Browne Jacobson - Elderly Care Conference 2016 - Keynote presentations

Elderly Care Conference 2016
Keynote presentations

Welcome to the
Elderly Care Conference 2016
21 April 2016
Birmingham
Tweet about the conference
#ECC_2016

Professor Martin Green OBE
Chief Executive
Care England
Age Discrimination in an Age of
Equality
Browne Jacobson Elderly Care Conference
21st April 2016

The Act
The stated aim of the Act is to reform
and harmonise discrimination law
and to strengthen the law to support
progress on equality.

Protected Characteristics
‘Protected characteristics’ (formerly referred to as ‘equality
strands’) are the grounds upon which discrimination is unlawful.
The protected characteristics under the Act are:
 age
 disability
 gender reassignment
 marriage and civil partnership
 pregnancy and maternity
 race
 religion or belief (including lack of belief )
 sex
 sexual orientation

Public Sector Equality Duty
The duty covers all of the protected characteristics and will require
local authorities to have due regard to the need to:
 eliminate discrimination, harassment, victimisation and any
other conduct that is prohibited by or under the Act
 advance equality of opportunity between people who share a
relevant protected characteristic and people who do not share it
 foster good relations between people who share a relevant
protected characteristic and people who do not share it

Public Sector Equality Duty
To advance equality of opportunity, local authorities will need to have
due regard, in particular, to the need to:
 remove or minimise disadvantages suffered by people who share
a relevant protected characteristic or that are connected to that
characteristic
 take steps to meet the needs of people who share a relevant
protected characteristic that are different from the needs of
people who do not share it
 encourage people who share a relevant protected characteristic
to participate in public life or in any other activity in which
participation by such people is disproportionately low

The Reality
 The funding for older peoples’ care
 Dementia (an illness that is means tested)
 The ambition in care plans (process v wellbeing)
 Local authorities’ social care budget (learning disability vs older
people % of spend)
 Means testing for older people, not for Children

The Challenge
 To ensure equality of opportunity
 To ensure equality of resource access
 To redress the paucity of ambition in care planning
 To deliver on the spirit and letter of the law
 To regulate the system for commissioning

Professor Martin Green OBE
Chief Executive
Care England
mgreen@careengland.org.uk
@CareEnglandNews
@CareEngOfficial
Professor Martin Green
Care England

1. Integration
2. Bringing care home
3. Workforce issues
2

Mrs Confused
–
Bouncing around 15 different settings
3
Candesic.com
Billing – all done separately
Mrs Confused bill:
• NHS
• Mental health
• Primary care
• LA
• 3rd sector
• PMI
• Mixtures above
Total: ??
Confused as nobody collates receipts
together
Patient journey – Mrs Confused – a
‘frequent flyer’

The Future: Care more personalised
customised
Source: Adapted from aruba
Networks
4
Candesic.com
Hospital RoomMobile Apps
the patient experience to b
e
The birth of the mCloud –
a centralized, secure mobi
le cloud hub –
will deliver a 50% increas
e in operational efficiencie
s
Prediction
:
By 2025
50%
More operational
efficiency
Smart waiting
mCloud Room
Mobile technology will hel
p realtime medical informa
tion become a reality thro
ugh the use of mobile sof
tware and wearable devic
es
Prediction
:
By 2025
75%
Reduction in
patient
misdiagnosis
Wearable Virtual
Devices
Assistant
The use of WiFi technologies
and a secure network will all
ow hospitals to move to a
modern way of working
Prediction
:
By 2025
80%
Wireless and
paperless
Wireless ElectronicSpace
Records
New technologies will allow
for
transforme
d
Prediction
:
By 2025
100
Personalised and
Experience Connected

What is etype care?
etype care is a cloud based platform consisting of,
•
•
•
•
Web portal,
Ipad app,
wearable
devices,
room and bed
sensors
etype care connects and benefits,
•
•
•
•
care home operators,
residents
relatives,
healthcare providers
Operators are able to deliver care more efficiently and make better business
decisions,
residents to receive higher quality care and have their voice heard, relatives to easily
monitor their loved ones and have peace of mind, and healthcare providers to access
the enormous elderly care home market

Key features of etype
care
Resident profiles enabling carers
to keep track of updates (medical
notes and records, social notes,
photos, calander, alerts, etc.)
Surveys to easily get feedback
from residents and relatives
Wearable integration and big data
intervention
analysis to enable early
Immediate GP access via Skype-like interface to give piece of
mind to relatives and residents

Louise Hunt
Senior Coroner for
Birmingham and Solihull
Elderly Care Conference
April 2016

