report to: health scrutiny standing panel - enfield · 2016-01-26 · public health gp engagement...

Public Health GP Engagement Scrutiny Report

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EXECUTIVE SUMMARY i. Despite improvements there remain significant health inequalities

within and across the borough, and wide variation in GP outcomes related to proactive management of long-term conditions.

ii. These remain a priority within the Health and Wellbeing Strategy. iii. These inequalities tend to be more pronounced within 5 wards. iv. Public Health continues to conduct activities, both focused within the 5

high-priority wards, and elsewhere to help with mitigation of these issues.

v. Primary care provides holistic healthcare of the population. High quality primary care is associated with better health outcomes and lower dependency on acute and social care sector.

vi. Enfield GPs face a huge challenge related to high level of long-term conditions. A supportive environment facilitated by health and wellbeing members in their own right will help improve the outcomes in health and social care economy.

vii. One of the measures is the engagement and partnership with our local GPs by public health team.

1. BACKGROUND Enfield has significant needs in terms of health and wellbeing, and significant inequalities in health outcomes. Life expectancy is the ultimate measure of health outcomes and there are currently 8.6 years gap for female and 6.4 years gap for male between the worst and best ward life expectancy (Source: GLA 2015). The health inequalities of Enfield can be further studied in the Annual Public Health Report 2014. (http://www.enfield.gov.uk/downloads/file/10021/enfield_annual_public_health_report_2014)

REPORT TO: HEALTH SCRUTINY STANDING PANEL DATE: 26 January 2016 REPORT TITLE: Public Health GP Engagement Report REPORT AUTHOR/S:

Dr Tha Han Consultant in Public Health. Public Health team, Dept. of Health, Housing and Adult Social Care London Borough of Enfield

PURPOSE OF REPORT:

An update to the Health Scrutiny Standing Panel on Public Health Engagement with Primary Care

http://www.enfield.gov.uk/downloads/file/10021/enfield_annual_public_health_report_2014

http://www.enfield.gov.uk/downloads/file/10021/enfield_annual_public_health_report_2014


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Evidence suggests that the biggest contributor to the life expectancy gap in Enfield is cardiovascular diseases (CVD) which include heart diseases and stroke. The key to reduce the burden of CVD lies in high quality prevention and primary care. The term primary care is thought to date back to about 1920, when the Dawson Report was released in the United Kingdom. That report, an official “white paper,” mentioned “primary health care centres,” intended to become the hub of regionalized services in that country. The WHO identifies four main features of primary care services: first-contact access for each need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere. The Alma Ata Declaration V states that Primary Healthcare is the key to attaining a level of health that will permit peoples of the world to lead a socially and economically productive life. Systematic reviews widely reported that the quality of the structural and functional characteristics of primary care determines population health.i ii Firstly a good primary care practitioner provides preventive services for children.iii Secondly they give holistic healthcare including long-term conditions. More importantly, GPs are the most trusted professionals to the public,iv so they are best placed for empowering patients for self-care and managing their own health. It is also known that an adequately supplied primary care system reduces mortality and mitigates the adverse effects of income inequality.v,vi A good primary care system also helps to limit the rise in hospital admissions related to long-term conditions.vii viii In Enfield, like other areas in England, there is much variation within the borough for primary care management of long term conditions according to Quality and Outcomes Framework (QOF) indicators (Appendix 1). Research also suggests that primary care improvement through Quality and Outcomes Framework (QOF) has reduced health inequalities substantially and can keep in check hospital use related to long-term conditions.ix x Subsequently good primary care outcomes may limit the rising demand on social care as every client in adult social care has one or more long-term illnesses such as stroke, mental health problem, heart diseases or diabetes. In addition, the Health and Social Care Act 2012 stipulates that it is a mandated requirement of Local Authorities to provide Specialist Public Health advice and support to local NHS commissioners. The Enfield Joint Health and Wellbeing Strategy 2014-2019 sets out the following five priority areas: • Making sure children have the best start in life • Helping people to be safe, independent and well, and delivering high

quality health and care services • Creating stronger, healthier communities • Narrowing the gap in life expectancy • Promoting health lifestyles and making healthy choices


