3.1 Patient and public engagement - Dr Jim O'Donnell

Listening to Patients,
Engaging with the Public
Dr. Jim O’Donnell, Clinical Chair,
Slough CCG
Slough CCG
at the
GP Transformation Champions Conference
7th March 2017
‘Working Together, Improving Health’

Nothing as rewarding as listening to our patients
• As individual patients in consultations, “the golden minute”
• As groups of patients: Patient Participation Group in the Farnham Road
Practice in Slough – feedback, service improvements, support with the
wider pt. population, complaints, patient behaviour, support with the
CQC inspections. Group Consultations – DM, COPD, Obesity
• Slough-wide Patient Representative Forum, 150,000 pts. The
ultimate local patient “authority”. (HealthWatch)
• The Slough “Open Day” – annually in May, 1,100 feedbacks
• Across three CCGs: 450,000 pts. Sharing Innovation,
e.g. “Healthmakers”, Community Partnership Forum
• The National Patient Survery
• UK-wide: GPs: Behind Closed Doors, Channel 5 Weds 8pm

The Patient Voice…
We are committed to ensuring that the
voice of the patient community is
reflected in the design of the health
services we deliver and commission

The Slough CCG Story – Year One…
Our journey began with one
simple question …. “I can’t get
an appointment with my GP
– how can you help me?”

Slough Clinical Commissioning Group 6
Slough’s landscape…
• Diverse community where English is often not the first language
• High need, significant deprivation & health inequality
• A quarter of children living in poverty
• Growing & ageing population (up 17.1% since 2001)
• Berkshire receives some of the lowest levels of health funding
per head in the nation
Slough CCG has achieved improved health outcomes, in challenging circumstances and
within budget.
Committed to ensuring that the voice of the patient community is reflected in the
design of the health services we deliver and commission ……..The Patient Voice.
Our journey began with one simple question …. “I can’t get an appointment with my
GP – how can you help me?” on 30th April 2013 : Slough CCG’s first Board meeting in
Public.
We responded, and used prescribing savings to increase the number of G.P.
appointments – 5,000 extra over the Summer/Autumn and then used Winter
Pressures funding to add to this further – 6,000 more)

Slough Clinical Commissioning Group
• 30th April 2013: Slough CCG Board meeting in Public – that question
• (We responded, and used prescribing savings to increase the number of G.P.
appointments – 5,000 extra over the Summer/Autumn
• Then we used Winter Pressures funding to add to this further – 6,000 more)
• 18th October: PM announcement of £50m funding for improving access
• December: Slough practices committed to application – led by our patients &
public
• January: Used the ELC process to co-design our bid for funding
Prime Ministers Challenge Fund
(PMCF)…

• Application submitted 14th February 2014 – 48,000 appointments, 11
additional projects
• Patient-led: What would “good” or “great” general practice look like?
• Notified of our success 14th April 2014 - £2.95m awarded
• Practices & Patient Representative Group Forum mobilised
• Feverish activity, Late evening meetings, concrete plans
• 1st July: phased start of extended hours
• 2nd week in August: full implemented across Slough
(PMCF)…

• Covers all patients registered at a Slough practice
• G.P. appointments to 8 p.m. Monday to Friday and
Saturday & Sunday from 9 a.m. to 5 p.m.
• Delivered from 4 Cluster practices – Crosby House, Bharani MC, Farnham
Road and Langley HC
• Very popular, well subscribed, mainly routine bookable appts., walk-ins also
• Sustainability: part-time GPs increasing their commitments
• Weekend and evening appointments look set to increase as a proportion of
the general practice total – the times suit many people
(PMCF)…

• The Slough PMCF also includes an additional eleven projects
• A condition-specific Clinical Support Group in each practice – patients chose
• Primary School Health Education programme – seven key areas
• SMS texting to allow patients to cancel appointments, and get health info
• Online facility for booking appointments
• Bespoke programmes in each practice wrapping care around the “Top2%” of
patients with the highest risk of needing unplanned care episodes in next
year
• ……………..and 6 more projects
(PMCF)…

