Delivering better services for people with long term conditions

Delivering better services for people with long term conditions

Share your thoughts:#BASSCpromise

Building Better Support for Carers | The Adult Services Stakeholder Conference | 19 November 2013

Paul WhiteProgramme Director, ProMISE programmeNHS Bromley Clinical Commissioning Group [email protected]


What is ProMISE? A quick reminder!ProMISE stands for:

Proactive Managementof Integrated Services for the Elderly(and Vulnerable)



Our aims for residents in Bromley:• Promote independence • Identify health and social care needs at

an early stage • Integrated working• Keep people well and at home• Improve value for money.



What is integrated care?• Integrated care starts from the needs of the

whole person. It is about:– Prevention of poor health through self care or

expert patient programmes– Empowering people to make choices, together

with health and care professionals– Intervening at an early stage before health

problems such as long term conditions get worse– Maintaining independence– Providing more care at, or closer to, home.



Some of our projects:• Free Urinary tract Infection (UTI) training

for carers• Risk stratification and case management• FLORENCE (FLO) award winning Simple

Telehealth system• St Christopher’s End of Life Care• Falls and Fractures Prevention Service• Patient liaison officers in GP practices


Bromley Healthcare



Rachel StreetOperations ManagerBromley Healthcare [email protected]


Who are Bromley Healthcare?• Bromley Healthcare is a community

interest company offering community health services to the NHS

• This means any money we make or money we do not spend can be put back into services

• Bromley Healthcare is run by everyone who works for us.






Case study examples



Dr Ruchira ParanjapePrincipal Clinical LeadNHS Bromley Clinical Commissioning Group


A tale of two patients


Mrs Smith

85 year old ladyFrailty and recurrent fallsCarer needsDementiaChronic Kidney DiseasePoor eyesightPresbycusis (Going deaf)

Mrs Jones

87 year old ladyFrailty and marked weight lossCarer needsAlzheimer’s dementiaChronic Kidney DiseaseDiverticulosis: condition that affects the large intestine (colon).


Mrs Smith and Mrs Jones

Mrs Jones and Mrs Smith have the same GP. She used clinical judgement to identify them as high risk patients and referred them for a detailed assessment by one of our Community Matrons, Sue.

Mrs Smith was happy to work through a proactive care plan with our integrated team, with the support of her carer, including social care assessment, advice on benefits, a carers assessment and offered additional help through local voluntary organisations.

Both Mrs Smith and Mrs Jones have similar symptoms but Mrs Jones declined the offer of additional support through the ProMISE programme.

Mrs Jones’ husband was naturally concerned about the financial implications of accepting a package of care but would not allow the Community Matron to arrange for the assessments and support that Mrs Smith received.

Mr Jones told the GP that his wife was becoming increasingly aggressive but that his two daughters would look after them and that they ‘did not need help’. One of the daughters has since given up work to act as a full time carer. They have called the GP out to the house twice as they feel worried that their mother is not being monitored.

Share your thoughts:#BASSCquestion


Key questionsWhat are your experiences of services – good or bad?

How do we improve services?

What’s missing from the services we currently offer?

What can we do differently?

How can we tackle health inequalities?



What are the challenges in Bromley?NHS England believe that everyone with a long term condition, including those with mental health problems, should be offered a personalised care plan that reflects their preferences and agreed decisions.

How can we ensure that we become dramatically better at involving patients and their carers and empower them to manage and make decisions about their own care and treatment?











NHS England – A call to action• How can we support people with long term conditions to

stay well? • How can the NHS and Local Authority work better

together?

• What other things could health and care services do to support people with their own care?

• Do you have any further comments on your experience of local health services, either through personal experience, or where you have cared for someone else?



Thank you!


Documents

Delivering better services for people with long term conditions