APRIL 2010 – MARCH 2013
WORKING DRAFT 30 SEPTEMBER 2010
CONTENTS
Item / Theme / Page/s1) / Cross Cutting Issues
(Whole Population) / 3-11
2) / Alcohol/Drugs
(Substance Misuse) / 12-14
3) / Early Years and Young People / 15-21
4) / Demographic Change
(Ageing Population) / 22-25
5) / Vulnerable Groups and People
(Additional Needs) / 26-29
6) / Health Inequality
(Closing the Gap) / 30-34
CHP Delivery Plan Theme: Cross-Cutting Issues (Across Themes & Population Wide)
SOA Outcome 6.1 – Improve the overall health and well-being of the people of Aberdeen City through focusing on the factors that are harmful to health and well-being and in particular by supporting those most vulnerable
CHP Committee Link: Ian Paterson, ACVO
SOMT Link:Shona Smith, Primary Care Development Manager
Target/Objective / HEAT* / SOA* / GHP* / Lead Officer/s / Actions required / Public Involve-
ment / Timescale - Overall Completion Date / Progress Report
Underway / Reported / Completed
To re-design Primary Care within AberdeenCity.
/ x / Gary Newbigging / Agree vision for the future delivery of primary care services in the City by December 2010 to include:
Workforce and premises requirements to deliver services.
Clarity over how services will be accessed by patients.
In developing the vision consideration will be given to the following:
(1) What services do we want?
(2) Who will deliver the services?
(3) Where will services be delivered, e.g. GP practices, the Health and CareVillage / x / July 2011
Better Care Without Delay A10: Deliver 18 weeks referral to treatment from 31 December 2011. / A10 / x / Shona Smith / To engage city GP’s in the targeted specialty based pathways work being led by the BCWD project team. / Ongoing / As part of the city primary care re-design programme, a number of GP’s have been identified to work on priority pathways and clinical guidance internet proprieties.
Target/Objective / HEAT* / SOA* / GHP* / Lead Officer/s / Actions required / Public Involve-
ment / Timescale - Overall Completion Date / Progress Report
Underway / Reported / Completed
To implement the priorities set out in the LTC National Action Plan, achieving improvements for people living with a long term condition in AberdeenCity / T6
T8
T12 / x / x / Sandy Reid/ Pam Gowans / To support the development of case finding methods e.g. via SPARRA and local knowledge.
To support the implementation of Anticipatory Care Planning for those at high risk of unscheduled care events.
To support the introduction of Personal Management Plans for self management
To support pathway development of
COPD
Heart Failure
Diabetes
Falls and Bone Health pathways.
To support the implementation of tele-healthcare solutions in the management of COPD, via home monitoring
To co-ordinate the development of self management via social marketing and staff development programmes.
To support the application of Productive Community Services as an enabling approach for service redesign. / x
x
x
x
x
x
x / x / March 2012
March 2012
March 2012
March 2011
March 2012
March 2012
Nov 2011
March 2012
Oct 2011
March 2011 / Considerable work is already underway to achieve these actions and this work progress will continue to be facilitated via the City LTC Steering Group – multi-agency group. The group is set to meet monthly to monitor and maintain momentum.
Improvement plans and events are already in place for COPD, Falls and Bone Health, Anticipatory Care Planning and the Social Marketing of Self Management has commenced with staff groups across the CHP, the public campaign will run in conjunction with the national Self Management awareness campaign in Oct 2010.
Discussions have taken place with local authority leads to consider applying ‘productive community ‘ methodology in local authority teams also to support the development of more integrated working.
Target/Objective / HEAT* / SOA* / GHP* / Lead Officer/s / Actions required / Public Involve-
ment / Timescale - Overall Completion Date / Progress Report
Underway / Reported / Completed
Provide 48 hour access or advance booking to an appropriate member of the GP Practice Team by 2010/11. / A8 / Shona Smith and Practice Development Support Managers / To measure performance in relation to HEAT target A8 using the results obtained from the national ‘Better Together’ Patient Survey.
To produce a report and an action plan to address key findings of the survey in relation to access.
This information will also be reviewed as part of the annual GMS contract reviews with individual practices in relation to compliance with access and advance booking.
For those practices participating in ‘QOF Plus’ in 2010/11 there will be more detailed review of access where appropriate. / June 2010
September 2010
March 2011
March 2011 / TheResults of the 2009/10 ‘Better Together’ survey has now been produced. A report of the findings in relation to Aberdeen City Practices has been written and an action plan prepared. The action plan will be implemented over the coming months.
