Community Services in Brent and Harrow

The contract is to provide the following paediatric services for Brent CCG population: • Children Nursing • Children Looked After • Consultant Paediatric • Paediatric Occupational Therapy • Safeguarding • Paediatric Speech & Language Therapy • Paediatric Physiotherapy • Paediatric Audiology • Paediatric Asthma In addition the contract is to provide the following adult community services for the populations of Brent CCG: • Nutrition & Dietetics • Respiratory • Podiatry • Integrated Diabetes • HIV • Bowel and Bladder • District Nursing • Tissue Viability • Stoma • Community Neuro-Rehabilitation Bedded Service • Integrated Rehabilitation and Reablement - under a Section 75 Agreement with Brent Council • Direct Access MSK • Direct Access Speech & Language Therapy • Community General Rehabilitation Bedded Service • STARRS - Rapid Response • Integrated Care Team • Patient Transport The contract includes the following services for Harrow CCG: • Palliative Care • Direct Access MSK • Patient Transport The services are mainly consultant led supported by multi-disciplinary teams of specialist community nursing and allied health professionals. A number of services have strong clinical interdependencies with our local acute services. The provider will jointly develop an integrated community model which will focus on the collaboration of staff and resources in the system to ensure we can deliver proactive and coordinated care to all our patients, actively utilising a population health management approach, with shared data. The provider will ensure that primary care is supported to manage long term conditions out of hospital with the purpose of improving outcomes for patients. It is anticipated that the majority of people with one or more long term conditions or with challenges in life impacting on their health and wellbeing will be stable and maintained in primary care. However, there will be some people with more complex needs who will require on-going case management by the integrated teams, with additional support from specialists e.g. specialist nurses, consultants and geriatricians. This will require the development of clear pathways for all onward care needs. The provider will work with primary, community, mental health and the voluntary sector to develop integrated pathways and protocols for care homes as required under the network DES arrangements. In all cases, population health and prevention will drive pathway design as well as the need to address inequalities of access and outcomes. Whole system information and data will be used to prioritise groups or conditions that are currently not well managed out of hospital.