Transforming Services, Changing Lives
Report of engagement 9 July to 21 Sept 2014 Analysis of Responses
October 2014
TSCL Engagement report
The engagement process, and the compilation of this document was co-ordinated by NEL Commissioning Support Unit on behalf of Newham Clinical Commissioning Group, Tower Hamlets Clinical Commissioning Group and Waltham Forest Clinical Commissioning Group.
TSCL engagement report
Contents
1. Executive summary ...... 3 2. The engagement process ...... 7 2.1. Background ...... 7 2.2. The resources ...... 8 2.3. Evaluation of engagement ...... 10 3. Activity ...... 11 3.1. Meetings, information stands, emails and phone calls ...... 11 3.2. The questionnaire – demographic analysis ...... 15 3.3. Focus groups and interviews ...... 18 3.4. Clinical engagement ...... 20 4. The responses ...... 21 4.1. Meetings, information stands, emails and phone calls ...... 21 4.2. The questionnaire ...... 25 4.3. Focus groups and interviews ...... 32 4.4. Clinical engagement ...... 40 Appendix 1: Clinical engagement ...... 41 Introduction ...... 41 Children and Young People ...... 44 Maternity and Newborn Care ...... 48 Unplanned Care ...... 52 Planned Care: Long Term Conditions ...... 56 Planned Care: Elective Surgery ...... 60 Clinical Support Services ...... 63 List of clinical stakeholders engaged on the CWGs cases for change ...... 66 Recommendations for CWG phase 3 work plans ...... 67 Appendix 2: Patient and public engagement on care pathways, enablers and CWGs ...... 68 General / process / equalities ...... 68 Workforce and organisational development ...... 69 Information technology ...... 71 Finance ...... 71 Estates ...... 73 Primary care ...... 74 Unplanned care ...... 76 Maternity and newborn ...... 77 Children and young people ...... 79 Long term conditions ...... 82 Planned care ...... 84 Clinical support services ...... 85 Appendix 3: Healthwatch report of a meeting at Whipps Cross on 18 August 2014 ...... 87
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1. Executive summary
330,000+ opportunities to engage: 2,800 people engaged
90 meetings and 1,300+ visitors to the 64 questionnaires events attended website completed
See footnotes1,2,3,4
The Transforming Services, Changing Lives (TSCL) engagement aimed to inform people, test commissioners‟ and providers‟ ideas, invite comment and, ultimately, start building a community for change. We aimed to increase the number of people engaged with the programme from the 150 involved in developing the interim Case for Change, to 1,500. We estimate around 2,800 people were actually engaged.
Our engagement focused on Newham, Tower Hamlets and Waltham Forest but included organisations, patients and members of the public from neighbouring boroughs as people from these communities use our services and could be affected by service change.
We presented at 575 stakeholder meetings. Mainly these were as an item on a wider agenda, but a number of events were specific to the interim Case for Change, for example the Healthwatch event at Whipps Cross Hospital. Almost without exception, the programme was welcomed. Everyone who responded to the questionnaire wanted the NHS to change in some way.
Clinical engagement developed the ideas of the clinical working groups and involved additional meetings with 375 clinicians, particularly across Barts Health.
Focus groups and interviews provided the programme with a greater depth of understanding in areas where the clinical working groups felt that the public and patient voice was either not strong enough (for instance, the Patient and Public Reference Group had no young representatives) or had particular needs.
The engagement itself was well received with comments made that the programme is a good way of getting people together, sitting round a table and discussing the important issues. The documentation was described as clear and honest.
1 Opportunities to engage: the number of people engaged figure (see below) plus the estimated number of opportunities for people to hear about the Case for Change through receiving an e-bulletin, reading a newspaper etc: 337,683 2 Number of people engaged: estimated number of people reached through face-to-face presentations and discussions at meetings and events (including clinical), questionnaires filled in, personal email discussions, phone conversations etc: 2,775. The number of meeting attendees was not recorded on every occasion – so this figure has been estimated by using an average of the attendees at meetings where figures were recorded 3 Meetings and events attended: number of meetings (clinical and non-clinical), events and focus groups attended or run by TSCL: 90. 4 Visitors to the website = 1,368 unique visitors (as per google analytics) viewing website over 2,000 times between them 5 Excludes clinical meetings and focus groups. Some of the stakeholder meetings were specific to one borough, others were cross-borough. Full list can be found on p13. TSCL engagement report The responses
The need for change was almost universally agreed and the direction of travel broadly welcomed, with support for the overall vision. Responses also supported the way in which local challenges and areas that need to change had been described.
Patients and the public did praise plenty of clinical practices and procedures. When patients get to see a clinician they are generally satisfied – although there was some concern about different expertise and performance between different Trusts / sites. But administrative issues, poor patient experiences and inefficient and confusing patient pathways were highlighted as being particularly problematic. Late appointments, appointments when tests or scans were not available, being passed from one specialist to another and a feeling of being not being in charge of their own care gave patients a strong sense of frustration.
Some respondents expressed concern that the TSCL process would lead to the closure of services. Others wanted assurance that staffing levels would be appropriate, with good staff being retained, and that staff morale would be considered. There was nervousness that the NHS is changing, but not always for the good, and sometimes driven from national policies.
The staff who responded recognised all the points made by patients and the public. Staff felt frustrated at the poor internal communications which left them unaware of the different support options available for patients or the involvement of other NHS staff. They said poor IT systems and fragmented pathways make the job more difficult than it needs to be, and variations in commissioning mean that there are unnecessary differences in the care that people receive. In summary, staff feel that there are significant inefficiencies in the NHS that make it hard for them to do their jobs.
There was no clear difference of opinion on these matters between patients and the public, different age groups, ethnicities, genders or amongst people with disabilities. The themes were recognised by people regardless of where they live, but some geographical differences were noted. For instance:
People in Waltham Forest were particularly concerned about the future of Whipps Cross University Hospital, the quality of the estate; and the cost of running The Royal London People in Newham were concerned about the future of Newham University Hospital People in Tower Hamlets were particularly concerned about the administrative systems at The Royal London.
I am impressed with the engagement process and development of the Case for Change PPRG member
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The three key themes arising from staff, patient and public feedback were:
1. Patient experience and ‘customer’ satisfaction Patients explained that the NHS seems to separate patient experience from clinical care (with patient experience seen as of secondary importance) whereas they view their care in a more holistic way. Patients see clinical quality and patient experience as inextricably linked – and encouraged the NHS to look at care in a totally different way by focusing exclusively on patient experience.
Services must be integrated; staff need to be well informed and welcoming; premises need to be of high quality; and a patient‟s personal circumstances – friends and family, their age, housing and employment etc all need to be considered.
The NHS needs to invest in staff – not just more staff, but retaining good staff and developing skills in training, leadership, customer care etc.
Patient The NHS view The patient view experience
Clinical quality
Friends and Clinical Patient family quality experience
2. Health and wellbeing Patients and the public accepted that there was a need for better prevention of illness and for people to take more responsibility for their own health if the population is to become healthier. However there was a general view that people needed support in order to make changes to their own lives and that the NHS is not currently set up to provide this support. Significantly enhanced information and better support mechanisms are required if patients and the public are going to be able to manage their own health better.
3. Efficiency and productivity Whilst there was some call for greater funding of the NHS, there appeared to be considerable acceptance that the NHS can improve efficiency and productivity to reduce waste. Staff and patients identified numerous instances where inefficient processes were adding to the financial burden; and a great many opportunities for introducing smarter working.
The following word cloud visually represents the comments made throughout the engagement – with the most common statements represented in the largest size text. TSCL engagement report
Conclusion
Part of the purpose of consultation has been described as to: “allow those consulted to give intelligent consideration and an intelligent response... One of the functions of a consultation process is to winnow out errors in the decision-maker‟s provisional thinking. True consultation is…not a matter of how many people object to proposals but how soundly based their objections are”6
Whilst this was an engagement process – our aims were almost identical. The engagement has allowed intelligent consideration and response. It has allowed us to understand errors in our provisional thinking, and to a great degree, we can take comfort from the considerable consensus that there is a strong case for change and agreement about what change is required.
The responses to the engagement have been shared with clinical working groups and the programme executive. Appendices 1 and 2 detail the key changes to the Case for Change.
6 R (Brompton and Harefield NHS Foundation Trust) v Joint Committee Of Primary Care Trusts & Anr - Court of Appeal (19 April 2012) Page 6
TSCL Engagement report
2. The engagement process
2.1. Background NEL CSU was commissioned by Newham, Tower Hamlets and Waltham Forest Clinical Commissioning Groups (CCG) to engage with members of the public, healthcare staff, patients, clinicians and key stakeholders about how they could improve people‟s health and well-being.
The interim Case for Change was developed and agreed by the programme team, clinical working groups (CWG), clinical reference group, programme executive and programme board, and was published on 9 July 2014. The emerging key themes for the interim Case for Change were also discussed at clinical and other forums, and shared at an engagement event on 6 June 2014.
An engagement process was developed and agreed by the communications steering group, the programme executive and programme board. The patient and public reference group played an important role here too, particularly in suggesting additional engagement activities to extend the reach of the programme.
Patient and public reference group
The patient and public reference group (PPRG) was established in April 2014. There are 23 members in total. Public and patient representatives were invited from the organisations below (some nominated representatives from existing patient groups): Healthwatch: Waltham Forest, Tower Hamlets, Newham, Redbridge, Barking and Dagenham, Hackney, City of London, and Essex Clinical commissioning groups: Waltham Forest, Tower Hamlets, Newham, Redbridge, Barking and Dagenham, and Hackney Hospitals: Whipps Cross University, Newham University, The Royal London, Mile End, London Chest, and Homerton University Community and mental health providers: North East London NHS Foundation Trust and East London NHS Foundation Trust.
The group met seven times between April and September 2014. However due to the short timescales and the changing agenda, different people came on different occasions. The fast pace of the programme also impacted upon the group‟s ability to consider all the issues. The purpose of the group was to help ensure the „patient voice‟ was part of the process from the outset, both from the sponsoring CCG and surrounding areas. In particular the group helped develop the Case for Change by providing ideas and feedback to the clinicians leading the TSCL programme, and giving advice on (and support with) public and patient engagement activities.
Communications Steering Group
The Communications Steering Group includes membership from CCGs in Waltham Forest, Tower Hamlets, Newham, Barking and Dagenham, Redbridge, Havering, and City and Hackney; Barts Health NHS Trust, Homerton University Hospital NHS Foundation Trust (FT), East London NHS FT, North East London NHS FT, the Trust Development Authority and NHS England.
The group met four times between March and September 2014. Members helped to communicate information about the Case for Change to local communities, patients, clinicians and other key stakeholders (for instance through CCG annual general meetings), and supported the gathering of information to be used to update the Case for Change. TSCL engagement report 2.2. The resources
The resources were developed within the programme and then tested with the programme executive, the patient and public reference group and the communications steering group. The resources consisted of:
publicity – flyers and media releases informing people of the engagement, where to get further information and how to give their views documentation – aimed at providing the right information to the right people. We produced a summary and full version of the Case for Change. In general, summary documents were provided at public meetings, whereas full documents were provided at clinical or partner events. We also developed various PowerPoint presentations questionnaire – this was included in the documentation and on the website, and allowed the programme to build up a quantitative understanding of the views of respondents website – that provided a repository for the significant number of documents produced, and ensured that anyone could access the information at any time.
The formal process of engagement started on 9 July 2014 and ran until 21 September 2014. Emails and bulletins were sent to more than 40,000 people; patients, staff, clinicians, members of voluntary organisations, community groups and other key stakeholders in the area7 inviting them to read and provide feedback on the interim Case for Change.
Promotion and publicity
Press releases were distributed to key east London media, with three newspaper articles appearing in East London Advertiser, Barking and Dagenham Post and East End Life. A radio interview was also broadcast on Time FM‟s breakfast programme. These activities provided an estimated 289,0008 opportunities for engagement.
Documents
2,500 copies of the summary interim Case for Change were produced and sent to the following for onward distribution:
Libraries, town halls, community centres and voluntary organisations Barts Health NHS Trust Healthwatch Tower Hamlets, Newham, Waltham Forest, Redbridge and Barking and Dagenham clinical commissioning groups
7 This was in the following areas: Tower Hamlets, Newham, Waltham Forest, Hackney, Redbridge, City of London, Havering and Essex. Range of organisations and individuals included Barts Health, local authorities, Health and Wellbeing boards, MPs, Healthwatch. Excludes emails distributed by external partners 8 Estimated readership/listenership of media outlets Page 8
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The summary of the interim Case for Change was translated into an Easy Read document (which was distributed) and was also available in 21 languages on request although none were requested. A number of other, more detailed products, supported the interim Case for Change, for instance:
A variety of presentations Full version of the interim Case for Change (81 pages) Appendices (primarily available on the website): o The growing population o Health of the population o Unplanned care (UPC) emerging Case for Change (summary slides) UPC interim report (summary of clinical working group discussions so far) overview of policy, quality standards and best practice technical data pack o Maternity and newborn (MNB) emerging Case for Change (summary slides) MNB interim report (summary of clinical working group discussions so far) MNB overview of policy, quality standards and best practice o Children and young people (CYP) emerging Case for Change (summary slides) CYP interim report (summary of clinical working group discussions so far) CYP overview of policy, quality standards and best practice CYP technical data pack o Long term conditions (LTC) emerging Case for Change (summary slides) LTC interim report (summary of clinical working group discussions so far) LTC overview of policy, quality standards and best practice LTC technical data pack o Elective surgery (ES) emerging Case for Change (summary slides) ES interim report (summary of clinical working group discussions so far) ES overview of policy, quality standards and best practice ES technical data pack o Clinical support services (CSS) emerging Case for Change (summary slides) CSS interim report (summary of clinical working group discussions so far) CSS overview of policy, quality standards and best practice CSS technical data pack
Questionnaire
A questionnaire was available both in the printed copies of the summary of the interim Case for Change and on the website.
Website
In addition to the interim Case for Change documents and feedback survey, the website provided:
background information on the programme a frequently asked questions section information about events and how to get involved a list of the clinicians involved in the programme and the members of the PPRG contact information two videos created by the clinicians and the public and patient reference group to help explain the programme TSCL engagement report
Website address and links to the resources:
www.transformingservices.org.uk
Full interim Case for Change Summary interim Case for Change
Video – clinicians view Video – public and patients view
Easy read version of Case for Change
Technical and supporting documentation for interim Case for Change
2.3. Evaluation of engagement
In order for the CCGs to understand the views of the community, the engagement aimed to:
Inform stakeholders, patients and the public about the NHS‟ thinking and direction of travel Test the robustness of the interim Case for Change Invite comment and new suggestions on the interim Case for Change Set the scene for future work Build a community for change.
An evaluation of the engagement process, using these aims as a starting point, will be undertaken. This process will include lessons learned; and will be used to develop engagement plans for any future phases of the programme.
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3. Activity
This section describes the range of techniques we employed to enable patients, the public, stakeholders, staff and others to make their views known. Section 4 analyses the responses:
3.1. Meetings, information stands, emails and phone calls 3.2. The questionnaire 3.3. Focus groups and interviews 3.4. Clinical engagement
N.B. Whilst the engagement used a variety of methods to understand the views of the public, staff, patients and stakeholders the responses cannot be assumed to be representative of the population.
3.1. Meetings, information stands, emails and phone calls
A range of opportunities were provided for the programme to gather valuable insight into people‟s views. Section 4.1 analyses:
Meetings. An email was circulated at the start of the engagement period to a wide range of stakeholders including local authorities, health and wellbeing boards, Healthwatch, MPs and voluntary organisations. The email asked stakeholders to get in touch to request a TSCL speaker for an event. We attended 579 meetings and events during which we highlighted and discussed the Case for Change with around 2,000 people. Some events were specific to the programme, some were presentations as part of a regular meeting (e.g. Health Scrutiny Committees) and some were organised on behalf of the programme (e.g. Healthwatch event). Barts Health arranged a series of staff engagement events and ensured an explanation of the programme was included in the regular staff briefings held across its six sites. The nature of the meetings varied; some were formal, others informal; some meetings were held at our request, others were agenda items at existing meetings. In particular we are indebted to all the various Healthwatch organisations which distributed leaflets, provided information and made comments on the Case for Change and, in the case of Redbridge, Waltham Forest and Newham – arranged for a joint event attracting around 100 members of the public. Information stands. We organised information stands at The Royal London, Whipps Cross University and Newham University hospitals, where we spoke to around 200 people. Staff recorded the feedback received at the stands. We also had information stands at local events, such as CCG annual general meetings (AGM) and Healthwatch Tower Hamlets AGM.
9 Excludes clinical and programme meetings and focus groups TSCL engagement report
E-mails and phone calls received by the programme office. Emails and phone calls received were exclusively from NHS staff representing Homerton, Barts Health and NEL CSU (individuals outside the TSCL programme team). The responses primarily identified specific points in the Case for Change and requested amendments to improve clarity, consistency and accuracy.
List of meetings, information stands and events:
No. Date Meeting or event Nature of Main stakeholder group meeting or event Organise TSCL invited by Other NHS staff Patients Local d by stakeholder or and public authority / TSCL TSCL other key requested slot stakeholders at existing meeting 1. 7 July Barts Health staff briefing
Mile End Hospital 2. 9 July Barts Health staff briefing
Newham Hospital 3. 9 July Barts Health staff briefing
Whipps Cross Hospital 4. 9 July Newham CCG governing body
5. 10 July Barts Health staff briefing
Prescot Street 6. 10 July Barts Health staff engagement
event West Ham Football Club 7. 10 July Inner North East London Joint
Overview and Scrutiny Committee informal briefing 8. 11 July Barts Health staff briefing
The Royal London Hospital 9. 11 July Barts Health staff briefing
St Bartholomew‟s Hospital 10. 11 July Barts Health staff engagement
event Great Hall, St Bartholomew‟s 11. 14 July Barts Health staff engagement
event Great Hall, St Bartholomew‟s 12. 14 July NHS England NE London
Strategic Plan Review meeting 13. 15 July Barts Health staff briefing
London Chest Hospital 14. 15 July East London and City Mental
Health Commissioning Forum 15. 15 July Tower Hamlets local residents and Organised
members of 38 degrees by TH CCG (campaign group) 16. 16 July North East London Foundation
Trust senior management and clinical leads 17. 18 July Homerton Hospital Executive and
Divisional Teams 18. 18 July Waltham Forest, East London and
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City Clinical Strategy Group
19. 21 July North and East London
Foundation Trust heads of clinical services and managers 20. 22 July Outer North East London 10 Joint
Overview and Scrutiny Committee 21. 23 July Tower Hamlets CCG lunch and
learn session 22. 23 July City and Hackney CCG meeting
with CCG leads 23. 23 July Waltham Forest CCG governing
body 24. 24 July Barking and Dagenham CCG
Patient Engagement Forum 25. 25 July Newham GP Practice Council
26. 28 July Redbridge Health and Wellbeing
Board 27. 30 July London Borough of Newham
Safeguarding Adults Board 28. 31 July Waltham Forest CCG GP member
practices 29. 5 Aug Tower Hamlets CCG Governing
Body seminar 30. 6 Aug Newham CCG Cluster Leads
31. 7 Aug Barking and Havering Local
Medical Committee 32. 14 Aug Tower Hamlets Healthwatch
community day and Annual General Meeting 33. 15 Aug Waltham Forest, East London and
City Clinical Strategy Group 34. 18 Aug Healthwatch event Whipps Cross
Hospital11 35. 22 Aug Newham CCG Practice Council
36. 26 Aug Tower Hamlets Locality Chairs
Board 37. 28 Aug Whipps Cross Hospital Patient
Panel 38. 2 Sept Tower Hamlets CCG Annual
General Meeting 39. 2 Sept The Royal London Hospital
information stand 40. 4 Sept Whipps Cross Hospital information
stand 41. 4 Sept Newham CCG patient
engagement forum 42. 4 Sept Waltham Forest Local Medical
Committee 43. 5 Sept London Borough of Tower
10 Covers the boroughs: Barking & Dagenham, Havering, Redbridge and Waltham Forest 11 Organised in partnership with Healthwatch Newham, Healthwatch Redbridge and Healthwatch Waltham Forest and TSCL TSCL engagement report
Hamlets Summer Night Lights information stand 44. 8 Sept Newham Co-Production Forum
meeting 45. 8 Sept Newham Health and Wellbeing
Board 46. 9 Sept Newham Hospital information
stand 47. 9 Sept Tower Hamlets Health and
Wellbeing board 48. 9 Sept Barking and Dagenham Health
and Wellbeing board 49. 9 Sept Tower Hamlets Local Medical
Committee 50. 9 Sept London Borough of Waltham
Forest Health Scrutiny Committee 51. 10 Sept Save NHS Newham, Save NHS Organised
Waltham Forest and Save NHS by Barts Health Tower Hamlets 52. 10 Sept London Borough of Waltham
Forest meeting with director 53. 11 Sept Barking, Havering and Redbridge
CCG Joint Executive Team 54. 11 Sept Inner North East London12 Joint
Overview and Scrutiny Committee 55. 11 Sept London Borough of Redbridge
Adult Social Care Board 56. 13 Sept Barts Health Open Day, Newham
Hospital 57. 16 Sept London Borough of Tower
Hamlets Health Scrutiny Panel 58. 16 Sept Redbridge CCG Patient
Engagement Forum 59. 17 Sept Newham Safeguarding Board
60. 23 Sept London Borough of Redbridge
Health Scrutiny Committee 61. 23 Sept Newham Local Medical Committee
62. 24 Sept Waltham Forest CCG Annual
General Meeting 63. 25 Sept Newham CCG Annual General
Meeting 64. 26 Sept City and Hackney CCG Governing
Body 65. 26 Sept Waltham Forest Health and
Wellbeing Board 66. 26 Sept City and Hackney CCG Governing
Body 67. 30 Sept Barking and Dagenham Health
and Adult Services Select Committee
12 Covers the boroughs: Hackney, Newham, Tower Hamlets and City of London Corporation Page 14
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3.2. The questionnaire – demographic analysis
We received 64 questionnaires. All percentages have been rounded, and so final figure may add up to just under or just over 100%.