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All of these priorities may at least in part be addressed by Public Health engagement with General Practitioners within Enfield. This task is addressed in our work-plan accordingly. 2. ISSUES AND CHALLENGES As stated, the ultimate measure of health outcomes is life expectancy which is poorest in the 5 [priority] wards: Upper Edmonton, Ponders End, Enfield Lock, Chase and Jubilee wards. These wards are also known for their socioeconomic deprivation. In addition to poverty, many areas of these wards have a high population churn which makes it challenging for the primary care to inform the residents about prevention, healthy lifestyle and how to properly use local healthcare. Long-term conditions (LTCs), such as diabetes, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Stroke and coronary heart disease (CHD), are prevalent, and the management of these conditions in general practices is a major challenge. Activities to address these issues will be focused on the GP practices in the Wards with demonstrably greater health inequalities, but will not be confined exclusively to those areas. As Kawachi and Woodward wrotexi, “Inequalities are unfair; they affect everyone; they are avoidable; and the interventions are more cost-effective than non-intervention.” Enfield is one of the most deprived boroughs in London (Appendix 3). In addition, NHS Payment per registered patient to Enfield GPs is third lowest in London at £118 (London average £131, England average £141). Nonetheless the detection and recognition (‘recorded’ prevalence) of chronic illnesses is higher than the London average (Appendix 4). Therefore it has become a particular challenge to manage a high proportion of patients with long-term conditions. As a result, Enfield GPs’ achievement of Quality and Outcomes Framework indicators is recorded as one of the lowest in London and England. Nonetheless, Enfield GPs report very low rate of exception in QOF which indicates that they do not attempt to game the reporting system (Appendix 5). Since the implementation of Health and Social Care Act 2012, primary care commissioning was removed from local NHS commissioning. Being a part of the Health and Wellbeing Board (HWB), and having the rare expertise to facilitate primary care improvement, the Enfield public health team has been supporting the primary care improvement in many aspects: access, efficiency, equity, effectiveness, patient experience, and relevance to the situation. Public health has come forward to act as a catalyst of change, working in collaboration with local NHS and with other council departments especially with environment, schools & children, community, communications and sports.


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Activity Target issue Level of support

Primary care quality area

Practice visits Variation in outcomes of primary and secondary prevention of LTCs at GP practice level e.g. COPD/ Diabetes/ CHD/ Cancer

Tactical, operational

Clinical effectiveness, efficiency, patient experience, equity and relevance

GP engagement events

Improved referrals to COPD rehab, to health trainers service in deprived areas; improved LTC recognition and management; invitation of leading speakers; Working with the GP Networks to improve the health of the local population utilising them to support the delivery of key health promotion and prevention strategies

Strategic, tactical

Access, efficiency, effectiveness and relevance

Newsletters (Quarterly)

Improved LTC recognition and management of CVD, hypertension, smoking, diabetes, cancer, COPD etc.

Tactical Efficiency, effectiveness and relevance

Hilo High blood pressure and cholesterol management by GPs in pilot sites

Operational Effectiveness, patient experience, efficiency

NHS Transformation Board

Strategic steer, clinical and scientific evidence, and operational support related to engagement and data;

Strategic, tactical

Effectiveness, access, equity and relevance

Locality meetings

Meetings and engaging with local GPs and practice managers; and also to appreciate and better understand both local issues and local culture. Strengthening the effectiveness of services working together across PC, social services and acute care

Strategic, tactical and operational

Structural improvement, building relationship and trust


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PLT sessions Disseminating best practice for reducing the burden of long-term conditions; Supporting staff to ensure that residents make effective use of existing local assets to improve their health

Tactical Structure and process improvement (efficiency, equity, effectiveness, patient experience, and relevance)

Stroke and Dementia prevention programme

Support CCG commissioning to improve identification and management of atrial fibrillation, high blood pressure and other major risk factors for stroke and dementia


Efficiency, equity, effectiveness and relevance

Ward Health Profiles

Understanding needs and challenges in primary care; Identifying greatest are of need based on Locality health and demographic profiles

