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Services Available in a Locality
We want to provide more services in the community by strengthening the capacity of community and
primary care services, to better reflect local need. These local services will also be complemented by
services from community hospitals and those specialist services which district general hospitals are
uniquely able to provide.
In order to facilitate the changes we have considered the services that our population expect to
receive. First, it is essential to identify the community based services that are needed. Then, we can
consider the workforce, buildings, equipment and facilities required to best deliver those services for
each locality.
Services will only be provided from district general hospitals if they cannot be delivered effectively,
safely, and efficiently in communities. As technologies and services develop there are greater
opportunities to deliver care and treatment in people’s homes or closer to people’s homes which have
historically been provided from hospital settings. Recently such service developments include
chemotherapy and renal dialysis. As such provision is piloted and evaluated; recommendations will
be made to localities to develop further services in their communities.
There are no new monies to invest in the development of new primary and community services, and
consequently there will be a need to transfer resources from other areas, including services in district
general hospitals.
We must therefore describe and agree the models of community led ‘out of hospital’ care to allow us
to understand the changes needed for our ‘in-hospital’ services.
Infrastructure for the delivery of Locality Services
The aim is to develop and enable local community services to provide the bulk of care for our
population alongside local general practices. There are a range of buildings and sites across each
locality which already provide the facilities for some of these services. However, new facilities will
need to be provided to support the service changes required for a locality population. Increasingly
these premises will be shared with other organisations to provide easy access for the population and
encourage staff to work closely together eg. Leisure centres, local health centres and clinics.
The ‘hub’ of these could be referred to as the ‘Community Campus’ or ‘Strategic Site’ and for most
localities will be based around a community hospital.
Each Campus could be ideally placed to serve as a base for urgent care such as GP out of hours
services and minor injuries services (that can be safely provided outside of an acute hospital), local
diagnostics, treatment, advice and specialist services such as consultant outpatient clinics, ‘step-up
and step-down’ beds. The location and number of Strategic Sites will ultimately be determined by the
level of need for services in a locality as well as travel times. This will be considered on an individual
locality basis.
Across North Wales there are currently 20 community hospitals. The distribution of these hospitals
mainly reflects history, rather than any service plan. A number pre-date the NHS and were
established in small towns by local benefactors; some were built with local donations as war
memorials. It is essential that all facilities and services in place support the locality care model. This
will lead to a number of premises being reviewed, including community hospitals to ensure that they
are appropriate to deliver the services required, and are ‘fit for purpose’ to be able to best support
services in the localities.
LSG – Briefing Note
April 2012
Proposed Locality Service Model
In each Locality:
(A) Patient
(B) Family & Carers
People will continue to be encouraged to take more responsibility for their own health
and well-being. There will be a greater availability of services and information to support the
prevention of ill-health, with a focus on smoking cessation, helping people to achieve and
maintain a healthy weight, sensible alcohol consumption and more opportunities for taking
regular exercise. Patients will continue to be able to receive immunisations such as for flu and
children’s vaccinations from local surgeries and clinics, as well as in their own homes.
Patients will be supported to be more involved with their own care. There will be a
greater emphasis on ‘helping people to help themselves’ through better access to advice,
information about their condition and self-care services such as exercise referral schemes at
local leisure centres. Community support will be encouraged (for example ‘buddy’/befriending
schemes managed by the voluntary sector), expert patient programmes available for people
with a long-term condition such as diabetes or asthma, and a further roll out of
telecare/telehealth in people’s homes so that their condition can be closely monitored and care
provided when needed.
LSG – Briefing Note
April 2012
(C) GP Practice and Community Pharmacy
Local primary care practitioners (GPs, Pharmacists, Dentists, Optometrists) will
continue to provide a full range of core services to treat minor illnesses and minor injuries as
well as the prevention services described above. Where minor injuries services are not
available in a GP Practice setting, they will be available from an alternative setting within the
locality. There will be more diagnostics and monitoring available locally, for example
community pharmacists could provide more blood pressure and cholesterol monitoring.
