Healthier Together and five year strategic business plan Local

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RIGHT CARE RIGHT TIME RIGHT PLACE
Healthier Together and five year strategic/
business plan Local Conversation
www.traffordccg.nhs.uk
Welcome
Conversations about health and social care
happening across Greater Manchester
Why? To update communities and gather views,
about:
• Joining up health and social care
• Enhancing GP and community services
• Transforming hospital services
www.traffordccg.nhs.uk
Where we have come from…
For the last two years, the Trafford and Manchester
health and care economy have been working on the ‘New
Deal for Trafford.’ This is a service redesign process that
has resulted in changes to the health service locally.
Neighbouring hospitals, GPs, community, social and
ambulance services have been working together to
ensure that the changes will be delivered in a safe and
effective way.
www.traffordccg.nhs.uk
Where we have come from…
A new consultant-led Urgent Care Centre has replaced
the A and E Department to provide treatment for adults
and children every day from 8am - midnight.
The Manchester Elective Orthopaedic Centre has opened
at Trafford General Hospital
www.traffordccg.nhs.uk
Here’s where we have listened before
In the last two years engagement during the New Deal for
Trafford has consisted of:
•Trafford-wide listening events throughout the borough
(Nov 2011 to Feb 2012)
•Focus groups with ‘seldom heard’ audiences
•Liaison meetings and visits to community and
stakeholder groups
•Telephone surveys
•Online surveys
www.traffordccg.nhs.uk
Here’s some of what was said…
•Improving communications between health and social
care is key
•Need to improve access to primary care
•Patients with long term conditions need to be supported
as a priority, prevent illness
•Transport and access issues need to be considered
•Have an open and honest dialogue in communities
www.traffordccg.nhs.uk
Our challenges in Trafford
•Changing health needs which mean more people are living longer
and need ongoing treatment and support
•Large differences in health across the borough
•New technologies and medical advances now enable most patients
to be cared for close to or in their own homes.
•Nearly eight out of ten deaths are due to one of three causes: heart
disease, respiratory disease and cancer.
•Financial pressures
www.traffordccg.nhs.uk
Why is change needed across Greater Manchester?
•More people need care
•The care available is getting more advanced, able to
work flexibly and using technology
•We expect better quality and outcomes
•Financial challenges in the future for health and social
care
www.traffordccg.nhs.uk
Where we want to be..
•Support people to retain their independence
•Provide easy access for patients to GPs and primary
care
•Offer a better experience of care
•Provide safe and high quality hospital services
•Provide more care closer to home
•Provide a more streamlined system of care
www.traffordccg.nhs.uk
The vision in Trafford
•Trafford people will be fully involved in all our decisions and work to
transform services
•GP and primary care services are to be expanded through a continuous
improvement programme
•There will be a modern system of joined up care for local people making
use of technology and information sharing
•We will achieve high quality urgent and emergency care services
•We will achieve a more effective system of planned care for patients
•We will contribute to achieving centres of excellence providing specialist
services for patients
www.traffordccg.nhs.uk
Trafford ambitions
•To secure additional years of life for patients with treatable conditions
•To improve the quality of life for patients with long term conditions
•To reduce the length of time in hospital through more effective
treatment elsewhere
•To increase the proportion of older people living at home safely
following discharge from hospital
•To increase the level of positive patient experience of hospital care
•To increase the level of positive patient experience of GP, primary and
community care
•To make progress in eliminating avoidable hospital deaths through
poor care
www.traffordccg.nhs.uk
How will we achieve our vision?
We will review a range of current health services that can
be organised in better ways to benefit patients and release
resources.
Amongst these are diabetes services, dermatology services,
podiatry services, anticoagulation services, tissue viability
services, macular services, palliative care services, respiratory
services, neuro-rehabilitation services, older and frail people,
mental health services
www.traffordccg.nhs.uk
How will we achieve our vision?
We will continue to develop community, rather than
hospital based services, if this is feasible. These will
be more accessible and release funds.
Amongst these are cardiology services, podiatry services,
physiotherapy services for musculo-skeletal problems,
pain management services, minor eye conditions services
www.traffordccg.nhs.uk
How will we achieve our vision?
We will invest in new systems and facilities that will
lead to a faster, more efficient NHS for local people.
Amongst these plans are changes in the way people are
treated for example intensive therapy at home for stroke
patients
Also changes to systems and processes for example
introduce a Patient Care Co-ordination Centre to speed
up appointments and booking
www.traffordccg.nhs.uk
How will we achieve our vision?