89% of respondents were from individuals and 8% from people representing groups (3% provided no response to this question).
The following groups responded o Local authority (not stated which one) o „The Public – Young People‟ o Waltham Forest Support Group o Useyourcommunity.com o Hornchurch & Upminster constituents (this was from Dame Angela Watkinson DBE and MP).
34% of respondents were male and 56% female (6% preferred not to say and 3% provided no response).
Responses came from all age groups o 2% were under 16 o 2% were 16-25 o 38% were 26-40 o 38% were 41-65 o 13% were over 65 o 8% preferred not to say.
The majority of respondents are, or have been, service users.
Number who answered: 63
Respondents could be in more than one category
TSCL engagement report
A range of ethnicities and beliefs/religions were represented amongst respondents.
11.11% (7) Number who answered: 63 1.59% (1)
3.17% (2)
3.17% (2)
4.76% (3) 38.1% (24)
4.76% (3)
1.59% (1)
7.94% (5)
6.35% (4)
1.59% (1) 6.35% (4)
1.59% (1) 7.94% (5)
Number who answered: 63
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20% of respondents considered they had a disability.
Number who answered: 60
Where do respondents live?
Number who answered: 63
11 out of the 16 respondents who stated „other‟ for their place of residence (outside north east London) were NHS staff.
64 respondents cannot be seen as representative of the east London population. However, when compared to the demographic profile of Tower Hamlets, Newham and Waltham Forest, responses from White British/Irish or disabled or over 65 is higher than the area average. Responses from Asians, Black/Black British and those under 25 is low when compared to the area average13. The programme will need to bear this in mind as engagement on the programme progresses. The other engagement we undertook (meetings, events, information stands, focus groups and interviews) ensured we reached a much broader group of people, in terms of geography, age and ethnicity.
13 Information taken from 2011 census and ONS data TSCL engagement report 3.3. Focus groups and interviews
The programme considered the responses and the likely demographics of respondents throughout the period of engagement. Some CWGs were satisfied that the general responses (coupled with their own informal patient and public engagement) provided them with sufficient information needed to develop their ideas.
Three CWGs: planned care / long-term conditions; maternity and newborn care; and children and young people requested more targeted engagement with patients given their particular target audiences and to ensure their voices were heard. This was organised as follows: Long-term conditions
We invited people living with a long-term condition in east London to attend a focus group on Tuesday 16 September, 5.30pm – 7.30pm at Stratford Town Hall14,15. Fifteen attendees came from Hackney, Newham, Tower Hamlets and Waltham Forest aged 48 – 81. Attendees had received care at The Royal London, Whipps Cross, Newham and Homerton hospitals.
Attendees were living with the following long-term conditions: diabetes (type 2), asthma, arthritis, chronic obstructive pulmonary disease (COPD), lupus, hypertension, spine damage, ankylosing spondylitis, renal and lung conditions, deep vein thrombosis and conditions following a stroke.
Attendees were asked to rate their care using the following questions: How does having a long-term condition impact on your life? What do you find most frustrating about the way your care is delivered? Think about the last time you visited hospital for your long-term condition. o What was good about it / what did you value? o What was not good / what could be better? How can care better suit your needs? Focus areas: information / support / skills
14 The invite stated that the hospitals being focused on were The Royal London, Whipps Cross University, St Bartholomew‟s and Newham University Hospitals 15 Invites were sent out via: Barking and Dagenham, Havering, Newham, Redbridge, Tower Hamlets and Waltham Forest CCGs; Barking and Dagenham, Waltham Forest, Newham and Tower Hamlets Healthwatch; the PPRG; Barts Health; local charities and support groups. Page 18
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Maternity and newborn care
We invited women who were pregnant or had given birth within the last year to a focus group on Wednesday 17 September, 1.30pm – 3.30pm at Stratford Town Hall16,17,18. Khaleda Maleque from Social Action for Health (SAFH), organised attendance from some women from Tower Hamlets, and a group of women from Waltham Forest (accompanied by an advocate) described as „hard to engage‟. Twenty eight attendees came from Tower Hamlets, Newham and Waltham Forest. One person who couldn‟t attend submitted their comments via email. Attendees were / had been under the care of The Royal London, Whipps Cross, Newham and Homerton hospitals and the Barkantine Birth Centre. The Chair of Tower Hamlets maternity services liaison committee (MSCL) attended the group.
The agenda was shared and discussed with Shabira Papain, Director of SAFH who runs Tower Hamlets and Newham MSLCs, and Kelly Drake, Chair of Newham NCT.
Attendees sat on three tables. Facilitators asked attendees to: rate their experience of antenatal / birth / postnatal care on a continuum using coloured stickers and then to explain their ratings provide „top three‟ things that would improve their experience of maternity care.
Children and young people
It was agreed that a focus group was not the best way to elicit the views of young people. Instead we used two different techniques:
• Conducted interviews with young people in The Royal London paediatric outpatients department (diabetes; surgery and neuro; orthopaedics; irritable bowel disease) between 8 and 10 Sept. We conducted 28 interviews with parents and/or children and young people aged 7 months – 17 years old. Interviewees lived in Essex, Hackney, Haringey, Havering, Islington, Newham, Redbridge, Tower Hamlets and Waltham Forest. We asked them what was good about their care, what wasn‟t so good and what could be better.
• Met with seven young advisers19 (aged between 15 and 21) from Waltham Forest including the young mayoress on 15 Sept.
• We asked them for: a) positive and negative views of the NHS b) views on the interim Case for Change c) views on the feedback received in paediatric outpatients.
16 The invite stated that the focused was The Royal London, Whipps Cross University, St Bartholomew‟s and Newham University Hospitals 17 Invites were sent out via: Barking and Dagenham, Havering, Newham, Redbridge, Tower Hamlets and Waltham Forest CCGs; Barking and Dagenham, Waltham Forest, Newham and Tower Hamlets Healthwatch; Newham, Tower Hamlets and Waltham Forest MSLCs; the PPRG; Barts Health; Newham National Childbirth Trust 18 Attendees were paid £16 for their time, in line with guidance and best practice 19 The Youth Engagement and Participation Officer at Waltham Forest Council organised this session on our behalf TSCL engagement report
3.4. Clinical engagement Following the launch of the interim Case for Change each of the clinical working groups (CWGs) embarked on a wider clinical engagement piece with an overall aim to: • obtain and collate further feedback on the interim CWG reports • build clinical consensus amongst local clinicians • build appetite for collaboration through existing relationships • to capture where opportunity could exist • introduce the TSCL programme to any new clinical stakeholders.
Feedback on each of the CWGs interim reports was sought through a range of briefing and engagement sessions attended by local clinicians across north east London. Engagement took place throughout July, August and September. Approximately 375 clinicians were engaged on the CWGs interim reports. Clinicians from a variety of care settings were involved in the following organisations:
• Barts Health NHS Trust • East London NHS Foundation Trust • Homerton University Hospital NHS Foundation Trust • Newham Clinical Commissioning Group • North East London NHS Foundation Trust • Redbridge Clinical Commissioning Group • Tower Hamlets Clinical Commissioning Group • Waltham Forest Clinical Commissioning Group
Overview of clinicians engaged
Clinical Scientists 1% Consultants GPs Other Secondary and Surgeons Care Doctors Health Visitors 12% 2% Matrons Others Nurses and GPs Midwifery 49% Pharmacists 16% Therapists Nurses and Midwifery Therapists Other Secondary Care Doctors 8% Clinical Scientists
Pharmacists Others Consultants and Surgeons 2% 8% Matrons n=375 2%
The pie chart details the groups of clinicians that were recorded as being engaged through the clinical engagement. Page 20
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4. The responses
This section summarises the views of respondents to the engagement. Further analysis can be found in:
Feedback from the clinical engagement (Appendix 1) Feedback for each clinical working group and by theme/enabler (Appendix 2) Report of a Healthwatch event on 18 August 2014 (Appendix 3).
4.1. Meetings, information stands, emails and phone calls
There was broad similarity of views expressed through feedback via phone calls and emails, information stands and meetings and those expressed in the questionnaire. The responses via meetings had a greater focus on geography/locality and individual establishments – perhaps reflecting more focused discussions with people from a defined area, or often in a particular NHS building, but the themes were broadly the same. There was one universal theme that stood out from all the rest…
Patient experience and „customer‟ focus
Time and time again we heard that poor patient care and a lack of „customer‟ focus was the biggest problem. Patients explained that the NHS seems intent on separating patient experience from clinical care (with patient experience seen as of secondary importance) whereas patients view their care in a much more holistic way.
Respondents commented on a few clinical issues (the analysis can be found in Appendix 2) but the focus of their attention even when asked about a clinical specialty was on how their: wellbeing was being compromised. E.g. by not being fed for long periods whilst in hospital; by not understanding information provided to them; or by having treatments delayed because scans weren‟t available at the right time, or couldn‟t be accessed, or had been lost; by being discharged in the middle of the night or without a care plan experience was poor. E.g. poor communications – people with a visual impairment being sent letters and deaf people being phoned; or patients been given meat despite stating they were vegetarian; having too little time to discuss their condition. Often respondents felt confused as their care was not integrated and they were left in a bureaucratic system which was not coordinating their care in a holistic way time was being wasted by inefficient administrative processes which mean long waiting times, cancelled appointments at the last moment, being passed from pillar to post etc.
NHS staff often recognised these issues and felt frustrated that they are working with: inadequate IT systems that do not share appropriate data poor patient pathways that either do not work, or are inefficient.
Resolving these inadequacies (and these examples were seen as such) were considered to be a win:win situation, improving patient care whilst at the same time reducing inefficiencies in the system.
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“How can we win hearts and minds to convince that something is going to change this time? Within this we need to be mindful of the need for quick wins and to keep people up to date with how the work is progressing.” Waltham Forest Local Medical Committee
“The NHS knows the cost of everything and the value of nothing. It would be good to make establishment of expert patient programmes an obligatory part of a GP‟s role.” Whipps Cross Patient Panel
Enablers
In general, the enablers identified in the Case for Change were recognised by patients and the public – often they were identified unprompted.
Improved communications Better communications was seen as a major issue for many respondents and worked (or didn‟t work) in tandem with health and wellbeing (see below). There is confusion in the system. Patients told us that they cannot be in control of their own care without being provided with timely and reliable information. Some of the staff who are supposed to direct patients to services, don‟t seem to know the system themselves. Care plans on discharge are often missing or poor; letters are late and/or poor; there is a lack of community facilities to aid well-being or, if there are the facilities then they are not offered/communicated to patients. Clinicians highlighted the difficulty in sharing data and developing good clinician to clinician communications and this was picked up by patient and public respondents who gave examples of receiving conflicting information from different parts of the NHS, finding that patient information hadn‟t been shared, and diagnostics weren‟t made available at the right place at the right time. Staff identified IT difficulties as a major cause of the problems.
Health and wellbeing Health and wellbeing was of concern to a many respondents, with a key focus on the need for education, education, education. Respondents said they don‟t know what is good for them, how to deal with illnesses etc – not just acute illnesses but a range of health and wellbeing issues e.g. guidance for parents about the mental health of young people. Responses tended to focus on: prevention joint-working with partners, community groups and support networks.
Information Technology (IT) IT was a recurrent theme for both patients/public and particularly for staff. Patients find the appointments system hard to navigate and cannot access their own records. GPs and hospital consultants often cannot see the same patient data (and different parts of the same hospital cannot see the same patient data). Staff told us that they spend far too much time trying to resolve IT issues such as finding, transferring and viewing information.
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Finance and productivity/efficiency
The issue of finance was a theme, but set in a much broader context of privatisation, PFI, contracting out, procurement rules, use of management consultants and competition – with all of these being blamed for increasing administration, purchasing and overall costs. There was a general recognition that the NHS budget was limited, and that simply increasing the budget would not resolve the problem. There was significant comment that the NHS is inefficient – a view held by staff as well as patients and the public.
Estates The hospital estate was only a key theme in Waltham Forest/Redbridge – recognising the poor condition of Whipps Cross. There was some unease that this meant that the Whipps Cross site was vulnerable to disinvestment. There was also frustration at the way in which the NHS deals with redundant buildings – and a number of meetings focused on why these were not being used for nursing accommodation etc.
Workforce Staff said they feel frustrated at their inability / lack of opportunity to make improvements in patient pathways that they feel are not fit for purpose. Patients and the public identified the poor morale and attitude of the workforce as a key reason why some patient contacts are so poor.
Additional themes
Some respondents felt that the CWGs (and the programme as a whole) were too narrowly focused and that there needed to be a wider consideration of the whole health economy and a greater focus on, for example, mental health, public health, equality and two additional themes:
Involvement of the community Whilst the Case for Change does identify partnership working as critical to success, a number of meetings discussed the need to better engage with the community – really getting involved in grass roots organisations and ensuring NHS staff are engaging on every street and with every person. Local community groups suggested they could facilitate presentations and clubs, clinics and classes. They also said they could provide assistance, carry out research and „spread the word‟. The public said they would welcome better information so they could understand the health system and how to take better care of themselves – but not just in the form of more leaflets
Primary care The role of primary care was seen as critical in improving the health economy in the area and there was some disappointment that there wasn‟t a CWG for primary care. Some respondents felt there is variability in the quality of GPs; there is little consistency in the access routes to primary care; and that access is generally difficult.
Other concerns were around the lack of a holistic approach. Short consultations; a lack of interface with acute, social and community care; a lack of continuity of care – seeing different GPs each visit, were all raised as problematic.
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The Healthwatch event at Whipps Cross, 18 August
Healthwatch Newham, Redbridge and Waltham Forest arranged a meeting at Whipps Cross Hospital on 18 August 2014. The issues raised are included (but not always referenced) throughout this report. The issues raised were circulated to CWGs to consider. The key recommendations broadly reflect the outputs of the engagement as a whole and were:
Improve communication between service and patient Improve communication between providers Ensure proper staffing levels, morale and good staff are retained Streamlined booking system across medical services Coordinate health services with other services in the community.
The patient and public reference group
The patient and public reference group provided feedback on drafts of the interim Case for Change. They recorded their views on a video which was played at various meetings and was available to download on the website. The group encouraged the programme to be ambitious in its engagement and in developing the Case for Change. The group identified with the general direction of the Case for Change and supported the inclusion of many of the themes. The group offered to develop its own response to the engagement which was welcomed by the programme.
The most common words or phrases used in the meetings feedback:
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4.2. The questionnaire
Due to the self-selecting nature of the people who decide to fill in a questionnaire, the responses below, whilst quantitative, cannot be taken to be representative of the population. We also believe that many people who attended meetings decided not to fill in a questionnaire, but relied on the meeting notes taken by the TSCL staff to represent their views (See section 4.1). Q1: How satisfied are you with the NHS?
28.31 (17) Number who answered: 64
Fewer than half (45%) of the respondents were very or quite satisfied with the NHS and just over a quarter (27%) of respondents were very or quite dissatisfied with the NHS.
"Sadly few good experiences that I have are outweighed by the many bad ones. All the real care that had made a difference to my wellbeing had been received from private care providers."
"The NHS is able to and does deliver an excellent level of care, however at times the system for access can let us down."
"An amazing resource which meets millions of people's needs. We need to nurture and support it."
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Q2: How much do you think the NHS needs to change?
Number who answered: 64
No-one felt the NHS doesn't need to change (therefore this option is not show in the diagram above). The majority of respondents felt that the NHS needs to change a lot (55%) or a little (42%).
Patient care: Needs to be easier to access and choose a GP; online appointments; more emphasis on prevention e.g. obesity and not just when it is financially rewarded; better use of technology so people can be monitored at home. Continuity of care is lacking. Some respondents felt their GP did not recognise each patient's own experience in managing their condition. There was a view that the NHS delivers intrusive, bland and mediocre care when compared to the private sector. Receptionists ask personal questions in the reception area just for an appointment. Waiting...waiting...waiting... for appointments, at appointments, for tests etc. Some clinics tell people of an expected waiting time even if they are the first to be seen in the day. Turning up for an appointment, only to find the results of the required tests haven't arrived is infuriating. Staff/patient communications was highlighted as an area for improvement: Whether it is bedside manner (respondents felt there was not enough time to discuss a patient‟s condition – and therefore less likelihood that the patient would properly contribute to their own care), unintelligible or late letters, language challenges (both staff and patients) or simply a lack of discussion. Efficiency: Some respondents felt the NHS is very inefficient. Some made direct reference to service delivery, with one example of a patient turning up for an appointment only to be sent away for tests, which could have been carried out while waiting for the appointment. Others commented on waste arising from a lack of coordination among services or from bureaucracy. Finance: Some respondents felt privatisation (and profit) and competition are adding to the NHS‟ administrative burden. Others said the current system of funding is no longer adequate – comments ranged between getting rid of payment by results, letting acute trusts fail rather than bailing them out, moving funding from the acute to the primary/community sector and cancelling debt. Others felt there should be a reversal of the break-up of the NHS to improve buying power. Workforce: There was a view that the NHS should stop re-grading staff or downgrading jobs but also a view that the NHS should not tolerate poorly performing staff. A shortage of staff was identified in a range of specialties and a surfeit of managers. Respondents felt there needs to be better weekend staffing and people told us they cannot understand a system that allows home grown staff to go abroad only for us to then recruit abroad. A focus on mental health: particularly Children‟s and Adolescent Mental Health Services. Page 26
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Q3: Do you agree with our vision of care? What does a good NHS looks like?
Number who answered: 64
There was significant support for the TSCL vision. The majority of respondents agreed with the vision of care described in the interim Case for Change (56%). Most comments were about strengthening parts of the Case for Change or emphasising certain aspects:
Good access: Wherever you live and whatever time you need assistance, you should be able to access the same high quality care. GP surgeries should be open 8am til 8pm, six days a week with everything available online (prescriptions/appointments/support etc) Clear communications: NHS staff need to have better listening skills. Patients are often confused about how to get information and to access care Well organised services and a joined up approach: Planned activity/surgery is cancelled too often. There needs to be better links with local authorities (e.g. social care) and educational institutions. We need to make better use of facilities (e.g. using operating theatres 24/7) A motivated workforce: Investment in staff to ensure they are well motivated with a good work life balance will result in better care Patients in control: Targets should be relevant – not political. Patient choice seems to be diminishing. Patients should have the ability and freedom to voice their concerns. Some respondents suggested that: there are too many managers in the NHS hospitals are so big they are too impersonal to provide high quality individual healthcare. There was also concern that the NHS is too focused on clinical specialties and does not look at patient pathways. For instance, the TSCL programme generally looks at acute services and then separates these services into planned, acute, support etc. The vision is based around primary care, local hospital care and specialised care. But patients told us they identify with an illness along the lines of … prevention, identification, assessment, treatment, recuperation, adaption of lifestyle i.e. a patient-centric and patient pathway approach. Often the main source of irritation is the difference between these approaches.
"The NHS should treat the patient holistically and ideally be able to offer the treatment or clinical investigations within a shorter time frame." TSCL engagement report
Q4: Do you think we have described the challenges facing the NHS?
