How we’re improving health services in west Hertfordshire
We are bringing care closer to home where we can, helping people stay healthy and making it easier for people to use our services.
Our main programmes of work are:
- Adult services
- Children, young people and maternity services
- Mental health
- Primary care development
Further details are available in the full Annual Report and Accounts.
During 2017/18 we successfully returned the CCG to a stable and sustainable financial position. We started 2017/18 needing to make £38m of savings (4.5 per cent of our total spending) to end the year with a balanced budget.
Actions to return the CCG to financial balance included stopping discretionary spending and reducing spending on some products and treatments with limited clinical value. We have made some difficult decisions to make sure we can continue to resource areas of most pressing need. Savings measures are described more fully on pages 26 and 27 of the annual report.
The CCG met all its financial targets for 2018/19. Specifically we
- achieved our target surplus
- operated within our running cost limit
- met our cash targets
- operated within our capital limits
- met the requirement to pay our suppliers (of health and non-health services) promptly
Strengthening the organisation
Following an external review and listening to feedback from stakeholders we have taken action to strengthen our leadership, internal processes and governance to put the CCG in better shape to move forward. Improvement actions have included:
- Strengthening our finance, business intelligence and contracts functions
- Tighter governance arrangements including establishing a finance and performance committee
- Strengthening our workforce through training and development for senior managers and improving staff appraisals.
Services for adults
This covers a wide range of services from planned operations and outpatient appointments, to treatment for long term conditions such as diabetes or respiratory disease, support for older people to help them stay well and remain independent, dementia support and end of life care. It includes continuing healthcare (for when people come out of hospital but still need support) urgent care services such as A&E, ambulance services, NHS 111, and urgent care centres.
This year we have:
- Improved support for people with diabetes
- Reviewed more than 800 people with very high blood pressure and offered them support from a specialist pharmacist
- Continued to increase numbers of people diagnosed with the respiratory disease chronic obstructive pulmonary disease (COPD) who are getting support
- Set up a Breatheasy group to help people manage respiratory conditions
- Reduced the number of strokes in people with atrial fibrillation (AF).
In 2018/19 we will:
- Improve support further for people living with diabetes, blood pressure, lung conditions and cardiovascular disease
- Offer better services for people with long term conditions to help them manage their physical and mental health
- Improve referrals and access to care for people with breathing problems
- Improve the blood pressure monitoring service for patients with high blood pressure
- Focus on people with heart failure to make sure that their condition is well managed.
Medicines optimisation is about working in partnership with patients, doctors, nurses and other health professionals to access the best possible health outcomes from medicines.
This year we have:
- Worked with GPs and pharmacists to ensure medicine waste is reduced, prescribing is cost effective and good systems are in place for repeat prescriptions
- Commissioned clinical pharmacists to visit frail older people at home who are having problems with their medicines and support them to take their medicines safely and avoid waste
- Reduced inappropriate use of antibiotics as part of a drive across England to reduce the development of resistance.
In 2018/19 we will:
- Ensure people are on the most effective drugs which represent value for money, particularly focusing on pain killers and inhalers
- Ensure that patients with rheumatoid arthritis, inflammatory bowel disease and psoriasis receive the best possible treatment
- Provide pharmacists to help ensure that medicines are used safely and effectively in nursing homes
- Support patients to make best use of medicines and involve them in decisions about their medicines
- Continue to work alongside our hospitals and neighbouring CCGs on medicines through our South East London Area Prescribing Committee
- Continue our work to reduce medicines waste and making sure that health professionals know which medicines a person should be taking when they move from a care setting, for instance from hospital to home
Planned care describes those services and treatments which are not carried out in an emergency, for instance operations and care which patients are referred for by their GP.
Once patients have been referred for treatment we want to join up the different services they need so that their treatment is well coordinated.
We also want to make sure that people have the same good experience of receiving care and receive the same level of service, wherever they live in west Hertfordshire.
We are developing new community-based services that reflect our Your Care, Your Future ambitions to provide coordinated care closer to home - preventing people from having to go into hospital unnecessarily.
Providers, patients and others have been involved in work to redesign services that reflects all of these aims.
Here we outline just a few examples of these new-style services that we have been developing in the last year.
Our newly launched integrated diabetes service means that patients now have most of their treatment in their local community rather than in hospital and care is better coordinated. West Hertfordshire Hospital NHS Trust (WHHT) is the lead provider for the service, working with community, mental health and GP services.
An enhanced community-based gynaecology service for patients aged 16 years upwards started on 1 April 2018. Patients have appointments and receive care in locality hubs rather than in hospital. If patients need secondary care, including surgery, they can chose which hospital they go to.
Coordination between health and social care provides makes sure that patients moving from hospital stroke units have smooth handovers to specialist community teams to continue their care and rehabilitation. As a result many people spend less time in hospital after a stroke. The average length of stay in Watford General Hospital following a full stroke reduced from 19 days in 2015/16 to 15 days in 2017/18.
