West Wakefield Health & WellbeingMCP Vanguard

Dr Chris Jones, GP Chair, Programme DirectorThe Five Year Foreward View

Sharing Best Practice

Open Forum Event ManchesterDec 9th 2015

@westwakefield www.westwakefieldhealthandwellbeing.nhs.uk

@westwakefield www.westwakefieldhealthandwellbeing.nhs.uk

Contents

1. Background and context2. Rationale for change3. The model of care4. Some tangible changes5. Challenges

@westwakefield www.westwakefieldhealthandwellbeing.nhs.uk

Networks 3,5 and 6• 17 Practices• 152,000 patients

1. West Wakefield’s 3 networks

1. Local health profile

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

High mortality rate high for cardiovascular, respiratory disease and cancer in under 75’s

High rate of tooth decay in 5 year olds

19.6% of children in year 6 are obese

High rates of teenage pregnancy, alcohol related admissions, road injuries and deaths.

Low rates of breast feeding and high rates of smoking in pregnancy.

Wakefield 2015 Health Profile

2. Rationale for change

NATIONAL• Demographic changes - Ageing population, increasing burden of LTC• Pressures on primary care

LOCAL• Meeting the Challenge: Bed reductions• Pressures on A&E attendances• Workforce challenges: GP and nursing• HealthWatch Young Persons Survey on GP access

So immediate pressures on hospital services which will worsen, with access difficulties and a workforce in crisis lead to the creation of three hypotheses…

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

2. The Hypotheses

50% of work done by GPs could be carried out by a more cost effective resource

30% of elderly people admitted to hospital acutely for a short stay of between 0 and 5 days do not need to be

admitted and could be cared for differently in an alternative setting

30% of patients occupying an acute hospital bed do not need to be there because their episode of acute care is over

We have devised 90 logic models with which to evaluate the programme and test these hypotheses.

The new model of care must also achieve the three objectives of the Triple Aim.

Lower CostBetter patient experienceImproved outcomes

THE TRIPLE AIM

Disruptive Prevention Self Care Care

NavigationImproved

AccessSupport at

HomeAdmissions Avoidance

Early Supported discharge

Schools App Challenge

Oral Health• Fluoride Varnish• Flouridation• Joint consent

Childhood Obesity

Mental Health

Digital• Service Directory• Symptom Checkers• App Library• Big White Wall

Patient Education

Expert PatientsCare PlanningSocial PrescribingMicro-commissioning

Care Navigators• Phone, Email,

Chat, Web• ‘Apple Store’

Kiosks

Care Navigation App

7-day service

Physiotherapy FirstPharmacy FirstPharmacist in GPSocial WorkerMental Health WorkerTriageVideo ConsultationsE-Messaging

Shared visiting service

Care Home ProjectHealthPod

Integrated Multi-Professional Community Teams inc Nursing, Carers and VCS

Information Hub

Proactive Care

Primary Care Champions Consultants in the Community: Elderly, Cardiology, Respiratory, Mental Health

Intermediate Tier Beds in CommunityIntensive Home-Based TherapyFor physical and mental health

Connected Home

Prime Minister’s Challenge on GP Access Connecting Care

3. The model of care

Shared records: Citizen-held care record

“Through expanded primary care, proactive teamwork and new technology to deliver health and social care at scale to the GP registered list of West Wakefield”

Working with Wakefield CCG and building on the Prime Minister’s Challenge to generate primary care workforce engagement as a key catalyst for lasting change.

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

The Vision

GP

Admissions avoidance

Early Supported Discharge

Call Centre

Central HubWaterton House

ConnectedHome

Assistive Technology

ImprovedAccess

Integrated Teams

Video, E-messaging

HealthPod

Extended Hours

Care Homes

Consultants

Citizen-held care record

Care Navigation

Digital self-care

Social PrescribingUnified Communications

Federation & Collaboration

Pharmacy First

Physio First

Nursing United Carers Framework

Provider Alliance: MYT, SWYPFT, WMDC, WDH, Nova (all VCS), Age UK, YAS (111,999), LCD, Spectrum

Integrated Teams

C3 Ops Centre

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

4. Integrated MDT

Elderly Care Consultant

Respiratory Consultant

Community Psychiatrist

VCS

Specialist Nursing Teams

Therapists

Social Worker

Community Matron

Community NurseCommunity Mental

Health Nurse

Care Navigator PharmacistHub Manager

Community Cardiologist

Hub Clinical Lead

Practice Nurse GPAcknowledgement for images: Lesley Carver NHS NW Surrey CCG

Co-located

Shared mission

Shared culture

Shared records Mutual trust

Authority to act

Daily virtual meeting

Proactive approach

Information Hub Access 24/7

Tactical TeamsGenerates Care Package

Strategic View

Health Visitor

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

4. Information HubGP System Notifications

GP System Population Data

Ambulance Service

A&E Metrics & Notifications

Hospital Admissions

Hospital In-patient Status

Community Notifications

Met Office

Local Authority Records

Mental Health RecordsPublic Health Statistics

Police Comms Link

Housing Comms Link

Fire Comms Link

Smart Home Notifications

Informs the Integrated MDT

4. Citizen-held care record

• Owned by the individual, cloud based

• Fully sharable

• Health and well-being information, LTC management, care plans, social

network, social care package data, EOL planning etc.

