Download Healthcare for London: Quick reference guide care settings

Care settings
About this document
The following care settings are outlined in this report:
Home
This is the person’s usual place of residency and can include a house,
residential or nursing home, or long term supported accommodation.
Polyclinic
•
Community based
• Hospital based
Polysystem
•
A clinically led model of care involving all partners in a local
network for a 50-80K population with a polyclinic at its heart.
Secondary care
•
Local hospital
•
Major acute hospital
•
Elective centre
Specialist care
Mental health settings
1 Care settings
Maternity
Home
Currently only about 2% of London births take place at home. Numbers could increase as
a real choice of homebirth for those with uncomplicated pregnancies is better enabled and
promoted.
In anticipation of an upward trend for home births, workforce considerations should
include staff numbers and team configuration. An element of retraining may also be
necessary.
Much immediate postnatal care is already delivered in the home and this is likely to
continue to be the case.
Polyclinic
Primary care is the main point of access to maternity services for most women. Primary
care settings could offer a range of care – preconception, antenatal and postnatal,
including classes (linked to children’s centres where appropriate) and triage to establish the
onset of labour.
In order to deliver this range of services some GPs will need to upskill and there will need
to be sufficient numbers of community midwives available to provide high-quality care.
Some primary care settings have the potential to offer a standalone, midwife-run unit
where women with uncomplicated pregnancies can give birth. The Barkantine Centre in
East London is an example of such a unit.
Secondary care
Local hospital
Most women currently receive most of their antenatal care at their local hospital and
most births, both low risk and high risk, take place there, in co-located midwife-led and
obstetric units.
Most London obstetric units deliver between 3000 and 6000 births a year, with some
delivering more than 6000. Healthcare for London is currently writing a detailed
commissioning specification for an obstetric unit which will consider whether larger units
offer economies of scale, as well as identifying resourcing requirements and facilities codependencies.
Major acute
Women with complex and high risk pregnancies will be able access antenatal care and to
give birth here. As with local hospitals, obstetric units should be collocated with midwifeled units.
Specialist care
Foetal medicine is currently out of the scope of the Healthcare for London project but is
likely to be provided at a small number of major acute hospitals.
Care settings
2
Children and young people
Home
It is anticipated that more care will be delivered for children and young people in the
patient’s home. This will include treatment of complex health needs and long-term
conditions as well as acute care such as IV antibiotics.
Community focused multi-disciplinary teams will be needed to support this shift in care
setting.
Polyclinic
A significant amount of current acute based outpatient activity should be moved out into
the community through polyclinics and other local settings. More work is now needed to
understand the local workforce and critical mass requirements for facilitating the activity
shift.
In the shorter term consultant paediatricians may move a number of their clinics out of
hospitals, and looking longer term there is a need to up-skill community children’s nurses,
community paediatricians and GPs to carry out more planned care.
Polyclinics need to be seen in the context of wider local children’s services, such as
children’s centres and extended schools, to understand where services are best sited.
Secondary care
Local hospital
An ambulatory care service will be on the front of each hospital. It will include GP-led
urgent care services and a paediatric assessment unit (specialist paediatric- led), which will
be open 12 hours a day, seven days a week (hours locally determined). This facility will
see the vast majority of patients who would typically stay for up to a day in a paediatric
inpatient unit.
A paediatric inpatient unit will no longer be onsite. A transport protocol will be developed
for safely transferring patients who need inpatient care to a major acute hospital.
Activity modelling has been carried out to examine the potential shift to a paediatric
assessment unit.
Major acute
Major acute hospitals will have an ambulatory care facility and will also continue to have a
paediatric inpatient facility onsite. Activity modelling has been carried out to examine the
number of paediatric inpatient beds needed in London.
Specialist care
A small number of hospitals will be designated as tertiary paediatric specialist centres.
A case for change and model of care is currently being developed and is expected to be
available in November 2009.
3 Care settings
Dementia
Home
Currently some memory assessment services, which provide multi-disciplinary team
assessment, diagnosis and early intervention, are provided in the patient’s own home. This
involves the carer where appropriate and is seen as useful when taking a full functional
assessment.
Following a diagnosis of dementia ongoing interventions can take place at home. This can
help reduce the distress that some people with dementia experience when being cared for
in an unfamiliar environment. This service could be provided by mental health providers.
People with a diagnosis of dementia that are admitted to A&E should be returned to their
usual place of residence if their medical or surgical symptoms can be effectively treated
there.
Polyclinic
While it is preferable to assess people in their own homes, memory services could take
place in the polysystem.