GPs will be better supported in delivering mental health care. Treatment will be
strengthened with the development of local primary care mental health support services. This
will be done jointly between health and social care with improved support for people of all ages
who have mild to moderate and/or stable, but enduring mental health problems. Community
Mental Health Teams will provide on-going care for those patients who require longer term
(D) GP Practice or cluster, and Community Services
Community nurses, including district nurses, health visitors and school nurses will
continue to have an important role in caring for people in their own homes and communities.
Some district nurses will be trained with advanced skills to support and care for very
frail patients and/or patients with more complicated care requirements in their own homes.
Enhanced, more specialist services, such as sexual health and diabetes care, will also
be provided by GPs. Some of these services will be available in all surgeries whilst some may
be undertaken by a local GP who has gained an expertise in treating patients with a particular
condition. To support this approach GP practices will be encouraged to work closely together,
within a “cluster” of practices.
Such enhanced service provision will also be complemented and supported by more
hospital consultants and specialist nurses working in community settings or providing ‘virtual’
support with the use of telehealth and helplines.
Pharmacists will continue to work closely with GPs, with increased support to
community hospitals and care homes leading to improvements in prescribing the best
medications to meet each patient’s needs. This will reduce the amount of waste and also
improve the quality of care for patients; particularly those who require a complex range of
different medications.
There will be joint health and social care MDTs who will work together to best identify
the most vulnerable people in our communities and jointly agree and provide the best package
of care. By working closely together they will support and care for patients in their own homes
and communities to try and stop their condition worsening, keeping them as well as possible
and prevent them being admitted to an acute or community hospital unnecessarily.
Vulnerable patients will also have access to “intermediate care services” where nurses,
therapists, social workers and the voluntary sector work closely together either in their own
homes or in an alternative care setting (such as a care home or extra care housing), to
support patients to be independent, prevent them having to be admitted to an acute or
community hospital, and when patients have to stay in hospital, support them getting home as
soon as possible.
LSG – Briefing Note
April 2012
Community staff will also work together to support patients, their carers and families
with their particular care needs during the last days of life, and wherever possible care will be
provided in the patient’s own home.
Out of hospital dementia services will be further developed to better support patients
and their carers, both in their own homes and in care homes.
(E) Locality Community Campus
There will be a better availability of outpatient services and specialist clinics, preassessment clinics, family planning, specialist treatments, such as intra-venous antibiotics and
local diagnostics.
For those patients who require intermediate care or palliative care, and it is not possible
to provide this care in their own homes, inpatient beds will be available.
Urgent care will be available from the GP out of hours service, supported by advanced
nurse practitioners and enhanced care at home, and minor injury services.
(F) 2 or more Localities
For some more specialist services the number of patients requiring a particular
treatment may be so small a very local provision is not viable. This does not necessarily mean
that patients will not be able to receive a service locally but the way it is delivered will have to
be carefully considered. For example for Speech and Language Therapy the number of
patients requiring the service means that current staff cover more than one locality. However
use of technology can provide ways in which IT facilities enable a service via VideoConferencing from the therapist to the patient in their own community. Given the geography of
North Wales, strategically located Telehealth facilities could improve access considerably and
ensure effective use of clinical time.
Common Locality Priorities
In developing this model the following common priorities across all the localities have been
1 Further development of Intermediate Care Services
A review of intermediate care services has been undertaken across North Wales to consider equity of
provision. In addition the Home Enhanced Care Service or HECS has been developed and piloted in
the North Denbighshire Locality. This is now referred to Enhanced Care at Home.
Enhanced Care at Home is a primary care based model of care, providing ‘step up’ and ‘step down’
care in people’s own homes for individuals who have an increased medical need and who, without
this support, would be admitted to a hospital bed (acute and/or community) and/or who would remain
in hospital for longer to have their medical need met. The patient’s GP practice acts as the
gatekeeper of the service (deciding whether or not a patient can be safely cared for at home) and
provides enhanced medical care to the patient at home. The GP is supported by a multi-agency,
multi-disciplinary ‘team’, including regular Consultant support
LSG – Briefing Note
April 2012
Enhanced Care at Home provides rapid, intense and short term support, with the anticipated
maximum length of stay of 14 days. This can be extended for up to an additional 14 days should the
individual’s needs require this (for example, in the provision of terminal care).
