Southall Initiative for Integrated Care

Stakeholder Workshop

18th November 2010

Neighbourly Care, Southall

1. Identify lessons from 2010 projects

2. Generate consensus about 2011 projects

3. Suggest how the Southall model could help GP Commissioning

Aims

Annual Learning Cycle

February

Training

AprilReview Rapid Appraisals 2 Shape new Projects 5 Showcase completed projects

JulyAgree Coordinated

Actions3 Agree pilot changes & improvement measures

NovemberEndings and Beginnings1 Identify new priorities4 Feedback conclusions

Southall Initiative for Integrated CareDebate Priorities. Stakeholder Workshop

Date Venue Tasks

Wed 25th Nov 2009 Milan Palace, Southall Listen to perspectives. Identify priority issues

Dec – Feb. Form Core, Project and Oversight Teams. Secure all formal approvals including access to databases. Test extraction of data. Form team to redesign website. Prepare leadership course (course materials, accreditation, mentors).

E-Star Training

Date Venue Tasks

Wed 10th Feb 2010 Dominion Centre Respond to learning needs expressed. Pilot questionnaires

Feb-Apr. Rapid Appraisals, system models & baseline data. In-practice learning. REC Approval. Recruit into leadership course. Agree mechanisms to connect with Integrated Care Organisation, Health Communities and Polysystems.

Shape system-wide changes. Stakeholder Workshop

Date Venue Tasks

Thurs 22nd Apr 2010 Neighbourly Care, Featherstone Rd Review information and progress. What now needs to be known?

Apr-Jul. Find required information. Set up database searches. Test website. Residential teambuilding workshop. Start leadership course. In-practice learning.

Agree pilot system-wide changes. Stakeholder Workshop

Date Venue Tasks

Thurs 8th Jul 2010 Neighbourly Care, Featherstone Rd Agree pilot changes in each theme and improvement measures.

Jul – Nov. Pilot changes. Ongoing Improvement Measures. Monthly action learning sets. Local focus groups and in-practice support for learning and data-gathering.

Southall Initiative for Integrated CareConclusions. Stakeholder Workshop

Date Venue Tasks

Thurs 18th Nov 2010 Neighbourly Care, Featherstone Rd Feedback conclusions. Identify new priorities

Nov – Feb. Gather data. Compare outcomes with other places. New project teams lead new priorities, learning from previous year teams.

E-Star Training

Date Venue Tasks

Jan – March 2011 Various Training in the new systems and use of web resources.

Feb – Apr. Write training manual about how to use this approach in other PCTs. Put information on website.

Showcase the projects. Shape new projects. Stakeholder Workshop

Date Venue Tasks

Thurs 7th Apr 2011 TBC Critique Handbook. Export to other places.

Apr – Jul. Papers for publication. Present at Conferences. Complete leadership course. Close down this cycle of inquiry and action, as the next cycle gathers pace.

Southall Initiative for Integrated Care - Professional engagement by type

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Identify Priorities:First stakeholder

w orkshop

Southall CollaborativeLearning Workshop:

E-star Training

Shaping System-w ide Changes:

Second stakeholder

Tow ards LocalHealth Communities:

Residential w orkshop

Agreeing the PilotProjects for 2010 and

Priorities for 2011:

Event title

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Academic & Applied Research Unit Commissioning Community Services

General Practice IT & Education Local Government

Mental Health Intermediate Care Public Health Senior Management

Specialist Services Patient & Voluntary Groups

Professional engagement by type

Relay race

Boundary spanning

Community Learning

Southall Initiative for Integrated CareNov 2009-2010

DiabetesNeha Unadkat

Jayshree Patel

Harpal Rai

National SituationDiabetes UK Statistics:– 2.8 million people have diabetes in the UK (2009)– 16% have undiagnosed diabetes (0.5 million people)– By 2025 > 4 million people will have diabetes

Risk: – South Asian, African, African-Caribbean, Middle-Eastern populations

have higher than average risk of Type 2 diabetes– Poor quality of care received by less affluent and socially excluded

people, e.g. prisoners, refugees, people with learning disabilities or mental health problems

Complications– Diabetics have higher emergency admissions than the general

population from complications - coronary heart disease, stroke, peripheral vascular disease, kidney damage and failure, infections and other conditions

Local diabetes prevalence • 18,878 diabetics in Ealing (4.97%), 7,773 in Southall (6.97%)• 29% of Ealing’s population live in Southall, but 41% of diabetics live

in Southall• 1,413 diabetic patients from shared practice population of 17,350

(8.14% prevalence, April 2010)• Ethnically diverse population in Southall

• In Ealing, Emergency admissions rose by 95% between 2003/04 and 2008/09

Local Situation

The Project

PCT Project Group

1. Oversight of Southall project

2. Link with Ealing-wide developments for diabetes

3. Link with hospital-led diabetes care pathway improvements

Southall Pilot Practices

1. Two patient consultation workshops

2. Baseline data assessment

3. Specialist Diabetic Clinic to enhance practice systems

1. Patient Consultations

55 diabetic patients from all pilot practices participated in twoworkshops. Patients strongly recognised the important role of generalpractice as a source of advice and information