Number who answered: 64
Over half (53%) of respondents felt that the Case for Change either completely or mostly described the challenges, a number of other challenges were raised including:
Patients need to be in control: Respondents stressed the need for people to get involved with their own communities and not isolate themselves. There was also concern regarding how patient information would be used, and whether it would be used inappropriately – the proposal was that the patient should have control of their own data. Some respondents felt patients were disempowered – there is a need for greater respect – and did not have a real choice. Whilst the NHS was seen to be information rich (and some patients would benefit from this) there were concerns that not everyone would be in a position to benefit and this would increase inequalities. There was some support for electronic communications and online appointments. Young people need to have more of a say in their own care. The NHS is poorly organised: a concern that efficiencies tend to fall on backroom / administrative staff, whereas this is where the NHS faces the most criticism (clinical services may be very good in many places but its administration is almost universally poor) and is a defining difference between NHS services and the private sector There needs to be better investment in the NHS, specifically the workforce: the need for improved training; better plans for retaining good staff; and a need to adequately resource services. There needs to be fewer management consultants There is a lack of strategic planning: the need for some services to be distributed on a national level (as determining them locally brings about a postcode lottery). Good access to services is still not a reality The demand for mental health services has been underestimated.
“Surgery cancelled five times with no explanation… GP uninterested until letter from hospital said I had failed to attend! Forced to go privately…as no-one willing to help.”
“Ensuring that the right people are in the right jobs to improve our overall efficiency.”
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Q5: How do you think we could work better with our partners?
The general approach described by the programme was supported.
Health and Wellbeing Boards were identified as having good potential to improve joint working, particularly as the links with social care and public health were seen to be poor.
Respondents highlighted the need for more emphasis on partnerships and better communications between all organisations involved in health and social care – particularly local authorities.
A lack of joined up IT was cited as a particular problem. Other suggestions included:
Better involvement of the community – seeing them as a partner Getting rid of private suppliers Asking local authorities to do the administration of the NHS, allowing the NHS to concentrate on clinical/medical aspects More advice available locally on what specialist support groups are available
"Listen to public views and experiences"
Case study
The London Wanstead branch of the National Ankylosing Spondylitis Society (NASS) is an example of local partnership working. NASS offers physical and emotional support to patients living with Ankylosing Spondylitis.
The London Wanstead branch of the NASS is run by volunteers who raise funds and work in collaboration with physiotherapists and rheumatologists to provide a well-respected support service for over 60 people in Waltham Forest, Redbridge and surrounding areas.
The branch is based at Whipps Cross Hospital and once a week around 15-20 members meet to make use of the hospital hydrotherapy pool and the gym, with group exercise sessions being overseen by two physiotherapists. Tea, coffee and refreshments are available.
There is a small charge of £3 per evening which helps cover expenses for physiotherapists and refreshments.
TSCL engagement report Q6: How can we help patients and the public to take more responsibility for their care and encourage them to self-care?
Whilst there was some support for the vision (for more people to take responsibility for their own health and for them to self-care), not everyone accepted this.
The reasoning behind some of this disagreement was a concern that the NHS is trying to offload responsibilities onto patients and the public without providing them with suitable information, tools and permissions. So, although the need for personal responsibility may seem self-evident, the NHS still needs to explain this message; to describe the benefits; and establish a mechanism of support if it is to convince a greater proportion of the community that this is a positive move. Respondents suggested they were more open to the idea of „shared-care‟ rather than „self-care,‟ but that the NHS would need to take positive action if patients are to take more control of their own health.
Better access to GPs and other clinicians; a respectful attitude; the skill of listening; making time in the health system for staff to talk to patients; and recognising and respecting the individual were all cited as areas for improvement that would allow patients to become better at caring for themselves.
It was also recognised that the NHS cannot make the changes alone. The NHS needs to reach out and make connnections with schools, housing, social care etc. Other suggestions included:
a more authoritative approach or „tough love‟ for people who do not take care of their own health - charge them for minor treatments more health promotion first aid to be compulsory at school a health TV channel.
"Incorporate self-care participation including involvement of self-help voluntary groups as part of the diagnosis/treatment."
“I think people would be happy to „self-care‟ if they knew they had easy and flexible access to a healthcare professional if needed - for example, a 24-hour phone number or email address they could use if they had a question (rather than booking a GP appointment).”
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Q7: Do you think we have described well the key areas we need to change?
Number who answered: 64
Over half the respondents (58%) felt that the Case for Change well described the key areas the NHS needs to change. A number of respondents felt that the document read well, but there was some concern that:
there needs to be a greater focus on patients; in particular communications for patients, to patients and by patients the information is quite superficial and describes challenges that are well known PFI and privatisation are not discussed waiting times. For example one respondent suggested that whilst waiting three months for an appointment for acute back pain, a visit to a physio could have helped reduce the pain and improve the situation better recognition of the part voluntary and charitable organisations can play in prevention and treatment there is little discussion about better prevention of ill health, GPs working together to provide a network of care, and delays for appointments.
"I like that it was a very honest report. More needs to be done about healthy eating. From local businesses to government on policies about the number of fast food chains allowed in a certain parameter, as it is a national problem. I have to say a lot is being done at the moment in the NHS, and even talking about it, and conducting this survey is a start."
TSCL engagement report 4.3. Focus groups and interviews
Long term conditions a) How does having a long term conditions affect you?
Day to day life Can feel like normal life is compromised. Had to make lifestyle changes and modifications, such as the way I do my shopping as I can‟t carry much. Changes your identity and how you see yourself. Need to „find the balance‟ and figure out what to manage first. Important to keep occupied. Can‟t follow my action plan (care plan). Not sure where I can get support on practical day to day questions – don‟t want to have to ask a doctor.
Physical health Having arthritis means I can only walk short distances. Adjusting to the things you can no longer do can be frustrating. You forget you can‟t do what you used to do. Mismatch between what your body wants to do and what your body can do. Can‟t take kids to the park. I just wanted to stay indoors a lot. Every movement was painful. Life of carers slows down. It can be expensive –often have to take taxis, including to hospital appointments.. It‟s time consuming going to different hospitals. Some medication can make you gain weight.
Mental and emotional health Good days and bad days. Anxiety and depression. Grieving for lost identity. Disparity between the way you look and how you feel. You compare yourself to other people.
Perceptions Others seeing you differently (as a disabled person). Assumptions made by others about how you feel. The way you look affects the way people interact with you. Defining you as your condition, and we are not all the same. People thinking you‟re letting them down. Don‟t want to waste time or make a fuss. Don‟t always feel like I‟m in control.
Waiting times Long waits between appointments.
Longer term issues It‟s frustrating not knowing what the outcome will be of having diabetes. It can take a patient a long time to accept having a long-term condition – felt there was a real lack of support during this time. Missed opportunity.
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b) The care continuum. Participants were asked how well they were supported
c) Positive aspects of your care
TSCL engagement report d) Areas of frustration / where care could be better
Hospital consultations (could be longer) Diagnosis Patients should be asked about their mental and physical health (and their whole history) Coordination of care Continuity of care Discharge from hospital Follow-up care Navigating through the system was difficult The system was inefficient at times Waiting times Access to care Staff communication and attitude They should be better informed about support available There should be more support and support groups They wanted more information and control about medication and side-effects They shouldn‟t be offered treatments that aren‟t available Patients had some specific comments about their consultant / GP
Maternity and newborn care
Summarised below are the themes arising from discussions on the three areas: antenatal (before birth); birth; and postnatal care (the period beginning immediately after the birth and extending for about six weeks) and where women wanted improvements. The boxes show the answers to the question „what are the top three things that you would change about your maternity care?‟ a) Antenatal care
Antenatal check-ups appointments need to be with the same midwife, easy to get to and fit in with working hours, particularly early in pregnancy. The appointments should not feel rushed, and women need to be asked how they are – as well as having checks done.
Antenatal classes need to be able to secure a place more easily; to not be patronised. There needs to be better choice and information (that is talked through not just handed out in a leaflet) particularly about range of options for where to give birth. Women need support in making their choices; the opportunity to discuss birth plans; the same consideration
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and information, even if it‟s 2nd or 3rd baby; and to be offered things like whooping cough vaccines, and not have to ask.
Communication and medical information sharing there needs to be better sharing of medical information between midwife teams; better communication between obstetricians and midwives; more sensitivity in use of language; electronic notes rather than carrying large files; and more support for women who do not have English as their first language.
Staffing midwives should be trained to same standard so you don‟t have to see different ones for different issues; and there needs to be more staff – to reduce waiting times and to operate specialist equipment.
Top areas where women wanted changes in antenatal care:
Less rushed midwife appointments, give women time to express concerns
More information on birth centres to allow women to make good decisions
More staff on antenatal wards and shorter waiting times.
b) Birth care
Communication regular updates and communication – not to be left alone for too long with no information; not to be given confusing messages or asked lots of questions during birth; to be informed of the different options. There should be people available on-site to interpret or sign and women need to be listened to.
Equipment equipment to be available and in working order.
Privacy more privacy in reception areas and labour wards.
Staffing women need to be looked after by experienced staff who care and offer reassurance; and there needs to be more staff at night.
Top areas where women wanted changes in birth care:
Shorter waiting times. For inductions, only two people should come in at 8am, then when beds become available the others should be phoned to come in More attention and closer supervision during labour.
TSCL engagement report c) Postnatal care
Breastfeeding support both in the hospital and at home and support in their breast/formula choice
Communication and information to be told why they have to do things, as well as what to do; the same consideration and information, even if it‟s 2nd or 3rd baby
Discharge and environment to be sent home when ready – not too early or too late; a quieter, more restful, comfortable and private environment to recover. Husbands should be allowed to stay
Medical information information to be recorded and updated correctly, and mistakes to be amended
Specific conditions / issues more practical support in hospital, for caring for baby after a C-section; more support for tongue-tie and awareness; to receive vitamin K for baby if they ask for it; and earlier diagnosis of cleft palate.
Top areas where women wanted changes in postnatal care:
More staff on wards so women can be discharged quicker if fit and healthy After C-section support needs to be better Breastfeeding support improved, available 24/7 in the hospital and women should feel ok if they decide to give formula Tongue-tie support needs to be more freely available Staff need to be more informative and caring, treat us like humans and listen to our choices. Manner and smiles important
Facilities for husband to stay in postnatal ward
Regular follow-ups and information on aftercare after an episiotomy Food in observation ward needs to be same as in postnatal ward Sheets on bed to be changed after giving birth.
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d) Whole pathway
Top areas where women wanted changes across maternity pathway:
Better communication between departments More reassurance and better communication Improved staff attitude Treat women as individuals Midwives to remember mothers are the reason they are there Continuity of care Better environment More support for midwives Electronic rather than hand-written notes Midwives should read notes Nurses and midwives working to same level More beds.
Young people
The interviews with young people in The Royal London paediatric outpatients
Positive feedback – top five areas Negative feedback – top three areas:
Communication by NHS staff: explanations in Waiting times: too long waiting in clinic simple language, put at ease, able to ask for appointments or for diagnostic tests. questions One parent sent downstairs for blood test, but phlebotomy was closed and Communication between appointments: parents had to come back next day. found it reassuring to be able to contact specialist nurses and consultants Care setting: some comments about moving between hospital floors e.g. one Care setting: size and cleanliness of the hospital. parent noted that x-ray department is Appreciated child-friendly care setting e.g. TV on a separate floor to orthopaedics. mounted to ceiling in X-Ray, balloon-blowing technique to keep calm before anaesthetic. Role of school: some suggested more awareness in schools about conditions Continuity of care: respondents liked being able such as diabetes and ulcerative colitis, to see the same consultant or nurse at their to make it easier for those suffering appointments so their background was known and from these conditions. One parent said it speeds up the appointment her daughter wasn‟t allowed to leave Willingness to travel for specialist care: some lessons when her blood sugar was low, commented that they didn‟t mind travelling/ and the communication between transferring from local hospital, to receive more hospital and school could be better. specialist care. TSCL engagement report
The meeting with seven young advisers from Waltham Forest a) Positive and negative views of the NHS
There were more negative comments than positive. • Most young people didn’t identify the NHS being free as an advantage • London waiting times were seen to be a particular problem identified by many • Quality of NHS seen as not good; some referred to quality of staff, others to shortage of beds and space • Budget cuts were mentioned and Waltham Forest „receives less funding because it‟s in outer London‟ • Lack of mental health provision • Others noted the NHS was a ‘fantastic institution‟ that „makes you better‟ and is „available in lots of locations‟ • Some thought the NHS offered a very good service, with some specialities/services highlighted (intensive care unit/ NHS Direct)
b) Views on interim Case for Change
Comments broadly echoed the views expressed in other parts of the engagement.
• Communications between clinicians is poor o Students living away from home and visiting GPs can‟t seem to access any of their medical records – even if they have re-registered o One person had seen various GPs in their practice who had been unable to resolve their problem, and yet when they saw the fourth one (after a year of problems), the GP solved the problem immediately. Why was there no case review discussion?
• Experience of GPs was varied o Some young people having very poor experiences. Others (generally those who had a doctor who was well known to the family) having good care o Concerned with the lack of enthusiasm of GPs (and others in the practices).
• Technology o A&Es don‟t seem to be able to access their own records. Examples were given when people had revisited an A&E and did not appear on the database.
• Advertising o The young people felt that advertising was an effective way to improve the health of the local population. Most could recall the FAST stroke advertisements and thought that impactful/hard hitting ones for diabetes/obesity etc would be worthwhile.
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• Workforce o Why can we not make conditions better in the UK/London for nurses and other health workers (pay/accommodation etc) rather than let them emigrate, forcing us to recruit from all round the world (the London Ambulance Service was recently in the news for recruiting in Australia) o The group suggested there was more opportunity for the NHS to be promoted to young people in schools etc so that bright, local people became interested in a career e.g. open days, presentations, trainee and apprenticeships, work experience.
c) Views on feedback received in paediatric outpatients
The young advisers recognised and identified with most of the comments made and added: • Continuity of care and communications between departments, although a positive experience for the interviewed young people, could also be a negative. A number of participants described their experiences, when there were problems with continuity of care. • The group agree that waiting times were problematic – particularly for families with young families who were trying to juggle caring for other children • The group agreed that the care setting was important and added to the concern of moving between floors (made by interviewees at The Royal London) with experiences on other sites of having to walk between different buildings in the middle of winter • The group agreed that more health promotion in schools would be useful • The young people identified a difference in attitude and professionalism between generic nurses and intensive care unit nurses (the latter being more positive) • They also identified a different staff attitude to children (positive) and young people/teenagers (less positive).
TSCL engagement report 4.4. Clinical engagement Throughout engagement on each of the CWGs‟ Case for Change, comments were captured and categorised by the programme team into themes. For a full list of clinical stakeholders engaged and a snapshot of some of the comments captured as part of this workstream please see Appendix 1 of this document. Feedback related to each of the CWGs‟ interim reports is shown in the appendix. However a number of cross cutting themes were identified as emerging themes. A summary is shown below.
Communication and better care coordination for three out of the six Clinical Working Groups. Feedback suggested that teams often felt isolated from each other and did not always feel completely aware of the different support options available for patients. This was noted as often impacting of the quality of care that a patient received and a key reason for why services and patient pathways felt fragmented. Communication around who was coordinating a person‟s care and GPs often struggling to access specialist advice were highlighted as examples of where improvements were needed. Ideas captured for how these problems could be resolved included introduction of 24/7 consultant advice lines, IT improvements for community services, midwives and health visitors on Twitter and co- location of services across estates.
Fragmentation of services and clarity of clinical pathways was a consistent theme. Clinicians reported that clinical pathways were unclear and difficult to navigate. They felt this confused clinicians and had an effect on patients‟ understanding of the system. This impacted on the patient journey and also made the system feel fragmented. Clinicians felt that continuity was an important factor to delivering excellent patient care and highlighted the need to ensure that pathways were reinforced and communicated more widely. Ideas on how some of these issues could be resolved included ambulatory care models at scale and across the patch as well as standardising pathways.
Variation in access to services as well as health outcomes was highlighted as a concern for clinicians engaged as part of four out of the six CWGs' engagement. Local clinicians reported that due to a range of different commissioning arrangements in place across the patch there is significant variation in access and quality of care received. Examples given included access to postnatal appointments, the level of specialist input into community services and local transition points for children‟s and adolescent services. Ideas on how variation could be reduced included introducing co-commissioning models and increasing the provision of anticoagulation services in the community.
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Appendix 1: Clinical engagement
Introduction
As part of phase 2 of the Transforming Services, Changing Lives (TSCL) programme each of the programmes Clinical Working Groups (CWGs) committed to embarking on a wider clinical engagement piece to test the emerging themes and principles documented in their cases for change. As a result of this they have successfully engaged with a broader range of clinicians that they wished to engage with to strengthen their developing cases for change. This document outlines the approach that was adopted to ensure that each of the CWGs successfully tested and refined the emerging clinical case for change. As well as presents the key findings captured as part of the delivery of each of their clinical engagement plans.
Aim
The aim of this engagement piece was to test the CWGs emerging themes and ideas in order to collate feedback that strengthen the clinical case for change by:
• Capturing feedback on the CWGs developing cases for change in order to answer the following questions: o Does the case for change accurately reflect the current state of services? o Does the case for change accurately reflect what is working well across the local health economy? o Does the case for change accurately capture where things are not working well? o What might the opportunity areas for change be? • Gaining consensus on the developing clinical case for change amongst local clinicians; • Giving local clinicians the time and opportunity to ask questions about the case for change and give their feedback; and • Introducing the TSCL programme to a range of clinical stakeholders.
Approach
To reduce the burden on clinical time, and where possible, engagement was undertaken in the following groups of clinical areas: • Unplanned care, planned care (long term conditions), planned care (surgery), CSS. • Children and young people and maternity and newborn care, CSS. A range of briefing sessions were scheduled through existing clinical meetings to support the CWGs in their engagement with clinical stakeholders. This ensured that their interim cases for change was shaped by local clinicians and that there was broad buy-in for the findings documented. Briefings took place throughout July, August and September and were attended by CWG Co-Chairs, CWG members as well as members of the Programme team.
Whilst each of the CWGs approach used existing meetings as their platform for engaging other clinical stakeholders in their emerging cases for change, this was sometimes challenging given the limited time available on meeting agendas. People presenting the case for change encouraged people to feedback and contribute to interim reports during the meeting when there was adequate time available or via the programme electronic feedback mechanisms at a later stage (eg. Programme website, email address or directly to the programme team). TSCL engagement report Who was engaged?
The CWGs successfully engaged with a range of clinicians across the local health economy in primary, acute and community care. A total number of 375 clinicians were recorded as being engaged throughout phase 2 of the Transforming Services, Changing Lives clinical engagement work stream. The pie chart below details the groups of clinicians that were recorded as being engaged through the clinical engagement work stream. For a comprehensive list of clinical stakeholders engaged please refer to list at the end of this document. Consultants and Surgeons Overview of clinicians engaged 12% Other Clinical Secondary Scientists GPs Care 1% Doctors Health Visitors 2% Matrons Nurses and GPs Midwifery 49% 16% Others
Pharmacists Therapists 8% Therapists Pharmacists 2% Others Matrons n=375 8% 2% Where were clinicians engaged?
Each of the CWGs engaged with a broad range of clinical groups throughout July, August and September. A comprehensive list of forums and events can be found in the table below.
