In  Introduction

Background: the need for change

There are many and significant national, regional and local issues, which necessitate change in local health services.  Locally significant issues include:

·         Changing population:  It is expected that there will be a 14% decrease in the under 19 population and a 56% increase in the over 65 population by 2020 in the area.

·         Financial pressures:  In addition, the local health economy – made up of Southport & Formby PCT, Southport & Ormskirk NHS Trust and West Lancashire PCT - is forecasting an end of year deficit this year of approximately £20 million.

·         Changes to Southport & Ormskirk NHS Trust:  Recently, Southport & Ormskirk NHS Trust w as assessed as to whether it was fit to graduate to Foundation Trust Status, a status that all Hospital Trusts are eligible to obtain by 2008. The outcome of this assessment, which modeled the financial future of the Trust, indicated that such graduation would not be possible and that significant change needs to take place.  It should be noted that an additional programme of work, Best Care Practice, is underway which seeks to improve clinical and cost effectiveness within the hospital trust and across community care. This programme also requires change in the way health and social care is provided in the future.

·         Changing workforce and workforce regulations: New Europe-wide regulations to control the working lives of doctors mean  that in some specialties the current model of delivery of health services is unsustainable without risking patient safety.

·         The need to raise standards: The NHS is required by the Department of Health constantly to drive up standards in clinical care.

Locally there is widespread recognition that the pattern of delivery needs to change dramatically over the next decade or so in order to meet these challenges.  Change is needed in terms of how and from where services are to be provided more efficiently and effectively in the future.

Review of health services across West Lancashire and North Sefton

Local health services are currently undertaking a review of where people across West Lancashire and North Sefton access healthcare currently, what the health and social needs of the local populations are, and assessing the current provision of health services against this information.  The review has included a series of public consultations and the Shaping the Future event.

The aim of the review and subsequent debate and consultation on its findings is to ensure that services available for our local populations meet their needs and they have access to the highest standards of care.  This means that there are real opportunities for redesigning health care services around the patient and a real need so to do given the particularly challenging financial situation locally.

Shaping the Future event

On 5^th December, the local health organisations hosted an event, facilitated by OPM, to bring together a wide range of stakeholders from the health service and its public sector partners and opinion formers in local communities to:

·         Consider the implications of the forces and drivers for change operating in the national and local health and social care economy.

·         Reflect on the implications of the NHS Improvement Plan, the recent delivery guidance, Commissioning a patient-led NHS and the implications for Eastern Cheshire generally and specific sub-areas in particular.

·         Produce a shared view of what a modern health care system would be like and the outcomes that the Future Healthcare Project can expect from it. 

·         Develop a ‘blueprint of the future’ that will inform more detailed service planning, public and professional consultation and guide current investment and disinvestments decisions.

The event focused on the following key service areas, as triggers for thinking about health services more widely:

• Paediatric services – This service requires change in the context of current service delivery and recent and planned developments such as the Walk In Centre and the Minor Injuries Unit.

• Urgent care - This is generally accepted as an area that needs both centralisation and decentralisation. As A&E consultations have been increasing in many parts of the country with significant consequences for finance and performance, this would appear to be a useful topic to tackle-up front.

• Long-term conditions – Given the rise in the older population, enhancing these services is central to future care

• Maternity care – Cheshire and Merseyside SHA are currently reviewing Maternity and Paediatric services.  Locally, there are high tariff costs for Maternity and Paediatrics and across the health economy there are also falling birth rates.

This report

This report summarises discussions held on the day.  The day was underpinned by a detailed Data pack describing local and national challenges and drivers for change, and current services.  We have specifically sought to avoid repeating information already contained in the Data pack.

In this report, for each of the service areas, we present a summary of the current configuration of services and some of the pressures facing them, the proposals for the service model which emerged from the event and some of the challenges that need to be addressed in implementing these proposals, which were identified by participants themselves.

1. Paediatric services

The current arrangements

 

• Inpatient care is currently provided to local people from the following sites:

o        Ormskirk DGH (this site also has an A&E and observation and assessment unit for children). The unit also provides some paediatric surgery, mainly for day cases and short stay. Children under 5 and those requiring more complex surgery are referred to Alder Hey (specialist children’s unit)

• Some day surgery for children is undertaken at Southport General Infirmary
  
   
• Visiting surgeons from Aintree provide some surgical sessions at Southport General Infirmary
  
   
• Outpatient clinics are provided on these sites plus:
  • Southport and Formby DGH
  • Southport General Infirmary
  • Formby health centre
  • Churchgate health centre
  • Ormskirk Child Development Centre
  • Burscough health centre
    
     
• There are children’s centres in:
  • Skelmersdale (3)
  • Alder Hey (5)
  • Southport (2)

• Children can get minor injury assessment and treatment at the Skelmersdale Walk In Centre.
  