Further guidance is awaited regarding how ‘access’ will be assessed, in the future, nationally.
To increase the percentage of new GP outpatient referrals into consultant led secondary care services that are managed electronically to 90% from December 2010. / E7 / x / Shona Smith / Maintain current levels of GP outpatient referrals, in line with E7. / Ongoing / GP practices are currently meeting target c. 90%.
Target/Objective / HEAT* / SOA* / GHP* / Lead Officer/s / Actions required / Public Involve-
ment / Timescale - Overall Completion Date / Progress Report
Underway / Reported / Completed
The maximum wait from urgent referral with a suspicion of cancer to treatment is 62 days; and the maximum wait from decision to treat to first treatment for all patients diagnosed with cancer will be 31 days from December 2011. / A9 / x / Shona Smith / To continue to work jointly with GP's and the Better Care Without Delay team to meet HEAT target A9. / Ongoing / To establish if there is a regular report produced within NHSG that demonstrates the city GP’s performance in relation to this target?
To support shifting the balance of care, NHS Boards will achieve agreed reductions in the rates of attendance at A&E, between 2007/08 and 2010/11.
/ T10 / x / Jackie Bremner / Work with Unscheduled Care Network to understand data and identify particular issues for action re A&E attendance within the City.
To confirm city allocation of target.
Develop an action plan to address A&E admissions from the city. / March 2011 / Data has been sought to commence analysis.
Target/Objective / HEAT* / SOA* / GHP* / Lead Officer/s / Actions required / Public Involve-
ment / Timescale - Overall Completion Date / Progress Report
To create a hub from which the city diagnostic and treatment services will be delivered.
To create replacement facilities for specific services inWoolmanhillHospital, Denburn Health Centre and other buildings which are subject to disposal. / x / Jackie Bremner / Achieve approval to revised Outline Business Case for the HealthVillage.
Planning Permission obtained.
Achieve Full Business Case approval.
Agree a Hubco private sector partner.
Agree timetable for construction of the building.
/ December 2010
September 2010
March 2011
December 2010
March 2011 / Revised OBC to be presented to the NHGS Board in November.
Planning Permission expected in September/October 2010.
Work to produce the Full business case well underway due to be completed in December.
To create a Joint Equipment Service for Aberdeen city with ACC colleagues. / x / Heather Hardisty/
Nicola Dinnie / To reach agreement between ACC and NHSG on a model for the future delivery of the Joint Equipment Service.
To develop and implement a Joint Equipment Service action plan reflecting national guidance. / December 2010 / Option appraisal completed.
Final decision on service design and location of stores to be agreed by March 2011.
To improve the interface between primary and secondary care for dementia care management (integrated care pathway). / x / x / Bill Cowling and Stuart Watson / To align the secondary care register with the GMS register of patients with dementia.
To provide education for GP’s and primary care teams regarding improving dementia diagnosis and treatment.
To create a Dementia Liaison Service at WoodendHospital. / March 2011
March 2011
May 2010 / Work to align registers and provide education underway.
Education event held in September 2010.
Liaison service at Woodend established.
Target/Objective / HEAT* / SOA* / GHP* / Lead Officer/s / Actions required / Public Involve-
ment / Timescale - Overall Completion Date / Progress Report
Underway / Reported / Completed
To influence the management of overweight and obesity in AberdeenCity. / Judith Hendry / Implement the Integrated Care Pathway for Adult Weight Management through, e.g:
Deliver ‘Healthy Helpings’ and 'Counterweight' sessions / interventions;
Deliver skills training for community based professionals e.g. Community Learning & development staff;
Sustain community capacity to deliver the Integrated Care Pathway for Adult Weight Management through provision of venues etc. / Ongoing / Report available.
Requires engagement with Community Learning & Development.
13 sessions have been run but free venues becoming increasingly difficult to find. 12 people per session. 150 people attend and engaged.
To improve treatment for people with depressive illness. / x / Bill Cowling and Stuart Watson / To work with mental health colleagues to develop a revised Anti-depressant selector.
To encourage/enable use in general practice of the newly developed ‘Depression Toolkit’ for prescribing medication and non pharmacological interventions when available. / August 2010
March 2011 / City GP’s involved in developing the revised anti-depressant selector.
