SUMMARY ANNUAL REPORT - southwarwickshireccg.nhs.uk

Summary Annual Report 2013/2014 B

better healthcare for everyone

SUMMARY ANNUAL REPORT

2013/2014

NHS South Warwickshire Clinical Commissioning Group11

Welcome

Welcome to the South Warwickshire Clinical Commissioning Group 2013/14 Summary Annual Report.

Since coming into full operation in April 2013 we have had a very busy and interesting 12 months, with many exciting, innovative initiatives and activities taking place.

Inside these pages we’ll tell you all about what has happened, including why we have done it and, most importantly, the impact it is having on the lives of the people of south Warwickshire.

Everything we do at the CCG, including the close work we undertake with the public and our partners, is geared around improving the services and care provided to local people and improving efficiency and value for money.

Whatever developments take place, both within our organisation and externally, these guiding principles never change. Because we know that it is this that will, in turn, lead to better healthcare for everyone.

better healthcare for everyone

Dr David Spraggett

This report is a summary version of our Annual Report 2013/14. The full version of the report is available online at [email protected]

Summary Annual Report 2013/2014 2

NHS South Warwickshire Clinical Commissioning Group (CCG) came into full operation in April 2013.

The CCG is made up of 36 GP practices and covers a population of 271,000 people over the geographical area of Warwick and Stratford-upon-Avon districts. GPs from each practice – as the people closest to dealing with people’s healthcare needs on a daily basis – are responsible for leading the CCG and making sure that everything we do provides real benefit to the public.

We receive a set amount of money each year from the government (nearly £300 million in 2013/14) in order to undertake our work.

Our responsibilities include commissioning (or ‘buying’) services from partner organisations such as NHS South Warwickshire Foundation Trust (acute and community services) and Coventry and Warwickshire Partnership Trust (mental health and learning disability services).

We also work closely with NHS England who directly commission primary care (GPs, dentists, opticians), specialised services, military and offender health services, to ensure local needs are taken into account at all times.

We work in partnership with Warwickshire County Council, Warwick District Council and Stratford-on-Avon District Council to ensure healthcare, public health and social care services are joined up, and deal with other groups such as charities, education providers and community organisations to make sure that as many people as possible have their voices heard.

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About us

Leamington Spa

Southam

Shipston on Stour

AlcesterStratford upon Avon

Henley in AdenWarwick

Kenilworth

Royal

NHS South Warwickshire CCG


What we doOur vision is:

To build relationships with patients and our communities to improve health, transform care and make the best use of resources.

To deliver this we have consulted with GP practices and the public, identified areas for improvement and taken on board the key needs of local people in order to produce four aims that guide all we do:

To build relationships with patients and our

communities

To improve health and reduce health

inequalities

To improve the quality of care and transform services

To make the best use of our

resources


How we do itOur four aims contain 12 individual objectives:

1 Primary care is able to provide the flexibility and expertise that people want;

2 People are able to work with us to co-produce services;

3 People remain independent and manage their own care needs;

4 Improve health and reduce health inequalities by supporting people to make healthy

lifestyle choices for themselves and their children;

5 People who are socially isolated are supported to engage with their local community;

6 Ensure that both the physical and mental needs of people are addressed equitably;

7 Where people need support to manage their care ensure that the care system

responds in a co-ordinated way;

8 People will receive a consistent response from the care system 24/7;

9 People will be confident that their care is safe and they will feel that they have been

treated with respect and dignity;

10 People will receive care that is evidence based and contributes to the improvement

outcomes that they have agreed with professionals;

11 People will experience less duplication and waiting because of more efficient

processes;

12 People will have confidence that the CCG uses public money wisely and is in control of

its finances.

These objectives are delivered by what is called the QIPP programme (Quality, Innovation, Prevention and Productivity). This allows us to track the results (our ‘outcomes’) of all our work to make sure things are performing as they should. We can then set objectives for the QIPP programme and monitor performance in a transparent and quantifiable way to keep delivery on track at all times.

This ensures our vision to improve health, transform care and make the best use of resources becomes – and continually remains – a reality.


