We need to talk about Sophie Sarah Clegg Dona Milne
Background • Getting it right for Every Child • NHSL Strategy for Children and Young People 2013 -2020 • “Life stages” approach • Understanding the health needs of children and young people in Lothian
Background • NHSL Strategic Planning • Patient Pathways • Hannah, Scott, Callum, Sophie
• Patient pathway approach: – “will inform large and significant parts of the final plan” – “seen as major focus for staff, patient carer and third sector involvement”
Urgent local service planning and redesign continues across acute and primary care 1. Use our intelligence and evidence to agree about five fictional patients with varying degrees of care needs who illustrate key patient pathways. Callum 38, depression, alcohol, drugs 2. Map the care needs of these patients and how we currently meet them. Include both planned and unplanned care. Agree principles we are working to. Callum’s care pathway now 3. Get everyone together (patients, clinicians) to agree how we can meet these needs in a radically different way, taking into account agreed principles. 4. Use our data to plan how we deliver these pathways as services. Callum’s new care pathway Hannah’s care pathway now (LTCs, multiple morbidity) Scott 75, confusion, ↑BP, arthritis, diabetes Scott’s care pathway now Hannah’s new care pathway Workforce Finance Facilities IT etc… Hannah 60, diabetes, ↑BP, COPD PRINCIPLES e. g. workforce 6 dimensions of quality integration of H&SC etc… (younger, frequent use of emergency/urgent care) Scott’s new care pathway (frail, elderly) Sophie 3, epilepsy Sophie’s care pathway now Sophie’s new care pathway March 2014 April 2015
Hannah – overview of approach
The House of Care • Co-ordinated service delivery model • Oct 2013 report from The Kings Fund • All individuals with long term conditions not just “high risk” • Active role for patients – personalised care planning • Health professionals move from “primary decision maker” to partnership model
The House of Care • Link between care planning for individuals and commissioning for local populations • Best use of local authority services, community services and more traditional health services • Focus on reducing health inequalities, on prevention, anticipation and supported self -management • Person at the centre of all decisions
The House of Care
Sophie’s team • Clinical Team: Sarah Clegg, Lesley Ross, Edward Doyle • Public Health: Dona Milne • Strategic Planning: Mike Massaro-Mallinson, Fraser Mc. Jannett • • Public Involvement: awaited Modernisation Team: awaited Social care: awaited Data visualisation: Becky Kaye
GP record • • • Meds from 3 BNF chapters 9 med requests in last 12 months 3 courses steroids in last 12 months Letters from practice requesting asthma review Practice nurse 1 attended, 1 DNA 6 gp appts in last 12 months 1 gp DNA 1 dermatol referral – DNA 1 RHSC ARU admission– acute wheeze 1 referral CAMHS - ? ADHD 1 call NHS 24 – chicken pox contact query
TRAK record • 3 medical paediatric clinic appts – none attended • 1 community child health referral for behavioural difficulties - CAMHS • 2 IRD in last 2 years – exposure to domestic violence, concerns re level of care • 1 phone consultation with dieticians re weight gain/healthy diet
Sophie’s story • • Feels real to me What are the challenges What about school? Elephants in the room
Quality ambitions • Person centred • Safe • Effective • How do we make sense of it? • Where do we want to get to? • Principles
Next steps • Engage education and social care colleagues • Engage out with Edinburgh – already met with Midlothian and West Lothian colleagues • Voluntary sector engagement • Patient representatives • Planned event Spring 2015
? • • • What do you think? Is it a reasonable approach? Do you recognize Sophie? What have we missed? Who should we involve and what do we need to do next? • Where will we end up? What will we change?
Thank you sarah. clegg@luht. scot. nhs. uk 01315360471 07872417569
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