City and Hackney Clinical Commissioning Forum Members Forum
City and Hackney Clinical Commissioning Forum & Members’ Forum Thursday 2 nd November 2017 West Reservoir
Agenda Items Led by 1. Welcome Clare Highton Members’ Forum: 2. Ratification of appointment of Jane Milligan as Single Accountable Officer (SAO) Ratification of Consortia Leads Plans for other GB 3. 4. David Maher GP members – Clinical Vice Chair and GB GP Member; Options for proceeding with the CCG Chair election Children and Young People Commissioning Intentions Unplanned Care Commissioning Intentions Pauline Frost May Cahill
Thursday 7 December 2017 Members Forum MATTERS FOR DECISION
Items for discussion and decision 1. Ratification of appointment of Jane Milligan as Single Accountable Officer (SAO) for the NHS City & Hackney Clinical Commissioning Group (CCG) Governing Body (GB); 2. Ratification of Consortia Leads appointments from 1 April 2018 to 31 March 2020; 3. Plans for other GB GP members – Clinical Vice Chair and GB GP Member; 4. Options for proceeding with the CCG Chair election; Item for information: 1. Future Constitution & Scheme of Reservation and Delegation changes.
SAO Background and recommendation • Jane Milligan was appointed as Single Accountable Officer (SAO) for North East London (NEL) CCGs (City & Hackney, Tower Hamlets, Newham, Waltham Forest and Barking, Havering & Redbridge) on Monday 6 November 2017 through an open application process; • Jane takes on statutory Accountable Officer status for the CCGs from Friday 1 December 2017; • Jane will be available at the Members Forum to field questions and has provided the biography available on the following slide; • RECOMMENDATION: The Members Forum is asked to ratify Jane Milligan's appointment to the CCGs Governing Body as our Accountable Officer.
Jane Milligan biography Jane has worked in the NHS for nearly 30 years having first qualified as a Chartered Physiotherapist in 1987 working in London, Cornwall and Devon, then returning to London in 1996, to take up clinical and management roles within the specialism of neurosciences at St George’s NHS Healthcare Trust. Jane has worked in Tower Hamlets for over 15 years and joined the PCT as Head of Physiotherapy but has had a number of roles during this time including Director of Primary and Community Care Commissioning and Managing Director of Community Health Services. Jane completed her MBA in 2004 and a clinical leadership strategist course at INSEAD in that same year. In September 2012 she was appointed as Accountable Officer for NHS Tower Hamlets CCG. She co-chairs the Mental Health Transformation Board for London, part of the Healthy London Partnerships Programme. She took on the Executive Director lead for North East London Sustainability and Transformation Plans in March 2016. Jane is has been a non-executive on the board Family Mosaic Housing Association since March 2013 and has recently joined the Designate Peabody Board. She has also been a trustee for St Pauls Way School in Bow since 2010. Jane also holds a Diploma in Wine and Spirits.
Consortia Leads Background and recommendation • Current Consortia Leads latest two year term of service comes to a close on 31 March 2018. As such, Consortia discussed and actioned election or selection exercises that they wished to undertake under the terms of our Constitution earlier this year; • Each Consortia debated their preferred route towards securing Consortia Leads in October and November 2017 and selected, or held votes on who would lead their Consortia from 1 April 2018; • The result of this process was no change in Consortia leadership, with the individuals indicated on the following slide continuing their roles from 1 April 2018 to 31 March 2020; • There is no term limit in our Constitution, but Consortia's do need to hold these conversations every two years; • RECOMMENDATION: The Members Forum is asked to ratify these Consortia Lead appointments from 1 April 2018 to 31 March 2020.
