Leicester, Leicestershire & Rutland Better care together in Hinckley and Bosworth www.bettercareleicester.nhs.uk 27 March 2017 Scope of the evening What we’re doing now, and what we want to do in the future How our proposals might affect you and your local area • Caring for you at home • Your local GP practices • Local community hospitals • Access to urgent care services The NHS does amazing things every day The national view Introducing our Sustainability and Transformation Plan (STP) • Health and care proposals for Leicester, Leicestershire & Rutland (LLR) • Progression of Better Care Together work, but with clearer focus on implementing a few key system priorities • Engaging across the area to hear the public views • 44 STP areas in England, and some changes may impact on residents here Tackling the gaps in the system Health Finance Care and and and quality wellbeing efficiency Making us fit for future care Across Leicester, Leicestershire and Rutland our population is growing The older population is predicted to increase by 11% in next five years Long term illnesses are also increasing This leads to a greater demand for health and care services Identifying the health and care financial gap What patients tell us they want I want to stay in my own I want the knowledge to care for home or in my local area ourselves and stop myself from getting sick I want all the services to work together so I don’t have to keep repeating my I want to feel more in story or attending so many control and independent appointments Addressing the areas for action New models of care focused on prevention, moderating demand growth Redesign specific services to meet patient needs and Operating more efficiently improve outcomes Getting the enablers right Configuring our services to ensure clinical and financial sustainability The journey through care for patients Patient GP practice “Federations” Community Care when you managing their co-ordinates of GPs working based care need urgent own conditions care together to and support medical and preventing deliver from local attention illness through enhanced care teams healthier living and diagnostics Introducing Mrs. Irene Taylor • 78 years old • Widowed • Lives alone in Loughborough • Frail older person who suffers from – Diabetes – Heart failure – Hypertension – Chronic Kidney Disease – Angina – Osteoarthritis Primary care and the principles of Home First Keeping patients where they tell us they want to be We believe that being at home with support is the best place for many people to stay well and manage their conditions or illnesses. In practical terms this means everyone should ask: “Why is this patient not at home?” or “How best can we keep them at home?” We call this principle “Home First” The first step on the care journey Patient managing their own conditions and preventing illness through healthier living Increasing self care and prevention • More control over long term conditions • More people will be encouraged to lead healthy lifestyles to prevent the onset of long term conditions • Patients will have the skills and confidence to take on more responsibility for their own physical and mental health care The next steps on the care journey GP practice co-ordinates care Federations of GPs working together to deliver enhanced care and diagnostics Hinckley and Bosworth Medical Alliance • 13 practices in Hinckley and Bosworth • Chair - Dr Will Priestman • Our Patient Participation Groups were already working as a locality in Hinckley and Bosworth, chaired by Roy Priestley • Now working together to improve services for patients Federations delivering change • Delivering more through the Federations so we can offer more care and services in the community • Adding different types of skilled clinicians into General Practice to allow GPs to focus on the most complex cases • Closer working with community nursing and social care teams • Sharing back office functions and reducing bureaucracy to increase time for direct patient care What does this mean for Mrs. Taylor? She will no longer have to travel into Leicester Royal Infirmary for minor procedures – they’re delivered by her federation locally The improved mix of clinical staff across practices, means better access in practices and time to see your GP for longer when needed for more complex care More support for self care from the mix of staff available If she needs further diagnostics many will be done locally Supporting patients in the community Community based care and support from local teams Supporting patients through Integrated Locality Teams How will a integrated locality team work for our patients? Proactive Co-ordination and Ongoing support identification and implementation and monitoring assessment Patients identified and Joint holistic care plan Patient supported where assessed proactively and and patient education needed by primary care, at early stage programme developed social care and community resources. Objectives and plan Multi-Disciplinary Team designed by team and involved