GENERAL HOSPITAL

1. PAST HEALTH CARE SYSTEM Slide 1 PATIENT GENERAL HOSPITAL Residential home home A&E gatekeeper Nursing home Ambulance 999 Cottage hospital Mental health Rest of Acute Trust Services GP consultants critical care Medical Centre outpatients surgery ? Under who’s care Community nursing services Diagnostic’s Wards / bed discharge rehabilitation sub teams Local Authority Social Services Rehabilitation Team pharmacy Voluntary Sector opticians Home care packages

2. THE PAST Slide 2 • Scoop and run ambulances • Admit to assess need and treatment • Large uncontrolled demand which is unscheduled and urgent • Inappropriate use of A&E – patients with alcohol, drug and mental health issues which cannot be dealt within the hospital environment • Overcrowded, understaffed, under-resourced “casualty” departments • Trolleys • Sickest patients seen by most junior doctors • Patchy primary care • FRAGMENTATION

3. The Future Vision – 2008 HEALTH CARE SYSTEM Slide 3 Ambulance Trust General Hospital No A&E A&E 999 ECP NHS Direct Complex surgery Super GP Surgeries Community Hospital Urgent Care Unit Urgent Care Centres PATIENT HOME Minor Surgery W I C ESS EMS Diagnostic Tests Acute Alcohol Team MIC Outpatient Clinics PCC Rapid Response Team ECP Well Being Clinics Acute Substance Abuse Team I S T C Long Term Conditions Clinics Local Authority Low Vision Services Rehabilitation Team Voluntary Sector pharmacy opticians

4. KEY TO FUTURE VISION OF HEALTH AND SOCIAL CARE SYSTEM 2008 WIC Walk in Centres MIC Minor Injuries Centres ESS Emergency Social Services Team EMS Emergency Mental Health Team ECP Emergency Care Practitioner ISTC Independent Sector Treatment Centres PCC Primary Care Centre Slide 4 Patient self referral Practitioner referral Dashed box indicates service sits in community and is co-located with other services in one site. This depends on model adopted by PCT Increase in the type and access to urgent care services in the community Principle is to assess need before admission. Treat in the field nearer to home. Reflecting the closure in A&E Departments. More choice, easier to access, more convenient, improved quality of care, faster care. Services are centred around the patient.

5. THE SERVICE IN 2008 Slide 5 • PATIENT FOCUSED • Community centred • Care close to home – where possible • Simple access • “Seamless” pathways • High quality • CONTROLLED DEMAND, planned surgery and admission to Independent Treatment Centres or Super Sugeries • Offers choice • Encouraging all health partners to work together in a system-wide approach to developing urgent care services

6. Slide 6 The Future Vision 2008: Introduction of New Models of Service Delivery New Health Surgeries Increased investment into GP Practices giving rise to new Health Centres, Polyclinics, Super Surgeries, or Primary Care Centres. • 125 such centres to open by December 2006, outside general hospitals, by 2008 the total will be 750 units • Offering a wide range of services under one roof. The services provided will reflect the needs of the locality. This should be achieved through the PCT’s understanding the needs of their population through research evidence and consultation with service users about want they want.

7. Slide 7 • GP’s with specialist interests and Consultants e.g. ophthalmology, community nurse, district nurses, midwifery, dentistry, physiotherapy, pharmacy, optometry, podiatry. • Management of long term conditions such as Diabetes, Heart Disease, Elderly Care, Asthma, Well being clinics, Outpatient Clinics and wide range of diagnostic tests. • To facilitate this budget control has been transferred from national control to local level. • 5% of the NHS budget has been transferred from the Acute Trust (general hospital) to the PCT’s. This means PCT’s and GP hold the purse strings to commission or provide services, they deem appropriate.

8. Slide 8 New Community Hospitals Will offer patients wide range of access to health and social care which will be co-located on the same site. They will complement the specialist general hospital, providing speedy access to key medical tests, day case and outpatient surgery. They will be integrated with Social Service Departments. • providing care closer to home in six specialities – ear, nose and throat, trauma and orthopaedics, dermatology, urology,  gynaecology and general surgery. • £700 million into new buildings through NHS LIFT, by the end of 2005, 54 new buildings were opened and in 2006, a new LIFT building is expected to open every week. • Purpose-built facilities, where GP services are on the same site as pharmacies and social services, The centres are more convenient for patients, particularly older patients and those with long-term conditions, as they offer more care closer to home. some models of community hospitals will provide Urgent Care Units

9. Examples of Community Hospital Developments Slide 9 Reference to CISP, 2006 Developing Community – Hospitals – Models of ownership [1] pdf, gives cases of community developments of hospitals. Recommended referencing to the Funding Team as it explains how voluntary organisations can fund services from the NHS.

