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Bay Health andCare Partners:guide to our plansfor 2017 - 2018

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Bay Health and Care Partners is a partnership which is working to improve the way health and care is delivered across the Morecambe Bay area. Bay Health and Care Partners is made up of ten health and care organisations who are working together to deliver the Better Care Together strategy.

Together we want to:

• Enable our communities to be as healthy as possible

• Ensure that health and care services that are provided across north Lancashire and south Cumbria are the best possible

• Meet the health needs of the local population, now and well into the future

How do we plan to do this?

Health professionals will work in partnership with their communities in local areas to keep people as fit and well as possible, both mentally and physically.

They will do this by helping people manage their own conditions – either at home or within their local community, and by developing an “Accountable Care System” to allow health organisations to work more closely together to maximise the impact of our resources, and stop unnecessary duplication.

What will we do during 2017 – 2018?

We want to build on the successes of the past two years: we have already developed a number of new models of health care. This is thanks to the hard work of staff from across the Morecambe Bay area and the support and funding we have received by being an NHS England Vanguard site. For more details of the successful projects that have been delivered so far, you can read our booklet: Better Care Together – What have we done so far?

There are a number of plans for the year 2017 -2018, and the following is a brief snapshot of the improvements we want to make. We really value patient, public, community, voluntary and faith sector input into our planning, and will continue to learn from their feedback and their own community-led health initiatives. Please do get in touch if you would like to be involved in anything you read about in this guide.

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IntroductionThe Better Care Together strategy often arranges new models of healthcare by working in clinical “workstreams”. These are areas of health which have been grouped together due to their similarities, either in the location they provide care, or in the type of healthcare they are looking at.

During the next year we will be looking at

1. Elective care – sometimes known as planned care could include referrals for outpatient appointments, or surgery which is planned to take place (as opposed to surgery during an emergency)

2. Women’s and Children’s – which covers everything from pre-conception health to pregnancy, birth and children’s health

3. Out of hospital care – which includes people looking after themselves at home (self-care), keeping people living with frailty at home and independent, GP surgery appointments, and personal health and wellbeing.

4. Prescribing – which covers how to use prescribing budgets in, and out of hospital, to best effect

These clinical workstreams are supported by other worksteams who ‘enable’ them to do their work. These include:

Patient and public engagement and communications so that people can get involved in changes to healthcare and find out more about them

Information Technology to help people work differently in a more convenient and efficient way – e.g. sharing data across health professionals to speed up patient care, using telehealth so patients or clinical staff reduce their need to travel, an locally-developed Advice and Guidance scheme by which GPs can have secure electronic conversations with hospital specialists to establish the best treatment options for patients, sometimes without the need for a hospital outpatient appointment.

Workforce and Organisational Development who focus on projects to recruit and retain high quality and talented staff, and also offer excellent apprenticeship schemes to increase the number of young people from the local area choosing a health and social care career. They also help to ensure health and care staff have the skills to carry out their current job as well as plan for future roles.

This guide focuses on the work of our clinical workstreams, if you would to know anything more about the supporting workstreams that act as ‘enablers’ please do get in touch: The contact details are at the end of this guide.

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Elective careclinical workstreamOur vision:

To deliver consistent care pathways, which require fewer hospital outpatient appointments and more care delivered closer to home. This will lead to better access to services both in and out of hospital, increase the number of people managed in the community, help us develop Specialist Community Teams; and improve joined up working. This will result in a better patient experience.

Our plan:

1. Work to ensure that hospitals focus on the care that only hospitals can provide by providing more non-complex care in local communities.

2. Offer the ‘Patient Initiated Follow Up’ service to more people with stable long terms conditions so they can access clinical teams when most needed, such as a flare up of their condition.

3. Where follow up appointments are needed, we want to ensure individuals are consulted by the right professional, in the right place - this may not be face to face as we explore the use of telehealth. Telehealth refers to receiving health advice using a video camera and a screen, and it allows people who are not in the same room as each other to give and receive health advice.

4. Improve care pathways: we have already made positive changes to care pathways in, for example, ophthalmology. Going forward, we want to make improvements to the care pathways for pain management, musculoskeletal care, rheumatology, ear nose and throat and maxillofacial

5. Offer self-care support for people on these care pathways to empower them to manage their own conditions at home, where it is safe and appropriate to do so.

6. To offer more cost effective ways of delivering care to make the most of the scarce NHS resources

We hope patients and public will benefit from:

• Reduced travel e.g. Patient Initiated Follow Ups and telehealth appointments will act as alternatives to face-to-face appointments, so will reduce the need to travel.

• Increases in the number of people managed in the community so that people can maintain their independence, where safe and possible.

• The provision of more care, closer to home e.g. in local communities, so it is more convenient for people.

