Introducing our new model of careSteven Edgar

Vice Chair, Symphony Programme Board and Lead for New Models of Care

135,000 population, older age profile30,000 with long term conditions19 GP practices2 community hospitalsCommunity mental health team1 district general hospitalPoor public transportPredominantly small market towns and villages

About South Somerset

The Idea: Our enhanced primary care modelThe patient and key worker are supported by the wider care team and a number of care programmes and services

Patient with Chronic Condition

Key Worker / Health Coach

GP

Care Programmes & Specialists

Other programmes…

Extended Care TeamTherapies e.g. Physio

Mental Health

Social Care

CHF

Respiratory

Diabetes

Dementia

Network of Services

Care HomeAcute Care

Advanced Diagnostics

InterfaceCore Care Team Key Elements

Team Working and Huddle

Triage

Stratification and Proactive Outreach

Care Planning and Coordination

Defined Workflows and Programme Integration

Aligned Resources and Incentives

Shared Clinical Data and Population Health Analytics

Practice Nurse

Other services…

Symphony Integrated Healthcare

• Impact and success - what we have learnt• Building partnerships and sharing our success

with others• Our key message for the health and care

system.

Wellbeing Erewash• Carol Foster, Programme Lead• Stephen Reid, Person-centred approaches co-

ordinator• Julie Wagstaff, Citizen of Erewash

We are supporting the implementation of person centred approaches for all organisations working with people within

the Erewash area, across all services, people and communities to change conversations.

Group level change

J Michael McGinnis, Pamela Williams-Russo and James R. Knickman. The Case For More Active Policy Attention To Health Promotion Health Attention Affairs, 21, no. 2 (2002): 78-93 – adapted from http://www.kingsfund.org/time-to-think-differently/trends/broader-determinants-health

Health and wellbeing

Choice, no responsibility

Health and safety dictates lifestyle

Balance

Circles of support

PayKnow

FriendsLove

My wellbeing plan1. How do I keep well day to day and what does ‘good’ look like? (daily

maintenance plan)2. People who can help me3. Challenges/ Triggers (things that make me less well) and my action plan4. My early warning signs/ wake up calls and my action plan5. When things get worse - crisis plan6. Advanced decisions.

Wellbeing planning

• End of Life Care in South Derbyshire• A&E at the Derby Royal Hospital• Sharing information with Shropshire STP• North Derbyshire

How we are applying that learning further afield in other

communities”

Accountable Clinical Network for Cancer

Ben Gilchrest

Health as a social movement and the Greater Manchester Cancer Vanguard

• Connecting and catalysing a social movement for cancer prevention – what we are doing…

• Learning – ‘the truth is out there!’• Recommendation – the golden thread through the six

principles for new care models

Better Care Together (Morecambe Bay)

• Sophy Stewart, Head of Engagement and Communications

• Jacqui Thompson, Senior manager for planning and partnerships 

What are “people”?

Lets talk about men…

“Men over 60 are….”

Not the same!

What are “communities”?

• Communities of interest: may share common interests e.g. sport and social club

• Communities of action: want to bring change e.g. suffragettes• Communities of place: bound by geography e.g. Morecambe• Communities of practice e.g. people who share a concern or a passion

for something they do• Communities of circumstance e.g. brought together by events

This what we have learnt in our “communities”

Millom

This is how we are applying that learning further afield in other

“communities”

Carnforth

This is how we are applying that learning further afield in other

“communities”

Barrow Morecambe Kendal

Our key message for the health and care system is…

Thank you for listening

System Level Change in Stockport

Nick DixonCommissioning Manager

Stockport Metropolitan Borough Council

Application of learningA ‘Stockport Call to Action’

Four areas to consider

Workforce training and tools

• Who are your workforce?• Relationships matter so

much• Transformational change

can only go at the speed of trust

• We hired workers but human beings came instead

• Resistance- understand why

• Single organisational development strategy with agreed vision

• Leaders set the culture• System translators.

Workforce training and tools

• Rich resource in the community and the voluntary sector

• Work in neighbourhoods people identify

• Go where the fires are burning

• Use the community hubs which exist- map the assets

• Provide information and advice, signposting, digital hubs, link to the prevention services

• Bridge Place and Health: connect to the new care model team

Workforce training and tools

• Activated patients taking more responsibility• More aware citizens wanting change• Community champions and conversations• Compassion inherent in communities;

loneliness- an unnatural disaster• The VCSE can broker the conversations:

“the Council kills it”• Faith groups, businesses, arts, housing,

leisure, fire• Top down, bottom up AND outside in

change.

Workforce training and tools

• How is the VCSE commissioned?

• Commission for outcomes including social capital

• Alliance contracting• Asset based

commissioning across age and label

• Creative use of the resources available

• Commitment devices• Investment funds

Empowering patients and communities

Chair: Anu Singh Director of Patient and Public Voice

and Insight

The NHS Five Year Forward View People and Communities Board have given us six principles to

engage people and communities.

Six principles

• Empowering people is about enabling people to become active partners in their own care, to have the confidence, knowledge and skills to manage their health.

• Empowering communities is about making connections and enabling community activities that provide a network of support options from support groups to gardening clubs to give people the opportunities to self care.

What does this mean?

Using proven evidenced based approaches:

• Health coaching• Peer support• Self management education• group based activities• Volunteering• Community development

How do we do this?

At whole population level: partnerships with communities to mobilise assets, build social capital, address the wider determinants of health and tackle inequalities through approaches such as community development, asset based approaches, volunteering and social action

For people with long term conditions: an increase in the number of people with the confidence, knowledge and skills (activation) to manage their health in partnership with their care teams. Personalised care and support planning and a range of self-care support, routinely offered to those who need it and access to community resources through social prescribing For those with complex care needs: more people who feel in control over their care by having integrated personal commissioning (IPC) and personal health budgets; and providing personalised support for carers.

What might we see in five years time?

• Changing behaviours and relationships takes time• Need to be able to identify the people who find managing

their health difficult otherwise we may widen inequalities• This approach does improve peoples lives and reduce

demand, however it all needs to be implemented to be successful.

What are the challenges?

North East Hampshire and Farnham has recently launched its recovery college – offering health and wellbeing courses to service users and members of the public. These educational courses aim to help people improve their health and wellbeing, and include courses in a range of psychological, mental and physical health conditions. Early evaluation of the first cohort has indicated a 26% improvement in self-reported wellbeing.

What's already happening?

In All Together Better Sunderland multispecialty community provider vanguard more than 18,000 volunteers have been engaged as community health champions and they have in turn reached over 104,000 others.

What's already happening?

Our support team• Five delivery partners who will directly support vanguards in developing and refining their

local approach.

Communities of practice• We want to enable health and care communities to learn from each other, and have an

opportunity to develop themselves personally and professionally. • We will build relationships within, outside and across the health and care system that will

encourage ambition, learning, motivation and energy to help deliver initiatives that will empower people and communities.

Contact: england.epc@nhs.net

Support from the Empowering Patients and Communities team