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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 Portland House Stag Place 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.