   

Pressure points

 

The identified pressure points are:

 

·           A very limited community paediatric service has poor integration between this service and acute paediatrics. This is counter to the trend in many parts of the country where there has been a significant development of care for children outside hospital linked to the hospital service

 

·           There is no community children’s nursing service of any kind and no specialist community nurses with responsibility for children’s care.

·           As a consequence of the above, waiting times for some community paediatric services are relatively long

·           There is a paucity of transport links and infrastructure across the area.

·           There has been an increase in GP referrals, which is attributed to a lowering of referral thresholds rather than increased levels of need. This assertion will need to be tested

·           A&E attendances have increased significantly – this is mainly attributable to self referrals

 

·           There are relatively good relationships between Alder Hey and Ormskirk paediatricians but there are no formal joint appointments or shared care protocols in place. There is a Managed Clinical Network with the two A&E departments and we have shared policies.

 

·           There are concerns that existing plans to develop a walk in centre at Southport would reduce the flow of patients through the Ormskirk A&E department, making it potentially unviable

·           There are pressures on Child and Adolescent Mental Health Services across the patch.

·           A number of young patients have to – or feel they have to – travel to Alder Hey hospital for emergency care, who could potentially be treated more locally.

·           There is concern that if NHS providers fail to meet the demand for more community-based, accessible services, independent providers could fill the gap

Opportunities for financial savings

Participants felt that paediatric services are operating at a relatively low level and need investment rather than disinvestment. The following areas were identified as possible options for savings:

 

• Introducing a hospital at home service  - an initial pilot suggested that investment in community nurses linked to the acute ward could reduce admissions to the paediatric ward , as well as reducing the length of stay in hospital for children. What this means in financial terms is difficult to determine. On the one hand the care episode is likely to be costed at a lower tariff than an in-patient admission. On the other the Southport and Ormskirk Hospital NHS Trust will still have to cover the fixed costs of the paediatric ward.
  
   
• Outpatient follow up clinics could be reduced through a combination of nurse led clinics or GP shared care. If this were to be successful some telephone access to consultant opinion would need to be offered.
  
   
• Reducing the double handling of urgent care cases. Patients currently seen at the Walk in centre for example are frequently referred on to the A&E department at Ormskirk. There is also thought to be some inefficiency in having GP out of hours services separate from other urgent care services such as A&E.
  
   
• It was felt that no new buildings for children’s treatment should be constructed as there may be scope for using existing facilities more effectively.
  
   
• There may be scope for some modest management cost savings should acute and community paediatric services be brought under the remit of one organisation.
  
   

Principles underpinning changes to services

The future model of care should be based on the following principles:

 

• There should be immediate triage for children with health needs.

• Children who have long-term conditions or periods of acute illness should, wherever possible and safe, be treated outside hospital.
  
   
• Children with urgent care needs should be seen as close to home as possible, and travel should be minimised as far as possible.

• There should be better access to care for minor complaints.
  
   
• Best use should be made of the range of professional skills.
  
   
• Care pathways should be co-ordinated – this can be achieved more easily if community and hospital based paediatric services are integrated and run by a single provider.  This would also support the development of integrated services that meet the full range of needs across the patch.

• The needs of children in transition to adult care need careful planning.

• Services should provide appropriate reassurance for parents.

Proposed changes

Urgent care

 

·          An emergency service for children needs to be established with paediatric A&E consultants acting as clinical leaders for paediatric emergency care for a defined population of children and young people, not all of whom would be treated in the A&E department The service could be provided by a number of hospitals but would be clinically run by one organisation

 

·          All urgent care services from GP surgeries to walk in services to full A&E would be supported by common protocols and guidelines. The range of clinical conditions capable of being diagnosed and assessed in local centres (e.g. the Skelmersdale walk-in centre) should be expanded. Investment in advanced diagnostic skills could help retain a wider range of patients within these local urgent care services, preventing referrals on to the A&E department

 

·          Urgent care services that are distributed across the area will need to be networked to promote information sharing and common file storage. Child protection arrangements need to be particularly robust  

 

·          Ideally it was felt that a seaside resort such as Southport with its larger tourist population  should have access to urgent care for children. The costs of this could, however,well be prohibitive.

