Presentations from Session I11 at the International Forum on Quality and Safety in Healthcare, London 21-24 April. http://internationalforum.bmj.com/ Introduced by Robert Varnam, this session reviewed the lessons being learned since groups of primary care practices were given 75% of the health budget of England in 2013. More information can be found in our Storify at

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Session I11
Clinicians steering the
design of health services
#qfi11 #Quality2015

2. @robertvarnam #qfi11 #Quality2015
Dr Robert Varnam
Head of general practice
development, NHS England
@robertvarnam Introduction
Dr Chris Jones
West Wakefield CCG
@DrChrisJones1 Engagement of professionals and
practices in shaping future primary
care
Dr Caron Morton
Clinical accountable officer,
Shropshire CCG
@DrCaronMorton Creating a distinct approach to rural
health
Sir Sam Everington
Chair, Tower Hamlets CCG
Making a reality of outcomes based
commissioning

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Commissioning in the
NHS in England
@robertvarnam
#qfi11 #Quality2015

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Commissioning in the NHS
• Single national health system, funded from taxes,
free at the point of care. Planning = hospital
committees.
• Growing focus on planning services at meso level.
• Interest in quality, workforce, clinical
microsystems.
• Internal market to improve quality, appropriateness
& cost.
• Commissioners as place-based system leaders.

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New Government 2010
• Contain costs, improve quality, widen patient
choice of specialist provider.
• Address primary care frustrations.
• Greater clinical power. Greater competition.

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Clinical Commissioning Groups 2013
• 212 groups, 70-80% NHS budget (secondary care).
• Statutory body / membership body … composed of
primary care practices.
• Strong clinical leadership, mostly medical, mostly
primary care.

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Dr Chris Jones
@DrChrisJones1
#qfi11 #Quality2015

9. Engaging primary care practices in
radical service redesign
Dr Chris Jones
Project Director, West Wakefield Health and Wellbeing Ltd
GP, Ossett, West Yorkshire
Chair, Wakefield Commissioning Network 6
@drchrisjones1
@westwakefield
uk.linkedin.com/in/drcjones

10. Declaration of interests
Organisation Role Interest
Wakefield CCG 111 Clinical Governance Lead Paid role
Church Street Surgery GP Partner
Wakefield Clinical Commissioning Network 6 Chair Time reimbursed
West Wakefield Health and Wellbeing Ltd Chair, Project Director Paid role
Shareholder
Wave 1 PMCF Funding
Wave 1 MCP Vanguard Site
365 Response Ltd Medical Director Co-owner
SBRI Grant funding
IQUS Limited Executive Chair Owner

11. Wakefield is at the centre
Wakefield

12. West Wakefield
• 6 Practices
• 63,910 Patients

13. The Challenge
Extended Hours
Extended
AccessHealthPod Care Navigators
Extended Team
• 7 day service 8am to 8pm
• Routine & urgent appointments
• Physiotherapy
• Pharmacy
• Social Worker
• Mental health worker
• Health and wellbeing
• worker etc
• Extra training
• Detailed knowledge of local
services
• Able to signpost internally and
externally

14. The Challenge
New contact types
Digital
AccessPopulation health and
Wellbeing
Service Directory
Digital Resources
• Video consultations
• Electronic messaging
• Telephone consultations
• On-line chat
• Care Navigation app
• App library
• HealthPod app
• Unified Communications
• Self-service kiosks
• Schools app project
• On-line Mental Health therapy

15. The Challenge
Social Prescribing
IntegrationHospital District Hub
Care Home Project
• Mild cognitive impairment
• Mild depression
• Link to voluntary/third sector
services
• Record sharing
• Virtual ward rounds
• Prescribing support
• Consultants
• 111
• 999
• A&E
• Co-location
• Admissions avoidance
• Early supported discharge
• Frailty tool

16. ?
The
Challenge:
Quite difficult
The Context:
Quite adverse
Progress
The recipe

17. 3 key
ingredients
The
Challenge:
Quite difficult
The Context:
Quite adverse
Progress
The recipe

18. 3 key
ingredients
The
Challenge:
Quite difficult
The Context:
Quite adverse
Progress
The recipe
Clinical Leadership
Full Engagement
Communications
Knowledge & evidence
A good plan
Sufficient resources
Disciplined project management

19. Clinical Leadership
Who?
• Local
• Respected, with substantial relevant clinical experience
• History of success in other extended roles
• Already a leader in smaller role (practice, CCG)
• Willing, not obliged or persuaded
• Freed up

20. Clinical Leadership
How?
• Having found them your clinical leaders must be properly supported
– Time to lead
– Funding. ‘Backfill’ pay and recognition of responsibility
– Sustainable: reasonable tenure, planned exit
– Training
• Development
– Invest in your leadership
– Develop skills and experience, training, mentoring, networking
– Find the next generation and plan succession

21. Clinical Engagement
• Clinically, not managerially led
• Principles of engagement still apply
• Start at the beginning
• Create a compelling vision
– Develop a shared vision of the future
– Grounded in the here and now but with a roadmap to the end goal
– Consult widely, test and refine. Be prepared for disassembly.
– Get a mandate
• Make it happen
– Business case, bidding

22. Patient & Carer Engagement
• Essential, incorporate from the beginning
• Proper dialogue, not just informing
• HealthWatch Wakefield
• Dedicated project manager
• Liaise with existing PPGs
• Created new Patient Reference Panel
• Involve in major decisions
– (premises, video consultations, apps)
• Regular contact, come to national meetings Engagement Infographic