Elected Consortia Leads Role Title Abdul Pathan Consortia Lead Rainbow & Sunshine Kawal Sabharwal Consortia Deputy Rainbow & Sunshine Gary Marlowe Consortia Lead (job share) South West Paul Kelland Consortia Lead (job share) South West Nikhil Katiyar Consortia Lead North East Hackney Geraldine Miller Consortia Deputy North East Hackney Mark Rickets Consortia Lead North West Hackney Katie O'Beirne Consortia Deputy North West Hackney Haren Patel Consortia Lead KLEAR Suresh Tibrewal Consortia Deputy KLEAR Kathleen Wenaden Consortia Lead (job share) Well May Cahill Consortia Lead (job share) Well
GB GPs Background and recommendation • As our current team of Governing Body (GB) GPs are coming towards the end of their terms of service, the newly elected Consortia Leads have been discussing whom from amongst their number will step in to fill the Clinical Vice Chair (and Chair of the Clinical Executive Committee) and GB GP Member roles on the GB from 1 April 2018 to 31 March 2020; • The current CCG Chair, Dr Clare Highton has reached the maximum term of service on the Governing Body under our Constitution (5 years), as has Dr Haren Patel (5 years), the current Clinical Vice Chair. Neither will now be able to stand for Governing Body membership for two years; • The current GB GP Member, Dr Gary Marlowe cannot fill the same position on the GB from 1 April 2018, but is eligible to stand for either of the other two roles; • After discussion amongst the Consortia Lead GPs, they have selected Dr Gary Marlowe to fill the Clinical Vice Chair role and Dr Nikhil Katiyar to fill the GB GP Member role for 1 April 2018 to 31 March 2020; • Both Dr Gary Marlowe and Dr Nikhil Katiyar will be present at the Members Forum to field any questions and will not be able to take part in voting on their own appointments; • RECOMMENDATION: The Members Forum is asked to ratify the appointments of Dr Gary Marlowe as Clinical Vice Chair and Dr Nikhil Katiyar as GB GP Member on the CCG Governing Body.
CCG Election Background and recommendation • Applications to stand for election as CCG Chair from 1 April 2018 closed on Wednesday 22 November 2017. We received two applications, both of which passed the shortlisting process and both candidates were invited to interview with the panel on Friday 1 December 2017; • One of our two candidates withdrew their application on Monday 27 November 2017, leaving us with a single candidate who was interviewed on Friday 1 December 2017; • Dr Mark Rickets, who was found to be a suitable candidate by the interview panel is our only candidate for election as CCG Chair from 1 April 2018; • We contacted all GPs eligible to vote, practice leads and managers on Tuesday 28 November 2017 with a series of options on how we could proceed with a single candidate for CCG Chair. We also postponed the next stages of the process – the hustings event and electronic vote until the Members Forum has decided how to proceed; • We now need to ask the Members Forum to discuss our options and decide how to proceed in this process with a single candidate. We’ve indicated what we think the options available to us are on the next slide; • The covering letter from Dr Mark Rickets is included in these slides as his ‘manifesto’, on which the Members Forum may wish to ask questions if option 3 is selected.
Members Forum Decision on CCG Chair process 1. Proceed as planned with a single candidate and run both the Hustings Event on Tuesday 12 December 2017, 1830 2030 and electronic voting process to open on Wednesday 13 December 2017 and close on Wednesday 27 December 2017, but with a single candidate to vote for. 2. Proceed broadly as planned above, but cancel the hustings event with a single candidate. The election would then be able to open shortly after the Members Forum reach a decision on how to proceed. We could open the election with a single candidate to vote for on Friday 8 December 2017 or Monday 11 December 2017. 3. That the Members Forum approves cancellation of the Hustings Event and election, since we have a single candidate. If this option is chosen, the Members Forum could then proceed to receive a presentation from Dr Mark Rickets, ask him any questions and then proceed directly to a vote on whether to ratify the appointment of this candidate as CCG Chair from 1 April 2018.
