It’s clear we need large-scale cultural and behavioural change if community services are to provide high–quality care for patients at home while still achieving savings to the NHS and social care budgets.
For the past few years, there has been a great deal of focus on integrated care, with the ultimate goal of simplifying the patient journey and preventing the need for individuals to repeat their story to several professionals.
Integrated care, we believe, means looking at how the different community teams that these patients come into contact with are managed, in order to avoid a crisis and keep people independent and at home for as long as possible. Our community services are provided by a unique partnership called County Health Partnership (CHP), involving three partners – a primary care and GP out-of-hours provider (Central Nottinghamshire Clinical Services), a mental health provider (Nottinghamshire Healthcare Trust) and a new primary care provider of GP and community services (South Nottingham Integrated Clinical Services).
Working with front-line staff, Nottingham North and East CCG and CHP have identified the problems with the way our community services are structured.
These can be summarised as:
⦁ Too many access points, creating duplication and confusion for patients
⦁ Insufficient capacity in community teams to provide care outside standard 8am–6pm Monday–Friday working hours
⦁ Skill mix and competencies of community service teams that no longer meet the needs of patients who have increasingly complex needs.
Our plan, which we started to put into place in September, is to completely overhaul the way our community services are structured. We will develop a new culture to improve the interface between primary care, mental health, secondary care and community services and social care. And we will increase the skills of those working in the community to manage a wider range of health needs and match the demand.
Through this restructure – which is all about changing how teams interact with one another, rather than setting up a new organisation – we want to provide a rapid-response crisis team in the community available in extended hours, seven days a week. This will reduce the number of patients ending up in hospital through unplanned admissions as a default setting and increase support in the community. Savings will be used to further improve our community services.
Patients do not recognise the distinctions between different health and social care services – that is a delineation put in place by bureaucracy and management. Commonly patients struggle to know what is available or how to access it and we hope to make that much simpler. We also need to future-proof the service we offer. Two decades from now, patients will be far more savvy in the way they use health services and will have greater expectations. They will be confident with the internet, looking for health providers, looking at their records and quality of services and making decisions on how to spend their personal health and social care budgets. We are preparing to meet their needs.
Too many access points
There are too many access points to services, all working to different protocols and recording information in different ways. This creates duplication, especially of visits, and confusion for service users. For instance, an elderly patient with COPD who also needed a leg dressing would currently be visited by two different nurses – quite conceivably on the same day – with a third visit from a social care support worker. A GP may need to ring three different numbers to obtain a service for one patient.
We are spending almost £600,000 non-recurrently over the next 12 months to switch from what is currently six different segments of the service – primary care team, intermediate care team, district nursing, matrons, COPD team and heart failure team – into three community ‘wards’ set up along the CCG geographical populations.
Within each ward there will be one team leader allocated to patients who is responsible for their physical, mental or social health. In addition to these nine team leaders, most of whom are likely to be nurses, we are employing a practice nurse, a mental health nurse and an in-reach nurse to speed up health and social care discharge packages and support. The Crisis Intervention Community Support Service run by the Red Cross will now also be based within the community wards. In total we will be funding 12 new full-time-equivalent posts. The money will also cover equipment and IT.
What will develop is a single point of access for health and social care so, once a patient or carer needs assessment, the care coordinator can visit, to outline what is available in terms of health and social care and mental health services, in addition to support for carers. Should they need to go into hospital, the same community team helps them return home as quickly as possible. The three physical team leaders, who are already in post, are currently following patients on their journey from ambulance to the hospital to the community to look at where the efficiencies can be made and to inform the model for a single point of access.
The existing skill mix and competences within our teams do not meet the needs of increasing numbers of patients with complex needs. This is either because a nurse is solely working on one type of care rather than complex case management or because there is too little input from secondary care, mental health or general practice. For instance, the community matron’s case load includes a large number of patients with mental health problems. The district nursing teams have full case loads and cannot take on clinical work outside their current remit, despite actually being able to provide care for a range of planned care procedures such as pre- and post-operative treatments or care.
Staff will see changes to their day-to-day roles. We want our teams to be providing a full range of complex care, and phase one of the restructuring includes training for staff on issues as diverse as advanced assessment and triage, diagnostics, minor ailments, rehabilitation, social and personal care, case management, prescribing and mental health.
Increasing community capacity
We saw that the community teams had insufficient capacity with too few staff to provide care outside standard 8am–6pm, Monday–Friday working hours, when elderly patients may well end up in hospital after a late GP home visit. Emergency health problems do not conveniently fit into the working week.
The aim is to have a transformed workforce, providing an extended, highly competent service – until 10pm, seven days a week – to patients with long-term conditions. The changes will reduce inappropriate admissions and enable us to close acute beds. Patients will be on one case load rather than three, so there will be better continuity of care. In phase two of the project, social care will become part of this team rather than the patient being passed from one service to another.
Strong engagement with the community teams and the respective trade union representatives will be key to ensuring that all the relevant staff are involved, are allowed to input concerns and ideas, and feel empowered and supported to do so. We want clinical leadership to be demonstrated at every level with a new culture that takes responsibility and is accountable while striving to provide safe, personalised and innovative care.
Increasing skills and competencies in the workforce will reduce hospital admissions and increase the number of people cared for at home. Increasing mental health skills and capacity will mean more people managing their condition at home and more people with dementia and physical health problems cared for at home.
Increasing practice nurse capacity in the community will mean more patients receiving care at home for long-term conditions and more people receiving planned interventions (pre- and post-op) nearer home.
Our changes will also see more people being supported to die at home if they choose to and more people retaining their independence.
We will see an increase in primary care prescribing and we will need direct access to diagnostics and secondary care outpatient appointments/second opinion.
We have pump-primed year one, but phase two will be funded through existing community healthcare resources and savings achieved.
We want to develop a new culture and new behaviours across organisational boundaries, focused on the nurses and support workers, who spend the majority of time with patients. Despite evidence-based pathways and procedures, we continue to operate in silos and have not developed clear, trusting relationships around patients and service users.
The key to success is allowing all professionals the space to develop a new culture so a discharge from hospital is no longer complicated by tensions and pressures across individual services but based on mutual trust and confidence.
For example a patient with a PEG feed can be managed in the community, but the response can be ‘we don’t do that’, so the ward has to find alternative solutions. Similarly, hospital procedures can be seen as ‘too risky’ for the community but can be done quite safely, for example managing ventilated patients.
We have only just begun this process but the biggest barrier so far has been to overcome the cultural traditions of the existing structures and this is an ongoing issue. When you talk about integration, people are worried about moving organisations or having a new boss. But our take is that the old system does not make the best use of the skills of NHS and social care staff.
We have been working in silos and that is a difficult issue to overcome. People believe the way they are providing works – and I am not saying otherwise – but when you look at the bigger picture we are not efficient in the way we do what we do.
A year from now we hope to have a service designed around the population rather than the population having to fit the service on offer.
Tracy Madge is clinical director for Nottingham North and East CCG and CHP