Paper: 5.3
Date / 22 December 2014
Title of paper / Commissioning Learning Sets report
Presenter / Dr Rachael Garner, WLCCG
Author / Romi Bose, Locality Manager
Responsible Director / Simon Hope, Deputy Managing Director
Clinical Lead / Dr Rachael Garner, Chair CLS Leads Group
Confidential / No
The Governing body is asked to:
Note the contents of the report.
Summary of purpose and scope of report
This report provides an overview of the key points of discussion at the CLS meetings in November 2014 and December 2014. The main agenda items were as follows:
•November: Prescribing Standardisation Scheme,Outpatient Programme Board,Review of CLS Plan, Whole Systems Mental Health Needs
•December: Emergency Admissions Audit,Community Cardiology Update, Operating Plan Targets – Dementia and Primary Care Mental Health Service (PCMHS), Whole Systems Update
Soft Intelligence:
NOV.
NW CLS / Time taken for the MSK service to see patients from telephone triage to first face to face appointment and whether the service can see a patient with 2 problems.
Action: / Physical Therapy (PT) New - as of 27/10 the wait was 7 days, depending on the choice of MSK clinics the patient is willing to attend. MSK should see 2 problems at once but if not the case please email and copy
NW CLS / Does the London Ambulance Service (LAS) always take patients to A&E?
Action: / LAS takes patients to numerous access points -not just A&E. Common pathways for West London include: St Charles UCC, St Charles mental health and The Royal Brompton. Frequently do not convey at all and refer instead to Rapid Response, GP in hours, GP OOH, social services, pharmacy, mental health teams and hospices.
NW and NC CLS / Practices wanted to know the time taken for the MSK service to see a patient from initial referral to first telephone triage
Action / Patients referred to Physical Therapy (including Physiotherapy or Osteotherapy) will be contacted by physiotherapist/osteotherapist from Physioline by phone (depends on the info provided by GPs on the referral form). The time the patient was contacted by Physioline will also depend on the availability of the patient to respond to the telephone call. Physioline - as of 27/10 the wait was 1 day.
NW CLS / Practices wanted to know the waiting time data for PCMHS, broken down by CLS, which is the time taken from initial referral to being seen face to face.
Action / Service Manager confirmed that ‘the target for PCMHS is 15 days from receipt of referral to entering treatment. This includes a triage in between. This is currently being met for all elements of the service across all CLS.’ The data set has been requested and is yet to be presented to CCG.
NE CLS / Practices wanted to know if they can self-refer patients to the IAPT services.
Action / Patients registered with QPP practices can self-refer and Patients registered with K&C practices can be referred by their GP or follow supported self-referral (where patient is provided an information leaflet from the GP practice and they can then contact the IAPT service directly – no written referral needed)
SW CLS / Community Dermatology Service does not accept referral for Wandsworth patient although patient is registered with a GP in K&C.
Action / Send patient specific query to
SW CLS / Mental Health Referrals restricted to post codes – Practice said that Charing Cross and Chelsea and Westminster are not accepting referral if outside boundary, although post codes are within tri borough.
Action / IAPT and ABT are borough based, IAPT/ABT K&C sees patients registered in Kensington and Chelsea, IAPT/ABT QPP for practices in Westminster borough. Secondary care teams should accept patients regardless of where they live or are registered. If you are having issues with Mental Health services please email
SW CLS / Re: SAS Smart Card - IT is only issuing 2 SAS smart cards to each practice, One for reception and one for locum which is not enough. The access rights are also an issue.
Action / Registration Authority will provide SAS smartcards (number not limited) to doctors only as these smartcards are for emergency clinical care. Nurses cannot get SAS smartcards as they should all have their own (can be transferred between areas). SAS smartcards only for emergencies as audit trail is not as robust with SAS cards, need to be able to trace which patients were seen by which clinicians.
SW CLS / Re: Ophthalmology Referral - An ophthalmology referral was made via C&B and asked the patient to call for appointment. When patient called, he was told no appointment was available and called later, patient called 3 times on different occasions but nothing available. After a month C&B referral was expired.
