fit for the future

North West Community Provider Alliance Clinical Pathway Workshop 2009 2

CONTENTS

Introduction p 3

Pathway Review Summary p 4

Long Term Conditions p 7

End of Life Care p 23

Urgent Care p 39

Planned Care p 50

Staying Healthy p 54

Health Improvement p 61

Mental Health p 66

Child Health p 75

Maternity and Newborn Care p 88

Acknowledgements


North West Community NHS Services Clinical Pathway Workshop

Introduction

Across the North West, the NHS Providers of Community Services are working together as an Alliance to support collaboration in the promotion and

development of high quality and innovative community services.

Transforming Community Services has recognised the crucial role that community services have to play in the delivery of Quality, Innovation,

Productivity and Prevention (QIPP) and that an essential element of the transformation process is the effective engagement of community clinicians

and practitioners in shaping community services that are fit for the future delivery of high quality productive care.

This report is the output of a half day workshop attended by over 100 community expert clinicians and practitioners from across the North West. They

met to debate and agree a consensus view of the high impact changes that could be made by community services to enable service, pathway and

partnership reform, and contribute to the wider system delivery of Healthier Horizons and QIPP.

The event involved practitioners working in PCT provider services. However, it was recognised that it is vital for similar pathway discussions to be

extended to include a range of stakeholders (including NHS, social care, third sector and independent sector providers, as well health and social care

commissioners) if any of these proposals are to be taken forward and the anticipated QIPP benefits realised.

We hope that this summary report provides the basis for these new conversations at service, health and social care economy, and regional levels.

Dr Barbara Green on behalf of the North West Provider Alliance

October 2009


Pathway Review Summary

Process

The reviews brought together clinical experts, from all disciplines, to offer high level evidence based and clinically supported proposals of the key

community service changes that could be commissioned to deliver the aspirations of the Darzi vision, Transforming Community Services and the

implementation of Healthier Horizons.

Eight expert multidisciplinary panels met, each focussing on a specific clinical pathway: Long term conditions, End of Life Care, Planned Care, Urgent

Care, Health Improvement, Staying Healthy, Child Health and Maternity and New Born Care.

Each panel was asked to:

a) Provide a consensus of the top three to five high impact changes for community services, with reference to the evidence base and best practice

examples where possible

b) Identify the benefits of each, from the perspectives of the patient/client; the commissioner; and system reform agenda

c) Consider the enablers and barriers to delivery

The outputs from each panel are reproduced within this report including a summary of the relevant recommendations from Healthier Horizons and

Transforming Community Services Best Practice Guides. As can be seen, there is considerable synergy between all three.

Summary of the themes across the pathways

• Community Services were seen as crucial levers for positive change in terms of improving the health and well being of the population of the North West

and in enabling radical system reform.

• There was unequivocal support for the ambitions contained within High Quality Care for All, Transforming Community Services and Healthier Horizons

and a clear commitment that community staff – whether directly or indirectly providing care – would actively participate in the transformation process.


• There was a realistic understanding of the scale of the challenge and that leadership at all levels was needed to successfully deliver the pace of

change that is required.

• Practitioners were excited by the prospect of working collaboratively at service and system levels to improve quality and productivity. They also

identified significant opportunities for the co-production and adoption of innovative practices for improvement.

• It was hoped that there would be wider recognition of the expertise that already exists within community services and that commissioners would

actively support existing examples of excellent practice, delivered in some areas of the North West, being spread and adopted by all.

• The engagement of communities and patients and the whole community service workforce was seen to be fundamental to the success of the

transformation process. Community services are very close to the needs of the communities they serve. They are part of the stories that families and

individuals share and can offer a valuable insight into the real experiences of people of their lives, health and health care.

• Community service practitioners have a strong ethos and commitment to empowerment and enablement. They have extensive experience of the co-

production of interventions with clients and communities to improve health outcomes and address health inequalities. The importance of building on

existing community insights and relationships was highlighted and all panels emphasised the importance of strengthening universal services and

prevention, health improvement and early intervention functions.

• There was consistent support for integrated clinical pathways to be jointly commissioned by health and social care with clearly defined outcomes and

benefits. It was proposed that the design and delivery of the pathway should then be determined by providers working together to co-design and re-

design effective integrated practice throughout the patient or client journey.

• There was strong support for the development of collaborative clinical networks and integrated care pathways, with a balance between a standardised

approach and the flexibility to respond to individual choice and needs.

• Collaboration and competition were major themes with both being seen as providing the potential for improvement. It was suggested that

commissioners might incentivise horizontal and vertical co-operation across a number of the pathways.

• Integration was offered as a philosophy to clinical practice enabling improved client experience and outcomes, as opposed to a focus on financial

alignment or organisational form. Integrated practice and co-operation with a wide range of providers was seen as offering significant opportunities to

improve access and quality.


• Most community services are commissioned to operate during a typical 9am – 5pm weekday period. It was suggested that a simple and rapid

improvement to patient experience, access and choice could be made if many community services were commissioned to deliver over more extended

or flexible hours.

• Many of the panels identified workforce development and redesign to be essential for successful transformation. The general view was that this was

recognised by the community services workforce who would welcome the opportunity for greater engagement in service and system reform.

• It was felt that there was a need for clinical leadership within community services to be specifically commissioned and the further development of

generalist, specialist and expert practitioner roles.

• Knowledge management and the lack of reliable and comparable data were frequently seen as barriers to improved service delivery. Clinicians were

keen to co-produce a range of meaningful metrics with commissioners so that energy and effort is focussed on measures that are valued and enable

transformation.

• The panels identified significant variation in the scale and range of community service provision across the North West. There was no apparent

rationale for this variation and very few standard service models.

• There were concerns expressed about the emerging tension of collaboration and competition between NHS community providers within the new

market, and a worry that colleagues may become less willing and open to sharing their innovative practices.

• There has been an absence of a forum for community staff to meet and share best practice and therefore limited cross-fertilisation of knowledge and

innovation between community services.

• The participants were very positive about the workshop and wish to develop the work further. They were keen for clinicians and practitioners to

continue to work together in multidisciplinary pathway groups.


LONG TERM CONDITIONS


1.

Top 3-5 Improvements

Benefits for Patients

Benefits for Commissioners

Benefits for System Reform

Enablers To Delivery

Barriers to Delivery

Continue with

health and

social care

integration

Health and social care

integration means less

duplication/number of

assessments and number of

handoffs, which produces

seamless care and links to

care pathways. A single

point of contact improves

quality and the number of

acute episodes. This means

holistic needs are met. A

single number to access

services means increased

satisfaction with a decreased

‘scatter gun’ effect. Right

treatment first time for

patients.

Able to efficiently

manage economic

markets, therefore,

opens up markets.

Brings increasing

value for money and

improves productivity

by reducing

duplication.

Encourages

integrated

commissioning by

Health & Social

Care. Developing

‘care bundles’

reduces costs and

increases quality

control. Right

treatment first time

and so reduced

waiting times.

Encourages a

community tariff.

Integrated commissioning by

Health & Social Care with

improved market

management. Patient

involvement will give a more

definite view of what patients

want and need from a

service. Breakdown of roles

and boundaries. Encourages

professionals to ensure that

services are person led not

service led. Lean.

Streamlined. Empowers

patients to use Choose and

Book. Links to other

pathways e.g. urgent care,

end of life. Embedded Single

Assessment Process.

Integrated teams co-

located with shared

reporting systems and

pooled budgets and IT

systems.

Shared priorities/

protocols/information.

Commitment from

organisations, staff and

GPs.

Common

understanding of

‘integration’ as practice

rather than

organisational form.

Clear pathways linked

to electronic Directory

of Services.

Staff training.

Inadequate IT

systems.

Financial barriers and

freedom to act.

Terms and conditions

of Service Level

Agreements.

Systems/policies.

Different remits e.g.

free at point of

care/subject to

eligibility.

Respect for decision

making.


Priorities in Transformational Guides

Priorities in Healthier Horizons for the North West

• Develop personalised care plans using joint care planning, integrated

assessments and joined up multidisciplinary working along the care pathway.

Intermediate care and rehabilitation services should form part of the long

term conditions pathway preventing inappropriate admissions to the acute

trusts, facilitating early discharge and enabling people to achieve the

optimum level of independence for their long term future.

• Ensure that community teams and matrons make close linkage with

continuing healthcare services so that, where appropriate, packages of care

can be set up effectively and efficiently with no time delay for patients. Work

closely with community mental health teams to develop referral pathways to

improving services such as: improving access to psychological therapies

(IAPT) or cognitive behavioural therapy (CBT) for patients who require

specialist advice, support and treatment.

• Extend the hours of service according to patients needs. This may include

telephone access for on-call and out-of-hours home visits. Offer services in

local and convenient venues to reach patients who may not engage in

traditional ways. This may include church halls, supermarkets, and train

stations.

• Use technology to implement shared care planning, so that all involved in the

patient’s care including the emergency services, such as the ambulance trust

or out-of-hours provider, have an understanding of the patients needs and

treatment plan.

• Use technology as a form of documentation. This may include remote access

devices such as palm tops and tablets which can be synchronised easily with

IT systems, avoiding unnecessary travel or time wastage;

• A new model of care should be commissioned that

enables integration of health and social care, with the roles

of professionals changing to meet patients' needs. There

needs to be a clear description of what primary care

should be like to incorporate social care, community care

and specialists.

• A designated care co-ordinator will have responsibility for

ensuring that a plan is developed and agreed.

• The role of primary care should be strengthened and

developed with new skills and ways of working to deliver

more personalised care around patients.

• The development of a virtual care campus to deliver health

and social care provision within primary care for

specialised problems.

• Greater use of technology to enable patients to be

maintained /monitored in primary care.


2.




Benefits for System Reform Enablers to Delivery Barriers to Delivery

Integrated

discharge

planning,

continuity

across primary

and secondary

care

This approach

will increase

safety and

provide

seamless

crossover care

to community

services. There

will be fewer

complaints,

reduced re-

admissions,

reduced length

of stay as a

result of positive

care planning

There will be

fewer

complaints,

reduced re-

admissions,

therefore,

reduction of cost

of emergency

admissions.

Improved

delivery of A & E

4 hour standard

and 18 week

pathways.

Increased health and well being

outcomes.

Improved quality and efficiency

subject to genuine investment in

community services to deliver

tangible benefits of care closer to

home.

Shared commissioned

services with shared priorities

for staff and patients.

Shared IT systems means

more efficient ways of

working.

Creation of new roles to

enhance the service.

PbR/block contracts –

restriction of the

development of local

integrated care pathways.

‘Blame culture’ in the NHS.

Organisational boundaries.

Lack of shared knowledge




• Intermediate care and rehabilitation services should form part of the

long term conditions pathway preventing inappropriate admissions to

the acute trust, facilitating early discharge and enabling people to

achieve the optimum level of independence for their long term future.

• Ensure that community teams and matrons make close linkage with

continuing healthcare services so that, where appropriate, packages of

care can be set up effectively and efficiently with no time delay for

patients.

• A new model of care should be commissioned that enables

integration of health and social care, with the roles of

professionals changing to meet patients' needs. There needs to

be a clear description of what primary care should be like to

incorporate social care, community care and specialists.

• A designated care co-ordinator will have responsibility for

ensuring that a plan is developed and agreed.

• The role of primary care should be strengthened and developed

with new skills and ways of working to deliver more

personalised care around patients. The development of a

virtual care campus to deliver health and social care provision

within primary care on specialised problems.

• Greater use of technology to enable patients to be maintained

/monitored in primary care.


3.





Enablers to Delivery Barriers to Delivery

Self care

management -

tele-health,

personalisation,

empowerment

Patients have

greater autonomy,

choice and

improved access.

This enables them

to stay well, at

home and gives

them reassurance

and increased

confidence, which

empowers them.

Therefore, they are

in control and

independent. This

would be a patient

led pathway which

enables choice and

involvement,

improvements in

waiting times and

is a timely

intervention, i.e.

choice of where

and when for the

patient.

