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Better care, closer to home

Our strategy for high quality care

March, 2011Draft document

1

Changing health needs are placing increasing pressure on health and social care

SOURCE: JSNA, CSP submission

Hounslow’s health trends

▪

Area of relatively high population growth: the number of under 19s living in the borough is forecast to rise 10% by 2020 and the number of over 85s by 15%.

▪

The proportion of residents suffering from diabetes is forecast to rise 43% in the 6 years to 2015.

▪

Significantly more deaths from heart disease and stroke than the

England average.

▪

40% of year 6 children in Hounslow are overweight or obese, which is significantly higher than the London or national average

▪

Life expectancy in Hounslow is around 1 year less than the national average

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2

This is due to services working separately resulting in patients falling through the gaps

IV

Community Matrons

ART and social work

District Nursing

Community Rehab

Mental health

Different services work separately Resulting in patients falling though gaps

After being stabilised by great care from the ICRS Ms Smith was readmitted after she was passed to core services

Inexperienced district nurses refer many patients to GPs unnecessarily

Many stroke patients are confused about who is co-ordinating their care after they are discharged

Hospital is unable to discharge early because they don’t trust services to coordinate

1

3

Today, Hounslow has high acute spend per weighted population compared to other boroughs

,000 weighted population

A&E attendance Spend on unscheduled care

434

350373 +24%

HounslowONSpeer group

London

176163157

HounslowLondon

+8%

ONSpeer group

£/weighted population

2

SOURCE: HES 10/11 (First 8 months)

4

We have a clear vision for how OOH care will look in the future

▪

The out of hospital strategy is about multi-

professional staff working together to deliver quality primary, intermediate and social care and managing long term conditions out of hospital in the most cost effective way

▪

GWCCG wants secondary care consultants supporting general practice and working together to ensure effective joined up case management that provides quality of care and value for money and reduces duplication

SOURCE: GWCC Commissioning Strategy 2012/13 –

2014/15

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Our vision is that all care will be planned care

A joined a system of care…

2 Simplified planned care pathways to enable local/self management

3 Rapid response to urgent needs sign posting patients to the best service

4 Providers working together to effectively manage the

elderly and LTCs out-of-hospital so patients feel secure and receive seamless care

5 Appropriate time in hospital when admitted, with

timelysupported discharge to well supported community care

1 Patient has easy access to high quality, responsive primary careA single point of access means patients go directly to the most appropriate service 2

3

4

1

General practice

Hospital Care

Acute hospital at home

care

Planned care

Health and social

care teams

Urgent care

5

6SOURCE: GWCCG Commissioning Strategy 2012/13 –

2014/15

This will mean delivering across 5 key areas

Easy access to high quality, responsive primary care through continuous drive to improve performance and access and reduce inappropriate variation led by education and peer pressure with performance management when necessary. To

seek to develop Heston Health Centre and a primary care facility on the WMUH site.

High quality elective care and well understood planned care pathways with

minimal numbers of attendances at secondary care to reduce the time patients have to take from their daily lives, detailed care and management plans sent to GPs and patients to enable local/self management.

Rapid response to urgent needs so that fewer patients need to access hospital emergency care. Telephone first –

patients to know that this is the best way to good signposting to an efficient and seamless service. Patient education on how to get best value from their NHS. Palliative care to move to an elective service.

Providers (social and health) working together,

with the patient at the centre to proactively manage

LTCs, the elderly and end of lifecare out-of hospital., resulting in patients feeling secure in referral into an effective and safe partnership between the community providers, social services with support from their GPs

or hospital consultant.

Appropriate time in hospital when admitted, with

early supporteddischarge into well organised community care

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Easy access to high quality, responsive primary care

Claire is 36. She is a working mother who struggles to manage her work and home life. She has a young son, Jason who is 4 years old and has a fever.

Claire understands that 111 can direct her to the most appropriate care

She is relieved and reassured, feeling confidence in the system

Claire is reassured and feels confident to see episode through

Record is taken of the event and communicated to the family’s GP via SystmOne

In future, patients will have better access to primary care and know how to get it . . .

Primary care has been difficult for some patients to access, putting pressure on other parts of the health system…

Stressful and time consuming process for Claire to find a solution

A&E staff feel overwhelmed by flow of unscheduled patients

Claire grateful for treatment and idea of A&E as place to get care is reinforced

Claire uncertain what best course of action is and who to contact

Claire comes home form work at 6pm to find her son has come back from nursery with a fever

Claire rings her GP but cannot get through. After several attempts decides to take Jason to her local A&E

A&E is crowded and there is long wait. The conditions are stressful and Jason’s condition worsens.

