Principal Community
Pathways
h
Sunderland & South Tyneside
Principal Community Pathways
A programme to design and implement new, evidence-based community
pathways for adults and older people.
Our ambition is high and is matched by the expectations of service users
and carers. The new pathways will:
• Significantly improve quality for the patient
• Double current productive time of community services by redesigning
current systems
• Enhance the skills of our workforce
• Improve ways of working and interfaces with partners
• Reduce reliance on inpatient beds and enable cost savings
This is not achievable in isolation and to be successful we need it to be part
of integrated work with partners
Principal Community Pathways – Timeline
Jan 14
Tranche 1 –
Sunderland & South
Tyneside
Tranche 2 –
Northumberland &
North Tyneside
Tranche 3 – Newcastle
& Gateshead
Design
Apr 14
Test
Pre-engagement
July 14
Oct 14
Jan 15
Apr 15
Implement
Design
Pre-engagement
Test
Design
Implement
Test
Implement
What will be different?
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Current Experience
There are lots of confusing ways to access
services
Most non urgent services operate Monday
to Friday 9 – 5, and there are waiting lists
Treatment episodes cannot always be
linked to an outcome or a nice guidance
recommended treatment, staff often have to
refer to others for treatment
Patients can bounce around the system
Staff time is taken up with typing, driving
and admin
Patients stay in services for a long time due
to lack of joined up working and support to
help them recover
Patients don’t want to be discharged
because it’s hard to get back into services
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Our Commitment
There will be a single point of access for all
referrals
Most non urgent services will work from
8am – 8pm, and waiting lists will be minimal
Treatment packages will be evidence based
and staff will be trained to deliver a broader
range of nice recommended interventions
Principle of ‘no Bouncing’
Staff will have twice as much time to spend
with patients
Services will have a recovery focus from
day 1. Integrated working will improve the
quality of life for service users.
Service users will be able to re access
services easily and quickly if they need to.
Single Point of Access
UCT
IRT
Urgent
Home Based
Treatment
Rapid
Response
11
Nurses
Assessment
Gatekeeping
Triage & Action
Single
Point of
Referral
Triage
Team
Noncomplex
Clinical
Diary
Routine
Complex
Huddle
Clinical
Diary
Sunderland Team Configuration
Psychosis and Non-Psychosis
Cognitive
Learning Disabilities
Psychosis and Non-Psychosis Teams
Sunderland
x 3 teams
South Tyneside
x 1 team
Psychosis
EIP
Shared Resource
Step Up hub
Step Up
Step Up
Non-Psychosis
Non Psychosis
PD
Psychosis/Non Psychosis
Clinical Leads
Psychosis
PD
Shared Resource
EIP
Cognitive & Functional Frail Teams
Sunderland
Community
Team
South Tyneside
MPS
Community
Team
YPD
Step-up / Day
Service
Cognitive & Functional Frail
Clinical Leads
Challenging
Behaviour
Central
Resource
Step-up / Day
Service
Learning Disability Teams
Sunderland
Challenging
Behaviour
Physical Health
Mental Health
Learning Disability
Clinical Leads
Phased Transition Process
May 14
Dec 14
Staffing
Future State
Communication
Clinical Risk and
Continuity of Care
Caseload Migration
Current State
Performance Management
Evaluating PCP
PCP Benefits
Strategic
Driver
PCP Benefits
Improve QUALITY for the
patient
Improved outcomes and
experience
Improved safety
Strategic
Driver
PCP Benefits
Improved outcomes and effectiveness: Substantially more
evidence-based interventions; recovery focus; care pathways and
packages; time well spent with patients
Improved experience: patient and carer-centred services; care
closer to home in the community; partnership approach; service user
and carer involvement in design, collaborative ways of working, easy
access and re-access of services
Improved environments: good quality venues, accessible
locations
Reduce COST
Improved flow: Alignment of the pathway across community and
Reduced reliance on inpatient
beds
inpatient services; fewer admissions; reduced length of stay; better
discharge planning; better transitions & partner working; balanced
flow of access and discharge
Efficient clinical services: New systems and processes; IT
revolution; reduced bureaucracy and waste
Efficient services
Strategic
Driver
SUSTAINABLE services
Improved skills: Clinical skills development programme;
evidence-based interventions
Improved teams and team-working: Aligned to patient need;
Skilled workforce
PCP Benefits
Partnership and integration
new systems and processes; MDT working; team resources aligned to
demand
Willing partners and integrators: This can only work well as
part of an aligned whole system
What to expect - the Numbers (adult and older people)
What
Current
Future
% direct time with patients
% time non-patient activity
% record keeping
% Travel
20%
45%
25%
10%
49%
36%
5%
10%
The difference we can make by
having more time with patients
Contain patient risk; little
opportunity for evidencebased interventions
Focus on a range of evidencebased interventions that support
recovery and improved
outcomes
Variable system, team
allocation meetings,
bouncing
Simple, standard system; early
allocation of pathway; booked
directly; no bounce
4-6 weeks
6 weeks (range 2-10 wks)
1 week
< 2 weeks
Community clinicians
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System of Access for patients
(non-urgent referrals)
Typical Waits
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To first contact
Assessment to treatment
% split of resources Community
to Inpatient
48%
52%
60%
40%
How will we know what difference has been made?
Quality and Safety Data Suite
Developed by senior clinicians to monitor and measure the impact of
transformation across the Trust, designed to answer:
Is Transformation safe?
Does the PCP model work?
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Have outcomes for patients improved?
Do service users and carers think the
service has improved?
Are we delivering more evidence based
interventions?
Is there a greater recovery focus leading
to reduced reliance on inpatient beds?
Have waiting times reduced?
Are clinicians spending more of their time
with patients?
Does the skill mix match demand for
services?
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Has there been an impact on out of area
referrals?
Has the number of readmissions and rere-referrals changed?
Are community services contributing to
delayed discharges?
Has the average length of stay changed?
What is the impact on community
workload?
Has there been an impact on the
proportion of incidents?
What has the impact on staff – sickness,
morale, vacancy rates?
How will we know what difference has been made?
For Service user and Carers:
• Service User led narrative interviews. To be carried out over a longer period of
time to assess cultural and behavioural changes including: recovery focus,
collaboration, co-production, self-management
• Satisfaction with services. To assess service user and carer satisfaction with
services as delivered at a point in time
• Current feedback sources: Points of You, Family and Friends Question
For Staff:
• Staff Wellbeing evaluation. To understand the impact of the model on staff
morale and well-being
• Satisfaction with services. To assess staff feedback on the PCP model covering
efficiency, effectiveness, quality and safety of services
• Current feedback sources: Staff Survey, Family and Friends Question
For Partners:
• Satisfaction with services. To assess the impact of the model on the range of
partners we work with including Commissioners, GPs, Social Care and other health
providers. To include ease of access to services, satisfaction with service response
as well as overall satisfaction with services