Patients want:

• More support and encouragement to manage their own condition

• Patient support groups

• More patient education about– Medication– Diet and cooking for entire family– Foot care– Exercise

2. Baseline Data Assessment

• We looked at the QOF data as a group and found that we were very good at recording:

– BMI, – retinal screening, – peripheral pulses, – neuropathy testing, – blood pressure – micro-albuminuria testing, – eGFR or serum creatinine and – total cholesterol

But:• As a group our HbA1c control needs improvement And:• The exception reporting in some practices is unusually high

3. Specialist Diabetic Clinic to enhance practice systems

Clinical Competencies: Knowledge, skills, consultation styles, competencies framework

Effective Care Planning: Good control as manifested by HbA1c measurements, negotiated and understood person centred care plans, targeted interventions, goal setting

Effective self care: Patient held records, literature for self-help resources, patient education about self-management, education for the wider family

Governance: Call and recall systems; protocols for blood and urine tests, systems to capture regular non attendees, language alerts on practice systems

Recommendations to Other Practices

Recognise key role of receptionists• Training for receptionists so they can advise patients

Improve communication during consultations• Encourage patients to bring an interpreter • Include alerts on patient’s notes about interpreter requirements

Devise strategy to reach patients that regularly DNA• Receptionists book patients for review opportunistically• Where possible have HCA available for on the spot review

2011 Action Plan

1. Training for all practice staff including receptionists

2. Up to date literature in a variety of languages

3. Continue close working with diabetes specialist nurse

4. Monthly meetings inside practices and quarterly meetings of whole group to oversee developments and communicate findings to the GP Consortium

Recommendations for the Future

1. Expand links between the Southall Initiative and Ealing-wide strategic developments

2. Develop the Intranet to support decision-making for diabetes care

3. Continue to gather data to scrutinise performance across Southall

Recommendations for the Future

4. Scrutinise and pilot improvements at each stage of care pathway

• Screening – who to target and how?• Entry into the system – the newly diagnosed diabetic (including

emotional support)• Care planning – goal setting, treatment plans, monitoring, review• Involvement of/referral to extended team members – dietician,

specialist nurse, eye care, self help groups, education programmes

5. Improve practice skills at dealing with depression in diabetics

Acknowledgements

Pilot Practices (GPs and other practice staff)• Health promotion Centre• Northcote Medical Centre• Somerset Medical Centre• St George’s Medical Centre• Sunrise Medical Centre• The Town Surgery

Diabetes UK • Roz Rozenblatt

Wider team• Harpal Rai (and DSN team)• Dawn Stewart (and Podiatry team)• Diljit Sidhu (and Dietetics team)• Dawn Karim• Jo Snowden• Louise Taylor• Rachel Krausz• Gilly Stoddart• Paul Thomas• Debbie Kelly• Sapna Chauhan• Sheelah Watson• Raj Swaris• Sylvia Parry

• Dr Kevin Baynes• Dr Sanjeev Mehta• Satty Aulakh-Clarke• Laura Windebank• Dr A K Sandhu• Dr P J Sandhu• Dr Sandar Cho• Cyprian Okoro

Southall Initiative for Integrated Care2009-2010

Support for Children & FamiliesCamille Adams

Mary FordSumarah Iqbal

Dr Qadan

National Situation

Between 1999 and 2009 the Government published over 20 policies relating to the health of under fives

Key points:• An increase in Childhood Obesity prevalence

• Factors affecting the health of children include lifestyle, socio-economic, cultural and environmental factors

• A decrease in the uptake of MMR from 93 to 89%

• The need for local services to work together to improve the health of children

• The need to increase the level of GP engagement in delivering high quality care for children and their families

The Project

1. Rapid appraisal including perspectives of a) GPs, b) Local support agencies for children and families c) Public Health

2. Develop a Children and Families Directory for general practice

3. Support practices to refer to MEND and SAFE

4. Support practices to act on their ideas for improvement

1. Rapid AppraisalGeneral Practice Perspective• Agreement that social needs affects physical health, but no easy way to refer to,

or work with other agencies • Insufficient awareness of what different agencies offer• Need for guidelines for referral and easy self-referral

Perspective of Voluntary Groups and Children’s Centres• These groups are (unlike general practice) well informed about the range of

services that can support children and families • Children’s Centres staff are keen to work in partnership with a range of health

colleagues including general practice

Public Health Perspective• Several initiatives operate to improve the wellbeing of children and families, e.g.

