Caring for patients is increasingly complex and complicated, and this is particularly true for frail, elderly patients.
This isn’t just because medical care offers more opportunities or that it is more challenging. There are always issues of resources, but often the parts for an excellent care service – including the NHS, social care, mental health and the voluntary sector – are all there, but somehow there is something missing. That something is called integration, in the current parlance, but really embodies something more than that. It is about a sense of cohesion - a team working together and not being bound by traditional boundaries, the efficiencies of the whole being greater than the parts, the gestalt.
In North Tyneside, the CCG is working with other agencies in an attempt to produce this. It is hoped that significant changes can be made to the way the NHS and other partners from across the region works together to support those with the highest needs.
In its first pilot site we are working with GPs in a single locality, Northumbria, the local secondary care trust, North Tyneside Local Authority, local mental health trust NTW, and the voluntary sector, especially Age UK.
We have a great opportunity to develop a new team to deliver care planning, rapid response and to get patients out of hospital faster, within a defined group of high needs patients. We want to rationalise their care and assist them in getting that in the best place, and keep them at home when that makes more sense.
We aren’t able to put a great deal of money into this, but are re-using well tried and trusted parts differently. But where we are linking in a new service we are in a great position to try out ideas and real transformation. A good example is with Age UK, where using Promoting Independence Coordinators workers, who will find out patients’ goals and aspirations and develop a plan to match this.
Widening skill mix
The goal is to re-focus patient support away from the typical medical choices. There is also a chance to look at how traditional general practice, which will have resource freed up, can develop a different ways of working. This will address issues such as widening skill mix, developing more effective long-term conditions plans and how we deliver urgent care.
This sounds like it should either be very easy, as it’s not much different to what happens now; or very difficult, because it’s not much different to what happens now, but appears not to deliver. So this is very much about an iterative development of this new service, which allows all of the disparate members, including patients, to have their say from the ground floor, where sometimes small developments, or changes in relationships, will make the biggest gain to the system.
- Dr Martin Wright is a GP in North Tyneside and North Tyneside CCG’s medical director