Deputation Request – Disabled Adaptations

This flat rate will be used as a basis for negotiating new contracts with the voluntary sector clubs which provide these services.  The flat rate will not be modified according to the relative deprivation of the elderly populations in any of the four areas even though it is known that a far higher proportion of more deprived people use these day services. 

This is out of line with Wandsworth Council’s normal approaches which do take account of the significant differences in relative levels of wealth among different groups of elderly people and attempt to overcome the disadvantage this causes. 

The Wandsworth LINk representative attending the meeting argued strongly for an approach which took account of deprivation but this was not agreed.

These headlines are for rapid briefing purposes about the lay/user issues arising in the meeting. It is not a full report from the meeting.

PEC and PCT Board papers are available on the NHS Wandsworth website: www.wandsworth.nhs.uk   contact Sandra Allingham on 020 8812 7740 or e-mail sandra.allingham@wpct.nhs.uk

The contents of this briefing note are for information only and are solely the responsibility of Andrew Craig, PEC Lay Member, including errors and omissions. They do not necessarily represent the views of the PEC or NHS Wandsworth.

Matters Arising

COPD and Pulmonary Rehabilitation Needs Assessment

Both of these related areas are being targeted for service redesign. The report stated that “patient and public Involvement is key to these projects and a patient group will be established to work with the clinicians to develop the proposals.” The PEC recommended that an “invest to save” model be used, reflecting the importance of COPD to the QIPP programme.

I asked that user engagement begin before the formulation of proposals – reflecting the government’s commitment to “nothing about us without us” – so that it would be clear that the redesign of the pathway reflected service users’ contributions. The national literature on patient views on these services should be used to test out local views.  Having one patient on the working group was tokenism and inadequate and must be reconsidered.

Items for Discussion

Teenage Pregnancy Performance Update

This subject is really about young people’s sexual health and wellbeing, not just teenage pregnancy.  Funding streams were coming to an end and there was a need to integrate activity with the local authority to get the right reach into the target group.  There was good evidence of service user input to this work.  Reliable data showed Wandsworth pregnancy rates falling, but the overall rate remained above the London and national averages. The rate of conceptions in young women under 18 was still the 10^th highest in London and 43^rd highest in England. 

Wards with the highest numbers of under 18 conception rates are: Queenstown; Nightingale; Latchmere with rates nearly three times that in low rate wards.  Numbers of conceptions are highest in Latchmere, Queenstown, Roehampton and Furzedown.  Black and minority ethnic groups had much higher probability of pregnancy than the white population and this had to be addressed in terms of vulnerability and aspirations from an equality point of view.  The emergency contraception pathway and access to it was not clear enough to young people.  A text service had been used for this, but it had been discontinued.   

I supported the integration with the local authority approach for strategy and funding and hoped that the action plan would be considered by the new Health and Well Being Board led by the Council at an early point.   This subject should be part of the Joint Strategic Needs Assessment.  Any communications method that increased awareness and access to emergency contraception had to be used with this target group.  We needed to understand why comparison boroughs like Westminster and Hammersmith and Fulham had achieved greater success than we had in Wandsworth.

Breastfeeding Update

Evidence was that breast feeding initiation rates were high immediately post birth, but in the 6-8 week period after that things broke down, especially for some groups of white mothers. The target for 2010/11 is that 75.7% of infants are recorded as being partially or totally breastfed by the GP practice at the 6-8 week check. Mothers from black and ethnic minority groups were much more likely to continue breast feeding. Locally, we were only just meeting this target and the evidence suggested performance was slipping as mothers were reporting not being advised by health visitors about breast feeding.   PEC agreed that this had to be a mainstream service and must not be left to a specialist.  The outcomes in the contract had to be tightened, including financial penalties for not meeting breastfeeding targets, rather than funding found for a specialist post.  

I expressed strong concern if the so-called “universal service” provided by midwives and health visitors locally seemed – on the basis of this report at least – to be failing where adherence to breast feeding was concerned. This is such a crucial issue that it cannot be left to a specialist to pick up the pieces.  The Health and Well Being Board should consider this as a public health priority and the message to Community Services Wandsworth needed to be strong that performance had to improve.

Items for Approval

TB Needs Assessment and Action Plan

Tuberculosis is a significant public health problem in Wandsworth, with the highest TB mortality rate in SW London and the biggest incidence (new cases per year) 29/100,000. Most cases occur in non-UK born ethnic minorities from sub-Saharan Africa (particularly Somalia) and the Indian sub-continent (India, Pakistan and Bangladesh).  This is reflected in the considerable geographical variation in incidence that is seen within the borough, with the highest rates occurring in Tooting, Earlsfield, Graveney, Roehampton, Furzedown and Latchmere.   