This will reduce the need

for professional

interventions and need for

services. Produces a

healthier population who

have choice. Self

monitoring reduces

exacerbations, hence,

decreased GP

visits/admissions. A good

opportunity for looking at

new

developments/innovation

through re-investment with

a prevention and education

agenda.

Re-investment

opportunities across the

pathways which supports

a shift from illness to

wellness.

Patients in control of their

own health which reduces

the burden of Long Term

Conditions.

Financial benefit across

economy - with a return to

work.

Enhances Choice and the

self care agenda with a

consistent message and

approach to patients.

Individualised budgets.

Reduced burden of care.

Technology to be available

with the possibility of using

Expert Patients who can

and wish to self care. This

would reduce system

costs.

Condition specific

programmes.

Quality and Outcomes

Framework for Pathways

eg. COPD, so that

quality/data can be

collected for evidence.

Partnership working with

Voluntary sector e.g.

MIND.

Reliability of technology.

Patients - culture.

Financial investment.

Trust /confidence.

Programmes are

condition specific.

Knowledge of how to

access.

Engagement.

Safeguarding issues.

Capacity for services to

address real demand.

Today's business - what

about tomorrows -

double running.

Priorities.




• Support and enable people to manage their own health.

• Invest in tele-health and tele-care to empower patients to take, maintain

and maximise their own health potential.

• Develop personalised care planning using joint or integrated

assessments.

• Use a ‘buddy system’ to support patients.

• Teach patients and carers to recognise the signs of deterioration/acute

exacerbation and how to take action.

• Provide staff with appropriate training. This may include non-medical

prescribing, advanced assessment, motivational interviewing or

cognitive behavioural therapy skills.

• Replace where appropriate visits with a telephone contact. This may be

useful to monitor a patient’s condition remotely.

• Offer choice through personalisation. Work with local authority to

support patients wishing to make use of ‘self directed budgets’.

Maximise the opportunity for patients to participate in the Expert Patient

Programme.

• Place individuals with LTC and /or their carers in charge,

enabling them to live well with their condition.

• Greater use of current technology to enable patients to access

their health records and test results remotely, for example,

kidney care: MySpace.

• Address the skills gap of health 'educators' for LTC within a

primary care setting.

• Consider the person's social, cultural and family circumstances

- not just clinical.

• Develop and apply the social care model for personalised

budgets and payments.

• Increased support for patients, their families and carers in

managing LTC, including from voluntary groups.

• A named patient advocate and care co-ordinator for all patients

with a LTC.

• Exploit the use of technology to maximum effect by providing

support to dedicated staff on how to introduce new technology

and how to measure its effectiveness.


4.


Benefits for Patients Benefits for Commissioners



Improve

transitional care

for children with

long term

conditions.

Improved quality of care

and reduced anxiety of

patients, carers and

professionals, which in

turn improves

independence.

Reduction in long term

complications with

increased life

expectancy/opportunities.

Long term cost

benefits which

address inequalities

and increase

reported mental

health and wellbeing.

Increased mortality

rates and reduced

admissions.

Invest to move

forward and

improve health.

Re-engineer

pathways as

patients have

improved

wellbeing and

chronic illness.

Open to new ideas/ways of

working -

Technology/communications and

transitional care can be caught

electronically.

Making the agenda personalised.

Specialist commissioning with

integrated care pathways.

Commissioning across adult and

children's services. Use of NSF

for Long Term Conditions to move

this forward.

Different models of care

for children/adults.

Episodic nature of adult

services /children's more

preventative/ maintaining.

Lack of knowledge in

adult services.

Paternalistic services.

Lack of flows on

neurological Long Term

Conditions



• Practitioners closest to patients to lead change themselves and realise their own high ambitions for the care that they provide.

• Provider Organisations to align high quality care to organisational vision and strategy.

• Commissioners to understand the constituents of high quality care and enable world class commissioning decisions to be made that are clinically led and focus on achievements.

• Strengthen partnership working across health and social care.

• Start discharge planning as soon as possible, make sure all practitioners are

• Place individuals with Long Term Conditions and /or

their carers in charge, enabling them to live well with

their condition.

• Greater use of current technology to enable patients to

access their health records and test results remotely,

for example, kidney care: MySpace.

• Address the skills gap of health 'educators' for Long

Term Conditions within a primary care setting.


involved in this process, care is co-co-ordinated, and discharge summaries provided for all key services involved in the patients care.

• Addressing variability, working efficiently, demonstrating high levels of productivity and achievement of ambitions for quality.

• Support teams to develop creative approaches to service provision.

• Support and empower practitioners.

• Ensure that there are robust systems in place.

• Develop personalised care plans using joint care planning/integrated assessment and joined up multidisciplinary working along the care pathways.

• Intermediate care and rehabilitation services should form part of the Long Term Conditions

• Maximise the potential for modern targeted, community services to improve efficiency and effectiveness of the wider health and social care system. This may include joint health and social care team development. Extend the hours of service according to patients needs.

• Use case managers as key workers.

• Use technology as a virtual means of asking advice or a second opinion from a specialist, Allied Health Professional or GP.

• Use a 'buddy' system to support patients.

• Consider the person's social, cultural and family

circumstances - not just clinical.

• Develop and apply the social care model for

personalised budgets and payments.

• Increased support for patients, their families and carers

in managing Long Term Conditions, including from

voluntary groups.

• A named patient advocate and care co-ordinator for all

patients with an Long Term Conditions. Exploit the

use of technology to maximum effect by providing

support to dedicated staff on how to introduce new

technology and how to measure its effectiveness.


5.





Improve

Primary Care

Improved primary care will

ultimately improve access for

patients and reduce the need

for Out Of Hours care.

Ultimately this will improve

quality of care and reduce

complications.

Enables care closer to home

giving patients seamless care,

continuity, good relationships

with their carers and

professionals.

Medicine Management is more

effective and efficient with a

choice for patients.

Reduced acute

admissions and

interventions.

Reduced need for

services.

Increased self care

and quality of life.

Reduction in

medication costs.

Opportunities for re-

investment -

illness/wellness with

increased evidence for

quality assurance.

Improved community

health and wellbeing.

Improved and better co-

ordinated working

relationships between

GPs/community services.

Use of shared IT

systems.

Improved effectiveness

and efficiency. i.e.

Choose and Book.

GPs/QOF.

Organisational

boundaries.

Relationships between

GPs/Community

Services.

Shared IT Systems.

Lack of

awareness/knowledge of

services available.

Referral criteria.

Access to services.




• Know about local health needs and plan services accordingly.

• Work with Commissioners to agree outcome data that needs to be

collected to demonstrate effective intervention.

• Develop systems and processes, which encourage constant patient,

service user and carer feedback. Audit changes which have been

made as a result of feedback on user experience

• Create effective health and care partnerships.

• Implement new services approach - addressing viability, working

efficiently, demonstrating high levels of productivity and

achievement of ambitions for quality.

• Provide local health information about your services, access,

availability and choices for patients, the public and professionals.

• Provide clear information about OOH service provision to patients,

public and practitioners.

• Provide the right resource, in the right place, at the appropriate time

in accordance with need.

• For people with LTC or complex health care needs - provide a

personalised care plan and, where appropriate, use joint care

planning or integrated assessments such as the single assessment

process or CAF.

• Use technology to implement shared care planning.

• Further development of practice based registers to target screening

- developing appropriate pathways for preventing further

progression of disease.

• Commissioners (PCTs and Social Care) should jointly develop 'care

passports'.

• PCTs should maximise the defined role of pharmacists in self care

of long term conditions.

• The role of primary care should be strengthened and developed

with new skills and ways of working to deliver more personalised

care around patients.


6.







Joint working

and integrated

access to care

pathway.

Joint working/single

assessment

process/planning means

that patients only have to

tell their story once which

reduces duplication.

Increased continuity and

co-ordination of care.

Joint working so there is

always a professional

knowledge base if unable

to communicate with

patients or other

colleagues.

Improved treatment and

outcomes.

Timely and efficient

service.

Improved efficiency of

care packages.

Improved quality and

outcomes.

Measurement of

outcomes and

benefits.

Improved

safeguarding.

Hits government

targets.

Agencies committed

to use of Single

Assessment Process.

Progressive way to make

systems lean - spend to

save.

Funding is linear and

therefore able to support

timely and efficient pathway

response to patients needs.

More patients cared

for/maintained in the

community.

Reduced demand for

hospital services.

Joint commissioning

arrangement for efficiency

and effectiveness and links

to Mental Health and

Physical Health agenda.

Promote local specialist

networks/peer support.

Peer support with

increased knowledge

base for sharing =

shared core skills.

Sharper focus at

interfaces between

services and agencies

through improved

collaboration which

breaks down 'silos'.

Location.

Co-location a benefit?

Healthcare

professionals to charge

for services?

Differences in NHS and

Social Care legislation.

Culture.

Protection of existing

roles.




• Invest in telehealth and telecare to empower patients to take control of

their health needs, under the guidance and support of the case

manager.

• Develop personalised care plans using joint care planning/integrated

assessment and joint up multidisciplinary working along the care

pathway.

• Engage service users and carers as a means of offering choice and

personalisation. Include encouragement to participate in expert patient

programmes with personalised budgets.

• Intermediate care and rehabilitation services should form part of the

LTC.

• Work closely with the Mental Health teams to develop referral

pathways.

• Extend the hours of service according to patients needs.



• Use technology as a virtual means of asking advice or a second

opinion from a specialist, AHP or GP.


• Place individuals with LTC and /or their carers in charge,

enabling them to live well with their condition.

• Greater use of current technology to enable patients to access

their health records and test results remotely, for example, kidney

care: MySpace.

• Address the skills gap of health 'educators' for LTC within a

primary care setting.

• Commissioners (PCTs and Social Care) should jointly develop

'care passports'.

• Develop and apply the social care model for personalised

budgets and payments.

• Increased support for patients, their families and carers in

managing LTC, including from voluntary groups.

• A named patient advocate and care co-ordinator for all patients

with an LTC.


7.





Intermediate

Care as a

philosophy

rather than

separate team

plus priority for

local systems

to implement.

Care does not

need to fit into a

‘box’, there

should be no

criteria for

exclusion.

Services to be

needs led, not

criteria driven.

Open access

across a range

of services.

Underpinned by

NSF which is

measurable.

Improves and

increases

accessibility with

equality of

access.

Patient

pathways should

include

intermediate

care as part of

package of care

rather than

separate care.

Links nicely to urgent care reform,

self-care, end of life care.

Links with mental and physical

health agenda.

Provides care closer to home.

Reduces hospital admissions.

Enables development of

the rehabilitation agenda

with increased clarity for

the efficient use of

resources.

Less specialism and more

joint working promoted.

Links to clinical/medical

support i.e. Geriatrician.

Cultural change.




• Intermediate care and rehabilitation services should form part of the LTC pathway.

• Work closely with the Mental Health teams to develop referral pathways.

• Extend the hours of service according to patients needs.



• Use technology as a virtual means of asking advice or a second opinion from a

specialist, AHP or GP.


• Create effective health and care partnerships.

• Provide the right resource, in the right place, at the appropriate time in accordance with

need.

• For people with LTC or complex health care needs - provide a personalised care plan

and, where appropriate, use joint care planning or integrated assessments such as the

single assessment process or CAF.

• Invest in telehealth and telecare to empower patients to take control of their health

needs, under the guidance and support of the case manager.

• Develop personalised care plans using joint care planning/integrated assessments and

join up multidisciplinary working along the care pathway.

• A new model of care should be commissioned

that enables integration of health and social

care, with the roles of professionals changing to

meet patients' needs.

• There needs to be a clear description of what

primary care should be like to incorporate social

care, community care and specialists.

• A designated care co-ordinator will have

responsibility for ensuring that a plan is

developed and agreed.

• The role of primary care should be strengthened

and developed with new skills and ways of

working to deliver more personalised care

around patients.


8.



Benefits for Commissioners Benefits for System Reform

Enablers to Delivery


Improve staff

skills in

generalist and

expert roles

and develop

advanced

practitioners.

