Southall Initiative for
Integrated Care
Stakeholder Workshop
18th November 2010
Neighbourly Care, Southall
Aims
1. Identify lessons from 2010 projects
2. Generate consensus about 2011 projects
3. Suggest how the Southall model could
help GP Commissioning
Annual Learning Cycle
November
Endings and Beginnings
1 Identify new priorities
4 Feedback conclusions
February
Training
July
Agree Coordinated
Actions
3 Agree pilot changes &
improvement measures
April
Review Rapid Appraisals
2 Shape new Projects
5 Showcase completed
projects
Southall Initiative for Integrated Care
Debate Priorities. Stakeholder Workshop
Date
Venue
Tasks
Wed 25th Nov 2009
Milan Palace, Southall
Listen to perspectives. Identify priority issues
Dec – Feb. Form Core, Project and Oversight Teams. Secure all formal approvals including access to databases. Test extraction
of data. Form team to redesign website. Prepare leadership course (course materials, accreditation, mentors).
E-Star Training
Date
Venue
Tasks
Wed 10th Feb 2010
Dominion Centre
Respond to learning needs expressed. Pilot questionnaires
Feb-Apr. Rapid Appraisals, system models & baseline data. In-practice learning. REC Approval. Recruit into leadership course.
Agree mechanisms to connect with Integrated Care Organisation, Health Communities and Polysystems.
Shape system-wide changes. Stakeholder Workshop
Date
Venue
Tasks
Thurs 22nd Apr
2010
Neighbourly Care, Featherstone Rd
Review information and progress. What now needs to be known?
Apr-Jul. Find required information. Set up database searches. Test website. Residential teambuilding workshop. Start leadership
course. In-practice learning.
Agree pilot system-wide changes. Stakeholder Workshop
Date
Venue
Tasks
Thurs 8th Jul 2010
Neighbourly Care, Featherstone Rd
Agree pilot changes in each theme and improvement measures.
Jul – Nov. Pilot changes. Ongoing Improvement Measures. Monthly action learning sets. Local focus groups and in-practice
support for learning and data-gathering.
Southall Initiative for Integrated Care
Conclusions. Stakeholder Workshop
Date
Venue
Tasks
Thurs 18th Nov 2010
Neighbourly Care, Featherstone Rd
Feedback conclusions. Identify new priorities
Nov – Feb. Gather data. Compare outcomes with other places. New project teams lead new priorities, learning from previous year
teams.
E-Star Training
Date
Venue
Tasks
Jan – March 2011
Various
Training in the new systems and use of web resources.
Feb – Apr. Write training manual about how to use this approach in other PCTs. Put information on website.
Showcase the projects. Shape new projects. Stakeholder Workshop
Date
Venue
Tasks
Thurs 7th Apr 2011
TBC
Critique Handbook. Export to other places.
Apr – Jul. Papers for publication. Present at Conferences. Complete leadership course. Close down this cycle of inquiry and
action, as the next cycle gathers pace.
Southall Initiative for Integrated Care - Professional engagement by type
Professional engagement by type
Number of attendees
70
60
50
40
30
20
10
0
25-Nov-09
Identify Priorities:
First stakeholder
w orkshop
10-Feb-10
22-Apr-10
28-30 April-10
08-Jul-10
Southall Collaborative Shaping SystemTow ards Local
Agreeing the Pilot
Learning Workshop:
w ide Changes:
Health Communities: Projects for 2010 and
E-star Training
Second stakeholder Residential w orkshop Priorities for 2011:
Event title
Academic & Applied Research Unit
Commissioning
Community Services
General Practice
IT & Education
Local Government
Mental Health Intermediate Care
Public Health
Senior Management
Specialist Services
Patient & Voluntary Groups
Relay race
Boundary spanning
Community Learning
Southall Initiative for Integrated Care
Nov 2009-2010
Diabetes
Neha Unadkat
Jayshree Patel
Harpal Rai
National Situation
Diabetes UK Statistics:
– 2.8 million people have diabetes in the UK (2009)
– 16% have undiagnosed diabetes (0.5 million people)
– By 2025 > 4 million people will have diabetes
Risk:
– South Asian, African, African-Caribbean, Middle-Eastern populations
have higher than average risk of Type 2 diabetes
– Poor quality of care received by less affluent and socially excluded
people, e.g. prisoners, refugees, people with learning disabilities or
mental health problems
Complications
– Diabetics have higher emergency admissions than the general
population from complications - coronary heart disease, stroke, peripheral
vascular disease, kidney damage and failure, infections and other conditions
Local Situation
Local diabetes prevalence
• 18,878 diabetics in Ealing (4.97%), 7,773 in Southall (6.97%)
• 29% of Ealing’s population live in Southall, but 41% of diabetics live
in Southall
• 1,413 diabetic patients from shared practice population of 17,350
(8.14% prevalence, April 2010)
• Ethnically diverse population in Southall
• In Ealing, Emergency admissions rose by 95% between 2003/04
and 2008/09
The Project
PCT Project Group
Southall Pilot Practices
1.
