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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
Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson
Bringing clinical leadership to local health needswww.aylesburyvaleccg.nhs.uk
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
Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson
Bringing clinical leadership to local health needswww.aylesburyvaleccg.nhs.uk
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
Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson
Bringing clinical leadership to local health needswww.aylesburyvaleccg.nhs.uk
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
Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson
Bringing clinical leadership to local health needswww.aylesburyvaleccg.nhs.uk
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)
Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson
Bringing clinical leadership to local health needswww.aylesburyvaleccg.nhs.uk
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)
Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson
Bringing clinical leadership to local health needswww.aylesburyvaleccg.nhs.uk
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
Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson
Bringing clinical leadership to local health needswww.aylesburyvaleccg.nhs.uk
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
Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson
Bringing clinical leadership to local health needswww.aylesburyvaleccg.nhs.uk
Existing examples of Integrated Care in Bucks
Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson
Bringing clinical leadership to local health needswww.aylesburyvaleccg.nhs.uk
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
Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson
Bringing clinical leadership to local health needswww.aylesburyvaleccg.nhs.uk
• 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
Chief Officer: Louise Patten Clinical Chair: Dr Graham Jackson
Bringing clinical leadership to local health needswww.aylesburyvaleccg.nhs.uk
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