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Creating long-term condition pathways fit for the future

If out of hospital care for adults is to be truly transformed, one of the things that will have to happen is greatly increased joint working.  ‘Planning All Care Together (PACT)’ is a commissioning philosophy which aims to revolutionise how patients in Wandsworth with long-term conditions are cared for through a radical redesign of community health and adult social care services, and a transformation of primary care. We have over 90,000 people (135,000 cases in total) in Wandsworth with long-term conditions and the ageing population (particularly those aged over 80) will only increase this number – we have to plan for the future.

PACT is a partnership approach with Wandsworth CCG and Adult Social Services (Wandsworth Borough Council) working in cooperation with local providers such as St George’s NHS Healthcare Trust to reduce utilisation of secondary care and help patients live better, more independent lives. The umbrella approach currently covers around 30 different initiatives.  The programme is being developed by the CCG and the Council together.

To date we have worked too frequently in silos with people and services not efficiently working with each other. This is no longer a reasonable, sensible, efficient or viable way to deliver services from a patient or whole system perspective. A patient with, for example, COPD, dementia and diabetes would currently be offered three discrete care pathways. With PACT we are trying to address this with commissioning managers working together with GPs and also involving patients and working with other key partners to redesign care pathways from the bottom up so in future patients will see one service as opposed to separately commissioned services. The development work is primarily delivered in GP-led Clinical Reference Groups for the main LTC conditions which are subsequently pulled together to focus on whole-system patient pathways.

Our vision is that community health and adult social care services will work as one service, from both a clinical and a patient viewpoint, to help patients remain as independent as possible and prevent trips to hospital and delay the need for residential or nursing care. When admission to hospital is necessary, we will aim to support discharge home at the earliest opportunity.

The work is focused around a five-tier model.

Tier zero

Patient self management is tier zero. We are asking practices and their populations to become part of a comprehensive Wandsworth Self-Management programme. We have a thriving Expert Patient Programme community which is being expanded. Attached to this our approach is ‘if a patient needs self-help courses/information, then we will provide it to them’. We will do this through a central hub with a detailed “Knowledge Bank” of local courses / non course based options (such as DVDs).

We are actively commissioning the voluntary sector to maintain an interactive database of local community/voluntary groups and also for an organisation to help establish and sustain self-help groups of interested patients.

We are also looking to develop a whole established community of self-help organisations which will be many and varied across conditions, need, culture and religion.

Tiers one and two

Primary careis tiers one and two. A Local Enhanced Service (LES) for GPs to identify patients at risk of admission and to develop comprehensive care plans has been piloted in 2012/13. For 2013/14 the LES is being expanded to include additional Wandsworth pathways, for example, compliance with the falls and bone health pathway that has greatly reduced incidences of fractured neck of femurs in Wandsworth.

The LES pays for practices to backfill senior clinicians to spend an hour with identified patients to develop a comprehensive, personalised care plan and to follow-up appropriately. This is one of the transformations in the primary care setting that will take place. The second is to definitively put the money where the need is. For example, a practice in a deprived community with high LTC registers will receive more than a practice in an affluent area with a younger fitter population.

The use of risk stratification software has been piloted and will be fully rolled out as part of the LES to pro-actively identify patients who, if intervened with now can have future hospital admissions avoided.

Practices have to commit to minimum entry criteria in order to sign the LES, for example, a commitment to Coordinate my Care training and usage which has become an integral component to our 111 and GP Out of Hours service.

In care planning for housebound patients, GPs will spend time in understanding the external factors affecting patients and make appropriate referrals to other agencies. This approach will be mirrored with GPs developing closer links to nursing homes helping to increase provider confidence by ensuring they feel more closely engaged with the whole health and care system.

Additional payment is offered based on the direct feedback from patients on their experiences. This will form a central plank of our evaluation approach which has been developed by public health colleagues.

We also have a LES for our local pharmacies to home visit our patients referred by their GP to make sure they are using the medication that they’ve been prescribed appropriately. Time spent in a patient’s home to help them understand when and how to take their medication really can make a difference to preventing unnecessary hospital admissions. Whilst in the home they will be able to identify other areas of concern and report this to the patient’s GP.

We are aiming to use the self-help groups that are prevalent in Wandsworth as an extra resource in our care planning approach and from next year GPs are going to carry out full carers’ assessments to see what support the carers need.

We are also looking at training and education for practice staff including GPs and practice nurses – a variety of things including training to help the clinician empower the patients to ensure they get the most out of the consultation and feel in charge of their own condition.

Tier three

Specialist community based services is tier 3.This includes specialist nurses and consultants working in the community. This will gradually expand as we introduce other specialities. These are being redesigned with the aim of fully integrating professionals across health and social care to deliver person centred, holistic care.

