NHS NORTH LINCOLNSHIRE CLINICAL COMMISSIONING GROUP

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North LincolnshireTransforming Services for the Frail and

Elderly

Caroline BriggsDirector of Commissioning

North Lincolnshire CCG

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Population c.167,000

328 sq. miles

Dispersed population across urban Scunthorpe, 6 market towns and 80 villages.

Population growth - increased by 9.5% from 2001 to 2011 compared with 7.9% nationally

Demographic older than national average, with a predicted 21.3% over 65 by 2018 compared to England average of 18.5%.

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North Lincolnshire

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CCG - 19 GP practices

North Lincolnshire Council - Unitary

Northern Lincolnshire and Goole NHS Foundation Trust – Scunthorpe General Hospital and community services

Rotherham Doncaster and South Humber NHS Foundation Trust – Mental Health Services

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Local structure

Health and Wellbeing Board identified Frail and Elderly as a priority for focus in 2013

Population context

Healthy Lives Healthy Futures - creation of future sustainable health and care services across Northern Lincolnshire

Increasing admissions to hospital

22% increase in 65-74 in last 12 months

8% increase in 75+ in last 12 months

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Why Frail and Elderly?

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NHS IQ team engaged to support how we could work together across the partners

Workshops - Alliance included staff from CCG, GP’s, Acute hospital, Community services, Council from across different areas, commissioning support, older people mental health team, NHS England, Healthwatch

6 workshops held March to October9

Transforming Care

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Partners in Frail and Elderly Programme

“To keep well, I need to be able to live as independently as possible so I feel in control and can pursue my life purpose (which may well be caring for others), supported by a close social network of family, friends and share and understand my experience. I want one main trusted contact with whom I feel safe, who is linked the health and care ‘system’ (not necessarily a clinician). I want that person to respect me, and guide me. I want them to join up conversations between services – especially concentrate on coping and keeping well; doing as much as possible to care for with support of my family and friends. This person also needs to understand my story and see being impacts on my physical wellbeing – and vice versa. Preserving my mobility is special because it’s about me staying in control and being independent. The NHS has to recognise my physical and emotional well-being to keep me well. Often talking and being listened to by helps me with the emotional stuff - more than clinical people

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What do people want?

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• Model for future services for frail and elderly created – trialled in ‘perfect weeks’

• Design of approach to Better Care Fund plan –Approved

• Detailed business cases being finalised

• Significant target reductions in non elective admissions 11.5% on Nov 14 baseline

• Changes being implemented

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Impacts of Programme

Prevention Well being hubs supporting independence and reducing isolation Extra support to carers Team working with Care homes to support them to keep residents well

Out of hospital support Enhanced Locality teams working with primary care Rapid Assessment within and hour and time limited support at times of

crisis Ambulance service working with community teams to access support at

home rather than take to hospital where appropriate

In hospital dedicated multi disciplinary Frail and Elderly Assessment and Discharge

teams – experts to proactively manage care and plans for discharge 7 day social work input Older peoples mental health liaison team

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Future Model for Frail and Elderly

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I will be supported to maintain my independence for as long as possible

I will feel confident to remain living at home for longer

I will be in control of long term conditions and helped to manage it appropriately

I will feel safe

I will have my health and care needs met closer to home

I will feel part of the community and are less isolated

My carer will feel able to continue in their caring role

I will be supported back into the community following a medical intervention

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What does this mean for individuals?

Relationship building through sustained development over a period of time

People working together who would never normally do

Tools and techniques learnt and practised in context of what we want to achieve

Workshops provided a ‘safe’ environment to think differently and lose organisational boundaries

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Benefits of NHS IQ support

HWB adopted a suite of documents to support integrated working – including recommending the innovation culture tool for use with teams

Webex’s being organised for how to use NHS IQ innovation culture and collaborative teams tool to share with wider audience across partners

Learning and individual development

Tools used in other programmes including driver diagrams

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Broader outcomes

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“Had the programme been very rigid it would not have been successful at all”

“complete tailoring to us”

“The programme has given people the space to have these discussions”.

“Better outcome than the traditional approach”

“Practical sessions and meaningful discussions”

“Made me feel brave enough to share difficult experiences”

“Exceeded my expectations.”

“Really thought provoking.”

“Made me think outside the box.”

↑Permission to try – Perfect Week↑Ideas developed through the discussions with wide range of inputs

– RATL↑Relationships↑Pace of discussions↑Excellent and flexible facilitation – the car park discussion!↑Good engagement and attendance throughout including GP’s↓Frustrations when people had missed one of workshops and

needed to catch up!↓We failed to get Consultants engaged↓Realising we have lots of people across our system who ‘do’

engagement, leadership and a gap re delivery and measurement (NHS Change Mats)

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Highs and Lows!

Yes!!But needs to be the right challenge – we chose

well

Would seek stronger sign up at the start from all

Would aim to share the workload a bit more to get real buy in from key partners

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Would I do it again?