About us

Encompass - a new model of care

The new model of care being developed by Encompass is a multispecialty community provider (MCP).

Led by the Whitstable, Northgate and Saddleton Road medical practices, this has already expanded to include an additional 13 practices across the Canterbury and Coastal Clinical Commissioning Group (CCG) area.

The new model will ensure health and social care is integrated and based around local needs and patients can receive more of their treatment in their communities, rather than having to travel to hospital. It will involve joint working across professions and organisations to improve efficiency and reduce duplication.

We want to create a more cost and clinically effective service by treating patients closer to home using specialist GPs, allied health professionals and community based consultants. There will also be a greater use of information technology, to enable people to maintain their independence through self-care and self-management, and a shared single electronic patient record. Paramedic practitioners are already accessing this using an iPad on home calls in Whitstable.

Five Health and Social care hubs have been developed. These allow key people from health and social care organisations to work together to look after specific patients and discuss the best interventions for them. These hubs include GPs, social care, mental health geriatricians, social prescribers and community nurses.

Additionally, focusing on prevention will ensure that the whole health and social care system is working seamlessly to support people to stay well.

The MCP operates on an inclusive basis with a federation of GPs working in partnership with everyone involved in health and social care, including the voluntary sector and patient groups.

 

The priorities and plan for the MCP is called the Value Proposition and can be found here.

 

The MCP reports into the Governing Body of the  Canterbury and Coastal Clinical Commissioning Group regularly and those reports can be found here.

MCP Vision

The vision for our MCP is to develop a new model of care that that delivers “high quality, outcome focused, person centred, coordinated care that is easy to access and that promotes wellness and enables people to live independently for as long as possible”.

Our MCP vision aligns to the NHS Canterbury and Coastal CCG vision which is to:

“Improve the health and wellbeing of local people by working in partnership with local communities to create a sustainable health care system, integrating hospitals, GPs, social care and community services including the voluntary sector”.

It also aligns to the National Voices narrative statement of coordinated care. This sets the standard for what patients and carers should expect from good integrated care across the MCP area:

“I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me.”

MCP Values

Our MCP values underpin the proposed new model of care:

  • Patient and primary care at its heart - pro-active care and prevention through early identification, coordinated care planning and delivery in a primary and community care setting.
  • Care should be patient-focused, easy to access, and well-coordinated via “care navigation” enabling clear transition through services based around clearly identified and agreed “care decision points”.
  • People are supported to stay well and maintain their health and independence for as long as possible, living in the place of their choice, supported by appropriate integrated multi-agency community service provision.
  • Self-care and self-management is promoted and supported.
  • Carers are effectively supported.
  • Care should take place in the most appropriate setting, based on what is clinically appropriate, safe and effective – shifting unnecessary activity out of the acute setting and into the community.
  • Services are underpinned by integrated IT across the whole system (including community IT solutions for all community staff).

As our MCP develops we will share our learning both locally and nationally so that others can benefit from our experience.

Community networks: co-designing our new care model

The MCP is being developed to align with NHS Canterbury and Coastal CCG’s vision to improve the health and wellbeing of local people.

The CCG believes that people should be at the heart of everything it does and that more needs to be provided in communities. It knows that the NHS has to do more with less money and services need to be better joined-up. It also wants people to have a say on what is important to them and their area.

To make sure the right care is being delivered in the right place, the CCG has established five Community Networks across the CCG area. Network members include Patient Participation Groups, organisations that provide health and social care services, voluntary and community organisations, GPs and the CCG.

What are Community Networks?

Networks are the foundation for building a new way of working that joins health and social care. These groups bring together a wealth of experience and knowledge on current services and how they are used by patients. The network programme will run for three years and will assist and advise the CCG in making sure future services are based around individuals and the communities in which they live and work.

