![Out of Hospital Services
• Better Care Fund to deliver more services provided
in the community, developed in partnership with
social care [example - Hospital at Home and Neighbourhood clusters]
• Primary care investment to place GPs at the centre
of coordinating care for people with long term
conditions
• A single point of access to health and social
services for patients, carers and professionals
• Responsive, integrated health and social care
services to get hospital patients home sooner](https://image.slidesharecdn.com/ctapresentation-150310121737-conversion-gate01/85/Newbury-Call-to-Action-slides-5-March-2015-6-320.jpg)
Newbury Call to Action slides - 5 March 2015
- 1. Berkshire West CCGs Operating Plan Refresh 2015/16 Working together to keep people well and out of hospital
- 2. Five Year Forward View • New models of care and joint commissioning • A stronger role for the voluntary sector • Valuing the role of District General Hospitals • Transformed primary care • Greater emphasis on improving public health • Patients more in control of their own care • Better use of innovative technology
- 3. Changes needed • New model of care provision which meets financial constraints • Coordinated “wrap around” care enabled by different resourcing for primary, community and social care • Hospital care delivered in the community – building on the success of our diabetes work in Berkshire West; professionals working together beyond hospital walls • Focus on health and wellbeing, collaborating with Public Health to support patient self care
- 4. Our focus areas Hospital services Urgent care system Out of hospital sector Integrated primary, community and social care at scale
- 5. The right care in the right place • Physical and mental health needs of equal status • Improving access to Mental Health services - particularly Tier 3 Child and Adolescent Mental Health • Piloting new technology-enabled care • Innovative approaches to transform clinical pathways • Highly responsive urgent and crisis care services outside of hospital • Helping people to know where to go and providing better information to support individuals to self care • Meeting waiting time targets for A&E, cancer and outpatients
- 6. Out of Hospital Services • Better Care Fund to deliver more services provided in the community, developed in partnership with social care [example - Hospital at Home and Neighbourhood clusters] • Primary care investment to place GPs at the centre of coordinating care for people with long term conditions • A single point of access to health and social services for patients, carers and professionals • Responsive, integrated health and social care services to get hospital patients home sooner
- 7. A Call To Action The vision of your local CCG Dr Abid Irfan – CCG Chair
- 8. Our local Health Challenge • Age Profile: we have a larger proportion of older children aged 10 to 19 and adults aged 40 to 49; and a smaller proportion of younger adults aged 20 to 34 • Ageing population an anticipated growth in the over 65 population of 34% (or 8,000 people) by 2021 • Pockets of relative deprivation The most deprived areas are in parts of Greenham, Thatcham North and Victoria. Greenham is in the 20% most deprived nationally. • Obesity Overall is lower than national average but approximately 30% of year 6 children are overweight or obese. • Smoking prevalence lower than the national average. • Disease prevalence: cardiovascular diseases, COPD, diabetes, chronic kidney disease, mental health disorders, depression and dementia are lower than the national prevalence rates and comparator CCG group. The prevalence of asthma is higher.
- 9. • New models of care and joint commissioning e.g. Diabetes, chronic respiratory disease and Hospital at Home. • Transforming primary care e.g. Increased Access (Winter pressures & Saturday Opening) and focus on Admissions avoidance through Community Enhanced Services • Greater emphasis on improving public health e.g. Pre Diabetes and Health Checks • Parity of Esteem for Mental Health Services e.g. Hospital Psychiatric liaison service and Crisis Concordat. Support for carers. Focus on Dementia • Better use of innovative technology e.g. Connected Care project (MIG & Orion), DXS, E-prescribing, tele consultations Delivering in line with the NHS 5 year forward view
- 10. Operating Plan refresh 2015/16 -Local objectives • Draft ‘Plan on a Page’ within welcome pack showing refreshed commitments, alongside examples of areas we have focussed on following previous Call to Action events. Feedback welcome • Promote healthy lifestyles in partnership with Public Health • To develop a sustainable model of Primary Care locally. • Continue to Increase the timely diagnosis of dementia rate • Work in partnership across Berkshire to improve outcomes for people experiencing mental health crisis through the crisis concordat, street triage and increasing self- referrals to talking therapies. • Create joint system-wide integrated pathways across key areas such as frail elderly. Develop new models of delivery of care. • Continue to deliver our constitutional commitments such as bringing health and social care system together to ensure consistent delivery of the 4 hour A&E target, 18 week waits and Cancer • Ongoing development of services at West Berkshire Community Hospital
- 11. Importance of integration with Social care Introduction to Tandra Forster Head of Adult Social Care West Berkshire Council
- 12. Importance of integration with Social care Tandra Forster Head of Adult Social Care
- 13. The headlines
- 14. Challenges Austerity Health funding gap from rising demand is set to be £30bn by 2021 (Nuffield/NHS) Local Government Association project gap in local government funding of £16.5bn by 2020 Ageing population By 2030 the number of older people with care needs is predicted to rise by 61% Ageing workforce – recruitment challenges Burden of disease People with Long term conditions account for 70% of health and care spending As of 2011, 52% of over 65s had a limiting long-term health condition or disability – a 50% increase since 2001.