All referrals are managed via a single referral point – a ‘Communications Hub’. The ‘Hub’ also hosts a
daily ‘virtual’ ward round, attended by members of the multi-disciplinary/agency team to discuss all
new (and existing) patients and agree care plans. A 24/7 care plan is agreed for each individual,
encompassing health, social and personal care. Personal care is provided free of charge to the
individual whilst under HEC care.
As a result of the evaluation of this new service, BCUHB are now committed to rolling-out this model
of care across the 14 localities to enhance the intermediate care teams already in place. These
would be undertaken on a phased approach across North Wales and work has already commenced
with key partners in planning and implementing the service in Anglesey, Meirionnydd, Central/South
Denbighshire and South Wrexham.
2 Out of Hospital End of Life Care & Anticipatory Care Planning
A ‘YOUGOV’ survey conducted by Marie Curie Cancer Care (MCCC) in 2005 found that, when given
the choice, 75% of people would prefer to be cared for at home in the end-of-life period. This is
consistent with findings from other surveys and studies. However in 2009 only around 30% of
patients in North Wales died at home.
In order to improve this we will look to implement the recommendations within ‘High Impact Service
Changes - Delivering high quality, cost-effective care in the Community’ which are relevant to End of
Life Care. A pilot project has already commenced in the North Denbighshire Locality to progress this
High Impact Changes - End of Life (EOL) Care:
Robust education for primary and community teams, including care home staff, in identification
and management of patients nearing the end of life, including accurate diagnosis of reversible
conditions. Support for primary care to be available for anticipatory care and advance care
planning, particularly out of hours.
Localised evidence-based care pathways for heart failure, COPD, epilepsy, diabetes, End of
Life. Generic pathway to be developed for frail elderly patients with co-morbidities.
Development of advance care planning within all settings to record preferences for future care
of patients whose care management is complex or palliative. Processes for planning and
provision of social care, NHS funded nursing care & NHS continuing health care need to be
responsive and timely.
Support for End of Life Care at home through skilled multidisciplinary assessment and
provision of essential equipment. Patients offered Advanced Care Planning and anticipatory
provision of essential medications.
Access to comprehensive specialist palliative care service, including inpatient beds, is
required. All healthcare professionals involved in providing care to patients in the palliative
phase of their illness should be trained in communication, recognition of the end stages of life
and End of Life Care.
Encourage of GP Practices and Community Healthcare teams to take part in structured
training programmes focused upon End of Life [EOL] care.
LSG – Briefing Note
April 2012
3 Further improvements to Chronic Conditions Management
Chronic diseases result in very high numbers of unplanned admissions to hospital and represent
significant potential for efficiency savings. A number of chronic diseases could be managed primarily
on an ambulatory basis, ensuring appropriate levels of specialised care in hospital are accessible
when required.
Those with high numbers of emergency admissions that will be reduced through enhanced
community care include:
COPD / asthma / chest infections
Angina / heart failure / hypertension
Epilepsy / convulsions
Diabetes with complications
There will be a continued effort to implement the key service changes and resources required to shift
care for chronic conditions out of the acute hospital setting to provide high quality services in the
4 Further development of community based services
The following services will continue to be developed across localities:
IV therapies in the patients own home and community hospitals
Rehabilitation at home
Further utilisation of telehealth
5 Improved access to specialist clinics
In 2010/11 91.5% (388,471 patients) of the consultant outpatient activity provided by BCUHB
happens across secondary care hospital sites and only 8.5% (36,222 patients) of the activity is
undertaken from 22 community locations.
There is clearly an opportunity to increase the level of activity available in the Localities and work is
now being undertaken to detail the potential for providing more outpatient services from the identified
‘Strategic Sites’.
