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Healthier Futures - Transforming 'out of hospital' care

In 2019 local Healthwatch organisations carried out engagement activity (questionnaires and focus groups) in the Black Country and West Birmingham to gain insight into how people view local health services. This activity uncovered strong support from local people for services that helped older people to stay in their own home for as long as it is safe to do so and people viewed communities as playing a central role in helping them to live their lives the way they wanted.

Focus group feedback identified gaps in primary care being able to consistently link people with community services that could support them to manage their conditions. Increased use of pharmacists in care management was also identified.

Our population is ageing. The number of local people aged 65+will increase by 14% over the next 10 years. We do not all age in the same way, some people are severely frail at 65+ while others are still fit at 95+. Caring for someone living with severe frailty is very costly and we know that if we can reduce the level of frailty we could reallocate resources to support more people.

People with frailty do not always get the care they need in the right setting and at the right time and we are committed to preventing inappropriate hospital admissions for these people. We are working together to identify the good practice in places with lower admissions and spreading this to other areas. 

Local people want as much care as possible in their local communities rather than in hospital. Transforming the care outside of the hospital setting and doing more in community and primary care to stop people needing to go into hospital is key. 

Admission to hospital and delayed discharge can affect people’s mental and physical wellbeing and make them increasingly dependent on support services. So it is also key to have services in place to get people out of hospital as soon as they are able to do so. We are committed to delivering improved community crisis response within two hours of referral, and reablement within two days. Reablement plays an important part of helping people relearn how to perform their daily activities, like cooking meals, washing and retaining their independence.

There are around 5,000 people living in care homes in the Black Country and West Birmingham. These people account for a large proportion of our A&E attendances, emergency admissions and emergency bed days. Unfortunately many ofthese emergency admissions are potentially avoidable. 

Evidence suggests that many people living in care homes are not having their needs assessed and addressed as well as they could be, often resulting in unnecessary, unplanned and avoidable admission to hospital. We are working to change this through:

  • Stronger links between PCNs and their local care homes, with all care homes supported by a consistent team of healthcare professionals.
  • Ensuring that individuals are supported to have good oral health, stay well hydrated and well-nourished and that they are supported by therapists and other professionals in rehabilitating when they have been unwell.
  • Care home residents getting regular clinical pharmacist-led medicine reviews.
  • Providing emergency support to care homes, including where advice or support is needed out of hours.
  • Easier, secure sharing of information between care homes and NHS Staff.

In the Black Country and West Birmingham we will transform out of hospital care through our efforts to:

  • Implement local models of care for each place that delivers improved access to local services for the whole population. This will give greater continuity of care for all people and help local teams to coordinate care for those most vulnerable in our communities. 
  • Create, a coordinated system of primary care by developing Primary Care Networks (PCNs)
  • Work together to transform primary care workforce, buildings and digital solutions
  • Act together in partnership to address the wider determinants of health such as employment, education and housing to understand where primary care can support this.

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