Our achievementsEach year the CCG is required to deliver against a number of key NHS Constitution rights and pledges that cover a wide range of areas, from waiting times for treatments to emergency response rates and cancellation of operations.

Below is a brief summary of some of the key highlights relating to 2013/14 performance targets:

• Significant improvement in Referral to Treatment (RTT) waiting time targets at specialty level;

• Successful delivery of the A&E wait targets;

• Significant improvement in Category A Ambulance Red 1 calls (response arriving within 8 minutes);

• No occurrences of mixed-sex accommodation breaches throughout the year;

• Delivery of the Care Programme Approach (CPA) target in Mental Health.

However, we are aware that there is still much work to be done, and continued areas of focus are:

• Referral to Treatment times (RTT) at specialty level - this remains a challenge at South Warwickshire Foundation Trust (SWFT) despite improvements during 2013/14, and so joint work will be progressed in 2014/15 through a new Elective Care Working Group;

• Diagnostic waits - lengthy (over 6 week) waits for diagnostics (x-rays, MRI scans etc) continue to be a challenge and can impact on other areas of delivery. Together with SWFT we have a detailed action plan to address the issues;

• Cancer waits (specifically the 2 week breast symptoms wait and the 62-day wait from GP referral to first definitive treatment) - the CCG is meeting regularly with SWFT to review and revise action plans across primary and secondary care;


• Ambulance targets - at times local delivery continues to fall short of expectations, and so better performance will continue to be pursued through Sandwell and West Birmingham CCG as lead commissioner.

We will continue to work closely with our providers and practices, utilising the tools we have available (including penalties and incentives within the contracts) to improve performance in the services provided for our local people.

As part of ongoing assurance process NHS England uses the NHS National Outcomes Framework (NOF) to assess how well we are operating as a CCG.

The diagram below shows the whether the CCG achieved the targets for 2013/14. (Green = achieved, Red = not achieved)

There are four measures which are based on the NOF:

Reducing potential life years lost via

amenable mortality

Reducingavoidable emergency

admissions

Ensuring roll-out of the Family and Friends Test and

improving patient experience of hospital

services

Preventing healthcare associated infections

Increasing the number of people on the End of Life

Register

Reducing the length of stay for the over 75 year olds from 10.5 to 9.5 delays

Reducing the number of paediatric

admissions by 3%

There are also a further three measures that we monitor locally:

The CCG is performing well against these measures. Despite a steady decrease, the target to reduce paediatric admissions was not achieved due to above average numbers in the last quarter of 2013/14.


Our impact

The CCG needs to ensure that it commissions the right services for its local population and that services are safe and of a high quality.

The following case studies show the highlights of our work during 2013/14.

All names have been changed to protect patients’ privacy.



Aim one: To build relationships with patients and our communities

The CCG is continuing with a successful process that ensures key stakeholders have the chance to continually review, comment upon and challenge all major decisions made.

With everything done at the CCG geared around improving the services and care provided to local people, as well as improving efficiency and value for money, a key part of the decision-making process involves ensuring adequate challenge and rigour has been applied at all stages. The Gateway process, launched in 2012, ensures that this is the case.

The process involves regular meetings attended by patient representatives, GPs and project leads from the CCG, at which proposals and business cases can be thoroughly examined from both a patient’s and clinician’s perspective. Feedback from the meetings is then adopted into the wider process of deciding whether a scheme should be approved for further development.

The Gateway process ensures that schemes develop with the necessary quality assurance, supporting a consistent approach and a transparent evidence base for the project. It also ensures that member practices, patients and patient groups are part of the commissioning process.

Commenting on the value of this process, CCG Executive GP Dr Adrian Parsons said:

One local resident and Chair of a patient participation group who is part of the Gateway process, Andy Matthews from Kenilworth, explains his reasons for participation:

New process provides gateway to improved, efficient decision making

“As a member of the public it is really interesting to see how publications and ideas go through the Gateway meetings. The CCG captures views and opinions from a range of people including health professionals and patients, which helps to ensure that new initiatives are relevant and user friendly. At the Gateway meetings, we see ideas develop into tangible products and I’ve enjoyed the opportunity to work with GPs and the CCG. I also appreciate the general use of plain English in our meetings, which helps the patient representatives make sensible, informed contributions.”