Oversight of Southall project
1.
Two patient consultation
workshops
2.
Link with Ealing-wide
developments for diabetes
2.
Baseline data assessment
3.
Specialist Diabetic Clinic to
enhance practice systems
3.
Link with hospital-led
diabetes care pathway
improvements
1. Patient Consultations
55 diabetic patients from all pilot practices participated in two
workshops. Patients strongly recognised the important role of general
practice as a source of advice and information
Patients want:
•
More support and encouragement to manage their own condition
•
Patient support groups
•
More patient education about
–
–
–
–
Medication
Diet and cooking for entire family
Foot care
Exercise
2. Baseline Data Assessment
•
We looked at the QOF data as a group and found that we were very good at
recording:
–
–
–
–
–
–
–
–
BMI,
retinal screening,
peripheral pulses,
neuropathy testing,
blood pressure
micro-albuminuria testing,
eGFR or serum creatinine and
total cholesterol
But:
• As a group our HbA1c control needs improvement
And:
• The exception reporting in some practices is unusually high
3. Specialist Diabetic Clinic to enhance
practice systems
Clinical Competencies: Knowledge, skills, consultation styles,
competencies framework
Effective Care Planning: Good control as manifested by HbA1c
measurements, negotiated and understood person centred care
plans, targeted interventions, goal setting
Effective self care: Patient held records, literature for self-help
resources, patient education about self-management, education for
the wider family
Governance: Call and recall systems; protocols for blood and urine
tests, systems to capture regular non attendees, language alerts on
practice systems
Recommendations to Other Practices
Recognise key role of receptionists
• Training for receptionists so they can advise patients
Improve communication during consultations
• Encourage patients to bring an interpreter
• Include alerts on patient’s notes about interpreter requirements
Devise strategy to reach patients that regularly DNA
• Receptionists book patients for review opportunistically
• Where possible have HCA available for on the spot review
2011 Action Plan
1.
Training for all practice staff including receptionists
2.
Up to date literature in a variety of languages
3.
Continue close working with diabetes specialist nurse
4.
Monthly meetings inside practices and quarterly meetings of whole
group to oversee developments and communicate findings to the
GP Consortium
Recommendations for the Future
1. Expand links between the Southall Initiative and Ealingwide strategic developments
2. Develop the Intranet to support decision-making for
diabetes care
3. Continue to gather data to scrutinise performance across
Southall
Recommendations for the Future
4.
Scrutinise and pilot improvements at each stage of care
pathway
•
•
Screening – who to target and how?
Entry into the system – the newly diagnosed diabetic (including
emotional support)
Care planning – goal setting, treatment plans, monitoring, review
Involvement of/referral to extended team members – dietician,
specialist nurse, eye care, self help groups, education programmes
•
•
5.