Right skills, in

the right place,

at the right time,

which ensures

minimum

intervention,

with maximum

quality and

effectiveness..

Less input but the same

productivity with a flexible

workforce.

Uses a flexible approach with one

person rather than numerous

professionals.

Commissioning pathways

increases efficiency and

effectiveness

Extended career

opportunities as

professionals

become multi-

skilled.

Uses modernised

training to gain

skilled

professionals.

Trans-disciplinary.

More modern

training is required

with defined roles to

reflect this. Most of

this can be work

based

learning/competency

based on KSF

Training not up-to-date.

Job descriptions/roles not fit for

purpose.

Staff confidence.

Professional bodies.

Culture.



• Provide staff with appropriate training. This may include non-medical

prescribing, advanced assessment, motivational interviewing or cognitive

behavioural therapy skills.

• Entrepreneurial practitioners maximising opportunities and demonstrating the

ability to lead and develop effective and productive nurse and AHP services.

• Seeking out business opportunities to develop care closer to home initiatives.

• Display expert leadership skills ensuring that the attributes become embedded

within work. Display influencing skills and ability to implement change. Work

with commissioners, managers and others to redesign care pathways which

will address all the elements of LTC management.

• A review of the capacity and skills mix needed in primary

care to support LTC.

• A new model of care should be commissioned that

enables integration of health and social care, with the

roles of professionals changing to meet patients' needs.

There needs to be a clear description of what primary

care should be like to incorporate social care, community

care and specialists.


END OF LIFE CARE


1.







Standardised care

pathway for end of

life care to enable

equitable access,

regardless of

clinical diagnosis.

Standardisation of

care pathways

promotes equity,

quality, experience,

support, and

advanced care

planning.

Clinical Pathways

set out clearly

defined expectations

which promote

consistency.

Integrated Care

Pathway is well

evidenced.

Clinical pathways are

clearly commissioned as

an integrated and

complete service. They

are cost effective and

enable advanced

planning which supports

World Class

Commissioning.

Benchmarking of quality

and efficiency.

Care delivered closer to

home, which promotes

patient choice.

Develops Integrated

Care Pathways for

efficient service delivery.

The North West End of life

pathway is already in

place with some evidence

locally about using this to

meet local needs/map

service.

The pathway is well

evidenced. It promotes a

high profile of end of life

care nationally.

Some areas of the North

West already have

baseline measures of

available resources.

Ambiguity - where is

the patient on the

pathway?

Personalisation of care.

Change process for

staff groups – ie. move

from established roles

and functions,

competencies.

Getting partners to

agree to work

collaboratively.

Unknown resource

issues.

Gaps in knowledge/

gaps in service

provision.


Priorities in Transformational Guides Priorities in Healthier Horizons for the North West

• Ensure early identification of patients and have sensitive conversations about death, dying, choice

and personalisation with patients, carers and families

• Ensure that care for those approaching end of life is accessible, responsive and available 24 hours

a day. All patients should have a case manager and documentation (where appropriate) on

advanced care wishes and preferences for care.

• Work in partnership with other practitioners to co-ordinate interventions at all stages of the

patient pathway. Ensure GPs, ambulance trusts, out-of-hours providers, specialist palliative

teams, district nursing teams, acute sector, hospices, care homes, social care and all other

practitioners who have a contribution help devise care plans and agree roles, responsibilities and

communication channels.

• Ensure that all providers who support end of life care within the home, and proactively work to

prevent admissions into an acute trust, work together to understand their role in clinical care and

prevention.

• Familiarise yourself with your SHA and PCT end of life care strategic plans which encompass

patients with all diagnoses, care provided in any setting by a collective of organisations and

providers, and covers each step of the end of life care pathway.

• Ensure that all end of life care teams make close linkage with continuing healthcare services so

that, where appropriate, packages of care can be set up effectively and efficiently with no time

delay for patients.

• Identify all local agencies and third sector organisations who provide end of life care provision and

support, including those offering emotional and bereavement support for children and adults.

Develop collaborative relationships to complement and co-ordinate care.

• Integrated pathways are a widely accepted model to improving standardisation, continuity /

collaboration among multi-disciplinary teams.

• The pathway should be underpinned

by strategic partnerships with co-

ordination across all organisations

and at operational level between

services delivered by hospitals,

PCTs, social care, ambulance

services and the voluntary sector to

provide seamless service.

• It is vital to have a robust, integrated

commissioning framework, based on

the North West end of life care

model across health, social care,

voluntary, charitable and

independent sectors, with strategic

leadership. This will ensure

consistency of approach,

personalised care and choice,

facilitating timely and appropriate

access to services for patients and

their families.

• A joint health and social care

commissioning framework should be

in place for the end of life care

services.

• A financial investment programme

should be identified to support the

delivery of the health and social care

commissioning strategy.


2.





Ring fenced funding

with robust tiered

access to support

people in their last

days/weeks of life.

Ring fencing means the

money is available,

therefore there will not be

time delays to access this

service for patients.

There will be speedier

discharge home which

helps patients make the

right choice.

Ring fencing means that

organisation and forward

planning is easier, hence,

freeing up precious time

for care of patients.

Promotes fair access. An

example is Stoke on

Trent PCT - who ring

fenced their equipment

service.

Management of

costs are more

predictable.

Allows speedier

safe discharges -

which are relevant

to

economy/finance

as care at home

may be cheaper.

Avoids

acute/emergency

admission as care

is managed.

Time is freed up

through

management of

patients,

therefore, it is

better use of

resources - more

time to care and

not chase up

equipment etc.

Enables patients and

professionals to make

choices.

Rapid discharge

through pathways.

Admission avoidance.

Examples from other areas

can be replicated.

Predictable costs may be

attractive.

Preferred priorities for care (PPC) audit demonstrates where people have not had access to resources to enable their choice.

By definition, limited

resources.

Access criteria,

equity across other

client groups.

How much is

enough?

What are the right

criteria for access:

open to misuse?




• Work with commissioners to agree the outcome data that needs to be collected for a specific service area to demonstrate effective intervention.

• Create effective and health and care partnerships.

• Implement new service approaches.

• Provide the right resources, in the right place, at the appropriate time in accordance with need Benefits realisation: demonstrate that the benefits envisaged are actually derived. Actions to create the change and the delivery of outcomes should be monitored through a plan to track the implementation and the service improvements.

• Advanced care planning (ACP) and all three end of life tools are used in all care settings (NICE,2004:11) .

• A financial investment programme should be identified to support the delivery of the health and social care commissioning strategy.

• Protocols for continuing healthcare funding are consistently and equitably applied and accessible in a timely manner (fast tracked).


3.





Access to

appropriate

knowledgeable

generalist care 24/7,

supported by

specialist

practitioners (Multi

Disciplinary Team) -

to include sitting

service respite for

carers.

Provides continuation

of care and increases

quality of life.

Patients and carers

have an improved

experience of

palliative care and

support. This relieves

burden and supports

positive grieving with

psychological support.

Preferred Priorities for

Care (PPC) gives

patients and carers

the confidence to stay

at home.

Crises are managed

more effectively.

Decreased pressure on

the system overall as it

is managing more

specialist care in the

community.

Decreased pressure on

bereavement services

as patients and carers

are supported at home.

Fewer emergency

admissions.

Enables speedier

discharge.

Promotes engagement

with charitable

agencies and other

partners.

Promotes reliable

community service

provision and increases

staff morale.

NICE promotes a more

positive end of life

strategy.

A change in working

practices is needed in

line with World Class

Commissioning,

NICE promotes a

more positive end of

life strategy.

Patients able to

exercise more choice.

Skill mix, of integrated

working and

professionals

supports patients and

carers better at home.

Admission avoidance

relieves pressure on

the whole system e.g.

hospices.

At the moment good practice is

available, but in pockets - this

can be replicated as the

infrastructure is already

commissioned. This just needs

strengthening and building.

This will provide a good

evidence base.

Reluctance of staff to

change.

Short term costs -

long term gains.

How to measure

success?

Guidelines support

development of

specialist roles but

these don't have

capacity to deliver - or

have the capacity to

build.



• Use an established framework such as the gold standards framework or Liverpool care pathway to optimise care delivery.

• Work in partnership with other practitioners to co-ordinate interventions at all stages of the patient pathway. Make sure GPs, ambulance trusts, out-of-hours providers, specialist palliative teams, district nursing teams, acute sector, hospices, care homes, social care and all other practitioners who have a contribution help devise care plans ad agree roles, responsibilities and communication channels.

• Ensure that all end of life teams make close linkage with continuing healthcare services so that, where appropriate, packages of care can be set up effectively and efficiently with no time delay for patients.

• Identify all local agencies and third sector organisations who can provide end of life care provision and support, including those offering emotional and bereavement support for children and adults. Develop collaborative relationships to complement ad co-ordinate care.

• Ensure that all providers who support end of life care within the home, and proactively work to prevent admissions into an acute trust, work together to understand their role in clinical care and prevention.

• Advance care planning (ACP) and all three end of life tools are used in all care settings (NICE,2004:11) .

• Where ACP is in place, it needs to be timely and regularly reviewed (Henry C & Seymour 2007:61) .

• All GP practices have a supportive register in place for patients who are known to be in their last year of life.

• End of life services need to be comprehensive and available to all 24/7.

• A single point of access for individuals and their carers also needs to be put in place and would include access for carers and family during the bereavement phase, ensuring the provision of appropriate support.

• To ensure a comprehensive, co-ordinated and seamless approach, it is crucial that professionals and organisations work together so that when people need to use the service it is a 'one service' that is clear and easy to access.


4.





Commission

clinical

leadership in

community

services in End

of Life care -

moving to drive,

quality, access,

innovation

Clinical leadership will

drive the service,

therefore, access/quality

of care systematically

improves. Innovations

are delivered, profile is

raised, infrastructure is

developed, leading to a

happier and more

productive workforce so

enabling increased

service delivery.

There are long

term gains plus

quick wins for

patients, with

increased quality

assurance.

As this is service driven then

access/quality of care

systematically improves.

Innovations are delivered,

profile is raised as

infrastructure is developed.

A happier and more

productive workforce will

increase service delivery.

Patients have long term

gains plus quick wins.

Quality assurance

Using evidence of good

practice gives existing

practitioners a good base to

deliver a robust and quality

service.

Expensive resource

undervalued by

commissioners.

Avoid commissioners

over-managing.

Is it for the provider to

deliver from whole

pathways costs?


• Support teams to develop creative approaches to service

provision, which will improve choice, personalisation, efficiency.

• Support and empower practitioners to develop multidisciplinary

teams using approaches such as transformational attributes

• Create effective health and care partnerships

• Use technology to support shared care, joint care planning.

• Joint working between specialist hospital care teams and

community services can be particularly beneficial.

• Commissioners and Providers work together to ensure that

where good evidence exists this is implemented within local

services.

• NHS North West should work closely with all services to determine and meet workforce requirements and to ensure education and training programmes are available for all health and social care staff (NICE,2004:13).

• The North West will work closely with all education providers including the hospices and third sector in particular to develop a more strategic approach to education and training for end of life care.

• Individual practitioners should ensure they have the knowledge and skills required for the roles they undertake within the spectrum of end of life care (NICE, 2004:14).

• All provider organisations should identify the end of life training needs of

staff and should facilitate their participation in training and ongoing

development.







Use of Primary Care

Local Enhanced

Service (LES) to

improve GP case

management in the

community

More people will die

at home, well

supported in the

community.

Provide a working

model of case

management. This

way of working

enables patient

and professional

choice and co-

ordination of care.

Work towards the

Gold standards

framework where

there is evidence of

GP change of

behaviour with QoF

incentive.

The use of

Preferred Priorities

for Care (PPC)

allow patients

wishes.

Better

communication in

multidisciplinary

team.

Outcomes are

commissioned which

decrease inpatient

costs.

This enables care closer

to home giving patient

choice. All services are

integrated.

There will be a financial

reward for GPs who are the

most likely people to have

awareness of client base.