 Tell you about Birmingham and Solihull
Coroner’s court and its work
 Overview of the new coroners’ system
 Conclusions
 DOLS and the Coroners court
 Issues with the elderly

 Population of 1.3 million
 4754 deaths reported
 606 inquests
 1702 post mortems – 36%
 99% deaths completed within 6 months
 Busy office with Senior Coroner, an Area
Coroner and 5 Assistant Coroners

 New Chief Coroner HHJ Peter Thornton QC
 Putting the bereaved at the heart of the
coroners’ service
 Consistency across coronial areas
 Open and transparent service
 Faster investigations and inquests
 Compulsory training

 S1 CJA 09 - the trigger to investigate a death occurs where
a body is within the coroner’s area and there is reason to
suspect:
 Violent or unnatural death
 Cause of death is unknown
 Died in custody of otherwise in state detention
 S5 CJA 09 the purpose of the investigation is to establish:
 Who, when, where and how the deceased died
 Particulars to register the death
 S5(2) CJA 09 in certain cases how = by what means and in
what circumstances to satisfy Art 2 Human Rights Act 1998

 No determination may be framed in such a
way as to appear to determine any question
of:
 Criminal liability on the part of a named person
 Civil liability

 S48(2) CJA 09 = compulsorily detained by a
public authority within the meaning of the S6
Human Rights Act 1998.
 Immigration detention centres
 Secure mental hospitals
 Prisons
 Deprivation of liberty orders

 Acid test from Cheshire West case
 Mental disorder and lack capacity who are under
continuous supervision and control and a lack of
freedom to leave
 Irrelevant:
 P’s compliance or lack of objection;
 the relative normality of the placement
(whatever the comparison made); and
 the reason or purpose behind a particular
placement
 Standard authorisation – usually care homes
 Urgent authorisations for 7 days

 Dementia – 75%?
 Acquired brain injury
 Severe learning disability
 2m people “may…at some point due to
illness, injury or disability”

 Hospital and registered care homes (LAs)
 Supported housing (CoP)
 Community settings including own home
when deprived of liberty there by the state
(CoP)
 ITU
 Hospice
 Respite care

 Manage families expectations
 Natural cause death = paper inquests
 Unnatural deaths inquest with a jury
 Falls in care homes
 Choking
 Self harm
 Death following absconding
 Neglect
 Industrial disease

 S47 Expanded list inc:
 Spouse, civil partner, partner, parent, child, brother,
sister, grandparent, grandchild, child of a brother or
sister, stepfather, stepmother, half brother, half sister.
 PR of deceased
 Medical examiner
 Beneficiary under a policy of insurance
 Insurer who issued a policy of insurance
 Person whose act or omission may have contributed to the
death.
 Trade union where death was at work or from prescribed
disease.
 Chief constable where it’s a homicide or related offence
 IPCC
 Appointed Government department
 Any other person with sufficient interest.

 The coroner directs whatever
examination is required inc toxicology and
histology
 IP’s can have a doctor attend a PM
 CTPM Rotsztein decision 2015
 Discontinue with natural COD

 Opened as soon as reasonably practicable
R5(2)
 Completed within 6 months – R8
 Fixed date inquests
 Statements requested within 4 weeks of
opening
 Case review after 6 weeks
 Pre inquest review hearing

 S7 Inquest must be held without a jury unless
 Died in custody or state detention AND death is
violent, unnatural or of unknown cause
 Death resulted from an act or omission of a police
officer in the purported exercise of their duty
 Death caused by a notifiable accident, poisoning or
disease.
 Coroner thinks there is sufficient reason for doing so

 Neglect as a rider to a conclusion – Jamieson
1995
 Where there is a Gross failure to provide basic
medical attention to a person in a dependent
position which directly causes, or materially
contributes to the death
 Examples of Gross failures
 Failing to put a care plan in place to prevent
pressure sores with high waterlow score
 Failing to switch on a non-invasive ventilation
machine in a patient who had COPD

 Mandatory
 Applies during the investigation and inquest
 Concern that circumstances creating a risk
continue and action should be taken
 Not restricted to matters causing the death
 Responses due within 56 days
 May be national issues

Oral evidence
Medical records
R23 written evidence
 All interested persons have to
agree
 If statements are provided quickly
this allows me to write to the
family to agree that the statement
is read
 If the family agree – witness will be
de summonsed

 All statements of witnesses on the witness
list are disclosed if requested by interested
persons
 So when writing any statement remember it
will be disclosed and read by others including
lay people

 Falls versus collapse
 Lack of attending Dr to provide COD
 Pressure sores
 Alzheimer's and dementia
 Nursing/care home concerns
 Safeguarding concerns

 Law Commission consultation on DOLS
 Proposal that CJA 09 be amended to so that
an inquest is only required where Art 2 ECHR
is engaged
 Coroners and Justice Act 2009 (Duty to
Investigate) (Amendment) Bill
 Second reading 29/01/16
 Medical examiner consultation
 Watch this space

The role of comissioner/provider
in an integrated environment
Rob Dyer
Medical Director
Torbay and South Devon Foundation
Trust.

