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New models of care

Clinicians have also been working closely with patients to develop new models of care for specific services, including:

Diabetes

Stroke

Older people and adults (including Rapid Response and Community Beds)

Outpatient services

Diabetes

In Herts Valleys around 30,000 people are living with diabetes – around 1 in 20 residents. About nine out of 10 people have type 2 diabetes, which is often linked to lifestyle issues such as an unhealthy diet and lack of exercise.

Type 2 diabetes usually appears in people over 40 but more children and younger people are now getting it. The number of people diagnosed with diabetes is gradually increasing each year.

Diabetes can lead to lots of complications such as heart disease, blindness, kidney damage and amputations. By taking a different health approach we hope to stop people developing type 2 diabetes in the first place and help those diagnosed with either type 1 or type 2 diabetes to manage their health and diabetes better so there is less risk of them having complications.

Herts Valleys CCG is working with local hospitals and Hertfordshire Community Trust, who provide services locally, and with patients and Diabetes UK to develop an integrated diabetes service.

We have already introduced closer monitoring of diabetics within the community so that patients are offered six monthly check-ups with their GP and eye examinations. If any issues are identified patients are referred for follow-up support, with the most urgent cases being seen by the following day.

The integrated service will increase the amount of support available to people in the community including:

More prevention services – Herts Valleys is in the first wave of the roll-out of the NHS Diabetes Prevention Programme. People identified by GPs as being at risk of developing type 2 diabetes can take part in a nine month healthy living programme delivered at local venues.

Better and ongoing education to help patients look after themselves. At the moment newly diagnosed patients can take up structured education programmes to help them manage their diabetes but in the future patients will be able to access top-up advice sessions and other courses.

Strengthening GP support for patients, including more training and education and giving them direct access to specialist advice that will equip them to provide more complex care closer to home.

Bringing together the various clinical services that support diabetics including retinal screening, community nurses and mental health services, and linking with other providers such as social services, nursing homes and the voluntary sector.

The new integrated diabetes service is planned to be in place from April 2017.

Stroke

Developing stroke services has been prioritised so that patients have a clear treatment path from diagnosis and initial care to rehabilitation or recovery. The services will include:

  • Hyper Acute Stroke Unit (HASU) based at Watford General Hospital
  • Acute Stroke Unit
  • Specialist Stroke Rehabilitation Beds
  • Early Support Discharge (including social care elements)

We will work with incumbent providers to develop the model throughout 2016/17 with a view to full implementation starting in April 2017.

Services for older people and adults

Work is underway to strengthen links with local care homes. For example, GP practices/federations are being aligned with care homes, whilst one 'care home pharmacist' will be rolled out in each locality. We are also developing a model for a fully integrated frailty team, with access to 'step-up' or 'sub-acute' beds in the community and links to the end of life care pathway. Access to primary care services is also being improved and, by October 2016, we will develop a commissioning framework to increase capacity through improving access to primary care for implementation from 2017/18.

Rapid Response

The Rapid Response service includes health professionals such as paramedics, specialist nurses, physiotherapists and occupational therapists together with social care and mental health services who can act quickly to provide support for older people to prevent hospital admissions or support early discharge. This includes things like:

  • reducing the severity of injuries from falls
  • treating infections
  • IV therapy
  • home-based treatment for long term conditions
  • emergency palliative care
  • mental health assessments
  • supporting carers.

Community beds

We are working towards implementing the new model for community beds in 2017/18. This will include commissioning rehabilitation beds from residential care homes alongside wrap-around therapy and nursing services.

For example, in Dacorum this includes a ‘rapid response’ service and resolving the future of the Gossoms End beds.

Outpatient services

We are working with clinical experts and patients to redesign outpatient services over the next two years. Hopsitals and primary and community health service providers are working together to improve services so that people with less complex needs can be seen and treated at local centres rather than having to go to hospital. This will mean that more people can be seen closer to home, more quickly and hospitals are freed up to focus on more complex cases. This new approach will cover Ophthalmology, Ear Nose and Throat, Gynaecology, Dermatology and Musculoskeletal services.