Meeting/ Event/Forum Clinicians engaged Barts Health (BH) Clinical Support Services Clinical Directors, Consultants Imaging Board BH Emergency and Acute Medicine Clinical Consultant Physicians, Nurses, Matrons Academic Group (CAG) Board Clinical Directors, Consultant BH MDT and Consultants meetings Paediatricians, Nurses and other ward staff BH Morbidity and Mortality Joint Anaesthetists Surgeons, Anaesthetists, Nurses, ward staff and Surgeons Audit Meeting Anaesthetists, Cardiologists, Colorectal Surgeons, Community Midwifes, Community Nurses (Learning disabilities), Community Nutritionists, Consultant Haematologists, Consultant Community Paediatricians, Consultant Gynaecologists, BH Staff Engagement Events Consultant Neurologists, Consultant Obstetricians, Consultant Paediatricians, Consultant Physicians in Geriatric Care, General Surgeons, Matrons, Midwifes, Neonatal Nurses, Neurologists, Nurse Educational Practitioners, Oncologists, Orthoptists, Pathologists,
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Physiotherapists, Radiotherapists, Senior Nurses, Senior Sisters, Specialist Nurses, Specialist Leads in Geriatric Medicine, Speech and Language Therapists BH Women‟s and Children‟s CAG Board Clinical Directors, CAG Directors Chingford Locality Group GPs BH Clinical Support Services CAG Board Therapists, Pathologists, Consultants Homerton Adults Engagement Session Consultant Physicians, Consultant Chest Physicians Midwifes, Consultant Paediatricians, Community Homerton Children‟s Engagement Session Nurses, Consultant Obstetricians, Consultant Gynaecologists, Neonatal Nurses Leyton and Leytonstone Locality Group GPs Mental Health Focus Group GP Mental Health Leads Psychiatrists, Psychologists, Community Matrons, NELFT Engagement Session Consultant Physicians in Geriatric Care, District Nurses, Health Visitors, Consultant Haematologists Newham CCG Children and Young People‟s GPs Board; Newham CCG Cluster Leads Meeting Community Pharmacists, Acute Pharmacists, Pharmacy Focus Group Prescribing Advisors Redbridge CCG Practice Learning Event GPs, Practice Nurses Tower Hamlets: Children's and Young People‟s Board; CVD Working Group; Locality GPs Chairs Board; Respiratory Working Group; Urgent Care Board Tower Hamlets Practice Nurse Forum Practice Nurses Tower Hamlets Quality in General Practice GPs, Nurses Group GPs, Health and Social Care Leads, Intervention and Waltham Forest Best Start in Life Board Prevention Leads Waltham Forest Primary Healthcare GPs Education Session WELC Maternity Quality Board GPs
What clinicians said
As part of the delivery of each of the CWGs clinical engagement plan comments were categorised by the programme team into themes. It is important to note that although every attempt to classify each comment to a correct theme sometimes responses are open to interpretation. No specific „weighting‟ was given to any of the clinical stakeholders when grouping comments into the emerging themes and for the purposes of reporting this report only includes those responses that were relevant to the scope of the CWG‟s interim case for change, rather than more general comments about the programme.
The key findings and themes captured as part of the delivery of each of the CWG‟s clinical engagement plans are detailed below under the relevant CWG heading. TSCL engagement report Children and Young People
The key findings and themes captured as part of the delivery of each of the Children and Young People‟s CWG clinical engagement plan are detailed.
1. Communication and better coordination Feedback on the CWGs interim case for change highlighted the need for better communication and care coordination within children‟s services across East London. Clinicians engaged as part of the CWGs clinical engagement plan reported that teams often felt isolated and were unaware of the different services that their patients were able to access as part of their care. This theme was consistent throughout many of the comments captured in forums attended by GPs and acute clinical staff with one Waltham Forest GP highlighting that he was „„not always clear about who and what services are available to access specialist advice for patients‟‟.
Additional comments captured as part of this theme included the following:
„„There is no understanding of the shared resources available across the trust … we don‟t know what is available for us to draw on‟‟ Anonymous, Barts Health NHS Trust
„„We are not always fully aware of the services available‟‟ GP, Waltham Forest
„„There is a real need to coordinate children‟s care‟‟ Anonymous, Barts Health NHS Trust
This however was not the experience of all clinicians engaged as part of the CWGs clinical engagement. Where a model of key workers effectively coordinating patient care, IAPT and clinical psychology teams and therapies all being highlighted as areas that were working very well within Homerton children‟s services.
Suggested models of care captured as part of the CWGs clinical engagement to help improve communication and coordination within children‟s services included:
o Coordinated pathways for the top ten to twenty conditions o Midwives and Health Visitors on Twitter and located within local A&E‟s o Co-location of services across estates o Telephone triages o Pathways or care coordinators who have access to all information o Introduction of a co-commissioning model across health and social care.
What has the CWG done to address these comments? This supports the CWGs description of what good looks like for a model of integrated community care (principle 2) and demonstrates that there is clinical consensus amongst local clinicians for the view that „„children and young people should receive coordinated care across teams, within and between acute, community and primary care‟‟ (Children and Young People‟s Clinical Working Group, 2014, pg11).
The CWG recognises the importance of good communication and the importance that this has on ensuring excellent care coordination across children‟s services. As a result of the clinical feedback Page 44
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that the CWG has received on this theme, CWG members have agreed to include the following text as a sub principle under principle number 2 in their final case for change:
„A directory of services should be developed to aide transparency of all services available, improve and facilitate communication between professionals, parents and carers‟.
A directory of services will provide a central point of information for professionals and parent to help them navigate the breadth of services.
2. Prevention and early intervention Early intervention and the role of prevention was discussed as key to improving the health outcomes of East London‟s children. Although the CWG mention the role of prevention within their case for change as part of principle number 4 and identify Tower Hamlets as a borough that is „„good at educating families in first line care‟‟(Children and Young People‟s Clinical Working Group, 2014, pg17). Those engaged as part of the CWGs clinical engagement plan felt that these types of message were key to improving children‟s health as well as being an enabler to reduce activity within acute settings.
Early intervention in particular was mentioned throughout the CWGs clinical engagement activity and was not shown to be the view of any particular clinical group. Comments on prevention and early intervention were captured across all care settings and focused on not only preventing children from becoming ill but also working with those children that are already ill to better manage their care and prevent unplanned episodes of ill health that require care. One clinician engaged on the case for change suggested the introduction of „„established packages of care to ensure that people stay well and stay out of hospital‟‟. Further comments captured as part of this theme are detailed below:
„„Need to instil good behaviour/education from birth‟‟ GP, Waltham Forest
„„Early year‟s intervention in schools and children‟s centres as a way of accessing health provision‟‟ Anonymous, Barts Health NHS Trust
„„Public health messages via song …. Connecting to young people‟s interests
e.g. through social media‟‟ Anonymous, Barts Health NHS Trust
Clinicians engaged felt that a lot more could be done to tackle issues related to concerns such as obesity, alcohol misuse and smoking. An example of which was provided by a community pharmacist engaged on the Children and Young People‟s case for change who felt that there was a strong link between unplanned care activity and potential provision and support in the community. Community pharmacy teams were highlighted as an example of where clinicians based within the community could promote healthy living amongst young people and potentially have a strong impact on health behaviour in adult hood. In addition to this, opportunities to visit schools, work alongside health visitors to build resilience in childhood and equip young people with life skills were all potential opportunities to improve health outcomes for children and reduce problems developed later in life such as obesity and mental health problems.
Other suggested models of care captured as part of the CWGs clinical engagement to help improve early intervention within children‟s services included:
o Council priorities, parenting skills, healthy schools initiative, health promotion o Early year‟s intervention, school, children‟s centres to access health provision TSCL engagement report
o Information leaflets and talks in community centres could be used to educate parents and communities o More pharmacy first campaigns.
What has the CWG done to address these comments? The CWG agrees with the feedback on the importance of prevention and early intervention and the impact that this has on improving the health outcomes of East London‟s children.
As a result of the clinical feedback that the CWG has received on this theme, CWG members have agreed to include the following text as a sub principle under principle number 2 in their final case for change:
“A greater emphasis on early intervention and the provision of effective universal services to limit the impact of developmental delays and improve public health outcomes”.
3. Transitions Transitions of care was highlighted by those clinicians engaged as a concern. Issues regarding the clarity of transition points, understanding the different requirements across the patch and the impact that this has on patient experience were common themes throughout the CWGs engagement with local clinicians. Although these issues were mentioned throughout the CWGs engagement piece, the majority of comments against this theme were raised by those clinicians working within primary and community care settings.
This feedback supports the CWGs description of what good looks like for a model that delivers seamless transitions of care (principle 1) and demonstrates that there is clinical consensus amongst local clinicians for the view that „„transitions between different health and non-health services should be simple and easy for patients‟‟ (Children and Young People‟s Clinical Working Group, 2014, pg10). Comments captured as part of this theme included the following:
„„Clarity is needed on what local transition points are within local services regarding age and what services children should be transitioning to‟‟ Anonymous, North and East London NHS Foundation Trust
„„In the midst of the transitions that young people have to navigate
when moving to adult services, general practice can provide continuity‟‟ GP, Tower Hamlets
Transitions of care was also an area discussed in relation to CAHMs commissioning at a mental health focus group. Clinicians present at the session highlighted that commissioning plans to extend services to 0-25 year olds – with an overlap transition to adult services during this period were being developed and in place to address this.
Suggested models of care captured as part of the CWGs clinical engagement to help address some of the issues experienced as a result of unclear transition arrangements within children‟s services included:
o Standardised cut off points for local authorities, primary care, community and acute care o Clearer transition ages „striving‟ e.g. neonates to early years/early years to school/adolescent to adults o The introduction of phased transitions between children's and adults services. Page 46
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What has the CWG done to address these comments? The CWG recognises the importance of clearly defining transition points within a young person‟s journey of care and are encouraged to see that local clinicians engaged on their case for change feel that this is an area where change is required. The CWG have already included a principle on in their case for change entitled „seamless transitions of care‟ and feel that the issues related to this have already been addressed.
4. Variation Feedback on the CWGs interim case for change highlighted the need to reduce variation across the patch in service provision for children and young people‟s services. This theme was prominent amongst those clinicians that attended the Barts Health engagement events with issues raised relating to the impact that variation can have on the quality of care received based on where within East London a patient resides. Some of the comments captured as part of this theme are detailed below:
„„The differences between boroughs means that some conditions are not picked up early and we then see them in hospital when this needn‟t of happened‟‟ Anonymous, Barts Health NHS Trust
„„There are large differences within community provision across boroughs meaning people get different care depending on where they live‟‟ Anonymous, Barts Health NHS Trust
This view was furthered by clinicians engaged as part of a mental health focus group where concerns around the overall fragmentation of the commissioning of CAMHS services was discussed. In particular the group noted that the lower tier services provided in schools varied across the patch and was particularly a concern in relation to free schools.
The only recorded suggested model of care to help reduce variation within children‟s services was noted as being the introduction of commissioning arrangements that support a joint system
What has the CWG done to address these comments? These comments support the CWGs principle on consistent hospital pathways that states that „children & young people should receive consistent, evidence based standards of hospital care regardless of where they live‟‟ (Children and Young People‟s Clinical Working Group, 2014, pg13) and demonstrate clinical consensus on the CWGs case for change. The CWG feel that issues related to variation and the quality of care received as a result have already been addressed and do not require strengthening.
TSCL engagement report Maternity and Newborn Care
The key findings and themes captured as part of the delivery of each of the Maternity and Newborn Care CWG clinical engagement plan are detailed.
1. Patient education Patient education and the need to support pregnant women and new mothers more effectively was discussed throughout engagement on the CWGs interim case for change. Clinicians reported that there was not always information available to support women to make informed decisions about their care or the choices available to them. These issues were raised by a broad range of clinicians. Comments on patient education were captured in acute and primary care settings ranging from concerns around the quality of information available to support both clinical staff and women during pregnancy, through to the support and advice available to new mothers following their birth. Example comments captured as part of this theme are detailed below:
„„Better information and advice for mothers on feeding and nutrition‟‟
GP, Waltham Forest
„„Poor information on choices available‟‟ Anonymous, Barts Health NHS Trust
„„Education of choice …… access to information‟‟ Anonymous, Barts Health NHS Trust
This view was furthered at an engagement session with a selection of Homerton clinicians who highlighted patient choice and the information available for women with high risk pregnancies as an area where change may be required. Delegates highlighted that more work to better inform women on the choices that they were able to make in terms of where they are able to give birth was needed. The group noted that often women assume that as a default their local hospital is where they will give birth. Women should book for antenatal care at the hospital which best meets their clinical needs rather than be transferred for delivery. An example of this is women who are at high risk of preterm delivery; they should be encouraged to book at a unit with a level III neonatal unit.
Suggested models of care captured as part of the CWGs clinical engagement to help improve patient education within maternity and newborn care services included:
o Introduction of a rolling training rota to examine staff opportunities and develop some consistency in messages given to women o Maternity mates model (bump buddies) to enable continuity of care/support o Promotion of services such as Mumsnet for support networks outside NHS services.
What has the CWG done to address these comments? These comments support the CWGs interim case for change and key messages on what good maternity and newborn care should look like and demonstrate clinical consensus amongst local clinicians across the patch. The belief that patient choice should be at the heart of good antenatal, intrapartum and post natal care is stated throughout the CWGs case for change with the CWG expressing views such as „„women should be given an informed choice for their location of birth‟‟ (Maternity and Newborn Care Clinical Working Group, 2014, pg11) and should feel empowered to
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„„take a central and active role in their own care during pregnancy, labour and postnatal period‟‟ (Maternity and Newborn Care Clinical Working Group, 2014, pg11). The CWG feel that access to good patient education to enable choice has been well documented in their case for change and are assured that colleagues have further validated this finding.
2. Better communication Feedback on the CWGs interim case for change highlighted the need for better communication across teams and care settings in order to deliver high quality maternity and newborn care. This theme was prominent amongst some of the GPs engaged as part of the CWGs engagement piece with reports of clinicians being unable to access specialist advice for some of their high risk patients to not knowing what obstetrician within the trust had oversight of their patient‟s care. This was discussed as being a barrier to delivering high quality care and an area where clinicians felt that change was required. Some of the comments recorded as part of this theme can be found below.
„„GPs are not always clear which obstetrician is dealing with a complex patient‟s care‟‟ GP, Waltham Forest
„„Coordinated care with jointly agreed goals‟‟ Nurse, Tower Hamlets
„„Lack of communication between hospital and primary care‟‟ Anonymous, Barts Health NHS Trust
Suggested models of care captured as part of the CWGs clinical engagement to help improve communication within maternity and newborn care services included:
o Introduction of consultant advice line 24/7 o IT improvements for community services
What has the CWG done to address these comments? These comments support the CWGs interim case for change and key messages on what good maternity and newborn care should look like. The CWG have highlighted the need for effective communication between teams and care settings as fundamental to delivering high quality and continuous maternity and newborn care. An example of this can be found detailed as part of the CWGs principle on high quality postnatal care within the CWGs case for change whereby the CWG states that there is „„poor communication between hospitals, GPs and community services‟‟ (Maternity and Newborn Care Clinical Working Group, 2014, pg18) „„constraining high quality, seamless care‟‟ (Maternity and Newborn Care Clinical Working Group, 2014, pg18). The CWG feel that the issues highlighted around the need for better communication have been well documented in their case for change care and as a result does not require further strengthening.
3. Access to services and variation across sites Variation in access to services across sites was highlighted as a concern for some of the clinicians engaged as part of the CWGs clinical engagement piece. Variation in the quality of care received and outcomes delivered was also highlighted as an area of concern. One example highlighted with regards to variation was noted at a mental health focus group where delegates discussed the gap in post-natal care provision for women with low to medium level needs. The main provider of service provision for women with these needs is IAPT, although there are different models operating across the CCGs to support this. This theme was consistent throughout the comments TSCL engagement report captured in forums attended by GPs and acute clinical staff with one Waltham Forest GP highlighting that there were „„not enough postnatal care appointments available across the patch‟‟.
„„The quality of care received differs across the patch as a result of reciprocal arrangements‟‟ GP, Waltham Forest
„„Lack of a home birth team in Newham‟‟ Anonymous, Barts Health NHS
Trust
„„Access to antenatal services through the referral process is not working‟‟ GP, Waltham Forest
New models of care to help improve access for women within the community were noted as being developed in some areas of the patch. For example the Homerton is currently changing its community model to ensure that low risk women have their care nearer to their home. Clinics will take place within children centres, GP surgeries and the Shoreditch maternity centre. This will take the clinics out of the acute setting but will also enable women to access other services which include breastfeeding drop-ins, postnatal clinics and early year‟s services.
A suggested model of care captured as part of the CWGs clinical engagement to help tackle access and variation included:
o The introduction of antenatal clinics in supermarkets (Tesco/Asda). Increasing the number of group antenatal classes available across NHS and Local Authority providers.
What has the CWG done to address these comments? Issues with variation in access to services is discussed throughout the CWGs interim case change and supports the engagement feedback received from local clinicians. The CWG have highlighted the need to reduce variation in outcomes, access to services and the quality of care received by all women throughout the case for change. Women are highlighted as „„not consistently being given appropriate referrals or receiving full and accurate information about care‟‟ (Maternity and Newborn Care Clinical Working Group, 2014, pg18) with „„too few women in East London‟‟ (Maternity and Newborn Care Clinical Working Group, 2014, pg12) starting their antenatal care early enough. This point is captured throughout the CWGs case for change and does not require further strengthening.
The CWG agree with the feedback in this area and believe it is vital to understand and address issues related equitable access and reduce variation with any future model of care – and will ensure that this forms part of the work plan for the next steps of the Transforming Services – Changing Lives programme.
GP education Feedback on the CWGs interim case for change highlighted the need for better GP education and support to primary care practice staff when delivering high quality maternity and newborn care. Some of the GPs engaged on the CWGs interim case for change felt that they were not always fully aware of new guidelines and protocols on antenatal care. Some of the comments captured recorded against this theme are detailed below:
„„There is a general feeling that GPs need to be supported with being updated on protocols and new guidance to feel confident when delivering Page 50
this type of care‟‟ GP. Waltham Forest „„More GP education around maternity care‟‟ Anonymous, Barts Health TSCL Engagement report
Suggested models of care captured as part of the CWGs clinical engagement to support better GP education in maternity and newborn care services included:
o Guidelines to share on website for community GPs o Introduction of a primary care model to support GP education in maternity.
What has the CWG done to address these comments? The CWG recognise the role of the GP in providing excellent maternity care closer to women‟s homes and express the view that as „„we do not have a standard pathways and there is a lack of clarity about responsibility for different elements of care across different CCGs and GP practices‟‟ (Maternity and Newborn Care Clinical Working Group, 2014, pg12). This supports the feedback received through engagement and will inform some of the discussions around roles and responsibilities within future models of care for maternity services.
TSCL engagement report Unplanned Care
The key findings and themes captured as part of the delivery of each of the Children and Young People‟s CWG clinical engagement plan are detailed.
1. Improved access to information Improved access to the information available on services and how to access them was discussed throughout the CWG‟s engagement on its case for change. Clinicians engaged reported that they felt that some patients are not always fully aware of the choices available to them and often present in unplanned care settings as a result. Although this view was consistent there were comments captured that highlighted the need to consider patient choice rather than information not being available. As some patients may choose to attend places such as A&E as this may be where they feel most comfortable to be treated. The comments captured against this theme were mainly recorded at the Barts Health engagement events. Example comments captured are detailed below.
„„Patients are often not informed of the services available and where to go to access them. This results in A&E attendances‟‟ Anonymous, Barts Health NHS Trust
„„The thing is everyone knows where their local hospital is. Does everyone
know where their local Walk in Centre is?‟‟ Practice Nurse, Tower Hamlets
„„Patients do not know where to go and attend A&E as they know that
they will be seen‟‟ Anonymous, Barts Health NHS Trust
This theme was also highlighted as part of a focus group held with acute and community pharmacists who suggested that there were significant opportunities for educating patients to make more use of their pharmacists rather than attending A&E. An example was given of an audit which showed a number of patients attending A&E for constipation. This is an issue that could have been addressed by a community pharmacist. There is a need within this to better understand why people choose to access certain services.
Local pharmacists also commented that the links between community pharmacy and 111 could be strengthened, suggesting that referral to community pharmacy could be built into the model.
Other suggested models of care captured as part of the CWG‟s clinical engagement to improve patient education included:
o Improved information for staff and patients on Intranet site, internet guidelines, mobile apps o Virtual “ask gadget” app.
What has the CWG done to address these comments? The CWG recognises the importance of improving access to information and the impact that this has on the patients receiving the right advice, in the right place the first time. This view has been expressed by the CWG throughout their case for change and in particular is captured in principle two in the Unplanned Care CWG interim report. Whereby the CWG states that „„the system should enable and support people to make the right decisions in the easiest way possible‟‟ (Unplanned Care Clinical Working Group, 2014, pg17) in order to help „„patients understand where to go for their urgent care needs‟ (Unplanned Care Clinical Working Group, 2014, pg17). Page 52
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2. Fragmentation of services and clarity of pathways Fragmentation of services and the clarity of pathways was also a prominent theme throughout the CWG‟s clinical engagement. Some of the clinicians engaged reported that pathways of care were often unclear and difficult to navigate through. Services were noted as being fragmented with community based clinical staff highlighting ambulatory care services as being a particular issue. Some of the comments recorded against this theme can be found below:
„„Ambulatory services could be clearer and better‟‟ Anonymous, North and East London NHS Foundation Trust
„„Continuity is important and is sometimes lost in the current system. This is at two levels; patient level continuity and system continuity‟‟
Anonymous, North and East London NHS Foundation Trust
Suggested models of care captured as part of the CWG‟s clinical engagement to help improve the clarity of pathways and reduce the fragmentation of services included:
o Ambulatory care models at scale across the patch to help reduce A&E attendances/admissions.
