Caring for people beyond tomorrow
'Caring for people beyond tomorrow' sets out the Department's policy position through a vision statement for a future primary care service, and a policy framework designed to steer the future development of policies and services in primary care.
Key aspects of the Strategic Framework are:
- a service focused on providing comprehensive person-centred care
- a first point of contact that is readily accessible and responsive to meet people's needs day or night
- a co-ordinated, integrated service employing a team approach with multi-agency linkages
- an emphasis on engagement with people and communities about their care and the way services are designed and delivered
- a focus on prevention, health education and effective self-care
'Caring for people beyond tomorrow' will be a significant driver of reform and modernisation, designed to influence the planning and work of HSS Boards, Trusts and other providers of primary and community based care.
Outcomes envisaged will include:
- making primary care services more responsive by encompassing a wider range of services in the community
- making primary care services more accessible, by way of time to see practitioners, greater number of locations, enabling people to see appropriate practitioners and greater provision of information
- developing more effective partnerships and team working across organisational and professional boundaries, as a means of increasing the effectiveness of theservices
- more proactive engagement with service users about service planning, design and delivery
- improved premises and infrastructure, harnessing new technologies and clinical advancements
The strategic framework includes an implementation plan (Annex 1) that sets out key actions planned for the next five years. This plan will be monitored and updated to reflect progress and ensure change is undertaken to achieve the vision, aims and goals set out in the strategic framework.
Reform Programme for Primary and Community Care Services 2005-2008
In June 2005, the Enhancing Primary and Community Care Steering Group was established under the chairmanship of Andrew Hamilton, Deputy Secretary, DoH.
Terms of reference
The Steering Group will lead and monitor the development and implementation of tangible service improvements aimed at enhancing primary and community care services, reducing avoidable reliance on hospital services and improving discharge arrangements, to achieve health and social care economy efficiencies. This will involve regional 'whole system' approaches focusing on the patient and client pathway across organisations and sectors, building on best practice as developed locally.
Specific responsibilities included considering ways to
- change work practices to improve the patient experience
- reduce unnecessary hospital admissions and readmissions
- rationalise long stay provision/reduction in length of stay in acute beds
The Group agreed to focus on three areas of change to work practices:
- integrated working
- nurse-led discharge
- in-reach, non-medical prescribing
and two areas of service design:
- community rehabilitation/intermediate care
- case management
These initiatives were considered to have the greatest potential to increase the capacity to deliver services in the community, improve access and to make most effective use of secondary care services.
Sub-groups were established and final position papers were submitted in April 2006. In May and early June 2006 workshops were held in each of the Board areas, in order to share the findings of the reports, illustrated by examples of existing good practice and to seek views on the best way to take the initiatives forward.
The initiatives were well received at all four workshops and the Department is currently drawing up proposals as to how the series of reforms should be taken forward.
The then Health Minister, Paul Goggins, announced on 26 June 2006 "a seismic shift in the way health and social care services will be delivered in the future". The key plank of his reform was to get many more people cared for in their homes and communities, rather than in hospital beds.
Specifically, he stressed that he wanted to see a comprehensive reform and service improvement programme that will cover integrated working, nurse-led discharge, intermediate care, case management and non-medical prescribing taken forward by commissioners and providers in all these areas by 31 March 2007.
New ways of working - integrated working
The development of seamless working across the interface between primary, community and acute care to improve access to assessment, diagnostics and treatment and the development of a "skills mix" of specialists and generalists for nurses, AHPs, GP's and other clinicians working in primary and community care
- the GP practice patient list should be the common patient/client list for the team
- a managerial partnership should be developed between the manager of Trust team members and GP practice leadership
- primary care teams should be grouped in natural localities with a population of 30,000 or more
- budgets should be devolved to management teams in natural communities or localities
- all disciplines should contribute to a single assessment through a shared assessment framework
- practitioners should have appropriate access to each others information systems
- Reform Programme for Primary and Community Care Services/Integrated Working June 2006
Workshop on long-term conditions - 19 April 2010
The Department organised a workshop to help share the development of policy guidance for improving the health and wellbeing of people with long-term conditions. The workshop brought together a range of commissioners and service providers, together with voluntary sector representatives, to identify the key themes and priority areas for the further development of integrated health and social care services to help support people with long-term conditions.
The keynote speakers at the workshop were:
- Dr Anne Hendry, Clinical Lead, Long-Term Conditions Collaborative, Scotland;
- Susan Douglas-Scott, Chief Executive, Long-Term Conditions Alliance, Northern Ireland;
- Heather Monteverde, Kate Fleck and Nancy Toner, Long-Term Conditions Alliance, Northern Ireland;
- Dr Sloan Harper, Director of Integrated Care, Health and Social Care Board, Northern Ireland.