Drug resistance is an emerging problem within Wandsworth with 13% of culture-confirmed cases resistant to at least one anti-tuberculosis drug and 3.5% resistant to more than one drug in 2008. The problem is compounded by considerable stigma around TB in minority ethnic populations, which results in late presentation and poor treatment rates.  Against this, local providers are meeting local and national metrics for finding and treating cases. Universal BCG vaccination about to start.  Wandsworth Prison is included in the action plan as TB is a significant problem in that facility.

PEC agreed the action plan and recommended it to the Board

Reports for Information

Cancer Diagnosis Audit

This is another area where late presentation and delays in treatment make the problem much worse than it should be in terms of survival rates.  An audit across the sector showed: 46% of patients diagnosed with cancer had been referred via the two week wait rule (ie 56% FAILED to be referred within the required time; 47% of the audit patients were referred to secondary care after one visit to the GP surgery, ie for 53% it took MORE than one visit and in some cases many more.

The median average total pathway was shortest in breast cancer cases (27 days) followed by lung cancer cases which took an average of 27 days in total.  Colorectal cancer cases took 54 days on average whilst prostate cancer cases took longest of all at 64 days.  The biggest reason for the variance was patient delay, see below.

GPs participating in the audit identified that there had been 146 (22%) avoidable delays out of 704 cases.  Of these:

45 cases (31%) were due to the patient delaying presentation, investigation or hospital referral, 

34 cases (23%) were delayed due to the GP not initially thinking about diagnosis,

27 cases (18%) were delayed after referral to secondary care,

16 cases (11%) could have been referred earlier using the two week rule

14 cases  (9%)  were delayed due to communication problems between primary and secondary care and

10 cases (7%) were delayed due to other causes.

PEC agreed the action plan of the Cancer Network and recommended it to the Board.  The February PEC will receive a report based on interviews with the public analysing views about signs and symptoms of common cancers.

Open Space

I raised two issues

Comparative GP practice performance data.

Despite promising to produce it since July last year, the PCT has not delivered comparative GP practice performance data accessible to the public to facilitate choice and changes of GP practice. Work to make this suitable for the website was done by the comms department but never materialised.  Government has confirmed it is proceeding in the forthcoming HSC Bill with abolition of practice boundaries, so user friendly comparative information to enable choices and changes is essential.  It is not acceptable to the public to say that NHS London is doing this work – there is no sign of it on their website –  so the PCTs do not have to.   

PEC agreed that a “balanced score card” showing comparative performance of all Wandsworth GP practices by name will be completed in the next 4 weeks and put up on the PCT website.

Hospital discharge.  

Wandsworth LINk published its hospital discharge study in mid December based on patient and carer interviews.  This is important user-focused intelligence, so how will the existing and future commissioners take account of it?

Next Meeting of the NHS Wandsworth Board: Wednesday 26^th  January 2011 in the Richmond/Barnes Room at Queen Mary’s Hospital, London SW15.

Next Meeting of the PEC: 09h30 on Tuesday, 8^th February 2011.  I have given my apologies and there will be no Lay Member’s report from this meeting.

Monday 17th January’s meeting looks to be pretty action packed, with Elections to the LINk Executive prior to the meeting from 5- 6pm, the business meeting from 6-7pm and a two presentations at 7.30pm. Dr Jeremy Gray will be giving an update on Government plans for GP commissioning and Jenny Weinstein, Wandsworth LINk Vice Chair, will be presenting on future plans for Health Watch.

In addition to this everyone is invited to make suggestions on what issues they think the LINk should focus on in 2011.

The meeting will be taking place at Tooting Leisure Centre and there will be refreshments available. We look forward to seeing you there!

The Department of Health have produced a report on the information produced in the Annual Reports of Local Involvement Networks (LINks) across the country.

The report shows £126 mil gross annual benefit from LINks which equates to a return of £4.10 for every £1 spent.

