Local care in west Kent How things are changing #KMlistens Local - - PowerPoint PPT Presentation

Local care

in west Kent

How things are changing

Local care is care not in a main hospital, providing better access to care and support in people’s own communities.

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• prevent ill health by helping people stay well
• deliver excellent care, closer to home,

by connecting the care from the NHS, social care, community and voluntary organisations

• give local people the right support to look

after themselves when diagnosed with a

condition

• intervene earlier before people need to go

to hospital.

We aim to:

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What you say you want for local care…

• More end of life care and dementia care
• More support with healthy lifestyles
• Health and social care working together
• More services alongside GPs
• More services near or in people’s homes
• More support for family carers
• To see the same person regularly
• Faster and easier appointments.

1,925 people responded to survey

100 people came to listening events in west Kent

Your main concerns are

• Having to travel further for care
• Are there enough staff to go round?
• Mental health services and social care
• Funding.

To find out what you think, we use:

• Listening events
• Online surveys
• Patient Participation

Groups

• Roadshows
• Patient and Public Advisory

Group “Who wouldn’t support better joined up care and more care locally?” “Good quality social care is so

• important. It has to be equal to the

NHS.” “Expertise will attract expertise and be good for the workforce.” “The STPs should be screaming for more money.”

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Challenges in Kent and Medway

Our population is growing

About 1.8 million people live in Kent and Medway. By 2031 this number will increase by almost a quarter, compared to 2011

+ 414,000

By 2031

The number of people

• ver the age of 70 will rise

by 20% in the next 5 years More people have long-term conditions like diabetes, lung and heart disease 1 in 4 people in Kent and Medway will have a mental health problem at some point

Challenges in Kent and Medway

Find out more about the challenges we face in our case for change booklet: www.kentandmedway.nhs.uk

As many as four in 10 emergency admissions to hospital could be avoided if the right care was available in the community

when they no longer need to be

We have real challenges recruiting enough GPs and practice nurses

Evidence shows that every day around 1,000 people in Kent and Medway are in a hospital bed

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Prevention – we will:

• Help you to improve your health by providing

integrated support that works with you

• Use every contact with you to check how you are,

training health, care and public sector professionals to give you tailored advice

• Help you quit smoking
• Help you live well with your health

conditions such as diabetes

• Help you if your health problem flares up

making sure you know what to do

• Encourage you to get into the best possible

shape before surgery.

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Everyone has a role to play

Self care is: “The ability to live with my condition in my own way, with the best possible support and information, so I can make my own medical and lifestyle choices: my life, in my hands, with the best possible support to help me.”

Our foundation for local care

Local care in west Kent has four different levels: General practices Clusters – groupings of GP practices working together Local care hubs West Kent-wide services.

Even better care provided by your GP practice

• Strong and resilient general practice at the

heart of local care

• Working differently through better use of

technology

• We are already looking at workload and

workforce

• We are supporting practices to co-operate,

collaborate and combine.

Evening and weekend GP appointments

By March 2019:

• Both pre-booked and same day

appointments until 8pm Monday to Friday

• Saturday and Sunday opening as needed
• We will develop plans with our practices and

seek feedback from patients. 54 of our 60 practices currently offer some appointments over and above ‘core hours’

Changing patient care by working together

• We have seven GP clusters serving between 46,000

and 82,500 people each – with clinical leadership in place

• Each will have a team of health and care

professionals - for example, community nurses and

therapists, mental health workers, social care, pharmacists

• The team’s focus is keeping people with

more complex needs well at home and

supporting them after a hospital stay.

Mental health

Mental health is as important as physical health and we need to do more to join up services. We will:

• Deliver rapid access to individuals and their families during

their first episode of psychosis

• Include more liaison psychiatry in all acute emergency

departments

• Transform children’s services and improve the transition

between children’s and adult services

• Improve prevention and early intervention
• For women, babies and families, deliver screening,

assessment, intervention, training and support during their physical and mental health journey.

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Changing social care – joining up with local care – focused on your outcomes

Pathway for Young People

The Young Person will remain with the same team from 16- 25 avoiding the current cliff edge at 18.

Kent Pathways Service

Providing support to achieve the best long term outcomes for people and enabling them to become more independent

Information and Advice

There will be more info and guidance about community services available to me.

Safeguarding

People will be safeguarded throughout their journey.

Joined Up Service Delivery

I will have different kinds of support working well together; I might need a nurse and a carer at the same time

Staying Well in Your Own Home

I will receive the right level

• f support at the right time

to meet my needs which will be enabling and

• utcomes-based

Self - Care

I will be able do my own self assessment or access support to help do it when I need it

Self Management

I will be able to use telecare and equipment to support me in my own home

Care Navigation

There will be Promoting Wellbeing Coordinators to help connect me to my community

“Own Bed Best”

If I need support to recover from a hospital stay I can have this arranged from my

• wn home if appropriate

An example: meet Dorothy

Dorothy’s care now

• Inconsistent and
• verlapped
• Decided without her

involvement

• Difficult to access
• Focused only on her

health needs

• Only assessed by a

specialist when she visits hospital

In the future

• Consistent and well-
• rganised
• Decided with her
• Simple to access
• Focused on her
• Assessed by an

expert without going to hospital

Our 8 ambitions for Dorothy and those like her

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Hubs will be for services that:

• don’t need to be in a main hospital
• are for a larger population than clusters
• need equipment, rooms or staff to be in one

place

• need to be based with specific other services.

Local care hubs

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• Falls service
• Community mental health services
• Some outpatient clinics: cardiology, diabetes,

medical care for older people

• Health improvement services – stop smoking,

weight management

• Rehabilitation and therapy services – OT, physio
• Psychiatry for older people and dementia

services

• Respiratory services

What might be in a local hub?

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• Patient education classes
• Diagnostics – such as X-ray, scans
• Pharmacy
• Children’s services
• Maternity services, such as midwife clinics,

antenatal classes

• Social services
• District council services
• Musculoskeletal services – hip and knee pain,
• steoarthritis, back pain, pain management

What might be in a local hub?

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Some services, especially those needed round the clock, are for the west Kent area as a whole. These include:

• Beds in the community
• for people at risk of going into a main hospital and

for rehabilitation and assessment after coming out

• f hospital
• Urgent care services - this will be covered in the

next presentation

Services across west Kent

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We don’t know yet. To find out we will: Carry out a review of all local NHS buildings,

including GP practices, so we understand their condition and suitability for the future

Consider:

• the needs of our population, growth, what services they

require, and what workforce is needed to deliver them

• what is safe, cost effective and sustainable

Produce possible options based on this information.

What will be where?

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Better use of technology

• For you and your family: apps and online information to

support you, text messaging reminders, online booking of appointments, prescriptions

• By teams: all able to see and update (with consent) patient

digital records

• By the system: all referrals will be online. So will advice

and guidance from hospital doctors to local teams

New roles and an integrated approach in general

practice and our cluster teams – for example:

• Care navigators, paramedic practitioners, clinical

pharmacists

To deliver local care we need

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• More self-care thanks to better tools, information and

services

• Able to get a same-day GP appointment 8am-8pm

and at weekends in your local area

• Chance to be linked with “what’s out there” –

groups, volunteers, services near you

• More services locally

What does this mean for you?

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Connected care from NHS, social care and voluntary sector:

• One team in each area specialising in looking after people

with more complex needs

• Telling your story once
• Looked at as a whole person – mentally and physically
• Fewer hospital visits

What does this mean for you?

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