Dr Mark Rickets covering letter / manifesto I would like to apply to undertake the role of Chair of City and Hackney CCG in the upcoming election. I have thought long and hard about undertaking the role; it is both challenging and exciting. I would feel honoured to be given this opportunity to build on the great work that the CCG has undertaken since its creation in 2012. Around 25 years of experience working as a GP, the majority of the time in Hackney, including 16 as a partner (with a few years in Tower Hamlets before that) has required me to develop skills in dealing with: complexity, uncertainty, risk management, putting evidence into practice, and the need to build relationships with patients and colleagues – all skills vital to becoming successful in the role of Chair. Added to which, I have experience working in academia and teaching and latterly as Clinical Lead for Primary Care and lead for the North West consortium for the CCG. These roles have also contributed to me being able to use evidence to plan interventions, engage with highly complex systems and work with people to facilitate change in behaviour. The NHS faces a time of unprecedented challenge and change. As we know, many factors are contributing to the situation: fiscal, demographic, clinical advances, demand workforce (eg pressures on training, recruitment, retention and morale). They exist throughout the NHS but have particular characteristics at locality and STP levels. The situation is exacerbated by pressure from regulators and the government to continually improve performance with finite resources that have become reduced in real terms over recent years (eg historical under investment in GP practices’ core contract). However, City and Hackney is in a relatively good place compared with other CCGs. A position that has taken many years to develop and is a testament to how successful the CCG has been in engaging with local GPs, other provider organisations, the local authority, colleagues across the STP and critically: with patients and the public. I see developing these relationships as increasingly important and a key challenge for the in coming Chair as we face the challenges listed above.
Dr Mark Rickets covering letter / manifesto (cont) Other important issues I want to work toward achieving: • Continue the movement towards developing a strategic approach to commissioning characterised by defining outcomes and measuring performance at the level of an accountable care system. A system underpinned by a commissioning framework that requires and facilitates effective working between provider organisations structured to deliver pathways of care. Although the structure of the system must be informed by its functional requirements (not the other way round), it will take time for providers to develop the trust and governance arrangements necessary to share financial and clinical risk. • Managing the balance between working at scale with neighbouring CCGs across North East London (and beyond where necessary), whilst respecting the need for subsidiarity for place based services to deliver on the ground. • Continue the work already started to pool health and social care commissioner budgets and develop contracting arrangements to create capitated longer term budgets (with reduced transaction costs) covering a whole population’s care for local providers to manage collectively. As we know, this will require moving towards a relationship with providers that is much closer than in the past, with many of the traditional commissioning responsibilities moving into the responsibility of providers working in a system of care. • Supporting changes in the jobs for the individuals within commissioning and provider organisations – all will be affected (not least in primary care) as change progresses. For the CCG this takes the form of progressing the work of the integrated commissioning work streams and enabler groups as changes occur on the ground (the neighbourhood model being a good example).
Dr Mark Rickets covering letter / manifesto (cont) • Ensuring the parity of esteem for mental and physical health and that we do not forget the impact of the inverse care law. • Develop a successful relationship with the new STP level Accountable Officer and with other colleagues to work effectively on the issues highlighted and to ensure financial probity, good governance and the discharging of statutory responsibilities continues. • Continue to engage clinical and social care colleagues (primary, secondary and other areas of health and care) and patients in our work. We must develop the best model of care we can for (and with) patients, but it must also be a model in which people want to come and work. • Support a system where the management of poor performance is done thoroughly, but in a targeted way. For the majority, promoting good performance is about education, openly sharing data and developing the workforce’s skills in undertaking quality improvement etc. Why me? I think my competence is demonstrated by my experience and skills outlined above and in more detail in my accompanying CV. But I think it is also important to describe some of my values; since these will inform the decisions I take.
Dr Mark Rickets covering letter / manifesto (cont) • Firstly, whilst values are very important, it’s a person’s behaviour that people see. I work hard, am fair, loyal and consistent; can remain calm, focused and resilient under pressure, and am keen to maintain a spirit of good humour. Behaviour shapes the culture of organisation especially, as in this case, where an individual has a leadership role. I want to promote a culture of openness, respect, hard work and enjoyment. Characteristics I already see in our CCG, and want to foster. • Continue to promote the underpinning values of the NHS as a service that provides high quality of care, free at the point of delivery, to everyone regardless of their ability to pay and continue to address the wider determinants of disease and ill health. • The most important people in the care system are those who work directly with patients and the public. The further a person’s role sits from that point, the less important becomes their work. But potentially the power of their decisions to shape the organisation of care increases – power that needs to be managed with humility and compassion. • Good outcomes for patients are not possible if the staff delivering those outcomes are not happy and healthy – the two are inextricably linked. • Decisions we make must be driven by what represents best quality for patients (shaped first by evidence, then by professional and public opinion) within the resources available. • Trust colleagues’ professionalism and work as part of effective teams.
