North Norfolk Primary Care
Quality Account
2021/22
“Putting the patient central to the delivery of quality healthcare for the local community and beyond”
CONTENTS
Section One: OUR MISSION, VISION, AND VALUES .................................................................. 3
1.1 Our Mission and Vision ........................................................................................................... 3
1.2 Our Values ................................................................................................................................ 3
Section Two: THE ORGANISATION - NNPC ................................................................................ 4
2.1 Introduction .............................................................................................................................. 4
2.2 Forward from our Chair & CEO............................................................................................... 4
2.3 CQC Statement of Purpose ..................................................................................................... 6
2.4 Our services ............................................................................................................................. 7
2.4.1 Core .................................................................................................................................... 7
2.4.2 Innovation, Elective Recovery, & Community Services ................................................. 8
2.4.3 Urgent and Emergency Care............................................................................................. 9
Section Three: CLINICAL QUALITY & SAFETY ......................................................................... 10
3.1 Clinical Governance strategy ............................................................................................ 10
3.2 Information Governance and data protection strategy ................................................... 12
3.3 Our Key Achievements in 2021/22........................................................................................ 13
3.3.1 Clinical, Quality Assuring, & Patient Safety auditing ................................................... 13
3.3.2 HSJ awards ...................................................................................................................... 16
3.3.3 CQC inspection June 2021.............................................................................................. 17
3.3.4 Supporting Staff – Culture & Well-being........................................................................ 17
3.3.5 Education and Training ................................................................................................... 18
3.3.6 Service Evaluations and performance ........................................................................... 18
3.4 Our Key Priorities in 2022/23 ................................................................................................ 20
3.4.1 Clinical supervision implementation ............................................................................. 20
3.4.2 Patient & Staff experience – bespoke questionnaires.................................................. 20
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3.4.3 Performance Scorecard .................................................................................................. 20
3.4.4 Quality & Safety Meetings at Service Level................................................................... 20
3.4.5 Development of Quality & Safety Committee Agenda .................................................. 20
3.4.6 Clinical education & Training ......................................................................................... 20
3.4.7 Development of investigations into incident reports ................................................... 20
3.4.8 Safeguarding .................................................................................................................... 21
3.4.9 Complaint Handling ......................................................................................................... 21
3.4.10 Communications............................................................................................................ 21
3.5 Patient Safety & Quality......................................................................................................... 21
3.6 Patient & Staff Feedback ....................................................................................................... 23
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SECTION ONE: OUR MISSION, VISION, AND VALUES
1.1 OUR MISSION AND VISION
Our mission is to be a “leading force in healthcare innovation and delivery, making the system better by working with and on behalf of Primary Care in North Norfolk and beyond – with improvement in patient care at the heart of our work” James Leeming, NNPC CEO Our vision is to be an outstanding provider of healthcare services with the unified, passionate drive to delivering innovative, high-quality services. We aim to ensure that the organisation is sustainable to enable it to attract a forward thinking, highly skilled and committed workforce to work towards this common goal.
1.2 OUR VALUES
Care – Quality patient focussed, holistic health care in the local community and beyond. Integrity – Acting ethically and remaining accountable
Collaboration – Partnering to work together to deliver quality health care services
CARE
INTEGRITY
COLLABORATION
CORE VALUES
Leadership – Leading the way, building relationships & trust and being efficient
LEADERSHIP
ACCESSIBILITY
TEAMWORK
Accessibility – Inclusive and open to all
Teamwork - We aim to ensure that our shared values are adopted and incorporated into our team. We aim to appreciate and value each other to enable us to undertake our work in a safe, happy environment
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SECTION TWO: THE ORGANISATION - NNPC
2.1 INTRODUCTION North Norfolk Primary Care Ltd (NNPC) was incorporated in July 2017. It is wholly owned by the 19 Practices in North Norfolk and has seen growth from a small company to an organisation with 65+ employees which has successfully embedded in the delivery of innovative, high quality health care services in North Norfolk and beyond. The aim of the organisation is to support resilience and sustainability by focusing on improving care for patients within the health care system of Norfolk and Waveney, in conjunction with supporting the diverse workforce within Primary Care. It also aims to provide high quality clinical services working closely with the NHS Norfolk & Waveney ICB to integrate communities and services for the benefit of patients. The ongoing aim and goal for NNPC is to form part of a team which co-ordinates innovation in healthcare delivery by developing a strategy together, and in partnership with, Primary & Secondary Care, Community services, Mental Health Services, Ambulance Trusts, local councils, Social Care, and Voluntary Sector providers. We aim to be key players in a system which is facing the biggest challenges in healthcare yet. The purpose of this Quality Account is to provide information and assurance to our patients, staff, Board and stakeholders about how NNPC does and will continue to provide safe, high-quality services which is responsive to the needs of patients, communities, staff and stakeholders. It will provide the reader with information to understand our organisation and how we implement measures to ensure that patient safety and quality of care is delivered and how we have performed during the 2021-22 year (April 2021 – March 2022). 2.2 FORWARD FROM OUR CHAIR & CEO Now in its 5 th year of operating, NNPC has continued to provide support to the 19 North Norfolk GP practices. Just to give some examples of the support we provide, we have continued to respond to the impact of the ever-present challenges of the COVID-19 pandemic of the past 2 years, supported with and co-ordinated the delivery core services, continued with providing a PCN support team, co-ordinated and supported with the employment of Additional Reimbursed Role Staff (ARRS) for the PCN’s . These challenges have required our workforce to adapt and change the way they work to respond to rapidly changing demands in Primary Care. We have continued to work in collaboration with the local Community Trust to plan and deliver a covid vaccination programme, amongst other pilot schemes to improve patient care to bring healthcare delivery to the heart of the community. We have also worked to support Secondary Care in their post-pandemic recovery in areas such as elective care / waiting lists – in specialities such as gynaecology, cardiology, ophthalmology, and ENT, which has brought patient care closer to home.
