Transforming Clinical Services. Our developing clinical strategy

Transcription

1 Transforming Clinical Services Our developing clinical strategy

2 Transforming clinical services A developing clinical strategy for the new Foundation Trust Since 1 April 2011, County Durham and Darlington NHS Foundation Trust has been an integrated acute and community provider. Our ambition over the next year is to establish ourselves as a leading edge integrated care provider, offering the services that commissioners want to buy, and where patients and users want to receive treatment. This document outlines our thinking so far about the future shape of clinical services. The proposals contained reflect the ambitions of clinical staff to develop more accessible patient centred services and to reduce the amount of time patients spend in hospital sometimes unnecessarily. While still in development, we feel that our proposals are now at a stage where they can be shared with commissioners for debate and discussion. Although there are to be changes to the coming health bill, clinicians are set to be in the driving seat in future planning and purchasing of health services. We look forward to working with the consortium to take this agenda forward over the coming months. Stephen Eames Chief Executive Robin Mitchell Medical Director 2

3 Our vision and strategy We see the creation of a new integrated provider as an opportunity to: shift the centre of gravity from hospital to community and develop fully integrated care pathways. Our principal target outcomes are: The best health outcomes for patients delivering evidence based care, using best practice An excellent patient experience measured by regularly asking patients what they think Improving efficiency so we provide high quality, low cost services for commissioners Being a best employer so that care is delivered by a flexible skilled and motivated workforce Our emerging strategy for the new integrated FT is: To be the first choice provider of community and hospital healthcare in County Durham and Darlington As an integrated acute and community organisation, we have three areas of core business: Prevention and enablement Community services Planned and emergency hospital care We plan to embed prevention and enablement in all of our pathways of care, taking advantage of all of our touch points with patients and service users. We want to streamline community and hospital services to provide a seamless service with less reliance on hospital admission. 3

4 To be a major provider of women s and children s services in the North East We believe we are well enough resourced to deliver current service & training requirements at Darlington Memorial Hospital, as well as Durham. Looking ahead, there are workforce and quality pressures for instance around increasing consultant hours on obstetric wards which will, in the future put pressure on the existing delivery model for consultant led care in medium maternity sized units, such as those in Darlington Memorial and UHND. As yet, there is no national or regional consensus around future models. However, a single site option for consultant led care in County Durham and Darlington would not meet current patient and commissioner needs, or the Trust s desire to retain its position as first choice for new mothers across the whole of our catchment area. With regard to related pressures in children s services, contingency plans are being put in place to safeguard the level of service. We plan to explore the future service models that we may need to have in place in 3-5 years to maintain this position and we also plan to discuss these issues with you in the coming months. 4

5 To build a reputation for excellent specialist services The Trust already provides specialist services such as colorectal surgery and bowel function which are recognised in North East and beyond, as well as sub-regional specialties in plastic surgery and dermatology. Greater specialisation is driving centralisation in many specialties, and we expect this to continue as choice, competition and commissioning practice raises the quality bar. We have already seen this in stroke services. We have the critical mass to develop each hospital as centre of excellence in a distinctive range of specialties, supported by more community based services. We plan to work with commissioners and stakeholders over the next few months on plans to develop our specialist services. 5

6 To develop a national profile as a pathfinder for new ways of offering health services in hospital, home and community This objective has been the initial focus of our work to develop a detailed clinical strategy for the new Foundation Trust. Working with stakeholders, we have developed proposals to shift the centre of gravity from hospital to community and increase integration in the following areas: Long term conditions Care of older people Women and children Acute medicine and emergency care Surgery End of life care We understand that these are the key areas where PCT and GP commissioners want to make progress to develop locally sensitive services which improve care, and broadly reflect commissioning intentions. 6

7 To shift from treatment to prevention Improving health and well being and developing preventative health care is part of the Trust s core business. This includes: recognising, anticipating and responding to the changing health needs of the local population working with partners to tackle the preventative agenda utilising marketing techniques in order to influence and achieve specific, sustainable behavioural change. embedding prevention in care pathways delivering innovative prevention services for improved health outcomes. reducing health inequalities Prevention First strategy 7

