1 Critical Interfaces within the Project Luton 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 Practices Advanced Primary Nurse GP’s Receptionists District Nurse Practice Nurse Practice Manager Practice staff

6 What we did….

Ups and Downs How they reacted How we felt

Process (The Sell) Collaborative meetings 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!!!

10 Other Key Primary Care Interfaces Social services Home care on prescription training Out of hours Patient identification Communications

11 Walk in Centre Treatment Centre Evercare Learning & Research Primary Care Contractors

12 Walk In Centre EvercareModel P2 Autonomy Patient Choice Nurse Led Services Training & Development Luton Treatment Centre Referral & monitoring Referral & diagnosis Referral & Rehab. The Future of the Workforce

13 Treatment Centre Walk in Centre Evercare Nurse-led Single encounter Acute & minor injury & ailments Mainly 1:1 Drop-in with some booked group sessions Self-referral and primary care referral Long-term case management Prevention & management of chronic conditions 1:1 and with carers/families Case management: anticipatory care Primary and secondary care Term approach Short/long term Chronic disease Multi-disciplinary assessment Mainly booked appointments Self-referral and primary & secondary care 3 Dimensional Integration

14 GP APN/P PN/P Trained, 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