6 Improved access to diagnostics
A review of access to diagnostics and monitoring will be undertaken with the aim of increasing
provision closer to the patient’s home, ensuring a shift of some services from the acute hospitals to
the Strategic Sites. These would include:
Imaging : Plain film X-ray and ultrasonography
Pathology : A full range of Blood science investigations (U&E, FBC, LFT, glucose, HbA1c, INR,
thyroid etc ) to support chronic disease management as well as some diagnostic and "rule-out"
investigations. This could be delivered at one stop clinics.
LSG – Briefing Note
April 2012
7 Improved Community Transport
We recognise that the development of more community based services and the movement of some
services to new sites may have a negative impact on individuals who will have to travel further to
receive them. This impact maybe due to cost in terms of the economic situation, non car owners, lack
of public transport or not meeting the eligibility criteria in place for receiving ambulance transport
which is based on having a specific health need.
We have started to work with WAST, Local Authorities and Community Transport providers to
address these transport issues. A specification for Community Transport to be commissioned in
defined geographic areas has already been produced and discussions are taking place with WAST
and Local Authorities about developing much more integrated transport arrangements to maximise
the use of ambulance, local authority and community transport providers as well as encouraging the
establishment of social enterprise transport schemes to support citizens access affordable and
accessible transport in the future and provide more efficient transport arrangements for the public
sector in all.
What are acceptable travel times?
It is recognised that the geography of North Wales is extremely varied containing both densely
populated urban areas and very rural areas. As a result the way services are provided in each
Locality will vary according to the population served. A guideline for Localities indicating expectations
in terms of physical access to services relating to travel time is being developed.
The Rural Health Plan (WAG, 2009) recognises that providing the right care in the right place and by
the right person in rural communities presents additional challenges. From their research, it is broadly
recognised by people living in isolated communities in Wales that the delivery of more complex
healthcare may need to be centralised in a small number of specialist centres where the expertise is
concentrated to provide best possible outcomes.
Such models will require patients and their families to travel, sometimes making long journeys, to
access care and where this is proportional to their need. This appears to be accepted as an inevitable
consequence of rural living.
Alongside this however, core services and less specialist care should be accessible within local
communities, drawing on specialist care as and when necessary. The Rural Health Plan compares
this with other every-day activities undertaken such as shopping, providing a powerful illustration of
acceptability and appropriateness.
Travel times and distances to out of hospital services, therefore need to be considered for:
Core GP services
Enhanced GP Services
Community pharmacy services
Intermediate care & rehabilitation in ‘step-up’ and ‘step-down’ facilities
Basic diagnostic services including xray
Urgent care including minor injury services
Outpatient services
Therapy services
In addition many services are also be provided in the patients’ own home and consideration is being
given to travel times for care staff travelling from their base to a patient’s home.
LSG – Briefing Note
April 2012
Implementing this Service Model & Actions Required
It is recognised that additional investment in some services in the community is required, but also that
this has to be considered within the overall context of a very challenging financial environment. There
are no new monies to invest in the development of new primary and community services, and
consequently there will be a need to transfer resources from other areas, including services in district
general hospitals.
BCUHB has already agreed a number of developments, jointly with Local Authorities, totalling
£8.95million. However it will also be necessary to reduce the amount we spend on some services to
invest in others. A high level overview of current services has already provided examples of where
we are duplicating local services with different staff groups providing the services to meet the same
patient need. An example of this is minor injuries services which are, in some localities, available in
local GP practices as well as the community hospitals.
There is clear evidence that by developing community services and capacity, the demand on district
general hospitals will be better managed. We have referred to work previously undertaken for North
Wales eg. Secondary care Review (2006), A Shift in the Balance of Health Services (York
Consortium, 2008), CCM Demonstrator learning papers and reports.
The Locality Leadership Teams have begun to consider the service model described and look at what
is currently available within their locality. It is recognised that the geography of North Wales is
extremely varied containing both densely populated urban areas and very rural areas. As a result is
must be accepted that the way services are provided in each Locality will vary according to the
population served.
Work will continue with the Locality Stakeholder Groups to recognise the challenges and
opportunities each Locality has in being able to deliver the service model in the most safe and
efficient way.
LSG – Briefing Note
April 2012