Better care, closer to home

1. Better care, closer to home Our strategy for high quality care Draft document March, 2012

2. Introduction by Nicola Burbidge, Hounslow CCG Chair • There are reasons that care in Hounslow needs to change As the Chair of Hounslow CCG I am committing to commissioning and delivering an out of hospital service that gives patients and our clinical colleagues confidence that care at home and in primary care will be high quality and responsive. At the moment variable quality of primary care services and poor co-ordination between services mean that more people end up in hospital than need to, or should do. • We have a clear vision for the future where things are differentWe are committed to a continuous drive to improve performance and access in primary care and reduce inappropriate variation. We will ensure high quality elective care and well understood planned care pathways with minimal numbers of attendances at secondary care to reduce the time patients have to take from their daily lives. Telephone first will be the norm: patients will know that this is the best way to good signposting to an efficient and seamless service. Patients will received coordinated care from all services with a single, detailed care plan. • We are taking action to make this vision realOur integrated community response service is helping patients get home quicker and avoid unnecessary hospital admission. The UCC is allowing A&E to focus on emergencies and we are improving primary care through our referral facilitation service and mentoring cells. IT in Hounslow connects services well and gives us solid ground to build on. We also have specific plans to make things better in the future. One focus will be better performance management, increased transparency and master classes on providing primary care to meet modern demands. Another is expanding our care at home services through a joined up rehabilitation and reablement team and Ambulatory Care in the Community. Third, we will identify patients using different medical and social services and give them and their carers the opportunity to develop care plans with clinicians, which will be used by all services they use. • But we recognise that we need to coordinate care betterOur integrated community response service provides a local example of successful multidisciplinary care but in other areas coordination of services negatively affects patients. Care for long term conditions is too reactive, there is a lack of communication between GPs, community services and social services and there is a lack of coordination in care after discharge. To address this we are making IT compatible across services, creating a single point of access for health and social care, which will direct patients to the right service first time, and developing a new role for care navigators to stop patients getting lost in the system. Six multi-disciplinary groups covering the whole of Hounslow will increase the coordination of care and build links between professionals. In each of the six groups, a GP locality lead will be able to champion collaboration, and challenge and support different services, based on being able to see what is being done and with what results by each. • We will put in place the things needed to make this happenFor our plans to be effective we will need to engage with patients and carers more systematically. To work together better we will have to develop our own behaviours and attitudes. Providing opportunities to develop and managing performance will be key. We already have the base of joined up IT system, but this needs to go further so that it connects all services and we make full use of its potential. We are confident that we can get these things right and improve care for Hounslow residents.

3. We have a clear vision for how OOH care will look in the future • The out of hospital strategy is about multi-professional staff working together to deliver quality primary, intermediate and social care and managing long term conditions out of hospital in the most cost effective way • GWCCG wants secondary care consultants supporting general practice and working together to ensure effective joined up case management that provides quality of care and value for money and reduces duplication SOURCE: GWCC Commissioning Strategy 2012/13 – 2014/15

4. A joined a system of care… 1 Patient has easy accessto high quality, responsive primary care A single point of access means patients go directly to the most appropriate service Planned care 2 4 Health and social care teams 2 Simplified planned care pathwaysto enable local/self management General practice 1 Acute hospital at home care 3 Rapid response to urgent needssign posting patients to the best service 3 5 4 Providers working togetherto effectively manage theelderlyand LTCsout-of-hospital so patients feel secure and receive seamless care Urgent care Hospital Care 5 Appropriate time in hospitalwhen admitted, withtimely supporteddischargeto well supported community care Our vision is that all care will be planned care