Improve practice skills at dealing with depression in
diabetics
Acknowledgements
Pilot Practices
(GPs and other practice staff)
•
•
•
•
•
•
Health promotion Centre
Northcote Medical Centre
Somerset Medical Centre
St George’s Medical Centre
Sunrise Medical Centre
The Town Surgery
Diabetes UK
•
Roz Rozenblatt
Wider team
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Harpal Rai (and DSN team)
Dawn Stewart (and Podiatry team)
Diljit Sidhu (and Dietetics team)
Dawn Karim
Jo Snowden
Louise Taylor
Rachel Krausz
• Dr Kevin Baynes
Gilly Stoddart
• Dr Sanjeev Mehta
• Satty Aulakh-Clarke
Paul Thomas
• Laura Windebank
Debbie Kelly
Sapna Chauhan • Dr A K Sandhu
Sheelah Watson • Dr P J Sandhu
• Dr Sandar Cho
Raj Swaris
• Cyprian Okoro
Sylvia Parry
Southall Initiative for Integrated Care
2009-2010
Support for Children & Families
Camille Adams
Mary Ford
Sumarah Iqbal
Dr Qadan
National Situation
Between 1999 and 2009 the Government published over 20 policies
relating to the health of under fives
Key points:
• An increase in Childhood Obesity prevalence
• Factors affecting the health of children include lifestyle, socio-economic,
cultural and environmental factors
• A decrease in the uptake of MMR from 93 to 89%
• The need for local services to work together to improve the health of
children
• The need to increase the level of GP engagement in delivering high quality
care for children and their families
The Project
1.
Rapid appraisal including perspectives of a) GPs, b) Local support
agencies for children and families c) Public Health
2.
Develop a Children and Families Directory for general practice
3.
Support practices to refer to MEND and SAFE
4.
Support practices to act on their ideas for improvement
1. Rapid Appraisal
General Practice Perspective
•
•
•
Agreement that social needs affects physical health, but no easy way to refer to,
or work with other agencies
Insufficient awareness of what different agencies offer
Need for guidelines for referral and easy self-referral
Perspective of Voluntary Groups and Children’s Centres
•
•
These groups are (unlike general practice) well informed about the range of
services that can support children and families
Children’s Centres staff are keen to work in partnership with a range of health
colleagues including general practice
Public Health Perspective
•
Several initiatives operate to improve the wellbeing of children and families, e.g.
MEND and the Childhood Immunisation Programme
2. Directory of Local Services
3. Referrals to SAFE
Number of referrals to SAFE
Referrals from Health Professionals
to SAFE
GP
Health Visitor
Other
225
18
200
16
175
14
Number of Referrals
Number of Referrals
Unknown
Health Professional
Non Health Professional
150
125
100
75
50
12
10
8
6
4
25
2
0
0
April - Sept 2010
Other Dr
Midwife
Unknown
April - Sept 2010
4. GP Achievements
• Increased awareness of need. Now approx. 2-3 times
each week GPs direct patients to receptionist for further
information about a service
• Increased awareness of need for self referral - patients
are very happy to self refer
4. Receptionist Achievement
• Increased knowledge about local support for children
and families
– Visited local community groups to establish relationships
– Used the Children and Families Directory
– Handed out literature in the surgery
Recommendations
to Other Practices
1.
Develop receptionist to keep up to date information about local
support for children and families
•
•
•
Display posters and leaflets about e.g. domestic violence, housing,
isolation and depression, drop-in centres for children, nurseries,
playgroups, debt advice
Hand out leaflets
Outreach
2.
Visit and befriend local support services
3.
Invite leaders of local services to visit the practice and continue
debate about collaborative improvements
2011 Plans
1.
Each cluster practice will continue present success areas:
•
•
•
2.
Develop reception as information repository with a lead receptionist
Monitor referrals to MEND, SAFE and other services for children & families
Build relations with schools and other agencies
Cluster practices will meet together quarterly to oversee:
•
•
•
3.
Recommendations to Southall practices
Support the PCT in developing the Intranet and coordinated data gathering
Collaborative working with school nurses, health visitors and others
Need to do a rapid appraisal of new issues that have become priorities:
•
•
Domestic violence
Partnership e.g. with school nurses to improve immunisation uptake
Acknowledgements
• SAFE
– Nick Bidmade
– Chantelle Antoine
• General Practice
–
–
–
–
–
Dormers Wells Medical Centre
KS Medical Centre
Chepstow Gardens Medical Centre
The Saluja Clinic
Southall Medical Centre
• Children’s Centres Project Manager, Southall
• Shilpi Mehra
Southall Initiative for Integrated Care
Nov 2009-2010
Dementia
Lynne Read, Sujoy Mukerjee, Frances
English, AK Sandhu
National Situation
National dementia strategy and NICE decision to treat Alzheimer’s at
an early stage have refocused attention on dementia care. Early
dementia diagnosis is desirable because:
