transforming primary care for children and young people
TRANSCRIPT
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
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Transforming London’s health and care together
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
6
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.
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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
Transforming London’s health and care together
Child Health General Practice HubsDr Mando Watson, General Paediatrican, St Mary’s Imperialconnecting care for children (C4CC)
30
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
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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
AWholePopulationApproach:PatientSegmentsinChildHealth
HealthyChild
Vulnerablechildwithsocialneeds
Childwithsinglelong-termcondition
Childwithcomplexhealthneeds
Acutelymild-to-moderatelyunwellchild
Acutelyseverelyunwellchild
Thereareanumberofcross-cuttingthemesthatcanbefoundwithinmanyorallofthesegments.Examplesincludesafeguarding,mentalhealth,educationalissuesaroundschoolandtransition.
DrBobKlaber&DrMandoWatsonImperialCollegeHealthcareNHSTrust
SafeguardIng
Mental
Health
TransitIon
School
Issues
Inequalities
AWholePopulationApproach:PatientSegmentsinChildHealth
HealthyChild
Vulnerablechildwithsocialneeds
Childwithsinglelong-termcondition
Childwithcomplexhealthneeds
Acutelymild-to-moderatelyunwellchild
Acutelyseverelyunwellchild
Thissegmentationmodelalsoallowstheactivityandspendonapopulationofchildrenandyoungpeoplewithinadefinedlocality,andsplitintoagegroups,tobeassessedandanalysed.Thispresents
theopportunityforutilisingdifferentpaymentandcontractingmechanismsforchildhealth.
DrBobKlaber&DrMandoWatsonImperialCollegeHealthcareNHSTrust
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
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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
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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
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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
Vulnerablechildwithsocialneeds
Childwithsinglelong-termcondition
Childwithcomplexhealthneeds
Acutelymild-to-moderatelyunwellchild
Acutelyseverelyunwellchild
Thisfigureillustrates5importantstagesofworkthatneedtobeundertakentoutilisethesegments.Thiswillhelpustomovetowardsmodelsofcarecommissionedforpatient-centredoutcomes:
DrBobKlaber&DrMandoWatsonImperialCollegeHealthcareNHSTrust
(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
Transforming London’s health and care together
Bexley Asthma Assessment Project in PharmaciesDr Karen Upton – Bexley CCG Clinical Lead for Children and Young People
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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
59
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
67
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
Transforming London’s health and care together
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
8
1
2
4
7
9
10
11
12 13
14
15
16
18
19
20
22
23
24
25
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…
Service TransformationCollaboration and coordinationClinical support and education
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
Service TransformationCollaboration and coordinationClinical support and education
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
Transforming London’s health and care together
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
Transforming London’s health and care together
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
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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.
Copyright Trustees of Dartmouth College
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.
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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)
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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
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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
Copyright Trustees of Dartmouth College
DeliverWhatisValued
ProcessesCosts
OutcomesPreferences
LearnfromVariation
TheStrategicIntent:LearningfromVariationtoDeliverWhatisValued
Copyright Trustees of Dartmouth College
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
Copyright Trustees of Dartmouth College
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
Copyright Trustees of Dartmouth College
TheBMJ-DartmouthInitiativeChallengingAssumptionsandTestingHypothesesonaGlobalScale
Children and Adolescents with
Mental and Behavioral Health
Needs
The Care They Need and Want – No Less But No More
Copyright Trustees of Dartmouth College
iTHRIVE:UnderstandingaPriorityPopulation’sNeedsandWants
• ANationalInnovationAcceleratorbringingtogetherthemodelofcareforchildren&youngpeople’smentalhealthcalledTHRIVEwithtoolstosupportSDM;CollaboRATE,InteGRATE andOptionGrids.
• Thiswillenabletheimplementation(i)ofTHRIVEusingtheSDMtools.
ConceptualFramework
ToolsSupportingSDMImplementation
CombinedInnovation– newmodel
care
Copyright Trustees of Dartmouth College
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
Copyright Trustees of Dartmouth College
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
Copyright Trustees of Dartmouth College
SomeClosingQuestionsforDiscussion
1. WhichoftheseideasaremostrelevanttoprimarycareatscaleintheHealthyLondonPartnership?
2. Whicharemostrelevanttotransformingcareforchildrenandyoungpeopleinprimarycare?
3. Whatwouldprimarycareteamslooklikeiftheyweredesignedtolearnthewantsandneedsofchildrenandyoungpeople?
4. Whatsupportwouldyouneedtodesignandimplementsuchteamstodeliverdeliver primarycareatscaleintheHealthyLondonPartnership?
5. Whatarethe‘socialcaresensitiveconditions’youwouldwanttoidentifytotestthe‘sustainabilityhypothesis’amongchildrenandadolescents?
Copyright Trustees of Dartmouth College
Thefollowingareback-upslidesforresponsestoquestionsanddiscussion.
Copyright Trustees of Dartmouth College
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
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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
Copyright Trustees of Dartmouth College
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
Copyright Trustees of Dartmouth College
T
TheBMJ-DartmouthInitiativeChallengingAssumptionsandTesttheSustainabilityHypothesis
Copyright Trustees of Dartmouth College
T
TheBMJ-DartmouthInitiativeChallengingAssumptionsandTestingtheSustainabilityHypothesis
Copyright Trustees of Dartmouth College
PrimaryCareResidencyTraining
ContinuingClinicalEducation
HealthCareManagementTraining
TertiaryAcuteCareHospital
SystemsBalancingAcuteCarewithCommunityHealthCare
CommunityHealthCenters
HealthCareDeliveryScienceResearch
113
TertiaryAcuteCareHospital
Copyright Trustees of Dartmouth College
07
Transforming London’s health and care together
Q&A / Panel discussion
114
Q&A / PANEL DISCUSSION
TEA & COFFEE
08
Transforming London’s health and care together
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
Transforming London’s health and care together
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/
10
Transforming London’s health and care together
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?
171
Healthriskfactors
• Smoking• Alcohol• Substancemisuse• Dietandexercise– BMI/centile• Sexualactivity– HPV• Mentalhealth– sleep/mood/selfharm
173
174
Resources/followup
• Linkstolocal/nationalservices
• Careplan– pt’smobilenumber/facilitatereview.
Anyquestions?
11
Transforming London’s health and care together
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
Transforming London’s health and care together
Feedback/ Q&A/ Panel discussion
179
13
Transforming London’s health and care together
Next steps for the programme Eugenia Lee, GP lead, Healthy London Partnership’s Children and Young People’s Programme
180
Lunch and closeThank you for attending
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