Often people with dementia have co-morbidity with long term conditions. In the
polysystem medical and mental health professionals can provide integrated care plans,
assessing the person with dementia holistically to ensure their physical and mental health
and social needs are addressed in one place.
The mental health aspects of care and treatment could be moved out of the current
mental health hospital or community mental health setting and instead be delivered by
mental health providers in the primary care setting
Secondary care
Local hospital
Assessment will be made in a local hospital when the person with dementia is admitted to
hospital.
Medical treatment will be provided in local hospitals when effective community based
treatment cannot be provided. Workforce competency in local hospitals needs to be
enhanced to provide dignified and competent care to people with dementia and support
for their carers. Local hospitals’ treatment plans should also have psychiatric input.
Mental health settings
In-patient care for people with severe dementia and associated behavioural or psychiatric
symptoms.
5 Care settings
Urgent care
Home
Information, help and advice that enables self management could be provided. For
example, the development of streamlined (single point) telephone access alongside digital,
web and tele-health access.
Polyclinic
Every A&E in London will have a front-end, primary care led centre operating directly in an
onsite polyclinic or as an integrated part of a wider polysystem.
This will be the first point of contact for self-referred patients attending hospital with
unscheduled care needs. Patients would be seen, treated and discharged or transferred/
referred following assessment to the emergency department and other services where
necessary.
Every polyclinic in London is to offer primary care led urgent care services.
Hospital-based polyclinics are expected to open 24 hours a day, seven days a week,
offering primary care-led urgent care with basic diagnostics including x-ray, ultrasound
scan (USS) and blood tests and advanced diagnostics including MRI/CT. Community
polyclinics will offer 12 hours a day, seven days a week, primary care led urgent care with
basic diagnostics including x-ray, USS and blood tests.
Urgent care services will be centred around polyclinics and look towards providing the
current broad range of services (WiC, MIU, OOH, Extended Hours DES/LES,NHSD, ECPs
etc.) in a more cohesive and consistent way through polysystems.
An assessment will need to be undertaken to deliver clinically appropriate pathways to
meet the needs of patients conveyed by ambulance.
Pre-emptive care, rapid assessment and support (including home support) will be delivered
through integrated multidisciplinary (health and social care) teams.
Secondary care
Local hospital
Where urgent care is delivered as described above it is recommended that an impact
assessment and future planning for emergency services is undertaken. For example, local
hospitals without an emergency department could enhance the range of services they
offer through onsite polyclinics.
Major acute
Where urgent care is delivered as described above it is recommended that an impact
assessment and future planning for emergency services is undertaken.
Care settings
6
Trauma
Home
Some patients will require long-term care in their home environment, which may include
some long-term rehabilitation.
Polysystems
Treatment for minor injuries will be delivered in polyclinics as part of the polysystem.
Patients who have been discharged home will have rehabilitation delivered in the
community as part of the local polysystem.
Secondary care
The trauma units will be situated in local acute hospitals with A&E and surgical facilities.
Patients with less serious injuries will be diagnosed and receive their treatment in trauma
units, and either discharged home form A&E or admitted onto a ward. Follow-up of these
patients will take place in an outpatient setting.
Patients who are taken to a trauma unit, but who require more specialised care because of
the severity of their injuries will be immediately transferred to a major trauma centre.
Some patients will be transferred to their local trauma unit from the major trauma
centre for rehabilitation. Others will be discharged home for community rehabilitation as
appropriate.
Specialist care
London Ambulance Service crews will use agreed protocols to take patients with suspected
serious injuries to the appropriate major trauma centre. These specialist centres will provide
a 24-hour consultant-led service for patients. This will include stabilisation, complex
diagnostics, surgical intervention, intensive care, ward care and acute rehabilitation. All
the appropriate specialties are available in these centres depending on the type of injury
sustained.
Certain patients will require rehabilitation delivered in specialist centres. Examples include
neurorehabilitation following brain injury, and rehabilitation following spinal injury or
spinal cord injury. Patients will be transferred for this specialist care from their original care
setting.
Elective centre
Some patients will require elective procedures following major trauma such as removal of
metalwork from fractured limbs. These procedures could take place in the major trauma
centre, trauma unit or an elective centre.
7 Care settings
Stroke
Home
Rehabilitation following stroke could take place at home. Stroke survivors will often need
long term support.
Polyclinic
Stroke survivors will often need long term support, some of which could be appropriately
delivered through polysystems, including the three month, six month and 12 month
reviews, which would benefit from a multidisciplinary approach.
Stroke prevention – both promotion of healthy lifestyles and medical management of
risk factors – should be delivered through polysystems. This includes the national vascular
check programme.