“The Gateway meetings provide a useful forum for discussing emerging schemes with project leads. It enables us to be involved with new projects at an early stage and to ensure that a project’s direction and emphasis reflects clinical priorities. I also find it interesting to hear the patient perspective at the meetings, and there have been some constructive debates on how a scheme should develop, balancing patient needs and concerns with clinical views.”


The CCG has introduced a new, education-focused initiative in a bid to reduce the number of young children being unnecessarily admitted to hospital in south Warwickshire.

Between December 2011 and November 2012, nearly 2,500 emergency admissions resulting in a stay of less than 48 hours took place at South Warwickshire Foundation Trust, with 63 per cent of these involving children aged under four years old.

It was therefore decided that alternative approaches focusing on education, information and awareness raising for parents and carers

should be explored and now, led by Dr Richard Lambert, a new booklet and an online presence have been developed.

With admissions of children often causing significant distress for both children and their parents or carers, anything that can reduce these cases, especially where alternative treatment is more suitable, was thought to be worthwhile.

Explaining the motivation for producing these new resources, Dr Lambert, a GP at Alcester’s Arrow Surgery, said:

“Preventing avoidable hospital admissions and maintaining children at home is a key priority for the CCG. And with nearly two-thirds of emergency admissions being of the type that are for one day or less and which could have been prevented with prior care involving young children, it is definitely an issue that needs addressing.

“The new booklet and section on the CCG website will help parents and carers of infants and young children understand more about the common childhood illnesses and what to do if their child is ill. There is also information about local health services such as pharmacies and GP surgeries, and the right times to access these, and all information can be downloaded to mobile phones.

“We hope that this information will be used as a reference guide by parents and carers throughout the early years and will help them choose the best treatment and most appropriate health service if their child is ill.”

The information contained within the booklet can be accessed online at:www.southwarwickshireccg.nhs.uk/Health-Services/Guide-to-Childhood-Illnesses

New booklets aim to reduce avoidable childhoodemergency admissions

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The booklet has been available since March 2014 at GP surgeries, while health visitors have also been distributing it through children’s centres and during home visits.

Rebecca West, a health visitor at the Orchard Centre for Community Health, says that the booklet is proving extremely popular:


“I love this new booklet as it covers such a lot. As I was previously a paediatric nurse in A&E I’ve always said that all parents should be given this information as it could potentially save a visit to A&E. By having this information to hand it will help them to manage a minor illness confidently at home. A lot of parents have been picking the booklet up from the children’s centre as the family support workers have been recommending it.”


As winter brings with it hugely increased demands on healthcare services, the CCG took part in a campaign aimed at encouraging local people to take preventative measures to look after their own health over the coldest season and in turn reduce unnecessary attendances at health services, particularly A&E.

Organised in partnership with NHS Coventry and Rugby CCG, and NHS Warwickshire North CCG, as well as local councils, public health teams, hospitals, and Coventry and Warwickshire Partnership Trust, the two-stage Feel Well, Choose Well campaign took place between November 2013 and February 2014.

Phase one, Feel Well, during October and November 2013 involved encouraging the public to feel well by taking preventative measures to help them stay healthy and providing them with useful hints and tips, while phase two, or Choose Well, concentrated on educating people about selecting the right health service at the right time. To support this a mobile phone app

was developed, over 50 on-the-street public engagement events were held, local radio station support was secured and an integrated social media campaign took place throughout the campaign period.

The overall aim was to promote self-care for minor illnesses, ailments and injuries; increase awareness of NHS 111; provide information about the broad scope of NHS services available locally; and to reinforce the message that 999 and A&E services are for life-threatening and serious health emergencies only.