• Complementary to NHS record

• Several example in development– Patient Knows Best

– Leeds Care Record

– Kirklees Self care Hub

– Vitality/Digital life Sciences

– eRed Book

– Vitrucare

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

• Growing array of monitoring and wearable tech

• Develop the smart home concept

• Start with social housing stock – all have broadband

• Already wide array used in Wakefield

• Make people feel connected, safe and looked after

• Detect signs of illness. Raise alerts

4. Connected Home

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

4. Extended Hours

• 6.30pm – 8.00pm Weekdays,

• 8am – 8pm Weekends

• Routine & Urgent appointments

• Routine booked during normal hours

• Urgent from 111 as ITK message into SystmOne

• Staffed by internal personnel

• Run from dedicated premises inside high quality new build Health Village

• Augmented by the 24/7 digital access solutions

NEXT STEPS

Create consistent service across three networks to cover full population of 152,000 with consistent offer

Consider hours of operation Broaden skill mix

4. Extended Primary Care Team• Physiotherapy First

• Pharmacy First

• Heath & Wellbeing Worker

• Care Navigators

• Health Champions

NEXT STEPS

Pharmacist in General Practice Mental Health worker Community Consultants Social Worker Primary care

020406080

100120140

Physio First Contacts

Viral cough No cough

Fever without

viral symp-toms

Sore throat

HayfeverAllergy symp-toms (skin)

Insect bite/sting

Oral thrush

Vaginal thrush

Teething

Cold sore

Headache/mi-

graineThreadwormsOther

4. Pharmacist in General Practice

• 0.5 Session per 1,000 patients

• Post-discharge medication reconciliation

• Medication reviews, reduction in polypharmacy

• Minor ailments advice

• Interface with community and hospital pharmacists & CCG MO team

• Management of repeat prescribing process and formularies

• Implement MRHA guidance, safety alerts and changes in indications and availability

• Medicines advice to whole team

4. HealthPod

• Out reach• Hard to reach• Menu of services

– CAB– Housing– Carers Wakefield– Age UK– Youth groups– Mental health worker– Sexual health outreach– and more…

• Own Twitter account• Tracking app

4. Care Navigation

• Care Navigators• Training Course devised• Over 70 trained• Supported by primary care health champions• Using Service Directory and other on-line tools

4. Care Navigation App

• Web-based decision tree

• Public access

4. Service Directory

4. Kiosks

• Care Navigation App & web site

• Kiosks in Reception

• Part of West Wakefield web site

• Service Directory

• Real-time signposting to resources

• App Library

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

4. Schools App Challenge

• Year 6

• Design a health and wellbeing app

• Think about healthy living and own family and friends

• Strong prevention messaging

• Supported by Microsoft– Touch develop

– Mentors by Skype

• Teamwork, coding, presentation skills

• Dragon’s Den style judging

• Engagement with Schools

NEXT STEPS

Roll out to wider population Version 2.0 Lessons learned Sponsorship

Team Friendship Forever (Dragon in the Attic)

4. Dragon in the Attic

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

5. Challenges

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

• Workforce

• Technical Infrastructure

• Estates

• Provider Management

• Delivering at Pace

• CCG Governance

• Local Engagement

MCP

Network 3

Network 5

West Wakefield

MYT

Nova

CCG(partner)

WDHSWFPFT

Spectrum

Age UK

YAS

Fire & Rescue

Local Authority

HOST

• Shared accountability• Hosted by West Wakefield – contract holder• Chaired by CJ• Supported by JJ• CCG as invited attendee, not present for

commercial/sensitive provider discussions

What about other providers?

To develop:

• MoU/Business Rules• Terms of Reference

6. Accountability Model

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

MCP

NHS England

Connecting Care Executive (Commissioning)Adults, Children & Young People

Vanguard Subcommitte

e

CC Health & Social Care Partnership

Operational Commissioning

Group

Wakefield CCGWakefield District

Health and Wellbeing Board

Wakefield Council/Cabinet

6. Governance model

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

7. Milestones

@westwakefield www.westwakefieldhealthandwellbeing.org.uk

• Hub Manager in place 12/12/15

• Mental Health Worker roles embedded in Hub 11/01/16

• CrossLead Senior leadership event 21/01/16

• Schools App v2 Judging 28/01/16

• HealthPod 2 operational 01/02/16

• Community Consultants in Hub 15/2/16

• Information Hub IOC and SOP established 18/01/16, Full

07/03/16