Community Networks will help us to create a sustainable care model which makes best use of our resources and is better value for money. They are there to:

  • Simplify services and removing unnecessary complexity
  • Wrap services around patients, including mental health, social care, specialist nursing and community resources
  • Use these services to build care programmes for patients with complex needs
  • Reduce the need for patients to be admitted to hospital
  • Reach out into the wider community to improve prevention, provide support for isolated people, and create healthy communities.

Members are drawn from GP practices, frontline staff from key services such as community nurses, social care workers, mental health services, patients, voluntary organisations and charities such as Age UK.

  • NHS Canterbury and Coastal Clinical Commissioning Group
  • Kent County Council Social Services
  • East Kent Hospitals University NHS Foundation Trust
  • Kent Community Health NHS Foundation Trust
  • Sussex Partnership NHS Foundation Trust (community mental health services)
  • Kent and Medway NHS and Social Care Partnership Trust (inpatient mental health services)
  • Kent County Council Public Health
  • Voluntary and community services
  • Pilgrims Hospices
  • South East Coast Ambulance Service
  • Red Zebra Community Solutions
Frequently asked questions

What is an MCP vanguard?

MCP stands for multi-speciality community provider.  They are organisations looking at how to move specialist care out of hospitals and into the community.

There are 14 MCP vanguards across the country. These are areas which bid for special funding from NHS England to test new ways of delivering care and avoiding hospital admissions.

The MCPs are testing different approaches to see what works best in their area so that the lessons can be scaled to other parts of the country.

 

Why is there an MCP in East Kent?

When additional funding from NHS England was announced, a group of GPs, led by the Whitstable, Northgate and Saddleton Road surgeries, thought that they could make a good case for improving local care whilst developing new ideas that could be used nationally. A gruelling process to apply began, supported by the Canterbury and Coastal CCG (Clinical Commissioning Group). Funding was granted and the GPs started work to look at how moving some specialist services into the community could help patients and reduce admissions.

 

What is the East Kent MCP?

The East Kent MCP vanguard is called encompass.  It started in late 2015 when funding was first agreed. It is now made up of 13 GP surgeries and covers around 170,000 patients.

 

Who does encompass work with?

The purpose of encompass  -and the MCP vanguard model – is to bring organisations involved in health and social care together to improve experiences for patients.  The 13 practices that make up Encompass work with:

  • NHS Canterbury and Coastal Clinical Commissioning Group
  • Kent County Council Social Services
  • East Kent Hospitals University NHS Foundation Trust
  • Kent Community Health NHS Foundation Trust
  • Sussex Partnership NHS Foundation Trust (community mental health services)
  • Kent and Medway NHS and Social Care Partnership Trust (inpatient mental health services)
  • Kent County Council Public Health
  • Voluntary and community services
  • Pilgrims Hospices
  • South East Coast Ambulance Service
  • Red Zebra Community Solutions

 

 

But we don’t just work with health and social care professionals. We work with the communities we are embedded in via:

  • Community networks (which involve voluntary and charity groups, social care workers, mental health services and patients)
  • Patient groups (via GP surgery Patient participation groups)

What is encompass MCP doing?

Encompass are trialling a variety of projects that have been identified as being able to improve patient experience and reducing hospital admissions.

The projects currently in progress are (these will be headlines and link back to the services page for descriptions)

 

Community Hub Operating Centre development (CHOCS)

Five sites have been provisionally identified as physical locations where multi-disciplinary community services can be based.  There will be 2 in Canterbury and 1 in Whitstable, Faversham and Ash (covering Ash and Sandwich).

 

Integrated case management

GPs at the Community hub operating centres have identified patients who are most likely to benefit from having a team around them. A team of professionals,  from different disciplines; mental health, social care, community nursing, voluntary organisations, GPs etc.  are working together to help make sure that the identified patients have a joined up care plan, which meets their needs, and focuses on keeping them well at home in order to avoid being admitted to hospital.  Sharing knowledge means that gaps which may have occurred previously, are being picked up and acted upon. These teams work with specific patients for short periods of time, known as “step up care”, helping avoid hospital admission. Once everything is in place they then ‘step down’ into normal care.

