Beverly Ingram- Head of Primary Care Applying a Whole Systems Approach to Care

1. Beverly Ingram- Head of Primary Care Applying a Whole Systems Approach to Care Dudley Beacon & Castle Primary Care trust Heading in the right direction

2. Applying a Whole Systems Approach to Care ‘ ’ Partnerships and Integration “As a Catalyst for Change” Rising to the Challenge Heading in the right direction

3. Applying a Whole Systems Approach to Care ‘ ’ • Examples of our effective Model of Care • Rapid Care Key workers • Primary Care Clinical Leadership • Integrated Pathways • New Skills = New Services • New Teams • So Who Benefits? Heading in the right direction

4. The ‘Kaiser Pyramid’ Incorporating the Dudley Beacon & Castle Model of Care LEVEL 3A HIGHLY COMPLEX PAITENTS WHO ARE THE TOP 100 RETURNERS INTO HOSPITAL Nurse Consultant + Community Matrons 100 TOP RETURNERS LEVEL 3 HIGHLY COMPLEX PATIENTS WHO MAY NOT HAVE BEEN ADMITTED TO HOSPITAL Case Managers x 9 Comprehensive PREVENTION FOR ALL CASE MANAGEMENT SPECIALIST DISEASE MANAGEMENT LEVEL 2 HIGH- RISK PATIENTS Rapid Care Teams/ Key workers Specific Disease Management Pathways Team GP Primary Care Teams Specialist & Overview SUPPORTED CARE AND SELF CARE LEVEL 1 MOST PATIENTS Expert Patients Contact Screen & overview Heading in the right direction

5. ‘ Applying a Whole Systems Approach to Care ’ The Story So Far… • Successes • Clinical Engagement • Influence local policy • Apply a practical approach to service design & redesign systems • Better local evidence • Simple IT solutions • Flourishing patient centred best practice • New relationships Heading in the right direction

6. ‘ Applying a Whole Systems Approach to Care ’ The Story So Far… • Challenges • Managing demand in the context of key national targets • Really listening to perceptions, ideas & experience • Mapping the patients journey / fill the gaps • Reducing ‘Inequalities’ (health & resource) • Influencing the commissioning processes • Embedding new ways of working Heading in the right direction

7. ‘ Applying a Whole Systems Approach to Care ’ Supporting Independence but Recognising Interdependence ? The Million Pound Question “ How did we design a Model of Care which delivered better patient care and made us ALL excited?” Heading in the right direction

8. ‘ Applying a Whole Systems Approach to Care ’ • ‘Our Principle’ • Care Closer to Home • ‘Our Safe Guard’ • Clinical Governance Framework + Process • ‘Our Backbone’ • Clinical engagement, training & development, Workforce • ‘Our Evidence’ • Data collection & patient stories We Never Gave Up!!

9. ‘ Applying a Whole Systems Approach to Care ’ The Impact Heading in the right direction