Minute of Meeting - NHS Tayside

Minute NHS Tayside
ANGUS COMMUNITY MEDICINE AND REHABILITATION REDESIGN (CMRR) PROGRAMME
Note of meeting held on Thursday, 19 January 2012 at 10.00 a.m. in Room B, Angus House, Forfar.
Present:
Dr Douglas Burt, GP, Academy Medical Practice (representing Forfar & Kirriemuir)
Dr Greg Cox, Associate Specialist (Chair, South Angus Locality Group)
Dr Gordon Crosby, GP, Carnoustie Medical Practice (Chair)
Mr Dave Davidson, Scottish Health Council
Ms Helen Dryden, Palliative Care Clinical Lead, Angus CHP
Mr David Gill, Head of Pharmacy
Ms Rhona Guild, Primary Care Manager Project Lead Community Medicine & Rehab Redesign
Ms Susan Hamill, Ward Manager (Chair, North West Locality Group)
Dr Kristien Hintjens, GP, Townhead Practice, Links Health Centre, Montrose
Dr Douglas Lowden, Consultant, Medicine for the Elderly
Dr James Shaw, Consultant, Medicine for the Elderly
Mr Ken Shaw, Partnership Representative, Stracathro Hospital
Ms Gail Smith, Clinical Services Development Manager/Lead Nurse, Angus CHP
Mr Dita Stanis-Traken, Staffside representative
Ms Susan Wilson, General Manager, Angus CHP
Apologies:
Ms Alison Angus, Public Involvement Manager
Ms Hilde Barrie, Corporate Services Manager, Angus CHP
Ms Jackie Bayne, Workforce Manager, Angus CHP
Ms Morag Cave, Highly Specialist Occupational Therapist (Chair, North East Sub Group)
Dr. Ian Gillanders, Consultant Physician
Ms Liz Goss, Clinical Services Manager, Community Hospitals & Older People Services, Angus CHP
Dr Mark Jacobs, GP, Edzell Surgery
Ms Alison McDonald, Principal Pharmacist
Ms Anna Michie, Communications Manager, NHS Tayside
Ms Kaye Wiseman, Clinical Development Co-ordinator, Angus CHP
Attending:
Fiona Waddell, Project Support Officer, Angus CHP
1. WELCOME AND INTRODUCTIONS
Apologies were noted. Dr Crosby welcomed new member Dr Kristien Hintjens.
2. MINUTES FROM LAST MEETING (PREVIOUSLY CIRCULATED)
Agreed as an accurate record of the meeting
3. ACTION POINTS UPDATE -
These were noted
4. LOCALITY GROUP UPDATES
NE locality – NE Angus is well under way in terms of planning. Dementia pathway
progressing well. Neurological conditions are an unknown quantity – a scoping
document is out with practices to get a feel for prevalence. Ms Wilson noted the
variation in requirements for care depends on age and condition.
Obesity – a test of group education for Impaired Glucose Tolerance (IGT) is about
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to start in Edzell. Good results were obtained when this programme was run in
Bolton. Our programme has been developed in conjunction with Dietetics, and will
also be run at Springfield practice, being targeted at high BMI smokers in the first
instance, supporting them to change. There has been a 50% uptake by patients
offered this education, and evidence shows that education early on is far more
effective than treatment through medication at a late stage.
Polypharmacy – this has been completed at Edzell, and is due to start in Brechin
on 1 st April.
Patient flow – Dr James Shaw now oversees North East Angus patients in
Ninewells.
Winter planning, an agreement has been reached to admit Montrose patients
directly to Brechin infirmary if there is no space available at Montrose Infirmary.
Blood transfusion - currently not available at Montrose Infirmary, but it is hoped to
provide this in future, starting with an inpatient service. There is a blood fridge
currently available, but it is not fit for long term use.
New orthopaedic pathway – discussion on how to prove benefit and evidence
improvement. Currently there is early indication of a decreased length of stay in
Ninewells, but need to ensure that the whole patient journey is shorter, not just the
stay in Ninewells. The significant number of metastatic fractures, which present
their own particular problems, means that oncology involvement is also crucial to
the success of this pathway.
NW locality – A new improvement plan has now been developed for NW locality.
Key priorities have been identified as Dementia Diagnosis / Management and
Daycare Services including Medicine for the Elderly and Palliative Care.
There are outstanding actions relating to Care Homes. Work is being undertaken
outside of the group to assist with educational input and address inequalities. A
particular issue in the NW is the number of Care Home patients who are not
registered with the practice holding the LES contract.