We’ve made great progress in …..
GP access
A&E targets – from fifth to first quintile
Transformation of our local Acute Trust
Diabetes
Cardiovascular Disease
Cancer Mortality
Asthma care in children
COPD outcomes
Prescribing quality & budgets

 National Patient Survey July 2016: Q. 12 when asked if they could get a GP appointment when
they last tried at their surgery, the decrease in patients responding “No”:
HSJ: “Slough CCG most improved
CCG on GP access 2013-2016” 25th July 2016 by Rebecca Thomas
Rank CCG % decrease in those answering “No”
1. Slough CCG -4.94%
2. Chorley and South Ribble CCG -3.11%
3. Rushcliffe CCG -2.99%
4. Leeds North CCG -2.24%
5. Hammersmith & Fulham CCG -2.21%
6. South Gloucestershire CCG -1.94%
7. Southport & Formby CCG -1.9%
8. Oldham CCG -1.83%
9. South Manchester CCG -1.56%
10. Warwickshire North CCG -1.54%

 Diabetes – All Slough practices meeting national targets for delivering the 8 care processes: No.2 in England.
Slough practices improved diabetes control, particularly in the following indicators from 13/14 to 14/15:
o HbA1c target (<59) Improved from 58.41% to 64.48%
o BP target (<140/80) Improved from 72.5% to 80.06%
o Cholesterol (<5) Improved from 72.86% to 76.48%
 Under 75 Mortality Rate – Cardiovascular: Reduced to 98.3 per 100,000 population, down from 101.6 prior year
 7-Day working in Primary Care: Slough CCG first to implement 7-day working in GP practice with the Prime
Minister’s Challenge Fund (GPAF)
 Non-Elective Admissions Reduction: NELAs are -2.5% YTD M09 December c/w last year (range - 2.5% to - 6%)
 Slough CCG Complex Case Management Scheme: -33% reduction in NELAs and A&E attendances, and -29%
reduction in OPFA in the specific CCM cohort of patients (568 patients; second cohort of 608 pts in progress)
 NELAs from Care Homes: Reduced by - 33% from 274 in 14/15 to 184 in 15/16.
 Paediatric Asthma – NELAs down - 29% at M09 December YTD for childhood asthma (207, down from 290).
 Under 75 Mortality Rate – Cancer: Reduced to 138.7 per 100,000 population, down from 156 the previous year,
from above to below the England average of 141.5
 Deprivation:
 The number of ‘highly deprived’ neighbourhoods (10% most deprived in England) down from 1 in 2010 to 0
in 2015.
 The number of neighbourhoods in the 10% - 20% most deprived category also fell from 9 (11.5%) in 2010 to
5 (6.3%) in 2015.
 Our 2016 Right Care Commissioning for Value pack gives new opportunities different from those in 2015, showing
delivery on Right Care priorities. Work already well underway in the areas identified for 2016-17:
 Asthma – we have already real progress in this area with our Paediatric Community Asthma Service
 COPD – as part of our CCM scheme, COPD is included as one of the key morbid conditions
 Stroke – currently reconfiguring our stroke service to implement the ‘London model’ for better outcomes.
Some Slough CCG Indicators

• Within PMCF resource we commissioned additional, longer GP appointments in
primary care for all patients on a Complex Patients list, with each patient being
seen once every 3 weeks, for up to 30 minutes.
• The initial pilot ran for 6 months from 1st October 2015 – 31st March 2016 and the
scheme continues into 16/17.
• The extra appointments supported an overall care plan for each patient around
their medication and treatment regime. GPs are also working with the specialist
teams like the COPD and Heart Failure nurses.
• Some of the interventions include:
o Review reasons for any A&E attendances, emergency admissions and 999
ambulance call outs
o Develop a crisis management plan including alternatives to A&E attendance
and 999 ambulance call-outs
o Discuss with the patient how they can help manage their conditions,
maintain their overall health and prevent unnecessary hospital admissions
Complex Case Management

