The first publication by NHS Clinical Commissioners, which includes the combined forces of the National Association of Primary Care (NAPC), NHS Alliance and NHS Confederation, features examples from 12 CCGs across England where clinically-led initiatives have both improved the quality of healthcare services for patients and saved money. This week we look at the first six examples. Later this month we look at the remaining six.
1. Newcastle West and Newcastle North and East CCGs
LEARNING: How GPs’ understanding of problems and clinical involvement can lead to better care.
PROBLEM: Three care home residents admitted as emergencies daily at cost of £8,225. Third of these patients were discharged on the same day, half within two days but 18% died, many within five days of admission. Suggestion some patients were being admitted to die, often as an emergency which could contribute to a lack of dignity and lead to interventions unlikely to make a difference to the final outcome.
SOLUTION: Each care home was given a link GP who would make regular visits and care home staff were invited to educational events. The link GP works with the home to support adoption of best practice guidelines. Education events support care home staff to help residents who wanted to die in their care home. Cost £250,000 in year one, this includes set up and ongoing costs will be lower.
RESULTS: 9% reduction in unplanned admissions from care homes, same day discharges down 25% and 27% fewer patients dying within one day of hospital admission.
QUOTE: David Thorne, chief operating officer of Newcastle West CCG, says: ‘I have not met a GP yet who doesn’t say that this is really important work.’
2. Kettering locality of Nene CCG, Northamptonshire.
LEARNING: Identifying a local solution to a problem; improving access for patients.
PROBLEM: Minor injuries patients putting pressure on A&Es.
SOLUTION: Training practice nurses to treat minor injuries and order X-rays without doctor involvement. Patients who are in a practice (two of eight locally) that does not offer minor injury services are able to access a practice that does.
QUOTE: Dr Raf Poggi, locality chairwoman, says: ‘In my locality with eight practices and a local district general hospital, I can get clinicians around a table.’
3. Corby CCG, Northamptonshire
LEARNING: CCG tackling key issue of referrals successfully.
PROBLEM: Area had highest referral rate in county but many patients did not need a procedure once referred to hospital.
SOLUTION: Review of all hospital referrals – except for time-dependent ones including pregnancy termination and suspected cancer – introduced September 2010. Each practice has a different method of reviewing referrals. In some a multi-disciplinary team will discuss all proposed referrals once a week to decide whether they could be treated in primary care. In the largest practice (45,000 patients) GPSIs discuss referrals with originating GP.
Referral management has been tried by many PCTs over the last decade but often through a team external to the originating practice examining referrals with little opportunity for practices to learn from the experience.
RESULTS: GP referrals cut 25% in a year saving £300,000.
QUOTE: Nicki Price, CCG chief operating officer, says: ‘This came as a bottom-up approach, as we had one practice in particular which started this and had good results.’
4. Sandwell CCG, West Midlands
LEARNING: Willingness to engage and address key issue of end-of-life care; listening to what people want.
PROBLEM: Need to improve end-of-life care.
SOLUTION: CCG engaged with over 100 individuals and organisations to find out how great end-of-life care should be.
Work started to develop primary care clinicians to diagnose dying and proactively support people and their carers at the end of life to have the experience they choose. Hospice care offered everywhere to support people to die in the place of their choice. Building ‘compassionate communities’ where people feel relaxed about discussing death and end-of-life care
CCG invests in 15 ‘improvement champions’, from voluntary sector and key provider organisations as well as commissioners.
QUOTE: Dr Niti Pall, the joint clinical lead for the programme, said: ‘Because we had the right people in the room – commissioning with the CCG as equal partners from the start – we now have an army of supporters with a shared route map towards great care.’
5. West London CCG
LEARNING: CCGs identifying groups who ‘fall between the cracks’ of existing services; redesigning services to meet those needs.
PROBLEM: Many patients fall between the gaps of mental health services – not needing the intense level of intervention offered in secondary care but needing more than the counselling or anti-depressants typically available through GPs.
SOLUTION: Patients in Kensington and Chelsea now have access to a range of mental health services – thanks to a ‘single point of access’ integrated service which has been developed by the West London CCG.
The integrated service aims to support primary care in looking after patients with mental health problems which are not severe enough to need secondary care intervention.
Options for treatment include guided self-help: CBT; and intermediate care and support for more complex cases. More severely ill patients will be case managed by a community psychiatric nurse. Delivery is through three community hubs with multi-disciplinary staffing. Each is open until 8pm.
QUOTE: Dr Fiona Butler, West London CCG mental health lead, said: ‘The model has come from the ground to meet what GPs wanted.’
6. Great Yarmouth and Waveney CCG, Norfolk
LEARNING: Willingness of CCGs to use innovative methods to understand patient needs and behaviour – and involve them in redesigning services.
PROBLEM: Gorleston is a relatively deprived area with an ageing population and high levels of long-term conditions such as arthritis and diabetes close to the main district general hospital. Many people accessing the emergency care system rather than using community health facilities.
SOLUTION: 15 local people with experience of long-term conditions trained as community advocates and looked at redesigning the system. Research suggested co-locating health and voluntary sector support services at surgeries, improving patients’ perspective of the continuity of care between different health and social care agencies and offering more opportunities for self-management and peer support.
QUOTE: Rebecca Driver, director of engagement for HealthEast (the area’s CCG), says: ‘Key areas of work in the next nine months include supporting self management of long-term conditions, connecting vulnerable people to information and resources and joining up services.’
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