What has the CWG done to address these comments? These comments support the CWG‟s vision for the future model of unscheduled care. The CWG feels that the future model of unscheduled care should have „„clear, consistent and intuitive care pathways‟‟ (Unplanned Care Clinical Working Group, 2014, pg17). Since June, the CWG have completed a mapping exercise to better understand the differences in the models of urgent care operating in each borough. This will form the basis of future discussions between the urgent care boards in the patch about how urgent care should be delivered in the future.
The improvement of pathways and clarity on these for patients, carers and clinicians will form an important part of the CWG‟s work plan for phase 3 of the programme.
3. Improved patient discharge processes Feedback on the CWG‟s interim case for change highlighted the need to improve patient discharge processes. This theme was highlighted across care settings and was not the view held by any particular clinical group engaged with. Clinicians within acute settings reported not always being fully aware of the support options available for patients once discharged into the community. While those clinicians based within community settings felt that acute teams often delayed the discharge process. Example comments captured as part of this theme are detailed below:
„„We are not always aware of what services are available to discharge patients to from the ward. This is very confusing and needs to be highlighted‟‟ Anonymous, Barts Health NHS Trust
„„There is a reluctance to discharge patients even when the ICM team are keen to take home‟‟ Anonymous, North and East London NHS Foundation Trust
This view was furthered when the CWGs clinical case for change was engaged on at a mental health focus group where delegates highlighted that although RAID services are in place and do TSCL engagement report offer a provision of support to specialists in acute settings in relation to referral and advice for patients suffering with mental health problems. Awareness of this provision needs to be raised to ensure that the support on offer is maximised and that all clinicians within these settings know how to access them when needed.
There were no suggested models of care captured against this theme.
What has the CWG done to address these comments? The CWG recognises the importance of clear discharge processes that operate efficiently and are easily understood by the patient and clinician. The CWG note in their final case for change that „„Delayed transfer of care data indicates that the system could be working more efficiently. For example, in 2012/13 discharge was delayed for 457 patients at Barts Health. 26% of delays were for patients awaiting further NHS non-acute care and a further 19% were awaiting completion of an assessment. While at the Homerton, 35% of delayed transfers of care were for patients awaiting a care package in their own home‟‟.
The CWG recognise the importance of ensuring safe and efficient discharge processes are implemented across the patch. In phase two of the programme, the group undertook further work to understand the factors influencing delays to discharge, length of stay and the work that is being undertaken locally to address them. In particular, variation in the effectiveness of discharge planning arrangements were found between sites in east London, with a lack of engagement in the discharge planning process cited as a particular issue. Additionally, difficulties in repatriating patients to referring hospitals, back home or to nursing homes were identified. Access to neuro- rehabilitation and social care packages were cited as particular problems.
4. Increased access to primary care Increased access to primary care was highlighted as an area that required change. Many of the acute clinical groups engaged on the Unplanned Care CWGs interim case for change highlighted the need to strengthen primary care in order to deliver care closer to home and reduce the activity within unplanned care settings. Comments captured recognised the need for more investment within primary care settings in order to deliver this effectively and to a high quality. Example comments recorded as part of this theme are detailed below.
„„A lot of the weight sits with unplanned care more must be done to strengthen primary care‟‟ Anonymous, Barts Health NHS Trust
„„Primary care could support a reduction in unplanned care activity but only if there was more capacity in primary care‟‟ Practice Nurse, Tower Hamlets
„„Access to GP services and appointments is very limited across the patch
There were no andsuggested can oft modelsen result of care in attendances captured against at A&E‟‟ this theme Anonymous, Barts Health NHS Trust
What has the CWG done to address these comments? Feedback captured within this theme strongly supports some of the obstacles to achieving the CWG‟s vision of what good care looks like and demonstrates clear clinical consensus for where change is needed. The CWG recognises that there is a „„stretched workforce‟‟ (Unplanned Care Clinical Working Group, 2014, pg28) in primary care that will need further investment to support Page 54
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some of the changes need to deliver an improved model of unplanned care within the community. This has been further enhanced since the interim case for change through completion of a mapping exercise to better understand primary care provision across the patch.
5. Workforce Many of the clinicians engaged on the Planned Care: Surgery CWG‟s case for change were concerned about the current pressures on workforce and the impact that this had on their ability to deliver high quality care. One clinician engaged with as part of the Barts Health engagement events highlighted as an example that „„there are not enough theatre staff‟‟. Others felt that there was a loss of expertise amongst the current workforce impacting on the skills and capabilities needed to deliver high quality care. Although this theme was recorded as part of discussions on the Planned Care: Elective Care CWG‟s case for change and relate to the delivery of surgical care within the Trust. It is not possible to tell if the comments captured relate to elective or emergency surgery and have therefore been included in this report for consideration by the Unplanned Care CWG. Example comments captured as part of this theme are detailed below:
„„There is a loss of expertise in areas such as enhanced recovery‟‟ Anonymous, Barts Health NHS Trust
„„There is double the work in theatre, we need staffing‟‟ Anonymous, Barts Health NHS Trust
„„We need two anaesthetists‟‟ Anonymous, Barts Health NHS Trust
What has the CWG done to address these comments? The CWG recognises that there are both current and future staffing challenges, this has been included as an additional paragraph within the final case for change focusing on emergency surgery. In terms of looking at future models of care – and changes to the delivery of services workforce will continue to be a key factors. In the design, development and discussion of any future models of care.
TSCL engagement report Planned Care: Long Term Conditions
The key findings and themes captured as part of the delivery of each of the Planned Care: Long Term Conditions CWG clinical engagement plan are detailed.
1. Better communication and care coordination Feedback on the CWG‟s interim case for change highlighted issues with communication and care coordination. Clinicians reported not always understanding the support options available for patients and carers and were often unsure of who the lead clinician for coordinating a person‟s care was. Comments captured suggested that clinicians often found this frustrating and impacted on the quality of care received by their patients. Some of the clinicians based within community settings described this as a particular concern. As in their experiences the support available post discharge was not always clear and was not often communicated in an effective way to carers. Comments captured against this theme were not found to be exclusive to any particular clinical group engaged as part of the CWG‟s clinical engagement piece and was prominent throughout. Example comments recorded through engagement can be found below.
„„A range of clinicians and services currently coordinate different parts of a person‟s care. More clarity is needed on who should take responsibility and
how this model will operate‟‟ Anonymous, North and East London NHS Foundation Trust
„„Not knowing who to contact for what‟‟ Anonymous, Barts Health NHS Trust
“Different organisations use different care plans‟‟ Practice Nurse, Tower Hamlets
This view was strengthened by some of the pharmacists and mental health leads. The pharmacists felt that there was a strong opportunity for community pharmacy to support patients with long term conditions in areas such as medication reviews and support with care plans. Whereas the mental health leads highlighted the need for better coordinated care plans that do not complicate a person‟s care through additional appointments and travel but work towards supporting patients care for their physical and mental health needs.
Some of the suggested models of care captured as part of the CWG‟s clinical engagement to improve communication and care coordination included:
o A single person to help coordinate care better i.e. core navigators o More key workers in the community o Better communication between primary care and secondary care through the use of e- referrals. o All GPs to provide a contact when making a referral to ensure contact can be made on discharge o Named pharmacists for all patients with one or more long term conditions o Online resource – this is what clinics are available.
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clinicians for the view that „„health and social care teams based around a locality provide joined up personalised services‟‟ (Long Term Conditions Clinical Working Group, 2014, pg18) that are „„underpinned by positive reciprocal relationships between primary and specialist teams‟‟(Long Term Conditions Clinical Working Group, 2014, pg18). The CWG have already included a principle in their case for change entitled „a high quality, interdisciplinary coordinated care approach is the norm for everyone with long term conditions‟ and feel that the issues related to this have already been addressed.
2. Improved pathways and variation in the quality of care Improved pathways and variation was a consistent theme throughout the CWG‟s clinical engagement. Feedback captured as part of this theme highlights the need for improved pathways of care and the need to look at the „patient and the pathway in total‟. Concerns surrounding variation in the quality of care across the patch were also discussed. Clinicians engaged on the CWG interim case for change reported that pathways were often changed and not clearly communicated, felt fragmented due to commissioning arrangements and varied significantly across East London. It was noted that depending on where a patient lived within the patch the quality of care that they would receive varied. This view was not unique to any particular group engaged as part of the CWG‟s clinical engagement plan and was consistent across the organisations engaged. A selection of comments captured as part of this theme can be seen below.
„„Fragmented commissioning arrangements impact on the quality of care
received locally creating variation in the continuity of care‟‟ Anonymous, North and East London NHS Foundation Trust
„„There is variation between boroughs in the way diabetes care is managed. Some boroughs have made a lot more progress with this through the use of
care packages and specialist input into the community.‟‟ GP, Tower Hamlets
“Pathways keep changing and no-one tells you” GP, Waltham Forest
This view was furthered at a mental health focus group where clinicians highlighted the variation in mental health support for patients with long term conditions. A model of care that they felt would help to reduce variation in this area would include consultant level oversight and expert opinion, specialists supporting clinicians to identify mental health needs and raise awareness of the support options available and all clinicians taking an active role in considering mental health needs and referring on. Another suggested model of care captured as part of the CWGs clinical engagement to improve pathways and reduce variation was to move towards a joint commissioning arrangement.
What has the CWG done to address these comments? The CWG‟s principles for what good long term condition care looks like describes the need for patients to be treated holistically regardless of their condition. In particular, the group points to primary care based teams as needing to be the coordinator of care drawing in specialist expertise (Long Term Conditions Clinical Working Group, 2014).
In its interim case for change the CWG identified variation in the quality of care between sites and boroughs. For example, primary care access and quality scores for all of the boroughs in east London are below the national average. Variation is also seen in secondary care, with length of stay and readmissions varying by site (Long Term Conditions Clinical Working Group, 2014). In its TSCL engagement report vision for good long term conditions care, the CWG is committed to people only being in hospital when they clinically need to be rather than because of system inefficiencies or because there is nowhere else to go. This will require collaboration across the health and social care system.
3. Support for patients and patient empowerment Supporting patients and empowering them to take more control over their health was discussed throughout the CWG‟s clinical engagement. Clinicians discussed the different ways that this approach could be implemented and also considered the problems attached to such a model. Many of the clinicians engaged agreed with the approach to enabling patients to self-care and better manage their care, but felt that more needed to be done to ensure that clinicians valued „patients‟ knowledge on their condition‟ and listened to their opinions. While others felt that there needed to be a focus on „training people to take care of themselves‟ with consideration to the fact that each patient is different and may not feel comfortable with this concept. These discussions were recorded throughout engagement with opinions differing amongst individuals. Example comments captured against this theme are detailed below.
„„Control needs to be given to the patients …… clinicians need to give up control‟‟ Anonymous, Barts Health NHS Trust
„„Patients are still very much passive recipients of care. We need to think about how we engage patients more‟‟ Anonymous, Tower Hamlets
Suggested models of care captured as part of the CWGs clinical engagement to improve support for patients included:
o Patient activation measures that inform individualised care plans o „First person care plan‟ for mental health patients o Introduction of a patient passport.
What has the CWG done to address these comments? This supports the CWG‟s principle on patients with long term conditions being empowered to manage their condition by supportive health and social care professionals (Long Term Conditions Clinical Working Group, 2014). This point in the report has been further enhanced since the interim case for change and now includes further detail on how this can be achieved taking into account individual patient needs. As well as ensuring that every patient is supported to manage their condition as part of a joint decision making process in conjunction with health and social care professionals.
Support for patients and patient empowerment is vital to understanding any future model of care – and forms part of the work plan for the CWGs next steps.
4. Workforce Feedback on the CWGs interim case for change highlighted some of the concerns that local clinicians have on the current and future workforce. An increase in specialisation was noted as „threatening the diversity of skill mix within the workforce‟ where as others raised their concerns regarding high turnover of experienced and the need for more specialist input into the community. Some of the feedback captured against this theme are detailed below.
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„„There are issues with the skills of clinical staff within community and
primary care. We need more programmes across the patch that help to train staff in these types of areas e.g. Open door policy in Tower Hamlets for Practice Nurses‟‟ Anonymous, Tower Hamlets
There is an increase of specialisation amongst clinicians which threatens the diversity of skill mix within the workforce‟‟ Anonymous, North and East London NHS Foundation Trust
There were no suggested models of care captured as part of this theme.
What has the CWG done to address these comments? The CWG recognises this issue as part of principle three where they state that „primary care teams are not set up, or have the support systems in place from the wider health and social care system‟ and that „there needs to be a refocusing on the GP as the “expert generalist‟‟ (Long Term Conditions Clinical Working Group, 2014, pg18). As the CWG have already included detail on the current and future workforce challenges identified with delivering a high quality model of long term conditions model of care, the CWG feel that these issues have already been addressed.
TSCL engagement report Planned Care: Elective Surgery
Whilst every attempt was made to engage clinicians across the local healthcare economy on the CWGs case for change, the majority of feedback for this clinical area was captured at the Barts Health Engagement event and is reflected in the sample quotes documented. The key findings and themes captured as part of the delivery of the CWGs clinical engagement plan are detailed below.
1. Demand and capacity Feedback on the CWGs interim case for change highlighted issues with demand and capacity. Clinicians engaged as part of the CWGs clinical engagement plan reported problems with bed capacity and the need for a trust wide review focused on elective surgery. This was a view largely reported through the Barts Health engagement events. The comments captured against this theme are detailed below:
„„We need a proper analysis of elective surgery beds. We can‟t ignore emergencies and have an equal responsibility‟‟ Anonymous, Barts Health NHS Trust
„„After surgery there isn‟t a bed for the patient‟‟ Anonymous, Barts Health NHS Trust
„„Ring fence elective surgery beds‟‟ Anonymous, Barts Health NHS Trust
The issue of capacity was also an area of concern discussed at an engagement session with a selection of Homerton clinicians where it was suggested that in order to help solve these issue Barts Health NHS Trust could potentially consider moving some of the more low risk surgical procedures to alternative sites. Other suggested models of care captured as part of the CWGs clinical engagement to help improve some of the demand and capacity issues within elective surgery services included:
o A designated area that is purely for elective surgery and run by surgeons o Ring fencing elective surgery beds o Beds in flexible places.
What has the CWG done to address these comments? This supports the CWG‟s inclusion of an understanding of demand and capacity as a crucial enabler for change. This point in the report has been further enhanced since the interim case for change and now includes further detail on how capacity, demand and management of this across hospital sites is vital in improving the provision of surgery. It is acknowledged throughout the case for change where improved flow and capacity management would improve care.
Capacity and demand is vital to understanding any future model of care – and forms part of the work plan for the next steps. This includes examining models of care that would enable ring-fenced surgical beds.
2. Fragmentation of services and clarity of pathways Fragmentation of services and clarity of pathways was a consistent theme throughout the CWGs clinical engagement. Feedback captured against this theme highlights concerns that surgical
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pathways are often confusing to navigate through and are unclear to the clinician and patient. Comments suggest that more needs to be done to improve both pre-operative and post-operative planning to help improve patient experience and help clinicians to understand the pathway. Example comments captured as part of the Barts Health engagement events against this theme are detailed below:
„„Explain the challenge and then reinforce the pathway‟‟ Anonymous, Barts Health NHS Trust
„„The explanation of actual surgery is good but the pathway is not clear or well defined‟‟ Anonymous, Barts Health NHS Trust
„„There is a lack of information available in terms of how the pathway operates‟‟ Anonymous, Barts Health NHS Trust
This view was furthered when the CWGs clinical case for change was engaged on at a Pharmacy Focus group. Community pharmacists present at the session highlighted that in elective care, there were opportunities to increase the role of the community pharmacists in planning pre and post- operative care. This would help to support patients both before and after their operation as well as provide advice and information about the clinical pathway and the impact that this will have on their care.
What has the CWG done to address these comments? The CWG sees clear pathways and agreement on where patients can best receive their treatment as essential to improving services. This feedback strongly supports the CWGs view that good access to high quality surgery (principle 1) should ensure that „„patients are making informed choices about their care‟‟ (Elective Surgery Clinical Working Group, 2014, pg9) and are enabled to do so through clear and robust pathways that ensure they “receive the right care in the right place at the right time” (Elective Surgery Clinical Working Group, 2014, pg17)
The improvement of pathways and clarity on these for patients, carers and clinicians will form an important part of the work plan for the next stages.
3. Cancelled Operations Cancelled operations was discussed as an issue for those clinicians engaged on the CWGs case for change. Concerns were raised around the timing of cancellations as well as the volume of cancellations across the trust. Some of comments captured as part of this theme are detailed below:
„„Patients are being cancelled at the last minute‟‟ and „„on arrival‟‟ Anonymous, Barts Health NHS Trust
„„There are too many cancellations‟‟ Anonymous, Barts Health NHS Trust
Suggested models of care captured as part of the CWGs clinical engagement to reduce the number of cancellations across the trust included:
o Amend theatre times to start later in the day o Move the 10am meeting to reduce cancellations. TSCL engagement report
What has the CWG done to address these comments?
The CWG strongly agree with this feedback and articulated that in their view:
“All cancellations are unacceptable from a patient point of view and we should aspire to cancel none.”
This is linked to the CWGs view that there is a need to reduce „„the number of cancelled operations through more effective and robust planning‟‟ (Elective Surgery Clinical Working Group, 2014, pg13) as well as the separation of elective and emergency surgery (principle 3).
4. Workforce Many of the clinicians engaged on the CWGs case for change were concerned about the current pressures on workforce and the impact that this had on their ability to deliver high quality care. One clinician engaged on as part of the Barts Health engagement events highlighted as an example that „„there are not enough theatre staff‟‟. Others felt that there was a loss of expertise amongst the current workforce impacting on the skills and capabilities needed to deliver high quality care. Example comments captured as part of this theme are detailed below:
„„There is a loss of expertise in areas such as enhanced recovery‟‟ Anonymous, Barts Health NHS Trust
„„There is double the work in theatre, we need staffing‟‟ Anonymous, Barts Health NHS Trust
„„We need two anaesthetists‟‟ Anonymous, Barts Health NHS Trust
Suggested models of care captured as part of the CWGs clinical engagement to help improve some of the workforce issues within elective surgery services included:
o One team to provide all elective surgery across Barts Health o Combining and defining roles.
** Although the comments captured as part of discussions on the Planned Care: Elective Care CWGs case for change relate to the delivery of surgical care within the Trust. It is impossible to tell if the comments captured relate to elective or emergency surgery and therefore may not be relevant to the scope of the Planned Care: Elective Surgery CWG. To ensure that the feedback is not lost this theme will also be shared with the Unplanned Care CWG for consideration when strengthening their case for change.
What has the CWG done to address these comments? The CWG recognises that there are both current and future staffing challenges, this has been included throughout the case for change where appropriate. In terms of looking at future models of care – and changes to the delivery of services workforce will continue to be a key factors. In the design, development and implementation of any changes.
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Clinical Support Services
The key findings and themes captured as part of the delivery of each of the Clinical Support Services CWG clinical engagement plan are detailed.
1. Demand and capacity Feedback on the CWGs interim case for change highlighted issues with demand and capacity. This was a theme that mainly emerged as part of the Barts Health engagement events. Clinicians engaged reported problems associated with high demand and not enough capacity within the service to keep up. Concerns were raised around the current volumes of referrals into services such as breast and skin while others expressed their concerns around upward trend in demand and the need to meet this in the future. Examples of some of the comments captured against this theme are detailed below
„„Rising demand impacts on access and the ability for staff to keep up‟‟ Anonymous, Barts Health NHS Trust
„„Volumes of referral in areas such as breast and skin referrals need extra investment‟‟ Anonymous, Barts Health NHS Trust
„„Demand is so high, even now can‟t meet the demand‟‟ Anonymous, Barts Health NHS Trust
Suggested models of care captured as part of the CWGs clinical engagement to help improve some of the demand and capacity issues within clinical support services included:
o One stop clinics o Walk in diagnostics “on the day” o Intelligent software booking system – user friendly, clinical advice, education and information links, demand management o Mobile diagnostics - Transform services i.e. hip x-ray sat on back of ambulance.
What has the CWG done to address these comments? This supports the CWG‟s inclusion of a principle of „„ensuring there is enough capacity to meet growing demand‟‟ (Clinical Support Services Clinical Working Group, 2014, pg7) and demonstrates that there is clinical consensus amongst local clinicians as an area for where change is required. This principle has been further enhanced since the interim case for change and now includes further detail on some potential causes of potential rising demand. Both in terms of legitimate testing and potential over investigation.