Local Enhanced Service

(LES) is used positively

elsewhere as an enabler of

change.

Improving case

management will release

capacity in secondary care.

GP competencies in end

of life care.

GP compliance with

system and best practice

(culture).

Competing priorities for

GPs.

5.



• Create effective health and care partnerships - strengthen partnership

working across health and social care.

• Implement new service approaches.

• Provide the right resource, in the right place, at the appropriate time in

accordance with need.

• Ensure that all patients who are approaching end of life are identified

early and sensitive conversations are had about death and dying, choice

and personalisation with patients, carers and families.

• Ensure that a local practice register is kept and available for all health

and social care practitioners involved in palliative and end of life care.

The register should hold information regarding advance care plans and

the do not attempt resuscitation (DNAR) status of the individual subject

to their consent.

• All GP practices have a supportive register in place for patients

who are known to be in their last year of life.

• End of life services need to be comprehensive and available to

all 24/7.

• A single point of access for individuals and their carers also

needs to be put in place and would include access for carers and

family during the bereavement phase, ensuring the provision of

appropriate support.

• To ensure a comprehensive, co-ordinated and seamless

approach, it is crucial that they work together across professions

and organisations so that when people need to use the service it

is a 'one service' that is clear and easy to access.

• Advanced care planning (ACP) and all three end of life tools are

used in all care settings (NICE,2004:11) .

• A financial investment programme should be identified to support

the delivery of the health and social care commissioning strategy.


6.






Advanced care

planning - level 4

Gold Standards

Framework (GSF)

Integrated Care

Planning (ICP)


Care (PPC)

Advance planning will

help with medicine

management by

allowing anticipatory

prescribing.

Developing pro-active

care planning across

End of Life Care and

into bereavement

means that patients

and carers receive a

seamless service.

Quality care = improved

patient pathway, patient

choice with better care

experience, which

reduces inappropriate

admissions to hospital.

Advance planning

enables rapid

discharge.

By using advance

care planning there

will be increased

home deaths,

therefore, a 10%

reduction in

hospital deaths -

saving money in

the acute sector.

Prescribing costs

will be reduced as

they are managed

better = Value for

money.

Better, managed

care will achieve

quality markers -

increasing patient

and carer

experience

because of

reduced hospital

stays.

Care management will help

to streamlined services and

by using integrated services

duplication reduced.

By using three

tools, fully

implemented in all

care settings.

GSF - level 4 – in

all care settings.

Substantive End of

Life Care facilitator.

Extend principles

of End of Life Care

to all end of life

threatening

illnesses.

Use peer review -

against quality

markers.

Optional not compulsory.

Lack of

awareness/confidence.

Cost/ funding.



• Implement new service approaches

• Provide a personalised care plan and, where appropriate, use joint care

planning or integrated assessments such as the single assessment

process or common assessment process (CAF).

• Provide patients and carers with a named key worker or case manager,

with a care plan, to ensure high quality, safe and effective continuity of

care.

• Use and develop evidence based practice and validated research to

improve clinical practice. Ensure that care for those approaching the end

of life is accessible, responsive and available twenty four hours a day.

• Offer all patients approaching the end of life the opportunity to express

their preferences and wishes for care, death and dying.

• Patients should have access to 24hr emergency medicines

• Care should be avail 24hrs a day to enable people to live and die at the

place of their choice.

• Advance care planning (ACP) and all three end of life tools are

used in all care settings (NICE,2004:11) .

• Where ACP is in place, it needs to be timely and regularly

reviewed (Henry C & Seymour 2007:61) .

• All GP practices have a supportive register in place for patients

who are known to be in their last year of life.

• End of life services need to be comprehensive and available to

all 24/7.

• A single point of access for individuals and their carers also

needs to be put in place and would include access for carers and

family during the bereavement phase, ensuring the provision of

appropriate support .

• To ensure a comprehensive, co-ordinated and seamless

approach, it is crucial that they work together across professions

and organisations so that when people need to use the service it

is a 'one service' that is clear and easy to access.


7.





Education,

training including

communication

skills and non

malignancy care.

Improved care for

patients will be further

enhanced by up-to-

date training for all

staff.

This will increase

patient, carer and staff

confidence and help

staff deliver choice for

patients and carer,

therefore, more likely to

achieve Preferred

Priorities for Care

(PPC)

Achieves better patient

and carer experience

There is likely to be a

reduction in

complaints/clinical

incidents as there are

the right skills in

teams

It is cost effective

Improved quality of

end of life care

Recruitment and

retention will be

improved as training is

part of their job

description, hence,

better and more

rewarding job

satisfaction and

productivity

Enables succession

planning where staff are

aware of service

development

There needs to be an

established, robust

education and training

strategy to develop the

provider workforce and

strategic development

plans.

Key worker scheme and

development.

Seen solely as a nursing

responsibility.

Education takes away

from face to face contact.

Costly/staff not released.

Difficult to sustain in care

homes (staff turn-over)



• Commissioner and provider management teams must be responsible for developing a competent workforce that will deliver sufficient current and future services safely, effectively and which have a positive impact on service user experience.

• Practitioners and clinical teams need to review best practice and prioritise development plans for service delivery

• Provide access to robust training and education, clinical supervision and improved clinical leadership, managerial and business skills to improve health outcomes

• Use and develop evidence based practice and validated research to improve clinical practice

• Ensure practitioners are trained in assessment and care planning, symptom management and advance care planning relating to end of life

• NHS North West should work closely with all services to determine and

meet workforce requirements and to ensure education and training

programmes are available for all health and social care staff

(NICE,2004:13).

• The North West will work closely with all education providers including the

hospices and third sector in particular to develop a more strategic approach

to education and training for end of life care.

• Individual practitioners should ensure they have the knowledge and skills

required for the roles they undertake within the spectrum of end of life care

(NICE, 2004:14).

• All provider organisations should identify the end of life training needs of

staff and should facilitate their participation in training and ongoing

development.

• The development of competencies for end of life care, particularly

communication skills, are identified and used to inform learning and

practice.


8.





Access to 24hr

Specialist Palliative

Care ( SPC) advice

including 7 day face to

face core hours

contact 9-5

Improved access helps

to keep patients at home

with better pain and

symptom control,

therefore achieving


Care (PPC).

Patients and carers

have increased

confidence in their end

of life team.

Reduction in

complaints/critical

incidents.

Reduction in

prescribing costs.

Improves patient and

carers experience.

Reduction in length of

stay

Increased support for

generalist staff.

Opportunity for system

reform and service re-

design through

collaboration between

provider partners.

Review existing team and

skill mix.

HR and staff side

engagement.

Commissioning intent.

Robust partnerships.

Single point of

access.Information on

services (in SPC Packs)

Funding,

Fragmented

approach.

Patient and carers

not accessing

services.

Reduced core

service.


• Use an established framework such as the Gold Standards Framework.

• Work in partnership with other practitioners to co-ordinate interventions at all stages of the patient pathway.

• Make sure all practitioners who have a contribution help devise care plans ad agree roles, responsibilities and communication channels

• Ensure that all end of life teams make close linkage with continuing healthcare services so that, where appropriate, packages of care can be set up effectively and efficiently with no time delay for patients

• Develop collaborative relationship with all local agencies and third sector

organisations who can provide end of life care provision and support.

• Advance care planning (ACP) and all three end of life tools are used in all care settings.

• Where ACP is in place, it needs to be timely and regularly reviewed (Henry C & Seymour 2007:61).

• All GP practices have a supportive register in place for patients known to be in their last year of .

• End of life services need to be comprehensive and available to all 24/7.

• A single point of access for individuals and their carers

needs to be put in place.


9.






Rapid Response

type services

(24 hr)

Increases

patient choice

with reduced

hospital

admission at

end of life.

Rapid response

also supports

carers

Rapid response

type service can

contribute to

10% reduction in

hospital death

and also

improves patient

and carer

experience.

Opportunity

for integrated

service

delivery

Encourages partnership working across pathway

with engagement from commissioners. Helps to

develop robust contracts, equipment etc with

other providers. Procurement is across

partnerships.

Define and develop robust service model and

service spec to develop quicker response times.

Supports the provider/commissioner

relationship.

Commissioner awareness of

what provider services can

deliver. No clarity around

definition of rapid response for

End of Life Care.

Workforce resource issues

Funding. Public expectations.

Media message re: Macmillan

Marie Curie


• Provide local information about your services: the access, availability, choices, for patients, the public and

professionals.

• Check against the experience of those using your services to ensure understanding. Provide the right resources,

in the right place, at the appropriate time in accordance with need. Ensure that all providers who support end of

life care within the home, and proactively work to prevent admissions into an acute trust, work together to

understand their role in clinical care and prevention.

• Implement new services approaches and expand end of life care. This should include developing end of life

services for patients with long term conditions and older people with co-morbidities. This should also include

supporting the delivery of services in settings such as care homes, hostels and prisons.

• Care should be available 24hrs a day to enable people to live and die at the place of their choice, this may also

include partnership working, joint systems planning with those who already provide a 24hr service e.g. ambulance

services, Out of Hours.

The pathway should be

underpinned by strategic

partnerships with co-ordination

across all organisations and at

operational level between

services delivered by hospitals,

PCTs, social care, ambulance

services and the voluntary

sector to provide seamless

service (DH,2006.)


URGENT CARE


1.







Rapid Clinical

Assessment

and treatment

in the

community.

Patient Based/Centric

Patients prioritised

Reduced cross Infection

Increased Rehabilitation

Reduced Health Inequalities

Improved Medicines

Management

Reduced hospital admission

Care close/in the home

Holistic/ seamless service

Joined up/signposting

One person assessing

coordinating

Rapid assessment of

clinical/social need

Reduced Waiting time

Increased Carer/family benefits

Value for money –

quality outcomes.

Reduced Health

inequalities.

Reduced hospital

admission.

Improved Medicines

Management

Population focused

Workforce

development and

transformation.

Integrated health and

social care.


outcomes

Innovative use of

technology

Transformed

community function

Appropriate avoidance

of hospital admissions

Business principles

applied by community

services.

Integrated health and social

care

Access to diagnostics

Common IT System

Integrated Budgets

Integrated Governance

Single point of access

Marketing

Resistance to

change

Clinical Ownership

Lack of care

pathways

IT not fit for purpose

Nobody owns the

patient

Community

infrastructure

Lack of engagement

of GP’s and primary

care.




• Rapid Clinical Assessment/ admissions avoidance

• Identify common reasons for hospital admission or attendance.

• Work in partnership with other organisations to provide creative solutions to joined up care. Identify new

service solutions to hospital admission or attendance such as community matron facilitated discharge or

nurse practitioner triage in A & E. More complex wound care provided in a community setting aligned to the

dermatology care pathway, all clinicians must be skilled and competent in providing high quality, safe and

competent wound care

• Use technology as a virtual means of getting specialist advice or a second opinion from a specialist nurse,

allied health professional, GP or consultant.

• Deliver new and innovative services in the community such as drug therapies or outpatient services

Ensure that community teams and matrons make close linkage with continuing healthcare services so that,

where appropriate, packages of care can be set up effectively and efficiently with no time delay or hospital

wait for patients.

Implement 'new service approach' - Services have to be seen to be cost effective and deliver the right care, in

the right place, at the right time. Community staff should be knowledgeable about the cost benefit involved in

hospital admission tariffs and facilitated discharge. This should be balanced against the cost benefit of

developing new services in the community

• Identify solutions to unplanned hospital admissions and attendance at A & E. Community matron facilitated

discharge, nurse practitioners and occupational therapists in A & E

• Be clear about the access points for service: a single point of access, triage or referral system

• Work with primary care, the out-of-hours provider, adult services, ambulance trust and the acute sector to

develop shared care records. This will ensure the most vulnerable, or those at risk of health deterioration are

known to all services along the clinical care pathway.

• Develop three multi-

professional, clinical urgent

care networks in the North

West, which will be

responsible for driving the

implementation of change,

auditing the effectiveness of

change through clinical

outcomes and horizon

scanning for innovation.

• Regionally, commission the

five levels of care

recommended by the

College of Emergency

Medicine.

