To receive a presentation from the Corporate Director of Commissioning for
Trafford CCG and Trafford Council.
The Associate Director of Commissioning for Trafford CCG delivered a presentation to the Committee on the Trafford Coordination Centre. The Committee were told that the TCC had evolved and so had its role and purpose in line with the changes within the Trafford health economy. The Committee were told that the TCC had performed over 4000 Care Coordination interventions in the past year.
The Associate Director of Commissioning then focused upon the innovative work that had been done over the year. 300 people had received support on the falls pathway, which had been introduced during the year. The service consisted of a devoted clinical team who could direct patients to a number of services targeted at preventing further falls. The service had been developed with the North West Ambulance Service so the TCC was alerted whenever someone had a fall.
A winter wellness programme had been created for all people who had been admitted to hospital during the previous winter. The team arranged wellness calls to check that these patients were receiving the correct support. During Christmas the TCC were going to ring patients who had been identified as being at risk on Christmas Day and Boxing Day to check on them and offer support if needed.
The TCC had managed 75% of all referrals made within Trafford in 2018 and over 1000 referrals had been redirected into community services instead of secondary services. A diabetes clinical triage had been created which reviewed all referrals relating to diabetes to ensure that they were appropriate and had been made to the correct services.
A key service which was to be introduced in 2019 was the smoking cessation pilot. GP’s were to identify patients who wanted to quit smoking and then refer them to the TCC. The clinicians were then to contact these patients to support them through the difficult time whilst they quit smoking. All of the clinicians within the TCC had received motivational interview training to enable them to provide this support. The service was to work alongside the respiratory pathway to prevent respiratory problems and reduce demand.
An alerts service for carers had been developed and was to be implemented in 2019. The TCC would be alerted whenever carer was admitted hospital so adequate support could be provided for the person they cared for. The TCC were also working with care navigators in MFT to improve the discharge process and to ensure the right support networks were in place including; care, equipment, and social interactions. It was hoped that this work would prevent readmissions.
The Committee were then shown the basic package of care provided by the TCC. They were told that patients were identified by GPs or the community care team and then referred into the TCC. These individuals were then contacted and their level of need, the services they required, and how often they needed to receive follow-up wellness calls was assessed. The information was stored within the system and made available to the team whenever they dealt with that patient so they could effectively coordinate their care.
The Associate Director of Commissioning for Trafford CCG described the whole system from referral through to the patient being placed on a pathway. The Committee were told how alerts were received and fed into the system. The different outcomes that the TCC was to meet were then displayed and the Committee were informed how they were delivered. One of the main outcomes was to prevent readmissions within 28 days of discharge. The TCC strived to achieve this, and the other outcomes, by working in partnership with teams including the One Trafford Partnership, the Trafford Enhanced Care Home Team, and MFT care navigators.
The Associate Director of Commissioning then gave a list of the types of referrals that were clinically triaged by the TCC in line with the Effective Use of Resources (EUR) policy. The Committee were informed that any referral that was not in accordance with the policy was sent back to the GP with points of why it was not appropriate. This review of referrals had streamlined the process for GPs and patients and had ensured that Trafford GPs operated in line with EUR the policy.
The Committee were shown the pathways developed by the TCC in collaboration with secondary and community care partners. The Committee were told how these pathways had been developed and were assured that they were reviewed on a regular basis. They were then shown the number of those enrolled on the service mapped against the number of interventions. The goal was that the numbers would be matched meaning that each patient enrolled would have had some contact with the team.
The Committee were informed of the financial benefits of the TCC’s referral management in 2018.Over 35000 referrals had been processed by the service in the last 12 months with over 5000 referrals having been checked against the clinical pathway. This had saved over 7300 hours of GP time, when compared to the previous system, which equated to roughly £80,000 saved. The Committee were then given two case studies which demonstrated the types of patients that the TCC supported and illustrated the wider benefits of the service.
The Associate Director of Commissioning for Trafford CCG then spoke about the work that the TCC had done to communicate with patients and the positive feedback that they had received. She read out a card from a patient, who had suffered from cancer, expressing their gratitude for the impact that the TCC team had during their treatment.
The next steps and the areas where the TCC would look to grow and expand in 2019 were then outlined. The next step included performing a benefit analysis to show the full impact that the TCC had across the system. The plans for growth and expansion involved bringing more analytics into the system to enable ‘smart’ commissioning and to work closer with social care partners to provide a holistic approach to commissioning.
The TCC was to be a key element in Trafford CCG’s savings plans as the coordination of the proposed service changes would be instrumental in ensuring savings were realised. TCC would also have an important role in Trafford CCGs move towards a neighbourhood model by linking patients with services within their community.
