Bay Health & Care Partners (BHCP) is the Integrated Care Partnership (ICP) for Morecambe Bay. It seeks to integrate care across Morecambe Bay focusing on the triple aim of Better Health, Better Care and a Sustainable Model of delivery.
The MBRN was born out of this wider vision. From the prevention of illness to
the diagnosis of the conditions and the management of the patient
throughout their life, the aspiration of the MBRN is to impact on the whole
journey of the patient with respiratory disease.
We want to structure the service in such a way that the clinical staff find it easy to do the right thing, first time for our patients. By working closely with the various MDT members, valuing everyone's input we aspire to bring a culture of joy and professional fulfilment to the whole team.
In order that we might meet this task the founding principle has been that we seek to increase the capacity, skills and support offered to Primary Care, in the form of the nine Integrated Care Communities. A proportion of patients will be seen by colleagues in the community or secondary care teams over the course of their respiratory condition, however all patients will come into contact with their Primary Care team. Therefore, to address the needs and concerns of the whole population we must focus on Primary Care and build the service around that team.
With this enhanced primary care in place we must then provide the structure of an integrated service which allows early and focussed support from the specialist teams. We must increase the capacity of the teams within the community providing the high-value and therapies which have historically been poorly funded.
The enhanced primary care team, working closely with specialist and community colleagues, will then be in a position to enable to both prevent deterioration of respiratory conditions and see that more patients with acute illness are treated safely and effectively within their own homes, avoiding admissions where safe to do so.
This shift in care will enable us to release capacity within the specialist teams so that tertiary level services can be repatriated to Morecambe Bay, enabling better access to advanced therapies for our patients, closer to their homes.
Morecambe Bay covers a
large geographical area, we have patients living in cities and rural hamlets,
patients with the highest level of deprivation and patients with the lowest
level of deprivation. We have 35 GP practices with lists sizes varying from less
than 1000 to over 65,000. There are three county council, three major hospital
sites and countless community and voluntary teams.
The challenge is therefore how we integrate across this wide and varied ICP.
Our plan is organise the ICC Respiratory Teams into three localities each with their own GP lead, community teams, specialist nurses and consultants. This team will meet monthly in the MDT and report directly to the steering group via an MBRN Service Manager. The MDT’s will, within the remit of the MBRN Service Specification, be responsible for delivering on the various targets and metrics set by the MBRN Steering Group. They will also be encouraged to develop the service locally, to meet the particular requirements and challenges in that locality.
Standardisation of the delivery of care, and resources for patients and clinical teams is vitally important. To this end we will provide an MBRN website to act as a single resource for all staff with the most up to date and relevant material.This will also provide patient-facing resources and support material.
Sub-groups will be set-up to oversee certain key areas of integration and quality improvement such as Pulmonary Rehabilitation, Education, Medicines and Clinical Resources.
The MBRN steering group and sub-groups will set the standards and overall goals and it will be up to the ICC Respiratory Teams within their MDT to deliver locally for their patients.
If any CCG, ICP or ICS staff would like to see our visioning document or discuss the MBRN in more detail please do contact us using the address MBRN.Website@mbht.nhs.uk