MEND and the Childhood Immunisation Programme

2. Directory of Local Services

3. Referrals to SAFE

Number of referrals to SAFE

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April - Sept 2010

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Referrals from Health Professionals to SAFE

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4. GP Achievements

• Increased awareness of need. Now approx. 2-3 times each week GPs direct patients to receptionist for further information about a service

• Increased awareness of need for self referral - patients are very happy to self refer

4. Receptionist Achievement

• Increased knowledge about local support for children and families

– Visited local community groups to establish relationships– Used the Children and Families Directory– Handed out literature in the surgery

Recommendations to Other Practices

1. Develop receptionist to keep up to date information about local support for children and families

• Display posters and leaflets about e.g. domestic violence, housing, isolation and depression, drop-in centres for children, nurseries, playgroups, debt advice

• Hand out leaflets• Outreach

2. Visit and befriend local support services

3. Invite leaders of local services to visit the practice and continue debate about collaborative improvements

2011 Plans

1. Each cluster practice will continue present success areas:• Develop reception as information repository with a lead receptionist• Monitor referrals to MEND, SAFE and other services for children & families• Build relations with schools and other agencies

2. Cluster practices will meet together quarterly to oversee:• Recommendations to Southall practices • Support the PCT in developing the Intranet and coordinated data gathering• Collaborative working with school nurses, health visitors and others

3. Need to do a rapid appraisal of new issues that have become priorities:• Domestic violence• Partnership e.g. with school nurses to improve immunisation uptake

Acknowledgements

• SAFE– Nick Bidmade– Chantelle Antoine

• General Practice– Dormers Wells Medical Centre– KS Medical Centre– Chepstow Gardens Medical Centre– The Saluja Clinic– Southall Medical Centre

• Children’s Centres Project Manager, Southall

• Shilpi Mehra

Southall Initiative for Integrated Care

Nov 2009-2010

Dementia

Lynne Read, Sujoy Mukerjee, Frances English, AK Sandhu

National SituationNational dementia strategy and NICE decision to treat Alzheimer’s at an early stage have refocused attention on dementia care. Early dementia diagnosis is desirable because:

1. Anticholinesterase inhibitors can help ~20% of patients with dementia

2. Diagnosis permits family conferences to plan coordinated care, e.g. writing advanced directives when a patient is still able to make informed decisions. This reduces need for institutionalised care

3. Diagnosis provides impetus to preventative efforts including control of diabetes & hypertension, and attention to problem drinking & good mental health

4. Diagnosis helps access resources for patients and carers

Local SituationExpected numbers of patients– Estimated number of people with dementia aged >65 = 5% – Number diagnosed on Southall GP registers = 289 – Expected number of patients on GP registers = 498

The CMHT asked pilot general practices their views:– The referral form for dementia is cumbersome– Help with acute dementia crises is slow and unreliable– What happens to referred patients is not clear – Uncertainty when and how to screen for dementia, especially in

languages other than English – Uncertainty of what practical help can be offered to patients &

carers

The 2010 Project

1. a) Audited the number of patients with diagnosis of dementia on GP Computer systems, b) Audited numbers of patients referred for memory decline from pilot practices

2. a) Improved the referral form for patients with suspected dementia, b) Revised procedures for supporting GPs with a difficulty, c) Developed a new memory clinic in William Hobayne Centre for patients aged under 65

3. Translated the Mini Mental State Examination into Hindi and Punjabi

4. Worked with partners to link the Southall work into an Ealing-wide strategy for 2011: a) Dementia Concern, b) General Practices

Number of dementai patients per 1000 patients for Soutall Practices

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Pilot practices

1a. GP dementia diagnosis audit

Practice Number Practice Nov 2008-Nov 2009 Nov 2009-Nov 2010

E85717 Western Road Surgery 1 0

E85006 Waterside 1 1

E85049 Belmont Medical Centre 1 1

E85090 Hammond Road Surgery 2 1

E85061 Norwood Road Surgery 2 3

Y02342 Bondcare N/A 4

Note: Bondcare established in April 2010

Referral for memory decline

1b. Dementia referral audit

4a. Dementia Concern

• DVD on dementia in different languages

• Able to befriend and support

• Drop in Centres

• Multi-lingual staff

4b. General Practice

• Patients and families know and trust GPs

• GPs can screen at an early stage

• GPs can prevent deterioration of dementia by controlling blood pressure, diabetes and stress

