The main health challenges facing the communities across County Durham are linked to an increasingly ageing population that has significant and complex long-term conditions.
Some of our main priorities are listed below with an explanation of what we are doing to tackle some of these conditions.
Diabetes
Type 2 diabetes is largely lifestyle related as opposed to type 1 diabetes which is an autoimmune disease. The number of patients with type 2 diabetes is due to increase significantly in future years. The cost of diabetes to the NHS equates to 10% of the budget.
There are a number of complications that can arise from Type 2 diabetes that have a long term impact on health.
We need to focus on how we can prevent people developing diabetes and some of the complications that can arise from poorly controlled diabetes.
We spend a significant amount of funding on diabetes drugs and more than man of the other CCGs in the North East, There is a huge variance in spend between our GP practices. Spending more on drugs doesn’t translate into better outcomes for patients.
We want to focus on the following:
- Identifying those at risk of developing diabetes and working with them to prevent diabetes developing. We will do this by participating in the National Diabetes Prevention Programme.
- Identifying those that have developed diabetes an offering as many patients as possible education to enable them to manage their condition.
- Providing the best care for people with diabetes to ensure it is well controlled and that complications do not develop.
- Ensuring that our prescribing is as efficient and effective as possible to free up funding to spend on other areas of diabetes prevention and care
- Support out GPs and practice nurses to provide as much care as possible close to home for patients with support from local diabetes consultants and specialist nurses. Professionals will work together to provide seamless care across the whole pathway, with a focus on making best use of the funding available for diabetes care.
Cancer
We recognise that there’s a significant life expectancy gap between our localities and the national average and that cancer is a significant contributor to this. In our area we have higher than national average rates for smoking, including during pregnancy and there are significant inequality gaps with too many people being diagnosed at a late stage.
These are the things we know we need to get better at:
Early diagnosis
- Increase detection rates of stage 1 & 2 cancers (including better use of 2ww referrals)
- Improve cancer screening rates in hard to reach groups
Survivorship
- Increase survival rates of patients with a cancer diagnosis
Patient experience
- Improve the quality of life for people living with and beyond cancer
Cancer waiting time performance
- 2 week wait (from referral to 1st outpatient appointment)
- 62 days (from referral to 1st treatment)
What we are doing to improve things
Improvements to lung cancer pathway
- Abnormal chest x-ray – direct referral to CT scan
- Supporting optimal lung pathway implementation
Introducing cancer champions (community posts)
- Raising awareness of signs & symptoms
- Promoting uptake and breaking down barriers to cancer screening in hard to reach groups
- Increase the number of people seeking help with concerns
Introducing cancer navigators (secondary care posts)
- Coordination and streamlining of diagnostic imaging
- Additional focus on pressure areas of upper GI, lower GI and head & neck pathways
- Improved patient experience
- Improved communication between primary & secondary care
Working in partnership with Cancer Research UK
GP Practice visits to support:
- Strategies to improve uptake of cancer screening
- Practice level cancer improvement plans
- 2ww e-referral proforma advice
- Training on safety netting of patients
Working in partnership with Macmillan Cancer Support
- Commissioned Macmillan Primary Care Nursing service
- Supporting patients through diagnosis and treatment in the community
Working with Durham County Council
- Co-production of Joining The Dots model of holistic support for patients with a cancer diagnosis.
Learning Disabilities
Too many of our residents with Learning Disabilities are staying in hospital beds for longer than they need to and we need to work with Local Authority colleagues to improve options for people. We also want to make sure that people are invited to come for a health check every year to make sure they stay healthy and happy.
We are working with our patients who have learning disabilities to understand what they want and with the Local Authority to try to provide it. We want all patients to be able to access annual health checks in a way that suits them so that they get any help they need.
Some of the areas that we are focussing on are:
- Autistic Spectrum Disorder Diagnosis
- Transforming Care
- Pathway review to address the increased demand in the longer term. Working with TEWV and other participants in the multi-agency pathway to reduce waiting times in the short term.
- Active involvement with the Regional Board to ensure people have the most appropriate care in the lease restrictive environment.
Mental Health
The three main issues for us at the moment are:
- Crisis Care
- Children and Young People’s mental health
- Improving access to psychological therapies (IAPT/Talking Changes)
We are actively driving forward work identified through the Crisis Care Concordat such as pathway review, introduction of Street Triage.
We have strong working relationships and are actively working with Durham County Council to address gaps in provision as a partnership. This is driven by the Local Transformation Plan which is refreshed every October.