New Care Model – Intentions
We will
• Improve people’s experiences of health and care;
• Support people in improving their wellbeing and in managing
their own health;
• Shift the focus of our services from reactive to proactive with
preventative interventions at all levels;
• Help to reduce inequalities in health and care;
• Continue to support and develop a motivated, flexible workforce
Through improved quality of services, reduction in duplication and
waste and reduced clinical risk we will
• Maintain a financially stable and sustainable health and care
system for the long term.
42

Employees
SDHFT 4500
TSD 1500
Turnover
SDHFT £232m
TSD £142m
Beds
SDHFT 500
TSD 193

Employees
SDHFT 4500
TSD 1500
Turnover
SDHFT £232m
TSD £142m
Beds
SDHFT 500
TSD 193
Integrated Care Organisation
Acute services
Community services
Adult health and social care

Employees
SDHFT 4500
TSD 1500
Turnover
SDHFT £232m
TSD £142m
Beds
SDHFT 500
TSD 193
Integrated Care Organisation
Acute services
Community services
Adult health and social care
Complexity
DGH
9 community hospitals
120 services over 70 sites

New care model
• Less dependent on bed-based care
– Increase in Intermediate care
– Increase in community care – GP providers
• New or developing partnerships
– Voluntary sector
– Care home and domicilary care market
• Changing role of specialist services
• Move from specialist to generalist
• Greater focus on prevention, well-being and self-
care

Role of commissioner/provider
• We have one commissioning CCG (councils,
specialist commissioning)
• Role of CCG with an ICO as it’s main provider
• Block contract
• The provider has become the commissioner
– Complexity
– Risk ?visible
– New partners and new risks

New challenges
• Transactional
• Poor performance in some areas (CQC)
• Financial challenge
• Worsening of relationships with CCG
• Sustainability and Transformation Plan (STP)
• Devon Success Regime
• Unstable partners
• Multiple regulators (who disagree)

Transforming
care in Hampshire
Our multi-specialty community provider

Overview
• NHS Five Year Forward View set out new models of
care needed for sustainable future
• Initially 29 ‘Vanguards’ across England to pilot them
• Hampshire Vanguard is a Multi-specialty Community
Provider (MCP)
• NOT one size fits all: Local variation
• MCP is about transforming how care is organised and
delivered to improve out-of-hospital care.
• We were awarded Vanguard Status in March 2015
Your health, in your hands, with our help.

What is a Multi-specialty
Community Provider?
• An extended team of GPs and specialists offering
more straightforward access to a wider range of health
and care closer to people’s homes.
• Centred around GP practices and primary care hubs.
• Supporting a population based around a natural
community of care.
• Enhanced support and promotion of self-care and
prevention.

Our MCP in Hampshire:
Better Local Care
• Our vision is for better health, well-being and
independence for people living in our natural communities
of care. For People to take greater control of their own
health and happiness and to feel confident about the
support they receive when they need it.
• We aim to do this by delivering a step-change towards more
accessible and higher capability out-of-hospital care,
designed with and by the people living in our communities,
and founded on the things that are important to them.

Our MCP in Hampshire:
Better Local Care
• Initially around 30 GP practices working in partnership
with Southern Health NHS Foundation Trust.
• Supporting population of 220,000 in three initial
localities (Gosport, East Hants and South West New
Forest)
• Supported by 16 local health providers, commissioners,
local authority and third sector partners.
• Significant growth across Hampshire since inception
(coverage approx 1m people)

Listening to our patients
Top themes :
• “I am happy to be seen by a healthcare professional
other than my own GP for same day appts”
• “I am happy to travel to be seen somewhere other than
my own practice for same day appts, however I have
concerns about public transport”
• “I am less confident in pharmacists than my GP or
experienced nurses but that is because I don’t
understand what pharmacists are qualified to do”

