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NHS do we need change? YES & WE MUST WHY? (66 years old & chronically disabled) The NHS must Change or Die BMJ July 2012 Hospitals on the Edge? Time for.

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Presentation on theme: "NHS do we need change? YES & WE MUST WHY? (66 years old & chronically disabled) The NHS must Change or Die BMJ July 2012 Hospitals on the Edge? Time for."— Presentation transcript:

1 NHS do we need change? YES & WE MUST WHY? (66 years old & chronically disabled) The NHS must Change or Die BMJ July 2012 Hospitals on the Edge? Time for Action Royal college of Physicians October 2012 Professor Bim Bhowmick OBE DL MD FRCP

2 So how do we do it? “The gap between hospital & home is unsustainable and, for the sake of our frailest and most vulnerable patients it must be closed” BMJ 24 November 2012 A novel & radical approach Rhetorics to Reality Professor Bim Bhowmick OBE DL MD FRCP

3 Bhowmick Innovative Model(BIM) Rhetorics (undisputed) to reality. Care to be provided at home Care to be provided near home Early intervention Prevent Hospital admission Integrated service Whole system delivery Professor Bim Bhowmick OBE DL MD FRCP

4 BIM Rhetorics to reality Primary care, secondary care and Community Care-joined up Care must be patient centred Privacy and dignity, compassion and respect must be maintained Resources must be transferred from acute services to the community sector. Professor Bim Bhowmick OBE DL MD FRCP

5 BIM Some facts: Wales has the highest elderly population compared to other countries in the U.K Over 75s will increase by 75% in two decades Hospitals are full to bursting 70% of beds are occupied by patients with chronic diseases especially Elderly 70 pence of an NHS pound is spent for the elderly. Professor Bim Bhowmick OBE DL MD FRCP

6 Unscheduled Emergency Care: The Way Forward BHOWMICK INNOVATIVE MODEL (BIM) Torfaen Ynys Mon/ Anglesey PROFESSOR BIM BHOWMICK OBE DL MD FRCP CONSULTANT COMMUNITY PHYSICIAN – Powys Teaching Health Board

7 Unscheduled Emergency Admissions ‘Minus Ten Bed Syndrome’ Professor Bim Bhowmick OBE DL MD FRCP 2000 beds( )

8 Creation of virtual beds and ward in the Community Increasing emergency admissionElderly DTOC Delayed discharge (old and very old) “Blocked Beds” PRESSURES ON NHS Delivery of Clinical Futures (Reduction of acute beds) Professor Bim Bhowmick OBE DL MD FRCP Silver tsunami

9 Primary Care Secondary Care Voluntary Professor Bim Bhowmick OBE DL MD FRCP Social Care TRIBALISMTRIBALISM Patient and Carer

10 WHOLE SYSTEM APPROACH LOCAL INTEGRATED PLANNING/COMMISSIONING/EVALUATION Patient and Carer Primary Care Secondary Care Voluntary Professor Bim Bhowmick OBE DL MD FRCP Social Care BIM INTEGRATED CARE BIM

11 SECONDARY CARE Physicians A&E MAU SERVICE DEPARTMENTS Biochemistry, Haematology, Radiology. LEADER Forming the team VOLUNTARY ALLIANCE CARERS GROUP CARE HOMES - Proprietors SOCIAL SERVICES Chief Exec. Officer, Director, Head of Adult Services, Councilors, CHC AMBULANCE SERVICE FALLS TRANSPORT COMMUNITY PHARMACIST GENERAL PRACTITIONERS Mon Enhanced Care (MEC) / TORFAEN GROUNDWORK TO LINK UP SERVICES Patch MDT Old Age Psychiatry Palliative Care Professor Bim Bhowmick OBE DL MD FRCP District Nursing CARE & REPAIR

12 GOING GONE Normally just ableOff to HOSPITAL Time away from carers and social network Care package interrupted or withdrawn Ward admission Reduced confidence Disorientation, loss of routine Reduced mobility Increased confusion MDT review ‘Unsafe for discharge’ DTOC Bed blocking Earliest Intervention The ‘3G’ Syndrome Professor Bim Bhowmick OBE DL MD FRCP