8 To ensure sustainability by exceeding national targets and financial performance and investing in our infrastructure and capacity Across acute and community services, we have a history of achieving often challenging targets for services for the Department of Health and commissioners. We also have a strong track record for financial delivery, which gives commissioners the assurance that they are working with a stable and sustainable organisation. Over the first four years of the FT, we have made efficiencies which have allowed us to invest in our facilities and services, such as extending our A&E departments in Durham and Darlington, a new critical care unit in Darlington Memorial, as well as 26 million investment in the hospital infrastructure. We have also created a Cataract Centre at Bishop Auckland Hospital and a new Dermatology unit in Durham. We plan to continue investing in high quality services and facilities over the coming years. 8

9 New ways for offering care Under our objective to be a pathfinder for new ways of offering care we have focused on six areas, which we believe are key to improving outcomes and experience and shifting care out of hospital. Long term conditions The number of people living with long term conditions and in increasing numbers of cases, multiple long term conditions is growing. The aim of the long term conditions workstream is to provide a more integrated community based service. We want to offer better support for patients and service users, more education in self management, and, when people have problems managing their conditions, quick support to specialist help to avoid an acute episode and hospitalisation. We want to introduce common pathways for long term conditions, improved education and referral guidelines and a common register for patients with long term conditions. We are initially focusing on diabetes, respiratory illness, and the management of heart disease. 9

10 Key proposals 2011/ / / Long term conditions Access to specialist support Referral guidelines for specialist services (nurse/ consultant) Community clinics (reorganising current tier 2 resources) Education :Self management plans GP s/practice/secondary care Facilitated discharge Common LTC pathway Common Register Centralised oxygen service Integrated Dermatology Service Community based Heart Failure Team Single Pathway for COPD 10

11 Older people We have an ageing population, and older people account for the majority of admissions to hospital. In many cases, admission results in a permanent loss of independence, and, where admission is necessary, an older person does not necessarily require admission to an acute hospital. We want to: Increase prevention and screening at the earliest part of patients pathway (eg GP / FRAX scores) Improve future care planning - with in reach to, patient s homes, nursing and residential homes to promote health and well-being, prolong independence, and prevent or delay the need for higher intensity or institutional care. Introduce an Early assessment Team at the front door - A specialist integrated MDT disciplinary team comprising of nurses, therapists, social workers and doctors, dedicated to strengthening emergency care systems for frail older people with complex needs (including dementia) through comprehensive assessment Set up an appropriate admission unit for patients with less acute needs, to be assessed by a multidisciplinary team in a day hospital type setting. This will allow an appropriate detailed assessment with instigation of appropriate care needs (both physical, social and mental) at the earliest opportunity. Standardise admission criteria to community hospitals 11

12 Key proposals 2011/ / / Older people Dementia roll out of Dementia Collaborative training book across the Trust, and community / social care services - Community Hospitals standardisation of admitting criteria Community Hospitals offer a rapid access to medical outreach for rapid assessment hospital avoidance scheme to be piloted from Sedgefield Prevention and Screening - introduction of screening tools at the earliest part of patients pathway Ie GP / FRAX scores Future Care Planning - with in reach to, patient s homes, nursing and residential homes Introduction of an Early assessment Team at the Front door - A specialist integrated MDT disciplinary team, dedicated to strengthening emergency care systems for frail older people with complex needs Late 2011/12 Late 2011/12 Appropriate Admission Unit / Direct Access - For patients with less acute needs an assessment by a multidisciplinary team in a day hospital type setting to allow a detailed assessment 12

