“Wrapping care around you”

Joining up care for people with long-term conditions

Welcome

Graham Foulkes

CCG Lay Member for Patient & Public Involvement

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What is Oldham CCG? • We’re your local healthcare commissioner, and we’re here to work towards delivering

healthier lives for everyone who lives in Oldham.

• Our vision is simple. We want to deliver improved healthcare for everybody in Oldham by commissioning (planning and buying) the highest quality services available.

• We want to provide these high quality services as close to our patients as we can, in a joined up way, giving them the best possible value for money.

• Our objectives are based on a ‘triple aim’ approach, and are closely aligned with our vision. They are…

• To improve the health of the people of Oldham• To improve the care they receive and their experience of it• To deliver best value for money by using our resources effectively

Setting the scene…

People are living longer, often managing one or more long-term conditions such as diabetes or respiratory conditions

These patients often receive care (both health and social care) from a range of sources.

This care is generally good but it is often un-coordinated, leading to fragmented care, duplication and avoidable admissions to hospital.

Today, we want to hear your experiences of community care and exchange ideas for joining up care more effectively.

And we want to identify people who are keen to help us shape the way our services are commissioned in the future.

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Why we need to do things differently

Dr Ian Wilkinson

Chief Clinical Officer

Oldham CCG

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The end of the current contracts for community services presents an opportunity to rethink how community services are managed and delivered.

People with long-term conditions may have a whole range of people caring for them, including their GP, Practice Nurses, District Nurses, Community Matrons, Hospital Consultants, Audiologists, Podiatrists, Social Care workers etc.

This is on top of their families, carers and the voluntary sector who all provide a vital role.

But these people often do not work as a team. They work for different organisations, with different working practices and may not communicate with each other well.

For patients this can mean repeating your details several times and potentially getting confused about who is looking after you for which problem – and who is responsible.

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Why we need to do things differently…

Lack of co-ordination means patients can lack confidence that their conditions are being managed properly.

Patients aren't sure who to call when they are worried or their condition exacerbates.

All too often, they end up being admitted into hospital via A&E. Each one of these unplanned admissions is an expensive failure of the system.

Here in Oldham, we’re taking a joined up approach to improving health, but it’s not a new concept.

It’s not about cost reduction. Integrated care is about doing the right things, in the right places, at the right cost, at the right time.

Our progress on integration so far…

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• We’ve developed partnerships between health and social care both in terms of commissioning (buying the services) and delivering (providing the services) over many years.

• Joint commissioning of services such as mental health has been around in Oldham for several years.

• The arrival of 'clinical commissioning' and the development of local clusters of GP practices has put a renewed focus on the whole patient journey, holistic care, and opportunities to move to devolve the running more locally.

• All the providers of care are 'up for' working closer together to deliver local, responsive, integrated care. The time is right!

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Our progress on integration so far...

Have your say…

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We’d like to hear your experiences of receiving joined up or fragmented care and hear your thoughts about what really top quality, joined up, responsive community services would look like to you.

Maybe you’ve had a really great experience that you think could be used as a model for the way we do things in the future, or perhaps you’ve had a not so great experience that you think should be flagged up as the thing to avoid doing?

Perhaps you’ve got some ideas about how communication between care organisations and providers could be improved, or about the way you receive communication about your condition?

Everyone’s experience and opinion counts, so tell us what you’re thinking, and how you’d like to see services wrapped around you in the future.

• Tell us about your recent experiences of receiving care, or caring for someone who’s been receiving care.

• Was it joined up? Did it feel complicated? Were there obstacles in the way of getting things sorted out?

• How could we have been better at joining the dots between local services within the time, cost and capacity constraints we’re facing to improve patient care?

• Jot your experiences down and let us know how it felt.

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Tell us about your current experiences of receiving care in Oldham: 20 minute exercise…answers on a Post It Note!

Feedback

• Three key points from each group on what primary and community care feels like at the moment.

• All feedback will be collated and fed into the Wrapping Care Around You programme team.

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Sharing our thoughts, testing our ideas:Developing integrated care further

Dr Zuber Ahmed

Clinical Director for musculoskeletal services

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We’d like to create 8 locality teams across Oldham, designed to deliver care in a co-ordinated way around the patient, and join up the services they need to access across health and social care.

And we’ll also create four locality planning teams, who will plan patient care – each responsible for two of the locality care delivery teams

Local GPs would lead these teams, which would consist of staff from a number of organisations across local care.

Patients meeting the criteria for this approach would continue to receive care locally, with visits from health and social care team members at the same time.

And we want our patients to influence this new approach to care, by helping us to shape the way we commission (buy) these services.

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Locality teams: wrapping care around the patient

What would these locality teams provide?

• A joined up patient experience, bringing together the different kinds of care and support that patients need from various providers.

• Planned, timely care especially for patients with a long term condition.

• Reducing repetition and duplication, preventing the need to explain your needs and experiences to numerous health and social care professionals.

• Genuine continuity of care.

• A personal, tailored service wherever possible.

• Shared decision making between patients and the people who look after them

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And what do we want locality teams to achieve?

At locality level, care reflects local needs, concerns and cultures instead of a one-size-fits-all approach.

We want patients and their carers to see a positive difference in the way their care is provided. It should feel like treatment is being co-ordinated and the care givers are communicating with each other and duplication is removed.

We want patients’ total needs to be co-ordinated, interventions connected, pathways of care to be seamless.

We want all involved care providers to be working to the highest possible standards so that the patient experience is improved.

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We want to get from this…

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To this…healthcare wrapped entirely around the patient

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Over to you…again! Group exercise, 20 minutes

Answers on a Post it again please, but focus on giving us your comments one of the following areas – see handouts for more information:

• Access

• Locality Teams

• Patient Involvement in local services

• Working Together

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Feedback

Three key points from each group on each key topic – what are your big ideas, key concerns and top suggestions?

All feedback will be collated and fed into the Wrapping Care Around You programme team.

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Thanks and next steps

Graham Foulkes

Lay Member, Patient and Public Involvement

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Wrapping care around you…what now?

Thank you to all of you for coming along and sharing your thoughts, ideas and concerns with us today.

The aim of this engagement work is to understand the problem of fragmented community care and share ideas with us for making things better.

When we’ve gathered your ideas and feedback, we’ll share this with our members, our Governing Body and our partners who will work with us to develop a new way of providing community services through the locality teams, which we think will both lead to more joined up care and more locally responsive services.

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Wrapping care around you…what now?

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• We’ll use your experiences, ideas and thoughts to identify and group the most popular ideas for further development which we will come back and present to you.

• We’ll also tell you more about how these ideas would work, alongside the plans and ideas our members have had, and give you the opportunity to help refine our plan before we put it into action.

• We’d like to recruit a team of volunteers to help us and input their thoughts and ideas into the reprocurement of our community services.

• If you’d like to get involved with shaping the specifications for the locality teams, helping us to buy services that you think would really benefit patients in the longer term and giving us your input into what might work best, please let us know.

Thank you

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