Improvements being delivered through One Bromley

Proactive Care  

Patients with complex and long term health conditions are able to get extra support on the ‘proactive care pathway’. GPs identify from their patient lists, those who are at more risk of going into crisis and ending up in hospital.  A community matron does an initial assessment and then a package of care is put in place and delivered by a multidisciplinary team made up of health, social and voluntary sector staff. The purpose is to help keep patients well, enhance their quality of life and reduce the risk of them falling into crisis and ending up as an emergency admission to hospital.

  • As of November 2019, there has been a 26% reduction in urgent hospital admissions & 22% reduction in un-elective inpatient admissions for those patients who are 13 weeks post their multi-disciplinary team assessment on the proactive care pathway (2,966 patients).  This represents an estimated Emergency Department cost save of £81k (443 fewer contacts) and Un-elective Inpatient Admission cost save of £267k (259 fewer contacts) across the same period.

Bromley @Home

The Bromley @home service has been piloted to create a more integrated, community based system that prevents the need for hospital attendance and admission.  The pilot was successful in increasing the number of patients supported by community healthcare services after discharge from hospital. The learning from the pilot is being taken forward through the streamlining of community pathways out of hospital to provide a single point of access for patients leaving hospital who require health and care support.

Improved GP services in residential care

We have created a new general practice specifically for people living in Bromley’s care homes. Recognising that people in care homes have a higher rate of hospital attendances and admissions, and more longer term conditions and medications needs, a GP practice service has been commissioned that will provide both proactive (ward round) and reactive (urgent) care to the 1,800 people living across Bromley’s 40+ homes. The service will use doctors, nurses and pharmacists to work with the care homes as well as the patients and their families to avoid unnecessary hospitalisation and improve the quality, access and experience of primary care for these patients.

The service provides:

  • Regular weekly/biweekly visits to all homes
  • A comprehensive medical assessment of each resident upon admission to the care home and follow up medical assessments at least twice a year
  • A comprehensive medical assessment and medicines review following any patient who has been admitted to then discharged from hospital
  • A medicines review at least once a year.
  • Urgent same day visits.
  • Close working with care home staff and other health and social care services.

There have been other improvements including:

  • Pathway changes such as the virtual respiratory pathway, community heart failure, end of life and diabetes
  • 8 Primary Care Networks including all practices in Bromley have been established as the basis of a population based approach. Currently 24 practices in Bromley are providing online consultations with a further 10 practices pending.
  • A review of the Transfer of Care Bureau, located in the hospital, has been completed and there is a programme of work currently in place to improve the efficiency of the service it delivers to those patients requiring a supported discharge.
  • The new Orpington Health & Wellbeing centre opened in September 2019. This is a significant achievement where the new centre includes services from various providers including GPs, Community services & others. Work is about to start on the new MRI suite.
  • The Wave 4 funded increased Utilisation of Beckenham Beacon project is also well under way and due to complete at the end of November with Oxleas moving in and joint working across seven organisations in Bromley.
  • Mental Health Wellbeing trailblazer in schools has commenced with 2 hubs (teams) working in schools to support C&YP with mental health challenges
  • Investment in CAMHS via the mental Health Investment Standard has increased staff skill mix and capacity

Planned programmes

One Bromley schemes will be delivered via a phased approach. Phase 1 will focus on urgent and emergency care and management of winter pressures.

Key schemes in phase 1:

  • Proactive Care
  • U&EC including @home service
  • Frailty pathway
  • End of Life care
  • Care homes

Key schemes in phase 2:

  • Outpatient Transformation
  • Primary Care Networks
  • Diabetes
  • Mental Health
  • Children and Young People 

Enablers

  • Workforce and Organisational Development
  • Communications and Engagement
  • Finance
  • Estates
  • Business Intelligence and Population Health Management
  • Contracting and Organisational Structure
  • Digital and IT

An update on One Bromley was discussed at the Bromley Health and Wellbeing Committee on 21 November 2019.  You can read the paper here.

NHS Bromley CCG, Global House, 10 Station Approach, Bromley, BR2 7EH

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