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In the 2021/22 period, we have sadly seen the Phlebotomy and Enhanced Care Home Team being locally decommissioned. On a positive note, however, we have seen the continuation of the Dermatology Service providing remote advice and treatment services. This service was initially commissioned as a pilot in January 2021 by NHS Norfolk and Waveney CCG, in which NNPC facilitates the clinical delivery between practices and an external dermatology service provider. This service was subsequently successfully rolled out to North Norfolk and beyond, which saw the service continuate until May 2022. We have also been successful in the GP Front Door Steaming Service being effectively implemented at the James Paget University Hospital NHS Trust in late September 2021, which was followed by The Queen Elizabeth Hospital NHS Trust in early January 2022. Working in collaboration with the Trusts have made an impactful, demonstratable, positive difference to the patient experience and is reducing the flow of activity through the ED departments. In June 2021, we successfully developed and implemented one of the first Primary Care Led Rapid Diagnostic Service in North Norfolk, which was rolled out to other areas in September and December 2021. This service has brought together the Cancer Alliance and NNPC to deliver a vital service wholly to the benefit for patients who do not meet the 2 week wait cancer referral criteria but have suspicious symptoms. Needless to say, the patient feedback has been very positive and has provided much valued and needed support to the Acute Trusts and General Practice. NNPC has also continued to liaise and work in collaboration with other healthcare organisations, such as Norwich Community Health and Care (NCHC), East Coast Community Health (ECCH) & East of England Ambulance Service Trust (EEAST), as well as working with Acute services and other health service providers on pathway change and implementation. Throughout this time, our objectives have continued to be to: • Develop an at scale Primary Care provider that is ready to serve the local population • Drive funding into Primary Care • Develop the Primary Care workforce • Integrate and develop services where needed to improve efficiency and productivity • Support practice collaboration across North Norfolk • Influence, contribute and lead system change and transformation We remain fully committed to our mission, vision, values and strategy for the delivery of high- quality service provision for patients, whilst also supporting our staff in achieving these goals. We are enormously proud of the persistent hard work displayed by our teams who are all dedicated to ensuring high quality, patient-focused care. We aim to provide quality assurances to our patients, staff, Board, and stakeholders via this Quality Account, and to use this as a platform to demonstrate plans for continuous care quality improvements as we head into 2022/23.
NNPC Quality Account 2021/22 Dr Peter Lawson, Chair James Leeming, CEO
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2.3 CQC STATEMENT OF PURPOSE The objectives in the CQC statement of purpose reflects the organisations mission, vision, values, beliefs, culture, and purpose. NNPC has held an APMS contract for Improved Access and an NHS standard or sub-contracts for other services. Our clinical services are delivered in GP Practices, Acute Emergency and Urgent Care, and in the Community setting. They are delivered by a range of clinicians such as General Practitioners, Consultants in specialist areas, Advanced Nurse Practitioners, Clinical Pharmacists, Pharmacy Technicians, Physiotherapists, and Paramedics. The main aims outlined in the statement of purpose are: • To work in partnership with our service users towards a positive experience and understanding, involving them and their parents/carers/guardians in decision making about their treatment and care • To be a learning organisation that continually improves what we are able to offer patients • To treat service users as individuals and with the same respect we would want for ourselves or a member or our families, listening and supporting people to express their needs and wants and enabling people to maintain the maximum possible level of independence, choice and control • To ensure that we take close account of feedback about the services that we offer • To ensure that all staff have the competency and motivation to deliver the required standards of care ensuring that all members of the team have the right skills and training to carry out their duties competently • To operate with a wide range of policies that ensure the ongoing safety of patients, as well as delivering an effective and responsive service • To operate on a financially sound basis • To improve the service through feedback from patients • To ensure confidentiality and data protection for each patient
The skills framework for the Board encompasses General Practitioners, Senior Nurses, General Practice Managers, Finance, and Business Managers.
