Southall Initiative for Integrated Care Stakeholder Workshop

1. Southall Initiative for Integrated CareStakeholder Workshop 18th November 2010 Neighbourly Care, Southall

2. Aims • Identify lessons from 2010 projects • Generate consensus about 2011 projects • Suggest how the Southall model could help GP Commissioning

3. Annual Learning Cycle

4. Southall Initiative for Integrated Care

5. Southall Initiative for Integrated Care

6. Professional engagement by type

7. Relay race

16. Boundary spanning

21. Community Learning

30. Southall Initiative for Integrated CareNov 2009-2010 Diabetes Neha Unadkat Jayshree Patel Harpal Rai

31. 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

32. 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

33. PCT Project Group Oversight of Southall project Link with Ealing-wide developments for diabetes Link with hospital-led diabetes care pathway improvements Southall Pilot Practices Two patient consultation workshops Baseline data assessment Specialist Diabetic Clinic to enhance practice systems The Project

34. 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

35. 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

36. 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

37. 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

38. 2011 Action Plan • Training for all practice staff including receptionists • Up to date literature in a variety of languages • Continue close working with diabetes specialist nurse • Monthly meetings inside practices and quarterly meetings of whole group to oversee developments and communicate findings to the GP Consortium

39. Recommendations for the Future • Expand links between the Southall Initiative and Ealing-wide strategic developments 2. Develop the Intranet to support decision-making for diabetes care 3. Continue to gather data to scrutinise performance across Southall

40. Recommendations for the Future • 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 • Improve practice skills at dealing with depression in diabetics

41. 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 Gilly Stoddart Paul Thomas Debbie Kelly Sapna Chauhan Sheelah Watson Raj Swaris Sylvia Parry Acknowledgements • Dr Kevin Baynes • Dr Sanjeev Mehta • Satty Aulakh-Clarke • Laura Windebank • Dr A K Sandhu • Dr P J Sandhu • Dr Sandar Cho • Cyprian Okoro

43. Southall Initiative for Integrated Care2009-2010 Support for Children & Families Camille Adams Mary Ford Sumarah Iqbal Dr Qadan

44. 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

45. The Project • Rapid appraisal including perspectives of a) GPs, b) Local support agencies for children and families c) Public Health • Develop a Children and Families Directory for general practice • Support practices to refer to MEND and SAFE • Support practices to act on their ideas for improvement

46. 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

47. Midwifery Services Children's Centres Health Visitors Poly Clinics Child Minders Day Nurseries A&E School Local Health Comm (LHC) GP HV, School Health Clinical Specialists Health Advisors Admission to hospital Public Health Intergrated Care Organisation (ICO) Secondary Care ESCAN HOME Hospital LA Care Home Specialist acute care SAFE Local Authority & intergrated services Library Services Schools Voluntary Sector Other eg. non accidental injury Early Intervention Services Social Services CPR Contact a family Victoria Climbie Foundation Southall Community Alliance 2. Directory of Local Services

48. 3. Referrals to SAFE

49. 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

50. 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