Action / Chelwest aware, patients have also complained directly to the Trust. Currently have capacity restrictions but working to free up clinic space, should have improved this month.
SW CLS / Re: Consultant Advice Line - GP advice line as advertised should be consultant led but that’s not the case. They are also not replying within 48 hours. Chelsea and Westminster has introduced online advice query form but it is limited to only few characters which is not enough to provide examination/blood test results etc.
Action / The Trust test the line a couple of times a week and have not had any problems. Have suggested practices keep a log of when they can’t get through (dates and times) so this can be investigated. For messages that have not been responses to, fill out form with details. Space on online form has recently been extended to 800 characters. Trust will extend to another 400 characters to trial. Survey sent out to practices to feedback on service, available at
SW CLS / Re: Primary Care Mental Health Service - Practice had sent a referral to psychological therapies which then ask him to refer patient to ABT Team as patient was not suicidal. PCMHS should triage referral internally rather asking GP’s to refer.
Action / Practice has been put in touch with Ross O’Brien (PCMHS Service Manager) who is investigating.
SW CLS / All GP’s are in the opinion of having a flow diagram for Mental Health Primary Care Services.
Action / To date, Steps of Care have been produced and is being distributed at CLS. A newly appointed General Mental Health Clinical Lead has been appointed, Dr Neera Dholakia, , who will be looking into mental health criteria, pathways and access points. Mental Health leads will also be attending December CLS to answer queries.
SW CLS / Re: Funding for treatments in Europe/EEA – Practices raised this as more clarification was needed. Katrina Mindel to pass on information to all GP’s regarding Funding for treatments in Europe/EEA.
Action / Katrina sent this information out after the meeting.
SW CLS / 1. MSK referral from practice was not forwarded onto Orthopaedics but referred back to GP. 2. MSK appointment letter was received after appointment date and MSK service referred back to GP and asked to re-refer patient. 3. Patient referred to MSK from Orthopaedic Dept and on discharge was referred back to GP instead of being referred back to Orthopaedics.
Action / As all of these are patient specific queries, email Please copy email to MSK clinical lead, Imran Sajid, on
DEC.
NW CLS / MSK (Physio) - Practices nothappy that the MSK team can’t leave voicemails on patient mobiles, even though patients have stated on form that they are happy to receive voicemails. Can the MSK service confirm if they are happy to leave voicemail if patient gives consent?
Action / The support team are aware to note the check box on the referral each time they contact a patient and will leave a message if consent is noted on the form.
NW CLS / MSK service not taking ownership or being accountable for referrals/appointment– practices said they had sent referrals to MSK team on numerous occasions, without acknowledgment whether received or not. Practices wanted to know if MSK service could confirm via some method (for example, email) thatthey had received a referral from the practice for the patient.
Action / MSK has been working on an acknowledgement email in response to emails sent to the generic nhs.net account. However, this is not the agreed referral pathway, can practices use C&B to refer their patients which has the functionality to let the GP know when the referral was accepted or rejected.
NW CLS / Check if MSK patient leaflet is on SystmOne
Action / As this patient information leaflet does not hold any patient identifiable data, it can be saved to the practice desktop and should be given to all patients given a MSK referral.
SW CLS / Re: ChelWest – US Dept : Patient sent for Neck US Scan, radiologist found cancer. No onward 2 week wait referral was done by Chelwest, instead referred back to GP. GP saw the report after two weeks. Onward referral for 2 week wait should have done by the radiologist.
Action / ChelWest already investigated and reported back to practice. Awaiting details from Justine Currie
SW CLS / Re: ChelWest – Cardiology Appt Letter : Practice raised an issue that their patients are receiving cardiology appointment letter after the appointment date. Some patients received their DNA letter before their appointment!
Action / ChelWest already investigated and reported back to practice. ChelWest changed postal provider in September due to such issues, and have not received any complaints in relation to letters since then. If issues with letters since September email
SE CLS / A number of practices have reported they are receiving multiple responses from pathology, occasionally one of the responses says the sample was not received and needs to be re-sent.