The CQC Registered Manager is James Leeming, CEO.
The nominated individual for regulated activities is Dr Peter Lawson, Chair.
The CQC regulated activities for NNPC are:
- Treatment of disease, disorder and injury - Diagnostic and Screening procedures - Maternity and Midwifery Services
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2.4 OUR SERVICES
2.4.1 CORE Improved Access (IA) & Extended Hours (EH)
IA and EH has been delivered since the inception of NNPC and we have traditionally delivered this from HUB sites in the early evening and at weekends. Over the course of the COVID-19 pandemic, IA was used to deliver a ‘Hot Site’ and extra clinical capacity to practices via V irtual Clinical Teams. When we stood down the Hot Site in March 2021, we then progressed with discussions within the PCNs to understand exactly what practices wanted from the IA service. As expected, each PCN wanted something slightly different, and more practices wanted to become HUB sites – which is now standing at 8 hub sites. We deliver a more locally bespoke service within each PCN than what was initially launched. We utilise a ‘locum’ workforce and/or local practice GPs, ANPs and NPs to staff this service. With the advent of extended hours being evolved into enhanced access though the network contract DES in October 2022, it is expected that NNPC will again provide a bespoke model to the PCN’s to support delivery of this model. This will involve working closely with the PCN’s to ensure that it meets the needs of the patients with flexible working for staff. Primary Care Network (PCN) support Team - Additional Roles Reimbursement Scheme (ARRS) The PCN support team has continued to work with the 4 North Norfolk PCNs to develop networks, shared ways of working, interpreting NHSE and local policy, general practice direction of travel and the implementation of the Additional Reimbursable Roles Scheme (ARRS) within the PCN areas. The PCN Support Team has also continued to work throughout the year to support the recruitment and employment of incoming shared staff to the networks via the Additional Roles Reimbursement Scheme (ARRS), such as Clinical Pharmacists, pharmacy technicians, and First Contact Physiotherapists. By end of March 2022, NNPC directly employed 22 members of staff in ARRS roles over the 4 PCN areas and has facilitated in the employment of many more which are directly employed by the Practices. The PCN Clinical Support Manager role was developed in 2021 to act as a facilitator between NNPC and the practices ensuring smooth induction and ongoing clinical supervision as well as dealing with day-to-day HR issues. NNPC provides quality assurance in many aspects of the management of the ARRS staff. Phlebotomy In October 2019 NNPC commenced the Phlebotomy Service located at Cromer Group Practice providing primary care-based phlebotomy for practices who were not signed up to the LCS for Phlebotomy. The service continued to support the Practices and was decommissioned by Norfolk & Waveney CCG in March 2022 due to the introduction of the new LCS for phlebotomy to being delivered at local Practice level.
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Enhanced Care Home Team (ECHT) As an award-winning team, the ECHT has continued to provide flexibility and support to the Practices throughout the year, working to support care homes with extra capacity for general home visiting and the delivery of the care home covid vaccination programme. This service was decommissioned as of 31st March 2022 with Norfolk & Waveney CCG. NNPC Health and Safety Service The appointment of a Health and Safety (H&S) Officer in February 2020 has enabled NNPC to provide a service to practices throughout the pandemic, and beyond. The H&S Officer has visited practices to complete risk assessments for safe working environments and helped practices with changes to Fire Safety, PPE and IP&C requirements. The H&S officer has also provided expertise to practices in completing risk assessments and checking policies in preparation for CQC visits and to help practices comply with their legal responsibilities. COVID specific health and safety risk assessments have been completed at practices were requested and for NNPC staff. 2.4.2 INNOVATION, ELECTIVE RECOVERY, & COMMUNITY SERVICES Elective Recovery – Primary Care Triage and Elective Waiting List Optimisation As part of the national drive to deliver elective care recovery we were awarded short term contracts in October – December 2021 to provide elective triage to patients who have waited for elective care in excess of 40 weeks within the North Central London CCG. This service has been provided in partnership with Prescribing Services Ltd (PSL) and uses Eclipse Live, a risk-assessment system which applies an algorithm to assess the health risk to patients in conjunction with the patient’s own views on their health and condition, including pain, quality of life and need to be seen quickly. The service is provided under an NHS contract and has potential to be rolled out more widely if this contract is successful. Community Gynaecology Service The community gynaecology service demonstrated collaborative working with the Norfolk & Norwich University Hospitals NHS Trust (NNUH) and was commenced primarily for patients who were on a waiting list with a Heavy Menstrual Bleeding referral. The aim of the service was to review, assess and treat (where necessary) 150 patients in the community setting. This commenced on the 1 st to15 th March 2022, and it is hoped that this type of specialist service will lead to further work in this area and other specialties with other Acute Trusts to aid patient care in a timely manner. After this project has ended, a service evaluation will take place to provide stakeholders with evidence of the value of the service for them and patients alike. Community Dermatology In January 2021, NNPC launched the Dermatology pathway providing remote advice and treatment services. This service was commissioned by NHS Norfolk and Waveney CCG and NNPC facilitated the clinical delivery between practices and an external Dermatology provider. This was initially rolled out to 6 practices in North Norfolk before being implemented more widely across Norfolk & Waveney. The service operates by providing practice clinicians with specialist advice on dermatological conditions via a digital communication platform called Cinapsis. This allows dialogue between the practice clinician and the specialist to establish a detailed management
