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SRG 5 - Tiered Models of Care

The fifth Stakeholder Reference Group (SRG) for the Moving Forward Together (MFT) Programme took place on Tuesday the 13th of February. The Group of 16 patient, service user and carer representatives (details at the end) heard a presentation and engaged in discussion about how care might be structured across different settings to meet the future needs of the whole population of Greater Glasgow and Clyde.

The Co-Chair, Liz Porterfield, opened the meeting and welcomed everyone, thanking them all for their participation and input to date. Dr David Stewart, Lead Medical Director for Acute Services in NHS Greater Glasgow and Clyde then delivered a presentation about tiered models for the delivery of care. He explained that this was about how system-wide care might be planned and organised to meet the future needs of the whole population of Greater Glasgow and Clyde. He also said that some highly specialist services are delivered via Glasgow and Clyde to people from across the West of Scotland, or as a national service to the whole of Scotland.

Overall the Programme, taking direction from national policy and plans, would aim to deliver more care at or closer to people’s homes and promoting independence and self management.

David recapped that aim of the Programme, taking direction from national policy and plans was to deliver more care at or close to people’s homes and promote independence and self-management by reducing the amount of care provided in hospitals to. This was recognised in the early phases of the Programme where the review of national and local policy and plans also identified the principles that would act as a checklist against which any transformational ideas would be assessed:

  1. People can look after and Improve their own health and live in good health for longer
  2. People are able to live independently and at home or in a homely setting in their community
  3. People have positive experiences of those services, and have their dignity respected
  4. Care is centred on helping to maintain or improve the quality of life of people
  5. Services contribute to reducing health inequalities
  6. Unpaid carers are supported to look after their own health and wellbeing and to reduce any negative impact of caring
  7. Service users are safe from harm
  8. Our staff feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide
  9. Resources are used effectively and efficiently

He said that the current Phase of the Programme had been to present information and evidence at first to a whole range of staff from across specialty groups plus others from the primary and community setting and engage them in discussion about how they might work differently to meet future demand. Following this the specialty groups are now being tasked to think about how they might work together to better share resources to provide more coordinates and seamless person centred, safe and effective care for the whole population. Several hundred staff have been engaged with and one of the approaches presented to help them think about how care might be planned was a tiered model of care.

David explained that a tiered model of service delivery is a system based on increasing level of complexity; the lower tiers would be provided across the whole of Greater Glasgow and Clyde at or close to people’s homes to promote independence and self management; and as treatment or care becomes increasingly more complex with severity of illness it is provided in fewer and more specialist centres that serve an area or even a region. This approach had been taken as services can be designed and organised with the essential facilities and systems to fit the needs of the whole population and offers a whole system view of how health and social care might be structured across primary, community and hospital based care.

He then described in more detail how the tiers might be structured looking at unscheduled care, older peoples care, planned care and cancer care pathways as examples stating that these were early high level drafts needing revised for wider public use. However, the tiered approach had been embraced by the clinical and multidisciplinary teams and was also being used to model primary, community and social care services. Now that the speciality teams are considering the interdependent services they will rely on the approach is helping define the infrastructure required to deliver services across the different settings for the whole population 

David said that feedback from the clinical engagement has seen all the specialities identifying elements of their service that can be moved from hospital to community. To do this they will require more specialist nurses and allied health professionals could deliver expert care, but that these and others in the primary care and community setting will require better support and stronger links back to hospital teams and consultants. This would allow expertise to be focused where it’s needed most and free up time for highly specialist staff to deal with more complex patients. Throughout the engagement it has been recognised that there is the need for better communication comprehensive e-Health solutions such as joined up records. This would also enable better cross system working and better integration to provide a more seamless journey for those using services no matter the setting.

Following the discussion Liz facilitated discussion with the group who asked questions or provided feedback on a range of topics. All the participants stated that they understood the rationale behind providing services using the tiered approach however; Anne Marie, Gordon and others said that they’d probably like it illustrated in a more beneficial way. They said that providing more services closer to home was a positive move, with Martin saying that for many people this is a priority, and that the Programme should describe the tiers in a way that aligns them with independence and self management. Others said that this might begin to help with the perception that the best place to be was a hospital when in fact they should be reserved for when people are seriously ill or require complex treatment and care.

