Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local...

Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson

Bringing clinical leadership to local health needswww.aylesburyvaleccg.nhs.uk

Creating a Coherent Common Vision for

Integrated Care

Dr Graham Jackson, Clinical Chair AVCCG

On behalf of Aylesbury Vale and Chiltern CCGs



Everyone working together to provide high quality personalised care, to help keep

Buckinghamshire people happy and healthy (optimising value from our collective efforts)

Our vision:

Healthy Bucks Leaders



Our Community

• Buckinghamshire - population 500k, wealthy county with better than average health outcomes and longer life expectancy

• Considerable variation underlies these figures

• Most common cause of death is heart disease and stroke (31%)

• Long term conditions account for 70% of health and social care spend

• Health receives 17% less than average through funding formula



Our Health & Social Care Stakeholders

• Aylesbury Vale and Chiltern Clinical Commissioning Groups• Buckinghamshire County Council

– (with 4 district councils)• Buckinghamshire Healthcare NHS Trust

– integrated community, acute and specialist care• Buckinghamshire Urgent Care

– out of hours primary care and Minor Injuries Unit at Wycombe• Oxford Health NHS Foundation Trust

– providers of mental health services to Buckinghamshire• South Central Ambulance Service



What is Integrated Care?

Professionals and services working together as a ‘team around the patient’ (National Voices, A Narrative for Person-Centred Coordinated Care, March 2013)



Meet Ethel

• Age 78 years, diagnosed recently with Dementia

• ‘Prisoner at home’; husband at end of tether

• Falls out of bed one evening when neighbour is sitting for husband (who’s shopping at Tesco – his only chance to go)



Ethel’s urgent care experience

Neighbour calls 999

Admitted to Dementia Care Home

Arrives in A&E•3 hour wait•Sprained ankle, no fracture•Drs have no idea of Ethel’s usual cognitive ability •No transport back to Winslow at midnight - admitted•Three week stay (average for dementia patients)•decreased mobility, increased confusion so increased medication

Ambulance performance based on time to respond – need to get Ethel to hospital and move to next patient, no incentive to keep her at home

Hospital fined for A&E waits over 4 hours, increased funding for admission rather than just A&E attendance, no funding for transport home

Dementia care home happy for income, early admission means quicker loss of independence. Ongoing cost to Local Authority and to family



What Ethel’s experience should have been

Early diagnosis, support

networks set up for Ethel and her

husband

Home with additional support for two

weeks

Arrives in Minor Injuries centre

Ethel remains at home for a longer period of time, with maximum independence. Husband happy to continue care as he has regular breaks and robust local support

• Ambulance has seen patient notes and transports Ethel to GP led unit for check x- ray.

• Dr aware of Ethel’s cognitive ability and knows to avoid admission if at all possible

• Transport organised home• Social services assessment

following day• Exercise programmes on you

tube to maximise mobility Physio follow up booked at local community hospital

Community Prevention worker, Alzheimer's society, regular breaks for carer husband. Weekly music therapy and maximum independence in a Dementia friendly Town where people are trained to support dementia sufferers



Existing examples of Integrated Care in Bucks



Next steps

Enhancing self care and long term conditions managementHigh quality information, education sessions, expert patient programmes, support groups and online networks. Shared decision making, increased use of technology and population outcomes commissioning.

A tailored approach for higher risk groupsUnderstanding our populations and the different health challenges they face

Prescribing lifestyle changes social prescribing that requires changes in behaviour, front line staff raising lifestyle issues at every opportunity, signposting to support services

Addressing mental wellbeing needs for patients and carers including advice on staying healthy and being emotionally resilient



• Establish shared leadership; develop a persuasive vision • Create time and space to develop understanding and new ways of working• Bottom up as well as top down approach• Welcome to Lesley Perkin as our Programme Director for Integration!• Share information • Use the workforce effectively • Innovate, innovate, innovate!

Healthy Bucks Leaders is working to the Kings Fund ‘16 steps to integration’ which include:

Next steps



1. We are learning organisations – and need educational support

2. We work to evidence based practice3. We want to innovate – but with academic rigour to ensure we

do this properly for our patients

Why we need an Institute of Integrated Care

Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson Bringing clinical leadership to local...

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