Thursday 2nd July 2015

CCG Clinical Commissioning Forum

What is HIE?HIE = Health Information Exchange

• Technology to query and view data to create a consolidated virtual patient view from more than one IT System

• Vendor neutral• Joint venture between Homerton Hospital & C&H CCG to

start joining data sources across City & Hackney

Health Information Exchange UpdateThursday 2nd July 2015

Clinical Commissioning Forum

HIE: Phase OneHUH Acute: Cerner Millennium Data

• Admissions & Visits• Future appointments• Basic clinical information• Pathology and Radiology results/reports• Discharge Summary• Future Appts

HUH Community: RiO Data (Coming Soon)• Basic clinical information• Visit Data

City & Hackney GPs: EMIS Data (via MIG)• EMIS Summary Care View

Demo – Cerner Millennium

Demo – Cerner Millennium

Pilot UsagePilot of GP HIE service ran at Barton House Practice• Apr 15 – 144 Patient lookups

Pilot of Acute HIE service ran at Homerton A&E department• May 15 – 52 Patient lookups, 7 Emergency lookups

Activating HIE across City & HackneyEMIS

• GP Connectivity to HIE in two parts• Data Sharing Agreements activated (40/43) 93%• Cerner Portal Tab activated (14/43) 33%• EMIS upgrade to v5 caused delays with rollout• Currently resolving N3 networking issues for rollout

Project RolloutEMIS Users - GPs

• Susan Leake visiting practices for set-up and trainingEPR Users - Acute

• Clinicians to have access across the trust within EPR in next few weeks

RiO Users - Community• Web portal version to rollout to key Community Clinicians

Future Phases• Extra MIG Views• Mental Health• BLT Link

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Children’s and Maternity Programme Boards Joint CCF Background Report

Maternity and Early Years (0 to 5) Services:

Pathways & Development Ideas

1. What are the current health priorities?

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Key factors for consideration:

• Low rates of immunisations for children and pregnant women

• High levels of complexity in pregnancy (social and medical)

• Poor oral health in children

• High rates of infant mortality

• High rates of low birth weight babies

• High rates of child poverty & family homelessness

• High rates of A&E attendances (under 4’s)

• High rates of hospital admissions for asthma (under 19’s)

• High rates of child obesity for 4/5 and 10/11 year olds

• Children from BME groups around 85%

Sources: City and Hackney 2014 JSNA and Hackney and City of London Child Health Profile 2014 and 2015 Chimat

20,400 children aged 0-4

4,500 live births per

year

Very high levels of

deprivation

2. What is commissioned now?

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Commissioner Programme Board

Contract Content / Priorities

CCG Maternity • Homerton Maternity service • Antenatal and postnatal GP contract• Hackney Play Bus – Bonding with

Baby• Targeted antenatal classes• MSLC development• Breastfeeding support • Mothers champion pilot

• Antenatal, birth and postnatal service• 16 week AN & 6w PN checks including risk

assessment, liaison with midwives and identifying vulnerable women

• Support for vulnerable new mums and families• Antenatal classes for women who don’t attend NHS

classes• Strengthening involvement of women in service

developments

CCG Children’s • VCC• Social Prescribing pilot• Epilepsy Nurse • Interface Paediatrician• MARAC service • SEND designated medical officer

• LTC identification and management / oversight• Vulnerable children through MDT with HVs• Identification of child carers• Up-skilling GPs and bringing paediatrics to primary

care• You’re Welcome – GP practices

CCG Mental Health • CAMHS follow up• Self Harm follow up

LBH N/A • Health Visiting• Children’s Centres• Family Nurse Partnership• Weight management

NHS England N/A • Immunisations Increasing rates of childhood immunisations and maternal flu vaccinations and

3. Feedback from CEC

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• Support for developing care pathways – to ensure a clear journey, joined up services and a strong service offer.

• Also support for “navigators” in primary care for families with additional needs – such as socially vulnerable families and children with LTCs / disabilities.

• Greater focus on emotional wellbeing and mental health for parents and children including enhanced screening in primary care.

• More focus on identifying risk as early as possible for pregnant women and families.

• Introduction of primary care pre conception support for targeted groups.