West Hertfordshire Hospitals Trust and the specialist neurological and stroke rehabilitation unit at Langley House in Watford are ‘A’ rated based on national measures.
During 2017/18 we have worked with providers to ensure that heart failure patients quickly get tests, advice and guidance within the community. This reduces admissions to hospital or reduces the length of stay if patients are dmitted.
New referral hubs provide a single point of access for patients to see the right specialist as soon as possible. This replaces the testing service, previously provided by Concordia, which we decommissioned in 2017 due to concerns with the quality of the service. Local hospitals are now seeing this group of patients.
Community, musculoskeletal (MSK), pain and postural stability
In January 2018 we launched a new comprehensive community service for patients with musculoskeletal (MSK), rheumatology and pain-related conditions and people who are at risk of falls. The single service provided by Connect Physical Health replaces a number of smaller contracts.
Over 6000 patients have been transferred to the service from the previous main provider, Hertfordshire Community Trust. The service has a range of specialists on hand and means patients can be seen more quickly – which avoids their condition worsening and increases their chance of making a full recovery.
More information be found at www.hertsvalleys.connecthealth.co.uk
Older and frail people
We commission services that help people to stay at home and remain independent when they are unwell, and joining up services in the community supporting someone returning home from hospital. We do this by helping older people avoid falls, treating infections straight away, and supporting people to lead a healthy lifestyle.
We are working with Hertfordshire County Council through the Better Care Fund to join up health and social care services. The Better Care Fund is a national programme to improve the lives of some of the most vulnerable people in our society, placing them at the centre of their care and support, and providing them with fully integrated health and social care.
This year we have:
Community nursing and therapy services
In 2017 we introduced new integrated care teams to provide comprehensive home support for over 65s. The service, which replaced ‘rapid response and linked community services, is focused on preventing hospital admissions, helping patients to be discharged from hospital with the right support and supporting people with complex needs or long term conditions.
Services are coordinated through a centralised hub that supports all four localities and helps contact between GPs, practice teams, care home teams and patients.
- Developed initiatives that help older people remain independent at home, managing their health - this has reduced admissions to hospitals and care homes
- Changed local health and social care to support more community based care - for example, the @home health and social care service provides intensive medical support for a short period of time in a patient’s home, helping patients avoid going to hospital or to return home sooner with extra support
- Reduced the number of emergency admissions
- Reduced the number of older people being admitted to long term residential care by providing alternatives that support independence, such as extra care flats
- Increased the dementia diagnosis rate to 85 per cent, one of the highest diagnosis rates in London
- Agreed health and social care support for patients leaving hospital, helping them regain independence and continue to live at home.
In 2018/19 we will:
- Develop a service for people with disabilities and those who are frail or recovering from illness or injury to help them relearn the skills needed to keep them safe and independent at home
- Continue to develop and deliver effective Enhanced Rapid Response and @home services which provide short-term support and rehabilitation in the home
- Commission a range of new health and social care services to support people with dementia and their families and carers
- Improve the assessment and review process of continuing healthcare. Continuing healthcare is a package of care that is arranged and funded solely by the NHS for individuals who are not in hospital and have been assessed as having a ‘primary health need’. We will also make sure we have the right level of support in place for people with continuing healthcare needs at a price which represents value for money
- Help more people benefit from the new version of the Coordinate My Care (CMC) register which is an electronic record that can be accessed by a patient’s GP, community nurses, hospital team, nout of hours doctors, specialist nurses, London Ambulance Service and NHS 111.
Urgent care services support patients with non-life threatening health problems or injuries who need to be seen by a doctor or nurse straight away. This includes urgent care or treatment centres, minor injuries unit, NHS111 and GP out-of-hours services.
The urgent care programme works with GP services, mental health, hospitals and ambulance services to ensure patients can access urgent care services appropriately
In June 2017 we launched an improved Hertfordshire 111 service that provides a ‘front door’ into urgent care services for most patients. Healthcare advisors who take calls are supported by a clinical assessment team including GPs, nurses, dentists, prescribing pharmacists, paramedics and mental health professionals. This makes sure patients quickly get the right help and can speak to a professional if needed.
In December 2017 the urgent care centre at Hemel Hempstead became an urgent treatment centre as part of a national roll-out. In addition to all the services previously available, the UTC offers patients booked appointments through NHS111 and on-site testing for some conditions such as sepsis and deep vein thrombosis.
In early 2018 we consulted on opening hours for the UTC. We concluded that low overnight demand and ongoing problems with GP shift cover made it impractical to reinstate a 24 hour service but that we would explore the possibility of extending hours from 10pm to midnight.
In 2018/19 we will:
- develop the UTC to provide tests for respiratory infections and anaemia and grow the professional team to include pharmacists and emergency care practitioners and with better links to mental health services and community nurses.
- develop urgent treatment approaches in other localities
- carry out a workforce review to look at how we make best use GPs’ and nurses’ time to support the various urgent care services.
