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Appendix C of “Options Appraisal for the Commissioning of Adult Community
Health Services”
Interview Transcripts (Camden CCG)
Value for Money
Are you aware of what services are provided by CNWL for Camden?
o
o
o
o
Aware of the following services being provided to Camden by CNWL:
o Adult community nursing service
o Rapid response service
o Palliative care
o Podiatry
o Pulmonary rehab
o Stroke rehab
o Frailty team
o Twilight services
o Diabetes education
Unsure of tissue viability as thought that this was provided by CNWL and contracted
out to the Whittington Health. However there have recently been issues as referrals
into the service have been bouncing back with the Trust stating that this is not part of
the service. Noted that there had been similar issues with occupational therapy.
Highlighted that local GPs are not always aware of what services are being provided
by CNWL. This is largely due to a lack of marketing and visibility around services are
on offer.
Also highlighted that part of the problem with CNWL is the lack of visibility and
communication of the service portfolio to the GPs
What do you think of the current services provided by CNWL?
o
o
o
o
o
o
Massive amounts of inequality across the patch with some practices receiving a better
service than others.
There is a high turnover of staff within the Trust and GPs are often having to liaise with
different members of staff about a patients care. This impacts on continuity of care and the
integration of services. It would be useful to understand what the underlying cause for
such a high turnover of staff within the Trust is.
Moving forward services should be embedded in primary care to support the new GP
Federation models. This would increase the quality of care within the community and
improve staff satisfaction. If the Trust are to make the service an excellent service then
they must tackle the issues that they have around staff satisfaction. One way of doing this
would be organise groups of Nurses around local groups of GPs to help create continuity
in the system as nurses will have their own caseloads to manage.
The District Nursing service and Palliative Care service works well but struggles due to
capacity issues. Noted issues around nurses not being able to send through urgent
communications to GPs until 4:30pm in the afternoon due to their workload. This is also
driven by the fact that they do not have access to EMIS web and other primary care
systems and can only send through these communications via Fax.
If we are going to move more activity into the community then the workforce issue needs
to be resolved.
The Rapids team has also worked well for our patients. But it would be useful to know
what the demand of these services are and if it was to increase would they cope?
Quality
What do you think your patients think about the community health services provided by
CNWL?
o
The lack of continuity in their caseloads and high turnover of staff has also been an issue
with care continuity. As patients are left not knowing who to call when there is an issues
and unsure of who will be visiting them.
Can you tell us a bit more about the relationship that you have with the Trust?
o
As a GP my practice has been lucky as we share joint premises so have found it very easy
to access some of the services available.
Strategic Alignment
What is the CCGs long term vision for CHS in Camden?
o
Camden CCGs vision is to work with the people of Camden to achieve the best health for
all.
What is your understanding of your CNWL’s long term vision?
o
Unsure of this as has never seen it.
What is Camden’s plan to keep people out of hospital and what role does CHS/CNWL role
play in delivering this?
o
o
o
o
Camden has a large proportion of frail and elderly patients and CNWL have worked with
us to manage some of the most vulnerable patients at a borough wide MDT. This has
been really successful in avoiding admissions into hospital and we need to continue to
build on this success.
There potentially needs to a needs assessment in this area and where need is the highest
community based resources are organised around this.
A key part of the Frail and Elderly programme is being able to identify those in need. This
is mainly done in primary care.
In general any provider could support the delivery of this but it would have to be
commissioned on a lead provider basis.
Other
How well do you think CNWL works with other service providers in Camden?
o Highlighted issues around patient discharge into the community. There is REDs service in
place but unsure of what formal arrangements are in place with acute providers to ensure
that this operated effectively.
o The whole system appears to be working in silo.
o There have been problems related to Boarder issues. Patients have been unable to
access CNWL community health services if they are registered with a Camden practice
but live within another borough. This should be able to be resolved through commissioning
arrangements as it does not currently align to the national agenda that allows patients to
register with any practice.
Is there anything that we may have missed that you would like to add?
o In general CNWL have been very engaged with setting up teams in programmes such as
the Frail and Elderly and LTCs and have contributed to supporting the delivery of
integrated care. There is still quite a bit of work to do as it does feel that organisations are
working in silo.
Page 2 of 16
o
It would helpful to understand exactly to what extent the community services
commissioned are utilised. This could then help to identify where resources could
redeployed in the system and drive up quality in other areas.
