforafurther20CCGsandupto1200schools– May2017

EvidenceBasedTreatmentPathways

• CommunityEatingDisordersServices

• CrisisCare

• GenericPathways

Participation• CYPMHservicesengageyoungpeopleintheirtransformationthroughinnovative,creativeactivities

• Youngpeoplelearnskills,gainconfidenceandmeetpeers

• Someyoungpeoplesaytheparticipationactivitieshavehelpedthemmorethantreatment

• Settingupparticipationgroupsinprimarycare?• Youngpeopleco-producingpathwaysbetweenGPandCYPmentalhealthservices

DebatingProgramme• CollaborationbetweenCollaborative,SWLSTG&EnglishSpeaking

Union• Youngpeoplewithexperienceofmentalhealthservicestrainedin

debatingover12weeksbeginningendOctober2016– Culminatingin1dayofcompetitionataprestigiousvenue

• Propositionsaroundmentalhealth,serviceprovision,socialmedia• 7groupsofyoungpeoplefromacrosstheCollaborativealready

involved• Objectives:

– Newskillsandconfidenceforyoungpeople– Engagingyoungpeopleinservicetransformation– Valuablefeedbackforservices

AMPLIFIED:NationalParticipationProgramme

• FouryearNHSEprogrammetoincreaseyoungpeopleandparent/carerinvolvementinCYPMHservices

• LedbyYoungMindsandNELCSU• DevelopingnetworksinIRLandonline• ConnectingCYPMHserviceswithGPs

+ =

HackathonsYoungpeople

Clinicians

SoftwareDevelopers

App:BreathwithMe

https://breathe-with-me.github.io/user-test/

Tochat/findoutmore:

@LDNSECYPIAPT

[email protected]

www.cypiapt.com

10


The Well Centre and Teen Health Check: an integrated approach to adolescent healthDr Stephanie Lamb, GP, The Well Centre

162

TheWellCentreandTeenHealthCheck:anintegratedapproachtoadolescenthealth

Improving Care for Children and Young People in Primary Care

HLP - 25th April 2017

Dr Stephanie Lamb

TheWellCentreandTeenHealthChecks

Doubleclickoniconondesktop

WHYITMATTERS?

• 80%oflifetimecannabisandalcoholuseisinitiatedbytheageof20

• 50%oflifetimementalillnessstartsbyage15

• 8/10obeseteenagersbecomeobeseadults

• 8/10adultsmokersstartasteenagers

• Stronglinksbetweendifferentrisk-takingbehaviours:<16yrswhoaresexuallyactivearemorelikelytoabusesubstances

MOREREASONS WHYITMATTERS:

• 70%ofadultpreventabledeathsaretheresultofbehavioursinitiatedorreinforcedinadolescence.

165

•Adolescentsgetshorterconsultationsthanadults…

•AndintherecentHBSCsurvey,although80%hadvisitedtheirGPinthelast12months

•48%feltuncomfortablediscussingpersonalissueswiththeGP

166

ANDYET?

WHYFOCUSONADOLESCENTHEALTH?

• Timelyinterventionsatthisdevelopmentalstagecanhavelongtermbenefitsinallaspectsoflife

• Healthybehaviourscanbeestablished

• Longtermmentalhealthproblemscanbeprevented

• Appropriateuseofhealthservicescanbeencouraged

167

TeenHealthCheck

• BiopsychosocialassessmentbasedonvalidatedHEADSSSmodel

• AdaptedforuseattheWellCentre

• AbridgedversiondevelopedforPrimaryCareconsultation– Emis,readcoded

VulnerabilityIndicators

• Confidentialityexplained

• Home• Education/Employment• Carer?• Socialserviceinvolvement?

Healthriskfactors

• Smoking• Alcohol• Substancemisuse• Dietandexercise– BMI/centile• Sexualactivity– HPV• Mentalhealth– sleep/mood/selfharm

Resources/followup

• Linkstolocal/nationalservices

• Careplan– pt’smobilenumber/facilitatereview.

Anyquestions?

• [email protected]

11


Table discussion

177

Table discussion

• What can Healthy London Partnership do to support better care of children and young people in primary care at scale?

• What can we do at organisation level and as individuals?

12


Feedback/ Q&A/ Panel discussion

179

13


Next steps for the programme Eugenia Lee, GP lead, Healthy London Partnership’s Children and Young People’s Programme

180

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