NHS 5YFV Vanguards-Dr Chris Jones presentation
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Transcript of NHS 5YFV Vanguards-Dr Chris Jones presentation
West Wakefield Health & WellbeingMCP Vanguard
Dr Chris Jones, GP Chair, Programme DirectorThe Five Year Foreward View
Sharing Best Practice
Open Forum Event ManchesterDec 9th 2015
@westwakefield www.westwakefieldhealthandwellbeing.nhs.uk
@westwakefield www.westwakefieldhealthandwellbeing.nhs.uk
Contents
1. Background and context2. Rationale for change3. The model of care4. Some tangible changes5. Challenges
@westwakefield www.westwakefieldhealthandwellbeing.nhs.uk
Networks 3,5 and 6• 17 Practices• 152,000 patients
1. West Wakefield’s 3 networks
1. Local health profile
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
High mortality rate high for cardiovascular, respiratory disease and cancer in under 75’s
High rate of tooth decay in 5 year olds
19.6% of children in year 6 are obese
High rates of teenage pregnancy, alcohol related admissions, road injuries and deaths.
Low rates of breast feeding and high rates of smoking in pregnancy.
Wakefield 2015 Health Profile
2. Rationale for change
NATIONAL• Demographic changes - Ageing population, increasing burden of LTC• Pressures on primary care
LOCAL• Meeting the Challenge: Bed reductions• Pressures on A&E attendances• Workforce challenges: GP and nursing• HealthWatch Young Persons Survey on GP access
So immediate pressures on hospital services which will worsen, with access difficulties and a workforce in crisis lead to the creation of three hypotheses…
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
2. The Hypotheses
50% of work done by GPs could be carried out by a more cost effective resource
30% of elderly people admitted to hospital acutely for a short stay of between 0 and 5 days do not need to be
admitted and could be cared for differently in an alternative setting
30% of patients occupying an acute hospital bed do not need to be there because their episode of acute care is over
We have devised 90 logic models with which to evaluate the programme and test these hypotheses.
The new model of care must also achieve the three objectives of the Triple Aim.
Lower CostBetter patient experienceImproved outcomes
THE TRIPLE AIM
Disruptive Prevention Self Care Care
NavigationImproved
AccessSupport at
HomeAdmissions Avoidance
Early Supported discharge
Schools App Challenge
Oral Health• Fluoride Varnish• Flouridation• Joint consent
Childhood Obesity
Mental Health
Digital• Service Directory• Symptom Checkers• App Library• Big White Wall
Patient Education
Expert PatientsCare PlanningSocial PrescribingMicro-commissioning
Care Navigators• Phone, Email,
Chat, Web• ‘Apple Store’
Kiosks
Care Navigation App
7-day service
Physiotherapy FirstPharmacy FirstPharmacist in GPSocial WorkerMental Health WorkerTriageVideo ConsultationsE-Messaging
Shared visiting service
Care Home ProjectHealthPod
Integrated Multi-Professional Community Teams inc Nursing, Carers and VCS
Information Hub
Proactive Care
Primary Care Champions Consultants in the Community: Elderly, Cardiology, Respiratory, Mental Health
Intermediate Tier Beds in CommunityIntensive Home-Based TherapyFor physical and mental health
Connected Home
Prime Minister’s Challenge on GP Access Connecting Care
3. The model of care
Shared records: Citizen-held care record
“Through expanded primary care, proactive teamwork and new technology to deliver health and social care at scale to the GP registered list of West Wakefield”
Working with Wakefield CCG and building on the Prime Minister’s Challenge to generate primary care workforce engagement as a key catalyst for lasting change.
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
The Vision
GP
Admissions avoidance
Early Supported Discharge
Call Centre
Central HubWaterton House
ConnectedHome
Assistive Technology
ImprovedAccess
Integrated Teams
Video, E-messaging
HealthPod
Extended Hours
Care Homes
Consultants
Citizen-held care record
Care Navigation
Digital self-care
Social PrescribingUnified Communications
Federation & Collaboration
Pharmacy First
Physio First
Nursing United Carers Framework
Provider Alliance: MYT, SWYPFT, WMDC, WDH, Nova (all VCS), Age UK, YAS (111,999), LCD, Spectrum
Integrated Teams
C3 Ops Centre
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
4. Integrated MDT
Elderly Care Consultant
Respiratory Consultant
Community Psychiatrist
VCS
Specialist Nursing Teams
Therapists
Social Worker
Community Matron
Community NurseCommunity Mental
Health Nurse
Care Navigator PharmacistHub Manager
Community Cardiologist
Hub Clinical Lead
Practice Nurse GPAcknowledgement for images: Lesley Carver NHS NW Surrey CCG
Co-located
Shared mission
Shared culture
Shared records Mutual trust
Authority to act
Daily virtual meeting
Proactive approach
Information Hub Access 24/7
Tactical TeamsGenerates Care Package
Strategic View
Health Visitor
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
4. Information HubGP System Notifications
GP System Population Data
Ambulance Service
A&E Metrics & Notifications
Hospital Admissions
Hospital In-patient Status
Community Notifications
Met Office
Local Authority Records
Mental Health RecordsPublic Health Statistics
Police Comms Link
Housing Comms Link
Fire Comms Link
Smart Home Notifications
Informs the Integrated MDT
4. Citizen-held care record
• Owned by the individual, cloud based
• Fully sharable
• Health and well-being information, LTC management, care plans, social
network, social care package data, EOL planning etc.
