Transcript Northfleet and Gravesend West Neighbourhood Forum 24th

Better Care Together
Joining up health and care for local people - one service
meeting your needs
6th November, 12-4pm, Princes Park Stadium, Dartford
Welcome and Introduction
Better Care Together – working together to improve
the patient’s experience
Debbie Stock – Chief Operating Officer
Introduction –
setting the scene
• People are living longer, healthier lives due to
improvements in medicine and care
• With this brings challenges
• Many people live with several complex conditions,
• Children are born with complex conditions.
• Patients with learning disabilities have lifelong needs.
Local Health Challenges
• Population expected to increase:
o 5% in next five years
o 11% in next ten years
o 13% increase in over 65’s
o 26% increase in over 85’s
• Bottom 20% of most deprived areas in the
Country
• Workforce sustainability
Local Health Challenges
• More obese adults in than nationally
• Increasing alcohol related admissions
• Higher prevalence of hypertension, chronic kidney
disease and hyperthyroidism
• 73% of all deaths related to cancer, circulatory
disease and respiratory diseases.
National Drivers
• The Health and Social Care Act 2012 and Care Bill 2013 put
integration as a key area of focus:
 promotion of overall well-being
 focus on prevention / delaying the development of need
 Ensure the right services are available
 Carers
• Health and Well Being Strategy
• Integration Pioneer Programme
• Better Care Fund
• 5 Year Look Forward
NHS England- 5 Year Forward View
• Radical upgrade in prevention and public
health
• When people do need health services,
patients will have greater control of their own
care
• The NHS will take decisive steps to break
down the barriers in how care is provided
e.g.
between family doctors and hospitals; physical health and
mental health and social and health care
NHS England- 5 Year Forward View
• One size will not fit all areas - Small number of radical new
care delivery options
– Multispecialty Community Provider – GPs with nurses,
hospital specialists; mental health and social care etc.
creating integrated out of hospital care
– Primary care and Acute Care systems – integrated hospital
and primary care provider
• Sustainability relies on:
– Reducing high cost demand
– Increasing efficiency in use of services
– Pump priming initially to close the £30billion gap
Benefits of
integrated care?
• Patient centred care
• Breaking down the organisational barriers
• More cohesive and joined up services
• Smoother transitions in a patients care between
services for patients
• Improved patient care and experience
Social Care Challenges
• Do more with less - financial challenges
• Own Home is best - avoiding decisions about
long term care being made in acute settings
• Maintaining efficiencies whilst progressing with
integration
• Care Act
• Market development
• Ensuring safety of Vulnerable Adults
So, what are we doing and how?
5 Year Plan
Integrated Primary
Care Teams (iPCT)
• Phase 1 implemented on 27 October 14.
• Multi-disciplinary teams (MDT)
• Named individuals assigned to work with specific
practices
• Regular MDT meetings to discuss how needs of patients
are best met
• Proactive, preventative and responsive care
• Further expansion planned
Integrated
Discharge Team (IDT)
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•
•
•
•
Team of Health and Social Care staff
Focussed on the patient and their needs
Planning for discharge – day 1
Patients more informed and involved in their care plan
Improved working with voluntary sector organisations re
dementia
• Improved patient experience
• Better planning and well co-ordinated discharge process
Integrated Dementia
Care
• 11 Mental Health Nurses aligned and supporting GP
practices based within IPCTs.
• Cognitive impairment care plan completed
• KMPT initiating care plan at point of diagnosis.
• Reconfiguration of crisis services underway with KCC
• Alzheimer’s & Dementia Support Services (ADSS)
working with patients at DVH
• 24/7 crisis support for patients and carers
• Dementia forums established to support dementia
friendly communities development.
• Cantab mobile tool implemented
Any Questions?
What you’ve told us
Dr Bhaskar Bora –
Principal Clinical Lead for Quality
How you told us
We asked patients and carers to:
• Give feedback on the set of National Integrated
Care statements (known as “I” statements) and,
from this
• Give feedback on key related ‘better care together’
themes
The following ‘I’ statements received the lowest scores
(levels of agreement) as part of the initial review
Lowest Scoring Statements
[Scale: Disagree strongly (1), Disagree (2),
Agree (3), Agree strongly (4)]
Key Heading
Scores out of 4
(3-4 = acceptable)
Goals and Outcomes
“My carer/family have their needs recognised and are given support
to care for me” (2.6)
Communication
“I always know who is co-ordinating my care” (2.4)
Information
“I am told about the other services available to someone in my
circumstances, including support organisations” (2.3)
Making Decisions
“I have help to make informed choices I need and want it” (2.8)
“My family or carer is also involved in these decisions as much as I
want them to be” (2.8)
Care Planning
“My care plan is clearly entered on my record” (2.4)
Transitions
“When I move between services and settings there is a plan in place
for what happens next” (2.3)
‘Better Care Together’ themes in priority order
Based on peoples’ top three priorities
Access to expertise to support me keep my independence, stay well and manage my own
condition/circumstances for as long as possible.
Care that focuses on me as a whole person rather than my individual illness or need.
Services that fit round me (instead of me having to fit in with services).
Having one assessment of my needs that finds the right solution, instead of being asked the
same questions time and again.
Advice and guidance provided by professionals who know and understand my particular needs
and circumstances.
Less chance of needing hospital stays. It is especially important for older people or people with
dementia to stay at home when they can - better for me a better use of public money.
Better care for me when needed.
What do you think….
• About the findings?
• Does this reflect your own experience?
• Are these your priorities?
Stakeholder discussion regarding
experiences
• 10 minutes to speak on your table about some of the
experiences you may have had.
Integrated care for the future - delivering the
services you need
Debbie Stock – Chief Operating Officer
Urgent Care Re-design
• Undertaking a review of the urgent care access points.




A&E
Walk-In Centres (WIC)
Minor Injury Units (MIUs)
Primary Care In and Out of Hours (OOH)
• Why are we doing this?



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
Keogh Urgent and Emergency Care Review
Contracts for the WIC and OOH care are due for renewal
Increased pressures of A&E departments
Need to support patients better in the community
Opportunity to shape a more cohesive urgent care access system
Non-Elective Provision
Vision for change –
future system
urgent but
non-life
threatening
needs
more serious
or life
threatening
emergency
needs
Community Care Services
Re-design
Aim
• More services closer to home
• Increase the services offered in the community
• Increase capability and capacity of staff
• Move from reactive care to preventative and proactive care
• Promote independence and well-being
• Stop silo working
Information Sharing
• Feedback shows frustrations at having to keep repeating
the same information
• The sharing of information is imperative to ensure timely
and appropriate care
• Implementing a solution to help share basic patient
information between GPs and the hospital
• Need to consult with patients in terms of how they wish
their information to be shared – if at all.
Mental Health Service
review
Aims
• Supporting patients to access the right care when they need
it, by:
– Increasing and improving access to early psychological
intervention services to prevent deterioration of health
– Improve access to support services before crisis point
– Supporting those patients in a crisis
– Focus on recovery and staying well
• Achieving this by working together with public services,
voluntary sector and the independent sector – reducing
stigma, social isolation and deteriorating physical as well as
mental health.
Any Questions?
Break
Doing it better together
Corrine Stewart –
Interim Head of Commissioning
Doing it better together:
• Your opportunity to comment on what you have
heard today.
• Tell us of your experiences
• How do you access these services ?
• What worked well?
• What hasn’t worked well?
• What would you like to see changed?
• What would the perfect service look like?
Table top discussions
• Prompt questions for topics covered
• Please discuss all topics – 15mins each
Plenary
Thank you