10. Slide 10 • Services which may be provided in Community Hospitals • Long term conditions Clinics • a resource Base for management of LTC with Specialist GP interest and Consultants for chronic disease management in the community. • Older people • Multidisciplinary Assessment Centre, for falls / mobility and complex needs. Integrating intermediate, social, urgent care and mental health. • step- up / down intermediate care • In / out patient clinics for comprehensive assessment for long term packages of care. • Children and Young Peoples Centres • Focusing on the Family and preventive health. Based on integrated and co-ordinated care across wide selection of agencies. Plan is for 3,500 Children’s Centres by 2010.

11. Service which may be provided in Community Hospitals • Self Care and Self Management • The following facilities will be provided to enable self care of own health • Education Rooms for Action on Personal Health • terminals for personalised support packages for lifestyle changes, • rooms to meet with health trainers and personal advisors • gym equipment, yoga, dance, drama and music facilities • kitchen facilities for cooking and learning new skills • Facilities fpr Self Assessment • enabling an individual to complete own health check • enable to check own blood testing, borrow, learn and use self testing equipment. • Facilities for Information Encompassing • provision of both general and local information • enabling individuals to obtain help and learn how to access it and how to personalise it. • Sign posting Slide 11

12. Service which may be provided in Community Hospitals Mental Health Facilities The principles of Self care and self management extends to Mental Health Services. Priorities focus on the development of community Well-being Resource Centres providing services and access to agencies in community locations e.g. Employment Advisers • increased uptake of Direct Payments and advance directives, will enable service users to receive services in more local facilities • more culturally specific services, contact points and information services and • better use of community facilities to provide information signposting on mental health and mental health services. Our health, our care, our community: investing in the future of community hospitals and services, 2006) p 40 Slide 12

13. Slide 13 Super surgeries The NHS Plan (2000) describes a vision of the new GP surgery as, “ many of the GP’s will be working in teams from modern multi-purpose premises along side nurses, pharmacists, dentists, therapists, midwives and social care staff. Nurses will have new opportunities and some GP’s will tend to specialises in treating different conditions. An increasing number of consultants will take outpatient sessions in local primary care centres.” PCT’s are being encouraged to set up one-stop health centres which bring services, such as GP. Health visitors, dentists, pharmacy, a cardiology clinic, x ray facilities, optometry services, Sure Start and healthy living café under one roof. Work on about 50 centres is underway. (The NHS in the UK 2006/07)

14. An acute hospital admission is a failure of the Health System. The real challenge to the NHS is how to manage chronic disease better Slide 14

15. Slide 15 URGENT CARE is all unscheduled, urgent and emergency care, i.e. anything which is not a programmed activity Current Admissions - 70% elderly, Majority with long term conditions of which 50% are unnecessary. • The 20% of Patients who need 80% of the Care • `Older People • Decreased Functional Ability • Mobility, sight loss, daily living skills • Revolving Door Admissions • COPD & Heart Failure • End of Life • Psychological & Social Support • Packages of care tailored to the individual

16. Slide 16 Urgent care Services Our health, our care, our community: investing in the future of community hospitals and services, 2006) p 40 states, • Community Hospitals have a future major role in Urgent and Unscheduled care. • It anticipates an increase in this type of provision which will be set out in future government Urgent Care Strategy. • Minor injury units (MIU) and NHS Walk in Centres (WIVs) are providing much urgent / unscheduled care in the community. • A network of Urgent Care Centres are planned which will be nurse led and co-located with out of hours GP’s, emergency social services team and emergency mental health teams, ambulance base with Emergency Care Practitioners (ECP) • Central will be Diagnostic Facilities, X-Rays for example will prevent unnecessary attendances to acute general hospitals. • Urgent Care Centre will additionally act ( in some models of practice) as a resource for management of chronic disease.

17. Slide 17 • The Urgent Care Strategy • The new focal point for integrated unscheduled/ urgent care • URGENT CARE PLUS • The link to Long Term Conditions (LTC) • Base for community matrons • LTC diagnostics • LTC review clinics

18. our health, our care, our community: investigating in the future of community hospitals andservices (DOH, 2006) Slide 18 • A new generation of community hospitals and services • The White paper defines what a “community hospitals and services” are as covering the following • • The broad range of services that are sited in defined local • communities with small populations rising to about • 100,000 • Any clinical or social care functions that can be provided safely • and appropriately away from large specialist centres and those • services and functions that benefit from close links to other local • services, for example intermediate care services aimed at enabling an • older person to regain independence in their own home . • Will not undertake complex surgery requiring general anaesthetic nor • provide fully fledged accident and emergency. • It means that some larger hospitals will concentrate on specialist • services and some will merge or close