• Complementary to NHS record
• Several example in development– Patient Knows Best
– Leeds Care Record
– Kirklees Self care Hub
– Vitality/Digital life Sciences
– eRed Book
– Vitrucare
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
• Growing array of monitoring and wearable tech
• Develop the smart home concept
• Start with social housing stock – all have broadband
• Already wide array used in Wakefield
• Make people feel connected, safe and looked after
• Detect signs of illness. Raise alerts
4. Connected Home
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
4. Extended Hours
• 6.30pm – 8.00pm Weekdays,
• 8am – 8pm Weekends
• Routine & Urgent appointments
• Routine booked during normal hours
• Urgent from 111 as ITK message into SystmOne
• Staffed by internal personnel
• Run from dedicated premises inside high quality new build Health Village
• Augmented by the 24/7 digital access solutions
NEXT STEPS
Create consistent service across three networks to cover full population of 152,000 with consistent offer
Consider hours of operation Broaden skill mix
4. Extended Primary Care Team• Physiotherapy First
• Pharmacy First
• Heath & Wellbeing Worker
• Care Navigators
• Health Champions
NEXT STEPS
Pharmacist in General Practice Mental Health worker Community Consultants Social Worker Primary care
020406080
100120140
Physio First Contacts
Viral cough No cough
Fever without
viral symp-toms
Sore throat
HayfeverAllergy symp-toms (skin)
Insect bite/sting
Oral thrush
Vaginal thrush
Teething
Cold sore
Headache/mi-
graineThreadwormsOther
4. Pharmacist in General Practice
• 0.5 Session per 1,000 patients
• Post-discharge medication reconciliation
• Medication reviews, reduction in polypharmacy
• Minor ailments advice
• Interface with community and hospital pharmacists & CCG MO team
• Management of repeat prescribing process and formularies
• Implement MRHA guidance, safety alerts and changes in indications and availability
• Medicines advice to whole team
4. HealthPod
• Out reach• Hard to reach• Menu of services
– CAB– Housing– Carers Wakefield– Age UK– Youth groups– Mental health worker– Sexual health outreach– and more…
• Own Twitter account• Tracking app
4. Care Navigation
• Care Navigators• Training Course devised• Over 70 trained• Supported by primary care health champions• Using Service Directory and other on-line tools
4. Care Navigation App
• Web-based decision tree
• Public access
4. Service Directory
4. Kiosks
• Care Navigation App & web site
• Kiosks in Reception
• Part of West Wakefield web site
• Service Directory
• Real-time signposting to resources
• App Library
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
4. Schools App Challenge
• Year 6
• Design a health and wellbeing app
• Think about healthy living and own family and friends
• Strong prevention messaging
• Supported by Microsoft– Touch develop
– Mentors by Skype
• Teamwork, coding, presentation skills
• Dragon’s Den style judging
• Engagement with Schools
NEXT STEPS
Roll out to wider population Version 2.0 Lessons learned Sponsorship
Team Friendship Forever (Dragon in the Attic)
4. Dragon in the Attic
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
5. Challenges
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
• Workforce
• Technical Infrastructure
• Estates
• Provider Management
• Delivering at Pace
• CCG Governance
• Local Engagement
MCP
Network 3
Network 5
West Wakefield
MYT
Nova
CCG(partner)
WDHSWFPFT
Spectrum
Age UK
YAS
Fire & Rescue
Local Authority
HOST
• Shared accountability• Hosted by West Wakefield – contract holder• Chaired by CJ• Supported by JJ• CCG as invited attendee, not present for
commercial/sensitive provider discussions
What about other providers?
To develop:
• MoU/Business Rules• Terms of Reference
6. Accountability Model
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
MCP
NHS England
Connecting Care Executive (Commissioning)Adults, Children & Young People
Vanguard Subcommitte
e
CC Health & Social Care Partnership
Operational Commissioning
Group
Wakefield CCGWakefield District
Health and Wellbeing Board
Wakefield Council/Cabinet
6. Governance model
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
7. Milestones
@westwakefield www.westwakefieldhealthandwellbeing.org.uk
• Hub Manager in place 12/12/15
• Mental Health Worker roles embedded in Hub 11/01/16
• CrossLead Senior leadership event 21/01/16
• Schools App v2 Judging 28/01/16
• HealthPod 2 operational 01/02/16
• Community Consultants in Hub 15/2/16
• Information Hub IOC and SOP established 18/01/16, Full
07/03/16