Highlights from the report include:

• There was an estimated total of 70,300 members of LINks in England in 2009/10, almost three times the number of members in 2008/09. The average number of members within a LINk for 2009/10 is 489, made up of individuals or groups. This is three times the average membership of last year.
• LINks engaged with an estimated total of 192,000 people in 2009/10, with 42% of engaged people relating to social care.
• Activity has significantly increased this year. There were 3,980 requests for information estimated in 2009/10, seven times the requests of last year.
  There were an estimated 1,300 reports and recommendations made this year, 16 times the number of reports in 2008/09.
• LINKs activity has led to an estimated 460 plus service changes and over 520 service reviews in 2009/10.
• Case studies have shown LINks activity to be cost effective. Using four of the case studies, a gross annual benefit of £126 million can be estimated, a return of £4.10 for every £1 spent.

Local Involvement Networks ( LINks) Annual Reports 2009/2010

These headlines are for rapid briefing purposes about the lay/user issues arising in the meeting. It is not a full report from the meeting.

PEC and PCT Board papers are available on the NHS Wandsworth website: www.wandsworth.nhs.uk   contact  Sandra Allingham on 020 8812 7740 or e-mail sandra.allingham@wpct.nhs.uk

The contents of this briefing note are for information only and are solely the responsibility of Andrew Craig, PEC Lay Member, including errors and omissions. They do not necessarily represent the views of the PEC or NHS Wandsworth.

Items for Discussion

Performance Area Presentation – Screening

Breast screening: The target is for 70% of women aged 53-70 to have received screening for the early detection of breast cancer over the last three years. In 2010/11, the target will be extended to include all women aged 47–73. 

Local performance was consistently underachieving (63%) compared to other sector PCTs (London average 65.1%; Islington 66% highest).  Issues of  venues, sites and times and list cleaning were being pursued to improve this.  Language issues are sighificant factor. A pictorial version of the invitation was being trialled.

There is significant patient opt out and also professional doubt about effectiveness in early detection and intervention for breast cancer.  This could be an example of chasing targets not in the patients’ best interest and spurious in terms of improving the health of the population.   Not part of current GP contract, so GPs less likely to be asked about it than cervical screening.  And patient information usually not transferred to EMIS patient records. 

General view that changes won’t take local performance up to 70%.  Breast screens done privately  (probably about 1%) not counted for the target as not quality assured. 

Cervical screening:  The 2010/11 target is for 80% of women aged 25-49 to have had a technically adequate smear within the last 3.5 years and 80% of women aged 50-64 to have had a technically adequate smear within the last 5 years.

Local performance (68% and 74.5% for the respective groups) improved by 2% this year, but consistent underperformance issues are the same as for breast screening.  Data reconciliation has revealed large inconsistencies in patient lists ( reflecting our highly mobile and diverse population).

For both types of screening, PEC agreed that there must be much more engagement with the target community to find out what kind of service they would use and where it should be offered.

My conclusion from this is that the NHS is underperforming because it is trying to promote uptake of a product that many customers don’t recognise as something they need and should want. Women called for screening are not “patients” and are unlikely to respond to top down services that take no account of language, culture, convenience and other consumer factors.  We do not know what kind of service women would like to have and until there is reliable user-led intelligence, it will not be possible to commission something more appropriate.  Tinkering with the existing model is futile and wastes resources.  Getting this right presents a big opportunity for the NHS, Wandsworth Council  and Third Sector bodies to work together in an engagement exercise with a public health objective. This fits the new White Paper’s approach to public health. It is astonishing that data collection at practice level is still so fragmented.  

Naitonal GP Survey – Practice Nurses

Wandsworth’s results for patient satisfaction with access to and services from nurses in general practice are getting worse.  PEC agreed the final version of a practice nurse developmehnt strategy aimed at improving the situation. This includes better performance measures than the national survey questions. Performance data is not understood in practices and by individual nurses in the practices and this must be remedied.   

Nursing outside of hospital remains disjointed and nurses employed by GPs are professionally isolated.  The new practice nurse strategy will help, but it cannot overcome a problem whose cause is inherent in the way these practitioners are employed by GPs as private businesses.  We need a primary care nursing service that is not just confined to GP practices.  In my view the practice nurse task model is a dinosaur and impedes innovation. An alterantive is to employ primary care nursing staff through Healthcare Federations as legal entities and not through individual practices and arrange professional development and leadership across Wandsworth. Another option to consider is the  “chambers” approach where nurse employees own their own business as a mutual society and contract services to practices (and to GP commissioning consortia in future).  That would require a solution to the NHS pensions issue but there are strong signals from government that this model would be supported.  