Dr Mark Rickets covering letter / manifesto (cont) In summary, I would greatly value having the opportunity to build on the successes you, Clare and Paul, have guided the CCG in achieving; I am therefore keen to take up the role of Chair. I believe whilst I have much to learn (and a period of shadowing will be very important in this regard) I believe I come with many of the attributes necessary to make the job and therefore the purpose of the CCG a success. Many thanks for considering me for standing for election.
Constitution and SORD Background and information • Changes to our Constitution and Scheme of Reservation and Delegation (SORD) will be required to enable the Joint Commissioning Committee (JCC) to be setup and grant it the powers it needs to operate; • CCGs in North East London (NEL) will be asked to adopt some shared language and delegation of authority to bring our governance structures into alignment; • We are expecting final proposals on these changes to be available in late December 2017 and will be bring them to the January 2018 Members Forum with a new version of our Constitution and the changes detailed.
Notes 18
January – March 2018 Friday Education Fridays, 1 pm – 2 pm (lunch from 12. 30 pm) at the Homerton Education Centre
City and Hackney Clinical Commissioning Forum Thursday 2 nd November 2017 West Reservoir
CCG Commissioning Intentions 18/19
CCG Commissioning Intentions Children and Young People Workstream 2 11 Unplanned Care Workstream 12 15
Children & YP Workstream – CCG Intentions 1 The opportunity to improve health outcomes – from pre-conception to school We see the time from pre conception to when a child starts school, as one seamless period of time in which to identify risks and needs as early as possible, and to provide targeted, tailored support to women, children and families to increase their health outcomes and life chances. Some of the statistics below help reflect the complex needs of our population, and the opportunities we are seeking to maximize through our Early Years and Maternity Commissioning work. • There are just over 8, 000 women aged 20 ‐ 45 years with one long ‐term condition (LTC) and 1, 200 with two or more LTCs • Around 4, 500 women deliver babies each year, with around 77% having their baby at the Homerton Hospital • We are ambitious and want to reduce further the rate of 3. 5% of women who were known smokers at the time of delivery in 2016/17 • In City and Hackney forty per cent of children live in poverty, contributing to poorer health outcomes and continued health inequalities such as life expectancy and life chances • There are high rates of childhood obesity (27% of 4‐ 5 years olds) 23
Children & YP Workstream- CCG Intentions 2 Safe and Effective Maternity Care We will also review local services against “Better Births” which is the Five Year Forward national maternity review, and develop a shared local plan that focuses on: Pregnant women continue to present with high levels of complexity (medical, obstetric, social and psychological) and in 2016/17 approximately 52% of deliveries at the Homerton fell under the category ‘with comorbidities and complications’. We will require the Homerton to deliver a number of actions and improvements to provide assurance that local maternity care is safe, effective and responsive to women’s needs. These will include: • Personalised care and care planning • Improved postnatal care and perinatal mental health support • Choice and continuity of carer • Community hubs where different services are provided in one central location and care close to home We will ensure there is adequate local maternity provision that is women centred and needs led. Ø Increasing the numbers of women who book an appointment to see their GP or a midwife by 10 weeks of pregnancy We have committed in our Sustainability and Transformation Partnership (STP) to reducing the rate of infant deaths and stillbirths in line with national expectations (20% by 2020). Our actions will include: Ø Increasing the numbers of women receiving continuity of care from their midwife Ø Ø Review of staffing levels to ensure these reflect the medical needs of the women booked in to have a baby strengthening the monitoring and escalation of raised blood pressure (BP) & increasing prescription of aspirin to women identified at risk of pregnancy related high BP Ø Carbon Monoxide screening & swift referral to smoking cessation services Ø Raising awareness with women of reduced fetal movement
Children & YP Workstream- CCG Intentions 3 Reducing health inequalities – Support for vulnerable women Through joint working between our health and voluntary services, we will provide targeted support for women who may be socially vulnerable, such as: Ø Perinatal mental health Ø Ø We will deliver a new model of perinatal care with our local community and hospital partners We will contribute to development of work on good emotional health in children under 5 years and support for parents to access mental health services in the perinatal period. Targeted antenatal and postnatal support Ø We will provide tailored services for women who may struggle to access mainstream services and measure their impact e. g. : Ø Targeted antenatal classes Ø Bump buddies peer support in pregnancy service Ø Postnatal group support (bonding with baby) Ø We will deliver breastfeeding peer support services with our local authorities and support some groups of Black and Asian women who may have low levels of exclusive breastfeeding Adapt the bereavement module for bereaved parents Launch a vulnerable women’s pathway in 2018 We will measure the uptake and impact of these services on our vulnerable women. Ø Ø Ø
