1. How much different could life be if we shared information across traditional boundaries? Mark Pugh Medical Director Isle of Wight NHS Trust

2. Aims Describe Isle of Wight Context Review a number of on-going schemes Describe some of the background around the implementation of these schemes Describe the impact of the schemes

3. NHS

6. More Money Less Stuff

7. NHS More Money Less Stuff Be More Efficient Design a better system

8. Options Atlas of Variation Lord Carter of Coles

10. ISLE OF WIGHT OVERVIEW Accessible only by sea/air (weather dependent) 23 miles wide by 13 miles long Single system, single boundaries Increasing elderly population; 26% over 65 (17% England av) & over 75 12% (8% England av) Recruitment & retention issues Low earnings; higher than av. long term unemployment; 20% children live in poverty; low GCSE attainment (45%) Population of 142,000; est’d £300m health & social care budget 2.5m visitors p.a.; 2 large music festivals

11. AGE PROFILE Over 65s expected to increase by 47% & will account for 36% of the total population by 2037 (vs England 24%)

12. Isle of Wight Council (incl. fire & children’s srvs) Isle of Wight Clinical Commissioning Group Voluntary Sector Independent Sector (Care Homes & Home Care) Isle of Wight NHS Trust One Wight Health (All 17 GP Practices) Town & parish councils Hampshire constabulary The Island’s citizens MY LIFE A FULL LIFE: Partners

13. My Life a Full Life; AIMS Person-centred, allowing & enabling individuals to take control of their lives & their care Services based in the community/at home, delivered by integrated teams Prevention-based, promoting health & wellbeing Quality of life & keeping well Linking together & building on schemes already up & running/being planned across our communities

14. Integrated care, co-ordinated around the needs of patients and service users Patients and service users actively involved in the design of their care and working with professionals as part of the care team Re-designing the care pathway, with greater specialisation in hospitals, increased capacity and more consistent standards in primary care Stronger focus on prevention. Kings Fund Characteristics of future Health Care Systems

15. OUR ‘MY LIFE’ MODEL http://www.nurturedevelopment.org/ Based on ABCD approach – Cormac Russell Our integrated ‘My Life’ model is: Prevention-based Health and wellbeing promoting Built on experience-based co-design Founded on self care and empowered communities. At the centre of our model is the person My Life coordination supports the individual to navigate the community and system. This single point of access triages, reduces the perceived system complexity, increases awareness of services, and maximises efficiency. The Integrated Locality Teams deliver person centred care and support in the community, with GP clinical leadership and multi-specialist teams. Intimate / Family Key enablers My Life, A Full Life – care services Associated Life Friendships Support Groups Home One information One Leadership One empowered people and workforce One Technology-enabled Care System One Island £ Hospital Services Integrated Locality Teams Ambulance Service Public Health Commissioned voluntary sector Adult social care Children’s social care Integrated single point of access Community Faith Groups Voluntary Sector Isle Help Town and Parish Councils Family Friends Colleagues My Life Coordination Informal community links Transport Education Housing Association Environment Health- watch People Matter Crisis Response Team Domiciliary Care Out of Hours Independent Sector Palliative Care 10.06.2015 Home 09.06.2015 Community Health Services MH & LD Services

16. 1. eCare Logic Programme What do you do with 34 different records ?

17. GP Acute Services The Isle of Wight A&E Service Mainland Acute Hospitals GP Surgeries A&E Despatch The Beacon Health Centre Isle of Wight Council Community Health Centres The Prison Service Patient Design & Delivery – Isle of Wight Integrated Services Information System Patient Portal IoW Portal Mobile working Integration with Vision 360for patient summaries GPs to launch IoW portal from Vision IoW Portal IoW Ops Centre Integration with Valentia And mobile access to IoW Portal Access to a New IoW Patient Portal,SMS Reminders Access to IOW Portal IoW Portal Mobile Phone Isle of Wight Information Hub E-CareLogic Database Operational DB Reporting Database Clinical Portal

18. GP Acute Services The Isle of Wight A&E Service Mainland Acute Hospitals GP Surgeries A&E Despatch The Beacon Health Centre Isle of Wight Council Community Health Centres The Prison Service Patient Design & Delivery – Isle of Wight Integrated Services Information System Patient Portal IoW Portal Mobile working Integration with Vision 360for patient summaries GPs to launch IoW portal from Vision IoW Portal IoW Ops Centre Integration with Valentia And mobile access to IoW Portal Access to a New IoW Patient Portal,SMS Reminders Access to IOW Portal IoW Portal Mobile Phone Isle of Wight Information Hub E-CareLogic Database Operational DB Reporting Database Clinical Portal

19. Care Hub 999 / 111 GP or other professional SimpleComplex Non- surgical Out - patient Day caseIn-patientStep-down Home & Follow-up TreatmentDiagnostics Initial appointment / contact Patient Need Triage To the right point of the right care pathway GP or other professional Urgent Care Centre A&E / Trauma unit / MAU Ambulance Community response Self Care Pathway Redesign Opportunity High Low To do the right care in the right place at the right time ‘IPIM’ Informatics Programme Integration Model – providing functionality to support service redesign Phase 1 Phase 1 – Core infrastructure & systems - Creates the core infrastructure for subsequent phases whilst delivering a NHS first of type integrated Electronic Patient Record journey through Primary Care, Ambulance and up to & including the ‘Hospital Front Door ’ Phase 2 Phase 2 – Integration & interoperability - Builds on Phase 1 and using Integration supplier, creates a NHS first of type Electronic Patient Record journey from Primary Care into Secondary Care. Firstly by building the system for a Pilot Ward (MAU) and then rolling this out across remaining hospital Phases 3&4 Phase 3 – Purchases new Child Health, Community & Mental Health systems and integrates them into the wider system to create a NHS first of type patient journey through Primary and Secondary care, into Community and Mental Health Phase 4 – Integration with Social Care & other partners for which an Options paper is being developed jointly with the council and, upon completion, will be NHS first of type integrated Electronic Patient Record across all care settings