Complex Case Management
• Patient-level risk prediction (also known as case identification or case finding), for clinical use;
• Population-level analysis utilising the combination of primary and secondary care data, for describing and
comparing populations and healthcare costs.
The analysis of Slough CCG data showed that multi-morbidity (more than one chronic condition) was the main
driver of high healthcare use, cost and emergency admission activity, as opposed to age and other factors.
There is a relationship between which long term condition a patient has and their risk of an emergency
admission
•The table below lists some common conditions, the number of patients in the Slough dataset used in this
analysis with those conditions and the average risk of emergency admission
•The table also gives two examples of the average risk of emergency admission in patients with two
combinations of conditions
Based on the analysis, the following unique cohorts of patients were identified by the ACG tool as having the
highest risk of emergency admission:
•CHF & CRF
•CHF & COPD
•Diabetes, CHF & CRF
•Diabetes, IHD & CRF
•The Slough CCG clinical leads conducted an audit of their patient lists and endorsed these multi-morbidity
groups through clinical audit as the ones which they felt had the most potential to be managed better in
primary care.

SAME DAY
DEMAND
Complex
Case
Management
Self-Care
Digital Access to health and
health services information
See Right Professional
first time
Centralised Service to
improve efficiency
Eliminate
Avoidable
Hospital
Admissions
Improve Care Out
of Hospital
Increase Investment in
General Practice &
Community & Social Care

SAME DAY
DEMAND
Complex Case
Management
Self-Care
Digital Access to health and
health services information
See Right Professional
first time
Centralised Service to
improve efficiencyEliminate
Avoidable
Hospital
Admissions Improve Care Out of
Hospital
Increase Investment in General
Practice & Community & Social Care
Commissioning
opportunities
TransformingPrimaryCare

Emergency Surgery Audit - FRP
• September 2016 to February 2017
• Seen personally by me
• 207 patients, age range 4/52 – 80yrs
• 0-2 yrs: 51 (24.6%)
• 2-19 yrs: 35 (16.9%)
• 20-65 yrs: 97 (46.9%)
• 61yrs+ : 24 (11.6%)
• Most common presentations:
• Cough: 42 (20.2%)
• Abdominal Pain: 32 (15.5%) L:23, U:9
• LBP: 15 (7.2%)
• V&D: 12 (5.8%)
• Rashes: 11 (5.3%)

• Most common presentations (cont):
• Skin infections: 8 (3.9%)
• MSK chest pain: 8 (3.9%)
• Leg/foot pain: 7 (3.4%)
• Oral thrush: 6 (2.9%)
• High B/P: 6 (2.9%)
• Other conditions seen:
• Knee pain, neck lump, neck pain, abn. lab.
result, GDM, SoB, chest pain, CTS, TATT, RTA,
constipation, blepharitis, tonsillitis, pharyngitis,
ear pain, LD behavioural issues, sprains, falls,
etc.

• Referred from which source:
• Front desk: 106 (51.2%)
• Telephone triage: 91 (44%)
• Nurse: 7 (3.4%)
• AHCP: 3 (1.5%)
• Clinical management provided:
• Prescription: 117 (53.1%)
• General advice: 96 (46.4%)
• Investigations requested: 29 (14%)
• Referred on: 16 (7.7%)
• Necessity of this appt.:
• Not urgent: 110 (53.1%)
• Avoidable if self-cared: 101 (48.8%)
• Needed same day: 66 (31.9%)
• Needed advice or info: 23 (11.1%)

• What does this tell us?
• Children represent 41.5% of the appts.
• 46% have conditions amenable to education,
information, self-assessment, just need the
tools
• 49% appts. rated as avoidable
• 53% got a prescription, ? OTC opportunity,
clinical pharmacy
• Only 32% needed appt same day
• 53% were non-urgent clinically
• Conclusions:
• We could change the demand profile but it
would need broad system co-operation, and
would take time.

• What would we need to do or
change?
• Explain to patients the current demand profile
and listen to what they think of it.
• Discuss the impact of providing this service as
we do now on the quality of the services we
provide to those patients who need significantly
more input.
• Ask: “How do you think this could be
improved?”
• Present the evidence to partners, our staff, the
CCG and NHS England to get broad support to
make these changes that could transform our
impact on patient outcomes.