Value for Money
Are you aware of what services are provided by CNWL for Camden?
o
As lead for the one of the CCGs flagship programmes aware of the following services
provided by CNWL:
o Reablement
o Rapid response
o PACE
o Heat failure
o Community and District Nursing
o Diabetes
o COPD
o Podiatry
How has the landscape changed over the past few years for CHS?
o
o
o
The CCG have done a lot of work with community services, primary care and acute care to
radically shape the way that services are delivered.
More care is now being provided in the community and there are different ways that these
services are being delivered. Examples highlighted included the introduction of case
management leads for the frail and elderly, Physiotherapists and Occupational Therapists
working as multi-disciplinary teams with GPs.
The main issues in terms of the services provided by the Trust have centred on the District
Nursing teams. There have been issues with recruitment and retention of staff both of
which have impacted on the service provided. If we were being really innovative about how
we could resolve some of these issues it be worth considering either a model such as the
Dutch one or potentially think about how we may combine the practice nurse and district
nursing role to make it more attractive.
What do you think of the current services provided by CNWL?
o
o
o
o
o
o
o
Noted that the rapid response and reablement teams worked very well. PACE is also a
great service that has delivered great clinical outcomes and has very strong clinical
leadership.
Unfortunately clinical leadership within the District Nursing service is not so well defined.
This is largely due to the recruitment issues however it does not feel that it is an issue
unique to Camden.
On a whole the Trust have been very proactive at engaging in the integrated care work
that the CCG have been working on and have contributed to the Frail and Elderly MDT
and Diabetes integrated practice unit.
Noted that it would be interesting to know exactly what the other options for CHS really are
and how big the market actually is.
Recently the Trust have tried to align to District Nursing teams to practices however this
hasn’t worked well for all practices as the approach to distributing resources has not been
equal across Camden.
Acknowledged that when concerns have been raised the Trust have been very proactive
to try and address them. An example cited was when the Trust responded to ensure that
the Heart Failure Teams were able to access advice from secondary care clinicians when
needed.
Acknowledged that quite a lot of resource has already been taken out of CHS through the
delivery of their CIPs. It is important that going forward both good clinical and management
leadership are maintained in order to deliver a good service.
Page 3 of 16
o
Noted that CHS should aim to wrap care around the patient and services such as PACE
do this very well. Suggested that this approach to delivering care could be part of the
reason as to why the District Nursing service doesn’t operate very well as they under
resourced and unable to always go the ‘extra mile’ on visits.
Quality
What do you think a good community health service for patients in Camden looks like?
o
A good community health service should be centred on the patient, joined up and
integrated between services and care settings. It should provide additional expertise and
capacity around the patient as close to their home as possible. Overall it should work to
support early identification and support the avoidance of unplanned admissions.
What do you think patients think about the community health services provided by CNWL?
o
o
Noted the CPEG have expressed concerns around the quality of the District Nursing
service provided by CNWL. Issues around the variation in quality and continuity of care
have all been raised.
Discussed some of the challenges around ensuring that the voice of housebound patients
are heard. Cited example of a video made by the Kilburn older voices exchange where an
older lady shares her patient experience of CHS.
Based on your experience do you think there any issues with recruiting & retaining staff in
the CHS workforce? What is the impact of this on commissioning?
o
o
Services that are well established have a really clear remit and deliver a good service. The
main issues related to recruiting and retaining staff relate to the District Nursing team.
Acknowledged that the Trust have worked to recruit more junior members of staff to help
grow the workforce and provide more capacity.
The PACE and Rapid response teams have recently been given more support from
secondary care and this has worked really well and has had a positive impact on the
service provided.
Can you tell us a bit more about the relationship that you have with the Trust?
o
The Trust have been really engaged in all of the CCGs projects and are always very open
and proactive about what’s working well and where things can be improved.
Strategic Alignment
What is the CCGs long term vision for CHS in Camden?
o
o
The CCGs long term vision for CHS in Camden centres on improving outcomes for
patients by integrating care across services and pathways.
The CCG have been developing value based commissioning community projects and are
exploring new contracting models to achieve this. A recent example cited was the CCGs
work on community diabetes.
What is your understanding of your CNWL’s long term vision?
o
Unclear of the Trusts vision but acknowledged that the Trusts main business was based
on providing community mental health services. Noted that their community vision would
be different to their overall strategic vision but would be interesting to know whether there
are any plans to align the mental health aspects with the physical aspects of care going
forward.