4. Universal pathway: Antenatal

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1st contact with health

professional (proposed to

commission GPs)

Anomaly scans at

18-20 weeks

31 weeks (nulliparous

only)

28 week appointment(midwife and health visitor)

34 week appointment

41 week

25 weeks (nulliparous

only)

16 week appointment

(GP)

Booking appointment –

target of 10 weeks

36 week appointment 38 week

appointment

40 week (nulliparous

only)42 week

Early scans (11-14 weeks)

Targeted pre-conception care? GP?

Maternal Flu jabs?

Boxes are midwifery led, or Obstetrician led in more complex medical case

CO screening (smoking) by midwives?

5. Universal pathway: 0-5

24/48hr post discharge

visit @ home (midwife)

6 week maternal

review with focus on MH

(GP)

2nd immunisation 2 months(GP / PN)

1st immunisations

1 month(GP or practice

nurse)

3rd immunisations

(GP / PN)

Immunisations 3-4 years (GP / PN)

6 week baby review (NIPE)

(GP / paediatrician) &

& BCG (PN)

New birth visit 10-14

days(Health visitor)

Newborn blood spot 6-8 days (midwife)

Child development review 8-10 months (HV)

Immunisations 12 months (GP / PN)

Newborn hearing

screening 0-3 months

(screeners)

Newborn exam (NIPE)

by 72 hrs (midwife)

Child development

review 2-3 years (HV)

New HV commissioning may mean support but

not delivery of immunisations…

Child health clinics

design?

6. Targeted and specialist pathways• Recognise the impact each stage of the pathway has on the achievement and

emotional wellbeing of the parent, child, and family at the next stage of their development.

• Services commissioned along individual conditions or need cluster pathways.

• Alongside the clear and comprehensive universal offer have easy access to targeted care

for:• Vulnerable women, children and families

• Children with LTC / complex care needs

• Children with special educational needs and disabilities (SEND)

• Maternal and child obesity

• Maternal or child mental health needs

• Safeguarding including child protection

• Promote continuity of care wherever possible.

7. Enhanced Primary Care antenatal offer

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A. Targeted preconception care for women with chronic diseases.

• Diabetes, Hypertension, Asthma, Epilepsy, Mental health needs, Thyroid disease and Rheumatological conditions

• Women with complex medical/obstetric history or with more than one chronic disease should be referred to the pre-conceptual clinic at the Homerton.

• Wider health promotion on preparing for a healthy pregnancy (healthy eating, physical activity, stopping smoking, folic acid/healthy start vitamins, early booking, antenatal classes) part of universal pathway.

B. Pregnancy presentation appointment (1st contact)

• Patients who present to their GP when first pregnant

• receive advice on diet, smoking, alcohol and healthy start vitamins, have their BP and BMI checked, be prescribed aspirin if indicated

• Have a social psychological and medical risk assessment undertaken

• Have medical issued addressed e.g. thyroid, mental health, asthma

• be referred on for antenatal care

• be referred for specialist services if indicated, e.g. MH, voluntary sector services

C. Strengthened liaison between GP, midwife and health visitor

• A joint meeting scheduled between all 3 agencies to discuss vulnerable families?

8. Enhanced Primary Care 0-5 offer

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Enhanced Child Health Clinic in each quadrant

Referring families with medical and/or social needs Referring families who cant access clinic at their own GP practice Opportunistic health checksImmunisations Involvement from GPs, Practice Nurses, Midwives, Health Visitors, Community Paediatricians, Navigator

Navigator / Clinical coordinator per quadrant

Key worker for children with LTC,Liaison and follow up with secondary care (e.g. admissions) Information sharing with primary care, liaison with practice specialist nurse

Helping keep children with LTCs out of hospital by better coordination in primary care

Children’s Continuing Care Nurse in each quadrant

New requirement to have named CCN per GP practiceMonitor care of children with complex care needs, update practices on needs and treatment of children.Support families in accessing support servicesUpdating continuing care plans (where required)

As well as enhanced support for Primary Care

Support and education for primary care on child health (up-skilling)Immunisation support (to increase local uptake) Information sharing framework (e.g. delivering MDT meetings for vulnerable families)

Existing Universal

Healthy Child Programme

Offer delivered by Primary

Care:

6 week mother and baby

checks, BCG and child

immunisations up to age 5

9. Questions for CCF • Should we re-configure child health clinics? What works

well and less well right now?• What role should community paediatricians play in these

clinics? Rarefied and costly resource – focus on frequent flyers, LTC management, disabilities?