A&E pressures (Wexham Park)…

• Federated Quality Committee – three CCGs
• Concerns re: Maternity, Stroke & A&E parameters and performance, & others
• Raised through the quality mechanism to CQRG level
• CQC unannounced inspection of HWPH, reports, Assurance Process
• Currently seeing significantly improving performance in some areas
• Slough CCG provided additional GP appointments over the winter period –
made possible through savings via the expertise of our prescribing team, re-
invested in GP appointments, whilst delivering improvement in the quality of
our prescribing
Quality Concerns at HWPH & Prescribing
Advisor Team initiatives

New services and improving the patient
experience…
• Maternity – by implementing an experience-led commissioning approach and
listening to patients we have allowed this to influence our commissioning
strategy and achieved improvements in the quality of care and patient
satisfaction
• Physiotherapy – by de-commissioning and re-commissioning a new provider we
have a much enhanced, faster and more comprehensive service in place
• Community Gynaecology Clinic – this has enabled faster access to treatment
and an improvement in patient choice and convenience.

We kept going forward…
• Continuation of GPAF, now BAU, roll-out of eleven related projects
• Frimley Health’s acquisition of Heatherwood & Wexham Park – supported,
the Agreements, monitoring of quality, CQC - “Transformation”
• The frail older patient: home treatment teams, whole system change, the
Better Care Fund (BCF), The Frimley STP
• Asthma Care – had highest admission rates in England among children , poor
levels of understanding of asthma management, and compliance with inhaler
treatments and personalised asthma management plans. Transformed.
• Cancer care: the 2-week-wait referral system, End-of-Life care – Mortality
falling from 10% above to 10% below the England average.
• Stroke Care: unsatisfactory aspects – recommissioned to “London” HASU
model

The Better Care Fund (BCF)
• Joint Budget Spend between Slough BC & Slough CCG
• £8.762m in 2015/16: SBC £689k; CCG for Social Care £3.43m; CCG excluding
s256 £4.65m
• Focused on the frail older patient: home treatment teams, whole system
change, four priority areas:
• 1. Proactive Care Plan for the most vulnerable, most at risk of ill health,
access to a named professional, targeting effective interventions.
• 2. Single point of access for professionals to obtain information on health and
social care services that are needed by a patient/person in need
• 3. Integrated Care: co-ordination of the range of locally available services that
support people in crisis or with short term need

The Better Care Fund (BCF)
• 4. Strengthening Community Capacity:
• Greater utilisation and development of the voluntary and community sector
through a co-ordinated and integrated commissioning approach
• A Prospectus approach that will deliver better outcomes for people by
supporting them within the community
• BCF: partnership working – from SBC, Slough CCG, Frimley Health – Wexham
Park Hospital, Community & Mental Health Services (BHFT), Voluntary Sector
• Slough Wellbeing Board at Slough Borough Council
• The frail older patient aged 65 plus, and those aged 20-64 with 7 or more long
term conditions, children also in Slough’s BCF

Slough CCG & the Voluntary Sector
Three relationships:
• 1. Partner in co-designing integrated services around young children
or/and their parents - input welcome
• 2. Provider from whom we might commission elements of an
integrated care pathway : admission avoidance, pro-active care
• 3. Patient Participation Facilitator by increasing the representation of
young parents in practice Patient Participation Groups to make your
voices heard, various “hard to reach” groups, carers, offspring who
find it difficult to make headway in obtaining for their parent(s) the
support they deserve
• Roles need to be understood and kept separate

Slough CCG & the Voluntary Sector
• Discover our population’s priority needs = our commissioning needs
• Shape & promote your skills and services matched to our needs
• Living well, Home from Hospital, Handyman support, Befriending, Dementia
Support workers
• Strategy to provide health & social care support at home or as close to home
as possible
• 1% of our population are in the final year of life: End-of-Life Care – identify,
prognostication, advanced care planning, dying well
• Dementia: early screening, early referral, early treatment, ongoing support
• (Telephone) advice/lay support from the voluntary sector: might be able to
reduce dependence on the NHS & Social services: pilot, audit, prove concepts

Thank you for listening…….
Questions?

3.1 Patient and public engagement - Dr Jim O'Donnell

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