East and North Hertfordshire CCG - the change challenge. Slides from the impact and celebration event held in London on 24 February 2015.

1. Jacqui Bunce
Associate Director
Chris Badger
AD Integration CCG & Herts CC

2. The Change Challenge
‘Develop integrated physical, mental health and
social care pathways to prevent inappropriate
hospital admissions’

3. GPs, CCG Associate Directors, Social Care
Senior Managers

4. Impact & Benefits
• Improved relationships between
Health & Social Care
• Protected time for learning &
Development
• Skills and competencies to take
forward large scale change
• More confidence in using tools &
techniques
• More confidence in questioning
challenging data and use of metrics
• Tangible resultant outcomes for
patients:
– ESD, Homefirst, Better Care Fund

5. Highs & Lows
Enjoyable
Relationships developed
Positive relationship with
key NHSIQ facilitators
Tools and techniques, e.g.
SPC
Time commitment
Staff changes
Role of elected Members?
How to engage providers?

6. Significant Tools & Techniques

7. To ensure
60% of
people
who have
expressed
preferred
place of
death
achieve it
by 2019
Find out
where they
want to die
Find out
where
patients and
carers know
their
preferred
place of
care for
death
Ensure
resources
are
available
delivered to
support
different
choices of
Get ACP/PPD in
place
Share ACP/PPD
Culture where
people expect
to discuss death
to PPD / culture
of death being
demedicalised
Identify
resources
needed and
commissioning
contracts
AIM PRIMARY
DRIVERS
SECONDARY
DRIVERS
INTERVENTIONS
Social services contact with older
people – death wish 50% of SC
manager interactions include
discussion ACP by October 14
ACP talk and agree plans with
those with LTCs
Advanced care planning: GPs /
hospital / community / nursing
homes
Develop support for families in
helping them agree ACP / PPD
GP contact with older people –
death wish
Single assessment – advanced
care plans. Consent - DNAR
Develop a consistent way of
recording ACP
Place of residence i.e. patient’s
home – clear about ACPs
Staff education on how to do
DNAR
Apps or IT programs available to
make online choices
Train staff in discussion /
recording of ACP (HCP / SCP /
residential nursing home staff)
Funeral plan – incorporate ACP /
PPD / death wishes into pre-
payment plans
Funeral directors learn how they
talk - ACP/PPD/death wishes –
training?
Collate
responses
Carer support and training for
carers of patients who are
palliative
Peer support
development
Amber project
Public education: value of ACP
/ PPD
AIHVS
Create entry on patient record /
social care file
Ensure each provider ensures
everyone in organisation knows
the client’s ACP 100% of patients
with ACP have them avail in the
notes
Agree a process for sharing
ACP/PPD with providers %
admissions from NH for EoLC
Good death for patient and
family – who gets to decide?
Post-death
What support do families get
after the death?
Engage with
carers
Living
will
Perceptions about death in
society / from films / as failure /
dramatic & unpleasant
Power of attorney
Develop community services to
support EoL care at home Care home 1° care
project
Holistic
assessment unit
A&E navigator
NH contract for 1° care to encourage high
quality ACP/PPD - KPIs
Acute medical consultant
triage
Create capacity to fulfil
expectation
Standalone unit – hospice and hospital
Nursing home staff to avoid admissions for EoL
patients
Staff in care homes are trained
and not risk averse
How do we enable/commission
hospital to provide approp. EoL
care?
Ambulance Trust
– avoid
Voluntary sector
roles
Keep a shared register
move to share ACP / PPD
Develop hospice services for
those choosing them on PPD
Dedicated block capacity
for fast track care
Comms.
strategy
Ensure all
staff in
partner
organisation
s have
awareness
of how to do
a DNAR
50% SC
records with
ACP for O75s
asked if they
knew about
ACP and want
to start the
processAcute care
colleagues to
engage with
supporting good
deaths
No. of funeral
directors
participating in
the project /
who has
bought a
funeral plan in
the last 5 yrs
90%
of
NH
pts
with
PPD
at
hom
e
achi
eve
wish
12/1
2
No. of admissions by
Nursing Homes by
condition per quarter
Register of
shared ACP /
PPD
Balancing
measure:
1. reduce bed
occupancy
for EoL
patients
2. Increase
home care
costs

8. Statistical Process Control Charts
Used , and
understood,
across Health
and Social Care

9. What challenges have you faced
and how did you overcome them?

10. What contribution has the NHS
IQ programme made?

11. We’re on a journey………

12. Health and Social Care ……
Speed Dating

13. What was most useful about the
programme?
Relationships across health and social care
Joint understanding of health and social
care commissioning
Underpins ambitious Better Care Fund of
c.£120m

14. If you knew then, what you know
now, what would you do
differently?
• Think differently about elected
member engagement
• Spend time earlier on shared health
and social care issues
• Understand need to co-design with
NHSIQ and be flexible

15. What are your personal insights,
reflections and learning?
• Relationships drive integrated care
• Successful transformation of care built on
effective relationships across health and
social care system
• The importance of quality, facilitated,
time-out to plan and deliver change

16. Taking things forward