1. Anticholinesterase inhibitors can help ~20% of patients with
dementia
2. Diagnosis permits family conferences to plan coordinated care, e.g.
writing advanced directives when a patient is still able to make
informed decisions. This reduces need for institutionalised care
3. Diagnosis provides impetus to preventative efforts including control
of diabetes & hypertension, and attention to problem drinking &
good mental health
4. Diagnosis helps access resources for patients and carers
Local Situation
Expected numbers of patients
– Estimated number of people with dementia aged >65 = 5%
– Number diagnosed on Southall GP registers = 289
– Expected number of patients on GP registers = 498
The CMHT asked pilot general practices their views:
–
–
–
–
The referral form for dementia is cumbersome
Help with acute dementia crises is slow and unreliable
What happens to referred patients is not clear
Uncertainty when and how to screen for dementia, especially in
languages other than English
– Uncertainty of what practical help can be offered to patients &
carers
The 2010 Project
1.
a) Audited the number of patients with diagnosis of dementia on
GP Computer systems, b) Audited numbers of patients referred
for memory decline from pilot practices
2.
a) Improved the referral form for patients with suspected
dementia, b) Revised procedures for supporting GPs with a
difficulty, c) Developed a new memory clinic in William Hobayne
Centre for patients aged under 65
3.
Translated the Mini Mental State Examination into Hindi and
Punjabi
4.
Worked with partners to link the Southall work into an Ealing-wide
strategy for 2011: a) Dementia Concern, b) General Practices
E85743
E85733
E85721
E85656
E85623
E85103
Y01221
E85745
E85731
E85717
E85682
E85671
E85663
E85633
E85121
E85119
E85096
E85090
E85083
E85061
E85051
E85049
E85023
E85012
E85006
Number of dementia patients per 1000 patients
1a. GP dementia diagnosis audit
Number of dementai patients per 1000 patients for Soutall Practices
30
Pilot practices
25
20
15
10
5
0
1b. Dementia referral audit
Referral for memory decline
Practice Number
Practice
Nov 2008-Nov 2009
Nov 2009-Nov 2010
E85717
Western Road Surgery
1
0
E85006
Waterside
1
1
E85049
Belmont Medical Centre
1
1
E85090
Hammond Road Surgery
2
1
E85061
Norwood Road Surgery
2
3
Y02342
Bondcare
N/A
4
Note: Bondcare established in April 2010
4a. Dementia Concern
• DVD on dementia in different languages
• Able to befriend and support
• Drop in Centres
• Multi-lingual staff
4b. General Practice
• Patients and families know and trust GPs
• GPs can screen at an early stage
• GPs can prevent deterioration of dementia by
controlling blood pressure, diabetes and stress
• GP recall systems can help follow up patients
Recommendations
to Other Practices
• Screen & Refer
• Monitor & Recall
• Health Promotion
Proposals for 2011
• Quarterly steering group meeting to oversee dementia plan in Southall
– Embed the referral form on EMIS computers
– Audit referrals from all Southall practices
– Audit numbers of patients with dementia, number and cost of unscheduled
care (including admissions) by practice
• Develop a ‘Supporting Dementia at Home Pack’
– For families and carers as well as individuals
– Information about making wills, family conferences, end of life planning,
posting Special Patient Notes, advanced directives
– Tactics to support someone with dementia at home
• Develop a ‘Primary Care Resource Pack’
– How to identify and refer for dementia, and avoid deterioration
– Mini-Mental State Examination in various languages
– Facts and Figures, a) Care Pathways and care options, b) Supporting
Dementia at Home Pack, c) Posting Special Patient Notes
Acknowledgements
General Practices
Waterside Medical Centre
Norwood Road Surgery
Belmont Medical Clinic
Hammond Road Surgery
Featherstone Road Health Centre
Western Road Surgery
Dementia Concern
Community Mental Health Team
Southall Initiative for Integrated Care
2009-2010
Helping people of BME background with
depression / anxiety
Kiran Sharma
Dr Mohan
Nina Kaler
Mohammad Shuja Hoda
Mandy Hewey
Damayanti Modi
Mental Health Statistics
• One in four GP consultations have a mental ill-health
component.
