• Two-day simulation event: 28th October and 5th November 2014
  • Context is development of Whole Systems Integrated Care in Hounslow and North West London. This involves delivering integrated care.
  • Simulation showed that the Out of Hospital model (delivering care in the community rather than in hospitals) holds good
  • Findings support the direction of travel and balances Out of Hospital care with hospital strategic plans implementation.
  • Purpose was to develop and test our approach to developing a model of integrated care for Hounslow
  • Over 90 people attended the two full-day simulation workshops
  • Run by Imperial College Health Partners; hosted at the Sequential Simulation Suite at the University of Buckinghamshire, High Wycombe
  • Each day was structured around three real-life scenarios covering areas of general practice, adult social care and community health.
  • The workshops were designed as a practical approach to engage front-line staff in visualising how the current system works (on day one) and (on day two) to co-design how a new system could look and their part in it.
  • Allowed us to explore if we could develop a different conceptual approach (‘step-change’) to developing a Hounslow-specific model of care. We are on the right track with our four step model in NWL
  • Helped us to test the robustness of existing arrangements and share our thinking around detailed implementation of the proposed new Model of Care
  • Allowed us to test certain elements of our proposed model of care without having to do it for real first (eg, more clarity needed on the role of care coordination, thinking through the practicalities of implementing MDTs)
  • Brought together and got buy-in from front-line professionals delivering care across the Hounslow health and social care economy as well as third sector organisations, patient, and service users and carers representatives
  • A lot of energy and enthusiasm for positive change

Findings Summary

  • A wide range of issues were raised. They addressed broadly:
    • Fragmentation and complexity
    • Lack of continuity of care
    • Not making the best use of existing resources, people or services
    • Lack of communication between services and of sharing of knowledge
    • Patients / service users / carers should be better supported to self-care, monitor & manage their own condition(s)
  • What’s not working or missing?
    • Fragmentation and complexity
      • Multiple systems, appointments, assessments, referrals, care plans, points of access to services – and usually only 9-5, weekdays
      • Services simply not orientated to growing numbers of increasingly frail and more elderly people*
      • Gaps in systems where people get lost – eg DNAs, referrals. Also gaps across systems – eg patient / service user consent to share data
      • Services reactive, not proactive: statutory priorities, finance, resource and capacity constraints drives existing service delivery
  • Lack of continuity of care
    • Peoples needs are compartmentalised or medicalised – no view of the needs of a person as a whole
    • No one person takes responsibility for the patient / service user across different services. Even within one service a person can be seen by different people even in the same settings (eg GPs, hospital appointments etc)
    • Lack of shared information (eg care plans) precludes effective joint working across organisations; (IT and IG constraints compound this)
  • Not making best use of existing resources: people and services
    • Mental health needs under-recognised and not addressed; timely psychiatric or counseling interventions needed
    • Voluntary sector all but invisible?
    • Paid carers – often closest to the person, but not sharing knowledge with health / social care staff
    • Carers (partners, friends, family) need to be involved and supported as far as practicable
    • Pharmacists – also closer to the person. Could be more involved eg medication reviews, prescribing, help with multiple medications sharing knowledge with other professionals
    • Training of existing staff, eg in use of language to communicate more effectively, listening skills, body language, dealing with difficult behaviours (eg aggression, dependency)would be helpful
  • Lack of communication between services and sharing of knowledge
    • Information is simply not shared across organisations – only the patient or carer has the ‘full picture’ of their care
    • Staff in health and social care often don’t know what other colleagues do let alone what other services exist
    • Lack of ‘signposting’ of patients / services users to other services that would help them
  • Patients / service users / carers should be better supported to self-care, monitor & manage their own condition(s)
    • Lack of knowledge about their conditions – especially at point of diagnosis, but also following
    • Fatalism / lack of motivation
    • Dependency behaviours are rewarded (call ‘999’); support for self-sufficiency difficult to find
    • ‘Triggers’ to increased dependency / need for support (eg bereavement) can be missed
    • A stronger focus on partners or carers to support patients and service users
    • Keeps coming up again and again – isolation, lonliness, need for transport to access services

WSIC - Where do we want to get to?

  • Proposed solutions included…
    • Fragmentation and complexity
      • Promote GP specialists in care of frail elderly with LTCs, SMART assessments, a new role – Physician assistants?
      • Create the abilities, skills and time for GPs to manage these more complex cases;
      • Develop a single point of access system
      • A Care Coordinator streamlines appointments, assessments, chases referrals etc across all services; more flexibility over setting in which care delivered
      • Identify gaps (eg DNAs, referrals) and design a trigger to pick these up and a system to follow them up
      • Get patient consent for sharing information during GP / other registration
  • Lack of continuity of care
    • Make sure everyone has a care plan who needs one and – critical – engage the patient / service user / carer in its creation / maintenance to get ‘buy-in’
    • Implement an electronic real time shared joint care plan – focus should be on personalised, outcome orientated care and giving a person options
    • Create a care coordination role whose purpose is to consider needs of a person as a whole and to ensure that the care plan effects this
    • Institute multi-disciplinary teams to review care plans for complex patients when needed
    • Longer assessments with GP (eg 30 minutes) with further support (eg 40 minutes) from eg practice nurse at same appointment
  • Not making best use of existing resources: people and services
    • Include partners, family, friends and social / voluntary groups in delivering support and care
    • Develop the role of paid carers so information about a person’s circumstances are systematically captured and shared with other health and social care staff
    • Bring existing services together around the patient, such as psychological support, smoking cessation, dieticians, pharmacists, dentists, voluntary sector groups, diabetic support, financial advice – whatever could be relevant to the needs of the person
    • Think about ‘triggers’ to identify when a proactive intervention might be best targeted (eg following bereavment, notification from an undertaker)
    • Can more be done around use of paramedics (eg 999, 111) to direct people to most appropriate care – eg understand and empower to use community services?
  • Lack of communication between services and sharing of knowledge
    • Develop joint shared care plans and give the patient / service user / carer the most recent hard copy they keep with them for all appointments etc
    • Organise cross-organisational training around aspects of integrated care (eg people skills, services offered); mix the disciplines. Include paid carers and voluntary organisations / services. Mix learning styles
    • Share information across organisations: central directory resource, leaflets
  • Patients / service users / carers should be better supported to self-care, monitor & manage their own condition(s)
    • Create time for health and social care professionals to educate patients / service about what they can do to help themselves; most importantly, when people are first diagnosed
    • Include carers, family and friends in this ‘circle of information’
    • Promote expert patient groups, the Desmond system and similar programmes
    • Target specific groups where there are cultural and other barriers to self care (eg around some Asian men and diabetes)
    • Recognise there can be mental health issues around lack of self-care, even if it doesn’t always appear so at first
    • Encourage self-referral, rather than relying on GPs alone. Also encourage patients and service users to chase up referrals too.
    • Improve ‘signposting’ to services available, from all sectors of the health and social care economy
    • Think about social factors (eg loneliness, lack of mobility) as equally important alongside other health and social care needs

Whole Systems Core Deliverables

Leave a Reply

Please log in using one of these methods to post your comment:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s