Training underway and being rolled out.
To work with mental health colleagues to enhance clinical governance for Primary care Mental Health Workers. / March 2011 / Generic clinical supervision has commenced and IPT training will be provided.
Target/Objective / HEAT* / SOA* / GHP* / Lead Officer/s / Actions required / Public Involve-
ment / Timescale - Overall Completion Date / Progress Report
Underway / Reported / Completed
To optimise the general health of people with severe and enduring mental illness.
As a consequence to reduce the likelihood of re-admission (delivering for mental health target). / x / x / Bill Cowling and Stuart Watson / To encourage primary care practitioners to provide 15 month physical health reviews for those with severe and enduring mental illness. / March 2011 / Discuss internally how best to address this issue, possibly audit current positioning relation to reviews.
To support the Community Planning Partnership to develop an action plan for mental health improvement to support implementation of ‘Towards a Mentally Flourishing Scotland’ (TAMFS) / x / Chris Stewart/ Claire Wilkie / To develop and implement an action plan for mental health improvement in the City / March 2011 / An NHS Grampian TAMFS Action Group has been established and workshop planned for November 2010 with City CHP input.
Fairer Scotland Funding secured for existing community based mental health and wellbeing projects. / x / Val Tweedie / To secure continued Fairer Scotland Funding for existing community based mental health and wellbeing projects.
Find a way to mainstream finding from 2011-2012. / April 2010
March 2011 / Fairer Scotland Funding for 2010/11 in place.
Target/Objective / HEAT* / SOA* / GHP* / Lead Officer/s / Actions required / Public Involve-
ment / Timescale – Overall Completion Date / Progress Report
Underway / Reported / Completed
To support the implementation of CEL 41 – Gender Based Violence. / x / Linda Smith / Through training and support to facilitate the development of Health Visitors in routine enquiry regarding domestic abuse. / March 2011
Aim for DDA and HAI compliance within GDP practices across the city. / x / Rosemary Hutcheson / Review the GDP Dental Premises Audit (undertaken in 2009) findings for the city to agree how to respond in terms of service delivery and premises improvement in the current financial climate. / 2012 / Audit information available majority of practices now compliant and on target.
Confidence to Cook Programmes available in AberdeenCity.
/ H3 / x / Judith Hendry / To undertake an option appraisal to identify options in relation to the provision of kitchen facilities to enable people to participate in 'Confidence to Cook' programmes.
Ensure continued provision of ‘Confidence to Cook’ programmes, taking account of future closure of Summerhill Education Centre by ACC. / December 2010
Target/Objective / HEAT* / SOA* / GHP* / Lead Officer/s / Actions required / Public Involve-
ment / Timescale - Overall Completion Date / Progress Report
Underway / Reported / Completed
Improve access to dental care in communities where registration and oral health are known to be poor. / x / Rosemary Hutcheson/Jackie Bremner / To plan for a 3-chair dental practice in the new Woodside Medical Practice.
To plan for a 3-chair dental practice in the new Health and CareVillage.
To plan for a 5-chair dental practice in the north of the city. Also to identify and suitable site using specific primary care modernisation monies. / OBC approval March 2011
OBC approval December 2010
March 2011 / Outline Business cases for both Woodside and the HeathVillage being developed. Once approval obtained full business cases will be developed.
Site currently being sought in discussion with ACC colleagues.
CHP Delivery Plan Theme: Alcohol / Drugs (Substance Misuse)
SOA Outcome 6.1 – Improve the overall health and well-being of the people of Aberdeen City through focusing on the factors that are harmful to health and well-being and in particular by supporting those most vulnerable
CHP Committee Link: Councillor Jim Kiddie
SOMT Link:Sandy Kelman, ADP Team Leader
Target/Objective / HEAT* / SOA* / GHP* / Lead Officer/s / Actions required / Public Involve-
ment / Timescale - Overall Completion Date / Progress Report
Underway / Reported / Completed
Encourage all employers in Aberdeen (initially focusing on NHS Grampian) to develop and implement effective internal workforce alcohol policy to reduce alcohol related harm in the workplace. / x / x / Sandy Kelman / Improve access to information e.g. online information resources, information sheet to GP’s.
Deliver alcohol awareness sessions to health professionals from a range of disciplines.