2. Collaborative working Collaborative working and the need to better plan for clinical support services in conjunction with other healthcare services was captured as a theme throughout the clinical support services clinical engagement piece. Clinicians engaged in the CWGs interim case for change expressed the need for better planning and less silo working when planning for the rise in demand on services and ensuring that the best clinical support services were in place to support other clinical teams. Those engaged within community settings reported better collaborative working between services when communicating test results and arranging diagnostics to help improve patient care. Comments recorded against this theme were not unique to any particular clinical setting and were expressed throughout engagement. Example comments recorded are detailed below. TSCL engagement report
„„Lack of effective partnership working with clinical teams and primary care services‟‟ Anonymous, Barts Health NHS Trust
„„Issues with silo thinking/planning‟‟ Anonymous, Barts Health NHS Trust
„„Rapid diagnostic availability in the community‟‟ Anonymous, North and East London Foundation Trust
Suggested models of care captured as part of the CWGs clinical engagement to facilitate collaborative working within clinical support services included:
o Agreed diagnostics work up between primary and secondary care o Cross fertilisation of CSS with other pathways.
What has the CWG done to address these comments? This feedback supports the CWG‟s view of what a good model of care looks like for clinical support services and can be found documented as part of principles 3 and 4. Whereby the CWG state „„high quality and efficient services provided across all care settings which support delivery across all pathways‟‟ (Clinical Support Services Clinical Working Group, 2014, pg15) encompass a good model a care.
These principles have been strengthened since the interim case for change and now include further detail on the importance of improved communications across organisational boundaries. The group have also highlighted the need to ensure that clinical support services are part of any future planned changes as part of their work plan.
3. Access to services and variation across sites Feedback on the CWGs interim case for change highlighted issues with access to current services and variation across sites. Variation in access to services across sites was highlighted as an area of concern and was particularly an issue discussed with Barts Health‟s anti-coagulation service. Those engaged at the Homerton also highlighted similar issues with interventional radiology services at The Royal London site. Comments on the differences with IT systems and their ability to support the delivery of integrated care for mental health were also noted as an issue for some clinicians engaged. This theme was captured mainly at the Barts Health events with one clinician expressing that variation in these services were because„„Whipps Cross hasn‟t had the same investment as The Royal London‟‟. Additional comments are detailed below.
„„There are issues with variation across sites e.g. access to anti-coag is different across sites‟‟ Anonymous, Barts Health NHS Trust
„„Nurses and pharmacists at The Royal London operate on C-Run but Whipps Cross is still using the old model‟‟ Anonymous, Barts Health NHS Trust
One suggested new model of care that could potentially reduce the variation in access to anticoagulation services was captured as part of the CWGs engagement with a selection of community pharmacists. Where it was identified that there were significant opportunities to
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increase the provision of anti-coagulation services in the community through pharmacies. This was a model that they noted as currently operating well in Barking and Dagenham. If implemented this model of anti-coagulation services would be a standard service that operated in every community pharmacy and could help to reduce variation in access to these services.
What has the CWG done to address these comments? This supports the CWG‟s inclusion of principle 2 entitled „„high quality access to services‟‟ (Clinical Support Services Clinical Working Group, 2014, pg12) and demonstrates that there is clinical consensus amongst local clinicians as an area for where change is required. The CWG acknowledge the current issues related to variation across the patch and note that „„there is variation in the use of diagnostic testing across the patch‟ and a need „„provide equal access across boroughs‟‟ (Clinical Support Services Clinical Working Group, 2014, pg12). This principle has been further enhanced since the interim case for change and now includes further detail on gaps and potential steps to tackle these within the groups work plan.
4. Reporting of results Timeliness of the reporting of results was a prominent theme discussed throughout the CWGs engagement piece. Comments recorded against this theme were captured across care settings and were not the view of any particular clinical group. Some clinicians engaged raised concerns that related to delays, lack of communication and the impact that this had on length of stay. This however, was felt not to be the experience of GPs in City and Hackney of those engaged as part of the Homerton sessions. One GP raised concerns of sometimes waiting up to six months to receive a patients test results. Some of the comments captured are detailed below.
„„There are issues with outpatient appointments and the delays of test results‟‟ GP, Tower Hamlets
„„Timely results to reduce length of stay‟‟ Anonymous, Barts Health NHS Trust
„‟Timeliness and communication of investigations‟‟ Anonymous, Barts Health NHS Trust
A suggested models of care captured as part of the CWGs clinical engagement to improve the timeliness of reporting results was for greater flexibility in providing results e.g. telephone follow ups/Skype.
What has the CWG done to address these comments? The CWG recognise the current issues with the reporting of results and discuss this throughout the case for change. Examples of this can be found where the CWG stress how important it is that „„patients get the right tests they need and get the results quickly‟‟ (Clinical Support Services Clinical Working Group, 2014, pg7). The CWG further this view by outlining that a good model of care to help address the issues with the reporting of results involves „„intelligent reporting and timely access of results in a suitable format‟‟ (Clinical Support Services Clinical Working Group, 2014, pg15) that „„can be seen by those involved‟‟ (Clinical Support Services Clinical Working Group, 2014, pg15) in patients care. This element of the CWGs case for change has been strengthened and now includes further detail on the importance of clinical support services in ensuring timely discharge and potential steps to tackle issues within the groups work plan. TSCL engagement report List of clinical stakeholders engaged on the CWGs cases for change
Clinicians Engaged Setting Acute Pharmacists Acute Care Anaesthetists Acute Care Cardiologists Acute Care Colorectal Surgeons Acute Care Community Matrons Community Care Community Midwifes Community care Community Nurses Community Care Community Nutritionists Community Care Community Pharmacists Community Care Consultant Chest Physicians Acute Care Consultant Community Paediatricians Community Care Consultant Gynaecologists Acute Care Consultant Haematologists Community Care Consultant Neurologists Acute Care Consultant Obstetricians Acute Care Consultant Paediatricians Acute Care Consultant Physicians Acute Care Consultant Physicians in Geriatric Care Acute and Community Care District Nurses Community Care General Surgeons Acute Care GPs Primary Care Health Visitors Community Care Midwifes Acute Care Neonatal Nurses Acute Care Neurologists Acute Care Nurse Educational Practitioners Acute Care Oncologists Acute Care Orthoptists Acute Care Pathologists Acute care Physiotherapists Acute Care Practice Nurses Primary Care Prescribing Advisors Commissioning Support Psychiatrists Community Care Psychologists Community Care Radiotherapists Acute Care Senior Nurses Acute Care Senior Sisters Acute Care Specialist Leads in Geriatric Medicine Acute Care Specialist Nurses Acute Care and Community Care Speech and Language Therapists Acute Care and Community Care
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Recommendations for CWG phase 3 work plans
The following recommendation to the CWGs has been made in order to build on the clinical engagement elements of their phase 3 work plans:
In addition to those already engaged, include the following clinicians and professional groups when testing any agreed future service model options: o Healthcare Assistants o Mental health nurses (RAID/IAPT/ CAHMs) o Adult Nurses (A&E/ITU) o Phlebotomists o Social Workers o School Nurses. o Health Visitors o Occupational Therapists o Dermatologists
References
Children and Young People‟s Clinical Working Group (2014), Children and Young People’s Interim report (summary of clinical working group discussions so far): London: NEL CSU; http://www.transformingservices.org.uk/downloads/appendices/cyp/CYP%20Interim%20Report.pdf [30 September 2014]
Clinical Support Services Clinical Working Group (2014), Clinical Support Services Interim report (summary of clinical working group discussions so far): London: NEL CSU; http://www.transformingservices.org.uk/downloads/appendices/css/CSS%20Interim%20Report.pdf [30 September 2014]
Elective Surgery Clinical Working Group (2014), Elective Surgery Interim report (summary of clinical working group discussions so far): London: NEL CSU; http://www.transformingservices.org.uk/downloads/appendices/es/ES%20Interim%20Report.pdf [30 September 2014]
Long term Conditions Clinical Working Group (2014), Long Term Conditions Interim report (summary of clinical working group discussions so far): London: NEL CSUnit; http://www.transformingservices.org.uk/downloads/appendices/ltc/LTC%20Interim%20Report.pdf [30 September 2014]
Maternity and Newborn Care Clinical Working Group (2014), Maternity and Newborn Care Interim report (summary of clinical working group discussions so far): London: NEL CSU; http://www.transformingservices.org.uk/downloads/appendices/mn/MN%20Interim%20Report.pdf [30 September 2014]
Unplanned Care Clinical Working Group (2014), Unplanned Care Interim report (summary of clinical working group discussions so far): London: NEL CSU; http://www.transformingservices.org.uk/downloads/appendices/up/UP%20Interim%20Report.pdf [30 September 2014]
TSCL engagement report Appendix 2: Patient and public engagement on care pathways, enablers and CWGs
The following section provides more detail on feedback regarding the specific care pathways and enablers/themes. Each section is divided into an introduction giving examples of where things need to improve and often suggesting how they might be improved. These points, whilst noted, have not generally resulted in a specific change in the Case for Change, as they support or expand upon previously discussed issues.
Each table details where specific issues have been addressed or prompted a refinement of the Case for Change.
General / process / equalities
The engagement process was seen in a positive light.
Some respondents felt it was difficult to disagree with the overall vision and ambition as it was at too high a level – and some questioned the NHS‟ ability to deliver on such aspirations.
There were a number of comments regarding the wording or technical accuracy of the Case for Change and some regarding the process.
Examples of where specific issues have been addressed or prompted a refinement of the Case for Change in this area:
The Case for Change: You said We did
Communities in Redbridge, City and As the process has progressed we have Hackney, South Essex, and patients who reached out to neighbouring communities attend Homerton and Barking, Havering and the responsible organisations have and Redbridge University Hospital that become more involved. may be affected by changes – there needs to be consideration of their views. There is a need to be more specific and The original Case for Change had around better explain some of the detail behind 600 pages of appendices. We have included the overall Case for Change. more of this in the main document. There needs to be greater focus on There is now a greater focus on health health inequalities and the issues faced inequalities and the need to address the wider by the various groups with protected determinants of ill health, in addition to characteristics. improving healthcare services. A section has also been added to section 6 about „protected characteristics. Ensure you explain implications e.g. why This is included under the antenatal care is early bookings of pregnant women principle and we look at the variation in early important? booking across our CCG areas.
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and problems in commissioning. patients and clinicians when managing care, the importance and impact of education in early intervention and health prevention as well as the need for improved pathways.
Workforce and organisational development
This section is divided into a) feedback from the general patient and public (although there were quite large numbers of NHS staff responding to this engagement) and b) feedback from staff at drop in events and meetings arranged by Barts Health.
a) General feedback
Patients and the public supported the Department of Health proposal included in the interim Case for Change to have a named clinician for every patient. The vision of the NHS working with an active voluntary sector was supported. Respondents identified there are staff shortages and agreed that low staff morale needed to be addressed – this was seen as a reason why some patient contacts are so poor. Key themes included:
• Training. Highest group of 999 callers is care home staff – so it would be worth engaging with them to reduce usage. Need a better use of the NHS Leadership Academy which has lots of free courses. Staff skills in communications (and their knowledge) need to be improved e.g. patient letters are confusing; and referrers do not seem to know the systems. “Poor staff morale is transmitting itself to the patients” • Access for patients. e.g. Learning disabled people need to be offered longer consultations. GP triage at urgent care centres is seen positively – but respondents felt that this should not be seen as a substitute (or more easily accessible way) to get a GP consultation. Respondents recognised that better access could require additional staff. • Accommodation for staff is an issue; and respondents identified the nursing accommodation at Whipps Cross and other buildings as having been idle for years. Respondents felt this would make recruitment easier.
b) Staff feedback
There were positive comments about the way in which Barts Health was embracing public health and a suggestion that there should be better/more investment in primary, community and public health.
The most significant feedback is real frustration at a system where staff recognise problems but either are, or feel, powerless to change for the better:
• Care pathways were felt to be poor, inefficient, ineffective and a real struggle for staff. Access for patients need to be improved and pathways and performance need to be standardised. Need to get away from looking at specialties and focus on patients and the patient journey. There is a need for better working between primary and secondary care and to redesign the workforce to better meet patient needs. TSCL engagement report
• Consistent staffing is needed. Staff turnover is perceived to be high and related issues included the use of bank and agency staff and loss of good staff due to pressures. The recent Barts staff consultation was a source of frustration for some respondents. o There was a specific concern over Acorn ward at Whipps Cross regarding specialist paediatric nurse recruitment; whether specialist posts would remain; and whether possible changes to neo-natal would affect other children's services. • Leadership at all levels needs to improve. • Efficiencies. Staff felt that the NHS was inefficient e.g: o Stop patients attending for follow ups – use the telephone. Getting patients to come to hospital to be told everything is fine is a waste of time and resources for both sides o Take on apprentices and work experience people from schools, colleges etc o Theatre times should start after the 10am meeting to reduce cancellations. Examples of where specific issues have been addressed or prompted a refinement of the Case for Change in this area:
The Case for Change: You We did said
Staff need to be at the centre of We have strengthened the Case for Change to making the vision outlined in the highlight: Case for Change into a reality. • the link between staff morale, staff engagement and their ability to deliver high quality care • the importance of aligning workforce skills to service needs.
We have included examples of where work is already underway, such as: • the clinical leadership programme being developed at Homerton Hospital • Barts Health target to have 95% permanent staff by December 2015.
We have developed a workforce plan that includes emerging recommendations around improving: • recruitment • workforce planning • staff retention • performance management • training and development • transition of staff between different care settings. There needs to be a greater To try to understand and better reflect the current and consideration of the role of future role of community pharmacies in health provision, pharmacies and the new north each of the CWGs has engaged further with local Page 70
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east London pharmaceutical pharmacists. The outputs of these discussions have model been used to strengthen the Case for Change.
The new north east London pharmaceutical model along with other pharmaceutical models of care has informed the discussions of the CSS clinical working group. This model along with others will continue to inform any future discussions around the potential role that pharmacies may have in east London.
Information technology
IT was a key issue for staff, patients and the public, with both groups frustrated at the lack of connectivity and accessibility of data and information.
Examples of where specific issues have been addressed or prompted a refinement of the Case for Change in this area:
The Case for Change: You said We did
There needs to be better connectivity with social We have reflected this in the services to enable better discharge and joint working. Case for Change Staff told us they were frustrated about IT systems We have reflected this in the that did not provide them with the information or failed Case for Change – wasting time that could be spent on patient care. Patients want to see one access point where they can This is reflected in the Case for view their records. Change.
Finance
The issue of finance was a significant focus of responses. Much of the feedback focused on privatisation, PFI, contracting out, procurement, use of management consultants and competition – with all of these blamed for increasing administration, purchasing and overall costs. The PFI at The Royal London was seen as causing financial difficulties of Barts Health.
• Some respondents said there needs to be a shift of funds away from the acute sector and into primary care • The NHS was encouraged to consider whether the NHS should bail out failing trusts. The same issues were generally the focus of the finance and estates workshop at the Healthwatch event at Whipps Cross. An additional point raised at the workshop was a perceived inequality of funding (i.e. Waltham Forest‟s per head funding compared with Tower Hamlets and Newham).
“In my experience as a patient and as an NHS employee: there is too much inefficiency, a lack of coordination among services, underperforming staff, incompatible technology (patient databases), overspending on overpriced supplies from "preferred" contractors. There are also far too many highly paid managers not involved in direct delivery.” TSCL engagement report
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Examples of where specific issues have been addressed or prompted a refinement of the Case for Change in this area:
The Case for Change: You said We did
There was a difference of opinion between people who We have strengthened thought the NHS needed more resources and those that felt the documentation on that the NHS was inefficient (some respondents felt more efficiencies and made resources and greater efficiencies were needed). There was it a central focus of the some support for recouping costs from people not entitled to Case for Change free care / investigating means testing / allowing the NHS to make profits / charging for inappropriate use of facilities and ambulances / charging for non-attendance at consultations. Better use of the third sector / alternative therapies e.g. for mental health patients would save money.
Estates
The issue of estates, other than at Whipps Cross, was not a major focus of responses (although see the finance section regarding PFI costs etc).
• The poor quality of the estate at Whipps Cross is a source of concern – leading to a worry that the NHS will take a decision to disinvest in the whole site • The quality of food was criticised • Need to make better use of existing assets e.g. using theatres 24/7 • The environment and ambience of estates is often the differential between the NHS and the private sector. NHS is often bland, uninspiring and not conducive to recuperation • In deciding where to locate facilities the NHS needs to look at where is actually best for the local populations, not just where it has existing estate • There needs to be a quicker roll out of hot-desking across Barts Health. Examples of where specific issues have been addressed or prompted a refinement of the Case for Change in this area:
The Case for Change: You said We did
Need to better explain an estates strategy This is included in the Case for Change Key worker accommodation is an issue This is included in the Case for Change The NHS needs to better manage its estates. This is included in the Case for Change.
Health and wellbeing TSCL engagement report
Health and wellbeing was of concern to many respondents, with a key focus on the need for education. Respondents said they don‟t know what is good for them, or how to deal with illness (not just acute illness) e.g. guidance for parents about mental health of young people). • Need a focus on obesity; prevention; mental health and CAMHS; primary and community care; communications; information; community involvement etc • Need to support foster parents and carers • Incentivise people to lose weight • Get more staff working in the community • Get schools and colleges to teach first aid • More basic classes (adult education style) and specialist groups e.g. menopause clinic • Primary care estate is not fit for purpose e.g. lack of meeting rooms for classes • Involve community groups in partnerships e.g. fitness classes, dance and drama. Examples of where specific issues have been addressed or prompted a refinement of the Case for Change in this area:
The Case for Change: You said We did
Social determinants of health are The Case for Change now includes further detail on critical but outside the this point and the role that other organisations such responsibility of NHS. as local authorities and public health need to play.
Primary care
The role of primary care was seen as critical in improving the health economy in the area and there was some disappointment that there wasn‟t a clinical working group for primary care. • Need better communications between hospital and GPs • GPs need more funding • GPs need to take time to listen and discuss. Doctors are not approachable at surgeries. o poor access was identified as why many people said they attend A&E. GP surgeries need to be open 8am to 8pm, 6 days/week - with online everything (appointments, prescriptions, even consultations) o phone numbers are expensive to ring o can never get an appointment on time o personal questions are asked in the reception area for all to hear o there should be totally free choice of doctor for patients – wherever they want o proper preventative medicine – not based on offering services that are monetarily rewarded...like asthma clinics, or poorly targeted 'tests' – like mammograms, but based on good medicine (like annual check-ups with a doctor) Page 74
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• Needs a better system of managing appointments to GPs e.g. one local contact number which will allocate a patient to a GP at their own practice or offer an appointment at another practice.
“When I want an appointment with a GP the rules changes every week and we are never informed… and when I get an appointment the GP doesn't have the decency to see me even though I am on time. Each time I had to go in walking centres or A&E because my GP never has a slot. They want us to book appointment online but there isn't any slots available which means most of time self-medicated or takes months to be seen.” Examples of where specific issues have been addressed or prompted a refinement of the Case for Change in this area:
The Case for Change: You said We did
Issues in primary care need a greater There is now a fuller section in the Case for focus in the Case for Change. Change on primary care, and the specific clinical summaries make greater reference to the impact of and relationship to primary care on what is happening in a hospital setting.
TSCL engagement report Unplanned care
Generally respondents didn‟t disagree with the vision, challenges and opportunities in the Case for Change regarding unplanned care. Most responses supported the need to change or provided suggestions on what they would like to see. Unplanned care was the focus of a workshop at the Healthwatch event at Whipps Cross Hospital, the feedback from which reinforced views made elsewhere:
• Co-ordinate unplanned care through a central east London hub • Positive feedback/experiences about 111. Big Front Door also singled out for praise • Get the appointments system working properly and then charge for missed appointments • Waiting times for A&Es and for physiotherapists are poor. A&E is very bad. Emergency doctors are overworked. If occupational therapists and social workers are working at the weekends – why are more doctors not doing so? Why can‟t people be referred to a physiotherapist to help ameliorate excruciating pain whilst waiting three months for an urgent consultant appointment – rather than having to put up with it for three months and then get referred? Mental health patients waiting in A&E for 6 hours is not acceptable • Too many people being admitted unnecessarily • People go to A&E because access to other services is poor. NHS staff who are meant to signpost people don‟t know where patients should go. Care homes are seen as the biggest users of 999 – support/education is needed to stop them using A&E as a default • Rebalance the funding between acute and community – so that elderly and frail people can be better supported in the community rather than in hospitals. Social care and rehab are often unavailable or too late (we heard four years for social care in one instance) • Discharge procedures are poor – with elderly people waiting for hours and then going home in the night • Needs greater focus on personal responsibility so A&E can concentrate on those most in need. Lifestyle advice should be planned into the unplanned care pathway. Need to get more people registered with GPs. Too many ambulances are being used unnecessarily. Better patient education is needed – particularly around pharmacists • Better medical facilities in schools would mean fewer visits to A&E • Technology needs to be embraced – but patients must still have choice • The role of community pharmacists is vital • Unclear how neurological services fit into the jigsaw
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Examples of where specific issues have been addressed or prompted a refinement of the Case for Change in this area:
The Case for Change: You We did said
Redbridge and Waltham The Unplanned Care CWG has completed a mapping Forest CCGs are currently exercise to better understand the differences in the procuring urgent care – the models of urgent care operating in each borough. This will work needs to dovetail into form the basis of future discussions between the urgent TSCL. care boards about how urgent care should be delivered. Further detail is included in The Case for Change and will build on local work already underway.