where needed Patient discharged by agreed with patient, team into periodic carers, home staff and GP Plan implemented monitoring when clinically safe to do so Integrated locality leadership teams – Hinckley and Bosworth West Leicestershire CCG Dr Darren Jackson Clinical Locality Lead and Chair West Leicestershire CCG Jade Atkin Service Improvement Manager West Leicestershire CCG Jas Kaur Commissioning Pharmacy Lead Federation Dr James Ogle Hinckley and Bosworth Federation Clinical Lead and Deputy Chair Federation Beverley Fall Federation Manager Leicestershire Partnership NHS Trust Emma Camp Provider Operational Nurse Leicestershire Partnership NHS Trust Helen Wilkes Provider Clinical Nursing Leicestershire Partnership NHS Trust Kim Fox Provider Clinical Coordinator Leicestershire County Council David Tuohy Adult Social Care Hinckley and Bosworth Borough Sharon Stacey Adult Social Care Council What does this mean for Mrs. Taylor? The team will support her with managing her long term conditions They will develop an effective care plan for her which covers her health and social care needs and supports her to stay as well as she can She will have better access to specialist support and won’t have to have as many separate appointments with different teams She will have fewer unnecessary admissions to hospital and be discharged more efficiently if she does need to attend. Table discussion Primary care and the principles of Home First • How could this impact on you and your family in keeping well and supporting recovery? • What else would you encourage us to think about when developing our proposals for this area? 24/7 access to urgent care that gets you the right care and treatment in a crisis Supporting patients when it’s urgent Care when you need urgent medical attention Keeping you well 24/7 How will services be different? • Clinical navigation working 24/7 to provide enhanced clinical assessment and advice, onward referral and direct booking into local services. • GP practices will continue to see people with urgent needs during surgery opening hours (Monday to Friday 8am to 6.30 pm) • Out of Hours GPs will be based within primary care hubs and Urgent Care centres to provide a seamless service, making best use of clinical time • New urgent primary care service in Hinckley and Bosworth hospital for patients referred through NHS 111. • 24/7 visiting service across the whole of Leicester, Leicestershire and Rutland providing home based assessment and treatment • Strengthened services for people with mental health problems, including specialist What does this mean for Mrs. Taylor • If her GP identifies her as needing further support, and she is too unwell to travel to the surgery, the GP can refer her to a home visiting service to come to her home to see her • When her surgery is closed, if she calls 111 the clinical navigation team can arrange a home visit for her 24/7 to avoid her reaching a crisis point when she needs to call 999. • If she needs to see a GP when her surgery is closed, and can travel she can be referred to primary care services in Hinckley and Bosworth Hospital until between 7-10PM on weekdays and 8-8PM on weekends. • The Clinical Navigation service can provide her with enhanced pharmacist advice about her medicines when her surgery is closed Table discussion 24/7 Urgent Care in Hinckley and Bosworth • How could this impact on you and your family in keeping well and supporting recovery? • What else would you encourage us to think about when developing our proposals for this area? Table discussion Break and discussion Looking forward Changes to hospital services in the community Care wrapped around the patient • Home First, and our integrated locality teams in the community mean that more patients will be able to be cared for at home • GP Federations will be able to deliver more planned care and surgical procedures in the community • Community Hospitals still have an important role to play Community Hospitals Deliver planned care and Caring for patients when they are diagnostics in the community not able to be cared for at home New models of care could mean that less inpatient beds may be needed as Home First is implemented Implementing care at home • Started engaging 2013 – Ashby Community Services Review – Positive feedback from patients around care at home • Currently some rehabilitation happens in the community and some happens in hospital – Our new model of care means, where clinically safe, all rehabilitation care will be carried out in the home. • Before any changes to beds we will ensure that we have credible and sufficient alternatives for patients in line with National test. Investment in Hinckley and Bosworth • We believe that there need to be changes to where services are delivered in Hinckley and Bosworth • These changes will mean that we can deliver the clinical services that the growing population needs • However, these proposals require significant capital investment from national funding • No changes would be made without consultation.