new models of care and the prevention agenda: an …€¦ · 10.10am interview session with...

NEW MODELS OF CARE AND THE PREVENTION

AGENDA: AN INTEGRAL PARTNERSHIP

CHAIR: CHRIS HOPSON, CHIEF EXECUTIVE, NHS PROVIDERS

10.10am Interview session with Samantha Jones 10.30pm Key note presentation Professor Sir Muir Gray, director, Better Value Healthcare and chair, NHS Health and Social Care Digital service 11.15am Vanguard case study – Sutton Homes of Care 12.00pm Vanguard case study – West Wakefield Health & Wellbeing Ltd. 12.45pm Lunch and networking 1.30pm Panel discussion: addressing prevention through the development of new care models 2.15pm Table discussions: addressing prevention through the development of new care models 2.45pm Panel discussion: working with local partners and communities 3.30pm Final thoughts 4.00pm CLOSE #futurenhs

Key note presentation

PROFESSOR SIR MUIR GRAY, DIRECTOR, BETTER VALUE HEALTHCARE AND CHAIR,

NHS HEALTH AND SOCIAL CARE DIGITAL SERVICE

11 April 2016

We have had 2 healthcare revolutions, with amazing impact

• Antibiotics • MRI & CT

• Coronary artery bypass graft surgery

• Hip & knee replacement

• Chemotherapy • Radiotherapy

• Randomised controlled trials

• Systematic reviews

The Second has been the technological revolution supported by 50 years of increased investment & 20 years of evidence based medicine, quality and safety improvement eg

The First was the public health revolution

after 50 years of progress all societies still face three massive problems. The first is unwarranted variation in healthcare ie ”Variation in utilization of health care services that cannot be explained by variation in patient need or patient preferences.” Jack Wennberg Variation reveals the other two problems

Benefits

Investment of resources

Harms

Increment in Value with each increment in resources

Point of optimality

The first is OVERUSE of lower or zero value interventions which results in

1. waste of resources 2. harm

The second is Underuse of high value interventions which results in 1. Preventable disability and death eg if we managed atrial fibrillation optimally there would be 5,000 fewer strokes and10% reduction in vascular dementia, and 2. inequity

Hipreplacementinmostdeprivedpopula onscomparedwithleastderivedpopula onsKneereplacementinmostdeprivedpopula onscomparedwithleastderivedpopula ons

ProvisionlessthanexpectedProvisionmorethanexpected100

3133

Hip replacement in most deprived populations compared with least derived populations Knee replacement in most deprived populations compared with least derived populations

Provision less than expected Provision more than expected 100

31 33

THERE IS ALSO TRIPLE WHAMMY HEALTHCARE ! OVERUSE + UNDERUSE + UNWARRANTED VARIATION

In the next decade need and demand will increase by at least 20 % so what can we do? Well, we need to continue to 1. Prevent disease, disability, dementia and frailty to reduce need 2.Improve outcome by provide only effective, evidence based interventions 3. Improve outcome by increasing quality and safety of process 4. Increase productivity by reducing cost These measures reduce need and improve efficiency

BUT we also need to increase value

The Aim is triple value

• Allocative, determined by how well the assets are distributed to different sub groups in the population

– Between programme

– Between system

– Within system

• Technical, determined by how well resources are used for outcomes for all the people in need in the population

• Personalised value, determined by how well the outcome relates to the values of each individual

waste is anything that does not add value and as the Academy’s re[port emphasises we need to develop a ‘culture of stewardship’ to ensure the NHS will be with us in 2025 and 2035

1. Ensuring that every individual receives high personal value by providing people with full information about the risks and benefits of the intervention being offered and relating that to the problem that bothers them most and their values and preferences

2. Shifting resource from budgets where there is evidence from unwarranted variation of overuse or lower value to budgets for populations in which there is evidence of underuse and inequity