Page 4 of 16
What is Camden’s plan to keep people out of hospital and what role does CHS/CNWL
play in delivering this?
o
The CCGs approach to supporting people to stay out of hospital and live independent
lives focuses on early identification and intervention. Community health services has a
really important to role to play with supporting this. As they help to manage patients in
community as well work collaboratively with secondary care and primary care to deliver
this.
Camden CCG have two flagship programmes (LTCs & Frail and Elderly). Can you tell us
about CNWL’s role in delivering these?
o
o
CNWL are a part of the partnership for delivering value based commissioning for the
CCGs community diabetes programme. They are also actively involved in the COPD
value based commissioning pilot and provide specific community services support to
primary care.
Relationships are key to the success of these programmes and CNWL have built these
relationships up with both providers and commissioners. There is still however further
work to be done to strengthen their relationships with local GPs.
Other
How well do you think CNWL works with other service providers in Camden?
o At a managerial level these relationships work very well. Examples highlighted included
the partnership working with the UCLH to deliver the Heart Failure service as well as their
input into the diabetes IPU.
In the last few years have there been any examples of new or innovative ways to the way
that community health services are being delivered in Camden?
o Cited the following examples of where innovative ways of working in CHS had been
adopted:
o Introduction of three case managers for complex to support practices and patients
to manage their care.
o Team provided to support community diabetes as part of the IPU.
o The reablement and extended reablement teams that provide a night sitting
services in partnership with the British Red Cross.
o Implementation of the practice based multi-disciplinary teams.
o PACE, Rapid response services.
Is there anything that we may have missed that you would like to add?
o
o
Would be interesting to know what the alternative for CHS services in Camden would be
and whether a change in provider would resolve any of the issues that Camden are
experiencing.
Now is the time to really think innovatively about how we design and deliver these
services. GPs are now federating. This provides a really good opportunity to think about
this. Noted that CNWL could potential set up a reference group of GPs to work through the
potential options for this.
Value for Money
Are you aware of what services are provided by CNWL for Camden?
o
o
Services provided to Camden include intensive case management for patients with LTCs,
rehabilitation, occupational therapy, physiotherapy and a rapid response service.
Other services noted included district nursing and MDT management.
Page 5 of 16
How has the landscape changed over the past few years for CHS?
o
o
Increased clinical leadership within the CCG. With a shift toward commissioning for
outcomes.
Within CHS there has been a workforce challenge with recruiting and retaining community
district nurses. This is not exclusive to CNWL and is a national problem. This has had an
impact on the frail and elderly programme as a key component of the service model makes
use of intensive case management delivered by District Nurses.
What do you think of the current services provided by CNWL?
o
o
o
o
Experience with the Trust so far is that their rapid response service operates very well,
they have a good range of experienced clinical staff and offer a wide range of services to
the frail and elderly patients living in Camden.
DN is a good service and the clinical staff are very energetic, enthusiastic and passionate
Highlighted that concerns around the quality of services provided by CNWL had been
raised in the past by the Camden Patients Experience/Expert Group.
Acknowledge that some GPs have raised some concerns with CNWL. But some of these
issues might not be specific to CNWL but be London-wide / national issues. Hence a
change in provider might not be the best answer to this.
Quality
What do you think a good community health service for patients in Camden looks like?
o
A good community health service should be integrated across the pathway, wrap care
around the patient, intervene early and appropriately. Services should be easily
accessible, aim to keep people out of hospital and should be easy for patients and
clinicians to navigate through.
What do you think patients think about the community health services provided by CNWL?
o
The frail elderly patients are a vulnerable patient group and tend to be happy with and
thankful for any service they can get. Hence they may not be representative of overall
patient experience.
Based on your experience do you think there any issues with recruiting & retaining staff in
the CHS workforce? What is the impact of this on commissioning?
o There have been ongoing issues with the recruitment and retention of District Nurses.
Although these challenges are not unique to CNWL.
o The lucrativeness of being a district nurse has always been an issue – this could be due to
an imbalance in the cost of provision of the service and the value of the contract
historically.
o Acknowledged that the Trust have made an effort and have implemented a recruitment
programme reaching as far as advertising for staff in Ireland.
o Community Services have been neglected in the past and now that there is a shift towards
providing more care in the community. These historic trends could also be an underlying
reason as to why not many professionals are/were drawn towards working in the
community.
Can you tell us a bit more about the relationship that you have with the Trust?
o
o
o
My relationship with the trust is limited to the frail elderly programme.
The relationship with the Trust has been positive. They have engaged with the Value
Based Commissioning Programme by attending workshops as well as a series of action
learning sets also being facilitated by the CCG.