• How could navigators or clinical co-ordinators work? 1 per quadrant, link for families, organise MDT, follow up, focus on reducing hospital use?

• Do GP practice staff need any support in the delivery of childhood immunisations?

Children’s and Maternity Programme Boards Joint CCF Report

Maternity and Early Years (0 to 5) Services:

Pathways & Development Ideas

1. Feedback from CEC

20

• Support for developing care pathways – to ensure a clear journey, joined up services and a strong service offer.

• Also support for “navigators” in primary care for families with additional needs – such as socially vulnerable families and children with LTCs / disabilities.

• Greater focus on emotional wellbeing and mental health for parents and children including enhanced screening in primary care.

• More focus on identifying risk as early as possible for pregnant women and families.

• Introduction of primary care pre conception support for targeted groups.

2. Enhanced Primary Care antenatal offer

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A. Targeted preconception care for women with chronic diseases. • Diabetes, Hypertension, Asthma, Epilepsy, Mental health needs, Thyroid disease and

Rheumatological conditions

• Women with complex medical/obstetric history or with more than one chronic disease should be referred to the pre-conceptual clinic at the Homerton.

• Wider health promotion on preparing for a healthy pregnancy (healthy eating, physical activity, stopping smoking, folic acid/healthy start vitamins, early booking, antenatal classes) part of universal pathway.

B. Pregnancy presentation appointment (1st contact)• Patients who present to their GP when first pregnant

• receive advice on diet, smoking, alcohol and healthy start vitamins, have their BP and BMI checked, be prescribed aspirin if indicated

• Have a social psychological and medical risk assessment undertaken

• Have medical issued addressed e.g. thyroid, mental health, asthma

• be referred on for antenatal care

• be referred for specialist services if indicated, e.g. MH, voluntary sector services

C. Strengthened liaison between GP, midwife and health visitor • A joint meeting scheduled between all 3 agencies to discuss vulnerable families?

3. Enhanced Primary Care 0-5 offerEnhanced Child Health Clinic in each quadrant

Referring families with medical and/or social needs Referring families who cant access clinic at their own GP practice Opportunistic health checksImmunisations Involvement from GPs, Practice Nurses, Midwives, Health Visitors, Community Paediatricians, Navigator

Navigator / Clinical coordinator per quadrant

Key worker for children with LTC,Liaison and follow up with secondary care (e.g. admissions) Information sharing with primary care, liaison with practice specialist nurse

Helping keep children with LTCs out of hospital by better coordination in primary care

Children’s Continuing Care Nurse in each quadrant

New requirement to have named CCN per GP practiceMonitor care of children with complex care needs, update practices on needs and treatment of children.Support families in accessing support servicesUpdating continuing care plans (where required)

As well as enhanced support for Primary Care

Support and education for primary care on child health (up-skilling)Immunisation support (to increase local uptake) Information sharing framework (e.g. delivering MDT meetings for vulnerable families)

Existing Universal

Healthy Child Programme

Offer delivered by Primary

Care:

6 week mother and baby

checks, BCG and child

immunisations up to age 5

4. Questions for CCF • Should we re-configure child health clinics? What works

well and less well right now?• What role should community paediatricians play in these

clinics? Rarefied and costly resource – focus on frequent flyers, LTC management, disabilities?

• How could navigators or clinical co-ordinators work? 1 per quadrant, link for families, organise MDT, follow up, focus on reducing hospital use?

• Do GP practice staff need any support in the delivery of childhood immunisations?

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2 JULY 2015

CHANGES TO THE CLINICAL COMMISSIONING FORUM

Changes made

• Speakers reminded to keep to time• Presentations limited to 5-6 slides• Discussion items distributed before the CCF• Making changes to presenters coming along to talk about their

service• Not booking slots at the CCF and Consortia meetings unless

requested to do so by Consortia Leads• Summary notes prepared and included on the CCG website with

agenda/presentations• Members Forum now a separate part of the CCF• Process in place to record votes

Clinical Commissioning Forum

How’s it going?

Are the changes working?

How would you like to be consulted on with the Commissioning Intentions?