Quarter Four GP Survey Results

PEC discussed the access to primary care results.  London and all South West London sector PCTs are underperforming in most areas.  Wandsworth is poor in practice nurse and  out of hours areas.   Government has announced that the specific target of seeing a GP within 48 hours will be abolished.

Because of the importance of providing information to patients to enable informed choices, PEC agreed that this information should be put on the PCT website in a clear and accessible way relating to individual practices.  This would enable people to choose a GP practice or switch from a poorly performing one.  PEC also agreed that the PCT should ask patients if this was the kind of data they wanted, what will they do with it,  whether it helped them make choices and whether they would recommend others to use it.    

 Implementing Coalition Government Policy

The Chief Executive provided information based on a recent briefing with NHS London and London PCT CEOs.  The following issues were highlighted:

The mismatch between having to achieve management savings quickly compared to the requirements of the legislative timetable to have changes completed by 2013 is a serious complicating factor and will make the PCT’s job more difficult in managing change and retaining its skilled staff to enable the transition to GP commissioning and closer work with the Council.

Commissioning consortia will be statutory organisations with an accountable officer (CEO) and geographical responsibilities.  Consortia will be in shadow form from from 4/11.  No mention of Boards in the accountable structure (consortia CEOs will be accountable upwards to the NHS CEO in England).  

Re-negotiation of GP contact will be simultaneous with setting up of consortia.  Providers will take most assets with them required for provision of services (et Queen Mary’s Hospital, health centres);  only assets requried for commissioning would remain with GP consortia.

The NHS Commissioning Board from 2012 will commission all primary care and maternity care.  GP consortia will not commission GP (primary)  care, for obvious conflict of interest reasons, but would take an interest in quality and effectiveness (how this would happen has not yet been specified).  Some SHAs will turn into offices of the NHS Board by 2012.  

Public health,  wellbeing and health improvement – will essentially transfer to local government  as a core cabinet level responsibility to be integrated with social care. In London this could mean the Mayor taking control of them.  Directors of Public Health would be employed by Councils not the NHS.  Overview and scrutiny arrangements will change.  London would have a public health focus.

Healthwatch nationally and locally would relate to the Care Quality Commission and absorb the LINk.  Local Healthwatch would be Council funded and accountable.   See the diagram at the end of this report.

Monitor would become the universal healthcare economic regulator.  All NHS Trusts would have to become Foundation Trusts or merge with viable FTs. Private patient income cap will be removed.  Social enterprise and employee ownership models are being heavily promoted and incentivised.

Independent health care sector will play a role mainly in market testing rather than mainlyin service provision.  

Key documents for the White Paper Liberating the NHS launched on 12/7are grouped on the Department of Health website and are essential reading www.dh.gov.uk/en/Healthcare/LiberatingtheNHS/index.htm 

 David Nicholson, CEO of NHS England, letter to CEOs of NHS organisations 13 July outlining stages and pace of transition www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_117406.pdf  stresses  four key change principles: subsidiarity, co-production,    clinical ownership and leadership, and system alignment.  The message is the need to understand the NHS as a system of services linked by common principles of access, equity and quality, not a monolithic organisation of buildings and 1m+ employees.

NHS England Governance Model in White Paper Liberating the NHS July 2010

 Next Meeting of the NHS Wandsworth Board: Wednesday 28^th July 2010 in the Richmond Room, Queen Mary’s Hospital, commencing at 09h30.

 Next Meeting of the PEC: 09h30 on Tuesday, 14^th September 2010.

See our poster for the two events on the 8th and 16th September 

If you are interested in attending, please call Daniel at the Wandsworth Carer’s Centre on 0208 675 0811

This meeting is open to anyone with an interest in local health and social care services, including voluntary groups, service users, carers and the wider community.

Speakers at the meeting:

• Roy Benjamin, Chair of LINk Merton on our work and priorities

• Peter Jenkinson, Trust Secretary at St Georges Hospital Foundation on plans to create a foundation Trust

• Helen Bainbrige, NHS Sutton and Merton on the new PCT equalities scheme

The meeting will take place at Grenfell Housing and Training, 16-20 Kingston Road, South Wimbledon, SW19 1JZ.

To book your place, call 8685 1771 or e-mail justin@mvsc.co.uk

There has been a huge amount of interest in this meeting and there is now a waiting list. If you would like to register your interest please contact Wandsworth Voluntary Sector Development Agency on 020 8875 2846.  

Wandsworth Voluntary Sector Development Agency, 170 Garratt Lane, SW18 4DA

Please see poster for more details