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 combining our resources to work more closely together to help people get the support they need in the right place and at the right time.

Better Together is Warwickshire’s programme for the allocation of the national Better Care Fund, the first time government funding has been ring-fenced for NHS and social care integration.

First introduced in 2015, this initiative supports stronger working relationships between Warwickshire County Council (WCC), the five district and borough councils, three regional Clinical Commissioning Groups (CCGs) and major local health service providers. These include the South Warwickshire Foundation Trust, George Eliot Hospital and Coventry & Warwickshire Partnership Trust.

Background – ‘The Journey’

The Better Together programme’s move from a cycle of annual planning to a two year plan now allow’s the partners involved to be even more ambitious with our plans for 2017-19, simultaneously reducing the volume of reporting and administrative work required. To understand the programme please see the plan on a page, including the collective aims and ambitions of the partner organisations and links to other key programmes from across Warwickshire, including Better Health, Better Care, Better Value, previously known as the Coventry & Warwickshire Sustainability and Transformation Plan.

So what’s different for 2017-19?

In order to be eligible for the Better Care Fund, there are now only four criteria to be met, replacing the eight previous conditions. The new conditions are:

  1. Partners must work to a jointly agreed plan
  2. NHS contribution to adult social care is maintained in line with inflation
  3. An agreement to invest in NHS-commissioned out of hospital services, which may include seven day services and adult social care
  4. A commitment to ensuring people’s care transfers smoothly between services and settings

In early 2017, a major injection of funding for adult social care was announced in the government’s spring budget. This new grant allocation (referred to in documents as the Improved Better Care Fund or IBCF) is focused predominantly on supporting health and social care by reducing delayed transfers of care (DTOC) – this is a real challenge for Warwickshire in particular where DTOC levels are currently running close to 10%, compared to a target of 3.5%.

Another change in 2017-19 is Warwickshire’s acknowledgement that housing is a key element in driving better quality care for local residents, and must form one of the projects within the 2017-19 programme.

Further details of the 2017-19 BCF policy framework can be found at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/607754/Integration_and_BCF_policy_framework_2017-19.pdf

In total  £117m from existing health and social care budgets will be aligned  for 2017/18 to continue to develop, deliver and support 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 will fit:

1. Community capacity

A key facet of the Better Together programme will be the development of connected, informed, resilient and self-supporting communities which utilise local assets, help and advice, and universal services to meet the needs of their residents.

2. Care at home

A key aim of Better Together is to support people to remain independent for as long as possible, and for many this means being able to remain in their own homes, receiving care but reducing or delaying the need for that care to be delivered in acute settings such as hospitals or nursing homes. At its core, this portfolio’s focus is to help people remain in control, and will include well-coordinated local support for carers.

3. Accommodation with support

As part of the process of ensuring specialist services are directed where they are needed most, this portfolio will focus on delivering high quality, responsive residential and nursing care. This includes residential and nursing homes, extra care housing, discharge to assess and moving-on beds, plus new and innovative solutions like Shared Lives.

4. Integrated care and support

It is important for proactive and jointly delivered care to be provided for the most vulnerable people and their carers, and this will be achieved through the establishment of integrated teams and joint processes that support admission avoidance and timely discharge from hospital. Customers will only need to tell their story once, knowing their needs will be met by staff who work together to achieve the best outcomes.

5. Housing

Customers of health and social care services should have significant or full control of their lives, including a home of their own they are happy with, where appropriate adaptations have been made to ensure they can live independently and receive support where and when it is needed. The housing partnership is responsible for this.

 

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. We all, including Warwickshire residents have a role to play in helping the people of Warwickshire remain safe, healthy and independent for as long as possible.

With the right support from health and social care partners, people can remain self-sufficient, supported in and by their communities, and only required to call on health and social care services when intervention is required. Decision-making would be made easier for individuals through improved access to information and advice, with care delivered as close to home as possible.

Five projects were identified for 2017-19 by all the organisations represented within Better Together, based on the needs of Warwickshire’s residents, and are either new or continuing from 2016.

Public Health guidance and expertise around prevention and early intervention approaches will underpin the work of all five of the portfolios identified.

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.

Plan on a page 2015 2020

Plan on a page 2015 2020

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 key measures of success are:

  • Improved effectiveness of reablement / rehabilitative services enabling people to stay at home;
  • Less admissions (non elective) into hospital;
  • Less delayed transfers of care when leaving hospital;
  • Less long term admissions into residential and nursing care.

 

Supported by the following outcomes:

  • 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 to support self care;
  • 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 an established visual identity with the name and our logo appearing on information and updates we regularly share with you .

Getting the views and feedback from the people of Warwickshire is 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 three years’ time we want to be able to say ‘we listened, we heard and we delivered’.

Our achievements over the last two years and our progress over the next three years will be regularly updated on these pages.