Gordon asked who would coordinate care for people with complex or multiple conditions and the group discussed that this would be vital to ensure that people don’t fall through the cracks The Group recognised that providing more in the community setting was better and Martin said that having services closer to home was a priority for many people; however Thomas said that although he understood this that there was a big job to sell the idea to the public as they still think hospital is where the experts are. The group discussed that people need to feel more empowered to be in control of their own health and decisions about it and Gordon said that technology had been used in Mental Health Services to do this with people being able to access and update details about their treatment and care.

Susan again reiterated that we need to describe the model differently so that people feel safe accessing services no matter the setting, but there also needs to be better marketing so people know where to go. Martin said that that if people are already not clear on what services they can access then the tiers and the terminology could create further confusion and the group discussed that the use of acronyms to describe services was unhelpful. Karen said that in Inverclyde the New Ways work had used and shared the positive experiences that patients had via videos and this had helped change culture locally. Anne Marie asked if still treat people who turn up at the wrong place e.g. accident and emergency with a relatively minor and that this doesn’t help to change people’s behaviour. Janice said that elsewhere people are told they may be diverted and Betty said that often even when people follow procedure such as calling NHS 24 they are still directed to A&E as people to minimise risk.

Martin asked why the ambulatory care hospitals like Stobhill were currently not being used properly and there was discussion about how newer models would potentially better use these sites. Martin then asked how services will be financed with the Integrated Joint Boards deciding local spend and with considerable financial pressures how would monies be distributed across hospital, community health and social care to do deliver new ways of working. There was discussion about how some Health and Social Care Partnerships had progressed further and Anne Marie said the relationship between health social care preceded the formation of the Joint Boards so worked well in East Renfrewshire.

Ian Good discussed the Beatson Cancer Centre and how the recommendations set out to the Board of NHS Greater Glasgow and Clyde in December 2016 with the Programme being more about the long-term future would it delay or limit these. There was wider discussion about how some of the changes to deliver transformation would be smaller and accumulative and the group agreed that this won’t happen overnight. Betty said that what she had heard across all the meetings provided hope for the future and was glad to see and be part of all the work done in the background to ensure high quality services. Morag Cullen asked that with more being delivered by specialist nursing or allied health professionals then when would someone get to see a consultant?

There was discussion about how other specialists would free up consultant time to deal with the more complex patients and Aileen said that better use of other roles and could do this but people had to trust that they were seeing the right professional at the right time. Gordon spoke about how in mental health there was recognition that people also had complex physical health problems and campaigns to empower people to be more in control of their own health what been used and that in the future technology could be used to empower people better. Thomas joining up services better for people with multiple conditions was vital and that care needs to be coordinated and if the person isn’t able to do that for themselves then having someone assigned to them would be good.

Karen said that the use of other roles such as physiotherapist and pharmacists in the New Ways work in Inverclyde meant that people seen the right person and freed up time for GPs to see more complex patients; however if this was to be expanded elsewhere then would their be a need to recruit people to these roles. Susan asked about timescales, priorities and the staff resources to make changes as it looked like new or adapted roles would be needed; and that if more care was to be delivered in the community this need to be high quality. There was discussion that community services need to be more than a range of people who pop in and out of people’s homes for 5 minutes at a time with Janet saying that the current support available to people in their own homes is better than nothing, but sometimes only just.

Alison feedback that there had been a lot of discussion about a changing the culture and expectations of those who use health and social care services, but there is a need to consider that there also has to be a change in mindsets and attitudes from those providing the care and services too. A “buy in” from everyone involved.

 

In Attendance

Liz Porterfield (Co-Chair)

NHSGGC - MFT Core Team

John Barber (Facilitator)

NHSGGC - MFT Core Team

 

Presenting

Dr David Stewart

NHSGGC - Lead Director for Acute Medical Services

 

Patient, Service User and Carer Representatives

Aileen Hills

 

Alison Stewart

 

Anne Marie Kennedy

 

Betty Graham

 

George Brown

 

Gordon McInnes

 

Ian Good

 

Janet Nicholls

 

Janice Woodburn

 

Karen Haldane

 

Margaret Telfer

 

Martin Brickley

 

Morag Cullen

 

Morag McIntosh

 

Stacey Highfield

 

Thomas Cassidy