East Merton Post Model of Care Workshop Update briefing January - - PowerPoint PPT Presentation

East Merton Post Model of Care Workshop

Update briefing January 2016

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• 1. It’s not a Model of Care but a Model of Health & Wellbeing
• 2. The Model needs to be local and based on ‘natural communities’ as much as possible (the ‘Goldilocks Zone’

being between 20,000 and 50,000 population) – integrating prevention and self care into peoples lives where they live

• 3. It requires working with these natural communities to understand and map with them what they already have

and what they already use

• 5. It then requires looking across health, social care, the voluntary sector, etc. to see what could be reorganised

and deployed differently, to meet the needs expressed, within some shared features, practices and enablers

Executive Summary

• 6. An assessment is then required of what can be done to achieve sufficient critical mass in each locality to keep

the model economically sustainable - which means understanding what can be deployed locally and what may need to be shared across several localities (sometimes within a single hub and sometimes through a more virtual model)

• 4. Then understanding with them what more they need within their natural community to improve their health

and wellbeing and take greater responsibility for it – informed by emerging best practice from elsewhere

• 7. Finally it requires the development of the organisational models to operationalise and incentivise the new

arrangements The emerging direction of travel from the first workshop to develop a Model of Care for East Merton is: There follows a summary of these emerging themes, and some high level descriptions of what this means health and wellbeing could look like, for testing and further discussion

Contents

• 1. What the data says about East Merton
• 2. What the Design Group say it is like today
• 3. What the Design Group say it should be like
• 4. Emerging themes
• 5. Next Steps

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Not Enough Over reliance

Locally based Chronic disease management (self care through to good rehabilitation & reablement) Intensive care Tertiary health care New cancer drugs Secondary health care inc. accident and emergency, planned care, etc. Screening programmes for cancer Prevention and health improvement (smoking cessation, weight management, dealing with social isolation & loneliness, childhood immunisation, etc.) Well managed locally based end-of-life care Neonatal screening

Relative health impact on a population Low High Relative costs per person per day £0 £10’s £100’s £1000’s

Summary – What the data says about East Merton

East Merton has a profile of deprivation and complex care consistent with

• London. Shows signs
• f late diagnosis and a

tendency towards

• ver reliance on

secondary care intervention. Work by the Nuffield Trust and others suggests in these circumstances there would be significant benefit in moving to a more locally deployed person centred and integrated model of care rooted in prevention, health improvement, self care and earlier lower cost interventions

What the Design Group say care is like today

Specialist Care Other Council Services Voluntary Sector Social Care Other Health Services

Specialist Level Local Level People, family & carers

System Level

People, family & carers

A paternal system that can be over complex and at times dysfunctional where we don’t take enough responsibility for

• ur own health and

we all don’t reach-

• ut, prevent,

detect, and act early enough

Local Level –

We don’t work together enough and lack the skills and capacity to keep care local – so its become too complex and makes us all even more dependent than we need to be

Specialist Level

We don’t deploy enough skills and capacity round the clock locally to manage preventable and deteriorating conditions – so too many people go to hospital and when admitted stay too long

System Level

The wider system is dysfunctional, reacts too slowly, is not aligned and too inflexible to meet our

• needs. How funding

flows, incentives work,

• ur culture and skills,

capacity and how it is deployed, how we exchange information, communicate, engage and relate to each

• ther need to change

There is insufficient focus on Older people, adults with long term conditions, and families with children People die relatively young

• f preventable and

treatable conditions We have a population more like London than the rest of England with relatively high deprivation and ‘churn’ No one understands all the needs of our community especially for those that are hard to engage

| People can expect to:

• Be supported to change

unhealthy lifestyles

• Receive care in their local

area from a Local MDT with the GP and practice at it’s core, supported by specialists when their situation or conditions become more complex to manage

• Have a care plan that they or

their family / carers hold and co-write

• Use technology to monitor

changes in their condition

• For a range of public sector

data to be used to help identify if they may need more proactive care

• If they have multiple &/or

complex needs have a care navigator / co-ordinator

• Have frailty identified and

managed as a LTC

Specialists Local Team People, family & carers

System

People, family & carers At the centre of a proactive integrated system supported to maintain health and wellbeing through self help, self care and, when needed, supported to navigate to the right care to retain independence Local Level An enhanced and effective MDT (multi- skilled & multi- agency) with GP and practice at its core supported to have the capacity, capability and relationships to be resilient and meet the core needs of local people to keep them independent as long as possible Specialist Level Other ‘specialists’ meeting the remaining needs whilst working with and supporting the MDT with meeting the core needs of keeping us independent, avoiding unnecessary admission to hospital, and getting us back home for enhanced care when we are ready System Level We are working together to deliver a series of system principles, enablers and features that support and help drive us towards greater integrated ways of working

Specialist Care Voluntary Sector Other Health Services Social Care Other Council Services

What the Design Group say it should be like – A Model of Health & Wellbeing

People live and remain independent longer by maintaining health and wellbeing We are working closely and better with our communities even the hard to engage groups There will be more focus on families with children, adults with long term conditions and older people

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A better start, a better life and better ageing

Behaviour – Promoting

quality of life, healthy development and healthy behaviour across all life’s stages

Equity – Helping improve

all our lives through dealing with the determinants of ill health

Prevention – helping

reduce loneliness, disability, injury, preventable disease and premature death

Health, social, council and voluntary services working together with local people to improve health by:

By engaging and equipping ourselves to make better choices for our life, health and wellbeing, so we know how to take better care of ourselves and others through all life’s stages and are fully included and empowered By creating Local Integrated Teams (MDTs) that makes every contact count to improve the determinants of health, using social prescribing, as well as managing our core primary and social care needs Providing intensive integrated care when needed by adding the right experts to enhance the local team for those at higher risk:

• Families with children
• Adults with long term conditions
• People with multiple conditions

Making urgent and emergency care part

• f the above so people only go to hospital

when they need to for those things that can’t be managed locally and come home as soon as they are well enough to be looked after by the local team

Environment – Helping

create physical and social environments that promote it

Emerging Themes

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Community Health GP Practices Mental Health Acute Hospitals Council Services Social Care Voluntary Sector

The Workforce of Existing Organisations Redeployed into 2 or 3 Natural Communities across East Merton (which

could include a consolidated site / hub at The Wilson)

Next Steps - to redeploy into 2 or 3 Geographic Groups ?

Requires the engagement of ‘natural communities’ with the staff of the existing

• rganisations to answer the following questions…

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• 1. How Many ? – The RCGP consider the ‘Goldilocks’ zone for geographic groups to be for a population of

between 20,000 and 50,000. The Kings Fund believe it to be at the higher end of this range and above. The actual size depends upon the local circumstances, how support is being provided to the geographic group through the network arrangements and whether there is a hub, etc. At this stage it may help to identify where the ‘natural communities’ are and how these can be combined into 2

• r 3 geographic groups for East Merton and configure the network and support arrangements so they give these

the ‘right’ critical mass to work operationally and financially (see appendix)

• 2. Whether each geographic group is a consolidated single hub, hub & spoke, or federated ? – Depends largely
• n what relationships can be made to work, what is to be included, how they can be best fitted to the natural

communities, and what network arrangements are needed to achieve critical mass. It is also possible to combine these arrangements with one geographic group acting as a wider hub for some services for the other two (see later slides) to help achieve better critical mass

• 3. Where ? – Location is a combination of geography, natural communities, transport / access and pragmatism. If

there is to be a hub will obviously be dependent on the physical infrastructure in the locality – such as a community hospital or another community facility. Co-location opportunities will also increase the potential for critical mass eg. minor injuries unit, out of hours service, children’s centre, community centre, etc. Previous work identified The Wilson as a location for some form of consolidation / hub and it’s possible it could also act as the wider hub for some services for the other geographic groups depending upon their configuration

• 4. What other local assets should be included ? – Depending upon the geographic locations there are likely to be
• ther community assets that could be included to help increase critical mass and impact. This is perhaps best

determined by mapping with the communities what they use and what they need to take better responsibility for their own health and wellbeing. This is potentially a powerful way of getting local people and staff engaged

Questions

• 5. How the natural communities inter-relate ? – the relationship between the communities is important to help

achieve the right level of critical mass for the new configuration to work operationally and financially. Combining

• ptions as outlined above is more likely to lead to better critical mass and viable solutions than totally stand

alone approaches.

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How Health, Social Care & Voluntary Services are deployed and shared will help determine critical mass – as an example:

• This is just for illustrative purposes. The services

shown on the next slide would need to be reviewed and allocated to A, B, C, & D

• Other local assets could also be included
• The model in principle can also be applied to

Children’s services including a Children’s Centre

• GPs in enhanced Practices inc. GPOOH
• Life coach, care co-ordinator / navigator
• Community Matron & Nursing
• Independent living & enablement
• Social Care & Home Care
• Social Prescription provider
• Volunteers (expert and non)
• Housing and other council service advice
• Mental Health Nursing

Extended Team

• Physiotherapist
• Housing Officer
• Long term social care, council LD & OT
• Specialist Community Services
• Specialists (Geriatrician, Paediatrician)
• Podiatry
• Mental Health Specialists
• Clinical Pharmacist
• Equipment
• Discharge co-ordinators
• End of Life Specialists

Geographic Groups 1, 2 & 3 where A & B may include: Geographic Group 3 hosting C & D which may include:

East Merton

D A B C A B A B

Geographic Group 3 with A & B and also hosting C & D for the wider network Geographic Group 2 Geographic Group 1

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Your views and advice

What is your advice on how to identify and engage natural communities in the next steps?

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Appendix

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The East Merton Public Transport Accessibility Levels & Hospitals

The Wilson St Helier Hospital St George’s Hospital The Nelson

Whatever locations you choose won’t be perfect but transport is important for a solution to work for local people

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14 What’s a Natural Community ?

People generally consider themselves to be part of a community of place - a geographical area. Communities of place exist within towns, villages or neighbourhoods. The term Natural Communities has come to be used to describe communities of place where people can identify their own area, form associations and local groups - but they will also relate to larger geographical areas. Council wards and other named localities can be seen as Administrative localities - areas designated for electoral or other purposes. These two levels of ‘community’ co-exist. Communities are central to the integration of health and social care and so require good levels of community engagement and involving service users. Merton is made up of many natural communities. Information from all available sources around which to plan services is not usually available at this level but at an Administrative Locality level such as a Ward A level of pragmatism and compromise is therefore likely to be needed when determining geographic groupings for service purposes to take account of natural communities (for engagement) whilst also being able to associate these with administrative localities (for data) and existing community assets (around which services may be developed.