• Shared IT between care

providers must be

implemented as a priority.

• Develop an inter-

professional workforce with

a culture of joint teaching

and learning.

• Mental health, alcohol and

drug services and social

care to be fully integrated

into urgent care response.


2.





7 Day Working

Continuity of care

Reduced Admissions

Increased speed of discharge

Access to equipment

Timely care

General Benefits to patients

Reduced cross infection.



joined up/signposting


coordinating – ACM

Rapid assessment –



Increased rehabilitation

Increased Carer/family

benefits

Continuity of care

Reduced

Admissions

Increased

discharge

Access to

equipment

Timely care

Population focused

Workforce

development and

transformation

Value for money

Integrated health

and social care

Improved quality

and better

outcomes

Innovative

Community services

applying business

principles

Use of technology

Funding/resources

Appropriate clinical priority

Flexible workforce

Staff Side

Agenda for change

Change fatigue

Integrated working with other

organisations

Equipment users




• Extend the hours of service according to patient need. This may

include telephone access for on-call and out-of-hours home visits

making the best use of in-house provision or co-ordinating this through

partnership working with the ambulance trust and out-of-hours

provider.

• Be clear about the access points for service. This may mean

developing a single point of access, triage or referral system.

• Work with primary care, the out-of-hours provider, adult services,

ambulance trust and the acute sector to develop shared care records.

• Use technology to expand access to diagnostics and to seek advice.

This may include access to PACS (digital imaging x-ray) in the

community. This may also include the development of liaison and care

planning systems so that the ambulance trust can admit appropriate

patients direct to community services.

• Use technology as a virtual means of asking for advice or a second

opinion from a specialist nurse, allied health professional, GP or

consultant.

• Replace visits, where appropriate, with a telephone or videophone

contact - (monitoring acute illness or LTC).

• Use technology to empower patients to monitor their own condition.

• Use technology as a form of documentation i.e. remote access

devices - palm tops, tablets which can be synchronised easily with IT

systems avoiding unnecessary travel or time wastage.

• Any required service configuration will be evidence based, follow

audit of patient outcomes and take account of the geography of our

region to ensure best outcomes for the public wherever they live.

• Develop and support the regional clinical network, working with

commissioners to develop and maintain high quality service

delivery.

• Standardisation of out of hours service delivery and access to acute

care and diagnostic services across the North West.

• The national number should allow a locally integrated telephone

access and triage system and facilitate the development of

integrated urgent care and community service access

people get the right treatment in the appropriate setting is the

provision of integrated urgent care services, available if required 24

hours a day, seven days a week (24/7) .


3.





Assisted

Technology

Continuous, automatic and remote

monitoring of real time emergencies and

lifestyle changes

Reduced unnecessary hospital admission,

and visits by GP, Community

Matron/Active Case Manager, District

Nurse

Increase patient independence - patients

can take control of their condition

Reduced cross infection


Holistic/seamless service joined

up/signposting

One person assessing coordinating

Rapid assessment – clinical/social need




Value for money

Population

focused

Reduction in

health

inequalities

Workforce

redesign

Integrated health and

social care


outcomes

Innovative use of

technology

Transformed community

services more business

minded

Funding the system

changes

Training for staff

Systems monitored by

the company and

maintained

Audit effectiveness

Fear of technology

taking over clinical

roles

Patient fear/resistance

choosing the right

company to provide

cost effective support

and training

Lack of funding




• Make sure services have the right skills in the right place to treat

patients safely and competently. Train staff to recognise, assess,

diagnose and treat those who unexpectedly fall ill and require care.

Practitioners may have to have advanced level knowledge, including

physical assessment and non-medical prescribing.

• Develop new roles such as the assistant practitioner role of foundation

degree practitioner at NVQ 4 level, working in partnership with other

organisations to integrate roles.

• Use technology to expand access to diagnostics and to seek advice.

This may include access to PACS (digital imaging x-ray) in the

community. This may also include the development of liaison and care

planning systems so that the ambulance trust can admit appropriate

patients direct to community services. Use technology to expand

access to diagnostics and seek advice.

• Use technology as a virtual means of asking for advice or a second

opinion from a specialist nurse, allied health professional, GP or

consultant .

• Replace visits, where appropriate, with a telephone or videophone

contact - (monitoring acute illness or LTC).

• Use technology to empower patients to monitor their own condition,

e.g. telehealth.

• Use technology as a form of documentation i.e. remote access

devices - palm tops, tablets which can be synchronised easily with IT

systems avoiding unnecessary travel or time wastage.

• Review the role of telemedicine for CT scan interpretation and

trauma resuscitation review, given the geographical constraints of

distance and access in parts of the region.

• The national number should allow a locally integrated telephone

access and triage system and facilitate the development of

integrated urgent care and community service access.

• Shared IT between care providers must be implemented as a

priority.


4.


Benefits for patients Benefits for Commissioners



IV Therapy

Holistic/Seamless Care

Less disruption and care closer to

home

Value for money

General Benefits to patients



Holistic/seamless service

One person assessing coordinating

– Active Case Manager

Rapid assessment – clinical/social

need




Value for money

Population

focused

Reduction in

health inequalities

Workforce

Integrated

health and social

care

Improved quality

and outcomes

Innovative use of

technology

Transformed

community

services more

business minded

Skilled workforce

Resources

Marketing

24/7 Workforce

Secondary care `buy in’

Clear clinical pathway

Lack of commissioning

Lack of engagement from GP’s

Lack of resources

Lack of buy in/engagement by

secondary care

Public Perception




• Make sure services have the right skills in the right place to treat

patients safely and competently.

• Train staff to recognise, assess, diagnose and treat those who

unexpectedly fall ill and require care.

• Practitioners may have to have advanced level knowledge, including

physical assessment and non-medical prescribing.

• Develop new roles such as the assistant practitioner role of foundation

degree practitioner at NVQ 4 level, working in partnership with other

organisations to integrate roles. This will require commissioning

changes in education pathways

• Develop three multi-professional, clinical urgent care networks in

the North West, which will be responsible for driving the

implementation of change, auditing the effectiveness of change

through clinical outcomes and horizon scanning for innovation.

• Regionally, commission a piece of work together to further refine

the five levels of care recommended by the College of

Emergency Medicine.

• Develop an inter-professional workforce with a culture of joint

teaching and learning.

• Shared IT between care providers must be implemented as a

priority.


5





Integration of

social services and

health care

services

Agencies working in

partnership to promote

health

Patients needs prioritised

and quicker response

promotes improved high

quality service

Reduced depression,

anxiety which causes

distress in Long Term

Conditions which has major

impact on health as causes

distress and deterioration of

physical health and

increase in hospital

admission and mortality

rates

Continuous, automatic and

remote monitoring of real

time emergencies and

lifestyle changes over time

in order to manage the risks

associated with

independent living

Reduction in unnecessary

hospital admission; improve

care home standards

Continuity of care

Working in partnership with

Agencies working in

partnership to promote

health

Patients needs prioritised

and quicker response

promotes improved high

quality service

Reduce depression

anxiety which causes

distress in Long Term

Conditions which has

major impact on health as

causes distress and

deterioration of physical

health and increase in

hospital admission and

mortality rates

Continuous, automatic

and remote monitoring of

real time emergencies

and lifestyle changes

over time in order to

manage the risks

associated with

independent living

Reduction in

unnecessary hospital

admission; improve care

home standards

Integrated health

& social care

Quality and

better outcomes

Innovative

Community

services

applying

business

principles

Use of

technology

Combining social and

healthcare budgets

Employing

social/health workers

in social or health

teams

Common IT systems

Use of Hospital

Anxiety and

Depression measures

Develop clinical

pathway for Advanced

Practitioners or

specialist nurses to

refer to mental health

services

Improve Single

Assessment Point

Funding

System in place to

identify the right

patients

GP Support

Use of available

evidence base

Resistance to change Services being protective of their role Poor referral system at present. SAP documentation not appropriate Fear of technology taking over clinical role. Patient resistance choosing the right company to provide support and training ‘possible’ Lack of funding Lack of training Lack of GP Support


GP, care home staff,

families and the patient and

other agencies.




joined up/signposting


coordinating

Rapid assessment –




Continuity of care

Working in partnership

with GP, care home

staff, families and the

patient and other

agencies

Value for money

Population focused

Reduced health

inequalities

Workforce development



• Work in partnership with other organisations to provide creative

solutions to joined up care.

• Extend the hours of service according to patient need. This may

include telephone access for on-call and out-of-hours home visits

making the best use of in-house provision or co-ordinating this through

partnership working.

• Work with primary care, the out-of-hours provider, adult services,

ambulance trust and the acute sector to develop shared care records.

This will ensure the most vulnerable, or those at risk of health

deterioration are known to all services along the clinical care pathway.

• Use technology as a virtual means of asking for advice/second opinion

from a specialist nurse, allied health professional, GP or consultant .

• PCTs should commission intermediate care that is needs led, not

restricted by age.

• Nationally, social and healthcare should be funded as a single

service line. Shared IT between care providers must be

implemented as a priority.

• Develop an inter-professional workforce with a culture of joint

teaching and learning

• Urgent care services should be integrated and barriers between

primary, secondary and social care should be removed. The key

to ensuring that people get the right treatment in the appropriate

setting is the provision of integrated urgent care services,

available if required 24 hours a day, seven days a week.


PLANNED CARE


1. Top 3-5 Improvements



Benefits for System Reform Enablers To Delivery


Single point of

access

Single Point of Access

means less confusion

for patients as it

simplifies the patient

journey. This means

that patients are seeing

the right person, in the

right place, at the

appropriate time.

Patients gain good pain

management

Commissioners know what

they are paying for as they

have access to the right

Business Intelligence

There are benefits for providers i.e.

they can forecast demand and make

arrangements to manage this. This

helps to avoid bottlenecks into the

system and supports the

development of standardised

measures of quality and the

capturing and use of patient

experience.

Modern IT drives

efficiencies and so

becoming more

effective.

Modern staff training

enables professionals to

give a more efficient and

effective service to

patients

IT Culture Organisational boundaries



• Build and develop multidisciplinary and interagency teams to

deliver person centred rehabilitation.

• Invest in services that maximise a return to work.

• Use evidence based care pathways as a tool to provide shared

vision.

• Ensure that care is provided by a provider best able to meet the needs of

the patient, and deliver high quality evidence based care which is valued by

the public.

• Care should be provided by the provider best able to meet the needs of the

patient irrespective of whether they are an NHS organisation, as long as

NHS values are maintained.


2.





Integrated IT

systems that

`talk’ to each

other and

enable rapid

communication

and the use of

real time

information.

Supports single assessment process and

promotes patient choice.

Reduces duplication and improves access for

patients. Patients understand the process which

in turn reduces complaints.

Healthcare records are updated and supported,

therefore, the most current information is

available.

Reduces waiting times.

Business

Intelligence is up-

to-date.

Change in

behaviour

and culture

for a

modernised

workforce.

Able to target finance to

ensure care in the right

place and at the right

time.

Modernised staff training.

IT support for data

sharing.

Costs.

National agreements.

Sharing information

across organisations.



• Use assistive technology including telecare to optimise

health and wellbeing including maintenance.

• Use technology such as telehealth to enable and empower

people to monitor their own conditions.

• Use regular telephone support/video linkage as part of the

rehabilitation programme

• Shared IT between care providers must be implemented as a priority


3.





Increased business acumen/ business relationships by community services

This approach

offers value for

money to

taxpayers and

provides

efficient &

accessible

services. There

are more

opportunities to

be involved.

By using

Business Models

other providers

can be brought

into the market

place.

Using the World Class

Commissioning guidelines to

identify and incentivise

outcomes.

Increased collaboration between

providers for effective pathway

delivery.

Transforming Community

Services - providing services in

a community setting in line with

Department of Health Policy

using the market place to

tender for and obtain the best

services possible. This will

involve competition from other

providers and opportunities for

collaboration.

Challenges of Transforming

Community Services.

NHS Culture.

Economic climate.