Case for change
GP capacity: 1 in 6 GPs in Wessex plan to retire in next 2
years
Access to appts: 1 in 10 people in Fareham & Gosport say
they cannot get an appt at a convenient time; 1 in 4 people
say their surgery is not open at a convenient time
Long term conditions: The number with two or more LTC
is projected to increase from 5 million to about 6.5 million
Demographics: Predicting a national increase of 10% in
number of people aged 75+ by 2019

Better Local Care at a glance
Prevention
and self
care
Extended
Primary
Care Team
Improved
access
De-layering
specialist
support
Access
Hub
Access Hub, the epicentre of the care
model, linked to out of hours service,
with care navigators. MSK therapists
and pharmacists delivering care in the
hubWeb GP
E-consults
Apps
WebGP enabling online triage and e-
consultations, & use of Apps to
support self care
New
pathways
of care
Multi-disciplinary team with
specialist input, eg for end of life
care, mental health, diabetes and
wounds and leg ulcer care
Recovery
café and
education
Recovery café and patient education
supporting people with long term
conditions
Carousel clinics providing improved
access to specialist care for people
with complex long term conditions
Carousel
clinics

Our MCP in Hampshire
East Hampshire
 10 practices / 70k patients
 Semi-rural “new town”
Gosport
 Urban deprived
New Forest
 Rural – older demographic

Some achievements to date
• Set up Better Local Care localities – initially three
locations, now expanded to cover much of Hampshire,
based around local GPs and their practice populations
• Launch of extended primary care access hubs in the
New Forest and Gosport
• Physiotherapy, mental health nursing and respiratory
specialist input into GP practices
• Campaign to protect all care/nursing home residents in
Gosport from flu
• Care navigators and surgery sign posters piloted in the
New Forest and Gosport

Some achievements to date
• Launch of bespoke team development programme to
bring together extended team including health, care and
local community to co produce and deliver new services
• Formal partnership between Southern Health and GP
practices in Gosport
• Integration of information systems to ensure
professionals in localities have access to the same
patient information

Three levels of transformation
Commissioner
reform
Provider reform
A new model
of care
Pooling the combined
resources for the local
population and
commissioning
services using long
term outcome and
capitation based
contracts
Primary Care and
Southern Health
coming together to
deliver the new model
of care that has been
co-designed with local
people, is seamless
across health and
social care services
and is cost effective
A new care model
with better access to
care, extended
primary care team
proactively managing
need, and specialist
advice and support in
the community.

A new model
of care

A new model, built around
natural communities of care
Wider primary care at scale
Improved access to care
An extended primary care team
Fewer steps to access specialist support

Prevention and self-management
We want to put people in control of their own health and wellbeing and we know that, to
achieve that, we need to change the dynamic of the relationship between health
professionals and patients.
 We will adopt a patient activation approach and embrace ‘co-production’ in its fullest
sense
 Use our clinical systems and the Milliman analysis to profile risk factors and health
behaviours in our localities
 For patients, we’ll provide viable alternatives that give them the skills, knowledge and
means to self-manage
 For primary and community care, we need to support practitioners to take a whole
person approach in every interaction.
 We will support voluntary and community providers to work alongside health

Primary Care Sustainability
 Retain individual identity – registered list
 Reduced workload
 Services backed into general practice
 Working at scale
 Create new career structure
 Education, teaching and training – more specialties
 Partnership model remains, but New Practice Model - employed
 Consultants in Primary Care
 Risk – premises, staff
 Skill mix

Improved access to care
Example of new model:
Primary Care Access Centre
 Co-located with MIU in local
hospital
 Open 8-8 for walk-in or pre-
booked appointments
 Staffed by GPs,
physiotherapists, clinical
pharmacists, nurse practitioner,
paramedic, paediatric nurses
 Able to read and write to a single
shared clinical record
 Going live from late summer
2015
multiple points of
access that are not
integrated
Current model of care:
Multiple, disjointed access points

Extended primary care team
+
Bringing primary, community and adult social care together, with
specialists from local hospitals and third sector organisations, to work
as a single extended primary care team: the MCP
Social care services
Older People’s Mental
Health Teams
Community Care teams
Single integrated teams based
around General Practices

Fewer steps to specialist support
See GP
Planned Skype conversation:
GP, consultant and patient.
Management plan agreed.
Respiratory team review
investigations.
Patient sees GP,
investigations on site.
Investigation
Referral
Seen in OPD
to review
results
GP sees
patient
Letter to GP
Example of traditional
respiratory care
Example of new model
of respiratory care

