Primary and Community Care Strategy:
Key Themes for Nursing and AHP Conference

Workshop Feedback

Over 150 nurses and AHPs attended a DH event to seek clinical views on the emerging Primary and Community Care Strategy (PCCS) on 15th May 08. Key themes are summarised below. These were identified several times across all workshop topics as critical to successful PCCS.

A separate paper sets out specific examples of current good practice and will be posted on this website shortly.

These key themes have been passed to the policy leads for the PCCS. These themes will be particularly helpful in the ‘Transforming Community Services’ Programme Board which has just begun a 1 year programme.

What works well? (also paper on good practice examples)

Staff

• Staff are committed to improving patient care
• Well developed workforce committed to delivery of the care pathway(s)
• Patient being integral to “the team”
• Working with a team who know the individual [patient] is essential
• Joint Roles/Secondments/students placements across organisations (SW students/GO registrars
• Joint CEOs (PCTs and LAs)
• Liaison professionals (between hospital and community care including for vulnerable groups)

Patients/Service Users and Carers

• Clinical/patient relationship i.e. trust, personal knowledge/continuity & consistency, respect, dignity
• Support provided by team of skilled & competent staff who respond [promptly] when contacted.
• Acting on feedback from carers
• Clarity with carers eg with projects/engagement be clear what advice/input is required to ensure appropriate input is accessed.
• Use carer input throughout care pathway
• Case Managers for LTC
• Rapid Response + Assertive Outreach in MH
• The ability to deal with what presents (even when pushing the clinical boundaries)

‘Enablers’ of effective working

• Good clinical leadership
• Develop leadership skills within the clinical teams – at all levels
• Benefits of shared learning to personalise care + understand patient needs
• Effective IT –
• Co-location, if not possible need to share information
• Section 31 – pooled budgets
• Accessibility – e-consultation- proactive telephone calls
• Understanding each others cultural needs and work parameters
• Not too many specialist teams – generic practitioners who are well skilled being mindful that competence must maintained knowledge of care pathway + which competencies are required at each point
• Joint strategic needs assessment that is meaningful & owned by commissioners & patients
• Incentives: need to have robust KSF framework that is consistently applied, positive reinforcement
• Individual team contracts – taking ownership
• Definition of roles, responsibilities and outcomes
• Time to be pro-active and plan
• Clinical input to commissioning body

Challenges to effective working

Staff

• Time – for reflection
• Time/evidence/research to develop solutions which are sustainable
• Culture change – ‘can do’
• Need for more entrepreneurialism – ‘Commercial Savvy’/ ‘Proactive business minds’
• Do we have the capacity to make change happen?
• Capacity – difficult for some professions (AHPs especially) to be released for development, participation in redesign etc
• Feeling need to ‘wait for permission’

Commissioning and Business Issues

• How to get frontline intelligence fed to commissioners
• Effective user involvement
• Commissioners need to have stronger relationship with provider
• Commissioners need to support strategy in action
• Commissioners want to see an effect on the whole population achieved in 12 months, this is not often possible.
• ‘We] don’t have ‘quality commissioners’
• Mixed messages from commissioners
• No agreed terms of engagement
• ‘Power’ struggles need to balance power i.e. acute/community balance, inter professional balance
• Less fear of destabilising acute providers (FTs) from moving services out of acute into community services

Service/Public issues

• Transition – CYP to adults equipment /healthcare
• Fragmentation of service delivery i.e. hospital/service responsible to one part of care and another responsible for another
• [What about] those who don’t want to be empowered? These could be at risk of being missed and must not be labelled or disadvantaged because of this.
• Fit for purpose facilities/ Estates – [lots of frustration around this]

Performance/Information/IT

• Communication (IT/Clinical systems/Public Health)
• Knowledge management
• Mechanism to monitor …but ‘not an industry in itself and not to stifle innovation’
• How do we get better at measuring outcomes?
• Better information systems
• No real autotomy to compete with other agencies

Would should happen in the future

National/strategic development/enablers

• Strategy – should not be top down, [presumptive] but have clarity and enable local services to develop solutions/“Greater Autonomy” don’t tell us how to do it
• Complexity is vast need multi industry approach (diet supermarkets etc)
• Need for ‘going global’ – learning from other businesses + how they approach/solve these issues eg serving diverse population/communities/public
• Making criteria (eg social care)more flexible – remove boundaries between health and social care need to address charging issues
• Higher level integration eg at DH level not just at team level/ Integration at senior level
• Integration at senior level to develop joined up approach – shared vision + values
• Improved integrated systems as well as care
• Better communication (two way) with Dept of Health
• Multi-professional approach to client care not just medical model
• National Based outcomes (against evidence based practice)
• Deal with perverse incentives
• Should be “health & community care records” i.e. joint/shared
• Primary/community provider communication network across UK to share good practice
• More local control/authority of budgets/info/performance

Commissioning improvement

Clinical (and other stakeholder engagement)

• Framework of collaboration bet commissioners & providers
• Meaningful engagement with commissioning for community services
• Better engagement of commissioners with provider services eg. Commissioners visiting/ discussion with clinicians

Clinical Leadership

• ‘Matron’ commissioners – i.e. clinicians with experience + skills
• Maturity of commissioners to respect clinicians ideas & solutions
• Capacity, skilled commissioners, commissioners with a clinical background
• Clinical advisors- secondments units commissioning
• Commissioning plans should demonstrate that they have included clinicians (This is a way of recognising involvement)
• Funding mechanisms – not being consulted in multi-professional way
• Clinicians take off “patient experience to the commissioned” that to make culture shifts on the ground