Treatment is transactional. Jason misses out on opportunity for broader child welfare e.g., staff do not make sure jabs up to date, check Claire is coping

GP sees her son and has access to child's (and family's) health record, they check child over, look for rash and send home. They send record of attendance to Claire’s own GP

If it was something more serious (e.g. rash with query meningitis, then the GP could have given a injection of penicillin before sending on to paeds unit)

She is given an appointment for 8,30pm at the Urgent Care Centre to see a GP

Claire comes home form work at 6pm to find her son has come back from nursery with a fever and calls 111

A

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Paul is 43. He is in good health but has been experiencing severe discomfort in his knee following a recent bout of exercise

Clearly understood planned care pathways that ensure out of hospital care is not delivered in a hospital setting

Sometimes the pathway to receive planned care is complex and disjointed…

Paul meets with his GP who is unsure of best treatment options and lacks equipment to diagnose

Paul is referred to an OP clinic for a scan

After 2 weeks Paul is called in for a follow up appointment and receives 2nd scan and is advised he needs a hospital appointment

2 weeks later Paul has not received a followup

and returns to GP for further advice

In future, the pathway with be simpler, understood by all clinicians and joined up. . .

Paul feels immediate progress is being made and information is efficiently passed between GP and consultant

Paul is reassured by the structured approach

His GP is able to check in on Paul’s progress with rehab

Paul goes to hospital 2 weeks later for operation. He has a brief stay on the ward and is discharged with a rehab plan

On arriving home receives an email from the hospital explaining plans for rehab and treatment plan is recorded in GP records via SystmOne

MSK specialist physio

carries out assessment, including a scan at the diagnostic clinic and books Paul a hospital admission and discharge date. Treatment is recorded in GP records via SystmOne.

Paul meets with GP who discusses options and shares information about treatment and impact. Books patient for MSK assessment with community services

B

Paul still does not understand what his treatment options are

Paul has to take time off work to attend

Paul does not have his results with him and his GP is unable to give further advice

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Urgent care has been stressful when patients need support . . .

Rapid response to urgent needs so that fewer patients need to access hospital emergency care

Ethan is 84. He lives alone and usually stable Parkinson’s disease and walks with a stick. Recently he has developed an urinary tract infection which has led to him becoming confused

Ethan’s wife is worried and calls an ambulance

In A&E, the strange surroundings make Ethan even more confused and he becomes disruptive and aggressive

While struggling, Ethan rolls out of bed and severely hurts his leg

Three weeks later, Ethan is still in hospital and his mental state has deteriorated, he is discharged into a care home

In future, we will meet patients’ needs at home . . .

Ethan is able to stay at home. His wife knows who is responsible for coordinating care

Stress is minimised

and the people with the most appropriate skills are available

Early intensive support accelerates recovery

A smooth transition is made to a locally based multi-

disciplinary care team

Days 1 to 4 –

cared for in bed with regular visits from nurses in the team

Day 5 –

confusion much improved. Eating and drinking well and wants to get out of bed

Day 5 onwards –

physio

working with carers

increasing patient’s mobility and exercise tolerance

GP, social worker and physiotherapist from ICRS visit Ethan at home. They review his medication, move the furniture in his lounge and set up a hospital bed and pressure-relieving equipment

Ethan is referred to ICRS by his GP. He has been unable to get out of his chair for the past few days. His wife is caring for him

Day 7 –

Referred to community rehabilitation service

C

Hospital nurse are not sure how to deal with him, causing them stress

Ethan becomes more dependent on care and regaining independence is unlikely

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And this won’t be more of the same, we’ll hold providers to high clinical standards to ensure delivery

These standards will set our aspirations for the future …▪

They emphasize the central role of the GP in the coordination and delivery of out of hospital care

▪

They intentionally go beyond the current minimum contractual requirements of the GP contract

▪

They are designed to address core primary care delivered by GP practices and broader set of care delivery outside of hospital

▪

They aim to shift care delivery from more reactive unplanned care to more proactive planned care

The standards are covered in four key domains1. Individual Empowerment & Self Care:

–

Individuals will be provided with up-to-date, evidence-based and accessible information to support them in taking personal responsibility when making decisions about their own health, care and wellbeing

2. Access convenience and responsiveness:–

Out-of-hospital care operates as a seven day a week service. Community health and care services will be accessible, understandable, effective and tailored to meet local needs.

–

Service access arrangements will include face-to-face, telephone, email, SMS texting and video consultation.

3. Care planning and multi-disciplinary care delivery: –

Individuals using community health and care will experience coordinated, seamless and integrated services using evidence-based care pathways, case management and personalised care planning.

