Richard Main Informatics Integration Lead

NHS Wakefield CCG

For citizens of Wakefield district to live longer, healthier lives and to be supported by people

with the right skills, in the right place

Our vision

• One team - GPs, community nurses, social care workers, therapists, volunteers and pharmacists

• One care plan designed around the person

• One care co-ordinator for every person with multiple, on-going health problems

• Single ‘gateway’ to care

• Same day response if needed• Faster access to home adaptations and

equipment• Care at home or near home wherever

possible • Care in hospital only when really necessary • Discharge home as soon as possible

Utilise digital technologies to provide the appropriate information, to the right person, at the right time, and in the right location to support the care of the citizen.

Where we are now…• SystmOne - large district-wide footprint

– 34 out of 40 GP practices (other 6 on EMIS Web)– Significant footprint in Acute >25 modules including all Inpatient areas, Diabetes, Health Visitors,

Community Nursing, EoL and Hospice care.– South West Yorkshire Trust – Rio and SystmOne

• Sunquest ICE Order Comms – Integrated within Acute Trust (and 7 local acute trusts) and with Primary Care– Discharge– e-Consultation– Scope for further development

• Adult Health & Social Care HubsCommunity Nursing, Therapy, Social Care, 3rd Sector, Social Housing

• Childrens & Families Integrated Early Help HubsHealth Visitors, Social Care, 3rd Sector, Police, Social Housing, substance misuse etc

• PMCF (West Wakefield)Extended hours, additional access routes, Unified Communications, digital care navigation.

What we’ve done so far…

Integrated Adult Health and Social Care Hubs Mid Yorks NHS Trust CQC report November 2014

Overall rating for Community health services for adults “Good”

“The Proof of Concept team was an innovative way to provide integrated services including pharmacy support and the

independent/charity sector.”

But“Barriers to integration had been identified, including …..managing different computer systems, particularly

health and social care.”

What we think we’re doing well

Real integrated working through joint CCG & Council appointments supporting the

districtwide ICT strategy group.

What we’re planning to do…

Double Vanguard success

Two Wakefield initiatives were amongst 29 nationwide to be selected from 269 entrants who bid to participate in the prestigious Vanguard programme to promote radical redesign of care services

To effectively deliver these programme of requires:

• Technology advancements to support new models of care - “Needed Now” vs. 2018 & 2020• Digital Care Records - All team members able to view and input to shared electronic record• Patient Held Records – Patient able to hold, input to, and control access to their personal health data• Optimisation and integration of existing systems - not wholesale replacement - Open Approach ?• Proportionate approach for care homes and small organisations to IG requirements • Culture change – eg GP view of sharing “NHS data” with non-NHS organisations.

Enhanced Care Home Vanguard (NHS Wakefield CCG) Joining up services for older people in supported housing and care homes.

West Wakefield Health and Wellbeing Ltd, a federation of six GP practices

Multi-specialty community provider (MCP)