• GP recall systems can help follow up patients

Recommendations to Other Practices

• Screen & Refer

• Monitor & Recall

• Health Promotion

Proposals for 2011

• Quarterly steering group meeting to oversee dementia plan in Southall– Embed the referral form on EMIS computers– Audit referrals from all Southall practices – Audit numbers of patients with dementia, number and cost of unscheduled

care (including admissions) by practice

• Develop a ‘Supporting Dementia at Home Pack’ – For families and carers as well as individuals – Information about making wills, family conferences, end of life planning,

posting Special Patient Notes, advanced directives – Tactics to support someone with dementia at home

• Develop a ‘Primary Care Resource Pack’– How to identify and refer for dementia, and avoid deterioration– Mini-Mental State Examination in various languages– Facts and Figures, a) Care Pathways and care options, b) Supporting

Dementia at Home Pack, c) Posting Special Patient Notes

Acknowledgements

General PracticesWaterside Medical Centre

Norwood Road Surgery

Belmont Medical Clinic

Hammond Road Surgery

Featherstone Road Health Centre

Western Road Surgery

Dementia Concern

Community Mental Health Team

Helping people of BME background with depression / anxiety

Kiran SharmaDr MohanNina Kaler

Mohammad Shuja HodaMandy Hewey

Damayanti Modi

Southall Initiative for Integrated Care2009-2010

• One in four GP consultations have a mental ill-health component.

• At any one time one worker in five will be experiencing depression, anxiety or problems relating to stress.

• “In general, rates of mental health problems are thought to be higher in minority ethnic groups than in the white population, but they are less likely to have their mental health problems detected by a GP.” (National Institute For Mental Health In England, 2003)

Mental Health Statistics

Aim: • To make it easier for users to access services for

common mental health problems, and improve access to psychological services for people of ethnic minority background.

Key Challenges:• Ensure good access for all groups• Minimise waits• Match need to skill within stepped care framework• Optimise cost effectiveness• Ensure data collection

Project Overview

Accessing the Mental Health

and Well-being Service

Self Referral

Formal referralby professional

Telephone Assessment

Flexible Engagement, Full Assessment & Treatment

GP

Occupational Health

Resident in Southall

Community Groups

Secondary MH

Provided an integrated service that:• educated patients to be their own therapists,• improved their well being, • reduced the risk of recurrence and• promoted social inclusion.

Increased number of referrals from BME groups

Project achievements 2010

Anxiety and Depression in Hard to reach groups

NHS Ealing and Central and Northwest London Mental Health Trust Project Team

Ealing Matters & GP magazineGo to Practice Managers meetings

Go to Practice Based Commissioning meetingsEducation of other health professionals

GP increased awareness & engagementGP liaison: MHWBS in person in practices

GP education & awareness of MHWBSLearning Packs

Training of Practice Managers & other staffMH measures translated into other languages and audio

AIM

DRIVERS

INTERVENTIONS

Improve client experience

Increase awareness amongst general

population

Increase number of self-referrals

Improve appropriateness &

increase numbers of GP referrals

GP- prompted self-referral

systems set up for receiving and managing self-referrals

Training for Community Centre StaffHealth promotion events

Liaise with community leaders – link worker

Education in the communityCommunity based radio and newspapers

Posters in key strategic areas, and business cardsSet up website

Promoting self-referral

TranslationMulti-lingual staff

Multi-lingual call back serviceMaterials

Improve accessibility to Mental Health (MH) services

for hard to reach groups, including BME groups, Older People and

disabled people

Key:

Ealing siteBoth sitesCNWL site

Referrals by ethnicity 2010

86% 77%

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Core practices 2010 Southall PBC 2010

Chinese or other ethnicgroup

Black or Black British

Asian or Asian British

Mixed

White

Ethnicity of referrals: 2009 & 2010

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Core Practices 2010

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• By working closely with the Mental Health and Well-being Service GPs can develop relationships and clarify the best use of the services available.

• Create a shared ethos of improving mental health and well-being within the community setting for the population of Southall.

• Planning services- involve communities and service users.

Recommendations for others

• Provide tailored mental health training to all stakeholders, information on referral responsibilities and options.

• Work together to prevent and better manage mental illness in black and minority ethnic groups.

• Identify gaps in service provision for BME client's through the work of the Southall Initiative and develop local action plans to meet the identified needs.

• Develop integrated community based services for mental health. Example work closely with Southall Norwood CMHRC.

Plans for 2011

Pilot Practices• Cecil Road Surgery• Guru Nanak Medical Centre• Jubilee Gardens Medical Centre• Somerset FHP• The MWH Practice• Woodbridge Medical Centre

Southall Team, Mental Health and Well-being Service

CLAHRC

Acknowledgements

Tabletop discussions

• In what ways might the model be useful to GP Commissioning?

• Next steps– Leadership teams meet 8th December at 4pm– ESTAR training January to March– Stakeholder workshop 31st March and 7th July

• Evaluation and research