5. This will mean delivering across 5 key areas Easy access to high quality, responsiveprimary care through continuous drive to improve performance and access and reduce inappropriate variation led by education and peer pressure with performance management when necessary. To seek to develop Heston Health Centre and a primary care facility on the WMUH site. High quality elective care and well understood planned care pathwayswithminimal numbers of attendances at secondary care to reduce the time patients have to take from their daily lives, detailed care and management plans sent to GPs and patients to enable local/self management. Rapid response to urgent needsso that fewer patients need to access hospital emergency care. Telephone first – patients to know that this is the best way to good signposting to an efficient and seamless service. Patient education on how to get best value from their NHS. Palliative care to move to an elective service. Providers (social and health) working together,with the patient at the centre to proactively manageLTCs, the elderly and end of lifecareout-of hospital., resulting in patients feeling secure in referral into an effective and safe partnership between the community providers, social services with support from their GPs or hospital consultant. Appropriate time in hospitalwhen admitted, withearly supported dischargeinto well organised community care SOURCE: GWCCG Commissioning Strategy 2012/13 – 2014/15

6. Claire uncertain what best course of action is and who to contact Stressful and time consuming process for Claire to find a solution A&E staff feel overwhelmed by flow of unscheduled patients Claire grateful for treatment and idea of A&E as place to get care is reinforced Easy access to high quality, responsive primary care A Claire is 36. She is a working mother who struggles to manage her work and home life. She has a young son, Jason who is 4 years old and has a fever. Primary care has been difficult for some patients to access, putting pressure on other parts of the health system… Treatment is transactional. Jason misses out on opportunity for broader child welfare e.g., staff do not make sure jabs up to date, check Claire is coping Claire comes home form work at 6pm to find her son has come back from nursery with a fever Claire rings her GP but cannot get through. After several attempts decides to take Jason to her local A&E A&E is crowded and there is long wait. The conditions are stressful and Jason’s condition worsens. In future, patients will have better access to primary care and know how to get it . . . Claire comes home form work at 6pm to find her son has come back from nursery with a fever and calls 111 She is given an appointment for 8,30pm at the Urgent Care Centre to see a GP GP sees her son and has access to child's (and family's) health record, they check child over, look for rash and send home. They send record of attendance to Claire’s own GP If it was something more serious (e.g. rash with query meningitis, then the GP could have given a injection of penicillin before sending on to paeds unit) Claire understands that 111 can direct her to the most appropriate care She is relieved and reassured, feeling confidence in the system Claire is reassured and feels confident to see episode through Record is taken of the event and communicated to the family’s GP via SystmOne

7. Paul still does not understand what his treatment options are Paul has to take time off work to attend Paul does not have his results with him and his GP is unable to give further advice Clearly understood planned care pathways that ensure out of hospital care is not delivered in a hospital setting B Paul is 43. He is in good health but has been experiencing severe discomfort in his knee following a recent bout of exercise Sometimes the pathway to receive planned care is complex and disjointed… After 2 weeks Paul is called in for a follow up appointment and receives 2nd scan and is advised he needs a hospital appointment Paul meets with his GP who is unsure of best treatment options and lacks equipment to diagnose 2 weeks later Paul has not received a followup and returns to GP for further advice Paul is referred to an OP clinic for a scan In future, the pathway with be simpler, understood by all clinicians and joined up. . . MSK specialist physio carries out assessment, including a scan at the diagnostic clinic and books Paul a hospital admission and discharge date. Treatment is recorded in GP records via SystmOne. Paul goes to hospital 2 weeks later for operation. He has a brief stay on the ward and is discharged with a rehab plan On arriving home receives an email from the hospital explaining plans for rehab and treatment plan is recorded in GP records via SystmOne Paul meets with GP who discusses options and shares information about treatment and impact. Books patient for MSK assessment with community services Paul feels immediate progress is being made and information is efficiently passed between GP and consultant Paul is reassured by the structured approach His GP is able to check in on Paul’s progress with rehab