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plan for the patient, all within 72 hours of the initial contact. This service was provided until March 2022, after which a business case was requested by the Commissioners. This is due to be considered by the ICB CEO’s in June 2022. Community ECG Service Commenced in early March 2022 and is due for completion by September 2022, the community ECG service was a collaboration with the James Paget University Hospital NHS Trust (JPUH) and the Queen Elizabeth Hospital NHS Trust (QEH) to provide a high quality ambulatory diagnostic cardiology service which enables the patient to receive a package of care delivered at home instead of having to travel to the Acute Trust to be provided and fitted with an ambulatory ECG machine. This service has seen the advent of an innovative, remote monitoring system solution which is patient friendly with no gels, patches or wires. It provided a full disclosure ECG data and diagnostic reports which are provided within 24 hours of test completion. Referral Support Service The referral support service commenced in October 2021 and is due to be completed in June 2022, with the aim of reducing the numbers of patients waiting to be seen by multiple specialties. This work was in collaboration with the Royal Free London NHS Trust (RFL) to identify patient groups who were ‘referred but waiting to be seen’. These patient cohorts were reviewed, triaged, optimised or escalated by a Primary Care Team. An overview of the numbers of patients who will benefit from this service is 700 ENT Patients, 1335 Dermatology Patients, & 2000 Ophthalmology Patients. Rapid Diagnostic Service Commenced in April 2021, NNPC was awarded a contract to provide a rapid diagnostic service across Norfolk & Waveney which supported the national cancer plan. This hugely valuable service provided support to both GP’s and the acute Trusts for the benefit of patients who did not meet the 2 week wait cancer referral pathway, but still had identifiable suspicious symptoms. It continues to provide the patients with timely access to dedicated GP’s, whom NNPC employs, who co-ordinates a plan of care to identify a diagnosis by access to timely investigations and clinical expertise. The service has a mixture of telephone triage, and face to face appointments. As this type of service remain a national priority until March 2024, and NNPC are hopeful that we can retain funding from the Cancer Alliance and bid for substantive funding from the commissioners to establish and expand the service as a permanent pathway across the system.
2.4.3 URGENT AND EMERGENCY CARE GP at the Front Door (GPFD)
In late September 2021, we commenced a ‘ GP at the front door ’ service at the James Paget Hospital University NHS Trust (JPUH) and at the Queen Elizabeth Hospital NHS Trust (QEH) in early January 2022. The clinical delivery is based on a simple streaming model, and it function as a GP ‘branch practice’ . With full access to patient records, it enables the safe and effective delivery of primary care to patients who would have otherwise been seen in the ED department.
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SECTION THREE: CLINICAL QUALITY AND SAFETY
3.1 CLINICAL GOVERNANCE STRATEGY
We have a well-established Quality & Safety Committee reporting system to the Board which provides assurance on the provision of safe and high-quality care to the population of patient who we serve. The Committee is established in accordance with the Articles of Association and Board Terms of Reference. The implementation of our clinical governance strategy, which is incorporated into the Quality & Safety Committee, includes:
1. Clinical Effectiveness ▪
Clinical audit
▪
Prescribing compliance Policies and protocols
▪
▪ Project/service delivery review and evaluation
2. Service user safety ▪
Incident reporting and management
▪
Safety alert management
▪
Risk management
▪
Fit and proper persons/safe staffing
3. Service user experience ▪
Patient feedback
▪
Service user experience surveys Quality of care surveys/audits
▪
4. Staff experience ▪
Mandatory training
Revalidation & appraisal Education and training
▪
▪
The Committee has the duty and responsibility to review and have oversight of quality, safety and information governance in relation to the following areas, which are standing items on the monthly agenda: Pan Domain: Project/service overview for existing & developing services, which incorporates all aspects of risk management, governance (clinical and IG), quality and safety in the delivery of healthcare Safety & Caring Domain: Review, approve and monitor those risks on the Corporate Risk Register which relate to Patient Safety & Quality and high-risk operational risks which could impact on patient care. Ensuring that an appropriate comprehensive quality & information governance framework and system is in place throughout the NNPC organisation which is in line with national standards. New projects are designed and implemented using Project Initiation documents which include Quality, Equality and Data Protection Impact Assessments with risks being identified and managed throughout. All new projects are taken through the Quality Committee for quality assurances and reported through to the Board.