13 Prevent admission Reduce DTOC Prevent premature admission to care homes VIRTUAL WARD Resident at own home, care homes or sheltered housing Diagnostics SINGLE POINT OF ACCESS Health Care Assistants, Nurse Assessors, Consultant. REFERRING BODIES Health practitioners, Step up to Admit Community Hospital EMI Specialist Nurses COPD Stroke Heart Failure General Practitioner Patch Reablement Team Emergency Social Care Voluntary Services Ambulance Professor Bim Bhowmick OBE DL MD FRCP Out of hours service Palliative Care Minor Injury Unit Hospital at Home (MEC/TORFAEN) Integrated Care General Practitioner Time response – 2 hours Community Equipment

14 Types of Emergency Admissions in the Elderly ITU Critically Ill UTI Urinary Tract Infection TUI Totally unnecessary inpatient TIU To inform the undertaker Professor Bim Bhowmick OBE DL MD FRCP

15 Types of Emergency Admissions in the Elderly ITU Critically Ill UTI Urinary Tract Infection TUI Totally unnecessary inpatient TIU To inform the undertaker Professor Bim Bhowmick OBE DL MD FRCP

16 Integrated Management Team Hospital Admission Avoidance Scheme MINDING THE GAP/ WORKING TOGETHER (BIM) GP, Social Services, Matron, Consultant. JOINT CO-ORDINATOR Large Multi-Disciplinary Group Steering Board MEC Steering Board Torfaen Intermediate Care Directorate (Clinical Director, Business Manager, Locality Manager). LHB’s, Trust, Social Services, GP’s, Consultants & Voluntary Bodies Professor Bim Bhowmick OBE DL MD FRCP

17 MEC CASE STUDY 1 86 year old retired Anaesthetist. PMH: AF, PPM, CKD Stage II, hypertension, progressively slowed down, recurrent chest infections Fell in bathroom at night Partner noticed noisy chest and commenced abx as per previous advice from GP. GP visited next morning, sleepy ++. Diagnosed chest infection. Referred to MEC. Lab results satisfactory. Undiagnosed PD. Aspiration pnuemonia right side. Professor Bim Bhowmick OBE DL MD FRCP

18 MEC CASE STUDY 1 Managed at home with significant improvement. ANP visited daily for 5 days, then once weekly for 3/52. Consultant visit x 2 Mobilising easily, discharged from MEC back to GP. No further admissions last 7 months Professor Bim Bhowmick OBE DL MD FRCP

19 MEC CASE STUDY 2 GW – 84, Female, lives alone, manages with home care. Recently Fractured Neck of Femur. Discharged 3 weeks ago. PMH: Breast Ca 5 yrs ago with mets to spine. Uterine cancer with daily PV bleeds (on tranexamic acid), CKD stage III, hypertension, chronic anaemia. 2 nd June 2012 sudden onset of acute pain, left axilliary region and became breathless. GP referred to MEC Provisional clinical diagnosis – Pulmonary embolism Professor Bim Bhowmick OBE DL MD FRCP

20 MEC CASE STUDY 2 Commenced appropriate treatment at home and arranged CTPA next morning confirming the diagnosis. GP & ANP continued to manage her at home with increased support from Social Services and family. Professor Bim Bhowmick OBE DL MD FRCP

21 MEC CASE STUDY 3 Nov year old female in a residential home. GP referral to MEC Fall; Slurred speech; Weak right side; Gone off legs; Diarrhoea for 2 Days; ? AF. PMH: CCF; HTN; CKD stage 3; Hypothyroidism; Diverticular disease. MEC Diagnoses Rapid AF (heart rate 124pm); T.I.A. (resolving); Diarrhoea due to faecal impaction Professor Bim Bhowmick OBE DL MD FRCP

22 MEC Case Study 3 cont’d Blood Results: Hypokalaemia(2.7mmol); Osteomalacia (low Ca ++ : low phosphate: raised alkaline phos). Managed at the residential home with Physiotherapy. Repeat Bloods/ Repeat visits: All well. Discharged back to GP in 2 weeks. Professor Bim Bhowmick OBE DL MD FRCP