We will continue to support plans to develop hospital
centres of excellence for specialist services
Amongst the priority areas is the development of acute
cancer services
We will also continue to develop services that work out of
hospital to feed patients into specialist care, for example
RAID (dementia assessment) and RADAR (detox
treatment)
www.traffordccg.nhs.uk
Next steps
•We will record your views, consider them locally and
feed them into the wider Healthier Together process
•We will be participate in the Greater Manchester wide
public consultation in the Spring (Healthier Together), with
proposals (We’ll be back)
•We value your views and opinions and will use them to
inform the final draft of our Strategic/Business Plan
www.traffordccg.nhs.uk
More information from
www traffordccg.nhs.uk
www.healthiertogethergm.nhs.uk
www.traffordccg.nhs.uk
Case Studies
www.traffordccg.nhs.uk
What this means for Brenda now
Brenda is in her early 70’s and has been a smoker all her life. Her
chronic obstructive pulmonary disease (COPD) is beginning to
seriously affect her health, in particular her breathing. Brenda’s
breathing, exacerbated by a cold snap, had been deteoriating all
week. On Friday afternoon, she had no choice but to ring her GP
before the weekend, in order to access help. With no appointments
available, she waited to ring the GP out of hours service who were
unfamiliar with her and were concerned by her state. A 999 call took
Brenda to a local hospital where she was admitted and stabilised.
She was assessed by a consultant on Monday who advised she stay
in, given a hospital acquired infection was now also taking hold.
Brenda stayed in hospital for two weeks and was discharged home in
a frailer state than before her flair up.
www.traffordccg.nhs.uk
What this means for Brenda in the future
On Friday afternoon, Brenda rang her local GP surgery and was able
to make an appointment for early that evening. Worried by Brenda’s
condition, the GP provided treatment and told her to attend the
Saturday clinic if things didn’t improve. She accessed the Saturday
clinic after which the GP called upon the urgent wrap around care
team of specialist nurses and therapists. They went to Brenda’s
house later on Saturday to administer enhanced care. After two days
of intensive support from the team Brenda was able to stay at home
and get her COPD back in control.
www.traffordccg.nhs.uk
Mrs Trafford’s experience now…….
• Mrs Trafford is 86, lives alone and has COPD and
suspected heart failure
• Her GP, Community Matron and carers support her
• She was referred to the heart failure clinic and received
an appointment after four weeks
• She arranges for non - emergency ambulance
transport
• After the hospital visit she contacts her GP to make an
appointment to discuss the clinic results
www.traffordccg.nhs.uk
Mrs Trafford’s experience now…….
• She attends the GP appointment only to find the clinic
results have not been received
• When the results are received, Mrs Trafford attends
again
• GP tells Mrs Trafford the results and the care plan
• Mrs Trafford tries to relay all information to her
Community Matron
• Unnecessary and avoidable delays
• Poor patient experience
• Duplication of effort and resources
www.traffordccg.nhs.uk
Mrs Trafford’s experience in the future…
• The Patient Care Co-ordination Centre (PCCC) liaises
with the hospital, Mrs Trafford and the transport
provider to make all necessary appointment details
• After attending the clinic the results are sent
electronically to the GP system
• GP discusses the results and care plan with Mrs
Trafford
• Care plan shared with Community Matron
• Timely, positive patient experience
• Seamless, co-ordinated service
www.traffordccg.nhs.uk
What this means for Daniel now
Daniel is six and lives with his parents and siblings in Partington.
He has all the signs of asthma but no treatment plan to manage his
condition. He doesn't see his GP unless there's a problem.
One afternoon Daniel develops breathing problems whilst at school.
His mum is eventually called out of work and she takes him to the GP
for an emergency appointment.
Concerned that Daniel's condition may become worse overnight, the
GP sends him to hospital where he is admitted to stabilise his
condition. In two days he is discharged after his respiratory problems
ease and is diagnosed with asthma.
www.traffordccg.nhs.uk
What this means for Daniel in the future
Although he is only six, he already has an asthma diagnosis and treatment
plan. Daniel’s plan ensures he sees his GP at least once a year to review his
condition and to remind him and his family of signs and symptoms of asthma,
as well as remedies and techniques. This learning is also provided to Daniel's
school by the community nursing team. Despite this, during a cold snap, Daniel
became poorly at school and his mum was quickly called as staff recognised
his symptoms. Daniel's GP prescribed medication and referred him back home
under the care of the community nursing team who monitored him until he was
safely recovered.
An intensive period of monitoring and support from the nursing team was
followed by follow-up visits to his home until his stabilisation was complete.
Continued monitoring of Daniel's condition would help to prevent further
episodes like this.
www.traffordccg.nhs.uk
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