Programme for the workshop and the presentations given by the keynote speakers
- Long-Term Conditions Workshop Programme -19 April 2010
- Dr Anne Henry - Presentation
- Susan Douglas-Scott - Presentation
- Long-Term Conditions Alliance - Presentation
- Dr Sloan Harper - Presentation
Nurse led discharge
Nurses assess the patient, liaising with the multi-disciplinary team and plan timely discharge based on an agreed clinical protocol management plan. It may also involve the writing of discharge letters, making follow up calls and giving advice to patients, carers and other health and social care professionals involved in the patient's care, in collaboration with the patient.
A team, maybe multi-disciplinary, who actively case manage a patient out of hospital or the service they are receiving to their end point destination.
In-Reach may also provide specialist advice prior to transfer or discharge.
To implement nurse led discharge and in-reach on a regional basis, the following recommendations are suggested:
- review the current cultural context and organisational arrangements to create systems to support innovation and new ways of working
- review and redesign the purpose and timings of ward rounds to facilitate timely patient discharge
- provision of 24 hour community nursing services
- facilitation of treatment of acute episodes outside of hospital
- provision of clear budget streams with pooling of resources to meet patient need
- implementation of clinical management systems to include governance and audit to evidence outcomes, performance and benefits for patients
- Reform Programme for Primary and Community Care Services/Nurse Led Discharge and In Reach June 2006
Non medical prescribing
Also known as supplementary and independent prescribing. Essentially this is 'a voluntary partnership between and independent prescriber, a doctor or dentist, and a supplementary prescriber, to manage an agreed patient-specific Clinical Management Plan, with the patient's agreement'.
A non-medical prescribing budget should be created to facilitate current nurse prescribing and future prescribing by pharmacists, AHPs and optometrists in primary care.
A new system for monitoring prescribing patterns of all prescribers should be designed to take account of clinical governance requirements of all current and future prescribers.
Options to enable electronic transfer of information from non-medical prescribers to GP clinical records and appropriate access for non-medical prescribers to GP clinical notes needs to be explored to facilitate easier record keeping and enable non-medical prescribing to reach its full potential, particularly in locations remote from GP practices.
Service design - case management
Case management is defined as 'the process of planning, co-ordinating, managing and reviewing the care of an individual. The broad aim is to develop cost effective and efficient ways of co-ordinating services in order to improve the quality of life' (Kings Fund 2004).
There are different models of case management in chronic care, however, the broad principle is to assign each person a "case manager to assess patients' needs, develop a care plan, arrange suitable care, monitor the quality of care and maintain contact with the patient and their family.
- to improve quality of life issues for patients and carers
- admissions avoidance
- early detection of disease deterioration and proactive interventions
- reduction in length of stay within hospital
- improved way medication is given and administered, rationalising the medication to aid patient concordance
- promoting a seamless service for the patient and improving communication through the patients journey
- improve awareness of disease progression through avoiding crisis situation through education and advice to patient and carers
- Empowered and informed patients
- improve provision of consistent and integrated care
- provide more effective use of healthcare resources
This will be achieved by targeting the following:
- self management for people with chronic conditions
- provision of care at the right place and the right time
- redesigning of staff roles and workforce development
- using information to ensure health and social care resources are more effectively used
- using and exploiting technologies within the context of case management to more effectively aid the monitoring of people with chronic diseases
- Policy paper DoH/Reform Programme for Primary and Community Care Services/Case Management June 2006
- A Model Framework for the Implementation of a Case Management Approach January 2008
Intermediate care can also be called community rehabilitation, step-up step-down or rapid response. Generically it is defined as 'Services provided in the community to enable people to regain, in part or in full, independence which has been impaired by illness or injury, giving them back, as far as possible, control over their own lives, including the better integration of services'.
The group concluded that Community Rehabilitation/Intermediate Care services should:
- be targeted at people who would otherwise face inappropriate admission to acute in-patient care; long-term residential/nursing home care; unnecessarily prolonged hospital stays; or continuing HPSS in-patient care
- be provided on the basis of a comprehensive person-centred assessment of need, resulting in a structured individual care plan that, where appropriate, involves active therapy, treatment or opportunity for recovery; have a planned outcome of maximising independence and typically enabling service users to remain or resume living at home; be time-limited, usually no longer than 6 weeks and frequently as little as 1-2 weeks or less
- involve cross-professional working, with a single assessment framework, increasingly integrated professional records and shared protocols.
- Reform Programme for Primary and Community Care Services/Intermediate Care/Community Rehabilitation