3. Ensuring that those people in the population who will derive most value from a service reach that service

4. Implementation of high value innovation funded by reduced spending on lower value interventions for the population

5. Increased rates of higher value intervention eg helping a higher proportion of people die well at home funded by reduced spending on lower value care in hospital in that population

THE RIGHTCARE METHOD OF INCREASING VALUE FOR POPULATIONS AND INDIVIDUALS IS BY CITIZENS & COMMISSIONERS

PATIENTS & CLINICIANS & PROVIDERS

Evidence,

Derived from

the study of

groups of

patients

The value this patient

places on benefits &

harms of the options and

on risk taking

The clinical condition of this patient; other

diagnoses, risk factors including genomic

information and in particular their problem,

what bothers them psychologically & socially

Decision

Patient Report of the impact of the decision on problem that was bothering them most

And if genomic information is included the term used is usually precision medicine rather than personalised medicine

5.The Rightcare method for ensuring that every individual receives high personal value is providing people with full information about the risks and benefits of the intervention to prevent overuse through over diagnosis and overtreatment by • Ensuring that what is bothering the individual patient most is

articulated and recorded by the service • Providing information about the risks and benefits of every decision

eg the decision to offer a drug, is presented in absolute numbers • Providing decision aids for complicated decisions in which there is a

significant risk of harm • Helping the patient reflect on their values, both online and face to

face, in the light of the information presented, • Eliciting patient feedback to ensure these steps are taking place

We are now in the thirdhealthcare revolution

• Antibiotics • MRI • CT • Ultrasound • Stents • Hip and knee

replacement • Chemotherapy • Radiotherapy • RCTs • Systematic

reviews

The First The Second the Third

Citizens

Knowledge Smart Phone

Population healthcare focuses primarily on delivering care to populations defined by a

common need which may be a symptom such as breathlessness, a condition such as arthritis or a common characteristic such as frailty in old age,

not on institutions , or specialties or technologies. Its aim is to maximise value for those populations and the individuals within

them and New Models of Care are evolving to meet

the needs of populations and individuals

The Healthcare Archipelago

GENERAL MENTAL PRACTICE HEALTH COMMUNITY HOSPITAL SERVICES SERVICES

JURISDICTIONS INSTITUTIONS

PROFESSIONS

REGULATORS AND INSPECTORS

Complexity is the dynamic state between order and chaos Kieran Sweeney, Complexity in Primary care

SELF CARE INFORMAL CARE GENERALIST SPECIALIST SUPER SPECIALIST

Dr Jones is a respiratory physician in the Derby Hospital Trust and last year she saw 346 people with COPD and provided evidence based, patient centred care, and to improve effectiveness, productivity and safety

Dr Jones estimated that there are 1000 people with COPD in South Derbyshire and a population based audit showed that there were 100 people who were not referred who would benefit from the knowledge of her team

All people with the condition

People receiving the specialist service

People who would benefit most from the specialist service

3. Ensuring that those people in the population who will derive most from a service are in receipt of that service if necessary by reducing the number of people seen by that service directly

This requires clinicians including specialists to become population focused as well as delivering high quality care to referred patients and the surgical services initiative which is part of the Efficiency programme will develop this approach

Dr Jones is given 1 day a week for Population Respiratory Health and the co-ordinator of the South Derbyshire COPD Network and Service has responsibility, authority and resources for Working with Public Health to reduce smoking Network development Quality of patient information Professional development of generalists, and pharmacists Production of the Annual Report of the service

She is keen to improve her performance from being 27th out of the 106 COPD services, and of greater importance, 6th out of the 23 services in the prosperous counties

Population Medicine

We want to help footprints develop solutions and are producing tailored advice at a national & local level

•Work in progress focuses on developing ‘solution-based’ topic guides for footprints. This information will be disseminated through national joint ALB ‘How-to’ guides, and via resource packs to Centres. The objective for these is to provide evidence-based, cost-effective (and cost-saving) interventions that footprints can consider to close their health and being gap.

