Issue - items at meetings - Integrated Primary Care Teams

94.1    Geraldine Hoban, Chief Operating Officer CCG, Consultant Nurse Deirdre Power, Clinical Leader IPCT at CCG and Louise Mayer, Head of Service at Sussex Community Trust provided an update on Integrated Primary Care Teams (IPCTs). Members were reminded of the previous update to HWOSC in April 2012.

94.2    Formerly different services, mostly nurses, looked after frail housebound people in the community. This was ‘episodic’ and task-based, so some people had not been well served and needed more integrated pro-active support.

94.3    The current service model was developed with Public Health based on patient need using demographic data; this helped to increase engagement with GP practices. There were now 11 multi-disciplinary IPCTs focussed around GP hubs (of between 3- 5 practices each) with advanced practitioners, nurse case managers, occupational therapist case managers, physiotherapists and care support workers.

The main aims of the service are preventative care, coordination of care and supporting self-management.

An evaluation at the end of the transitional year, year 1 was carried out against a background of 'huge transformational change,’ said Ms Power. Patient satisfaction was found to be high. However feedback from GP practices indicated some good progress though, as expected, some practices were late in engaging with the service.

94.4    Figure 2 showed that on-going work was needed to have all IPCT clusters working well with GP practices all across the city. Increased patient complexity was a factor that had hindered full delivery of pro-active care; therefore the teams were being broadened to bring in mental health and social care support. This is being shown to work very well.

94.5    Ms Hoban told HWOSC that working alongside social care workers enabled pro-active services. However there had been insufficient capacity to be both a responsive and pro-active service. IPCTs wanted to go into carehomes as well as to the housebound. She said the evaluation had been helpful in showing improvements although more work was needed to provide a better quality service.

94.6    Members commented that transition to community-based services can seem ‘traumatic’ after discharge from hospital for example following a stroke. Ms Power said coordination with secondary care was needed in a ‘seamless service’ that would anticipate people’s needs. Ms Mayer said the IPCT service works closely with the hospital discharge service and will often track the IPCT’s known patients from admission to discharge. IPCTs were also looking to work more closely with the homeless and people living in hostels.

94.7    The speaker replied to queries from Members:

• Learning from the transition year will be used to benefit patients.
• There have been large transitional changes in both primary care and at a community level and ‘there have been too many joins in the service that can break down.’ Work is continuing including on proactive integrated care.
• More mental health support, especially dementia care is needed for the IPCTs
• Lessons learned on support needed for discharged patients are being captured from ‘in-reach’ to hospitals and discussion with the hospital discharge teams.

94.8    HWOSC Chair Councillor Sven Rufus thanked the speakers for their progress report. Members noted progress and asked to receive an update as necessary.