Procedures for discharging The Unplanned Care CWG agreed that timely and patients need to be proactive discharge planning is important. The Case for improved Change has been strengthened and states that new ways of working may mean more people can return home safely and earlier.
Maternity and newborn
There was little feedback in the questionnaire relating to maternity and newborn care. The issues raised included:
• perinatal mental health services are an essential part of preventative care and yet are very thin on the ground • antenatal groups at supermarkets were suggested as a way to improve the current service • there are communication and language barriers during appointments for women with interpreters – sometimes there are mistakes in translations. Culturally appropriate services and pre-pregnancy advice are crucial to improving low birth weights • focus on information needs to shift from postnatal to pre-natal. More attention needed on working with young women and diverse communities around contraception, healthy eating, and exercise • care for women used to be shared between Whipps Cross Hospital and the GP, but GPs now do not always have the records. Linked IT systems are vital to the provision of good quality care. Booking systems are different in different hospitals • there needs to be a particular focus on care for girls/young mothers • the importance of investment in school nurses was highlighted “My wife had complications when she gave birth. There was not enough staff during the night.”
TSCL engagement report
Examples of where specific issues have been addressed or prompted a refinement of the Case for Change in this area:
The Case for Change: You said We did
The specific issue of how / if Since June, the Maternity and Newborn Care maternity units will cope with rising CWG (MNB CWG) has considered demand and birth rates needs to be included capacity management as part of the whole pathway. Further detail based on the outputs of these discussions can be found in the Case for Change and are also captured within the MNB CWG‟s final report
Perinatal mental health services The Case for Change states that we need to do need to be improved more to minimise the risk and impact of postnatal depression for new mothers throughout the entire maternity care pathway
Pregnant women often do not know This is recognised in the Case for Change and the choices available to them, and the need to integrate health care with other local would like more information in this services to improve support for women is regard emphasised
Women had mixed experiences of, The MNB CWG recognise this. The Case for and access to, antenatal care Change states the need to effectively map antenatal care across east London in order to improve antenatal care
Women want more support in the The MNB CWG recognise this. The Case for postnatal period, both immediately Change states that there is a need to both after birth and the weeks that follow standardise the provision of postnatal care and improve communication between hospitals, GPs and community services
Care that is culturally appropriate and This is recognised and is reflected in the MNB takes into account language barriers CWG report, which underpins the maternity and will improve outcomes newborn care section of The Case for Change.
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Children and young people
We received information regarding services for children and young people (CYP) from a number of questionnaires and discussions at meetings. These comments broadly fell into two categories:
Access and communications • Young people need to be enabled to access services • There is a stigma and lack of transparency on how young people access services. A visible presence in schools and other public spaces would be helpful • Newham has had a paediatric helpline for years, every morning Monday to Friday. Would be good to replicate this elsewhere • More use of email for patients and GPs.
The service • The NHS needs to get better at addressing mental health issues for children and young people, working with parents and carers in conjunction with psychologists • The clinical working group needs to reflect the outcomes of the Transforming Primary Care in London work (chaired by Clare Gerada) • The CYP group needs to work in a patient-centred way (rather than split services into unplanned care, surgery, long term conditions etc) We also gained valuable insight into patient and public views of the service through the Healthwatch co-ordinated event at Whipps Cross Hospital. A workshop specifically discussing services for children and young people discussed:
Early years • There are problems before the child starts school. Need for coordinated services: health visitors need to link with schools. NHS is always chasing the same families for immunisations so we need to coordinate better. There is no clarity or consistency in schools and children are sent to a GP when it is not necessary • Perception that school nurses have been cut back. The consultation in Newham seen as not following best practice and didn‟t engage with parents & children • Medical facilities in schools were suggested, particularly for children whose parents do not take their children to the GP. These children could be seen by a school nurse. Primary care could potentially make savings and reduce pressure on GPs where there is often a two week wait. Coordination of care, communications and equalities • Lack of coordination of care - consistent hospital pathways needed throughout patient journey with seamless transitions (which often is not the case) • Lack of follow up after initial occupational therapy and physiotherapy • Perception that some groups of children and young people get restricted healthcare – for instance ethnic minorities • People with learning disabilities experience some conditions earlier than others; care pathways need to take this into account • Children should be treated as a whole person not just a condition TSCL engagement report
• Communication between hospitals, trusts and GPs highlighted as being important. Main hospitals should have clinical records systems; there should be paperless notes systems; GP systems should be connecting in; and patients should have access to personal records • There is a need for patient education and awareness raising campaigns about what services are available and where and how to access them – particularly urgent care. Communicating with patients and the public in ways that they understand and can connect with was seen as vital. Good practice • Services for CYP should be protected and improved. In Redbridge - children seen as a priority, with good early interventions and immunisation rates. • The Youth Council in Newham helped design children‟s services and this should be the model for other boroughs. • „Home Start volunteer‟ for children and young people was a good initiative but was left to the Council to fund. Mental health • There is a need to focus on children's mental health services and change them to suit the changing society • Depression in children 8+ has become prevalent • Will alternatives to medication-only treatment be provided? Suggestions of cognitive behavioural therapy and group support were raised. The role of schools and pharmacies was highlighted • Access to mental health rapid intervention was raised as an issue, as were early identification of eating disorders and suicidal thoughts. • To reduce the stigma of mental health, „emotional support‟ would be a better descriptor.
Examples of where specific issues have been addressed or prompted a refinement of the Case for Change in this area:
The Case for Change: You said We did
Children and young people‟s voice / Children and young people were interviewed representation is missing from the in outpatients departments and engaged with Case for Change / governance at a meeting (Waltham Forest „Young Advisers‟) to discuss their experiences in more detail. The outputs of this have been included in the Children and Young People‟s CWG (CYP CWG) report and have strengthened the Case for Change in this area.
Access to services for children and The CYP CWG agree and the Case for young people needs to be better Change states that developing consistent, standardised pathways across east London
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will provide more equitable services for children and young people. The Case for Change also recognises the role that clinical networks have to play here.
The NHS needs to get better at The Case for Change now has a new and addressing mental health issues for separate section on mental health. This section children and young people emphasises the need to ensure: support is available 24/7 for children and young people with urgent mental health needs high quality children and adolescent mental health services (CAMHS) are in place effective transition for children and young people from adolescent to adult mental health services
Health provision and prevention during The importance of early identification and a child‟s early years is important intervention is recognised in the CYP CWG report, which underpins the children and young people section of the The Case for Change.
The coordination of care for children The principle around „seamless transitions of and young people needs to improve care‟ for children and young people in The Case for Change has been strengthened and states that: young people need to be well supported into adult services children and young people should receive coordinated care across teams in acute, community and primary care care should be provided with as few contacts as possible
TSCL engagement report Long term conditions
Generally respondents reinforced the Case for Change, and agreed with the need to plan for greater demand for health and mental health services. However there were some areas of concern / disagreement / different emphasis:
• The physical and mental health needs of the patient should be considered together • Need transparent long term care plan developed with the patient, particularly for patients with co-morbidities • There was a difference of opinion regarding self-care and personal responsibility. Some respondents supported the idea and suggested that people should be charged for missed appointments (but only if the appointment system is improved). Others disagreed highlighting that: support is lacking; information provided to patients to enable them to make their own decisions (especially about referrals) is minimal/confusing; accessing care is extremely difficult when the patient requires it – hence the overuse of A&E • Available technology has not yet been widely introduced to enable patients to be monitored remotely for a range of long term conditions (e.g. COPD, diabetes), preferably by a named clinician(s) to enable continuity and confidence • There is a need to rebalance funding between acute and community care; to enable early discharge of elderly frail people from hospital and free up acute beds / reduce waiting times • The NHS needs to work in partnership with local community organisations e.g. www.useyourcommunity.com “I believe it's community projects...that improve quality of life. Things like this are inexpensive and have a wide range of impact.”
Access, information and communications • Need to make better use of pharmacies • Monitor the number of referrals to long term condition (LTC) support / expert patient programmes • People with learning disabilities generally need longer consultations but this isn‟t considered. Administration • Procedures frequently cancelled with particular impact for LTC patients with multiple conditions that rely on one procedure to follow another; no-one to help navigate this • Need for better support for elderly people coming out of hospital. Often kept waiting for hours for medication and end up going home in the dark. If there is a delay they should go home and have their medication delivered • No facility to return health and social care equipment / aids (in Waltham Forest in particular) but a common situation. “My experience of primary care GP services locally has been very poor compared to those I've received living in other parts of the country. As a patient with a chronic condition, I also do not feel that my GP recognises my experience in handling my condition, which is very frustrating.”
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Finance • Need for better discussion / information about personal health budgets and care at home • Introduce „a year of care‟ tariff for patients with LTCs like there is for HIV. This allows open access and efficient use of face-to-face care and there is an incentive to keep patient well Treatment • We need more partnership working e.g. Whipps Cross rheumatology physiotherapists supporting an after-hours patient self-help group, using Trust hydrotherapy facilities • GPs are not always capable of effectively managing / understanding LTCs. Too much focus on diabetes and not enough on other illnesses with fewer support groups e.g. Arthritis • The role and resource of unpaid carers was noted, and it was felt specific reference needs to be made of them. “Example of good practice is HIV multidisciplinary meeting at...Newham General Hospital (Greenway). The meeting occurs weekly and involves the voluntary sector as well as clinicians. This enables health as well as social care and support needs to be addressed. It ensures a seamless holistic experience for clients/patients.”
Examples of where specific issues have been addressed or prompted a refinement of the Case for Change in this area:
The Case for Change: You We did said
There needs to be recognition The CWG has strengthened their principle on patients that for self-care to happen, being empowered to manage their conditions by the individual needs to be including further detail on how this can be achieved by supported taking into account individual patient needs and goals
The role (and needs) of carers Carers attended a focus group to discuss their needs greater emphasis experiences in more detail. The outputs of this have been included in the CWG‟s final report and have strengthened the Case for Change in this area – in particular in relation to the role of carers in ensuring care is tailoured to the needs of the individual.
The link between physical and Mental health leads, commissioners and community- mental needs should be based mental health clinicians attended a focus group strengthened to identify where the system could change. The outputs of this, and issues identified around physical and mental needs have been included in the CWGs final report and have strengthened the Case for Change
The health and financial The Case for Change is strengthened in terms of the benefits and opportunities of role of the voluntary and community sector in support partnership working with health and wellbeing community groups should be recognised
Patients need to be The CWG has strengthened this area of the Case for TSCL engagement report
empowered to manage their Change, and one of the aspirations is that we need to own conditions engage patients and the public in redesigning long- term condition care. In addition, greater emphasis has been placed on ensuring people with long-term conditions can use new technology in managing their care.
Planned care
There were relatively few comments received in the questionnaire and the meetings that related to planned care specifically. Key themes were around:
• the need for more social care and support for elderly people at hospital discharge and a perceived „postcode lottery‟ • hospital specialists telling the patient they need specific support (e.g. equipment following joint surgery) but the local authority says there is no money • the need to reduce cancellations. At Whipps Cross Hospital when we held an information stand we met people who had turned up for surgery appointments which had been cancelled. Several said that they had got cancellation letters the day after the date of their appointment. “Surgery cancelled five times with no explanation… GP uninterested until letter from hospital said I had failed to attend! Glad I kept the cancellation letters! Forced to go privately in the end as no one willing to help.”
Examples of where specific issues have been addressed or prompted a refinement of the Case for Change in this area:
The Case for Change: You said We did
A lot of overlap between this group and Each of the CWGs have identified and shared children and young people, long term the emerging themes within the Case for conditions, unplanned care, and Change that were cross cutting and relevant surgery. The Case for Change needs to to more than one clinical area. These overlaps recognise this and integrate common have now been considered and have been interests addressed in each of the CWG final reports and overall Case for Change.
The cancellation of procedures needs The CWG agreed and this is stated as an to be reduced ambition in the Case for Change.
The discharge of elderly people needs This was a focus of the CSS CWG – see next to be better section
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Clinical support services
There was relatively little comment on the questionnaire regarding clinical support services but there was more discussion at the various meetings the programme attended.
• Need to promote the role of pharmacies – particularly for children and young people “We (pharmacist) would like to support patients with discharge medication changes. We are able to collect and copy the discharge medication letter from the patient‟s home and send it to their GP with a summary form of the change. The patient would be informed of the changes by the clinical pharmacist visiting their home or at our pharmacy. This service would mean there would be minimum waste and their new prescription has no duplication. However the patient must consent for our pharmacy to handle their first prescription...”
• Need to make sure clinical support services are better involved in service planning • Need to use diagnostics to underpin radical change – diagnostics currently miles away from hospital. Need to introduce walk-through diagnostics with results available before appointment • Need for better support for elderly people coming out of hospital. Often kept waiting for hours for medication and end up going home in the dark. If there is a delay they should go home and have their medication delivered “Pharmacy – big issues with time taken to receive TTA‟s (To Take Away) and medications not stocked on the ward.” Barts Health Staff
“Result of x-ray / urine / MRI… should come quickly even in 3rd world country. If you give any test you will get result within few hours or same day but unfortunately in this advance country result always comes more than 2-3 weeks.”
“…crazy that local GPs do not have to use Whipps for treatments i.e. MRI scans.”
“People with learning disabilities not being treated as equal citizens and carers are finding it frustrating in getting checks, blood test. Not enough health checks being done for people with learning disabilities.”
“Clinical Support Services – very good principles, demand is so high even now can‟t meet the demand, volume of referrals, increase in breast and skin referrals need extra investment, have to look at changing minds. Fresh, educated people now go for screening who wouldn‟t have before.”
Examples of where specific issues have been addressed or prompted a refinement of the Case for Change in this area:
The Case for Change: You said We did
Role of pharmacists could be The potential role of pharmacists in relation to greater unplanned care and prevention has been strengthened in the Case for Change
Role of London public The new north east London pharmaceutical model TSCL engagement report
pharmaceutical model released along with other pharmaceutical models of care shortly – would be good to look at have informed the discussions of the CSS clinical that and feed into TSCL. working group when strengthening this area of their Case for Change. This model along with others will continue to inform any future discussions around the potential role that pharmacies may have in east London to support the delivery of care.
You had concerns about the Ensuring new technology is implemented, and future demand on clinical support ensuring patients can access it, are two areas services and investment in new detailed in the Case for Change. technology
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Appendix 3: Healthwatch report of a meeting at Whipps Cross on 18 August 2014
Transforming Services, Changing Lives (TSCL): Patient and Public Engagement Event
Monday 18 August 2014 Report
Subject: Feedback on the NHS in east London from Newham, Redbridge and Waltham Forest Source: Patient and Public User Engagement Event, 18th August 2014 Purpose of the Report: To document the attendees views of the health services in east London
This report is an account of what the attendees said, and through the voice of the patients.
Author: Charlie Ladyman, Healthwatch Newham Manager
Report Contents
1. Summary Page 1 2. Key Recommendations Page 3 3. Background Page 3 4. Questions and Answers session Page 5 5. Workshop sessions Page 6 (a) Maternity Page 7 (b) Estates and finance Page 8 (c) Children Page 9 (d) Urgent Care Page 11 6. Comment cards Page 15 Acknowledgements and contacts Page 17 Glossary of terms Page 18
TSCL engagement report
1. Summary
On Monday 18th August 2014 Healthwatch Newham, Redbridge and Waltham Forest held a joint event to inform people and gather feedback on the Transforming Services, Changing Lives (TSCL) at Whipps Cross Hospital Lecture Theatre.
The event promoted lively discussion, approximately 100 people from all 3 boroughs attended. Attendees were both familiar with one or more of Barts Health NHS Trust Hospital sites through personal experiences as patients, carers, relatives and visitors ensuring health services across the boroughs remain ‘fit for purpose’ meeting local needs and demand.
The purpose of the event was to:
inform patients and local people about the TSCL programme provide them with the opportunity to feedback on their personal experiences of health and care services and raise any queries or concerns about services received input into the development of TSCL programme
Workshops were held on Unplanned Care, Finance and Estates, Children and Young People and Maternity and New-borns, these were 4 of the 11 work streams in the TSCL programme. Healthwatch selected these topics as they are some of the areas of the greatest concern to local people.
Attendees were encouraged to choose 2 of 4 different workshops to attend Maternity, Estates and Finance, Children and Urgent Care and encouraged to make a note of any outstanding questions or queries they had in relation to the TSCL programme, what it stands for and what it might mean for the future of health services across east London.
Throughout the event attendees were invited to note down questions and comments using ‘comment cards’ and hand these in at the end of the event, for consideration by the TSCL Programme and Healthwatch.
The event was a discussion of observations and concerns around Barts Health NHS Trust and the wider health economy.
This report is an account of what the attendees said, and through the voice of the patients.
The feedback will be used by TSCL programme staff to develop a final ‘Case for Change’ document which is due to be published in autumn 2014 and will help to shape the future of east London’s NHS services.
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2. Key Recommendations
a.) Improve communication between services and patients b.) Improved communication between providers c.) Ensure proper staffing levels, morale and good staff are retained d.) Streamlined booking system across medical services e.) Coordinate health services with other services in the community
3. Background
3a) What is Healthwatch?
Healthwatch Newham, Healthwatch Redbridge and Healthwatch Waltham Forest are separate local Healthwatch organisations, established by the Health and Social Care Act 2012 to act as local independent consumer champions for health and social care for their respective London boroughs.
Local Healthwatch organisations have statutory duties to:
Gather the views and experiences of patients and public Make those views known to providers and commissioners Promote and support the involvement of people in the commissioning and provision of local care services and how they are scrutinised Recommend investigation or special review of services via Healthwatch England or directly to the Care Quality Commission (CQC) Provide information and signposting about access to services and support for making informed choices including independent advocacy support to make an NHS complaint Make the views and experiences of people known to Healthwatch England, providing a steer to help it carry out its role as national champion
3b) What is Transforming Services Changing Lives (TSCL)?
Transforming Services, Changing Lives (TSCL) is a clinical programme established by local Clinical Commissioning Groups (CCGs) in Waltham Forest, Tower Hamlets, Newham, Barking and Dagenham, and Redbridge, NHS England and Barts Health NHS Trust.
The aims of the programme are to:
Describe the current state of NHS services in east London Identify if change is needed to services for patients Provide an opportunity to think about what we want our local NHS services to look like Begin to develop a shared vision of how we could improve services TSCL engagement report Enable joint planning across east London for changes to health services locally Start planning for the future
A key element of the TSCL programme is to consider how best to ensure safe, effective and sustainable hospital services at The Royal London, Whipps Cross University, St Bartholomew’s and Newham University Hospitals which are all part of Barts Health NHS Trust and how any changes may impact on the continuing development of hospital and community services at Homerton University Hospital NHS Foundation Trust.
The TSCL programme focusses on 6 specific areas: Unplanned care, Maternity and new- born, Children and young people, Long term conditions, Elective surgery and Clinical Support services.
The TSCL programme states that ‘significant change’ is required in order to manage the health economy, by making savings, providing quality services and addressing the forthcoming population increase. TSCL states that there needs to be a saving of £400 million to make the health service more sustainable and that a population increase of 250,000 is expected in east London (notably across Olympic legacy sites in Newham) by 2030.
For more information on the TSCL programme and Case for Change please see here.
3c) Engagement and involvement
Healthwatch organisations were invited for involvement and input into the TSCL programme during the initial stages of its development (from April – July 2014).
Healthwatch took part in introductory discussions and debate and provided patient experience data it holds on local services.
After three months of intensive work by partners the TSCL programme established a ‘Case for Change’ which identified why change is needed but not yet what those changes are.
From the outset, Healthwatch championed for wide public and patient engagement and involvement in the TSCL programme, and the event of 18 August was a coordinated effort to ensure our borough residents were provided with their first opportunity to do just that.