Tactical and operational

Structural support related to equity, effectiveness, patient experience

Prevention framework in NHS planning

Evidence-based strategy for 5-y plans

Strategic and tactical

Structural support related to equity, effectiveness, patient experience

Patient and community engagement

Promote, support and design self-care/ self-management/ prevention programmes for AF, high blood pressure and healthy lifestyle

Tactical and operational

Access, effectiveness, patient experience

Health inequalities (HWB)

Improving wider determinants of Health in Enfield, promoting GP registration


Access, equity, patient experience, relevance

GP Clinical Improvement Facilitator

Variation in recognition and treatment of ischaemic heart disease, atrial fibrillation, stroke, diabetes and COPD, and cancer screening

Tactical, operational

Clinical effectiveness, efficiency, patient experience

CCG transformation programme and strategic

To facilitate referrals to lifestyle interventions; Supporting the delivery of the Framework locally to


Effectiveness, efficiency, relevance


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framework for prevention

benefit Enfield citizens.

Primary care estates

To support and work with CCG, local GPs and other providers to enable the development of new premises that meet the health and social care needs of local population and accessible to all.

Strategic and tactical

Access, equity, efficiency, relevance

Table. Public health team’s activities to improve primary care impact 3. RECOMMENDATIONS Using the evidence of what works from various sources, including National Audit Office, NICE and Health Inequality National Support Team (HINST), the public health team sets out a plan to address these issues. The aim of the plan is: To reduce the death and burden of illness from both preventable conditions and conditions modifiable by healthcare such as cardiovascular events, cancer, diabetes and respiratory diseases. The objectives are: 1. To reduce the variation in the clinical care of the long-term conditions among general practices across Enfield, by raising awareness of best practice among the GP peers with similar population challenges and supporting the dissemination of good clinical practices 2. To improve the management of long-term conditions which are already identified by local GPs (e.g., diabetes, heart disease) 3. To further improve the identification and management of major diseases and risk factors in primary care (e.g., high blood pressure, atrial fibrillation, COPD) 4. To improve access to effective community services commissioned by LBE and the local NHS via GPs Most of this work is to be done through specialist public health advice and relationship building with primary care colleagues. Nonetheless some small structural and functional support will be invested to areas of greatest need. The additional cost to improve health inequalities through primary care is taken by the core offer team. 4. NEXT STEPS/ CURRENT ACTIVITIES .


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i. The plan of activities includes practical, scientifically sound and socially acceptable methods. We will work with LBE colleagues, NHS and academic partners to improve the processes in terms of access, patient knowledge, patient experience, clinical effectiveness, equity and efficiency.

ii. Public Health representatives are a member of the Enfield Primary Care Transformation Board hosted by Enfield CCG. Public Health team provides strategic steer, clinical insight, scientific evidence, and operational support related to primary care engagement and data.

iii. Public Health representatives are attending GP locality meetings to engage with local GPs and practice managers; and also to appreciate and better understand local issues and local primary care culture.

iv. Director of Public Health chairs Health Improvement Partnership Board, a sub-group of HWB, where progress and transformation related to primary care are reported by LBE teams and NHS, for discussion, collaboration and cooperation with relevant partners.

v. Public Health representatives have been attending GP surgeries for practice visits since July 2015. This is part of a formalised process to disseminate good practices and to address the underlying causes of variation in performance and outcomes across the borough as a whole. When we looked at high performing GPs, many of them are single handed GPs yet did manage to achieve so much. Therefore we are facilitating similar achievement across general practices of a range of capacity in Enfield. We are also soliciting the GP’s support in smoking cessation activities and other initiatives commissioned by the LBE and NHS. Our current visit status is set out below:-

Practice Date of Visit CCG joint visit? Follow-Up Booked

Intended date of follow-up.

Carlton House 15/07/2015 No No

Dean House 14/10/15 No Not required.

Evergreen Practice, Edmonton Green

09/11/15 No Yes 03/16

Riley House Practice

02/12/15 Yes Yes 03/16

Freeezywater 18/12/15 No No

Bowes Medical Centre

6/1/15 No Not required.

