NHSScotland Event 2015 LEADING INTEGRATION FOR QUALITY B:1 Think Different – Creating a New Model...
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Transcript of NHSScotland Event 2015 LEADING INTEGRATION FOR QUALITY B:1 Think Different – Creating a New Model...
NHSScotland Event 2015 LEADING INTEGRATION FOR QUALITY
B:1 Think Different – Creating a New Model for Primary Care
Think Different
“We must constantly look at things in a different way. Just when you think you know something,
you must look at it in a different way. Even though it may seem silly or wrong, you must try.
Dare to strike out and find new ground”
Think Different
“To the crazy ones. Here’s to the misfits. The rebels. The troublemakers. The people who see
the world differently”
Think Different
“The people who are crazy enough to believe they can change the world are the
ones that actually do”
General practice : bottom up approach
Enabling practices to look at their local population demographics and explore new ways of working to
promote health and wellbeing
GP Leadership time
QOF 50 points : Access and Quality
National support for Local connections
Scottish Government : Primary Care Division support• David Thomson• Dr Tricia Donald• Dr Gregor Smith• Frank McGregor• Lynda Nicholson• Lorna Hall• Jan Beattie
Key Focus
• Vulnerable Families • Multiple Conditions in over 45‘s
with the GP practice as the "hub" and utilising the asset approach to health inequalities
informed by research from the Deep End and Prof Stewart Mercer on Multi morbidities
• Release time to be creative and innovative• Empower practice• Test out interventions• Make community connections• Tell the stories• Measure impact• What could be sustainable or scalable ?• No detriment to practice or patient
Ideas being developed
• Targeted Consultations• Extended Patient Records : social and behavioural
determinants of health
• Connecting to communities : asset mapping
• Access to meet the Individuals Needs
• Social prescribing• Collaborations eg Public Health , Social Enterprise, Nursing,
Voluntary organisations , Social Care, Cycling
• Transient Populations / Travellers• Frail Elderly
OutcomesGolden nuggets and silver threads
• Building relationships
• Encouraging self management for patients
• Improving access
• Better communication / extended
teamworking
• Developing code set for social and
behavioural determinants of health
• Improving morale!
Headroom
• Transformation• Person Centred• Health Inequalities• Social Prescribing• Integration• Collaboration Therapeutic Relationships
Headroom EastEdinburgh
Total Place
Transformation of Health Care SystemSocial PrescribingPerson Centred CareHealth InequalitiesCollaborationIntegration
Focus onVulnerableHealth Inequalities
Mainstream Public Services
Community Assets
CommunityConversation
Housing
SocialIsolationLibraries
Public Service Usage including NHS Lothian
Social Prescribing
NUKA
MentalHealth
InteragencyEngagementIntegrationCollaboration
RelationshipsConversations Consultations
House of Care
Headroom
Third Horizon
The First Horizon• Established valued silo, major capacity issuesThe Second Horizon• Engagement of professionals and community in change
HeadroomThe Third Horizon• Established Health and Social Care Integration • Balanced medical & social model of health• Truly person centred: Rights & Resonsibilities
“If the choice is between a society that generates illness and then thrives on therapy to put it right, or a society that generates health through social capital and social responsibility, the answer is a no-brainer.”
2009 Brandling and House BJGP
Areas of Exploration
• Respiratory Choir• Social isolation/Loneliness• Good Conversations• Frequent attenders • Teenage Health/GIRFEC• End of life care for patients with COPD• Pregnant women with high BMI presenting with little
English• Chronic pain & Opiate prescription
• Team• Obesity• Depression• Nuka
• Large Group work ST1’s• Quality Improvement Activities & Group Work• Agenda Setting in GP training• GP Trainers: Small and Large Group work
GP Education
“You depend on each other at every phase, teams within teams, scrums, lineouts, ruck ball, tackles.
….So it is an awesome task you have, it will only be done if everyone commits themselves now…”
Telfer 1997
Which relationships matter?
Headroom EastEdinburgh
Total Place
Transformation of Health Care SystemSocial PrescribingPerson Centred CareHealth InequalitiesCollaborationIntegration
Focus onVulnerableHealth Inequalities
Mainstream Public Services
Community Assets
CommunityConversation
Housing
SocialIsolationLibraries
Public Service Usage including NHS Lothian
Social Prescribing
NUKA
MentalHealth
InteragencyEngagementIntegrationCollaboration
RelationshipsConversations Consultations
House of Care
Headroom
Headroom Achievements
• Empowerment of Teams• Building Relationships• Good Conversations• Commitment to Community• Education• Leadership: Bottom Up!• Alignment/Values• Scottish Government
Headroom Themes
• Transformation
• Person Centred
• Health Inequalities
• Social Prescribing
• Integration
• Collaboration
Therapeutic Relationships
The Govan SHIP Project(Social & Health Integrated Partnership)
Dr John Montgomery, GPThe David Elder Practice, Govan
GPsDistrict Nurses
Health Visitors
Social Work
Rehabilitation
Links Workers
Acute Hospital Consultants
MidwiferyMental Health
Multidisciplinary Teams
Aims and Objectives• Communication• Person Centred• Anticipatory and preventative approach• Crisis Hospital Admission• Unscheduled Care