The key contacts within the Trust for the Frail and Elderly programme are very responsive
and are always keen to engage.
Page 6 of 16
Strategic Alignment
What is the CCGs long term vision for CHS in Camden?
o
o
The CCGs long term vision aims to promote independence and support people to live at
home, reduce unplanned episodes of care and move from outputs to outcomes based
model of providing care.
In terms of the delivery of the Frail and Elderly programme the CCG work closely with
CNWL.
What is your understanding of your CNWL’s long term vision?
o
o
o
There has been quite a lot of engagement between the Trust and the CCG and the CCGs
long term vision focuses on improving the quality of care for Camden’s patients and would
be hard to disagree with. The vision of Trust would be to deliver against this vision and
achieve the CCGs long term goals.
Expect the provider to align their vision to delivering the commissioner’s vision.
The trust’s current portfolio being too broad, there is some scepticism on if the trust has
the capacity and the intention the focus on the specific areas of interest for Camden.
Camden CCG have two flagship programmes (LTCs & Frail and Elderly). Can you tell us
about CNWL’s role in delivering these?
o
o
o
o
o
o
o
o
The frail and elderly programme focuses on prevention, identification, assessment and
treatment.
At the moment the CCG are testing a range of models of care to evaluate their impact.
These include:
o Prevention (recruiting frail and elderly people to help facilitate and encourage
people to access services, rapid response team to prevent admissions to A&E)
o Identification (use of a frailty register, risk stratification tool used by GPs to help
with care planning and case management, piloting of social workers within GP
practices)
o Assessment & treatment (community based geriatricians, borough based MDTs)
CNWL provide some of these services with others such as the community based
geriatricians being provided by the Royal Free Hospital.
Currently 25% of the Frail and Elderly programme CHS is provided by CNWL. The
programme also pulls in resources from services being provided as part of the core
contract. MDT and Case managers are being provided as a separate investment.
Acknowledged that part of implementing the value based commissioning model of care an
IPU will be set up and hosted by a prime provider for April 2015. The decision of who will
host this is yet to be decided. Ideally this would be hosted by CNWL as they currently
provide CHS for Camden, however local GPs have expressed that they are not satisfied
with the services being provided by CNWL. Noted that the outputs of this appraisal will
influence the timescales of implementing the IPU.
Agreed that the risk of CNWL not being awarded the contract for the IPU could result in
delays to the programme and a loss of engagement.
Areas that are currently working well for the Trust include:
o Telehealth
o Rapid Response service
o MDT Hub
o Engaged clinical staff.
Areas where the Trust could improve include:
o Recruitment and retention of case managers
o Increased capacity for District Nurses
o Managing expectation with local GPs (re: boundary issues and raising awareness of
what services are on offer).
Other
Page 7 of 16
How well do you think CNWL works with other service providers in Camden?
o There is great integration at a clinical level and this can be seen through the successes of
the borough MDT.
In the last few years have there been any examples of new or innovative ways to the way
that community health services are being delivered in Camden?
 Rapid Response Service has been very successful.
 MDT hub has reduced approx. 50% of admissions and has demonstrated outcomes.
Is there anything that we may have missed that you would like to add?
 Must also consider the impact of Local Authority cuts and what the impact this will have
on the Frail and Elderly.
Value for Money
Are you aware of what services are provided by CNWL for Camden?
o
Was aware of what services were provided by CNWL for community health services
across Camden. Highlighted that this may not be the case for all Local GPs across
Camden as they access community services on a whole regardless of who provides
them.
How has the landscape changed over the past few years for CHS?
o
o
o
o
Noted that the main focus should be on the way that we want community health
services to work more integrated with Primary and Secondary care. Integration is
happening more and we need to think about how our community health services can
become more integrated with other providers.
Highlighted that it can often feel that services are still working in silo of each other but
acknowledged that progress had been made to integrate providers more.
Work was also needed to better support the planned care agenda to reduce unplanned
episodes of care. Noted that the current Heart Failure and COPD services had done
well to support this and that this model of operating needed to be embedded across all
community health services.
Highlighted that some local clinicians have expressed that they feel that the solution
would be to bring services back into Primary care. This would be complex and the
implications around this would need to be thought through in detail.
What do you think of the current services provided by CNWL?
o
o
o
o
o
Highlighted that this was a difficult question to answer without access to any
performance or benchmarking data.