–

Effective care planning and preventative care will anticipate and avoid deterioration of conditions

4. Information and communications: –

With an individual's consent, relevant parts of their health and

social care record will be shared between care providers.

–

Monitoring will identify any changing needs so that care plans can be reviewed and updated by agreement. By 2015, all patients to have

online access to their health records

SOURCE: Out of Hospital Standards sent to Clinical Board 1 March

2012

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Key issues faced by GWCC and measures in place to solve them

We have identified areas we are making progress in the challenges we face and issues that still remain

1

General practice

Hospital care

Acute hospital at home

care

Planned care

Health and social care teams

Urgent care

Responsive emergency care▪

Too many people going to A&E

▪

Admission to hospital when care could be better at home

C

Support at discharge▪

Lack of support for patients leading hospital

▪

Lack of coordination between community services

E

High quality planned care▪

Inconsistent referral patterns

▪

Lack of options out of hospital

BProviders working together

D

▪

Care for LTCs

more reactive than proactive

▪

Lack of coordination between

▪

community services

Access to Primary Care▪

Poor access to GP▪

Patients entering system in wrong place

▪

Inappropriate A&E attendances

A

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Existing and new initiatives will address the issues we currently face and improve care for patients (1/2)

1

▪

We are developing primary care by supporting GPs to improve access, improving education opportunities for clinicians, increasing GP access to consultants and increasing accountability for access and quality

▪

A joined up system of 111, out of hours provision and the urgent care centre will direct patients to the right place in the system first time and stop inappropriate A&E attendances

Our visionEasy access to high quality, responsive primary care

Initiatives to deliver our vision

A1

A2

▪

The Integrated Community Response Service has been running since June 2011, supporting patients go home from A&E and wards or stay at home

▪

Ambulatory Care in the Community is a new service led by a consultant from WMUH to provide care needing consultant supervision in the community

▪

A joint rehabilitation and reablement team will provide multi-

disciplinary care at home for longer spells than the current service

Rapid response to urgent needs so more people can be cared for at home

C1

C2

Issue we faced

▪

Poor access to GP▪

Patients entering system in wrong place

▪

Inappropriate A&E attendances

Access to Primary Care

▪

Too many people going to A&E

▪

Admission to hospital when care could be better at home

Responsive emergency care

C3

A

▪

Our Referral Facilitation System is creating consistent planned care: 29 Hounslow GPs triage patients and ensure patients get straight to the right place for them

▪

Consultants in the community are providing clinical leadership, inputting into care of individual patients and seeing patients in the community themselves

Clearly understood planned care pathways that patients have confidence in

B1

B2▪

Inconsistent referral patterns

▪

Lack of options out of hospital

High quality planned care

B

C

Shifting settings of

care in mental health?

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1 Existing and new initiatives will address the issues we currently face and improve care for patients (2/2)

Integrated care– to proactively manage long term conditions and other at risk groups

▪

The Integrated Community Response Service and the joint rehabilitation and re-ablement team will create a more continuous transition from hospital to home

Supported discharge into well organised community care

▪

SystmOne already enables more informed clinical decision making by letting GPs, the UCC view the same records: in future this will play a greater role in integrating care from all providers

▪

Our end of life care programme is already supporting more people remain in their place of choice

▪

Risk stratification, care planning and case conferences will increase the coherency of care and empower patients and carers

▪

Care navigators will play a new role, supporting patients and joining up health and social care

D2

E1

▪

Care for LTCs

more reactive than proactive

▪

Lack of coordination between

▪

community services

▪

Lack of support for patients leading hospital

▪

Lack of coordination between community services

Providers working together

Support at discharge

D3

D4

D

E

Care for patients with LTCs and mental health needs

Acute psychiatric liaison

Issue we facedOur vision

D1

Initiatives to deliver our vision

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Our goal is, all patients will “phone before they go”

▪

All non-emergency calls out-of-surgery hours, made to 111

▪

Patients who may need a home visit, referred to out-of-

hours service

▪

Some patients given advice on phone

▪

Others seen at home by GP

▪

Patients seen without a wait because they have booked an appointment

▪

Their attendance recorded on their GP clinical system through SystmOne

▪

Operators provide direct advice to some patients

111

Out-of-hoursservice UCC

▪

Patients needing an appointment, but not a home visit, booked into UCC

A2Support for non-emergency patients out of hours

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Consultants in the community will play a key role, ensuring out of hospital care is of the highest standard

▪

Clinical Networks are groups of local experts in a disease area, which includes consultants, GPs, patients and carers. Clinical networks currently exist for diabetes…

