Better care, closer to home Our strategy for high quality care Draft document March, 2011 0
1 Changing health needs are placing increasing pressure on health and social care 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 SOURCE: JSNA, CSP submission 1
1 This is due to services working separately resulting in patients falling through the gaps Different services work separately Resulting in patients falling though gaps After being stabilised by great care from the ICRS Ms Smith was readmitted after District Community she was passed to core services Nursing Rehab Inexperienced district nurses refer many patients to GPs unnecessarily Community ART and Matrons social work Many stroke patients are confused about who is co-ordinating their care after they are discharged Hospital is unable to discharge early Mental IV because they don’t trust services to health coordinate 2
2 Today, Hounslow has high acute spend per weighted population compared to other boroughs A&E attendance Spend on unscheduled care ,000 weighted population £/weighted population 434 176 163 157 +8% 373 350 +24% London ONS Hounslow London ONS Hounslow peer peer group group SOURCE: HES 10/11 (First 8 months) 3
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 4
Our vision is that all care will be planned care A joined a system of care… Patient has easy access to high 1 quality , responsive primary care Planned A single point of access means care patients go directly to the most 2 appropriate service 4 Health Simplified planned care General and social 2 pathways to enable local/self practice care 1 management teams Acute Rapid response to urgent needs 3 hospital sign posting patients to the best 3 5 at home service care Providers working together to 4 Urgent Hospital effectively manage the elderly care Care and LTCs out-of-hospital so patients feel secure and receive seamless care Appropriate time in hospital 5 when admitted, with timely supported discharge to well supported community care 5
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 supported discharge into well organised community care SOURCE: GWCCG Commissioning Strategy 2012/13 – 2014/15 6
Easy access to high quality, responsive primary care A 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. Primary care has been difficult for some patients to access, putting pressure on other parts of the health system… Treatment is transactional. Claire comes home form Claire rings her GP but A&E is crowded and there Jason misses out on opportunity work at 6pm to find her cannot get through. After is long wait. The conditions for broader child welfare e.g., son has come back from several attempts decides to are stressful and Jason’s staff do not make sure jabs up nursery with a fever take Jason to her local A&E condition worsens. to date, check Claire is coping Claire uncertain what best Stressful and time consuming A&E staff feel overwhelmed Claire grateful for treatment course of action is and process for Claire to find a by flow of unscheduled and idea of A&E as place to who to contact solution patients get care is reinforced In future, patients will have better access to primary care and know how to get it . . . Claire comes home form GP sees her son and has access to If it was something more serious work at 6pm to find her child's (and family's) health record, (e.g. rash with query meningitis, son has come back from She is given an appointment they check child over, look for rash then the GP could have given a nursery with a fever and for 8,30pm at the Urgent and send home. They send record injection of penicillin before calls 111 Care Centre to see a GP of attendance to Claire’s own GP sending on to paeds unit) Claire understands that She is relieved and Claire is reassured and feels Record is taken of the event and 111 can direct her to the reassured, feeling confidence confident to see episode communicated to the family’s GP most appropriate care in the system through via SystmOne 7
Clearly understood planned care pathways that ensure B out of hospital care is not delivered in a hospital setting Paul is 43. He is in good health but has been experiencing severe discomfort in his knee following a recent bout of exercise Sometimes the pathway to receive planned care is complex and disjointed… After 2 weeks Paul is called in Paul meets with his GP who for a follow up appointment 2 weeks later Paul has not is unsure of best treatment and receives 2nd scan and is received a followup and options and lacks equipment Paul is referred to an OP advised he needs a hospital returns to GP for further to diagnose clinic for a scan appointment advice Paul still does not understand Paul has to take time off work to Paul does not have his results what his treatment options are attend with him and his GP is unable to give further advice In future, the pathway with be simpler, understood by all clinicians and joined up. . . MSK specialist physio carries out assessment, including a scan at Paul meets with GP who discusses the diagnostic clinic and books Paul goes to hospital 2 On arriving home receives an options and shares information about Paul a hospital admission and weeks later for operation. He email from the hospital treatment and impact. Books patient discharge date. Treatment is has a brief stay on the ward explaining plans for rehab and for MSK assessment with community recorded in GP records via and is discharged with a treatment plan is recorded in services SystmOne. rehab plan GP records via SystmOne Paul feels immediate progress is being Paul is reassured by the structured His GP is able to made and information is efficiently approach check in on Paul’s passed between GP and consultant progress with rehab 8
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