To support the development of Place-based Care in City Northwest, Dr Andrew Kitchen from Park Farm Medical has been identified as Clinical Lead for six months commencing from April 2017.
Working in partnership across GP practices and organisations that impact on health and wellbeing, and with local patients and community groups, the aim of the role is to provide leadership and agree a joint vision and purpose for the ‘Place’. In recognition of the evolution of the role as the Sustainability and Transformation Plan (STP) and needs of the ‘Place’ develop, we will look to review this in six months with full involvement of the stakeholder group.
What we are working on
Since January 2017, we have established a stakeholder group across City Northwest, including representation from the Local Authority, Public Health, Adult Social Care, Community Services, the Mental Health Trust, and Third Sector organisations, who meet on a bi monthly basis.
We are continually in the process of building a shared understanding of what exactly our ‘Place’ is and learn from each other about the wide variety of assets and opportunities we have to work with, to benefit the lives of people in the community. We are looking at our population data and linking it with data from other providers and local knowledge.
We have also set up task and finish groups to focus on different priority areas under operational issues (sustaining General Practice as it is) and transformational (move towards new models of care) and create a place development plan, with timescales.
Initial priorities being looked at are:
- Redesign & GP access - winter pressures / same day access / extended hours
- Proactive Care - efficient use of the community team / chronic disease management/visiting service/ elderly and frailty
- Reactive integrated care - efficient clinical navigator system / the notion of developing a community hub as a resource
- Operational & governance structures - back office functions/contracting models - liabilities
- Mapping our assets, greater understanding of the resources and the use of them including waiting times
- Development of information technology for a variety of different uses, including developing a single point of contact, place discussion forum, increasing the uptake of on-line access for patients in practices, the use of self-management tools for patients, consideration of virtual befriending to address loneliness and isolation.