The success of the campaign was highlighted by the fact that the mobile app was downloaded over 2,250 times, more than 55,000 views were recorded on YouTube for the specially created ‘Dee’s A&E Fail Tale’ video, while a flurry of activity on Twitter was generated throughout the campaign. The campaign has been nominated for an E-Health Insider Award in the ‘best use of social media to deliver a health campaign’ category.

Impact of joint winter awareness campaign really starts to bite

Aim two: To improve health and reduce health inequalities


“The winter period is a very busy time for health services, in particular A&E departments, with many long-term conditions made worse by the cold weather and colds and viruses spreading rapidly,” says Anna Hargrave, South Warwickshire CCG Director of Strategy and Engagement. “As a result, it is vital to remind people of the alternative health services available. Also, with pre-campaign research telling us that 94 per cent of people feel it is important that local NHS services raise awareness about winter health and 78 per cent wanting to know what the alternatives are to A&E, the public clearly felt that a campaign such as this was necessary.

“By pooling resources with partners from health and public health organisations across Coventry and Warwickshire we were able to use effectively the resources we had available, both in promoting messages and paid external resources. The single mobile app created also meant that we covered a much wider area than if we had created individual ones, while again also saving money. A key factor in the success of the campaign was working with local NHS and local authority organisations to achieve a shared goal. In total, ten organisations contributed to the campaign, not only financially but in promoting the campaign’s key messages.”



A number of small projects are aiming to have a big impact on the health of the public, thanks to a joint project the CCG is undertaking with a number of key local partners.

During 2012/13 the CCG, Public Health Warwickshire and both Stratford-upon-Avon and Warwick district councils all contributed funding that saw £30,000 made available in both Stratford and Warwick localities for small public health-focused projects.

Utilising Warwickshire County Council’s procurement processes, a tendering exercise was launched that attracted bids in excess of £121,000. Thanks to these joint-funding arrangements, the following projects have now successfully got off the ground:

Garden Organic - Stratford and Warwick: Garden Organic will develop a project to share food growing skills, knowledge and materials among the users of food banks in Stratford and Warwick. Staff and volunteers will work with the team behind each of the food banks and, typically, a Master Gardener will share how to sow, grow, cook and eat home-grown food to the individuals and families that use and have used the food banks in the past, as well as the wider community. The project will target and encourage those with unhealthy eating habits to eat fresh food and eat in a way that will reduce obesity and complications that can exacerbate long-term conditions.

Inclusive Leisure Educational Activities Project - Stratford District: The ILEAP 4 Health and Wellbeing project will provide vulnerable people with community-based leisure opportunities designed to build their confidence, raise their self-esteem and

promote independence. The project will target people with a mild/moderate learning disability who may fall through the net of statutory funding but who remain isolated and vulnerable in their communities. The project will focus on the holistic health of participants, providing personalised user-led leisure opportunities in communities of place and interest for individuals and small groups of friends. The activities will reduce obesity and related long-term conditions by supporting and educating individuals to lead a healthy lifestyle.

Entrust Partnership - Stratford District: Research suggests that there is an acknowledged link between disability and obesity, but it is also acknowledged that it can be difficult for disabled youngsters to access mainstream activity sessions that many non-disabled young people take for granted. Entrust Partnership will run seven Let’s Get Healthy skills workshops for disabled young people aged 14 or above, which will encourage them to access mainstream facilities. The workshops will be staffed both by skilled specialist staff and volunteers to ensure individual needs are met.

Nuneaton and Bedworth Healthy Living Network - Warwick District: Nuneaton and Bedworth Healthy Living Network will deliver an outreach project in places where long-term reliance on low cost, low quality, processed food has eroded knowledge, confidence and skills. Growing Families will support families with children under the age of five to change their eating habits, attitudes and knowledge about food, fruit and vegetables, thereby improving nutrition, health and wellbeing, fitness and, in the long term, prevent disease and obesity. The project will be delivered through a train-the-trainer approach to ensure sustainability.