•These topics are aligned with PHE strategic priorities as well as NHS Shared Planning Guidance, the CCG IAF, NHS clinical priorities and Right Care. It also picks up on the forthcoming ‘library of resources’ that proposes key areas for footprints to consider when articulating their HWB gap.

25 Sustainability and Transformations Plans

1. Falls and MSK 2. Smoking 3. Alcohol 4. Physical Activity 5. AMR 6. Sexual health 7. Maternity (early years)

8. Mental health 9. Inequalities (cross cutting) 10. Health and work (cross-cutting) 11. HCPH (cross cutting inc. hypertension) 12. Diet, obesity 13. Diabetes 14. Dementia

Draft topic list

AGEING DISEASE LOSS OF CHANGING FITNESS ATTITUDES

Ability

Birth 20 40 60 80 years

Life consists of only 2 phases •growth and development •decline

A fitness gap opens up between how able a person is and how able they could be ; The actual rate of decline is almost always faster than the best possible rate of decline

The fitness gap

Best possible rate of decline Actual

rate of decline

20 40 60 80 years

Ability needed to climb stairs

This person loses the ability to climb a flight of stairs at 76, simply by increasing fitness they could once more climb the stairs

20 40 60 80 years

After sixty the fitness gap can be closed , starting at any age

Ability needed to climb stairs

Rate of decline after onset of heart failure

Best possible rate of decline after onset of heart failure

Additional preventable Loss of ability

What it means for Care Home

Residents, Staff and Sutton

38

Sutton Homes of Care

Caroline Pollington, Lead nurse Darzi fellow, Vanguard programme Dr. Stephanie Machin, Sutton care home link GP

The Population of Sutton

1077 Care Home Beds

74 Care Homes 203,048 Residents in Sutton

14166 aged 75+

4450 aged 85+

2014/15 £1.1M

275 people were

eligible to receive Funded

Nursing Care

2014/15

1770 A&E presentations

from Care Homes

2014/15

1034 Emergency

Admissions

2014/15

106 Health funded home

care packages

2014/15

319 Fully

funded

nursing home

placements

£6,25 M

594 residents in NHS

Funded Nursing Home

placements

39

Our Partners (1/2)

40

41

Our Partners (2/2)

… All our Care Homes

in Sutton

Our Vision

Care

an ability to demonstrate that a high standard of

care is being delivered with constant improvement

evidenced;

Compassion

a workforce and environment that is able to

meet the increasing demands of our aging population and their

physical and emotional needs;

Competence

availability and access to other services across

health, social care and the voluntary sector to support the care being delivered,

ensuring the most appropriate care is

delivered in the most appropriate place for the

residents and their families;

Communication

care homes that are a pivotal partner in the delivery of other local

strategies including end of life care, managing long term conditions, out of hospital strategies and

reductions in the burden on our acute hospital

sector;

Courage

care homes that listen and work with residents,

families and carers who need to access the care provided by care homes either in the short or long term to provide a positive experience of this care;

and

Commitment

the ability to utilise social capital to value and trust the contribution of this sector in the care of our population as a key part of health and social care provision.

Our vision is to ensure we have a vibrant high-quality care home market in Sutton that delivers care

that embraces the national nursing values of patient care – Care, Compassion, Competence,

Communication, Courage and Commitment (the six Cs);

42

43

Programme Pillars (1/4)

Quality and Safety (2/4)

44

Work so far

• Joint Intelligence Group (JIG) o Monthly meetings o All key stakeholders including CQC o Hard data and soft intelligence shared to pick up

trends within the care homes • Developing a dashboard

o Kent Health Observatory o Inform partners and care homes

Care Home Provider Network (3/4)

45

Work so far

• Care home forums • Concerned About A Resident (CAAR) • Multi-format education Packages:

o Dementia o Diet and nutrition o Falls prevention and management o Diabetes o Catheter and bowel management study days o Podcast for Managing Challenging Behaviour

• Website and Newsletters • Focus groups • Hospital Transfer Pathway (Red Bag) • https://www.youtube.com/watch?v=XoYZPXmULH