Secondary care
Local hospital
Stroke unit capacity is being increased in local hospitals to ensure that all stroke patients
receive their inpatient care on a specialist stroke unit.
Transient Ischaemic Attack (TIA) services will be located in both local hospitals and major
acute hospitals. Most weekend services for high risk patients are likely to be delivered
through the hyper-acute stroke unit.
Across local and major acute hospitals there will be a significant increase in the number
of doctors (consultant and junior), nurses, physiotherapists, occupational therapists and
speech and language therapists.
Rehabilitation following stroke could take place in a range of bedded facilities (ranging
from dedicated rehabilitation units within local and major acute hospitals, intermediate
care beds and specialist neuro-rehabilitation units). Long term care may similarly be
delivered in a variety of community settings including bedded facilities.
Major acute
All acute strokes will be taken by London ambulance service to one of eight hyper-acute
stroke units. Hyper-acute stroke units are located in major acute hospitals.
Stroke unit capacity (both hyper-acute stroke units and stroke units) is being increased in
major acute hospitals to ensure that all stroke patients receive their inpatient care on a
specialist stroke unit.
TIA services will be located in both local hospitals and major acute hospitals. It is likely that
most weekend TIA services for high risk patients will be provided by hyper-acute stroke
units at major acute hospitals. Most TIA services will be provided as ambulatory care, but
some patients will require admission.
Care settings
8
Specialist care
Hyper-acute stroke units will need to have access (either onsite or off-site through agreed
protocols) to neuro-imaging, neurosurgery and vascular surgery.
9 Care settings
Long-term conditions (diabetes)
Home
Patients should be supported to manage their care at home, using tailored education
and joint care planning. Patients and carers have access to advice and support by
telephone and email.
Polyclinic
Tiers one, two and three of the diabetes pathway can all be delivered as part of a
polysystem:
•
Tier one will include essential care provided by GPs and other practice staff in
a primary care setting. This tier can be delivered across the polysystem through
both the hub and spoke practices. It will include other enhanced services such
as email, telephone support and care planning.
•
Tier two enhanced essential care with extra provision including insulin
initiation and patient education programmes. Generally tier two care can be
delivered by practices, but the cost effectiveness of running this tier’s services
is questionable and may be better delivered from the hub of the polysystem.
•
Tier three services will include specialist care and advice for patients with
complex needs. Care should be provided in the polyclinic hub by the
intermediate diabetes team. These services would include multidisciplinary
clinics, consultant level support, access to other specialists, research,
development and training, healthcare professional training, family planning
and pregnancy planning advice.
Secondary care
Local hospital
The intermediate diabetes team provides tier four care, delivering and coordinating
many services including in-patient management.
Major acute
This is for unplanned emergency admissions. For example, diabetic ketoacidosis
(DKA).
Elective centre
This may provide planned care for other conditions and awareness of additional
complications associated with diabetes.
Specialist care
This would include diabetes-related complications or complications associated with
diabetes when treating other specialist conditions. For example, cancer.
End of life care
Home
More patients should be supported to die at home. At present in London the figure
for home deaths is 20% and for care homes 5%. The objective of the strategy should
be to increase this to around 50% with appropriate community and specialist input.
This will require an increase in workforce numbers and competence.
Polyclinic
Care will be more home-based towards the end of life but a variety of outpatient,
GP and community services that provide care across the spectrum of disease could
manage aspects of end of life care in polyclinics. Palliative care teams could be based
in a polyclinic to link with other community colleagues.
Secondary care
Local hospital
Local hospitals will manage a percentage of deaths (around 40%). There is a
need to improve the quality and co-ordination of care to reduce complaints, and
consideration should be given to developing a bespoke environment for patients
who are on the end of life care register. Specialist teams will continue to have an
input and liaise with other clinical teams in the management of patients. Workforce
competence in managing end of life care needs to be enhanced.
Major acute
This care setting is the same as local hospitals, where they are the local site. They may
see a higher proportion of deaths for people with illnesses such as renal disease or
other less common conditions. The issues of environment for care of people who are
dying also apply here. Workforce competence in managing end of life care needs to
be enhanced.
Specialist care
Cancer hospitals have well-developed provision but should adopt the Hospital 2
Home scheme introduced by the Royal Marsden. Specialist heart and lung hospitals
need to improve capacity to identify patients who are nearing death and ensure their
care is effectively coordinated.
October 2009
www.healthcareforlondon.nhs.uk
Healthcare for London
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London SW1E 5RS
Tel: 020 8433 6800
Email: [email protected]
Healthcare for London is part of Commissioning Support for London – an organisation
established to provide clinical and business support to London’s NHS.