Children & YP Workstream- CCG Intentions 4 Mental Health 26 • Perinatal draft STP bid has been shared – increasing staffing of community specialist perinatal mental health services. National bid not released yet, but STP well placed for submission • Investment an large scale programme to integrate mental health workers in all schools in City and Hackney • Increased funding for CYP Psychiatric Liaison to provide extended hour cover (up to 8 p. m. 7 days a week) • Funding for CYP step down workers to liaise with primary care • Increased ASD funding • Increased Eating Disorder Funding
Children & YP Workstream- CCG Intentions 5 Improving Pregnancy Outcomes We will commission additional support for pregnant women who have Long Term Conditions (LTCs) or other specific medical needs. This will include delivering and monitoring the impact of: • Efficacy and uptake of preconception care for women with LTCs • Better management of pregnant women with LTCs. • Increased local uptake of folic acid, aspirin and healthy start vitamins for a healthy pregnancy and healthy growth and development of the child (Healthy Start vitamins are freely available to all City and Hackney pregnant women and children under 4 years) We will: • Refer women early to local services when social or psychological risks are identified • Ensure there are clear services for women with a high Body Mass Index (BMI) • Achieve a significant increase in the number of women who receive Pertussis and Flu jabs during their pregnancy • Ensure pregnant women, partners and parents have the opportunity to provide feedback on their experience of using maternity services, and are kept informed on what steps have been taken to improve services
Children & YP Workstream- CCG Intentions 6 Reducing health inequalities - Vulnerable Children We want to join up our work with health and social care partners, identifying and supporting vulnerable children, at every opportunity. This helps us to ‘make every contact count’, to create more ‘fail safes’ and to help families experience one pathway of care. Ø Through our contract with GPs, children who are ‘vulnerable’ are identified jointly with the practice’s named Health Visitor Ø Those children who are identified as Universal Partnership Plus have a joint action plan agreed between the GP and HV, and the actions are carried out to support the child and family, and to reduce further risks. We will also: Ø Review and continue to develop the communication and joint working between general practice and social care We will continue to offer structured support for all children and young people to support early identification of needs: Ø Continued offer and delivery of new patient checks to 5 17 year olds upon registering with a City and Hackney practice Ø Reviewing the take up of assessment / ongoing support available to children identified as carers Ø Promote the offer of a 16 th Birthday health check to encourage young people to take ownership of their own health and well being
Children & YP Workstream- CCG Intentions 7 Improving the health offer for Looked After Children • Through the CYPMS work stream we will review what the offer of health support is for looked after children • We will continue to focus on the delivery of initial health assessments and reviews • We will improve the join up of care for looked after children when they need integrated support and funding across health, education and social care to ensure their needs are met regardless of where they are placed in care and the complexity of their care needs • The CCG’S Designated Nurse for Safeguarding will support our assurance of high quality care and coordination of services for all City and Hackney looked after children and young people Special Educational Needs and Disability • We are working across education, health and social care in Hackney and the City to identify needs and to meet these needs as early as possible through clear, accessible services that support children and their families from 0 to 25 years • We are responding to the recommendations of the Children’s Disability Needs Assessment, improving how we record and share information about local needs, health service activity and compliance with statutory timeframes for Education Health and Care Plans (EHCPs) • We will quality assess EHCPs and support plans for children with SEND to determine whether health needs are appropriately identified in plans, whethere are outcomes that are relevant, achievable, that have been informed by the child / young person and their family, and have been monitored • We will continue our joint work with the Orthodox Jewish community regarding equity of service provision for children in independent schools • We intend to commission an ‘audiology led’ Tier 2 (hearing assessment) audiology service. Currently the service is delivered by audiologists and community paediatricians. The Tier 3 service for ongoing management and complex needs will continue to be audio vestibular consultant led, with audiologist support 29