In-patient care

 

·         There was consensus that more effective use of the facilities at Ormskirk should form the bedrock of any changes.  The Ormskirk assets should be used more effectively by reducing the number of inpatient cases and  increasing day surgery cases, leading to an increase in resources.  This should be done  in partnership with Alder Hey – with the latter only receiving cases where specialist tertiary care was needed. Indeed, the current problem of Alder Hey having a strong brand image meant that parents often took their children there rather than to Ormskirk. This led the group to suggest using the ‘Alder Hey brand’ to boost the status of Ormskirk with local people, recognising that the two paediatric departments work closely together already.

·          Inpatient care for children should remain at Ormskirk for the time being, subject to the following changes:

 

o        Reduction in the number of inpatient beds to release funds to invest in community nursing and community paediatrics.

 

o        Exploring the scope for more flexible use of paediatric nurses between day care, A&E and in-patient wards

 

o        Investment in a community nursing team to provide support to children at home. There may be a case for some specialist roles within the team e.g. for respiratory conditions

o        Clear specification of the types of conditions that can be supported at home.  The team would provide support to children with long term conditions, complex needs and palliative care.

 

·           Hospital paediatricians would work both in the hospital and in the community once          community services were established.

·          There may be case for closing the in-patient paediatric facilities at Ormskirk in due course but not before investment has been made in community based services and the  public and parents  accept there has been a demonstrable improvement in access to care closer to home.

 

Ambulatory care

 

• There is already an observation and assessment unit at Ormskirk. If in-patient care were to cease, Ormskirk should continue to offer day case observation, assessment and treatment.

• One group suggested establishing a nurse-led coastal Walk-In Centre – this suggestion stemmed from the claim that patients further down the coast (for example in Formby) found accessing the out of hours/A&E services in Southport or Ormskirk difficult due to poor transport links. There was therefore felt to be a need for some kind of emergency care centre for minor problems, which after much discussion was felt to be best located in Ainsdale. The group did not describe exactly what the scope/remit of this WIC should be, although it was felt that it should mirror an expanded version of the  existing WIC in Skelmersdale. However, several GPs attending the day felt that GPs along the coast were able to provide the necessary urgent care and that a walk in centre at Ainsdale would not therefore be necessary.

Community paediatric services

 

·         There is a need to increase the number of community-based outpatient paediatric clinics, and perhaps to link these to clusters of practices, which could themselves be linked to the  clinical network of paediatricians.

·          There is a very low level of investment in these services at present. Additional investment in medical staffing may be needed. However, it was also felt that changes to management arrangements could help make better use of the existing resources. The following options should also be considered:

 

o        A single paediatric team for hospital and community paediatrics across Southport, Formby and West Lancashire managed by Southport and Ormskirk Hospital NHS Trust

 

o        Bringing the whole paediatric workforce within the management of Alder Hey. Whilst there are potential risks that the current investment in community paediatrics is diverted in favour of more acute care, on balance it was felt that the philosophy of care offered by Alder Hey was community oriented and could offer appropriate clinical leadership of paediatrics across the whole area. The advantage of this would be the potential to apply the Alder Hey brand to the whole children’s services network which should help improve confidence in the services offered whether in hospital or in community settings.

 

·          In addition to this there was support for bringing the Child and Adolescent Mental Health Service (CAMHS) together under one management with a preferred option for this being led by Alder Hey.

 

There are several different locations for the delivery of community based child health services – health centres, children’s centres and a child development centre. It was agreed that there should be a review of the distribution of community health, social care and education support to see whether further use could be made of children’s centres.

 

Implications of these changes

·          Any downsizing of the inpatient capacity at Ormskirk will have an impact on maternity services provided there.  In particular, concerns were raised regarding whether the Royal Colleges would be prepared to accredit the facility if paediatric services lacked the critical mass to provide support to the maternity unit.   Clearly any changes need to manage the impact on other services and particularly on maternity services.

·          To ensure appropriate expert coverage of the new, more devolved arrangement for paediatric services, a  clinical network of consultant paediatricians, many drawn from Alder Hey, would be necessary. These could work on a rotating basis, revolving between the main centres in the new system (Southport, Ainsdale, Ormskirk and Skelmersdale, possibly with others) as appropriate.