E • Reference cards

https://www.youtube.com/watch?v=XoYZPXmULHE

https://www.youtube.com/watch?v=XoYZPXmULHE

http://www.suttonccg.nhs.uk/vanguard/Pages/default.aspx

46

New Models of Care (4/4)

Work so far

• “Health and wellbeing review” o Weekly GP and Care coordinator resident review o Supported by Care Home pharmacist

• NH Pilot launched October (6 homes) o Agreed enhanced GP specification o Agreed enhanced nursing specification and role

description o Supported by 4 community nurses (2 EOLC, 2

district nurses) • Using new Older Persons Assessment form

o Holistic and comprehensive o Hospital transfer pathway (NICE)

6/12 reviews • Multidisciplinary • Comprehensive geriatric assessment • Developing standardised pro-forma

Dr Stephanie Machin BSc

MBBS MRCGP

Salaried GP and link GP to

Shirley View Nursing Home in

Sutton

47

My experience of the Vanguard

pilot

• Graduated in August

2015

• Special interest in

care of the elderly

and palliative

medicine

• Some concerns?

• 18 bed nursing home

for patients with

dementia

• Two trained nurses,

larger staff of HCAs

• Already 'ours' but no

structured ward round

in place

• As needed visits and

annual health check

48

The Vanguard pilot

• 1 of 6 GPs in Sutton

• The black sheep – no

structured weekly

ward round in place.

'as needed' visits

when need

highlighted by staff.

• A benefit?

• Focused training,

forums, resources

online

• Aim to improve

communication within

the MDT and to

regulate training/skills

across the care

homes

49

My Team

• Myself, the 'link GP'

• Logan – care home manager

• Caroline – staff nurse

• Hai – community pharmacist

• Caroline 2 – Vanguard link

• Patients and their families

50

51

Our aims

Get to know each patient individually

Optimize control of chronic diseases

Rationalize medications

Pre-empt deterioration and

plan end of life care

Avoid unnecessary hospital admissions

Improve communication

Keep families up to date

Achieve best possible care

Our 'mission statement'

52

PROACTIVE RATHER

THAN REACTIVE

In the beginning...the Health and

Wellbeing checks

53

Medication reviews

• Stop any unnecessary medications • Alter dosages based on up to date blood results

Optimize chronic disease control

• BP and blood sugar charts • Primary prevention e.g CHADSVASC scores in AF • Seizure control, amending dosages • Asthma/COPD reviews • Foot checks

End of life planning

• DNARs • Adding to Coordinate my Care • Ceiling of care discussions • Talking to families • Power of Attorney

Along the way

• Identifying and reviewing

unwell patients

• Calling families in for

discussions

• Ceilings of care clear to

everyone

• Ongoing medication

reviews, dependent on

results, clinical change

• Avoiding admissions,

managing things in

primary care for longer

• Making any unavoidable

admissions as smooth as

possible; handovers, the

introduction of 'the red

bag'

54

Now

• Time has flown!

• 6 monthly health reviews, revisiting the personalised

care plans

• Structured approach; recognised risk of 'overlooking the

well'

• Select 1 or 2 'well' patients each week

• Review their personalised care plans/medications/need

for bloods

• Unwell patients reviewed alongside

• I know everyone's names!!!

55

Challenges

• A blank canvas but overwhelming

• Time

• Access to IT

56

Benefits

• Improved communication – fewer phone calls/home visit requests

• I have fed back to colleagues weekly to keep them in the loop

• BETTER CARE!!!

• Managed in the nursing home for longer, avoiding unnecessary and

distressing trips to A&E

• Earlier interventions , 'could you just have a look at'

• Better outcomes; BP control, HBA1cs, asthma control

• Bosses are happy - QOF

• Fewer medications wasted

• Money saved through medicines management

• Increased job satisfaction; doing it properly

57

And it's not just me! Some

quotes from our away day

• "I find it rewarding to be able to properly

care for end-of-life patients and now have

more time to do so"

• "The Vanguard pilot has given us the gift

of time to do our job properly"

• "I feel like we work as more of a team now,

like we're all on the same page"

58

A case study from Shirley View

• David

• 'Can you just have a quick look at this doctor?'

