Agenda item

This report updates the Committee on improving outpatient services across Medway and Swale. This in line with the Medway Model and community service redesign, which will enable care to be delivered closer to people’s homes. The improvement programme will be bringing services together, this will enable health and care staff to work more closely together and develop services that focus on the needs of the patients.

This report from NHS Medway Clinical Commissioning Group (CCG) updates the Committee on the progress of the programme since the previous paper on the Community Service Redesign and the Medway model that was sent to the Committee in January 2019.

Discussion

The Committee had previously considered reports on the Community Services redesign and information on the Medway Model. The report now under consideration outlined how proposals to improve outpatient services in Medway fitted into that model. There had been significant feedback showing that patients wanted care to be provided closer to their home than at present. The current outpatient model was condition led, with patients allocated a set number of appointments based on their condition. The aim of the proposals was to make services patient led and needs focused. Consultants would have direct access to GPs to help eliminate unnecessary referrals.

The CCG was working with partners, such as Medway Foundation Trust, the Council and Primary Care Networks to consider how consultants could spend time in community hubs, rather than in the hospital, so that consultant appointments could be provided in the hubs. Consultants and GPs would work in a multi-disciplinary team to enable patients to see the correct professional at the right time and in a non-hospital setting. Rheumatology, neurology, elderly care, clinical haematology and respiratory services would be included in the first phase of the proposed changes. Patient engagement would be used to inform the redesign of specific pathways. These redesigned pathways would benefit patients and free up consultant and clinician time. Appointments would be patient led with patients being able to request appointments to meet their needs rather than being allocated a fixed number of appointments in a period. Where appropriate, use would also be made of telecare services. Patients would be able to access crisis support quickly rather than having to first attend the Accident and Emergency Department.

Questions asked by Committee Members were responded to as follows:

Use of telecare and engagement – A Member expressed concern that not everyone was willing or able to use electronic services and asked what confidence those taking part in engagement could have that their views would be listened to in view of the outcome of the Kent and Medway Stroke Review.

The Committee was assured that services would be matched to the needs of the population and that other options would be available for those unable to make use of technology. There was an aspiration to design services that fitted with the needs and wishes of the local population. No groups had yet been identified that would be disadvantaged by the proposals.

Outpatient Services – In response to a Member who asked for clarification of where patients would attend for outpatient appointments in the future and also, how it would be ensured that services were provided in a single visit, it was confirmed that most patients would be seen in community hubs. Discussions were taking place with the Foundation Trust about how to relocate rheumatology appointments and provide the necessary x-ray facilities in a community setting. Mobile units were being considered. The aspiration was for a range of services to be provided to patients on a single visit. It was noted that this was not always possible currently when patients attended hospital for outpatient appointments. Telehealth would be a significant part of the programme for patients who wanted to make use of this provision. This would, for example, enable a specialist to receive patient health data and make any necessary changes to medication without necessarily having to physically see the patient first. Face-to-face appointments would still be available when required. However, feedback from the Community Services Redesign suggested that patients tended to want less such appointments and be enabled to manage their condition in their own time to best meet their individual needs.

Delivery of arrangements and patient perspective – A Committee Member asked whether consultants would monitor outpatient appointments. He noted that other professionals, such as pharmacists and nurse practitioners, already had specialist skills that could potentially be utilised as part of the new arrangements. It was requested that patient feedback and perspectives be included in the next report presented to the Committee. In response, the Committee was informed that specialist pathways of the new model had not yet been developed. This would be undertaken with the close involvement of patients.

Timescales for Implementation – Outpatient appointments for rheumatology were due to move from a hospital to community setting but the service was not due to change otherwise. This was likely to be implemented in April 2019, which would be before the next opportunity for the Committee to consider the proposals further at its next meeting in June. Neurology outpatient provision would be transformed as well as outpatient appointments moving away from Medway Maritime Hospital. This was expected to start in June or July with the transition being phased. 

Patient pathways, support for rheumatology move, GP provision and use of technology – A Member asked whether there was support for moving rheumatology outpatient appointments, questioned how patients would receive an initial referral and asked how the expected 6% reduction in outpatient appointments would be achieved in view of the difficulty many people currently faced in getting GP appointments. She also asked whether the new arrangements would address concerns raised by patients attending appointments with multiple clinicians covering different specialisms. These patients had found that clinicians did not have records of what had been discussed at the other appointments or details of outcomes. Details of the proposed telecare offer was also requested. In response, the Committee was advised that the relocation of rheumatology outpatient provision had been initiated by hospital consultants. Initial referrals would continue to be via patient GP referral. Patient requested appointments would be for patients with an ongoing, long term need for appointments following initial referral.

The model being introduced would be similar to that used elsewhere in the country. GPs would be able to have direct communication with consultants during patient appointments. This Consult Connect service would reduce outpatient appointments as GPs and patients would be able to speak directly to consultants and would therefore be able to get immediate advice. Evidence from elsewhere showed a resultant reduction of more than 6% in outpatient appointments. Where a consultant was not available locally, a link could be made to a consultant elsewhere. The telecare services available would depend on patient need but one example was a telehealth monitor. This could collect data, such as patient weight, blood sugar and oxygen saturation and transmit it automatically to a specialist. The specialist would then be able to contact the patient if concerns were identified.

Further information and engagement – Committee Members said that there was not enough detail included in the report and that they could not yet be assured about the proposals. It was questioned whether there had been engagement with Medway Healthwatch. Healthwatch had been involved in the wider community services reprocurement but specific engagement with small groups was undertaken by Involving Medway, which was funded by Medway NHS CCG, rather than by Healthwatch. Community engagement would be undertaken in relation to new patient pathways and Heathwatch would be involved in this work. The CCG was working closely with Medway Foundation Trust and Medway Community Healthcare in developing the proposals. GPs and consultants had attended a joint workshop in 2018 with these groups being supportive of the proposals. The Committee would be provided progress updates as the proposals were developed.

Consideration of Substantial Variation – Committee Members considered whether the proposals relating to outpatient services could amount to a substantial variation in provision of the health service in Medway. It was asked what the implications would be if the Committee judged the proposals to be a substantial variation and whether full details of the plans could be provided to the Committee ahead of this decision being made. The Committee was advised that this could delay the work. Further information in relation to neurology could be provided in the near future but as the work was phased, there would be a be a significant delay in implementation if full details of all initiatives were to be provided to the Committee ahead of work commencing. Determination of whether the matter was a substantial variation at the Committee’s June meeting would be after some of the changes had been made.

A Committee Member considered the proposals to be a substantial variation because there was an intention to reduce the number of outpatient appointments. She also felt that the Committee had not yet been provided enough information. Judging the proposals to be substantial would enable the Committee to consider full details of the plans and the Member did not consider that such a judgement would significantly disadvantage the process.

The Director of Public Health advised the Committee that the CCG needed to make changes to outpatient provision and that innovation and technology was a key part of NHS Long Term Plan.

Decision

The Committee:

i)    Considered and commented on the report and proposed development or variation to the health service, as set out in the report and Appendix 1.

ii)   In consideration of Medway NHS CCG’s assessment of the proposal, determined that the proposal does represent a substantial development of, or variation to, the health service in Medway.

iii) Requested that a further update be provided to the Committee and that the Consult and Connect team attend this meeting to demonstrate telecare provision.