Day assessment and treatment tests have proven successful in Isla. The next step
is to develop a model of day treatment (factoring in estates issues) for all day
treatments in the North West, including palliative care.
South locality – The south sub group is very active, with a current focus on
Medicine for the Elderly issues.
Concern re the accommodation and environment for palliative care in South Angus.
Dr Cox’s Falls development sessions have now become clinical sessions, with an
additional clinic at Arbroath Infirmary on a Friday afternoon. There may be scope
in the future to service Monifieth and Carnoustie directly.
Self management is another priority, and it would be good to get GPs round a table
as they do in the NE with the Clinical Improvement Group.
Ms Wilson would like to be involved in the South Group re addressing the estate
and making it fit for purpose, particularly with regard to palliative care. Suggested
that Clinical Group meeting be set up for this purpose in February, and Dr
Rodriguez be invited.
Monifieth is an unusual practice, as they already have the predicted 24% elderly
population, as well as boundary issues and a big pocket of nursing home
development. A programme is planned for 2012/13 to review the role of general
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practice and support services, cover support and community resources/resilience.
The experience of Monifieth will be very useful for regional/national discussion of
GP contracts to suit an increasingly elderly population.
In fact, Community Geriatric Modelling pan Tayside will be in the spotlight through
Steps to Better Healthcare. NHS Tayside is carrying out a review of all specialist
nurses, and there may be the opportunity to consider a new role of specialist
geriatric nurse who could assist in this. In fact nurses in day hospitals are already
carrying out similar types of geriatric assessment, so there is already a skilled pool
to draw on. The emphasis will be around dementia and general frailty, with needs
possibly perceived by relatives and carers rather than the patients themselves.
5. NATIONAL STRATEGIC DIRECTION OF TRAVEL (Susan Wilson)
Draft paper circulated.
This concerns the disbanding of CHPs and the planned integration of Health and
Social Care, primarily for older people, but extending into adult care as a whole.
More detailed guidance from government due by end of month on what will be
integrated and how budgets will be pooled, following which there will be a 3 month
consultation period, with aim of completing integration by April 2013. There will still
be two employers, Social Work and NHS, but they will be working closer together.
Nicola Sturgeon, Health Minister, will govern this new partnership. The CHP
Committee and the Social Care Committee are likely to be amalgamated, and will
deal with any governance issues. A Health and Social Care integrated
management group is also to be formed.
An integrated locality model will be developed, starting with NW Angus in the first
instance. Resource has been secured through the Change Fund and Integrated
Resources Framework (IRF) for this. Processes and Communications will be
examined to find ways of providing a better, slicker service, and this will be
influenced by staff working on the front line. The process will be kick-started by a
week long Rapid Improvement Event, which will build on the work already done by
the North West locality group. Support of key players will be crucial to the success
of this. While the actual model of care will be different in each locality, if the
method of execution is successful in the NW Angus trial, this will be repeated in the
other localities. Dundee has been highly successful in using this method to
transform their Drug Services.
Dr Burt was happy to hear that front line workers are to drive the changes, although
unclear how this will be achieved, and expressed concern over where GPs, as
independent contractors working with Social Work but not accountable to Social
Work, will fit into the new plan. Ms Wilson agreed that governance of the new body
would be interesting, and suggested that an informal discussion with Aberdeen City
GPs would be beneficial, as they have been doing a lot of work on the integration
agenda and seem to have established a good dialogue between General Practice
and Social Work.
6. ANNUAL CMRR PROGRESS REPORT (Rhona Guild)
This document was included with the meeting papers, and summarises the key
achievements pan Angus, such as pulmonary rehabilitation, active screening for
COPD, dementia improvements, and a big push on self management for long term
conditions. Ms Guild commended all staff and public members for pushing forward
these programmes.
Polypharmacy has been very successful in 2011 and funding is secured for an
almost complete roll out during 2012. Polypharmacy is very cost effective, and a
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test of progress one year on shows that patients are not back on the medications
that were stopped or changed. Feedback from patients and carers is extremely
positive, illustrating that the improvement is qualitative as well as quantitative. Dr
Lowdon confirmed that all medications will be examined under Polypharmacy,
including psychoactive drugs, but appropriate specialists will be consulted when
changing medications prescribed by them. An interesting outcome of
Polypharmacy has been occasional problems due to patients starting to take the
medicines they should already have been taking following their review.
The emphasis in 2012 is on locality groups leading the changes/improvements.
Some elements of CMRR work are now being channelled through Change Fund.
Key Measures
Focus is now turning to the under 65 age group, as good improvements have
already been made for the over 65s.