• At any one time one worker in five will be experiencing
depression, anxiety or problems relating to stress.
• “In general, rates of mental health problems are thought
to be higher in minority ethnic groups than in the white
population, but they are less likely to have their mental
health problems detected by a GP.” (National Institute
For Mental Health In England, 2003)
Project Overview
Aim:
• To make it easier for users to access services for
common mental health problems, and improve access to
psychological services for people of ethnic minority
background.
Key Challenges:
• Ensure good access for all groups
• Minimise waits
• Match need to skill within stepped care framework
• Optimise cost effectiveness
• Ensure data collection
Accessing the Mental Health
and Well-being Service
Community Groups
Resident
in Southall
GP
Occupational Health
Secondary MH
Self
Referral
Formal referral
by professional
Telephone Assessment
Flexible Engagement, Full Assessment & Treatment
Project achievements 2010
Provided an integrated service that:
• educated patients to be their own therapists,
• improved their well being,
• reduced the risk of recurrence and
• promoted social inclusion.
Increased number of referrals from BME groups
Anxiety and Depression in Hard to reach groups
NHS Ealing and Central and Northwest London Mental Health Trust Project Team
INTERVENTIONS
DRIVERS
AIM
Improve
accessibility to
Mental Health
(MH) services
for hard to
reach groups,
including BME
groups, Older
People and
disabled
people
Key:
Ealing site
Both sites
CNWL site
Increase awareness
amongst general
population
Training for Community Centre Staff
Health promotion events
Liaise with community leaders – link worker
Education in the community
Community based radio and newspapers
Posters in key strategic areas, and business cards
Set up website
Promoting self-referral
Increase number of
self-referrals
Improve
appropriateness &
increase numbers of
GP referrals
Improve client
experience
GP- prompted self-referral
systems set up for receiving and managing self-referrals
Ealing Matters & GP magazine
Go to Practice Managers meetings
Go to Practice Based Commissioning meetings
Education of other health professionals
GP increased awareness & engagement
GP liaison: MHWBS in person in practices
GP education & awareness of MHWBS
Learning Packs
Training of Practice Managers & other staff
MH measures translated into other languages and audio
Translation
Multi-lingual staff
Multi-lingual call back service
Materials
Referrals by ethnicity 2010
100%
90%
Chinese or other ethnic
group
Black or Black British
80%
70%
60%
50%
86%
77%
40%
Asian or Asian British
Mixed
30%
White
20%
10%
0%
Core practices 2010 Southall PBC 2010
Ethnicity of referrals: 2009 & 2010
140
120
Number of referrals
100
80
60
40
20
0
White
Mixed
Asian or Asian British
Core Practices 2009
Core Practices 2010
Ethnicity
Black or Black British
Chinese or other ethnic
group
Number of referrals: 2008 - 2010
350
300
Number of referrals
250
200
150
100
50
0
Southall PBC 2008
Southall PBC 2009
Year
Southall PBC 2010
Recommendations for others
• By working closely with the Mental Health and Wellbeing Service GPs can develop relationships and clarify
the best use of the services available.
• Create a shared ethos of improving mental health and
well-being within the community setting for the
population of Southall.
• Planning services- involve communities and service
users.
Plans for 2011
• Provide tailored mental health training to all
stakeholders, information on referral responsibilities and
options.
• Work together to prevent and better manage mental
illness in black and minority ethnic groups.
• Identify gaps in service provision for BME client's
through the work of the Southall Initiative and develop
local action plans to meet the identified needs.
• Develop integrated community based services for mental
health. Example work closely with Southall Norwood
CMHRC.
Acknowledgements
Pilot Practices
•
•
•
•
•
•
Cecil Road Surgery
Guru Nanak Medical Centre
Jubilee Gardens Medical Centre
Somerset FHP
The MWH Practice
Woodbridge Medical Centre
Southall Team, Mental Health and Well-being Service
CLAHRC
Tabletop discussions
• In what ways might the model be useful to
GP Commissioning?
• Next steps
– Leadership teams meet 8th December at 4pm
– ESTAR training January to March
– Stakeholder workshop 31st March and 7th July
• Evaluation and research
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