• Cut on top of head, keeps bleeding

• Glued, swab taken

• MRSA treated

• Still no better?

• Dermatology outpatient clinic – risk of absconsion

• Working out another way...

• Finally, a diagnosis.

59

Great care

is a partnership

NHS Sutton CCG Vanguard Programme

60

For more information: www.suttonccg.nhs.uk/vanguard Email:[email protected]

Sutton Homes of Care

Any questions?

Programme Overview

• CCG will co-commissioned using Chris and Melanie as Chair of Vanguard sub-group of CCE with delegated Authority and SFI compliance

• CCG will produce PMO Spec to contract WW to run a series of projects at Hub level (similar to CCCTF) • PMO (funds allocated directly to WW) • Non-PMO (CCG)

• WW to produce:

• PID (as per CCCTF) • Project outlines • Project Plan

Five Year Forward View into Action

Multi-specialty Community Provider Vanguard

West Wakefield Health & Wellbeing

David Haslewood, Programme Manager

David Cowan, Care Navigation and Social Prescribing

Lead

@westwakefield www.westwakefieldhealthandwellbeing.org.uk


• A population health and care model focussed on proactive and preventative care tailored around the needs of the individual

• Empowering patients and local people to support each other and themselves in their health and care

• Multi disciplinary health care professionals working within an organisation that has accountability for the delivery of health and care services for their population

• Contracting and payment systems that incentivise and enable the delivery of services for population health

• A regulatory and assurance environment which supports organisations to commission and deliver population health benefits

The Emerging MCP Framework

Wakefield District • 40 Practices • 332,000 patients


Wakefield District

Central Connecting Care Team Networks 3, 5 & 6

East Connecting Care Team Networks 1, 4 & 7

South East Connecting Care Team Network 2

Networks 3, 5 and 6 • 17 Practices • 152,000 patients


The West Wakefield MCP


• NATIONAL – Demographic changes – ageing population, increasing burden of LTC

– Pressures on Primary Care

• LOCAL – Meeting the Challenge: Bed reductions

– Pressures on A&E attendances

– Workforce challenges: GP and nursing

– Access and sustainability of Primary Care

Immediate pressures on hospital services which will worsen, with access difficulties and a workforce in crisis lead to the creation of three hypotheses…

The Challenge

50% of work done by GPs could be carried out by a more cost effective resource

30% of elderly people admitted to hospital acutely for a short stay of between 0 and 5 days do not need to be

admitted and could be cared for differently in an alternative setting

30% of patients occupying an acute hospital bed do not need to be there because their episode of acute care is

over

The new model of care has been designed to achieve the three objectives of the Triple Aim.

Lower Cost

Better patient experience

Improved outcomes


The Hypotheses

GP

Admissions avoidance

Early Supported Discharge

Information Hub and Response

Centre

Improved Access

Fusion Cell

HealthPod /Pop-up

Primary Care

Extended Primary Care Access

including additional modes

of access

Care Navigation & Social Prescribing including

Digital Self care Citizen-held record

Pharmacist in General practice

Physiotherapy First

GP Federations, MYT, SWYPFT, WMDC, WDH, YAS (111,999), LCD, Spectrum, Fire & Rescue, Carers Wakefield, Age UK, Other VCS