Noted that overall Camden does need more care in community delivered
collaboratively by primary care secondary and third sector organisations. To achieve
this we would probably need to invest more. However, this approach has already been
tried with CNWL to help resolve some the issues that they have with staff shortages
and the absence of clinical leadership. Unfortunately this approach has not been very
successful and is not any easy issue to fix as issues such as recruitment still remain.
Suggested that one potential way to resolve some of these issues may be around
implementing contractual requirements as a way of embedding these services whereby
the Trust are obligated to deliver.
Noted that it was difficult to comment on what was working well as many of the
services were quite niche. However services such as district nursing, community heart
failure, COPD were working well in some areas. Acknowledged that for areas where
things weren’t working well it would be difficult to know if these services would be any
better should the CCG commission them from another local provider.
Must also consider that the metrics in place to monitor some of these services only
monitor whether they are meeting their targets and do not specifically measure against
outcomes. It is therefore very difficult to determine the level of quality being provided.
Page 8 of 16
o
Complaints about the services that they provide usually centre on the lack of patient
continuity as a result of changes in staffing. As well as confusion around roles and
responsibilities, poor communication in teams. All of which reflect the issues that the
Trust have with recruitment and the retention of staff.
Quality
What do you think your patients think about the community health services provided by
CNWL?
o
o
o
In terms of the basics the Trust deliver what they are contracted to do well.
Highlighted that that the Trust are not very good at providing a sense of competence to
patients, carers, partners and clinicians. This was noted as being very important for
any community health provider as perception is incredibly important as it forms the
basis for how well a service is perceived. If staff respect the organisation that they work
for and feel that the service they provide is of a high quality those that they come into
contact with will perceive this to be the case.
The Trust do not appear to be an organisation that is able to respond to changing
circumstances. This is incredibly important for any community health service as the
work is varied and is always changing. This must be managed effectively without
compromising on quality. This in particular was a concern as the Trust do not appear
able to flex as well as they may be needed to when demand increases.
What do you think your patients think about the community health services provided by
CNWL?
o
o
It can be difficult to know how patients perceive the service as we may only be
receiving feedback from a particular group of people.
Noted that it would be useful to have the option for a translator services as there are
many patients within Camden that may be excluded from providing feedback as
English is their second language.
Based on your experience do you think there any issues with recruiting & retaining staff in
the CHS workforce? What is the impact of this on you as a commissioner and as a
provider?
o The Trust have had ongoing issues with recruitment. Noted an example where the time
taken to mobilise staff into new posts had caused delays and impacted on the quality
of services. Explained that commissioners had pulled together a business case to
agree funding for three community nurses for the care planning and management of
frail and elderly complex patients. Once funding had been agreed it took the Trust up
to a year to recruit into the three new posts.
Can you tell us a bit more about the relationship that you have with the Trust?
o
o
Senior leadership have been good at maintaining relationships with the CCG and have
always been very responsive. Senior leadership appears to be disconnected to those
working within the community.
The Heart Failure service was acknowledged as a service that was working well and
was an area where this didn’t appear to be the case. This however could be more
about the individuals working within the service rather than the service itself.
Strategic Alignment
What is the CCGs long term vision for CHS in Camden?
o
The Main aim for community health services in Camden is to work towards drawing
care away from hospitals through the delivery of a much more integrated healthcare
system.
Page 9 of 16
o
Highlighted that what needs to be decided is whether this is done by packaging
community health services as a whole or separately.
What is your understanding of your CNWL’s long term vision?
o
o
As a Trust their vision is probably to grow their organisation like any business.
Noted that they are predominantly a mental health trust but beginning to expand in
community health services.
What is Camden’s plan to keep people out of hospital and what role does CHS/CNWL role
play in delivering this?
o
o
To work towards providing a fully integrated system whereby all local providers are
working to deliver against the same vision and pathways. The main goal is to ultimately
keep people out of hospital.
Highlighted barriers to achieving this with one example being the lack of shared IT
systems. Noted that CNWL has a role to play in resolving this challenge but haven’t to
date made an effort. It is important that the community provider are not the blockage
within the system as they have a role to play in improving integration.
Camden CCG have two flagship programmes (LTCs & Frail and Elderly). Can you tell us
about CNWL’s role in delivering these?
o
o
Highlighted that CNWL had proactively attended borough wide multi-disciplinary team
meetings as part of the frail and elderly programme and have also worked well to deliver a
good community heart failure and respiratory services as part of the LTCs programme.