8. Hospital nurse are not sure how to deal with him, causing them stress Ethan becomes more dependent on care and regaining independence is unlikely Rapid response to urgent needs so that fewer patients need to access hospital emergency care C Ethan is 84. He lives alone and usually stable Parkinson’s disease and walks with a stick. Recently he has developed an urinary tract infection which has led to him becoming confused Urgent care has been stressful when patients need support . . . While struggling, Ethan rolls out of bed and severely hurts his leg Three weeks later, Ethan is still in hospital and his mental state has deteriorated, he is discharged into a care home Ethan’s wife is worried and calls an ambulance In A&E, the strange surroundings make Ethan even more confused and he becomes disruptive and aggressive In future, we will meet patients’ needs at home . . . Ethan is referred to ICRS by his GP. He has been unable to get out of his chair for the past few days. His wife is caring for him GP, social worker and physiotherapist from ICRS visit Ethan at home. They review his medication, move the furniture in his lounge and set up a hospital bed and pressure-relieving equipment Day 5 onwards – physio working with carers increasing patient’s mobility and exercise tolerance Days 1–4 – cared for in bed with regular visits from nurses in the team Day 5 – confusion much improved. Eating and drinking well and wants to get out of bed Day 7 – Referred to community rehabilitation service Ethan is able to stay at home. His wife knows who is responsible for coordinating care Stress is minimised and the people with the most appropriate skills are available Early intensive support accelerates recovery A smooth transition is made to a locally based multi-disciplinary care team

9. D … Providers (social and health) working together, with the patient at the centre Laura, 75 years old smoker has recently been diagnosed with COPD and lives at home with her husband Jim. Urgent care has been stressful when patients need support . . . After visiting her GP, Laura is diagnosed with having a Stage 2 COPD and is put on an inhaler. After a period of no improvement Laura’s GP prescribes her a stronger dose After a series of complications, Laura is referred to a pulmonologist. Laura’s visit is extended as the specialist does not have access to Laura’s records, and has no indication about the progression of Laura’s condition. Unexpectedly, Laura is admitted to A&E and inpatient care for one week later with breathlessness Laura is discharged to home, but her records and history are not available to either social care works or district nurses during their follow up visits. … … In future, we will meet patients’ needs at home . . . Laura is indentified as a patient in need of an integrated care plan by her GP. Her care plan is made available to all health care professionals involved in her care Laura is discussed by her GP at a case conference with a specialist pulmonologist. As a result her GP refers her for a course of pulmonary rehab and she is put on list for care navigator. Nonetheless, Laura experiences complications, however on referral, her pulmonologist has access to Laura’s care records through full information to assess her progression Admissions to A&E or interaction with social care are also supported by having her care plan accessible to all. Upon discharge the care plan recommends multi-disciplinary pulmonary rehab and self management. At start of next cold period, care navigator call to ensure she has taken rescue pack. … … … …

10. E … … … Appropriate time in hospital when admitted, with timely supported discharge into well organized community care Brenda is 79. She is a complex elderly patient with both diabetes and COPD. She has recently fallen, fractured her hip and been admitted to hospital Urgent care has been stressful when patients need support . . . However, the review happens on a Friday and physiotherapists are not available until Monday, leaving Brenda in hospital over the weekend Additionally, nurses assume that discharge to a community hospital is needed, however the local hospital is full Finally, after several further days in community hospital social care takes 3 weeks to organise a package of care for discharge The duty doctor reviews her case and deems her fit to leave following physiotherapist review In future, we will meet patients’ needs at home . . . The care navigator talks to her family, calls her social worker and speaks to a community home to pass on information Next steps are captured in clear care plan and all pieces are in place for discharge when the time comes First week after discharge, she receives daily visit by physiotherapist to stabilise her When Brenda was admitted to hospital she was flagged as on the high risk patient register and her history was available to staff Her care navigator is notified and discharge planning begins immediately Hospital staff feel less anxious as they have a support structure around the patent The care navigator takes paper work off nurses, freeing their time to care for patients Early intensive support accelerates recovery

11. 2 Today, Hounslow has high acute spend per weighted population compared to other boroughs A&E attendance Spend on unscheduled care ,000 weighted population £/weighted population +8% +24% London ONS peer group Hounslow London ONS peer group Hounslow SOURCE: HES 10/11 (First 8 months)