Monitor ADP website hits. / March 2011 / Work has been carried out in order to improve NHS G policies on alcohol and drugs. Meetings held with Occupational Health (OH) to get alcohol screening (and brief interventions where applicable) mainstreamed within OH management referrals processes where they arise from staff members having regular short term absences.
Since the last update, further awareness sessions have been carried out through Healthy Working Lives, a Sexual Health Conference, and AberdeenUniversity.
Target/Objective / HEAT* / SOA* / GHP* / Lead Officer/s / Actions required / Public Involve-
ment / Progress Report
Underway / Reported / Completed
Achieve agreed number of screenings using the setting-appropriate screening tool and appropriate alcohol brief intervention, in line with SIGN 74 guidelines by 2010/11. / H4 / x / Linda Smith / Support the implementation of 6419 alcohol brief interventions in the City CHP:
To ensure delivery of ABI training to GP's and Practice Nurses across the city.
To encourage practices to return quarterly reports on ABI. / March 2011 / 2439 ABI’s achieved within general practice as at end June 2011.
Majority of practices have signed LES agreement (all but 2).
To support the U of A Community Pharmacy Pilot to enable Community Pharmacies to deliver alcohol brief interventions. / H4 / x / Dr Margaret Watson, U of A & Linda Juroszek / To assist the CHP in delivering its ABI target. / March 2011 / Recruitment completed and 6 month follow-up due to be completed December 2010.
Final report to funder in February in 2011.
Increased capacity of alcohol counselling/ support and specialist services (NHS and Non-NHS) resulting from an anticipated increase in demand generated from achieving HEAT 4 (Alcohol Brief Interventions) targets. / x / Sandy Kelman / ADP to re-commission appropriate counselling/support and specialist services.
Award service contracts to meet the needs of the service. / April 2010 / Commissioning process complete and all services in operation from August 2010 onwards.
Target/Objective / HEAT* / SOA* / GHP* / Lead Officer/s / Actions required / Public Involve-
ment / Timescale - Overall Completion Date / Progress Report
Underway / Reported / Completed
To offer drug mis-users faster access to appropriate treatmentto support their recovery
Short term target from December 2010, 90% of all clients will have:
Referral to assessment - 4 weeks.
Assessment to treatment - 4 weeks. Total - 8 weeks.
Medium term target from April 2013, 90% of all clients will have:
Assessment to treatment - 3 weeks. Total – 3 weeks. / A11 / x / Sandy Kelman/ Simon Rayner / Support the redesign of Substance Misuse Services (SMS), including the development of the Integrated Drug Treatment & Rehabilitation Centre, to meet the short and medium term target:.
Realign nursing staff into three clusters across the City.
Provide support to GP’s through regular meetings, review of care plans and case management reviews. / March 2011 / SMS has redesigned and nursing staff are in three clusters, which match the GP practices.
Review meetings take place with GP practices.
To improve the oral health status of drug treatment and rehabilitation clients. / x / x / Rosemary Hutcheson / Implement pilot project to deliver oral health care to former drug users who have successfully completed rehabilitation.
Evaluate pilot project at 6 months to gauge attendance rates, clients’ adherence to oral health advice (e.g. tooth brushing), completed dental treatment, clients’ dental fitness and readiness to move into/access mainstream dental care. / April 2011 / 50% are dentally fit, 50% have completed treatment. Process is continuing with uptake of new patients.
CHP Delivery Plan Theme: Early Years and Young People
SOA Outcome 5.1 – Children and young people enjoy the highest attainable standards of physical and mental health, with access to sustainable health care and safe and healthy lifestyles
CHP Committee Link: Councillor Gordon Leslie
SOMT Link:Chris Stewart, Deputy General Manager
Target/Objective / HEAT* / SOA* / GHP* / Lead Officer/s / Actions required / Public Involve-
ment / Timescale - Overall Completion Date / Progress Report
Underway / Reported / Completed
80% of all three to five year old children to be registered with an NHS dentist by 2010/11. / H2 / x / x / Rosemary Hutcheson / Maintain dental registration levels for 3-5 year olds. / Ongoing / Currently meeting H2 target
At least 60% of 3 and 4 year olds in each SIMD quintile to have fluoride varnishing twice a year by March 2014 / H9 / x / Rosemary Hutcheson / Continue to deliver Childsmile programme to 3 and 4 year olds in both nursery and primary schools -P1/P2 and start rolling out Childsmile Practice. / 2014 / Continue and instigate P1/P2.