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Dr Gary Marlowe

Planned Care Board

Developing Community ENT services

The current community service provision -

Lower Clapton Service offer Service details Conditions treated

• Consultant & GPSI• One day a week – Capacity varies

15-30 patients• Undertake diagnostic tests• Provide follow-up where clinically

relevant• Offer choice of referral to

secondary care where surgical intervention is required

• 5 week waiting times• Patients usually only seen

once or twice• Carries out diagnostic

procedures plus nasal cautery, Pure Tone and micro suctioning of ears

Aural Toilet, Otitus Externa, Otitus Media, Perforation of eardrum, Nasal Polyps, Chronic Nose Bleed (Epistaxis), Recurrent tonsillitis (for advice), Globus, Tinnitus, Nasal Trauma non urgent, Mastoid Cavities requiring evaluation and toileting, Dizziness / Vertigo, Sinusitis, Impacted Ear Wax removalOther ENT conditions suitable for the service

AQP Hearing test Service offer Service details Conditions treated

The Direct Access Adult Hearing Service is for adults over the age of 30

with suspected or diagnosed age related hearing loss

• Waiting - 16 days/ 20 days• Locations: Royal London,

John Scott, Islington Medical Centre

Hearing tests and hearing device fitting and maintenance

Proposal for new service model

•Integrated approach between ENT at Homerton and

community service allowing for Direct listing (where appropriate)

•Integration with some audiology service support – this may include basic hearing tests but possibly other pathways•GP focussed education and training for ENT (Tinnitus etc)•Shorter waiting times by increasing capacity and days of operation•Operate from 2 or more sites

Continued

• Advice line and/or email for GP diagnosis and management

• Emergency Clinic pathway (Homerton?)

Next steps

• The GP group at our initial workshop will act as a reference group throughout this development

• Views on the model proposal from GP members, HUH and Barts invited to participate, finalise and agree the service specification

• Patient feedback – generally patients appreciate the community option though further work will be undertaken in refining the service specification

• Model and cost the service, capacity and determine an appropriate % shift in first attendance activity from secondary care

• Agree community price and contracting options for 16/17• Agree the non –recurrent investment and the shift from secondary

care to secure the service on a recurrent basis

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Dr Gary Marlowe

Planned Care Board

Developing Community Dermatology services

Current Service Issues - • Long waits in secondary and community for routine• GPSI community locations limited (mostly John Scott)• Knowledge and skills vary across practices• High 2 week waits for changing moles• GP focussed education needed• Acne clinics referred via secondary care• High DNA and FU in community GPSI service• GPSI - Poor communications – no discharge/outcome

letters• Lack of clarity of offer from GPSI service (Children)

Proposed changes• Re negotiate GPSI Service to take role of front line

service for dermatology (See – Treat – Discharge)by providing:

Discharge and management plans for GPs Clinical advice and GP focussed education Clear offer different from secondary care that includes

children and develops pathways (acne)

• Embed KPIs around discharge/outcome letters, follow up ratios, DNAs and reporting

• Review capacity for GPSI service post changes & teledermatology (if taken forward)

Continued

• Investigate teledermatology with Homerton to improve primary care referral

• Develop community pathways across primary, intermediate (GPSI) and secondary care

Next steps

• The GP group at our initial workshop will act as a reference group throughout this development

• Views on the model proposals from GP members and HUH to participate, finalise and agree changes to service specifications and pathways

• Patient feedback – generally patients appreciate the community option though further work will be undertaken in refining the service requirements

• Develop business case for Homerton teledermatology via GP practices

• Re-model and cost the GPSI service, capacity and determine an appropriate % shift in first attendance activity from secondary care

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The Contracts Committee approved the ICBCF Programme Board recommendation to roll-over the existing Community

Matrons service up till September 2015

Total Value of the contract: £258k pa

The Community Matrons are employed by Elsdale and Shoreditch practice and are a resource to their respective Consortia. The service has been operating for a number of years and these are legacy contracts inherited by the CCG. The CCG is now in the process of going through the advised procurement process and appropriate contractual framework.

The ICBCF Programme Board is reviewing this service with the intention of submitting an options appraisal paper to Sept 15 Contracts Committee. The Forum is requested forum to consider, discuss and feedback on the following points

Benefits of existing model to all Practices. Would a similar model work for all 4 Consortia?

Is the existing model working? How well is it linked with HUH Community Matrons?

Ideal Community Matrons service model in City and Hackney

Practice Based Community Matrons Contract

Elsdale Street Surgery: £139kShoreditch Park Surgery: £129k

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