Table. General Practice Visit Status

vi. Newsletters for local health professionals focusing on hypertension, cardiovascular risk, and diabetes have been produced and delivered to all GP practices in Enfield. These inform about local epidemiology, health needs, evidence based practices, and variation in practices across the borough. They celebrate improvement and local good


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practices in order to motivate and encourage improvement across Enfield. These provide additions to the information base relating to long-terms conditions such as hypertension and diabetes. Public Health officers also attend and contribute to GP Locality Meetings and present detailed analyses of QOF. Most cost-effective QOF indicatorsxii are prioritised in improving population outcomes.

Rank Description Indicator codes in 2014/15 and 2015/16 (codes change frequently)

Net monetary benefit per patient treated

1 Anticoagulant AF 007 £45,162 to £46,222

2 BP 150/90 in last reading HYP 006 £13,249

3 ACE/ ARB for Heart Failure

HF 003 £4,175

4 Antiplatelet/ Anticoagulant post-Stroke

STIA 007 £3,029

5 ACEi/ ARB for Diabetic nephropathy

DM 006 £2,4081

6 Smoking cessation support/ referral

SMOK005 £303 to £812

Table. Most cost-effective live QOF indicators (Source: University of York) vii. In Protected Learning Time [PLT] educational activities undertaken by

local GPs, The Public Health team will talk to the audience and invite speakers to disseminate best practice for reducing the burden of long-term conditions

viii. A Stroke and Dementia prevention programme is in development. This

will be focused on GP and other community engagement work.

ix. Ward Health Profiles had been produced for the target 5 wards by the Public Health Intelligence. The profiles highlighted health needs of the residents in these wards and informed the health inequality programme. As part of the development of Ward Health Profiles, GP practices that serve the population in the targeted wards have been identified. A health Inequality Matrix was then developed to understand needs and challenges in primary care serving Enfield.

x. Management of blood pressure amongst patients with Hypertension

has been improving. 33,239 people with diagnosis of hypertension (80.9% of all those with diagnosis) had their blood pressure controlled effectively, which was an increase of 5,230 since 2008/09.


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Appendix 1. Variation in primary care performance

Fig. Example of variation of practice performance in this case in blood glucose control for patients with diabetes, Source: QOF 14/15

Appendix 2: QOF What is QOF?

Around 25% of GPs’ income relates to a complex set of quality indicators. Data drives payments and information on quality of care is also made publicly available.

Clinical Outcomes are given more points than process outcomes e.g., monitoring the total cholesterol level of known patients with CHD can earn 7 points, and if the clinical outcome of cholesterol level below 5 mmol/l is achieved, 16 points can be earned.

Although the cost-effectiveness of QOF indicators varies, QOF has been instrumental in the reduction of inequalities in the delivery of clinical care related to area deprivation. (T Doran, C Fullwood, E Kontopantelis, D Reeves. Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the quality and outcomes framework. Lancet 2008; 372: 728–36. http://dx.doi.org/10.1016/S0140-6736(08)61123-X)

Which conditions are covered by QOF? 1. Coronary heart disease 2. Heart failure 3. Stroke and Transient Ischaemic Attack 4. Hypertension 5. Diabetes mellitus 6. Chronic obstructive pulmonary disease 7. Epilepsy 8. Hypothyroid


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9. Cancer 10. Palliative care 11. Mental health 12. Asthma 13. Dementia 14. Depression 15. Chronic kidney disease 16. Atrial fibrillation 17. Obesity 18. Learning disabilities 19. Smoking

What is exception reporting in QOF? Exception reporting for clinical indicators • Patient refused • Not clinically appropriate • Newly diagnosed or recently registered • Already on maximum doses of medication Appendix 3. Deprivation levels of London boroughs


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Appendix 4. Trend of recorded prevalence (recognition) of diabetes

Trends in recorded prevalence of

diabetes (2008/09–2014/15)

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15

Per

cen

tage

pre

vale

nce

Enfield London England

Source: Quality Outcomes Framework 2014/15

Appendix 5. Exception reporting of Enfield GPs, overall domains, QOF 13/14.


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report to: health scrutiny standing panel - enfield · 2016-01-26 · public health gp engagement...

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