The Model

It was thought that the model was a little narrow, and that a broader journey was required. Far greater professional and public input was required to improve it. The aim is a smooth journey through care, but health and well being should be emphasised. There is an opportunity for radical changes, but there need to be explicit incentives for change. A 'care-manager' or similar was required to act as a travel agent and guide the patient into the most appropriate type of care. There should be multiple entry points into the service, and organisational barriers such as local authority or health boundaries should be broken down or blended to allow closer working. Patient ownership of their health information was proposed, and then they could make decisions on with whom to share that information.

Community Health and Well Being. There are a number of generic issues - social inclusion, jobs, money and housing. To allow community planning across the widest range of community services it is necessary to have the knowledge of the services and the work being done. Attitudes and values need to change. There should be lifestyle and skills training. People should have an informed responsibility for their own health. Good communication is vital throughout.

Self care needs to be taught from nursery school. This should take priority over Community Health and Well Being. It is important to establish good behavioural patterns, and responsibility for health should be part of the national curriculum in schools. Modern media such as the internet and digital television could be used here. The emphasis should be on informing patients what is normal and what is abnormal. There is a conflict here with a person's autonomy and choice if they decide on a self-destructive lifestyle. If a person is heading for abnormal, there could be an NHS Direct type service for self referral - perhaps run by LHCCs so that it is likely to be someone known to the patient. Although the NHS Direct has a role, it was thought there should be a broader based helpline with information on where to access the service.

Primary care is the first stage where the patient meets professional knowledge. It will be important to demolish professional boundaries. Professionals need knowledge and respect of each others capabilities to work effectively as a primary care team in a redesigned service. There will need to be a major shift in resources. Should best practice by adopted by choice or central diktat? The diabetes model used in Tayside was demonstrated and an amended version for stroke is shown below. This depends upon multidisciplinary agreement and teamwork.

Mental Health

There should be an increased emphasis on education and support in the community to remove the stigma and increase understanding of mental health. Improved multidisciplinary involvement was also necessary. Speed of access to services was important, to prevent a drama becoming a crisis. However, although entry to the system was important, there is also a need to manage patients out of the system too.

Children's Services

Education was important at all stages, and it should be comprehensive and started as early as possible. It was important to recognise that the child and parent are a unit and should be treated as such, although the relative importance of the two will change over time. From the child's birth, the influence of the parent will gradually reduce and the influence of the child will increase until the child reaches adulthood. There needs to be more help and support for tertiary referrals with appropriate speed and level of referral. There must be a solution for children in care and those with mental health problems who often fall through the current cracks in the system. The roles of health visitors, school nurses and the voluntary sector should not be ignored. It is also necessary to be in accord with the increasing Children's Rights framework.

Age and need should both be considered. There is likely to be gravitation from secondary to tertiary care as fewer numbers of centres exist. The challenge is to make these centres more local. The move from generalisation to specialisation can be considered as "de-skilling", as practitioners are expert in only one field.

Care of the Elderly

There should be a multidisciplinary team working across primary, secondary and tertiary care. It should not be a matter of where, but how the service is delivered, and is it effective? The hospital at home concept needs more evidence for the effectiveness of outreach rehabilitation. It is necessary for the elderly to demand health, not expect illness. The West Dunbartonshire 75^th birthday card scheme was discussed. Here, people receive a birthday card on their 75^th birthday detailing the services available to them and asking them to contact a named individual if they have any problems. The service should aim at crisis prevention rather than crisis management. The division between nursing homes and residential homes should be scrapped and replaced by 'care homes'. There should be some sort of 'flagging' process which notes if a person accesses various parts of the system and indicates if they might be 'at risk'. Discharge delays and bed blocking are usually down to problems between health and social care - there are blocks in the system which could be removed by commonalising the budgets for both.

Coronary Care

In prevention, there should be a consistent resource informing and educating local communities. The goals must be achievable and realistic. In self-care, the messages must be repeated and be consistent and accessible. Too often there are conflicting messages from different health professionals. "Drink more orange juice - it's good for you" from one "Drink less orange juice - the acid attacks your teeth" from another. Taxation could be extended to things like Irn-BruÒ and Mars barsÒ . Sensitivity to other cultures must be incorporated and should extend beyond printing in different languages.

Trauma

Again specialisation is leading to de-skilling in this area. Many practitioners now practise defensively to avoid possible lawsuits. What is the definition of 'minor trauma'? This is an added complication to the patients journey unless they are educated as to the appropriateness of the type of care provided at each stage and at different centres e.g. Trauma centre / casualty / ACAD / GP surgery. The public can only use the services effectively if they have the knowledge, or someone who does.

Stroke

There should be a strong emphasis on primary and secondary prevention with, for example, an annual health check for everyone. There should be support for a nationwide improvement in acute stroke treatment , with an explicit statement in the plan and increased investment in stroke units and rehabilitation units.

There are major education issues for the community and well being area. Screening was suggested, but would require to be worked out more fully.

Within secondary care, it will be necessary to plan for discharge from day 1, working with primary care. There must be close liaison between the acute stroke unit and the rehab unit with, preferably, the same people involved in both.

Once the patient is discharged follow up is important. This may be where the intermediate care level comes in.

• Devolve budgets to lowest appropriate level - although there needs to be accountability and a balance between local and national initiatives.
• Remove the process of bidding for funds.
• Simplify the administration.
• Provide incentives.
• Reduce knee-jerk reactions and stick to the needs of the plan.
• Either lose capital charging or complete the circle. Introduced originally to ensure competitive use of facilities, the money raised in this way has never been available for reinvestment.
• Resource transfer from health to local authorities for social work etc.
• Pilots should be conceived rather than changing, finding it doesn't work and changing back.
• 3 year budgeting instead of annual budgeting. Either longer term or rolling budgets.
• Fundamental review of primary care funding and of the different payment schemes which don't fit into the LHCC model.
• Proper vacancy planning. Often used as a financial device to save money, it can be interpreted as providing a service beyond the funding. In which case, if it, and other financial devices, are removed, how does the service cope?
• Retention of a percentage of efficiency savings. Use it as an incentive for front line staff. Instead of the Health Boards claiming back all the funds, some could be retained.
• No cherry picking of services. If services are to be provided by LHCCs, for example, there should not be a situation where only certain services are provided, because others are too difficult or expensive.
• Output targets. Political imperatives require to see quick results, so some measurement must be possible.

• Smart cards / alternatives to discharge letters
• Improve training
• Flexible services in the right place. The public need to be involved.

Managing people effectively

Communication, the quality of the communication and the degree of caring inherent in that communication are all important.

• How to identify people
• How to improve training
• How to monitor and appraise
• Facilitate mechanisms to voice concerns and get a proper response

Identify and break down professional barriers

Principles of teamwork -

• Establish Educational Development Board for all professions
• Clinical Governance
• National strategies set and implemented at local level by Clinical Network Groups

• Should be overall governance, not just clinical and financial, with responsibility for service provision and management
• Accountability. There is a degree of accountability within organisations, but outwith these organisations it is difficult. When teams are defined, individual responsibilities could be defined.

Performance Management

There needs to be an overall approach, and the Clinical Standards Board are the key to a lot of it. It has to be done so that an individual service looks at itself critically. External audit should praise when things are going right and disseminate good practices. An agreed plan of action is required, and a need to simplify Trust financial structures to free up some people and time. There should be an increase in centralisation and central control.

back to top