Introducing Warwickshire Cares: Better Together

Being ill or needing care can be a very difficult time for all concerned.

It can also be a challenging and frustrating finding your way through the health and social care system.

As a result of this Warwickshire County Council and the 3 local Clinical Commissioning Groups (Coventry and Rugby CCG; South Warwickshire CCG and Warwickshire North CCG) are looking at how we combine and use our resources to work more closely together to help people get the support they need in the right place and at the right time.

This programme of work is known locally as ‘Warwickshire Cares: Better Together’  and the following information explains  in a little more detail what has been done so far and what is planned over the next 5 years to improve services.

Background – ‘The Journey’

In 2013 the Government created The Better Care Fund (BCF) with the aim of transforming and joining up health and social care services to ensure local people receive better care. This will be achieved by shifting existing budgets and resources from health into social care and community services to benefit people who need support. Schemes have now launched around the country in local authority areas and locally it is known as Better Together.

The agreed aims for the work that will take place as part of the Better Together programme are:

  • People are helped to remain healthy and independent;
  • People are empowered to play an active role in managing their own care and the care they receive;
  • People get the right support at the right time and in the right place – which means services will envelop individuals in or close to their home.

In total  £36m from existing health and social care budgets will be combined  for 2015/16 and this will see the start to develop a range of services that can prevent people going to hospital and if they do go to hospital getting them home as soon as possible.

What does this mean?

Better Together is all about everyone working together to make things better for the people of Warwickshire.

We know that being ill or needing care is a difficult time and getting the help and support required can be both frustrating and at times challenging. People regularly tell us that organisations and services don’t join up well or aren’t ‘integrated’; that they have to tell their stories to lots of professionals and that we don’t always listen to what people want.

It is also very important to recognise that in a time of austerity it is really important that we utilise resources as effectively as possible; reduce duplication and ensure we support the people of Warwickshire to get the care and support they need in the most appropriate place, which is often in or as close to their own home as possible.

Hospitals are really important when you need them, but no-one should go into hospital unnecessarily or indeed stay there longer than is needed.

We want people to be able to look after themselves better where they can,   to be supported in their communities and have access to information and advice that helps them maintain their independence.

As you can see we have high ambitions.

It is our desire to change or ‘transform’  health and social care to make sure the people of Warwickshire get the right care and support, the right way, when and where they need it.

To help us achieve this, we’ve identified the five themes under which all Warwickshire Cares: Better Together projects and will fit:

  1. Community Resilience
    1. Reviewing how we fund community and voluntary organisations and what services we ask them to provide whilst making sure we’re asking them to promote people’s independence. For example, we are piloting approaches that aim to link local community and voluntary sector activity directly into GP Practices through Social Prescribing where doctors advise wellbeing activities as part of treatment packages and the use of Care Navigators to help people overcome isolation by helping them to access local services.
    2. Delivering a range of public health campaigns, some of which are already underway, to support people to achieve and maintain well-being. For example, we have produced and distributed a Living Longer, Living Well handbook to residents.
    3. Developing ways to support local community initiatives and organisations such as promoting volunteering and the development of local community enterprises.
  2. Integrated Care
    1. Enabling teams of professionals to work with GP Practices to bring together social care, community health and other services around patients as required. Pilot projects to test this approach are already in place in some parts of the county targeting the most vulnerable patients.
    2. Moving towards a joint assessment across health, social care, public health and housing. This requires significant technical preparation to ensure systems are linked up and processes can be shared. We are in the early stages of developing the necessary technology to do this.
    3. Looking at different ways in which community health services are delivered to increase flexibility of support.
  3. Care at Home
    1. Making sure that people’s homes are equipped to support them so they can remain there as long as possible. We already work with district and borough councils to deliver a Housing Improvement Adaptation Service that is reducing the time taken to make changes to homes and further enabling independence.
    2. Providing more support to all carers, so they can access what they need to enable them to continue to care for loved ones whilst making sure they remain fit and healthy.
    3. Redesigning the way in which home care services are delivered across the county; making sure they are responsive to real local needs and are focussed on outcomes rather than tasks.
  4. Accommodation with Care
    1. Improving the ability of our care homes to consistently provide the highest level of care possible through the introduction of new quality standards and increased support.
    2. Developing services within care homes to meet the needs of an increasingly older and frailer population
    3. Developing ways to help people rehabilitate more quickly by moving them out of hospital and into more appropriate environments as soon as possible.
  5. Long Term Care
    1. Providing early support to people with long term conditions so they can remain as healthy as possible and manage their own care for longer.
    2. Designing and commissioning more support services for those diagnosed with Dementia. We will continue to develop the Warwickshire Dementia Portal and have begun to introduce Dementia Navigators to help people manage the condition.
    3. Working on a joint approach to give people more choice and control about the last stages of life.