20. Electronic Record Often takes longer than planned, fans and luddites Significant expense, not delivering what everyone wants Takes longer for front line clinicians, effort rewarded, with a record many can access, simultaneously, instantly Information can be used smartly, e.g. record searches, pathology informs your prescribing system

21. Madrid

22. The Hub

23. FUTURE Explore how other sectors/services can offer support to and benefit from joining the integrated access service provision for the community. Outline IG review for compliance Review assistive technology to support services and enable transformation System integration review analysis Enablers to support further integration and expansion: Options appraisal to the location and needs of the Hub to be undertaken as part of the Estates Review. Use the pathways developed through the Whole Integrated System Review. Support moving the system towards a prevention and community based intervention model and away from statutory services where possible and appropriate Understand health and social care commissioning needs and support the development of alliance contracting to generate true integration of services working successfully to evidence value for replication in other areas The integrated access and triage centre will provide Isle of Wight residents with the most appropriate response quickly by bringing together the various emergency and non- emergency services in a seamless and efficient way. July 2016 Over the next 12-months, we will continue to move towards a fully integrated access hub that has a single management structure and that utilises technologies to give a co-ordinated and consistent point of contact for all people. By collecting and analysing data from calls received we will be able to work towards identifying demand trends and complete predictions of localised need and prevention strategies based on needs and trends and issues observed in the community. The end result of this will be to be more proactive in planning service response so as to broaden community resilience. Integrated Access: 2016-17 Milestones April 2016 Oct 2016 Decision on Estates Review will be circulated by Estates workstream Explore how integrated access can support a single org form. Oct 2016 January 2017 Review data from call centre log system to begin to analyse trends in demand on services and whether we are gathering the right info to enable us to predict future demand trends. Workers trained across the functions. 23

25. Information Strategy Agreed framework with local authority- provides and umbrella agreement but each new share is put through a process Undertook a public census to get agreement to share primary and secondary care information. Done with patient’s consent or in their best interests if they can not give this.

26. EOLC Strategy End of LIfe CareGPsHospitals NHS Community Care HospicesPrivate Sector Professional Bodies Voluntary SectorLocal AuthoritySpiritual Care Patients and Families / Carers Prisons

27. Shared Information Single Record Community Care Hospice Trust ACP General Practice Ambulance Service Nursing/Care Home Flags to hospital record

28. Results of Population Management

29. Population Management of Gout

30. Eclipse

32. Improvement plan. Circulate audit results Educational seminars Eclipse alerts Near Patient testing Vision treatment template In Practice seminars Re-audit

33. % to target Gout Patients,Urate <360,Allopurinol therapy

34. Management of Gout Overcoming Current Challenges In The Management of Gout in Primary and Secondary Care Through Audit. BSR 2014

35. Sources of Information Fire Service- Smoke Alarm Installation Who else has data? Plumbers, Rubbish Collectors, Postmen Citizens, Relatives, Community Support Groups How to access move that information around system for people’s benefit, who and what.

36. Community Crisis Response

37. Managing referrals Referral received from GP,111,Adult First Response, Beacon or Community Nursing Ensure that referral form completed reason for crisis intervention meets criteria Within 4 hours arrange to assess patient dependant upon need with relevant discipline Perform full assessment in home environment then follow assessment guidelines Ensure that Referral is placed upon the Crisis response shared drive under Surname

38. Management of assessment If health assessment required Duty nurse and Band 4 or Duty Nurse and OT to carry out assessment of the patient within their own home If social care assessment the accepting member of the team must liaise with the Consultant practitioner to discuss Ensure that full assessment is carried out and refer to necessary health or social care professional (Community nurse, specialist nurse, therapist or voluntary sector) Decide what intervention the team will provide for 72hours and agree on care plan at virtual ward rounds On assessment from the referral does the patient require health or social care intervention to assist in crisis If the patient requires immediate assistance ensure that 1 member of PTS support other member of the team whether OT or Nurse to carry out assessment and liaise with Operational Manager to decide on course of action Ensure that full assessment is carried out and refer to necessary health or social care professional (Community nurse, specialist nurse, therapist or voluntary sector) Decide what intervention the team will provide for 72hours and agree on care plan at virtual ward rounds Does the patient require immediate assistance following a fall or injury that does not require hospitalisation Make sure that the patient has a care plan for 72hours crisis support During the support devise and Anticipatory care plan in agreement with patient, their family & carers where appropriate Once Assessment is Completed

39. Principle Issue

40. Source Referral

41. Outcomes-2014

42. Analysis of Admissions Saved Approximately 80 referrals per month Team believe half would have been admitted Perhaps real figure is one quarter Cost avoidance easily pays for the cost of the team

43. Conclusion Trust required, high level buy in, compelling shared vision Being able to share information is vital to success It is possible to alter patient management flow at a population level, but this takes time to set up and deliver results

44. Any Questions?

45. In Hospital Death Rate YearHospital 11/12641 12/13736 13/14554 14/15548 15/16492

46. % to target Gout Patients,Urate <360,Allopurinol therapy