Noted that the CCG would like to make the MDT hub a more formal arrangement and
CNWL had expressed an interest in becoming the lead provider of this. Highlighted
concerns around this as the CCG had previously offered funding of up to £1mil to all
providers who were able to reduce admissions and improve patient outcomes. CNWL did
not manage to obtain any of it and didn’t even appear to try.
Other
How well do you think CNWL works with other service providers in Camden?
o Noted that Trust had worked well with organisations such as the Royal Free when
delivering PACE and other services such as community diabetes and rapids.
In the last few years have there been any examples of new or innovative ways to the way
that community health services are being delivered in Camden?
o
Examples highlighted included:
o RAPIDS
o Reconfiguration of the therapies teams around local practices
o Community LTCs services. `
Is there anything that we may have missed that you would like to add?
Would be interested to know further detail around:
1. How we could structure the contract to get the things we expect? (i.e. metrics etc)
Value for Money
Are you aware of what services are provided by CNWL for Camden?
o
o
Noted that as a Commissioner knowledge of CNWL’s commissioning arrangements for
Adults CHS is limited.
As a GP accesses CHS services provided by CNWL including:
o District Nursing
o Podiatry
Page 10 of 16
o
o
Phlebotomy
Health Visiting
How has the landscape changed over the past few years for CHS?
o
o
o
Over the past few years as a GP there has been difficult in accessing services such
podiatry and district nursing.
Particular examples around wound care and being able to get a patient’s dressing
changed with an acceptable time frame were noted.
Acknowledged challenges related to the recruitment of District Nurses but highlighted that
the recruitment issues have definitely had an impact in the quality and responsiveness of
service.
What do you think of the current services provided by CNWL?
o
o
General feeling is that value for money has been compromised as GPs are having to take
on additional responsibilities to ensure that their patients receive a good quality of care.
Issues have been more prominent in Camden’s West Locality and as a result there has
been a large volume of complaints.
Quality
What do you think a good community health service for patients in Camden looks like?
o
o
A service that provides a District Nursing that is easily accessible, has good
communication links with local clinicians, is cost effective, available 24hrs a day (in line
with 7day services).
Noted that given the current financial climate and changes in demographics this may not
be easily achievable. Suggested solution highlighted as up skilling staff to take on
additional responsibilities to fill the current gaps in service.
What do you think your patients think about the community health services provided by
CNWL?
o
o
Main concerns highlighted by patients include:
o Staff not showing up for appointments or at an inappropriate time
o Staff not informing patients that they will be visiting
o Issues with continuity of care and patient’s care being managed by many
different Nurses. This can be confusing and often frightening for frail elderly
people as they do not recognise some of the staff being sent for appointments.
On balance the service is well respected by patients. However, it is these types of
issues that make a big impact on its reputation.
Based on your experience do you think there any issues with recruiting & retaining staff in
the CHS workforce? What is the impact of this on you as a commissioner and as a
provider?
o There has been issues with recruiting and retaining District Nurses. This however is a panLondon issue and not just a problem for CNWL.
o Experience as a GP is that the District Nurses that you do recruit are overworked as the
Trust hasn’t been able to plan effectively and meet demand. This can often result in low
staff morale and eventually a high turnover in the workforce.
o The Trust need to ensure that they have good incentives in place to retain staff (e.g. good
pay, staff benefits, support mechanisms)
Can you tell us a bit more about the relationship that you have with the Trust?
o
o
As a provider the relationship is poor. Their District Nurses haven’t attended a practice
MDT meeting in over 12 months.
Their management team have attended a locality meeting in the North to inform GPs about
the changes/improvements to the District Nursing Service.
Page 11 of 16
o
As a commissioner reports are submitted to us monthly in line with contractual
requirements.
Strategic Alignment
What is the CCGs long term vision for CHS in Camden?
o
To improve patient care and get the best value for money on an outcomes based model of
commissioning.
What is your understanding of your CNWL’s long term vision?
o
o
o
From a children’s commissioning perspective the Trust have been very proactive in
helping to coordinate services locally and rectify and performance concerns.
Only concern is that with regards to the District Nursing shortage the Trust failed to plan
effectively and mitigate against this risk before it materialised and impacted on the care of
Camden’s residents.
They have been a good partner to engage with, however better planning is needed.
What is Camden’s plan to keep people out of hospital and what role does CHS/CNWL role
play in delivering this?
o
o
To target those at high risk of being admitted to hospital and prevent any unplanned
episodes of care.