We are also increasing the scope of the Talking Changes service in line with the 5 Year Forward View for Mental Health.
Maternity
We want to make sure all our patients can access safe and responsive services. We want our services to be places where staff want to work so that we have an effective workforce.
We are working with our local maternity services board to understand the pressures on services across the region. We will implement the regional action plan along with our providers.
A Maternity Service specification has been developed on behalf of three CCGs; North Durham, Durham Dales Easington and Sedgefield, and Darlington.
This reflects guidance given in the national maternity review better births which was undertaken in 2016, and also areas identified for improvement by NHS England.
The specification has been developed in consultation with Public Health colleagues at Durham County Council and Darlington Borough Council, and County Durham & Darlington NHS Foundation Trust.
The national maternity review Better Births identified what a successful service would look like by 2020 outlined below.
- Personalised care, centered on the woman, her baby and her family, based on their needs and their decisions, where they have a genuine choice informed by unbiased information.
- Continuity of carer, to ensure safe care based on relationships of mutual trust and respect, in line with the woman’s decisions.
- Safer care, with professionals working together across boundaries to ensure rapid referral and access to the right care in the right place; leadership focussed on a culture of safety across organisations and investigation leading to honest and open discussions and learning when things go wrong.
- Better postnatal care and perinatal mental healthcare, to address under provision in these two vital areas.
- A culture of multi-professional working, breaking down barriers between midwives, obstetricians and other professionals to deliver safe and personalised care for women and their babies.
Ultimately, success will be measured by improvement in outcomes for women, babies and their families, and services will need to deliver improvements against these outcomes.
Four maternity-related measures have been included in the CCG Improvement and Assessment Framework:
- Neonatal mortality and stillbirths
- Maternal smoking (at time of delivery)
- Women’s experience of maternity services
- Choice in maternity services
County Durham CCG is working hard with CDDFT and Public Health and practices to deliver this service.
Dementia
We continue to work closely with neighbouring CCGs and Tees, Esk and Wear Valleys NHS Trust so we can plan and support people with dementia.
There are 3 main priorities for us:
- Identifying levels of need
- Ensure consistency of service across County Durham and Darlington and improve partnership working
- Early diagnosis
We are also working with Public Health colleagues to develop an Integrated Needs Assessment which brings together people living with dementia, their carers, care providers, commissioners and other stakeholders to help them understand what’s available to support them. This will create a shared understanding of dementia care pathways for patients and carers
We will continue to work with colleagues across County Durham and Darlington to deliver the revised Strategy. Find out more about our Dementia Strategy.
We will also continue to work with GPs to diagnose dementia early and provide support to families and patients following diagnosis.
Care Closer To Home
The NHS and Adult Social Care system both nationally and locally require a change to the way services are provided, to meet the needs of a population . We want to make sure the system is sustainable for the next generation.
There are around 15 million people living with one or more long term conditions (LTCs) in England and in tern they are high users of health services. While the number of people with any LTC should be relatively stable over the next 10 years, the Department of Health estimates that there will be a 30% increase in the number of people with three or more long term conditions over a 10-year period (2010-2020).
Critically, patients universally say that they wish to be treated as a whole person and for the NHS and social care to act as one team. Despite this, those people who have more than one condition, particularly older people, tend to receive a fragmented service based on organisational boundaries rather than holistic care. It is widely recognised that integrated services help support a better pathway in and out of services for older and vulnerable patients and a multi-disciplinary approach helps support independence and maintains the health and wellbeing of older people for longer, so avoiding admissions to acute and long term care provision. In County Durham an Accountable Care Network has been established to further develop an integrated model which aims to provide a way of wrapping services around individuals within a local population.
The development of an Integrated Community Service across County Durham supports a shared commissioning vision to improve access, continuity and coordination of community-based health and care services for the local population.
The Five Year Forward View (5YFV) provided the national policy context of reshaping of care in England over the next five years and beyond. It presented two emerging care models: Primary and Acute Care Systems (PACS) and Multi-speciality Community Providers (MCPs). Having engaged extensively with local communities and clinicians through the Better Health Programme (BHP) and the Sustainability and Transformation Plan (STP), North Durham CCG, Durham Dales, Easington and Sedgefield (DDES) CCG and Durham County Council have reconfigured out of hospital care around the fundamentals of an integrated Accountable Care model.
The foundation of the CCG’s plans has been the development of the Primary Care Home Model and Teams Around Patients (TAPs) and the reshaping of care around them increasing the responsibility and accountability for a defined (registered) patient population.