19. Individual and Community Oriented Preventative Action for Health Slide 19 Individually oriented preventative action Health Hazards Environmental hazards Community oriented preventative action poor education poor food & nutrition unemployment poor housing poverty Intersectoral action for Health. WHO. 1986

20. Delivering Choosing Health (DOH 2004) Slide 20 Key messages: • Making healthy choices easychoices • Interventions for the disadvantaged • Health policy to inform and support Principles: • Informed choice • Personalisation: supporting people to make healthy choices, especially deprived groups and communities • Working together through effective Choosing Health’ priorities • Reducing health inequalities • Reducing smoking, obesity, alcohol consumption, • Tacking hypertension, poor dietary intakes, lack of exercise, • Improving mental health and well being

21. Slide 21

22. Slide 22 Level 3 Patients with highly complex needs and co-morbidities Case management Disease management & equally shared care Level 2 High risk patients Level 1 Largely self care 70-80% population

23. Future Health Care Trends – an overview • There are many powerful forces for change in our population’s health and the way we deliver health care. • The population is ageing. The balance between young and old is shifting. Life expectancy is increasing, as premature mortality rates fall. The average family size of 1.77 (2004) sits below the replacement level of 2.1. The number of single person and single parent households is growing. The number over 60 are expected to grow by nearly a third by 2021, while the numbers of young people under 16 will fall. The ethnic population is also ageing. However, there is significant uncertainty about the net impact of the ageing population on health care demand.

24. The workforce is changing and ageing. The national and international competition for skilled staff will grow. The workforce is demanding a better work/life balance. • Current lifestyles present major risks to the future health of the population. Obesity, sedentary lifestyles, sexually transmitted disease, and alcohol consumption are growing, especially amongst the young. This is driving increased incidence in diabetes, osteoarthritis, heart disease and kidney disease. Over a quarter of the population still smoke. This creates a significant burden of respiratory disease and cancer. • Health inequalities continue to present a challenge. People from lower socio-economic groups are much more likely to adopt risk taking lifestyles and yet are frequently handicapped in accessing health services and taking on board positive health messages - 40% of those from social classes D&E have poor literacy skills.

25. The disease profile is changing. Previously fatal acute conditions such as cancer and heart disease can now be treated. Ageing related and chronic diseases, such as diabetes, respiratory illness, renal disease and arthritis, are becoming much more significant. More people are living with long term illness, and with multiple conditions. • Medical advance can improve health outcomes, but will create budgetary pressures. Significant advances in medicine and surgery are anticipated, supported by the increasing insight offered by genetics. The “capacity to treat” is increasing, especially the older frail. This magnifies the potential demand of an ageing population. • The expectations of society are changing. Rising education and income levels are helping to drive higher public expectations of health and health care services. The future old are expected to be much more demanding than their current counterparts.

26. Advances in information technologies enable improved models of care. The capacity to share clinical information and expertise between professionals and patients offer many opportunities for patients to take a positive and active role in their care and improve the quality of patient care and outcomes. • These forces bring threats and opportunities to the health of the population and health care services. The impact on health care demand and our capacity to meet that demand is very difficult to foretell. • There is significant debate about the impact of an ageing population. The incidence of chronic disease grows markedly in those over 60, but there is also evidence that the old of today are fitter than the old twenty years ago, postponing the onset of chronic disease. As chronic conditions are diagnosed earlier, treatment is likely to be more effective. One of the greatest uncertainties is that of the impact of current lifestyles on the population over the next two decades. Will the young of tomorrow have even greater levels of obesity, sexually transmitted disease and drug misuse than the young of today, and will the old be sicker and more dependent? A lot will depend on society’s attitude and response to risk taking behaviours. We have the opportunity to live longer and healthier lives than ever. Will society grasp that opportunity, or will we see health inequalities increase as some do and some don’t, or perhaps can’t.

27. Large growth in the number of older people – what will be the impact on total health care costs? Per capita costs are greater for older people • Starting from 2006, the post-war baby boom will boost the year-on-year growth rates in the elderly populations, with growth rates peaking in 2012. • The number of people over 65 is expected to grow by • 527,000 - 2010 • 1,619,000 – 2015 • 2,390,000 - 2020 Hospital and community health service expenditure by age of recipient (£ per head, 2002/03) Source: DH

28. An increased capacity to treat and reduced age discrimination are raising intervention rates in older people Demographics and Medical Demand (% increase, 1990-2000) (1) • Coronary Artery Bypass Grafts • Source: DH, ONS

29. New technologies offer a means to bridging the care gap New technologies enable a different relationship with older service users • Social Care is developing a number of new care models • Extra care housing • Homeshare • Adult placement • Technology-enabled services • Connected care centres

31. The Planning FrameworkIt outlines four objectives for the future NHS

32. Our health, our care, our say People want to keep themselves well, and take control of their own health. They wanted more help through: • Better information • Advice • Support