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Critical Interfaces within the ProjectLuton NHS tPCT

What we’ve achieved in Luton

•The team

•Caseloads

•Training and education

•Funding from WDC

•Links & modernisation

•Patient database in place

•Retrieval of data

What we know about our patients?

3% of >65’s make up 47% of total emergency admits

Key challenges faced in Luton

•Pace

•Funding

•Data capture

•Building key relationships

•Limited resources

5

Key intervention – GP PracticesKey intervention – GP Practices

Advanced Primary

Nurse

GP’s

Receptionists

District Nurse

PracticeNurse

Practice Manager

Practice staff

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What we did….What we did….

Ups and Downs

•How they reacted

•How we felt

Process

(The Sell)

•Collaborative meetings

•1-2-1 meetings

•Lead Nurse involvement

•Feedback

•Action Learning

•Celebrating Success Conference

•Gave it some time

How are we getting on• Joint visits

• The system works!!!!

• referrals to APN from GP

• referrals to DN from APN

• messages being passed on

• Smiles

• Invite to xmas party!!!

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Other Key Primary Care InterfacesOther Key Primary Care Interfaces

Social services• Home care on prescription• training

Out of hours• Patient identification• Communications

                             

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Walk in Centre

Treatment Centre

Evercare Learning & Research

Primary Care Contractors

12

Walk In

Centre

Evercare Evercare ModelModel

•P2•Autonomy

•Patient Choice•Nurse Led Services

•Training & Development Luton Treatment

Centre

Ref

erra

l & m

onito

ring

Referral & diagnosis

Referral &

Rehab.

The Future of the WorkforceThe Future of the Workforce

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Tre

atm

en

t C

en

tre

Walk

in C

entre

Everc

are

Nurse-led

Nurse

-led

Single

enco

unte

r

Acute

& m

inor i

njury

& ailm

ents

Main

ly 1:

1

Drop-

in with

som

e

book

ed g

roup

ses

sions

Self-re

ferra

l and

prim

ary c

are

refe

rral

Long-term case management

Prevention & management of chronic conditions

1:1 and with carers/families

Case management: anticipatory care

Primary and secondary care Ter

m a

ppr

oach

Sho

rt/lo

ng t

erm

Chr

onic

dis

ease

Mul

ti-di

scip

linar

y as

sess

men

tM

ainl

y bo

oked

app

oin

tmen

tsS

elf-

refe

rral

and

prim

ary

& s

econ

dar

y ca

re

3 Dimensional Integration

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GP

APN/P

PN/PTrained, Skilled Staff

Cadet Scheme

Modern Practice Underpinned/Enabled

by Education

Skills Escalator

“High Level Practice”

What we learned•Role definition & clarity

•How people react to change

•Don’t avoid difficult situations

•Don’t underestimate how difficult this is for all involved

•It takes time – well 8 months!!!

•Humour can be powerful