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Don't believe CCGs can't achieve

Forget the negativity - our CCG has transformed mental health services, says Dr John Orchard.

We have heard so much negativity from all corners of the profession towards Clinical Commissioning Groups it is time to redress the balance. Here in Hardwick CCG in Derbyshire, the most underfunded CCG in the most underfunded CCG cluster, we have plenty to smile about.

Firstly, we have brought together enthusiastic creative health professionals with a can do approach keen to share ideas that improve patient care.

Second, we have a fantastic lean management team who share our goals.

Third, our local trusts have all undergone an epiphany and now see our views as important.

What  we can clearly see is a major opportunity to move our patients from their perennial position as the lost tribes of Derbyshire to the first beneficiaries of the new Health and Social Care Bill.

So what has really changed?

A) Mental Health Services

Hardwick CCG is lead commissioner for Mental Health in Derbyshire. In the past twelve months we have re- configured the commissioning process to put the Clinical Reference Group at the centre of all reforms. Previously, the CRG was a poorly attended group, occassionally asked to rubber stamp trust decisions with one general practice representative.

Now we chair this group, have GP representatives from each Derbyshire CCG and include consultant from psychiatry, psychotherapy , public health and substance abuse. Trust management is only invited for specific items.

Substance abuse is now provided by the Mental Health Trust increasing the treatment of so called " dual-diagnosis". Such patients previously were treated by neither psychiatry or substance abuse. In addition, we have increased community substance abuse clinics from six to fifteen. 

Psychodynamic psychotherapy was a major bone of contention with a long waiting list of direct GP referrals in the south of the county and no service in the north. There was no demographic or pathological differences between the populations, nor significant differences in criminal behavior or substance abuse.

What was this expensive service doing? Apparently, seeing the same people, regularly, for up to five years. Surely, this is general practice? Extensive public consultations followed, along with constructive meeting with therapists. The result is service re-design with the following aims:

  1. Early assessment of each individual patient who reaches Tier 4 (having needs not met by IAPT) by a psychotherapist who can signpost them to the therapy most likely to help.
    Many patients complained of receiving years of inappropriate therapy.
  2. A commitment to step down services to return patients to Primary Care as the goal of therapy. This is to be underpinned by a pathway allowing stepped down patients to return to secondary care rapidly in the event of relapse.
  3. Equity of access to all modalities of therapy across the county.
    Moving therapists to the patients rather than a post code lottery

This has been a painful learning exercise. Chinese whispers led patients and therapists to believe the intention was to cease the services as a cost cutting measure. Strikes were mooted and patient consultation sessions initially acrimonious. The listening exercise has been well worthwhile, resulting in new energy and focus for all parties.

 

B) Care Home Services

Hardwick CCG is lead commissioner for Care Homes in Derbyshire. Within our CCG a group of practices undertook a funded project to revamp Care Home service provision.

Based on the work in Sheffield, which used a geriatrician, the group identified one GP who had the Diploma of Care for the Elderly as a clinical lead. He carried out initial assessments on all 221 care home residents including medication reviews right care plans (End of Life) and Dnar forms.

This was followed by significant change:

  1. All residents of one Care Home were registered with one practice only
  2. Each practice identified one named GP to be responsible for that Care Home
  3. The named GP would visit the allocated home at the same agreed time each week
  4. Only visits for life threatening emergencies were to be requested at any other time

The result was a saving of £107,000 on non elective admissions in the first year. Backfill for the initial assessment cost £57,000 which means we anticipate ongoing annual savings of £50,000 per year.

The real benefits are for the Care Home staff who now feel empowered and supported. Relatives who initially were concerned at loss of their familiar GP are delighted by the increased attention given to their loved ones. Relationships enable GPs and staff to identify training needs and address them together, for instance use of syringe drivers in End of Life situations. Of course, GPs benefit from massive reductions in trivial visits as Care Home staff have confidence in dealing with their clientele.

Refinements have been developed:

  1. Use of a standardized care plan based on the district nurse proforma,has resulted in standardized record keeping. 
  2. All the practices in the CCG have agreed to exchange patients to achieve one practice per home across the entire CCG
  3. Neighboring CCGs in Derbyshire are adopting the scheme.

 

C) The Virtual Ward Scheme

As previously discussed this scheme proactively manages in patients and patients at risk of admission. The key extra staff member, the Care Co-ordinator, has been funded for each practice in the CCG for the year 2012 - 2013. This will extend the scheme to all patients and crucially facilitate cross border working.

 

D) Cross Border Working

Hardwick CCG is lead commissioner for the Derbyshire practices contract with Sherwood Forest Hospitals Trust, Mansfield. This group of hospitals have recently undergone major refurbishment and reorganisation coupled with new inspired imaginative consultants.

They have developed a new pathway for urgent care for patients presenting at Accident and Emergency. All admissions are triaged by a senior clinician within an hour of arrival and were possible returned to Primary Care. This is facilitated by a private company employing care assistants who will take frail elderly patients, who would have been admitted for social reasons, home by car and visit them several times over the next 48 hours to ensure safety before Nottinghamshire Social Services take over care again. This avoids a) unnecessary admissions and b) loss of continuity of social care.

However, at the time of writing, Derbyshire Social Services are not engaged in this scheme meaning many unnecessary social admissions. High level discussions between hospital Chief Executives and commissioners have identified the need for an urgent care conference involving social services and Primary Care commissioners from Derbyshire and Nottinghamshire. Both sides perceive considerable gains.

Derbyshire is keen to implement the urgent care pathway as it links perfectly with our virtual ward scheme and the Trust would like GPs in Notttinghamshire to implement Virtual Wards across all their practices to maximize the effectiveness of the Urgent Care Pathway.

Further developments have been discussed:

  1. Community based geriatricians to support Virtual Wards
  2. Practice based Teach and Treat clinics run by hospital consultants to deal with poorly controlled patients with long term conditions such as Diabetes and COPD
  3. Improved access to diagnostic facilities for GPs at the Sherwood Forest Hospitals

This is a fantastic opportunity for commissioning where our previous preferred providers have been reluctant to embrace change and our patients not inconvenienced by change of provider. Indeed the driver for these discussions has been the increased attendances at the Accident and Emergency department in Nottinghamshire by Derbyshire patients.

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