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Transforming Healthcare in Oxfordshire

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Sir Jonathan Michael making the opening address at the Kassam Stadium event in April

Managers and GPs from OCCG, local hospitals, local GP Federations, voluntary groups and charities, the county and district councils met to discuss the progress being made to develop new ways of delivering care for local patients.

The event was held last month as partners in Oxfordshire seek to be part of a wider national move to deliver more innovative and cost effective services by introducing ‘new models of care’ across the country.

This is to meet the challenges facing the NHS which include keeping an ageing population healthy with less money to pay for health services; and to move towards treating patients, especially the frail elderly, more effectively at home or in the community where the outcomes for patients are better, rather than use the traditional approach of providing bedded hospital care.   

‘New models of care’ will see GPs having a more proactive role, supporting their frailest patients with additional support from other health and social care professionals. It will also include health and social care staff working together to provide effective care packages for patients closer to home.

The event held at the Kassam Stadium in Oxford attracted over a hundred participants. Sir Jonathan Michael, the Chief Executive at Oxford University Hospitals NHS Trust gave the opening address and stressed the importance of transforming health services to better respond to the needs of patients.

Dr Joe McManners, Clinical Chair at OCCG, said: ‘The traditional way of doctors, hospitals and community services working more or less separately is increasingly struggling to deliver effective patient care for the different populations we serve. The only way to deliver better care for patients is for all professionals involved in a patient’s care to work together and be involved in the planning of the changes. This includes GPs, hospital and community clinicians, social care staff, charities and the voluntary sector.’

Joe added: ‘There has been an increased demand on NHS and social care services with less money to spend on them. If we want to improve care with these challenges we need to find different ways of working. This particularly applies to patient groups with complex needs, but also applies to groups of patients for whom the traditional 20th century structures don’t work. The new approaches presented at this event should be able to support more responsive patient care in the community.’

Participants discussed the new ways of working already being developed by the NHS and partners in Oxfordshire through five on-going projects. These include:

  1. Better access to GP services helped by a successful funding award from the Prime Minister’s Challenge Fund:

For full details please see the story ‘Funding to Improve GP services In Oxfordshire’ in this newsletter or click here

  1. The Mental Health Partnership

This brings together six mental health organisations from the NHS and charity sector in the county who have signed up to work more closely together, to make it easier for people with mental health problems to get the best possible support when they need it. This partnership exists to deliver the mental health outcome based contract introduced by OCCG, to focus on improving patient outcomes (such as housing and employment) as well as providing usual services.

The partnership has developed three initiatives to offer local service users the best possible care, including:

  • A triangle of care – a therapeutic alliance between service users, professionals and carers that promotes safety, supports recovery and sustains wellbeing.
  • The Mental Health Recovery Star – a tried and tested model for supporting and measuring change for adults of working age experiencing mental health problems. It is designed to be completed collaboratively between service users and staff, to discuss issues and assess where they are now and where they are going.
  • The Recovery College – an educational approach to recovery which focuses on people’s strengths, supporting them to understand their own challenges and how they can manage them to achieve their aspirations.
  1. Oxfordshire Integrated Care Alliance Programme
  • In response to OCCG’s work on outcomes based contracting, Oxford University Hospitals NHS Trust and Oxford Health NHS Foundation Trust are working together, to transform urgent healthcare services for older people and adults who have complex health problems. Underpinned by an alliance agreement to deliver an outcome based contract, the two trusts are committed to change that is patient-centred, transformational and sustainable and delivered at scale and pace. They highlighted that structural process and change throughout the system is essential.

Their proposed model of care is based on supporting a hierarchy of need they have identified for this patient group, which ranges from general elderly patient care at the one end, to the acutely unwell patient at the other. In order to develop services to support this model, they will be focussing on the following key principles:

  1. a Unified Care Network – providing a seamless network of complex care for patients who are frail, comorbid and vulnerable involving, for example, community care hubs and effective use of telemedicine
  2. Ambulatory Care by Default – providing the best care, closer to home using infrastructure and teams adapted to outreaching care, managing frail patients proactively with a focus on enablement.
  3. Specialist Generalist Care – Model of Care – providing Geriatricians, Generalists and Psychological Medicine in both acute and community hospitals and hubs. Outreach support to primary care will be delivered from community hubs and relationships built with clinical colleagues in acute hospitals.
  4. Universal Best Practice – to deliver cost effective health care based on outcomes that patients told us they want. Key elements of this are; promoting self-care, enabling care, tailored multi-disciplinary care, zero delays, enhanced recovery approach, capable care 24-7 in care environments that are universally, frail and dementia-appropriate.
  5. Working with Others – the Alliance will work with all organisations across the Oxfordshire health and social care system including those in the voluntary sector.

4. Community Integrated Locality Teams

  • The vision for community integrated locality teams is around support for an individual person, so whatever intervention they are receiving, from any number of organisations and professionals, there is just one plan and approach to meet their needs.
  • For the individual this means: ‘I can plan my care with people who work together to understand me and my carer(s), and allows me control and brings together services to achieve the outcomes important to me.’
  • To do this, there will be one county model, delivered from locality bases to manage patients efficiently, by neighbourhood teams, supporting between 4 and 6 GP practices.
  • The teams will be made up of staff and teams from: community health including occupational therapists and physiotherapists, end of life care, community nurses, older people’s mental health, home care support service, falls prevention; social care: including social workers, occupational therapy co-ordinators and Health and Wellbeing Centres; and voluntary organisations: including: community networks, Circles of Support, and Carers Oxfordshire.
  1. Systems Leadership
  • This is a way of working, sharing ambitions and leadership to achieve results across organisations. This goes beyond joint working and is about leading together, rethinking services to put the user at the centre, tackling the underlying causes of complex social and clinical problems, and integrating services to improve quality and value for money.
  • Locally we are working to the Local Vision Initiative. This programme brings together local and national government, the NHS, social care, public health, the voluntary sector, user-led groups, the private sector and leadership specialists. Everyone involved in the programme has one shared purpose: to improve services by removing barriers between sectors and organisations.
  • Each Local Vision programme is supported by an experienced ‘enabler’ to support leaders in each project to come together and deliver successful outcomes. Our enablers will be meeting with key system leaders in May and will then facilitate a workshop in June. This work will run alongside current system working, to improve how we behave as a system.

Over the coming months’ progress will continue with the focus on testing these new models of care in certain areas of the county.


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