13 End of life care In the NHS we often struggle to support people effectively to have a good death in the place of their choice. We can improve this by better planning around the end of life, and by ensuring that the support exists during the last days and hours to make sure that these plans are fulfilled. We will implement advanced care planning for long term and malignant conditions; making better use of GP GSF registers. We will introduce the DH tool, the surprise question to identify those patients with long term or malignant conditions who are in the last year (or less) of life and require care and support in community. We are planning to provide 24/7 access to specialist palliative care advice, and standardise hospice admission criteria for end of life patients. This will be supported by a single Point of Access Coordination Centre to support 24/7 access and care for end of life. In addition to ensuring an appropriately skilled workforce to ensure patients have choice in their lasts weeks and days of life. Surgery Our surgery workstream has focused on changing our planned and emergency surgical pathways to reduce time spent in hospital, and the number of visits including preoperative assessment where appropriate by questionnaire, without a hospital visit. Specialisation has driven the need to centralise services. We expect this to continue. However, we believe we have the critical mass in terms of skills and patient flows across the Trust to sustain and develop excellent specialist services by focusing different services on different sites around the Trust. 13

14 Key proposals 2011/ / / End of life care Implement a Single Point of Access Coordination Centre to support 24/7 access and care for end of life Implement the DH tool Surprise Question to identify patients in the last year (or less) of life Implement advanced care planning for long term and malignant conditions; better utilise GP registers Following a review of commissioning and resourcing of the medical model to deliver 24/7 access to specialist palliative care advice recruitment to consultant and tier two posts has begun Standardisation of Hospice admission criteria for end of life patients Surgery Emergency Surgical Pathway Pilot DMH site Pre operative Assessment Initial health screen- pilot plastic surgery Urology Trial removal of catheter Vascular services Opd VV pathway Breast service 14

15 Women and children Integrated health and social care children s teams are already in place in Darlington, and will be in place in County Durham by the end of 2011, and we plan to align our midwives to these teams, in line with the -9months to +19 years pathway. We plan to carry out more of our work in the community, including more antenatal assessment. We are working with Dr Kate Bidwell on the pathway for the poorly child. An important development will be the development of a front of house A&E and urgent care model for children including the introduction of advanced paediatric nurse practitioners to ensure swift access to specialist care. A priority for the Trust is for us to remain a major provider of women s and children s hospital services, despite the national workforce pressures, coupled with demands for higher quality standards, in particular consultant hours on labour wards. We can sustain the current two site consultant model over the medium term period of three to five years, and are exploring options for continuing this model beyond that period. Emergency and urgent care We plan to integrate urgent care centres with the emergency departments including moving the urgent care centre at Dr Piper House to Darlington Memorial, so that we can direct patients more effectively and quickly into the right environment for their care. This will begin by agreeing a single pathway also to be used in stand alone UCCs followed by physical co-location. We have had some success over the last two years in reducing the number of unnecessary admissions to hospital through RAMAC, which has avoided up to 20 admissions per day. We will introduce a range of services in hospital and community that GPs can access as alternatives to hospital admission. We are also introducing a virtual ward to facilitate earlier supported discharge from hospital where this is appropriate. 15

16 Key proposals 2011/ / / Women and children Antenatal assessment: 1 st June pilot 3 months Integrated teams Darlington in place, Co Durham Alignment of midwives to teams Developing acute paediatric nurse specialists to support front of house assessment and treatment Links with community paediatrics / Health visiting Poorly child pathway Review of community venues for Maternity and Paediatric care Acute and emergency care Clinically integrate UCC/EDs, agreed single pathway, including at stand alone UCCs Physically co locate Integrate UCC and ED UHND UCC/ED Physically co locate Integrate UCC and ED (DMH) Agree paediatric model for UCC/ED and develop implementation plan Directory of services ( community and hospital) that will enable alternatives to admissions 16