CNWL can support the delivery of this by being proactive in the steps that they take with
regards to prevention, communicate more efficiently with other local providers such as
GPs and practice staff, be adaptive and attend practice MDT meetings.
Other
How well do you think CNWL works with other service providers in Camden?
o Based on experience as a commissioner, CNWL have worked well with other local
providers and have made improvements. Eg. Children being seen out of the borough
o Improvements are also being made in terms of establishing communication links between
local GPs.
Is there anything that we may have missed that you would like to add?
o Co-commissioning with a joined up service improves patient outcomes. We should be
planning jointly with providers to implement a patient centric model of care that monitors
outcomes in the community (e.g. frail and elderly hubs)
Value for Money
Are you aware of what services are provided by CNWL for Camden?
o
o
o
o
Noted that as a GP accesses services provided by CNWL on a daily basis. As a
commissioner has only been involved in the Long Term Conditions work.
Highlighted that not all GPs may be aware of the services currently being provided to
CNWL.
Must take into consideration that CHS were originally provided by PCTs and were bundled
together as a result of changes within commissioning.
Noted the following services being provided to Camden by CNWL:
o Adult community and specialist nursing services
o Rapid response service.
How has the landscape changed over the past few years for CHS?
o
o
Has only worked in the borough for a short period of time but has noticed a gradual decline
in the quality of services provided.
As more activity shifts into the community there is and will continue to be a demand on
adult’s community health services. Particularly when you consider how dependant patients
with long term conditions or frail and elderly are on these services.
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What do you think of the current services provided by CNWL?
o
o
o
Many local GPs feel that the community nursing and health visiting services provided by
the trust are a cause for concern. Particularly around the quality of services.
There is clearly variation in quality across the patch. This could be due to a lack of clinical
leadership. The Trust appear to operate in an ‘old fashioned’ way driven by activity rather
than quality.
Noted that it is often difficult to identify what is working well as our perception of what is
good is based around expectations. These may not always be realistic.
Quality
What do you think a good community health service for patients in Camden looks like?
o
A service that is fully integrated, communicates well and works closely with other
healthcare providers and patients.
What do you think your patients think about the community health services provided by
CNWL?
o
o
Fortunately as a GP doesn’t hear a huge amount of negative feedback. Occasionally have
had reports that Nursing teams haven’t attended an appointment but this is very rare.
Most of the negative feedback from patients focuses on the Health Visiting service that the
Trust provides.
Based on your experience do you think there any issues with recruiting & retaining staff in
the CHS workforce? What is the impact of this on you as a commissioner and as a
provider?
o There have been issues with recruitment and retention of staff. Staff appear to generally
have a low morale and are not valued. More needs to be done to retain good quality staff
and attract them to working within the Trust. Discussed example whereby funding had
been agreed for 2 ½ full time Heart Failure Nurses within a new heart failure service.
There were initially issues with the speed of recruiting into these posts and subsequently
retaining those that were recruited. Similar issues were noted within the Respiratory Team.
o There were also delays to the Frail and Elderly programme to due issues with recruiting to
the Case Management positions needed for implementation.
o Noted that Trust must proactively focus on recruiting and retaining staff as a priority.
Can you tell us a bit more about the relationship that you have with the Trust?
o
o
Highlighted that there are a number of issues related to the ways that some of the services
communicate with GPS. Examples noted included:
o District Nurses faxing through patient information with a contact number that
connects your call to head office.
o Lack of continuity in the District Nursing service impacts on relationships with
practices as well as overall patient experience.
Noted that as community providers use different IT systems there is direct impact on how
well integrated GP services and community services integrate. A potential solution would
be to implement EMIS web within the community. This would enable Nursing Teams to
update patient records electronically. This solution has been suggested however it doesn’t
appear to be on the Trusts immediate list of priorities.
Strategic Alignment
What is the CCGs long term vision for CHS in Camden?
o
As CHS will only become more important as the demand for these services increases it is
fundamentally important that there is capacity within the system to support this. Therefore
community services within Camden will need to be of a high quality, able to meet demand
and fully integrated across health and social care.
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What is your understanding of your CNWL’s long term vision?
o
Unsure of the Trusts long term vision. This has never been communicated to us.
Camden CCG have two flagship programmes (LTCs & Frail and Elderly). Can you tell us
about CNWL’s role in delivering these?
o
The CCGs plans to avoid admissions to hospital for those patients who are Frail and
Elderly and/or suffer from long term condition centres around actively detecting those in
need and the proactively providing care in the community. CNWLs role (or any community
providers role) in providing the support and coordination elements for this model of care in
community is critical.
