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What we were working on

Quality and Health Action Plans

What good ideas / ways of working we found


Linking CDLT GPs
Contract monitoring for Health Providers Annual Health Check etc
People being prepared for appointments
Training to GPs
Health facilitation for carers/supporters
GPs working with local learning disability teams to get people in for their health
check (Wakefield)
To get health indicators in health contract monitoring

What big issues we identified


No link to the GPs
Not going to health checks with good support people are unprepared and staff
are unprepared
Not enough time for annual health checks recommended 45 mins 1 hour
Terminology for HAPs - GPs v local teams

Any feedback / actions we need to record


To go to the CCG to ask for money to produce My Health Passports (Kirklees)
Use Mencaps Getting it Right in Primary Care campaign
Health groups in York need to be saying to GPs What is the problem? Why
dont we get our health checks?
Working together - GP, CDLT, Providers
Lack of consistency CCGs need to give consistent message

What we were
working on

Cancer Screening

What good ideas / ways of working we found


Barnsley C Quinn for improving cancer screening rates
Easy Read links to annual health checks for cervical and bowel cancer
screening
Visits to breast screening units desensitise
Cervical Screening community nurses, individual work. Anatomical dolls
speculum.
Breast awareness for those exceptions
DVD re Bowel Screening training in care homes
Kirklees Linked with carers so joint screening sent out

What big issues we identified

Reliable Data? Best interest discussions people being ceased


Consent + Capacity?
Send out easy read info to anyone on GP learning disability register
Bowel screening:- How to get a sample some people not happy to have
sample done

Any feedback / actions we need to record

Easy read invites for everyone so the flagging issue is not a problem
Reasonable adjustments re timing and appointments
Easy read template for Breast screening letter to share
Get the champions/lead learning disability person send to Inclusion North
Breast screening accessible portacabin
Post diagnosis support? Chemo
Can people be put back on if ceased from GP
Cancer change books really useful
Educating practice nurses and GPs about screening in general maybe
reluctant

What we were working on

Registers being up to date

What good ideas / ways of working we found


Electronic folders for each GP practice
Sub regional board look at good practice
Confusion around the co-host
Rotherham health support team who work closely with GP
Sharing of info Electronic flag in acute host
Difficult to get information not willing to share
Visiting each GP practice
Start with the small, initial cohort
Helping GP understand NHS
Focus on community nurses practice nurses
Outcome based commissioning responsibility of s. Providers to do AHC
What big issues we identified

Use the Better Care Fund may help data sharing systems
Difficult to find out 14+
Contract has been widened GP can decide who they see, so why validated
GP not being paid NHSE said not validated
People have lost the liaison post CCG think funding is with local authority its
about people getting HC
Joint register with social care health and social care
Capacity
Co-working
Need to know everyone to do strategic plan
Client versus GP Action Plan
Working together access to each register
Active health facilitator or clinical leads
Leadership is important
Protected learning time for GP
Building relationship

Any feedback / actions we need to record


Need to look at how people share data local authority (use Better care Fund),
CCG, and look at initial cohort
Commissioners monitoring contract with providers
More complex people seem to be missing out
Commissioners need to invest in resources to sort this out cross worker with
other people who are doing screening written into contracts. Incentive
schemes with GP doing double appointments

Using managers who want to keep their registration look at where you can cowork with people
The more you prepare and get the GP ready, support templates etc at
beginning the more they are likely to carry on.
GP on the CCG board. Sign up in all CCG coaching
Children
If not working jointly missing people
The criteria being widened is an issue DES
Some of the GPs have not signed up
The way in which GPs do the health check is still an issue who is checking
them and driving up quality
DES payment not worth it for some GPs
Wideneing criteria has stretched resources
Monitoring of the DES to get GP to demonstrate quality
GP learning disability champion has worked local leadership relationship
Delivery against learning disability objectives central may help
Electronic Health Action Plan across South Yorkshire and Humber linked to system
one, EMIS, self populate, part of contract, copy to person and copy to CCG

What we were working on

Transition

What good ideas / ways of working we found


Pooled Budgets are a good idea
Joint commissioning
Adult workers commencing a Year 9 review and on incremental and staged
approach thereafter
Enable people to have advocates
Joint training/including people with learning disabilities
Pooled budgets

What big issues we identified

Not having a pooled budget is an issue


Expectations formed in childhood (pre- transitions)
Shaping outcomes at an early stage
What are expectations and visions for the future
What does independent living mean
Strategy between childrens and adults
Care Act compliant transition assessment required
Different approached and models to transition eg what age people are picked
up by transition teams
Manage expectations exit strategies for people in out of area education
We have created transition by separation of children/adults

Any feedback / actions we need to record

How we work back into Childrens services


How we bridge the gap between childrens and adults
Services are not always the solution consider options eg PHBs
Knowledge and skills set of adult/childrens worker need specialist knowledge
Sharing data and information system and governance issues