Disruptive prevention / Schools App

Challenge

Primary Care

Health Champions

Community Anchors & Micro-

Commissioning

PMO & Governance

Business intelligence

OD & Leadership

The Vision


The Providers


Why is it so difficult? • Multiple Providers each operating in their own silos

– Separate teams

– Differing cultures / value systems

– Inclusion / exclusion criteria, Referral forms

– Poor information sharing, lack of IT and IS integration

– Lack of trust and mutual understanding

– Differing KPIs and targets

– Tendency to shunt problems around

– Gaps and overlaps

– Reactive not proactive

– Slow to respond

– Organisational hierarchies

– Lack of communications technology

– Focus on caseload and no situational awareness

– Struggling workforce

• Lacking clinical leadership on the ground

In Iraq in 2003 the US led coalition was fighting an enemy that was: • Ill-equipped • Poorly trained • Small in number • Lacking command and control But it was also: • A de-centralised network with empowered

sub-units • United by a common goal • Using technology in innovative ways to

disrupt coalition operations


A Different Approach


Joint Special Operations Command

Assumed command of Joint Special Operations Command in 2003 Realised things were not working and Al-Qaeda was winning the battle


Remolded the Task Force into something new: • An multi-disciplinary network • Transparent communications • Decentralised decision making authority • Tore down walls between silos • Established a oneness through technology • Best practice from the smallest units extended to large groups • Adopted ‘Team of Teams’

General Stanley McChrystal

Common Purpose

Trust

Empowered Execution

Shared Consciousness


‘Team of Teams’

@westwakefield www.westwakefield.org.uk

Information Hub

• Proactive

• Command and Control approach

• Shared mission

• Fully connected

• 24/7

• Use all the data – Fusion Cells

• Multi-professional ‘tactical’ teams

GP System Notifications

GP System Population Data

Ambulance Service

A&E Metrics & Notifications

Hospital Admissions

Hospital In-patient Status

Community Notifications

Met Office

Local Authority Records

Mental Health Records Public Health Statistics

Police Comms Link

Housing Comms Link

Fire Comms Link

Smart Home Notifications

Informs the Integrated MDT


Fusion Cells

Elderly Care Consultant

Respiratory Consultant

Community Psychiatrist

VCS

Specialist Nursing Teams

Therapists

Social Worker

Community Matron

Community Nurse Community Mental

Health Nurse

Care Navigator Pharmacist Hub Manager

Community Cardiologist

Hub Clinical Lead

Practice Nurse GP

Acknowledgement for images: Lesley Carver NHS NW Surrey CCG

Co-located

Shared mission

Shared culture

Shared records Mutual trust

Authority to act

Daily virtual meeting

Proactive approach

Information Hub Access 24/7

Tactical Teams Generates Care Package

Strategic View

Health Visitor


Integrated MDT


Citizen Held Care Record • Owned by the individual, cloud based

• Fully sharable between agencies

• Health and well-being information, LTC management, care plans, social network, social care package data, EOL planning etc.

• Complementary to NHS record

• Several examples in development – Patient Knows Best

– Leeds Care Record

– Kirklees Self care Hub

– Vitality/Digital life Sciences

– eRed Book

– Vitricare


Connected Home • Growing array of monitoring and wearable technology

• Develop the ‘Smart Home concept’

• Start with social housing stock – all have broadband

• Already wide array used in Wakefield

• Make people feel connected, safe and looked after

• Detect signs of illness and proactively raise alerts

• Physiotherapy First

• Pharmacist embedded in General Practice

• Care Navigation

• Social Prescribing

• HealthPod


Extended Primary Care Team

• Practice based Care Navigators and User Kiosks

• Supported by primary care health champions

• Training Course devised with 114 trained to date

• Accredited course in development with VLE


Care Navigation

Search for ‘healthpod’

Care Navigation (Digital)


Care Navigation Example • Total GP time saved

– 1 sign post =10 minutes of GP time saved

– 3,500 sign posts per year = 35,000 minutes = 583.3 hours of GP time saved per year

• GP time saved by 1,000 patient population

– Church Street Surgery Patient Population 12,000 (Approx).