Effectiveness & Responsive Domain: Demonstrating service improvement and safety through audit which, for example, demonstrates compliance with safeguarding adults & children, infection
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prevention & control, and all aspects of patient care delivery. Ensuring that information is effectively managed, and that appropriate policies, procedures and management accountability are provided and approved in relation to confidentiality, security and records management. Effectiveness & Well Led Domain: Demonstrate to the Committee any education, training and research which contributes to the delivery of high standards in patient care and clinician support. Assuring the NNPC Board that all person identifiable information is processed in accordance with the General Data Protection Regulations and that all staff are aware and comply with the NHS Code of Confidentiality and other professional codes of conduct. An example of how quality assurances are achieved is through the consistent approach of an impartial, detailed, qualitative and quantitative internal and / or third-party service evaluation. We aim to provide these for all of our pilot projects to demonstrate clinical effectiveness through critical appraisal in a way to suggest quality improvements where required. There will be illustrations of these for selected clinical services later in this account.
NNPC Clinical Governance Framework
LEARNING AND SHARING
IMPROVING QUALITY OF CARE
ACCOUNTABILITY & TRANSPARENCY
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3.2 INFORMATION GOVERNANCE AND DATA PROTECTION STRATEGY NNPC recognises the need for an appropriate balance between openness and confidentiality in the management and use of information. Information Governance requires the organisation to set a high standard for the handling of information. The aim is to demonstrate that we can be trusted to maintain the confidentiality and security of personal information, by helping individuals to practice good information governance. NNPC’s Data Security and Protection Toolkit overall score for 2021/22 was ‘standards met’ . NNPC has appointed an external Data Protection Officer (DPO) and the information Governance Lead and SIRO meet every other month to discuss IG risks and how these are managed. The fair processing, privacy notices and systems access lists are reviewed annually and approved by the Data Protection Officer.
The NPPC Senior Information Risk Officer (SIRO):
• leads and fosters a culture that values, protects and uses information for the success of the organisation and benefit of its customers. • owns the organisation’s overall information risk policy and risk assessment processes and ensuring they are implemented consistently by Information Asset Owners / Administrators. • Owns the organisation’s information incident management framework. The nominated NNPC Caldicott Guardian is a member of the Board, alongside with the SIRO and the DPO, is committed to the privacy of its patients, staff, and the public. In the year 2021/22 there has been no data security or data protection incidents reported. The annual data security audit did not highlight any issues. This was validated by the DPO.
NNPC Information Governance Framework
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3.3 OUR KEY ACHIEVEMENTS IN 2021/22
3.3.1 CLINICAL, QUALITY ASSURING, & PATIENT SAFETY AUDITING Clinical audit is undertaken to systematically review the care that the Trust provides to patients against best practice standards and is an essential activity to take actions to improve the care provided. In 2021-22 we have conducted audits which evaluates the quality and safety of services across infection control, safeguarding, administrative, information governance, and quality assurance. Examples of some of the audit activity is listed below in Table 1, relevant to the services we provide. The way in which audits are presented provides a clear and concise method, benchmarks of standards, outcomes of the audit, and action plans put in place when required. These are all agreed and validated by the service and clinical leads who then presents them to the Quality Committee monthly.
The number of clinical and administrative audits carried out in 2021/22: 27
Table 1
Service
Standard Area
Audit Aim
Date
Outcomes: Key findings
Recommandations, changes, comment, or improvements
Criteria 1 - The process for the storage and provision of Emergency Drugs and resuscitation equipment at the IA hubs is clear to all Practices. 100 % compliant. Criteria 2 - All 4 sites had emergency equipment in line with the recommendations and was readily available in one place. 75 % compliant. Criteria 3 - All 4 sites had emergency equipment readily available in one place. Awaiting confirmation of weekly checks from Site 1. 100 % compliant. Criteria 4 - All 4 sites have completed risk assessments in the areas of legionella, PAT testing, Fire RA, Cleaning schedules and audits and IPC audits are being chased from sites 1, 2, and 3. 25 % compliant. This audit demonstrated an overall 90% compliance with the standards set in each of the 8 criteria’s (previously 72.5%, 83%, & 72%). Therefore, this demonstrates some success in the ongoing training and education programme, and the implementation plans of 1:1 clinical supervision. The implementation of both of those elements were based on the results of the 2 nd re-audit, and the results of the 3 rd re-
Improved Access & Enhanced Access (IA/EA)
Quality Assurance & Patient Safety
The audit is designed to measure compliance against criteria set from the CQC recommended set of emergency drugs and equipment which should be available at GP practices, H&S, and IP&C standards at all 6 IA hubs.
04- 05.2021, undertaken quarterly
The QA visits to continue 4-6 weekly until such time as the hubs are 100% compliant. Outcome: Achieved over the period of 08-12.2021
Enhanced Care Home Team (ECHT)
Quality Assurance & Patient Safety
This ongoing audit is designed to demonstrate compliance with good governance in documentation of consultations and to facilitate the identification of any further ongoing training needs.