Services for children, young people and maternity
Our children, young people and maternity programme provides services from pregnancy to 18 years old (up to 25 for young people with a disability). They include services provided both in hospital as well as in the community which are planned and bought to make sure:
- Children have the best start in life
- Children and young people are strong and have positive lifestyles and behaviours
- Children and young people achieve their ambitions and do well at school.
The children and maternity programme is made up of three overarching areas of work:
- Children and adolescents mental health services (CAMHS)
- Child health and early intervention services
- Maternity services.
This year we have:
- Talked to young people and community members to inform policy and developed an emotional and wellbeing strategy for CAMHS
- Invested money to reduce waiting times for CAMHS
- Commissioned a seven day a week highly flexible and responsive children’s nursing pilot, called Hospital@Home for children and young people with acute and short term conditions
- Improved communication with parents of young children through the Common Childhood Illnesses booklets distributed by health visitors to all families with a child between the ages of birth and five years
- Exceeded our target of 25 per cent take up for the enhanced vitamin D programme for pregnant women and children aged from birth to four years
- Achieved Stage 2 UNICEF Baby Friendly Initiative for Breastfeeding
- Improved support and services for children with asthma
- Continued to support the Lambeth Early Action Partnership (LEAP) programme to transform early years services
- Worked with King’s College Hospital NHS Foundation Trust to improve its community midwifery service. Improvements include women having a named midwife throughout their pregnancy, easy access to homebirth and the offer of specialist provision for all women with significant mental health problems.
In 2016/17 we will:
- Invest in training to improve the emotional health and wellbeing of children and young people
- Increase support for young people with eating disorders
- Ensure that children and young people with asthma are appropriately diagnosed and supported
- Provide an effective alternative
Adult mental health services support and treat people with mental ill health including depression, anxiety, and more serious mental health conditions. Many people with mental health problems also have long term physical health conditions. Mental health care can be provided by a GP, in the community, in a patient’s own home, or in a hospital.
This year we have:
- Changed the way we contract mental health services to improve services and personalised packages of care and support
- Reduced referrals to community mental health teams from an average of 120 per month in October 2014 to around 25 per month
- Improved waiting times with most people being seen within 10 days since September 2015 for non-urgent mental health support (the previous waiting time was at least a month and the aim is 48 hours)
- Improved the way we work with GP practices to provide support
In 2018/19 we will:
- Improve support from GP practices for people with mental health issues
- Work better with others to develop sufficient housing supply that can cater for the needs of individuals with mental health needs
- Improve access to talking therapies for people who have long term conditions as well as black and minority ethnic groups
- Achieve new NHS England waiting time targets for accessing talking therapies
- Develop a range of services to support people who experience mental health crisis
- Ensure that hospital mental health services help people recover faster so that less support is needed in hospital and more support is provided in the community
- Ensure that all patients with potential psychosis receive an assessment within two weeks of referral
Primary Care – GP services
From April 2017, NHSE England passed on responsibility to the CCG for planning, buying and monitoring GP services in west Hertfordshire. This means we are in charge of GP premises, overseeing performance and quality of general practice, making sure that patients have good access to GPs and keeping track of GP practices’ budgets.
We now have more control over developments in general practice and we are working with our practices to deliver national plans and proposals.
Increasing access to primary care
A key national priority is providing patients with increased access to appointments with GPs and nurses outside normal working hours on evenings and weekends. We are working with our four localities make sure that patients can book evening weekday appointments up to 8pm and xx at weekends.
GP practices are working together and are sharing resources so that patients can be seen at a practice within the locality or at an ‘extended access’ hub.
Watford and Three Rivers, one the national pilot sites, already offers extended access across all practices. The number of appointments and sites the service is delivered from will increase over 2018 to reach the national target of 100% coverage across the west Hertfordshire by October. This will also help alleviate pressure on our local acute trusts
Improving GP premises
2017 saw improvements to a number of GP premises.
- Manor Surgery and Attenborough Surgeries moved into new premises
- A refurbishment of Bennetts End surgery created a bigger treatment space for patients
- Improvements are underway at Carpenders Park, Parkwood Drive, Milton Surgery and Boxwell Surgeries in Berkhamstead, Lattimore and Village Surgery, Markyate and The Elms in Watford.
During 2018/19 we will progress work to relocate Haverfield Surgery in Kings Langley into new purpose built premises and to upgrade Chorleywood Surgery.
Milton Keynes health services in safeguarding and looked after children were inspected in August 2016 and revealed examples of good practice and strong multi-agency working.
This year we have led improvement work across partner agencies relating to fabricated and induced illness and will be developing a tool-kit for professionals.
We have reviewed cancer pathways to support Milton Keynes University Hospital NHS Foundation Trust achieve the national cancer targets. This review has led to the development of breast cancer rapid access and follow-up pathways and improvements to the urology pathway.