Introducing Warwickshire Cares: Better Together

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

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

As a result of this Warwickshire County Council and the three 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, University Hospital Coventry and Warwickshire 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 for 2017/19 allowed partners involved to be even more ambitious with our plans, which continued in 2019/20 and will continue to do so in 2021. 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 the Health & Care Partnership, previously known as the Coventry & Warwickshire Sustainability and Transformation Plan, or Better Health, Better Care, Better Value.

So what’s different for 2019-21?

In order to be eligible for the Better Care Fund, the same four criteria as 2017-20 continues to apply:

  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 2019-20 a new condition to implement the High Impact change model was also introduced.

New in 2019 was the incorporation of the Adult Social Care Winter Fund (Winter Pressures Grant) into the Better Care Fund.

Further details of the 2019-20 BCF policy framework can be found at: BCF_Planning_Requirements_2019-20

In total £189m from existing health and social care budgets were aligned in 2019-20 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 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, access self-care, 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 and 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?

Local health and social care organisations have joined together in partnership 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.

The five portfolio areas identified in 2016 by all the organisations represented within Better Together, based on the needs of Warwickshire’s residents, continue through 2019-20. Through the portfolios the following three areas were prioritised for additional attention in 2019-20:

  • Social Prescribing
  • Accommodation with Support
  • Housing, underpinned by Assistive Technology

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 Eliot 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?

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 in every year of the programme. It 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.

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 has and continues to change?

Our vision for 2019/21 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 is made through better access to information and advice and care 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 know how to navigate the health and social care system;
  • People with health and/or social care needs are able to access the right information at the right time and are able to access the support they need;
  • Warwickshire people have an increased understanding of the benefits of wellbeing and will utilise local community resources to put this into practice;
  • People in local communities 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 support people to get to the right support and avoid more expensive and often unnecessary interventions;
  • Integrated teams work closely with GP practices and envelop individuals and work closely with provider services including local community and voluntary sector services;
  • People with long term conditions 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 have the ability to see and share their health and social care records;
  • People are able to have repairs, adaptations and improvements made to their homes quickly and within timescales acceptable to them;
  • Carers are supported to have a life outside of caring and will be supported in their caring role;
  • There is 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;
  • There is 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:

  • Engagement as part of Commissioning plans and pilot activities
  • Feedback from Healthwatch – independent health and social care watchdog
  • Public and patient partnership groups
  • Survey feedback on primary care and community services
  • Home Truths report
  • ‘Have Your Say Day’ engagement events in north and south Warwickshire
  • Artist in Residence using art to help people express their experiences of health and care

Activities like this 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.

At the end of the programme we want to be able to say ‘we listened, we heard and we delivered’.

Our achievements over the last four years have been regularly updated on these pages: www.bettertogetherwarwickshire.org/latest-news/