• A smoother patient journey between different parts of the health and care system.

• By reducing the number of people seen in outpatient clinics, we hope that for those who still need to be seen, they will be seen sooner.

• Further improvements to the quality of care and services, which people receive.

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Women’s and children’s clinical workstreamOur vision:

To provide improved care for women and children from pre-conception to birth, childhood and adolescence; resulting in long term improvements in the health of the population.

Our plan:

1. To ensure more children undergoing support from health care have specialist nurse support both in and out of hospital.

2. To create an Integrated Children’s Nursing Team to improve joined up working between hospitals and community care.

3. To offer more appointments in local community bases, with Paediatric hospital specialists working outside their normal hospital bases.

4. To improve the care for emotionally distressed children and young people, and their experience of being an in-patient on a children’s ward.

5. To arrange shared training for health professionals working in hospital and community settings, to improve consistency of care for patients.

6. To trial the use of telehealth to reduce travel for children with outpatient appointments in other places


• Specialist nurse support to cut down multiple trips to GPs and hospital outpatients which will mean more consistent care, reduced travel, and more convenient care.

• A reduction in children being admitted to hospital: the majority of children, and their families and carers prefer to be at home than in a hospital bed, unless they absolutely need to be there.

• Children and their families having to make fewer trips to the Emergency Departments (also known as Accident and Emergency).

• Easy access to advice on the common conditions children suffer with e.g. coughs and colds, fever, constipation and gastroenteritis.

• More streamlined and joined up services for young people with long- term conditions.

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Out of Hospital Clinical WorkstreamOur vision:

To provide local populations with community-based care and access to integrated services (including primary and social care) at the right time. 12 “Integrated Care Communities” (ICCs) have been created to help bring together local health and care organisations– and their work will ensure that local people are supported to improve their own health and wellbeing, and that when people are ill or need support, they receive the best possible joined up care. The work of ICCs will help reduce some of the pressures in hospitals.

Our plan:

1. To work across the Morecambe Bay area to achieve a consistent approach to population health, prevention, self-care and health and wellbeing.

2. To support communities to develop of a network of community health champions and initiatives that help to make communities happy and healthy places to be.

3. To deliver programmes of self-care for long term conditions, including Type 2 Diabetes, Cardio Vascular Disease, Respiratory, Cancer and Frailty.

4. To improve the care planning for people living with frailty, intervening earlier so we support people before they need acute medical attention.

5. Offer an Intermediate Care Facility in north Lancashire to complement provision already available in south Cumbria, which will offer short term residential and nursing care for people who no longer require acute hospital care – but still need support before they return to independent living, and “step up” care for people who need additional support but don’t need the specialist services a hospital provides.

6. To work with colleagues in the elective care clinical work stream on a care pathway for people with musculoskeletal conditions.


• Not being in hospital any longer than they need to be.

• Staying healthy longer through the availability of more preventative care.

• Their conditions not worsening because of earlier intervention.

• A rapid response for people who deteriorate so they recover quicker.

• Feeling supported to manage their own long term conditions e.g. diabetes.

• More care being provided in their local communities with speedy access to specialist advice when required.

• Intermediate care being offered to the people of north Lancashire for those needing additional support but not requiring specialist hospital services.

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Prescribing Clinical WorkstreamOur vision:

Our vision is to make best use of the prescribing budget to improve the health outcomes of people in the Morecambe Bay area. We will do this by offering the right treatments that are of good quality, that are evidence based and improve the consistency of care across the area.

Our plan:

To focus on a variety of areas of prescribing across the Morecambe Bay area with the aim of achieving prescribing savings without adversely affecting patient and public care e.g. through avoiding waste and ensuring cost effective buying processes. Across Morecambe Bay we spend approximately £90m every year on prescribing.


• A more consistent offering from their clinician, wherever people are treated in the Morecambe Bay area.

• The knowledge of which products or treatments can be bought over the counter without a prescription.

• Being prescribed a treatment that is evidence-based i.e. it has proven benefits.

• Being prescribed treatments, including newer products, that have been clinically reviewed to ensure people benefit from up to date treatments.

Further information and contact details:

If you require any further information, or would like to get in touch, you can do so by one of the following ways:

www.bettercaretogether.co.uk

[email protected]

@BCTMorecambeBay

Better Care Together NHS Moor Lane Mills Moor Lane, Lancaster LA1 1QD

Tel: 01524 518638

Other formats

If you would like to receive this information in an alternative format, then please contact: 01524 518638. Useful Contact Details - NHS Direct (24 hour health advice): 111.

Documents

Bay Health and Care Partners: guide to our plans for 2017 ... · PDF fileBay Health and Care ... Bay Health and Care Partners: guide to our plans ... that are evidence based and improve