Joint funding allows small public health projects with big ambitions to flourish


Warwickshire Association of Youth Clubs - Warwick District: Active South Leamington will establish the habit of regular physical activity in residents of Brunswick and Willes who do not currently have active lifestyles and who are overweight or obese. A behavioural change approach will be employed to work with low-income households, targeting 14–16 year olds, 16–25 year old men and women, single mothers and their families, and middle-aged men. Up to four sports sessions will be delivered each week, for 40 weeks in the year, divided into five 8-week programmes, with additional taster sessions.

Warwickshire Community and Voluntary Action - Stratford District: The New Man Project will work with men with learning disabilities and/or autism, physical disabilities and mental health problems. However, it will also be open to men with any sort of social care package or identified need such as social isolation or family difficulties. The project will address the wider issues that have negative impacts on men’s lives such as lack of community involvement leading to social isolation and loneliness, which increases the risk of depression. Through topic-specific sessions, men will be invited to engage in workshops that provide information and tools to adopt healthier lifestyles by changes to diet, alcohol consumption and exercise.

“These projects are great examples of small, community-focused initiatives that can have a really big impact on people’s lives,” says Anna Hargrave, South Warwickshire CCG Director of Strategy and Engagement. “We are delighted to be working with them all and look forward to seeing them flourish over the coming months and years. Together, we can make real efforts to ensure that as many people as possible in south Warwickshire lead healthier, happier lives.”



The important messages behind the nationwide ‘mid-life MOT’ are starting to have an impact across south Warwickshire, including hitting home with some of the most hard-to-reach patients.

The NHS Health Check is for adults in England between the ages of 40 and 75 and assesses a person’s risk of developing heart disease and other vascular diseases such as stroke, kidney disease, Type 2 diabetes and some forms of dementia.

After the check, currently available throughout Warwickshire, the person is given advice and support in order to help them reduce their risk and encourage them to use local healthy lifestyle programmes such as stop smoking, weight management, physical activity programmes and others. If necessary, individuals are offered medication to help reduce cholesterol levels and blood pressure.

While the offer of these free checks has been taken up by many local people convinced of their prevention-is-better-than-cure value (between October 2103 and March 2014 more than 4,500 received a health check), for others the effects have proven to be more of an eye opener.

One such patient is 46-year-old Wendy, who for a number of years has been reluctant to visit her GP at Shipston Medical Centre. Phlebotomist at the centre Louise Woolley explains:

‘Mid-life MOT’ starting to check in with even the most hard-to-reach patients

“When Wendy came in for her health check it felt like a real breakthrough. However, while there she made it quite clear that she wasn’t going to change, the whole thing was pointless and no one would be able to persuade her to do anything she didn’t want to. I tried to reassure her that it was all purely for information and spoke to her about her smoking, her high blood pressure, diet and general lifestyle, but when she left all of the information I’d given her I was convinced we wouldn’t see her again.

“You can imagine how surprised I was, therefore, when she returned one month later and discovered that her blood pressure had come down and she had lost 2kgs in weight. She said that as much as she didn’t want to be there, everything I’d said had made sense and so she was making an effort to aim for a proper healthy balanced diet. Because she said she felt much better in herself I told her that I would always be willing to see her and encourage her, and look forward to seeing how much weight she loses over the next few weeks.”

To find out more about NHS Health Checks, visit:

www.nhs.uk/Conditions/nhs-health-check/ Pages/What-is-an-NHS-Health-Check.aspx


New support measures have been put in place that will see the often-complex medical needs of residents in care homes given streamlined attention and, in turn, greatly improve their quality of care.

Via a transparent tender process, the CCG recently entered into additional NHS contracts with GP practices throughout south Warwickshire to provide medical cover to nursing homes in the area. The aim is that one GP practice will look after one care home and therefore provide a single point of contact for medical advice and support. At the present time, contracts have been awarded to GP practices for 20 of the 24 nursing homes in south Warwickshire.

This should help to ensure that local GPs’ time is used to the maximum effect and assist in building strong relationships between practices and nursing homes. Previously, nursing homes have had to work with a number of different GP practices, which made it harder to develop a consistent approach to the care of residents. It will also reduce the over-reliance on emergency services for management of care, improve care planning, especially around discharge and end of life, and enhance communication between the various parties involved in the care of frail and elderly people. All of this will enable patients to choose to die in the home of their choice supported by staff they are familiar with instead of being rushed inappropriately to hospital.