Change of Government.


• Maximise opportunities and demonstrating the ability to lead and further develop

effective productive services which promote self-referral wherever appropriate

and multidisciplinary ordering of investigations and onward referrals.

• Seeking out business opportunities to develop new ways of delivering

rehabilitation services either with existing providers or through new service

development. This may include thinking about social enterprise or integrated care

organisations.

• Developing positive risk opportunities when delivering rehabilitation.

• Understand the business process, impact of the economic downturn and

productivity /efficiency measures and how to put together a business case which

can evidence value for money whilst ensuring high quality care and patient

safety.

• Deliver Advancing Quality programme to ensure that the

payment mechanism rewards the delivery of quality

outcomes including the patient's experience of the health

service.


STAYING HEALTHY


1.






Proactive

Health Care

Screening for

vulnerable

groups,

learning

disabilities and

older people.

This is

everyone's

responsibility.

Staying healthy

for longer

increases health

and well being

(physical &

mental). This in

turn increases

economic

independence,

therefore,

reduces ill health

payments by the

government.

Patients gain

knowledge,

empowerment,

confidence

which increases

their choice of

services as they

are able to

navigate around

the NHS system

Earlier

intervention to

prevent

specialised

service

requirements i.e.

long term

conditions.

Reduced hospital

admissions.

Creates

independence.

Maximises the

input of current

services.

Focus on health care screening in

community services decreases demand

for acute care and increases enablement

of self care. It also enhances the skills

knowledge of community staff to deliver

inclusive, comprehensive services.

Productivity/ capacity gains in the

community from co-location and

coordination which enables innovation in

the long term which could reverse the

increase in lifestyle related illness reliant

on professional care. Increases co-

ordination of services which reduces

duplication and inappropriate referrals

and multiple staff visits. This also

reduces DNA's and increases

safeguarding of vulnerable adults.

Supports common data sets, quality

indicators, and measured improved

health outcomes through the effective

commissioning of health and well being

services. This is part of tiered/stratified

services targeting vulnerable groups who

may be excluded or not available from

the current services.

Develop the evidence of

needs through partnership

working through the

political/cultural/will/policy

context. It should focus on

inequalities.

Training for the workforce will

increase system capacity

and capability for prevention.

Focusing on value for money

makes radical change

possible.

Through demonstrator sites

contestability can be tested.

Professionals can work with

patients to re-design

services.

Greater use of technology.

Commissioners will

have to decommission

secondary services to

invest in pro-active

care.

Professionals may

protect their own

service area and not

engage fully.

Balance between

quality & value for

money.

Shared insight vs buy

in.

Clinical pathway

design, people do not

follow single pathways

neither do services.

Productivity vs

personalised services



• Change is inevitable. There is more in common between services than

Embraces a philosophy that health, wellbeing and reducing

inequalities is every practitioner’s role.

• Know the range of intervention which promote positive behaviour

Extend their impact of health outcomes through joint working with local

partners.

• All practitioners can maximise their role in promoting health and

wellbeing.

• Make good use of ‘teachable’ moments.

• Educate teams in accessing and understanding information, initiating

an d managing difficult conversations and delivery of health messages

in ways that are culturally appropriate.

• Services are planned and delivered in ways that actively seek to

reduce health inequalities.

• Provide the right resources at the appropriate time in the right place in

accordance with need. Overnight/ weekend care/24 hr care. May

mean working with other partners to ensure that systems are in place

to access care. This may include capacity management systems,

access points, and telephone triage.

• Partners should include the out of hours provider and Ambulance

Trusts.

____________________________


2.





Coordination/ co-location of wellbeing services/ lifestyle advice (sensitive/ responsive to vulnerable groups) including links to acute care and mental health to enable opportunistic advice.

Increased expectation of own health (breaking negative cycles in communities and families). Experience of co-ordinated care. Easy access to services which are responsive to vulnerable groups. Holistic/ responding to your health needs which are person centred.

Increase in the

uptake of

services.

Improved

outcomes.

Increased

uptake from

vulnerable

groups,

therefore,

reducing health

inequalities.

Efficiency and

productivity

gains.

Opportunity to

innovate across

services.

Focus on health care screening in community services, therefore, decreases acute care and increases enablement of self care. It also enhances the skills knowledge of community staff to deliver inclusive, comprehensive services. Productivity/capacity gains in the community from co-location coordination which enables innovation in the long term which could reverse the increase in lifestyle related illness reliant on professional care. Increases co-ordination of services which reduces duplication and inappropriate referrals = multiple staff visits, This also reduces DNA's and increases safeguarding of vulnerable adults. Supports common data sets, quality indicators, and measured improved health outcomes through the effective commissioning of health and well being services. This is part of tiered/stratified services targeting vulnerable groups who may be excluded or not available from the current services

Develop the evidence of

needs through partnership

working through the

political/cultural/will/policy

context. It should focus on

inequalities.

Training for the workforce will

increase system capacity

and capability for prevention.

Focusing on value for money

makes radical change

possible.

Through demonstrator sites

contestability can be tested.

Professionals can work with

patients to re-design

services.

Greater use of technology.

Commissioners will have

to decommission

secondary services to

invest in pro-active care.

Professionals may protect

their own service area and

not engage fully.

Balance between quality &

value for money.

Shared insight vs buy in.

Clinical pathway design,

people do not follow single

pathways neither do

services.

Productivity vs

personalised services




• Embrace philosophy that ‘promoting health and wellbeing and

reducing inequality’ is every practitioners role.

• Provide a personalised care plan, and where appropriate, use joint

care planning or integrated assessments such as the single

assessment process.

• Provide patients and carers with a named key worker or case

manager to ensure high quality, safe and effective continuity of care.

• Ensure that you are familiar with your PCT’s local carers strategy,

providing all carers with a holistic assessment in their own right and

giving appropriate information, support and advise for them to remain

healthy and within their own home.

• Commissioners and provider management teams must be responsible

for developing a competent workforce that will deliver current and

future services safely, effectively and which have a positive impact on

service user experience.

• Practitioners and clinical teams need to review best practice and

prioritise development plans for service delivery.

• Provide access to robust training and education, clinical supervision

and improved clinical leadership, managerial and business skills to

improve health outcomes.

• Work with Care Services Improvement Partnership to ensure that all

relevant partners develop their workforces to deliver health

improvements and reduce health inequalities.

• Identify and increase preventative health spend in PCTs, ensuring

that health improvement activity is commissioned as part of service

level agreements and new prevention services are developed and

delivered by a range of providers.

• Work with the North West Regional Development Agency to support

the development of workforce capacity and capability to deliver the

Staying Healthy agenda through sustainable public sector

procurement and the Good Corporate Citizen Group.

• Develop a new regional, cross sector system that offers regional

funding streams, stronger regional accountability frameworks and

more space for local services to be tailored to individual need.


3.



Benefits fo Commissioners


Awareness

training to

respond to the

needs of

vulnerable

people. (Linked

to no 1.)

All health

professionals

trained to be

responsive to

the patients

health needs.

Increased

flexibility of how

services/advice

is provided.

Consistent

advice/support.

Essential

enabler to

realise the

benefits of 1 & 2.

Increased

quality of care.

Patient safety

benefits and

reduces risk of

complaints and

adverse

incidents

(reputation of

commissioners).

Focus on community services,

therefore, decreases acute care and

increases enablement.

Tiered services targeting vulnerable

groups who may be excluded or not

available from the current services.

Enhances the skills knowledge of

community staff to deliver inclusive,

comprehensive services.

Productivity/capacity gains in the

community from co-location and

coordination which enable innovation in

the long term which could reverse the

increase in lifestyle related

illness/reliance on professional care.

Increased co-ordination which reduces

duplication/inappropriate referrals -

multiple staff visits, DNA's.

Improved safeguarding.

Supports common data sets, quality

indicators. Measured/improved health

outcomes through the effective

commissioning of health and well being

services.

Develop the evidence

of needs through

partnership working

through the

political/cultural/will/p

olicy context. It should

focus on inequalities.

Training for the

workforce will

increase system

capacity and

capability for

prevention.

Focusing on value for

money makes radical

change possible.

Through

demonstrator sites

contestability can be

tested.

Professionals can

work with patients to

re-design services.

Commissioners will have to

decommission secondary

services to invest in pro-active

care.

Professionals may protect their

own service area and not

engage fully.

Balance between quality & value

for money.

Shared insight vs buy in.

Clinical pathway design, people

do not follow single pathways

neither do services.

Productivity vs personalised

services.




• Make full use of ‘teachable’ moments – opportunities to tackle lifestyle

factors when people are receptive.

• Explore opportunities for joint working with local services that promote

health and wellbeing to maximise the health impact, for example

working with health trainers and health and wellbeing partnerships i.e.

local councils.

• Agree joint goals with local partners and monitor whether they are

being achieved and the impact. This should include how, together, you

are impacting on local health inequalities.

• Make best use of service users: using this resource in the promotion

of health, wellbeing and reducing health inequalities. Use programmes

such as peer education, peer-led services, buddying and mentoring.

________________________________


Health Improvement

HEALTH IMPROVEMENT


1.






Whole systems

IT approach

No duplication, saving time and money. Easier to track patient pathways (cradle to grave). Easier to identify patient health problems. Easier to identify patients health improvement needs. Smoother integration into mainstream services

No duplication -

saving time and

money. Robust

collection of data

information.

Easier to track

patient pathways

(cradle to grave).

Smoother

integration.

No duplication. Saving

time and money.

Robust collection of

data information.

Easier to track

patients pathways

(cradle to grave).

Easier to identify

patient's health

improvement needs

Funding.

Communication.

Multi-agency working.

Agreement of core data set.

Dedicated IT resources.

Staff training.

Change in culture -

'information sharing'.

Funding.

Timescales to implementation.

Reluctance to change - 'stuck in

the mud'.

Silo working.


_____________

______________


2.







Health Improvement to underpin every community/ acute pathway

Reduces health

inequalities.

Long term

health benefits.

Helps to

reduce Long

Term

Conditions.

Keeps patients

on a health

improvement

programme

even when

they are on a

different

pathway.

Reduces acute

admissions.

Reduces

morbidity.

Improved

quality of life

Reduces

inequalities.

Tracks patients

and money

through

pathways.

Reduces acute

admissions,

therefore, long

term financial

savings. Data

analysis of local

population

morbidity etc.

Financial benefits

as people are

included in

pathways and are

kept healthy for

longer, therefore,

reducing acute

incidents.

New culture of delivering

Health Improvement through

whole pathway system.

Reduces cost of Long Term

Conditions and acute

admissions.

Training for all health care

professionals in health

improvement and health

promotion.

Workforce development.

'Buy in’ of clinicians.

`Buy in’ from

commissioners.

Training and education.

Quality over quantity.

Patients more likely to

change behaviour and

keep new lifestyle.

Health improvement

written into every

SLA/Contract/Service

Specification.

Management backing at

SHA level.

Evidence based practice

Commissioners overly

focussed on activity and

short term targets. i.e.

quantity versus quality.

Time pressure on clinicians.

Time spent on 'fire fighting'

not on health improvement.

Misinterpretation of

evidence based practice.


________ ________


3.






One point of

access/contact

for health

improvement

services

Reduced

duplication of

services.

More user

friendly, Easier

to access

services.

Quicker more

direct access to

appropriate

services at the

right time in the

right place by

the right

professional.

Improved

communication

Reduced

stigma

Reduces

duplication.

Quicker more

direct access to

appropriate

services.

Improved 'joined

up' working.

Improved

communication

with other

healthcare

professionals.

Reduces duplication.

More user friendly,

therefore, easier to

access services.

Improved 'joined up'

working with other

health care

professionals.

Clear vision agreed by all partners. Partnership working in health and local authorities - third sector partnerships. Accommodation - agreement of use. Communication. Inter-agency working relationships

Lack of agreement with all

partners.

Lack of useful

accommodation.

Staff resistance.


_______________

_________________


4.





Addressing

health

inequalities

Long term

health gain for

children and

young people.

Reduced social

exclusion.

