East Merton Post Model of Care Workshop Update briefing January 2016
Executive Summary The emerging direction of travel from the first workshop to develop a Model of Care for East Merton is: 1. It’s not a Model of Care but a Model of Health & Wellbeing 2. The Model needs to be local and based on ‘natural communities’ as much as possible (the ‘Goldilocks Zone’ being between 20,000 and 50,000 population) – integrating prevention and self care into peoples lives where they live 3. It requires working with these natural communities to understand and map with them what they already have and what they already use 4. Then understanding with them what more they need within their natural community to improve their health and wellbeing and take greater responsibility for it – informed by emerging best practice from elsewhere 5. It then requires looking across health, social care, the voluntary sector, etc. to see what could be reorganised and deployed differently, to meet the needs expressed, within some shared features, practices and enablers 6. An assessment is then required of what can be done to achieve sufficient critical mass in each locality to keep the model economically sustainable - which means understanding what can be deployed locally and what may need to be shared across several localities (sometimes within a single hub and sometimes through a more virtual model) 7. Finally it requires the development of the organisational models to operationalise and incentivise the new arrangements There follows a summary of these emerging themes, and some high level descriptions of what this means health and wellbeing could look like, for testing and further discussion | 1
Contents 1. What the data says about East Merton 2. What the Design Group say it is like today 3. What the Design Group say it should be like 4. Emerging themes 5. Next Steps 3 15 June 2016
Summary – What the data says about East Merton East Merton has a profile of deprivation and complex care consistent with London. Shows signs Secondary health care inc. accident New cancer drugs and emergency, planned care, etc. of late diagnosis and a £1000’s Over Relative costs per person per day tendency towards Tertiary health care reliance over reliance on Screening programmes for cancer Intensive care secondary care intervention. Work by the Nuffield Trust and others suggests in these £100’s circumstances there Locally based Chronic disease management (self care through to good would be significant rehabilitation & reablement) Not benefit in moving to a Neonatal screening Enough more locally deployed £10’s Prevention and health improvement Well managed locally person centred and (smoking cessation, weight management, based end-of-life care integrated model of dealing with social isolation & loneliness, childhood immunisation, etc.) care rooted in £0 prevention, health improvement, self Low care and earlier lower High Relative health impact on a population cost interventions
What the Design Group say care is like today We have a population more like London than the rest of England with relatively high deprivation and ‘churn’ People die relatively young of preventable and Voluntary Other treatable conditions Sector Social Council There is insufficient Care Services focus on Older people, People, adults with long term No one understands all the Specialist Local System family & conditions, and Level Level needs of our community Level carers Other families with children especially for those that Health are hard to engage Services Specialist Care System Level People, family & Specialist Level Local Level – The wider system is carers We don’t work dysfunctional, reacts We don’t deploy too slowly, is not enough skills and together enough A paternal system and lack the skills that can be over aligned and too capacity round inflexible to meet our the clock locally and capacity to complex and at needs. How funding keep care local – so times dysfunctional to manage its become too flows, incentives work, preventable and where we don’t our culture and skills, deteriorating complex and makes take enough us all even more capacity and how it is conditions – so responsibility for deployed, how we too many people dependent than we our own health and exchange information, need to be we all don’t reach - go to hospital and communicate, engage when admitted out, prevent, and relate to each stay too long detect, and act other need to change early enough
What the Design Group say it should be like – A Model of Health & Wellbeing People can expect to: Social • Be supported to change Care Voluntary Sector unhealthy lifestyles Other • Receive care in their local Council People, Local Services family & area from a Local MDT with Team carers the GP and practice at it’s Specialists System Other core, supported by specialists Health Specialist Services Care when their situation or conditions become more complex to manage • Have a care plan that they or System Level Specialist Level People, family & their family / carers hold and Local Level We are working carers co-write Other ‘specialists’ together to deliver An enhanced and • Use technology to monitor meeting the remaining At the centre of a a series of system effective MDT (multi- changes in their condition needs whilst working proactive principles, enablers skilled & multi- • For a range of public sector with and supporting integrated system and features that agency) with GP and data to be used to help the MDT with meeting supported to support and help practice at its core identify if they may need the core needs of maintain health drive us towards supported to have the more proactive care keeping us and wellbeing greater integrated capacity, capability • If they have multiple &/or independent, avoiding through self help, ways of working and relationships to complex needs have a care unnecessary self care and, when be resilient and meet navigator / co-ordinator admission to hospital, needed, supported the core needs of • Have frailty identified and and getting us back to navigate to the local people to keep managed as a LTC home for enhanced right care to retain them independent as care when we are independence long as possible ready We are working closely and better with our communities People live and remain independent There will be more focus on families even the hard to engage groups longer by maintaining health and with children, adults with long term wellbeing conditions and older people |
By engaging and equipping ourselves to make better choices for our life, health Equity – Helping improve and wellbeing, so we know how to take all our lives through better care of ourselves and others Emerging Themes through all life’s stages and are fully dealing with the included and empowered determinants of ill health By creating Local Integrated Teams Environment – Helping (MDTs) that makes every contact count to Health, social, create physical and social improve the determinants of health, using environments that council and social prescribing, as well as managing our promote it core primary and social care needs voluntary services working together Behaviour – Promoting Providing intensive integrated care when with local people quality of life, healthy needed by adding the right experts to development and healthy enhance the local team for those at higher to improve health risk: behaviour across all life’s by: • Families with children stages • Adults with long term conditions • People with multiple conditions Prevention – helping reduce loneliness, Making urgent and emergency care part disability, injury, of the above so people only go to hospital preventable disease and when they need to for those things that can’t be managed locally and come home premature death as soon as they are well enough to be looked after by the local team A better start, a better life and better ageing |
Next Steps - to redeploy into 2 or 3 Geographic Groups ? GP Community Practices Community Health Health GP Practices Social Care Mental Acute Health Hospitals Social Care Council Voluntary Services Sector Mental Community Health Health GP Practices Acute Social Care Hospitals Mental Acute Health Hospitals Community Health Council Voluntary Services Sector GP Practices Social Care Mental Acute Health Hospitals Council Council Voluntary Services Sector Services Voluntary Sector Redeployed into 2 or 3 Natural Communities The Workforce of across East Merton (which Existing Organisations could include a consolidated site / hub at The Wilson) Requires the engagement of ‘natural communities’ with the staff of the existing organisations to answer the following questions… | 8
Recommend
More recommend