- 15. Key drivers of change
- 16. Care Act 2014 – more challenge Embeds personalisation Opens up key role of carers Wellbeing Prevention Good quality information and advice Robust care market – quality and choice Caps the cost of care to the individual (April 16)
- 17. ‘Whole Place’ approach to Health and Social Care Integration Health and Social Care is a complex network with many different essential services Better Care Fund - government initiative to kick start integration We need to focus on: Developing a shared understanding of local need Plan together Integrate services
- 18. Making change happen Service improvement by improving: Communication Coordination Teamwork Simplification Aligned budgets
- 19. Shift our focus Focus on strengths not deficits ‘Doing with, not to’ Part of the solution Creating resilient communities
- 20. Vision for 2019 Person centred services that focus on outcomes rather than outputs Provision of good quality information and advice that empowers people to make good choices and self-manage Flexible services that operate across 7 days where appropriate. Services will be simpler to access, have less duplication and reach service users/patients earlier. Delivery of health and social services to be localised wherever possible including access to crisis, A greater range of local services that promote independent living Reduction in avoidable hospital admissions. Lengths of stay in Hospitals will be kept to a minimum Increased numbers taking up of personal budgets
- 21. Angus Tallini GP Lead for Primary Care NDCCG 5th March 2015
- 22. Monday Morning… Rising Demand from multiple sources, including GPs themselves Demographic changes Workforce changes Organisational factors
- 23. Hospital care Urgent care system Out of hospital sector: Integrated primary, Community and social care at scale
- 24. Alleviating current pressures Effective co- commissioning of primary care services Incentivising innovation
- 25. A Rewarding Place to Work – with a training focus Offering timely appointments over extended week in accordance with patient need Integral part of urgent care system Continuity where it matters most to give proactive and coordinated care for ‘at-risk’ patients Preventative Supporting patients and their carers to self manage Long Term Condition Fit-for- purpose premises Sustainable and good value Signposting to facilitate appropriate usage of GP and wider services by patients Continuing to provide high quality care Using Technology to optimum effect Offering defined level of care through varying delivery models
- 26. Comprehensive Directory of Services and active signposting at the front door Supported self care extending to long term conditions Continuity when it matters most with a team supporting each GP within the practice Urgent primary care capacity co-operative approach to on the day demand
Editor's Notes
- #3: MCPs = Multispecialty Community Providers. PACs = Primary and Acute Care Systems
- #6: We will continue to enable patients to access the appropriate service to meet their needs: All elements of the system need to work together to ensure that patients get the right response to meet their needs – well oiled machine Achieving the national standard for dementia diagnosis
- #7: Our plans include...
- #10: Crisis Care Concordat is a shared agreed statement, based on a national initiative across the whole of Berkshire. It covers what needs to happen when people in mental health crisis need help – anticipating and preventing mental health crises wherever possible, and in making sure effective emergency response systems operate in localities when a crisis does occur. http://www.crisiscareconcordat.org.uk/about/ for more info Street triage is a initiative seeing the police and mental health services work together to ensure people get appropriate care when police are called to a person in distress.
- #11: Frail elderly pathway to deliver high quality, efficient and patient centric care working closely with our partners at West Berkshire Council and the Community Voluntary sector through the new Better Care Fund to reduce potentially avoidable unplanned admissions and reduce delayed transfers of care. This work is inextricably linked to developing 7 day working across social and health service providers. Working in partnership across Berkshire to improve the outcomes for people experiencing mental health crisis through the Crisis Care Concordat and a planned introduction of a street triage service in 2015. Crisis Care Concordat is a shared agreed statement, based on a national initiative across the whole of Berkshire. It covers what needs to happen when people in mental health crisis need help – anticipating and preventing mental health crises wherever possible, and in making sure effective emergency response systems operate in localities when a crisis does occur. There will be a number of meetings before the action plan is finalised. It was agreed that we should start to raise awareness of the action plan with all six Health and Wellbeing Boards and it will come to their meetings in a few months’ time. Street triage is a initiative seeing the police and mental health services work together to ensure people get appropriate care when police are called to a person in distress. In the Oxfordshire pilot, there are currently two mental health professionals who work alongside police officers between 6pm and 2am, seven days a week. The mental health professionals are there to attend incidents with police officers so they can offer face to face advice, make accurate risk assessments and give the right care to the patient. They have also been working in the police enquiry centres, offering advice to the police call handling staff and are able to talk to the person in crisis over the phone. http://www.thamesvalley.police.uk/aboutus/aboutus-street-triage.htm
- #19: Personal Recovery Guide/Joint Provider and Hospital@Home Connected Care
- #31: Sunday Night… Monday Morning…