·          There would need to be clear protocols (e.g. for when a patient should go where) and a ‘unified management approach’. The latter is particularly important in order to meet the principle of integrated services meeting the full range of needs of the community.

·         The new community-based model of care  might help to alleviate some of the problems associated with child and adolescent mental health services and child protection, if these are built into their design and operation.

Commentary

 

There was a general acceptance from participants that the model of paediatric care currently offered in Southport, Formby and West Lancashire is relatively old-fashioned and dominated (in terms of resources and emphasis) by hospital-based care, only because the community service is seriously under-resourced.  There are relatively good links with the tertiary unit at Alder Hey but these have not been formalised into a clinical network.

In terms of fit between proposals for paediatrics and the other trigger specialties considered for ‘Shaping the Future’ it was striking that neither urgent care nor long-term conditions had considered children in their discussions. The group commented that this was too often the case in health care planning. There are significant issues to be addressed at the transition from child to adult services, particularly for people with long-term conditions. The main concerns expressed about the model for paediatrics came from those considering maternity services. Any move away from 24-hour paediatric cover on the Ormskirk site would mean a change in the type and volume of maternity care that could be accommodated in the hospital. There are examples in other places where maternity care is provided without 24-hour paediatric cover but participants were reluctant to accept that they could work locally.

In terms of next steps, the following would help:

 

·          Review of the hospital at home pilot to identify the range of cases and impact

 

·          Identification of any wider conditions that could be supported at home by a community children’s nursing team

 

·          Description of the level and type of team needed to support those conditions and economic analysis of the costs and potential savings

 

·          Contact with services in other places that have made significant progress in shifting the balance of emphasis in child health services from a hospital to community based model.

 

·          Formalisation of the paediatric network with dedicated medical and nursing leadership. The network should encompass A&E and surgery as well as paediatric medicine. Early priority should be given to the establishment of common protocols and pathways.

2. Urgent Care

The current arrangements

Although there are A&E services, a walk-in centre and minor injuries unit, the following issues with current arrangements were identified:

·         No 24 / 7 access to unplanned non-emergency care services – currently the walk in centre and minor injuries unit are not open all day every day.

·         Variation in availability of unplanned care in GP surgeries: GP surgeries vary significantly in size and their ability to handle unplanned care, particularly during surgery hours.  It is common that due to appointments at a practice, patients needing rapid access cannot be seen until the evening, and instead they call an ambulance and are taken to hospital.

·         Range of service models and organisational differences:  The large number of organisations serving the patch – i.e. 2 ambulance trusts, two social services departments, two PCTs and numerous acute trusts at some distance – means that there is a very wide range of service models as well as organisational differences. This has also led to lack of clarity for the public and lack of “joined-up” planning for the area.

·         Services located outside the area:  Many unplanned care services are located at hospitals outside  the area.  In addition, the public also travel for specialist treatment.

Pressures to change

·         The infrastructure supporting primary care services is generally weak.

·         The low level of diagnostic support in primary care means that a lot of people go to hospital for tests when they could be done much more locally. This would be both more cost effective and better for the patient – e.g. patients attending the walk-in centre in Skemersdale who require diagnostics currently have to travel to Ormskirk.

·         The transport infrastructure is poor in some parts and car ownership is patchy, particularly in Skelmersdale, rural West Lancashire and central Southport – so local solutions are needed.

·         Mental health emergencies are not consistently managed.

·         There is very poor signposting of services from one agency/professional to another leading to confusion and replication of activities between service providers.

·         There are not clear messages to the public about which services should most appropriately be used when, or what level of urgency or need particular services are able to respond to.  As a result of this, “too much unscheduled care happens in hospital…” Patients don’t always use the services appropriately, for example there are currently many people attending A&E at Southport who could be treated more cost effectively elsewhere.

·         It was recognized that ‘It’s nice to have a hospital on your doorstep but it’s not necessarily what you need…’

Principles underpinning changes to services

The future model of care should be based on the following principles:

 

·         Emergency care needs to be considered in the context of ‘unplanned care’ as a whole.

·         ‘Unplanned care’ should cover medical, social and nursing care that patients feel cannot wait for an appointment, and should provide better integration between health and social care.  

·         The framework should also consider services in terms of what care is available when – i.e. during the daytime; out-of-hours; in hospital; and, out of hospital. 

·         Any changes should take account of unplanned care services for children, mental health services and care for people with long term conditions:  Any changes to unplanned care as a whole need to be linked in to how unplanned care is provided for children, provision of mental health services, and provision of services to people with long term conditions.

