Individual approach

Nottinghamshire is putting its plans for a primary and acute care system into action

A local health and social care transformation programme has been selected as one of NHS England’s 29 vanguard sites. It bid for a share of a £200 million fund created to help local care bodies to accelerate plans that will radically change and redesign the way health and social care works together.
Being named as a vanguard for integrated primary and acute care systems is a huge boost to the Better Together Programme – an ambitious five-year plan to integrate health and social care services, bringing professionals closer together to improve care for the populations of Newark, Sherwood, Mansfield and Ashfield.
The programme is in response to a projected £140million funding gap predicted by local health communities if nothing is done to tackle the demand on NHS services and social care.

The programme
The programme, in its second year, is a partnership comprising NHS Newark and Sherwood and Mansfield and Ashfield Clinical Commissioning Groups (CCGs) and Nottinghamshire County Council working alongside a group of seven coordinating health care organisations, who in turn are working in primary care and the voluntary sector. Working with staff, patients, carers and the public has enabled the programme board to develop a transformation vision that will radically change the way health and social care looks in five to 10 years. The programme looks to integrate services with the basic principle that care is based around the individual, not the organisations that provide that care.
There is a strong emphasis on supporting people to manage their own conditions; helping people to choose the right service at the right time and working with hospital and primary care staff to establish the best possible elective referral pathways.
Transformation on the scale needed requires the whole system to work differently so commissioners are changing the way they will buy services; moving to an outcomes based commissioning model that provides incentives to deliver the best outcomes for the health of the population.
Outcomes based commissioning works where commissioners still maintain statutory responsibility to commission core services but have shared objectives with the providers. The focus is on prevention of crisis, stabilising long-term conditions management, maximising independence and resilience, empowering people to access supported self care and supporting people in their own homes wherever possible to deliver the highest quality of hospital care if needed. This new commissioning process is set to be in place by April 2016.
To make sure that the contribution of the third sector is maximised, the local voluntary sector is also creating a centrally coordinated contracting model between the provider and the
third sector.
Better Together is divided into four distinct areas:

Proactive care that focuses on the providing services closer to home.
Appropriate admission avoidance (supported discharge and access to self-care)
Women and children’s services.
Urgent care and elective care.

Long-term conditions
The programme has already been making a difference to patients with long-term conditions. Integrated care team coordinators have brought together therapists, community nurses, social care staff and self-care workers in the same room, alongside GPs and consultants to discuss patients who are identified as having complex health needs or, without support, are at high risk of admission to hospital. They work with the patient to discuss their needs – both medical and social and with an added focus on any mental health needs too.
Those who benefit remain independent in their own homes in their own communities so they don’t need hospital services but do have access to community services, which can be specialist interventions or voluntary support.
Professionals from the whole multi-disciplinary team work together focusing on each individual using their knowledge to ensure that every part of the patient’s health history can be taken into account when planning their care needs with them, their family and carers. Because the voluntary sector has been so well engaged in the programme, the coordinator can also call on voluntary support organisations as part of the package of care given to individuals. This may be the case if a patient has or needs help and support to find more suitable housing or is in financial hardship or simply needs to access a befriending service if they live alone.

A&E
Proposals for a ‘single front door’ at the two local hospital sites that serve the local populations will simplify urgent care services. A new self-care hub at a former community hospital in Kirkby in Ashfield will become a centre for health and wellbeing providing a base for community health and voluntary sector organisations.
To understand what drives people to use A&E departments inappropriately the programme will lead a social marketing exercise to establish some sustainable behaviour change solutions.

Public engagement
Better Together is about organising the existing system to address what the population needs. A programme of this complexity is challenging, and the leadership team is working through issues such as payment mechanisms, contract models, governance and workforce development.
Another challenge is public engagement. This forms a vital part of the programme. Seven hundred people have joined the programme’s champions scheme to act as ambassadors to colleagues and patients. The views of more than 450 people have been gathered through targeted outreach work in supermarkets, libraries and at special events. A Citizens’ Board including patients has a fundamental role in shaping the development of new health and social care services. There are 40,000 individual stakeholders that receive regular updates by email and through social media.
Being a vanguard will enable our programme to benefit from specialist subject matter experts to provide advice on particular models of care and contractual and workforce issues that come with reorganising care systems. The programme has already established governance structures and a strong leadership partnership across health and social care, commissioners and providers. Areas of focus as a vanguard will include performance measurement and benchmarking and devising new payment mechanisms to deliver outcomes.

How it will help the population
It is clear from the increasing demands and diminishing funding that change is needed. Vanguard status will help organisations to realise that change sooner than had been hoped. Commissioners and providers also recognise that the current system can be confusing and fragmented so by being able to simplify the system, it is hoped patients will start to feel that all of those involved in caring for, treating and supporting them are focussed on the same outcomes and work together; providing care seamlessly.
All those involved hope it will allow hospitals to focus more on improving the quality and efficiency of planned care, rather than always be subsumed by every day pressures.

The bidding process
The Better Together team was required to distil the programme into something that demonstrated something really different and where best practice can be accelerated to help other care systems.
This process was fair and open and has resulted in a strong network of peers from across the country.
Better Together is not about planting a thousand flowers and hoping five will bloom. Equally it recognises not one size fits all.
There are more similarities in other reform programmes than there are differences and everyone involved wants to harness what works to create scalable changes than can be replicated to make a difference.

Lucy Dadge, director of transformation at Newark and Sherwood/Mansfield and Ashfield CCG.