The issue of lost bed days is still challenging, with certain’ hotspots’ in Angus. For
elderly patients, a protracted stay in hospital once they are fit for discharge can
lead to loss of function, so it is vital to tackle these delays.
Four years ago, Angus was 7% above the Scottish average for prescribing costs.
Now we are on the Scottish average, and moving down towards the Tayside
average. Although still overspending, there have been huge improvements. The
cost of drugs and the volume of patients have both increased, which may explain
why the progress hasn’t been even better.
Case management is a key focus for 2012, as is Diagnostics, and a considerable
amount of effort is being put in to agreeing on a single, electronic version of an
Anticipatory Care Plan.
Angus is looking at the Rheumatology pathway in its entirety, eg education for the
newly diagnosed, where day care services are delivered and changing the
emphasis from routine recall to dedicated flare-up clinics.
Asthma clinics have up to a 40% non-uptake for review clinics, with many of these
being children. Aim to improve this.
Chronic pain self management strategies – the first group education class is just
starting in Forfar, and this class is full with a waiting list. There is funding for 2
more programmes. An on-line course has also started. There has been huge
interest from Angus patients for these services.
The quality of data continues to cause some difficulty in evidencing improvement,
and work is in progress to improve quality of data both at input and extract stage.
Ms Wilson explained that over 2012, 20% of Change Fund money is to be directed
towards Carers and the support of Carers. Each locality will have a ‘Carer Support
Worker’, as Carers are highlighted as partners in care, rather than standing on the
sidelines.
Innovative volunteering mechanisms can provide excellent support for people living
in social isolation, and a properly vetted network of volunteer visitors is to be
established.
The aim is to build capacity and resilience within communities, and the new
partnership will be very interested in supporting such schemes.
A draft Medication Administration Pathway has been written. Health Care
Assistants have been appointed locally through Change Fund money to assist in
administering medication, but there is some concern that this service will be
overwhelmed with requests, when it should not be seen as the long term solution.
This issue has been put back into the plan, as it is likely to become more
significant.
The group approved the recommendations of the report. A new CMRR action plan
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will be developed based on this.
Next Steps for the CMRR Programme Board
This board will remain as a governance body and will need to dovetail with the new
integrated Health and Social Work committee. The board will need to drive forward
the action plan for coming years, whilst recognising that there will be significant
change. Integration will be a major focus in 2012, and the group discussed the
possibility of a merge with the Social Work ‘Change Programme’ committee.
Ms Guild shared a revised Terms of Reference (TOR) and proposed membership
for the Programme Board. ‘Planning/influencing the Integration Agenda’ to be
added to the TOR.
Ms Wilson reminded the group that while we have been very successful in Shifting
the Balance of Care, we have been less successful in shifting the balance of
resources. Spending the most money doesn’t always give the best outcome, while
small spends can result in big improvements. Improving the pathway of care will
remain the number one priority of the CMRR project.
7. INFORMING, ENGAGING & CONSULTING PLAN
The plan is available for viewing at each meeting.
Ms Hamill commended the Self management special newsletter which was recently
distributed, and urged that it should have an even wider distribution. Ms Waddell to
review the distribution with Hilde Barrie when she returns to work.
Members were reminded to inform Ms Guild of any engagement activity
undertaken so that it can be included in the plan.
8. ANY OTHER COMPETENT BUSINESS
Medicines Pathway – Mr Gill advised that the Royal Pharmaceutical Society is to
produce guidance on the use of compliance aids, which will assist in deciding when
these would be useful. The Community Pharmacy contract is now fully
implemented, and pharmacists are being asked to identify suitable patients for the
Chronic Medication Service (CMS), and develop care plans for them. Part of
pharmacists’ remuneration has been laid aside nationally and to maintain their
share of this, pharmacists must ensure their activity in CMS is proportionate to
national activity. The first focus will be on patients taking certain high risk
medicines. Pharmacists will soon have a greater role in identifying and monitoring
compliance issues and side effects, and will be expected to counsel and monitor
patients commencing new medication, which will provide an assurance for
prescribers when new medicines are prescribed.
Clinical Director – Dr Rebecca Wheater has completed her term as acting Clinical
Director, and this position is now vacant. Ms Wilson advised that an interim
Clinical Director is being sought to support medical business in the CHP, with the
possibility that in the future this role will be jointly fulfilled by a GP and a secondary
care lead clinician.
9. DATES OF FUTURE MEETINGS
Thursday 17 May at 10.00 a.m. within The Board Room, Angus House,
Orchardbank Business Park, Forfar.
Thursday 20 September at 10.00 a.m. within Room A St Margaret’s House,
Orchardbank Business Park, Forfar.
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