How we are integrating care
Dr Sam Everington talks about how GPs in Tower Hamlets have managed to span the gaps between primary and secondary care, and between the NHS and the local authority
Data is quite critical to any form of integration. In Tower Hamlets, there was a clear agreement among all GPs that they were going to openly share information. We set up a clinical effectiveness group that was led by three very senior and respected GPs in the local area. They collect all the information and feed it back to us and create guidelines, so it's very clinically focused. As a result, all practices in Tower Hamlets now use one computer system. That wasn't the case a few years ago, but we absolutely put it as a top priority. We really encouraged the PCT to invest heavily in all GPs using the same system, which also means the community nursing team are able to use the same system too.
Engaging with public health
In a deprived area like ours, there is a very clear understanding among GPs that if you're really going to improve outcomes, you have got to go way beyond the biomedical model.
Our health centre provides traditional healthcare, but is also about people's environment, their employment and their education. There is clear evidence that if you improve people's education, you'll improve their health, and it's clear that if you get people a job they will be much healthier.
Part of the work I've been doing over the past three years has been around the fit note, which is driven by a Government that feels there are people on incapacity benefit who shouldn't be – but also clinically by the idea that if you get into long-term unemployment, that in turn causes physical and mental ill-health. The idea is to do something across the board to encourage a process of getting back to work rather than signing somebody off sick.
There are problems, namely that there's not a computerised version – which is massively frustrating. If there was, you could audit it, search on it and much more actively manage people who are off sick in terms of getting them back to work.
Integrating with local authorities
The local authority holds a lot of the keys to health in the community. I recently had a meeting with the local authority about developing the local health and wellbeing board. It should be a joint project with equal scrutiny on both sides. We developed balanced scorecards for primary care, but one of our ideas is to create a balanced scorecard for schools. Why not ask how many immunisation books are checked before school entrance? How many children by the age of seven are having regular swimming classes? How often do lunch boxes get checked?
We're not asking them to set up outpatient departments in schools, but Dr Michael Marmot's research1 shows the impact social determinants have on the health of a child at a very early stage. Because of our integrated approach, our immunisation rate is now the highest in London. But the next step is schools asking for a copy of the immunisation record when they take someone on at the age of five. Reducing the infection spread within schools is critical and comes back to this integrated approach.
Networking GP practices together
We have got all GPs working as part of networks – so for example in diabetes care, a geographical group of practices will get 70% up-front funding for diabetes and 30% further funding depending on the outcomes of all those practices as a collective. That's quite a stimulus, but clinically, what's behind that is recognition that – in the example of diabetes care – you put patients on drugs and insulin, but their exercise, diet and lifestyle generally is absolutely critical. If you're to deal with that, you need to be doing something in a much wider area. There are 25 practices in Tower Hamlets, and there are eight networks. They have a board meeting every month and are constantly talking about clinical and financial issues, and how they can provide much more integrated care for patients.
One of the things the PCT did was ask the very basic question of what resource we needed to put into primary care. Most PCTs don't do that, even though they're shifting all this stuff out of hospitals.
Once they started doing that, so many more things became possible. The investment in public health from Tower Hamlets has been much higher as a result.
This has brought all sorts of practical things on the ground like health trainers, who you can refer to for any lifestyle advice. Sometimes health trainers sit in practices, but they work across geographical areas – a network.
Using data to drive change
Within a network, GPs will see the data based on the practice in that network. We can go down to the doctor level on some things too, so there's an absolute transparency. It requires a lot of trust initially because it's quite nerve-wracking to sit in a meeting and see that you're the worst antibiotic prescriber, for example. But it's led by GPs. That creates a massive level of trust – otherwise, there's a very real risk it's seen as just a stick. It's not about that, it's about creating information so people can change to become more evidence-based in their practice.
With the best will in the world, as a GP in the most deprived area you are going to have lower cervical screen rates and things like that. One of the advantages of this is you have an opportunity to say why.
Putting a new care package inplace for diabetes
A consultancy came in and said diabetes care in Tower Hamlets was awful. But what our data showed was that we were way ahead in terms of blood pressure and cholesterol, so the message went back that they needed to be more sophisticated about their analysis.
The consultancy came back and said: ‘You're right. What else do we need to do?' Out of that came the diabetes care package. There developed an understanding that it needed a much broader approach to sorting out diabetes as opposed to the sense that somehow it was going to be delivered just in primary care.
We started by identifying a group of patients who needed much more active management for a short period of time. We decided to give a care package for everyone and also define patients at risk that might need something extra. Part of this is integration with the acute sector. We call it ‘Tazzing' after the diabetologist Dr Taz Chowdhury. He is fantastic.
It's about taking a population approach. Dr Chowdhury came round to the fact that he wasn't there just to sit in outpatients and deal with referrals, and that fundamentally his responsibility was to every diabetic patient in Tower Hamlets.
He is on a mobile phone so we can ring him any time we like and he goes round all the practices and does training sessions with GPs and nurses. He will sit and talk through complex cases with you, which is a great help.
Tackling urgent care
Part of the integration we really need to happen is in urgent care. I now chair an urgent care board with a consultant in casualty. We manage urgent primary care from our GP out-of-hours service, urgent primary care in casualty and then our three walk-in-centres. So we're managing the whole of urgent care in a far more integrated way. We are also going to do that in elderly care. It's very successful in terms of creating good relationships across the sector. You will not control the costs unless you are working closely together. Our local hospital is absolutely signed up to working with us. We recognise it's in both of our interests to have a stable health economy.
Building relationships with acute providers
So many of these things come down to relationship building. There is more and more effort to get GPs and consultants talking. We've got about 25 clinical leads, so we employ GPs to be clinical leads in certain areas. I'm in urgent care, we've got another GP in elderly care, one in palliative care, one in drug prescribing and so on. That creates leadership among GPs and expertise that is used in terms of relationships with the acute sector and ensuring agreement around clinical pathways, or in helping the commissioning process.
As urgent care lead I am on the provider side, but also I go back to the commissioning side and negotiate changes. It creates a level of expertise in primary care. So in most areas I know who we go to for advice on the primary care side on a commissioning decision.
Dr Sam Everington is chair of NHS Tower Hamlets CCG and a GP in Bromley by Bow, east London
1 The Marmot Review, 2010. http://www.marmotreview.org