·         Improved access in terms of where services are provided geographically:  Whilst appreciating that the public travel now for specialist treatment, there was consensus that the public should not have to travel great distances for the majority of unplanned care.

·         Simple to access:  It should be clear to people where and how to access the service that they need, and it should then be straightforward to access that service. This has the potential to make unplanned care services more efficient and cost-effective, allowing for disinvestment in hospital services.

·         Provide one point of access into the services (a physical building locally situated) where a range of unplanned care services – A&E, Minor Injuries Unit, out-of-hours doctors’ services and pharmacies - are accessed, ‘through one door’.  This will also provide patients with the sense of security that, at the moment, is provided by A&E.

·         Integrated 24 / 7 service provision:  Move away from the notion of ‘out of hours’ and ‘in hours’ towards an integrated 24/7 service which meets the needs of the local population.

·         Reduce use of A&E for unplanned care:  Reductions in the use of A&E for unplanned care can only be achieved if there is an over-arching community service to deliver effective, appropriate unplanned care.  This should include, for example, increased access to diagnostic services in the community, and directing people with minor injuries to other services.

·         Different elements of care co-ordinated:  There should be a triage system that means that if a patient calls for advice the person at the end of the phone should organise care for you and not just sign post—i.e. care manage.

·         Improved integration between different agencies and services:  Organisational and political boundaries should be simplified and there should be more integration so that patients receive integrated services.

Proposed Changes

The following proposals were made for how services should be developed in the future:

·         One ‘call centre’ to triage all queries regarding where to access unplanned care – in addition to the usual 999 service – this call centre would not only be able to provide appropriate medical guidance, but would also have details of the current bed availability across the region.  It was felt that this should provide a ‘human voice at the end of the ‘phone’.  NHS Direct might have a role to play, linking into the principle of creating a single point of access for patients.

·         The ambulance service also provides an opportunity for redesigning services.  In 2006 non-urgent calls will be triaged by a health professional and many will receive advice or treatment from a primary health care professional, as opposed to an ambulance taking the patient to hospital.

·         Review primary care provision with a view to creating a better service, extending what might be done during 9-5 (and maybe extended into the evenings) by GPs and their teams to avoid hospital admission.  The view was that some savings could be re-directed from the selling of outdated NHS and social services premises and reviewing current deployment of GP surgeries – i.e. undertake a review and rationalise them – particularly the single handed practices that are not able to meet demand or quality standards.

·         Provide an Urgent Treatment / Diagnostic Centre in Southport which would be the first physical point of contact for patients.  An opportunity considered was the re-location of the planned Walk in centre for Southport General Infirmary site to the Southport District General Hospital site.  It was agreed that investment in developing this service could be made by diverting monies currently going to the acute trust.   By providing the Walk in centre in the Urgent Treatment Centre, alongside GP Out of Hours services and Accident and Emergency services, patients would benefit from a single triage system and direction to the most appropriate service to meet their needs. Financial savings would also accrue from the integration of services and better management of patients resulting in fewer referrals to A&E and secondary care. The Urgent Treatment Centre needs to have access to beds when patients need them.

·         Provide the following services from Ormskirk:

·         Minor Injuries Unit

·         GP Out Of Hours service

·         Walk in centre

·         GP and primary care services

·         Rapid response team

·         Social Care

·         Paediatric A and E.

·         It was not agreed whether a similar service would be needed for both Ormskirk and Skelmersdale, although providing this in both locations would probably be the most effective way to simplify access for patients and avoid patients drifting back in the acute sector.

·         Increase the flexibility in how existing resources are utilised – for example, by enabling ambulance paramedics to provide more treatment on-site rather than taking every patient to hospital. or, by training doctors’ receptionists to be able to provide basic medical guidance in order to triage patients effectively.

·         Improve communication with the public about which services to access when.

Implications of these changes

These changes would need to be supported by:

• Improved and increased joint working between organisations.

·         Education and promotion campaign to the public

·         Integrated computer/ telephony systems

·         Training for a range of healthcare staff

The changes would also need to link closely to any changes to services provided to people with long-term conditions.

These changes imply a disinvestment from hospital services.

Commentary

The groups found it difficult to specify the exact arrangements currently provided as there is not currently a shared understanding of what services should be defined as ‘urgent care’ as opposed to ‘unplanned care’.  There was also disagreement in identifying unplanned care in terms of in-patient, outpatient and ambulatory. 

