SaHF DMBC Volume 1 Edition 1.1.pdf - Shaping a healthier future

Delivering routine care close to home
The local hospital is designed to provide care close to patients‟ homes as part of a
seamlessly integrated system including GPs, community services and major hospitals. The
local hospital will provide the base from which much routine care is offered to patients in the
future.
Earlier intervention and better coordinated care - we recognise that people,
particularly the elderly, frequently have several different conditions; they do not fit
neatly into one specialty or another, and their needs are wider than their medical
diagnosis – in short, people want, need, and deserve a holistic approach. This
implies a multi-disciplinary approach that spans across primary, community, mental
health, and specialist care and between health, social care, and other public
services. The local hospital will act as a resource for specialist care for people with
long-term conditions. Furthermore, the local hospital will act as a community
resource. It will be a place to bring patients and carers together in self-care and
support groups, expert patient programmes, structured education, and so on. Some
GP practices and community services may be based in the local hospital, and it may
also host the coordinators of health and social care
Specialist opinion - there will be times when specialist opinion is required to provide
high quality care for patients. This specialist opinion will be accessible through
multiple channels: through email or phone consultation between GPs or other
professionals and specialists; through discussions at multi-disciplinary case
conferences; or through traditional referrals from GPs to specialists for assessment,
recommendations for treatment options, and the updating of care plans
Specialist care - in some cases, patients may require on-going specialist outpatient
care. Many of these outpatient consultations will be provided in local hospitals,
including pre-operative assessments and post-operative reviews. Some patients, for
example, with Parkinson‟s Disease or children requiring insulin for diabetes, will
require a lifetime of specialist care, which will be provided close to home at the local
hospital. In addition, some local hospitals will have the facilities to provide
community-based treatments such as medical oncology, renal dialysis, day-case
surgery, and other interventions
Complex diagnostics - Both generalist and specialist physicians will sometimes
need investigations to enable them to make a diagnosis or to follow up on the
efficacy of a course of treatment. Complex diagnostics such as x-ray, ultrasound,
Endoscopy or MRI may be provided in local hospitals, supporting patients and
professionals with the information they need to make the best possible decision
about what care is required
Services located together - The local hospital will act as a venue for co-locating
services to be organised around disease groups. This might include day assessment
and planning facilities for elderly patients, with co-ordinated transport to and from
home, an integrated facility for musculoskeletal and pain management services, or a
urology and gynaecological one-stop-shop. Bringing together the breadth of clinical
practice and diagnostics, it will enable patients and their carers to agree a diagnosis
and a revised care plan
Enhanced nursing, therapy and rehabilitation services - Local hospitals will have
the facilities to offer enhanced nursing, therapy, rehabilitation and community
services such as physiotherapy, well-baby clinics, chiropody and wound clinics. In
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