Paul Maubach, Chief Accountable Officer Dudley CCG. Paul's slides from the presentation at the West Midlands 7 Day Services Event on 11th June, 2014

1. Moving to 7 Days Services in
Dudley
Paul Maubach
Chief Accountable Officer
Dudley CCG

3. Local Dudley
Service Provider
‘Our caring, compassionate and highly
experienced staff are available 24 hours a
day where you can be guaranteed of a
personal service from the first call. If you
can't get to us don't worry, we will be
happy to visit you in the comfort of your
own home’

4. Deaths by Day in
Dudley - 2012
Weekday Deaths Day Count
Average
Deaths per
Day
Sunday 400 53 7.547
Monday 411 53 7.755
Tuesday 396 52 7.615
Wednesday 396 52 7.615
Thursday 420 52 8.077
Friday 436 52 8.385
Saturday 398 51 7.804
Grand Total 2857 365 7.827

5. Strategic Priority
 Privileging Population Health and Wellbeing
• Autonomous individuals
– Preventing / resolving dependency
• Registered population
– Aligned, networked service delivery
• Mutual responsibility
– Understanding the value of what we do
– Sharing our social capital as a community

6. Dudley CCG: context
 CCG registered population = 312,000
 48 practices
 10 single handed practices
 Mixture of wards including some in the lowest
20% for most deprived across the country and
some in the top 20% of most affluent.

8. Dudley Health and Social
Care Economy – The
Opportunity
 Unnecessary emergency admissions
 Excessive service usage by over 80s
 Too many admissions to nursing and residential
care
 Recognition by partners of the need for a step
change in service delivery
 Commitment to redesign urgent care
 Evidence that 5 day working creates dysfunctional
service pressures

9. 7 day services:
variation in delivery
-15
-10
-5
0
5
10
15
20
Mon Tue Wed Thu Fri Sat Sun
Average Net flow of Patients (admissions vs discharges)

10.  Post weekend peaks in admissions
 Postponement of discharges due to absence
of support services – therapy, pharmacy etc..
 Unnecessary admissions due to absence of
more appropriate primary and community
health services
 Inconsistency of patient experience and
response, 7 days per week
7 Day Response To
Avoid…..

11. Person
GP
Practice
Community
Clinical
Commissioning
Group
Registered Member
Based in a Locality
Part of a System
Aligned, Networked Population Health and Wellbeing Services

12. Integration and Better
Care Fund 7 day services
Community
Rapid
Response
Team
OD:
Leadership
programme
Prevention
agenda and
tele-health
Risk
stratification
Single point
of access
Dudley Care
Home
programme
Integrated
teams

13.  Dudley was successful in applying to be one of
the National Early Adopters
 Cross health economy working group set up
 Working with NHS Improving Quality Team
Three main areas of focus
 Mapping of services
 Developing community standards
 Sharing best practice with other early adopters
7 day services

14. Community Mental
Health Teams: adults
and older people
Palliative
care team
Heart failure-
joint pathway
with acute
OT
Physio
Care home
nurse
practitioners
Stroke
Neurology
Social
service
teams
SLT
Current 7 day working
From July 2014
Potential to move to 7
days in 2014
MH Crisis
Resolution
Community
Rapid
Response
Team
Tele-care
services
Dementia
Gateways
District
Nurses
Current
7 day
working
Intermediate
Care
Community
Respiratory
Team
Virtual
ward (Case
Managers)
Care home
provision

15. 1. Patient experience
2. Integrated team review
3. Information and communication
4. Diagnostics
5. Speed of access and assessment in the
community
6. Mental Health
7. Quality Improvement
8. Palliative and End of Life
Community Standards

16. Evidence base:-
 19,500+ over 65 arrived at ED
 14,500 admissions over 65
 10,000+ over 75
 6,500 admitted for 2 days or less
 85% arrived by ambulance
Community Rapid
Response Team

17.  Team of 9 Advanced Nurse Practitioners
 Integrated with social care assistants and care
home nurse practitioners
 ANPs take a referral or intercept 999 green
code call
 Assess, diagnose, initiate treatment, instigate
social care package if required and step down
to integrated teams
Community Rapid
Response Team

18. Community Rapid Response Team for Older
People with Frailty
Integrated with Care Home Nurse Practitioners
and Social Care Assistants
PATIENTS
WMAS
NHS 111
GP Out of Hours Community
Nursing Teams
Assessment by ANP or Care Home Nurse Practitioner
Within one hour
Step down to Locality Integrated Teams
Single Point of Access for
Advanced Nurse
Practitioner
Based at WMAS
Admit to
EAU
- Initiate treatment →
- Initiate care package → up to 7 days (then review)
- Initiate care plan

19. Practice integrated teams
 To consist of GP, pharmacists,
community nurses, named
social and mental heath
workers. To review risk
stratification tools and agree a
Care Coordinator for complex
cases
Locality MDT teams
 GP Leadership posts in each
locality. Remit of reviewing
collective outcomes of all teams
in their locality and ensuring
pathways to locality to borough
wide services function
effectively
Service Integration

20.  Over 2,200 residents in nursing and residential
homes registered with a Dudley GP
 High number of urgent care admissions
 Dudley Care Home LES operates to provide
proactive care and initiate advanced care
plans.
 Team of 6 care home nurse practitioners to
double in size to be integrated with rapid
response team and become a 7 day service.
Dudley Care Home
Programme

21.  Community nursing and therapy services have
a single point of access
 Social services have a single point of access
 Both in the same building!
 Moving to joining together and include mental
health
Single point of access

22.  Develop self care programmes
 Develop remote monitoring tools (tele-health)
 Increase utilisation of voluntary sector
(community link workers)
 Social prescribing
Prevention agenda

23. 0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
Numberofadmissions/attendancesinfollowing
year
ACG Probabilityof Future High Cost
ActualAvg no FHS
ActualAvg no OPAs
ActualAvg no AE
Attendences
Risk Stratification
 Identification of risk using ACG tool
 MDT Care Planning
 Care gap

24.  Imperative that community practitioners have
access to pertinent information and
particularly for a 7 day service when practices
are closed.
 All practices now on EMIS web
 Piloting tablet using ‘Inchware’ technology to
access medical information remotely including
the ANPs
Mobile technology

25.  Representative approach:
 Patient perspectives a standard item on the integrated
working group
 Aim is to capture the actions and improvement that need
to be implemented.
 Feedback given to the patient, carer or advocate that
provided the story/experience.
 Participative approach:
 Development of systematic tool (PSIAMS) to record the
patient experience of care
 Enables patient to chart their progress against outcome
goals
Learning from patient
experiences

26. The Overall Purpose is:
 Improve patient experience, and their health and well being outcomes
 Improve patient engagement, to increase their autonomy to take control
over their own care.
 Develop collaborative relationships between patients & integrated teams.
 To improve collaboration and cross-boundary working between
organisations.
 To work towards a culture change, that demands values based care, and a
can-do attitude.
The Specific task is:
 To address the issues of complex cases demanding multi-agency
approaches
Mutual Networked Leadership, shared population, shared outcomes
Leadership programme

27. Strategic Priority
 Privileging Population Health and Wellbeing
• Autonomous individuals
– Preventing / resolving dependency
• Registered population
– Aligned, networked service delivery
• Mutual responsibility
– Understanding the value of what we do
– Sharing our social capital as a community

28. Questions?