Action / Imperial manages pathology results for ChelWest. Imperial need specific patient details to investigate, please email and copy in GP Liasion Manager, Shanika Forsythe at
SE CLS / Western Eye – patients attending as walk in,GP asked to refer for follow up but no information provided as to why.
Action / Imperial need patient specific details to investigate, please email
SE CLS / GPs not satisfied with District Nurse support, occasionally support worker attends MDT meetings instead of DN. GPs also wanted info on DN allocation per 100 patients.
Action / New MDT Coordinator in post who will be reporting back to CLCH directly on the issues relating to DNs, email . Re DN allocation, PPF team pulling together info for practices to include named district nurse and contact details. Currently DNs are at full capacity, awaiting further information from CLCH.
SE CLS / MSK – MSK referred patient on to secondary care but GP was not notified.
Action / MSK lead raised with service to address and ensure GPs are informed of any secondary referral following triage by the service.
Hot Topics:
NOVEMBER
NIL
DECEMBER
NW – Some practices were unsure of process that needed to be followed to comply with the Friends and Family Test from December and what was the bare minimum required.
Action – All practices will be receiving a starter pack to support them and should email ith any specific queries and support would be provided.
SW - Re: DN/Case Managers – MDT Meetings : Few GP Practices are complaining that Case Managers and DN are not attending their monthly MDT Meetings.
Action – New MDT Coordinator in post, email with issues relating to MDT meetings
SW - Re: Patient Status Alerts for Flu Patients: Systm1 is putting patient alerts on patients who have already received flu jabs.
Action – This is a practice specific query so needs to be raised by the practice with the IT Projects team on
Prescribing Standardisation Scheme:
The Prescribing Standardisation Scheme comprised of 2 elements:-
- Agreeing a Prescribing Improvement Plan for quality indicators and agreeing a QIPP action plan for expenditure control.
- Engaging in at least one progress review with their Practice Link Pharmacist.
Practice self-declaration topics were also discussed and practices were asked to choose from 2 out of the 3 topics below:
•Anti-epileptic brand prescribing
•Ezetimibe
•Nitrofurantoin in kidney disease
Relevant medicine safety information was provided along with some hints and tips on how to use SystmOne more effectively when prescribing.
Outpatient Programme Board:
This update showed how WLCCG and Chelsea and Westminster Hospital is working together to deliver better management of outpatient activity by providing :-
- Access to consultant advice. The programme has established new ways in which GPs can seek clinical advice from Chelsea and Westminster colleagues. Advice is available Monday to Friday from 8am to 6pm through a telephone hotline and direct email address.
- Helping increase the effectiveness of referral processes. The programme intends to agree a standardised dataset for referrals to CW and then integrate this into SystmOne to help prioritise referrals effectively.
- Reducing the overall number of inappropriate follow-ups in secondary care. Working with Chelsea & Westminster to identify where there may be unnecessary face-to-face follow-up appointments in secondary care or consultant to consultant referrals.
Quarter 2 updates on the CLS Plan targets were discussed in detail at all CLSs in November. This generated a great deal of discussion with practices regarding the quality of the data provided by secondary care, inaccuracies that are evident and the best way to deal with this issue.
Whole Systems Mental Health Needs:
Clinical leads as well as the management leads of the Whole System Long Term Mental Health Needs (LTMHN) attended to provide:-
•Update on LTMHN – why, progress through co-production and the emerging model of care
•GP survey & Data Analysis – results and reflection
•Raising awareness and seeking your participation in the next stage
Referral Standardisation Scheme Audit A&E Attendances:
A summary of the A&E audits conducted by most practices in October was provided at December CLS. This showed:-
•The greatest proportion of attendances for A&E and UCC was on a Monday.
•At A&E the greater proportion of cases are seen out of hours (58%), whilst at UCC the proportion of cases seen in hours is the greater (51%).
•The range of conditions seen is vast.