The re-design is being focussed on seven core functions to get away from historical silo commissioning, for example intermediate care / community matrons. The functions being specified are designed to promote a seamless ‘pull’ through community services, ranging from access and triage to complex case management and facilitated and supported discharge when a hospital admission is appropriate.

We view recent innovations as integral enablers, and to this end, we are embarking on an ambitious telehealth strategy to deploy kits to as many patients that need them via whole-system assessment/alert/intervention pathways.

In Wandsworth we have had a Community Ward since 2009 – a multidisciplinary community services team led by a GP to identify and case manage those very complex patients who may need a daily visit at home and are at risk of having to go into hospital. Community nursing services, pharmacists and social workers are all integrated with the model as well as a voluntary services coordinator from Age UK who provides links to local groups to help with aspects such as anxiety and depression or social isolation. The out of hospital care work we are doing through the PACT philosophy has been informed by the lessons learned from this. The community Ward also runs an acute visiting service to reduce unplanned admissions and was developed following a pilot called the Wandsworth Home Early Intervention Service Project.

Tier four

Specialist hospital based services, tier 4, are aimed at making sure the patient is only admitted to hospital if they really need to be. We have commissioned a GP and nurse led Urgent Care Centre at St Georges Hospital. Those presenting are immediately triaged and, if they should have been seen at their GP practice, are offered a same-day appointment at their practice. We also have admissions avoidance facilities to try to facilitate discharge through our Community Ward, and the UCC team have access to primary care medical records. There is another service at Queen Marys Hospital at the other end of the borough which runs a GP and minor injury centre.

We have recently commissioned one of the first integrated GP out of hours and 111 service so patients only need to make one call, and will either be advised or have a GP or ambulance sent out without having to make further phone calls. We have also developed a single point of contact for community services which prevents healthcare professionals from having to track down several phone numbers to make one referral.


There are three main benefits to the PACT approach.

Firstly, as a transformational way of delivering care it will change the way services are designed from the bottom-up to improve patient experience and to reduce secondary care admissions, which is ultimately how additional primary and community services will be funded.

Secondly, in the UK we have a multiple enhanced service framework with lots of different bits and pieces which it’s very difficult to keep a grasp on. What we are doing is bringing a whole range of enhanced services down into one contract so it’s all in one place with clear sets of goals that are aligned with each other. Integrated commissioning with the CCG, Wandsworth Borough Council and Public Health will harness the collective skills and knowledge of the organisations.

The third is that the out of hospital care strategy brings together LTC care in a consistent and cohesive way. From a commissioning perspective, this is a powerful tool to ensure we are not counting savings twice, and we can have a clear governance process for how initiatives are developing and where additional connections can be made.

By taking an integrated approach you can ensure that the benefits from revising one aspect of the pathway are not negated by something happening further down the line.

Furthermore, the PACT programme very much aligns with the strategy of the Health and Wellbeing Board in Wandsworth which wants to ensure that the principles of integrated health and social care are delivered and that community resilience is developed and supported.

Health inequalities

Another benefit of having a singular framework for delivering LTC and out of hospital care is to reduce health inequalities which vary hugely across Wandsworth. However, Enhanced Service contracts are only as good as the practices which sign up to it so theoretically this could make health inequalities even wider as the patients of those practices that sign up to it will be seeing all the benefits and those that don’t will get none. In order to combat this our locality managers and their teams have asked practice managers to consider sharing some of the back office functions such as recall systems, data keeping etc with other practices to make the programme easier to deliver. Also a group of practices could employ a new local dedicated GP to deliver parts of the programme. This would include some aspects of clinical delivery, on behalf of the other practices. Bringing together the resources of the capable practices with those that are less able to deliver on the programme can be a win-win-win for everybody; the patients, the GPs and the commissioners.


Previous pilots, such as the community ward and other local initiatives have contributed to Wandsworth having the sixth lowest emergency admissions rates in the UK (standardised by age and sex).

We are confident therefore that our work is based on local knowledge and evidence, and that further multi-disciplinary work, with stakeholders bought into the PACT philosophy will improve results even further.

The future

We are confident that this transformational approach and system change is essential to addressing the needs of the current and changing needs of our population and the future reconfiguration of services. It also anticipates changes in population demographics and aims definitively to enhance the quality of care. We are asking the public we serve, our CCG members and the provider services to travel on this journey with us. To ensure that we have it right we will be intensely evaluating the programme every step of the way.  The clear intention is the integration of care, developing primary care and creating “better care and a healthier future for Wandsworth”.

Andrew McMylor is director of delivery and development and Dr Peter Ilves is a GP and clinical lead, for Wansdworth CCG