1. Working Smarter for Better Health
The Journey towards
Integration
The vision for Wirral

2. • The need for change
• The new service model
• How it will affect you?

3. Working together
Wirral Community Trust
Wirral Council Department of Adult Social Services
Cheshire and Wirral Partnership NHS Foundation Trust
Wirral University Teaching Hospital NHS Trust

4. Represented today by
John Lancaster
Director of Operations, Wirral Community NHS Trust
Peter Tomlin
Senior Manager-Wallasey and West Neighbourhoods, Wirral Council Department of Adult Social Services
Val McGee
Service Director and Deputy Director of Operations, Cheshire and Wirral Partnership NHS Foundation Trust
Jo Goodfellow
Associate Director of Operations, Wirral University Teaching Hospital NHS Foundation Trust

5. “The management and care of people with
long term conditions has been described
by the World Health Organisation as the
health care challenge of the century”
Innovative Care for Chronic Conditions, WHO 2002

6. The Challenge for Wirral
Demographic
•A relatively high number of older people but fewer people in their twenties and
thirties, compared to the average for England and Wales
•An ageing population. The number of people aged over 65 and over 85 years of
age will rise significantly between now and 2021
•Long-term conditions* are more prevalent with age and deprivation. We are
predicting a massive increase in the number of people living with long term
conditions in Wirral.
“The World Health Organisation has defined a long term condition as a health/social
problem that requires ongoing management over a period of years or decades”
WHO (2005a) Preventing chronic diseases. Preparing a health care workforce, WHO

7. Doing nothing is not an option against a
backdrop of a growing demand for care
and increased financial challenges
We need to transform the way we provide
health and social care.

8. The Journey began
• Clinical and social care staff-led workshop – at Hulme Hall, summer 2012
• Engagement event for patients and public – at Heswall Hall, summer 2012
• Stakeholder organisations’ workshop – Autumn 2012
• A Programme Board was set up - November 2012. Representation from all
participating organisations
• Domain groups set up – January 2013. Chairs drawn from each participating
organisation

9. The Journey continues …
• Process-mapping exercises – demonstrated duplication of effort
• Working groups for discharge, “Pull” pilot and step down care
• Progress within Domain groups – April-September 2013
• Communication bulletin starts to appear – from January 2013
• Clinical and social care staff have contributed from the start, particularly to
Service Redesign, IT and Patient and Carer Engagement domains
• Workforce Action Plan produced – September 2013
• Working in partnership with your trade union representatives
• Building on our good practice that already exists

10. We have listened to staff at the
engagement events, who said …
• We need to manage people more proactively
• We need greater co-ordination of health and social care
• We want to support people to make informed and independent decisions about
their care
• We want to support people to make healthier choices

11. The Solution – the Wirral Vision
“Caring Together,” a strategy to develop integrated teams across
Wirral
•To involve people in decision-making about their care
•To support people to look after themselves, make healthier choices and live as
independently as possible
•To fully co-ordinate the management of people with health and social problems who need
ongoing care
•To look after people in their own homes as an alternative to hospital, where appropriate
•To work more efficiently together within multi-disciplinary teams
•Bringing together community nurses, community matrons, social workers and mental health
practitioners
•Access to responsive support services such as domiciliary care, night sitting, etc.

12. How will we do this?
Risk Stratification – a method of proactively identifying people who are, or could become, the
most regular users of hospital services in the future. Risk stratification classifies people
according to the complexity of their need, helping us to meet and manage their needs more
effectively
Integrated care Coordination Teams (ICCT) – creating multi-disciplinary teams, uniting
health and social care professionals to work together more effectively for the benefit of
individuals
Self Help – a significant number of people with long term conditions want to remain as
independent as possible and live as healthily as they can. Their feedback suggested that they
need more information, online and face-to-face. “Puffell” is a free, Internet-based portal which
allows people to create a Personal Health Account. It also enables them to self-refer to specific
services if they wish

13. The Care Model

14. Next steps
A phased approach - testing:
•A single assessment process
•Shared information and documentation
•Shared working practices
•Working to a mutually-agreed set of working standards
•Working towards a shared electronic patient record
October-March:
•Five teams created called Integrated care coordination teams
•Increasing to six teams, building on the feedback and lessons learned from early
implementers
•Eight teams, building on the feedback and lessons learned from previous implementers

15. Moving Forward - October 2013
What will happen:
•Testing of newly developed documentation
•One assessment and less duplication
•ICCT working
•A single gateway for referrals
What may happen:
•Change of location for ICCT MDT meetings
What won’t happen:
•Your Terms and Conditions will not change
•Your employer, line manager and supervision stays the same

16. Moving forward October-March 2014
17th
September
Integrated Teams
presentation
Q&A
Selected
MDT’s x2
Workshop
sessions to trial
document and
take feedback
Fluid October
roll out
Continue with
evaluation,
revision, and
sharing the
learning
Selected
MDT’s x2
Learn from before
and continue to
share the learning
Selected
MDT’s x2
Learn from before
and continue to
share the learning
8 MDT’s

17. Next steps-By April 2014
This will ultimately lead to
Integrated Care Coordination teams,
serving the whole of Wirral,
by April 2014

18. To Deliver
• More people living at home - Increase by 20% by 2015
• Avoidable non elective admissions reduced by 20% by 2015
• Reduced admissions to residential care by 20% by 2015
• Reduced length of stay for people with long term conditions in acute
care for non clinical reasons by 25% by 2015
• Reducing attendances and emergency admissions at Accident and
Emergency departments and mortality
• Continuously improve people’s (both the public and staff)
experiences

19. Working Smarter for Better Health
Over to you
Questions?
Any questions to: Caring.together@wirral.nhs.uk or petertomlin@wirral.gov.uk
For Video and FAQ: www.wirralccg.nhs.uk