06.2021, undertaken quarterly
Lessons learned from this is that the re-audit has clearly demonstrated that to provide regular, ongoing support, targeted teaching, clinical supervision does go some way to improve the outcomes and quality of the ECHT’s the quality of their consultation documentation. Outcome: Bespoke teaching and education programme is continually reviewed to meet the needs of the team. Clinical supervision sessions continue to be integral to the support given to the team.
audit clearly demonstrates some measurable success in those plans.
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Phlebotomy and Rapid Diagnostic Service (RDS)
Infection Prevention & Control / Patient Safety
06.2021
Phlebotomy: 100% compliance RDS: 90% compliance to 100% with measures to address areas of concern
Implementation and validation of standards maintained and checked with daily IP&C checks Outcome: 100% compliance achieved by end 07.2021
To provide NNPC with a framework with which to manage and monitor the practice for infection control purposes and CQC compliance (Regulation 15 re: premises, as well as the registration requirement that practices are charged with "assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated").
Child Safeguarding audit: Who is accompanying the child and clear documentation of who has given consent UTI Audit – ECHT clinician
Safeguarding To ensure compliance with standards set in the NNPC Policies - consent, safeguarding children, and phlebotomy & blood
06.2021
57% overall compliance against expected standards.
Education and training implemented to address areas of education and learning for staff. Recommended to re- audit in 6-8 weeks after training is put into place Outcome: Achieved 100% compliance in 08.2021 The first recommendation is for the clinicians to be reminded or the PHE (2020) guidelines for diagnosis and prescribing of UTIs in the over 65s. This recommendation would also involve clinicians ensuring they keep up to date with own learning and changes to guidance. The second recommendation is ongoing support and clinical supervision with ACP and NP clinicians specifically including telephone assessment. A third recommendation is ongoing training in leadership and improvement of services which in turn will help to support change of routine and habits within healthcare clinicians but also with care home staff. The lead clinician from each PCN involved in the audit will engage with care home staff to identify their current knowledge and what learning needs they may have regarding UTI management and diagnosis. The fourth recommendation is for continued training and support in the use of available IT tools such as templates and formulary guidance to allow for prompts, appropriate documentation and prescribing. Outcome: Audit results were distributed to Practices, learning needs identified, supervision and education to be implemented, and engagement with care homes about UTI management was undertaken. The staff member who carried out this audit left NNPC employment before a re-audit was undertaken.
handling. To highlight any areas of learning required by the clinical staff
Service improvement, Quality Assurance & Patient Safety
A service improvement audit will be undertaken as part of the clinicians MSc studies. The aim is to identify a specific area in the assessment / treatment of UTI and carry out the audit – medicines management. Title: ‘ A clinical audit to evaluate the compliance of using Public Health England: Diagnosis of urinary tract infections in diagnosing and prescribing for urinary tract infections in the over 65s’ Objective 1: To ensure diagnosis of UTIs in over 65s is accurate, evidence based and safe Objective 2: To ensure any prescriptions for treatment of UTIs in over 65s is in line with current guidance and formulary
Commenced 03.2021 Completed 06.2021
Overall compliance for objectives 1 & 2 diagnosis was 36%- not meeting the target of 100% Overall compliance for objectives 1 & 2 prescribing was 48% - not meeting the target of 100% The 25 consultations audited consisted of 12 GP, 10 Nurse practitioner (NP) and 3 Advanced clinical practitioner (ACP) consultations, with 19 of those being telephone based and 6 being face to face. All the 6 face to face consultations were carried out by NPs or ACPs which during this time were part of the care home visiting team supporting the surgeries throughout the pandemic. 21 of the consultations audited were female and 4 males, this equates to 84% and 16% respectively. 12 out of 25 (48%) consultations used a urine dipstick to aid in diagnosis. In 2 out of the 6 (33.3%) face to face consultations a urine dipstick was used compared to 10 out of 19 (52.6%) via telephone. In those prescribed antibiotics 16 out of 25 (64%) had an MSU sent. Of which 7 of these (43.7%) returned negative for infection, 4 out of these 7 (57.1%) consultations used a urine dipstick to aid their diagnosis. 43.7% of these patients received inappropriate antibiotics.