– 583.3 hours of GP time saved per year / 12 = 48.61 hours of GP time per 1,000 patient

population

– Typical GP practice with 1,750 patients (48.61 x 1.750) = 85.06 hours of GP time saved

per year at the practice

• GP time saved by GP

– Based on 1,840 hours worked per year = 4.65% GP time saved


Creating GP Capacity

of GP appointments saved could be redeployed to help the increasing population of frail elderly living at home /

other residential settings

⅓ of GP appointments saved

could be used for clinical leadership and management activities

⅓

of GP appointments saved could be used for other work and activities which require

‘headspace’

⅓


• Mostly when we talk about prevention in the NHS we mean reducing smoking, obesity and alcohol consumption and increasing physical activity. However, in Wakefield we are becoming increasingly interested in the impact social capital has on improving health.

• Lacking social connections is as damaging to our health as smoking 15 cigarettes a day.

• 10% of those aged 65 and over experience loneliness all or most of the time.

• This is magnified in areas of high deprivation – Areas where people experience higher morbidity and premature mortality, and are likely to

undertake higher risk taking behaviours.

Social Prescribing


• Social prescribing can include…

– Exercise

– Healthier lifestyles

– Carer support

– Money and benefits advice

– Meaningful activities to combat lack of purpose or social isolation

• We developed a small ‘micro-commissioning’ grant programme with Nova available to local VCSE groups.

– Help existing services expand and meet increasing demand

– Begin to fill gaps identified in local provision

Social Prescribing

Range of Provider involvement: • Citizen’s Advice

• Housing Association

• Carers Wakefield

• Age UK

• Youth groups

• Mental health worker

• Sexual health outreach

• Health Trainers

• Health and wellbeing

• Social prescribing

• and more…


HealthPod – Pop-up Primary Care

Promoting access to health checks & Health & Wellbeing promotion:

• CVD – Qrisk and cholesterol test

• Diabetes – HbA1c point of care

• AF – MyDiagnostic


HealthPod • Between February and December 2015:

– The HealthPod held 79 sessions across the West Wakefield area and was visited by

1,797 people.

– 626 people had their blood pressure checked with 12.63% identified as high-risk and

signposted to their GP.

– 441 had a CVD / Diabetes risk assessment of whom, 18.12% identified as high-risk

and referred to their GP for follow up tests (e.g. HbA1c).

– 540 people were screened for AF and 12 had a suspected AF case identified and were

signposted to their GP for an ECG to confirm the suspected case.

• We have now extended the services to offer follow up tests on site, for example if someone is “high risk” on our CVD/diabetes risk assessment we will offer them a cholesterol and HbA1c.

– This provides us with more information and a better understanding of their needs in

order to support them with behaviour change or refer them to a GP for diagnosis.


@ww_healthpod


Disruptive Prevention • In Wakefield we have poor record of childhood obesity, oral health,

educational attainment

• We are seeking to develop a population approach to physical and mental health

• Prevention should starts in school, before bad habits form

• We are already supporting ‘1k a day’ to get our children exercising every day at school

• To support this we have developed an App-building competition for our year 6 children

• This is about prevention and community engagement with long term ROI

• Challenge children to come up with health and

wellbeing ideas

• Work in teams, with specific roles

• Create their ideas on paper

• Build their concepts in ‘Touch Develop’

• Supported by teachers – coding now on the

curriculum

• Supported by Microsoft counsellors via Skype

• Present to Dragons Den style panel including

local GP, other children

• Shortlisted Apps go forward to Final judging

• Event in central Wakefield judged by local

health and social service leaders

• Fantastic prize – App gets developed – Trip to Microsoft games development studio


Schools App Challenge

Schools App Challenge


• Nationally replicable models

• More accessible, more responsive and more effective health, care and support services

• Fewer trips to hospitals

• Care closer to home

• Better co-ordinated support

• 24/7 access to information and advice

• Access to urgent help easily and effectively, seven days a week

What will Success Look Like?

THANK YOU PLEASE FILL IN YOUR EVALUATION FORM

11 April 2016

http://www.smartsurvey.co.uk/s/Newmodels11april/

#futurenhs




new models of care and the prevention agenda: an …€¦ · 10.10am interview session with...

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