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Partnership working to improve care of older people

Partnership working to improve care of older people
17 March 2014

An ageing population in Cornwall and the Isles of Scilly require innovative partnerships that bring together health and social care 
NHS Kernow, which is responsible for delivering health services across Cornwall and the Isles of Scilly, has recently been awarded Pioneer status for its plans to join up health and social care.

An ageing population in Cornwall and the Isles of Scilly require innovative partnerships that bring together health and social care 
NHS Kernow, which is responsible for delivering health services across Cornwall and the Isles of Scilly, has recently been awarded Pioneer status for its plans to join up health and social care.
Pioneer status means that the partnership of 15 organisations in the NHS, the council, community services and the voluntary sector will benefit from national health and social care expertise to become one of the first in the country to integrate its services, well ahead of the government’s deadline of 2018. Patients in these areas will see important changes to their health and social care services before other parts of the country, including being able to move easily from one service to another; only having to tell their story once to anyone involved with their care, regardless of who they work for; and knowing who is supporting them, and why. 
This accolade recognises the enormous amount of work we have undertaken and underlines our commitment to integrate health and social care services. We are creating local teams of social workers, health practitioners, GPs and volunteers to wrap support around people to ensure they don’t fall through the gaps between organisations. Our innovative approach has volunteers at the heart of this team and instead of waiting for people to fall into ill health and a cycle of dependency, we will proactively support them to improve their health and wellbeing.
Once integrated, our seamless system will not only meet people’s needs from the moment they are admitted to, and discharged from, hospital, but will also do more to reduce unnecessary admissions by supporting people in their home and remain independent.
Health and social care providers in Cornwall face a number of challenges in the provision of integrated, equitable and quality care. The population of 532,300 is gradually increasing and getting older.
In the Index of Multiple Deprivation (2010), eight Cornish areas are in the most deprived 10% nationally – in Camborne over 16.1% of the population (5,200 people) report themselves as having a limiting long-term illness.
The county, covering 1,376 square miles, is served by acute hospitals in Truro and across the county border in Plymouth and has 13 community hospitals. The acute hospitals are 57 miles apart, public transport is limited and many older people do not have cars. More than 34,000 people over 65 are living alone.
With the aim of improving the health of elderly patients and avoiding unnecessary hospital admissions, health, social care and voluntary services have introduced a number of new initiatives.
They include the Newquay Pathfinder – a new integrated approach to supporting and caring for people. The model is one of sustainability and flexibility, focussing on what the individual, their carer, their family and community can do for themselves instead of looking for the support of health and social care organisations.
We want to support human aspirations, to lift people out of formal dependency to an expanding world of choice, opportunity and mutual support. The individual is at the heart of our project. We make the time and have the skills to hear each person’s story so that together we shape a flexible care and support network around them that flexes with their condition and needs, improving their quality of life.
Our vision is this becomes the way of working across the whole of Cornwall and the Isles of Scilly. In Newquay we have proven this works on a small scale – our next step is to test it with a larger group and learn from that before rolling it out countywide. 
Our ‘whole person’ approach integrates physical and mental health and wellbeing. It is a system where people get the support they need without knowing who the provider is. At each stage every professional knows what happened to the person before they reached them and how what they do, adds value to what happened before and to what happens next. It integrates help from local volunteers with specialist interventions and creates a mix of providers to match a person’s needs, from walking the dog to home improvements. 
As well as the Newquay Pathfinder clinicians are working on a new way to care for the frail and elderly. Learning from our work with The King’s Fund and our visit to Sweden we are working to move people more smoothly through the system and are planning to provide older people’s clinics in community locations with speedy access.
Because cash is tight, we need to invest more in keeping people well. The challenge is to free money from treating ‘illness’ to investing it in ‘wellbeing’. Our plans must be financially sustainable using money already in the system, or from long-term sustainable social investment. We are seeking to understand how money flows across the system and where value is created by the unpaid contributions of families and carers.
Agreement of success measures can be challenging. In Newquay, we agreed a shared outcomes framework to measure success that has the support of health commissioners and providers, the local authority and voluntary and community sectors. We regularly invite external scrutiny from organisations and people benefiting from the pilot in order to test if we are actually delivering better outcomes and we are getting positive feedback from clinicians. 
An innovative early intervention service for intermediate care has also been implemented by health and social care providers. People receive a swift, personalised service with regular updates about what care and when it will be received, and service user satisfaction is high. However, a key learning point for us has been that other parts of the system essentially remained unchanged and the impact of the new service on them (movement of activity and costs) was not understood. Similarly, tightening of continuing healthcare eligibility has pushed users into the early intervention service, creating tensions between the two services. It has deepened our understanding of the need for a whole person, whole system approach. The next step is to work together to take forward the early intervention work as a whole system model – and thanks to the support being offered to Pioneers, we will be able to do that at increased pace.
Another area we are hoping to expand across the county is our end-of-life care pilot project in east Cornwall. Working closely with carers, and across care homes, mental health and GP practices, expertise has been developed in improving the care and quality of life for people in the end stages of dementia in care homes. Primary care dementia practitioners are based in GP practices and provide consistent care for people with dementia from diagnosis to end of life. They are a single point of contact, build relationships with individuals, their families and local volunteers, and get feedback from memory cafes.
Pilot projects at West Cornwall Hospital are testing integrated working between the hospital, community services and the out-of-hours GP service. We drove through a solution to the need for a 24-hour, doctor-led urgent care centre with the support of that community. A huge gap in local provision that had existed for years was closed within six months and has secured the future of an important community resource.
Councillor Judith Haycock, Chairman of Cornwall’s Health and Wellbeing Board, told us: “We’ve seen the positive benefits we can achieve for people by working more closely together. Our integrated service will be able to provide a greater range of care and support than traditional health and social care services alone.” 

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