Aim three: To improve the quality of care and transform servicesNew contracts ensure improvements in care of nursing home residents

“This model of care that we have adopted follows experience from elsewhere,” explains Dr John Fullbrook a GP at Clarendon Lodge Practice. “In north Staffordshire where this model has run for over two years there has been a 20 per cent decrease in emergency admissions from nursing homes with additional GP support compared to a nine per cent increase in nursing homes without the service.

“GPs providing this service have more time to listen and respond to what residents and their families want from their care and to explain options to them. It also means that GPs have the opportunity to build relationships with nursing home staff and can help develop their skills and expertise. This ensures that out-of-hours nursing home staff are more confident to manage residents who are unwell rather than calling an ambulance. Overall, there is no doubt that this new contract has improved the care that we offer to this very vulnerable group of patients.”


With widespread improvements in the quality of care for vulnerable people promised following the government review into Winterbourne View, the story of a south Warwickshire teenager is one example of the impact the local changes are having on individual lives.

Led by the Department of Health, the government review was launched after an undercover BBC Panorama investigation in 2011 at Winterbourne View Hospital near Bristol revealed criminal abuse of patients by staff. The review aimed to understand what lessons could be learned to prevent anything similar happening again elsewhere and recommend action to improve the quality of care for vulnerable people throughout the UK.

Since the government report the CCG has worked closely with other CCGs across Coventry and Warwickshire and the two local authorities to develop a joint plan for people with learning disabilities or autism, particularly those who also have mental health issues or challenging behaviour. The plan, backed by Coventry and Warwickshire Health and Wellbeing Boards, describes how we will commission local services so that people no longer have to live in hospitals and how we will work with individuals and families to put patients at the centre of care services.

One such patient is Carl who has a moderate learning disability and autism. When at the age of 17 his behaviour became difficult to manage he was admitted to a local hospital before being transferred to a series of other hospitals and providers of specialist residential care over seven years. Despite some successes with therapy, Carl’s condition became unstable and, as what is often referred to as a ‘revolving door’ patient, he was simply moved around from place to place.

Under the new joint plan, Carl’s issues were examined on an individual basis by a range of people responsible for his care and he now lives back in the community, with his own tenancy and front door, close to his family.

Carl’s return to community life highlights value of joint plan

“The joint plan developed outlines our commitment to working with individuals and families to put patients at the centre of care services. We have tackled this issue person by person and continue to do so to permanently reduce the number of people with learning disabilities and autism ‘living’ in hospital,” says Julie Lakin-Hubball, Strategic and Operational Lead for Mental Health and Learning Disability.

“Without exception everyone deserves a place to call home: no one is too challenging, no one is too complex and no one is too disabled to lead an ordinary life. Carl is a great example of how this approach can be successful. He now has the necessary support of a bespoke commissioned package of care, including support from his local community learning disability team, to allow him to engage fully in his local community. He enjoys gardening and watching and playing football, and chooses and engages in his own shopping and cooking. Carl’s life is not without risk, but he now has a home to call his own.”


A new initiative has been launched that should see major improvements in end of life care for all patients, relatives and carers in south Warwickshire.

Good to Great is the name of the 18-month pilot, launched in May 2014, which aims to improve continuity of care through the adoption of frameworks that will support healthcare clinicians proactively manage end of life conversations and care for patients towards the end of life. This will be achieved through the provision of specialist training, education and support based on evidence-based best practice.

Staff from local charity the Myton Hospice will work with care homes and GP surgeries throughout south Warwickshire to share their experience and knowledge on end of life care. They will highlight best practice and discuss evidence-based practices such as the Gold Standards Framework to help frontline staff tackle this sensitive issue in the most appropriate way in order to ensure unnecessary hospital admissions are avoided and death can be as peaceful and dignified as possible.