23. Patient & Carers
Together

24. Community Engagement
• Youth Café
• St Georges Community
Centre
• Community Anchor
• Getting involved in what
they are doing

25. Community Engagement
• Schools App project
– Connecting with kids
– Fun
– Healthy messages
– Not just around illness
– Demystifying health
services

26. Practice Engagement
• Practice engagement meetings
• Educational sessions
• Extra ad-hoc meetings
• Practice manager meetings
• Project team develop
• relationships at different levels
– Nurse for nurse engagement
– GP for GP engagement
– Network Development manager for Practice Manager engagement

27. Communications
• Never enough until it’s too much. Hard to get the right balance.
• Easy to forget without dedicated resource
• Communications officer
• Weekly activity report
• Branded email updates
• Ad-hoc emails from key personnel
• Dashboard in development

28. Last word…
“If the person or group you are engaging
with does not feel there has been a transfer
of power to them, they have not been
engaged”.
- Lord Victor Adebowale, 2015

29. Questions

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Dr Caron Morton
@DrCaronMorton
#qfi11 #Quality2015

31. Creating a Distinct Approach to
Rural Health
Dr Caron Morton, MBE
ImagecourtesyofPat138241atFreeDigitalPhotos.net

32. The Environment
 Whitchurch to Ludlow
o 50 miles, 1 hour 20 mins
 Bishops Castle to Shrewsbury
o 22 miles, 45 mins
 Shrewsbury to Cleobury Mortimer
o 45 miles, 1 hour
 Clun to Whitchurch
o 50 miles, 1 hour 25 mins

33. The Challenge
 The Royal Shrewsbury Hospital,
Shrewsbury
 The Princess Royal Hospital,
Telford

34. The Challenge

35. The Ask

36. The Approach
Changing to an asset based approach
A clinical vision for acute services
Community provision centred around
GP practices
Building real community resilience with
local people

37. The Offer

38. The Offer
 Partnering with local GPs
 Maximising care home impact
 Integrating provider teams
 Supporting community projects run by volunteers
 Working with the voluntary sector
 Investing in prevention
 “embracing bespoke local solutions within our
patch – equal outcomes”

39. The Impact and Outcomes
 Care Homes Scheme reduced A&E attendances and
admissions
 Care co-ordinators improved outcomes
 Compassionate Communities rebuilding local
communities
 Health Champions 300 young people as champions
 Street pastors significant reduction in weekend
attendances

40. Impact of Care Homes Scheme on Acute Sector
% reduction
GP appointments post intervention 66.40%
A&E attendances post intervention 52.20%
Hospital admission post intervention 22.73%
OOH calls/visit post intervention 65.71%
% increase
Voluntary agencies involved post intervention 83.70%

42.  Avoidable hospital admissions reduced in one
year by 11.5%
 Unplanned hospital attendances from Care
Home Sector reduced in 2013/2014 and flat in
2014/2015
 AE attendances shown only 3% increase over
five years – 2013/2014 dropped by 4.6%
“The Figures”

43. “Not everything that matters
can be measured”

44. @robertvarnam #qfi11 #Quality2015
Sir Sam Everington
#qfi11 #Quality2015

45. Dr Sam Everington
Making a reality of outcomes based
commissioning

46. THPCT legacy: Primary care networks
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Tower Hamlets before networks
• 8 LAPs
• 36 practices
• Total population of ~245,000
• Practice list sizes of 3,000 to 11,000
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Pop: 29,892
Pop: 18,027
Pop: 29,801
Pop: 35,720
Pop: 28,995
Pop: 33,186
Pop: 27,839
Pop: 31,975
8 Networks1 were formed in the borough during 2009
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Why networks?
• Focus on population health across a geography
• Collaborative relationships with wide range of partners (e.g. Borough, schools, charities)
• Sufficient scale for specialisation of staff, ability to access rare skills and ensure access, resources (e.g. equipment)
• Integration with estates plan
Outcome based contract linked to
improving population health
Page 2

47. Outcome- based
approach
47

48. MMR Immunisation 2006-10
Improving MMR vaccination rates: herd immunity is a realistic goal. Cockman P, Dawson L, Mathur R, Hull S, BMJ2011;343doi: 10.1136/bmj.d5703
60.0
65.0
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80.0
85.0
90.0
95.0
100.0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2007 2008 2009 2010 2011 2012
Intervention Post-Intervention
%withMMRbysecondbirthday
Tower Hamlets
London
England
Maintaining MMR improvement
48

49. Creation of one provider
Roles
• Supports integrated care
• Vehicle to commission from
• Platform for co-commissioning
36 practices
8 networks
1 provider
Page 3

50. Provider development in WELC – building the alliances
Page 8
Integration function delivered collectively by all providers in collaboration
Care Co-
ordination
Rapid Response
Discharge
M anagem ent
M ental Health
Liaison (RAID)
Social Services
CCG
Provider Specific Schedules
GenericScheduleforAll
Creating a specification for integration and adding
as schedule to all NHS contracts
Evaluation process provides focus for
provider collaborative discussion

51. Evaluation Process
• Stage 1 - Desktop
• Stage 2 – Collaborative panel interview
Domain for assurance
Rating
Initial
assessment
Direction of
travel
Final
assessment
1. Service delivery A → A
2. Corporate governance and operational management A → A
3. Clinical governance, quality and patient engagement A → A
4. Information and performance monitoring R ↑ A
5. Contingency and project planning R → R
6. Commercial framework G → G
• Process led to formation of the THIPP – Tower Hamlets
Integration Provider Partnership

52. Development of THIPP

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