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Profile: South Kent Coast CCG


17 March 2014

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Tackling co-morbidities and long-term health conditions is a particular priority for South Kent Coast
NHS South Kent Coast clinical commissioning group (CCG) is made up of the 31 GP practices in the district of Shepway and the towns of Deal and Dover. The CCG commissions hospital, community and mental health services for the 199,000 people living in this area. 

Tackling co-morbidities and long-term health conditions is a particular priority for South Kent Coast
NHS South Kent Coast clinical commissioning group (CCG) is made up of the 31 GP practices in the district of Shepway and the towns of Deal and Dover. The CCG commissions hospital, community and mental health services for the 199,000 people living in this area. 
There are some significant health challenges in our area. People here are older than the average for Kent and the number of older people is expected to grow rapidly over the next 10 years. 
More people in our area have long-term health conditions such as heart disease, stroke, diabetes, cancer, high blood pressure, epilepsy and learning disabilities than the national average for England.
More women smoke when they are pregnant and fewer breastfeed than the average for England, and more adults are obese. Teenage pregnancy is higher and the number of physically active children in Shepway is lower than the national average, although the opposite is true in Dover district. 
With the right support, people can live full lives for many years with long-term conditions such as diabetes, respiratory illness and heart disease. However, older people often have a number of long-term conditions which may impact on their health and their day-to-day lives. We want people in our area to get local health and care services whenever possible. We also want health and care services to work together so patients get better care faster. And along with social services at Kent County Council, we’ll make best use of the NHS funding that we manage on patient’s behalf. 
One of the things that we are consistently told in public meetings and when we meet with patients is that they want ‘joined up’ services. While they are often happy with the quality of the service they eventually receive, the process by which they access services is often confusing, bureaucratic and too slow. This is particularly true for the elderly population, those that are vulnerable and people who care for the sick. Our ambition is to change this.
In addition we will face a number of challenges over the next five years as the population grows older and more people are diagnosed with illnesses that will affect their quality of life in the long term. We will work with local people to really understand the things that can make a difference to how healthy they feel and the things that will help them recover and cope better when they become ill. 
We are pioneering a new approach to the care of people with complex health conditions. Pro-Active Care gives patients up to 12 weeks of intensive support from as many different teams as they need to help them live better. It helps people stay out of hospital or recover more quickly after a hospital stay. Pro-Active Care is a programme for risk-stratified patients with multiple comorbidities. The aim is to improve patient’s self-management, their quality of life, medicines compliance and reduce A&E and associated hospital admissions. 
The introduction of multi-disciplinary health and social care teams clinically led by a GP from the practice, or group of practices, that the patient cohorts come from, builds a team around the patient. This means that patients have an alternative to using the 999 service; they can either manage themselves following education they receive as part of the programme about their long-term condition(s) or they can call upon the community nursing team 24 hours a day. 
Community matrons and GPs discuss and choose a list of patients and invite a multi-disciplinary team of professionals to visit each patient. The matron carries out a health and social care assessment, the pharmacist offers a review of their medicines, a health trainer supports them to develop a healthier lifestyle and signposts the patient to other services in the community such as Age Concern, coffee mornings and other groups to help reduce isolation. Physiotherapists and occupational therapists review the patient’s needs. Social services and mental health services also visit to offer advice and services if required. 
A multi-disciplinary team (MDT) meeting then takes place where visits, referrals and any other issues are discussed. Two weeks later another MDT meeting takes place with the patient to ensure they are happy with the services, any issues have been addressed and to bring together the discussions the patient has had with each professional. 
An MDT form is completed by all professionals involved throughout the process and left with the patient as they are discharged from Pro-Active Care. This form gives the patient an overview of the education they have received and serves as a reminder for self-managing their condition.
Benefits of Pro-Active Care include: 
 – Elimination of patients experiencing multiple disjointed services.
 – Improved self-management for patients and consequent improvements in mental health outcomes. 
 – Reduction or elimination of inter-service referral waiting times because they are working as a team both in formal MDT settings and in the field. 
Measures include: 
 – Reduction in A&E attendances/admissions. 
 – Reduced prescribing costs. 
 – Reduced length of stay, particularly in older people and general medicine. 
Pro-Active Care has been integrated into the contract with Kent Community Care Trust to reflect MDT arrangements in primary care supported by community nursing staff and is integral to the agreement of a new community model. 
South Kent Coast CCG, along with Shelton CCG, commissioned the London School of Economics to carry out some qualitative research into Pro-Active Care. 
Interviewees included clinical commissioners, managers, GPs, community matrons, nurses, physiotherapists, health trainers and social workers. 
According to interviewees, Pro-Active Care leads to better health outcomes and a smaller likelihood of use of hospital services. Most suggest that there is a reduction of overall costs, although more community services are used. Many felt that Pro-Active care motivates them, makes their work more interesting and more connected to the community, and encourages collaboration with other professionals. 
One professional stated that Pro-Active Care had a “positive impact on (patient’s) mobility to go around their house and the area they live”. 
The programme is convenient for patients as it reduces the frequency that patients have to repeat the same story. It helps improve patient care as “professionals know patient’s needs better and (are able) to offer more (appropriate) services”. 
It is popular with patients; one interviewee stated that “eight patients asked to continue with it after their twelve week programme.” 
A few examples from the interviews of Pro-Active Care improving patient outcomes include:
 – A lady with stroke and her husband owned a house by the beach. The professionals involved in Pro-Active Care initiated physiotherapy for her and taught her techniques to transfer from chair to wheelchair and to her vehicle so the couple could make use of the beach. 
 – An elderly, married couple had Pro-Active Care and the husband was also the carer for the wife. The pharmacist consequently changed the husband’s medication and took him off “a painkiller that made him feel sleepy all day.” 
There were “fewer admissions to hospitals as patients could call their pharmacists and ask for their medications and prescriptions modifications”.
“Matrons helped a lot to the direction of reducing the hospitalisations rates as patients could call them in case of an emergency and most of the times the matron helped them with their advice over the phone. Moreover other patients learnt how to recognise their symptoms and call for help earlier than when they were really in a need”. 
These results are particularly interesting in the context of the A&E crisis currently being seen in the NHS, where hospitalisation rates are increasing around the country as people forgo seeing their GP and go straight to hospital for acute care. 

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