Improvements in commissioning process

• Commissioning needs to develop an understanding & skill to commission community services effectively
• Commissioning for an outcome and engaging key stakeholders in designing the pathway to go out to tender
• National model contract for CHS
• Implement LEAN thinking + “productive” services may need a primary care contract on which to model core services
• Commission on wellbeing model not medical model
• Multi Agency pathway from beginning
• Joint targets - social care – same community
• Commission across pathways aligned to Darzi areas (not from individual profession) – needs leadership each bidding for parts
• Incentives – what form – additional funds – individual or team for funds to go back into services
• Measure outcomes for communities not professions
• Extend PROMS (patient reported outcome measure) & PEMS (patient expect measures)
• Funding needs to be available especially on local level for innovations that can improve quality of client care and rapid access to funding
• Tariffs – need to reflect activity
• Ensure the development of metrics includes the quality of delivery of services for older people
• Commissioning tool kit for commissioning services for people with Learning Disability/ Tool kit for commissioning general H.C for people with LD

Practice [Population] Based Commissioning
Question – Why should we belief you in that PBC’s will have to engage with clinicians other than GP’s? (Sic)

• PBC to really be population based commissioning
• How do we measure outcomes?
• Make PBC more multi-agency/professional not inwardly focused
• PBC ‘bids’ All bids should demonstrate Public engagement, Health inequality, Quality, outcomes, resources utilisation
• Improve scrutiny of PBC/ Look at competencies of PBCS
• Improve demonstration of ‘plurality’
• Provider: commissioner vision for PBC
• More skills to develop service proposals to PBC’s + PCTs
• Commissioning for outcomes not details & desist from dictating detail
• PBC pushed towards time multi professional commissioning (population based)

Professional/workforce/staff development

Culture

• Change mindset of clinicians by using change agents /enablers
• Involvement of practitioners to identify solutions and develop
• Boosting confidence in staff to celebrate and share their good practice innovations
• Change mind set staff to recognise importance of health promotion/ change of cultural attitude – need to change from just giving care –to encompass prevention
• Change staff mindset to focus on outcomes.
• Customer services training
• Sustain respect dignity + choice

Roles/Scope of Practice

• Self-referrals – professional screening referrals making expert decisions/signposting to appropriate services
• Promoting more non-medical Consultant posts eg AHP, Nurse Consultants with joint appointments across health, social and local authorities

Education

• Reinvestment in Health Visiting Education pre & post registration & re-motivation of these Professionals who were once equipped to be able to deliver the goals of world class commissioning.
• Offering opportunities for community experiences eg Junior staff
• Extending skills – eg AHP’s prescribing skills

Public/client groups issues

Public engagement

• General public – how they want to shape services? Need to develop ‘can do mentality’ and supported self care/ Enabling the population to take greater responsibility for own well-being & health management
• Finding ways to reach the hard to reach with what they need not what we think they need
• Challenge public perception and own staff that NHS=Hospitals
• Public centred approach/user involvement at board level

Services for specific groups

• Roll out Health “passport” for vulnerable groups going into hospital i.e. a document that express the needs of the person, that they have contributed to, that is in clear concise format that is clearly accessible to all staff involved in the persons care.
• Transition (life ages and stages) needs more focus and quality improvement
• Healthy schools agenda – more assurance + accountability to outcomes information to make it adequate
• LD should remain e PCT (move to PCT) not sit within MH
• Early identification of people at risk & assisting them to access the right services
• Engagement with other sectors for delivery of older people services eg Voluntary organisations (formalised partnership)
• Re-invest/Re-focus on the preventative approach to rehabilitation
• Health promotion to non-english speaking clients

Provider/service issues

• Community development approach led by nursing team
• Flexibility in services 7 day week services from multi-professional competence based teams
• Public health support to provider services key as PCT divide.
• Developed services enabling self-referral eg Muscles- skeletal at level 1
• Self-referral/direct access central to changing some pathways eg musculo skeletal
• Allow us to innovative “change & innovate”
• Broadening scope of provision eg. Into target areas
• Ensure approaches for service developments are smoother and timely when putting bids forward (eg LDP bids)
• Integrated teams eg AHP, Nursing, Social Services particularly for LTC’s eg complex case team

Information and IT improvement

• Greater increase in the development of Information Services and data – Robust IT systems
• Need data robust systems to show quantity and activity – not in place yet
• Single point of access – eg telephone numbers
• Using technology better Assistive technology

Information sharing.

• Access to IT systems that talk to each other/IT – record sharing
• If unable to co-locate – IT sharing even more important.
• Shared records – electronic – extend to clients
• Safe systems – maintain confidentiality

Quality

National

• Standardised outcome measures
• Some national makers eg stroke
• Quality indicators designed for community services – some difficult to measure:

Commissioning

• Commissioning – assurance from provider that quality in place
• Commission services that is based on: “3 C’s”
• Continuity/consistency
• Confidence
• Courtesy
• Commissioners need to commission re evidence, but not always on random control etc. So look at research methodologies
• Value a range of different types of evidence

General

• Learn from other areas eg. Sure start/social care
• Longer-term outcomes - not good at measuring longitudinal outcomes eg several years down line
• Incentivise- Ability to sanction or reward – must follow through
• Need to reconsider needs of service users & competencies needed in community, do gap analysis, - PH look at what is required for future population
• Need to influence Pre& post registration Education, pre registration students need to be exposed to community
• Need to find clinical placements
• Workforce issue is SIGNIFICANT

Staff

• Clinical Supervision/quality assurance of clinician,
• Need to evidence change of practice which is reflected in better clinical outcomes –
• Measuring quality is difficult - need research-based tools – comparative measures, validated tools
• Ownership + accountability at Director level