Tuesday, 27 January 2015
Pioneer one year on event
Progress from sites
Greenwich
- Care navigators; person centred
- No evidence, reporting scheduled for April
Leeds
- Strategic starting point on enabling practitioners to read across care plans through
shared portal; rolled out across 13 integrated teams across Leeds
- 89 out of 113 GPs using it; only 44 people have not wanted information shared out of
100,000 plus
- Major PR exercise owned and developed by health and well being board to bring
people together and on message; regular meetings of leaders and providers to keep
everyone together and ensure coalitions between providers
- Good feedback from practitioners in using it, accessible remotely
- Single view of GP patients on hospital at any one time is next stage
- Evidence of trends on hospital admission following integration of care teams
demonstrating a reduction for those teams against trends in rest of the city; running
5/10% reduction from those areas
- City single strategy for informatics is a single version of the truth; moving forward to
patient portals to own their information with the degree of in reach for individuals into
this system yet to be determined
- The "Leeds" pound - bringing providers and commissioners together overseen and
managed by the Health and Well Being Board. H&WBB spent a year in shadow
format focussing on relationships and single priorities and not the "what"; ensuring
that organisational benefits are clear and what everyone gets from joining up
Staffordshire
- Focus on commissioning end of life and cancer outcomes
- Outcome is around increasing survival rates and improving patient experience
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Tuesday, 27 January 2015
- No one provider or commissioner has responsibility for ensuring that the system
works; focus on creating single provider responsibility across outcomes
- Desire to move to supply chain management and integration across outcomes
- Moving towards 10 year contracts for providers to ensure consistency and continual
improvement
- Co-designing outcomes and systems with people and community
- Practitioner and patient champions
Waltham Forrest, Tower Hamlets and Newham
- Focus on self care and self planning based on risk stratification
- Care navigators and case management into community
- Treating people in the most appropriate place
- A "PA" for the patient
- Evaluation through full time academic
- System wide metrics & informatics work stream
- Significant reduction in patient activity for the cohort
Islington
- Wide ranging cradle to grave
- Continual quality improvement
- Starting with complexity and moving across GP patient cohorts
- Lots of experience with pooled budgets and integrated commissioning
- Bringing staff together to support design; focus on patient narrative
- House of Care; motivational interviewing, peer support, clinicians and nursing teams
aware of and understand self care principles
- Value based commissioning and embedding person centred outcomes within
commissions practices; commingling across patient diabetes pathway for wellness not
managing ill health
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Tuesday, 27 January 2015
- Ambulatory care; real time review through MDT teleconferencing
- Opportunity for education provider network supported by NHS England; bringing
together agencies to debate collaboratively around workforce development and
planning for the future. Looking at acute/general practice interface, particularly across
geriatrics.
- Continual quality improvement, understanding what works, listening and adapting in
an iterative way
South Tyneside
- Social prescribing against a quality framework
- Embedding self care messages into community teams
- Workstreams looking at behaviours and messages across teams
West Norfolk
- Practitioners need empowering and liberating to deliver good services and good
relationships
- Alliance across providers including community to address issues raised by people in
the community
- Establishing software that shared data across primary care and other health partners;
Smart Cards to look at live data
- Telemedicine triaging in care homes
- Recruitment portal across all care teams to encourage people to come into care and
grow own staff teams
- Looking at upstream interventions to maintain independence; care navigators, data
base for later years (information gateway to provide advice and support)
- Focus on workforce development; need grass routes empowered teams; action
learning sets, joint induction, events to stimulate making a difference, clear routes
through to action and decision making
- Single decision making, shared assessment, shared locations, pooled budgets,
metrics and shared truth
Ian Dodge
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Tuesday, 27 January 2015
Pride and confidence is key for Pioneers, we need to be clear about our progress and
shout loud about our achievements. NHS often is embarrassed about self promotion and
poor at communication. Don't be.
7 messages from Pioneer programme as programme develops and move forward to
NMOC. Application sites are expected to demonstrate this in the bidding process.
- Has to be ground up for people to see the possible beyond the confines of their
structure and organisation
- Integration isn't the end goal, don't apply to be a Vanguard to test organisational form;
bid to test your value and purpose, to test quality of care, to improve experience and
to save money
- Patient centred is not a buzz word, it's about choice and control. It's about personal
health budgets, integrated personal commissioning. Be clear about people owning the
change and how you evidence this.
- Reflect how the bid will breakdown false demarcations
• between informal care provided by people, carers, communities - doing things for
people, and professionals , doing people for people
• the split between prevention and reaction
• the divisions between mental health
• The silos around commissioning versus providers
- Working on the enablers for integration, specifically the role of technology in
integration. Digital channels, tools and techniques, not just bolting it on but using it to
deliver differently. Workforce development needs to challenge the roles and traditional
skill sets not just integrate what we have. Procurement and competition as an
embalmer not as a blocker; how can we flex this to grow our own
- Sharing good practice, sites have to be able to respond quickly and share across
Cornwall. Not enough to spread within communities, must have a responsibility to
spread across country to be able to get bets value. It's incumbent on the centre to
help local sites to solve challenge faster and then deliver this in other sites.
- Pioneer predates 5YFV. Name checked Cornwall's boldness. "The boldest measures
are the safest". Be bold and brave in your ambition and in your application.
Norman Lamb
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Tuesday, 27 January 2015
Our responsibly to think beyond the traditional landscape of acute, secondary and
residential to think differently and shape around people.
This isn't about integration of health and social care, it's the integration of community,
practitioners and people.
Many pioneers are testing the 5YFV, which has all party support and will encourage
commissioners and providers to work with what you have, dig in and make it work. Years
of experience tells us that structural change from the centre doesn't give you what you
want and takes resource and time away from the system
Information sharing is a key issue and more resources will be available for Pioneers to
get solutions to information sharing.
Second wave launched; Sheffield combining budgets; Airedale, expanding programme
to integrated digital record; Camden developing multi rapid response and hospital and
home schemes plus another 8.
Focus going forward will be to align across priorities in 5YFV to test and develop this is
the blueprint for the future. Funding, resources and support will all be aligned to 5YFV
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