▪

Non-medical as well as medical consultants play a key role, e.g., consultant social worker for dementia and consultant nurse in learning disabilities

Consultant roles in out of hospital care

Ensure consistency and standards across the system

▪

Provide leadership for clinical networks–

Develop pathways for care–

Provide guidance to clinicians–

Provide clinical leadership on new developments in a disease area, such as new drugs

Provide direct care for patients

▪

Provide treatment for patients in community clinics–

For example, we have a new consultant led community opthalmology

service

How they will do this

Provide input into the care of individual patients

▪

Advise other clinicians on treatment by phone or email–

For example, mental health consultants are available from 12-2 to take calls from GPs on cases

▪

Discuss cases at case conferences as part of multi-

disciplinary groups: this will give experts from different fields the opportunity to input on a case

B2

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▪

Grade 4/5 staff

Care navigators will be…

▪

Highly knowledgeable of local health and social care provision

▪

Accessible to patients, carers

and clinicians via the single point of access

▪

Responsible for ensuring patient finds the right service

▪

Proactive in contacting these patients and co-ordinating

the care of high risk patients

▪

Working with a care list of ~150 patients high risk based on GP patient lists

▪

Report to GP locality lead

Next steps▪

Understand the economics of the care navigators in Hounslow, building on successful implementation of similar projects in i.e., Torbay and H&F

▪

Agree numbers, process to create role and location in the Borough

▪

Decide where care navigators would be located and who they would report to

▪

Taking referrals from social services, GPs and hospital

▪

Working with the voluntary sector and faith groups, which will play a role building networks of social support

D4 The new role of care navigators will help connect health and social care

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How we will work together

1 Care will be clinically led and consistent, through the leadershipof clinical networks and GP triagers

3 Care will become more coordinated, through clinicians and social

workers working together in multi-disciplinary team

5 Working together effectively will need new types of role and

developing our existing staff in new ways

6 As we take activity into the community, we need to allocate both

clinical and non-clinical space to this increased level of activity

4 Health and social care will be work together better because we they will share a single point of access, care navigators, the rehabilitation and reablement

team and partnership in multi-disciplinary teams

2 All clinicians will be fully informed of all diagnoses and care a patient has received in the past

7th bullet on care planning /expert carers?

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To realize our vision of increasing the quality and coordination of services there are a number of areas we need to address…

▪

Develop GP leadership within HounslowDevelop our professionals and our organisation

2

▪

Monthly dashboard showing performance and targets▪

Process for holding ourselves to account for these targetsAgree on how we will be governed3

▪

Unified IT systems providing shared records leading to better patient care and transparency on performancePut in place the right

information tools4

▪

Involve, consult and inform patients and carersEngage patients and carers1

▪

Align contracts and incentives of all providers, to ensure system-wide coherence of behaviour and spend

Develop the right contracts and incentives

5

RequirementsTo be successful we need to…

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Patients should be able to expect to be involved, consulted and informed so they can take part in a dialogue around healthcare

1

Our commitment How we’ll deliver

▪

We’ll create a patient engagement group, including GPs and practice managers will drive change

▪

We’ll ensure that each locality will have a patient group▪

We will pilot an online consultation forum▪

We will hold events to consult on key issues, such as commissioning intentions and our Out of Hospital strategy, working in partnership with LINk

(Health Watch) and other patient, user and carer groups

▪

You’ll be consulted

▪

We’ll set out the standards we are aiming for and report to you how

the CCG, localities and individual practices / care providers are performing against them

▪

We’ll explain what is changing, why it is changing, and how your input shaped decisions

▪

You’ll be informed

▪

You’ll be involved

▪

The HCCG Board will have 2 patient representatives and meet in public

▪

All local clinical networks will have a patient or public representative

20

An expert carer programme will empower carers1

▪

Carers will be able to use support of care navigators, particularly for dementia patients meaning that carers will acquire greater expertise of how to provide and access care, based on the care plan

▪

Carers will be involved in the development of care plans meaning that care stops being a series of dislocated events and becomes a continuous process

21

SystmOne is already well established and supporting better care for patients

4

GPs input case details into SystmOne

RFS

Referrals follow precisely defined pathways

Granular reporting on referrals to GPs and mentoring cells

GPs▪

Diagnose and prescribe

Consultants▪

Advise and treat

Acute/mental health▪

Treat

Care is visible to GP and prompts are given for follow-up actions

GP risk stratifies patients

Care plan in place and shared

Regular check ups and early intervention

Real-time shared records inform providers1 Planned care becomes more consistent2

Urgent care becomes better informed3 Long term care becomes more pro-active4

All information input by GP is visible to staff at UCC

GP UCC

Community▪

Maintain