The Associate Director of Commissioning for Trafford CCG noted that Trafford CCG had not done the best stakeholder engagement. The TCC wanted to do much more engagement in 2019 and to get people to understand what the TCC was and what they did. There was also a need to get stakeholders input on how the service should be developed.
Following the update Committee Members were given the opportunity to ask questions.
Councillor Bruer-Morris asked whether the connection between Wythenshawe and the TCC was working better, especially around transfers of care. The Associate Director of Commissioning for Trafford CCG responded that there were excellent working relationships between the TCC and colleagues at Wythenshawe Hospital. There had been great improvement in the last few months and the system was working well with patients receiving smooth transfers of care.
Councillor Bruer-Morris then asked how the TCC worked with diabetic patients. The Associate Director of Commissioning for Trafford CCG answered that all queries regarding diabetic referrals were sent to the specialist clinician who then contacted the GP. The clinician then worked with the GP to ensure that their referrals were appropriate in the future. This extra level was specifically added for diabetic referrals a there had been issues with large numbers of inappropriate referrals being made in this area.
Councillor Brophy asked for details of the educational programs for diabetic patients mentioned within the report. The Associate Director of Commissioning for Trafford CCG responded that the pilot had begun four weeks earlier with the aim of identifying gaps in service and GP referrals. Part of the primary care strategy was to see where services such as diabetic education were needed so that specialist services could be commissioned.
Councillor Brophy asked what the TCC were doing to address the gaps for patients with diabetes and learning disabilities. The Associate Director of Commissioning for Trafford CCG stated that the main issue that they wanted to address were inequalities in the availability of services. The aim of the primary care strategy was fill the gaps in services across the borough so that people received the same level of care in all areas. The Corporate Director of Commissioning added that the TCC was instrumental in finding the gaps but it was to be the commissioned services that would fill those gaps. Councillor Brophy the requested that more information on the diabetes pathway be sent to the Committee and the Corporate Director of Commissioning agreed.
Councillor Taylor asked what the Christmas call to patient’s entailed.
The Associate Director of Commissioning for Trafford CCG replied that it depend on the individuals identified need. The team would refer the patients to any services they needed and they would also call family members or anyone else that the person wanted to speak with. Councillor Taylor requested that the details of how the service performed be sent to the Committee after Christmas.
Councillor Taylor stated that the case studies were useful and asked whether they could be expanded upon with details of the whole patient journey through the system. The Associate Director of Commissioning for Trafford CCG thanked the Councillor for their feedback and said that she would ensure that this was done during the next update the Committee received.
Councillor Acton enquired as to whether the savings figures provided factored in the cost of the service. The Associate Director of Commissioning for Trafford CCG answered that the figures been provided were purely the savings that have been achieved through the work of the team.
Councillor Anstee asked how the TCC supported people with mental health issues. The Associate Director of Commissioning for Trafford CCG informed the Committee that the team had two mental health trained nurses within the team and that the team were going to be working alongside the mental health team in the New Year. The goal was to have the same level of support for mental health patients as for patients with physical ailments.
Councillor Evans asked for clarification around the savings figures attributed to referral management and how many patients had completed the satisfaction survey. The Councillor then stated that the reported 10900 diabetes patients dwarfed all other numbers reported and that this should be the main focus for the TCC. Councillor Evans requested that further information on the number of diabetes patients and what the TCC were doing to help them. The Associate Director of Commissioning for Trafford CCG agreed to provide the information requested and agreed with the Councillors point regarding the importance of supporting patients with diabetes.
Councillor Evans encouraged the proposed expansion of the service and advertising campaign but had concerns about the services ability to deal with the possible upsurge in demand. The Councillor requested that the contact number for self-referrals be sent to ward Councillors prior to the wider roll out. The Associate Director of Commissioning for Trafford CCG confirmed that she would send the contact number to officers to distribute to Councillors.
Councillor Taylor asked whether the TCC had statistics of the distribution of uptake of the service across the borough. The Associate Director of Commissioning for Trafford CCG stated that this had not been done but that they would be able to put this together pretty quickly for the Committee.
1) That the Corporate Director of Commissioning added that the TCC be thanked for providing the update.
2) That information on the number of patients with diabetes and details of the diabetes pathway be sent to the committee.
3) That the performance of the Call at Christmas service be reported to the Committee in the New Year.
4) That a case study covering a full customer journey be included in the next update on the service.
5) That clarification of how savings figures were calculated be supplied to the Committee.
6) That the number of patients who had completed the satisfaction survey be sent to the Committee.
7) That the number for self-referrals be circulated to all ward councillors.
8) That the distribution of patients accessing the TCC be mapped and sent to the Committee.