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RDS
Clinical Audit Aims: Explore the number of rejected patient referrals to the RDS Why the referrals were rejected
11.2021
To date 4 x patients have been rejected as not meeting the referral criteria. 1x patient – an elderly male denied any knowledge of the referral and refused our offer of an appointment so we could explain F2F. 3x patients had not had the SNSS Panel completed, the bloods had not been requested on ICE, the patients had not had recent bloods completed – although we have not formally agreed a criterion for “recent” 12/52 would generally be considered as recent. 1x of the referrals was made by an ANP – this was an excellent consultation, carefully documented with good broad questioning and thorough examination – sadly the patient had not had bloods for 17 weeks. This patient could have been placed on 2x 2WW from reading the consultation and this would have been more appropriate if the blood results had supported the clinical reasoning. Rejecting the referral on the day the referral was made prevent possible patient delay – we of course welcomed the resubmission once the bloods had been completed. 2x of the referrals we suspect were made by Trainees or possibly Locums – although Grade was not documented these were doctors who did not appear on staffing lists – this would perhaps explain their failure to meet the referral criteria. JPUH - Overall compliance with the standards is 99%. This demonstrates a good quality of consultation documentation when analysed against the 8 criterions. QEH - Overall compliance with the standards is 99 %. This demonstrates an excellent quality of consultation documentation when analysed against the 8 criteria. Completed for all clinical services and general aspects of the clinician and patient safety in S1 Community Unit. Shared with DPO / Governance Lead. Separate document to evidence audit & shared with Quality & Safety Committee. Plan to keep the audit updated as issues and resolutions to these arise, where required .
Reinforce in teaching/COMMS the need for the SNSS Panel. Agree within The Team on the criteria for “RECENT BLOODS” Outcome: Action planning included Teaching/Comms – clear message given to Clinicians. Explain clearly the reason why we have rejected a referral Agree within The Team on the criteria for “RECENT BLOODS” both actions were led by the RDS clinical team and led to changes in processes in relation to referral acceptance and rejection.
Can the Service improve its information “Comms” to prevent these rejections OR Should the RDS change its SOP to prevent any rejections.
GP at the Front Door Service (GPFD) at JPUH & QEH - Consultation Quality Documentation Audit Corporate – IG, Patient & Clinical Safety of the
Quality Assurance & Patient Safety
This ongoing audit is designed to demonstrate compliance with good governance in documentation of consultations and to facilitate the identification of any further ongoing training needs. To identify and address actual and potential patient and clinical safety issues across ALL services
02- 03.2022, carried out quarterly
Reaudit on a 3 monthly basis Communicate the audit results and standards expected to the GPFD clinicians to reaffirm and validate audit results Outcome: Audit placed on the audit schedule for continual review of the maintenance of standards. Outcome: As a result of this audit, there were several measures implemented to improve patient and clinician safety – such as the introduction of Docman, the admin processing of tasks and communications & letters, information governance procedures and handling. This is an ongoing process to assure the Board of corporate compliance with data privacy and security.
Quality Assurance & Patient Safety
02.2022
SystmOne Community Unit
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3.3.2 HSJ AWARDS
NNPC and Xyla Elective Care became the proud finalists in the 2021 Health Service Journal (HSJ) awards in the category of ‘ Primary Care Innovation of the Year ’ for the tele-dermatology project which was delivered across Norfolk & Waveney from January to December 2021. The HSJ award ceremony was held on the 18 th of November 2021, and was attended by the NNPC Chair, Senior Management Team, the service and clinical leads who were involved in the service delivery. Although not winners of the category, the service was recognised for the impact of the service on reducing waiting times from 50 weeks to 48 hours with photo advice and guidance. This hugely valuable service is a good example of how innovative ways of working in partnership can have a positive impact on patient care. It also demonstrated how the application of education and training can benefit the clinicians in Primary Care.
NNPC Quality Account 2021/22
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3.3.3 CQC INSPECTION JUNE 2021
The first CQC inspection took place in September 2019 and resulted in a ‘Requires improvement’ rating. Whilst we were disappointed in the rating of ‘ Requires I mprovement’, our reinspection of those areas, on 17 th June 2021, led to us being overall rated as ‘ Good ’.
3.3.4 SUPPORTING STAFF – CULTURE & WELL-BEING Our staff have a strong focus on the needs of the patients and the communities we serve, which is reflected in a display of outstanding resilience, flexibility, adaptability, commitment and dedication. The support which is embedded in the organisation has resulted in no staff safeguarding concerns being reported. The ‘Freedom to Speak up Guardian ’ and the deputy both sit on the Quality & Safety Committee and ensures that the staff are up to date with information on how to report any concerns which they may encounter. This validated by confirming that staff have undertaken their mandatory training, it is accurately recorded, and that the updating of policies is in line with requirements. A clear display of who and how to report any concerns is present in the appropriate areas of work. The organisation has developed a more effective sickness recording process, improved policies and processes with full access to an occupational health service to support staff with health conditions. Core and clinical staff surveys will be undertaken as an aid to highlight any areas which we are doing well and could do better. These will be used to formulate plans to make improvements, where required.