Children & YP Workstream- CCG Intentions 8 Work to reduce childhood obesity • Through the CYPMS work stream we will establish new weight management and obesity services, supporting children and young people with support to prevent weight management concerns following early identification, through to medical support for those who are obese and /or have complex health needs • A pilot Tier 3 service (for very overweight / obese children) will inform what services can be developed locally in the longer term Children with Long Term Conditions • City and Hackney GPs will continue to deliver support in primary care to children and young people with asthma, diabetes, epilepsy and sickle cell • Priorities include strengthening transition from children’s to adults services, and consistent personalised care planning to support the young person/ family to manage the condition with reduced need for emergency care Children and young people who experience child sexual abuse 30 • Across the Sustainability and Transformation Partnership in North East London, we are working to improve this care pathway, that includes medical examination, and a period of consistent psychological support • Children and young people will be able to access all components of the service in one location, with highly skilled and consistent staff support, reducing the number of times they have to share their experience
Children & YP Workstream- CCG Intentions 9 Childhood Immunisations • The achievement of ‘herd immunity’, where 95% of the eligible population are immunised, to protect from disease outbreak, is a priority for the CYPMS work stream • We will continue to support immunisations delivery in primary care through additional nurse funding in 2018/19 Child Health Clinics • 31 We will continue to work with the community paediatric service to develop joint working with primary care and support delivery of both routine baby clinics and early identification of developmental needs
Notes 32
http: //www. cityandhackneyccg. nhs. uk/GP/quality-issues. htm
Unplanned Care Workstream- CCG Intentions 1 City and Hackney plan to continue to deliver quality urgent care services to meet patients’ and residents’ needs. Our key priorities for 2018/19 are: To introduce the North East London (NEL) Integrated Urgent Care Service (IUC) – telephone advice service for patients; this includes 111, and the Clinical Advice Service (CAS). Further details are below: • 111: will provide patients with a single point of telephone access (accessed by dialling 111) to range of urgent care services, replacing direct calls to GP practices outside of Practice opening hours (termed Out of Hours). We believe that this will provide patients with one clear access option, and will reduce confusion across urgent care services. This service is currently delivered by City and Hackney Urgent Healthcare Social Enterprise, or ‘CHUHSE’; • Patients will have access to a range of clinicians in the Clinical Advice Service (CAS). We imagine that this will increase the likelihood of patient issues being resolved (with clinical advice); • We will continue the local service which manages referrals from the Integrated Urgent Care Centre (IUC) for urgent, face to face primary care consultations, Out of Hours; • We will develop a new model for ensuring that patients can make urgent face to face GP appointments Out of Hours – we will ensure that this is integrated with existing services which provide a similar function; • We are implementing and evaluating a local ambulatory care unit at the Homerton, the unit will deliver emergency hospital care to patients without them needing to be admitted to an inpatient bed; • Through our Proactive Care, Practice Based Service programme we will work with a number of professionals to provide effective case management for patients who are at risk of emergency admission to hospital, we will ensure that these patients are able to attend their GP Surgery for appointments; these features will supplement our existing service offer to housebound patients; • We are reviewing our Primary Urgent Care Centre (PUCC) at the Homerton, with a view to better meeting patient needs and robustly meeting national standards; • We will implement the pan London ‘Accident and Emergency (A&E) streaming and redirection model’, this will ensure that patients receive care in the most appropriate settings and better understand how to use urgent care services; 34 • We will be reviewing our falls pathway, particularly our Falls Prevention Service, with a view to improving falls outcomes across Hackney.