17 Care closer to home The Care Closer to Home strategy supports and enables the delivery of many of the aims of the other workstreams, including developing alternatives to hospital admission and enabling earlier discharge. The agenda recognises the need to increase the resources, skills and competencies of Community based staff to better meet the requirements and demand increases on the service as the Care moves out of the Acute setting. To help meet this challenging ambition a number of key opportunities for redesigning service delivery have been identified and in some instances implemented. These include: The transformation of Community Nursing Services enabling an increase in capacity of 10% patient face to face contacts; The transformation of Intermediate Care Services (Darlington) resulting in redirection of resources into more appropriate service functions; The redesign of Community Matron roles and responsibilities to include both reactive and proactive service requirements; The introduction of an additional 8 Care Close To Home Practitioners; The development of the Virtual Wards concept in the Community; The design of a short stay assessment unit to reduce inappropriate admissions to Acute care settings; The alignment of services with a single Co-ordination Centre that will enable improvements in patient information, signposting and co-ordination of clinical interventions. 17

18 Key proposals 2011/ / / / 2015 Care closer to home Coordination Centre - aligned to all workstreams within the Clinical Strategy, and delivering: 24/7 access to bespoke administrative and clinical support for patients and healthcare professionals; a single standardised referral and assessment process to reduce duplication and streamline services (particularly administration), ensuring management efficiencies and cost-savings; opportunities for income generation.(see scoping paper) Virtual Wards - transitioning patients out of hospital at an earlier stage in their care pathway, in order that they can receive holistic multidisciplinary services within a home or community setting Short-Stay Assessment Units - providing a clinically-appropriate alternative to automatic hospital admission/readmission, thereby alleviating unnecessary burdens upon the acute sector 18

19 Key proposals continued 2011/ / / / 2015 Care closer to home Transitional Care Packages - targeting discharged patients who are deemed to be at increased risk, and for whom high intensity care within a community setting can be provided in order to prevent avoidable emergency 30 day readmissions Chronic Pain Care Service - reducing unnecessary pain management referrals to the acute sector, and improving patient flows by providing timely assessment services which enable care plans to be developed in the shortest clinically-appropriate time Front of House Services complementing the Older People s workstream by ensuring alignment of appropriate community services following patient redirection from the acute sector Prevention identifying appropriate opportunities for preventative healthcare within all Care Closer to Home activities 19

20 20

21 Our community portfolio As well as hospital services, County Durham and Darlington Foundation Trust now provides a wide range of community and health and well being services for adults, children, specialist services and health and well being. Many of these are provided across all our communities, although some are specific to different areas. SERVICE Darl Dales Sedg Eas Dside D& C-l-S ADULTS Community Nursing Continence Chronic Fatigue Physiotherapy Community Matrons Integrated Teams Wheelchairs Home Loans CHILDREN Children s therapies Health Visiting School Nursing Integrated Teams 21

22 SERVICE Darl Dales Sedg Eas Dside D& C-l-S SPECIALIST SERVICES Urgent Care Osteoporosis & Falls CASH Enteral Feeding CHD (inc. HF and CVD) Choices & Occupational Health Respiratory Dentistry Medicines Management HEALTH AND WELL BEING Library & Knowledge Tobacco control & smoking cessation Macmillan Cancer information and Support Service Building Health Improvement Capacity Food & Health Children, young people and families Health networks and partnerships Talking changes (IAPT) Workplace health & wellbeing Public Mental Health Health Trainers 22

23 SERVICE Darl Dales Sedg Eas Dside D& C-l- S ADULTS Occupational Therapy x Physiotherapy x x x Orthotics x x x Intermediate Care x x x X Dietetics x Speech & Language Therapy x Podiatry x SPECIALIST SERVICES Tissue Viability x x x X COPE / OPAS x x x x Diabetes x x x x Tissue Viability x x x x X Retinal Screening x Non scalpel vasectomy x x x X Palliative Care x x x x Pain management x x x Lymphoedema x X Dermatology/Minor Surgery x X Neuro/MS x x x Community Hospitals x GP Practices x x x x x 23

24 SERVICE Darl Dales Sedg Eas Dside D& C-l- S HEALTH AND WELL BEING Physical Activity x Community alcohol service x Mental health and learning disability x Clinical psychology x Healthworks x x x x X 24