Critical Interfaces within the Project Luton NHS tPCT

1. Critical Interfaces within the Project Luton NHS tPCT

2. What we’ve achieved in Luton • The team • Caseloads • Training and education • Funding from WDC • Links & modernisation • Patient database in place • Retrieval of data

3. What we know about our patients? • 3% of >65’s make up 47% of total emergency admits

4. Key challenges faced in Luton • Pace • Funding • Data capture • Building key relationships • Limited resources

5. Key intervention – GP Practices Practice staff GP’s Practice Nurse Advanced Primary Nurse Receptionists District Nurse Practice Manager

6. What we did….

7. Ups and Downs • How they reacted • How we felt

8. Process (The Sell) • Collaborative meetings • 1-2-1 meetings • Lead Nurse involvement • Feedback • Action Learning • Celebrating Success Conference • Gave it some time

9. How are we getting on • Joint visits • The system works!!!! • referrals to APN from GP • referrals to DN from APN • messages being passed on • Smiles • Invite to xmas party!!!

10. Other Key Primary Care Interfaces Social services • Home care on prescription • training Out of hours • Patient identification • Communications

11. Primary Care Contractors Treatment Centre Walk in Centre Evercare Learning & Research

12. Evercare Model The Future of the Workforce • P2 • Autonomy • Patient Choice • Nurse Led Services • Training & Development Referral & monitoring Referral & Rehab. Walk In Centre Luton Treatment Centre Referral & diagnosis

13. 3 Dimensional Integration Self-referral and primary care referral Drop-in with some booked group sessions Acute & minor injury & ailments Walk in Centre Mainly 1:1 Single encounter Nurse-led Nurse-led Treatment Centre Self-referral and primary & secondary care Long-term case management Mainly booked appointments Multi-disciplinary assessment Chronic disease Short/long term Prevention & management of chronic conditions Term approach Evercare 1:1 and with carers/families Case management: anticipatory care Primary and secondary care

14. GP Modern Practice Underpinned/Enabled by Education APN/P PN/P Trained, Skilled Staff “High Level Practice” Cadet Scheme Skills Escalator

15. What we learned • Role definition & clarity • How people react to change • Don’t avoid difficult situations • Don’t underestimate how difficult this is for all involved • It takes time – well 8 months!!! • Humour can be powerful