Representatives from Epsom Health and Care Alliance will be in attendance and will provide an update on the work of the Alliance.
Minutes:
The Panel received a presentation from Sonya Sellar, Mid Surrey Area Director of Adult Social Care, Surrey County Council, Dr. Hilary Floyd, Medical Director, GP Health Partners Ltd, Stephen Cass, Chief Executive Officer CSH Surrey and Daniel Elkeles on the work of the Epsom Health and Care Alliance. The presentation set out to explain who made up the Alliance, what it had achieved in the last eighteen months and what it hoped to achieve in the coming year.
The partner organisations which made up the Alliance consisted of GP Health Partners Ltd, Epsom and St. Helier University Hospitals NHS Trust, CSH Surrey and Surrey County Council. It had been established as a legal joint venture (or equal partnership) based on shared interests and vision to provide coordinated and integrated care to the 200,000 people registered at the 20 GP practices which together comprised GP Health Partners Ltd. It was considered important that the Alliance’s Vision and Values had been developed in conjunction with local residents and staff from across the partnership – there were no organisational silos. In terms of governance arrangements, lay members were key; Surrey and Borders Partnership NHS Foundation Trust and the Borough Council also had places on the Board.
The work of the Alliance currently focussed on the frail and elderly over 65 and integration of care was at the heart of what the Alliance was working to achieve. This saw a shift towards more preventive working, listening and responding to the needs of patients. The service was one of the first of its kind in the country.
There were several elements to the @home service pioneered by the Alliance. Firstly, GPs had an opportunity to refer patients to the Community Assessment and Diagnostic Unit (CADU) for a multi-disciplinary approach to their needs. This team would thoroughly review an individual’s situation and needs and then arrange the required services, for example, for equipment to be delivered at home or for visits from nurses, physiotherapists, occupational therapists, community matrons or social care re-enablement assistants. Secondly, an enhanced @home team could arrange rapid additional short-term support at home for people who ran the risk of becoming acutely unwell or who needed extra support after being discharged from hospital. Finally, early discharge team on the wards assessed who could be assisted at home with the correct support negating the need for an unnecessarily prolonged stay in hospital.
It was considered that this approach had made a real difference with more people receiving better care, at home, people receiving care in the right setting and new ways of working as demonstrated by the following statistics:
· On average 3 patients remained at home and 3 brought home sooner each day;
· Equivalent 1 ward patient being actively looked after at home;
· Emergency admissions below 2015/16 (national increase 3-4%);
· People staying half a day less in hospital;
· Epsom Hospital achieved 4 hour Accident and Emergency target;
Staff felt part of one team and the challenge was now to grow the service. It was stressed that this service was not a Vanguard initiative and therefore not directly funded by NHS England. The initiative was funded on a local basis. Alliance Partners considered the model had proved itself in terms of outcomes and hoped to continue.
Over the next year, the Alliance was working on:
· Whole Service Transformation - Aligning how the partners worked together to get people the care they needed in the most appropriate place, including:
• developing a better pathway for people after their acute phase of illness;
• Integrating services together to build a better supported discharge process;
• Making more efficient use of our buildings to establish an integrated post acute/rehabilitation unit
• Epsom Centre for Stroke - Implementing a fully integrated, service for those recovering from a stroke from end of the acute phase through to life after stroke including providing supported discharge for people to go directly home, and acute and rehabilitation care for people needing to spend longer in a bedded service
· Neighbourhoods - Reconfiguring how out of hospital organisations work together to treat people closer to home, including:
• Promoting preventative services based on best practice across the country
• Developing primary care based neighbourhood hubs to share care resources effectively across Epsom.
It was recognised that caring for those recovering from a stroke may require a different approach and would have to flex around the patient. The variety of outcomes would dictate the care required but it was stressed that the services offered by the Alliance were not intended to be long term.