Whilst considering possible models our learning has included the need to develop a dedicated approach to promote independence and prevent acute and longer term care home admissions for vulnerable patients. This led to the development of 13 multi-disciplinary Teams Around Patients (TAPs) operating on a countywide footprint; split into eight groups, each aligned to the eight PCH groups within County Durham.
The aim of the TAPs, who sit within the PCH function, is to provide better outcomes for frail, older patients whilst alleviating the pressure on the system through smarter, more cohesive working arrangements across health and social care within our communities. A virtual budget exists for PCH activity and work is almost complete on aligning staffing budgets for TAPs.
Principle expected outcomes of both the PCH and TAPs are:
- Managing demand and activity
- Improved primary care access
- Reduced hospital admissions
- Enhanced preventative offer
- Enhanced independence and wellbeing through risk stratification
- Less presentation at A&E
- Reduction in bed days
- Less people in residential and nursing care
It is important to say at this stage that the development of TAPs has been an iterative process that has brought a wide range of organisations together to provide truly holistic preventative care for TAP populations. Our work will continue to enhance the community offer and to further develop collaborative working.
[1] NHS England LTC QIPP Work stream (no date) A Guide to the Implementation of the Long Term Conditions Model of Care
Primary Care
One of the main priority areas for Primary Care is the delivery of the General Practice Forward View (GPFV). The aim of the GPFV is to offer help for struggling practices, plans to reduce workload, expansion of a wider workforce, in technology and estates and a national development programme to speed up transformation of services.
As a CCG are developing and implementing a number of projects that will support the GP Forward View. These include aiming to increase the workforce by offering a GP and Practice Nurse career start scheme and being a committed partner in the North East Model for International Recruitment. The CCG have invested into improving access for patients to General Practice by providing nine Primary Care Services across the 3 localities offering additional urgent appointments on evenings and weekends. Mental Health Therapists have been aligned to all practices across the CCG to offer support to patient who have a mental health concern and ensure they are seen by the most appropriate health care professional. In an aim to reduce the GP’s work load and again increase access members of our practice reception teams will soon be trained to being Care Navigators which will again ensure patients can access the most appropriate health care professional within their practice.
This is just a snap shot of some of the work currently being undertaken to address the issues in Primary Care
Urgent and Emergency Care
From 1 April 2017, urgent care services during the day will be provided from your own GP surgery. GPs will also work together in hubs to provide extended opening hours up until 8 pm each weekday and on Saturdays and Sundays. In Easington, the GPs have decided to continue working in their urgent care hubs in Peterlee, Seaham and in Healthworks, but the ultimate aim is to improve access to patients within their own GP surgery where they will receive continuity of care from their own GPs and nurses.
North East Urgent Care Network (NEUCN)
The CCG is also part of the North East Urgent Care Network (NEUCN). The NEUCN vision is to improve the quality, safety and equity of urgent and emergency care provision by bringing together local A & E Delivery Boards and group stakeholders to look at the whole system to make improvements.
County Durham and Darlington Local A&E Delivery Board (LADB)
The LADB brings partners health and social care together to improving Accident and Emergency (A&E) performance.
There are five main improvements
- Streaming at the front door – to ambulatory and primary care: This will reduce waits and improve flow through emergency departments by allowing staff in the main department to focus on patients with more complex conditions.
- NHS 111 – increasing the number of calls transferred for clinical advice: This will decrease call transfers to ambulance services and reduce A & E attendances.
- Ambulances – Review of computer coding and workforce: This will help us move towards the best model to enhance patient outcomes by ensuring all those who contact the ambulance service receive an appropriate and timely clinician and transport response. The aim is for a decrease in conveyance and an increase in “hear and treat” and “see and treat” to divert patients away from the Emergency Department (ED).
- Improved patient movement through services: Our providers are working hard to reduce the length of a patient’s stay in hospital, and are implementing the S.A.F.E.R principles (Senior Review. All Patients. Flow of Patients. Early Discharge. Review). This aims to facilitate clinicians working more collaboratively in the best interests of patients.
- Discharge from hospital – All of health and social care developing a “Discharge to Assess” model will greatly reduce delays in discharging
As part of the A&E Improvement Plan, the Emergency Care Improvement Programme (ECIP) Team carried out an intensive whole system diagnostic in November 2016. As a consequence four key priority areas for improvement across the system have been identified:
- Leadership
- Assessment prior to admission
- Doing today’s work today
- Discharge to assess