NNPC Quality Account 2021/22
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3.3.5 EDUCATION AND TRAINING Dermatology Teaching Events
As part of the development of the dermatology service in January 2021, NNPC embarked on developing and delivering a Primary Care led dermatology events which focussed on elements of referrals which were the most common. These were held in November 2021, and February 2022. The feedback from this was positive, with 100% of scores either being ‘agree’ or ‘strongly agree’ to the events being valuable . Podcasts NNPC developed a ‘Health Watch’ podcast channel on Spotify and A pple Music. In July 2021, a monthly podcast was launched by our lead Nurses. It covers the NICE Guideline updates and is titled ‘NICE to see you, to see you… ..NICE ’ . The target audience was initially North Norfolk clinicians who can access these in short, easy-to-access sessions and is accompanied by a NICE newsletter update. Over time, the podcasts have widened its listening to a world-wide audience. We also have a broader podcast that is specifically written to showcase NNPC as an organisation and highlight the services and work that we do; this broadcast raises NNPC’s profile with Norfolk and the wider NHS. Journal Publications In July 2022, NNPC celebrated its first journal publication. This publication is entitled Testing for SARS-CoV-2 Infection in Care Home Residents and Staff in English Care Homes: A Service Evaluation and can be found at the Journal of Long-Term Care, (2022), pp. 154 – 162. DOI: https://doi.org/10.31389/jltc.99 This was jointly published with the University of East Anglia Norwich Medical School research team. As an aside to this, NNPC had two members of staff who sat on the advisory panel for a missed-methods study into exploring and understanding the lived experience in care homes for older people during the COVID-19 pandemic. Further journal publications are planned across some of our clinical services.
3.3.6 SERVICE EVALUATIONS AND PERFORMANCE Community Gynae Service (CGS) What went well
a) Superb collaborative working between NNPC, the Norfolk & Norwich Hospital Foundation NHS Trust (NNUH), & Lionwood Medical Practice (LMP) which focussed solely on delivering a high-quality service to patients. The overall delivery team comprised Consultants, GPs, managers, IT specialists, administrators, NNUH SSD and others. A special note of thanks is given to: i. NNUH Outpatients Booking team who worked tirelessly to contact patients and offer a choice of attending the CGS ii. NNUH Gynaecology OP Team who gave much of their time and expertise, often at little or no notice, in developing the initial stock list and then providing stock several times throughout the project b) 115 patients were seen in the CGS who would otherwise have continued waiting to be seen at NNUH c) Patients were seen on time and appointments did not overrun d) Patient experience feedback suggests that the vast majority of patients were extremely happy with the service, the location, and the clinical staff. e) The project ran to time and budget
NNPC Quality Account 2021/22
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What could be improved a) Any future CGS would comprise a direct pathway from Primary Care which would mitigate some of the difficulties faced by the Pilot service but, for completeness, the following items should be noted: i. Manual processes pose many risks e.g., potential data breaches, uncertainty as to whether a sent email has been received etc. Any future service will benefit from all administrative processes being automated wherever possible ii. Administrative processes split across more than one team always create additional work and increase the risk of errors iii. The process to identify and contact patients who could be appropriately seen in the CGS was more complex than had been though at first, hence there was a delay in getting referral information across to NNPC. It is probable that more patients would have been seen if appointments could have been booked earlier. Dermatology Carried out in January 2022 with NNPC in collaboration with the Univ ersity of East Anglia’s medical school, the service evaluation of the dermatology service highlighted that: • 67% of completed dialogues have resulted in the patient being retained in primary care rather than becoming additions to wait lists for secondary care. • Median elapsed time from dialogue initiation to decision was under 9 hours; more than 90% of dialogue outcomes were decided within 36 hours. • 20% of cases were transferred to the two-week cancer pathway. • With regard to wait list growth for secondary dermatology care, Norfolk and Waveney ICS is performing comparably to all-rest-England and a local comparator area (Lincolnshire CCGs). • Referrer feedback is overwhelmingly positive. Clinician feedback on resulting educational activity is overwhelmingly positive. • Patient feedback is limited but has been positive (as of October 2021). • Identification of most commonly asked clinical questions and cases and delivered learning outcome-based education to primary care work force which was highly positively received. GPFD at James Paget University Hospital NHS Trust (JPUH) & The Queen Elizabeth Hospital NHS Trust (QEH) Performance The GPFD service at JPUH commenced on 22.09.2021, and by 31.03.2022 had streamed 17,531 patients and seen a total of 5, 560 patients in a total of 2, 228 hours of service delivery. This equates to an average of 32% of all patients who were streamed were seen at GPFD, based on a 12 hour per day service delivery. The GPFD service at QEH commenced on 04.01.2022 and by 31.03.2022 has streamed 8, 033 patients and had seen a total of 2, 050 patients in a total of 1 011 hours of service delivery. This equates to an average of 25.5% of all patients who were streamed were seen at GPFD, based on a 12 hour per day service delivery. The data accumulated for both GPFD services from inception to current time will form a basis for full-service evaluation, research paper opportunities, and service development. It is anticipated that as both services develop over time that the service performances will only increase.
NNPC Quality Account 2021/22
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