Agenda item

Attending for this Item were:

Worcestershire Health and Care NHS Trust (WHCT)

Sue Harris, Director of Strategy and Partnerships

Melanie Roberts, Deputy Chief Operating Officer/Associate Director Integrated Community Services

Worcestershire Acute Hospitals NHS Trust (WAHT)

Jane Ball, Deputy Director of Planning and Development

Worcestershire Clinical Commissioning Groups (CCG)

Ruth Lemiech, Director of Strategy

Heather Macdonald, Deputy Director of Strategy

Worcestershire County Council (WCC)

Richard Keble, Assistant Director of Adult Services

By way of presentation, the background, current situation and future plans of Neighbourhood Teams was discussed.

It was noted that integrating care in Worcestershire was not a new concept and health partners had been working together for a long time to provide a place based integrated service in response to feedback from residents.

The work around Neighbourhood Teams was now a central theme of the Sustainability and Transformation Partnership (STP) under the STP Priority 3, 'developing out of hospital care'.  It would provide integration at a locality level, maximise the use of community hospitals and sustain general practice with a strong focus on frailty, end of life and dementia.

The teams would provide integration of all community services and be embedded in neighbourhoods, with populations of 30,000 – 50,000.  In Worcestershire, 14 teams were planned – 3 in Wyre Forest, 4 in Redditch & Bromsgrove and 7 in South Worcestershire.  All teams would have Leads from Social Care, GPs  and the Health and Care Trust Lead along with Nurses, Therapists, Healthcare Assistants, Promoting Independence and Administration Staff.

As the new teams would be working together from a variety of backgrounds, it would replace what was currently in place, focussing on the patient, not the process or the need to refer between services.  The team approach would also provide one single point of contact and allow for joint working, including developing consistency across documentation.

Each team would have monthly Multi-Disciplinary Team (MDT) discussions, resulting in patients being reviewed frequently and being referred and signposted if extra support was required.  The impact of MDT discussion and intervention would aim to reduce A&E attendance and admission and generally reduce the number of GP surgery contacts.

Expected outcomes from the Neighbourhood Teams would include support for people to live independently and self-manage their conditions, being proactive about care to avoid crisis where possible, more choice to stay at home and better care co-ordination.  Additionally, staff would receive a more satisfying work environment and more time to spend with patients as there would be less duplication.  For the health system, benefits would include reduced reliance on secondary care and emergency admissions, a reduction in inpatient stays and facilitation of discharge, finance advantages and a single point of contact for the Neighbourhood Teams.

It had been agreed not to launch the Teams, rather be incremental in their introduction, however, by June 2018 all 14 Teams should be operational and priorities for the coming year would include bringing back office functions together and increasing involvement of partners including housing and voluntary and community organisations.  In conclusion, priorities would also be shaped around the needs of people living in each Neighbourhood.

In the ensuing discussion, the following main points were raised:

·         Members felt that communication was key in any change, however, were disappointed to note that despite the incremental launch being in a matter of weeks, no attempt to publicise the change had been made.  In response, it was reported that advice on communication was sought from Healthwatch Worcestershire who advised not to advertise as this would potentially confuse patients

·         It was noted that the change was larger for the workforce than for patients, however, going forward patients would have a named contact for their care, which was an outcome well received by residents

·         Of the 14 Neighbourhood Teams, the smallest was to serve a population of around 22,000 and the largest a population of 58,000.  All would be based around a GP Practice and have a GP Lead.  Nurses with various backgrounds would complement each Team

·         In response to a question about the number of patients a Team may have, it was difficult to say as each Team was different, however it was hoped that no patient would be turned away

·         Not all Team locations were finalised, however, when settled, an invitation was extended to HOSC Members to visit a Neighbourhood Team.  In addition, Members extended invitations to Speakers to attend various Forums to share this new way of working

·         One Member questioned the danger of social isolation if the number of professionals a patient may see decreases.  It was reported that the County Council's Three Conversation social care work was consistent with the Neighbourhood Team approach and the model allowed for potential isolation to be identified quickly and acted upon.  Reconnections, a Countywide service to reduce loneliness and social isolation was cited

·         The dedicated Frailty Unit at the Alexandra Hospital in Redditch was working well, however, with 43% of patients going home the same day, it was hoped that the Neighbourhood Teams approach would alleviate some of the pressure and support patient flow.  Currently, the expertise was at Redditch and the Trust was working with West Midlands Ambulance Service to look at patient journeys.  In the future, it was a Trust aspiration to increase opening hours from the current Monday to Friday 9am to 5pm to perhaps 12 hours a day, 7 days a week.  When asked whether it could then be staffed, it was reported that a plan was in place and the enthusiasm within the team was positive, across Acute and Community teams. 

In response to queries about the wider STP:

·         The Committee was pleased to hear that the term 'Accountable Care' was no longer being used, rather 'Integrated Care' which was much more meaningful to residents

·         Members learned that in relation to reports of a reduction in community hospital beds, the CCGs were reflecting on the experience of last winter and would be in a position to report back to HOSC at the end of the Summer.