Provider
reform

Structures to deliver transformation
MCP Delivery Unit
PROVIDER STEERING GROUP
LCDG
WNF
LCDG
GOSP
LCDG
P&B
FF1 Etc.FF3FF2
MCP Board
NHS England New Models
of Care Programme
Locality Clinical Delivery Groups
LCDG
EH
MCP Sponsor Board

Enabling workstreams
Design and implementation of
extended primary care team
Putting in place the leadership
team and development support
Creating a single health record
and shared information
Getting the right estate for
the MCP
Developing governance
arrangements for the MCP
Ensuring the MCP represents
good value for money
Building a social movement for
change via effective
communications and engagement
Evaluating the impact of
the MCP

Challenges encountered
 Information governance / sharing: Inconsistent IG interpretations have lead to some
information not being shared with all partners
 Indemnity: In some cases providers’ indemnity policies preventing staff working in
new ways: (eg paramedics working in same day access hub)
 Transfer of estate: dominant primary care landlord with ability to delay transfers (eg.
Forton Medical Centre, Gosport)
 Maintaining clinical engagement: especially in new localities – linked to level of
funding allocation for 16/17
 Commissioner engagement: some very engaged commissioners but not universally
seen as a priority at all levels
 Sustainability of primary care / GP federations: In some areas primary care at
breaking point financially and/or in terms of workforce

Strengthening leadership
and building new teams
• Working in new ways across traditional barriers
requires a new, shared culture
• Development programme will build this through:
• Senior leadership development
• Developing emerging leaders and teams
• Developing the extended primary care teams

New paradigm = new organisation
• For the MCP to succeed, a new type of organisation
is needed.
• Our current organisations have come together to
determine how this will look.
• Provider board’s clear that future lies with MCP
• Will work with regulators to overcome hurdles of new
organisational form

The benefits

For people using services, families,
carers and citizens
• More straightforward access to a wider range of care via
your local GP practice or primary care hub
• Better outcomes based on what’s important to you
• More advice and guidance to help you make the right
choices and manage your own health and care
• Better access to local voluntary and community groups
• More involvement in design of care services near you
• In short, Better Local Care.

For health and care professionals
• Being part of developing new services that better meet
the needs of local people
• Working as one team with a much wider group of
professionals supporting the same people
• Access to team and leadership development and talent
management
• More time to support people who need your specific
expertise

For the health and care economy
• More tailored, better value services co-produced by the
people who use them and commissioned based on
outcomes rather than activity
• Reduced acute hospital activity (admissions and ED
attendance)
• More focus on primary care, education and prevention
• More sustainable services (esp. general practice)

Delivery

Natural Communities of Care (NCC)

Andover
Winchester
Stockbridge
Soton
Romsey Eastleigh
Totton
Hythe
Lymington
Alton
Basingstoke
Business Unit 3
Clinical Service Director
Juanita Pascual
Head of Professions
Susanna Preedy
MCP General Managers
Sarah England
Kate Smith
Vacancy – TBC – Basing/Alton
Burseldon
Business Unit 2
TBC
Head of Professions
Racheal Marsh
Phil A-Harris
Sarah Olley
Ringwood
FordingbridgeBusiness Unit 1
Peter Hockey
Head of Professions
Julia Lake
Laura Rothery
LR
SO
PAH
KS
SE
VAC
MCP localities
(west)

Delivering the new model locally
Newcomer sites Joined
Fareham 25 Feb 16
Havant, Hayling and Emsworth 28 Jan 16
Waterlooville 3 Dec 15
Avon Valley
Eastleigh, Romsey, Chandlers Ford 3 Dec 15
Eastleigh Southern Parishes 14 Jan16
Totton 17 Dec 15
Waterside and Hythe 11 Feb 16
Andover 14 Jan 16
Winchester 14 Jan 16
Winchester Rural South 14 Jan 16
Alton 10 Mar 16
Basingstoke 10 Mar 16
Southampton City 17 Dec 15

Programme management office
Paul Streat
Director of Provider Development
Alison Fowler
Programme
manager
Jane Druce
Evaluation
co-ordinator
Dominic Lodge
Community
Development
lead
Claire Little
Executive
assistant
General
managers
Paul Streat Tel: 07817998310 paul.streat@southernhealth.nhs.uk
Alison Fowler Tel: 07342 064786 alison.fowler@southernhealth.nhs.uk
Jane Druce Tel: 07827 823894 jane.druce@southernhealth.nhs.uk
Dominic Lodge Tel: 07785 433768 dominic.lodge@southernhealth.nhs.uk
Claire Little Tel: Claire.li

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