Kate Lee, Chief Executive Officer of Myton Hospice, explains why this project is so important: “As an organisation we are committed to ensuring as many people as possible in south Warwickshire have a good death and that their loved ones receive the necessary support. Whether they die with us at Myton, in a nursing home, in hospital or at home, everyone should have the chance to die with dignity and respect. We are looking forward to having the opportunity over the next 18 months to help our south Warwickshire GPs and nursing homes take their standards of end of life care from good to great.”

With the death rate in Warwickshire set to increase by 17 per cent over the next 15 years, and following publication of the government’s End of Life Care Strategy and NHS Outcomes Framework 2013/14, it is now more vital than ever that NHS organisations and hospices think

differently about how they support patients and their families with their end of life choices, as well as collaborate with other sectors that have experience in managing patients towards end of life.

This is also reflected in feedback the CCG has received from both clinicians and patients, who are keen to see improvements in end of life care put in place via a more joined-up approach. As a result, the CCG has made a commitment to improve the care of patients towards the end of life, hopes to see nearly one per cent of the south Warwickshire population have their preference for place of death recorded and is looking for a reduction by 30 per cent in the number of inappropriate patients admitted to hospital from nursing and resident homes.

Myton Hospice was appointed by the CCG to lead this work and support delivery of these objectives after a robust tender process, while at the same time a successful bid was submitted to Macmillan to secure a Macmillan GP for one session per week over the next three years. This role will support local health and social care teams in further improving end of life care services within south Warwickshire by utilising best practice current thinking on care delivery for patients towards the end of life.

Dr Ian Allwood, GP lead on end of life care for South Warwickshire CCG, believes these moves will be of great benefit to patients.

Pilot project provides great opportunity to improve end of life care

“We know end of life care is something very important for our patients and we will be building on all the hard work we have done so far around this area. It is great to be working with an organisation such as Myton, who have so much experience and expertise. I believe there is a lot of good practice out there but there is always room for improvement and with something this important we should always be striving to be the best we can.”



Being settled and happy in a place of choice is what most older people and their families wish for, and it is exactly what 72-year-old Jim* is now enjoying, thanks to the efforts of the multidisciplinary team from an innovative new project.

Discharge to Assess (D2A) is a programme that began in summer 2013 that aims to improve the experience of older patients being discharged from hospital. Involving NHS South Warwickshire CCG, South Warwickshire NHS Foundation Trust, local GPs and Warwickshire County Council Social Care, it is an example of health and social care teams working together to benefit patients who are unable to return home unsupported and who, previously, would have stayed in hospital longer than they needed to.

As part of the project D2A patients are moved out of hospital and into care homes once their treatment is complete in order to have their longer-term needs assessed by a multidisciplinary team. This promotes smoother, more joined-up working, which in turn improves patients’ outcomes, while all professionals working on a patient’s care share the same knowledge and understanding of each case. Regular meetings ensure everyone remains committed to the same goals.

Jim, who had been cared for by his wife following a stroke 15 years earlier, was admitted to Warwick Hospital in 2013 feeling unwell and, while there, developed further stroke and heart problems. This resulted in a number of issues, including lethargy and difficulty understanding what the medical staff were telling him.

As a result, the D2A process was explained and offered to Jim and his wife, a decision she found hard to deal with as she had always cared for him at home. Once she realised the benefits for Jim, however, she gave consent and arrangements were put in place for him to be moved to an interim bed at Avon Court Nursing Home, one of the care homes contracted to provide beds as part of the D2A project.

After only two weeks, and thanks to the individual support provided by health and social care staff,

occupational therapists, physiotherapists and nursing home staff, as well as daily visits from his wife, Jim began to show steady improvement in his all-round health. Further physiotherapy work and help from his carers meant he was soon joining other residents in the lounge or gardens – something that, as a keen nature enthusiast, meant a great deal – and he remained clinically stable.

After five weeks at Avon Court, because assessments deemed Jim not able to return home due to his care needs, a permanent place at a nearby residential home was secured, which is where he is now enjoying his life and independence once more.