Improved

healthy

lifestyle.

Reduced

chronic

conditions.

Reduced Life

threatening

illnesses.

Decreases

childhood

morbidity.

Improved

mental health

and well being.

Long term health

gain for children

and young

people. Reduces

social exclusion.

Improves a

healthy lifestyle.

Reduces chronic

conditions.

Reduces Life

threatening

illnesses.

Decreases

childhood

morbidity.

Improved mental

health and well

being. Financial

gains. Better

SLAs and service

specifications.

Reduces long

term costs.

Change of culture and delivery.

IT systems to track local

population and ethnicity.

Long term health gain for children

and young people.

Reduces social exclusion.

Improves a healthy lifestyle.

Reduces chronic conditions.

Reduces life threatening illnesses.

Decreases childhood morbidity.

Improved mental health and well

being.

Commissioning through

targeted funding.

Good social marketing.

Data packaging.

Total stakeholder ‘buy

in’ with a multi-agency

flexible approach.

Community health

development.

Partnership approach

involving all

organisations.

Lack of funding.

Staff,

organisations not

operating together.

Commissioners have a

'blanket' approach - 'one

size fits all'.


__________________ ____________________


MENTAL HEALTH


1.






Community single point of access and triage to mental health system that also meets the needs of people with mild-moderate common mental disorders.

Encourages a personal pathway plan by phone/person - who,what,where, when, why and how. Appropriate referral first time with a faster streamlined service. Outcomes will be more positive with informed choice

Value for money. Earlier intervention means a much more efficient and effective service with reduced queues and handoffs. Integrated lean system that enables better outcomes

Patients are deflected from A & E and reduced inappropriate referrals to secondary care. Patients are referred to the right person, in the most appropriate place. This increases capability of care system to meet mental health needs. Reduction in prescribing is achieved with improved outcomes.

Strong leadership is needed from providers to maximise the benefits from all resources; (ie financial, estate, workforce). Commissioners with effective investment plans in community services and commitment to pump-prime developments to support resource shift. Critical mass of community mental health providers. Flexibility for providers to shape workforce e.g. graduate worker. Standard specification across partnership working with benchmarking for quality and data recording. Governance across patient pathways for patient info/data sharing. By using intelligent commissioning there can be collaboration between commissioners and other partners.

Collaboration limited across

pathways as a result of

different incentives.

Insufficient community

resources.

Boundaries: registered

/resident .

Lack of leadership.

Commissioner development

of market - fragmentation,

competition, lack of co-

operation, reduced

innovation.

Capacity and capability

within community providers

to tender.

Staff morale.




• No specific guide for mental health services. • There is a need to ensure all health and social care staff are able to recognise and detect common mental health problems and quickly help the person find appropriate help through care pathways.

• Services will need to be designed to provide rapid access to a care pathway that is relevant to the person's needs and provided by staff with appropriate, up to date skills, to ensure people get the best help at the right time from the right people.

• This must also streamline access to mental health pathways not only to avoid fragmentation of care but also to ensure the benefit from new provider relationships across the independent, third sector and social enterprise, is sensitively managed.

• There is also a need to ensure all health and social care staff are able to recognise and detect common mental health problems and quickly help the person find appropriate help through care pathways.


2.





Alignment of community services - with community mental health expert practitioners working in an integrated way with Primary Health Care Teams.

Increased access and improved recognition. Mental Health aligned with other mainstream interventions through comprehensive and co-ordinated packages of care. Step up and step down of care. Clients can return to work, with increased choice, and empowerment. Clients can have a choice of opting in and out as needed with informed discharge.

Value for money. Robust Clinical Governance and national target delivery. World Class Commissioning targets are met and QoF delivery is improved. Improved GP practice based knowledge of population.

Systems will be more efficient – integrated and person centred.

Strong leadership is needed from providers to maximise the benefits from all resources. Commissioners with effective investment plans in community services and commitment to pump-prime developments to support resource shift. Critical mass of community mental health providers. Flexibility for providers to shape workforce e.g. graduate worker.

Pathway/Collaborative across

pathways - different incentives.

Resources.

Boundaries: registered/resident.

Lack of leadership.

Commissioner development of

market - fragmentation, competition,

lack of co-operation, reduced

innovation.

IAPT model still being tested.

TCS process.

Staff morale.


• No specific guide for mental health services

There is a need to ensure all health and social care staff are able to

recognise and detect common mental health problems and quickly help the

person find appropriate help through care pathways.


3.






Co-produced (commissionersproviders & service users) integrated care pathways and criteria that are dynamic and regularly reviewed in partnership .

Promotes choice through confidence and clarity of available pathways. Promotes full engagement and co-production. Delivers better outcomes and processes, with lack of duplication.

Value for Money. Reduced stigma and reduced DNAs. Improved efficiency and outcomes.

Shift of focus to address high level of need at an earlier stage and reduce worklessness

Strong leadership is needed from providers. Commissioners have clear investment plans to support resource shift. Critical Mass of community mental health providers with flexible workforce. Benchmarking for quality and data recording. Governance in patient pathways for patient info/data sharing.

Pathway/Collaborative across pathways -

different incentives. Pathway/Collaborative

across pathways - different incentives.

Resources: finance, workforce, capacity.

Boundaries: registered/resident. Lack of

leadership. Commissioner development of

market - fragmentation, competition, lack of co-

operation, reduced innovation.

De-stabilising historical pattern of service.

Capacity and capability with community

providers to tender. IAPT model still being

tested.

TCS process.

Staff moral.



• No specific guide for mental health services. • Services will need to be designed to provide rapid access to a care

pathway that is relevant to the person's needs and provided by staff with

appropriate, up to date skills, to ensure people get the best help at the

right time from the right people.


• This must also streamline access to mental health pathways not only to

avoid fragmentation of care but also to ensure the benefit from new

provider relationships across the independent, third sector and social

enterprise, is sensitively managed.

• The development and application of clinical pathways such as those in

the Map of Medicine offer clinicians and service users the opportunity to

access consistent quality of services.

• Appropriate clinical pathways will be developed and used to ensure

access to consistent quality of services.


4.





Fit for purpose of Community Mental Health Service delivery - non stigmatising, flexible hours, community/ primary care based and mainstream

Patients and Professionals promote recognition of common problem. Focus on mental well-being reduces stigma.

Results in fewer incidents/ complaints with improved access and inclusion. Promotes cultural sensitivity.

Patients are deflected from A & E. Reduce inappropriate referrals to secondary care. Patients are referred to the right person, in the most appropriate place. This increases capability of care re: Mental Health. Reduction in prescribing is achieved with improved outcomes.

Strong leadership is needed from providers with resources, financial, estate, workforce. Pump-priming by Commissioners and investment plans to support resource shift. Critical Mass of community mental health providers. There is flexibility for providers to shape workforce e.g. graduate worker. Standard specification across partnership working with benchmarking for quality and data recording. Governance in patient pathways for patient info/data sharing. By using intelligent commissioning there can be a collaboration between commissioners and other partners e.g. prison

Pathway/Collaborative across


Resources: finance, workforce,

capacity.


Lack of leadership.


market - fragmentation,

competition, lack of co-

operation, reduced innovation.

De-stabilising historical pattern

of service.

Capacity and capability with

community providers to tender.


TCS process.

Staff morale.




• No specific guide for mental health services. • Services will need to be designed to provide rapid access to a care pathway that is relevant to the person's needs and provided by staff with appropriate, up to date skills, to ensure people get the best help at the right time from the right people.

• This must also streamline access to mental health pathways not only to avoid fragmentation of care but also to ensure the benefit from new provider relationships across the independent, third sector and social enterprise, is sensitively managed.

• There is also a need to ensure all health and social care staff are able to recognise and detect common mental health problems and quickly help the person find appropriate help through care pathways.

• The development and application of clinical pathways such as those in the Map of Medicine offer clinicians and service users the opportunity to access consistent quality of services.

• That there is a greater recognition of the need for mental health promotion for the general population particularly those focusing on young people and prevention.

• There is a need to co-ordinate substance misuse services, recognising the wide range of actual and potential partnerships, not just in health, to reduce the risk of exclusion and ensure early and opportunistic interventions.

• The links between social issues and mental health from the impact of issues such as deprivation, homelessness and worklessness to be more widely recognised and the need for closer working between health and social care.


5.






Skilled workforce with capacity and capability to respond to clients in crisis.

Better outcomes Increased confidence with more responsive services, Greater enablement of self management, resilience and recovery for patients

Produces better outcomes. Value for money. Promotes Innovation to help sustain service development and improvement. Recruitment of innovative and creative staff

Encouraging innovation means pushing boundaries to obtain continuous improvement.

Strong leadership from providers. Resources: financial, estate, workforce. Pump-prime/investment plans to support resource shift. Critical Mass of community mental health providers. Flexibility for providers to shape workforce e.g. graduate worker. Benchmarking. Pathway governance + info/data sharing. Intelligent commissioning. Collaboration between commissioners

Pathway/Collaboration across


Resources: finance, workforce,

capacity.


Lack of leadership.


market - fragmentation,

competition, lack of co-operation,

reduced innovation.

De-stabilising historical pattern of

service.

Capacity and capability with

community providers to tender.


TCS process.

Staff morale.



• No specific guide for mental health services. • All staff will have the appropriate and up to date skills to support those who access services wherever they access it.


CHILD HEALTH


1.







Develop a

standardised

approach

across

organisations

This will enable

equity of service

for all patients

and give quality

assurance and

raise standards.

Develop

minimum

standards

across all

partners.

Improved

communication

and better

involvement of

GPs

Consistency across

organisations will

reduce confusion and

increase efficiency.

Consistency will

ensure minimum

standards for quality

assurance,

benchmarking/defining

tariffs. This will start to

improve efficiency and

effectiveness of staff

time

A business plan with a

standardised approach that

can move towards

delivering efficiency

savings.

A standardised approach will be

the driver to enable improved

leadership/capacity.

Pooled resources and creation

of minimum standards will

enable cost savings which in

turn could increase 'buy in’ from

other stakeholders.

IT systems that support a

standardised, consistent

approach to quality and

outcome metrics.

Lack of funding to

standardise systems

and services will lead to

inequity,

Reduce clinical

autonomy and

ownership.

Very local interpretation

of standards limiting

individualised care,

innovation and spread

and adoption of best

practice.



• Children, young people and families are involved in planning and

evaluating services.

• Work with commissioners to agree outcome data.

• Work with Commissioners to develop services so that children and young

people can be cared for at home.

• Identify those who may be disadvantaged or marginalised in society

Target need based on your Children’s and Young People’s Plan.

• Improving commissioning at local authority level. Joint

commissioning of all child health services.

• Commissioners and services work in ways that ensure

children, young people and their families are at the

centre of service design and provision, and that their

voices are heard throughout.

• Develop local hub services in collaboration with

secondary care - moving towards integrated service

models, including maternity pathways and featuring

mutual training and education.

• Build on good practice models of integrated working

across services, underpinned by strategic workforce

planning and training.

• Research and building of evidence base for healthcare

practice and interventions are supported and

developed at all levels.


2.






Facilitate

partnership and

integrated

working.

Smooth effective

care pathways.

Timely and

seamless care.

Care closer to

home.

Greater

involvement of

GPs.

Commissioners can

commission a complete

pathway (lead provider),

Shared resources and risk

assessment.

Opportunities for joint

training, better

understanding of roles,

increased opportunities for

clinical supervision

Shared and

measured

outcomes.

Shared

records/information

systems

Development of joint

assessment, joint posts, joint

training, pooled resources

(devolved budgets),shared

systems, joint planning,

Children's Trust opportunities,

shared outcomes .

New roles working differently

and committed to towards

partnership working.

Culture of

organisations.

Lack of information

sharing and record

keeping.

Commissioning

arrangements are

not standardised.

Commissioners may

not have a full

understanding of

roles required.




• Strengthen partnership working across Children’s

Trusts and children’s social care, community services

and organisations such as ambulance trusts, acute

trusts, children’s /social services, GP practices (and

practice based commissioners), voluntary and

independent sectors so that care and treatment can be

aligned along a care pathway and co-ordinated around

the needs of the service users.

