In Stockport, there are relatively high numbers of people admitted to hospital with chronic conditions. Some of these hospital visits could be prevented if these conditions were controlled at home. For example, if people were provided with:
- extra support at home.
- given advice and support from ‘expert patients’ with the same condition or
- supported to change an aspect of their lifestyle, such as, losing weight,
- one single health and social care record.
This could then prevent patients from being hospitalised for conditions, such as, asthma, COPD or diabetes.
There are several programmes of work being undertaken by NHS Stockport CCG that are driving NHS system reform in Stockport that will ensure better quality care for patients. These include:
Integrating Health and Social Care
Stockport Health & Social Care system has come together to bring about a reform that stretches from primary care, through community and social care, mental health and into the acute hospital.
In the coming months and years, GPs, health workers, social care staff and voluntary partners will be working more closely together, sharing information and taking a more co-ordinated approach to caring for people living in the local community. People with long-term health conditions and older people will be the first to see the benefits of these changes.
At the moment, if someone has regular support from their GP and has care visits from a District nurse for example, but also needs help to wash, dress or prepare a meal, they might have a number of different professionals arriving at their door and asking similar questions before help can be arranged. With health and social care organisations working more closely together, the process will become much smoother. District Nurses, Occupational Therapists, Social Workers and other professionals will be in a position to communicate with each other on a more regular basis, sharing information to support people better.
The aim is for people to have one team, one contact number, one assessment, one care plan and one care co-ordinator who is their main contact point. In fact, just one service!
This programme of work will take place over the next two years and will influence the way people work in all parts of health and social care. The Stockport One Service, an early pilot based in Marple and Werneth, has helped to kick start the programme and feedback from the people involved in this will be considered. Planning sessions are also taking place with staff, carers and people who use services – because after all they are in the best position to say what works well for them.
To view the presentation for the Marple and Werneth consultation meeting please use the following link – Marple Consultation – Integration
Click the following link to view a video describing how this service could work in practice –
Click the following link to take part in the consultation – https://www.citizenspace.com/stockport-haveyoursay
Outpatients/follow up reform
Many follow up appointments are offered to patients when they have been in hospital for an operation, had a recent stay in hospital, or for when they have a condition such as COPD or Heart Failure for example. There can be very long waits for these appointments and there are a high number of people that do not turn up.
Following a review of outpatients it has been discovered that not all these appointments are necessary and not all of them need to take place in the hospital. Therefore we are making some changes to how follow up care is organised.
Firstly we will try to ensure that any tests that you need following your operation are done at the end of that visit. Depending on your results you may be invited back, or you will be discharged with no follow up appointment.
Rather than needing to come back to hospital you may be discharged back to your GP or another health professional in the community for follow up treatment. Changing the system in this way will:
- Reduce unnecessary follow-up appointments releasing capacity for the treatment of new patient referrals.
- Lessen demand on hospital services which will reduce waiting times.
- Stop follow up appointments that are made ‘just in case’.
- Reduce the number of DNAs (Did Not Attend) from patients.
- Reduction in short notice cancellations of clinics.
- Increase the flexibility and convenience for patients.
- Reduced waiting times in clinic.