Kate Barker, D2A Programme Manager, reveals her delight at the outcome for Jim and his family:

Jim is settled and happy in his home from home, thanks to D2A scheme

“Having cared for my husband for such a long time, deciding to put him in a permanent nursing home was such a difficult decision,” says Jim’s wife. “However, Jim going to Avon Court straight from hospital gave me the opportunity to see what it was like and showed that he enjoyed it and that it was the best place for him. It also gave me more time to make the decision, and we’re now both happy that he is in the best place.”

“The concentrated efforts of all members of the team, each with their own field of expertise, ensured that Jim reached his optimum, and secured the best possible and most suitable outcome, not only for him but his family too. Work such as this is a great example of integration at its best.”


Primary care prescribingIt is estimated that around £300 million worth of medicines a year are wasted in the UK. We are undertaking a number of initiatives to help us reduce medicine wastage in south Warwickshire. Practices in the area have already achieved significant savings and made improvements to how they prescribe medicines for patients within their practices. We will continue to build on this to ensure that patients are receiving cost effective and most importantly appropriate medicines to treat them.


Reducing unnecessary follow upsIt is important that people have confidence that the CCG uses public money wisely that we provide the best possible services, which are value for money. Efficient processes mean lessduplication and waiting, resulting in smoother and more timely care for patients. Patients should not have to return to a hospital clinic for a follow-up appointment if they do not need to. We have looked at how we can free up both patient time and clinical capacity by reducing the number of unnecessary follow-up appointments. The aim is to support people appropriately outside of a hospital or clinical setting with advice on how to manage their recovery. It is hoped that this initiative will also reduce waiting times for patients.

Aim four: To make the best use of our resources


Our future plansOver recent months we have worked closely with the other CCGs and local authorities in Coventry and Warwickshire to agree a joint vision for what health and care services will look like in five years’ time.

We have created a document titled Transformational Change: Transforming Lives, which describes the changes we will work together on. This does not change our local plan but instead makes sure that we are all working in a way that supports each other. We know that the document contains some ambitious targets, but we are confident that we will deliver these in south Warwickshire by continuing to work on our four aims and 12 objectives.

We have recently published our plans for the next two years (2014–16), which explain how we are going to continue on the journey we have started to deliver better healthcare for everyone. We know that we still have a lot of work to do to achieve these plans, but are very much looking forward to the challenge.

You can access this document online at: www.southwarwickshireccg.nhs.uk



Our appeal to youThe vision of the CCG is to build relationships with patients and our communities to improve health, transform care and make the best use of our resources.

To do this, we need to make sure that patients are at the heart of all we do, and so we are working hard to give local people the chance to work with us in order to influence decisions and shape services.

There are two main ways you can get involved:

Become a Health ChampionWe currently have over 1,000 Health Champions in south Warwickshire, who have signed up to help improve and develop services in their area. We really value their input, which is gathered via surveys and consultations, events, health seminars and other regular engagement activities.

To find out more about becoming a Health Champion, call 01926 353810 or email: [email protected]

Health Champions

Join our Patient and Public Participation Group (PPPG)

The South Warwickshire PPG was set up to bring together in one place the views of the different GP practices’ patient reference groups (the Chair of each represents their group on the PPPG). The group also contains members from independent patient groups and voluntary sector representatives to ensure a wide cross-section of views are continually gathered. The CCG consults the group for feedback on a variety of issues, which in turn influences our commissioning decisions.

To become involved with the PPPG ask at your local GP practice about joining their patient participation group.

NHS South Warwickshire Clinical Commissioning GroupA

NHS South WarwickshireClinical Commissioning GroupWestgate House Market Street WarwickCV34 4DE Telephone: 01926 353 700Fax: 01926 495 074 Email: [email protected]

This report is a summary version of our Annual Report 2013/14. The full version of the report is available online at www.southwarwickshireccg.nhs.uk

SUMMARY ANNUAL REPORT - southwarwickshireccg.nhs.uk

Documents

Transcript of SUMMARY ANNUAL REPORT - southwarwickshireccg.nhs.uk