Other
How well do you think CNWL works with other service providers in Camden?
o Respiratory team are a great examples of where the Trust has integrated well with the
Acute Trust. Noted that this may be a result of individuals rather than the Trust’s approach.
Is there anything that we may have missed that you would like to add?
o There appears to be lack of clinical leadership within services. This impacts on the quality
of services provided and can create risks.
Value for Money
Are you aware of what services are provided by CNWL for Camden?
o
o
o
Acknowledged that more awareness around the services that CNWL provide would be
useful to manage expectations amongst local clinicians as there is uncertainty around
what is provided.
It would be useful to gain more of an insight into what local GPs and practices understand
as being provided by CNWL in comparison to what actually is (e.g. survey).
Highlighted that District Nursing, Inpatient community services and Rehab were provided
by CNWL. Uncertainty around podiatry and dietetics.
How has the landscape changed over the past few years for CHS?
o
o
As more activity moves into the community and the landscape changes the provider will
need to be able to respond to this level of demand.
There will be more of a need for better clinical supervision, working more effectively and
jointly with local providers. It would be useful to know what the Trusts plans are to support
this shift and deliver high quality community services.
What do you think of the current services provided by CNWL?
o
o
There have been complaints about some of the services that are provided by the Trust. In
particular around the service provided for managing ulcers as well as the competency of
some of their nurses in relation to prescribing. It would be useful to have a map of services
displaying the exact number of Nurses and in particular the detail around clinical
supervision arrangements.
To date the service hasn’t been consistent as some localities have received better quality
than others.
Quality
What do you think a good community health service for patients in Camden looks like?
o
Responsive, able to meet demand and have the capacity to be on top of things, able to
provide excellent continuity of care and communicate well with other local providers in
primary and secondary care.
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What do you think patients think about the community health services provided by CNWL?
o
o
Noted that we must be cautious of the patient satisfaction scores as response rates will
reflect the number patients on list sizes. Also consider the patient size of the service in
accounting the patient feedback for the service. For example a 90% response rate may be
from an inpatient service which is only a small percentage of the patient population.
The nurses have a lot of contact with frail and elderly housebound patients who have little
contact with the outside world and value the service that they receive. Hence it is critical
not only to consider patient feedback but also carers’ feedback. Camden carers have fed
back in the past that patients have reported being worried to highlight any issues they may
have through fear of care being withdrawn as a result.
Based on your experience do you think there any issues with recruiting & retaining staff in
the CHS workforce? What is the impact of this on commissioning?
o Noted that the Trust had recently restructured their services and could be part of the
reason why their vacancy rates appear to have reduced. It would be useful to compare the
number of nursing posts in the previous organisation structure to the number of posts in
the new structure. This may provide more of an accurate picture in terms of recruitment.
o Highlighted that the Trust had struggled to recruit band 7’s however also acknowledged
that this has been a pan-London issue.
o Clinical supervision, governance and reporting on issues has been really poor.
Strategic Alignment
What is your understanding of your CNWL’s long term vision?
o
Highlighted that the Trust have recently started to provide services in Milton Keynes and
appear to be more focused on this side of their business. Noted that within their annual
reports and Quality Accounts the Trust paid little attention to the services that they provide
to Camden and Hillingdon. This raises the question of how important the services provided
to Camden and Hillingdon are to the trust particularly on a strategic level. It was noted that
these concerns had already been shared with the Trust.
Camden CCG have two flagship programmes (LTCs & Frail and Elderly). Can you tell us
about CNWL’s role in delivering these?
o
The CCG are working on a number of transformational programmes and need assurance
from the trust that they are able to support the delivery of these (demand and capacity).
Other
How well do you think CNWL works with other service providers in Camden?
o There have been issues around discharging patients from the acute back into the
community as a result of the breakdown in communication between the different agencies
involved. It would be helpful to know what escalation processes CNWL have in place with
other providers to mitigate against these sorts of issues.
o These concerns have been raised with the Trust and the CCG have offered support
around addressing these issues with any local providers that are causing blockages in the
system.
o CNWL should be working with providers to think and plan for what a more integrated
health service would like.
o We know that the Trust are probably treating more patients with complex needs than ever
before. It would be useful to know how the Trust are planning for increase
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Is there anything that we may have missed that you would like to add?
o CNWL have become more transparent with raising issues before they materialise in the
last 12 months. They have been engaged through regular meetings with the CCG where
these issues are discussed.
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