NHSScotland Event 2015 LEADING INTEGRATION FOR QUALITY

B:1 Think Different – Creating a New Model for Primary Care

#thinkdiffpc

Think Different

“We must constantly look at things in a different way. Just when you think you know something,

you must look at it in a different way. Even though it may seem silly or wrong, you must try.

Dare to strike out and find new ground”

Think Different

“To the crazy ones. Here’s to the misfits. The rebels. The troublemakers. The people who see

the world differently”

Think Different

“The people who are crazy enough to believe they can change the world are the

ones that actually do”

#thinkdiffpc

Reducing Health Inequalities in General Practice

General practice : bottom up approach

Enabling practices to look at their local population demographics and explore new ways of working to

promote health and wellbeing

GP Leadership time

QOF 50 points : Access and Quality

National support for Local connections

Scottish Government : Primary Care Division support• David Thomson• Dr Tricia Donald• Dr Gregor Smith• Frank McGregor• Lynda Nicholson• Lorna Hall• Jan Beattie

Key Focus

• Vulnerable Families • Multiple Conditions in over 45‘s

with the GP practice as the "hub" and utilising the asset approach to health inequalities

informed by research from the Deep End and Prof Stewart Mercer on Multi morbidities

• Release time to be creative and innovative• Empower practice• Test out interventions• Make community connections• Tell the stories• Measure impact• What could be sustainable or scalable ?• No detriment to practice or patient

Implementing at scale….can it be done?

Ideas being developed

• Targeted Consultations• Extended Patient Records : social and behavioural

determinants of health

• Connecting to communities : asset mapping

• Access to meet the Individuals Needs

• Social prescribing• Collaborations eg Public Health , Social Enterprise, Nursing,

Voluntary organisations , Social Care, Cycling

• Transient Populations / Travellers• Frail Elderly

OutcomesGolden nuggets and silver threads

• Building relationships

• Encouraging self management for patients

• Improving access

• Better communication / extended

teamworking

• Developing code set for social and

behavioural determinants of health

• Improving morale!

#thinkdiffpc

Edinburgh Headroom Project

Headroom

• Transformation• Person Centred• Health Inequalities• Social Prescribing• Integration• Collaboration Therapeutic Relationships

Headroom EastEdinburgh

Total Place

Transformation of Health Care SystemSocial PrescribingPerson Centred CareHealth InequalitiesCollaborationIntegration

Focus onVulnerableHealth Inequalities

Mainstream Public Services

Community Assets

CommunityConversation

Housing

SocialIsolationLibraries

Public Service Usage including NHS Lothian

Social Prescribing

NUKA

MentalHealth

InteragencyEngagementIntegrationCollaboration

RelationshipsConversations Consultations

House of Care

Headroom

Third Horizon

The First Horizon• Established valued silo, major capacity issuesThe Second Horizon• Engagement of professionals and community in change

HeadroomThe Third Horizon• Established Health and Social Care Integration • Balanced medical & social model of health• Truly person centred: Rights & Resonsibilities

“If the choice is between a society that generates illness and then thrives on therapy to put it right, or a society that generates health through social capital and social responsibility, the answer is a no-brainer.”

2009 Brandling and House BJGP

23.6.2015 Dr Alex Connan

House of Care

Areas of Exploration

• Respiratory Choir• Social isolation/Loneliness• Good Conversations• Frequent attenders • Teenage Health/GIRFEC• End of life care for patients with COPD• Pregnant women with high BMI presenting with little

English• Chronic pain & Opiate prescription

• Team• Obesity• Depression• Nuka

• Large Group work ST1’s• Quality Improvement Activities & Group Work• Agenda Setting in GP training• GP Trainers: Small and Large Group work

GP Education

“You depend on each other at every phase, teams within teams, scrums, lineouts, ruck ball, tackles.

….So it is an awesome task you have, it will only be done if everyone commits themselves now…”

Telfer 1997

Which relationships matter?

Headroom EastEdinburgh

Total Place

Transformation of Health Care SystemSocial PrescribingPerson Centred CareHealth InequalitiesCollaborationIntegration

Focus onVulnerableHealth Inequalities

Mainstream Public Services

Community Assets

CommunityConversation

Housing

SocialIsolationLibraries

Public Service Usage including NHS Lothian

Social Prescribing

NUKA

MentalHealth

InteragencyEngagementIntegrationCollaboration

RelationshipsConversations Consultations

House of Care

Headroom

Headroom Achievements

• Empowerment of Teams• Building Relationships• Good Conversations• Commitment to Community• Education• Leadership: Bottom Up!• Alignment/Values• Scottish Government

Headroom Themes

• Transformation

• Person Centred

• Health Inequalities

• Social Prescribing

• Integration

• Collaboration

Therapeutic Relationships

#thinkdiffpc

The Govan SHIP Project(Social & Health Integrated Partnership)

The Govan SHIP Project(Social & Health Integrated Partnership)

Dr John Montgomery, GPThe David Elder Practice, Govan

GPsDistrict Nurses

Health Visitors

Social Work

Rehabilitation

Links Workers

Acute Hospital Consultants

MidwiferyMental Health

Multidisciplinary Teams

The Deep End

Aims and Objectives• Communication• Person Centred• Anticipatory and preventative approach• Crisis Hospital Admission• Unscheduled Care

Aims and Objectives• Chronic Illness• Early Years• Health inequalities

• Social Work attachment• GP Posts• MDTs• Targeted longer consultations / home visits• Case conferences• Admin support• IT / Evaluation• Partnership support

How