The TSCL programmes interim ‘Case for Change’ is out for public consultation over summer 2014, with the aim of producing a final ‘Case for Change’ in autumn 2014.
Healthwatch will continue to champion patient and public engagement and involvement in the programme as it moves forward and will seek to ensure partners provide varied and meaningful opportunities for local people to have their say on the future of health services in east London.
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4. Questions and Answers session
Hosted by Don Neame, TSCL Public and Patient Reference Group Facilitator, the Q & A session Panel was comprised of the following representatives:
Dr Steve Ryan, Medical Director, Barts Health NHS Trust Rob Rose, Hospital Director, Whipps Cross Hospital, Barts Health NHS Trust (recently appointed Dr Stuart Sutton, GP and member of Newham Clinical Commissioning Group Governing Body Lisa Henschen, TSCL Clinical Work stream Lead Terry Huff, Chief Officer, Waltham Forest Clinical Commissioning Group Mike Gill, Associate Medical Director and TSCL Clinical Lead, Barts Health NHS Trust
In this session questions from the audience were asked covering a broad spectrum of issues and concerns around health, and health and care services in east London. The issues raised and answered provided, where available, are summarised below:
A few attendees quizzed the panel about the need for TSLC to adequately address the ageing population as well as ageing health professionals.
A point was made about people with multiple and long-term conditions being frequent users of services.
A comment was made that the ‘prime focus’ of good care provision is retaining the ability of staff and teams, and that ‘any [service] changes are dependent on the quality of staff so we need to look at the interdependencies of staffing’.
One question related to the importance of the Voluntary and Community Sector (VCS) who provide front line services, and highlighted that local organisations are knowledgeable about local issues and it is vital to ensure that the VCS are included in any consultations.
Two significant questions on communication were asked: unsigned letters and unanswered telephones [on wards and service areas] were highlighted as frequent occurrences. Barts Health NHS Trust staff on the panel responded that they were aware this is a common issue and are working on it.
One attendee mentioned how a relative was discharged from hospital with no care plan in place and no communication between the hospital and social care services.
Another attendee reported they struggled with text and wondered why the hospital could not use an old fashioned letter.
Two members of the audience were profoundly deaf and concerned that the TSCL video presentation, shown for the first time at the event, had no subtitles and was therefore inaccessible.
Comments were made that the ‘Case for Change’ seemed like an extensive programme and that engagement should be ongoing with a year of events and consultations. The TSCL engagement report panel response reflected that, when commissioning there are ‘hoops to go through’ so we have to get it right, making use of valuable patient feedback. They also noted that changes will not go through the final hoop if not all parties – the Clinical Commissioning Group, for example, are signed up.
One attendee described how a care package had been removed and that it can take 6 to 12 months to re-apply. In the meantime, the family member was left to struggle with shopping and cleanliness.
Several comments highlighted that mental health appeared to be the ‘poor relation’ in health services, with one person pointing out that ‘there is nothing specific for people with mental health conditions, who have waited for 6 hours in A&E’. The panel responded that there was not a specific part on mental health within the TSCL programme because it was felt to be integral throughout all areas and would be captured throughout.
A member of the audience highlighted that Newham has a low cancer survival rate, 7% of people referred for screening being found to have cancer. The panel responded that there needs to be greater awareness of symptoms and screening and that people often don’t recognise the symptoms and are too embarrassed to ask. They confirmed that cancer mortality rate in Newham are above the London average.
An attendee described a recent personal experience when Whipps Cross was unable to provide elective surgery so they had to reluctantly go private. The panel believed possible solutions could be increased theatre provision and weekend work.
An attendee asked about Lord Darzi’s review of London’s health and social care services that challenges the Government to increase funding for London, due to increases in population and demand, and asked how this fitted into the TSCL programme. The panel responded to say that the NHS is working with the London Health Commission and ‘links are being made.’ They also highlighted that the predicted population growth for City and Hackney, Newham, Tower Hamlets and Waltham Forest is estimated at 250,000 over the next 15 years; with a 70,000 increase in the population of the Olympic Park alone.
5. Workshop sessions
During the next section of the event, attendees had the opportunity to attend two of four workshops covering: Maternity; Estates and Finance; Children, and; Urgent Care. At these workshops a mixture of further presentations, discussions and questions took place. Feedback and comments from workshop attendees touched on a number of areas, both those directly linked to workshop specific topics, and those more broadly associated with wider aspects of care and the Transforming Services, Changing Lives programme itself. Feedback is summarised below under each workshop area, themed whenever possible.
5a) Workshop session: Maternity
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Presenters Mike Gill, from Barts Health, and Kara Renno from the TSCL programme started discussions with some further information, stating the Transforming Services, Changing Lives interim ‘Case for Change’ highlighted out of 22 London hospital maternity services, Barts Health is ranked 19th and the Homerton 21st (source: Care Quality Commission 2013), although a recent CQC inspection of maternity services at the Homerton rated the services as ‘good’.
Communication, education and awareness
One attendee highlighted communication and language barriers during appointments for women with interpreters, with translators sometimes translating in error.
It was also noted by the group that there was too much focus on support after the baby is born, and more attention is needed on working with diverse communities around contraception, healthy eating, and exercise – all being important issues which could help in tackling the high number of low-weight births in in east London.
The topic of culturally appropriate services and pre-pregnancy advice was discussed as being crucial to improving the low-weight birth statistics.
Appointment booking
It was highlighted that booking systems are different in different hospitals.
One attendee noted that care for women used to be shared between Whipps Cross and the GP, but that GPs do not always have the necessary record-sharing capacity for this to take place effectively - the need for IT systems to be linked was highlighted as being vital to the provision of good quality care. Services and support
One attendee highlighted that girls (young mothers) are being sent home with their babies to no support and that systems and services need to be vigilant.
The workshop felt that mothers were not given enough support after discharge.
The importance of investment in school nurses was highlighted, as was the experience that young mothers suffer the consequences of a lack of support/advice/education – early on after birth, and in pre-pregnancy.
5b) Workshop session: Estates and Finance
Facilitated by Geoff Sanford, Don Neame, and Beata Malinowska from the TSCL programme this workshop explained that the finance Workstream within the TSCL programme had looked at opportunities to reduce costs and make savings through improvements in quality and productivity, in order to meet a £400m saving requirement over the next 5 years. TSCL engagement report
They explained that throughout this process TSCL had been reviewing buildings and facilities run by Barts Health – understanding how they are currently used and identifying opportunities to use them in a more efficient way that will benefit patients.
Attendees at the workshops expressed their concerns about the poor quality of some of the buildings and facilities – voicing their anxiety that there was not enough money allocated to run a safe and effective NHS.
A number of questions were asked about the Whipps Cross estate. There were concerns about potential closures and it was explained there was no indication for this, as there is strong demand for the services at Whipps Cross, and that demand will continue to grow. The A&E is one of the busiest in London and there are a substantial number of births at the hospital.
PFI
Questions were raised about Barts PFI arrangements and whether the Trust is looking at ‘radical means of re-financing’. The response from presenters highlighted that no solutions had yet been proposed. However, they went on to state that investment in estates is required, and Barts Trust is committed to developing an estates strategy linked to the TSCL programme.
Borough population
There was a lot of consternation that the funding for Tower Hamlets and Newham is greater than that for Waltham Forest. The speaker explained that overall the health of the population in Waltham Forest is better than it is in Tower Hamlets and Newham, which is why the funding is weighted in the way that it is. Funding between boroughs does vary per head; Tower Hamlets and Newham receive more per head of NHS funding than Waltham Forest as there is more demand on services in these boroughs.
5c) Workshop session: Children
Presenters Steve Ryan from Barts Health NHS Trust and Lisa Henschen from the TSCL programme introduced the session, noting that young people that are unwell deteriorate a lot quicker than adults suffering the same illnesses.
Pharmacies
Several attendees suggested the involvement of pharmacies in TSCL and highlighted the crucial role they can play in prevention support including Health Checks, advice, and much more.
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Children’s Voice
Redbridge was identified for having a good model of hearing the child’s voice; good early intervention and cover immunisation existed.
The Youth Council in Newham was also highlighted as having helped design children’s services and could be a good model for other boroughs to adopt.
School Nurses and health visitors
One attendee stated that ‘School Nurses have been cut back’ and that the school nurses consultation in Newham was more like ‘a force communication, about cluster schools rather than asking parents and children what their needs were.’
One attendee noted that ‘there is a need for coordinated services: linking schools with health service and we are chasing the same families for immunisations; we need to coordinate better.’ It was also highlighted that health visitors will often know about problems before a child reaches school.
The same attendee highlighted that there is ‘no clarity in schools, schools are not guided, and the child is sent to the GP when it is not necessary.’
‘Home Start volunteer’ was highlighted as a good initiative, but was left to the Council to provide funding.
GPs
One attendee suggested medical facilities in schools - particularly for children whose parents did not take them to the GP, and who could perhaps be seen by a School Nurse. It was also suggested that such an approach could potentially make savings in primary care, and make the borough [Newham] innovative in dealing with its shortage of GPs, and ageing GPs, and where there is often a two week wait, and a consequent pressure on urgent care services.
Staff
The group had many concerns relating to staff posts and specialist children's services. Regarding Acorn ward at Whipps Cross there were queries from the group relating to:
Specialist Paediatric Nurse recruitment If specialist posts would remain Whether/when the closed beds on the ward would reopen. If possible changes to the neo-natal service would affect other children's services in the future.
TSCL engagement report Mental Health
One workshop attendee suggested moving away from the term ‘mental health’ services and using a more friendly name, such as ‘emotional support’ particularly for CAMHS, stating that ‘there is a breadth to mental health, psychosis is mental health, but the term ‘mental health’ service is harsh for vulnerable and sensitive people to hear’.
It was noted by participants that neither ELFT (East London Foundation Trust) nor NELFT (North East London Foundation Trust) were present or involved in the TSLC panel. A query was raised as to whether the programme has the capacity to influence Mental Health services within the trust.
The group highlighted that the TSLC programme must take children's mental health services into account and were keen to point out that appropriate services were needed for a changing society. The following were highlighted and queried:
Depression in children over-8-years-old has become prevalent, how is it being treated and supported? Will alternatives to medication for treatment be provided? Suggestions of CBT (Cognitive Behavioural Therapy) group support were raised, and the role of schools and pharmacies highlighted. Access to Mental Health rapid intervention within east London is an issue. Early identification of eating disorders and suicidal thoughts are also issues that need addressing.
Communication
Communication between hospitals and other hospitals, trusts and other trusts, and GPs and hospitals was highlighted as being important. In relation to communication, IT, and patient record links, it was felt that:
Main hospitals should have clinical records systems There should be paperless notes systems GP systems should be connecting in Patients should have access to personal records
Other
Attendees pointed out that there was a need for consistent hospital pathways throughout the patient journey, and that sometimes this wasn't the case. A seamless transition in care was required.
There was general consensus amongst attendees who felt strongly that 'we need to maintain a good service’ and that there was ‘a lack of coordination of care’.
One attendee explained that occupational therapy and physiotherapy initially support families, and yet there is no follow up.
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One attendee felt that certain groups get more than their fair share, and that ethnic minorities were not getting enough.
Another attendee stated that people with learning disabilities experience some conditions earlier than others, and that care pathways need to take this into account.
In general the group felt that children should be treated as a whole person not just a condition.
5d) Workshop session: Urgent Care
Presenters were Dr Stuart Sutton from Newham CCG and Yasmin Peiris from TSCL programme.
Communications and connectivity
It was noted by several attendees that use of plain English is key for all materials, and they further pointed out that this is especially critical, especially when explaining complicated programmes such as TSCL and or service changes. Often when it is explained verbally it is makes sense, but participants felt strongly that written explanations must also make sense.
It was suggested that TSCL and other health partners could use patient groups such as Whipps Cross Patients Panel to test documents and information before they go out to patients and the wider public. Again it was reiterated by an attendee that ‘putting things in plain English is vital to ensuring they can be understood’.
It was noted by attendees that some of the people who are supposed to direct patients to services, don’t even know where to go, and further suggested that those providing signposting services must have good support systems to provide strong direction to patients accessing Out of Hours, urgent and unplanned care.
It was also suggested that a better system for directing people to services should be able to recognise where postcodes cross borough boundaries – the system must be sophisticated enough to recognise, for example, that some E7 postcodes are also part of Waltham Forest and therefore patients should be directed to their nearest appropriate service, not one associated with another borough that accounts for the majority E7 postcode.
In general workshop attendees were acutely aware of the need for patient education and awareness raising campaigns about what services were available and where and how to access them. Communicating with patients and the public in ways that they understand and can connect with was seen as vital. Educating children in particular was felt to be a useful avenue to explore.
It was noted by one attendee that Waltham Forest CCG together with Redbridge CCG were currently undertaking a joint procurement exercise for provision of urgent care services. The TSCL programme should connect in to this procurement. TSCL engagement report
Some attendees asked what the difference is between urgent care and walk in centres.
Social Services and Social Care
Social services and social care were highlighted by many as vital services, crucial to helping people avoid the need for unplanned urgent care. Attendees at one workshop spoke strongly about:
‘Care at home’ being unavailable Previous bad experiences and lengthy delays (up to 4 years) in receiving some basic provisions of social care A lady in a wheelchair almost injured herself whilst trying to vacuum the stairs from her stair lift as social services would not provide support.
It was suggested that full social support and back up services are needed for patients, especially around discharge and ensuring appropriate support is put in place at home from day one.
Workshop attendees clearly highlighted the vital connectivity of social care to unplanned health care. It was suggested that current work being pursued around integrated care is important and must be driven through more strongly, with interconnectivity, communication and onsite integration between health and social care professionals being paramount.
During this conversation it was also clearly noted that the thresholds and processes for acquiring social care and support are often inadequate and fail to meet what are deemed to be major needs to both patients and their families. It was reiterated that need is not being met by shortcomings in social care support.
GP
It was noted by several attendees that people use A&E and other urgent care services when they cannot access their GP. Attendees went on to query the role of the GP in the TSCL programme.
The use of GP triage at urgent care/ A&E was discussed positively, but it was felt there was a need to avoid people going straight to urgent care without attempting to see their GP first. The question of how this was would be avoided was raised. Some workshop attendees also highlighted concerns around GP locums being used at these services.
The ‘Big Front Door’ initiative was highlighted as being very positive (at the time of writing Healthwatch were not sure what this meant, potentially the triage system at the Urgent Care Centre at Newham University Hospital).
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As in other workshops, concern was also raised around the number of elderly GPs across east London.
Care Homes
It was noted by a workshop attendee that the highest group of ‘999’ users were the people who run care homes and that they are not trained specifically enough and use ‘999’ as their default position. They work under pressure and stress, are underfunded, and the care teams need help, support and education on appropriate use of urgent healthcare services.
Decision makers
It was felt that the patients need to engage more with their Councillors and the policy makers in the borough around health and social care needs.
Carers
The vital role and resource of unpaid carers was noted by several attendees, and it was felt specific reference needs to be made of them and where they fit into the TSCL programme.
IT and Equipment
It was noted by several attendees that technology needs to be used appropriately in health services going forward. The workshop highlighted that there is not one solution that fits all, and that whilst technology can and should be used to improve efficiency, access and choice, it should not result in the exclusion and isolation of others.
Attendees highlighted that there is currently no facility to take back health and social care equipment and aids in Waltham Forest. This was a common situation experienced by others present and there was strong feeling that a return/recycling service was needed.
Mental Health
It was noted that mental health is integral to all areas of the TSCL programme and that this needed to be clearer.
The quality of mental health services was questioned by some in the workshop who had heard from Doctors in Waltham Forest that they do not want to refer patients to the services because they are poor.
TSCL engagement report The approach to chronic care for those with mental health conditions in Newham was highlighted by attendees as needing improvement, as was the approach at A&E when people turn up in crisis.
It was also pointed out that deaf people with mental health conditions have to attend Springfield hospital as there is no support closer by.
Engagement and Involvement
People were keen to find out how their comments and opinions would be fed in and counted, and how they could be involved in making sure the changes proposed were in the right direction.
Centralisation
People were concerned about the possible centralisation of services as a result of this programme. They highlighted that appropriate investment in local hospitals was needed and could avoid the push to centralise. Travel was mentioned as a crucial factor for consideration in any service change and centralisation. Patients and the public present at the workshop expressed deep concern about travelling further and further to appointments and/or to receive hospital treatment.
Pharmacy
As came up in other workshops, the vital role of community pharmacists was also noted in this session, and their contribution to unplanned and urgent care was discussed. It was felt by attendees that their role should be fully explored, and that they should be fully involved in the TSLC programme.
Raising awareness of the pharmacy role amongst patients was highlighted as an area for development.
Other services and conditions
One attendee was keen to know what the programme was looking to do around blood testing and scanning services.
Another attendee expressed an interest in rehabilitation services, which also linked back to earlier discussion about the vital role of social support in preventing unplanned care needs arising.
An attendee noted that they were not clear how neurological services fitted into the TSCL programme, and went on to highlight a big impact on unplanned care services, for
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Several attendees noted the specific needs of those with learning disabilities and other disabilities. When dealing with this client group the time taken in consultation, and the approach by staff was highlighted as two examples that needed to be considered by the TSLC programme.
6. Comment Cards within the Delegate Packs
Throughout the event attendees were encouraged to use comment cards to note down any queries, questions or concerns they might have about TSCL. The following is a list of those relevant comments:
What are you doing about waiting times at GPs for Mental Health service users
How are you going to address GPs not being confident to refer Mental Health community services, regarding a recent ITV News report?
How is patient choice going to work for Mental Health service users?
Patient choice came in on 1st April 2014 but mental health service users are largely unaware of patient choice.
There is a lack of GP continuity of care
What opportunities will there be for entrusted parties such as Whipps Cross Patients Panel, or Walthamstow Watch to participate in decision making when it comes to decisions about reorganising services?
TB is on the increase in Newham. What is being done to monitor, immunise and treat cases?
Some would have liked a workshop around partnership working across all sectors – perhaps in future events this could be covered. Also – an assurance that the voluntary/community sector organisations are fully involved in transforming services going forwards.
The CCG (board members) are paid employees and do not represent the views of GPs. How are you going to involve GPs? Have you contacted the Local Medical Committees (LMC) and their statutory representatives? Will there be proper consultation?
There is a chronically bad blood-testing service in Waltham Forest. Over two and a half hours for a simple blood test.
Self care: we need to promote planned care via the pharmacy. It should be the first port of call to access a health professional as no appointment is needed. In relation long-term conditions (LTC) pharmacy can help, also with compliance of medication. TSCL engagement report
What is the future of A&E at King George?
How do Redbridge, Barking & Dagenham fit into the TSCL picture? What are the statistics and population data for those boroughs?
What will happen to the London Chest Hospital if services that are now being offered there are to be transferred to Barts?
‘Everyone has a responsibility for good health.’ Air pollution in this part of east London is at least two times the EU permitted maximum. Instead of doing something about this significant contributor to the local higher than average mortality rate, the efforts of the Mayor of London and his staff seem to be focused on hiding the true situation from EU monitors and the local population. Without a significant improvement in the quality of air we breathe, any transformation of services will be fighting a losing battle. What can we do? How do King George and Queens Hospital look into this?
Wellbeing and access to therapy services for adults with complex needs are required. Management of life-long chronic conditions was queried.
There are increasing numbers of people developing dementia.
There is population growth and the challenge of caring for increasingly diverse populations with specific health needs such as the haemoglobin
What plans are there to overhaul IT on wards?
The IT systems in community nursing are not fit for purpose and need addressing.
If change is to bring us a world class service, then services should be sustainable and maintained indefinitely. Therefore what plans will be in place to look at future and changing needs?
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Acknowledgements and further contacts
Note takers: Charlie Ladyman, Darren Morgan, Sol Pearch, Caroline Tomes, Cathy Turland and Jaime Walsh.
Many thanks for the energy and efforts of the Healthwatch volunteers, without whom the evening would not have been possible: Olu Adejimola, Nirmala Khagram and Caroline Tomes.
Thanks also to the panel speakers, workshop facilitators and TSCL programme staff.
And on behalf of the organisers – thank you to all the residents who attended, participated and gave their feedback.
If you have any queries on this report please email [email protected] or call 020 7473 9512
If you have and queries on the TSCL programme please email [email protected] or telephone 0203 688 1678
Healthwatch contact details
Healthwatch Newham [email protected] Manager: Charlotte Ladyman 020 7473 9512 Healthwatch Redbridge [email protected] Chief Executive Officer: Cathy Turland 020 8553 1236 Healthwatch Waltham Forest [email protected] Manager: Jaime Walsh 020 3078 9990
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