•At A&E 68% of attendances were judged to be self-referral whilst 88% were self referred to UCC.
•It was judged that A&E was the appropriate clinical pathway in 64% of cases, whereas this figure was 42% for UCC attendances.
•For UCC attendances, it was judged that 87% should have contacted the practice first.
•For UCC it was judged that 75% of patients could have been managed by the practice alone if the patient had contacted the practice first.
Emergency Admissions Audit:
The Emergency Admissions audit results were shared with all practices at December CLS. The following questions were asked and these generated lots of discussion amongst practices which included sharing best practice and discussing problems in the current systems and what different practices did to work round issues they faced.
•Had any of the admitted patients been identified as high risk for the Unplanned Admissions DES?
•Had they been care planned?
•Is there anything which you could have improved on with regard to the care plan if so?
Community Cardiology Update:
The Lead Nurse for the service explained the new community cardiology service that had been commissioned from St Charles Hospital from 15th December. She went through the referral pathway and the various cardiology services that they provided and the respective timelines.
Operating Plan Targets – Dementia and PCMHS:
The Dementia National and Local Targets were discussed - 67% of patients with dementia have to been diagnosed by March 2015. Currently 1147 patients of expected prevalence 1711 have been diagnosed.
The Clinical leads for dementia discussed the reasons for low dementia diagnosis rates and why timely dementia diagnosis matters. The Memory Assessment Service was discussed and why it should be the single point of referral for all people with a possible diagnosis of dementia.
Currently WLCCG are achieving 61% and a further 120 patients need to be identified by the end of year to reach the target. Support would be provided to practices by clinical leads and a dementia support team who can come to the practice to support your dementia diagnosis work. Also, services have been expanded in year to provide more assessment and post diagnosis support for patients identified with dementia. A leaflet detailing this was given to all practices at December CLS.
The Service Manager from PCMHS attended most CLSs in December and confirmed that PCMHS will be changing the way it reaches out to harder to engage groups including Older Adults and black, minority, ethnic refugee communities including the launch of a communication programme.
In 2014/15 the PCMHS activity target in CLS Plan is 15%. As of month 7 PCMHS have achieved 2,531 and are slightly below forecast activity (3,101). Based on our current activity levels, PCMHS would achieve 13% entering treatment. The PCMHS needs to increase referrals from surgeries in order to support WLCCG achieve our operating plan target, increase the offer of support to patients, and meet patient needs for mental health care.
The referral flowchart was shared with practices at December CLS as this is something that practices had requested. The current waiting times were also discussed and this generated some discussion as practices did not always agree with the data presented. However, the Service Manager was happy to meet with individual GPs to discuss patient specific issues and try to alleviate any problems in the system.
Whole Systems Integrated Care Update:
The updated diagram of WSIC model of care was shared with all at December CLS by the Clinical and Management leads. They confirmed that they have been working with a number of stakeholders, refining the model of care and building consensus. For primary care this means that:-
- Additional investment in frontline care capacity for patients
- Additional support for care coordination and case management from collocated health and social care teams in operational bases
- Focus on real cultural transformation at the frontline with more day to day integrated team working
Record Sharing Workshop:
West London CCG Record Sharing Workshop was mentioned at December CLS and this event is a practical educational session for GP Information Governance Leads and Practice Managers. It is taking place on 19 February 2015 and at Joint February CLS on 24 February 2015, the MoU (Memorandum of Understanding) will be available for practices to sign up to.
Quality & Safety/ Patient Engagement/ Impact on patient services:
The Commissioning Learning Sets are responsible for identifying key clinical governance, quality and access issues that may impact on the quality of services commissioned by the CCG.
Financial and resource implications
N/A
Equality / Human Rights / Privacy impact analysis
N/A
Risk
Risk is reduced by responding to queries raised by practices. Further to this, Commissioning Learning Sets have an important role in peer-review, which supports good commissioning decisions.
Supporting documents
N/A
Governance and reporting (list committees, groups, or other bodies that have discussed the paper)
Committee name / Date discussed / Outcome
N/A
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