Care and integration: our journey to the Doncaster vision

Featured article - 22 May 2017
By Jackie Pederson, Chief Officer, Doncaster Clinical Commissioning Group

Head-shot of the author, Jackie Pederson, Chief Officer, Doncaster Clinical Commissioning Group

So far 85% of patients have stayed at home and have not accessed acute hospital services.

Moving forward with Team Doncaster

Just over two years ago in the depths of winter we knew the hard work and commitment of colleagues had paid off. Patients were flowing around the health and social care system relatively well and were being admitted and discharged efficiently. We were working as a team-within-a-system for the people of Doncaster.

But there was something nagging at the back of our minds: how did we really know if the patients in our acute, community and social care system were getting the care that met their needs?

We knew instinctively that we were flowing patients through a system that had evolved over years of ad hoc investment and organisations working in silos. But we wanted to find out more about the needs and complexity of our elderly and frail patients as they access and leave our services. Critically, this had to involve our Local Authority colleagues.

We had input from every sector and we embarked on a statistically significant piece of work, jointly reviewing the needs of people who had accessed services the previous year. Looking back, it can only be described, as a mammoth task, but we found out interesting things including:

  • Our community-based health and social care system is too complicated for professionals and patients to navigate and this encourages A&E attendance
  • Although there was lots of duplication, there were other skills that can be accessed in a particular team and not in another, making it difficult to meet often complex health and social care needs without multiple hand offs
  • Multiple IT systems also add to poor communication and often lead to more duplication and inefficiencies.

So what happened next?

The evidence was clear - doing nothing wasn't an option. It was really obvious that we couldn’t keep working in organisational silos; and it was really clear that we were not using the Doncaster pound effectively or efficiently.

And most importantly, we could see that we weren’t always doing the best for our patients and citizens of Doncaster. Front line staff were working their socks off in an inefficient system that encouraged competition rather than collaboration.

And where are we now?

Well we’ve come together as a health and care system and developed our local Doncaster Health and Social Care Place Plan. Our ambition is to use our resources effectively as a system, to collaborate for the benefit of patients rather than compete, to integrate health and social care commissioning, and to develop an accountable care partnership of providers - partnership being deliberate use of language.

From an Intermediate Care perspective, we have a new model that has been designed by front line staff and we are now testing a health and social care rapid response and short term intervention service. So far 85% of patients have stayed at home and have not accessed acute hospital services. It’s early days but it feels positive.

The stars may be aligning just at the right time. There is real commitment from everyone to move forward as Team Doncaster.

The programme has been funded by the Better Care Fund and Doncaster are now getting ready to test a new integrated patient care record, which has also been funded via BCF.

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