All members of the team are involved in developing a robust care plan which is ultimately agreed and owned by the patient and reflects their own goals. The added value of having availability of social prescribing is proving a valuable asset in the process; as it aids identification of other areas for action, such as anticipating carer breakdown and / or other social care issues, which if not addressed may lead to the need for hospital or care home admission.

They are also looking at the best way of using IT to support the safe sharing of appropriate data for these patients between the different agencies who support them.

A ten week pilot of this project, working with 50 patients, has now been completed and the positive impact on patients’ health and satisfaction with the service they have received has led to encompass rolling the project out more widely.

 

Wound care and catheter services

Encompass wants to ensure that patients receive the right care, in the right place, at the right time. They are working in partnership with Kent Community Health NHS Foundation Trust, with developing specialist wound medicine centres of excellence and integrated wound care processes and procedures between community and GP practices. Using advanced computer software they are able to scan wounds and track progress on healing rates and on the use of the most appropriate dressings to apply to the wound. The hand held devices mean that an image can be taken of the wound and in the presence of the patient, which can be sent to a specialist Tissue Viability Nurse, for a second opinion if necessary. The results to date have been extremely positive with healing rates reducing dramatically and quality of life much improved.

Another initiative is the introduction of the community catheter clinics. A frequent cause of hospital attendance is when people have catheter related problems. This can cause infection which in turn can lead to further complications.  Catheter clinics are now located in three towns and open to anyone in the encompass area. To date the number of catheter related admissions has reduced by 34% so far this year (2016) since these clinics began.

 

GPs with special interests

Certain services are usually only available in hospital settings, but there could be capacity to deliver them more locally by GPs. Encompass is working with GPs to increase on the success of having ear nose throat (ENT) and epilepsy services within GP practices, and is now looking at other specialities bring care into the community.

 

Community paramedics

The community paramedic project was one of the first to be rolled out by encompass, working with the South East Coast Ambulance Service NHS Foundation Trust (SECamb). This project means that GPs are able to send community paramedics to home visits rather than attending themselves. The result of this is two-fold, GPs are able to spend more time in practice, and patients who need a home visit get seen more quickly.

Since this project was rolled out in November, 4,500 patients have received home visits and the ambulance conveyed A&E attendance has reduced by 5.5%. Both patient and practice satisfaction with the service is high.

 

Social prescribing

Social prescribing is looking at a person’s needs and helping them access, not tablets or formal health support, but other support or ways of helping their condition such as local support and community groups. For mental health conditions, and for age related conditions such as loneliness and social isolation, medication may sometimes not be the most appropriate course of action. It may be that some patients would be better served by attending a group or accessing a community service. Working with Red Zebra, a voluntary sector umbrella organisation, the project means that they have access to almost 400 voluntary and care organisations in the local community. Two social prescribers are in place and another is being recruited to who will signpost people to the most appropriate service.

 

How will encompass measure the results of the pilots of trials it is undertaking?

  • The MCP will be working with the University of Kent’s Centre for Health Service Studies to develop a robust evaluation arm to its programme, which will evaluate the impact of the changes in the way services are being provided for the future.
  • The Centre for Health Service Studies (CHSS) at the University of Kent has been working with Encompass to establish research capacity and a research support office within the Vanguard. This work has been in collaboration with the Kent Surrey Sussex Clinical Research Network to pool resources and ensure that high quality national studies can be delivered.
  • Research will contribute to the Vanguard’s development and activities by:
  • generating new knowledge
  • improving the quality of patient care
  • providing education opportunities for staff in practices and the Vanguard
  • improving staff recruitment
  • The MCP is also being closely monitored by NHS England, who are interested in what is working well, in order to understand what is working well that could be replicated in other areas across the rest of the country.