Unplanned Care Workstream- CCG Intentions 2 City and Hackney plan to reduce the number of delayed discharges from hospital by implementing two local plans – nationally termed ‘High Impact Change Model’. The Change Model suggest eight ways local health systems can reduce the amount of time patients stay in hospital – freeing up hospital beds in acute settings across the system, and making sure patients receive care appropriate to their needs. In summary, these suggestions are as follows: • Planning patient discharges earlier in their hospital stay; • Introducing new systems to monitor how patients move through hospital; • Working with the voluntary and community sector (among others) to create multi disciplinary teams; • Discharging patients home or to appropriate places in the community and assessing their needs from these locations; • Ensuring patients can access services at weekends and outside of regular opening hours (seven day access); • Ensuring we have designated staff (‘Trusted Assessors’) who assess patients’ long term care needs in hospital or the community; • Ensuring patients have choice in their how they are cared for, how long they stay in hospital and where they are discharged to; • Enhancing services in City and Hackney care homes (termed Enhanced Health in Care Homes), including plans to: Enhance our primary care support Ensure the correct range of clinical and professional support is available in care homes via Multi Disciplinary Teams (MDTs) Provide short term treatment (reablement and rehabilitation) to restore people’s abilities to perform their usual activities Ensure our end of life care and dementia care services are high quality and are patient focussed 35 Across all of the above, we intend to work in a joined up, collaborative way with all our partners (social care, community services and others), develop our workforce, improve our data, and IT and technology offer.
Unplanned Care Workstream- CCG Intentions 3 Our Neighbourhood Development Programme will support the development of eight neighbourhoods areas covering patient populations of between 30, 000 -50, 000. We are implementing this model based on emerging evidence from the following: NHS England’s Primary Care Home Model (range of health and social care professionals working together to provide enhanced care in their local community), and other network locality models in Tower Hamlets, Camden and Islington. Our plans are in line with the NHSE’s Five Year Forward View and Sustainability Transformation Plans (STP) and Devolution Plans. We will ensure that this model is sensitive to the needs of different areas such as the City of London, areas with significant cross boarder flow, and will reflect local neighbourhood differences. How will we do this? : • We will work with groups of General Practice surgeries, and will support them to provide a high quality model of care for their local population; • Neighbourhoods will then appoint ‘Leadership Teams’ – these teams will be multi disciplinary: comprised of a range of service users, voluntary and community sector groups and clinicians; These teams will be supported by neighbourhoods managers and administration support • To underpin the joint working all partners in their teams, Neighbourhoods will be required to create written agreements describing how they plan to work together called Memorandums of Understanding (MOUs); • Each Neighbourhood will have access to an integrated dataset to help them better understand their Neighbourhood population, identify areas for improvement and track their progress; • Neighbourhoods will develop an integrated workforce with partnerships spanning primary & secondary care, mental health, community care, social care and the voluntary sector; A specific model for high risk, vulnerable patients will be implemented across all neighbourhoods The model will focus on developing appropriate interventions based on need 36 • Teams will focus on the broader determinants of health, not just healthcare – for example, we understand that housing is very important for our population.
Unplanned Care Workstream- CCG Intentions 4 Mental Health 37 • 24/7 crisis and home treatments teams capable of 24/7 home assessment • Increased recurrent funding for Psychiatric Liaison services to ensure compliance with CORE 24 model • Dementia discharge to assess model • Implement DTOC protocol • Crisis plans for frequent A&E attenders • Improve discharge and reduce delayed transfers of care by implementing the two local Eight High Impact Change Models. • Integrate mental health into the Neighbourhood Care Model.
Notes 38
Well done to Richmond Road Medical Centre GP Practice Team of the Year, General Practice Awards 2017
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