Who is everyone?

Everyone is a partnership of local health and social care organisations that have joined together under the banner of Warwickshire Cares: Better Together.

The partners are:

  • Warwickshire County Council, including Public Health
  • NHS South Warwickshire Clinical Commissioning Group
  • NHS Warwickshire North Clinical Commissioning Group
  • NHS Coventry and Rugby Clinical Commissioning Group
  • General Practitioners
  • South Warwickshire Foundation Trust
  • District and Borough Councils (North Warwickshire Borough Council, Nuneaton and Bedworth Borough Council, Rugby Borough Council, Warwick District Council, Stratford District Council)
  • George Elliott Hospital
  • University Hospital Coventry and Warwick
  • Coventry and Warwickshire Partnership Trust
  • Warwickshire Voluntary and Community Sector
  • Providers of Care Homes and Domiciliary Care services

And of course the people of Warwickshire

What has happened so far?

It really is early days and despite the Better Together programme officially going live on 1 April 2015 with much having already been achieved there is still a great deal to be done.

The main focus so far has been behind the scenes. Working together, Warwickshire County Council and the 3 CCGs, have developed a shared vision for the people of Warwickshire and this has received Government approval meaning we can start our programme of work. This programme of work is summarised in the diagram below which explains the programme aims and demonstrates how services will be linked under themes and work with and around a person to meet their needs.

what has happened so far

The programme of work needs approval and observation and we must ensure we have all the correct governance in place so we are able to work effectively across all the organisations involved but that’s not all we have been doing.

Our main focus is to concentrate on the quality of care of Warwickshire’s frail and elderly populations which we believe could be greatly improved through better targeted, better organised and better integrated care. In other words by working better together!

So what is going to change?

Our vision for 2019/20 and beyond is for the people of Warwickshire to remain as well and healthy and independent for as long as possible. People can remain self –sufficient, supported in and by their communities and only required to call on health and social care services when needed for limited intervention. Decision making would be made through better access to information and advice and care would be delivered as close to home as possible.

This is best reflected in the diagram below which shows an individual at the heart of the system supported by the layers of health and social services that become more and more specialised as you work from the centre to the outer ring.

So what is going to change

Our measures of success will be:

  • People with health and/ or social care needs will know how to navigate the health and social care system;
  • People with health and/or social care needs will be able to access the right information at the right time and will be able to access the support they need;
  • Warwickshire people will have an increased understanding of the benefits of wellbeing and will utilise local community resources to put this into practice;
  • People in local communities will have a range of locally grown support mechanisms such as carer led support groups, patient led self-management groups for long term conditions;
  • Through social prescribing GPs will support people to get to the right support and avoid more expensive and often unnecessary interventions;
  • Integrated teams will work closely with GP practices and will envelop individuals and work closely with provider services including local community and voluntary sector services;
  • People with long term conditions will have the ability to hold their own personalised care records and use Personal Budgets and Personal Health Budgets to manage their own care;
  • People with long term conditions and those defined at risk will have the ability to see and share their health and social care records;
  • People will be able to have repairs, adaptations and improvements made to their homes quickly and within timescales acceptable to them;
  • Carers will be supported to have a life outside of caring and will be supported in their caring role;
  • There will be improved access to services (parity of esteem) for all patients/clients, including children and young people, with mental health issues. Mental health conditions will be treated and assessed on a par with physical conditions;
  • Over time we will create a flexible workforce that can deliver more than one service for the benefit of patients and carers and the health and social care system;

How will I find out what is happening?

Warwickshire Cares: Better Together has a visual identity and you will start to see the name and the plan diagram appearing on information and updates we will regularly share with you .

Getting the views and feedback from the people of Warwickshire will be one of the main measures of Better Together’s success. To date we have obtained public views of the current services via a range of events and activities. These include:

  • Home Truths report
  • ‘Have Your Say Day’ engagement events in north and south Warwickshire
  • Survey feedback on primary care and community services
  • Feedback from Healthwatch – independent health and social care watchdog
  • Artist in Residence using art to help people express their experiences of health and care

Activities like this will continue and it is absolutely necessary that we continue to seek, receive and act upon feedback from patients and customers. This programme of work will only be successful if it delivers better care for the people of Warwickshire. We believe that only by working in partnership with you that we’ll be able to create and deliver the health and social care services that are needed.

In five years’ time we want to be able to say ‘we listened, we heard and we delivered’

We are developing a series of webpages to keep interested people up to date with the progress of the programme and these will shortly be publicised. Information will also be shared via social media and by the organisations involved so watch this space.