• Improve commissioning at local authority level. Joint commissioning of all

child health services.

• Commissioners and services work in ways that ensure children, young

people and their families are at the centre of service design and provision,

and that their voices are heard throughout .

• Develop local hub services in collaboration with secondary care - moving

towards integrated service models, including maternity pathways and

featuring mutual training and education.

• Build on good practice models of integrated working across services,

underpinned by strategic workforce planning and training.


3.






Development of

clinical

pathways for

acute/complex

needs.

Improved access

to most

appropriate

assessment and

care packages.

Improved choice

with greater

awareness of

available services.

Timely access and

interventions.

Confidence in

quality, outcomes

and specialist

expertise of staff

operating in an

integrated way.

Quality assurance and

evidence will enable

commissioners to develop a

strong and complete

pathway,

Professional roles will be

clarified with the potential

for wider scope and

increased potential for

integration.

Better governance and audit

arrangement.

Monitoring of clear

standards will be more

successful and will also

address inequalities..

Shift from Acute to

Community i.e. In-

Reach model with

patients at the centre.

By using

standardised,

measurable

approaches with a

local focus, then,

shared care/expertise

will be attainable.

Increased quality and

efficiency.

Pathways will need clinical

leadership and ‘buy in’ from

professionals,

commissioners, providers

and other expert group

organisations.

Pathways designed with

reference to NICE guidance,

Lean Thinking, and examples

of good/best practice

Current lack of

business

acumen/support for

community services

to collaborate or co-

ordinate the pathway

delivery.

Lack of quality

metrics

Organisational

boundaries - staff

resistance.





• The voices of children, young people and families are central to

planning the pathways and the evaluation of services.

• Identify children who need safeguarding.

• Work collaboratively with others who work with local children and

families agreeing and developing a common vision, goals and models

of good practice.

• Develop additional healthcare services in their own homes or in

settings closer to their homes.

• Children's Clinical Pathway Groups.

• To involve Health Improvement.

• Reduction in obesity, emotional health and wellbeing,

teenage pregnancy, sexually transmitted diseases, drug

and alcohol use, targeting areas of deprivation.

• Early Identification.

• Poor or ill health managed through Primary Care, and

parents.

• Develop a range of assessment tools to support

identification, underpinned by clinical expertise through

networks, supporting primary and community care.

• Commissioners and services work in ways that ensure

children, young people and their families are at the centre

of service design and provision, and that their voices are

heard throughout.


4






Strengthen

universal and

health

improvement

role

The

underpinning

of health

improvement

within all

clinical

pathways will

provide easier

access, earlier

identification

and

intervention,

promote

patient

confidence and

self care.

Patients will be

empowered

through a

better

understanding

of services.

Promotes and

enables earlier

intervention,

better value for

money, reduces

inequalities and

improves

outcomes.

Patients are

helped towards

making informed

decisions.

Better

understanding of

local needs in the

short, medium

and longer term.

Resources can

also be

targeted

appropriately,

Value for money

across the

whole system.

Resources used

more efficiently.

Prevention and

earlier

intervention.

Local Health Improvement evidence,

policy documents, and local drivers

with dedicated professional staff can

all help to prove that Health

Improvement is a valuable tool for

underpinning all pathways.

Support of Health Protection Agency,

other organisations, agencies and

local councils. Existing equal

partnerships must drive this initiative

through to enable a clear service with

standardised specifications (look at

national templates).

Clear objectives/targets help to

reinforce the Health Improvement

roles.

Relevant information and the

standardised use of Informatics to

enable consistency across all

pathways and opportunity for

benchmarking and sharing innovation.

Staff and parents engaged in service

redesign.

Lack of resources: staff,

finance and estate.

Governance issues re:

partnership, different

organisations, cultures, budget

controls.

Increased contestability of

services.

Resources and expertise

needed to engage with the

hard to reach families.

Public expectations.



• Use of public data about ill and disabled children to inform and

agree local priorities.

• Empowers parents and carers to be able to deliver health care to

their ill or disabled child through the provision of adequate training

and ongoing support.

• Equip other partners such as teachers with the skills and knowledge

to recognise illness and exacerbations or deterioration in a child or

young people.

• Integrate and co-ordinate all services that contribute to caring for a

child through an illness or disability, making sure universal,

preventative services continue to be offered.

• Develop ‘buddy’ systems to support families.

• Develop services and approaches to support siblings of children

with illnesses or disabilities.

• Ensure staff have ongoing joint training.

• People are developed to be high quality community ‘practitioners,

partners, leaders’ who can clinically own and lead local change.

• Health Improvement is part of integrated pathways.

• Build on good practice models of integrated working across

services, underpinned by strategic workforce planning and

training.

• Develop local hub services in collaboration with secondary

care - moving towards integrated service models, including

maternity pathways and featuring mutual training and

education.

• Research and building of evidence base for healthcare

practice and interventions are supported and developed at

all levels.


5





Joined up

adequately

financed

commissioning

group

Less duplication,

improved service,

easier access,

economies of scale,

better communication,

clear roles,

responsibilities and

single point of access,

NSFs, Healthy

Horizons, NHS Plan,

Children's Plan,

Choosing health will

support and enable the

above

Better use of resources.

Standard and clear target

sand measured outcomes will

help with shared monitoring

and accountability.

All partners signed

up to shared

objectives and

vision,

Standardised

monitoring of

outcomes.

Improved quality,

efficiency and

productivity.

Clear standardised

service specs enable

clear objectives and

targets.

Increased resources.

Relevant information.

Audit.

A strong steer

towards networking

and partnership

working.

Clear and strong

governance

framework with Child

& Family at the

centre.

Dedicated

professional staff

producing clear

evidence, policy

documents, local

drivers. .

Lack of

resources/capacity.

Governance issues

Provider/commission

er split, where the

issue of

contestability will

increase.

There are also local

demographics - age,

complex health

needs, deprivation

and poverty to take

into account.

Appropriate

accommodation plus

costs.




• Work with Commissioners to agree the outcome data that needs to be

collected for a specific service area to demonstrate effective

intervention.

• Link this to quality framework and, if appropriate, contracts including

the payment framework for commissioning, quality and innovation.

• Target needs based on your Children's and Young People's Plan

Strengthen partnerships working across Children's Trusts, health and

children's social care.

• Support teams to develop creative approaches to service provision,

which reflect the five 'Every Child Matters' outcomes and will improve

choice and personalisation for children, young people and their

families.

• Support and empower practitioners to develop innovative

multidisciplinary teams using approaches such as transformational

attributes.

• Commissioners and provider management teams must be responsible

for developing a competent workforce that will deliver current and

future services safely, effectively and who have a positive impact on

service user experience.

• This will include thinking about workforce planning aligned to patient

need and the commissioning of sufficient education and training

places for the future.

• Work with education commissioners and universities to ensure

education programmes at all levels.

• Our vision for the future, in terms of the commissioning

and provision of services, is one where these are done at

the most appropriate level through formal joint

commissioning arrangements and integrated delivery.

• Develop local hub services in collaboration with

secondary care - moving towards integrated service

models, including maternity pathways and featuring

mutual training and education.

• Build on good practice models of integrated working

across services, underpinned by strategic workforce

planning and training

• Improving commissioning at local authority level.

• Joint commissioning of all child health services.


6.






Improving

outcomes for

children and

families (e.g.

admissions,

obesity,

accidents,

smoking will

reduce and

health will

improve).

Improved

parenting,

Children and

families are

engaged,

enabled,

empowered.

Increased

confidence in

services.

Improved focus

on:

self/homecare,

maternity health,

teenage

pregnancy,

safeguarding,

obesity, alcohol,

drug use.

Policies such as

Children's NSF,

Every child

matters used as

guidelines.

Target resources

appropriately to prevent

hospital admissions.

Evidence will be through

measured outcomes,

improvement, reduced

health inequalities

Better use of

workforce skills

with succession

planning.

Improved quality,

safeguarding,

service

improvements,

horizon scanning,

Reduction in health

inequalities.

Clear standardised service

specifications.

Clear and strong governance

framework. with Child &

Family at the centre.

System engagement and

support.

Lack of resources/capacity/recruitment + retention does not help new initiatives. Partnership governance issues re: partnership, different organisations, cultures, budget controls. Local demographics - age, complex health needs, deprivation and poverty to take into account. Public expectations.




• Information to empower children, young people and their families.

Clear comprehensive information and support regarding a child or

young person’s condition, including sources for further support,

enable children, young people and families to retain ownership of their

individual lives.

• Equip parents with skills and knowledge to recognise acute

exacerbations/ deterioration and to treat their child or seek expert

help as appropriate.

• Health Improvement is part of the integrated pathways .

• There should be a 'systematic' programme throughout the North West to reduce the need for inpatient care days, achieved through: Increased conversion to day case care, decreased length of stay for acute admissions through whole pathways redesign.

• Better co-ordinated team based and proactive care for children with long term conditions, involving the GP, children's community matrons and the team around the child.

• Commissioners and services work in ways that ensure children, young people and their families are at the centre of service design and provision, and that their voices are heard throughout .

• Build on good practice models of integrated working across services, underpinned by strategic workforce planning and training.


MATERNITY AND NEWBORN CARE


1. Top 3-5 Improvements






Commission

integrated

maternity and

child health

pathways.

Universal

Journey

Planner

signposting

access.

Continuity of care for the family. Improved access and choice. Improved outcomes for women and children.

Improved outcomes, access and choice. Greater efficiency in pathway delivery. More integrated care.

High quality and productive pathways. Greater co-operation between providers. Better use of workforce skills.

Clear outcomes agreed and monitored with clarity of exactly what is provided. Shared data collection Good IT systems will increase staff satisfaction. Children's strategy. Public Health agenda.

Maternity services are commissioned with

acute providers.

Culture and organisational boundaries.

Separate IT Systems.



________________

• Enhance the midwifery role to include public health approach to care and

greater autonomy in midwife led services. This will include outreach work to

teenage mothers, asylum seekers, substance misusers and other vulnerable

groups.

• Offer all women an individualised risk, needs, preferences and benefits

assessment at decision points during their care, where the woman and her

midwife will discuss the choices available to her and her family (The Child

Health Promotion Programme, DH 2008).

• Increased partnership working between midwives, midwifery assistants, health

visitors, social workers and other professionals involved in the woman's care.


2.






Commission

specialist

pathways.

Improved access to most appropriate assessment and personalised care package. Confidence in the quality and expertise of service providers. Improved communication.

Improved outcomes. High quality and responsive pathways. Improved safeguarding. Reduction in teenage pregnancies. Increase in smoking cessation.

Improved delivery of quality and productive care – right person, right place, right time.

Children's Act.

Children's plan.

Department of Health Targets.

Local targets.

Integrated training/modules.

Separate IT Systems.

Culture and organisational boundaries.

Separate performance monitoring, reporting and

accountability.

Separate governance arrangements.

Same quality measures.



_________________

• Collaboration across health communities to ensure women who require

specialist care can access what they need without delay and transfer

policies are in place.

• Strong commissioning partnerships between the community, hospital,

social services, education and the third sector will be developed to

ensure that women who require specialist services can access those

they need without delay.


With thanks to the workshop participants who shared their expertise and their passion for community services to effectively contribute to

addressing health inequalities and improving the health and well being of the people we serve across the North West.

The clinicians and practitioners were from the Community Provider Services of:

Blackpool PCT Manchester PCT

Bolton PCT Oldham PCT

Bury PCT Salford PCT

Central Lancashire PCT Sefton PCT

Cheshire East and Central Cheshire PCT Stockport PCT

East Lancashire PCT Tameside and Glossop PCT

Halton and St Helens PCT Trafford PCT

Heywood, Middleton and Rochdale PCT West Cheshire PCT

Knowsley PCT Wirral PCT

fit for the future

Documents

innovative community

urgent care p

planned care p

newborn care p

end of life care p

child health p

health improvement p

healthy p