23 MEC CASE STUDY 4 December 2012 Miss C.P. 101 year old lady independently living in a warden controlled bungalow. PMH: Hypertension on Atenolol; Cataract. GP referral to MEC: Diarrhoea for 4 days; short of breath on exertion for 4 days. Pulse 40pm Professor Bim Bhowmick OBE DL MD FRCP

24 MEC CASE STUDY4 cont’d MEC Diagnoses: Spurious Diarrhoea due to faecal impaction. Complete heart block. Managed at home. Arranged permanent pacemaker as a day case in 48hrs. Needed to speak with: the patient; the niece on the phone; another relative who was present; carer; warden; emergency physician on call in DGH. Met up with GP in the surgery to discuss the diagnosis and management. Professor Bim Bhowmick OBE DL MD FRCP

25 MEC RESULTS SO FAR Volume of activitiesTotal ReferralsTotal VisitsAdmission/Attendance Avoided July 2012-Date REFERRALS TO SOCIAL SERVICE 12 Professor Bim Bhowmick OBE DL MD FRCP

26 Torfaen Outcomes Volume of activitiesTotal ReferralsTotal VisitsAdmission/Attendance Avoided Jan 2007-Dec Jan 2008-Dec Emergency Admission/attendance Delayed Transfers of Care Daytime admissions from care homes Admission to Care Homes from the Community AND Social services underspent for first time Approximately 2million pounds savings (Audit Commission 2009 Professor Bim Bhowmick OBE DL MD FRCP

27 The Model Delivers the Changes we Need Older persons do not want hospital admission. We provided a choice. We changed the culture of patients and carers automatically wanting hospital admission. We changed the culture of GPs – ‘one size fits all’ by supporting them at the point of need. with urgent diagnostics and secondary care opinion. Professor Bim Bhowmick OBE DL MD FRCP

28 The Model Delivers the Changes we Need We broke down barriers between the ‘tribes’. Professional boundaries - medics, nurses, therapists, social workers - broken down (teams without walls) Mental health partnership very important Voluntary sector and independent sector must be inclusive Professor Bim Bhowmick OBE DL MD FRCP

29 Finally.....To Succeed... Strong & Persuasive CLINICAL leadership. Focused vision. Passion, Persistence, Pennies. Dedicated team. Professor Bim Bhowmick OBE DL MD FRCP

30 BIM VIRTUAL WARD IN THE COMMUNITY Rhetoric to Reality Treat & manage at home Treat & manage in the Community Hospital Urgent intervention Urgent Investigation YES Professor Bim Bhowmick OBE DL MD FRCP

31 BIM VIRTUAL WARD IN THE COMMUNITY Rhetoric to Reality INTEGRATION Working Together With G.P.’s Social Services District Nurses Voluntary Alliance E.M.I. Palliative Care Ambulance Care Homes YES Professor Bim Bhowmick OBE DL MD FRCP

32 BIM VIRTUAL WARD IN THE COMMUNITY Rhetoric to Reality Pts choice Alternative to acute admission Continuity of Care No boarding out Privacy & Dignity Pt & Carers Satisfaction Cost Effective Hard Work “Thick Skinned” YES Professor Bim Bhowmick OBE DL MD FRCP

33 BIM Bevan commission 2013 recommended to the Health Minister that BIM is adapted as the basis for a national standard for NHS Wales.

34 BIM VIRTUAL WARD IN THE COMMUNITY Rhetoric to Reality Finally Hospital ceases to be “somewhere” it becomes everywhere. YES Professor Bim Bhowmick OBE DL MD FRCP

35 Grateful thanks to MEC Team Advanced Nurse Practitioners. Health Care Workers. Dr Stephen McVicar –General Practitioner Mr Stephen Sloss – Interim Director of Social Services. Mrs Annwen Davies – Head of Adult Social Services Anglesey Mrs Kate Thomas – Locality Matron Mrs Cheryl Hindle –Joint MEC Co-ordinator Professor Bim Bhowmick OBE DL MD FRCP

36 BIM Further information can be found at the following websites –


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