Www.traffordccg.nhs.uk RIGHT CARE RIGHT TIME RIGHT PLACE Healthier Together and five year strategic/...

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RIGHT CARE RIGHT TIME RIGHT PLACE

Healthier Together and five year strategic/business plan Local Conversation

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


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.


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


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


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


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


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


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


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

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

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



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



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



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)


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


More information from

www traffordccg.nhs.ukwww.healthiertogethergm.nhs.uk


Case Studies


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.


What this means for Brenda in the futureOn 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.


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



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

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

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.

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.

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