Dr Richard Mejzner, GP in Budleigh and chair of the Woodleigh, Exmouth and Budleigh sub-locality of NHS NEW Devon Clinical Commissioning Group, said “We regret that we are unable to respond to speculation and/or rumour.
“We can, however, talk about how clinicians working within the Success Regime, also known as the Your Future Care programme are currently improving the care that is available in the community right across Devon.
“A series of working group meetings took place during the summer, led by clinicians from across the primary care, mental health and acute sectors, and involving local authorities and Healthwatch.
“These were the culmination of a 12-month process in which local clinicians have been further developing the model of care for health services, focusing on patients who are likely to benefit the most. These are frail and elderly people, people with dementia and people with long-term conditions affecting both their physical and mental health.
“The aim is to join up care more effectively in some areas so people are not being sent to hospital just because services are not available to keep them at home.
“Whilst people do sometimes need treatment in hospital, it is essential that they are then able to go home when they are well enough and it is safe for them to do so. For frail and elderly people, a stay in hospital can cause harm, exposing them to infection and reducing their ability to live independently at home.
The new model that is beginning to emerge focuses on three core interventions for frail and elderly people.
1. Comprehensive assessment and identification of patients at risk
- Identifies people who are frail or becoming frail and more likely to be admitted to hospital
- Develops plans with people and their carers – geared to supporting them to remain well and retain their independence
- Trained staff work in community to undertake assessment and planning
- Provide links with voluntary groups and work with social prescribing – playing a key role in bringing together the assessment of need and coordination of community activity to create a resilient service.
2. Single point of access
- This would make accessing care at home as easy as accessing care in hospital and 24/7
- Referrals made by any care service, initiating a clinical conversation based on patient need
- Referrals received by a clinician (nurse, therapist, doctor) with:
- Access to the comprehensive assessment record
- Knowledge of community-based and voluntary sector services
- A home-based first responder service acts within 2 hours to help support people to stay at home.
3. Rapid response
- Multi-disciplinary first responder team to care for people at home and in residential and nursing homes. Includes community nursing, therapists, health and care assistants, mental health and domiciliary care workers, voluntary sector agencies and administration support
- The team will make an initial assessment of need and put together a package of care at home
- They will have access to additional capability where required - and where necessary will escalate directly to the most appropriate level of care including the acute sector.
“It is primarily through these three interventions that clinicians believe we will make a much greater beneficial impact on people’s lives.
“Later this month we will share the work we have been undertaking and our approach to further public engagement and consultation with the Health Overview and Scrutiny Committees at Devon County Council and Plymouth City Council. We also have a range of meetings and assurance processes with NHS England and the Clinical Senate scheduled.
“We will be engaging widely on the model and are keen to hear from local communities. We recognise that a model that has prevention and involvement of individuals at its core must reflect local services and circumstances.”