There was also lack of clarity between healthcare professionals about what services are provided in the Minor Injuries Units and the Walk in centre.  This lack of clarity amongst service providers currently translates to service users, who are not clear about which services are most appropriately used when, leading to people using A&E as a ‘default’.

There was a willingness to divert funding away from acute services to support more unplanned care services in the community, but further developing these services will only be cost effective if people use the range of unplanned care services more appropriately.

3. Long-term conditions                            

The current arrangements

Long-term conditions include diabetes, coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), arthritis, dementia / neurological conditions, mental health and clinical obesity.

In-patient / acute services are currently provided through:

·         Southport District General Hospital – urgent care; in-patient medical; intermediate care

·         Ormskirk District General Hospital

·         Old infirmary (reduced service)

·         Ormskirk – pre-planned / maternity

·         Wrightington

·         Renacres (independent hospital) inpatient

·         Rapid Response Team (Southport, Ormskirk, Skelmersdale)

Out-patient / ambulatory care is currently provided through:

·         Southport and Ormskirk District General Hospitals - outpatients

·         Old Infirmary - outpatient department / audiology / blood tests

·         GPs / health centres (across the patch)

·         Skelmersdale walk-in service

·         Ainsdale eye-screening (diabetes) clinic

·         Formby diabetes drop-in

·         Renacres (independent) day care

·         Hospital based cardio rehabilitation (with dietetics and heart failure nurses).

Home care / intermediate care in community settings

·         Social Services Day care (provision currently under review), e.g. Brookdale Resource (result of partnership agreement with Sefton Social Services) is a community service for assessment and day care for older people with functional / organic mental health problems; Burscough day care.

·         Outpatient clinics run by consultants in social services based facilities, for Parkinson’s / TIA clinics.

·         Re-enablement (short-term homecare provided by social services, if after 6 weeks the patient still needs personal care, then assessment and homecare are purchased from private sector)

·         Community services, e.g. specialist nurses (diabetes/ respiratory) / District Nursing / Community Matrons (yet to come into operation) / healthcare assistants

·         Aintree intermediate care ward

There are moves towards increasing community based care (with the introduction of community Matrons) but these have not been fully realised yet.

In addition, patients currently travel out-of area to:

·       Aintree for rehabilitation for amputees, renal / dialysis, strokes and coronary care.

·       Royal Liverpool (Cancer, renal / dialysis)

·       Walton (neurological service)

·       Alder Hey commonly treats children.

·       Patients on East of patch may be treated in Wigan for A&E strokes, orthopaedic and trauma care.

·       Patients from the north of the patch may be treated in Preston.

·       Cardiothoracic Treatment Centre (south of patch).

Pressures to change

·         Changing demographics:  There is an increasing population with long-term conditions, both due to an aging population and an increasing incidence of long term conditions in younger people. More complex patients can now be maintained at home.  At the same time there is a shrinking pool of informal carers.

However, information management and local public health data on long-term conditions is better than it has ever been - in both PCTs Long-term Conditions Groups are trying to use this data to understand local needs and plan services accordingly (i.e. to promote best practice and reduce hospital admissions).  It will be increasingly important to know where the ‘clusters’ are for long term conditions in order to target services / awareness raising effectively.

·         Rising expectations of healthcare with the introduction of patient choice

·         There is no joint strategy or commissioning of services for these patients.

·         Services that are commissioned for these patients are not well promoted and patients are often not aware of the most appropriate place to be treated, leaving some services under utilised.

·         The healthcare system is currently focused on dealing with crises as they arise, rather than prevention, early detection and on-going management of long-term conditions.

·         Outpatient services are concentrated in Southport and Ormskirk.

·         The system is not patient-focused, as people with multiple conditions are seen in multiple locations, and patients have to visit different places for similar tests, both leading to unnecessary travel, inefficiency and confusion.

·         At present, many services associated with the management of long-term conditions (e.g. out-patient, diagnostic, rapid response team, intermediate care, social services day care) are centred on in-patient acute facilities (e.g. Southport District General Hospital). Follow-up appointments that could be carried out in primary care are generally held in acute settings, and many patients see a consultant for appointments when they could see another health professional.

·         There is no single point or person co-ordinating a patient’s care and information flows within and between organisations are poor.

·         There are pockets of good practice, but they are not consistently applied across the patch i.e.,

o